Presidential address: “These united colonies are …”

Abstract

Thank you for the opportunity to serve as your president for this past year. This recognition is more broadly addressed to the surgeons of my adopted state, Maine. Among them, Ferris Ray, who served as vice president of this society, stands out as the one surgeon who did the most to forge vascular surgery as a distinct specialty in Maine. The real heart of a surgical society is the secretary, and I want particularly to thank Jim Menzoian for his indefatigable efforts. Jim continues the distinguished line of strong secretaries with which this society has been blessed. “These United Colonies are...”—the phrase, of course, comes from the Declaration of Independence: “We, therefore, the Representatives of the United States of America, in General Congress, Assembled... solemnly publish and declare, That these United Colonies are and of Right ought to be Free and Independent States.”1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar What jars the modern ear is the plurality of the syntax: “These United Colonies are... Free and Independent States.” The verb is plural, which implies a plural subject. Today we would say, “The United States is a free and independent nation.” The third-person singular in the verb explicitly states our perception of a single nation, a concept that is not at all clear in our Declaration of Independence. The emphasis on the plurality of the colonies is not accidental; it fills the operative paragraph: “They are absolved from all allegiance to the British Crown... All political connection between them and the state of Great Britain is and ought to be totally dissolved... As Free and Independent States, they have full Power.”1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar The problem of unity and the tension between peripheral autonomy and central authority have been central to the history of the United States. Are we a single nation or a federation of sovereign states? This tension was most dramatically confronted during the roughly 100 years from 1763 to 1865. I should like to briefly review this interval in our nation's history, because I believe many of the issues that played out so dramatically are common to all human organizations, because organization itself is crucial to human endeavor, and because, as many people see it, the future quality of health care in this country depends, in part, on improving our organization of health care delivery. As you listen to this interpretation of history, you may hear issues familiar to your own experience. In 1763, the Peace of Paris concluded the Seven Years' War, one of a series of European wars stretching back to the late 17th century, which arose largely over the conflict between France's attempts to establish hegemony in Europe and England's attempt to thwart these efforts with a balance of European powers. These wars had spilled onto the North American continent as the so-called French and Indian Wars.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar In North America at Quebec, Wolfe's victory in 1759 on the Plains of Abraham (named not after the Old Testament patriarch, but after Abraham Martin, a French river pilot and farmer) gave Britain all of French Canada and all the land east of the Mississippi down to the lower Mississippi delta. It was a great victory, which cost the 32-year-old major general's life when he stood in front of one of his regiments ready to personally lead the bayonet charge that followed the devastating close-range British musket volleys that had already determined the outcome of the battle.3Keegan J. Fields of battle. Alfred A. Knopf, New York1995: 1-348Google Scholar Wars cost money as well as lives, and Britain's victory in the Seven Years' War increased the British national debt nearly 2½-fold.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar The king and parliament felt that the American colonies should be taxed to contribute to the cost of their own defense. The American colonists, like everyone else before or since, objected to taxes. The centers for the conflict of the colonies with England were Virginia and New England. New England had been populated largely by Puritan refuges from East Anglia, a section of England east of London with particularly strong traditions of both literacy and support of representation over arbitrary power.5Phillips K. The cousins war: Religion, politics, and the triumph of Anglo-America. Basic Books, New York1999: 1-707Google Scholar It was the regional power base for Cromwell and the Puritan parliament, which rose in revolt against the Stuart attempt at absolute monarchy during the previous century. Moreover, in New England, Virginia, and most other colonies, the representative assemblies, like their prototype, the English parliament, maintained control of the purse. Tax revenue raised by the assemblies provided the salaries for the royal governors and judges. Their financial dependence on the representative assemblies was a major factor in keeping these officials responsive to the colony's interest.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar It is important to understand, however, that these were already 13 very independent colonies; that is, they were independent from one another. New England was initially populated by parliamentary Puritans from East Anglia. New York began as a Dutch province. Quakers founded Pennsylvania. Prisoners were the initial colonists of Georgia. Aristocratic and religiously conservative planters ruled the tidelands of Virginia, Maryland, and the Carolinas. Travel among the colonies was difficult, over poor dirt roads and by small coastal vessels. Their governors reported back to proprietors in England. There was the most rudimentary of administration of the colonies as a whole, and that existed only in England as the Board of Trade and a large uncoordinated group of ministries and departments in the English government.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar There had been an early attempt of coordinated activity among the 13 colonies. The English called for a congress in Albany in 1754 to coordinate a common defense to the military threats of the French and the Indians. Representatives of only eight colonies attended. The plan of union that emerged, authored in part by Benjamin Franklin, proposed a union of the colonies with a relatively strong central government. It failed to be ratified by a single colony.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar Clearly local autonomy held sway. Despite these differences, there were important common features. The voting citizens considered themselves Englishmen, with the rights of Englishmen (women and slaves, among others, could not vote). They shared the still developing and imperfect English tradition of representative government, and, to a greater extent than their English cousins, they practiced these rights of self-government.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar, 4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar, 5Phillips K. The cousins war: Religion, politics, and the triumph of Anglo-America. Basic Books, New York1999: 1-707Google Scholar In this setting, a series of parliamentary acts were pushed through by the king's ministers and the king's purse, attempting to raise money from the colonies and establishing a more effective administrative system to extract that money. The challenge of these acts called forth responses from the colonies—responses that progressively shifted the argument from one of simply economic cost to that of political infringement, the reduction in traditional English liberties. Most important, through these responses the colonies gradually learned the value of cooperative activity. In 1765, the Stamp Act passed by parliament was the first direct internal tax laid on the colonies.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar, 4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar It was paid by buying a stamp affixed to a wide variety of necessary documents and publications. The Virginia Assembly voted on a series of resolutions objecting to the Stamp Act, focusing on the principle of no taxation without representation. The circulation of these Virginia Resolutions among the colonies began to unite public opinion in opposition. American politics has always had a rough-and-tumble character to it. In Boston, this united opposition presented as a temporary union between the North End and South End mobs, which had traditionally engaged in fighting one another. In response to the Stamp Act, they united in riot against the crown officials, forcing the stamp commissioner to resign, and then mobbed and wrecked the house of the lieutenant governor, Thomas Hutchinson. The lieutenant governor and his family, seated at dinner, fled just in time to save their lives. In Connecticut, stamp agent Jared Ingersoll was burned in effigy in Norwich, New London, Lyme, West Haven, and New Haven. Ingersoll also fled to save his life. This united and often violent opposition forced the repeal of the Stamp Act in 1766.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar Parliament, refusing to learn, the very next year passed the Townsend Acts, which added additional import duties in the colonies. Worse, it reorganized the customs service to make it more effective and established a board of commissioners of the customs in Boston. This efficiency interfered with one of the traditional and lucrative commercial enterprises of New England: smuggling.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar, 4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar Things were getting serious. Significantly, the money generated from these taxes was to be used to pay the salaries of royal governors and judges, allowing them to act independently of local colonial assemblies. In objecting, the colonies attempted to cooperate among themselves in economic warfare against England, creating nonimportation agreements that were applied with varying success. Again, riots ensued in New York City, and, in March 1770, the infamous Boston Massacre occurred. Parliament repealed the Townsend Acts, except for the three cents per pound tax on tea. In one of parliament's most misguided actions, the token tax on tea was kept simply as an assertion of parliamentary authority. “A peppercorn in acknowledgment of the right (to tax) is of more value than millions without it,” was the commentary of Prime Minister George Grenville.1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar Ironically, despite the violence and despite the residual tax, there was, at this point, a general prosperity, and most people really did not care to get actively involved. The average colonist found it fine to be relieved of paying the governor and judges.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar Then, in 1773, the East India Company, which was in financial difficulty, found itself with excess tea and was granted a monopoly to export it to the colonies. The company planned on selling it through its own agents, eliminating the independent merchants of the colonies and disposing of the tea at less-than-market price. The economic threat, as much as the political implications of taxation without representation, led the radical Sam Adams and the Sons of Liberty to dump a shipload of that tea into the Boston Harbor in December. George III wrote his prime minister, “The die is now cast; the colonies must either submit or triumph.”1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar In retaliation, parliament closed the port of Boston, strangling Boston's economic airway. However, instead of isolating Massachusetts as intended, the Coercive Acts rallied the other colonies to her support. The Virginia Assembly called on all colonies to send delegates to a congress of all continental American colonies, which met in September 1774 in Philadelphia. The First Continental Congress was indeed the first organization to act on behalf of all 13 colonies. It set up committees of inspection in every town and county to supervise nonimportation, nonexportation, and nonconsumption agreements. In short, it began creating an extra legal organization to govern, or at least impact on American daily life, in all 13 colonies. In the face of armed conflict at Lexington and Concord, the Second Continental Congress took over the militia besieging the British in Boston and appointed Washington commander in chief. Although the colonies were working together, independence was not yet a unanimous goal. In the autumn of 1775, the legislatures of North Carolina, Pennsylvania, New Jersey, New York, and Maryland went on record against independence. In January 1776 in the camp of the Continental Militia besieging Boston, the king's health was toasted nightly in the officers' mess, presided over by General Washington.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar There was considerable support for the colonies in Great Britain. Many in England saw the Coercive Acts pushed through parliament by the king and his ministers as threatening their own liberties as much as those of the colonies. The king's first choice for American military commander, Lord Jeffrey Amherst, who had won a major victory in New York during the French and Indian War, refused to serve against the Americans.5Phillips K. The cousins war: Religion, politics, and the triumph of Anglo-America. Basic Books, New York1999: 1-707Google Scholar William Pitt, the great former prime minister responsible for England's victory in the Seven Years' War, defended the American colonies on the grounds that “No subject of England should be taxed unless by his own consent,” adding, “You cannot but respect their cause and wish to make it your own.”1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar Even the great conservative Edmond Burke not only argued in support of the principles of representation for the colonies, but also summarized the pragmatic difficulties, saying, “But let us suppose all these moral difficulties got over. The ocean remains. You cannot pump this dry; and as long as it continues in its present bed, so long all of the causes, which weaken authority by distance, will continue.”1Commager HS Morris RB The spirit of ‘76: the story of the American Revolution as told by participants. Bonanza Books, New York1983: 1-1348Google Scholar Ultimately, there was sufficient unity in the colonies to declare independence in July 1776 and initiate a war of revolution. Whether there was sufficient unity and organization to win that war was another question, and in the event victory was a near thing. The Articles of Confederation passed by the Continental Congress in 1777 implemented the organization of government as it then existed. There were five executive departments, but no chief executive. There was no federal judiciary, no control over trade, and, most important, no direct taxing ability.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar With no power to tax, the Continental Congress had to requisition moneys from the states and had no authority or power to enforce this requisition. States recruited their own militias, often paying them more than Congress would pay the Continental Army. The state militias often fought only when and where their state was locally threatened. Washington recruited and trained the Continental Army of regulars, but maintained it with great difficulty. The Continental Congress found it almost impossible to provide the army with sufficient men, horses, food, clothing, and weapons, particularly in the crucial early years of the war. States continued to print their own currency, adding to the inflation of all paper currency. The pay of soldiers and officers alike was often months in the arrears and paid in depreciated paper money. But it was this national army of regulars, held together by Washington, whose endurance was symbolized in the harsh winter camp at Valley Forge, that was responsible for victory.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar It turned out to be a war of attrition, not so much of men, but of will. The American victory at Saratoga not only prompted the entrance of France and ultimately Spain into the war against England, but strengthened the political opposition in Britain. When Cornwallis surrendered his army at Yorktown to the combined force of Washington's Continental Army and the French Army under Rochambeau, political support in Britain for the war fell dramatically.4Middlekauff R The glorious cause: the American Revolution, 1763–1789. The Oxford history of the United States.in: Oxford University Press, New York1982: 1-696Google Scholar, 5Phillips K. The cousins war: Religion, politics, and the triumph of Anglo-America. Basic Books, New York1999: 1-707Google Scholar Two armies had surrendered at Saratoga and Yorktown. These troops were difficult to replace, given that the cost and the requirements of war now extended against France and Spain. Military activities on the North American continent ground to a virtual halt. Moreover, the corruption and incompetence of the British ministry were becoming increasingly evident. King George at one point even considered abdicating,5Phillips K. The cousins war: Religion, politics, and the triumph of Anglo-America. Basic Books, New York1999: 1-707Google Scholar but remained, allowing the opponents of war to take over the government and eventually make peace. Thus, despite all the parochialism and inefficiencies of the new American government, the fact that it and its army under Washington survived intact and were able to reach military stalemate was sufficient to win victory and independence. It is interesting to reread this history after our own struggle in Vietnam. Both struggles were viewed by one side as wars of revolution and independence. For Britain in the late 18th century and for the United States in the mid-20th century, the wars were fought far from home with considerable opposition on the home front. In both cases, the war became too costly in dollars, lives, and political support to continue. When the Revolutionary War ended, the compelling need for unity had passed. The organization provided by the Articles of Confederation proved unable to solve the problems of the day: inflation, trade, and colonization of the western lands. George Washington in 1785 addressed the root cause of this weak government: “We are either a united people under one head and for federal purposes, or we are 13 independent sovereignties eternally counteracting each other.”6Van Doren C. The great rehearsal. Time-Life Books, Chicago1948Google Scholar Recognition of the failure of the weak national government led to the calling of a convention to amend the Articles of Confederation. From a long effort of statesmanship and political horse-trading, a new Constitution emerged, providing a stronger union with the power to tax, to treaty, to wage war, and to sanction.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar, 6Van Doren C. The great rehearsal. Time-Life Books, Chicago1948Google Scholar It had a federal judiciary and an executive branch that was not strong initially, but was able to develop strength in the next 200 years. However, when speaking of the nation, the syntax continued to be plural: “The United States are...”7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar Despite the greater unity of the Constitution, many people still felt that states could pick up their marbles and go home if the game did not go their way. The threat of secession first appeared in New England. During Jefferson's first term after the Louisiana Purchase, unhappy Federalists from Massachusetts and Connecticut proposed a Northern Confederacy.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar This effort died with Jefferson's overwhelming re-election, but the economic frustration in New England, caused by the loss of trade during the War of 1812, again led to talk of secession. A convention of New England states met at Hartford to consider New England's leaving the union and negotiating a separate peace with Great Britain. Fortunately, these resolutions were turned down.2Morison SE Commager HS Leuchtenburg WE. The growth of the American republic. 7th edition. Oxford University Press, New York1980: 1-923Google Scholar The issue of slavery had been avoided by our founding fathers, because there was no hope of an agreement to limit it. For unity to be achieved, slavery was deliberately ignored, and the dreadful institution continued. Increasingly, it divided the country. During the Civil War that ensued, the United States Army grew from a force of 16,000 to nearly one million.7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar The development of the army medical service is one example of the increase in size and integration of organization required to manage this enormous increase in manpower.7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar, 8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar Three hundred thousand Union soldiers died, 100,000 from wounds and twice that number from disease. (Not until World War I would disease kill fewer than combat.) At the onset of the war, the largest army hospital contained 40 beds. Field care was based on regimental hospitals. Regiments at full strength generally had 1000 to 1300 men. The regimental hospital organization was originally taken from the British Army. The British argued that the patient does best with the doctor he knows. There was no articulated organization of these hospitals and no chain of evacuation. At the first Battle of Bull Run, that notorious, improvised Union disaster just south of Washington, DC, each regimental surgeon took care of his own unit, and soldiers wounded at a distance from the regimental surgeon were often left untended. The few ambulances available had civilian drivers who ran off at the firing of the first guns of the battle. Subsequent investigations were unable to learn of the single wounded man from the battle reaching the capital in an ambulance.8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar A year later at the second battle on that site (Second Bull Run or Second Manassas as its known to our Southern colleagues), Pope's improvised Union Army of Virginia not only lost the battle, but left 3000 Union wounded on the battlefield for 3 days, most of them untended. Six hundred wounded still lay on the battlefield 5 days after the battle.8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar Gradually, organization was improved in the Union Army. Regimental hospitals were replaced by larger brigade hospitals, which were, in turn, replaced by still larger hospitals attached to the division. By 1863, division hospitals were often clustered together as a single hospital in support of a corps. These larger units allowed for supervision and specialization of medical care. Only the most qualified surgeons were made primary operators. The combination of specialization and better supervision allowed by this concentration of medical care substantially improved the quality of care delivered to the sick and wounded.8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar In addition, a better ambulance corps was organized. The civilian drivers were replaced with disciplined soldiers. At Gettysburg in July 1863, Letterman, the medical director of the Army of the Potomac, commanded an organization of 650 medical officers, 1000 ambulances, and 3000 drivers and stretcher-bearers. Fourteen thousand Union wounded were removed from that field in the 3 days of combat, almost all on the day they were wounded. A chain of evacuation was established, with policies for early movement of patients to rear hospitals to keep the beds open for new casualties. By the end of the war, general hospitals averaged 600 beds, with the larger ones having nearly 4000 beds. The army, the largest hospital of which had been 40 beds before the war, now had a total of 136,000 hospital beds in an organized system of evacuation, the principles of which continue to this day.8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar There were, however, amusing anecdotes. According to Army policy, the surgeon in charge was also the military commander of the hospital. One of these commanding surgeons was so impressed by this position that he made daily rounds at the head of his entourage, which marched in full dress uniform through the corridors of the hospital to the accompaniment of marching fife and drum.8Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. Collier Books, New York1952: 1-224Google Scholar Through the horrible internecine carnage of the Civil War, Lincoln, like Washington before him, emerged as both the leader and symbol of the Union resolve to maintain the unity of the United States.7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar In the face of political opposition, painfully long casualty lists, at times military incompetence, draft riots, and Democratic party copperheads calling for ending the war by letting the South go loose, Lincoln persisted. Lincoln's struggle for leadership of the Union was as difficult as the struggle with the Confederacy. Even in August 1864, with Grant pinning Lee to the trenches before Petersburg and Richmond and with Sherman marching on Atlanta, Lincoln's popularity was so low that his own Republican party made tentative efforts to dump him as their presidential candidate in the forthcoming November election.7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar However, in a way his counterpart Jefferson Davis could never achieve, Lincoln held together opposing interests by using that strength to defeat both internal foes and, ultimately, to achieve a national victory. In contrast, the southern states remained just as jealous of their unique states' rights in the Confederacy as they were of the Union. Difficulties in uniting the states' efforts continually hampered the effective execution of the Confederate war effort.7Nevins A The war for the Union. 4 volumes. Charles Scribner's Sons, New York1959Google Scholar The Union victory in the Civil War ridded the continent of slavery and the nation of secession. The federal government was immeasurably strengthened, and another milestone on the long path to a strengthened executive branch had been passed. The war had shown the value and necessity of large-scale organization in the nation that now spanned the entire continent. Moreover, it gave the