In Vermont in 1843 there was a 50-cent fee for a doctor's visit at less than half a mile, a $1 fee between a half and 2 miles, $1.50 for 2 to 4 miles, and $2.50 for more than 4 miles. In a 1910 survey, 96 physicians using horses reported costs that worked out to 13 cents per mile, whereas for 116 doctors using cars for which they paid less than $1000, the cost per mile was 5.6 cents. The advent of the automobile considerably widened the market.¹⁰

Although ether anesthesia was first demonstrated at the Massachusetts General Hospital in 1846, postsurgical infections caused such high mortality that major surgery was nicknamed a "capital operation." Neither carbolic acid, needed to eliminate microorganisms during surgery, nor sterile procedures were accepted practice until much later. Joseph Lister published papers on antisepsis in 1867 and lectured for 3 hours on the subject at a medical congress in Philadelphia in 1876.¹¹ But at the first meeting of the American Surgical Association in 1883, more speakers opposed his principles than supported them, steadfastly disregarding reports that in European hospitals that implemented his methods, postsurgical problems such as gangrene were no longer rampant. As late as 1900 most surgeries were conducted in the home because hospitals were feared as filthy, foul houses of death.

In 1847, the American Medical Association (AMA) was founded in an effort to upgrade the profession. They vowed that raising educational standards was their ticket, but it took another 60 years for their train to pull into the station. The AMA tracked the career choices of 12,400 men graduating from elite colleges between 1800 and 1850, finding that only 8% became physicians, while more than three times that many entered the clergy and legal professions. The AMA interpreted this as signifying a disdain for medicine among "educated talent."¹⁰ Confirming their suspicions, in 1880 fewer students at medical schools had bachelor's degrees than at either law or divinity schools.

In those days, medicine offered more status than wealth--doctors were a cut above manual laborers. Unable to earn a living solely by practicing medicine, doctors cultivated livestock, pulled teeth, mixed herbal preparations, nursed patients through long and difficult nights, and embalmed the dead. Throughout medical history surgeons were regarded as the least sophisticated and learned craftsmen in the guild, trained principally in the use of their hands through apprenticeship, many with barber-surgeons. A carryover of this remains in England today--internists are referred to as doctor, and surgeons as mister, denoting their lesser rank.

As for the specialty of surgery, in 1876 Samuel Gross of Philadelphia wrote his observations about the American surgical scene: "Although this paper is designed to record the achievements of American surgeons, there are, strange to say, as a separate and distinct class, no such persons among us. It is safe to affirm that there is not a medical man on this continent who devotes himself exclusively to the practice of surgery."¹² It was Gross who founded the American Surgical Association in 1880, but it would take at least another 2 decades for surgery to become established as a legitimate profession.

Although doctors were aspiring to an image of erudition, few actually completed much higher education. Both of my grandfathers graduated from Long Island College Hospital in 1914 with high school diplomas, never having attended college. Henry Beinfield went on to perform tonsillectomies, earning S900 a week while his nurse and chauffeur earned $8, whereas Harry Roster set up his own research hospital, frequently publishing in JAMA and Archives of Surgery.