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The Merck Manual

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Physicians are earnestly requested to communicate... any suggestions that may tend to improve this book for its Second Edition...

Whatever the publishers can do to make Merck's Manual of still greater service to the medical profession will be gladly undertaken and promptly performed for all subsequent editions.

Therefore, any Physician who will propose improvements in the subject-matter... or in the arrangement, style, and form of this work, for future editions, will thus be rending valuable service, not only to its Publishers, but to the entire Profession as well!
- A note to the readers of the First Edition of The Merck Manual, 1899

Preceding h2g2 was a body of work that also encouraged readers to contribute to its extensive reference, with intent on improving it. This book, now an accepted medical text, is known as The Merck Manual and is the oldest medical textbook in the English language.

Who is Merck?

Merck is in fact no one person, but the publishing company which edits the book: Merck Research Laboratories, based in New Jersey, USA. Currently it runs as a non-profit agency; its only goal to provide an up-to-date service to the scientific community and the public.

It is important to note that Merck Research Laboratories is in no way associated with another company with a similar name, Merck Sharp and Dohme, that is also, rather confusingly, known as Merck. However, the latter is a very large, profit-making pharmaceutical company, unlike the publishers of The Manual.

History of The Manual

The initial title of the First Edition (1899) was Merck's Manual of the Materia Medica. This was a 192-page booklet based on the US Pharmacopoeia1, which had three parts. The first section, called Materia Medica was an alphabetically organised list of every medicine of any use at the time.

The second section, called Therapeutic Indications, was an alphabetical organisation of all symptoms, signs, disorders and diseases. These descriptions were each followed by a list of all known treatments, with a small explanation of how to use them.

The third section, called Classification of Medicaments, classified drugs according to their effect on the body. This included some categories which would now be seen as archaic: alteratives, amenogogues, discutients - terms that hark back to the ancient Greek roots of medicine.

Dr Harold J Morowitz, a writer for the journal Hospital Practice, wrote an essay entitled The Merck of Time, where he reviewed the First Edition of the book. He noticed that in this edition, there were a vast number of treatments of little or no value for most diseases. He wrote:

...there is a natural feeling that it is better to do something than to do nothing... the less a disease is understood, the larger the number of treatments available.

This statement is, to some extent, still true today.

The Manual was an instant success. However, it had to become a flexible body of work, owing to rapid developments in medical and drug therapy. The revised Second Edition (1901) aimed to do just that. Two years before its publication, the Bayer Company manufactured Aspirin - and this too, was included in the text. The Third Edition (1905) described the effect of adrenaline on the body's blood vessels, and noted that scurvy was due to an 'improper and insufficient diet'. By the time the Fifth Edition was published, it had grown to over 600 pages, and included hints on diagnosis at the bedside. Taking blood pressures with the sphygmomanometer2, a relatively new device, was recognised and a table of blood pressures was put in.

The Sixth Edition (1934) was the first to credit Dr Bernard Fantus with the development of blood banking. The vast advances made in organic chemistry prompted a change in name. Hence it was published under the title of The Merck Manual of Therapeutics and Materia Medica. At 1379 pages, it was the biggest thus far.

Some of its concepts can be regarded as a bit old-fashioned. For instance, it advises pregnant women not to travel, as that edition describes the car as 'a potent cause of abortion'. Although amusing now, considering the condition of many roads at the time, this belief may not have been totally unfounded.

The format of The Merck Manual changed with the publication of the Eighth Edition (1950). The title was now The Merck Manual of Diagnosis and Therapy. The alphabetical listing was scrapped in favour of division of the text into 20 specialised fields, demonstrating just how specialised medicine had become. The Materia Medica was replaced by descriptions and discussions on the new drugs at the time; ones now that we take very much for granted, such as penicillin and other antibiotics. Some vaccines for children's diseases were also described - Whooping Cough vaccine for example. However, at this time, no vaccine was available for rubella.

The Ninth Edition (1956) first listed the names of the Editorial Board3 of The Manual. It was also the first to be based not on the pillaging of contemporary textbooks, but on the writings of other researchers. In the words of the Chief Editor, Dr Lyght:

These authorities helped greatly. To a man, however, they wrote too long, and each in their own style and pattern. Much editing was necessary to achieve brevity, clarity, and consistency without altering the factual content.

Lyght feared that authors would be angered by the editing of their work. After all, they themselves were experts in their field. Much to his relief, most of the authors thanked him for making their contributions 'better'. However, they were still anonymous at this stage.

Dr Lyght continued to edit The Manual up through its Eleventh Edition (1966). Despite his calls for it to be brief, it had by then ballooned to kangaroo pocket size.

The Thirteenth Edition (1977) had exactly the same problems. Somehow, the editors had to fit in major advances in molecular and cellular biology, without expanding it so much that a vast room would be required to store The Manual. It was in this edition that authors were first credited.

The Merck Editorial Process

  1. Sections of the previous edition are sent to independent experts for their honest critique.

  2. Published reviews from the readers are analysed.

  3. The Editorial Board discusses the reviews and plans the next edition.

  4. Special consultants are enlisted to provided additional expertise.

  5. 290 authors, with the appropriate qualifications, are asked to write for the new edition.

  6. Their entries are painstakingly edited, with the aim of ensuring that valuable information is not lost, while eliminating unnecessary words, however elegant.

  7. Once edited, each entry is sent either to the Editorial Board or to a special consultant.

  8. The edited entry is sent back to the author with notes on additions or suggestions for improvements.

The whole process is then repeated. Any one entry may go through as many as 15 reviews, certainly at least 6 times, before it is accepted into The Manual. Although this may seem like overkill, it has to be said that this is a medical text, and any mistake in dosage, treatment or disease description may lead to the death of a patient - hence the importance of checking, re-checking, re-writing, editing, re-editing etc.

The Merck Manual Today

The Manual, still respected for its content and reputation, has evolved into a variety of different formats. The Sixteenth Edition was published on CD-ROM, and the whole Manual is also free on the Internet. Its continuing success can also be attributed to the translation of The Manual into 14 different languages. Two million copies of the Sixteenth Edition were sold, making it the most successful, or at least the most edited, medical textbook in the world.

1An encyclopaedia of pharmacology, ie every medicine licensed in the US.2A horrible name for such a simple instrument: basically the inflating arm cuff with the mercury level.3Similar to the Editors at H2G2.

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