Medical Mystery: A wintry day, a sore throat, and the father of our country

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George Washington after Gilbert Stuart, titled “Patriae Pater,” by Thurwanger, c. 1853.

George Washington, the father of our country, who endured no end of hardships as he led the Continental Army to victory, likely envisioned a quiet retirement as a gentleman farmer at his beloved plantation at Mount Vernon in Virginia. 

Thirty-three months after leaving the presidency, Washington, at age 67, rode out on horseback to inspect his property the morning of Dec. 12, 1799. It was a cold day — below freezing — and an ice storm turned to snow as Washington spent five hours in the saddle on his rounds. By the time he got home to dine with guests, he decided not to change out of his wet clothes so he wouldn’t delay the meal.  

He soon developed hoarseness and a sore throat. He awoke suddenly at about 3 a.m. Dec. 14, because he was having trouble breathing. Hours later, he could not swallow. He coughed, spit up phlegm and had chills and fever. An attempt to gargle a concoction of vinegar and tea caused more distress and vomiting. Washington ordered his staff to bleed him, which was the usual and standard home care of the day, though his wife Martha expressed reservations. 

Washington’s personal physician arrived at Mount Vernon and diagnosed the condition as life threatening. Two more doctors were called in, and more aggressive treatments were discussed. Washington was bled even more, losing about five pints in total, enough to cause shock. Calomel, a mercury-containing compound, was given as a purgative, depleting him even more. 

In the course of the afternoon, Washington appeared in great pain and distress with difficulty breathing, and frequently changed his position in bed, unable to sit up. At 4:30 P.M. surrounded by his family and plantation staff, Washington gave directions about his will. At about 8 P.M. it was noted that his condition remained unchanged. 

The youngest of the physicians suggested a then-radical surgical procedure, a tracheotomy, to open up his airway. The two senior physicians opposed the idea. For a while, Washington’s breathing appeared to ease, then suddenly became more labored, and he collapsed.  

Was George Washington in shock from blood loss? What caused the acute breathing distress? Should the tracheotomy have been performed?


Solution

Washington’s throat examination showed redness and swelling with an appearance of infection, especially in the back of the tongue, spreading to the pharynx and the epiglottis, the flap that covers the trachea, or airway opening. His sore throat (pharyngitis) was complicated by acute epiglottitis — a swelling and inflammation of the flap so severe, it blocked the passage of air into the trachea and lungs. 

In Washington’s pre-vaccination day, infections such as those connected with influenza type B would have been the most common cause of this condition. But without antibiotics or respiration equipment the doctors were stymied as they tried to get air into their patient’s lungs. 

Tracheotomy is a cut through the front of the neck, penetrating into the trachea to restore an airway and permit breathing. Then a (sterile) tube is placed through  the neck opening into the trachea to avoid the higher airway obstruction and allow breathing. Though it soon would be well-accepted, the procedure was experimental at the time and considered too risky. 

Having rejected the tracheotomy, the two older, more experienced physicians continued with bleeding in an effort to drain Washington’s body of “bad humors.” They even applied beetles to his legs to raise blisters, and gave him the mercury-laced remedy which gave him diarrhea and forced him to vomit. 

Finally, Washington ordered his doctors to stop the barbaric treatments and let him die in peace. “Doctor…I die hard, but I am not afraid to go,” he muttered.

Before his death, Washington had arranged to free his 124 slaves who were under his personal control. He died between 10 and 11 p.m. December 14, 1799, from respiratory complications of a sore throat at age 67.

Some medical scholars have posited that he might have survived if he had listened to his wife and foregone the bleeding that likely weakened him. And perhaps the tracheotomy could have restored his breathing — though under the hygiene conditions of his day, it might have led only to another infection.

Allan B. Schwartz, M.D., is a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine.