To anyone who saw him in the early 1850s, Mütter still seemed the picture of health. Now entering his early forties, he remained “a singularly handsome man”: youthful, slender, and graceful with a clear sweet voice of remarkable strength and carrying power. Years after he was reprimanded at his school for wearing “a style of dress not altogether proper for a boy his age,” Mütter’s style remained scrupulously neat. He was “in fact, almost a dandy,” one of his colleagues later recalled.
When his schedule allowed him to attend parties or gatherings, he continued to be praised, by men and women alike, for being both “a delightful conversationalist and an admirable raconteur.”
Few outside his close circle of friends knew that Mütter was not a well man.
• • •
Mütter was never able to fully shake the ailments that had plagued him since boyhood, but recently, they had grown much worse. What had always been frustrating, painful, and draining was now wholly unmanageable.
Mütter’s lungs never fully recovered from that brutal winter he spent at Yale. He was constantly overtaxing them—both by giving lengthy lectures in bustling, overcrowded lecture halls and by exposing himself daily to the harsh chemicals of the surgical room. His weak lungs couldn’t help but be irritated by the fumes of that confined space: alcohol, ether, even burning lamp oil. He caught colds easily, fought draining fatigue, and sometimes had trouble catching his breath. But recently, his lungs had begun to shudder and ache in his chest, and when an agonizingly long coughing fit finally subsided, he would look down and see his handkerchief stained with splashes of his own bright red blood.
Meanwhile, the gout he seemed to have inherited from his grandmother preyed endlessly upon him, making him “inconceivably sensitive to pain.” Without warning and seemingly without reason, the joints of his hands and feet would grow hot and red, painfully swollen to the point that even air passing over the affected part would cause searing pain, as if he were being poked by a dozen blistering needles. No matter what treatment he sought or to what preventive care he devoted himself, nothing helped.
As he was a surgeon, Mütter’s hands were one of his most valuable tools. Swift and nimble, quick and precise, they were one of the reasons he was able to do the work he did. It was rare blessing enough to be ambidextrous. But to be as skilled as Mütter was with both his hands was seen as near miraculous (“Few can boast of [being ambidextrous] . . . and often, many who can have in fact only two left hands,” a fellow doctor once quipped).
So when gout would temporarily cripple his hands, it would ruin days and sometimes weeks of effort and preparation, since he would be absolutely unable to perform any of the delicate surgeries he promised he would.
But Mütter knew he had to keep working. The famed clinic of Jefferson College was only becoming more popular as the Faculty of ’41 celebrated an unbroken decade together. His office was flooded with the ill and injured, the desperate and damaged, all happy to wait hours or days if needed to consult with him. Meanwhile, students and doctors from all over the country came to watch Mütter perform what would later be called “some of the greatest achievements of American surgery.”
Mütter could not step away from these incredible responsibilities, so instead he humbly asked Joseph Pancoast, his friend and colleague, if he could help him with his more difficult surgeries. Pancoast agreed.
“In the every-day surgical operations Mütter was careful and adroit,” a student would later write of him during this time, “in the performance of those of great magnitude he leaned a little, yet always gracefully, upon the strong arm of his Colleague in Anatomy, his co-worker in the Surgical Clinic.”
Indeed, Mütter and Pancoast made for a fantastic team: Pancoast’s steady hand and careful eye, and Mütter’s ever-ambitious forward-thinking innovations. Mütter realized that while his body might fail him on occasion, his mind was still as sharp as ever, and he began to offer his advice and aid in consultation to any doctor asking his help for as long as “his feeble physical abilities enabled him to.”
Mütter changed in other ways too. After years of having his students call him out of Mass for ersatz emergencies, Mütter became a devoted member of Philadelphia’s Protestant Episcopal Church, and he even spoke about working with the church to found a ward for incurables at its hospital.
“The consolations of religion supported him through his long sufferings,” a peer wrote about his turn toward religion, “which he bore with patience and hopefulness.”
Mütter had every reason to feel hopeful: Every attack of illness, from his boyhood to the present, had always passed . . . eventually. Although now it seemed the attacks were happening more frequently and severely, and his recovery was taking longer each time he fell ill, he still was happy to adapt and push through. He had a life to live, after all, and a very important one at that. His students and his patients depended on him, and he did whatever it took to keep moving forward.
• • •
The medical community in Philadelphia—still seen as the country’s medical mecca—was learning how to adapt too.
In an effort to standardize the profession (and not just the education portion of it), the American Medical Association was founded in Philadelphia in 1847, and the following year, the Philadelphia County Medical Society.
These organizations aimed to create a forum where all “respectable physicians” could meet, debate, and exchange experiences and ideas. It was envisioned as an association that would bind the profession together: Rules of gentlemanly conduct and honorable dealing would be observed, and each member physician would feel he owed a duty to his fellow doctors and to the greater public.
And in direct opposition to the insular medical societies that fractured the local medical community, membership in the newly formed county medical society was open to any Philadelphia doctor who graduated from a respectable school, was of good moral and professional standing, and was an active practitioner. However, wary of how this might bring an influx of “quacks” into their ranks, the society expressly forbade membership to anyone who “prescribes a remedy without knowing its composition.”
These societies were not only successful but influential. Here, finally, were professional organizations in which it didn’t matter how rich your grandfather was, or if the school from which you graduated was impressive enough to the gatekeepers. As long as you shared a passion and focus to push the profession forward, you were in.
To Mütter, it was hopeful progress compared to what he experienced during his earliest years in the city.
In addition to the new medical societies, a variety of other medical institutions were also popping up throughout Philadelphia as the community tried to keep up with the city’s voracious expansion.
The 1850s saw the founding of several new medical schools and hospitals, including the Children’s Hospital of Philadelphia, the Philadelphia Municipal Hospital, and Pennsylvania College of Dental Surgery. Medical institutions founded for the benefit of society also began to spring up, including some with odd names such as the Howard Hospital and Infirmary for Incurables, the Philadelphia Society for the Employment and Instruction of the Poor, and the Northern Home for Friendless Children (which the founder felt was a tactful way to describe what was essentially an orphanage).
But for all its progress, the Philadelphia medical community was still largely unwilling to concede one point: It was “long violently opposed to [the idea of] the female doctor.”
• • •
After numerous deserving and ambitious women were denied admittance to the lecture halls of the University of Pennsylvania, Jefferson Medical College, and every other educational institution serving the medical profession in Philadelphia, a group of Quakers (whose religious doctrines included complete equality of the sexes) founded the Female Medical College of Pennsylvania within the city limits in 1850. For the next decade and a half, the school grew more and more popular as hundreds of women flocked to the city to finally learn in its lecture halls.
When its board decided to change the institution’s name to the more striking and official-sounding Woman’s Medical College of Pennsylvania in 1867, the Pennsylvania Medical Society finally decided to take action and issued a scathing and definitive statement against women practitioners.
The statement declared that women should not practice medicine because women “cannot stand the strain of practice”; because “their physiological necessities forbid the attempt”; because “if married they will neglect home duties”; and because it was offensive that at the very least these women physicians would “not consent to only attend women”; and, finally, simply because women’s “nerves are too delicate for the work.”
The statement had no effect on the school, which still surged with new female students each year.
A year later, the society decided to push the issue even further by expelling any of its members who dared to teach at a women’s college, and furthermore to expel any member who was found to have consulted with women physicians in any medical capacity.
Still, these actions did nothing to stem the growing tide of women who were actively pursuing a career in medicine.
Soon, even larger institutions were being asked to allow women to attend lectures and witness surgeries. A high-ranking physician at the Pennsylvania Hospital was so appalled at the idea of having to lecture to “mixed classes” that he resigned his position to avoid the “indignity” of having to teach even one single woman.
Not every male physician held this opinion. And thanks to these allies, and especially to the persistence and bravery of those early groundbreaking women who insisted on their right to be physicians, the first female doctor was elected to the same Pennsylvania Medical Society that had just two decades earlier sought to end her role in the profession entirely. The decision was met with much relief and rejoicing from the younger members of the community.
“Woman, as usual, finally had her way,” a male member would later slyly write about the election. “And yet the earth did not rock, the sea did not overflow its banks, the stars did not fall.”
• • •
In other ways, medicine in Philadelphia was unambiguously moving forward. Mütter constantly marveled at his good fortune at being part of such a revolutionary time in medicine, which was largely fueled by, of all things, American discoveries.
He spoke with a youthful excitement about this progress in an introductory lecture that was later published in the Medical Examiner. He opened his speech by fiercely advocating for his favorite recent discovery:
“Anesthesia . . . I need not, on this occasion, enter upon the history of this purely American discovery. I repeat purely American discovery,” he stated emphatically, “for, notwithstanding the attempts made by some, to give the credit of this most valuable of all modern improvements in surgery to Europeans, we have yet positive evidence of its being in truth an offspring of the New World.
“In England, Scotland and Ireland, and on every portion of the continent of Europe . . . no surgeon of any grade, high or low, pretends to practice his profession without the constant use of some anesthetic agent,” he continued, unabashedly countering all anesthesia critics around him, including those of his own faculty. “When I asked my distinguished friends in London and Paris, if they employed the measure with the same degree of confidence as at first, they seemed surprised at the question and unhesitatingly declared, that no surgeon would presume to perform a serious operation without first bringing his patient into a state of anesthesia, provided always, there was nothing present to contraindicate the production of this condition. While there exists some difference of opinion as to the best agent to be used, there is none upon the great point of the value of the measure in the practice of surgery.”
Mütter didn’t waste time defending anesthesia, but instead spoke passionately about the new and ever-evolving possibilities that anesthesia could bring to the art of plastic surgery.
“You will be anxious, I doubt not, to learn the estimation in which European Surgeons, generally, hold what is called Plastic Surgery,” he said. “This department of our science, although in reality ‘old enough to speak for itself,’ may be considered a comparatively modern invention, for certainly the beautiful and perfect results attained in our time through its agency, far surpass anything that emanated from the hands of its original advocates and inventors. . . .
“These operations were for many years considered almost as fabulous, and have excited the ridicule of the wits of every age . . . ,” he stated. “But, gentlemen, both wit and opposition have been tried in vain, and the most distinguished men in Europe unite in awarding to the measure a high and commanding position among the most useful improvements of the age. . . . Plastic Surgery may be considered as having fought its battles, and will soon rest under the aegis of an established operation.”
This stand—and this open admiration of plastic surgery—had become increasingly important. While anesthesia provided an opportunity for surgical breakthroughs that previous generations could only dream about, it also had the potential to be grossly misused. Members of the larger medical community were beginning to voice their concern over what they considered to be “the exploitation of the manual art of surgery.”
A rift in the community was developing, and it divided those doctors who some fearfully felt had a “seemingly boundless enthusiasm for questionably appropriate surgical intervention” (a category in which Mütter would most definitely be placed, despite his constant appeals to his students that surgery be their last resort) from those doctors who felt surgery was used too often. From this rift, two new phrases were popularized in the jargon of American medicine: conservative surgery and radical surgery.
• • •
Defining what radical and conservative meant in reference to surgery was always difficult, as the art and practice of it were forever evolving. The words took on different meanings at different times. But in this period in history, the words were used to articulate a sharp philosophic difference between what surgeons considered to be appropriate and acceptable operations and those that could be seen as risky, unnecessary, and bordering on dangerous.
Earlier surgeons would define conservative surgery as operations that were absolutely necessary to perform, mostly after a traumatic and often life-endangering injury—amputations of mangled or useless limbs, surgeries to correct dislocations or fractures, the removal of lodged items (bullets, broken glass) from the body or its organs, and so on.
But as medicine entered the 1850s, the concept of “conservative surgery” took on new meanings. Some in the community felt that the relative ease of performing surgeries with anesthesia—no patients to hold down, no screams, no wails, no thrashing—made it so that surgery was suggested too liberally and too often.
Conservative surgery therefore was defined as any surgery “devised solely within the context of the growing science of surgery” and “not used indiscriminately on anyone who would hold still.”
If earlier generations feared surgeons because they viewed them as sadists who delighted in their patients’ pain, the new vision of surgeons in a postanesthesia world was as ghouls—fiendish men who sought to knock you out and then revel in slicing you open in a variety of disturbing new ways when you are unable to defend yourself.
This dark vision of surgeons is clearly apparent in an anonymous editorial printed in a New York City medical journal:
“The more bloody, and even the more uniformly fatal, the higher the huzza of the ignorant and vulgar multitude for the surgeon, so called, who figures in ‘deeds of blood,’” the vitriolic piece stated. “Students and junior practitioners will often run miles to witness a capital operation, and ransack neighborhoods and cities to find patients whose surgical diseases will furnish them opportunities to cut, or to witness cutting performed by others.
“And they too become partakers in the popular idolatry of the mere operators, whose frenzy for the use of the scalpel and saw, mallet and chisel, and even the red hot iron, upon the living bodies of their victims, becomes a passion, which too often degrades surgery into human butchery.”
Although the hyperbole and dramatics painted a nastier picture of surgery than he saw, it was true that Mütter shared some of the sentiments of those who criticized “radical surgery.”
Many of the surgeries he performed—especially the ones he did on the severely deformed—would most definitely fall under the category of radical, but Mütter had long preached that surgical intervention wasn’t needed for all cases that came to his doorstep.
This was a sentiment he felt especially strongly when it came to women, who—because of the enforced modesty of the time period—were more likely to come to doctors after it was already too late for treatment to be helpful.
In fact, Mütter was criticized for being cruel and inhumane for his opinion on the treatment of breast tumors, which he firmly believed should not be operated on, except in very specific circumstances. He simply didn’t believe there were nearly enough benefits to the surgical removal of a breast to outweigh the enormous negatives: the wretched pain of surgery and recovery; the inevitable infection that would turn the woman’s chest into a painful, throbbing wound leaking with foul pus; the days, weeks, months that the woman would be unable to leave her bed, to hug her children, or to sleep, eat, or love without searing, ceaseless pain.
But a woman is seeking your help, his critics would say. How merciless and cold must you be to refuse to aid her?
“To answer this question in a satisfactory manner,” he would reply, “it is necessary to investigate, first, the results of the disease when left to itself; and secondly, the benefits likely to accrue from the performance of an operation, its effects upon the progress of the disease, and its dangers. It is a melancholy truth that when left to itself this disease usually advances steadily, but with an unequal pace in different cases.”
He would then explain how, often by the time a lump in a woman’s breast has become so large, troubling, and painful that she would show it to her doctor, the cancer in the breast has likely progressed to all adjacent tissues, and—regardless of whether the tumor itself is surgically removed—would ultimately end in the death of the patient, who likely would see death at this point as “a welcome messenger,” having been for months of her brutal recovery “a martyr to unspeakable sufferings, and a loathsome object to her friends.”
“It is true, that some of the French, who adopt the view that cancer is invariably in its commencement a local disease, operate in cases where the English and American surgeons would hesitate to use the knife,” he would tell them, “but, as a general rule, they advise an early operation, before the system becomes involved, or none at all.”
But while this philosophy was grounded in rational and logical thought, even Mütter could not escape how difficult this decision inevitably is when faced with the distressed and frantic face of a woman who doesn’t know she will be dead soon anyway.
“It is urged by some, that we are justified [in performing surgery on] desperate cases, [to] escape the horrors of ulcerated or open cancer,” he said. “This is certainly a humane motive . . . where the patient is young, or has some especial reason for wishing the nature of her disease concealed, and is willing to take all the responsibility of the result upon herself, after having been made aware of the almost certain failure of the operation . . . and that she must die in a few months. . . .
“But, gentlemen,” he confessed to them, “whenever I have done so, it has been with an aching heart, and a most fervent wish that my patient had spared her surgeon and herself the terrible ordeal to which she is voluntarily subjected.”
To those who thought Mütter was of the camp that believed a surgeon’s knife could solve every problem, his opinion came as a surprise.
But Mütter’s students knew the truth. He had always taught them that “the knife promises nothing” and should be used only if the disease is caught early enough or if “it will serve to satisfy the patient in part, and prevent, to a certain degree, that terrible sickness of heart that overwhelms a poor sufferer when utterly abandoned by the surgeon.”
He shared the opinion of John Watson, an influential New York City surgeon who simply said: “Surgery . . . is a good thing, a useful thing, an excellent thing in its way; but too much of it is a great evil. And the sooner you find this out for yourselves, the better for your patients.”
• • •
The early years of the 1850s were a transformative time in Philadelphia—for its people, for its industry, and for its politics.
For Mütter, it was a time when, in so many respects, he was at the height of his power: a decade into his chair at one of the most prestigious medical colleges in the country; peerless in his ability to perform complex and visionary new surgeries; and an emerging yet powerful voice within the community whose opinions—though maybe not embraced by those around him—were at least heard.
But there was another side to this life, a painful truth Mütter could not escape: the increasing failure of his own body.
“The old axiom, mens sana in corpore sano (‘a healthy mind in a healthy body’) is full of wisdom,” he had told a class during a period of good health in the late 1840s, “and if there is one among you so unfortunate as to possess a feeble constitution, let me counsel him—as one who has dearly proven the misery of such a possession—to abandon the study of medicine at once, or at least until vigor and tone have been imparted to his frame.
“Without health,” he said bluntly, “the professional life of a man is one, long dreary night of suffering and disappointment.”
For the past year, Mütter had felt trapped in that “long dreary night.” There were more bad days now than good. He began to worry about how strained his body was becoming. His frame felt constantly fatigued. When his joints weren’t swollen with gout, they were stiff and painful to bend. In surgeries, his hands struggled to do what they once did so easily; movements that had been swift and light were now uncertain and laborious.
Mütter had trouble sleeping, trouble breathing, trouble putting on weight. His pale skin grew sallow, and his hair began to gray prematurely. He was spending a fortune on handkerchiefs because he had to constantly replace the ones that became irreparably stained by the blood he so frequently coughed up.
Mütter knew what he had to do: Go to Europe.
Throughout his career, Mütter had made professional visits to Europe—mostly to Paris and London, where he spent time with “numerous eminent friends.” It was his way of “rubbing up” on the latest medical innovations. He would visit hospitals, sit in on surgeries, and study and observe all he joyfully could. Mütter sometimes brought former students with him on these trips, allowing those young men he saw as being the most industrious and the most forward thinking to benefit from his reputation and stature.
One student who accompanied him on a European visit was amazed at how many doors were opened to him by Mütter, how he “was greeted warmly by the most eminent medical men of London and Paris, often meeting them socially, and attending, by invitation, their operations and consultations.”
To the European medical societies, Mütter was a bit of a celebrity: a dashing, outspoken, idiosyncratic American visionary. Even established American doctors would ask Mütter to be “favored by him with letters of introduction to distinguished medical men” and, after receiving such letters, “found them passports at once to the society and attentions of the recipients.”
And when in residence in a foreign city, his presence seemed “at once known among the numerous American health or pleasure seekers in Paris.” So though he was thousands of miles from his home, there were still throngs of people who both sought his company socially as well as wanted to be consulted by him professionally.
But Mütter knew this trip would have to be different. He had begun to feel a creeping fear about what was happening with his body. He wanted to address it—fully, boldly, and transparently—before it was too late and the damage became permanent. Or, worse—a thought he strove to chase from his troubled mind and from his devoted wife’s frightened lips—before it killed him.
This time, Mütter would arrive in Europe largely unannounced, and endeavor only to be among his most “distinguished and attentive friends,” esteemed doctors whom he trusted the most. In the confidence of their small offices, he would share with them the extent of the damage caused by the severe attacks of his “frequently recurring malady.” He would ask them for their advice, for their guidance, and, most importantly, for the truth.
• • •
Still, it was difficult for him to leave Philadelphia and the clinic he cherished so much.
He worried about the patients he wouldn’t be able to see, and whether, in his absence, their painful infirmities would be properly treated. He worried about his students, and whether their skills would slack or regress without his watchful eye. And he worried that the influence of doctors like Meigs might strengthen in his absence, stifling progress he had worked so hard to achieve.
While the sharply dressed yet ailing Mütter was tireless in his efforts to inspire Jefferson Medical College students, encouraging them to push further, dream larger, and move the profession forward, the grimly dressed yet robustly healthy Meigs would lecture them to instead stay “in the middle.”
In the speech he gave to the 1852 graduating class, Meigs proffered the following advice:
“You ought to conceive, therefore, of the tenor of a medical life as one subdued, and brought into conformity . . . ,” he told them. “I am far from recommending . . . habits of moping and dullness, but would have you shun all trifling and all frivolities, incommensurate with the dignity of your station, and the gravity of your concerns.
“You must go, in and out, before the people, daily; the boisterous laugh, the stormy carouse, and the discreditable spree are but evil antecedents of that visit . . . ,” he explained. “There is a just medium,” he flatly added, “and he is safest who touches neither extreme in anything.
“Therefore, we charge you: be good men, and learned men; join yourselves to every good work and purpose: oppose all evil; let your examples shine before all worthy men to encourage them,” he said, before adding this threatening conclusion: “Check and reprove whatsoever tends to the subversion of religion, of morals, of the public welfare in short.”
• • •
But what Meigs said or did didn’t matter—it couldn’t. Mütter felt he had no choice; he knew what he had to do. And shortly after graduation, he quietly left for Europe because he saw it as his “only means of securing relaxation and escaping the incessant calls for his services at home” and “his only hope for healing the same painful infirmities which always oppressed him.”
He was determined, now more than ever, to return a healthier, stronger man and continue the work he needed to do.