Washington’s Death and the Doctors 
945 
in the girl’s. 
Yet a vague disappointment showed in the woman’s a.s it. Inwl . 
But this time the man’s voice trembled as he ansvara&h^liao&fWitlß^ 
the words,— 
“‘Only the actions of the just smell sweet and blossom"*!®nmeb 
dust.’ ” 
WASHINGTON’S DEATH AND THE DOCTORS 
DECEMBER, 1799 
SOLOMON SOLIS COHEN, Ml). 
WHEN the author of “ The True George Washington” says, 
“ There can he scarcely a doubt that the treatment of Wash- 
ington’s last illness by the doctors was little short of mur- 
der,” he gives blunt utterance to an opinion quite widely held. Physi- 
cians have not spoken so bluntly, but there have not been wanting 
medical writers to question the wisdom of the “copious bleedings,” 
the blistering, and the purging that Dr. Craik and one of his colleagues 
deemed necessary. That patients are not so treated to-day is true; 
but it would be strange had medicine alone failed to advance in a hun- 
dred years, and the physicians of 1799 cannot justly be condemned for 
failure to have anticipated the discoveries of the nineteenth century. 
Let us briefly recall the facts: On Thursday, December 12, 1799, 
Washington “ rode abroad on his plantations” from ten o’clock in the 
morning until three o’clock in the afternoon. During the most of this 
time “ rain, hail, and snow fell alternately, with a cold wind.” The 
next day he complained of soreness of the throat and “had a hoarse- 
ness, which increased towards evening.” He thought so little of this, 
however, that but for a snowstorm he would again have ridden out on 
Friday morning, and in the afternoon he did go out in the snow to 
mark some trees to be felled—a work not urgent. He passed his 
evening as usual, rejecting Colonel Lear’s suggestion that he needed 
medicine with the remark that he “never took anything to carry 
off a cold, but let it go as it came.” At two o’clock the following 
morning, Saturday, December 14, he was seized with a violent chill. 
Breathing became difficult, and speech was painful. So soon as the 
house was stirring—about five o’clock—he sent for an overseer and 
ordered the man to bleed him. At this time he “could swallow 
nothing,” and was “convulsed and almost suffocated.” Only about 
twelve ounces of blood were taken, although the General urged that 
the opening be made larger and the flow encouraged. Not until some 
time later, when it became evident that he was rapidly growing worse, 
could he be prevailed upon to send for his old friend and physician. 946 
Washington’s Death and the Doctors 
Dr. James Craik, who seems to have been a man of scientific education, 
strong character, and good judgment. Washington placed entire trust 
and confidence in him; and the two had been intimately associated pro- 
fessionally, personally, and officially since the days of Braddock’s field. 
Dr. Craik did not reach Mount Yernon until eleven o’clock on Saturday 
morning. In a communication published in The Times, of Alexandria, 
Virginia, December, 1799, by Drs. Craik and Dick, the subsequent his- 
tory is given as follows: 
“ Discovering the case to he highly alarming, and foreseeing the 
fatal tendency of the disease, two consulting physicians were immedi- 
ately sent for, who arrived, one at half past three, the other at four 
o’clock in the afternoon. In the interim were employed two copious 
bleedings, a blister was applied to the part affected, two moderate 
doses of calomel were given, and an injection was administered, which 
operated on the lower intestines, hut all without any perceptible ad- 
vantage, the respiration becoming still more difficult and distressing. 
Upon the arrival of the first of the consulting physicians it was agreed, 
as there were yet no signs of accumulation in the bronchial vessels of 
the lungs, to try the result of another bleeding, when about thirty-two 
ounces of blood were drawn without the smallest apparent alleviation 
of the distress. Vapors of vinegar and water Avere frequently inhaled, 
ten grains of calomel were given, succeeded by repeated doses of emetic 
tartar, amounting, in all, to five or six grains, with no other effect than 
a copious discharge from the bowels. The powers of life seemed now 
manifestly yielding to the force of the disorder. Blisters were applied 
to the extremities, together with a cataplasm of bran and vinegar to 
the throat. Speaking, which AAras painful from the beginning, now 
became more impracticable, respiration grew more and more contracted 
and imperfect, till half after eleven o’clock on Saturday night, A\dien, 
retaining the full possession of his intellect, he expired without a 
struggle.” 
The diagnosis made by Dr. Craik and concurred in by Drs. Dick 
and Brown was “cynanche trachealis,” which they render in English 
as “inflammation of the upper part of the wind-pipe.” 
As the symptoms point to the somewhat rare affection now known 
as “ acute oedematous laryngitis,” it is usually assumed that they were 
mistaken; but the nomenclature of pathology has changed so much 
that it is by no means certain that part of the supposed error in diag- 
nosis is not merely a difference in terminology. 
Although Morgagni, in 1765, and subsequently Boerhaave and Van 
Swieten, had given from post-mortem studies an account of laryngeal 
oedema, even so great a pathologist as Bichat described it imperfectly 
in 1801, and it was not until 1808 that Bayle communicated to a 
learned society of Paris the clinical and pathologic studies through Washington’s Death and the Doctors 
947 
which the disease of which Washington probably perished became clearly 
differentiated. Granting, therefore, that a mistake in diagnosis was 
made, it was one that the imperfect knowledge of the day could not 
avoid. It is evident, moreover, that certain essential facts were clearly 
recognized by those country doctors of a century ago: namely, that 
there was present in the upper portion of the breathing-tube of their 
illustrious patient an inflammatory swelling obstructing the passage of 
air, making the act of swallowing difficult and painful, and interfering 
with speech, and that unless they could restore the normal flow of blood 
through the parts and thus reduce the'swelling, suffocation must take 
place. To this end, therefore, they directed their treatment. 
To understand both the wisdom and the ineffectiveness of that 
treatment it is necessary to understand the conditions present; and to 
make these clear it will be necessary to picture, though briefly, and in 
mere outline, the construction of the breathing apparatus of man. 
The human lung is made up of innumerable microscopic sacs with 
subdivisions known as air-cells, which are the expanded and specialized 
terminations of certain small tubes springing from each “bronchiole” 
or terminal twig of the respiratory tree, the whole being roughly com- 
parable to a bunch of grapes. Pairs of bronchioles unite to form 
larger, and these to form still larger “bronchial tubes,” which finally 
converge in the main “ bronchus.” The two main bronchi, one from 
each lung, then join with each other and form the trachea (or wind- 
pipe) like the branches of an inverted A- The bronchial tubes are 
made up in part of cartilage (or gristle) to give them stability, and in 
part of membrane and fibrous tissue to give them suppleness and 
elasticity. As the larger bronchi, and finally the trachea, are reached, 
the cartilaginous portions become larger and more frequent, and are 
disposed in a special manner. At the upper part of the air-tube the 
cartilages become still more highly specialized, and the structure known 
as the larynx or voice-box appears. This is functionally, structurally, 
and developmentally a continuation of the wind-pipe, modified for the 
production of voice. A cartilage (cricoid) thicker and stronger than the 
tracheal rings forms the base; then, passing upward, there appears as 
in the trachea a membranous interval, and then a large expanded shield- 
shaped cartilage (thyroid) the prominent upper and anterior portion 
of which forms the “Adam’s apple.” Above the thyroid cartilage is 
again a membrane, and then the ring of cartilage is replaced by a bone 
(hyoid) to which by muscles and ligaments is attached the tongue, and 
the breath-tube ends. But the open mouth of the breath-tube, just be- 
hind the tongue, must be protected from the entrance of food, and a 
little cartilage (epiglottis)—the lid of the voice-box—is found here, 
arranged by shape and muscular and membranous attachments to act 
as a valve, open during breathing and closed during swallowing. The Washington’s Death and the Doctors 
air-cells, the bronchioles, bronchi, trachea, and larynx are lined with 
mucous membrane, in which and beneath which, in the connective 
tissue between the mucous membrane and the cartilage or outer layer 
of fibrous tissue (submucous tissue), are found nerves, blood-vessels, 
lymph-vessels, etc. In the connective tissue are certain spaces that 
normally contain the fluid lymph, and which may become overfilled 
with a fluid of morbid origin in certain forms of inflammation. Within 
the larynx, attached to certain cartilages, are found two bands of mus- 
cular and fibrous tissue known as the vocal cords, or vocal bands, which 
during voice production are brought close together, leaving a mere 
chink for the passage of air, and during breathing are separated more 
or less widely. 
The wind-pipe is oval in section, its greatest diameter averaging 
one inch, while the “ chink of the glottis” or space between the vocal 
bands is a triangular opening, averaging one inch in length, and when 
at its greatest, about one-half inch in width at the posterior portion 
or base of the triangle. Small at best, yet sufficient for its purpose, it 
is the gate-way of the breath, the very portal of life. Its obstruction 
means danger; its occlusion, death. Here, probably, in the case of Gen- 
eral Washington, the fatal swelling took place; and concerning this a 
word may be necessary. 
In the process known as inflammation, the flow of blood through the 
affected part is obstructed, and sometimes completely cut off. The 
blood-vessels are engorged, and through this and cell-multiplication 
the part becomes much enlarged. Sometimes when the inflammation 
affects structures having much connective tissue with large lymph- 
spaces, and under certain exciting conditions, fluid will leak, as it were, 
out of the vessels, and the inflamed part will become greatly distended. 
This severe process is termed acute inflammatory oedema. Inflam- 
mation of the mucous membrane of any part of the respiratory tract 
necessarily interferes with breathing. In the larynx, a simple super- 
ficial or catarrhal inflammation without much swelling need not cause 
great discomfort or danger, but if the inflammation extend to the sub- 
mucous tissues and be so severe as to cause oedema, or if oedema arise 
from some non-infiammatory cause, as at times happens, the air may 
be entirely shut off from the wind-pipe, the bronchi, and the lungs. 
Catarrhal laryngitis is a common affection, the usual “ hoarse cold,” 
or throat cold, and yields readily to treatment. In some cases, whether 
from severity of the exposure, from complicating infection, disease or 
injury, from previous weakness of the part, or other cause, it may sud- 
denly take on the oedematous character, and the change usually occurs, 
as in the historic example we are considering, in the small hours of the 
morning, when the vital tide is at ebb. 
Sometimes (edematous laryngitis follows a “ sore throat,” or, in Washington’s Death and the Doctors 
949 
technical language, “ pharyngitis;” in still rarer cases it occurs pri- 
marily as laryngeal oedema, though concerning this qualified observers 
even to-day are not agreed. When the vocal bands are involved, the 
distress is intense and suffocation is imminent, for the chink between 
them, the door-way of the breath, may be reduced to a mere irregular 
slit. Even when the oedematous swelling is not sufficient to shut off 
the air-way, there may be from irritation, and even from the patient’s 
|)ain and fear, spasmodic closure of the vocal bands, and thus the 
victim become suffocated by an internal self-strangling. When the 
epiglottis is affected its mucous membrane becomes greatly swollen and 
every movement is painful; thus swallowing produces great agony and 
is finally refused. The distress in breathing, and at last the inability 
to draw breath, the painfulness, and at last the impossibility of swal- 
lowing and of speech, described by Colonel Lear and General Washing- 
ton’s physicians, are thus explainable upon the supposition that he 
suffered with acute inflammatory oedema of the larynx, determined by 
exposure and neglect. 
Are the physicians blamable for not recognizing the conditions? 
In 1799 it was not known that the larynx could be examined by 
means of its reflection in a mirror introduced into the throat above 
and behind the tongue. Not until 1855 had Signor Manuel Garcia, of 
London, devised a practical laryngoscope for the purpose of studying 
the movements of his own vocal bands in singing; and not until two or 
three years later did Dr. Czermak, of Buda-Pesth, perfect the instru- 
ment for medical purposes. It was only in 1896 that Dr. Kirstein, of 
AGenna, perfected an instrument by which in certain cases the tongue 
can be so drawn forward as to expose the interior of the larynx to direct 
inspection. It is true that in some cases of oedema of the epiglottis 
that structure projects up behind the tongue so that it can readily be 
seen, and that in the absence of a laryngoscope or of Kirstein’s “ auto- 
scope” one may sometimes detect with the finger the swelling of the 
epiglottis and of the folds of mucous membrane that bound the en- 
trance to the larynx. But again be it said, such cases are not of every- 
day occurrence, and the knowledge that these conditions were to be 
sought for could become possible only through repeated post-mortem 
investigations. Post-mortem examinations were not often permitted 
in America a century ago. Even in France, then the home of pa- 
thology, ten years were to elapse before Bayle’s publication of his re- 
searches made the facts accessible to students. 
In the existing state of medical science in 1799 the diagnosis of 
“ obstruction by inflammatory swelling in the upper part of the breath- 
tube” was the only one possible; and that this is what Drs. Craik and 
Dick designated by the term “cynanche trachealis” is shown by the 
manner in which they Englished it. Washington’s Death and the Doctors 
To-day the condition would not be treated by general bleeding. 
Leeches might be applied, or if thp oedema occupied the epiglottis and 
that portion of the larynx above the vocal hands, the tumefied struct- 
ures would be nicked with a knife (scarified), in such a way, however, 
that the blood should not run into the wind-pipe, and this would prob- 
ably afford sufficient relief to the obstruction in both circulation and 
respiration to bring about recovery. Drugs to relax circulation and 
overcome spasm, oxygen and a supporting medicament might be given 
by inhalation or under the skin. Ice might be applied over the larynx. 
Some physicians would inject under the skin a drug to provoke quick 
sweating, and a hydrogogue cathartic would be given to drain off some 
of the water of the blood, in order that through thirst on the part of 
the vessels generally the effused liquid might be reabsorbed. Were the 
vocal bands or the larynx below them so involved that scarification 
would be impracticable or dangerous, it might be necessary to open the 
wind-pipe below the swelling (tracheotomy). 
It is doubtful whether tracheotomy would have been consented 
to by General Washington and his family; and had it been performed 
without saving him, Mr. Ford’s “scarcely” and “little short” might 
have been omitted from the indictment. But this operation, though 
sometimes simple, is often extremely difficult, calling for the high- 
est degree of surgical skill and quickness to meet emergencies, 
even in these days of marvellous surgery. A hundred years ago 
it was rarely done even by the most celebrated surgeons, and the 
three doctors of rural Virginia might well be pardoned for not at- 
tempting it. 
But is there no other means than tracheotomy to restore the oc- 
cluded caliber of the breathing-tube? So late as fifteen years ago 
the answer would have been “No.” To-day, thanks to the genius, the 
patience, the industry, and the devotion of Dr. Joseph O’Dwyer, of 
New York, we have a tube that can be placed, and will remain, between 
the vocal bands, and instruments that enable one to insert or remove 
it through the mouth. Intubation has almost entirely displaced tra- 
cheotomy in the treatment of membranous croup and laryngeal diph- 
theria. It is applicable in some cases of laryngeal oedema. It has 
saved the lives of thousands. 
Would it have saved the life of Washington? Lacking, as we do, 
exact information concerning the seat of obstruction, the extent and 
degree of the oedema, and the existence of infection or complications, 
the question cannot be answered. 
The conception of inflammation entertained by the physicians of 
1799 is not the same as that taught in 1899. The cellular structure 
and the cellular pathology were unknown, the role of the blood-vessels 
Was the treatment described by Drs. Craik and Dick justified? Washington’s Death and the Doctors 
951 
was rather guessed at than realized. Infection and its processes were 
but vaguely and imperfectly understood. The very name of microbe 
was far in the future. 
In the absence of the knowledge that has since been given to the 
worlds what was Washington’s trusted friend and attendant, Dr. James 
Craik, to do? One thing first of all—to bleed his patient freely in 
the hope that by mechanical and nervous influence the general empty- 
ing of the vessels might bring about the renewal of the obstructed 
circulation in the larynx. Secondly, to try to drain the water of the 
blood by means of intestinal discharges and free sweating; hence the 
calomel and the antimony, which indeed served their immediate pur- 
pose. Thirdly, to remove serum from the blood in the neighborhood 
of the inflamed part; hence the blister. Fourthly, to try to allay the 
pain and oppose the local effects of cold by heat and sedative applica- 
tions; hence the inhalations of steam and vinegar. Modern research 
has given us better diaphoretics than antimony, and better medica- 
ments for inhalation than vinegar, but the principles dictating their 
employment were good. 
(Edematous laryngitis, even when promptly recognized and skil- 
fully treated, is very fatal; of Bayle’s seventeen cases sixteen perished, 
Sestier, studying in 1852 the recorded cases of laryngeal oedema of 
various kinds, found that death had resulted in one hundred and fifty- 
eight out of two hundred and thirteen cases in spite of tracheotomy 
having been performed thirty times. Of forty-one cases communi- 
cated in 1898 to the American Laryngological Association as having 
been all that had been recorded in the world’s literature of ten years, 
but twenty-nine recovered, tracheotomy having been performed seven 
times with six recoveries. The effusion is rarely simply serous, but in a 
number of cases is in part purulent. Whether or not, as claimed by 
some modern authors, the disease is always septic, and closely akin 
if not identical with erysipelas, it is true that in many cases blood- 
poisoning is added to the local dangers. That such was the case with 
General Washington his severe chill might indicate. Moreover, the 
prolonged impairment of breathing in itself causes the retention in the 
blood of impurities, carbonic acid especially, that should be removed 
through the lungs, and this increases the liability to death. 
Had Washington sent for Dr. Craik earlier, it is quite possible 
that some simple treatment might have averted the severity of the at- 
tack; or even had he adopted the good old-fashioned plan of taking 
a hot mustard foot-bath, and drinking a hot whiskey-toddy, and with 
blankets and hot bottles bringing on “a good sweat,” the occurrence 
of oedema might possibly have been prevented; but once the chill and 
the oedema had occurred, the chances of recovery were slight. Had he 
then been freely hied, or even had the bleeder he later sent for been 952 
Alphonse Daudet and his Intimates 
less timid, the morbid process might perhaps have been held in check; 
at all events, there was ample justification for the attempt so to “ jugu- 
late the inflammation.” Or, if the disease depended upon toxaemia 
(blood-poisoning) of any origin, it needed hut to follow the venesection 
with the infusion into the veins or beneath the skin of “ physiologic 
salt solution,” to conform with the best modern,- scientific practice. 
The subsequent bleeding offered less hope of success, but it did not 
greatly weaken one of Washington’s large frame and remarkable 
physique even at sixty-eight years of age; and it gave him the one 
chance of recovery that the knowledge of the day afforded.