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Davidson’s Principles and Practice of Medicine 21st Edition Sir Stanley Davidson (1894–1981) This famous textbook was the brainchild of one of the great Professors of Medicine of the 20th century. Stanley Davidson was born in Sri Lanka and began his medical undergraduate training at Trinity College, Cambridge; this was interrupted by World War I and later resumed in Edinburgh. He was seriously wounded in battle, and the carnage and shocking waste of young life that he encountered at that time had a profound effect on his subsequent attitudes and values. In 1930 Stanley Davidson was appointed Professor of Medicine at the University of Aberdeen, one of the first full-time Chairs of Medicine any- where and the first in Scotland. In 1938 he took up the Chair of Medicine at Edinburgh and was to remain in this post until retirement in 1959. He was a renowned educator and a particularly gifted teacher at the bedside, where he taught that everything had to be questioned and explained. He himself gave most of the systematic lectures in Medicine, which were made available as typewritten notes that emphasised the essentials and far surpassed any textbook available at the time. Principles and Practice of Medicine was conceived in the late 1940s with its origins in those lecture notes. The first edition, published in 1952, was a mas- terpiece of clarity and uniformity of style. It was of modest size and price, Portrait reproduced by courtesy of the but sufficiently comprehensive and up to date to provide students with the Royal College of Physicians of Edinburgh main elements of sound medical practice. Although the format and presentation have seen many changes in 20 subsequent editions, Sir Stanley’s original vision and objectives remain. More than half a century after its first publication, his book continues to inform and educate students, doctors and health professionals all over the world. For Elsevier Commissioning Editor: Laurence Hunter Editorial Project Manager: Wendy Lee Project Manager: Nancy Arnott/Glenys Norquay Designer: Stewart Larking Illustration Manager: Bruce Hogarth Medical Illustrator: Robert Britton Charts: Hard Lines Agency Davidson’s Principles and Practice of M edicine 21st Edition The Editors Nicki R. Colledge BSc FRCP(Ed) Consultant Geriatrician, Liberton Hospital, Edinburgh, and Royal Infirmary of Edinburgh; Honorary Senior Lecturer in Geriatric Medicine, University of Edinburgh Brian R. Walker BSc MD FRCP(Ed) Professor of Endocrinology, University of Edinburgh; Honorary Consultant Physician, Royal Infirmary of Edinburgh Stuart H. Ralston MD FRCP FMedSci FRSE ARC Professor of Rheumatology, University of Edinburgh; Honorary Consultant Rheumatologist, Western General Hospital, Edinburgh Illustrated by Robert Britton Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2010 An imprint of Elsevier Limited © 2010, Elsevier Limited. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request online via the Elsevier website at http://www.elsevier.com/permissions. First edition 1952 Twelfth edition 1977 Second edition 1954 Thirteenth edition 1981 Third edition 1956 Fourteenth edition 1984 Fourth edition 1958 Fifteenth edition 1987 Fifth edition 1960 Sixteenth edition 1991 Sixth edition 1962 Seventeenth edition 1995 Seventh edition 1964 Eighteenth edition 1999 Eighth edition 1966 Nineteenth edition 2002 Ninth edition 1968 Twentieth edition 2006 Tenth edition 1971 Twenty-first edition 2010 Eleventh edition 1974 Main Edition ISBN-13: 978-0-7020-3085-7 International Edition ISBN-13: 978-0-7020-3084-0 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the respon- sibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher The Publisher's policy is to use paper manufactured from sustainable forests Printed in China Contents v Part 1 PRINCIPLES OF MEDICINE 1 Good medical practice 1 A.D. Cumming • S.I.R. Noble 2 therapeutics and good prescribing 17 J.K. Aronson 3 Molecular and genetic factors in disease 39 D.R. FitzPatrick • J.R. Seckl 4 Immunological factors in disease 69 S.E. Marshall 5 Environmental and nutritional factors in disease 95 P. Hanlon • M. Byers • B.R. Walker • H.M. Macdonald 6 Principles of infectious disease 131 R.P. Hobson • D.H. Dockrell 7 ageing and disease 163 N.R. Colledge Part 2 PRACTICE OF MEDICINE 8 Critical illness 177 I.S. Grant • G.R. Nimmo 9 Poisoning 203 S.H.L. Thomas • J. White 10 Medical psychiatry 229 M.C. Sharpe • S.M. Lawrie 11 Oncology 255 G.G. Dark • A.R. Abdul Razak 12 Pain management and palliative care 279 D. Oxenham 13 Infectious disease 289 D.H. Dockrell • S. Sundar • B.J. Angus • R.P. Hobson 14 HIV infection and aIDS 383 E.G.L. Wilkins v Contents 15 Sexually transmitted infections 409 G.R. Scott 16 Clinical biochemistry and metabolism 425 M.J. Field • L. Burnett • D.R. Sullivan • P. Stewart 17 Kidney and urinary tract disease 459 vi J. Goddard • A.N. Turner • L.H. Stewart 18 Cardiovascular disease 521 D.E. Newby • N.R. Grubb • A. Bradbury 19 respiratory disease 641 P.T. Reid • J.A. Innes 20 Endocrine disease 731 M.W.J. Strachan • B.R. Walker 21 Diabetes mellitus 795 B.M. Frier • M. Fisher 22 alimentary tract and pancreatic disease 835 K.R. Palmer • I.D. Penman 23 Liver and biliary tract disease 919 J.D. Collier • G. Webster 24 Blood disease 985 J.I.O. Craig • D.B.L. McClelland • H.G. Watson 25 Musculoskeletal disease 1053 M. Doherty • S.H. Ralston 26 Neurological disease 1131 C.M.C. Allen • C.J. Lueck • M. Dennis 27 Skin disease 1237 O.M.V. Schofield • J.L. Rees 28 Laboratory reference ranges 1293 S.W. Walker Picture credits 1299 Index 1301 Preface vii Since Davidson’s Principles and Practice of Medicine was We are proud of Davidson’s international heritage. first published in 1952, over two million copies have As well as recruiting authors from around the globe, been sold and the book has acquired a large following particularly for topics such as Infectious Diseases and of medical students, doctors and other health profes- Envenoming, we have welcomed new members on to sionals all over the world. It has been translated into our International Advisory Board. These leading experts many languages, most recently Russian and Polish, provide detailed comments that, along with the feed- and has won numerous prizes, the last edition receiv- back received from our global readership, are crucial to ing an award from the Society of Authors and the Royal our planning of every chapter in each new edition. In Society of Medicine. Davidson’s has endured because 2006, we had the privilege of visiting several medical with each new edition it has evolved to provide compre- schools on the Indian subcontinent and were delighted hensive updated information in a format suitable for its with the enthusiasm of the students and teachers that contemporary readership, and yet it has remained con- we met, and the very useful criticisms and feedback they cise and easy to read. This 21st Edition has been exten- provided. We have tried to address as many of these as sively updated and revised, but has not increased in possible in this edition. length or size. Education is achieved by assimilating information Since its beginnings, Davidson’s has sought to explain from many sources and we are delighted that read- the basis for medical practice. The integration of ‘pre- ers of this book can enhance their learning experience clinical’ science with clinical practice is now a feature using complementary resources. The StudentConsult of many undergraduate medical curricula, and many platform continues to provide online access to the students use Davidson’s from the outset of their medical text and illustrations of the main edition. Davidson’s course. In recognition of this, the first part of the book, has had a long-standing association with its sister ‘Principles of Medicine’, highlights the mechanisms books, Macleod’s Clinical Examination (now in its 12th of health and disease, along with the professional and Edition) and Principles and Practice of Surgery (now ethical principles underlying medical practice. Many in its 5th Edition). The Davidson’s ‘family’ has now examples of clinical problems are included to bring the expanded with the publication of Essential Davidson’s, medical sciences to life for the new student and to reju- a long-requested pocket-size version of the main text; venate the interest of the experienced clinician. The sec- Davidson’s Foundations of Clinical Practice, an indispens- ond part of the book, ‘Practice of Medicine’, covers the able guide to starting work as a junior doctor; and major medical specialties. Every chapter has been rewrit- Davidson’s Clinical Cases, which contains over 90 cases ten for this edition to ensure that it reflects the ‘cutting based on the ‘Presenting Problems’ in the main text. edge’ of medical knowledge and practice, pitched at a We congratulate the editors and authors of these books level of detail to meet the needs of candidates preparing for continuing the tradition of concise, easily read and for examination for Membership of the Royal College of beautifully illustrated text. Physicians or its equivalent. The regular introduction of new authors and edi- Many of the innovations introduced in recent editors to Davidson’s is important to maintain the freshness tions have been warmly received. We have retained the of each new edition. On this occasion, Professor Stuart ever-popular ‘Clinical Examination’ overview pages Ralston has joined the editorial team and 14 new authors and the patient-orientated approach in the ‘Presenting have contributed material. We all take immense pride Problems’ sections, while enhancing the book’s practical in producing an outstanding book for the next genera- content with a new series of ‘Emergency’ and ‘Practice tion of doctors, and in continuing the great tradition first Point’ boxes. Embedding horizontal themes within the established by Sir Stanley Davidson and passed on by all book—for example, with the ‘In Old Age’ boxes—has the previous editors and authors, for what remains one been applauded, and we have extended this approach of the world’s leading textbooks of medicine. by adding ‘In Pregnancy’ boxes in relevant chapters. The inclusion of both SI and non-SI units in the last edition NRC, BRW, SHR proved popular and has been maintained. Edinburgh 2010 The Davidson family of textbooks viii Medical learning is a life-long process that is facilitated plines. It also provides an invaluable step-by-step guide by many different tools. Davidson’s Principles and Practice to undertaking a range of core clinical procedures, along of Medicine has stood the test of time because it provides with an insight into the non-clinical aspects of managing an overview that is both comprehensive and concise. a medical career. Much of the text is written by junior Its long-standing partner textbooks, Macleod’s Clinical doctors, and so provides a real view of what it is like to Examination and Principles and Practice of Surgery, share work as a trainee hospital doctor today. a similar ethos. To add value for readers of Davidson’s, Davidson’s is also closely linked to its two sister titles, its highly successful style has now been employed in a Macleod’s Clinical Examination and Principles and Practice ‘family’ of new companion books. These complement the of Surgery. main textbook, both by presenting its material in different formats to enhance learning, and by including sup- plementary material that could not be accommodated in the main edition. Davidson’s Essentials of Medicine is a ‘handbook’ version of Davidson’s Principles and Practice of Medicine, helping those who need portable information to study while on the move—whether com- muting between training sites, or dur- ing remote attachments and electives. It also serves as a condensed revision aid. Every effort has been made to maximise readability and avoid dry and unmemorable lists. The text presents the essential elements in a structured format, key Davidson’s illustrations are adapted and retained, and several new ‘added value’ sections have been included: Major Investigations describes key diagnostic tests; Therapeutics describes the clinical use of common drugs; and typical OSCE scenarios are included to help the reader to prepare for this examination format. In the real world, patients do not pres- ent with a specific disease; instead they come with problems that might involve many systems, and the primary pathology may not be at all clear. In recognition of this, Davidson’s Clinical Cases has been written by an impressive international group of physicians with wide clinical experience. This book guides the reader step by step to find the correct path in the maze between a patient’s presenting complaint and the final diagnosis. The selection of cases is closely based on the ‘Presenting Problems’ of Davidson’s Principles and Practice of Medicine and includes illnesses that reflect an international outlook. For those just qualified and starting out on their initial years of hospital training, Davidson’s Foundations of Clinical Practice provides key guidance on how to manage the practicalities of work- ing life. The emphasis is on acute rather than chronic symptom presentation and management in a wide range of disci- Latest one head Contributors ix Albiruni Ryan Abdul Razak Jane D. Collier MRCPI MD FRCP Clinical Research Associate and Honorary Specialist Consultant Hepatologist, John Radcliffe Hospital, Registrar, Northern Centre for Cancer Care, Freeman Oxford; Honorary Senior Lecturer in Hepatology, Hospital, Newcastle upon Tyne, UK University of Oxford, UK Chris Allen Jenny I.O. Craig MA MD FRCP MD FRCP(Ed) FRCPath Consultant Neurologist, Addenbrooke’s Hospital, Consultant Haematologist, Addenbrooke’s Hospital, Cambridge; Associate Lecturer, School of Clinical Cambridge, UK Medicine, University of Cambridge, UK Allan D. Cumming Brian J. Angus BSc MBChB MD FRCP(Ed) FRCP(Lond) BSc DTM&H FRCP MD FFTM(Glas) Consultant Nephrologist, Royal Infirmary of Reader in Infectious Diseases, Nuffield Department Edinburgh; Professor of Medical Education, of Medicine, University of Oxford; Director, Oxford University of Edinburgh, UK Centre for Tropical Medicine, UK Graham G. Dark Jeffrey K. Aronson MBBS FRCP FHEA MA DPhil MBChB FRCP FBPharmacolS FFPM (Hon) Senior Lecturer in Medical Oncology and Cancer Reader in Clinical Pharmacology and Consultant Education, Newcastle University, Northern Centre Physician, University of Oxford, UK for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK Andrew W. Bradbury BSc MBChB (Hons) MBA MD FRCSEd Martin Dennis Sampson Gamgee Professor of Vascular Surgery and MD FRCP(Ed) Director of Quality Assurance and Enhancement, Professor of Stroke Medicine, University of College of Medical and Dental Sciences, University of Edinburgh, UK Birmingham; Consultant Vascular and Endovascular David H. Dockrell Surgeon, Heart of England NHS Foundation Trust, Birmingham, UK MD FRCPI FRCP FACP Professor of Infectious Diseases, University of Leslie Burnett Sheffield, UK MB BS PhD DBA FRCPA MAACB FHGSA Michael Doherty Clinical Professor in Pathology, Sydney Medical School, University of Sydney; Director and Chief MA MD FRCP Executive, Pathology North, Royal North Shore Professor of Rheumatology, University of Hospital, Sydney, Australia Nottingham, UK Mark Byers Michael John Field MSc MRCGP MCEM MFSEM MD BS BSc FRACP Senior Medical Officer, Army Medical Professor of Medicine, University of Sydney; Directorate, Camberley, UK Associate Dean and Head, Northern Clinical School, Royal North Shore Hospital, Sydney, Australia Nicki Colledge Miles Fisher BSc FRCP(Ed) Consultant Geriatrician, Liberton Hospital, Edinburgh MD FRCP and Royal Infirmary of Edinburgh; Honorary Consultant Physician, Glasgow Royal Infirmary; Senior Lecturer in Geriatric Medicine, University of Honorary Clinical Senior Lecturer, University of Edinburgh, UK Glasgow, UK ix