But even in its first year, Jefferson Medical College broke new ground in teaching medicine. McClellan insisted that his own audacious idea be instituted from year one: that all students must take an active part in the care of patients. He considered it to be a deeply important factor in the training of medical students that they be taught by having them observe and work with their own professors as they treated patients. It was an idea that had never been tried before, and this revolutionary concept would prove to be McClellan’s most important contribution to medical education, reshaping the way medicine would be taught throughout the world.
• • •
Founding the new school, however, also made Philadelphia a battleground, for now there were two rival medical institutions, filled with brilliant, eccentric, and outspoken professors, clashing in private and in public, to earn the moniker of the best medical school in the country.
And young Thomas Dent Mütter was just about to jump into the fray.
CHAPTER FIVE
A FALCON FLIGHT
Jefferson Medical College
THE PHYSICIAN MUST ALSO BE A THINKING, OBSERVING, AND REASONING MAN.
Let me advise you to commence at once observing for yourself.
Don’t trust what you are told in lectures, or read in books, but make the knowledge your own, by your own labors.
Lectures and books will serve as guides and beacons, but the goals can only be reached by travelling the road yourself.
THOMAS DENT MÜTTER
From the absolute beginning, Mütter’s students adored him. Dr. Harris, for whom Mütter served as assistant at the Medical Institute, a “summer school of medicine,” was sick often. Mütter began to fill in for him regularly, much to the delight of the students, many of whom were not much younger than Mütter himself.
Stylish and fresh, quick with his wit and flashy in his presentation, Mütter was delighted and relieved that all the things that seemed to frustrate and alienate him from the staid medical establishment endeared him to this younger generation of students.
But it wasn’t just Mütter’s charm or flash that mesmerized his pupils. His lectures grew a reputation for being well devised, amply demonstrated, and outstandingly delivered. His love of the material, his eagerness to have the latest information spread quickly and accurately, and his natural energy and enthusiasm, combined with his clear demonstrations, unusual teaching specimens, and “sprightly oral elucidations,” helped fix his students’ attention on his lucid and methodical arrangements of his often extremely complicated subjects.
The art of teaching came so readily to him, those around him would say his ability seemed “almost intuitive.”
“At his first essay from this perch,” a colleague would later write, “he seems to have taken a falcon flight.”
“In orators, this early perfection is not often seen,” a peer noted, comparing Mütter’s great skill as a professor to “great generals, who learn to fight by fighting, and whose only real school is war.”
And perhaps that war metaphor was more apt than the speaker knew. As Mütter was just beginning his career in the late 1830s, Philadelphia was entering one of the most turbulent periods of its medical history.
Two long-simmering crises were coming to a head and would dramatically implode before the decade’s end. They would have a profound effect on the course of American medicine and, consequently, on the career of Thomas Dent Mütter.
The first crisis grew out of a challenge to the old private system of medical training, whereby various physicians around the city gave a series of private lectures to as many students as could be convinced to pay. When a pupil felt he had learned what he needed, he would undergo an examination for an MD degree. Needless to say, it was a highly profitable system for the medical community, especially those physicians lucky enough to be paid both by private students and by the university with which they were associated. But it had enormous flaws. There was no guarantee of the quality or accuracy of the lectures. Being a great physician didn’t always guarantee that you had the ability to be an effective teacher. Similarly, an impressive word-of-mouth reputation could be earned by a charismatic and outgoing professor, with the students never knowing that the information he was teaching was out-of-date, not entirely correct, or sometimes flat-out wrong. Lecturers worked in isolation, largely viewing one another as competitors, so there were no systems in place to correct the dramatic difference in quality among the various professors.
Even organized schools or lecture halls, like the Medical Institute (where Mütter was getting his first taste of success), were “purely private enterprise[s] whose standards derived entirely from the conscience and abilities of the individuals involved.”
Perhaps shaken by the new competition presented by Jefferson Medical College, the University of Pennsylvania began to seriously rethink how their medical training should and would be conducted. Their new objective: to standardize medical teaching by bringing it more consistently under the regulation of the administration.
The impulse came from a good place, but it was nonetheless met with strong resistance by private instructors. The University of Pennsylvania immediately set about crushing anyone who tried to oppose them, often using what their detractors called “rather unwholesome tactics.” One example, among many: The university was accused of conspiring to monopolize the supply of cadavers in the city, thus forcing out of business any private anatomists not in the university’s favor.
These tactics worked, and by the end of the 1830s it was said, and not without several notes of frustration and bitterness, that no man could look for success as a private teacher in any branch of medicine unless he be directly or indirectly connected with the university.
The second crisis the Philadelphia medical community faced was itself. Or rather, that the more contentious members of the community were becoming more flamboyant in their public battles with one another, and the situation was finally reaching a breaking point.
When Dr. George McClellan’s problems with the Philadelphia medical establishment led him to found Jefferson Medical College in 1824, it was certainly not the end of his clashes with the University of Pennsylvania or its faculty.
In the ten years following Jefferson’s founding, the “period of accommodation” between the university and its new rival was marked by bitter, unrelenting public confrontations, often instigated and led by the two public faces of these medical schools: McClellan for Jefferson and Dr. William Gibson for the University of Pennsylvania. Both men were chairs of surgery at their respective colleges, and both men had legendarily fiery tempers and sharp tongues.
“It is said that one should not speak ill of the dead. Far be it from me to do so,” a contemporary would later write of Gibson, “but I cannot ignore the fact, known to most of his professional contemporaries, that Gibson was not an amiable man. His ill temper often betrayed him into unkind expressions, even in the lecture-room.”
Indeed, though Gibson had rightfully earned his reputation as an “impressive lecturer” who never failed to command the attention of his classes with “clearness, accuracy and earnestness,” it was also a well-known fact that his practice—both as a surgeon and a physician—was extremely small, a situation owed largely to his temper and acerbic nature.
Gibson, like McClellan, often indulged in offensive language against his opponents. When the two encountered each other in public, they were not shy in expressing their mutual disdain.
In one oft-repeated story, while teaching in a packed University of Pennsylvania lecture hall, Gibson openly accused McClellan of falsehood for having asserted that he had repeatedly performed an operation (an “extirpation of the parotid gland” or removal of a large salivary gland in the back of the mouth) that Gibson himself thought “unfeasible.” For a long time, there was what was delicately referred to as “a warm controversy” on this subject between the rival schools,
with McClellan feeling personally attacked. The medical community at large soon became divided by the issue, though most seemed to side with McClellan.
Finally, Gibson—in a totally unexpected move—invited McClellan to the University of Pennsylvania to bear witness to Gibson’s performing the surgery he had previously denied was possible, in front of Gibson’s own class. McClellan agreed and, when the day arrived, was delighted to see the classroom packed not only with students from both schools, but also many local physicians “who had come to see the fun.”
Gibson, too, thrilled at the size of the eager audience, and skillfully performed the surgery with a trademark flourish. But when the operation was over, Gibson turned toward the audience and announced, “Gentlemen, I have performed what is generally called extirpation of that gland. However, the mass I have removed is only a tumor overlying that gland, not the gland itself.”
“Gentlemen,” McClellan coolly replied while standing up, “my distinguished friend has extirpated the parotid gland, but, unfortunately, doesn’t know it.”
The remark caused “convulsions of laughter” in the large assembly. The story of the surgery would go on to be written in medical journals across the country, only further intensifying the rivalry between the two great surgeons . . . and their schools.
Mütter’s entry into the Philadelphia medical school community in the mid-1830s coincided with a period second to none in America’s medical history. Gibson himself would later say that this time would be remembered for “rivalry marked with jealousy and unfairness.” Medical lore and literature would record abundant evidence of the personal abuse and criticism that medical men of the day rained upon one another, and of the bitter acrimony that often characterized any public discussion of important questions, especially that of treatment.
Because of this unhelpful and seemingly unending infighting, Philadelphia’s reputation as a medical mecca was slipping. It still possessed two great schools, and its doctors were still revered far and wide. Even with all this bitter discourse, every ambitious medical man in the United States looked toward a chair in a Philadelphia college as the crowning point of any serious career. But no one could deny that the city was gaining rivals in places like New York, Baltimore, and Chicago, and the current fractured state of the Philadelphia community did nothing to stop these other cities in their bid for the top.
• • •
Perhaps this is why the Philadelphia medical community began to pay attention to Mütter more closely in the wake of his professorial successes. Young, smart, ambitious, and blessed with extraordinary talents, Mütter was gaining a reputation as “one of the best of good fellows” and not just in the lecture hall.
“He possessed spontaneously, as it were, the art both of making and holding friends,” a fellow doctor would write of him, “a natural amenity of manner and gentleness of character, a manliness of bearing so intermingled with feminine graces that even children were attracted by it, and a love of approbation that induced him to do what he could to please others.”
When Dr. Harris grew too sick to make house calls, he asked Mütter to go on his behalf. Mütter’s skill, matched with his comforting and charming demeanor, endeared him to the patients. Soon, other doctors, including and especially the ever-encouraging Dr. Jackson, made a habit of sending Mütter to make house calls in their stead. As a result, within a few months, Mütter began to develop a healthy private practice.
He was also garnering an impressive reputation as a surgeon. His access to the medical school’s surgical rooms allowed him to attempt the kinds of ambitious surgeries he had learned about in Paris, many of which defiantly occupied “the difficult domain of reparative and reconstructive surgery.”
His first surgical patients found their way to him through the school itself, who promised citizens free surgical treatment, provided they agreed to the surgery’s being performed in a public setting.
But it didn’t take long for Mütter to also begin receiving surgical patients privately as word of his unusual skills began to spread. The first patients came from the Philadelphia area, but soon, “strangers from various parts of this wide domain . . . sought from his skill the relief which their various sufferings demanded.”
“He succeeded with patients for the same reason as with students,” it was written of him; “he was both respected and liked.” This seemed like a welcome change from the relentless acrimony and open hostility that now marred the reputations of McClellan and Gibson, the city’s two top teaching surgeons.
Mütter might have sensed that he was being groomed for something greater when three distinguished Philadelphia doctors—Randolph, Norris, and Anderson, all several years his senior—independently approached him and inquired if they might assist him in one of his next surgeries radicales. They each wanted to see firsthand how Mütter took cases so damaged and tragic, and fixed them so seamlessly.
Perhaps the most sensible response would have been to have each doctor come in separately and then select patients whose surgeries would be easiest to perform in front of such an esteemed audience. But that wasn’t Mütter’s way.
He knew it was risky, but he couldn’t help it. He decided to do a very difficult surgery, and asked all of them to be his assistants on it. It took some finessing, but Mütter assured them that each individual would serve a necessary part in the surgery.
Still, it was quite a sight to see: men at the prime of their careers, lining up to assist a twenty-nine-year-old surgeon who was perhaps best known to their wives as the doctor who liked to match the color of his expensive suit to the carriage in which he was riding. But the simple truth was that the doctors were happy to line up by Mütter’s side, to witness his surgical prowess, to be close to his quick, sure hands.
Less happy, however, were Mütter’s students, who grumbled in their seats on surgery day, upset that their own views of the operation might be blocked.
After a quick contented survey of the scene, Mütter began the process of tuning them all out so that the entirety of focus could be directed to the patient shaking and drooling in the surgical chair.
Nathaniel Dickey was a local Philadelphian whom Mütter had liked from the first time they met: intelligent, funny, and in perfectly good health, aside from the obvious. The twenty-five-year-old’s face was dramatically split down the middle. His lips and the top of his mouth were raw and open, and despite Nathaniel’s best efforts to prevent it, thick cords of spittle often poured from the opening.
It was Nathaniel who sought out Mütter, asking if anything could be done to help a person like him. With a thick slur but bright eyes, he confessed to Mütter how badly he wanted to have a wife and children, how much he dreamed of walking down the street with this beautiful family he so often envisioned having, and have not a single passing stranger gawk at his deformed face.
Now, weeks later, Nathaniel sat in front of Mütter, his head firmly supported against the chest of a seated Dr. Norris, and his arms held down against his torso by a tight white sheet.
Mütter had already explained the surgery to Nathaniel in detail. In the days leading up to it, Mütter would thrice daily massage Nathaniel’s face, attempting to desensitize his vulnerable palate. Even the slightest amount of vomit rising from his throat would threaten the entire operation, ruining the delicate work he was attempting to do, and inviting dangerous infection to nest in his already beleaguered mouth.
The risk of purging was one of the reasons the surgery had to be performed with the patient almost entirely sober. Mütter also needed him to stay still and stiff, to open his mouth wider and wider if need be, and to keep the contents of a nervous stomach in their place.
Nathaniel had to be more than a patient; he had to be a partner in seeing this difficult surgery to its end. Mütter knew this. And so they would meet multiple times a day for facial massages. And as Mütter’s hands gently explored Nathaniel’s handsome but broken face,
he would walk the young man through each moment of the surgery, carefully explaining each danger and tenderly warning of each increasing level of pain. Nathaniel never once wavered in his determination to see it through.
But now on the day of the surgery, Mütter saw Nathaniel’s eyes widen and his body become rigid as he moved toward him. Mütter paused for a moment, letting Nathaniel take several deep breaths. Nathaniel’s eyes unconsciously wandered to the table where Mütter had laid out his tools: a knife, a hook, a pair of long forceps, needles, waxed thread, scissors, sponges on handles, wine and water, cold water, towels, and—hidden under a handkerchief for emergency use only—leeches, opiates, and a sharp lancet.
After making his opening remarks, being sure to name and thank each of his impressive assistants, Mütter took care to position himself properly. He decided to stand a little to one side of Nathaniel, to obstruct the entrance of light into the mouth as little as possible. He then asked Nathaniel to throw his head back as far as he could and to open his mouth and keep it in this position as long as he was able. He placed a comforting hand on Nathaniel’s shoulder, squeezed just once, and then began.
Within moments of the surgery’s quick first step—the insertion of a sharp hook into the roof of Nathaniel’s mouth used to gently pull the deformed mass of muscle and skin back—the trio of doctors forgot who they were, or that anyone else was in the room. The students groaned and fussed, as the doctors blocked their view, closing their small circle in an attempt to get a closer look at Mütter’s whirlwind actions.
The trick to surgeries of this kind, Mütter knew, was twofold: You had to be quick so as to lessen the stress and pain of the patient, but slow enough to make sure you were doing it right. Mütter’s hands were a confident blur of motion as he cut and pierced, excised and sutured, flayed and positioned. He checked in with Nathaniel often, offering whatever words of comfort and support he could. And when possible, he tried to involve the doctors who had agreed to assist, but once he realized they were more than content to watch, he focused solely on the job at hand.
Dr. Mutter's Marvels Page 6