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2020_ME
Cecil Essentials of
Medicine
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TENTH EDITION
10
CECIL ESSENTIALS OF
MEDICINE
EDITORS
Edward J. Wing, MD, FACP, FIDSA
Former Dean of Medicine and Biological Sciences
Professor of Medicine
Warren Alpert Medical School
Brown University
Providence, Rhode Island
Fred J. Schiffman, MD, MACP
Sigal Family Professor of Humanistic Medicine
Vice Chair, Department of Medicine
Warren Alpert Medical School
Brown University
Providence, Rhode Island
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103- 2899
CECIL ESSENTIALS OF MEDICINE, TENTH EDITION ISBN: 978- 0- 323- 72271- 1
Copyright © 2022 by Elsevier, Inc. 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. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2016, 2010, 2007, 2004, 2001, 1997, 1993, 1990, and 1986.
Library of Congress Control Number: 2021932451
Content Strategist: Marybeth Thiel
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Publishing Services Manager: Catherine Jackson
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Printed in the United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
In Memoriam
omas E. Andreoli, MD
Dr. Thomas Andreoli, along with Drs. Lloyd Hollingsworth (Holly) Smith, Jr., Fred Plum, and Charles C.J.
Carpenter, was one of the four founding editors of Cecil Essentials of Medicine. He served as editor for editions
one through eight before he passed away on April 14, 2009. Dr. Andreoli was born in the Bronx, New York, in
1935, attended Catholic primary and high schools, and graduated from St. Vincent College and the Georgetown
School of Medicine. He trained as a resident at Duke University under legendary Chair of Medicine Dr. Eugene
Stead, who recognized him as a brilliant physician and scientist and encouraged his research career. Dr. Andreoli received his research training at the NIH and then in the laboratory of Dr. Tosteson at Duke. His research
focused on the biochemical and biophysical properties of renal tubular cell membranes and their role in water
and electrolyte transport. He made fundamental discoveries on the normal renal physiology, illuminating the
way to subsequent work by many others on renal health and disease. His research was recognized with numerous
awards and election to honorific societies both in the United States and in Europe. Dr. Andreoli also served as
editor of The American Journal of Physiology: Renal Physiology and Editor in Chief of Kidney International.
Tom’s national prominence and leadership qualities were recognized early in his career when he became
head of Nephrology at the University of Alabama in Birmingham. There he helped faculty and trainees develop
outstanding research, organized clinical services, and created a hemodialysis program to build one of the outstanding Divisions of Nephrology in the country. In 1979, Dr. Andreoli was appointed Chair of the Department
of Internal Medicine at the University of Texas, Houston, where he assembled an outstanding faculty focused
on research, clinical care, and teaching. In 1988, he accepted the position as Chairman of Internal Medicine
at the University of Arkansas School of Medicine, a position he held until his death. There he again assembled
a distinguished faculty who were outstanding researchers but also dedicated to outstanding clinical care and
teaching. Morning report and clinical rounds with Dr. Andreoli were rigorous and riveting, focusing on the
individual patient, not only their diagnoses and treatment but also on each patient’s personal concerns and
well- being. Dr. Andreoli was revered by medical students, his house staff, faculty, and colleagues, and I (EJW)
personally can attest to what he regarded as his most cherished role—the mentorship and education of the next
generation of physicians.
One of Dr. Andreoli’s great interests was Cecil Essentials of Medicine, for which he was the editor/chief editor
for eight of its ten editions, an interest that reflected his commitment to the education of students, house staff,
and other physicians in the “essentials” of Internal Medicine.
Dr. Andreoli was devoted to his family. He was married to Elizabeth Berglund Andreoli from 1987 until
his death. He was previously married to Dr. Kathleen Gainor Andreoli, mother of his three children and their
ten grandchildren. Being of Italian ancestry and from Bronx, New York, it is not surprising that Dr. Andreoli
was a passionate fan of the New York Yankees, Italian opera, which he could sing in Italian, and Frank Sinatra.
Dr. Andreoli’s legacy lives on in his numerous previous students, house staff, colleagues, and in this book.
Charles C.J. Carpenter, MD
Dr. Charles C.J. Carpenter joined Drs. Thomas Andreoli, Lloyd Hollingsworth Smith, Jr., and Fred Plum as a
founder of Cecil Essentials of Medicine. He served as editor for seven editions and was followed in that role by
Dr. Ivor Benjamin and then Dr. Edward Wing. Sadly, Chuck passed away on March 19, 2020, surrounded by
his wife and children. He was Professor Emeritus of Medicine at The Warren Alpert Medical School of Brown
University and Physician- in- Chief Emeritus at The Miriam Hospital.
Chuck was born in Savannah, Georgia, on January 5, 1931. He attended college at Princeton and medical
school at Johns Hopkins where he also did his house staff training, including chief residency, and then joined
the Johns Hopkins faculty. With his young family, he travelled to Calcutta, India, where he carried out landmark studies for the treatment of cholera.
Before coming to Brown in 1986, he was Chair of Medicine at Baltimore City Hospital and Case Western
Reserve University.
His contributions to medical science and clinical care were many. While in Calcutta, using basic scientific
evidence coupled with practical approaches, Dr. Carpenter developed “oral rehydration therapy” to address
the cholera epidemic there. This treatment has saved millions of lives. While at Case, one of his innovations
was to develop the nation’s first Division of Geographic Medicine because of his strong belief that all physicians should be medical citizens of the world. In 1987, as he became deeply involved in the clinical management of persons living with HIV, he initiated a unique program in which Brown University faculty and
trainees assumed responsibility for all HIV care in the Rhode Island State prison system.
Dr. Carpenter served as Chairman of the American Board of Internal Medicine and President of the Association of American Physicians. He has been a member of the NIH AIDS Executive Committee, the National
Advisory Allergy and Infectious Diseases Council, and the USPHS AIDS Task Force. He was Chair of the
Antiretroviral Treatment Panel of the International AIDS Society- USA and authored their recommendations
on antiretroviral treatment. He also served as Chair of the Treatment Committee to evaluate the President’s
Emergency Plan for HIV/AIDS Relief. He became the director of the Brown University International Health
Institute and the director of the Lifespan/Brown Center for AIDS Research with several Boston hospitals.
Throughout his career, Dr. Carpenter was the recipient of many international, national, and regional awards,
accepting each with characteristic humility. With both small and large groups of learners, Chuck made certain
that every member of his team was well educated, and each felt that they contributed to the well- being of their
patients. His ability to sit calmly at the bedside, hold the patient’s hand, comfort them, and listen in a genuinely focused way, influenced so many physicians. He was truly grateful for the opportunity to care for those
less fortunate than he, and the feeling of being privileged to do so was clearly transmitted to all. Dr. Carpenter
was a wonderful blend of profound compassion combined with the adherence to scholarship and teaching. Sir
William Osler wrote that physicians should “Do the kind thing and do it first.” Chuck lived by this precept.
Vigor and insight characterized his approach to clinical and ethical challenges, always with younger colleagues
at his side. In a recent tribute to him, many emphasized that Dr. Carpenter dedicated his life to his patients,
many of whom were the most vulnerable members of society. We hope that we will have some of his strength
and use his example as our compass as we are challenged to reduce suffering and improve the health of all for
whom we are responsible.
He is survived by his wife of 61 years, Sally; three sons, Charles, Murray, and Andrew; and seven grandchildren.
ABOUT THE EDITORS
Dr. Edward J. Wing was an editor of Cecil Essentials of Medicine, edi-
tions 8 and 9, and is the lead editor of edition 10. He graduated from
Williams College in 1967 and from the Harvard Medical School in 1971.
He was a resident in Internal Medicine at the Peter Bent Brigham and
completed an Infectious Diseases Fellowship at Stanford University.
Joining the faculty at the University of Pittsburgh in 1975, he focused
his NIH- funded research on mechanisms of cell- mediated immunity
as well as various clinical aspects of Infectious Diseases. From 1990 to
1998, the University and UPMC appointed him as Physician- in- Chief
at Montefiore Hospital, then Chief of Infectious Diseases, and finally
Interim Chair of Medicine.
In 1998, Dr. Wing became Chair of Medicine at Brown University
(1998–2008) where he consolidated the department across hospitals, practice plans, and training programs. As Dean of Medicine and
Biological Sciences at Brown University (2008–2013) he strengthened ties with affiliated hospitals (Lifespan and Care New England),
increased research, and oversaw the construction of a new medical
school building. International exchange programs with medical
schools in Kenya, the Dominican Republic, and Haiti were established during his years as chairman and dean. Dr. Wing has cared
for patients with HIV since the beginning of the epidemic in outpatient clinics. He continues to be active in research, clinical care, and
teaching.
Dr. Fred J. Schiffman, who along with Dr. Edward Wing is editor of
Cecil Essentials of Medicine, 10th edition, attended Wagner College
and then the New York University School of Medicine, from which he
graduated in 1973. He performed his early house staff training at YaleNew Haven Hospital and then spent two years at the National Cancer
Institute. He returned to Yale as Chief Medical Resident followed by a
hematology fellowship. He became Medical Director of Yale’s Primary
Care Center before coming to Brown University in 1983, where he has
been a leader in the medical residency program as well as Associate
Physician- in- Chief at The Miriam Hospital.
Dr. Schiffman holds The Sigal Family Professorship in Humanistic
Medicine at The Warren Alpert Medical School of Brown University.
His scholarly interests include the structure and function of the human
spleen and the intersection of the arts and medical care. He has directed
or championed many projects and programs, including those that
encourage and reinforce wellness and resilience in patients, families,
and caregivers. He began a novel program that places medical students
and physicians with other nonmedical professionals as they share in
the viewing of works of art in the Museum of the Rhode Island School
of Design. Dr. Schiffman recently led a Brown University edX course
entitled, “Artful Medicine: Art’s Power to Enrich Patient Care,” with
worldwide participation. Dr. Schiffman has also edited texts on hematologic pathophysiology, consultative hematology, and the anemias.
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