Doctor Ruhl stood tall as Gulliver’s giant, at least he seemed to be when I looked up and saw him bending over my fever-wracked bed of affliction. I was six and he appeared to be about the age of my grandmother.  I knew he was old, old enough to have a flowing mane of white hair and a droopy handlebar mustache to boot – a spitting image of Mark Twain.  As he went about listening to my chest and quizzing my anxious mamma, I wiggled deeper into the mattress, trying to evade the cold steel of his stethoscope.  All the time he was examining me, he soothed my mamma and me with a steady stream of comforting words.  By the time he finished thumping and listening to my chest, palpating my belly and gagging me with a wooden tongue blade, I was convinced of his curative powers.

     A. M. Ruhl, M. D. was a physician cast in the mold of most frontier doctors who journeyed west with the pioneers of the 19th century.  The practice of medicine during those times was 90 percent art and 10 percent science.   Any new settlement, town or village, that was established during this period was lacking unless a doctor took up residence and hung out his shingle.  Often he was also involved in other enterprises, such as farming or operating an apothecary that sold all kinds of nostrums.  He was subject to being summoned day or night, during blizzards, floods and storms, to the bedside of those in need.  There were many times when all he could do for the suffering patient was to relieve pain, bind up wounds, splint broken bones, perform minor surgical procedures, and on occasion, comfort the dying.  Occasionally, he was called upon to assist in a complicated birth when summoned by a frustrated midwife.  But the most priceless commodity, which he brought to the bedside, was compassion for the suffering being experienced by the patient and his or her family.

     The first medical schools in America were proprietary.  They sometimes gained recognition by obtaining an associate status with a school of higher learning such as Harvard University.  Opening a medical school required only a hall and a faculty that was usually a group of local physicians who would conduct lectures for a fee.  Students attended these lectures by buying tickets for the courses.  Other than having the cash to buy tickets, there were no educational prerequisites for any student seeking admission.  Some were nearly illiterate; consequently, oral exams were more commonly used to test the student’s knowledge.

     No clinical practice, aside from apprenticeships, was offered to augment lectures. The duration of time required to graduate ranged from eighteen to twenty-four months.  No clinical training was provided.  Students gained hands-on experience by entering an apprenticeship, commonly referred to as reading medicine, with a practicing physician who provided meals and lodging for the student.

     The development of medical education in America was slow in coming.  Physicians and surgeons did not enjoy a high level of social acceptance.  The extreme shortage of doctors and large profits possible from operating medical schools led to a rapid expansion.  Over two-dozen new schools opened between 1810 and 1840.  An additional forty-seven more would be established by 1875.  Such an expansion did not result in quality medical education.  It would require a number of medical-education reformers to bring about the necessary changes required to graduate competent practitioners.

     Most states prohibited dissecting human corpses, which required students to provide their own cadavers – frequently obtained by hiring body snatchers to steal them.  In 1830, Massachusetts became the first state to legalize the donation of bodies to medical schools.  The remaining states were quite slow in passing comparable legislation.

     In 1839, Saint Louis University, established in 1836, awarded the first M. D. degrees granted by a medical school located west of the Mississippi River.   

     Medical education began to improve between 1850 and 1900.  New discoveries in the uses of general anesthetic agents and the revelation of microbes being the cause of infectious diseases drove colleges toward improvement.  Charles Eliot, President of Harvard University, extended the medical college's school year in 1869 from four to nine months.  He also established a three-year curriculum and required both written and oral examinations.  Medical education improved significantly in 1876 when Daniel Gilman, founder of Johns Hopkins University, required hands-on clinical practice as an inherent part of training. The apprenticeship system was coming to its end in the East, but would continue longer in the West.

     A number of physicians who were educated in the East migrated westward with other pioneers searching for opportunities in the burgeoning new frontier.  For the most part, they founded medical practices in rural areas until larger towns and cities, such as Denver, Dallas, and San Francisco, were developed.  Until medical schools could be established in the West, those aspiring to become physicians had to pursue the apprenticeship route or seek education in the East.  One of the earliest medical schools founded in the West was the Medical Department of the University of the Pacific, San Francisco, California, in 1858.  Elias S. Cooper, M.D. was the driving force in establishing this school, which ultimately became the Stanford University School of Medicine.  Unfortunately, the school had rough sledding after the death of Dr. Cooper in 1862 at the age of forty-one.  Even then, most of the clinical training was obtained by apprenticing a practicing physician.

     Many of the physicians practicing on the Western frontier had very little knowledge about the science of medicine; however, they accumulated a great deal of practical wisdom.  Prior to the discoveries made by French scientist Louis Pasteur that led to acceptance of the germ theory in 1878, the treatments of the time were limited to medicinal agents with little proven attributes.  Many physicians adhered to antiquated practices such as the administration of emetics, cathartics, homeopathic remedies, and various nostrums that were popular at the time.  Opium and its derivative, morphine, were widely used for the control of pain and dysentery.  Laudanum, a mixture containing alcohol and opium, was frequently found in the medicine cabinets of the populace.

     Swiss physician, Paracelsus, introduced laudanum as a therapeutic agent in the 16th century.  English physician, Sydenham, recommended its use for relief of pain, insomnia and diarrhea in the 17th century. It became an important remedy advocated by many medical treatises during the 18th century.  Laudanum gained worldwide acceptance in the 19th century, becoming a standard medication for the relief of painful injuries and diseases.

     An example of the use of laudanum was addressed in the movie, The Shootist. Ailing J. B. Books, played by John Wayne, was given all the laudanum he wanted to control pain from prostate cancer by James Stewart’s character, Doc Hostetler.  Hostetler revealed a side of medical practice that was frustrating for any physician of the time.  All he could do for J. B. Books was to provide an element of pain relief by the liberal usage of laudanum.  He knew there would come a time when Books’ suffering could not be allayed by any dose less than lethal.  When Books pleaded for his advice, Hostetler responded by saying that if he had the courage any professional shootist like Books must have, he would not die that kind of death.

     We also find reference to this medicine by Galen “Doc” Adams, the lovable doctor played by Milburn Stone in the T.V. series, Gunsmoke.  Many of the series episodes portrayed “Doc” as being involved in numerous situations during the development of a small town in rural Kansas.  He depicted the lone town doctor being called upon to impart not only his medical acumen but also sage advice to the injured, ill or otherwise unfortunate patient.  It was not unusual for him to be led to some out-of-the-way place to attend a rustler or outlaw suffering from gunshot wounds received while on the job.  He brought out the true spirit of the Hippocratic oath that is sworn by physicians at the time of their graduation.  His self-sacrificing philosophy of life pictured him to be wise in all things, which attained for him an almost saintly station.  Thus, the series accurately pictured the role of many frontier medical practitioners in the West.  The fact is, however, there were a number of settlements that acquired medical quacks whose education and morals were deplorable.

     Narcotic controls were lacking until the Sixty-Third Congress of the United States passed the Harrison Narcotic Act of 1914.  Many Americans had already become addicted to opiates because of their persistent usage of laudanum to allay all physical and emotional distresses.

     Medical licensure of physicians slowly evolved during the 19th century.  Initially, physicians only needed a diploma from a medical college to practice.  The North Carolina Medical Board is the oldest continuing medical regulatory board in the United States, tracing its direct history back to 1859.  Gradually, all of the states have followed suit in establishing boards of medical examiners whose responsibility is to examine and license physicians to practice within their individual states.  It is interesting to note that even in the middle of the 20th> century, a remnant of the apprenticeship was present.  I was a member of the Wyoming State Board of Medical Examiners from 1965 until 1968.  The board often issued provisional licenses upon the applicant’s agreement to practice under the supervision of an established practitioner for a period of time specified by the board.  This requirement was necessary because Wyoming was, and still is, sparsely populated.  Most of the small towns outside of Cheyenne and Casper were rather remote, which made referral to a specialist physician somewhat difficult.  If the applicant lacked practical knowledge about handling medical emergencies, the board felt that it would serve the people best if he/she agreed to practice with an established physician until the board was satisfied with his or her performance.

     The 19th century was a century of changes that revolutionized medicine.  During the first fifty years, arcane theories abounded about diseases, their causes, diagnoses, and treatments.  Medical practices differed little from those of the 18th century. The foremost practitioner of the time was Dr. Benjamin Rush, who believed the body was a machine, and all disease was one disease—an over stimulation of nerves and blood. The cure for over stimulation was "heroic" medicine: bleeding, blistering, purging, and vomiting to restore the natural balance.  Many American practitioners ascribed to his theories and were slow to give them up.

     Conflicts concerning the tenets of medicine came to America during the second half of the 19th century.  Homeopathy, a system of medicine invented by Samuel Hahnemann, M.D. had its origins in France.  His theory was that “like cures like.”  In other words, if a medicine, such as ipecac, nauseated the patient, he would treat nausea with ipecac after attenuating it with excessive amounts of water.  Many physicians who were disillusioned by the archaic practices of the time readily adopted his approach.  A number of medical schools in America became colleges of homeopathic medicine during this period.  About the same time, another group decided that they would adopt an eclectic philosophy of medicine.  Some tenets of standard, also known as allopathic, medicine would be accepted along with homeopathic school of thought.  They called themselves eclectic physicians; consequently, several eclectic medical schools were started, such as the Eclectic Medical Colleges in Chicago and Cincinnati.

     Another medical pioneer was Andrew T. Still, M.D.  Still was a typical frontier physician, having been trained through apprenticeship and medical lectures.  Like nearly all frontier physicians, he did many things besides practice medicine.  He farmed and did mechanical work.  He also served as a surgeon during the Civil War.  His medical practice included caring for both settlers and American Indians.  He faced epidemics such as cholera, malaria, pneumonia, smallpox, diphtheria, and tuberculosis.  After the Civil War, spinal meningitis claimed three of his children and he began searching for a better system of medicine.  He developed osteopathic medicine, a system that strove to improve the practice of medicine, surgery and obstetrics by developing diagnoses and treatments that would augment the body’s natural ability to recover from disease.  He founded the first school of osteopathic medicine in 1892 at Kirksville, Missouri.  Today there are approximately 140 schools of medicine in the United States, nineteen of which are colleges of osteopathic medicine.

     A significant number of graduates of these four medical disciplines migrated westward and settled in many frontier towns.  This phenomenon produced some fairly intense competition between these practitioners.

     Several notable individuals were instrumental in medicine’s coming of age in the American West.  They were pioneering physicians who assisted medical education to reach, even surpass, many quality schools in other parts of the world.  One of these proponents was Dr. Nathan S. Davis, a country practitioner of Binghamton, New York.  He initiated a reform movement in 1845 that grew into a major positive influence, which brought about a genuine revolution in medical education.

     Arthur E. Hertzler, M.D., known 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 Kansas and ultimately settled in Halstead, a town with a population of less than 2,000, after a tornado severely damaged the village causing many injuries.  He continued to practice in Halstead while teaching 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 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.  He 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 a kitchen table – 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 practice and teaching, Dr. Hertzler died shortly after he retired in February 1946. The Hertzler Research Foundation, Agnes Hertzler Memorial Clinic, Kansas Health Museum and Halstead Hospital stand today as legacies of this outstanding Kansas country doctor.

     Another frontier doctor, Urling C. Coe, M.D, wrote Frontier Doctor, a book about his experiences while practicing in Bend, Oregon.  He was born in Missouri in 1881.  He graduated from the University of Missouri and the Eclectic Medical College of Cincinnati, Ohio.  In his book, he tells what it was like to be a young physician in frontier Oregon.  He traveled by a buckboard or on horseback to reach patients living on farms and ranches many miles from town, no matter the weather.  Payments for his services were often left owing.  Surgery and obstetrics were practiced often in less than desirable situations.  An interesting observation was how much the delivering of babies remained within the realm of midwifery.  It was not unusual for neighboring women to gather around the delivery bed to voice their advice regarding the event that was taking place.  He also addresses typhoid fever, which frequented the area, until better housing and sanitary conditions came about, mainly through his efforts.  His account is quite revealing of the trials and tribulations that confronted the West during its formative years.

     Any article about medicine in the 19th century would be remiss if contributions to medicine by Native Americans were not addressed.  Dr. Carlos Montezuma, a member of the Yavapai tribe, received his M.D. degree from Chicago’s Northwestern University Medical College in 1889. From 1889 until 1896, he worked for the Office of Indian Affairs as a physician at a number of different posts throughout the West. His final post was at the Carlisle Indian School Hospital in Pennsylvania. From 1896 until 1922, he was engaged in private practice in Chicago. During this time, Montezuma also taught courses at medical schools in Chicago. Montezuma's service at Indian Affairs hospitals in the West influenced his work as an author. From 1916 until his death in 1923, he published his own newspaper, WASSAJA, which called for the abolition of the Office of Indian Affairs. He titled the paper after his name, meaning "signal."  Montezuma's efforts to abolish the Indian Bureau were joined after World War I by Dr. Charles Eastman. Montezuma died on January 31, 1923.

     Another Native American, Dr. Charles Alexander Eastman, received his medical degree from the Boston University School of Medicine in 1890 and began medical service for the Office of Indian Affairs later that year. Dr. Eastman served at Pine Ridge Agency, South Dakota, and was an eyewitness to both events leading up to and following the Wounded Knee Massacre of December 29, 1890.

Pine Ridge was located only miles above the massacre site, and Dr. Eastman treated Indian victims of the United States Army's attack. He continued work at various posts as reservation physician until 1903. He served as president of the Society of American Indians following World War I, and then joined Dr. Carlos Montezuma in directing a Society campaign to abolish the Office of Indian Affairs. During the 1920s, Dr. Eastman served the government as an inspector of reservation conditions. He died on January 8, 1939.

     Dr. Eastman wrote an article for Pharmaceutical Era entitled, "The Medicine Man’s Practice," in 1919.  His words speak to the misunderstandings held concerning the ministrations of tribal medicine men.  "Perhaps the most important principle underlying the practice of the Indian medicine-man is one which the 'quacks' of civilization so largely utilize – they prey upon the weaknesses and superstitions of the human mind. Many people, even in an age of science, seem willing to risk their lives on treatments unexplainable, mysterious and bordering on superstition. This is the ground upon which the cunning medicine-man based his profession, and more, he did not hesitate to proclaim it openly. However good his medicines might be – and undoubtedly some of them were efficacious – he never lost sight of the spiritual side of health and disease. Invariably he began his treatment with an elaborate acknowledgment of the superhuman power, which gave him wisdom and the secrets of healing.  His technique had much in common with Christian Science and was frequently hypnotic in character."

     It is not surprising that the Indians should hold some peculiar and superstitious beliefs in connection with the human body, for they had very little knowledge of physiology and pathology. Their knowledge of anatomy was limited to such animals as they were accustomed to dress for food. They believed that most disease is mental – that it is caused by an "evil spirit" – (mental fatigue or depression?) Drugs alone cannot cure this; therefore, they call upon the "Great Mystery" through his creatures to drive away the evil spirit. This idea conveniently served two purposes – first, its effect upon the mind of the patient, and second, in case the treatment fails, the Indian doctor may claim that the spirits are offended and nothing will do."

     Generally, medical schools did not accept women during the 19th century.  This was another ramification of prejudices that attempted to keep women from entering any of the professions.  This situation was instrumental in the establishment of the Women’s Medical College of Pennsylvania.  Also, the majority of white society discriminated against Native Americans of either sex.  Consequently, the acceptance and graduation of a Native American woman by any medical school is of great importance.  Dr. Susan La Flesche-Picotte received her medical degree from the Women's Medical College of Pennsylvania in 1889, graduating at the top of her class. She spent her internship at the Woman's Hospital in Philadelphia.  From August of 1889 to October of 1893, she served on the Omaha Reservation in Nebraska as physician to her tribe, finally resigning for health reasons.

     During this time, she worked for the government's Office of Indian Affairs.  From 1891 to 1893, she also served as "medical missionary" for her tribe, so designated by the Women's National Indian Association. This dual workload included travel across the length and breadth of the Omaha Reservation, making house calls in addition to receiving patients in her office.  Dr. La Flesche married in the summer of 1894 and added her husband's last name, Picotte, to her own.

     Throughout the remainder of her life, Dr. La Flesche-Picotte worked for improved health conditions of the Omaha tribe.  This is borne out by her extensive correspondence with the Commissioner of Indian Affairs throughout her career, as well as local newspaper accounts of her community achievements in Walthill, Nebraska.  Dr. La Flesche-Picotte died on September 18, 1915.

     The frontier West was ravaged by contagious diseases that afflicted young and old, taking a terrible toll – many dying before their time.  Smallpox, pneumonia, tuberculosis, cholera, typhoid, malaria, dysentery, diphtheria, septicemia, and measles were some of the more prevalent infectious diseases.  Occasionally, outbreaks of pneumonic and bubonic plague would occur in seaport cities.  Flea infested rats would escape from ships, spreading their fleas that were infected with the plague bacterium.  Once conveyed to humans, the illness can be passed to others through direct person-to-person contact.  These diseases spread through the Native Americans with devastating results, because they lacked adequate genetic resistance to them.  Their immune systems had not received the genetic imprinting passed from generation to generation by those who had recovered from a disease such as smallpox and measles.  Both of these diseases along with tuberculosis killed many more Native Americans than bullets fired from the white Americans' guns and rifles.

     At the end of the 19th century, the average life span of an American male was forty-seven years.  It would require the development of vaccines begun by Sir Edward Jenner around 1800 and Louis Pasteur in 1885, and discoveries of antibiotics in the 20th century to lower the death rates from infectious diseases.  Probably most of the credit for overcoming many of these afflictions must be given to those pioneers who saw the need for and did something about sanitation.

     As we look back in time, it becomes obvious that the practice of medicine in the frontier West was sorely inadequate.  Frontier physicians had to rely on the knowledge of the times, which was replete with erroneous ideas about the causes and treatment of diseases.  The training of physicians was poor, sometimes pathetic.  The licensing of practitioners by states had a tardy beginning and was frustratingly slow in progress.  Having written this, I want to emphasize the courage and fortitude of the doctors that served the American frontier.  By in large, they were a noble lot who became masters in the art of practicing medicine.  There is a great deal more in caring for the sick than prescribing a medication, performing a surgical procedure or assisting a mother give birth to her baby.  The frontier doctor gave himself to helping the afflicted.  When needed, he went, no matter the cost from inclement weather or hazards that might await him.  Sometimes he was more ill than his patient – bone tired from overwork and lack of sleep – underpaid for his services – but always responding with what he had to offer.  Doctor Ruhl was that kind of physician.  I often thought his pills were nothing but sugar.  Maybe they were, but it seemed that I always recovered without any problems.

     Doctor Ruhl has been dead now for a lot of years.  Our family was devastated when he died in the mid-1930s.  I’ll always remember him, his kindness, especially the confidence he expressed that everything was going to be all right.  He had a picture of “The Doctor” by Sir Luke Fildes hanging on his waiting-room wall.  I’ve often thought about how much that painting conveyed to we who were waiting to see the doctor.  Maybe it is the quiet vigilance of a dedicated servant that impressed me – or it may be something I can’t put into words.  The frontier doctor is responsible in no small part for the development of the American West.