By the end of the nineteenth century, American surgery had achieved a remarkable level of maturity and excellence, firmly grounded in its professional principles. Major surgical centers had been established across the United States, and the field of surgery continued to advance and expand. However, American surgeons lacked the group solidarity that was fostered by organizations such as the Royal College of Surgeons of Great Britain or the French Academy of Surgery. Although associations and societies like the American Medical Association (AMA, founded in 1847), the American Surgical Society (ASA, founded in 1880), and various specialized group associations had been established, they lacked significant legislative power. These societies primarily served as educational gatherings and had no authority or supervision over the issuance of licenses or permits for physicians and surgeons. The absence of an organized system for the education and training of surgeons, as well as the issuance of certificates and licenses for surgical practice, persisted into the twentieth century. American surgeons, like their European counterparts, were individually distinguished and successful. Understanding the full details of the historical development and evolution of surgery in the United States is impossible without knowing about the personal lives of the surgeons. Nathan Smith (1762–1839), from Rehoboth, Massachusetts, studied at Harvard Medical School and graduated in 1790. Early in his professional life, he developed an interest in medical education and persuaded the trustees of Dartmouth College to establish a medical school. With his proposal accepted, Smith traveled to Edinburgh and London to further his education and enhance his professional abilities. In the fall of 1797, he returned to the United States and shortly thereafter began his medical education courses at Dartmouth. Smith served as a full-time professor at Dartmouth and taught his courses for many years.