Dr. Mutter's Marvels

by Cristin O'keefe Aptowicz

  Yet when Squibb had the opportunity to watch each man give a solo surgical lecture, his past critical view of Pancoast was not swayed. He wrote that Dr. Pancoast’s lecture on the anatomy of the abdomen was “the most bungling demonstration I ever saw,” and he was unnerved when Pancoast performed a difficult operation without aid of an anesthetic, and the shrieking patient’s “blood and tears detracted from the artistic effect.”

  Squibb seemed awed, however, by Mütter’s now-famous ether surgeries. He described in detail Mütter’s amputation of a forty-five-to-fifty-year-old man’s leg just below the right knee.

  “The patient was not easily etherized,” Squibb noted—a common problem during a time when the chemical makeup of ether anesthesia solutions was not standardized or entirely reliable—“but was finally brought under the full effect. . . . The double flap operation was performed just above-the-knee with the bone being sawed through at its middle. . . . At the end, just before the dressing, the patient was asked if he felt the operation and replied he did not know it was done.”

  Indeed, Squibb wrote that there had been no groaning or noise during the operation at all, except when the anesthetic effect would diminish—a signal for Mütter to swiftly renew the patient’s supply of ether. But despite the fact that ether anesthesia helped the operation to be “very well and prettily and quickly done,” it was still a gruesome sight to behold. “Some notable bleeding from the end of the bone but probably not serious,” Squibb wrote. “A large audience and only one case of fainting.”

  Still, he was deeply impressed with Mütter’s thrilling showmanship and his dedication to promoting the use of anesthesia. He described the operation as a grand performance—“Barnum by Dr. Mütter,” he jotted into his journal, comparing Mütter to P. T. Barnum, the wildly popular showman and famous fun house promoter.

  Mütter’s ability to use his surgeries to funnel the natural curiosity about anesthesia surgeries toward a faster and broader acceptance of them was no accident. Mütter found any resistance to anesthesia maddening. While even he would admit that it was far from a perfect discovery, there was no escaping the fact that having the ability to anesthetize a patient could alter, evolve, and improve the practice of surgery, and that these improvements outweighed the drawbacks of its “growing pains.”

  Mütter’s desire to experiment even more with this wonder drug was hampered by the constant need to find ways to do so without upsetting any of his peers, many of whom were undecided about anesthesia.

  Mütter had fought hard to make sure Jefferson Medical College provided recovery rooms to all patients who offered themselves up to the knife at the school’s surgical clinic. It proved to be a success with students, who visited and volunteered.

  Mütter’s fellow Jefferson Medical College professors Joseph Pancoast and John Kearsley Mitchell encouraged this development by offering to keep their clinics—the anatomical dissection room and medical clinic—open whenever the surgical clinic was open. Both Pancoast and Mitchell publicly supported anesthesia surgeries but did not perform them nearly as often as Mütter did.

  Together, Mitchell, Mütter, and Pancoast decided to make an even larger push and ask that all four areas—the surgical clinic, medical clinic, dissection room, and recovery rooms—open a full month before classes began each year and remain open for another full month after graduation. They argued that this would allow students to give “zealous and enduring attention” to the clinical medicine and surgery as well as give them “ample opportunities . . . for pursuits in practical anatomy” when “the student has much more leisure than during the session.” The college assented, under the strict understanding that the professors—and not the school—were responsible for the clinics when the school was not in session. The professors agreed.

  When the college was forced to halt all activities to undertake a thorough renovation of the building, the trio pushed for an even more ambitious vision: that the Jefferson Medical College hospital remain open year-round. This time the board agreed without any debate.

  “So satisfied are the faculty of the value to the students of clinical instruction,” they would later explain in their announcement, “that the clinic is open on appropriate days, not merely during the session, but throughout the year; and the medical and surgical practice is superintended and directed by the professors themselves, so that the faculty are, in truth, occupied incessantly through the year in the business of instruction.”

  With this news, Mütter now had unrestricted access to the school’s surgical clinic, where he could perform whatever surgeries he wished on whomever he wished, using whatever tools, innovations, and chemical agents he wanted. It was, for Mütter, an utter dream come true, and his work blossomed even more because of it.

  • • •

  In the 1846–1847 session—the academic year when Mütter first began working with inhalation ether—the Jefferson Medical College clinics treated 796 patients.

  The renovations of the school were being finished when the academic year began, so this number doesn’t even reflect a full year of clinical treatment—only eight months. Comparatively, the much larger Pennsylvania Hospital, with its full staff of doctors and nurses, treated 1,391 patients in its twelve-month period.

  “The Clinic enables the professors to exhibit to the class the mode of applying principles taught . . . to immediate practice,” the school advertised in its annual announcement. “It is most richly supplied with medical and surgical cases. . . . The patient is examined, prescribed for, and—if surgical aid be demanded—is operated on before the class.”

  Now that the evolved, year-round clinic was swiftly becoming the pride of the school, the board kept strict accounts of all the patients who came through the clinic’s doors, and those records show the diverse types of people that Mütter, Mitchell, and Pancoast attended.

  Of the 796 patients who sought medical attention that year, over half—an impressive 409 people—came to be treated in Mütter’s surgical ward. The majority of these patients were adult, but a significant number were children: 176 of the 796 patients were under the age of ten, and 82 of those were under the age of three. When it came to the sex of the patients, the split was much more even: 399 males and 397 females.

  Jefferson Medical College after the Renovations

  Mitchell and the students who volunteered to help at the medical clinic saw a variety of ailments common to the nineteenth century: diseases of the mouth, the stomach, and the intestines. They treated chronic enlargement of the spleen, herpes, psoriasis, scabies, lumbago, scrofula (tuberculosis of the neck), and impetigo (a highly contagious skin infection with painful, bursting facial sores). They treated tougher cases, like lupus, cholera, epilepsy, and gonorrhea, and even tried their best to help patients whom they would eventually diagnose with “idiocy” or “insanity” or “hypochondria.”

  But if the medical department could claim a colorful range of ailments, the diversity of the surgical department’s patients was even more astonishing.

  They arrived with mangled fingers that had been crushed between train cars, dangling thumbs that had been sliced almost completely off their hands, eyes blasted nearly to pulp by gunpowder, and broken bones of every shape, size, and position.

  There were countless cases of clubfoot. Mütter’s reputation for curing it had become so great that he asked Pancoast to help with the workload.

  Both Mütter and Pancoast were performing the most common operations: removals of tonsils, operations on glaucoma and cataracts, removal of foreign bodies from all types of flesh (including and especially the eye), and amputations of both arms and legs (though Mütter and Pancoast shied away from using the term amputation, which seemed pejorative to them, and instead referred to the surgery as the creation of “conical stumps”).

  They devoted themselves to delicate surgeries on the joints of the shoulder, the elbow, the wrist, the knee, and the
neck—ailments created by injury or from disease.

  Mütter swiftly and cleanly removed tumors from every inch of the body: the eyelid, the lip, the cheek, the jaw, the ear, the forehead, the scalp, the neck, the temple, the chin, and even the eyeball itself.

  He removed fatty tumors from the breast, the chest, the shoulder, and the shoulder blade, and cut them from limbs, spines, and labia.

  “Multitudes of surgical patients, as attested by the register, came under treatment in the clinic . . . ,” Pancoast would later boast. “This list included almost every variety of surgical disease, and more than the usual proportion of the more serious and important cases known in surgery. . . . [A] very large number of them were sent by practitioners from different and often distant places, and on which most of the resources of the art had been previously employed in vain.”

  • • •

  But what made the Jefferson Medical College surgical clinic so unique was the class of surgeries that Mütter listed as deformities.

  Of course, Mütter performed his namesake surgery—stitching back together the faces and bodies of burn victims—as well as his nearly equally famous surgeries on those who suffered from cleft lips and cleft palates of varying degrees of severity.

  He performed surgeries because of “spontaneous contraction of hands and feet,” “relaxation of ligaments of the ankle,” “loss of nose from fight,” “deformity of legs from Rachitis” (commonly known now as rickets), and a “deformed chest from a diseased sternum.” He even treated a man who suffered horribly from elephantiasis and, immediately afterward, took up a collection for the man, reminding the students that compassion for someone like this does not stop at the operating room door.

  Mütter tried to fix them all and, more often than not, was successful. Of the 796 patients who sought medical attention at the Jefferson Medical College clinics that year, the college recorded among them only three deaths—a stunningly small number.

  “He loved . . . to match himself with the most difficult cases,” Pancoast would say of Mütter. “He carefully prepared himself, even in the minutest points, for the difficulties he had to encounter, and then, with equal skill and firmness, with a sparkling eye and dilating faculties, advanced to his task, more like (than anything else with which I can compare him) to a warrior . . . his courage aroused with the danger and his pulse stirred with the energy of the strife.”

  As his reputation and popularity grew, patients—rich and poor, old and young—came from great distances just to be examined by this strange but compassionate genius.

  “His office was thronged with patients from every part of the Union, waiting patiently their turn, for hours, to consult him,” a student would later recall.

  “At the clinic of the College, on his entrance into the receiving rooms, crowded with patients attracted by his fame, they gathered around him with a confidence and infatuation which seemed almost to say, If I may but touch his garment, I shall be whole,” he continued, quoting a line from the New Testament (Matthew 9:21) about Jesus healing the sick.

  “At no time had the ample resources of Philadelphia for medical instruction been so diligently fostered,” the board said of the clinics, “or more triumphantly exhibited.”

  “In no hospital which I have visited, abroad or at home, could [students], in the same space of time, have witnessed so much or profited so richly,” Pancoast would later say in praise of the clinic Mütter had fought so hard to expand, “and [his students] must frequently recall to mind the ardor, the energy, the zeal, the soul, with which this portion of Professor Mütter’s duties were performed, whether in the treatment of surgical diseases by medical measures only, or by the severer, but not less necessary, application of instruments.”

  It was from this platform that Mütter wanted to help direct the future of medicine in a more compassionate direction—and to him, that meant more aggressively promoting the use of anesthesia.

  • • •

  However, Mütter had to face one hard fact: Despite his own surgical successes, anesthesia did not largely decrease the percentage of deaths that resulted from operations. It was true that the patients experienced much less pain if under the influence of ether during surgery, but overall, they still died at the same rate as surgical patients who endured operations without anesthesia. The reasons for this were complicated.

  First, inhalation anesthesia was not an exact science. In this time before standardization of medicine, the patient couldn’t always rely on the quality or consistency of the sulphuric ether he received. There were discrepancies among providers, among regions, even between the years in which the sulphuric ether was produced, all of which served to hinder doctors from being able to use it effectively.

  It was often a guessing game to determine how much was needed to sedate the patient . . . and how little could be used to kill them. However, accidentally killing a patient by overuse was a larger problem for the other inhalant some surgeons were exploring: chloroform.

  The use of chloroform as an anesthetic was introduced in 1847 (the year after ether anesthesia made its debut) by a professor at the University of Edinburgh in Scotland. The discovery was met initially with enthusiasm by American anesthesia supporters; however, that excitement was soon tempered by news of a surge in deaths on the operating table whenever chloroform was used.

  Afraid that the deaths caused by chloroform anesthesia would color public opinion about ether anesthesia, John Collins Warren wrote a second monograph, Effects of Chloroform and of Strong Chloric Ether as Narcotic Agents, in an attempt to educate the public on the subject.

  “The introduction of chloroform produced an excitement scarcely less than that of the discovery of the narcotic effect of ether . . . ,” Warren wrote. “We were soon awakened from our dreams of the delightful influence of the new agent by the occurrence of unfortunate and painful consequences, which had not followed in this country on the practice of etherization. . . . Now it appears that no less than ten well-authenticated fatal cases have presented themselves to the public eye within little more than a year.”

  Still, it is impossible to know how many surgeons and doctors who saw the troubling and fatal consequences of chloroform swore off the use of any form of anesthesia in their practice as a result.

  • • •

  Another reason for the medical community’s initial resistance to anesthesia was that it threatened to upset what had always been considered “normal” surgical procedures.

  Surgery was traditionally performed on a conscious patient, one who was able to communicate and express pain to his or her surgeon. Surgeons and doctors would use their patients’ reactions—either by asking them questions or listening carefully to their wails and cries—to help guide their surgeries. Removing this element from the act of surgery seemed strange and unnatural to some—like removing one of their senses.

  Additionally, some doctors believed that using anesthesia hampered the patient’s ability to heal and recover postsurgery. In an article in The American Journal of the Medical Sciences, army surgeon John B. Porter disparaged the use of ether anesthesia, explaining that “the blood is poisoned, the nervous influence and muscular contractility is destroyed or diminished, and the wound is put in an unfavourable state for recovery . . . in consequence . . . hemorrhage is much more apt to occur, and union by adhesion is prevented.”

  In his book A System of Operative Surgery: Based upon the Practice of Surgeons in the United States, future University of Pennsylvania professor Henry H. Smith attempted to address and dismiss those notions—especially the concept that preventing the patient from feeling the torturous pain of surgery could somehow be seen as a negative. He wrote, “In the majority of cases, the creation of pain by any operation can only be regarded, at the present time, as both unnecessary and injurious. The surgeon should therefore prevent it, and endeavor to save his patient the excitement arising from suffering, b
y resorting to the use of Anesthetics . . . and as its safety has been widely tested, philanthropy and that desire to ameliorate the sufferings of mankind, which is the true basis of sound practice, demand that neither prejudice nor ignorance of its effects should longer prevent its employment by every operator.”

  Still, it would be some time before this opinion was widely accepted.

  • • •

  And last, many surgeons who were excited about the surgical possibilities of using anesthesia—thinking they might finally have the opportunity to perform elaborate procedures they had previously only dreamed of doing—were crestfallen when these ambitious, well-thought-out operations still ended with the death of the patient.

  It might be thought that the increased complexity of these operations was the major cause for the rise in “operative mortality” associated with anesthesia surgeries, but that wasn’t entirely true. It was not the ambitiousness of the surgery that proved to be the killer, but rather the uncleanliness, since many physicians did not yet employ antiseptic or aseptic measures.

  Surgeons could spend weeks or months planning a procedure, then execute the operation swiftly and perfectly, and still be forced to watch helplessly as their “successful” surgery turned fatal when the patients died of common postoperative problems such as infection, wound sepsis, and shock. Indeed, Mütter’s success with anesthesia surgery likely had as much to do with his well-documented fastidiousness as it did with the swift and planned preciseness of his hands and tools.

  • • •

  Because of these factors, a significant number of doctors of the mid-nineteenth century thought the use of anesthesia in surgery was simply not worth the risk.