The Merck Manual of Medical Information Second Home Edition

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  • Edition: 2nd
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  • Copyright: 2004-05-01
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For more than 100 years doctors have been coming to us for advice. Now you can, too.TheMerck Manualhas traditionally provided exclusive, up-to-the-minute information to doctors, nurses, and other healthcare professionals. Now, with the special Home Edition, the general public can access virtually the same critical data contained in the physician's version -- but in everyday language and a reader-friendly format.With contributions from nearly 200 internationally respected medical experts, this fully revised edition offers vital, easy-to-understand information about almost every known medical issue, including: AIDS cancer eating, digestive, and nutrition disorders heart disease mental illness pediatric care -- including a new chapter on early-childhood development sexual dysfunction terminal illness viruses and infections...and much more. Featuring original illustrations and diagrams, an A-Z listing of brand-name and generic drugs, and an appendix of medical resources,The Merck Manual -- Home Editionis published as a not-for-profit service by Merck, a world leader in breakthrough medical discoveries with a long commitment to making the world a healthier place.

Table of Contents

A Guide for Readersp. liii
Understanding Medical Termsp. lv
Fundamentalsp. 1
The Human Bodyp. 1
Geneticsp. 7
The Aging Bodyp. 14
Communicating With Health Care Professionalsp. 19
Preventionp. 22
Exercise and Fitnessp. 27
Rehabilitationp. 32
Death and Dyingp. 41
Legal and Ethical Issuesp. 48
Drugsp. 53
Overview of Drugsp. 53
Drug Administration and Kineticsp. 57
Drug Dynamicsp. 62
Factors Affecting Response to Drugsp. 66
Drugs and Agingp. 70
Adverse Drug Reactionsp. 73
Compliance With Drug Treatmentp. 76
Trade-Name and Generic Drugsp. 79
Over-the-Counter Drugsp. 82
Medicinal Herbs and Nutraceuticalsp. 92
Heart and Blood Vessel Disordersp. 101
Biology of the Heart and Blood Vesselsp. 101
Symptoms and Diagnosis of Heart and Blood Vessel Disordersp. 105
High Blood Pressurep. 117
Low Blood Pressurep. 126
Shockp. 132
Heart Failurep. 134
Cardiomyopathyp. 142
Abnormal Heart Rhythmsp. 146
Heart Valve Disordersp. 157
Infective Endocarditisp. 165
Pericardial Diseasep. 168
Heart Tumorsp. 172
Atherosclerosisp. 174
Coronary Artery Diseasep. 178
Peripheral Arterial Diseasep. 194
Aneurysms and Aortic Dissectionp. 203
Venous Disordersp. 208
Lymphatic Disordersp. 216
Lung and Airway Disordersp. 219
Biology of the Lungs and Airwaysp. 219
Symptoms and Diagnosis of Lung Disordersp. 223
Pulmonary Rehabilitationp. 233
Bronchitisp. 236
Pneumoniap. 237
Lung Abscessp. 245
Asthmap. 246
Chronic Obstructive Pulmonary Diseasep. 253
Pulmonary Embolismp. 257
Bronchiectasisp. 260
Atelectasisp. 263
Occupational Lung Diseasesp. 265
Infiltrative Lung Diseasesp. 271
Allergic Diseases of the Lungsp. 278
Pleural Disordersp. 282
Cystic Fibrosisp. 286
Pulmonary Hypertensionp. 290
Respiratory Failurep. 293
Acute Respiratory Distress Syndromep. 294
Lung Cancerp. 296
Bone, Joint, and Muscle Disordersp. 300
Biology of the Musculoskeletal Systemp. 301
Symptoms and Diagnosis of Musculoskeletal Disordersp. 304
Osteoporosisp. 308
Paget's Disease of Bonep. 311
Fracturesp. 313
Bone Tumorsp. 323
Avascular Necrosis of the Bonep. 325
Bone and Joint Infectionsp. 327
Osteoarthritisp. 330
Rheumatoid Arthritis and Other Types of Inflammatory Arthritisp. 333
Autoimmune Disorders of Connective Tissuep. 340
Vasculitic Disorders of Connective Tissuep. 348
Gout and Pseudogoutp. 353
Hand Disordersp. 356
Foot Problemsp. 364
Muscular Dystrophy and Related Disordersp. 372
Disorders of Muscles, Bursas, and Tendonsp. 375
Sports Injuriesp. 379
Brain, Spinal Cord, and Nerve Disordersp. 389
Biology of the Nervous Systemp. 390
Diagnosis of Brain, Spinal Cord, and Nerve Disordersp. 395
Painp. 402
Headachesp. 411
Dizziness and Vertigop. 416
Sleep Disordersp. 421
Brain Dysfunctionp. 428
Delirium and Dementiap. 433
Stupor and Comap. 443
Seizure Disordersp. 447
Strokep. 454
Head Injuriesp. 463
Tumors of the Nervous Systemp. 469
Infections of the Brain and Spinal Cordp. 478
Prion Diseasesp. 490
Movement Disordersp. 492
Multiple Sclerosis and Related Disordersp. 504
Spinal Cord Disordersp. 508
Low Back Painp. 515
Peripheral Nerve Disordersp. 521
Cranial Nerve Disordersp. 534
Smell and Taste Disordersp. 539
Mental Health Disordersp. 542
Overview of Mental Health Carep. 542
Somatoform Disordersp. 546
Anxiety Disordersp. 549
Depression and Maniap. 557
Suicidal Behaviorp. 565
Eating Disordersp. 567
Sexualityp. 570
Personality Disorderp. 573
Amnesia and Related Disordersp. 578
Schizophrenia and Delusional Disorderp. 582
Drug Use and Abusep. 587
Mouth and Dental Disordersp. 601
Biology of the Mouthp. 601
Lip and Tongue Disordersp. 603
Salivary Gland Disordersp. 605
Mouth Soresp. 606
Growths in the Mouthp. 609
Tooth Disordersp. 612
Periodontal Diseasesp. 619
Temporomandibular Disordersp. 623
Urgent Dental Problemsp. 627
Digestive Disordersp. 630
Biology of the Digestive Systemp. 630
Symptoms and Diagnosis of Digestive Disordersp. 634
Disorders of the Esophagusp. 642
Peptic Disordersp. 646
Gastroenteritisp. 654
Hiatus Hernia, Bezoars, and Foreign Bodiesp. 661
Pancreatitisp. 663
Malabsorptionp. 667
Inflammatory Bowel Diseasesp. 671
Antibiotic-Associated Colitisp. 678
Diverticular Diseasep. 679
Bowel Movement Disordersp. 682
Disorders of the Anus and Rectump. 691
Tumors of the Digestive Systemp. 696
Gastrointestinal Emergenciesp. 707
Liver and Gallbladder Disordersp. 715
Biology of the Liver and Gallbladderp. 715
Diagnostic Tests for Liver and Gallbladder Disordersp. 717
Clinical Manifestations of Liver Diseasep. 720
Fatty Liver, Cirrhosis, and Related Disordersp. 725
Hepatitisp. 729
Blood Vessel Disorders of the Liverp. 733
Liver Tumorsp. 737
Gallbladder Disordersp. 740
Kidney and Urinary Tract Disordersp. 744
Biology of the Kidneys and Urinary Tractp. 744
Symptoms and Diagnosis of Kidney and Urinary Tract Disordersp. 747
Kidney Failurep. 752
Nephritisp. 760
Blood Vessel Disorders of the Kidneysp. 767
Tubular and Cystic Kidney Disordersp. 771
Urinary Incontinencep. 778
Urinary Tract Obstructionp. 783
Urinary Tract Infectionsp. 787
Injury to the Urinary Tractp. 792
Cancers of the Kidney and Urinary Tractp. 795
Disorders of Nutrition and Metabolismp. 799
Overview of Nutritionp. 799
Undernutritionp. 806
Vitaminsp. 809
Minerals and Electrolytesp. 818
Obesityp. 831
Disorders of Cholesterolp. 836
Water Balancep. 842
Acid-Base Balancep. 845
Porphyriasp. 847
Hormonal Disordersp. 851
Biology of the Endocrine Systemp. 851
Pituitary Gland Disordersp. 853
Thyroid Gland Disordersp. 860
Adrenal Gland Disordersp. 868
Diabetes Mellitusp. 873
Hypoglycemiap. 881
Multiple Endocrine Neoplasia Syndromesp. 883
Carcinoid Tumorsp. 884
Blood Disordersp. 886
Biology of Bloodp. 886
Symptoms and Diagnosis of Blood Disordersp. 888
Blood Transfusionp. 890
Anemiap. 894
Bleeding and Clotting Disordersp. 902
White Blood Cell Disordersp. 908
Plasma Cell Disordersp. 912
Leukemiasp. 916
Lymphomasp. 922
Myeloproliferative Disordersp. 928
Spleen Disordersp. 931
Cancerp. 935
Overview of Cancerp. 935
Symptoms and Diagnosis of Cancerp. 938
Prevention and Treatment of Cancerp. 944
Immune Disordersp. 950
Biology of the Immune Systemp. 950
Immunodeficiency Disordersp. 956
Allergic Reactionsp. 962
Autoimmune Disordersp. 971
Transplantationp. 973
Infectionsp. 982
Biology of Infectious Diseasep. 982
Immunizationp. 988
Bacterial Infectionsp. 990
Bacteremia, Sepsis, and Septic Shockp. 1012
Antibioticsp. 1014
Tuberculosisp. 1018
Leprosyp. 1022
Rickettsial and Ehrlichial Infectionsp. 1024
Parasitic Infectionsp. 1027
Fungal Infectionsp. 1039
Viral Infectionsp. 1044
Human Immunodeficiency Virus Infectionp. 1057
Sexually Transmitted Diseasesp. 1064
Skin Disordersp. 1073
Biology of the Skinp. 1073
Diagnosis and Treatment of Skin Disordersp. 1075
Itching and Noninfectious Rashesp. 1078
Acnep. 1090
Pressure Soresp. 1093
Sweating Disordersp. 1095
Hair Disordersp. 1096
Pigment Disordersp. 1098
Blistering Diseasesp. 1100
Parasitic Skin Infectionsp. 1102
Bacterial Skin Infectionsp. 1103
Fungal Skin Infectionsp. 1108
Viral Skin Infectionsp. 1111
Sunlight and Skin Damagep. 1112
Noncancerous Skin Growthsp. 1115
Skin Cancersp. 1119
Ears, Nose, and Throat Disordersp. 1123
Biology of the Ears, Nose, and Throatp. 1123
Hearing Loss and Deafnessp. 1126
Outer Ear Disordersp. 1131
Middle and Inner Ear Disordersp. 1134
Disorders of the Nose and Sinusesp. 1139
Throat Disordersp. 1144
Nose and Throat Cancersp. 1147
Eye Disordersp. 1151
Biology of the Eyesp. 1151
Symptoms and Diagnosis of Eye Disordersp. 1154
Refractive Disordersp. 1161
Eye Injuriesp. 1164
Eyelid and Tear Gland Disordersp. 1167
Disorders of the Conjunctiva and Sclerap. 1170
Corneal Disordersp. 1173
Cataractp. 1176
Uveitisp. 1178
Glaucomap. 1179
Retinal Disordersp. 1182
Optic Nerve Disordersp. 1187
Eye Socket Disordersp. 1189
Men's Health Issuesp. 1192
Male Reproductive Systemp. 1192
Disorders of the Penis and Testesp. 1194
Prostate Disordersp. 1199
Sexual Dysfunctionp. 1205
Women's Health Issuesp. 1211
Biology of the Female Reproductive Systemp. 1212
Symptoms and Diagnosis of Gynecologic Disordersp. 1217
Menopausep. 1224
Menstrual Disorders and Abnormal Vaginal Bleedingp. 1229
Endometriosisp. 1235
Fibroidsp. 1238
Vaginal Infectionsp. 1240
Pelvic Inflammatory Diseasep. 1243
Pelvic Floor Disordersp. 1245
Sexual Dysfunctionp. 1247
Breast Disordersp. 1252
Cancers of the Female Reproductive Systemp. 1265
Violence Against Womenp. 1274
Infertilityp. 1277
Family Planningp. 1282
Detection of Genetic Disordersp. 1291
Normal Pregnancyp. 1296
High-Risk Pregnancyp. 1305
Drug Use During Pregnancyp. 1318
Normal Labor and Deliveryp. 1323
Complications of Labor and Deliveryp. 1329
Postdelivery Periodp. 1334
Children's Health Issuesp. 1339
Normal Newborns and Infantsp. 1340
Problems in Newbornsp. 1350
Birth Defectsp. 1365
Chromosomal and Genetic Abnormalitiesp. 1380
Problems in Infants and Very Young Childrenp. 1383
Normal Preschool and School-Aged Childrenp. 1390
Behavioral and Developmental Problems in Young Childrenp. 1395
Normal Adolescentsp. 1403
Problems in Adolescentsp. 1405
Bacterial Infectionsp. 1410
Viral Infectionsp. 1418
Respiratory Disordersp. 1431
Digestive Disordersp. 1434
Ear, Nose, and Throat Disordersp. 1441
Eye Disordersp. 1447
Bone Disordersp. 1449
Hereditary Connective Tissue Disordersp. 1453
Juvenile Rheumatoid Arthritisp. 1457
Diabetes Mellitusp. 1458
Hereditary Disorders of Metabolismp. 1461
Childhood Cancersp. 1466
Cerebral Palsyp. 1469
Mental Retardationp. 1471
Mental Health Disordersp. 1474
Social Issues Affecting Children and Their Familiesp. 1481
Child Neglect and Abusep. 1486
Accidents and Injuriesp. 1490
Burnsp. 1490
Heat Disordersp. 1494
Cold Injuriesp. 1496
Radiation Injuryp. 1499
Electrical and Lightning Injuriesp. 1503
Near Drowningp. 1506
Diving and Compressed Air Injuriesp. 1507
Altitude Illnessp. 1512
Poisoningp. 1514
Bites and Stingsp. 1521
First Aidp. 1527
Special Subjectsp. 1533
Medical Decision Makingp. 1533
Surgeryp. 1536
Complementary and Alternative Medicinep. 1541
Travel and Healthp. 1545
Amyloidosisp. 1551
Familial Mediterranean Feverp. 1552
Diseases of Unknown Causep. 1553
Appendixesp. 1557
Weights and Measuresp. 1557
Common Medical Testsp. 1559
Drug Names: Generic and Tradep. 1566
Resources for Help and Informationp. 1592
Indexp. 1607
Table of Contents provided by Ingram. All Rights Reserved.


Air Travel and Medical Problems

Traveling by air can cause or worsen a variety of medical conditions, although very few conditions would prevent a person from flying. Those that may prevent flying include a pneumothorax, lung damage from tuberculosis, diseases that could be spread to other passengers, and conditions in which even a small expansion of air would damage tissues, such as intestinal surgery in the previous 10 days. Some conditions require planning and taking precautions before a flight. For example, people who have had a colostomy should wear a large bag and anticipate frequent filling.

Air travel poses problems related to changes in air pressure, reduced amounts of oxygen, turbulence, disruptions of the body's internal 24-hour (circadian) clock (jet lag), and psychologic or physical stress.

Changes in Air Pressure

Modern jet airplanes maintain air pressure inside the cabin (cabin pressure) at low levels, equivalent to the atmospheric pressure at 5,000 to 8,000 feet. At such levels, air trapped in pockets within the body - such as in the lungs, inner ear, sinuses, and intestinal tract - expands by about 25 percent. This expansion sometimes aggravates certain medical conditions, such as emphysema, blocked eustachian tubes, chronic sinusitis, and chronic gas pains. Problems may be particularly severe when an airplane accidentally loses cabin pressure or when the cabin isn't pressurized, as is the case with some smaller airplanes.

A sensation of pressure in the ears is common during airplane flights. It develops as the difference between pressure outside the ear and inside the ear increases, causing the eardrum to bulge. Eventually, the pressure equalizes when the eustachian tube (a passage that connects the middle ear with the back of the nose) allows air to flow in and out of the middle ear. Head colds or allergies may produce fluid and swelling that block the eustachian tube, and repeated infections may result in scarring that partially blocks it. Then air becomes trapped in the middle ear, producing pressure (barotitis media) and pain. Rarely, the eardrum ruptures. Similarly, air may be trapped in the sinuses (barosinusitis), causing facial pain.

Swallowing frequently or yawning during the airplane's descent and taking decongestants before or during the flight can prevent or relieve these conditions. Because children are particularly susceptible to barotitis media, they should chew gum, suck hard candy, or drink something during ascent and descent to encourage swallowing; babies can be nursed or given a bottle or pacifier.

Reduced Oxygen

The relatively low air pressure inside an airplane also causes problems because of its effect on oxygen levels. Low oxygen levels are particularly troublesome for people who have a severe lung disease such as emphysema or cystic fibrosis, heart failure, severe anemia, severe angina, sickle cell disease, or certain congenital heart diseases. Usually, such people can fly safely if provided with oxygen. Airlines can handle a request for oxygen if notified 72 hours in advance of a flight. People generally may fly 10 to 14 days after a heart attack. During flight, people who have breathing problems should not smoke or drink alcohol - which aggravates the effects of reduced oxygen. In general, anyone who can walk 100 yards or climb one flight of stairs should be able to tolerate normal cabin conditions without additional oxygen.


Turbulence can cause air sickness or an injury. People who are prone to air sickness may benefit from dimenhydrinate taken as a tablet or scopolamine applied to the skin as a patch. However, these drugs may cause adverse effects, particularly in the elderly The patches cause fewer adverse effects. To prevent injuries, passengers should keep their seat belts fastened while seated.

Jet Lag

Rapid travel across several time zones produces many physical and psychologic stresses known as jet lag (circadian dysrhythmia). A gradual shift in eating and sleeping patterns before departure may alleviate the problem. Some medication schedules may have to be adjusted; for example, the intervals between drugs normally taken at precise times throughout the day should be based on elapsed time - - such as every 8 hours -rather than on local time. People who have diabetes and who use long-acting insulin may switch to regular insulin until they've adjusted to the new time zone, food, and activity level, or they may make up the difference in time zone changes over several days. They should work out a medication and eating schedule with their doctor before departure and take with them a device to monitor blood sugar (glucose) levels.

Melatonin, a hormone that regulates the sleepwake cycle, is reported to help with sleep disturbances caused by jet lag. Its effectiveness depends on taking the doses on a precise schedule.

Because melatonin products are nutritional supplements rather than prescription drugs, the claims made by the manufacturers have not undergone rigorous scrutiny, and the quality of each formulation may vary.

Psychologic Stress

Fear of flying and claustrophobia can cause distress. Hypnosis and behavior modification help some people. Taking a sedative may relieve fears before and during a flight.

Because the behavior of some mentally ill people worsens during airplane flights, those with violent or unpredictable tendencies must be accompanied by an attendant, and they may need to take a sedative before the flight.

General Precautions

Cardiac pacemakers and metal artificial limbs, plates, or pins are affected by airport metal detectors used to scan for concealed weapons; however, newer models of pacemakers can withstand potential interference from such detectors. To avoid security problems, people who wear such devices should carry a doctor's note explaining the situation.

The risk of developing blood clots in the legs is increased in anyone who sits in one place for a long time. Pregnant women and people who have poor circulation are at particular risk. Walking around the airplane cabin every hour or two and contracting and relaxing the leg muscles while sitting help keep the blood flowing.

Dehydration, resulting from the low humidity (about 5 percent) in the cabin, can be prevented by drinking enough liquids and avoiding alcohol, which makes dehydration worse. People who wear contact lenses should apply rewetting solution to their lenses frequently to combat the effects of dry air.

Special foods, including low-salt, low-fat, and diabetic diets, are usually available from an airline by advance request.

Travelers should pack drugs in a carry-on bag rather than in a suitcase checked at the airport, in case their luggage is lost, stolen, or delayed. Drugs should be kept in their original containers. Travelers who must carry narcotics, large amounts of any drug, or syringes should have a doctor's note to avoid being detained by security or customs officers. Travelers may wish to carry a summary of their medical records, including electrocardiogram results, in case they become ill while away from home. Those who have a potentially disabling condition, such as epilepsy, should wear a Medic Alert identification bracelet or necklace.

Women with normal pregnancies can travel by air through the eighth month. Women with highrisk pregnancies should discuss their travel plans with their doctor and obtain approval before flying. Generally, air travel during the ninth month requires a doctor's note dated within 72 hours of departure and indicating the woman's anticipated date of delivery. Seat belts should be worn low across the thighs, not over the abdomen, to prevent injury to the uterus.

Infants under 7 days old aren't permitted to fly. Children with chronic diseases, such as congenital heart or lung diseases or anemia, have the same restrictions as adults with those conditions. There's no upper age limit for travel.

Airlines make reasonable efforts to accommodate the handicapped. Often, wheelchairs and stretchers can be accommodated on commercial flights; otherwise, air ambulance service is necessary. Some airlines accept people who need special equipment such as intravenous lines and mechanical respirators as long as trained personnel accompany them and arrangements have been made at least 72 hours in advance.

Information and advice about air travel can be obtained from the medical departments of major airlines or from the Federal Aviation Administration Regional Flight Surgeon.

Foreign Travel

Of the millions of people who travel or work abroad every year, about I out of 30 needs medical attention for an illness or injury. Gastrointestinal infections may result from drinking contaminated water, including ice, and beverages or eating uncooked or improperly cooked foods. Casual sexual contacts produce a high risk for contracting the human immunodeficiency virus (HIV), which exists worldwide, as well as other sexually transmitted diseases. Motor vehicle accidents, especially at night, and drowning are the leading causes of death or injury for travelers in foreign countries. Health risks vary according to country and region; the Centers for Disease Control and Prevention provides up-to-date health advisories.

In foreign countries, many insurance plans, including Medicare, are not valid, and hospitals often require a substantial cash deposit, regardless of health insurance held in the United States. A variety of travel insurance plans, including some that arrange for emergency evacuation, are available through travel agents and some credit card companies. Directories listing English-speaking doctors in foreign countries are available from several organizations, and United States consulates may help secure emergency medical services.


People planning a trip to another country should have the appropriate vaccinations, depending on their destination. In general, more preparation is needed when the trip lasts longer than 3 weeks, has several destinations in developing countries, or involves travel in rural areas or working with resident populations. Requirements for vaccinations change frequently. Some vaccinations must be given 2 to 12 weeks before the trip, so a traveler should inquire about vaccinations in advance. Information about vaccination requirements is available from various sources.


Excerpted from The Merck Manual Of Medical Information by Robert Berkow Copyright © 1997 by Merck & Co., Inc.
Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

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