FEATURES The Merck Manual: A Century of Medical Publishing and Practice Keryn AG Lane impotence. Occasionally, agents that defy but as an art.” He looked for the practical Executive Editor explanation were mentioned, such as aletris application of what has been emphasized so Merck Manuals Department cordial, which allegedly was “prepared from frequently, namely that the patient should be Merck & Co Inc Aletris farinosa or True Unicorn”. Surpris- treated as well as the disease. This feature of Blue Bell, Pennsylvania ingly, tobacco was recommended to treat combining savoir-faire with medication and asthma and nymphomania (“so as to cause accessory regimens represented, he said, Robert Berkow nausea; effectual but depressing”). A large a “refreshing departure from stereotyped Editor-in-Chief number of treatments were recommended therapeutics”. For example, for the treat- Merck Manuals Department for each symptom or disorder; for example, ment of insomnia, the Manual discussed Merck & Co Inc 102 treatments were listed for bronchitis. psychotherapy, physical measures, diet, and Blue Bell, Pennsylvania Some drugs mentioned in the first edi- relief of distressing symptoms before seda- tion (such as cocaine, codeine, colchicine, tives, hypnotics, or opiates. The year 1999 marks a milestone in medical digitalis, and atropine) are still of value, as The sixth edition acknowledged the publishing—the 100th anniversary of The is the use of poisons (such as some cancer work of Bernard Fantus, the founder of Merck Manual, the oldest continuously pub- blood-banking and professor of therapeu- lished general medical text in the English tics at the College of Medicine, University language. What a century for advances in The first edition reveals a remark- of Illinois, for his oversight of therapeutics, medicine! The history of the Manual pro- able reliance on poisons. and thanked the authors and publishers of vides a wonderful overview of how medical 11 other works “from which much has been practice has changed, as well as how the gleaned to add to the value of this edition.” book’s editing has evolved. chemotherapy agents). The seventh edition (1940) took into The first edition was an instant success. account considerable advances in medical The Early Editions A book reviewer in the Chicago Medical progress. Dr Dinkelspiel wrote, “Avita- The first edition of The Merck Manual, Recorder commented: “Although this little minosis, endocrine disturbances, and other titled Merck’s Manual of the Materia Med- book is gotten out by a manufacturing firm conditions have assumed definite and fun- ica, consisted of 3 parts: Part I (“Materia and with some view towards its advertising damental importance. The menacing Medica”) listed in alphabetical order every value, it nonetheless is of such merit that it spectre of the menopause no longer stalks agent thought to be of therapeutic value. is deserving of mention in this column.” undefeated during middle life. Typhoid fever Part II (“Therapeutic Indications”) listed Distribution of the first edition and of has ceased to be ubiquitous. Pneumococcal symptoms, signs, and diseases in alphabeti- many later editions was limited to mem- pneumonia is confronted by its formidable cal order and gave a list of all known treat- bers of the medical, pharmaceutical, or antagonist, sulfapyridine. .” For the first ments. Part III classified drugs “according allied-health professions—a restriction that time, circulatory failure, granulocytopenia, to their physiologic actions”, which included was not always well received by the general impotence, hypoglycemia, obesity, and now-archaic categories such as “emmena- public. roentgen-ray sickness appear, with many gogues” and “discutients”. The first edition was followed by the other new subjects. To establish The Merck In 1899 the Manual cost $1, about as second in 1901, the third in 1905, and the Manual as indispensable and authoritative, much as a week’s groceries: 2 dozen eggs, fourth in 1911. Wartime paper shortages Dr Dinkelspiel had each chapter approved 3 pounds of flour, one pound of bacon, 10 delayed the fifth edition to 1923. The sixth by leading specialists. pounds of potatoes, and a 1-pound round edition (1934) was also delayed, this time by Delayed by World War II, the eighth steak. The book now costs $35, about the the stock-market crash. edition appeared in 1950; it sold 350,000 cost of dinner for 2 at a Chinese restaurant. copies. A 4-man editorial board, an editor, The low price derives from a 100-year-old Beginnings of the Modern Manual 6 assistant editors—all physicians—and 8 Merck policy of selling all its books on a The Merck Manual followed the same gen- editorial assistants, with the cooperation of not-for-profit basis as a service to the medi- eral outline and format until the sixth edi- more than 100 noted clinicians throughout cal community. tion. The Manual had by then grown to 1379 the United States, spent almost 3 years plan- The first edition reveals a remarkable pages and begun to resemble modern manu- ning and preparing the eighth edition. This reliance on poisons, such as strychnine als, with definitions of diseases followed by was the first edition to be divided into spe- and arsenic. Arsenic was listed as a medica- full descriptions of diagnosis and therapy. cialties, as the Manual is today, and to have ment for more than 100 diseases, including The editor (Dr M R Dinkelspiel) noted that the characteristic thumb tabs. jaundice, hydrophobia, elephantiasis, and therapy was approached “not as a science, 112 ♦ CBE VIEWS ♦ VOL 22, NR 4, 1999 FEATURES Swift Advances in Medicine the early 1970s. The 12th edition (1972) was is new in medicine, the premise behind The The ninth edition (1956) reflected the grow- typed (yes, on a typewriter) by one person (!) Merck Manual has remained constant—to ing list of corticosteroids and new drugs for in the days when a few changes in a 60-page help clinicians achieve the best care for pain and the acceptance of psychoanalytic manuscript required retyping every word. patients by providing information that is theory. The editor (Charles Lyght) and 4 The 13th edition was a bit easier thanks to current, concise, and complete, because, editorial-board members were listed on the the advent of IBM mag cards and mag tape, as stated in the first edition, “Memory is title page for the first time. The 10th edition which were welcome enhancements because treacherous. But a mere reminder is all . (1961) saw the advent of newer antibiotics the content of the book was doubled in that . [the doctor] needs . to prescribe exactly and vaccines, metric quantities in dosage edition. Since then computers have been what his judgment tells him is needed for statements, and the advance of radioisotope used, although for the 16th edition (1992) the occasion.” Despite technologic advances diagnosis. The 11th edition (1966) covered the in-house editors were still editing on in information processing, communication, more than 1000 subjects, including a chapter hard copy with red pens and then giving typesetting, and book manufacturing, the on the growing importance of family plan- manuscripts to a word processor to incor- intellectual processes of evaluating the qual- ning, and reflected a new understanding of ity of information—especially for complete- the etiology of many diseases. The average manuscript is edited ness and accuracy—and providing it in clear, The 12th edition (1972) contained many readable language have not changed. new chapters, for example, on coronary about 10 times. The Merck Manual has a long tradition to care units, cardiovascular and malignant uphold. The book was used by Albert Sch- diseases, immunology and genetics, and the weitzer in Africa, and it accompanied Admi- chemotherapy of psychiatric disorders. The porate changes. ral Byrd when he discovered Antarctica. The 13th edition (1977) was the first for Robert The 17th (centennial) edition was edited Manual continues to be well received and Berkow, who is still the editor-in-chief. Rapid by 4 physician editors, an executive editor, is the most widely used medical text in the advances in such fields as immunology and and 4 staff (lay) editors. The physician edi- world—almost 2 million copies of the 16th pediatrics indicated that major changes were tors are responsible for evaluating manu- edition were sold, and it has been translated needed. The book was reorganized, and scripts received from outside authors and into 16 languages and is available in several about 80% of the chapters were rewritten. making content or line changes as necessary. electronic formats. Dr Berkow’s editorial standards have These editors scour the medical literature for Distribution of the Manual is no longer influenced the book for 25 years. His goal all advances in medicine, especially those in restricted to those in the medical and phar- was to have almost every manuscript rewrit- diagnosis and treatment. Staff editors are maceutical professions, although the book ten and reduced by at least 15% to conform responsible for editing manuscripts for style, is not intended for laypeople. To provide to house style. To this day, no manuscript organization, and content. Both physician laypeople with the same quality of infor- receives final approval until each word has and staff editors work on computers, using mation, the editors of The Merck Manual been scrutinized and the manuscript has the redlining feature of Microsoft Word to “translated” the book into lay language and been reviewed by at least one outside expert. track changes. Manuscripts are sent first to published The Merck Manual of Medical The average manuscript is edited about 10 outside reviewers (including a pharmacist Information—Home Edition in 1997. times, rarely fewer than 6 times; and 20 reviewer), then to the author for initial As an interesting endnote, all people who times is not uncommon.