Thomas Dent Mütter, a Philadelphia plastic surgeon in the 1840s, boldly championed anesthesia when few physicians were convinced of its virtues. He was an early advocate of handwashing and hygienic wound care and helped pioneer the concept of postoperative recovery units. A leader in education, Mütter used a highly interactive style of teaching and restructured medical school classes to raise the caliber of clinical training. He supplemented his lectures with a myriad of specimens that he amassed over 24 yr. In 1863, this vast collection would serve as the basis for the Mütter Museum, which remains active today. Mütter exemplified expertise by tirelessly pursuing new knowledge and methods for the benefit of his patients and students.
It is to America that we owe anesthesia, the greatest boon ever conferred upon suffering humanity by human means.
Joseph Lister (1827 to 1912), British surgeon and pioneer of antiseptic surgery1
Thomas Dent Mütter, M.D. (1811 to 1859; fig. 1), was a debonair and inventive surgeon who embraced new practices when he saw a clear benefit for his patients. He was Chair of Surgery at Jefferson Medical College (Philadelphia, Pennsylvania) from 1841 to 1856, inventor of the “Mütter Flap” still used today to treat burn victims, and collector of the teaching artifacts that originated the Mütter Museum (Philadelphia, Pennsylvania) when it opened in 1863.
Mütter is an exemplar of expertise for the modern clinician educator, as he strove tirelessly to improve perioperative conditions and medical education. During his brief lifetime, he surmounted resistance and changed the face of medicine by championing anesthesia, promoting hygienic surgical practices, and enlivening methods of education.
Champion of Surgical Anesthesia
Mütter lost both of his parents to sickness by the age of 7 yr and had to rely on his own creativity, charm, and determination to make a name for himself. When Mütter fell seriously ill during college, the compassion and skill of his own doctors inspired him to become a physician. Mütter’s ambitious nature, combined with a naturally keen aesthetic sense, steered him toward a career in surgery. During his year-long visit to Paris after graduating from medical school at the University of Pennsylvania (Philadelphia, Pennsylvania), Mütter gravitated toward a budding subspecialty, les opérations plastiques, which was led by giants of surgery like Guillaume Dupuytren (1777 to 1835).2
An impressionable young surgeon, Mütter marveled at plastic surgery’s ability to transform the visages and lives of people classified as “monsters.” These patients had severe physical deformities due to congenital disorders, tumors, or accidents such as burns in the home or workplace. Near the end of his year in Paris, Mütter purchased a wax model of the face of Madame Dimanche (fig. 2), a washerwoman who had allowed a 25-cm “horn” (cornu cutaneum) to grow from the middle of her forehead for more than 6 yr.2 The model was a visual presage to Mütter’s future clinical career.
The case of Madame Dimanche was a striking example of a common phenomenon of the era—patients avoided surgery due to the real and perceived risks. Mütter had a strong grasp of the fundamental impediments to safe surgery in the mid-19th century: undeveloped anesthetic agents and techniques, as well as a lack of hygienic practices. During his time, excruciating intraoperative pain was expected, accepted, and tolerated by patients and surgeons alike. The commonly administered remedies to alleviate agony—alcohol or laudanum (a tincture of opium in alcohol)—were often ineffective.
Mütter’s students admired not only his surgical skill, lucid lectures, and disarming wit, but also his sensitivity to patients’ distress. His pupil, Richard J. Levis, M.D. (1827 to 1890), penned a poignant memoir of his beloved professor in 1859, the year of Mütter’s death at age 48 yr. Levis praised his teacher’s remarkable compassion: “[Mütter] appeared often at operations to be painfully sympathetic with the suffering patient and was the first [in Philadelphia] to use ether for its anesthetic effect….”3
Mütter’s famous surgical colleague, Joseph Pancoast (1805 to 1882), similarly extolled Mütter’s sympathy for patients. In a eulogy to his friend, Pancoast wrote, “It is the sweetness of [Mütter’s] character which I love most to recall.” He continued, “[Mütter] felt it a glorious thing to be able to rescue a patient from present suffering or impending danger…by the achievement of a successful surgical operation.”4 Even before the advent of general anesthesia, Mütter would prepare his patients for the pain of surgery by desensitizing the operative areas with fingers and instruments for several days leading up to their procedure.4
Mütter’s ultimate remedy for the excruciating surgical pain he witnessed was to promote the use of anesthesia. On December 23, 1846, just 2 months after the first public demonstration of ether anesthesia by anesthetist W.T.G. Morton (1819 to 1868) and surgeon J.C. Warren, Mütter became the first Philadelphia physician to administer ether.
After inducing unconsciousness in a young male patient, Mütter successfully excised a large cheek tumor. “He soon became consumed with the idea of harnessing [anesthesia’s] incredible promise,” biographer Cristin O’Keefe Aptowicz would later write.2
Future pharmaceutical giant Edward Robinson (E.R.) Squibb, M.D. (1819 to 1900), a student of Mütter, marveled at the artistry of his instructor’s operations and use of ether. In his private journal, Squibb praised Mütter’s finesse during a flap surgery for a young man with a giant burn scar that encompassed the anterior neck and chin. “The operation was quite extensive and admirably performed, the patient being under the influence of Ether,” he wrote.5 Squibb also described Mütter’s success in anesthetizing a man whose leg he subsequently amputated: “The patient was not easily etherized but was finally brought under the full effect.… At the end…the patient was asked if he felt the operation and replied that he did not know it was done.”5
Even in the aftermath of Morton and Warren’s dramatic display of ether anesthesia, many American doctors, including some of Mütter’s closest colleagues, were skeptical about anesthetic safety. What prompted this caution? While anesthesia comforted patients and facilitated procedures, surgical mortality remained high in the pre-antisepsis era. In addition, techniques and tools for safe anesthetic delivery and patient monitoring had yet to be developed. Ether had yet to be purified, uniformly synthesized, and safely dosed—all eventual achievements of Mütter’s famous student, E.R. Squibb.
Regional rivalries also bolstered the initial resistance to anesthesia.6 Many physicians in Philadelphia, the leading medical center of the United States at the time, looked down on Morton’s demonstration as a Boston phenomenon. The heated dispute between three claimants to the “discovery” of anesthesia, as well as Morton’s aggressive pursuit of financial gain, lent an air of impropriety to the very notion of anesthesia.6
Some physicians, like leading obstetrician Charles D. Meigs, M.D. (1792 to 1869), Mütter’s colleague, archrival, and Chair of Obstetrics and Gynecology at Jefferson, staunchly opposed anesthesia on moral grounds. Meigs emphasized the potential of obstetric anesthesia to interfere with the uterine contractions that were required not only for labor and delivery, but also for what he described as the spiritual deliverance of women through suffering.2 Physicians who concurred with Meigs tended to view pain not only as a requirement for physical healing but also as an instrument of divine retribution and justice in a fallen world.6
While some contemporary surgeons, like Robert Liston (1794 to 1847), addressed patient suffering by maximizing efficiency and operating with great speed, Mütter focused on the deeper issue of a terrified, conscious patient in excruciating pain by refining the art of anesthesia. Committed to curing diseases and correcting deformities in the least painful way possible, Mütter championed anesthesia during a time when few physicians were brave or open-minded enough to do so.
Champion of Aseptic Practices
In addition to convincing skeptics of the virtues of ether anesthesia, Mütter had another hurdle to surmount. Infectious morbidity heightened patients’ fears and disheartened surgeons’ endeavors.
The antiseptic movement would ultimately revolutionize medical practice but still lay in the distant horizon while Mütter was alive. As early as 1843, Boston physician and poet Oliver Wendell Holmes, Sr., had argued that unhygienic physician practices transmitted puerperal fever in labor and delivery wards.2 In 1847, Hungarian physician Ignaz Semmelweiss had proposed that obstetricians wash their hands with chlorinated lime solutions before and after seeing patients to prevent the spread of disease. But it was not until the 1860s, after Mütter’s lifetime, that British surgeon Joseph Lister developed carbolic acid as an antiseptic spray to curb postoperative infections.7 At the height of Mütter’s surgical career, even preventive aseptic techniques like meticulous handwashing and the donning of surgical gloves remained unpopular.
Mütter’s antagonist, Meigs, not only denounced anesthesia for surgery and obstetrics, but also opposed handwashing. He emphasized that physicians, being gentlemen, had hands that were always clean.8 He also believed that pus in a postoperative wound signaled a successful operation. Jefferson students found themselves thrust into the dilemma of deciding where their loyalties lay—with Mütter, who celebrated anesthesia and cleanliness during surgery, or Meigs, who derided both.2
Ahead of his time, Mütter championed clean surgical technique and fastidious wound care. He decried a popular practice of the era that likely increased the risk of bacterial infection—the dressing of postoperative wounds with a moist poultice made of meal and seeds.2 Instead, he taught his students in his introductory surgical lecture to use “the mild, cleanly, and simple warm water dressing!”9 “Union by suppuration…is almost universally avoided,” he said.9
Mütter also questioned the common practice at Jefferson of immediately sending postsurgical patients through the dirty city streets to recover at home. He successfully cajoled and financially supported the institution to establish a recovery suite.2 Wanting to optimize surgical outcomes, Mütter conducted postoperative visits to assess his patients, fastidiously checking the cleanliness of their wounds.2 Although the antiseptic revolution had yet to take hold, and the discovery of antibiotics lay on the horizon, Mütter boldly championed hygienic practices.
Leader in Education
Thomas Mütter was a clinician educator whose passion for teaching rivaled his love for surgery and anesthesia. He practiced medicine during an era when relatively few medical schools existed. Although he was an 1831 graduate of the University of Pennsylvania School of Medicine, for many years the only medical school in Philadelphia, Mütter joined the famous “Faculty of ’41” of Jefferson when the school’s board of trustees ousted all of its old faculty, appointing an entirely new group in its place.10 From its founding, Jefferson was known for excellence in hands-on clinical training that older medical schools struggled to provide with their lecture-based curricula and overwhelming student-to-patient ratios.10
In his 1851 address to the Jefferson graduates, Mütter espoused his views on the traits of an ideal physician. Mütter shunned rote memorization, explaining that “[t]he physician must also be a thinking, observing, and reasoning man.” According to him, “the best part of every man’s knowledge is that which he has acquired for himself, by observing closely, pondering deeply, and diligently sifting the wheat from the chaff.” He continued, “Don’t trust what you are told in lectures, or read in books…but make the knowledge your own, by your own labors.”11 Mütter sought to cultivate a deep love of learning and the ability to think independently to analyze the existing literature.
To that end, Mütter became the first professor in the United States to formalize an interactive style and structure of teaching—the Edinburgh Medical School of the University of Edinburgh (Scotland, established 1726) “quizzing” system.12 Other Jefferson professors tended to employ the traditional lecture style—a one-way conversation with students. By contrast, Mütter frequently used the Socratic method to engage his students in a two-way dialogue.5 In addition, classes were restructured to facilitate bedside teaching. Inspired by the approach of Edinburgh’s Professor of Surgery James Syme (1799 to 1870), Mütter led efforts to split a large class of 300 to 400 medical students into small units of 6 to 8.12 These “quiz sections” were highly interactive in nature, with instructors guiding students to interview and examine patients before discussing diagnosis and treatment. The Jefferson medical students would work in these small cohorts once a week and convene as an entire class for lectures on the other four days of the week.12 This quizzing system contributed to the success of Jefferson and would be adopted by other medical schools in the nation.
Mütter’s excellence as an educator was undeniable and served as a cornerstone of his legacy. In 1926, surgeon John H. Gibbon (1903 to 1973), a second-generation Jefferson physician who later became the first to conceive of cardiopulmonary bypass, wrote an article about Mütter.10 In it, he recounted stories from his own father, a former Mütter student. Gibbon wrote, “Mütter was not the most distinguished, he was not the best surgeon, he was not the best or the most frequent contributor to surgical literature, but he was a most popular teacher, not only because of his personal attractions, features, voice and bearing, but because he was enthusiastic and always endeavored to make his lectures interesting and comprehensive.”10 Mütter’s teaching captivated his students while cultivating critical thinking skills and openness of mind.
Benefactor of the Mütter Museum
Mütter engaged his students through questions and dialogue, expanded with images and models to spark learning. Believing that a picture was worth a thousand words, Mütter avidly collected medical items of interest and displayed them to bring clinical knowledge to life.2 Similarly, Mütter embraced the “operating pit” (fig. 3) as a critical learning venue for students to observe surgery firsthand.2
Mütter supplemented his teaching during lectures and surgeries with the myriad of specimens that he amassed during 24 yr.2 Throughout his career, he spent more than $20,000 collecting and preserving more than 2,000 teaching specimens, including pictures, bones, casts, calculi, skeletons, instruments, and wet preparations.13,14 These pathologic wonders and oddities became Mütter’s gift to his students in the classroom, and later, Mütter’s gift to the world.
In 1858, 1 yr before his death, Mütter donated his collection to an organization to which he belonged: the College of Physicians of Philadelphia (Philadelphia, Pennsylvania; https://collegeofphysicians.org/). As the nation’s oldest professional medical organization (established 1787), the mission of the college was to promote education and research. Mütter’s stipulations upon making this donation, along with a $30,000 endowment, were that the college provide (1) a fireproof brick building to house the collection, (2) a curator to manage the collection, and (3) funded lectures to share knowledge about medical science.5 He also requested that museum admission be free to medical students and physicians, and that a study area with tables, chairs, paper, and ink be provided.13,14
The Mütter Museum (https://muttermuseum.org/; figs. 4 and 5) was established in 1863. Today, its vast educational reach encompasses a collection of greater than 25,000 specimens, and its yearly attendance is greater than 130,000 visitors. In addition, the renowned Historical Medical Library of the College of Physicians of Philadelphia (established 1788), features an extensive digital collection (https://www.cppdigitallibrary.org/) that complements the exhibits of the Mütter Museum.
It is fitting that Mütter, a true champion of medical education, would found a medical museum shortly before his death. While the Mütter Museum now mainly preserves and displays historical artifacts for the public, its creation signaled one of the highest achievements of medical education in the mid-19th century. At the time, similar museums could be found in almost all medical schools and many hospitals.13,14 In Philadelphia alone, the University of Pennsylvania, Hahnemann Medical College (later, Drexel University College of Medicine), and Female Medical College (later, Medical College of Pennsylvania) all had lively museums of their own.13,14
Before cadavers were readily available to medical schools, these museums provided an essential venue for students to learn pathology and anatomy firsthand. They housed preserved wet specimens, as well as dry models made of wax, wood, or plaster. The museums also served as libraries featuring a wide array of medical lectures, articles, and books. The museums could even serve as laboratories, providing microscopes for students to study histology and microbiology.13,14
Medical museums served such an essential educational function that Abraham Flexner (1866 to 1959), in his landmark 1910 report on American medical schools, painstakingly noted the condition of each institution’s museum. He pointed to the presence of a high-quality museum as an indicator of a school’s intellectual rigor.13,14 Most of these museums would eventually fold once their research and didactic functions became obsolete. However, the Mütter Museum flourished, acquiring other museums’ collections when they closed.13,14
Modern physicians face the same dilemma as our predecessors. How do we sift through and find nuggets of truth amid the continual production of new scholarship? Which practices should be challenged? We move medicine forward through a constant process of developing expertise—identifying existing problems and addressing them in informed, creative, and practical ways. Mütter was an exemplar of expertise by recognizing and effectively tackling several primary barriers to successful surgery at the time: (1) excruciating pain without anesthesia; (2) a high mortality rate due to postoperative infections; and (3) an antiquated medical education system that often stifled independent thinking.
As we reflect on Mütter’s remarkable life, we are encouraged to see that expertise is not an exceptional talent. Expertise is achievable through a constant process of learning, thinking, and considering the new. Mütter applied this “process of expertise” to his medical practice, allowing impactful advancements to occur in anesthesia, asepsis, and education.
Support was provided solely from institutional and/or departmental sources.
Dr. Schwartz is a Fellow of the College of Physicians of Philadelphia and Docent at the Mütter Museum (Philadelphia, Pennsylvania). He does not receive any remuneration from these affiliations. The other authors declare no competing interests.