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Merck Manual marks 100th year; Tome: Medicine has come a long way since the first Merck Manual in 1899 advised physicians they could cure disease with tobacco, strychnine and arsenic.

THE BALTIMORE SUN

Medical missionary Dr. Albert Schweitzer carried a copy up the Ogooue River in Africa. Rear Adm. Richard E. Byrd packed one in a sled as he crossed the Antarctic ice. Generations of general practitioners have relied on it. Military doctors and feverish Peace Corps volunteers have profited from its pithy counsel.

It is the Merck Manual, a book that tries to cram 1,800 years of Western medical tradition into a one-volume encyclopedia. This year marks its centennial. To celebrate, the hefty 17th edition comes packaged with a facsimile of the first, published in 1899.

The manual's century-long publishing history parallels the rise of modern medicine and pharmacology. And the slim first edition demonstrates just how far those scientific disciplines have come.

The 1899 Merck recommends 75 drugs for treating diphtheria -- including the liberal use of alcohol -- and 96 for gonorrhea. But this was the age before antibiotics, and none of the primitive nostrums had a prayer of working.

The manual also prescribes 38 therapies for rabies, including a diet of asparagus and a course of acupuncture. Again, none of these therapies were effective. Once symptoms appear, the disease is still always fatal.

Acute bronchitis? Try bleeding the patient, the manual suggests. Your teen-ager suffers from acne? Dose him with arsenic.

Yes, the manual recommends quinine for malaria -- still sound advice. But it also suggests mercury, a powerful toxin. In those pre-Viagara days, impotence called for a swig of turpentine oil or strychnine.

"Some of this stuff is pretty wacky," says Dr. John S. Andrews, who teaches pediatrics at the Johns Hopkins University's school of medicine. "Strychnine? There's no medical use for strychnine now."

He was struck by the 1899 edition's unbounded, and unfounded, confidence. "What tickles me the most about it is how very specific the recommended medications and dosage are, and how limited the knowledge must have been."

More than just a reference work, the original 192-page Merck's Manual was a pioneering marketing scheme. The name MERCK is printed in bold letters after every drug manufactured by the company. What better place to push pills than in a book designed for doctors to carry around in their coat pockets? Patients paid for drugs, but doctors wrote prescriptions and could be swayed by ads, too. (Promoting drugs to doctors is still a central sales strategy for pharmaceutical companies.)

Over the years, the manual became popular and more sophisticated. By the third edition in 1905, the editors stopped touting every Merck drug. They began to define, not just list, diseases, and to offer tips on diagnosis. World War II saw the advent of antibiotics, and the first studies of how drugs act inside the body.

The manual expanded and changed, tossing its simple alphabetical listing of diseases and replacing it with chapters describing 20 specialized medical fields.

By the early 1970s, the manual's reputation declined. Its 1972 edition had gone through several editors in quick succession, was outdated and didn't list contributors -- leading to questions about its authoritativeness. When Dr. Richard Berkow was named editor in 1974, he recruited new contributors, printed their names and more than doubled the amount of information.

Instead of promoting "Cocaine Hydrochlorate Merck," the current manual has a section on "Drug Use and Dependence." In 1899, Merck prescribed smoking tobacco for several ills, including asthma and nymphomania -- in the latter case, "so as to cause nausea: effectual but depressing." The 1999 Merck includes an article on how to stop smoking.

Cholera and malaria are still included. But articles on those topics are joined by others on Lyme disease and the human immunodeficiency virus (HIV). The 1999 manual has a long section on medical genetics; in 1899, the term "gene" had not yet been coined.

Berkow says modern readers of the 1899 edition shouldn't feel too smug. In 2099, physicians might view much of current medical practice -- such as the use of poisons in cancer chemotherapy -- as quaint or dangerous.

"We have to remember that the doctors of 1899 were on the cutting edge," he says. "They viewed themselves as highly educated, as good scientists. And they were, for their time."

Berkow says the manual, published in 15 languages, is as popular as ever, selling hundreds of thousands of copies, mostly to physicians, nurses and medical students worldwide. When editions first appeared in Hungarian, Czech and Polish, he says, some Eastern European doctors "had tears in their eyes."

Merck's 290 current authors include many who hold prestigious posts at Johns Hopkins, Harvard, Yale and the Mayo Clinic.

Though the manual's title alone is a form of corporate advertising, Merck's editors say they guard against bias in the text.

Describing a class of blood pressure-lowering drugs known as beta blockers, the manual focuses on Propranolol, manufactured by Wyeth-Ayerst Laboratories. Merck makes a beta blocker of its own, but Berkow says Propranolol was "the first one developed and the prototype," and deserved more prominent mention.

"It is critically important to Merck that this book not promote Merck products in any way, which would destroy the trustworthiness of the book," he says.

Not everyone shares this view. "I have had complaints from Merck," Berkow says. "Not from headquarters, but people from marketing and sales have complained that we didn't say enough about Merck drugs or specify that they are better than those of other companies."

But Berkow, a Baltimore native and graduate of the University of Maryland's medical school, jealously guards his editorial independence. His authors, he says, "write what they want to say."

Contributors say they are under no pressure to praise Merck's drugs. "The Merck Manual, as far as I'm concerned, is run by people who have no product promotion in mind at all," says Dr. John G. Bartlett of Hopkins, one of the world's authorities on infectious diseases, who wrote the manual's article on pneumonia.

If there is a threat to the venerable manual, it doesn't seem to be corporate bias or sloppy standards. It's the explosion of medical information. The field has advanced so quickly, on so many fronts, that some physicians regard the compact encyclopedia as an anachronism.

"My mother gave me a Merck Manual as a gift 10 years ago, thinking I would use it," says Dr. Dana Frank, a Baltimore internist. "And I never did."

When he needs information about an illness, he consults research journals, specialized reference books, the Internet or colleagues.

"I haven't seen anybody using it in the last couple of years," says Dr. Joel D. Howell, a professor in internal medicine and the history of medicine at the University of Michigan. Today's Merck Manual, he says, is far less important to the modern doctor than to those of a century past.

If today's Merck becomes a curiosity 100 years from now, it probably won't just be because the definitions of diseases will change and standards of treatment improve. Those looking back may well be astonished that anyone thought medicine could be summed up in a single, portable book.

Pub Date: 5/21/99

An article on the Merck Manual in yesterday's editions incorrectly named the editor of the publication. He is Dr. Robert Berkow. The Sun regrets the error.
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