Knowlton Biography, Chapter 41
Forty-one: Abscessed Lungs & That Pancreas
To note the absence of all the symptoms to which I directed my inquiries, would extend this paper to great length. Suffice to say, that with what little tact twenty years reading and practice had given me, I could not discover any immediate danger as to life, and told the patient so. The abscess was discharging not more than from one to two ounces of thin purulent matter in twenty-four hours; and nearly no cough…So much for not duly extending my inquiries into the history of the case.
By the early 1840s, Knowlton’s medical practice covered thirty towns in the Ashfield vicinity. His “ride” through the countryside took him periodically through another twenty towns and villages. There were physicians in many of these towns, and in several places Charles’s practice overlapped with other local doctors. Many of these doctors consulted with Charles, and called him in on difficult cases. Some regarded him as a threat.
Medicine in the 1840s was still largely a collection of old traditions and questionable cures. In spite of the challenges to these traditions brought by unorthodox, scientifically-minded physicians like Knowlton, there was still a lot doctors didn’t understand about health and disease. There were some patients that Charles and his associates couldn’t save, even when they worked together. In 1842, a farmer named Cook from Cummington came down with what his regular doctor called lung fever. After several weeks of illness, Cook developed an abscess in the middle of his back, about four inches from the spine. Charles was called in and examined Cook briefly, but he didn’t think there was “disease in any important organ.” He wasn’t asked to take over the case, so Charles merely suggested that the abscess, which was draining a “moderate” amount of puss, should be flushed with “a little chloride of soda.”
A month later, when he stopped by Cook’s father’s farm to take shelter from a sudden downpour, Charles was surprised to discover the younger Cook there. The abscess had not healed, and Cook “said that he should not live long.” He hadn’t seen his regular doctor again, but had been taking some medicines left by “a traveling doctress, now in parts unknown.” Charles examined the patient “from head to foot,” and found that his pulse was regular, there was no fever, and his breathing was normal. Although Cook was able to carry on a conversation, Charles noticed that his speech was drawling and his ideas “deranged.” He told the family “that if there was any immediate danger in the case, it must be owing to some disease of the brain, which was quite possible.” In a couple of days, Cook became paralyzed and slipped into a coma. Within a week, he was dead.
Charles and the two other physicians who had seen Cook were all surprised by the young man’s death, and Cook’s regular doctor asked Charles to do an autopsy. The two other doctors observed while Charles dissected the corpse. Cook’s regular doctor had suspected liver disease, but Charles found the liver “quite sound.” Cook’s lungs, however, were “pretty uniformly scattered” with “miliary tubercles,” indicating tuberculosis, and Charles found the abscess, which was the size of “a hen’s egg.” But Charles did not think this was “sufficient disease to account for the death of the patient,” so he opened Cook’s head.
Although Charles didn’t claim to be “competent for making a very nice examination of the brain,” he believed that there was something wrong with Cook’s. “The membranes of the brain exhibited many turgid vessels,” Charles said, and “at least a gill of serum flowed from the ventricles.” These ventricles exposed “cavities sufficient to receive…a man’s thumb,” and some parts of the brain were much softer than others. Charles suspected what he called “meningo-cerebritis,” and was very surprised when he later heard that Cook’s regular physician had put down consumption as the cause of death. Consumption—tuberculosis—was a catch-all cause of death in the early nineteenth century. While this may have been more comforting to the family than a mysterious brain disease, Charles said, using consumption to cover the fact that the physicians didn’t understand what had killed Mr. Cook didn’t advance their credibility or their medical knowledge.
Sometimes disagreements between competing physicians were much more heated. In the spring of 1843, Franklin County’s State Senator, Major Joseph Griswold, returned home from Boston. Physicians in the city had told him he was dying of heart disease, and his local doctor concurred. Charles knew the sixty-seven year old carpenter and farmer, who’d been his patient off and on for several years before going to Boston. So when he overtook the Major one afternoon, driving his carriage slowly on the road, several miles from home, Charles stopped and looked him over.
Charles was surprised the Major “had not the bloated, purplish appearance indicative of obstruction in the circulation of the blood,” but instead was pale and sallow. Griswold’s “respiration was easy; and, jumping from my carriage, I found his pulse about 75 and regular.” Charles told the Major he didn’t know what was wrong with him, but the problem wasn’t his heart. A few weeks later, when his regular doctor was out of town, the Major’s family asked Charles to visit him at his home in Buckland. Charles examined Griswold thoroughly, took a complete medical history, tested the Major’s urine,
and finally told the Major that I could not make out any disease of the kidneys, liver or bowels, and as for the heart and lungs, in my view they were entirely out of the question. This much, said I, is certain—“somewhere in that process by which food and drink are converted into flesh and blood, there is something wrong; but what or where, is more than I can say.”
Charles prescribed medications for the Major, “but without faith,” since by this time he suspected “the stomach to be laboring under some carcinomatous disease.” When Charles said he suspected a stomach disease, the Major admitted that he’d had digestive problems for a long time, but hadn’t thought them serious enough to mention. Charles saw Griswold several more times, but was unable to save him.
Major Griswold’s death was big news in Franklin County, and his physicians’ disagreement over what had killed him was fought out in a series of letters published in the Boston Medical & Surgical Journal. The day after the Major’s death, eight doctors converged on his house. Since he was the most experienced anatomist, Charles conducted the autopsy. There was no disease in the chest, Charles said: “nothing amiss about the heart excepting one slight point of ossification in one of the valves.” The stomach, which Charles had suspected, was also healthy. “But the pancreas was diseased in all its parts, firmly adherent to the duodenum…and but for the place in which it was found, it could not have been easily recognized as the pancreas.” This was the cause of death, Charles concluded. And the source of the mystery, since “diseases of the pancreas cannot be recognized with any degree of certainty during the life of the patient,” as he thought all the doctors would agree.
But all the doctors did not agree. Griswold’s regular physician, who had supported the Boston doctors’ diagnosis, sent the Journal his own interpretation of the autopsy. The heart, he said, was found to be in a “decided state of hypertrophy…and that this determination was the immediate cause of death must a priori be apparent to the merest tyro in medicine.” Charles responded that when he had been holding the scalpel, he’d seen nothing of the kind, and that another of the doctors at the autopsy had remarked, “he never saw a more healthy heart” in a man of Griswold’s age. Charles quoted a letter he’d received from another of the doctors, who was married to Griswold’s daughter and who had originally advised the Major to consult Knowlton. Griswold’s son-in-law and Stephen Tabor, who’d recently become Charles’s son-in-law, wrote their own letter to the Journal, saying the other doctor’s report of the autopsy was “erroneous and defective in several important particulars” and that his language was “impertinent and ungentlemanly.” The hostile doctor’s friends then wrote a testimonial letter, and the doctor himself wrote a “Final Reply to Dr. Knowlton.”
Charles had long since stopped giving public attention to the controversy, so Stephen Tabor had the last word in the Boston Medical & Surgical Journal. In a letter that ended the battle, Tabor observed that Knowlton’s original article in the Journal had cast no blame. Charles had merely written one of his reports from the field about a particularly difficult case—and had admitted that he, too, had been fooled by the symptoms. “With that frankness which can afford to be in an error, and which little minds never feel,” Tabor said, “Dr. Knowlton did not hesitate to write the entire truth.” In contrast, the other doctor’s Final Reply “was imbued with a worse temper, and manifested greater virulence than even his first article.” Charles never made the type of effort the other doctor had made to spare himself from judgment. Knowlton was well known, Tabor concluded, as a seeker of the truth, regardless of consequences. Although it was often personally difficult, Charles Knowlton’s dedication to truth was an approach that ultimately helped medicine become a science rather than a collection of old superstitions.