Between 1890 and 1920, surgery was in "a condition of development" in the words of A J Ochsner, an eminent surgeon and the College's first Treasurer. Dr Barnesby's book, Medical Chaos and Crime, exposed many deplorable failings of both surgeons and hospitals. Despite its inflammatory rhetoric, the book spoke to popular and, to some extent, professional concerns. The persistence of an expanding, unregulated market was becoming increasingly untenable. But individualist traditions, the perceived need for professional unity, and the difficulties securing even basic licensing laws, made state regulation or action by existing institutions unlikely. Franklin Martin and the ACS offered one way out of this impasse by setting standards for both surgeons and hospitals. Within a decade of the College's founding, 4,000 US and Canadian surgeons and >60% of North American hospitals surveyed by the College had met those standards.