Last week, I summarized the medical issues of a military and political figure in the American colonial period: George Washington (1732 – 1799). Today, I’ll describes briefly how each of those issues was treated.
At the time of the American Revolution, the biggest menace wasn’t the enemy in red coats – it was disease. Despite a rapidly expanding urbanization in the American colonies, virtually nothing was known about food, aerosols, close contact, fleas and mosquitoes as the sources of contagion. Without any protective measures or effective treatments, any day could bring a debilitating and often fatal illness to anyone, and sometimes to a whole family. Life – in a word – was tenuous.
We tend to think of medical practice during the 18th century as barbaric, and in a sense it was. It was not because physicians and other healers were reckless; rather they were guided by a time-honored concept of illness that happened to be wrong. It held that an imbalance of body fluids made people sick in various ways; treatment, therefore, meant getting rid of whatever fluid was mischievous.
They accomplished this end by causing vomiting, diarrhea, blisters, sweating and – the most enduring of all treatments – the removal (or letting) of blood. It should be appreciated however, that these tenaciously held practices were the bedrock of “Western” (or European) medicine, not the gentler methods used by healers of “Eastern” medicine nor by the shamans of the Native Americans.
We can assume that Washington had the ordinary childhood infections since contact with them throughout his life did not cause an illness. These include mumps and measles, each capable of causing serious complications and, particularly for the later, sometimes death. For these and the other common illnesses of childhood, treatment almost certainly included household remedies.
Popular staples of the time were honey and extract from boiled onions. Home grown for medicinal purposes were pepper, sage, horseradish, lavender, dill marjoram and spearmint. Rhubarb made an effective laxative. The well-stocked household medical cabinet also contained more exogenous herbals such as cinnamon, cloves, ginger, and nutmeg. For the more affluent families, there were patent medicines, such as the English “Turlington’s Balsam of Life”, containing 27 herbal and chemical ingredients to cure, among other things, “vomiting and spitting of blood, and other weaknesses and decays”. Of course, we cannot know what remedies our future Founding Father received in these early years, but we can be sure that whatever was ‘prescribed’ it under the direction of the woman of the house.
George in his teens came down with a more serious illness, “black canker”, today known as called diphtheria. Diphtheria produces a membrane in the pharynx that obstructs breathing. Profound malaise along with damage to the heart and nerves are commonly associated. The death rate from diphtheria is particularly high among children. Here, more aggressive treatment may have been tried, such as ipecac. Ipecac, from the root of an Amazonian plant and given as a syrup, was stronger than rhubarb for inducing vomiting.
An ‘outdoors’ person by nature, Washington grew up tall and robust. At the age of 17, certified in surveying, he contracted “river fever” while working in the swamplands of Virginia. Certainly malaria, symptoms of headache, general pain, disabling fever and malaise were suffered in the extreme. The severity of symptoms likely brought out more than the usual home remedies and probably included laxatives and emetics to cause vomiting. Salicin, an herbal prototype of aspirin was probably available for easing pain. Obtained from the bark of the willow tree, salicin was used extensively by Native Americans to ease pain, particularly headache.
A Bout With Small Pox
When he was 19, George accompanied his half-brother Lawrence to the Bahamas, hoping that the balmy climate and clear air would prove favorable for his brother’s tuberculosis. (It didn’t). His father died probably from tuberculosis when George was still a boy, and the infection later on proved rife within the family. Indeed, tuberculosis was generally considered to be a familial “weakness”.
There in the Bahamas, George, in his own words, was “strongly attacked by the small Pox”. He experienced “Raging fever, unquenchable thirst, excruciating headache and backache”. Red sores become pustules, then scabs, then turned into permanent scars, most on the face. (His portraitists would leave the pock marks out.)
The best treatment of the day for small pox could not change the 30-40% mortality of small pox. Most likely, Washington was treated with cold compresses, ointments, and laudanum. Laudanum, from the poppy seed of Asia Minor, was an unrefined form of opium, and therefore helpful for the relief of pain. It was shipped worldwide and during the 18th century was an enduring product for any well-stocked medicine cabinet. It was useful not only for pain but also for anxiety, insomnia, and perhaps a flagging well-being. The famous English physician Thomas Syndenham claimed that “medicine would be crippled without it”. In overdose, however, laudanum could cause drunkenness, difficulty breathing and death. We do not read of addiction being a problem in the same sense that it connotes today.
Returning to Virginia from the Bahamas in 1752, Washington described “violent pleurise which has reduced me very low”. The symptoms are highly suggestive of pulmonary tuberculosis, called at the time “consumption”. Numerous bouts of pleurisy, bronchitis, and pneumonia continued to dog Washington for the remainder of his life.
At least some of these setbacks surely were reactivations of pulmonary tuberculosis. Ipecac, primarily used as an emetic (to cause vomiting), was also an expectorant. It is highly likely that Washington took ipecac to promote production of sputum from the lung infection. Otherwise, treatment recommended for tuberculosis was rest and clear air, eventually leading to development of the TB sanatorium in the latter part of the next century.
A Citizen Soldier
As an officer in the Virginia militia at the age of 21, Washington barely survived a grueling campaign into the ‘western’ frontier, only to come down with symptoms of malaria on returning. Recovery was full but only after a protracted and sapping illness.
In 1755, Washington, now 23 years old, became an aide to the British commander on a march to confront French forces in the Pennsylvania frontier. On the way, he developed “bloody flux” complicated by a rectal abscess. Of course, problems of sanitation in a moving army produced its share of intestinal mishaps, but the extreme severity of Washington’s dysentery was more than ordinary camp diarrhea. The diet commonly prescribed for such morbid illnesses consisted of diluted barley water, flaxed tea and watery gruel.
A British doctor provided Washington with a patent medicine called “Dr. James’s Powders” popular for relief of fever and headache. Washington wrote that it “one of the most excellent medicines in the world”, although – despite it – he took a month to recover. The medicine, it turns out contained a phosphate of calcium (lime) and oxide of antimony. Repeated exposure to antimony, we now know, can cause abdominal pain, diarrhea, vomiting and intestinal ulcers as well as toxic effects on other organs.
Two years later, in 1757, it seemed that dysentery and tuberculosis had recurred and this time simultaneously. The deterioration of Washington’s health was so profound that his physicians and his family questioned his ability to survive.
Ipecac, by convention, was again recommended to induce vomiting and expectoration. Of course, blood-letting was performed in parallel, inadvertently adding to the problem of malaria-induced anemia and dehydration. On recovering but left Washington weakened from the illnesses as well as from his treatments. He decided to exchange army life for that of his plantation.
A Virginia Planter
Symptoms of malaria again appeared in 1761. Again, it left Washington profoundly ill, bringing him to “very near my last gasp”. “The Waters”, taken after a difficult trip over the mountains of Virginia to Warm Springs, did not seem to help. Slowly over a period of about six months, he recovered.
At this point, another remedy – calomel – is introduced into the story. It is not known just when and in what quantity Washington took calomel for his many ailments but likely it was common enough and in strong doses. Calomel was probably the most extensively used medicinal of the time, used as a purgative, a diuretic, and an anxiety-allaying agent. Reputedly, calomel scoured the intestine of harmful matter. So extensively used and with such utility, it appears to be the Tylenol, Valium, and Motrin of the day.
Calomel, the all-purpose drug in pill form, was mercury chlorine, sublimate of “quick silver”. Side effects with prolonged use caused inflammation of gums, loosening of teeth, various gastrointestinal symptoms, weakened bones and tremors.
The eight years of the Revolutionary War sorely tested the mettle of its army commander. Despite his several major illnesses before, General Washington remained in good health throughout the duration of the war. This fact, unquestionably, had a crucial impact on its outcome.
His only severe illness was at the terrible depravations during winter encampment at Morristown, New Jersey in 1779. Called “quinsy”, this was tonsillitis or a tonsillar abscess. The illness was enough to weaken him with fever and to doubt his ability to continue his leadership. We can also assume that the troops – including Washington – had some degree of scurvy owing to the scarcity of fresh vegetables, especially during the winter months.
During his service as Supreme Commander of the Continental Army, Washington noticed progressively decreasing vision, particularly the ability to read close up. The problem is one of aging when the internal lens becomes stiffer, a condition called “presbyopia”. Increasingly stronger reading glasses solved the problem but – at a time – wearing spectacles was considered a rather humiliating admission of a physical deficiency, hardly suitable for an army officer.
A toothache in the 18th century was treated with one good yank. Washington was particularly prone to dental decay, losing his first tooth at the age of 22 and subsequently losing about one tooth a year. One gum abscess eroded out through his left cheek, requiring opening and drainage. A scar from the surgery is visible in Peale’s portrait of 1776. By the time he turned 50, Washington had only one tooth left. Always self-conscious about his appearance, Washington was keenly aware of his sunken cheeks, hollowed voice, and indistinct speech. Ill-fitting dentures made for him were, it seems, for cosmetic purposes, not for improving chewing or speaking. (None, incidentally, were made from wood.) The bulging lips and cheeks in the 1795 portrait by Gilbert Stuart are likely from cotton padding.
A few words on wife Martha’s role in the General’s care are appropriate. She spent five of the wartime years close by. Martha was very familiar with household remedies, and there is little doubt that she maintained a prominent role in her husband’s day-to-day care.
His many maladies aside, Washington expended his health concerns outward, spelling out his army’s standards for cleanliness, what may have been closer to neatness than to the modern idea of sanitation. Believing in good diet, rest and avoidance of tobacco and excessive wine, Washington set the example with mixed results for his troops.
The major threat to the Continental Army was small pox. Soldiers dying from small pox greatly outnumbered those killed by British gunpowder and bayonets. Indeed, the casualties may have been an early form of germ warfare. Washington suspected that the British covertly distributed blankets – always welcomed by bivouacking soldiers – that were infected. Stringent dictates imposed for prevention of small pox and quarantine of those infected with it did not quell the recurring massive outbreaks.
Reluctantly, Washington decided that all troops should receive the current immunization available. The procedure of transferring matter from the pustule of a sick person to a well person usually caused a mild case of small pox, having an inherent mortality of 2 to 5 per cent. Nevertheless, the odds were highly favorable compared to the nearly 50 per cent fatality of contracting the disease directly. So successful were the results of immunizing the army against small pox, some argue that Washington’s order for inoculating all recruits was his most important strategic decision.
A Gentleman Farmer
Having retired from public life in 1783, Washington returned to manage his large estate at Mount Vernon. There, he maintained his personal physician, Dr. James Craik, Scotland trained and a Continental Army doctor throughout the war. Examining his now-famous patient, Dr. Craik claimed that “your disorder hath been long standing and hath corrupted the whole mass of blood.” The solution was frequent letting of blood to evacuate the poisonous matter.” His patient, it seemed, readily acquiesced.
In 1786, Washington again developed symptoms of malaria. This time he was treated with an effective drug: Peruvian bark. The bark was obtained from the cinchona plant of Peru and prescribed along with a cathartic. (It is noted that Peruvian bark was available for the army during the Revolutionary War but was in extreme short supply, perhaps given only to officers – and not to Washington.) Washington’s recovery was hailed and from then on, he took “the Bark” frequently for treatment and prevention of recurrence. Indeed, cinchona bark was widely taken by the general public for any febrile illness, although it is effective only against malaria.
By 1786, the symptoms of arthritis had become a problem. Washington found himself unable to raise his arms to his face. One drug available at the time was colchicine that was effective only in acute gouty arthritis, not the likely cause of his symptoms. Of course, that limitation did not prevent wide-spread use of colchicine for all types of arthritis.
Another problem emerged in prominence during this period: deafness. The cause, like presbyopia, is most like that of aging with a reduction in the mobility of the tiny inner ear bones, the ossicles, called “otosclerosis”. If there was a tangible solution to presbyopia, there was none for deafness. By 1789, he was embarrassed from difficulty hearing the spoken word. There is no evidence that he tried a popular remedy for deafness such as instillation of spirit of lavender or of the gall of the eel mixed with wine into the ear canal.
An American President
Shortly into the presidency in 1789, Washington developed a large and painful “carbuncle” on the upper thigh. Suffering from pain and almost wholly disabled from it for many weeks, he agreed that it should be opened and drained. To perform the operation was Dr. Samuel Bard, a loyalist during the Revolutionary War. Healing post-operatively required another six weeks. The description and the protracted course of the abscess suggest the possibility of a bone infection (osteomyelitis) from tuberculosis. (Parenthetically, Washington’s ‘inability’ to sire a child may have been another complication of tuberculosis, although certainly other illnesses – especially those occurring in childhood or later – could be responsible.)
Recovering in the fall of 1789, the President undertook a good will trip to Boston and ran head on into an epidemic of influenza. He developed cold symptoms with pleurisy along with inflammation of an eye, but the symptoms were not severe and soon abated.
In the spring of 1790 in New York, then the center of government, an influenza epidemic struck. This time, Washington developed a severe infection with pneumonia, high fever, bloody sputum and delirium. His family and his physicians considered him close to death. His fever broke in mid-May. In June, he decided to go on a three day fishing trip off Sandy Hook, accompanied by his Secretary of State. What wouldn’t we have given to eavesdrop on the conversation between George Washington and Thomas Jefferson on that boat! After spending another month to rest in Newport, Rhode Island, Washington returned to New York, evidently fully recovered.
In 1791, the abscess in the thigh recurred. This time it was incised and drained, as had been done earlier. After weeks of fever and discomfort, the wound apparently healed and that is the last we hear of it.
Yet, the symptoms of lung infection continue with cough, pain in the chest and shortness of breath. It was said that he appear pale, almost cadaveric and he himself wondered if he could continue to lead the country. While the portraits shown a rosy complexion, it was in reality said to be sallow. With Dr. Craik directing more blood-letting, the Reverend Charles Green suggested dietary supplements, namely wine and soft foods. Neither prescription led to improvement.
It seems truly miraculous that Washington did not come down with yellow fever when the city-clearing epidemic struck Philadelphia in September of 1793. He eventually left the depopulated city, then the temporary seat of the Unites States Congress, because of the lack of government workers. He returned in November with the onset of cold weather and the danger of yellow fever over.
Washington’s joint problems were further complicated by a fall from a horse in 1794. Injury to his back and shoulders but no fracture led a prolonged disability during which he used a splint.
In the same year, there was a cancer scare. An irritating growth on the right cheek was enlarging. A surgeon excised it, of course, without anesthesia or antiseptics. In fact, it may have been removed by frequent application of a scab-producing paste. At any rate, there was no recurrence. Modern authorities concluded that the diagnosis was probably a benign keratosis, frequent in older people and especially in those with much exposure to harsh weather.
Leaving a grateful nation behind, Washington returned to the quiet of Mount Vernon in 1797. His health there, however, was not uneventful. In 1798, he again came down with the symptoms of malaria. This time he lost 20 pounds despite intensive and eventually successful treatment with Peruvian bark. As always, each administration of the bark was preceded by a cleansing cathartic enema and the letting of blood.
Washington’s last illness at the age of 67 in 1799 began on December 12th with symptoms of a common cold for which he declined treatment. The symptoms rapidly advanced to include a sore throat. The following describes briefly what is probably the best-known deathbed scene in history.
Washington’s private secretary of many years, Tobias Lear, saw that his feet were place in warm water. Around the neck, he applied sal volatile, an ammonia-producing salt akin to the more modern Vicks Vapor Rub. He was unsuccessful in getting the patient to swallow even a drop of a slurry of molasses, vinegar and butter. At Washington’s urging, about a pint of blood was taken removing by cutting an arm vein.
Eventually, three doctors – including Dr. Craik – had assembled. They directed the use of calomel, laxatives, an enema of antimony tartar, and additional bleeding to a total of 3 ½ pints. To raise blisters, they placed a strong skin-irritating powder made from dried beetles to the throat and legs. Their patient almost suffocated trying to gargle vinegar with sage tea. Vinegar in hot water was then tried so that he could inhale stream.
The swollen tissues of the pharynx gradually blocked the airway, causing difficulty breathing, a muffled voice, cyanosis and further weakened. The junior-most of the physicians recommended opening a vent in the trachea below the obstruction but his seniors deemed the procedure too dangerous. Just after 10 o’clock in the evening of December 14th, Washington died. His final words were “Tis well.”
Illustration: 1787 Portrait of George Washington by James Peale.