MONSTERS

Even in the middle of the ocean, Mütter could not get her out of his mind. He excused himself early from dinner, stopped well-meaning conversationalists mid-sentence, and rushed down to his sleeping quarters just to hold her face in his hands.

To an American like him, she appeared unquestionably French: high cheekbones, full upturned lips, glittering deep-set eyes. For an older woman, she was impressively well preserved, her temples kissed with only the slightest crush of wrinkles. When she was young, Mütter imagined, she must have been very beautiful, though perhaps girlishly sensitive about the long thin hook of her nose, or the pale mole resting on her lower left cheek. But that would have been decades ago.

Now well past her childbearing years, the woman answered only to “Madame Dimanche”—the Widow Sunday—and all anyone saw when they looked at her was the thick brown horn that sprouted from her pale forehead, continuing down the entire length of her face and stopping bluntly just below her pointy, perfect French chin.

• • •

The young Dr. Thomas Dent Mutter had arrived in Paris less than a year earlier, in the fall of 1831. Even for Mutter, who had always relied heavily on his ability to charm a situation to his favor, it had not been an easy trip to arrange.

He was just twenty years old when he graduated from the University of Pennsylvania’s storied medical college. To an outsider, he may not have seemed that different from the other students in his class: fresh-faced, eager, hardworking. But he knew he was different—in some ways that were deliberate and in other ways that were utterly out of his control.

Perhaps the most obvious of these was Mutter’s appearance. He was, as anyone could plainly see, extraordinarily handsome. Having studied his parents’ portraits as a child—one of the few things of theirs he still possessed—he knew that he inherited his good looks. He had his father’s strong nose, impishly arched eyebrows, and rare bright blue eyes. He favored his mother’s bright complexion, her round lips, and sweet, open oval face. His chin, like hers, jutted out playfully.

Mutter made sure to keep his thick brown hair cut to a fashionable length, brushed back and swept off his cleanly shaven, charismatic face. His clothing was always clean, current, and fastidiously tailored. From a young age, he understood how important looks were, how vital appearance was to acceptance, especially among certain circles of society. He worked hard to create an aura of ease around him. No one needed to know how much he had struggled, or how much he struggled still. No, rather he made it a habit to stand straight, to make his smile easy and his laugh warm. He was, as a contemporary once described him, the absolute pink of neatness.

The truth was that, financially, he had always been forced to walk a tightrope. Both his parents had died when he was very young. The money they left him was modest, and thanks to complicated legal issues, his access to it was severely limited. Over the years, he grew practiced in the art of finessing opportunities so that he could live something approximate to the life he desired. At boarding school, he was known to charge his clothing bills to the institution and then earn scholarships to pay off the resulting debts. When he wanted to travel, he secured just enough money to get him to his destination and then relied on his wits to get him back home.

And now that Mutter had achieved his longtime goal of graduating from one of the country’s best medical schools, he focused on his next goal: Paris.

Paris was the epicenter of medical achievement: the medical mecca. Hundreds of American doctors swarmed to the city every year, knowing that in order to be great, to be truly great, you must study medicine in Paris. And that had always been Mutter’s plan: to be great. More than that: to be the greatest.

• • •

Getting to Paris, however, was not an easy endeavor. He knew—as all gentlemen of limited means did—that sailing as a surgeon’s mate with a U.S. naval ship in exchange for free passage to Europe was an option open to him, but competition was always considerable and fierce. Mutter spent months submitting letters and applications to the secretary of the Navy, trying to use charm, logic, and bravado to secure a position. He even implored his guardian, Colonel Robert W. Carter, to ask prominent men close to President Jackson to write letters on his behalf, explaining, “[I] am afraid that I shall not be able to obtain an order unless I can get my friends to make some exertions for the furtherance of my plan.” Despite all the effort he expended, no position ever materialized.

Mutter could only watch as the wealthier members of his graduating class departed for Europe with financial ease. Others returned to their hometowns with their new degrees, bought houses with their fathers’ money, and started their practices using their families’ connections. Mutter remained in Philadelphia, and his hopes remained fixed on Paris.

Mutter felt his luck about to change when he read about the Kensington in a local Philadelphia paper. For months, the Cramp shipyard had been building a massive warship. The rumor was that it was being built for the Mexican Navy, and that upon seeing its immense size—and cost—they opted to back out of purchasing it. However, the most recent update was that the giant ship had sold after all, to the Imperial Russian Navy.

Mutter saw an opportunity. He went to the Cramp shipyard and asked if the American crew in charge of sailing the Kensington to Russia was in need of a surgeon’s mate. That he was just twenty and only a few months out of medical school was a minor detail. He hoped that being present, able, and willing would be enough. Luckily for Mutter, it was. A few weeks later, he boarded the ship (later to be renamed the Prince of Warsaw by Tsar Nicholas himself), and left America for the first time.

• • •

The ocean was like nothing Mutter had ever experienced: vast and wild and so incredibly loud. He had hoped the enormity of the newly built warship—with its four towering masts and immense spiderweb of rigging—as well as its extensively trained crew would offer him comfort during the weeks at sea, but the experience was more taxing than any book or anecdote portended.

He did not anticipate that whether he was holed up in the bowels of the ship or clinging to the aft railing, his body would be trapped in a relentless cycle of emptying itself. That his stomach would never become accustomed to the rolling blue-black swells of the sea. Nor did he realize how intimate he would become with the ship’s beastly stowaways—bedbugs and fleas, weevils and rats. He would wake to bugs crawling in his hair and mouth, and fall asleep to sounds of the rats chewing through his clothes, attempting to suss out even the smallest morsel of food. And then there were the storms, the nights when he felt certain the vessel would break in two as mountainous waves crashed over it, the ship itself painfully groaning with each hit. The ocean seemed nothing but a frothing black maw, hungry to devour him.

When the sea was calm and the sky bright and blue, he forced himself to stand on the ship’s deck and look toward what he hoped was Europe. He tried to enjoy these moments, but he didn’t know true relief until the crew pointed out birds appearing in the sky, a sign that they were approaching land, after more than a month at sea.

• • •

When Mutter finally arrived in Paris, it immediately reminded him of the ocean; it too was vast and wild and incredibly loud. Unlike at sea, however, in Paris he felt perfectly at home.

Its streets were packed, people and buildings in every direction. His world was suddenly and delightfully filled with new sounds, new scents, new music. There were colorfully dressed women sweeping the streets, and strapping men carrying enormous bundles on their heads. There were strange-looking carriages that seemed like relics of a barbarous age, which were in turn being pulled by enormous and brash horses. Even the food being eaten at street-side cafes seemed strange and exotic to Mutter. The city avenue was a vast museum of wonderful new sights to gawk at, and it seemed that the French wanted it that way. They loved to look, and to be looked at. It was true what Mutter had heard: Those French who could spare the time would flamboyantly promenade every day. And on Sundays, absolutely everyone did.

Once Mutter had secured modest student housing, he set out to promenade himself. He’d been sure to pack his finest clothes for the journey: suits cut close to his slim frame (his natural thinness being perhaps one of the only benefits he’d gained from the illnesses that had plagued him since childhood) and made from the most expensive fabrics he could afford in the brightest colors in stock. Years earlier, a schoolmaster once wrote to Colonel Carter, Mutter’s guardian, that his pupil’s “principal error is rather too much fondness for a style of dress not altogether proper for a boy his age.” Clearly, that schoolmaster had never been to Paris.

Mutter enjoyed the moment, peacocking on Parisian streets for the first time, a master of his fate. The lines between Mutter’s starting points and his destination were not often straight, but he took pride and comfort in knowing that he always got there. And the next morning, he would begin the next phase of his mission, his true goal in Paris: to learn everything he could about modern medicine until his money, or his luck, ran out.

• • •

In 1831, over a half million people called Paris their home, and by royal decree, each French citizen was entitled to free medical treatment from any of the dozens of hospitals within the city limits. The hospitals were typically open to any visiting doctors, provided one could show them a medical degree and, when necessary, place the right amount of coins into the right hands.

Studying medicine in Paris became so popular that guidebooks were written just for the visiting American doctors. Nowhere else in the world, one wrote, could “experience be acquired by the attentive student as in the French capital . . . where exists such a vast and inexhaustible field for observation . . .”

Woman with Ulcer of the Face

And it was true. Where else but Paris would there be not one but two hospitals devoted entirely to the treatment of syphilis? Afflicted women were sent to the Hôpital Lourcine, a hospital filled with the most frightful instances of venereal ravages. The men were sent to the Hôpital du Midi, which required that all patients be publicly whipped as punishment for contracting the disease, both before and after treatment.

Hôpital des Enfants-Malades was a hospital for ill children, and was nearly always filled to capacity. It had a grim mortality rate—one in every four children who came for treatment died there—but the doctors on staff assured visiting scholars that this was because most of the patients came from the lowest classes of society and thus were frequently brought to the hospital already in a hopeless or dying condition.

Doctors specializing in obstetrics could visit Hôpital de la Maternité. It served laboring women only, and averaged eleven births a day. Some days, however, the numbers rose to twenty-five or thirty women, each wailing in her own bed, as the doctors and midwives (calledsages-femmes) rushed among them. New mothers were allowed to stay nine days after giving birth, and the hospital even supplied them with clothing and a small allowance, provided they were willing to take the child with them. Not all of the women were.

So the Hôpital des Enfants-Trouvés for abandoned children was founded. Newborns arrived daily from Hôpital de la Maternité from women unable or unwilling to keep their children, as well as those infants whose mothers died while giving birth, as one in every fifty women who entered Hôpital de la Maternité did.

The Hôpital des Enfants-Trouvés also allowed Parisian citizens to come directly to the hospital and hand over a child of any age. The hospital encouraged families to register and mark the children they were leaving so they might reclaim them at a later date, but the families who chose to do so were few. In fact, the vast majority of the children there had arrived via le tour.

Le tour d’abandon (“the desertion tower”) was merely a box attached to the hospital, constructed with two sliding doors and a small, loud bell. An infant was unceremoniously placed in the box, the door firmly closed behind it, and the bell was rung. Upon hearing the bell, the nurses on duty would go to le tour to remove the infant, replace the box to its original position, and wait. Every night, a dozen or so infants were received in precisely this way.

For a while, it had been in vogue for wealthy, childless individuals to adopt children from the Hôpital des Enfants-Trouvés to bring up as their own, but the practice had long since fallen out of fashion. At the time of Mutter’s visit, more than sixteen thousand children were considered wards of the Hôpital des Enfants-Trouvés, and of those, only twelve thousand would live to adulthood.

There were hospitals for lunatic women and for idiot men, hospitals for the incurable, for the blind, for the deaf and dumb, and even for ailing elderly married couples who wished to die together—they could stay in the same large room provided that the furniture they used to furnish their room became the property of the hospice upon their deaths.

And perhaps most astonishing to the visiting American doctors, Paris had the École Pratique d’Anatomie, which provided any doctor, for six dollars, access to his own cadaver for dissection. In America, cadaver dissection was largely illegal. Many doctors resorted to grave robbing to have the opportunity to examine the human body fully. In Paris, twenty doctors at a time would whittle a human body down to its bones—provided they could stand the smell and the ultimate method of disposal of the dissected corpses: At day’s end, the decimated remains were fed to a pack of snarling dogs kept tied up in the back.

However, more than any single hospital, what most attracted Mutter to Paris were the surgeons: brilliant and daring men who were to him living gods, redefining medicine and at the zenith of their renown.

• • •

Mutter had always loved surgical lectures and made sure he secured seats as close to the front as possible. In Philadelphia, there were two great medical colleges—the University of Pennsylvania and Jefferson Medical College—and it was customary for the rival schools to hold surgical demonstrations so that prospective students could choose between them, a glorified public relations exercise. Mutter loved the daringness of the surgeries attempted during this time. The lectures were often packed, as eager established and prospective doctors thrilled at the city’s best surgeons attempting to outdo one another with their skill and showmanship. However, the combination of ambitious surgeries and unprepared young men sometimes proved disastrous. On one occasion, a Jefferson Medical College professor attempted a daring removal of a patient’s upper jaw, using marvelous speed to incise the face and rip out the bones with a huge forceps. But the surgery was perhaps too much for a public display. Doctors who were present would later recall the spectacle of it, how the partially conscious patient spat out blood, bones, and teeth, while unnerved students in the audience vomited and fainted in their seats.

But regardless of how brutal or simple the case, all surgical lectures were a challenge to watch. The anxious patient would be publicly examined and forced to listen to his surgery loudly outlined to an audience of strangers. Next, the patient would nervously drink some wine with the hope that it would dull the nerves and lessen the pain. (In Paris, the need for medicinal wine was so great, the hospital system maintained its very own wine vaults, spending more than 600,000 francs a year on an extensive collection of red and white wine housed exclusively for its patients.)

The patient was then instructed to lie on the surgical table, where he would be held down by the surgeon’s assistants and told to stay as still as possible. Everyone—the patient, the doctor, even the students in their seats—knew how impossible this command would be to follow.

The first incision usually brought the patient’s first scream—the first scream of many. Soon came the blood, the struggle, the shock. The patient would beg the surgeon to stop, plead and shout, and yell to the students to come save him, his voice cracking, tears streaming down his face. The surgeon was expected to ignore it all, to move forward swiftly and surely, and to hope that his assistants were strong men with equal resolve. Every student had heard stories of patients who were able to struggle free, who leapt off the table and attacked their doctors—often with the surgeon’s own instruments!—before running out of the room, leaving a trail of their own blood behind them.

Man with Tumor of the Jaw

To Mutter, ignoring the patient was one of the most difficult parts of surgery. He struggled to develop the ability to temporarily see past the patient’s pain—their wide and desperate eyes—and focus solely on his goals as the surgeon.

It had always been explained to him that the most important quality of a good surgeon is confidence, born of both education and experience. You needed to know you were right and that your actions were right, regardless of what was happening around you. Mutter understood this, but in the moment, it was often still a difficult instruction to follow.

Of course, in spite of the skill and care of the surgeon, the patients often died. Sometimes they died in the middle of surgery, the trauma to their bodies becoming too much. Sometimes they would die after, because their wounds were unable to stop bleeding, or the unwashed tools of their own surgeon had given them a fevered infection that consumed their flesh from the inside out. Under the best circumstances, the patient not only lived but lived a better life.

And it was this opportunity to improve a life that caused Mutter to be deeply attracted to studying surgery. Having spent so much time as a patient when he was a child—being bled by lancet or by leech, fed tinctures and bitter weeds, left to sweat it out alone in his bed or soaked in a special bath—he was perhaps too familiar with other, nonsurgical branches of medicine, where recovery was often a guessing game. Sometimes, the relief would be almost immediate once treatment had begun, but more often, the results were undefined, his chest rattling for weeks, his body left to grow gray and thin.

Surgery, however, was not a guessing game; it was an art. People came in need of relief, and the surgeons used every ounce of their skill and knowledge to provide it.

• • •

There was one more reason Mutter revered surgery above all other medical pursuits. Surgeons, unlike other professionals of the medical field, were successes of their own creation. While other doctors found their patients—and their positions in society—based on the family they were lucky enough to be born into, surgeons earned their place through hard work, study, and skill. In fact, it seemed to Mutter that the best surgeons came from the lower or middle classes. It was a “natural consequence of this state of things,” one doctor from the era wrote, seeing that “very few persons entitled by birth or other advantageous circumstances . . . would condescend to study, much less engage in the practice of medicine,” thus “poor and ambitious young men from the provinces were induced to repair to Paris and enter upon the study of the only profession through which they could expect to obtain distinction and worldly prosperity.”

It was well known that several of the best-respected surgeons and physicians in France had risen from the lowest castes of life and many from the uttermost depths of poverty. Even the acclaimed chief surgeon of Hôtel Dieu, Guillaume Dupuytren, who was often referred to as the Emperor of Surgery, had been born poor and had struggled. Furthermore, he was not ashamed of it, but rather credited his background with his success, telling his students that “had not Monsieur Dupuytren been compelled from poverty to trim his student’s lamp with oil from the dissecting-room, he never would have succeeded in becoming Monsieur le Baron Dupuytren.”

• • •

Mutter knew that surgery was his calling, and raced through the streets of Paris to study the work of its greatest practitioners. He was aggressive in his pursuits, pushing through crowds to secure the best seats at the surgical lectures, or firmly staying as close as possible to the lecturing doctors as they made their rounds in hospital, no matter how much the other students pushed. Meals of spiced mutton and fresh bread went half-finished as he plotted the next week’s schedule. Bowls of café au lait were abandoned so he could make an early start every morning, eager to begin his day.

He had come to Paris assuming it would be the doctors themselves who would have the greatest influence on him, these men who were legends in their own time. Chief among them was Guillaume Dupuytren, who ruled over the Hôtel-Dieu, the city’s largest hospital, and single-handedly changed how surgery was done. An immensely brilliant operator, exhibiting marvelous dexterity, proceeding with almost inconceivable speed, his boorish arrogance became as famous as his accomplishments in the surgical room. Jacques Lisfranc de St. Martin was head of the Hôpital de la Pitié, the city’s second-largest hospital. He was Dupuytren’s greatest friend turned into his most bitter rival, and spent most of his life trying to escape Dupuytren’s shadow. Lisfranc was known to refer to Dupuytren as “the bandit of the river bank,” while Dupuytren frequently called Lisfranc “that man with the face of an ape and the heart of a crouching dog.” There was Philibert Joseph Roux—who so dazzled his classes with his graceful and brilliant work that it was said “his operations were the poetry of surgery,” but who had also earned Dupuytren’s scorn years earlier by winning the hand of the woman they both loved. And Alfred-Armand-Louis-Marie Velpeau, whose textbook on obstetrics was so influential, it had been translated into English by one of America’s most respected obstetricians: Philadelphia’s own Charles D. Meigs.

Mutter was deeply impressed with the audacity of each of these surgeons’ talents and their seemingly inexhaustible work ethic. However, it was not any single man who ended up changing the course of Mutter’s life but, rather, a new field of surgery freshly emerging in Paris, which even the French referred to as la chirurgie radicale.

Who sought out this radical surgery?

Woman with Severe Burns of the Face

Monsters. This is how the patients would have been categorized in America. Mutter was used to seeing them replicated in wax for classroom display, or hidden in back rooms away from the public eye. He had seen them in jars, fetuses expelled from their mothers, irreparably damaged. MONSTER, the label would read.

Some of these monsters were born that way: a cleft palate so severe the face looked to have been split in two with an ax. Hardly able to eat or drink, spit collected in pools on the child’s clothing as his tongue lolled around the open hole of his mouth, awkward and exposed.

Others were born “normal,” but their bodies would slowly turn them into monsters, as tumors laid siege to their torsos or limbs, swelling their legs like soaked wood, their eyes strained and nearly popping.

Other times, the monsters were man-made: men whose noses were cut off in battle, or as punishment, or for revenge, the centers of their faces evolving into a large weeping sore; women whose dresses caught fire, becoming houses of flames from which their owners couldn’t escape, the skin on their faces turned into melted wax, their mouths permanently frozen in screams.

Monsters. This is what they were called, and this was how they were treated. For such tortured people, death was often seen as a blessing.

In Paris, however, the surgeons had a solution. They called it les opérations plastiques.

Was it quackery? Mutter wondered when he first heard about it. Was it a trick? Would these unfortunates be presented like a sideshow? Were the doctors in the audience there to learn or to gape? What could surgeons possibly do to help such hopeless cases?

At the very first lecture, Mutter began to understand the difference between regular surgery and les opérations plastiques.

The patient, often greeted with gasps of horror and pity, stood stock-still and unafraid as the surgeon made his examination. These regrettables didn’t show the unease normal patients did; their eyes didn’t wander back to the door from which they entered and through which they could also escape. Gradually, Mutter grew to understand why.

In regular surgical lectures, patients rarely understood the trouble they were in. When the knife first pierced the skin, they could come to the sudden realization that a life without this surgery might still be a happy one. Thus, escape was the best possible solution and a choice they wanted to exercise right away.

Patients of les opérations plastiques, however, were often too aware of their lot in life: that of a monster. It was inescapable. They hid their faces when walking down the street. They took cover in back rooms, excused themselves when there were knocks at the door. They saw how children howled at the sight of them. They understood the half a life they were condemned to live and the envy they couldn’t help but feel toward others—whole people who didn’t realize how lucky they were to wear the label HUMAN.

It was not uncommon for these patients to enter the surgical room fully prepared to die. Death was a risk they happily took for the chance to bring some level of peace and normality to their mangled faces or agonized bodies. The surgeries weren’t physically necessary to save their lives; rather, they were done so the patient might have the gift of living a better, normal life. That is what les opérations plastiques promised.

Plastique was a French adjective that translated to “easily shaped or molded.” That was the hope with this surgery: to reconstruct or repair parts of the body by primarily using materials from the patient’s own body, such as tissue, skin, or bone.

The surgeries, of course, were not always successful—if a patient’s problem had been so easy to fix, it would have been corrected by lesser doctors years ago. But other times—and these were the times the audience waited for, the ones that made Mutter’s hair stand on edge—the end result was nothing short of miraculous.

With a careful hand, a steady knife, and a piece of bone, a surgeon could reconstruct a man’s nose with a twisted portion of his own forehead. A burned woman’s eye could close for the first time in ten years, thanks to a surgeon’s knife cutting the binding scar tissue and replacing it with skin from her own cheek. Cleft palates were fused back together—trickier than it might seem, for the sensitivities when working on the roof of the mouth meant the patient was in constant threat of vomiting, which would tear open delicate sutures and ensure infection.

Mutter seized every opportunity to witness these plastic operations firsthand. He used his charms to become an interne at the hospital to which Dupuytren was attached so he could watch the great master at work. But he didn’t limit his focus to Dupuytren, and soon became so familiar with each surgeon—their style and flourishes, their weaknesses and strengths—that he began to view them as his friends, even though they never shared a single word. He took copious notes, drew detailed diagrams, and bought every relevant book he could find and afford. It became his happy obsession.

Mutter hadn’t been in Paris even a year when he realized his time was running out. His limited funds were being swiftly exhausted, and he still needed to fund his trip back home. His newly made friends in the Parisian medical society tried to dissuade him. They adored the dashing young doctor with the “quick, active, appropriative mind . . . readily imbued with the spirit of his distinguished [Parisian] teachers.” They implored him to stay, pointing out how much work a charming American doctor could get in a bustling city full of English-speaking tourists.

Mutter loved his time in Paris, but his desire to return to Philadelphia was even stronger. He was twenty-one years old and felt healthier than he ever had in his entire life. He felt like a new man. He had even given himself a new name. He was no longer Thom D. Mutter from Virginia.

He had reinvented himself as Thomas Dent Mütter—with a perfectly European umlaut over the u.

With the last of his money, he purchased a wax model from a shop that specialized in reproductions for doctors. It was the face of Madame Dimanche, the French washerwoman who grew a large, brown horn from the center of her forehead. At first, the old woman hadn’t known what to make of the strange brown nub that appeared like an ashy smudge in the center of her head, but she knew to hide it from view, starting a decade-long habit of avoiding eye contact. But the nub grew relentlessly, larger and larger, until it was as thick and dark as a tree branch.

When she finally allowed it to be examined, she followed a chain of doctors that ended with a surgeon who told her he could remove it if she would trust him. She did. And so it happened the surgeon—practiced in this new art of les opérations plastiques—who promised her relief was able to actually deliver it. How happy she was to walk down the streets, her head unhidden. How thrilling it was to feel the wind kiss her bare face.

Mütter purchased a replica of Madame Dimanche’s presurgery face, her long, thick horn still intact. And on the long journey back to America, he took it out often, the sea bucking the boat beneath him. He took out her face and stared into it. In it, he saw his future.

CHAPTER TWO

THE CITY OF BROTHERLY LOVE

THE PHYSICIAN SHOULD BE AN AMBITIOUS MAN

To say to a young man “be not ambitious,” is to say to him live the life of a drone.

If ambition were a sin, is it probable that a wise Creator would have endowed nine-tenths of his people with it?

The love of praise is so congenial to our nature, and so powerful a spur to every undertaking, that the moral world would be a chaos without its animating influences.

It is like the sun; it gives life and heat to all around.

THOMAS DENT MÜTTER

Philadelphia in the early 1800s was an easy place to die.

The simplest thing could end your life: a broken bone from a fall, a leg gouged by a loose nail, a hand burned by a pot of boiling soup. In a time before antibiotics, infections could ravage a body in days. You could die from allergies. You could die from asthma. You could die from a single rotten tooth.

The food you ate and the water you drank could kill you just as easily as the guns that were bought and sold without regulation. Of course, there was cancer and diabetes, gout and heart disease. There was murder and suicide and accidental drownings, as well as executions by city and state.

Infectious diseases ran rampant through populous cities like Philadelphia, wreaking havoc on everything they touched.

There was smallpox, spread simply by human interaction. It caused the body to burst into blisters, lesions, and scabs, affecting adults and children equally and brutally. If you were lucky enough to survive it, the scars left behind—including sterility—could haunt you the rest of your life.

There was yellow fever, which no one knew was spread by mosquitoes and which earned its name by turning its victims yellow, before forcing them to bleed from the eyes and mouth and erupt with the black vomit of partially digested blood.

In 1793, yellow fever struck a rain-soaked Philadelphia so hard that the entire government shut down. Once symptoms were seen, the infected person was all but abandoned by friends and family. To protect their own patients, the Pennsylvania Hospital and Almshouse refused to receive yellow fever victims, forcing ailing citizens to eventually die alone in the streets. It became such a problem that local authorities annexed a circus ground on the outskirts of the city as a “depository [for] victims of the plague who had nowhere to go and nobody to care for them.” The city’s most prominent physician, Dr. Benjamin Rush, advised that all his patients leave the city at once, and anyone forced to remain should immediately engage in “heroic bleeding and purging.” Rush’s advice only caused more death. By the end of the disease’s reign, more than one-tenth of the city’s entire population was dead.

There was cholera, spread through contaminated drinking water, which painfully dehydrated its victims, the affected bodies retching liter upon liter of a fluid that looked like rice water and smelled like fish.

In 1832, cholera spread across the East Coast, finally hitting Philadelphia in July. It became such an overwhelming problem that Philadelphia publishing house Carey, Lea & Blanchard (at the time, the country’s leading publisher of medical books) began publishingThe Cholera Gazette, a weekly publication designed to inform the public of the progress and hopeful treatment of this terrible disease. It became wildly popular as the death toll from the disease caused Philadelphia to log in sixty to seventy deaths a day. It took nearly four months for the city to rid itself of the disease, and as testimony to the “heroic role of the medical profession in battling the infection,” the city council would eventually reward the physicians in charge of the hospitals during this time with silver pitchers of recognition.

There was also malaria and croup, diphtheria and dysentery, measles and whooping cough, consumption and scarlet fever. Even something as simple as the flu could kill hundreds in a city over one winter.

The swiftness and brutality of disease and death in the nineteenth century was something with which Mütter was already intimately familiar. It was a lesson he’d been forced to learn at an early age.

Lucinda Mutter was nineteen years old and in love when she became pregnant with Thomas in the summer of 1810. She and her husband, John Mutter, had happily married on Christmas Eve three and a half years earlier, when she was fifteen and he was twenty-five.

The two could not have been more different.

Lucinda had been born into the established Gillies family, which was connected, via marriage and blood, to some of the most prestigious families in the South: the military elite Armisteads (five Armistead brothers would fight in the War of 1812, and the British bombardment of George Armistead’s fort would later serve as the inspiration for “The Star-Spangled Banner,” the future U.S. national anthem); the prominent political family of the Lees (whose family would include not only governors, business leaders, and two signers of the Declaration of Independence, but also General Robert E. Lee, the future leader of the Confederate Army); and the influential Carters (whose patriarch, Robert Carter, was so powerful that he earned the moniker King Carter and, when he died in his late sixties, left behind fifteen children, three thousand acres of farmland, and more than one thousand slaves).

Lucinda and John Mutter

At age fifteen, Lucinda was a young bride even for an ambitious era in which women were frequently married in their late teens. However, she was bright and proudly educated. Early in their marriage, when she and her husband decided to have their portraits painted, she insisted that she be painted with an open book in her hand. John Mutter, on the other hand, was a scrapper. He was a first-generation Scottish immigrant whose father endeared himself to his new countrymen by fighting alongside them in the Revolutionary War. John, like his father, was a hard worker. He was also smart, ambitious, and extremely handsome, and was known to be a good neighbor and a good citizen. By the time he and Lucinda were ready to start their family, John ran a healthy business as a factor and commission agent. To have success in that field, you needed to be both resourceful and multitalented, for these men not only aided farmers in selling their crops but also helped them purchase farming supplies, gave advice concerning the condition of the market or the advisability of selling or withholding a crop, and sometimes even orchestrated the sale or purchase of slaves for a client. Mutter had built his reputation on his charm and his work ethic.

Lucinda gave birth to their first child on March 9, 1811, in the bedroom of their newly purchased home at 5th and Franklin Streets in Richmond, Virginia. The baby was born healthy and pink, and Lucinda named him Thomas, after her husband’s late father.

It was a happy time for the young family, but a troubled time for the nation. When President James Madison declared war on Britain in June, the ensuing two bloody years of unpopular battles forced the fledgling American economy to its knees. Businesses in both the North and South suffered, but luckily for his young family, John Mutter’s success continued. His businesses flourished and, as was expected during this time, so did his family.

Lucinda was soon pregnant again, and a second son was born in May 1813. She named him James, after her own late father, a beloved doctor who had died almost a decade earlier.

For a year, they were a family of four: John and Tom and James and Lucinda, living in a sunny house in Richmond, Virginia, flush with money and all in good health. But in 1814, the family’s uninterrupted string of good luck began to run out.

First, baby James got sick and declined rapidly. Just thirteen days after they celebrated his first birthday, James died. He barely beat a grim statistic, which noted that one in every five children born during this period died before their first birthday. John and Lucinda buried his thin, illness-ravaged body in the cemetery of St. John’s Church in Richmond, Virginia.

The family grieved all in black during a long hot Virginia summer. When autumn finally came, John thought a trip might brighten his sorrow-struck wife’s spirits and improve her unstable health, but this proved to be a mistake. Lucinda only grew more ill and weak as the journey progressed, and her body finally gave out in a Maryland inn. When she died, she was only twenty-two. Her stunned husband buried her small body in Baltimore’s St. Paul’s Church before traveling home.

Within a five-month span, John Mutter had buried his beautiful wife and youngest son. He was now thirty-three, a widower, and a single father to Thomas, who was only three.

The year after Lucinda died, John bought a large house in Henrico County, Virginia—a gesture meant to confirm that he intended to marry again, and that his family would continue to grow. He called it Woodberry, and he tried his best to make it a home for his young son, whom he loved deeply and spoiled often. But the next few years proved to be a relentless boot on John’s neck: His business and health begin to fail at an alarming rate; he was forced to sell all the furniture he had bought for his and Lucinda’s first home at 5th and Franklin Streets in Richmond, Virginia, and then finally to sell that home itself. He was tired all the time and couldn’t shake a rattling cough that took up residence in his chest. Sometimes he would return home from a long day of work with a handkerchief full of his own blood.

If you fell ill in the northern half of the United States, it was popular advice to go south to restore your health: the heat, the fresh air, the clean water and sulphur springs.

But if you already lived in the humid South—and especially if you ran in moneyed circles—you were told to go to Europe.

And so, in 1818, John Mutter left his young son behind and sailed to Europe with the hope that their doctors, the climate, and their medicine could bring him back to his former self. John assured everyone that he would make a full recovery, and even brought with him both a secretary for his correspondence and a private physician who would ensure his well-being every leg of the journey. But perhaps even he knew the truth: Before he left America, he penned a detailed will.

John Mutter said good-bye to young Thomas, now seven, on an autumn day in Virginia, placing him in the care of Tom’s grandmother, Frances Gillies, his late wife’s widowed mother. The boy sobbed at his father’s waistcoat once the carriage had been loaded. With his usual charm and a reassuring smile, John promised his son that he would return to him as quickly as he could, before climbing into the carriage and being driven away.

Thomas would never see his father again.

Four months into this journey, on a winter’s passage of the Alps, John Mutter died.

It would, of course, take weeks for the news to make its way to America. In Thomas’s mind, his father was still very much alive when the first alarming symptoms of his grandmother’s illness began to show.

Frances had been a martyr for many years to gout, a cruel and painful disease that caused various joints on her body—her fingers, her toes, her elbows, her knees—to swell painfully. The affected parts would turn bright red and become hot to the touch. She could scarcely stand for Thomas to be in the room with her when it got really bad, as air whipped up by his energetic body felt like a thousand needles piercing her skin.

But his grandmother’s health now seemed worse. As her body grew weaker, the pain grew more oppressive. A doctor’s widow, Frances tried to self-treat her ailment with food, drink, and rest, but nothing was working. Doctors were eventually called, and young Thomas could do nothing but watch as his grandmother endured the same treatments he’d watched both his parents suffer through: Her arms were sliced with small razors to “bleed out” her bad blood; heated glass cups were applied to skin to force out more “bad humors”; and unknown purgatives were given to her in liquid and solid form, causing her to vomit and her bowels to loosen and empty violently.

It was a truth that everyone in that era knew: Oftentimes the treatment was even worse than suffering with the disease itself.

Frances Gillies lived just long enough to hear the news of the passing of her son-in-law, and to share it with her devastated grandson. Then she passed away too.

Thomas Dent Mutter was just seven years old, and every person who had ever loved him was dead.

• • •

Thomas Dent Mütter’s story is not so surprising if you consider that a man did not need a medical degree to practice medicine in early nineteenth-century Philadelphia. In fact, he didn’t even need a license—a practice that Philadelphia would not embrace until the final decade of the nineteenth century.

Although the tide was changing, the clear truth was that anyone who wanted to put out a shingle and call himself a doctor could do just that.

Even those doctors who followed due process—apprenticed under local doctors, went to medical colleges and studied hard, practiced often and kept as up-to-date as possible with the latest innovations—still struggled with the medical limitations of the day.

Medicine was performed literally in the dark. Electricity was newfangled and unpopular. Almost every act a doctor performed—invasive examinations, elaborate surgeries, complicated births—had to be done by sun or lamplight.

Basics of modern medicine, such as the infectiousness of diseases, were still under heavy dispute. Causes of even common diseases were confusing to doctors. Benjamin Rush thought yellow fever came from bad coffee. Tetanus was widely thought to be a reflex irritation. Appendicitis was called peritonitis, and its victims were simply left to die.

The role that doctors—and their unwashed hands and tools—played in the spread of disease was not understood. “The grim spectre of sepsis” was ever present. It was absolutely expected that wounds would eventually fester with pus, so much so that classifications of pus were developed: A “yellow ooze” was seen as a good “laudable pus” while an “ichorous pus” (a thin pus teeming with shredded tissue) was viewed as “the stinking herald of cadaverous putrefaction.”

Medicine was not standardized, so accidental poisoning was common. Even “professionally” made drugs were often bulky and nauseating. Bleeding the ill was still a widespread practice, and frighteningly large doses of purgatives were given by even the most conservative men. To treat a fever with a cold bath would have been “regarded as murder.”

There was no anesthesia—neither general nor local. Alcohol was commonly used when it came to enduring painful treatments, although highly addictive laudanum (a tincture of ninety percent alcohol and ten percent opium) and pure opium were sometimes available too. If you came to a doctor with a compound fracture, you had only a fifty percent chance of survival. Surgery on brains and lungs was attempted only in accident cases. Bleeding during operations was often outrageously profuse, but, as comfortingly described by one doctor, “not unusually fatal.”

Physicians working in this time period were largely unaware that innovations were on the horizon that would make “a pauper in the almshouse more comfortable and cared for better after an operation than a king,” as one late-nineteenth-century Philadelphia doctor described the state of medicine in the first half of his century.

And it was a strictly enforced male-dominated field. In the early 1800s, there was not a single female physician in Philadelphia. More than that, women’s role in medicine in any form was often disparaged. In a speech given at the Philadelphia County Medical Society, female nurses were described as “very generally ignorant, often dirty and sometimes drunk.” The Boston Medical and Surgical Journal ran a letter to the editor decrying an ad for a woman practicing medicine, stating, “Science itself is not only disgraced by being made the instrument of a petty income to an ignorant, presuming, flippant-tongued female, but she thus brings contempt upon the sex, of whom better things are expected.”

“Individual discoveries are glorious and worthy, but we must give due need of praise to the hard working, obscure practitioners, who regardless of fame and wealth apply them,” a late-nineteenth-century doctor noted in a speech about mid-century medicine. “Our fathers did wonders with the resources they could command. The lesson of their lives is largely one of dignity, self-sacrifice, devotion to science and regard for the bonds of professional conduct and duty and carelessness as to wealth or fame. Men come and men go, but science lives and advances.”

And it was into this world that Thomas Dent Mütter, an orphaned boy now grown up and fresh from his experiences in Paris, returned.

CHAPTER THREE

TO RENDER EVIL MORE ENDURABLE

Philadelphia in the 1830s

The Willing Mansion seemed like a perfect place for Thomas Dent Mütter to open his first office for the practice of surgery. Built by former Philadelphia mayor Charles Willing, the mansion was a lovely brick building, three stories high with eleven large windows facing bustling Third Street just below Walnut. It was a stately and impressive place to start what he was sure would be a distinguished career.

Mütter knew that to become distinguished would require not only earning a favorable reputation with the public as a reliably successful surgeon, but also attaining distinction within a wide circle of his professional colleagues. He was sure he would do both and build an impressive practice by showcasing the fantastic techniques he’d learned in Paris.

“Adopting, with all the enthusiasm of his nature, the new precepts which he had been taught for the relief of these affections, he settled down among us,” a colleague would later write of Mütter’s first year in Philadelphia, “with such a trusting belief in his own resources, such a just confidence in the brightness of his future, that it seemed almost as if he felt that he would be able to renew the marvelous times of old, when supernatural powers came to mingle themselves with men in order to render their evils more endurable.”

But even months after opening his office, Mütter sometimes spent long mornings and afternoons alone. Patients were not forthcoming, even though he tried his best “to be agreeable, to be useful, and to be noticed.” In fact, Mütter had developed a reputation of “cut[ting] quite a swathe” as he rode around Philadelphia in a low carriage behind a big gray horse, driven by a servant in livery.

“Youthful looking, neat and elegant in his attire,” he was described by a fellow doctor, “animated, cheerful, and distinguished in his bearing, whether observed in the social circle, or encountered, as, with his tall gray horse and handsome low carriage, he traversed our fashionable thoroughfares.”

Mütter’s colorful silk suits were a shocking contrast to the staid black, gray, and brown Quaker-inspired fashions found on Philadelphia’s streets. But as always, he didn’t mind the stares. He wanted to be memorable during his relentless attempts to curry favor with the city’s best-known medical men by attending gatherings where they ate and drank and by trying to join the private societies they founded.

But unfortunately for the struggling physician, many of the doctors he tried so hard to impress thought this “immaculately dressed young man riding about Philadelphia” was “something of an intrusion.” They complained that his conversation was often too full of his French masters, and how he boasted, openly and often, of their superiority, explaining how when it came to surgery, “one Frenchman [is] equal to a dozen Americans.” The oft-repeated stories of the daring surgical exploits of his French idols “were not received with pleasure in every quarter.” He was often accused of exaggerating, or drawing a long bow, as it was referred to in nineteenth-century slang.

“Mütter’s early disappointment professionally was ironically due in part to the fact that he succeeded rather too well, both in his desire to be helpful as well as to be noticed,” a Virginia historian would later note. It seemed an odd stumble for someone whose welfare and happiness since the age of seven seemed wholly dependent on endearing himself to near strangers.

• • •

With the passing of his maternal grandmother, seven-year-old Thomas Dent Mutter entered a very vulnerable type of orphanhood. His life and future were now entirely dependent on the emotional charity of people who were all but strangers to the boy.

Patrick Gibson—John Mutter’s business partner and the trustee of John’s will—had trouble at first trying to secure Thomas a new home. He was a spoiled boy, having been heavily doted upon by his father and grandmother, and in a time before the medical world fully understood how diseases were transmitted, there were concerns about risks a family might be taking by inviting into their home a little boy whose entire immediate family had been felled by illness.

But Gibson was able to downplay young Thomas’s lack of discipline and disquieting family illnesses by shining a spotlight on his better qualities—specifically his keen intelligence and an unfailingly amiable disposition. To Thomas’s good fortune, Gibson convinced a very wealthy and prominent man to take the boy on as his ward.

Robert Wormeley Carter, known as Colonel Carter for most of his life, was born into one of the best-known families in the South, and was also a distant cousin through marriage to Thomas’s mother, Lucinda.

Once the agreement was struck, Thomas was taken directly to Sabine Hall, the Carter family’s sprawling estate. Built in the early 1700s on four thousand acres of rich Virginia soil, right on the lush banks of the Rappahannock River, Sabine Hall had been passed down through several generations of Carters. Colonel Carter was now its owner, and there he lived with his wife, his children, and several hundred slaves.

When young Thomas arrived at Sabine Hall, he brought along everything he could from his old life: two trunks of clothing, a small toy hobby horse, and a working single-barreled gun. He also brought a Shetland pony, with bridle and saddle, and a satchel filled with his dead mother’s jewelry: two gold lockets, two gold rings, a pearl necklace, and a pearl pin. He brought paintings of his parents and a small red book that contained only one thing: a drawing of his mother in ink. He brought with him a bright mind, a willful stubbornness, and a moderately effective charm.

And he also brought along a deep and troubling cough.

Sabine Hall

To a little boy who had known only the bustling energy and modest homes of Richmond, Virginia, Sabine Hall was an intimidating place to try to call home.

Robert “King” Carter—the family’s legendary eighteenth-century patriarch—had spared no expense in building the house for his son, Landon. The enormous brick and stone building featured four large white cypress columns that rose all the way to the second floor and were surrounded by six meticulously curated gardens extending over five opulent terraces, from the top of the hill down to the plantation’s fields. Entering the house, visitors were greeted by an enormous front parlor flanked by a hand-carved staircase. The house was decorated with numerous oil paintings of the Carter family: King Carter, Landon Carter, portraits of each of Landon’s three wives, and, of course, now, Colonel Carter himself.

Colonel Carter was just twenty years old when he took in seven-year-old Thomas, and while Carter was born into a comfortable life, he was not afraid of change. During Thomas’s stay at Sabine Hall, he made many dramatic alterations to the building and its environment. He constructed a giant portico on the front of the house, a broad classical pediment was added to the roof on the river facade, and a sixty-foot veranda that stretched the entire length of the house was built facing the river, taking more than seventy days of relentless carpentry to finish. Carter then requested that the entire redbrick exterior be painted white, and even demanded that the roof and chimneys be lowered.

In an odd coincidence—which might explain Mütter’s later attraction to the city—it was said that Carter’s main catalyst for making these changes was a visit he made to Philadelphia. He was deeply impressed with the “gay and splendid city” and was especially taken with its architecture, later writing in his journal that he found its streets “as beautiful as any in the world.” And indeed the new Sabine Hall did resemble some of Philadelphia’s best-known architecture. Philadelphia’s First Bank of the United States had a similar oversize portico and light-colored facade, and the city’s new Masonic Temple (designed by William Strickland), which Carter would later call “one of the most elegant buildings in America,” had a gate lodge of a style very similar to the Gothic one he had built for Sabine Hall.

However, the attention to detail and visionary execution that Carter had lavished on the reinvention of Sabine Hall did not extend to the small boy he had just accepted as his ward. From the beginning, Carter made it clear to Patrick Gibson that he would provide a roof over Thomas’s head, food on his plate, and a bed for him to sleep in, but it would fall to others to guide the boy in his life.

“I felt for our friend Mr. Mutter the most sincere friendship, and would most willingly do anything I could to promote the welfare and to place a foundation for the respectability and happiness of his son,” Carter wrote to Gibson shortly after receiving Thomas at Sabine Hall. “I should however wish clearly to understand the situation of the amount of the fund that Thomas must depend upon for his future subsistence and wishing at the same time to have as little to do with the fund of the Estate as possible.”

And perhaps feeling a bit of remorse at taking on such a large responsibility—and the criticism that might come with it—the twenty-year-old Carter noted, “I certainly feel much delicacy and reluctance by assuming a character which requires me so much judgment, care and attention, and which procures for you in return little less than actual loss, or unremitted condemnation.”

Money proved to be a constant source of frustration and concern for both Thomas and his guardian. Carter brought the boy in with the promise that his costs would be covered by his late father’s estate, but it wasn’t long before Carter himself would be forced to sell both Woodberry—the only home Thomas knew after the death of his mother—and its contents to pay off debts that no one knew John Mutter had.

Hopeful that the rest of the estate’s money would be free eventually (though he could have no idea that it would take years for the court system to release the funds to him), Carter kept strict records of the money he spent on the boy and began keeping him under a strict budget. It was during this examination of the budget that Thomas’s fondness for expensive garments was first documented.

“The charge Mr. Bradley makes for the child’s clothes, $23 apiece for his last two suits, is so very extravagant that they should if possible be made elsewhere,” a stunned Carter noted, “but not having his measure I must for the present submit.”

But if there was one area that Carter refused to cut corners on, it was the boy’s education. Charles Goddard, the man who had tutored Thomas when his father was still alive, was brought to Sabine Hall and continued to serve in that role for another four years. The established rapport between tutor and pupil was a huge comfort to Thomas, and had the added benefit of relieving the Carter household of some of the disciplinary duties associated with the puckish, outspoken boy.

However, when Thomas turned twelve, Carter decided it was time to look at boarding schools. He eventually selected for Thomas the Llangollen School in Spotsylvania County, a grammar school that prepared boys to attend college. There, for a bargain price of $140 a year, Thomas learned English, French, and Latin, studied geography and mathematics, and boarded with his own teacher, John Lewis, who wrote Carter often about his growing ward’s progress.

Thomas proved to a bright and willing student, and Lewis’s letters always showcased the latest subject in which Thomas was excelling. However, Lewis’s letters to Carter also revealed that the growing boy continued to struggle with his health problems.

“Early in the spring he had a slight attack of intermittent fever which soon yielded to the ordinary medicines . . . ,” Lewis wrote Carter before adding, “his general health I think is greatly improved from last month. He is stronger and more active and is considerably grown.”

The following year, Lewis wrote, “His general health has been better than it was the last year,” though he was forced to add that the boy was still “occasionally attacked by bilious colic,” a painful condition marked by severe cramping, vomiting, and jaundice.

In his own letters to Carter, young Thomas rarely mentioned his health or his scholastics. Rather, his letters were marked with frequent pleas for new clothing.

“I wrote to Aunt to send me two pairs of shoes as I have not any at present,” he wrote Carter in 1824. “Please write Aunt to get my winter clothes and some shoes and socks as I am in want of them.”

Six months later, he wrote, “As the warm weather is coming very fast I should like to get my summer clothes in time as I have but one very old suit. . . . I shall want some shoes about that time also. I do not wish to have any more made here as they cost as much as at Fredericksburg and are spoilt in the making.”

A few months later, in his first letter to Carter since returning to school, Thomas told his guardian, “I am in great want of shirts as I have but two in the world and they are very old and tattered. I got some summer clothes from Mr. Lewis, but they are not sufficient for me nor nice enough to wear in town.”

Thomas’s desire to appear stylish only grew when, in 1826, he finally left Llangollen School to attend college at Virginia’s Hampden-Sydney College. There, he ran up extravagant clothing bills and simply charged them to the school, with the hopes of earning scholarships and additional funds to pay off the debts. It was a ploy that didn’t always work. At the end of his first year there, a frustrated merchant sent Colonel Carter the overdue bill directly, demanding payment for the more than one hundred dollars’ worth of clothing and accessories Thomas had purchased on credit during the school year (and for which Thomas had only been able to pay back half).

The bill shows that Thomas—who was just sixteen years old—had made such eclectic purchases as a fashionable leghorn hat, several patterned vests, jackets and pants, yards of ribbons made from silk and velvet, several pairs of silk stockings, dog biscuits, a buck knife, and even several dozen cigars. In fact, Thomas’s clothing choices were so flamboyant in style that the college’s theater department was known to have borrowed from his wardrobe to outfit the actors in their plays.