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American Pediatricians at War: A Legacy of Service

2012; American Academy of Pediatrics; Volume: 129; Issue: Supplement_1 Linguagem: Inglês

10.1542/peds.2010-3797g

1098-4275

Mark W Burnett, Charles W. Callahan,

Medicine, History, and Philosophy

American pediatricians have gone to war for almost as long as pediatrics has been a specialty. A decade after Jacobi, Osler, and Forchheimer founded the American Pediatric Society in 1888, pediatricians, or “pediatrists” as they were sometimes called, were serving with the American military on foreign soil. Across more than a century of service, the role of pediatricians in armed conflict has often been unclear to military and civilian leaders, fellow physicians, and at times even to members of their own specialty. In a 2003 site inspection of an overseas US military treatment facility, the assistant secretary of defense for health affairs was briefed about pediatricians. “Why would we need pediatricians here?” was his reply. Despite the confusion, every major conflict since the Spanish–American War has witnessed American military pediatricians serving in a variety of roles. From Cuba to Kandahar, the beaches of Normandy to Mosul, the century of service continues around the globe and forms the fabric of the story of America’s uniformed pediatricians today.1–3At the close of the 19th century, pediatricians played a very different role than in today’s society. Pediatricians were considered specialists rather than primary care providers for children. There were very few pediatricians in America, and they mostly served in large academic centers or in urban hospitals. Because accurate records of medical specialists were not routinely kept at the time of the Spanish–American War, it is unclear how many pediatricians served in the US military during that conflict.Samuel Walter Kelley was one famous pediatrician whose record of service is known. Dr Kelley spent most of his adult life in Cleveland, where he was a professor of diseases of children in the Cleveland College of Physicians and Surgeons. He worked in Cleveland as both a pediatrist and a pediatric surgeon. He was commissioned as a brigade surgeon with the rank of major on August 17, 1898. After the war, he served as chairman of the Diseases of Children Section of the American Medical Association from 1900 to 1901. In 1909, he published The Surgical Diseases of Children, which was the first text of its kind published by an American author.4 He continued his military affiliation as a member of the Association of American Surgeons and later volunteered his services as a member of the Medical Reserve Corps of the United States Army to both the French and American armies in the World War I, although he was barred re-entry upon active duty due to age5 (Fig 1).Dr John Amesse, a future vice president of the American Medical Association from 1943 to 1944 and a charter member of the American Academy of Pediatrics (AAP), served during the brief period of fighting in Cuba and in the Philippine Insurrection that followed as an assistant surgeon in the Marine Hospital Service—the forerunner of the US Public Health Service. He later served as the first health officer in Havana during the American occupation of Cuba.6 At least 2 other practicing pediatricians, Dr Charles Boyton of Atlanta and Dr Everett Hawes who “served in the U.S. Marine Hospital Corps as an Assistant Surgeon,” also took part in the conflict. A rising star in pediatrics, Dr John Howland, served as an Army physician shortly after his medical school graduation from New York University. Howland worked on the hospital ships that brought troops suffering from typhoid fever from Cuba to New York. A decade later, Dr Howland created the first full-time university clinical department in pediatrics in the United States at the Harriet Lane Home at The Johns Hopkins Hospital in Baltimore.7When the next generation of Americans sailed off to fight in the trenches of Europe in World War I, pediatricians again went with them. Remembered one critic at the start of the World War II: “In the First World War, many of the pediatricians were used indiscriminately in the Army in all sorts of medico-military activities for which their specialized training was unsuited.”8Dr Phillip Moen Stimson, soon to be recognized nationally for his work in contagious diseases, joined the US Army Medical Corps in 1917 after completing his residency at the St Louis Children’s Hospital. He recalled that “In the United States Army in the World War, pediatrists were enrolled in great number, but comparatively few had opportunities to work on the contagious diseases.”9Dr Stimson served initially with the British forces in Flanders and was wounded in action when a piece of shell fragment hit and dented the brim of his helmet. He is thought to be one of the first American medical officers wounded in World War I. After his recovery, he served with the British 25th Stationary Hospital in Rouen, France, and finally with the American Red Cross Military Hospital in Paris. He later authored A Manual of Common Contagious Diseases, one of the classic infectious-disease texts of the time until its final edition in 1956.10A number of other pediatricians stood out for their individual service. Dr John Amesse continued his wartime service begun in the Spanish–American War by serving as a lieutenant colonel in the Army Medical Corps. He first commanded Base Hospital No. 29 organized by the Medical School of the University of Colorado, then was transferred to Base Hospital No. 15 in France where he served until the war’s end.6 Major James H. McKee, a pediatrician from Philadelphia, became one of this country’s first military flight surgeons serving in the United States Army Air Service. After the war ended, he also became one of the first Americans to fly from coast to coast, with a squadron commanded by Colonel “Hap” Arnold, who was later to become the only 5-star general in the history of the Air Force.11Dr Edward Clay Mitchell, a busy pediatrician in Memphis, Tennessee, was appointed commanding officer of Base Hospital No. 57 in Rheims, France, where he served in the Army Medical Corps in the rank of colonel. He later established the first American military hospital in Paris and gave lectures on pediatrics at the Sorbonne. For his efforts in France, he was awarded the French Croix de Guerre with Palm medal. Returning to the United States, he resumed his pediatric practice and became a charter member of the AAP. He later served as its president and as the chairman of the Pediatric Section of the American Medical Association.12Two other future founding members and presidents of the AAP served in the “War to End All Wars.” Phillip Van Ingen enlisted as a captain shortly after the declaration of war by the United States in 1917. By war’s end, he had been promoted to lieutenant colonel serving in France and Italy in command of Field Hospital No. 331, receiving La Croce al Merito di Guerra from the Italian government for his meritorious service.13 Dr Borden Veeder, a St Louis pediatrician who was on staff at the Washington University Medical School, deployed with Base Hospital No. 21, becoming the hospital’s commander by war’s end (Fig 2). Dr Veeder would later direct the wartime efforts of the AAP as one of its presidents during World War II, then go on to become editor of the Journal of Pediatrics during the postwar years.14 One of his staff physicians and fellow pediatricians at Base Hospital No. 21, Captain Hugh McCulloch, would later go on to be the founding editor of Pediatrics.15Two other pediatricians who were soon to be nationally known, Dr A. Graeme Mitchell and Dr Rustin McIntosh, served early portions of their medical careers during World War I. Dr Mitchell, soon to publish one of the preeminent texts on pediatrics, Diseases of Infants and Children, served with the American Expeditionary Force in France and Germany, finishing the war in the rank of major.16 Dr McIntosh, who would go on to be a long-term director of the Columbia-Presbyterian Medical Center in New York City, served for 3 months on the front lines with the 5th Marines before the war ended. He was then assigned to a translation bureau of the American Commission to Negotiate Peace.17Detailed records of wartime experience were left by other pediatricians. Captain Marshall Pease joined the American Expeditionary Force in April 1917 with a group of fellow physicians from the New York Post Graduate Hospital. His letters home and the tales they contained were later chronicled in book form, including his care of a French child dying of tuberculosis.18 In a letter to his old college newspaper, the Beloit Alumnus, he reported that “meningitis, diphtheria, pneumonia, dysenteries, and the many other infectious diseases, some of which are rare and some of which are feared, call for much investigation and instant action.”19The story of Wilburt C. Davison, who was to become the founder and first dean of the Duke University Medical School, as well as one of the nation’s most well known pediatricians, may be the most incredible of the wartime doctors’ tales. Davison won a Rhodes Scholarship in 1912 and entered Oxford’s Merton College as a medical student in 1913. At Merton, he became a friend of Sir William Osler and was often a guest at his home for dinner. With a letter of introduction from Osler and a year of medical school under his belt, Davison was given a position at the American Red Cross Ambulance Hospital in Neuilly, France. Over the course of his 6-week winter vacation of 1914–1915, he worked his way from being an orderly to being a wound-dresser to being an anesthetist.Taking a leave from classes at the end of his vacation, Davison accompanied a volunteer medical group to go to Serbia and care for patients during the worst typhus epidemic of modern times. Traveling back through Italy and Austria, he was later detained and interrogated when his group reached the German border. Allowed to leave with 2 soldiers as guards, Davison and his other American colleagues were able to slip their escorts and travel through Germany freely. In this time period before the American involvement in the war, they were even able to visit German military hospitals.From a German officer, the group learned of imminent German plans to use poison gas on the battlefield. Making their way through Holland and secretly back to England, Davison reported this information to the British authorities, but the threat was not acted upon. Ten days later, the Germans used chemical weapons successfully for the first time at Ypres, Belgium. Dr Davison returned to and graduated from Johns Hopkins in 1917. He returned to France as a first lieutenant with the American Expeditionary Force serving for the remainder of the war.20In the presidential address before the Twelfth Annual Meeting of the AAP in Chicago on November 7, 1942, then-president Mitchell remarked that “The history of World War One records great accomplishments by the medical profession and certain specialist groups. The contributions of pediatricians, however, not as individuals, comprise an unwritten chapter in that history. Future historians may be able to pass on to posterity a better record of achievement on the part of the pediatric group of this era.”21 Sadly, no complete record of pediatricians serving in the military during this conflict was ever compiled, and much of the story has been lost forever.The world was again engulfed in war two decades later, and America mobilized its resources for its seemingly inevitable involvement. There was dispute as to how pediatricians could best serve their country. Several of the founding members of the AAP and a number of past presidents were veterans of military service in World War I. Not all believed that their medical expertise had been used wisely in that conflict. The pre–World War II Army had no pediatrician serving on active duty. Care was provided to dependent children in the local community or in some instances by Army general practitioners as a part of their additional duties.One potential role for pediatricians became clear as soldiers were inducted into the Army and exposed to a range of infectious diseases. In an address before the Tenth Meeting of the AAP in Memphis in 1940, World War I veteran Dr Philip Stimson discussed what he had witnessed in his time in the service in that war: “It is not widely known that mumps, measles, scarlet fever and diphtheria between them caused a loss of almost six and a half million days of availability of United States soldiers in the last World War. . . . In fact, in 1918, the speaker was on duty at a British hospital for Contagious Diseases at Rouen, in France where at one time he had soldiers from eleven different nations as his patients in a single large ward for mumps.”In discussing the American experience, he related that “Boys who have grown up in backwoods districts, on farms, or in other rural communities have usually never been exposed to any such infections, and when thousands of these rural young men are first massed together in army camps, contagious diseases are apt to be very common. Therefore, in 1918 some army camps actually had relatively 100 times as many cases of a disease as did other army camps. It is in the hospitals of such camps where pediatrists can be useful.”9An anonymous editorial published as the lead article of the February 1941 issue of the Journal of Pediatrics suggested that AAP members should serve their country in a different manner. “In this time of national organization for the defense of American life and freedom, the question is frequently asked among ourselves as to what the pediatrician can do to help. On every side we find colleagues in other special fields, as surgery and its subspecialties and psychiatry, organizing to give their best knowledge to the new army which is being developed and to prepare technically for a war we do devoutly hope will never take place. The early days of American participation in the World War in 1917, when army medical preparedness was quite a different thing than it is today, found many pediatricians entering army service, and name after name of men of the older group comes to mind, who served in the field, or with field ambulances and hospitals, both abroad and at home. Not a few rose to positions of responsibility . . . . While in case of war, a number of pediatricians will enter military service either for the element of adventure, or in order to maintain a certain necessary self-respect arising from the dictates of their emotions, clear, hard, unemotional thinking leads definitely to but one conclusion. The trained pediatrician has a much more important function in the warfare of today than military service with the army or navy. It has been demonstrated clearly in the last year that war today is a total war, involving the civilian population as much as the troops in the field. To win a war, it is as essential to maintain the morale and health of the civilian population as it is to maintain the health of the troops or to care for the wounded after battle. Here, we sincerely believe is the field in which the pediatrician, because of his particular training and sphere of work, can be of most service. It is along these lines that our thoughts should be directed and our organization be pointed. The problem of the child and child health has been a major one in every country so far involved in the war. The pediatrician with his store of technical knowledge relating to child health and welfare can best help the nation as a whole by directing his efforts toward meeting the terrible situations which the warfare of today brings to the children of a nation at war or overrun by the enemy.”22Also recognized were the problems of human migrations that the war was causing, both for service members and for wartime plant workers and their families. An article in the Journal of Pediatrics in winter 1941 summed up the problem: “Migration of families has increased very greatly, with all its concomitant hazards to the health and welfare of children . . . . I do not need to tell you what life in a trailer camp means to children or to their mothers when a one room trailer becomes their permanent family dwelling place. . . . Add to this the withdrawal of physicians, including pediatricians, and the civilian population to enter the Army or Navy, and the situation becomes still more difficult to handle.”23At the AAP’s annual meeting in Boston, a “Symposium on the Role of the Pediatrician in National Defense” was held in October 1941, just 2 months prior to the attack on Pearl Harbor. Dr Stimson remarked that “It seems advisable to try and have pediatricians spared from being used as regimental medical officers, hospital supply officers and the like in the present emergency, but rather to keep them available to support civilian needs. Men especially trained in contagious diseases and in the field of nutrition could be of value to the armed forces . . . .”8Dr Davison, at that time the chair of pediatrics at Duke University, spoke from experience on how pediatricians could fit in the national defense program. In his article “Reduction of Communicable Diseases among Troops and Children during National Defense Program” published in the American Medical Association’s new journal War Medicine, Davison commented: “One in every 133 in the military services (of the United States in WWI) died of infectious disease. Judging by the experience of the last war, the best and most efficient way of utilizing a pediatrician is as a medical officer in the field of infectious disease. Training in pediatrics does not fit the physician for any other type of military duty unless as a mess or lab officer . . . . Therefore, whether pediatricians serve as medical officers with troops or practice as civilians with children, they must concern themselves with the reduction of communicable diseases, or preventive pediatrics.”“To reduce this incidence of infectious diseases in troops, pediatricians would recommend the adoption of the preventive measures which have been found to be efficacious in children. Some of these precautions at present are being used in the Army and Navy, but more of them should be applied. To be specific, as soon as a recruit is inducted into service he should have Schick, Dick, tuberculin and Wassermann tests, be vaccinated against smallpox and be inoculated with typhoid-paratyphoid vaccine and tetanus toxoid. . . . Alternate recruits should receive influenza vaccine in order that data on its immunizing value may be collected.”Dr. Davison closed his treatise with this recommendation, “During the last war, Brig Gen J.M.T. Finney served as consulting surgeon and Brig Gen W.S. Thayer as consulting physician. Perhaps in the present emergency, a consulting pediatrician who has had experience in preventing communicable diseases should be appointed. In the light of the figures on the frequency of children’s diseases in the Army and Navy during the last war, this suggestion is not as foolish as it may seem.”24By 1942, in the aftermath of Pearl Harbor and America’s declaration of war on the Axis powers, any hope that pediatricians could choose their assignments in the military had disappeared. AAP president-elect and war veteran Borden Veeder summed up the consensus feelings in his remarks at an AAP luncheon in summer 1942: “The first duty of the medical profession in a war such as this, whose outcome will determine our survival, is to the military forces . . . . Some sixteen months ago, almost a year before Pearl Harbor, before either you or I or anyone else knew what was in store for us, an editorial was drafted, approved by the Editorial Board, and published in the February, 1941, issue of The Journal of Pediatrics which stated that warfare today was a total warfare and that the pediatrician would probably be of more value in civilian life than in service. None could foresee at that time the extent to which this world madness would reach. Today the situation is different. I am sure, although I have not consulted with them, that the group who thought as I did then, would agree that our first essential duty is to win the war and that only an overwhelming military force can bring this about, and all else must be subordinated.”A second speaker, Major Robert Bier, member of the AAP and an assistant in the Medical Division of the Office of Selective Service, added these remarks: “The Army is in dire need of thousands of additional physicians to serve in their forces, and a somewhat smaller number is needed by the Navy . . . . It would appear to be unwise for any young physician, especially for the pediatrician, to attempt to start practice . . . . There are a few permanent stations where the attending physician is called upon to care for children of the post, but the needs in this respect are either filled or so small as to be discounted. For all practical purposes, there will be no pediatricians in the Army. Many of the younger pediatricians in practice and postgraduate training have complained that if they go into the Army for several years, they will forget their special training. If a pediatrician forgets in a few years of Army medicine all of the pediatrics he has learned to date, it does not speak well for his mental ability or interest in the specialty.”25By late fall 1942, 162 of the 1496 members of the AAP were serving in the military, along with “many pediatricians who are not yet eligible to the Academy who are now in the Army or Navy.” Dr Edward Clay Mitchell, Great War veteran and outgoing president, pledged “to offer the services of pediatricians to our country with no restrictions.”21 From June 1942 until June 1947, the Journal of Pediatrics, then the “Official Organ for the American Academy of Pediatrics,” published a monthly to bimonthly listing of AAP members in the service. Never before and never since has the AAP been so forthright with its support of its members serving in the military. AAP dues were not to be assessed against fellows while they were on active duty and for 1 year after their release from the service. Fellows in the military could continue to receive the Journal of Pediatrics for a discounted annual fee of $5.00 per annum. Candidates for examination for the American Board of Pediatrics could substitute 1 year of military service for 1 of the 2 required years of pediatric practice or continued study.For the first time in its history, the annual meeting of the AAP was cancelled in fall 1943 “in order to help the railroad transportation problem brought about by the war and the shortage of physicians in civil life.” Dr Veeder’s presidential address, published in the December issue of the Journal of Pediatrics, updated the situation of pediatricians in the war effort. “Pediatrics, we must realize, is not a medical specialty closely related to military medical efforts. Despite the fact that there is no particular place for the pediatrician as a pediatrician with the Armed Forces, 310 Fellows of the Academy, nearly 22 per cent of our membership are in the service. This is a high figure when we consider that only between 3 and 4 per cent of our membership are under 35 years of age, and 35 per cent are in the 35 to 45 year age group. There are, of course, many more pediatricians than this in service, as over 2,100 pediatricians have been certified by the American Board of Pediatrics. A very large portion of the 600 odd certified by the Board and eligible to Academy membership but are not members are in service. Of the men in service, a few have been assigned to contagious disease and sanitary service, and a very few are actually practicing pediatrics in Army and Navy camps. Letters from all over the world have crossed my desk from pediatricians doing a wide variety of medical military duties. Even if pediatrics is a specialty that does not fit directly into the medical picture of military organization, there has been ample demonstration of the spirit of the physician whose medical work is with children, and we can look with pride on our associates who have entered service.”26The roles that individual pediatricians played in the war effort were quite varied. Some pediatricians had small roles in the conflict but later went on to prominence nationally. Dr Benjamin Spock, rejected for Army service due to a previous pneumothorax, joined the Navy in 1944 and served as a psychiatrist at military hospitals in the United States until 1946. During his free time in the service, he wrote what was to become one the best-selling American books of all time, The Common Sense Book of Baby and Child Care, published in 1946 just in time for the postwar baby boom.27 Dr Julius Richmond volunteered his efforts and served as a flight surgeon stateside in the Army Air Forces Training Command from 1942 until 1946. He later was appointed as the first director of the national Head Start program and went on to become the 12th Surgeon General of the United States.28Other pediatricians played more substantial roles during the war. Captain George Lyon served as the chemical warfare officer on the staff of Commander, United States Naval Forces, Europe. He was “chiefly responsible for the training in defense against chemical warfare of the Naval forces organized in the United Kingdom for the assault on North Africa, and organized the program of instruction for all Naval personnel engaged in the operations against the coast of France.” He was awarded the Bronze Star by the commander of United States Naval Forces, Europe, for his efforts.29 Dr Harry Gordon served as the assistant chief of the Medical Service and was in charge of the tropical disease section of the sprawling 3000-bed Harmon General Hospital near Longview, Texas. Dr Gordon went on to serve on the editorial board of Pediatrics and to publish more than 100 papers in neonatology and developmental pediatrics.30 Dr Horace Hodes served as the officer in charge of the Virus Laboratory, US Naval Medical Research Unit No. 2 in Guam. In Guam he did seminal work with Japanese encephalitis and later in civilian life was a part of the research group to isolate the first known cause of viral diarrhea in humans, now known as rotavirus.31In this conflict, the first female pediatricians served on active duty in the military. Dr Anna Hays and Dr Joyce Hartman both served as lieutenant commanders in the United States Naval Reserve (USNR). Dr Marion Josephi finished her career as a commander in the USNR.Several other physicians served whose names, but maybe not wartime careers, are familiar to members of the Section on Uniformed Services of the AAP. Dr Leo Geppert was commissioned as a second lieutenant in the US Army in 1941. During the war, he served as both the executive officer then commander of the 309th Medical Battalion, which was attached to the 84th Infantry Division during the Battle of the Bulge. After the war, Dr Geppert had a distinguished career in Army pediatrics. He established the first pediatric service at an Army hospital at Brooke Army Hospital in 1946. He later served as theater consultant in pediatrics, Armed Forces of the Far East, then after stints as chief of pediatrics at Walter Reed and again at Brooke, he retired from the service in 1964.32One of the most recognizable names in military pediatrics is that of Ogden Bruton. In 1940, he was conscripted as a reserve officer to serve 1 year in the expanding peacetime Army. His conscription launched a 21-year career in the Army that took him around the world, from Washington, DC, to Germany to Panama and to Hawaii. In 1946, he became the consultant to the Army Surgeon General for pediatrics and was tasked with improving the health and safety of the infants of “war brides” as they made their passage to the United States from Europe. The importance of this mission was made even more urgent as an epidemic of diarrhea sickened 19 and resulted in the death of 6 infants on the US Army transport ship Zebulon B. Vance.33,34In spring 1948, again at the behest of the Army Surgeon General, Dr Bruton inspected the pediatric care facilities of the US Army in occupied Germany and Austria. Returning to the United States, Dr Bruton led the efforts to create the Army’s first pediatric training program at Walter Reed. It was during his time at Walter Reed that he published his landmark work on the disease that now bears his name, Bruton X-linked agammaglobulinemia, based on observations he made in the care of a “military dependent.”Much of the historic record of the pediatricians who bravely served in World War II has departed with the memories of those of the “Greatest Generation.” There are a few who served whose heroic wartime exploits have been documented. Dr William Wallace, a future driving force in the expansion of the Rainbow Babies and Children’s Hospital in Cleveland, served 4 years as an infantry battalion surgeon and took part in the North African Campaign, the invasion of Sicily, the landings in Normandy, and the Army’s final push into Germany.35 Saul Krugman, who would go on to be one of the most well-known pediatric infectious disease physicians in America, joined the US Army Air Corps in June 1941. He served until 1946 as a flight surgeon earning the Bronze Star. In one 13-month period alone, from August 1944 until September 1945, Dr Krugman flew more than 115 000 miles—mostly aeromedical evacuation missions.36 The August 1946 issue of the Journal of Pediatrics gives an account of the Bronze Star awarded to Lieutenant Harold A. Rosenberg of the USNR. The citation was made for “meritorious services in connection with operations against the enemy as a medical officer attached to a Marine Air Base in the Ryuku Islands, during the period April 5 to June 7, 1945.” Lieutenant Rosenberg, the citation read, “rendered extremely valuable service in the treatment evacuation of wounded personnel, frequently facing great danger in the performance of such duty. His courageous devotion to duty, tireless efforts and high professional skill contributed materially to