by Hillman Terzian, MD; Raphael Sun, MD;
Heidi Hon, MD; Priya Jadeja, MD; and Scott B. Grant, MD, MBE
Surgery comes of age:
The ACS and the evolution
of the surgical profession
Until the late 19th century, concepts that modern surgeons may take for granted, such as standards of
care, quality, education, and residency
training, were largely foreign ideas to
members of the profession. This article reviews how trailblazing surgeons
and leaders of the American College
of Surgeons (ACS) have led the evolution of surgery from an unregulated
business to a highly respected profession of well-trained physicians dedicated
to improving the care of the surgical
patient. This article also describes the
increasingly prominent role of women
and young surgeons in developing and
safeguarding standards of care.
Standards for education and practice
Most surgeons operating in the 19th century were self-taught
1 Until the founding of the Johns Hopkins
School of Medicine, Baltimore, MD, in 1893, U.S. medical
schools were disjointed and functioned without a defined
curriculum, allowing medical students to graduate without
examining a single patient.
2, 3 In 1910, the Flexner Report on
medical education was published, demonstrating the need for
a standardized medical school curriculum and education.
The lack of standards in medical education also was apparent
within surgical practice itself. Anyone could perform a surgical
procedure, regardless of training and background. The appendectomy, for example, was one of the first operations developed in the
U.S. in 1867, a procedure that resulted from a newly discovered
understanding of the disease process for appendicitis.
4 Hundreds of
new procedures were created in the final years of the 19th century;
unfortunately, morbidity and mortality rates for surgery as a whole
were horrific. In 1880, surgical wound infection rates were at 90
percent, and abdominal surgery mortality rates were at 75 percent.
In response to these growing concerns, in 1905 Franklin H.
Martin, MD, FACS, established Surgery, Gynecology & Obstetrics (now the Journal of the American College of Surgeons) in
an effort to share scientific knowledge and promote innovations
to improve surgical practices. In 1913, Dr. Martin led the founding of the ACS. Dr. Martin formulated what would become the
requirements for the foundation of the College while traveling
on a train: “A standard of professional, ethical, and moral requirements for every authorized graduate in medicine who practices
general surgery or one of its specialties....”
6 These same professional, ethical, and moral standards conceived by Dr. Martin
continued to be requirements throughout the 20th century
and exist to this day.
• Explores the College’s role
in the evolution of surgical
education and practice
• Describes the College’s relationship
to other surgical associations
• Illustrates the increasingly
visible role of women and
young surgeons in the ACS