Book Review by Emmett R Smith
The Horse and Buggy Doctor, by Arthur E. Hertzler, M.D. (‘Harper & Brothers’, New York, 1939)
‘THE Most common complaints of the aged are pain or cough. One can control each of these simply and efficiently. If they have high blood pressure or low blood pressure, all right they have high or low blood pressure and there is no use making them miserable either mentally or physically by trying to do what just can’t be done. If they get pneumonia or a brain hemorrhage you know a kind Providence has not forgotten them.’ (The Horse and Buggy Doctor, Hertzler, p 303) These are words of medical advice written going on seventy years ago, when we did not have as we do, to-day, all of the gifts of pharmacology now available to treat, precisely, high blood pressure and a host of other complaints bedevilling an ever-older population. Because of the great increase in medical knowledge and technique–and we of the 1946-64 generation are not like our parents and grandparents, least of all in demands and expectations–it is easy to lose sight of the wisdom needed to trust in to ‘a kind providence’ and, in the end, to the end of life. Still harder is it to keep in mind in the howling post-modern gale of ‘information’ that there is such a thing as that wisdom which may prefer a modest treatment-approach, which may enable the doctor freely to choose patient before prophylaxsis:
‘Not so long ago a fine old friend of mine came to me because he could not sleep. He was sent into the hospital. His examining physician found numerous organic diseases and set about to cure them, but neglected to secure the sleep which [the patient] so much desired. He left the hospital angry with me because I did not see to it that he secured the wanted sleep. Thus a friendship of more than forty years was broken. I regret it terribly but it was all my fault. He came to me as an old friend asking understanding. I turned him over to science. The only excuse I have to offer is no excuse at all–I was too busy with patients with curable diseases.’ (Ibid pp 303-4)
MY Friend Dr Warren Peiper, attended medical school during World War II. His teachers one-and-all were men of the same generation as Arthur E Hertzler, author of The Horse and Buggy Doctor. That I ever got to know Dr Peiper was a sheer accident of business-life, but that friendship has gone far to enable me to appreciate Dr Hertler’s book, even though I first knew Dr Peiper over thirty years ago, and only just met Dr Hertzler–through his 1938 book–a few weeks ago. The Horse and Buggy Doctor is a classic document of Americana, undeservedly little-remembered now. A great part of its value is its portrayal of the far-different idea doctors had then of themselves as opposed to to-day–when more than a few are the resentful pawns of managers and ‘service-delivery’ systems.
In the late 1970’s, at the height of the Ford-driven Carter-inflation, when the bills all came due for America, from Viet Nam and the Nixon-Watergate-Republican Party fiasco, I was unemployed and trying (successfully in the end) to dicker an Arabic-speaking Peace Corps-assignment. Eventually, I was to go to Morocco, but meanwhile I was to translate a passion for oriental rugs into a business-venture. Together with my friends, Jim Billings, who taught economics at Augsburg College (where I’d studied and then was employed for ten years), and Dr Warren Peiper, a radiologist who’d grown up in Chicago in the 1920’s and 1930’s, I would wait the long nights–and, sometimes, the days before!–to be first in the door at estate-sales throughout the Minneapolis-St Paul region.
DURING Those prolonged vigils, to obtain for re-sale collectible carpets, I learnt especially from Dr Peiper a great deal about the practise of medicine in America in the last decades of the late-modern age. That age, of course, is now over and has been since 1989, the collapse of communism and the yanking down of the wall in Berlin. Nevertheless, many of the artifacts of that time yet linger with us, even as the societies, the territorial states and, above all, the economies, of the West are in a state of free-fall into an unknown time. One of the symptoms of the fact that no age is hermetically sealed off from its successor–and, indeed, this is another example of the persistence of forms in history–is the inertial persistence of corporate and ‘managed’ medicine.
The fact that this ‘management’–as is any other economic structure–is all about the allocation of shortages has largely escaped many historians, perhaps, but I did learn something about it all indeed thirty years ago or more, especially from Jim Billings. His speciality was ‘health-management organisations’, or ‘HMO’s’, and I gained valuable insights into the economics of any service delivery-system. From Dr Peiper, in turn, I learnt more than one personally should care to know, perhaps, of the fisco-professional constraints imposed to-day on doctors, by their handlers. One way or another, choices as such such are limited, even while the array of glittering mechanisms and shiny pills in their capsules proliferate. A classic instance, I daresay, is that of ‘Viagra’.
THE Economic fact is that this recreational eroticant is, precisely, marketed–to draw down surplus cash for the pharmaceutical houses, not only to realise immediate profits but, more importantly, to underwrite other operations and research. Future profits, in other words. Already, three decades ago, Dr Peiper pointed out that clinic- and hospital-managers were at every point of the compass exerting pressure on practitioners to prescribe preferentially various drugs as the public fads (guided by advertising especially on Tee Vee). At this present, of course, we all know that contracted doctors often are ‘rated’ competitively by their managers, who tabulate closely the number and kinds prescriptions they utter to their befuddled patients.
Arguably, this is all of a piece; and, indeed, post-modern medicine would have been otherwise simply unable to capitalise its CAT-scan machines and other high-technological gizmoes. Dr Peiper’s speciality was radiology, and he was scathing about unrelenting management-pressure in those days, to use at every opportunity the then-new machinery:
‘EMMETT, The idea of having me shove every eighty-year-old lady who rolls along through a CAT-scan just to “prove” she has arthritis in her neck is just ridiculous! But, they have to PAY for the God-damned things!’
DR Peiper came up through medical school in the early 1940’s. A childhood episode of blood-poisoning had crippled his legs, and he was unable to serve in the military. On the other hand, the attentiveness of his doctor made a tremendous impression on the little boy, and so he’d grown up wanting to be a doctor, too. Ironically, none of this might well have happened had he been ill only a few years later:
‘I was sick just before they discovered the sulfa drugs–too late for me!’
Warren Peiper attended Northwestern University, and his mentors were men like surgery-chief Loyal Davis, the father of Nancy Davis Reagen. These were men of the same generation as Author-doctor Hertzler:
‘You know, Emmett, just like to-day lots of these people were in medical school just because they wanted to make a lot of money. Dr Davis used to lecture about this and said that it didn’t matter WHY you wanted to be a doctor–as long as the medicine was good!’
Another thing that he told me was how the teaching-hospitals had been in the forefront of care for the poor and indigent, as a means of training young doctors. Indeed, he told me that ‘medicine was altogether more socialistic in those days than now, with God and the government paying for everybody!’
The real inflation of medical-costs in America began during World War II, when wages were frozen, and employers began to compete by offering health-insurance. ‘It was no longer a matter between doctor and patient–now, with somebody else paying the bill, NOBODY gave a damn about “how much”! Needless to say lots of these doctors now are just full of themselves because of the big money. My God, the practise of medicine is mainly just common sense, but these people all think they’re a bunch of heaven-born GENIUSES!’ Nevertheless, third-party payments did not immediately sweep the whole field of medical-economics, and when young Dr Peiper began to practise–initially in Kansas, Dr Hertzler’s home state–patient-fees were very much an individual matter:
‘Some rancher would have me out to whack out a kid’s tonsils, and he’d pay me off with a quarter of beef in the Fall. And when the banker had me in to do his kid, I’d nail HIM three hundred dollars. That was REALLY a case of each one getting what he needed and paying according to his means. For a full side of beef I’d do all three kids and not have to try come back maybe in the dead of winter.’
So it was that in the late 1940’s, at the beginning of the baby-boom, Dr Peiper started out in Kansas doing kitchen-table surgeries just as had done Dr Hertzler fifty years before, being paid on a case-basis just as had been Dr Hertzler fifty years before.
ARTHUR E. Hertzler, MD, (1870-1946), known in his old age as the ‘Horse and Buggy Doctor’ from his book by that title, graduated from Southwest Kansas College in Winfield. He then enrolled at Chicago’s Northwestern University Medical School where he earned an M.D. degree. He returned to Moundridge, Kansas, and ultimately settled in Halstead, a town with a population of less than 2,000, after a tornado severely damaged the latter village causing many injuries. Dr Hertzler moved to Halstead originally to assist the casualties of the storm, and he then continued to practice in Halstead. Dr Hertzler’s was a real passion for medicine, and he did advanced study of pathology in Berlin, before the Great War, becoming in the process an excellent anatomist. In turn, he taught pathology, histology, surgery and gynecology at the University Medical College in Kansas City, and later at the University of Kansas School of Medicine.
His teaching methods were unconventional, which earned him affection and respect from his students. They claimed his lectures were much more enlightening than other professors. He believed that a good teacher should know already a student’s progress in class; therefore, the time required for giving final examinations was better spent taking his classes to baseball games.
In 1938, he wrote The Horse and Buggy Doctor, a personal account of his experiences.
It was an instant best-seller of the day, alas now undeservedly forgotten. Dr Hertzler relates the nature of the practice of medicine in rural America from the 1880’s through the 1930’s. His initial stories are those of a child observing the ravages of epidemic diseases in the face of medical futility. Dr Hertzler gives the reader an intimate view of a frontier doctor making do in the late 19th century – performing surgery on an infinity of kitchen tables! – observing an occasional home remedy that worked. Dr. Hertzler most certainly was a powerful force in the growth of medical practice and education in Kansas and her neighboring states. After more than fifty years of 18-hour-days, in practice and teaching, Dr. Hertzler died shortly after he retired in February 1946. To-day, the Hertzler Research Foundation, Agnes Hertzler Memorial Clinic, Kansas Health Museum and Halstead Hospital stand as legacies of this outstanding Kansas country doctor. The Hertzler Clinic in Halstead, Kansas, is named for Arthur E. Hertzler, MD, a pioneer in rural health care. The hospital tagged as, ‘the little Mayo’ serves a broad geographical population. Since 1902, when Arthur Hertzler, the ‘Horse and Buggy Doctor’, established his clinic and hospital, the city has been widely known as a medical community. Ironically in view of what Dr Hertzler wrote rather scornfully of ‘standardisers’ in medicine, the Hertzler Clinic is now owned and managed by a ‘Professional Association’ of physicians with specialties including: cardiology, internal medicine, neurology, oncology, orthopedic surgery, ear, nose and throat care, pathology, podiatry, psychiatry, pulmonary medicine, radiology, rheumatology, general, thoracic and cardiovascular surgery.
THE Real question about all of this progress is how well post-modern medical practise allows the ordinary MD to develop a wisdom similar to Dr Hertzler’s–whereas it does successfully not let ‘the poor mutt’ remain an ‘ordinary’ doctor! The pressure toward specialisation was already at work fifty years ago. Dr Peiper, on returning to school for advanced study, was ‘encouraged’ to specialise in radiology, reading X-rays for other doctors–because of his crippled legs:
‘The professors said to me: “‘Physician heal thyself!’ When the public sees you on crutches they’re not going to trust a ‘sick doctor’!”‘
Dr Peiper said that the role of the specialist was supposed to be to enhance the relation of the general practitioner and patient, but instead he perceived that it has gone far to minimise intimate doctor-patient contact. Or, worse, to falsify it:
‘Several times now I have returned a lung-cancer diagnosis of his patients to one individual–and the man has told people they’re OK. And, if I kick up a fuss, I’m told that I’M being “unethical”! It’s supposed to be an individual matter, I know, about how much the individual patient can “take”, but this bird doesn’t have the guts to give people bad news!’
Still worse, when my own middle sister was fatally ill in a large hospital it in the South, it was next to impossible to make contact with her ‘primary care’ doctor, and she died in unnecessary pain. All involved were health-care dedicated professionals–and, categorically they failed my sister on the most important point of all, namely her actual well-being, and well-dying.
Now, contrast the above miserable outcome of this high-technological system of organised medical irresponsibility to Dr Hertzler’s words of warning, written already as long ago as 1938, on the ultimate (NB) duty of the doctor:
‘…[NOWADAYS T]he doctor more or less ignores the bedside of the dying. The night nurse attends to these things. In the hospital, of course, the patient’s relatives go out after visiting hours, whether they wish it or not, and come back in the morning to see if their patient is still alive, and the doctor does likewise, an hour or two later.
‘But in the family doctor’s practice [sic], in the home it is different. There the family gather about the bedside. The doctor personally sees to it that the last hours are passed without suffering. If a quarter grain of morphine does not do it, perhaps a grain or five or six will. Not given subcutaneously under the cooling skin but into a vein. I ask only, for the reward of my labors in bahalf of others, to be accorded this attention in my last hours. (Ibid, pp 304-5, emphasis added–ERS)
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[Emmett R Smith all rights reserved 4 June 2006]