Dr. Mutter's Marvels

by Cristin O'keefe Aptowicz

  Despite the throbbing, shocking pain the young woman experienced, Mütter could see the gratification on her face. Without the thick webbing of scar tissue dragging her face down, she was able to blink her eyes easily and painlessly. She was able to close her mouth. She could turn her head for the first time in more than two decades.

  But, of course, Mütter had to remind her that the surgery was not over. There was more she would need to endure.

  After instructing her not to look down, Mütter made “a most shocking wound six inches in length by five and a half in width.”

  The next step in the operation was Mütter’s most daring innovation: the manipulation of skin to form the flap, which would give name to Mütter flap surgery.

  Mütter knew that in order for this change to be permanent, he could not leave the wound to heal as it was, writing “for I knew very well, that if permitted to heal by granulation only, the patient, so far from being benefited, would be made worse than before.” He would need to find skin to fill in the wound he had just opened, and this is where the untouched skin on her back would prove most useful.

  Mütter asked the woman to sit perfectly straight as he washed the skin on her back. Neither the front or the back of her body could be leaned against any fabric or wood because of the wounds. He positioned his two assistants to either side of the woman, there in case she needed to reach out and hold something to keep from collapsing.

  He acted quickly, carrying the scalpel downward and outward over the deltoid muscle. The woman tried to stifle her cry as Mütter carved out a piece of skin from her back—six and a half inches in length, by six in width, slightly larger but the same shape as the wound on the front of her neck—making sure to leave the flap attached by a thin strip of skin that traveled up the upper part of her neck.

  As with his work on the front of her neck, he was mindful not to cut too deeply. But despite his best efforts, one small vessel was opened. For the rest of the surgery, a steady stream of blood dripped onto the floor, ticking like an insistent clock.

  Mütter carefully loosened this flap of healthy skin, lifting it entirely off her back and bringing it around to the front of her body. As he lifted the skin over her shoulder, the thin strip of skin connecting it to her body folded over itself, but did not tear. He placed the skin in the gap that the front wound had created. It fit nearly perfectly, and with strong sutures he immediately began securing the edges of the wound to the edges of the fresh flap of skin.

  Once he saw that the edges of the wounds on the front of her neck were secured, Mütter then applied several clean cloth straps to support the sutures, but determined that no other dressing at this stage was advisable.

  Working his way back, he sewed up the wound left by the strip of skin on her neck, using straps and sutures as best he could, and fusing completely together the parts of her neck that he could without strain.

  Finally, all he was left with was the large wound on her back, the one making the floor slick with her blood. It was too large to seal, so Mütter unrolled a clean, damp compress made of fine lint across the raw surface of the wound. He carefully wrapped a bandage around both wounds, and then, realizing what needed to be done, applied a bandage around the woman’s head to hold her head tilted backward. Mütter realized that scars, by nature, contract, and that for the best chance at full mobility, her neck would need to heal in a stretched position.

  It was done. Of course, the true test was whether the new skin would take hold, making permanent the changes the patient felt. Mütter had given her the best possible chance he could. And while the doctors and students in attendance were left in awe of the work Mütter had done and the innovation it showed, Mütter redirected all praise to his patient.

  “The fortitude with which this truly severe operation was borne excited the admiration of all present,” he wrote. “Scarcely a groan escaped the patient, nor was it necessary to give her more than a mouthful or two of wine and water during the whole period of its duration.”

  With that, the patient was put to bed.

  “Rest and quietude were enjoined,” he wrote of the recovery process. It was all the woman could do, for eating or drinking of any kind had been strictly prohibited by Mütter.

  Mütter kept careful watch over her the first night, but other than a slightly raised pulse and understandable complaints of stiff neck and sore back, she seemed perfectly well. The next day was much the same; his notes read: “A little nervous, but no fever; no swelling or pain in the wound; some thirst and hunger, but willing to go another day without sustenance.”

  But Mütter’s luck seemed to have run out by the third day. The woman suddenly developed a fever, soaking the thin sheets with sweat. There was increased pain at the wound sites, and she was uncomfortable no matter what position she took. Restless, anxious, and unable to relieve herself, she was prescribed by Mütter “an enema to be administered at once” (the constipation that commonly followed surgery was often the source of numerous problems if left untreated) and “spoonfuls of cool barley water to be taken every hour or two.”

  The treatment, thankfully, worked. On the fourth day after the operation, Mütter finally had his opportunity to see if his vision was right. Had the surgery been successful?

  As the woman nervously sat in front of him, Mütter removed the bandages that were holding together the skin of her tender throat. As he loosened the straps, he steeled himself for what he might see: Would he be greeted with the sight of healing skin or the putrid scent and sight of a blackening, infected wound?

  When the last piece of fabric was removed, he saw what he had helped create. He smiled.

  “The wound united along the edges, with the exception of here and there a point,” he wrote, “a small pouch of pus at the most dependent part of the flap.”

  It had worked. Or rather it was working. Now Mütter just had to continue the good process that was already on its way.

  He evacuated the pus through a small opening in its vicinity; took out some of the pins; reapplied the straps; dressed the shoulder; and immediately ordered that the patient be fed for the first time in almost a week: “a little mutton broth” followed by an enema of salt and water to ensure against bowel toxicity.

  When he noticed a “troublesome circumstance” where “a band of tissue, certainly not thicker or wider than a small wire” was contracting, Mütter immediately brought the patient back into the surgical room to fix it.

  He also located a good dentist who could straighten her lower teeth—including the removal of one—allowing the angles of the lower jaw to change.

  After several long days and restless nights, Mütter felt the patient was ready to move about and “enjoy the full benefit of the operation.” When the woman was brought to a mirror, she could barely believe what she saw.

  “The whole appearance of the patient is so much altered,” he wrote, “that persons who saw her before the operation, scarcely recognize her as the same individual.”

  Mütter modestly wrote later, “It will be sufficient to state that no unfavourable symptom made its appearance.”

  The woman was less conservative in her praise.

  “The comfort and satisfaction I feel, cannot be expressed,” she wrote in a letter to Mütter. “Your exertions in my behalf have been blessed far beyond my most sanguine expectations. You have set my head at liberty, so that I can turn it any way, at pleasure, and without pain; you have relieved the drawing of my eye; and I am also enabled to close my mouth with comfort, a blessing that cannot be described!”

  The Mütter flap surgery was a success, and as news of it spread, patients came out of the shadows to seek his help.

  In June of that year, Mütter performed a surgery on a twelve-year-old girl who was severely burned when she was just four. “For nearly eight years she had been unable to turn her head to the left side, the lower lip was inverted, and the chin
drawn down nearly in contact with the sternum,” he wrote, and though he would remark that “this case was even more unfavourable” than the previous one in the severity of the condition and age of the patient, he was “determined to perform the operation which had proved so successful.”

  Though the operation was a success, he did note that perhaps one of the hardest parts was keeping a twelve-year-old girl from “speaking, swallowing, or motions of the neck of any kind.”

  Six months later, Mütter was brought an even younger patient, a nine-year-old boy who had “a deformity of the mouth and throat” as the result of his clothes having accidentally taken fire years earlier. The appearance presented by this boy was shocking: His mouth was kept permanently open, his incisor teeth were losing their perpendicular position, his chin was drawn to within an inch or two of his sternum, and a strong band of the scar tissue passed along the center of his throat from chin to sternum.

  This time, not only did Mütter rise to the challenge of performing a delicate and painful surgery on a fully awake nine-year-old child, but he did so in front of a full classroom of Jefferson Medical College students.

  He would later write: “The operation . . . was performed before the medical class on the second Wednesday in January, and on the first Wednesday in February he was brought into the amphitheatre with scarcely a vestige of the deformity remaining. . . . Here, in three weeks time, a cure of a deformity hitherto considered hopeless, was effected.”

  Finally, after two years of successful surgeries, Mütter was asked to publish his findings in The American Journal of the Medical Sciences.

  “Two years and more have elapsed since the first of the operations reported was performed,” he wrote in his introduction, “and the patient still continues relieved. No contraction has taken place, and the success of the experiment may therefore be considered complete: the other cases are also doing well.”

  Mütter was thrilled at the article’s release and the reaction to it. He realized how important publication was to having his vision for medicine be understood and adopted. But he also felt that every moment behind the quill and inkpot was a moment he couldn’t spend in the surgical room.

  “[Mütter] felt it a glorious thing to be able to rescue a patient from present suffering or impending danger, when everything else had failed, by the achievement of a successful surgical operation,” Pancoast wrote. “He had before him a beau ideal of the art and science of surgery, which he was striving first to reach before he made his final record, but which, with advancing knowledge and deepening insight, kept ever assuming higher and higher grounds.”

  But Mütter knew that if he wanted his work to effect real change in the field of medicine, there was only one thing he could do. Somehow, between his hours of lectures and his intense surgical workload—which included lengthy preoperative and postoperative care—Mütter would have to write his own textbook.

  CHAPTER FIFTEEN

  TO REMEDY EVILS

  THE PHYSICIAN SHOULD BE A SELF-RELYING MAN

  The physician should be one who, while he treats authority with all due deference, yet has the spirit to feel that he is no man’s man who knows that he can trust himself . . .

  Who feels that, when called to combat with the “King of Terrors” himself, he is fully armed at all points;

  Who is assured that the shield, which he boldly thrusts forward to screen his suffering patient, is polished, strong, unyielding; so that, however sharp or well directed the dart, it must glance or be broken.

  Such a man is indeed a treasure to the community in which he lives, and an honor to the noble profession of which he is a member.

  THOMAS DENT MÜTTER

  Jefferson Medical College knew within the first year that their ambitious experiment with this new faculty had succeeded. The popularity of the new faculty caused the student population to double after one year. And in two years, it tripled. It affirmed the ever-growing prestige of the college and it solidified its stature as an American institution.

  Students eagerly signed up by the hundreds for lectures on how to best mix their own medicines, the quickest way to amputate a limb, and the most effective ways to bleed and leech patients.

  Leeching—attaching leeches (a type of blood-sucking worm) to a patient’s body—was an important part of medicine at that time. Doctors kept their ample jars of medicinal leeches in their offices. Mütter shared with his students how Paris’s Hôtel-Dieu’s need for leeches was so great that a full-time “keeper-of-leeches” was a part of the hospital staff. Leeches were used in a variety of ways, but mostly to draw blood either to or from a specific area, in an attempt to relieve pain or inflammation. But doctors in that time period found a variety of novel ways to use leeches in their practices. John Kearsley Mitchell recommended that his students apply one hundred leeches to the stomach of anyone who was suffering from typhoid. And Charles D. Meigs advocated the use of leeches to cure several common gynecological problems, and made sure to eke out time each year to teach his students the best ways to apply wriggling black leeches directly into a woman’s uterus, using a sleek wooden speculum.

  Meanwhile, Mütter’s surgical clinics had grown so popular that he was finally able to demand the recovery rooms for which he had petitioned so heavily in his first year. The college refused to buy an entire building but agreed to rent floors above the two stores next to the college and remodel them to accommodate fifteen patients.

  It was not ideal for Mütter by any stretch, but this miniature surgical facility would serve as the place where he would perform his art for the next decade of his life, and would serve as the college’s only hospital for another thirty years.

  Mütter was thrilled that his patients—many of whom had traveled so far and would suffer so greatly in their quest to be made new—were now able to receive round-the-clock care. Students eagerly volunteered to provide nursing care to the patients in the recovery ward, and Mütter doled out the spots as rewards.

  With the students monitoring the patients—keeping their wounds clean and dry, strictly following the aftercare instructions, and feeding them meals brought from a nearby restaurant—Mütter could focus on his newest task: his textbook.

  • • •

  Mütter hoped the textbook might help him gain more influence and respect so that he could be a more effective advocate for the opinions and philosophies that were so important to him. While his position at Jefferson gifted him with a tremendous platform to share his ideas with the incoming generation of physicians, he still felt a disconnect when it came to having his perspective respected by his peers. He was aware that this was in some ways his own doing: his name-dropping, his flamboyant dress, his open frustration with those in his community who, he felt, failed to live up to the standard the medical profession demands were all qualities that often ruffled the delicate sensibilities of many of Philadelphia’s medical elite.

  “Mütter’s fancy was full and free, and in its brilliant play, was sometimes hard to govern,” Pancoast would later explain. “He had a desire for the possession of personal influence and position, which less ardent and more philosophic minds might deem excessive.”

  However, Pancoast was swift to clarify Mütter’s intentions.

  “These advantages were not coveted by him, however, for personal aggrandizement solely,” he said, “but rather that he might be able to promote the interests of those who were dependent upon him or courted his support.”

  However, no matter how much time Mütter spent in the service of self-improvement, he was also painfully aware that some of the factors that eased others into positions of power were utterly beyond his control. The significant income he was now earning would ultimately prove unhelpful in climbing the ranks of Philadelphia’s social hierarchy; in Philadelphia, family had always been valued above wealth.

  In the years before he became a professor at Jefferson, Mütter had met and marrie
d Mary Alsop, a quiet, pious young woman from the elite Connecticut Alsops. However, her esteemed family did not mean much in Philadelphia. The influence of the Alsop family name was felt most strongly in Connecticut and to some extent Washington, DC—where Mary’s aunts were persistent and successful in their goal to marry politicians—but carried much less weight in the City of Brotherly Love.

  Still, Mütter had held hope that the combination of his wife’s pedigree, his eminent position at the college, and the fashion and lifestyle that his new career allowed him could secure his entrance to the parties and social circles that even dull Franklin Bache could find invitation to just for having issued from the womb of Benjamin Franklin’s granddaughter.

  After all, it was not entirely unheard of that the upper class would accept some members of the “natural aristocracy” who had proved their right of entry by demonstrating talent and what was considered to be virtue. But it was rare.

  Even the new industrial and financial leaders and successful speculators in real estate found it hard to gain admittance to the upper social stratum in Philadelphia and indeed were generally seen as “vulgar.”

  “The lines of demarcation in [Philadelphia] ‘society’ were as strongly drawn as in Europe, or more so,” Philadelphia humorist Charles Godfrey Leland would later recall, “with the enormous difference [being] that there was not the slightest perceptible shade of difference in the intellects, culture, or character of the people on either side of the line. . . . Very trifling points of difference, not perceptible to an outsider, made the whole difference between the exclusives and the excluded.”

  And the upper echelons of Philadelphia society were tempting places to want to be accepted.

  “How am I able to communicate a just notion of the intelligence, the refinement, the enterprise of Philadelphians?” another British tourist would write of his time among the Philadelphia elite. “Their agreeable and hospitable society, their pleasant evening-parties, their love of literature, their happy blending of the industrial habits of the north with the social usages of the south? All this must be left to conjecture, as well as the Oriental luxury of their dwellings, and the delicate beauty of their ladies.”