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Allan Macy Butler (1894-1986)
PROFILES IN PEDIATRICS II
Allan Macy Butler (1894-1986) Allan Macy Butler's career spanned the greater part of the twentieth century, and his intellectual prowess, adventurous spirit, and activist nature led him to play a special role in the development of American pediatrics. He made major scientific contributions to our understanding of acid-base balance, fluid-and-electrolyte metabolism, and intravenous therapy. In searching for metabolic regulatory mechanisms, he and his students helped found the field of pediatric endocrinology. His interests expanded beyond scientific and academic medicine to encompass social and health care reform, aspects of his career that will be only briefly alluded to here because they have been addressed previously.a-3 Like James Gamble, his Harvard mentor and early collaborator, Butler was the product of a privileged upbringing but carved his own path (Gamble was the scion of the Procter & Gamble fortune). Allan Butler was born in Yonkers, New York, in 1894, the son of a prominent Wall Street stockbroker. He had British roots; his uncle, Sir Alfred Booth, was chairman of the board of the Cunard Line steamship company. After graduation from Princeton University in 1916, Butler served in World War I, first as a volunteer with the British infantry and then as an American artillery officer. After the w~, he worked with the Hoover Commission in Poland and then rettmaed to the United States as a bond salesman and labor negotiator, before entering Harvard Medical School in 1922. After graduation in 1926, he worked at the Rockefeller Institute with D. D. Van Slyke and J. P. Peters, and developed a special interest in acid-base balance and fluid-and-electrolyte metabolism. He returned to Harvard in 1928 to work with L. J. Henderson and Gamble at the Boston Children's Hospital, before being appointed professor of pediatrics and chief of the children's medical
Photograph from Crawford JD, Ganz RN. Harvard Medical Alumni Bulletin 1986-87;60:61-3. Used with permission. Reprint requests: Edgar J. Schoen, MD, Department of Pediatrics, Kaiser Permanente Medical Center, 280 W. MacArthur Blvd., Oakland, CA 94611-5693. The Journal of Pediatrics 1996;129:171-3 Copyright © 1996 by Mosby-Year Book, Inc. 0022-3476/96/$5.00 + 0 9/20/64853
The Journal of Pediatrics
service at Massachusetts General Hospital on the eve of World War II. In the early 1930s, Butler began the metabolic balance studies, some in collaboration with Gamble, which helped establish the physiologic basis for modem intravenous fluid therapy.4, s Proper analytic tools were essential, and his biochemical background helped him develop a method of determining the sodium concentration in biologic fluids6; he also devised methods of analyzing plasma proteins and ascorbic acid in plasma and leukocytes. 7-9 Butler used diarrheal dehydration, and later diabetic ketoacidosis, as clinical models for determining fluid and electrolyte deficits and for devising replacement solutions. Metabolic balance studies elucidated the role of intracellular losses of water, potassium, and phosphate, as well as the importance of administering a dilute, multiple-electrolyte solution to replace these lossesJ °, 11 Butler also recommended a two-step protocol for the management of dehydration, initially expanding the extracellular compartment
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with a solution mimicking the plasma electrolyte composition and then giving a dilute, multiple-electrolyte solution to replace both intracellular and extracellular needs.11 He cautioned against intravenous overload of water and electrolytes and, with Nathan Talbot and Jack Crawford, 12 defined the limits of safe parenteral fluid therapy by striking a balance between minimum requirements and maximum tolerance. In his "life raft" studies during World War II, Butler defined the important role of carbohydrates in preventing ketosis and limiting fluid loss, thus establishing an objective basis for proper lifeboat rations. While working with Gamble at Children' s Hospital in the 1930s, Butler realized the critical role of the endocrine system in maintaining metabolic balance. He established an adolescent endocrine clinic and began an association with Fuller Albright at Massachusetts General Hospital to study calcium metabolism and rickets. 13 He described calcification of the tubules in renal tubular acidosis5 and the association of hypertension with renal disease. 14 Although his training was mainly in biochemistry, he became an excellent clinician and was coauthor with Albright of an article describing the association of polycystic fibrous dysplasia of bone, caf6 au lait spots, and sexual precocity (McCune-Albright syndrome). 15 When he moved to Massachusetts General Hospital as chief of the children's medical service, he continued his interest in endocrinology but delegated most of the clinical responsibility in the field to Nathan Talbot, his assistant chief and successor. Under Talbot, the endocrine service grew to include Jack Crawford, Edna Sobel, Lytt Gardner, Juan Sotos, and many others to become one of the leading pediatric endocrine programs in the country. To pediatricians, Allan Butler was an outstanding academician and researcher, but he derived the most satisfaction from his contributions to health care reform. Although not a proponent of state-sponsored medicine, Butler favored group practice with capitation payments, analogous to what we now call "managed care," and he was opposed to the fee-for-service system. This position was radical at the time and placed him in direct confrontation with the American Medical Association. In the early 1950s, an era overshadowed by Senator Joseph McCarthy, Butler's patriotism was questioned. Those of us in training at the time remember his trips to Washington to testify in "loyalty" hearings. Although many of those being attacked were cowed or silenced, he was not intimidated. The trustees of Harvard Medical School and Massachusetts General Hospital were pressured to discharge Butler and others, but, to their credit, the organizations stood by their faculty and academicians. In 1969, Allan Butler won the Howland Award of the Arner-
The Journal of Pediatrics July 1996 ican Pediatric Society, probably the most prestigious prize in academic pediatrics. Butler took great personal interest in his house staff and fellows during their training and in their later careers. He and his wife of 60 years, Mabel, entertained us in small groups at their lovely home outside Boston, and we were invited to their bucolic retreat on Martha' s Vineyard, Tashmoo Farm, where he spent his last days. He died in 1986 at the age of 92 years. Because of the breadth of his knowledge and interests, Butler encouraged his students to enter careers varying from endocrinology and metabolism to community pediatrics. Whether he was discoursing on basic biochemical principles or social issues, Allan Butler was an inspirational teacher and courageous role model who not only helped develop the scientific basis for modem pediatric practice but also stimulated ideas on how to provide high-quality health care to all our children.
Edgar J. Schoen, MD Senior Consultant in Pediatrics Medical Director, Regional Perinatal Screening Kaiser Permanente Medical Care Program Oakland, Calif. Clinical Professor of Pediatrics University of California School of Medicine San Francisco, Calif.
REFERENCES
1. Crawford JD, Ganz RN. Allan Macy Butler 1894-1986. Harvard Medical Alumni Bulletin 1986;60:61-3. 2. Talbot NB. Presentation of Howland Award to Allan M. Butler. Pediatr Res 1969;3:471-4. 3. Schoen EJ. Allan Macy Butler (1894-1986): health care visionary. Eur J Pediatr 1994;153:867. 4. Butler AM, McKhann CF, Gamble JL. Intracellular fluid loss in diarrheal disease. J Pediatr 1933;3:84-92. 5. Butler AM, Wilson JL, Farber S. Dehydration and acidosis with calcification at renal tubules. J Pediatr 1936;8:489-99. 6. Butler AM, Tuthill E. An application of the uranyl zinc acetate method for determination of sodium in biological material. J Biol Chem 1931;93:171-80. 7. Butler AM, Montgomery H. The solubility of the plasma proteins. I. Dependence on salt and plasma concentrations in concentrated solutions of potassium phosphate. J Biol Chem 1932;99:173-95. 8. Butler AM, Cushman M. An ascorbic acid-like reducing substance in the buffy layer of centrifuged oxalated blood. J Biol Chem 1941;139:219-26. 9. Butler AM, Cushman M. Distribution of ascorbic acid in the blood and its nutritional significance. J Clin Invest 1940;19:45967. 10. Butler AM, Talbot NB, Burnett CH, Stanbury JB, MacLachlan
The Journal of Pediatrics Volume 129, Number 1
Schoen
EA. Metabolic studies in diabetic coma. Trans Assoc Am Physicians 1947;60:102-9. 11. Butler AM. Parenteral fluid therapy in diabetic coma. Acta Paediatr 1949;38:59-70. 12: Talbot NB, Crawford JD, Butler AM. Homeostatic limits to safe parenteral fluid therapy. N Engl J Med 1953;248: 1100-8. 13. Albright F, Butler AM, Bloomberg E. Rickets resistant to vitamin D therapy. Am J Dis Child 1937;54:529-47.
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14. Butler AM. Chronic pyelonephritis and arterial hypertension. J Clin Invest 1937;16i889-97. 15. Albright F, Butler AM, Hampton AO, Smith P. Syn drome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. N Engl J Med 1937;216:727-46.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1996 issues of The Journal of Pediatrics are available to subscribers (only) from the Publisher, at a cost of $81.00 for domestic, $103.79 for Canadian, and $97.00 for international subscribers, for Vol. 128 (January-June) and Vol. 129 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-453-4351, or 314-4534351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
Allan Macy Butler (1894-1986) Allan Macy Butler's career spanned the greater part of the twentieth century, and his intellectual prowess, adventurous spirit, and activist nature led him to play a special role in the development of American pediatrics. He made major scientific contributions to our understanding of acid-base balance, fluid-and-electrolyte metabolism, and intravenous therapy. In searching for metabolic regulatory mechanisms, he and his students helped found the field of pediatric endocrinology. His interests expanded beyond scientific and academic medicine to encompass social and health care reform, aspects of his career that will be only briefly alluded to here because they have been addressed previously.a-3 Like James Gamble, his Harvard mentor and early collaborator, Butler was the product of a privileged upbringing but carved his own path (Gamble was the scion of the Procter & Gamble fortune). Allan Butler was born in Yonkers, New York, in 1894, the son of a prominent Wall Street stockbroker. He had British roots; his uncle, Sir Alfred Booth, was chairman of the board of the Cunard Line steamship company. After graduation from Princeton University in 1916, Butler served in World War I, first as a volunteer with the British infantry and then as an American artillery officer. After the w~, he worked with the Hoover Commission in Poland and then rettmaed to the United States as a bond salesman and labor negotiator, before entering Harvard Medical School in 1922. After graduation in 1926, he worked at the Rockefeller Institute with D. D. Van Slyke and J. P. Peters, and developed a special interest in acid-base balance and fluid-and-electrolyte metabolism. He returned to Harvard in 1928 to work with L. J. Henderson and Gamble at the Boston Children's Hospital, before being appointed professor of pediatrics and chief of the children's medical
Photograph from Crawford JD, Ganz RN. Harvard Medical Alumni Bulletin 1986-87;60:61-3. Used with permission. Reprint requests: Edgar J. Schoen, MD, Department of Pediatrics, Kaiser Permanente Medical Center, 280 W. MacArthur Blvd., Oakland, CA 94611-5693. The Journal of Pediatrics 1996;129:171-3 Copyright © 1996 by Mosby-Year Book, Inc. 0022-3476/96/$5.00 + 0 9/20/64853
The Journal of Pediatrics
service at Massachusetts General Hospital on the eve of World War II. In the early 1930s, Butler began the metabolic balance studies, some in collaboration with Gamble, which helped establish the physiologic basis for modem intravenous fluid therapy.4, s Proper analytic tools were essential, and his biochemical background helped him develop a method of determining the sodium concentration in biologic fluids6; he also devised methods of analyzing plasma proteins and ascorbic acid in plasma and leukocytes. 7-9 Butler used diarrheal dehydration, and later diabetic ketoacidosis, as clinical models for determining fluid and electrolyte deficits and for devising replacement solutions. Metabolic balance studies elucidated the role of intracellular losses of water, potassium, and phosphate, as well as the importance of administering a dilute, multiple-electrolyte solution to replace these lossesJ °, 11 Butler also recommended a two-step protocol for the management of dehydration, initially expanding the extracellular compartment
July 1996
17 1
17 2
Schoen
with a solution mimicking the plasma electrolyte composition and then giving a dilute, multiple-electrolyte solution to replace both intracellular and extracellular needs.11 He cautioned against intravenous overload of water and electrolytes and, with Nathan Talbot and Jack Crawford, 12 defined the limits of safe parenteral fluid therapy by striking a balance between minimum requirements and maximum tolerance. In his "life raft" studies during World War II, Butler defined the important role of carbohydrates in preventing ketosis and limiting fluid loss, thus establishing an objective basis for proper lifeboat rations. While working with Gamble at Children' s Hospital in the 1930s, Butler realized the critical role of the endocrine system in maintaining metabolic balance. He established an adolescent endocrine clinic and began an association with Fuller Albright at Massachusetts General Hospital to study calcium metabolism and rickets. 13 He described calcification of the tubules in renal tubular acidosis5 and the association of hypertension with renal disease. 14 Although his training was mainly in biochemistry, he became an excellent clinician and was coauthor with Albright of an article describing the association of polycystic fibrous dysplasia of bone, caf6 au lait spots, and sexual precocity (McCune-Albright syndrome). 15 When he moved to Massachusetts General Hospital as chief of the children's medical service, he continued his interest in endocrinology but delegated most of the clinical responsibility in the field to Nathan Talbot, his assistant chief and successor. Under Talbot, the endocrine service grew to include Jack Crawford, Edna Sobel, Lytt Gardner, Juan Sotos, and many others to become one of the leading pediatric endocrine programs in the country. To pediatricians, Allan Butler was an outstanding academician and researcher, but he derived the most satisfaction from his contributions to health care reform. Although not a proponent of state-sponsored medicine, Butler favored group practice with capitation payments, analogous to what we now call "managed care," and he was opposed to the fee-for-service system. This position was radical at the time and placed him in direct confrontation with the American Medical Association. In the early 1950s, an era overshadowed by Senator Joseph McCarthy, Butler's patriotism was questioned. Those of us in training at the time remember his trips to Washington to testify in "loyalty" hearings. Although many of those being attacked were cowed or silenced, he was not intimidated. The trustees of Harvard Medical School and Massachusetts General Hospital were pressured to discharge Butler and others, but, to their credit, the organizations stood by their faculty and academicians. In 1969, Allan Butler won the Howland Award of the Arner-
The Journal of Pediatrics July 1996 ican Pediatric Society, probably the most prestigious prize in academic pediatrics. Butler took great personal interest in his house staff and fellows during their training and in their later careers. He and his wife of 60 years, Mabel, entertained us in small groups at their lovely home outside Boston, and we were invited to their bucolic retreat on Martha' s Vineyard, Tashmoo Farm, where he spent his last days. He died in 1986 at the age of 92 years. Because of the breadth of his knowledge and interests, Butler encouraged his students to enter careers varying from endocrinology and metabolism to community pediatrics. Whether he was discoursing on basic biochemical principles or social issues, Allan Butler was an inspirational teacher and courageous role model who not only helped develop the scientific basis for modem pediatric practice but also stimulated ideas on how to provide high-quality health care to all our children.
Edgar J. Schoen, MD Senior Consultant in Pediatrics Medical Director, Regional Perinatal Screening Kaiser Permanente Medical Care Program Oakland, Calif. Clinical Professor of Pediatrics University of California School of Medicine San Francisco, Calif.
REFERENCES
1. Crawford JD, Ganz RN. Allan Macy Butler 1894-1986. Harvard Medical Alumni Bulletin 1986;60:61-3. 2. Talbot NB. Presentation of Howland Award to Allan M. Butler. Pediatr Res 1969;3:471-4. 3. Schoen EJ. Allan Macy Butler (1894-1986): health care visionary. Eur J Pediatr 1994;153:867. 4. Butler AM, McKhann CF, Gamble JL. Intracellular fluid loss in diarrheal disease. J Pediatr 1933;3:84-92. 5. Butler AM, Wilson JL, Farber S. Dehydration and acidosis with calcification at renal tubules. J Pediatr 1936;8:489-99. 6. Butler AM, Tuthill E. An application of the uranyl zinc acetate method for determination of sodium in biological material. J Biol Chem 1931;93:171-80. 7. Butler AM, Montgomery H. The solubility of the plasma proteins. I. Dependence on salt and plasma concentrations in concentrated solutions of potassium phosphate. J Biol Chem 1932;99:173-95. 8. Butler AM, Cushman M. An ascorbic acid-like reducing substance in the buffy layer of centrifuged oxalated blood. J Biol Chem 1941;139:219-26. 9. Butler AM, Cushman M. Distribution of ascorbic acid in the blood and its nutritional significance. J Clin Invest 1940;19:45967. 10. Butler AM, Talbot NB, Burnett CH, Stanbury JB, MacLachlan
The Journal of Pediatrics Volume 129, Number 1
Schoen
EA. Metabolic studies in diabetic coma. Trans Assoc Am Physicians 1947;60:102-9. 11. Butler AM. Parenteral fluid therapy in diabetic coma. Acta Paediatr 1949;38:59-70. 12: Talbot NB, Crawford JD, Butler AM. Homeostatic limits to safe parenteral fluid therapy. N Engl J Med 1953;248: 1100-8. 13. Albright F, Butler AM, Bloomberg E. Rickets resistant to vitamin D therapy. Am J Dis Child 1937;54:529-47.
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14. Butler AM. Chronic pyelonephritis and arterial hypertension. J Clin Invest 1937;16i889-97. 15. Albright F, Butler AM, Hampton AO, Smith P. Syn drome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. N Engl J Med 1937;216:727-46.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1996 issues of The Journal of Pediatrics are available to subscribers (only) from the Publisher, at a cost of $81.00 for domestic, $103.79 for Canadian, and $97.00 for international subscribers, for Vol. 128 (January-June) and Vol. 129 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-453-4351, or 314-4534351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.