Column: The Futility of Bloodletting

George Washington died at the age of 67, just two years after he left the presidency. Like many of his contemporaries, he died from an infection. Accounts of his complaints and clinical course indicate that he had a disease of his airway that interfered with his breathing. Twentieth century physicians reviewing his case concluded that he had a bacterial infection of a structure in the throat, called the epiglottis, that would have been cured with a few days’ antibiotic treatment. The epiglottis is a flap of tissue that keeps food from going into the lungs.  If it is inflamed by an infection, it narrows the patient’s airway and may suffocate the affected individual. In severe cases of obstruction, a hole can be made in the neck extending to the airway below the infected tissue and bypassing the life-threatening obstruction: this is called a tracheostomy. Unfortunately for George, there were no antibiotics available as he struggled to breathe in the winter of 1799, and the only physician, Dr. William Thornton, within riding distance of Mount Vernon who was trained in the performance of tracheostomies was blocked from getting to George’s mansion before the President’s death by a recent, heavy snowfall.

Despite these factors diminishing President Washington’s odds of survival, his ultimate demise was more likely than not a consequence of the treatment he received from the three physicians who were able to get to his bedside. First to intervene were Dr. James Craik and Mr. George Rawlins.  Craik was what would now be called the primary care physician or family doctor.  Rawlins was highly experienced in bloodletting, a well-established technique for managing fevers and a variety of other medical problems. As Washington struggled to breathe, Dr. Craik applied caustic material to the General’s throat to raise blisters and draw out toxic material (humors) that were believed to cause the inflammation interfering with his breathing. This was, after all, more than half a century before the “germ theory” of disease was even seriously discussed. Diseases were still thought to be caused by toxic humors that needed to be drained from the patient’s body. Blistering and bleeding were two ways to get the poisons out of the sufferer’s body. Enemas and emetics (materials that induce vomiting) were also accepted options.

The blistering did not help. Enemas were also applied without benefit.  Efforts to get the former President to gargle or swallow various medicinal concoctions nearly choked him to death. With the failure of these painful and dangerous interventions, Eighteenth Century “standards of care” mandated bloodletting as the next appropriate measure to rid George’s blood of the “humors” that were killing him.

Initially Rawlins drew off about 14 ounces of blood, but when this bloodletting, in combination with the blistering and gargling and enemas, failed to improve Washington’s condition, he drew off an additional 18 ounces of blood. A messenger had already been sent to get a more renowned physician, Dr. Elisha Cullen Dick, to help manage the failing patient. Dr. Dick arrived in time to argue against additional bloodletting, but he apparently lost the debate and another 32 ounces of blood were drawn from Washington’s pale body.

Later in the afternoon of his illness, a third doctor, Gustavus Richard Brown, arrived and administered some oral concoctions that were intended to and succeeded in inducing intractable vomiting. The objective was again to get those toxic humors out of the body. The physicians on hand induced additional blistering over a variety of George’s body surfaces and applied poultices (topical dressings), neither of which proved helpful.  Given the President’s obvious deterioration, they decided on additional bloodletting as a last resort.

The records they kept indicate that they drew off about 80 ounces of blood from George over the course of a day, which would have accounted for about 40 percent of his total blood volume. The enemas, vomit inducing agents, and blistering would have added to his problems by depleting his body of vital chemicals called electrolytes, including sodium, potassium, chloride, and magnesium. Geoge died from a combination of infection, breathing problems, electrolyte imbalances, and exsanguination. The throat infection alone might have killed Washington, but the repeated bloodletting sealed his fate. The treatment he received was nearly as lethal as the disease for which he received this treatment.

These were not inexperienced or ignorant physicians working to save George Washington’s life.  They were each well-educated and highly regarded by their peers, but nothing they did on that December day helped their patient or diminished his suffering. They believed their methods could save the President’s life, and they ignored repeated indications that their interventions were simply making the situation worse.

This phenomenon of “stuck on stupid” still applies in the Twenty-First Century. We have seen it in the mass shootings that are happening on a daily basis throughout our country. Our national leaders have embraced the idiotic mantra of “only a good guy with a gun can stop a bad guy with a gun.” From the school massacre in Uvalde, Texas, we have videotape evidence that even dozens of good guys with guns and body armor and ballistic shields will cower in a hallway outside a classroom while children are being slaughtered inside and are begging for help. The videotape that was initially released had the screams of children and teachers being blown to bits by a monster with a military-style rifle edited out. The nation would be better served by an unsanitized record of the horror. These children were America’s treasure, and their screams for help should be broadcast to every American household and played before every National Rifle Association convention.

One would think the accounts of ten-year-old children smearing themselves with the blood from their dead classmates to fool the shooter into thinking they were dead would be information enough to move our legislators and Supreme Court Justices to ban all civilian access to these weapons. One would think that the repeated bloodletting of our children would be evidence enough that our current approach to firearms is as defective in its logic and as deadly in its effect as the remedies adopted by intelligent Americans more than two hundred years ago in their efforts to save George Washington, another national treasure. We obviously need to pursue new strategies to cure our nation of gun-related tragedies.  In recent years, we have allowed the proliferation of military-style weapons in the hands of millions of citizens. The justification for this has been the notion that it would somehow make us safer. It did not. It is time to adopt other remedies and stop the bloodletting.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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