5th Edition
KV Krishna Das BSc MBBS FRCP(E) FAMS (India) DTM and H (Edin)
Formerly Director and Professor Department of Medicine Medical College, Thiruvananthapuram, Kerala, India
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi 110002, India, +91-11-43574357
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559 Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com, Visit our website: www.jaypeebrothers.com
Branches
- ❑ 2/B, Akruti Society, Jodhpur Gam Road SatelliteAhmedabad 380 015 Phones: +91-79-26926233, Rel: +91-79-32988717Fax: +91-79-26927094 e-mail: ahmedabad@jaypeebrothers.com
- ❑ 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park EastBengaluru 560 001 Phones: +91-80-22285971, +91-80-22382956+91-80-22372664, Rel: +91-80-32714073Fax: +91-80-22281761 e-mail: bangalore@jaypeebrothers.com
- ❑ 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon RoadChennai 600 008 Phones: +91-44-28193265, +91-44-28194897Rel: +91-44-32972089 Fax: +91-44-28193231 e-mail: chennai@jaypeebrothers.com
- ❑ 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross RoadHyderabad 500 095 Phones: +91-40-66610020+91-40-24758498, Rel: +91-40-32940929Fax: +91-40-24758499, e-mail: hyderabad@jaypeebrothers.com
- ❑ No. 41/3098, B & B1, Kuruvi Building, St. Vincent RoadKochi 682 018, Kerala Phones: +91-484-4036109, +91-484-2395739+91-484-2395740 e-mail: kochi@jaypeebrothers.com
- ❑ 1-A Indian Mirror Street, Wellington SquareKolkata 700 013 Phones: +91-33-22651926, +91-33-22276404+91-33-22276415, Rel: +91-33-32901926Fax: +91-33-22656075, e-mail: kolkata@jaypeebrothers.com
- ❑ Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira NagarLucknow 226 016 Phones: +91-522-3040553, +91-522-3040554e-mail: lucknow@jaypeebrothers.com
- ❑ 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, ParelMumbai 400012 Phones: +91-22-24124863, +91-22-24104532Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: mumbai@jaypeebrothers.com
- ❑ “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred RoadNagpur 440 009 (MS) Phone: Rel: +91-712-3245220Fax: +91-712-2704275 e-mail: nagpur@jaypeebrothers.com
USA Office
1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734
Textbook of Medicine
© 2008, KV Krishna Das
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher.
First Edition : 1986
Second Edition : 1990
Third Edition : 1996
Fourth Edition : 2002
Fifth Edition : 2008
9788184483888
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
Medical College and Hospital, Thiruvananthapuram –
where I started learning the first principles of medicine and
thereafter; had the honour to serve as its staff and
continue my close association with the college
even several years after my retirement
7Contributors
- Ananda Kumar md, dm
- Professor, Department of Neurology
- Amrita Institute of Medical Sciences, Kochi
- Asha Kishore md, dm
- Additional Professor, Department of Neurology
- Sree Chithira Thirunal Institute of Medical Sciences and Technology, Thiruvananthapuram
- Aswini Kumar md
- Professor, Department of Medicine Medical College and Hospital, Thiruvananthapuram
- C.G Bahuleyan md, dm
- Formerly Professor and Head
- Department of Cardiology Medical College and Hospital, Thiruvananthapuram
- Consulting Cardiologist
- Ananthapuri Hospital and Research Centre Thiruvananthapuram
- S. Bhasi md
- Professor, Department of Medicine
- Sri Gokulam Medical College
- Venjaramoodu, Thiruvananthapuram District, Kerala
- S.R. Chandra md, dm
- Professor and Head, Department of Neurology
- Medical College and Hospital, Thiruvananthapuram
- Dinesa Prabhu V. md, dtcd
- Associate Professor Department of Respiratory Diseases
- Medical College and Chest Diseases Hospital
- Thiruvananthapuram
- A.S. Girija md, dm
- Formerly Professor and Head
- Department of Neurology
- Medical College and Hospital, Kozhikode Consultant Neurologist
- MIMS Hospital, Kozhikode
- Lt Col. V.P. Gopinathan md, mnams
- Professor and Head
- Department of Pulmonary Medicine
- Jubilee Mission Medical College and Research Institute, Trichur
- Formerly Professor of Medicine at AFMC, Pune
- Jacob George md, dm
- Associate Professor, Department of Nephrology
- Medical College, Thiruvananthapuram
- Jalesh N. Panicker md, dm
- Assistant Professor, Department of Neurology
- Amrita Institute of Medical Sciences, Kochi
- R.V. Jayakumar md, dm, frcp
- Professor and Head, Department of Endocrinology
- Amrita Institute of Medical Sciences, Kochi
- Formerly Professor and Head
- Department of Medicine
- Medical College, Thiruvananthapuram
- B. Jayakumar md, dm
- Professor and Head, Department of Medicine
- Medical College and Hospital, Thiruvananthapuram
- R. Kasi Visweswaran md, dm, mnams
- Formerly Professor and Head
- Department of Nephrology
- Medical College and Hospital, Thiruvananthapuram
- Consultant Nephrologist
- Ananthapuri Hospital and Research Centre
- Thiruvananthapuram
- K.V. Krishna Das bsc, mbbs, frcp(e), fams (india) dtm &h (edin)
- Formerly Director and Professor
- Department of Medicine
- Medical College, Thiruvananthapuram
- Consultant Physician and Hematologist
- Medical Writing – Medical Teaching
- S. Krishnakumar md, frcp(london), frcp(glasgow)
- Formerly Professor
- Department of Medicine and Nephrologist
- Medical College, Thiruvananthapuram
- Consultant Physician
- N. Krishnan Kutty md (psych)
- Formerly Professor, Department of Psychiatry
- Medical College, Thiruvananthapuram
- Consultant Psychiatrist
- B. Krishna Swamy md
- Formerly Professor and Head
- Department of Geriatrics
- Madras Medical College, Chennai
- Mathew Thomas md
- Department of Medicine and Hematologist
- Dr Somervel Medical College
- Karakonam, Trivandrum District
- Formerly Professor and HOD
- Medical College, Thiruvananthapuram
- P.K. Mohan (Late) md, dm
- Formerly Professor
- Department of Neurology
- Sree Chithira Thirunal Institute of Medical Sciences and Technology
- Thiruvananthapuram (Expired 2007)
- K.P. Poulose md
- Formerly Professor and Head
- Department of Medicine
- Medical College, Kottayam
- Physician and Endocrinologist
- SUT Hospital, Thiruvananthapuram
- Pradeep S. Nair md
- Assistant Professor
- Department of Dermatology and Venereology
- Medical College and Hospital
- Thiruvananthapuram
- Lt. Col. K.E. Rajan md
- Professor, Department of Medicine and Physician
- SUT Medical College, Vattappara
- Thiruvananthapuram
- Formerly Professor
- Department of Medicine AFMC, Pune
- Ramdas Pisharody md, dm
- Professor and Head, Department of Nephrology
- Medical College, Thiruvananthapuram
- Ronald Win B. md (chest diseases)
- Assistant Professor
- Department of Respiratory Diseases
- Medical College and Chest Diseases Hospital
- Thiruvananthapuram
- R. Sajith Kumar md
- Associate Professor, Department of Medicine
- (Infectious Diseases)
- Medical College, Kottayam
- National Trainer on AIDS, NACO, Govt of India
- P.K. Sasidharan md
- Professor and Head, Department of Medicine and Hematologist, Medical College, Kozhikode
- R.K. Shenoy md
- Formerly Professor and Head
- Department of Medicine
- Medical College, Alappuzha Consulting Physician
- Chief Investigator
- Filariasis Research Unit, WHO
- Medical College Hospital, Alappuzha
- S. Sivasankaran md, dm, dip, nb (cad)
- Additional Professor, Department of Cardiology
- Sree Chithira Thirunal Institute of Medical Sciences and Technology, Thiruvananthapuram
- K. Sreekanthan md
- Associate Professor, Department of Medicine
- (Infectious Diseases)
- Medical College, Thiruvananthapuram
- M. Sreelatha md, dm
- Associate Professor, Department of Nephrology
- Medical College, Kozhikode
- C. Sudheendra Ghosh md(Respiratory medicine), mph
- Professor and Head
- Department of Respiratory Diseases
- Medical College and Chest Diseases Hospital
- Thiruvananthapuram
- Susan Uthup md, dm
- Assistant Professor
- Department of Nephrology (Pediatric)
- SAT Hospital, Medical College
- Thiruvananthapuram
- K. Suresh md, dm
- Professor and Head, Department of Cardiology
- Medical College, Thiruvananthapuram
- T.K. Suma md
- Associate Professor, Department of Medicine
- TD Medical College, Alappuzha
- M. Thomas Mathew md
- Formerly Professor and Head
- Department of Nephrology
- Medical College, Kozhikode
- Nephrologist
- Baby Memorial Hospital, Kozhikode
- A.G. Unnikrishnan md, dm
- Assistant Professor
- Department of Endocrinology
- Amrita Institute of Medical Sciences, Kochi
- Usha Vaidhyanathan mbbs, dip nb (dermatology & venereology)
- Physician
- KIMS Hospital, Thiruvananthapuram
- A. Vimala md, dm
- Professor and Head
- Department of Nephrology Government
- Medical College, Kottayam
- K.R. Vinaya Kumar md, dm, mrcp
- Professor and Head
- Department of Gastroenterology
- Medical College, Thiruvananthapuram
This volume has evolved through four editions, the fourth one was published in 2002. The first edition was introduced as ‘A Short Textbook of Medicine’, now it has increased in the volume of contents and improved in its quality, commensurate with the quantitative and qualitative advancements in medical information.
Six years is too long a gap for a textbook to be up-to-date and useful, but the demand among students and teachers were the guidelines to continue with the fourth edition until 2008.
As mentioned earlier, the book has been given a new direction, both in its get up and format, so as to include the latest information and present it in a student-friendly manner. This book has been designed to include the up-to-date information obtainable from print material and electronic data and has been presented in a simple language in form of direct statements, so as to make the matter more vivid and comprehensible to the medical students and doctors in India and the neighbouring countries coming from different social and language backgrounds. In areas where more detailed information is desirable for the practitioners and the postgraduate students, authentic reviews and original works are referred to.
Several new figures, many of them taken personally by the contributors from their own clinical practice and flow charts and tables have been added.
Along with several chapters a short summary is given to serve as a ready-reckoner for the students preparing for the examination or the busy practitioners who have only limited time at their disposal.
This volume is intended for the use of undergraduate and postgraduate students of medicine, dental sciences and other allied subjects, students preparing for entrance examinations and practitioners working in India and the neighbouring countries.
All the sections have been thoroughly revised. The number of contributors has also increased including teachers in specialities who have made their mark in their respective specialisation.
The first edition of the “Short Textbook” was produced in 1986 to fulfil a long-felt and widespread need among the undergraduate and postgraduate students, majority of whom relied on class notes or handbooks written on the various subjects by several authors. Many had no access to textbooks and the big volumes available were beyond their understanding. Comprehensive textbooks catering to the needs of the undergraduate medical students written by Indian authors were only a handful. Books published in other countries are quite freely available to our students, but naturally their emphasis is on the conditions prevailing in those countries.
The medical problems of India are unique as the peculiar disease–spectrum here is a blend of what is seen in the affluent countries with what is seen in most developing countries. This Textbook of Medicine has been written with this picture in mind. The section on tropical diseases, which usually gets a separate deal in most of the western textbooks, has been dovetailed into the other sections such as infections, physical agents, nutrition and others to improve the understanding of these subjects. Almost the whole of India is in tropical belt and therefore diseases rampant in tropical countries with a few exceptions like trypanosomiasis, onchocerciasis and others are present in all parts of the country.
This book has its companion volume “Clinical Medicine” third edition edited by me and published by the same publishers in 2005. It gives in detail the clinical aspects of medical practice and investigations. The reader is referred to “Clinical Medicine” for further details on physical examination, clinical symptoms, signs and investigation procedures.12
Obsession with the printed matter is the habit of the mediocre; the wise go beyond it and use their common-sense, experience and creativity to form their own decisions.
My contributors have strived hard to collect the material and present it the way it has been done. All of them are veteran teachers and their presentations will be helpful to the entire readership. This book is the collective effort of the whole team, laying emphasis on several aspects of Internal Medicine with special emphasis on conditions prevailing in India and the neighbouring countries.
Human efforts by themselves are lifeless “karma tat jadam” (Ramana Maharshi in his Upadesa Sara). They get life and effect only when blessed by the Almighty to achieve the desired effect. This is especially so in medicine, in that both the patient and his physician have to be lucky to get the best results of investigation and treatment. I wish and pray to Almighty, the first physician in the universe to bless all and alleviate suffering. Yajurveda proclaims “prathamo daivyo bhishak” meaning the “first physician is God”. I would consider the work of my teammates and myself fulfilled, if the young entrants into the medical profession in India and the neighbouring countries find this book useful in his studies and career.
K.V. Krishna Das
13Preface to the First Edition
This book is written to fulfil a long-felt and widespread need among the undergraduate students. A questionnaire sent to several hundreds of clinical students revealed that majority of them rely on class notes, and handbooks written in the subject by several authors. Many had no access to textbooks in the subject and the big volumes available were beyond their understanding. Comprehensive textbooks catering to the need of undergraduates written by Indian authors are only a few. Books published in other countries are quite freely available to our students, but naturally their emphasis is on conditions prevailing in their lands.
The medical problems of India are unique in that the disease-spectrum is a blend of what is seen in the affluent countries with what is seen in developing countries. This book has been written with this picture in mind. The section on “tropical diseases” which usually gets a separate deal in most of the textbooks has been dovetailed into the other sections such as infections, physical agents, nutrition, etc. It is my feeling that with modern jet travel and the rapidly changing life-styles of Indian subjects, all diseases—the most modern and the most ancient are likely to be encountered by the clinical student in this country. Moreover, the so-called tropical diseases which used to be confined to the tropical belt, are now seen widely all over the world as a result of free and fast migration of population.
I consider my purpose fulfilled if the undergraduates in this country find this book useful.
K.V. Krishna Das
14Acknowledgements
I acknowledge with thanks the help, support and patience of my wife Smt L.N. Kamalam who encouraged me in my task and endured all the inconvenience and disruption of domestic routine due to my prolonged and generally untimely work schedule, I had to pursue in completing the task.
I had to depend heavily on doctors S. Aswini Kumar, K. Sreekanthan, Mathew Thomas and P.K. Sasidharan who helped me to review the chapters and offered suggestions for improvement and also reviewed the proofs critically.
I express my indebtedness to Shri J.P. Vij, Chairman and Managing Director of M/s Jaypee Brothers Medical Publishers (P) Ltd and his teammates especially Mr Tarun Duneja, Director (Publishing) who gave constant support in the form of timely suggestions, prompt execution of the work and appropriate technical help. I thank M/s. Krishnakumar and Associates for the typographical work and preparation of the matter in print and CD.
To all human efforts the divine influence has to be in constant attendance. I thank the Almighty to have allowed me to complete this task of editing the fifth revised and enlarged edition along with my team of section editors and contributors.
15Editorial Committee
Editor
K.V. Krishna Das
bsc mbbs frcp(e), fams (India) dtm and h (edin)
Section Editor | Section | Title | Chapters |
---|---|---|---|
K.V. Krishna Das | Section 1 | General Topics | |
K.V. Krishna Das | Section 2 | Diseases due to Arthropods, Marine Animals and Snakes | |
K.V. Krishna Das | Section 3 | Disorder due to Physical Agents | |
K.V. Krishna Das | Section 4 | Toxicology | |
K.V. Krishna Das | Section 5 | Nutrition | |
R Sajith Kumar, K.V. Krishna Das, R.K. Shenoy | Section 6 | Diseases Caused by Infections | |
R. Kasi Visweswaran | Section 7 | Fluid and Electrolytes | |
K.R. Vinaya Kumar | Section 8 | Gastroenterology | |
K.R. Vinaya Kumar | Section 9 | Hepatobiliary System and Pancreas | |
R.V. Jayakumar, K.P. Poulose | Section 10 | Diabetes Mellitus, Other Metabolic Disorders and Inherited Disorders of Connective Tissue | |
K.P. Poulose | Section 11 | Endocrinology including Geriatrics | |
K.V. Krishna Das | Section 12 | Rheumatology | |
C.G. Bahuleyan | Section 13 | Cardiology | |
C Sudheendra Ghosh | Section 14 | Respiratory System | |
K.V. Krishna Das, Mathew Thomas | Section 15 | Hematology | |
R. Kasi Visweswaran | Section 16 | Nephrology | |
A.S. Girija | Section 17 | Neurology | |
Usha Vaidhyanathan | Section 18 | Dermatology | |
N. Krishnan Kutty | Section 19 | Psychiatry |