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  • Presidential maladies: George Washington's emergency care

    by Halley Knigge

    In honor of Presidents Day this month, we've asked MultiCare's health experts to look back at the ailments of past U.S. presidents, then offer their perspective on how these conditions might be treated differently today. Fourth in our series is George Washington's emergency end-of-life care.

    The president: George Washington

    The year: 1799 

    The malady: Epiglottitis 

    Description: In 1799, George Washington was a man larger than life. He’d been retired from the presidency for less than three years, and was still one of the most recognizable figures in the country. Little wonder then, that his doctors were hesitant to try a risky new (but potentially life-saving) procedure on the former president. 

    Not all historians agree on the cause of Washington’s death, but he is generally believed to have died of acute bacterial epiglottitis. Epiglottitis occurs when the flap of tissue separating the entrance to the lungs from the throat (trachea) becomes inflamed. Even today it can be life-threatening because the swollen epiglottis can rapidly block the trachea and prevent breathing. In adults, it is often caused by complications of a strep infection or Haemophilius B – a type of flu caused by bacteria that has today been mostly eradicated by vaccinations. 

    On December 13, 1799, the retired president caught a cold, after taking a walk in the rain. Over the next several hours it developed into something much worse, until Washington was having trouble breathing and complaining of throat pain. Washington’s aide fed him a mixture of molasses, vinegar and butter which brought on near-fatal choking, while doctors bled him in an effort to decrease inflammation in his throat. 

    Doctors removed 5 pints of blood over the next 12 hours – half of the about 10 pints in an average adult male’s body. One of Washington’s physicians argued against the blood-letting, and suggested instead a tracheotomy. But the medical knowledge of Washington’s time would have found a tracheotomy to be the riskier choice. 

    “In 1799, even elective tracheotomy, let alone tracheotomy performed on an emergency basis, was rarely undertaken … Undoubtedly, the specter of failure with a grisly, painful (in the absence of anesthesia), and untried surgical experiment on the former president weighed heavily in [Washington’s physicians’] decision to veto this radical suggestion.” (Source: Death of a President, the New England Journal of Medicine) 

    Symptoms of epiglottitis may include:

    • Difficult or noisy breathing (stridor)
    • A high fever
    • Drooling and trouble swallowing liquids
    • A muffled voice
    • Problems lying down
    • A child with epiglottitis usually prefers to sit up and lean forward with his or her head and jaw forward to breathe. 
    How treatment is different today: Today, modern treatments and technologies have edged out the practice of bloodletting, especially the “heroic depletion” employed by Washington’s physicians of the time.

    “Modern physicians would doubt the beneficial effects of such therapy on local inflammatory swelling and would worry that aggressive bleeding might cause weakness and worsen the hypoxia associated with partial airway obstruction; they would also worry that iatrogenic dehydration might lead to electrolyte imbalance. Lacking such modern concepts, Washington's physicians may have reasoned that with death approaching, “heroic depletion” was their only option.” (Source: Death of a President, the New England Journal of Medicine)

    Indeed, Dr. Jonathan Chalett, an emergency department physician at MultiCare Mary Bridge Children's Hospital, says bloodletting would have had "no effect, whatsoever," on Washington's condition. He says Washington's physicians may have believed they could lessen the swelling in his throat by depleting some of his blood, but we know today that that would have been completely ineffective.

    The physician who suggested an emergency tracheotomy was on the right track, says Chalett. If the swelling in Washington's throat was so bad that he couldn't pull a breath, a tracheotomy below the swelling could have saved him. But if Washington were to visit the emergency department at MultiCare Tacoma General Hospital today, physicians would get him to an operating room immediately and intubate him under light anesthesia. The infection would then be treated with antibiotics.

    Unfortunately for Washington, the medical advances that could have saved him had not yet happened in 1799. Today, some historians attribute his cause of death to excessive blood loss. 

    Historical significance: Washington’s death was mourned for months. He was entombed at Mount Vernon in a lead-encased coffin to protect funeral-goers from any potential infections. Today, his legacy lives on as the “Father of our Country,” and his face is still one of the most recognizable – from his appearance on the U.S. dollar bill and quarter, and even our state’s road signs. Hundreds of cities and towns, and yes, our state, are named after him.

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    Posted on Feb 26, 2013 in History