The Washington University Manual of Medical Therapeutics began more than six decades ago as a mimeographed collection of typewritten lectures held together by brass fasteners. Today, it is the best-selling medical textbook in the world: More than 200,000 copies appear in break rooms, lockers and white coat pockets on every continent, helping medical students, interns and residents care for their patients with the most current information available.

"The manual is in some ways the 'peripheral brain' for medical students and residents when they're on call," says Sam J. Lubner, MD, instructor in medicine, one of the editors of the manual's 32nd edition, published in March. "It's a transition from the theoretical to the practical, bringing knowledge to the bedside. It presents the information that experienced practitioners typically have committed to memory and serves as a guidebook for navigating patient care."

The editors of the best seller proudly display their accomplishment: Hilary E.L. Reno, MD, PhD; Daniel H. Cooper, MD; Andrew J. Krainik, MD; Sam J. Lubner, MD.

Wayland MacFarlane, MD, chief of medicine in 1942, originated the manual. Observing the chief residents' rounds, he concluded that the material presented in the lectures was worth sharing. Hospital house staff and medical students received copies of what was, Lubner says, "basically a reference guide to inpatient medicine."

The manual followed its homegrown format through 15 editions. Then, in the mid-1960s, Robert Packman, MD, oversaw the book's first mass production. His mother typed the manuscript for a 4,000-copy printing of the 16th edition, which went to medical schools nationally. It scored an immediate success, and the 17th edition grew to 25,000 copies.

Since then, the manual has found its way into medical schools and hospitals worldwide. It appears in Spanish, Portuguese, Greek, Hungarian, Romanian, Turkish, Korean, Japanese and both simplified and complex Chinese, according to Kimberly Schonberger, marketing manager at Lippincott Williams & Wilkins, the manual's publisher. When Washington University doctors talk with colleagues from other countries, they hear about the manual.

"When an Italian colleague found out that I was to be one of the editors of the Washington Manual," says editor Hilary E.L. Reno, MD, PhD, "he was very excited. He enjoys impressing physician friends in Italy with his personal connection to this renowned text." Reno believes the manual's success lies with its depth and breadth.

"It's important because it's not basic," she observes. "It takes medical problems and diseases and covers them very thoroughly. As an infectious disease specialist, I can reference this book for diagnosis and treatment of a certain disease, but I can also make sure that I am managing a patient with an acute heart attack appropriately."

The manual's thoroughness poses one of its major production challenges: packing a lot of content into a minimum of paper. That challenge is key, because the book's convenient size — it fits handily into a white coat pocket — is essential to its usefulness.

Another challenge lies in the nature of medical science itself. Keeping up with medical knowledge is a daunting task.

"All it takes is the next issue of the New England Journal of Medicine to find some piece of groundbreaking material that needs to be included," says Lubner.

Reno agrees.

"During publication, a whole different class of medicines to treat fungal diseases was approved," she recalls. "We actually changed the page proofs to include it."

Occasionally, entirely new sections appear. Not too long ago, for instance, there was little need for concern about bioterrorism. Today the need is all too real, and the 31st edition added a bioterrorism section to the infectious diseases chapter.

The need to make this vast amount of information easily findable prompted the manual's publishers and editors to move from the outline format of previous editions to a bulleted design. The bioterrorism section, for instance, now has headings for various infectious agents, subheads for general principles, diagnosis and treatment, and bulleted items under the subheads.

The change accomplished its purpose, according to Barnes-Jewish Hospital intern James L. Smith, MD, a frequent user of the manual. "The information is very accessible and at the same time very thorough," Smith says. "I use it most often when I'm presented with a patient with a disease process I'm unfamiliar with; it's a real boon to my medical training."

Across its 32 editions, the Washington Manual provides an intriguing on-the-ground history of medicine. Successive manuals' chapters about ischemic heart disease, for instance, record a remarkable evolution in cardiology.

The editors believe that the manual and its 19 companion volumes, available in two specialty series, testify not just to medicine's advances but also to the strength of the School of Medicine.

"The Washington Manual really reflects the fine education offered at this institution," Reno says, "as well as the huge impact Washington University has on the medical community, both nationally and worldwide."