Knowlton Biography, Chapter 43
Forty-three: Erysipelas and Puerperal Fever
If my treatment of the cases is to be criticized at all, let it not be done by the city practitioner, who, instead of spending most of his hours in buffeting the winds and storms “o’er hill and dale,” as in country practice, may spend them at the bed side of the sick, acquiring practical experience—or in his study, treasuring up the experience of others; who can examine and re-examine both his patient and his library within the space of half an hour…But rather let it be criticized by the country practitioner…who knows what it is…to be caught, perhaps in the night, some five or ten miles from home, at the bed side of a patient presenting urgent and alarming symptoms with which he is not practically familiar, and all this without any aid at command beyond what he may chance to have in his pockets and saddlebags. These are the circumstances that “try men's souls,” and qualify country physicians to sit in judgment upon the practice of each other.
Although he was far from the centers of medical innovation, Charles read constantly and thought long and hard about his patients and their diseases. Knowlton’s personal medical library contained over eighty-five volumes from the United States and Britain, as well as forty issues of four American medical journals. One of his goals, when Charles began writing articles for the Boston Medical & Surgical Journal in 1842, was to help make the journal more “useful to numerous country practitioners” by reporting the lessons he learned from experience—both good and bad—in letters to the editor.
Because doctors like Knowlton questioned everything, medicine in the first half of the nineteenth century was beginning to outgrow its classical origins. As observations and speculations began pouring into medical journals from people like Charles, traditional medicines and heroic treatments were called into question. But scientific physicians like Knowlton weren’t the only critics of the medical status quo. “Eclectic” physicians, homeopaths, and Thomsonian herbalists were also challenging traditional medicine from outside the profession, prompting many doctors to simply dig in their heels and defend the old texts. Open-minded physicians like Knowlton had critics on both sides, but that didn’t stop Charles from honestly reporting what he saw in his practice.
As Stephen Tabor had observed in a letter to the Journal, Charles never tried to spare his own feelings or reputation when he reported what he learned. Knowlton’s attitude was that he was doing his best, exploring unknown territory under difficult circumstances—and anyone who wanted to accuse him should first walk in his shoes. Whatever he may have felt, Charles never hid from reality, even when it told him he’d done exactly the opposite of his life’s mission, and killed one of his own patients.
On a Sunday morning at the end of January, 1844, Charles was called to see a fifteen-year old boy named Hutchinson in Buckland, ten miles from Ashfield. A few days earlier, the boy had driven a sleigh from his home thirty miles away, on a particularly cold evening. The boy was chilled, dizzy, and vomiting. His pulse was weak and Charles thought he looked very feeble, “which to my view clearly forbade the use of the lancet.” Part of the boy’s forehead was raised and had a mottled, red appearance. Charles “prescribed half-grain doses of calomel once in two hours,” and promised to return in the morning.
The next day, the boy’s skin inflammation had extended down both cheeks and involved his eyelids. It was “malignant erysipelas,” which Charles knew had recently afflicted several people in Warwick, where the boy had come from. Erysipelas is now known to be an acute skin infection, caused by type A Streptococcus bacteria. It can be treated with antibiotics, and only rarely spreads to the bones, joints, or major organs—although it can still cause septic shock in some cases. In 1844, of course, there were no antibiotics. Physicians in Knowlton’s time had no idea that bacteria or viruses even existed. It would be another twenty to thirty years before Pasteur, Lister and Koch began the work that would lead to a germ theory of disease.
Charles rode over an hour each way, to visit the boy daily throughout the week. His patient’s erysipelas spread, covering the boy’s upper face and blocking his nostrils so he had to breathe through his mouth. Charles shaved the boy’s hair and bathed his head with “a strong solution of nitrate of silver.” The boy became delirious, and his infection spread into his ears, forming “large and numerous” blisters. Charles painted the inflamed areas with a tincture of iodine, which had recently been praised in “Dunglison’s New Remedies,” a new addition to Knowlton’s library. Unfortunately, these treatments could not stop the raging infection. On Friday evening, the boy died.
Thursday afternoon, when he’d finished treating the infected boy, Charles made three stops on his way home. After riding nearly ten miles from the boy’s bedside, he visited Sally Lilly, a thirty-nine year old mother of four who’d had a miscarriage a couple of days earlier. Charles examined Sally, and told her “to remain quiet and fear nothing, as she would probably have no more hemorrhage.”
On Friday and Saturday, Sally was “feeble, but had no symptoms which she thought required medical advice.” Sunday, however, she developed diarrhea and felt faint and exhausted. Sally’s family called for Knowlton, and he prescribed, “nine quarter-grain calomel pills, one to be taken every two hours, and as a supporting agent, four or five drops of laudanum between each pill.” Charles suspected puerperal fever, a disease that struck women after childbirth, but there hadn’t been a case of it in town for a dozen years. On Monday, he prescribed, “rather hesitatingly, on account of the prostration of the previous evening, one great-spoonful of castor oil mixed with half a tea-spoonful of oil of turpentine. From two to three grain doses of Dover's powders to be taken once in three hours after the oil has operated.”
Charles wasn’t able to get back to the Lilly farm until eight in the evening on Tuesday. Sally’s family had tried a folk remedy, and Charles
ordered off the stinking sheep's “inwards” which had been placed upon the abdomen shortly before my arrival; applied a three inch blister to the epigastrium, a flannel wet in spirits of turpentine to the abdomen, and this over a hot fomentation; administered an assafoetida enema, gave a pill of calomel and opium, ordered my horse into the barn, and sat down to watch the patient and to speculate.
Charles reviewed the case in his mind. In the twelve years he’d practiced in Western Massachusetts, Charles had only rarely seen puerperal fever or erysipelas. To lose two unrelated patients to acute diseases in such a short time was alarming; and for them “to sink right down, and go off so like the wind, there must he a malignancy about them which I am not at all used to.” Charles wondered “if I communicated any poison from Hutchinson to this woman at the time I examined her; and if so, how has it operated?”
While I was thus cogitating, the poor woman continued moaning and vomiting, and I gave some magnesia in a swallow of cold water. This did no good; and then I gave her ice in chunks as large as a chestnut, and told her to swallow them as soon as the corners were sufficiently thawed off. This she liked much. It did her good. The vomiting abated immediately. She took it frequently. I had no faith in calomel and opium, and at midnight I retired, directing the attendants to give only ice and gum water according to the patient's desires.
Charles returned at nine o’clock Wednesday morning, and spent most of the next three days at the Lilly farm. Sally’s abdomen became firm and distended, but she seemed to be improving. Charles reduced the small amounts of drugs he’d been prescribing, and “added arrow-root to the nourishment.” Thursday, Charles thought “the patient is delirious and too much disposed to doze.” Friday morning “the countenance, pulse, and breathing indicate that the patient is sinking. The tympanic distention of the abdomen…is very great.” Sally Lilly died in the early afternoon.
A couple of weeks later, as Charles was writing up his notes to send to the Boston Medical & Surgical Journal, he was called once more to the Lilly farm,
where I found her eldest daughter, who attended much upon her mother, sick with a fever, and having a diarrhoea resembling, according to accounts, that of her mother. From this patient I went some fifty rods to see a Mrs. Ward, who visited and more or less waited upon Mrs. L., and who was taken at about the same time and with the same febrile symptoms as this daughter, both having soreness of the throat. In Mrs. Ward's left ear erysipelatous inflammation commenced about eighteen hours before I visited her, yet I observed one blister upon the ear full one third of an inch in diameter, and the inflammation was fast spreading towards the cheek.
Knowlton treated both patients, and they both survived. But he couldn’t deny what had happened. Charles had carried disease from the boy in Buckland to Sally Lilly, and then it had somehow jumped to Sally’s daughter and neighbor. “On Thursday,” Charles recalled, “I did not wash my hands before leaving the house of the patient, though I sheared the head myself, and examined it rather closely.” Although he couldn’t explain how it had happened, Charles concluded, “after having witnessed the result of both cases, and subsequently referred to authors—that I was the medium through which an infection was communicated one patient to the other.”
Charles wasn’t the only physician struggling with the idea of contagion. About a year before Charles’s experience with the Hutchinson boy and Sally Lilly, Dr. Oliver Wendell Holmes had published an article in the New England Quarterly Journal of Medicine and Surgery, titled “The Contagiousness of Puerperal Fever.” Although he’s primarily remembered as a poet and Boston intellectual, Holmes was a physician who taught anatomy and physiology in the late 1830s at the medical school Charles had attended in Hanover. Like Charles, Holmes was not afraid to challenge the authority of medical tradition.
Holmes had researched his article by reviewing the medical literature and comparing it to hospital records in Boston. He concluded from this evidence, “The disease known as Puerperal Fever is so far contagious as to be frequently carried from patient to patient by physicians and nurses.” Although some British and European physicians had written about contagion in the 1820s and 1830s, the majority of American doctors were opposed to the idea. A leading Philadelphia obstetrician named Charles Miegs spoke for most of his profession when he declared, “Doctors are gentlemen, and gentlemen’s hands are clean.”
It’s not certain that Charles had read Holmes’s article, but he was familiar with all of the texts Holmes cited. Charles mentioned puerperal fever even though he concluded that Sally had died of “erysipelatous gastro-enteritis,” suggesting he’d heard of Holmes’s research. A freethinker like Charles, Oliver Wendell Holmes’s approach to medicine was “not to take authority when I can have facts, not to guess when I can know.” But although they had both managed to see the truth in spite of the weight of tradition, there were still more questions than answers. Charles noted in his article that the disease he had transmitted was not puerperal fever, and that the way the infection had attacked Sally was a mystery. “Why is the alimentary mucous membrane affected in preference to the genito-urinary, if I communicated any infection,” he asked, “for it was the latter only that was touched by me on Thursday?” Charles had discovered that infection was much more widespread and complicated than Holmes’s article on puerperal fever had demonstrated. But despite the important progress both men made, it would be decades before medical science caught up. “The fact is,” Charles concluded, “contagion is a real something which we do not know much about.”