Heritage Corner: Happy Birthday, Nelson!
It’s been called the “bible” of Pediatrics. During the pre-Internet days, it was among the most frequently consulted pediatric reference books, probably second only to the Red Book. This was the “Green Book”: Nelson Textbook of Pediatrics. Now in its 21st edition, this venerable tome marks its 100th birthday this year. Its origins have some interesting Cincinnati Children’s connections.
The book’s direct ancestor was called Diseases of Infants and Children and was written by Dr. J.P. Crozer Griffith at Children’s Hospital of Philadelphia in 1919. It was so well-received that, by 1924, a new edition was being planned, and Griffith brought in his protégé as co-author: Dr. A. Graeme Mitchell. That name should ring a bell: In 1924, Mitchell was recruited from Philadelphia to become Chair of Pediatrics in Cincinnati. These were exciting, transformative times for Cincinnati Children’s, the years when Board Chair and visionary William Cooper Proctor facilitated the relocation of the old private Children’s Hospital to its current site and established organizational ties to the medical college.
One might think that, having been tasked with opening a new hospital, expanding the faculty, and creating a research center, Mitchell would have had no time to re-write a comprehensive textbook. But he was a man of boundless energy who loved to be busy. It’s been reported that Mitchell used the five-minute breaks between meetings to dictate his notes on textbook revisions or to read galley proofs, often working with his secretary on this project until 2 am. The revised textbook was released in 1927, and Mitchell not only made plans with Griffith to publish the next edition in four years, but seriously considered writing a smaller pediatric text completely on his own
Mitchell was practical enough to realize that his many duties required the help of able assistants. One of his first hires, in 1928, was Waldo “Bill” Nelson, fresh out of his pediatric residency at UC. Nelson was a brilliant clinician but was also known for his organizational skills. He quickly became Mitchell’s right-hand man, the person who could “put out fires” so that Mitchell could keep one step ahead of his many responsibilities, including writing.
Mitchell co-edited four volumes of the textbook, all the while expecting the aging Dr. Griffith to eventually step aside and make him the sole editor. But this never happened. They both died—Mitchell somewhat unexpectedly—in 1941, the year that the book was renamed Textbook of Pediatrics.
It has been said that Mitchell “bequeathed” the editorship of the textbook to Nelson, but his valued colleague had left Cincinnati in 1940 to become Chair of Pediatrics at Temple University. Apparently, it was with great reluctance that Nelson agreed to take on the 1945 edition, the first to bear his name. But once he’d decided, he plunged in with both feet. This so-called “4th edition” sold six times as many copies as its predecessor and would go on to become the best-selling medical text of all time. A key reason for its success was that it read as if it had been written by a single person, instead of what would eventually be hundreds of contributors. Nelson was renowned for his tough scrutiny and attention to detail that went into this and all subsequent volumes for which he served as editor or consulting editor.
Even a casual side-by-side assessment of volumes spanning the century reveal both the textbook’s consistent style as well as the dramatic changes that have taken place in our profession. Of course, the number of pages has more than doubled over the years, but the organization of the material is fairly consistent.
The first sections deal with growth and development, nutrition, care of the newborn, including preemies, and infectious diseases. The second half covers system-specific conditions. In the early editions, the “Clinical Findings” sections contain long, florid descriptions, but the “Treatment” sections are often quite short. There were no treatments or, at least, effective treatments. Children were prescribed “tonics” for just about anything; these included cod liver oil, iron, arsenic and strychnine!
The early editions devote over 100 pages to infant nutrition, including many recipes for home-made formulas and instructions on “how to pasteurize cow’s milk at home.” Fifty years later, this same section is half as long and covers primarily nutritional deficiencies. Currently, this section is over 200 pages long and discusses genetic and metabolic disorders, most of which were unknown a century ago.
The oldest editions of the textbook devote over 30 pages to the diagnosis and treatment of diphtheria (including instructions on how to intubate a choking child); 50 years later, this disease merited only five pages, and currently, only one. Vaccines work!
A century ago, the average life expectancy of a child with leukemia was 6 to 8 weeks. Cyanotic congenital heart conditions were fatal. Meningococcal meningitis was sometimes treated with intrathecal horse anti-serum; occasionally, it actually seemed to work, although the disease had a 75-percent mortality rate with a 50-percent incidence of neurological sequellae.
The analgesic, antipyretic and anti-inflammatory effects of aspirin were known 100 years ago, but sponging remained the preferred treatment for fever. “Asthmatic bronchitis” was treated with epinephrine and oxygen. Even as recently as 50 years ago, oral Theophyllin was the mainstay of treatment for asthma; the efficacy and comparative safety of beta-2 adrenergics, inhaled steroids and leukotriene inhibitors were yet to be demonstrated. The discovery of insulin in 1922 was, of course, the first big breakthrough in the management of diabetes, but it was many years before the strict “diabetic diet” was discarded in favor of individualized insulin injections; use of the insulin pump and monitoring of HA1C are relatively new developments.
A century ago, physicians were not even sure that strep was the cause of scarlet fever. The early textbooks are full of tantalizing speculations as to the cause of common conditions: Rickets often occurs in the winter in dark-skinned children, suggesting a role for sunlight. But what? Why do some newborns develop “familial icteris gravis,” a pathological form of jaundice associated with hemolysis? What could cause the simultaneous development of such diverse symptoms as arthritis, endocarditis, chorea and rash?
One thing that hasn’t changed is an emphasis on prevention. In the early years, this involved good nutrition, basic hygiene, clean air and quarantine. We still recommend most of those modalities today, plus, of course, routine immunizations.
Nelson enjoyed a long and distinguished academic career, during which he served as editor or consulting editor for 12 editions of the textbook that bears his name. From 1959 to 1977, he was also the editor of the Journal of Pediatrics. He visited Cincinnati on many occasions, often to accept awards. His last visit was in 1995 when the Mitchell/Nelson Library was dedicated in honor of him and his mentor. He passed away two years later, at the age of 98.
A complete collection of these textbooks, from 1919 through 2011, can be found today in our library, along with the glass-front bookcases that once graced Nelson’s home. They make for absolutely fascinating reading!
-- M. Elaine Billmire, MD
