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PRINCIPLES OF INTERNAL MEDICINEEleventh Edition

Harrison's

Editors EUGENE BRAUNWALD, A.B., M.D., MA.(Hon.), M.D. (Hon.) Hersey Professor of the Theory and Practice of Physic and Herman Ludwig Blumgart Professor of Medicine, Harvard Medical School; Chairman, Department of Medicine, Brigham and Women's and Beth Israel Hospitals, Boston

KURT J. ISSELBACHER, A.B., M.D.Mallincrodt Professor of Medicine, Harvard Medical School; Physician and Chief, Gastrointestinal Unit, Massachusetts General Hospital, Boston

ROBERT G. PETERSOORF, A.B., M.D., MA.(Hon.), D.Sc. (Hon.), M.D. (Hon.), LH.D. (Hon.) Professor of Medicine, Dean and Vice Chancellor, Health Sciences, University of California School of Medicine, San Diego, La Jolla

JEAN D. WILSON, M.D.Professor of Internal Medicine, The University of Texas Southwestern Medical School, Dallas J O S E P H B. M A R T I N , M.D,, Ph.D.. F.R.C.P.(C), M.A. (Hon.) Julieanne Dorn Professor of Neurology, Harvard Medical School; Chief, Neurology Service, Massachusetts General Hospital, Boston

ANTHONY S. FAUCI, M.D.Chief, Laboratory of Immunoregulation and Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda

MCGRAW-HILL BOOK COMPANYNew York St. Louis San Francisco Auckland Bogota Hamburg Johannesburg London Madrid Mexico Milan Montreal New Delhi Panama Paris Seo Paulo Singapore Sydney Tokyo Toronto

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"" 1993

54.1 60 616.1/.4 (035)

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. 10 . 1. . ./ 60 . . , . . , . . . .: . 1993. - 560 : : [4J . .ISBN 5 - 2 2 5 - 0 0 5 9 9 - 3 ISBN 007100134 -4 1 , .. : , , . , , , , . .

410804000024039(01)93

7092

54.1

ISBN 5225005993 ISBN 0071001344

1987 by McGraw - Hill Book Company 3. . , . . , . . , . . , . . , . . , . . , ; , 1993

8 26

1. () 2. . (Lee Goldman) 27 36

I. 51 3. . , . (Raymond Maciewicz, Joseph . Martin) 4. . 62 . 75 82 101 123 123 138 155 155 160 170 5 (Eugene Braunwald) 5. . (William Silen) . 6. . . , . (Raymond D. Adams, Joseph . Martin) 7. . . , . (Henry J. Mankin, Raymond D. Adams) 2. 8. . . , . (Robert G. P.etersdorf, Richard . Root) 9. . . , . (Robert G. Petersdorf, Richard . Root) 3. 10. . . (Joseph . Martin) . . 11. . . (Edwin H. Cassem) 12. , , . . , . (Raymond D. Adams, Joseph . Martin)

51

13. . . (Shirley H. Wray) 14. . . (Robert . Daroff) 15. . X. , . (John H. Growdon, Robert R. Young) . . 16. , (Sid Gilman) .

184

199 205 231 240 247

17. , , . . (Robert . Griggs) 18. , . (Arthur . Asbury) .

19. , . . , . ( J a m e s . Snow, Joseph . Martin) 20. . . , . , . (William J. Schwartz, John W. Stakes, Joseph B. Martin)

257

267 278 294

21. . . , . (Allen H . Ropper, Joseph . Martin) . . . . 22. . . , . (Jay P. Mohr, Raymond D. Adams) 23. , , . , . (Maurice Victor, Raymond D. Adams) 24. . . , (Raymond D. Adams, Maurice Victor)

309

327 335 335 341 350 360 368 378

4. 25. . . , . ( G e n n a r o M. Tisi, Eugene Braunwald) 26. . X. , ., . (Roland H . Ingram, Jr., Eugene Braunwald) . . . . 27. , . . (Eugene Braunwald) 28. . . (Eugene Braunwald) 29. . . , X. (Eugene Braunwald, Gordon H. Williams) 30. - . . , . (Barton E. Sobel, Eugene Braunwald) 5. 6 -

391 391 409

31. . ( P a u l Goldhaber) 32. . . (Raj . Goyal)

33. . . , . (Lawrence S. Friedman, Kurt J. Isselbacher) 34. , . . (Kurt J. Isselbacher) 35. . . (Daniel U. Foster) 36. , . . (Stephen E. Goldfinger) 37. , . . , . (Kurt J. Isselbacher, James M. Richter) 38. . . (Kurt J. Isselbacher) 39. . Mi , . (Robert M. Glickman,, Kurt J. Isselbacher) . . 6.

114 421 425 430

438 445 457 465 465 483 508 528

40. . . (Frederick L. ) 41. . . (Norman G. Levinsky) 42. . . (Norman G. Levinsky) 7. 43. . . , . (Bruce R. Carr, Jean D. Wilson) 44. . . , . (Patrick . Walsh, Jean D. Wilson) 45. . (Peter Reich) 46. . . , . (William J. Kovacs, Jean D. Wilson)

523 528 536 545 551

Raymond D. Adams, . A., M. A., M. D., M. A. (Hon.), D. Sc. (Hon.), M. D. (Hon.) Bullard Professor of Neuropathology, Emeritus, Harvard Medical School; Consultant Neurologist and formerly Chief of Neurology Service, Massachusetts General Hospital, Emeritus Director, Eunice K. Shriver Research Center, Boston; Meedecin Adjoint, L'H6pital Cantinale de Lausanne, Lausanne John W. Adamson, M. D. Professor of Medicine and Head, Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle Elliot Alpert, M D. Professor of Medicine and Chief, Divison of Gastroenterology, Baylor College of Medicine, Houston Joseph S. Alpert, M. D. Professor of Medicine, University of Massachusetts Medical School; Director, Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester Robert J. Anderson, M. D. Associate Professor of Medicine, University of Colorado Health Sciences Center, Denver Jack P. Antel, M. D. Associate Professor of Neurology, University of Chicago Pritzker School of Medicine, Chicago Paul M. Arnow, M. D. Associate Professor of Medicine, Section of Infectious Disease, University of Chicago Hospital and Clinics, Chicago Arthur K. Asbury, M. D. Ruth Wagner Van Meter and J. Ray Van Meter Professor of Neurology, University of Pennsylvania School of Medicine and Hospital of the University of Pennsylvania, Philadelphia K. Frank Austen, M. D. Theodore B. Bayles Professor of Medicine, Harvard Medical School; Physicianin-Chief, Robert B. Brigham Division and Chairman, Department of Rheumatology and Immunology, Brigham and Women's Hospital, Boston Robert Austrian, M. D., D. Sc. (Hon.) John Iierr Musser Professor and Chairman, Department of Research Medicine, University of Pennsylvania School of Medicine, Philadelphia Bernard M. Babior, M. D., Ph. D. Head, Division of Biochemistry, Department of Basic and Clinical Research, Scripps Clinic and Research Foundation, La Jolla Jeffrey P. Baker, M. D., F.R.C.P. (C) Assistant Professor of Medicine, University of Toronto; Consultant Staff Gastroenterologist, Toronto Western Hospital, Toronto 8

M. Flint Beal, M. D. Assistant Professor, Harvard Medical School; Assistant Neurologist, Massachusetts General Hospital, Boston Harry N. Beaty, M. D. Professor of Medicine and Dean, Northwestern University Medical School, Chicago Arthur L. Beaudet, M. D. Investigator, Howard Hughes Medical Institute; Professor of Pediatrics and Cell Biology, Baylor College of Medicine, Houston John E. Bennett, M. D. Head Clinical Mycology Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Jeffrey D. Bernhard, M. D. Assistant Professor of Medicine, Director, Division of Dermatology, and Director of Phototherapy Center, Department of Medicine, University of Massachusetts Medical Center, Worcester Edwin L. Blerman, M. D. Professor of Medicine and Chief, Division of Metabolism, Endocrinology, and Nutrition, University of Washington School of Medicine, Seattle Alan B. Bisno, M. D. Professor of Medicine and Chief, Division of Infectious Diseases, University of Tennessee Center for the Health Sciences, Memphis Henry R. Bourne, M. D. Chairman, Department of Pharmacology, School of Medicine, University of California, San Francisco Walter G. Bradley, D. M., F. R. . . Chairman and Professor of Neurology, University of Vermont College of Medicine; Chairman, Department of Neurology, University Health Center, Burlington David L. Braff, M. D. Associate Professor, Department of Psychiatry, School of Medicine, University of California at San Diego; Director, Psychiatric Impatient Services, U.C. S. D. Medical Center, San Diego Eugene Braunwald, . ., M. D., M. A. (Hon.), M. D. (Hon.) Hersey Professor of the Theory and Practice of Physic and Herrman Ludwig Blumgart Professor of Medicine, Harvard Medical School; Chairman, Department of Medicine, Brigham and Women's and Beth Israel Hospitals, Boston Barry M. Brenner, B. S., M. 0., M. A. (Hon.) Samuel A. Levine Professor of Medicine, Harvard Medical School; Senior Physician and Director, Renal Division, Brigham and Women's Hospital, Boston Karen Thatcher Britten, M. D., Ph. D. Assistant Professor of Psychiatry, School of Medicine, University of California at San Diego, La Jolla Samuel Proder, M. D. Associate Director, Clinical Oncology Program, Division of Cancer Treatment and Deputy Clinical Director, National Cancer Institute, National Institutes of Health, Bethesda Michael S. Brown, M. D. Paul J. Thomas Professor, Department of Molecular Genetics, The University of Texas Health Science Center, Dallas H. Franklin Bunn, M. D. Professor of Medicine, Harvard Medical School; Senior Physician and Director, Hematology Research, Brigham and Women's Hospital; Investigator, Howard Hughes Medical Institute, Boston

John Burton, M. D. Associate Professor of Medicine, Johns Hopkins University School of Medicine; Deputy Director of Department of Medicine, Director of Division of Geriatric Medicine, Francis Scott Key Medical Center, Baltimore Alfred E. Buxton, M. D. Assistant Professor of Medicine, University of Pennsylvania School of Medicine; Director, Cardiac Electrophysiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia Charles B. Carpenter, M. D. Professor of Medicine, Harvard Medical School; Senior Physician, Brigham and Women's Hospital, Boston Charles C. J. Carpenter, M. D. Professor of Medicine, Brown University; Physician-in-Chief, The Miriam Hospital, Providence Bruce R. Carr, M. D. Associate Professor, Department of Obstetrics and Gynecology and Cecil and Ida Green Center for Reproductive Biology Sciences, The University of Texas Health Science Center, Dallas Edwin Cassem, M. D. Associate Professor of Psychiatry, Harvard Medical School; Chief, Psychiatric Consultation Liason Service, Massachusetts General Hospital, Boston Richard Champlin, M. D. Associate Professor of Medicine and Director, Leukemia/Bone Marrow Transplant Service, School of Medicine, University of California at Los Angeles Keith H. Chiappa, M. D. Assistant Professor of Neurology, Harvard Medical School; Director, EEG and Evoked Potentials Unit of the Clinical Neurophysiology Laboratory and Department of Neurology, Massachusetts General Hospital, Boston Wallace A. Clyde. Jr., M. D. Professor of Pediatrics and Microbiology, University of North Carolina School of Medicine, Chapel Hill Fredric L. , . D. Professor of Medicine and Physiology and Chief, Nephrology Program, University of Chicago Pritzker School of Medicine, Chicago Alan S. Cohen-, M. D. Chief of Medicine and Director, Thorndike Memorial Laboratory, Boston City Hospital; Conrad Wesselhoeft Professor of Medicine, Boston University School of Medicine, Boston Harvey R. Cotten, M. D. Professor and Chairman, Department of Pediatrics, Washington University School of Medicine, St. Louis Wilson S. Colucci, M. D. Assistant Professor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston Patricia Come, M. D. Assistant Professor of Medicine, Harvard Medical School; Director, Noninvasive Cardiovascular Diagnostic Laboratory, Beth Israel Hospital, Boston Max D. Cooper, M. D. Professor of Pediatrics and Microbiology, Cellular Immunobiology Unit, The University of Alabama in Birmingham, Birmingham Richard A. Cooper, M. D. Dean and Professor of Medicine, Medical College of Wisconsin, Milwaukee

Lawrence Corey, M. D. Professor of Laboratory Medicine and Microbiology and Adjunct Professor of Medicine and Pediatrics, University of Washington School of Medicine, Seattle Ronarld G. Crystal, M. D. Chief, Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda John J. Cush, M. D. Fellow in Rheumatology, Department of Internal Medicine, The University of Texas Health Science Center, Dallas David Dale, M. D. Professor of Medicine and Dean, University of Washington School of Medicine, Seattle James E. Dalen M. D. Professor and Chairman, Department of Medicine, University of Massachusetts Medical School; Physician-in-Chief, University of Massachusetts Hospital, Worcester Thomas M. Daniel, M. D. Professor of Medicine, Case Western Reserve University School of Medicine; Physician, University Hospitals of Cleveland, Cleveland Gilbert H. Daniels, M. D. Associate Professor of Medicine, Thyroid Unit, Massachusetts General Hospital, Boston Robert B. Daroff, M. D. Gilbert W. Humphrey Professor and Chairman, Case Western Reserve University School of Medicine, Director, Department of Neurology, University Hospitals of Cleveland; Neurology Service, Cleveland Veterans Administration Medical Center, Cleveland John R. David, M. D. Professor of Medicine, Harvard Medical School; Chief, Division of Tropical Medicine, Robert B. Brigham Division of Brigham and Women's Hospital; John LaPorte Given Professor and Chairman, Department of Tropical Public Health, Harvard School of Public Health, Boston G. Robert DeLong, M. D. Assistant Professor of Neurology, Harvard Medical School; Associate Neurologist and Associate Pediatrician, Massachusetts General Hospital, Boston Vincent T. DeVita, Jr., M. D. Director, National Cancer Institute, National Institutes of Health, Bethesda Marc A. Dichter, M. D., Ph. D. Professor of Neurology, University of Pennsylvania School of Medicine, Philadelphia Jules L. Dienstag, M. D. Associate Professor of Medicine, Harvard Medical School; Assistant Physician, Massachusetts General Hospital, Boston Robert G. Dluhy, M. D. Associate Professor of Medicine, Harvard Medical School; Associate Program Director of the Clinical Research Center, Brigham and Women's Hospital, Boston Raphael Dolin, M. D. Professor of Medicine and Head, Infectious Diseases Unit, University of Rochester School of Medicine and Dentistry, Rochester Andrew G. Engel, M. D. Professor of Neurology, Mayo Medical School; Department of Neurology, Mayo Clinic, Rochester Kenneth H. Falchuk, M. D. Associate Professor of Medicine, Harvard Medical School; Bringham and Women's Hospital, Boston 11

Anthony S. Fauci, M. D. Chief, Laboratory;of Immunoregulation and Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Murray J. Favus, M. D. Associate Professor of Medicine, University of Chicago Pritzker School of Medicine, Chicago Ralph D. Feigin, M. D. Professor and Chairman, Department of Pediatrics, Baylor College of Medicine; Physician-in-'Chief, Texas Children's Hospital, Houston : Bernard N. Fields, M. D. Adele Lehman Professor and Chairman, Department of Microbiology and Molecular Genetics, Harvard Medical School; Professor of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Boston Alfred P. Fishman, M. D. William Maul Measey Professor of Medicine, University of Pensylvania; Director, Cardiovascular-Pulmonary Division, Hospital of the University of Pennsylvania, Philadelphia Thomas B. Fitzpatrick, M. D., Ph. D. Edward Wigglesworth Professor of Dermatology and Chairman Department of Dermatology, Harvard Medical School; Chief, Dermatology Service, Massachusetts General Hospital, Boston Daniel W. Foster, M. D. Professor of Internal Medicine, The University of Texas Health Science Center, Dallas Michael M. Frank, M. D. Chief, Laboratory of Clinical Investigation and Clinical Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Stanley D. Freedman, M. D. Head, Division of Infectious Diseases, Scripps Clinic and Research Foundation; Associate Clinical Professor of Medicine, University of California at San Diego, La Jolla Laurence S. Friedman, M. D. Assistant Professor of Medicine, Jefferson Medical College and Thomas Jefferson University Hospital, Philadelphia Paul A. Friedman, M. D. Associate Professor of Medicine and Pharmacology, Harvard Medical School; Associate Physician, Beth Israel Hospital, Boston William F. Friedman, M. D. J. H. Nicholson Professor of Pediatrics and Executive Chairman Department of Pediatrics, Los Angeles Medical Center, University, of California, Los Angeles Lawrence A. Frohman, M. D. Professor of Medicine, Director of Division of Endocrinology and Metabolism, University of Cincinnati College of Medicine, Cincinnati John I. Gallin, M. D. Scientific Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Robert Gallo, M. D. Chief, Laboratory of Tumor Cell Biology, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health, Bethesda Pierce Gardner, M. D. Professor of Medicine and Pediatrics, University of Chicago Pritzker School of Medicine; Director, Infectious Diseases Training Program, University of Chicago Medical Center, Chicago 12

Marc . Garnick, M. D. Associate Professor of Medicine, Dana-Farber Cancer Institute, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston James L. German III, M. D. Professor' (Genetics), Department of Pediatrics, Cornell University Medical College; Senior investigator and Director, Laboratory of Human Genetics, The New York Blood Center, New York Eloise R. Giblett, M. D. Research Professor of Medicine, University of Washington School of Medicine; Executive Director, Puget Sound Blood Center, Seattle Bruce Gilllland, M. D. Professor of Medicine and Laboratory Medicine, University of Washington School of Medicine; Chief of Medicine, Pacific Medical Center, Seattle J. Christian Gillin, M. D. Professor of Psychiatry, University of California at San Diego, La Jolla Sid Gilman, M. D. Professor and Chairman, Department of Neurology, The University of Michigan Medical Center, Ann Arbor Richard J. Glassock, M. D. Professor of Medicine, School of Medicine, University of California at Los Angeles; Chairman, Department of Medjcine, Harbor-UCLA Medical Center, Torrance Robert M. Glickman, M. D. Samuel Bard Professor of Medicine, Columbia University College of Physicians and Surgeons; Director, Medical Service, Presbyterian Hospital, New York David W. Golde, M. D. Professor of Medicine and Chief, Division of Hematology/Oncology, School of Medicine, University of California at Los Angeles, Los Angeles Stephen E. Goldfringer, M. D. Associate Professor of Medicine and Associate Dean of Continuing Education, Harvard Medical School; Physician, Gastrointestinal Unit, Massachusetts General Hospital, Boston Paul Goldhaber, D. D. S. Dean and Professor of Perinatology, Harvard School of Dental Medicine, Boston Lee Goldman, M. 0. Associate Professor of Medicine, Harvard Medical School; Assistant Physician-inChief, Brigham, and Women's Hospital, Boston Joseph L. Goldstein, M. D. Paul J. Thomas Professor and Chairman, Department of Molecular Genetics, The University of Texas Health Science Center, Dallas Raj K. Goyal, M. D. Rabb Professor of Medicine, Harvard Medical School; Chief, Division of Gastroenterology, Beth Israel Hospital, Boston John W. Graff, M. D. Assistant Clinical Professor, Harvard Medical School; Director, The Lead/Toxicology Clinic, The Children's Hospital, Boston Igor Grant, M. D. Professor of Psychiatry, School of Medicine, University of California at San Diego, La Jolla: Harry B. Greenberg, M. D. Associate Professor of Medicine, Department of Medicine, Stanford University Medical School; Palo Alto Veterans Administration Medical Center, Palo Alto

13

Norton J. Greenberger, M. D. Peter T. Bohan, Professor and Chairman, Department of Medicine, University of Kansas School of Medicine, Kansas City James E. Griffin III, M. D. Associate Professor of Internal Medicine, The University of Texas Health Science Center, Dallas Robert Griggs, M. D. Professor of Neurology and Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester John H. Growdon, M. D. Associate Professor of Neurology, Harvard Medical School; Associate Neurologist, Massachusetts Genetal Hospital, Boston Richard L. Guerrant, M. D. Professor of Medicine and Head, Division of Geographic Medicine, University of Virginia School of Medicine, Charlottesville Bevra Hannahs Hahn, M. D. Professor of Medicine and Chief of Rheumatology, University of California, Los Angeles Robert I. Handin, M. D. Associate Professor of Medicine, Harvard Medical School; Director, Hematology Division, Brigham and Women's Hospital, Boston H. Hunter Handsfield, M. D. Director, Sexually Transmitted Disease Control Program, Seattle-King County Department of Public Health; Associate Professor of Medicine, University of Washington School of Medicine, Seattle James P. Harnish, M. D. Clinical Associate Professor of Medicine, University of Washington School of Medicine; Chief of Dermatology, Pacific Medical Center, Seattle Donald H. Harter, M. D. Benjamin and Virginia T. Boshes Professor of Neurology and Chairman Department of Neurology, Northwestern University Medical School; Chairman, Department of Neurology, Northwestern Memorial Hospital, Chicago Barton F. Haynes, M. D. Associate Professor of Medicine and Assistant Professor of Microbiology and Immunology, Duke University School of Medicine, Durham Harley A. Haynes, M. D. Associate Professor of Dermatology, Harvard Medical School; Director, Dermatology Division, Department of Medicine, Brigham and Women's Hospital; Chief, Dermatology, West Roxbury Veterans Administration Hospital, Boston William R. Hazzard, M. D. Professor and Chair, Department of Medicine, Bowman-Gray School of Medicine, Wake Forest University; Chief of Medicine, North Carolina Baptist Hospital, Winston-Safem Steven C. Hebert, M. D. Assistant Professor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston Fred J. Hendler, M. D., Ph. D. Assistant Professor of Internal Medicine, Division of Hematology Oncology, The University of Texas Health Science Center, Dallas Jane Ellen Henney, M. D. Associate Vice Chancellor and Associate Professor of Medicine, Division of Clinical Oncology, Department of Medicine, University of Kansas Medical Center, Kansas City 14

Raymond L. Hintz, M. D. Professor of Pediatrics and Head, Division of Pediatric Endocrinology, Stanford University School of Medicine, Stanford Martin S. Hirsch, M. D. Associate Professor, Harvard Medical School; Associate Physician, Disease Unit, Massachusetts General Hospital, Boston Infectious

Jan V. Hlrschmann, M. D. Assistant Chief, Medical Service, Seattle Veterans Administration Medical Center, Associater Professor of Medicine, University of Washington School of Medicine, Seattle. Fred Hochberg, M. D. Associate Professor of Neurology, Harvard Medical School; Associate Neurologist, Massachusetts General. Hospital, Boston Paul D. Hoeprich, M. D Professor of Medicine and Chief, Section of Medical Mycology, Department of Internal Medicine, Division of Infectious and Immunologic Diseases, School of Medicine, University of California, Davis John H. Holbrook, M. D. Associate professor of Medicine, Division of General Internal Medicine, Department of Medicine, University of Utah Medical Center, Salt Lake City Michael F. Holick, M. D., Ph. D. Professor of Physiology and Nutrition and Director of Vitamin D and Bone Metabolism Laboratory, U.S. Department of Agriculture/Human Nutrition Research Center, Tufts University, Boston Norman K. Hollenberg, M. D. Professor of Radiology, Harvard Medical School; Physician, Brigham and Women's Hospital, Boston King K. Holmes, M. D., Ph. D. Professor and Vice Chairman, Department of Medicine, University of Washington School of Medicine; Chief of Medicine, Harborview Medical Center, Seattle Thomas M. Hostetter, M. D. Associate Professor of Medicine, University of Minnesota School of Medicine; Director, Division of Renal Diseases, University Hospital, Minneapolis Leighton Y. Huey, M. D. Associate Professor of Psychiatry, University of California at San Diego; Chief of Psychiatry Service, San Diego Veterans Administration Medical Center, San Diego Gary W. Hunninghake, M. D. Professor of Internal Medicine and Director, Pulmonary Division, University of Iowa College of Medicine, Iowa City Sidney H. Ingbar, M. D., D. Sc. William Bosworth Castle Professor of Medicine, Harvard Medical School; Director, Thorndike Laboratory, Beth Israel Hospital, Boston Roland H. Ingram, Jr., M. D. Parker B. Francis Professor of Medicine, Harvard Medical School; Director, Respiratory Division, Brigham and Women's Hospital, Boston Kurt J. Isselbacher, . ., . D. Mallinckrodt Professor of Medicine, Harvard Medical School; Physician and Chief, Gastrointestinal Unit, Massachusetts General Hospital, Boston Khursheed N. Jeejeebhoy, M. B. B. S., Ph. D., F. R. P. (Lond.), F. R. P. (Edin.), F. R. . (). Professor of Medicine, University of Toronto; Director, Division of Gastroenterology, Toronto General Hospital, Toronto 15

Mark E. Josephson, M. D. Professor of -Medicine, University of Pennsylvania School of Medicine; Chief, Cardiovascular Section, Hospital of the University of Pennsylvania, Philadelphia Lewis L. Judd, M. D. Professor and Chairman, Department of Psychiatry, School of Medicine, University of California at San Diego, LaJolla Dennis L. Kasper, M. D. Professor of Medicine, Harvard Medical School; Chief, Division of Infectious Diseases, Beth Israel Hospital; Associate Director, Channing Laboratory, Brigham and Women's Hospital, Boston Satish Kathpalia, M. D. Assistant Professor of Medicine, University of Chicago Pritzker School of Medicine, Attenting Physician, Michael Reese Hospital and Medical Center, Chicago Donald Kaye, M. D., P. . . . Professor and Chairman, Department of Medicine, Medical College of Pennsylvania; Chief of Medicine, Hospital of the Medical College of Pennsylvania, Philadelphia William N. Kelley, M. D. John G. Searle Professor and Chairman, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor Philip Kirby, M. D. Instructor in Medicine, Division of Dermatology, University of Washington School of Medicine, Seattle J. Phillip Kistler, M. D. Associate Professor of Neurology, Haevard Medical School; Associate Neurologist, Massachusetts General Hospital, Boston Raymond S. Koff, M. D. Professor of Medicine, Boston University School of Medicine; Chief of Hepatology Section, Boston University Medical Center; Chief of Medicine, Framinghani Union Hospital, Framingham William J. Kovacs, M. D. Assistant Professor of Medicine, Division of Endocrinology, Vanderbit University School of Medicine, Nashville Stephen M. Krane, M. D. Professor of Medicine, Harvard Medical School; Physician and Chief, Arthritis Unit, Massachusetts General Hospital, Boston J. Thomas LaMont, M. D. Professor of Medicine, Boston University Medical Center, Chief, Gastrointestinal Section, University Hospital, Boston Lewis Landsberg, M. D. Professor of Medicine, Harvard Medical School; Director, Division of Endocrinology and Metabolism, Beth Israel Hospital, Boston H. Clifford Lane, M. D. Senior Investigator, Laboratory of Immunoregulation and Deputy Clinical Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Thomas J. Lawley, M. D. Senior Investigator, Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda Alexander R. Lawton, M. D. Professor of Pediatrics and Microbiology, Division of Pediatric Immunology, Vanderbilt University School of Medicine, Nashville 16

J. Michael Lazarus, M. D. Associate Professor of Medicine, Harvard Medical School; Physician, Brigham and Women's Hospital, Boston Norman G. Levinsky, M. D. Wade Professor and Chairman, Division of Medicine, Boston University School of Medicine; Physician-in-Chief and Director, Evans Memorial Department of Clinical Research, University Hospital, Boston Peter E. Lipsky, M. D. Professor of Internal Medicine and Microbiology and Chief, Division of Immunologic and Rheumatologic Diseases, Department of Internal Medicine; Director, Harold Simmons Arthritis Research Center, The University of Texas Health Science Center, Dallas Richard M. Locksley, M. D. Assistant Professor of Medicine, University of San Francisco; Chief of Infectious Diseases, University of San Francisco Medical Center, Moffitt-Long Hospital, San Francisco Dan L. Longo, M. D. Associate Director, Biological Response Modifiers Program, Division of Biology and Diagnosis, National Cancer Institute-Frederick Cancer Research Facility, Frederick Frederick H. Lovejoy, Jr., M. D. Associate Professor, Harvard Medical School; Associate Physician-in-Chief, The Children's Hospital; Director, Massachusetts Poison Control System, Boston Sheila A. Lukehart, Ph. D. Research Assistant Professor, Division of Infectious Diseases, University of Washington School of Medicine, Seattle Walter MacDonald, M. D. Chairman, GI Tumor Group, Cancer Control Agency of British Columbia, Vancouver Raymond Maciewicz, M. D. Assistant Professor of Neurology, Harvard Medical School; Assistant Neurologist, Massachusetts General Hospital, Boston Henry J. Man kin, M. D. Edith M. Ashley Professor of Orthopedic Surgery, Harvard Medical School; Chief, Orthopedic Services, Massachusetts General Hospital, Boston Francis E. Marchlinski, M. D. Assistant Professor of Medicine, University of Pennsylvania School of Medicine; Director, Arrhythmias Evaluation Center, Hospital of the University of Pennsylvania, Philadelphia Joseph B. Martin, M. D., Ph. D., F. R. . (), . A. (Hon.). Julieanna Dorn Professor of Neurology, Harvard Medical School; Chief, Neurology Service, Massachusetts General Hospital, Boston Henry Masur, M. D. Deputy Chief, Critical Care Medicine, Clinical Center, National Institutes of Health, Bethesda Roger J.' May, M. D. Instructor in Medicine, Harvard Medical School; Assistant in Medicine, Beth Israel Hospital, Boston E. R. McFadden, Jr., M. D. Argyl J. Beams Professor of Medicine and Director, Asthma and Allergic Disease Center, Case Western Reserve University, Cleveland James E. McGuigan, M. D. Chairman, Department of Medicine, University of Florida College of Medicine, Gainesville 17

Rima McLeoq , M. D. Associate Professor of Medicine, University of Chicago Pritzker School of Medicine; Attending Physician, Michael Reese Hospital and Medical Center, Chicago Mark S. McPhee, M. D. Clinical Associate Professor of Medicine and Director, Gastrointestinal Endoscopy Unit, University of Kansas, Kansas City Nancy K. Mello, Ph. D. Professor of Psychology, Department of Psychiatry, Haevard Medical School; CoDirector, Alcohol and Drug Abuse Research Center, McLean Hospital, Belmont Jerry R. Mendell, M. D. Professor of Neurology, Ohio State University College of Medicine, Columbus John Mendelsohn, M. D. Chairman, Department of Medicine and Head, Division of Medical Oncology, Memorial Sloan-Kettering Cancer Center, Professor of Medicine, Cornell University Medical College, New York Jack H. Mendelson, M. D. Professor of Psychiatry, Harvard Medical School; Co-Director Alcohol and Drug Abuse Research Center, McLean Hospital, Belmont Urs A. Meyer, M. D. Professor of Pharmacology and Chairman, Department of Pharmacology, Biocenter of the University of Basel, Basel Switzerland Martin Mihm, Jr., M. D. Professor of Pathology, Harvard Medical School; Chief, Dermatopathology Unit; Massachusetts General Hospital, Boston Edgar L. Milford, M. D. Assistant Professor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston Myron Miller, M. D. Professor of Medicine; Division of Infectious Diseases, Pacific Medical Center, Seattle John D. Minna, M. D. Chief, NCI-Navy Medical Oncology Branch, National Cancer Institute, National Institutes of Health; Professor of Medicine, Uniformed Services University for the Health Sciences, Naval Hospital, Bethesda Jay P. Mohr, M. D. Sciarra Professor of Clinical Neurology, College of Physicians and Surgeons of Columbia University Neurological Institute, New York Kenneth M. Moser, M. D. Professor of Medicine, School of Medicine, University of California at San Diego; Director, Pulmonary and Critical Care Division, U. C. S. D. Medical Center, San Diego Arnold M. Moses, M. D. Professor of Medicine and Director, Clinical Research Center, State University of New York Upstate Medical Center; Chief, Endocrinology Section, Veterans Administration Medical Center, Syracuse David B. Mosher, M. D. Clinical Instructor in Dermatology, Harvard Medical School; Assistant in Dermatology, Massachusetts General Hospital, Boston Haralampos M. Moutsopoulos, M. D., F. A. C. P. Professor and Head of Medicine, Medical School, University of Ioannina, Greece Frederick M. Murphy, M. D. Fellow in Neonatology, Baylor School of Medicine, Houston 18 Ioannina,

1

John F. Murray, M. D., D. Sc. (Hon.) Professor of Medicine, University of California at San Francisco; Chief, Chest Service, San Francisco General Hospital, San Francisco Robert J. Myerburg, M. D. Professor of Medicine and Physiology and Director, Division-of Cardiology, University of Miami Medical Center, Miami Theodore E. Nash, M. D. Senion Scientist, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Paul Neiman, M. D. Professor of Medicine, University of Washington School of Medicine; Member and Associate Director for Basic Sciences, Fred Hutchinson Cancer Research Center, Seattle Harold Neu, M. D. Professor of Medicine and Pharmacology and Chief, Division of Infectious Diseases, College of Physicians and Surgeons, Columbia University, New York John A. Oates, M. D. Professor and Chairman, Department of Medicine, Vanderbilt University School of Medicine; Physician-in-Chief, Vanderbilt University Hospital, Nashvilla Jerrold M. Olefsky, M. D. Professor of Medicine and Head, Division of Endocrinology and Metabolism, School of Medicine, University of California at San Diego, La Jolla Robert A. O'Rourke, M. D. Charles Conrad and Anna Sahm Brown Professor of Medicine, University of Texas; Director, Division of Cardiovascular Diseases, The University of Texas Health Science Center, San Antonio Thomas D. Palella, M. D. Assistant Professor of Internal Medicine, Division of Rheumatology, University of Michigan Medical School, Ann Arbor Darwin L. Palmer, M. D. Professor of Medicine and Chief, Division of Infectious Disease, University of New Mexico School of Medicine; Chief, Infectious Disease Section, Veterans Administration Medical Center, Albuquerque John A. Parrish, M. D. Professor of Dermatology, Harvard Medical School; Director, Wellman Research Laboratory, Massachusetts General Hospital, Boston A. William Pasculle, D. Sc. Associate Professor of Pathology, University of Pittsburgh School of Medicine; Associate Director of Microbiology, Presbyterian-University Hospital, Pittsburgh Richard Pasternak, M. D. Assistant Professor of Medicine, Harvard Medical School; Assistant Physician and Director, Coronary Care Unit, Beth Israel Hospital, Boston Maghukar A. Pathak, M. S., Ph. D. Senior Associate in Dermatology, Harvard Medical School; Dermatology Service, Massachusetts General Hospital, Boston Richard D. Pearson, M. D. Associate Professor of Medicine and Pathology, Division of Geographic Medicine, University of Virginia School of Medicine, Charlottesville Lawrence L. PelMier, Jr., M. D. Professor of Medicine, University of' Kansas School of Medicine; Chief, Medical, Service, Wichita Veterans Administration Medical Center, Wichita Peter L. Perine, M. D., M. P. H. Professor and Director, Division of Tropical Public Health and Professor of Medi19

cine, Uniformed Services University of the Health Sciences School of Medicine, Bethesda . Robert G. Petersdorf, M. 0., M. A. (Hon.), D. Sc. (Hon.). M. D. (Hon.), L. H. D. (Hon.) ; Dean and Professor of Medicine and Vice Chancellor, Health Sciences, School of Medicine, University of California at San Diego, La Jolla Kirk L. Peterson, M. D. , . , Professor of Medicine, University of California at San Diego; Director, Cardiology Service, U. S. D. Medical Center, San Diego James J. Plorde, M. D. < ;> Professor, Departments of Medicine and Laboratory Medicine and Chief, .Clinical Microbiology Laboratory, Veterans Administration Medical Center, .Seattle Francis Allan Plumer, M. D., F. R. P. (C) . , , , , ... Assistant Professor, Departments of Medicine and Medical Microbiology and Division of Community Medicine, University of Manitoba, Winnipeg : Daniel K . Podolsky, M . D . . . . Associate Professor of Medicine, Harvard Medical School; Assistant Physician, Gastrointestinal Unit, Massachusetts General Hospital, Boston John T. Potts, Jr., M. D. Jackson Professor of Clinical Medicine, Harvard Medical School; Chief of the Generaf Medical Service, Massachusetts General Hospital, Boston Lawrie W. Powell, M. D. , Professor of Medicine, University of Queensland; Physician, Royal Brisbane Hospital, Brisbane, Australi Darwin J. Prockop, . D., Ph. D. Professor and Chairman, Department of Biochemistry, Jefferson Medical College of Thomas Jefferson University; Director, Department of Biochemistry, Jefferson Institute of Molecular Medicine, Philadelphia Amy Pruitt, M. D. Assistant Professor of Neurology, Harvard Medical School; Associate Neurologist, Massachusetts General Hospital, Boston . Paul G. Ramsey, M. D. Associate Professor of Medicine, Department of Medicine, .Univer'sity of Washington School of Medicine, Seattle Joel M. Rappeport, M. D. Associate Professor of Medicine, Harvard Medical School; Physician, Brigham and Women's Hospital, Boston George Ray, M. D. Professor of Pathology and Pediatrics and Chief, Clinical Virology-Serology and Pediatrics Infectious Diseases Sections, University of Arizona College ot Medicine, Tucson Peter Reich, M. D. Professor of Psychiatry, Harvard Medical School; Chief of Psychiatry, Brigham and Women's Hospital, Boston Richard Reichman, M. D. ;; Associate Professor of Medicine, Infectious Diseases Unit, University of Rochester School of Medicine and Dentistry, Rochester Jack S. Remington, M. D. Chairman, Department of Immunology and Infectious Diseases, Research Institute, Palo Alto Medical Foundation; Professor of Medicine, Division of Infectious Diseases, Stanford University School of Medicine, Palo Alto . 20;

Edward P. Richardson, Jr., M. D. Bullard Professor of Neuropathology, Harvard Medical School; Neurologist, Massachusetts General Hospital, Boston Hal B. Richerson, M. D. Professor of Internal Medicine and Director, Allergy-Immunology Division, University of Iowa College of Medicine, Iowa City ' James M. Richter, M. D. Assistant Professor of Medicine, Harvard Medical School, Assistant Physician, Gastrointestinal Unit, Massachusetts General Hospital, Boston Craig Risch, M. D. Associate Professor of Psychiatry, School of Medicine, University of California at San Diego, La Jolla L. Jackson Roberts II, M. D. Associate Professor of Medicine, Pharmacology, and Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville R. Paul Robertson, M. D. Professor of Medicine, Director of Clinical Research Center, and Director, Diabetes Center, University of Minnesota, Minneapolis Allan R. Ronald, M. D. H. F. Sellers Professor and Chairman, Department of Medicine, University of Manitoba; Physician-in-Chief, Department of Medicine, Health Sciences Centre, Winnipeg Richard K. Root, M. D. Professor and Chairman, Department of Medicine, University of California, San Francisco Allan H. Ropper, M. D. Associate Professor of Neurology, Harvard Medical School; Director of Neurological/Neurosurgical Intensive Care Unit and Assistant Neurologist, Massachusetts General Hospital, Boston Leon E. Rosenberg, M. D. Dean and C. N. H. Long Professor of Human Genetics, Medicine, and Pediatrics, Yale University School of Medicine, New Haven Michael Rosenblatt, M. D. Vice President for Biological Research, Merck, Sharp and Dohme Research Laboratories, Wes Point John Ross, Jr., M. D. Professor of Medicine and Head, Division of Cardiology, School of Medicine, University of California at San Diego; Attending Physician, U. S. D., Medical Center, San Diego Arthur H. Rubensteln, M. O. Professor and Chairman, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago Cyrus E. Rubin, M. D. Professor of Medicine and Adjunct Professor of Pathology, Division of Gastroenterology, University of Washington School of Medicine, Seattle Daniel Rudman, M. D. Chief, Geriatric Medicine Division and Chief of Staff, Veterans Administration Medical Center; Professor of Medicine, University Health Science Center, Chicago Medical School, Chicago Arthur I. Sagalowsky, M. 0. Associate Professor of Urology and Surgical Director of Renal Transplantation, The University of Texas Health Science Center, Dallas 21

Professor of Medicine and Dean, F. Edward Hebert School of Medicine; President, Uniformed Services University of the Health Sciences, Bethesda . Dennis R. Schaberg, M. D. Associate Professor of Medicine, University of Michigan, Ann ArborAndrew I. Schafer, M. D.

Jay P. Sanford, M. D.

Assistant Professor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston I. Herbert Scheinberg, M. D. Professor of Medicine and Head, Division of Genetic Medicine, Albert Einstein College of Medicine; Attending Physician, Hospital of the Albert Einstein College of Medicine, New YorkAlan L. Schiller, M. D.

Associate Professor of Pathology, Harvard Medical School; Associate Pathologist and Chief, Autopsy Pathology and Bone Laboratory, Massachusetts General Hospital, Boston Professor of Medicine and Dean, School of Medicine, University of California, San Francisco Professor of Pediatrics and Internal Medicine and Director, Division of Metabolism, Endocrinology, and Genetics, The University of Kansas College of Health Sciences, Kansas City Assistant Professor of Medicine, Harvard Medical School; Massachusetts General Hospital, Boston Professor and Chairman, Department of Medicine, University of Colorado School of Medicine, Denver Professor of Psychiatry, School of Medicine, University of California at San Diego; Director, Alcohol Research Center, San Diego Veterans Administration Medical Center, San Diego William J. Schwartz, M. D. Assistant Professor of Neurology, Harvard Medical School; Assistant Neurologist, Massachusetts General Hospital, Boston David S. Segal, Ph. D. Professor of Psychiatry, School of Medicine, University of California at San Diego, La JollaJulian L. Seifter, M. D. Marc A. Schuckit, M. D. Robert W. Schrier, M. D. Robert T. Schooley, M. D. R. Neil Schimke, M. D.Rudi Schmid, M. D.

Assistant Professor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women's Hospital, Boston Associate Professor of Medicine, Harvard Medical School; Director, Cardiac Catheterization Laboratory, Brigham and Women's Hospital, BostonBhagwan T. Shahani, M. ., . S.

Andrew P. Selwyn, M. D.

Associate Professor of Neurology, Harvard Medical School; Associate Neurologist, Massachusetts General Hospital, Boston Gordon Sharp, M. D. Professor of Medicine and Pathology and Director, Division of Rheumatology, University of Missouri-Columbia School of Medicine, Columbia

22

Elizabeth M. Short, M. D. Director, Division of Biomedical Research and Faculty Development, American Association of Medical Colleges, Washington, DC William Silen, M. D. Johnson and Johnson Professor of Surgery, Harvard Medical School; Surgeonin-Chief, Department of Surgery, Beth Israel Hospital, Boston Fred E. Silverstein, M. D. Associate Professor of Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle James B. Snow, Jr., M. D. Professor and Chairman, Department of Otorhinolaryngology and Human Communication, University of Pennsylvania School of'Medicine, Philadelphia Burton E. Sobel, M. D. Lewin Professor of Medicine, Washington University School of Medicine; Director, Cardiovascular Division, Barnes Hospital, St. Louis Arthur J. Sober, 1. D. Associate Professor of Dermatology, Harvard Medical School; Associate Dermatologist, Massachusetts General Hospital, Boston Frank E. Speizer, M. D. Professor of Medicine, Harvard Medical School; Director, Occupational and Environmental Health Center, Brigham and Women's Hospital, Boston John W. Stakes, M. D. Instructor in Neurology, Harvard Medical School; Assistant Neurologist, Massachusetts General Hospital', Boston Walter E. Stamm, M. D. Professor of Medicine, University of Washington School of Medicine; Head Division of Infectious Disease, Harborview Medical Center, Seattle Allen Steere, M. D. Associate Professor of Medicine, Yale University School of Medicine, New Haven Kari Stefansson, M. D. Assistant Professor of Neurology and Pathology (Neuropathology), University of Chicago Pritzker School of Medicine, Chicago Gene H. Stollerman, M. 0. Professor of Medicine, Boston University School of Medicine; Attending Physician, University Hospital, Boston D. E. Standness, Jr., M. D. Professor of Surgery, University of Washington School of Medicine; University Hospital, Seattle David H. P. Streeten, M. ., D. Phil, F. R. . . Professor of Medicine and Head, Section of Endocrinology, State University of New York Upstate Medical Center, Syracuse E. Donnall Thomas, M. D. Professor, Department of Medicine, University of Washington School of Medicine; Associate Director for Clinical Programs, Fred Hutchinson Cancer Research Center, Seattle Gennaro M. Tisi, M. D. Professor of Medicine, Pulmonary and Critical Care Division, School of Medicine, University of California at San Diego; U. S. D. Medical Center, San Diego Phillip P. Toskes, M. 0. Professor of Medicine and Director, Division of Gastroenterology, Hepatology, and Nutrition, University of Florifa Colledge of Medicine; Veterans Administration Medical Center, Gainesville23

Marvin Turck, M. D. Professor of Medicine and Associate Dean, University of Washington School of Medicine; Medical Director, Harborview Medical Center, Seattle Kenneth L. Tyler, M. D. Assistant Professor of Neurology, Harvard Medical School; Clinical Assistant in Neurology, Massachusetts General Hospital, Boston John E. Ultmann, M. D. Professor of Medicine, Department of Medicine; Director University of Chicago, Cancer Research Center; Dean for Research and Development, Division of the Biological Sciences, University of Chicago Pritzker School of Medicine, Chicago Maurice Victor, M. D. Professor of Neurology, Case Western Reserve University School of Medicine; Director, Neurology Service, Cleveland Metropolitan Qenera.l Hospital, Cleveland James F. Wallace, M. D. Professor of Medicine, University of Washington Schoel of Medicine; Associate Physician-in-Chief, University Hospital, Seattle Patrick Walsh, M. D. David Hall McConnell Professor and Director, Department of Urology, The John Hopkins University School of Medicine; Urologist-in-Chief, James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore Peter D. Walzer, M. D. Associate Professor of Medicine, University of Cincinnati College of Medicine; Chief, Infectious Diseases Section, Cincinnati Veterans Administration Medical Center, Cincinnati Jack R. Wands, M. D. Associate Professor of Medicine, Harvard Medical School; Associate Physician, Gastrointestinal Unit, Massachusetts General Hospital, Boston Louis Weinstein, M. D., Ph. D., Sc. D. (Hon.) Lecturer in Medicine, Harvard Medical School; Senior Consultant in Medicine, Brigham and Women's Hospital, Boston John B. West., M. D., Ph. D. f D. S c , F. R. P., F. R. . . . Professor of Medicine and Physiology, School of Medicine, University of California at San Diego; Physician, U. C. S. D. Medical Center, San Diego Nicholas J. White, M. D., M. R. . . Tropical Medicine Unit, Nuffield Department of Clinical Medicine, Oxford University England; Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Richard J. Whitley, M. D. Professor of Pediatrics and Microbiology, School of Medicine, University of Alabama in Birmingham, Birmingham Grant R. Wilkinson, M. D. Professor of Pharmacology, Vanderbilt University School of Medicine, Nashville Gordon H. Williams, M. D. Professor of Medicine, Harvard Medical School; Chief, Endocrinology-Hypertension Division. Brigham and Women's Hospital, Boston Jean D. Wilson, M. D. Professor of Internal Medicine, The University of Texas Health Science Center, Dallas Sheldon M. Wolff, M. D. Endicott Professor and Chairman, Department of Medicine, Tufts University School of Medicine; Physician-in-Chief, New England Medical Center, Boston Alastair J. J. Wood, M. D., M. ., Ch. ., . R. . . Associate Professor of Medicine and Associate Professor of Pharmacology, Van24

derbilt University School of Medicine; Attending Physician, Vanderbilt University Hospital, Nashville Theodore, E. Woodward, B. S., M. D., D. Sc. (Hon.) Professor of Medicine Emeritus, University of Maryland School of Medicine; Distinguished Physician; Veterans Administration Hospital, Baltimore Shirley H. Wray, M. D., Ph. D., F. R. . . Associate Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Department of Neurology, Massachusetts General Hospital, Boston Joshua Wynne, M. D. Professor of Internal Medicine and Chief, Division of Cardiology, Wayne State University School of Medicine; Chief Section of Cardiology, Harper-Grace Hospital, Detroit James B. Young, M. D. Professor of Medicine, Harvard Medical School; Associate Physician, Beth Israel Hospital, Boston Robert R. Young, M. D. Professor of Neurology, Harvard Medical School; Neurologist and Director, Clinical Neurophysiology Laboratory, Massachusetts General Hospital, Boston

40- , 1950 1991 ., 12 . , , , , . . , , . , , , . . , , . . . , . , , . , , . , , - . , , , , . , . : , , , , , , , . , , . . .

1

() ? . . , . , , . , . . , . , , , , , , , , , . , . , . (, ), . , : , , -- , , , . , , . , , . , . , , , . . . , , , , . . , , , , . , ; . , , , , . 27

, , , , , . . , . , , , , . , . . . . . , , -, , . , , , , . , , , . , , , . , , , , , , . , , . , , . , , , , , , , , , , , , ., , , , , , . , . . . ; ; , ; ,, , ; ; (, ). , 28

. - ; , , . , . , , , , , , , , , - . , ( ) . : . , . - Francis Peabody, , , : , . , .. . . . , . , . , , . , . , , , . , , , , , . , , , , . - . * - . , , . , , . . , , , , , . , , . , . - , - , . , , , .- , . .' . -, 29

. -, , , . , , , . . , , , , . ' , , , . , . , , , . , , . , . . , , . . , . , , . , , . , , . - , . , - . . , , , . , . , . , . , , , . , . . . , . . , , , . , , , , , , , , , , , -, . , 30

. , , . , . . 24 40 . . , , , , IgG , . , , , . . - , . , , , , . -, . , , . 40 , , , . , , , , . , ( ) ( ) . . . , , , , , . , , , , , , , . . , , , , . , , , . , , , , . , , , , . . . . , . , . , , , 31

. , , , . . , , . , . , , . , , , , , , , , , . , , , , -. , , , - . , , , , . . , - , . , , , , . , , , , , , . . . . , , , . , , , , . , . , , , , , , . , , . . . . , , , . , , ; , . , . , , , 32

, , . ' . , - , , . , , , . ,' , . - , . , , , . , . .- ' , . , ; , . ., , . . ' , , . . , , . , . , . , , ( , ), ' . , . , . . , . , , , , . , , . , , , ; . . , . , , . . , , , . , , 15 , , , , . , (Medicare, Medicaid) - , 2-3,

(utilization review). , , . , . . , . , , , , . , , . . , . . , , , . , , , '. , , , , . , , . , , , , , , , ,' . , . , , , . , , , - . , . . , docere, . , , , , - . , , , . , . . , ; - . , , 34

, , . . . . , , , . , , ? , , . . , , ; . , , . , . , , . . , , , . : , , ... , [William Osier]. : , ?, , , , , , . , , . , , , . , . , , , , , . , . , . , , : 1) 2) , . , . , , , , ( , , , , ), . , . , , , , . , , : 1. , , - , , . 2. 35

, . , , . 3. , , . . \ 4. , , . * ., . - , . , , - , , . , , , , . , . , , , , . , , , , , . , , . , , , . 2 ,

(Lee Goldman) . , , , , , , . , , , , , , . - , , . , , ' , , . , , 36

. . , , . , , , . , . , . , , , . , , , . , , . . . : 1. ( ). 2. , . 3. ' . 4. . 5. . . , , , , , ,, . , , , . , . , , , , . ,, , , , , . , ?, , , . , , , , . . , , , , , 37

. - . , , . , , , , . , , . , , . . , . , , , , . . , , , - . , - . , , , , , . , , . , , , , , , , , , . , , , , , . , , 90 % - , , ' 81 % , . , , , . , , , . , - , , , , , , , . , , . , , . , .38

, , . . : , , , , , . , . , , . , , , , , . 1015% , , - . , . . . , . , , , : 20 1 200. , , . , , ,. . , . , , . , . , , . , , . , . . , , , . , , , , , . , , , , . , , . , , , 39

. , , . ' . 1, . , , , , . : , . . , . , () . , . , , , , (. 2.1). " , 2.1. , , ( ) () ()

( )

( )

t = ( + )/( + + ==

+ +) = /( + )

= /( + )

/ = / = / = / = /

= /( + )V

= /( + )

= /( + )

= /

40

= /( + ) = (+)/( + ++ + )

= / = /

(. 2.2). , , , . , . , . . , - , . . . - ( , , ), , . , (. 179) , , , , (), -. , , , , , , ' , Q .-, , . , , - , , , , , . , , , . . ( ) , , ^ , . , 41

2.2. , 10 % ( = 10%) 000 000 0,10 100 000 0,90 | 900 000 90 % 95 % , 50 % ( = 50 %) i 000 000 0,50 \ 500 000

i 501

90 % 95 %

500 000

+ -4-

90 000

10 000

45 000

855 000

+ +

450 000

50 000

25 000

475 000

-

- ( ( ) = 90 000/135 000 = 67 % ) = 450 000/475 000 = 95 % - ( ( ) = 855 000/865 000 = 99 % ) = 475 000/525 000 = 90 %

. 2.1. . . , : . , , , , .1,0 ,

0,9 0.4 0,2

- , , , . , - , , . (. 2.1) , , , , , , , , S7"He 0,5 , , , , , , , ST 2,0 , - . , , , , , . . , . - , : 100 %, . , . , , (, , , ) (. 187). . , ST, 1,0 , , , , , . . , . . 43

, , , , , . , . . - . , , , . , . , , , , , , , . , , . , . , , , , ., . ( ) , , , . , () (. 2.3). (, , ) ( , 1 ), (), . , , , , . , , , . , , , . , , , , , (. 2.2; . . 189). / , , . , , , 44

.

2.3. 1:. = 2 5 % ; ( ) 90 % 80 % ( 20%) . 1:3 25% 0,90 ' - 0,20 (1)6 2: , . . 80 %,' (1 ) 10 %. 25% 1:3 0,10 (1)" - 0,80 ' 0,10 = 0 , 1 2 5 : 3 = 1:24 (1:9)X 0,80

, 4,5 60% 7,5 " = 6 (1 ) =

" (1 ) = * =

.2

0,4

,

0,8

0,06

0,3

0,0

. 2.2. . , , . , ST I , ST 1 . , , 90 %, , , - ST 2-2,49 , 99,5%. , , 30 %, , 90 %. - , 5 %, 53 %. , ( New England Journal of Medicine, R. D. Riikin. W. B. Hood: Bayesian analysis of electrocardiographicexercise stress testin.N. Engl. J. Med., 1977, 297, 684).

, . , , , . , . , , , . , , . ( , ) , , , , . . , 46

, , , , . , . , , 50 %. - , , , . , , (.211). , , . , , ? , , , , ' ? , , ? , , , , , . : . , , , , , ( ) , . , .. , - , . , , , , . , , , . , . , , . , , . . : , ( ), . , , , . , , , (. 136). . 2.3 . , , , . , , , . : (Vidarabin), , , . . 47

,

- I / v

S. () . 51

S

. 3.1. () () . ( ) . : ( ) ( ) . , , . .

, , , . , , , , , . , . (, , ', ), () ( ). , , . . , , . (. 3 1 , ). , , . , , . , , (), ; 52

, . . , . , , I V, . . , . , , . . . . , , . : , , , . , , , , . , . . - , . . , , . . . , , ( ). , , . . , 1 ; , , . , , , , , . , ' , , , ( ); . , . , . . , (. 3 1, ). . 53

, , , , . , , , , , . , , . , , , (, nucleus raphe magnus). , . . , , . , , . ; . , , , . , , ., . . , , ; , - . , , , , . , . , , (. 3.1). , , ,

.

.

3.1.

-

1. 2. ; 3. , 4. 54

1. 2. 3. , 4.

. , , . , Ti Tiv , . , . , . , . , , . . , , . . . , . , . , , . . , , (. . 3.1). , , . , , ; ( ) , , . , (), . () (), (). , , . (, ) , . , , , , . , . , . - , . , , , . , . . , , 55

, , , . . , , . . . , , . . . . 30 % . . , . . , . , , . , , . , . . . : , . , , . , . , , , . . . . , . , , , , , . . , , , . , , . , . , . 56

, . . . , ; . , . , , . . , , (. 3.2). 300 600 4 600 , 4 . ,' , , ; , , . , - , . , , - , ; . . , , , . . 3.2. , : , , 7501250 7501000 600800 200400 5075 200400 250500 60120 , 3 * 3 3 4 4 4 4 4

10 , 1 , 6 7,5 4

1,5 2 4

57

, 10 10 15 75 60 130 . 20 60 30 300 180 200

'

.

, 100 200 1

,

68

6 6

. . 200 150 200 100 150 200 150

, /24 75400 75-300 75400 40150 75^300 75300 50600

'

. , , , 30 46 . , . , 60 4 , , , . . , - , , 6 , . , 23 , . , , ' 58

, ; , . , , . , , , . , , , , . . . , . , . , , . , , . . , , , ,-. , , , , . . , , , , , . . ; . , , , . . . . , , .. . , . , , , . , , , . . . . . , , , . 59

, , , , . . , , . . , , - . . , . , . , , , " , . (). . , , . . . , 6 , . . , . , . , , . , - , . . . , , . , , , . . . -, . . . ' , . , . -, , , . , . . 60

-, . , (, . .) , . . ; . . . : . . , , .

Aronoff G. . Psychological. aspects of nonmalignant chronic pain. In: Evaluation and Treatment of Chronic Pain/Ed. G. M. Aronoff. Baltimore: Urban and Schwarzenberg, 1985. Asbury" A., Field H. L. Pain due to peripheral nerve damage: a hypothesis. Neurology, 1984, 34, 15871590. Basbaum A. I., Fields H. L. Endogenous pain control systems: brainstem spinal pathways and endorphin circuitry. Ann. Rev. Neurosci., 1984, 7, 309338. Blumer D., Heilbronn. Chronic pain as a variant of depressive disease. J. Nerv. and Mental Dis., 1982, 170, 381406. Fields H. L. Pain II: new approaches to management. Ann. Neurol., 1981, 9, 101. Hackett T. P. The pain patient: evaluation and treatment. In: Massachusetts General Hospital Handbook of General Hospital Psychiatry/Ed. T. P. Hackett, 1978, 4163. Hannington-Kiff J. G. Antisympathetic drugs in limbs. In: Textbook of Pain/Eds. P. D. Wall, R. Melzach. Edinburgh: Churchill Livingstone, 1983. Maciewicz R., Fields H. L. Pain pathways. In: Diseases of the Nervous System/Eds. A. Asbury, G. McKann. London: Saunders, 1986. Sweet W. H., Poletti . . Causalgia. In: Evaluation and Treatment of Chronic Pain/Ed. G. M. Aronoff. Baltimore: Urban and Schwarzenberg, 1985. Tasker R. R. Deafferentation. In: Textbook of Pain/Ed. P. Wall, Edinburgh, Churchill Livingstone, 1984, 119132. Taub A., Collins W. F. Observations on the treatment of de nervation dysesthesia with psychotropic drugs: postherpetic neuralgia, anesthesis dolorosa, peripheral neuropathy. In: Adv. Neurol./Ed. J. J. Bonica. New York: Raven, 1974, 309315. White J. C, Sweet W. H. Pain and Neurosurgeon A Forty Year's Experience. Springfield, Illinois, Charles C. Thomas, 1969. Yaksh T. L., Hammond D. L. Peripheral and central substrates involved in the rostrad transmission of nociceptive information. Pain, 1982, 13, 185.

61

4

(Eugene Braunwald) , , ; ( ) ( ) . , , , , , , , , . . . , , (. . 3), . , , . ', . , , (), , , , , . , , . , , . , , , , . , . , , , , . . , , , , , , , . , , , , . . , , , . , , , , . , , 62

, . , . , , , (. . 189) , , , , , . , ; , . , , . . . , , , , . . , , , , , . , , , , , , . . , . . , , , , . , . : , ; () . , , (. . ), . , ( ) , , . . , . , , , . , , , , . . , , , . , , . , , - . i

63

, , , , 7 0 % ), , , . , , . , , , , , - . , , . , , , , . . , , . , , . . , ( , ), , . , , , / (.' . 187), . , , , . cq , , , , , , , 1 . , . , - , , , . , . , , (, , ' ) .' , , . , . 64

. : , . . 189. , , , . , , , . , , , , , ; . , ; , . , , , . , ; (, , ), , , . , , . , : , . , , ( 30 ) , . , . , (. . 190). , (. .. 178, 179 190). , . ST , ; , , , . S7">0,l , . . 189 . . , . IV ; , . , , , . . (. . 179) ( ). (. . 30). , . , . , , , , . , . . , , , 3-31

, , . , . , (, , .) , , , , , , . . , . . . ( ), , , , , . , , 610 , , , , . (., . 194). , / . , . ; ; , , . , , . . , . . , , , . . , - (. . ) , (. . 190 194). , , . ; , . , , . , , ; , , , , , . , , ; . , (. . 211). , , . (. . 214) , ; . , , , 66,

. , , ; , , . ' , (. . 197). - - . ( ), , . (), . , (. ). , . - . - - , . - , , , . (). , , , . , . , . , . , , , . , , , . ' , . , . , , ' , . . , , , , , , , . , ' . . , , - - . . - . , ( ) , . . , ,

, , . , ; . , , , . , , , . . , , , , . , . , . , - , , . , , , , . , . , , , , . . , , ( , ) . , , , . , , , , , . , , (. . 179) . ' . , . ; () . - . , (. . 32 234). , 0,1 1, . , , . . . , , . , , . , , . , . , , . , , 68

, ( , ). > , / - ST . , - , - . , . , , , , , , , . . , (. . 235), , I 1,5" . - . , - , , . , , , . - , . ; , . , , , . , . , , , , , , , . . ' . . . , , , , . , . (, , ), . , . - , (. . 189). (. . 179). - , . . , . , , . 69

. , , , . . , , , , . , , , - , . , . , , , , . , , . . , . , , , ] , , . , -; ST , , . , , , . , . , ( 5 ) , . . . , , , , , . . , . , , (. . 178) (. . 179), ' . , , , ; ST . ( 70 %) (. . 180 198).

70

.

, , . . - ; , , . , . , , . , , , ; ',, , . ; . , , ' . . . . -: , , , , , . . . ,, ^. , , , , . , , , . , . / , . , , , , , . , , (, , , .) . . . , . , . , , , , , . , (, , . ). , . 11

. , , . . . . 184. . . . . , , . , , ; , , , . . ,, . 184, - . ., , ;- , , - . ' , , , , , . ; , , . . . (. . 324), (. . 329), (. . 326), (. . 9) . , , , , , , , . . ' . . . . , " , . , , . , , : . , 72

', , , , .- - . , . , , , . Sf- , , ; , , , . , . , . , , . . , , ' ' , 80 . . , , , , , , . , , . , , . , , . , , . - , , , . . 4.1 , , . ' , . , , . - , 40 , , 400 , . 4.1. , : :. '

? , I , ?

120

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, , , ? , , , , , , , , , , ' " ? . , - . , .

, ,., , , , , ,

Areskog N. ., Tibbling L. Differential diagnostic aspects of chest pain. Acta ;i med. scand. (SuppL), 1980, 644. Braunwald E. Control of myocardial oxygen consumption. Physiological and clinical considerations. Amer. J. Cardiol., 1971, 27, 416. Christie L. G. et al. Systematic aproach to evaluation of angina-like chest pain. Pathophysiology and clinical testing with emphasis on objective documentation of myocardial ischemia. Amer. Heart J., 1981, 102, 897. Cohn P. F., Braunwald E. Chronic ischemic heart disease. In: Heart Disease, 2nd ed./Ed. E. Braunwald. Philadelphia, -Saunders, 1984, Chap. 39, 1334. Constant J. The clinical diagnosis of nonanginal chest pain. The differentiation angina from nonanginal chest pain. The differentiation of angina from nonanginal chest pain by hystory. Clin. Cardiol., 1983, 6, 11. DeMeester et al. Esophagial function in. patients with angina-type chest pain and normal coronary angiograms. Annu. Surg., 1982, 196, 488. Dressier W. Clinical Aids in Cardiac Diagnosis. New York, Grune and Strattori, 1970. Goldschlager N. Use of treadmill test in the diagnosis of coronary artery disease in patients with chest pain.Annu. Intern. Med., 1982, 97, 383. Hurst J. W. e.t al. The history. Past events and symptoms related to cardiovascular disease. In: The Hert. 6th ed./Ed. J. W. Hurst. New York, McGraw-Hill, 986, 113. Levine D. L. Chest Pain. Philadelphia, Lea and Febiger, 1977, 203. Patterson D. R. Diffuse esophagial spasm in patients with undiagnosed chest pain. J. Clin. Gastroenterol., 1982, 4, 415.

5

'

(William Silen) , . , , , . , . , . , . 5.1, , . , , - . , . . , . . , ; , , . , . , , , . , , . , , , . , , , . , , , , . , , . , , , , . , . , , , , . - . , 75

5.1. .1. , A. : 1. , , 2. , ( ), , . : 1. 2. 3. B. : 1. 2. 3. "' , 4. - . : 1. 2. . . , : II. , A. , , . , B. , III. . : 1. 2. t . : 1. 2. 3. 4. ( '1-) IV. . ; I. 2. 3. .

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. , , . . . . , . , , 76

. . , () . , . , , . . . , ; , . , , . , , , . . , , . , , , . , . , . , , , , , . ( ) , . . , , , : . , , . . , -, , . , , , , , . , . ' . . , , , , . . , , 7?

. , - , . . , , , , , , , . , , , , , . , , , (. . , ), . , , ; , . . . . , . , , , , , . . , . , , , , , , . . 3. , , , , . , - , , . , , . . . . , , , , , , . '1- . , , . (. . 271). 78

. - , . - ; , . , , . , . . , . . , , . . , , , . , ; , , , . . , . , . , , (. . 9). , , , , . , , . , , , , . . . . . , ; . , , . , . . , -. , . , , . ; (. . 11). . . , , . , . , . , , . 79

. , , , . ' , , . , . , , . , . , (. . 239). , , , . . , , . , . , . , , . . . . , , , . , , . , . , , , . ( ), . . , , . ' , . , , . , - , . , , , . , , , , . , . , , , . , . , , . , , . , , 80

, . . -' , . . . , , , . . , 20 000 I 3, , , , 1 . . , , . , . , . , , 72 , 200 . , 200 500 . 500 . . ', , " , , , . , . . , - , . , , . . , , , ' . . . , . 10 , , . - , . - , 81

. , , . , , , . . , , . , , . , , .

De Dotnbal F. . Acute abdominal pain. Scand. J. Qastroenterol. (Suppl.), ' 1979, 14, 29. Lee P W /J.The plain X-ray in the acute abdomen: a surgeon's evaluation. Brit. J. Surg., 1976, 63, 763. Leek B. F. Abdominal and pelvic visceral receptors. Brit. Med. Bull., 1977, 33, 163. Silen W. Cope's Early Diagnosis of the Acute Abdomen. 16 th ed. London, Oxford Press, 1983. Stanland J. R. et al. Clinical presentation of acute abdomen: Study of 600 patients. Brit. Med. J., 1972, 2, 393. Valman H. B. Acute abdominal pain. Brit. Med. J., 1981, 282, 1858. 6 '

. , . (Raymond D. Adams, Joseph . Martin) , , . , , . 7 352 (. 6.1). . , . , , . , , . , , , . . , , , , , . , , , . . , 82

, . , , , , . , . , , ' . , , . , . . . , ' , , , . , , , . . , , , . . , , , . - , , . - , , . . , , , , , . , . . , , ( I 2 ) ( , ) , ; . - , , , , 12 ; . 1 . , , . , , ( 2 3 ) , . , , , . , . , , , . , , , , . 83

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85

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.

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Patten J.

Neurological

Differential

Diagnosis. London,

Harold

, , ; 2- . ; , . , , , , , , . . (, ). . , , , . , , , , , , , , . , , ( 1 10 ) . . , . : , , , ; , ; ; , , , . , , . , , . 86 .

ConyfcTByioiUHe

.

Starke, Springer-Verlag, 1977.

, , . . IX X ( ) , . , , ; . ' . , , . , ; ; , ; , . , , , , , . , , (). ' , , . , ( ), , 50 , , , , , , , .- , . , , , , , , (. . 269). , - 87

; , -. ; . . : , ' ; (, , ; ). , ; , . , ; , , , . , , , ( ). . , , , , . , , , , , ; , . , , , , . , , . , . III , , , . , , , , () . ; . , . , . , . , , . , , . , ( ) . . , , . , . 88

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