E. Nelson, MD (1898–1997) Giant of Pediatrics

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Waldo E. Nelson, MD (1898–1997) Giant of Pediatrics

Vincent A. Fulginiti, MD

University of Colorado Health Sciences Center, 4260 North Osage Drive, Tucson AZ 85718, USA

E-mail address: vfulginiti@comcast.net

How to describe a man who was mentor to many, editor supreme, taskmaster, husband, father, grandfather, great grandfather, and overall a powerful influence on pediatric education and clinical care in the world? One could simply recite his biography and accomplishments but that would simply be the facts; underlying them is a force in pediatrics felt even today by his disciples throughout the world and continual publication of his seminal text and the journal he devoted his expertise to for many years. Perhaps the best way to start is to discuss this influence and force and then give the so-called backstory of his personal and professional life.

If one looks at current pediatric education and practice, one must consider what influences the educational process and the professionals in this discipline. Today, most learners in medical schools use the Nelson Textbook of Pediatrics as the Green Bible for comprehensive coverage of available knowledge. Most of us who were educators used this text as the basis for our students to learn about the art and science of pediatrics. For Dr Nelson, it was a labor of both love and dedication. Dr Nelson described its genesis in a note to his grandson, Ted, son of Jane Nelson Beatty. After describing his mentor and prior editor of the Textbook of Pediatrics, A. Graeme Mitchell, he goes on to state the reasons he should not be the editor, “1. I did not feel competent, 2. I had just assumed the chairmanship of the Department of Pediatrics at Temple and did not have the time, and 3. Not the least, that having come from a department where the textbook was published, I felt I would lose the respect of those in the pediatric world, whose friendship I valued, if I accepted such an offer.” Most of us who knew Dr Nelson do not believe any of these reasons. He was competent, he always did what was required and found the time, and taking on the task of upgrading and modernizing that text gained him more respect and friendship than he could even imagine. To the great delight of the pediatric world, he was urged to overcome his objections and to accept the assignment. He further states, “…I had the advantage of being solely responsible for the reorganization of the book. On this basis I started anew and selected contributors for those sections I did not feel comfortable in handling myself.” The rest of the story is known to all of us in pediatrics. He did change the nature of textbooks by insisting on multiple authorships by experts in a given area, in contrast to the previous efforts that had been a single authorship modified only by consultation with experts. He also made clear that although the content was the author’s area of expertise, “…material would be edited in order to maintain throughout the book a similarity in style of writing.” Those of us who participated learned what that meant. I can recall one submission of mine that I thought contained prose for the ages. When returned to me there were more words in the editing than I had written. The effect was enormous; the text caught on and became the sole authoritative source for thousands upon thousands of students of pediatrics the world over. Even today, many decades after his last editorial efforts, and 23 years after his death, students and practitioners refer to it for clear, concise, and lucid expression of almost all aspects of pediatrics.

Not to be forgotten was his family’s influence in making the book the ideal that it was. His wife Margery contributed mightily to the editing process; she was an accomplished grammarian and stylist and was the behind-the-scenes editor along with her husband. All of the family was involved. Dr Nelson said, “It was a hot Sunday in late summer of 1953. The long aluminum table had been set up in the living room and I faced ‘the three gals,’ Jane, Ann, and (Margery), with page proof in hand.” This scene was duplicated with each edition, with manuscripts strewn throughout the house, not just on the table. In the inscription for the fifth edition, he wrote, “Recognizing that children, like adults, prosper under the stimulus and responsibility of a task to be done, WE ACKNOWLEDGE the contributions that this book has made to JANE, ANN, AND BILL in providing them such privileges and the satisfaction in family living which has come from group activity.” Dr Nelson indicated that his role was “to edit for content, manner of presentation, and style.” Then Margery took over and determined if he had altered the author’s intent, edited his editing, and constantly searched for brevity in expression. It was truly a partnership of successful editing.

The success of the text is remarkable. It is used worldwide, has been translated into multiple languages, even obscure ones, and is read avidly by students. It is also used as a reference manual by experienced practitioners who seek complete, authoritative information about a given condition. I personally have used it that way more times than I can count.

Dr Nelson also gave credit to all those who contributed, including his family and his colleagues at St Christopher’s. In fact, that was a consistent trait; he always acknowledged other’s contributions in any arena in which he was involved. He was a tough taskmaster, some might even call him a martinet, but all who were associated with him came to appreciate that discipline and it often forged spine in their own activities and a sense of integrity, hard work, and dedicated purpose. Dr Nelson was a mentor to many throughout the world. He gathered a remarkable faculty at Temple/St Christopher’s Hospital for Children: men and women who were dedicated teachers, experienced clinicians, and avid researchers in bedside medicine and in the burgeoning laboratory emphasis on research in the 1960s and beyond. My own experience was in this early period as a student at Temple, a resident at St Christopher’s, and a colleague thereafter as I moved through my own career. I was asked to give a talk on the occasion of being selected as a St Geme awardee by the Federation of Pediatric Societies. My theme was mentoring and here is what I said about Dr Nelson:

Bill Nelson offered a model of unselfish, dedicated service to the profession, service that was totally child oriented. To all of his students, he stressed the appropriate application of skills, our duty to respond, and other aspects of pediatric care. He left those he mentored with inspiration to apply their best efforts always, without regard to self, and with an intense energy devoted to their professional responsibilities.

By those words, I was attempting to characterize the complex relationship Dr Nelson had with those he mentored. When one considers the persons who came in contact with him as students, residents and faculty, one can see the positive results of his influence. For example, he mentored several individuals who became department heads, deans, and academic educators and administrators, carrying the messages learned with him into another realm of those mentored. This mentoring put the stamp of Dr Nelson’s influence on an even greater range of health care workers than by his own direct contact. Angelo DiGeorge, one of Dr Nelson’s faculty and lifelong, dedicated friend, presented the introduction to the Howland Award of the American Pediatric Society and said this of his boss: “To work for him was like joining a monastic order, one took vows of poverty, dedication and self-denial. As a consequence the perceptive medical student’s sobriquets for the hospital became St Waldo’s.” Dr DiGeorge went on to say, “inculcating his staff and students in his values has far outweighed the pain of self-denial.”

A word about his personality: I have alluded to his strict taskmaster attitude toward the work of pediatrics. All of us have felt his stern admonitions and can relate anecdotes about such encounters. He appeared emotionless to many and his sharp assessments sometimes stung. But as I have looked at those who eulogized him and recounted this characteristic, all have pointed out that his treatment of them, harsh as it seemed at the time, was not only justified, but led to a better performance than might have occurred otherwise. His daughter, Jane, also indicates that this characteristic did not end with his professional associations but extended to his family as well. One must understand that Dr Nelson’s critique was always based on love, respect and a desire for those he interacted with to be the best they could be. His stimulation of their efforts sometimes seemed harsh and martinetlike, but he always lauded their talents, skills, and accomplishments, both of his own family and the St Chris family. I can personally attest to this as, at each junction of my academic life, he sent me a message of both approbation and a stern note to do my best, better than I had done before.

His editing style was also severe, as I have alluded to earlier. His role was not just as a text editor but as the Editor of the Journal of Pediatrics. He assumed this position in 1959 and continued until 1977, often with the able help of one that he had mentored, Joe Garfunkel, who succeeded him as editor. The journal rapidly rose in prominence under his editorship. Prior to his taking this position, the journal received only 200 manuscripts annually; it soon reached 1600 and the quality of submissions and publications improved dramatically. He ultimately worked 50 to 60 hours a week on editing and other necessary duties of his position. Dr Garfunkel wrote an editorial upon Dr Nelson’s death and said, “Within a few years the journal was receiving more manuscripts than any other pediatric publication, and both circulation and readership had grown steadily.” He also noted that Dr Nelson’s editorial style contributed to the clarity and expression in the published articles. Even after his retirement he continued to contribute to the journal as emeriti and defined the definition of emeritus as “no one pays any attention to you anymore.” Dr Garfunkel indicates he attended every board meeting and offered advice and occasional editing during the 18 years Dr Garfunkel was editor.

Now for the backstory

Dr Nelson was born in 1898 in McClure, Ohio, a town of 600. His father was a pharmacist, general store keeper, and postmaster. His mother fed and kept track of 7 sons and initiated and ran the only movie theater in town. He was named after Ralph Waldo Emerson but as with many children he did not like fancy names, so he insisted on being called Bill, which stuck for his lifetime. (Note: Most of us who were associated with him could not call him Bill even after he insisted and we had achieved mature status; it just seemed wrong, so we always called him Dr Nelson). After high school he wanted to go into finance; he applied to the Wharton School, was accepted, but could not attend for lack of financial resources. So he went to work as a mail clerk and office boy at the Willys-Overland plant in Toledo, Ohio. He sold peaches and insurance subsequently and the Saturday Evening Post and the Country Gentleman. He won a prize for selling the most Curtis Publications in Northern Ohio. As an accomplished salesman he sold fender braces, ordered from a Chicago mail order house, installed them on a car and asked for $1 for them (he paid $0.33 for each). In college at Wittenberg he became a steward at his fraternity and helped it climb out of a financial hole.

In 1917 he enlisted in the army and the next year entered the Student Army Training Corps at Wittenberg College. On his first night there he met another student, Marge Harris, whom he married after a 7-year engagement. When he finally married Marge she was teaching high school math in Illinois and he was beginning his final year of residency. His daughter Jane reports that he always wondered if they should have married earlier in the relationship. Marriage to Marge was eventful in later life as she was a professional helper in editing, as already pointed out, but also took advantage of Dr Nelson’s many invitations to visit former students and admirers across the world. They traveled extensively with Marge researching each trip’s possibilities. She was born in India to Lutheran missionaries and this may in part account for her wanderlust. Their travels included Europe, Japan, India, China, Iran, Greece, Turkey, Egypt, Spain, Argentina, Brazil, Hawaii, and many other places. Often his host was a former resident at St Christopher’s; Dr Nelson insisted on having excellent foreign students each year and they were integrated into the St Christopher’s family along with US trained residents. Upon leaving St Christopher’s and returning home, they would invite him to visit and speak. Hence, the many sites around the world that the couple visited. When traveling abroad they took time to write detailed letters back to their children and some to the faculty at St Christopher’s.

Dr Nelson attended medical school at Cincinnati College of Medicine graduating in 1926. He then became an intern and resident at Cincinnati General Hospital and the new Cincinnati Children’s Hospital. He came under the preceptorship of A. Graeme Mitchell, then a giant in pediatrics and author of the text that was to become Dr Nelson’s hallmark later. In a few years he became a member of the faculty and participated in the growth of the department into a major force in American pediatrics. There was a new model for academicians, the combination of teaching, clinical care, and research, which Dr Mitchell pioneered and in which Dr Nelson was his right hand man. Dr Nelson became interested in tuberculosis, diabetes, and nephritis. He developed clinical activities for each of these diseases and conducted clinical research, publishing a series of articles on each in the pediatric literature. The identification of diabetes and how to manage it, particularly with one patient, became a highlight for Dr Nelson. The child was Billy Talbert, who was encouraged by Dr Nelson to take up tennis, and who became captain of the United States Davis Cup Team and excelled as a tennis player for many years despite his diabetes. Dr Nelson often referred to this early patient association in his lectures to us as students at Temple, and later as an example of the kind of total patient care that gave children a chance at an active, productive life.

In 1940 Nelson was invited to become the Professor of Pediatrics and to head the department at Temple University Medical School. By his own accounts this decision was not an easy one; he had decided to go into more active research in diabetes. But Dr Mitchell encouraged him to consider the offer and after much hesitation and indecision, he did so. At Temple, by Dr Nelson’s own account, he found no pediatric residency, and he had only one full-time faculty, Dr Nina Anderson, a neonatologist who came with him from Cincinnati. He relied on volunteer pediatricians to staff the clinical and educational services and began to build a faculty, including John Bartram (also from Cincinnati), Walter Cohn, and Bob High. In sequence he developed a residency program, further developed the volunteer faculty staff, attempted to get an integrated program with the 5 Philadelphia area medical schools (failed), and decided to affiliate with St Christopher’s Hospital for Children, then a private hospital. This activity was both controversial and risky by his own account. However, he quickly completed the affiliation agreement, including a separate board for the hospital, and incorporation of the visiting clinicians. He built a full-time faculty representing the developing specialty fields in pediatrics; recognized the talent in his resident staff, and nurtured some of them into the full-time faculty after their training; built a 150-bed specialty pediatric hospital; found a way to finance the venture and developed a first-class, respected department with the combination of Temple and St Christopher’s. Dr Nelson often referred to the financial difficulties of managing this arrangement. He spent a great deal of time encouraging philanthropy and blending funds from Temple University, local and state grants, and federal support, wherever he could find it. As faculty joined him he encouraged them to assist in generating funding for the various academic programs and for clinical care. Many faculty commented on the low pay at St Christopher’s compared to other institutions. These comments were often heard after faculty attended national meetings and compared notes. Remarkably this was not a deterrent to most and long-term relationships grew with the St Christopher’s family. In a few instances, the rather meager offers led to promising individuals leaving for more lucrative positions, but these were few.

I have indicated the major accomplishments outside of St Christopher’s but it would be incomplete if I did not provide insight into the remarkable teaching/clinical care atmosphere there. Residents were recruited from promising students at Temple and from referrals to those who had gone elsewhere in pursuit of specialty training. The resident staff was tightly bound together in purpose. As co-chief resident with Ray Helfer, I found a spirit of cooperation that I learned later was unique to St Christopher’s. Residents helped each other constantly, substituted for each other when circumstances dictated an absence, and participated in teaching of medical students to a degree that they were often cited at Temple for their excellence in medical student education. But beyond the bonding among the residents, there was an intimate teaching relationship with faculty. I can recount numerous instances but will only cite a few from my own experience. In my first year I encountered a seriously ill young child and was puzzled as to why she was in shock. Because of my inexperience and because as a team we suspected that she possibly had an adrenal crisis, I asked Dr Angelo DiGeorge to come in from home. He did so in the middle of the night and we not only successfully cared for the child but had an entire session of the endocrinologic underpinning of the diagnosis and treatment of her condition, all at 3:00 AM. I have been in other settings where that simply would not have happened.

In another instance, I was caring for a child with a distended abdomen, high fever, and near unconsciousness. After examining him I thought he had an abdominal crisis and obtained a radiograph examination of his abdomen. John Kirkpatrick was head of pediatric radiology and I was startled to have him appear on the ward with a stethoscope. He handed it to me and said, “examine his chest now and carefully.” I did so and discovered lack of breath sounds low in his chest. Dr Kirkpatrick then explained that in the margins of the abdominal radiograph he saw obliteration of the costophrenic angles bilaterally and thought the child had empyema, which he had. His cultures grew Staphylococcus aureus, then epidemic in our community. Finally, there were many times when we all gathered in Dr Jim Arey’s pathology department for examination of either microscopic or autopsy evidence of the conditions our patients had experienced.

The St Christopher’s spirit was often cited by those involved in pediatric care there and among colleagues who went elsewhere. The spirit involved all members of the St Christopher’s family, nurses, administrators, hospital staff, and all those involved in patient care, regardless of their specific role. This concept that we were one group all striving to give the best care possible in a congenial atmosphere permeated the institution and inspired those of us who left to imitate it in our new settings.

I cite these examples as a few among many that profile the close working relationships that faculty, residents, and the entire health care team had and continued to have under Dr Nelson’s leadership and mentorship. We cherished the time we spent at St Christopher’s and carried many of the attitudes we perceived into our subsequent roles in academic medicine and clinical practice.

Finally, there is an anecdote that has been recounted numerous times that irked Dr Nelson sometimes, and caused him some paternal pride at other times. It is the famous “for the birds” insertion in his textbook’s index. He often said that this one incident had more impact than any other in his professional career. Although there are many versions, I am reporting his own account of what he called the consecration to the birds as follows: “Certainly no feature brought the book as much attention from the lay population and perhaps even the medical one.” After recounting the steps that led up to having the sixth edition in preparation for final editing of the index, he tells of each child having index cards with a single entry for each index point. By midafternoon on a hot Sunday he had exhausted his slaves and proposed a swim. Jane and Ann, his daughters, disappeared quickly, relieved that the task was over, but Ann returned, took a single index card and wrote “birds, for the” with the pagination for the entire book. The entry was caught and never made the index then. For the seventh edition, some 4 years later, Ann, now married to Dick Behrman, who would become a future editor of the textbook, returned for a visit and Dr Nelson put her to work. (Ann died in 2005.) The suggestion was made that the “birds, for the” be again entertained for the index. What happened subsequently is not as clear as the previous account. Somehow the entry made it into galleys, and even though crossed out, was inserted into the seventh edition’s index. When published, it created a sensation in the lay press, garnered publicity for Saunders, who published the textbook, and was widely discussed in medical circles, despite Dr Nelson claiming a lesser focus in that arena. The humor intrinsic to the insertion offered relief to students who used the text and smiles to those of us who appreciated the fact that his daughter, overtaxed by the taskmaster, saw the humor in such an insertion and perhaps a commentary on the impact on her life and participation. Dr Nelson did not like the insertion and often expressed his dissatisfaction to me and others. But in his letter to his grandson he also relates some of the humorous side to the incident. For example, he was occasionally introduced by allusion to the “birds,” and twice, in Rio and Atlanta, was introduced by a slide showing birds in flight. He cited Cleveland’s THE PLAIN DEALER comment: “They simply liked a light touch in high places.” As Dr Nelson often said, enough of the birds!

Dr Nelson received many official awards and numerous unofficial ones as he was invited to speak around the world. When I became head of the department of pediatrics at the University of Arizona, I asked him to become a visiting professor, as did many of his former students, residents, and faculty. He gave a wonderful talk on the need for town-gown integration and his activities in Philadelphia to bring that about. Two humorous incidents occurred during his visit. He was in his 90s at the time and an avid golfer. In our department, Grant Morrow was an expert golfer who had been almost professional in Philadelphia before choosing a medical career. Dr Nelson wanted to play golf and I asked Grant to arrange a foursome, which he did. Dr Nelson came back and told me that he enjoyed the course but that Grant was more avid than he. Dr Nelson had landed one shot in a tire track and thought that he could lift the ball onto a better surface, but Grant insisted that he hit it from where it lay. Dr Nelson was not amused.

We had placed him at the wonderful Arizona Inn, a local hostelry famed for its history, ambiance, and food. Speaking the next day he recounted two incidents that amused him. Upon awakening he saw snow on the threshold and thought that he had escaped that by coming to Tucson. It was one of the rare times that we had snow in the 20 years we lived there. Further, he complained publicly that the furniture in the Inn was older than his grandmother’s. It is true because in the interest of southwestern flavor many of the rooms have antique furniture with drawers that do not quite fit, and closet doors that are akimbo somewhat. His room was one of those.

Dr Nelson has received the highest recognition pediatric organizations and others can give. He was the recipient of the Abraham Jacobi Award of the American Academy of Pediatrics; the Howland Award of the American Pediatric Society; the Order of Mayo by the Government of Argentina; Honorary Professorships from Santos Tomas, Philippines and the University of Santo Domingo; Doctor of Humane Letters of Temple University; Honorary Member of the Latin American Society of Research; Doctor of Medical Science from the Medical College of Pennsylvania; Gold Medal Award of the Children’s Hospital of Philadelphia; and the University of Cincinnati’s College of Medicine’s Daniel Drake Award. He was interviewed at 97 years old for the Columbia University Oral History Research Office for hours. This project was an oral history project for the American Academy of Pediatrics.

This remarkable man did not end his career when he retired from the department chair at Temple, the editorship of the textbook, from the Journal of Pediatrics, and from other official titles and positions. Instead he began a quest for collaboration between town and gown. He gathered pediatric leaders in Philadelphia to promote the concept, preparing a missive indicating the steps that might be taken. He lectured on the concept and established a fund at St Christopher’s to promote the idea. He continued such an active life that he complained to his daughter that he did not have enough free time at 93 years old.

In short, Dr Waldo E. (Bill) Nelson was a major force in pediatrics by promoting education through his editorial efforts, by his development of a child-oriented clinical entity at St Christopher’s Hospital for Children, and by mentoring a myriad of professionals who carried his message of integrity, dedication, attention to the written word, hard work and focus on the health and well being of children. His reach went beyond Philadelphia to the entire country and to the world with his disciples spreading his philosophy and attitudes. He was an amazing, active, intelligent man who was and is an inspiration to students of pediatrics at all levels. One final note: If Dr Nelson were alive, he would edit this manuscript mercilessly and then suggest that it be ripped to pieces, never to see the light of day.

Acknowledgments

I am deeply indebted to Jane Nelson Beatty who provided me with many private papers of Dr Nelson’s from which some of the quotes in this narrative are taken. I am grateful for her careful review of the manuscript. Her editorial suggestions indicate that DNA transmits more than physical genes; she has her father and mother’s editorial skills and instincts!

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