ANATOMICAL DIRECTIONS

DIRECTIONAL
TERMS DEFINITIONS EXAMPLE OF USAGE
Le t To the le t o body (not your le t, the s ubje cts ) The s tom ach is to the le t o the live r.
Right To the right o the body or s tructure be ing s tudie d The right kidney is dam age d.
Late ral Toward the s ide ; away rom the m ids agittal plane The eye s are late ral to the nos e .
Me dial Toward the m ids agittal plane ; away rom the s ide The eye s are m e dial to the e ars .
Ante rior Toward the ront o the body The bre as tbone (s te rnum ) is ante rior to the he art.
Pos te rior Toward the back (re ar) o the body The he art is pos te rior to the bre as tbone (s te rnum ).
Supe rior Toward the top o the body The s houlde rs are s upe rior to the hips .
In e rior Toward the bottom o the body The s tom ach is in e rior to the he art.
Dors al Along (or toward) the ve rte bral s ur ace o the body He r s car is along the dors al s ur ace .
Ve ntral Along (toward) the be lly s ur ace o the body The nave l is on the ve ntral s ur ace .
Caudad (caudal) Toward the tail The ne ck is caudad to the s kull.
Ce phalad Toward the he ad The ne ck is ce phalad to the tail.
Proxim al Toward the trunk (de s cribe s re lative pos ition in a lim b The joint is proxim al to the toe nail.
or othe r appe ndage )
Dis tal Away rom the trunk or point o attachm e nt The hand is dis tal to the e lbow.
Vis ce ral Toward an inte rnal organ; away rom the oute r wall This organ is cove re d w ith the vis ce ral laye r o the
(de s cribe s pos itions ins ide a body cavity) m e m brane .
Parie tal Toward the wall; away rom the inte rnal s tructure s The abdom inal cavity is line d w ith the parie tal
pe ritone al m e m brane .
De e p Toward the ins ide o a part; away rom the s ur ace The thigh m us cle s are de e p to the s kin.
Supe rf cial Toward the s ur ace o a part; away rom the ins ide The s kin is a s upe rf cial organ.
Me dullary Re e rs to an inne r re gion, or m e dulla The m e dullary portion contains ne rve tis s ue .
Cortical Re e rs to an oute r re gion, or cortex The cortical are a produce s horm one s .

S upe rior
o make the reading o anatomica f gures a itt e easier, an
anatomica compass is used throughout this book. On many
f gures, you wi notice a sma compass rosette simi ar to those
on geographica maps. Rather than being abe ed N, S, E, and
Pos te rior Ante rior
W, the anatomica rosette is abe ed with abbreviated anatom-
P roxima l ica directions.
Tra ns ve rs e
pla ne
S

Dis ta l R L

e ra l I
La t

e ra l
La t
P roxima l A Ante rior P (oppos ite A) Pos te rior
D Dis tal P (oppos ite D) Proxim al
S a g itta l
Dis ta l l I In e rior S Supe rior
r o n ta p la n e
F ne
p la l L (oppos ite M) Late ral M Me dial
d ia
e
M
di
a l L (oppos ite R) Le t R Right
Infe rior M
e
CONTENTS IN BRIEF
1 Introduction to the Body, 2
2 Chemistry o Li e, 24
3 Cells, 42
4 Tissues, 70
5 Organ Systems, 92
6 Mechanisms o Disease, 112
7 Skin and Membranes, 144
8 Skeletal System, 174
9 Muscular System, 218
10 Nervous System, 248
11 Senses, 290
12 Endocrine System, 318
13 Blood, 348
14 Heart, 378
15 Circulation o Blood, 402
16 Lymphatic System and Immunity, 428
17 Respiratory System, 458
18 Digestive System, 492
19 Nutrition and Metabolism, 532
20 Urinary System, 554
21 Fluid and Electrolyte Balance, 582
22 Acid-Base Balance, 600
23 Reproductive Systems, 616
24 Growth, Development, and Aging, 652
25 Genetics and Genetic Diseases, 678

Ap p e n d ixe s
A Examples o Pathological Conditions, e1
B Medical Terminology; Hints or Learning and Using Medical Terms, e12
C Clinical and Laboratory Values; Conversion Factors
to International System o Units, e19
Glossary, 700
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THE
HUMANBODY
IN
HEALTH
&DISEASE
7th Edition
Ke v in T. P a t t o n , P h D
Fo u n d in g Pro fe s s o r o f Life S cie n ce ,
Em e ritu s Fa cu lt y
S t. Charle s Co m m unity Co lle ge
Co ttle ville , Mis s o uri
Pro fe s s o r o f Hu m a n An a to m y a n d
Phys io lo gy In s t ru ct io n
Ne w Yo rk Chiro practic Co lle ge
S e ne ca Falls , Ne w Yo rk

G a ry A . Th ib o d e a u , P h D
Ch a n ce llo r Em e ritu s a n d Pro fe s s o r
Em e ritu s o f Bio lo gy
Unive rs ity o Wis co ns inRive r Falls
Rive r Falls , Wis co ns in
 3251 Riverport Lane
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H E H UMAN BO DY IN H EAL H & DISEASE, ISBN: 978-0-323-40211-8 (So tcover)

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Notices
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our understanding, changes in research methods, pro essiona practices, or medica treatment may become
necessary.
Practitioners and researchers must a ways re y on their own experience and know edge in eva uating and
using any in ormation, methods, compounds, or experiments described herein. In using such in ormation
or methods they shou d be mind u o their own sa ety and the sa ety o others, inc uding parties or whom
they have a pro essiona responsibi ity.
W ith respect to any drug or pharmaceutica products identif ed, readers are advised to check the most
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contained in the materia herein.

Previous editions copyrighted 2014, 2010, 2005, 2002, 1997, and 1992.

Library o Congress Cataloging-in-Publication D ata

Names: Patton, Kevin ., author. | T ibodeau, Gary A., 1938- author.

it e: T e human body in hea th & disease / Kevin . Patton, Gary A.
T ibodeau.
O ther tit es: H uman body in hea th and disease
Description: 7th edition. | St. Louis, Missouri : E sevier, [2018] | Inc udes
bib iographica re erences and index.
Identif ers: LCCN 2016050640| ISBN 9780323402118 (pbk. : a k. paper) | ISBN
9780323402101 (hardcover : a k. paper)
Subjects: | MESH : Physio ogica Phenomena | Anatomy | Patho ogic Processes
C assif cation: LCC QP34.5 | NLM Q 104 | DDC 612--dc23 LC record avai ab e at
https:// ccn. oc.gov/2016050640

Executive Content Strategist: Ke ie W hite

Senior Content Development M anager: Laurie Gower
Senior Content Development Specialist: Karen C. urner
Publishing Services M anager: Je rey Patterson
Book Production Specialist: Caro O Conne
Design Direction: Ash ey Miner

Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
ABOUT THE AUTHORS
Ke vin Patto n has taught anatomy
and physio ogy to high schoo , com-
munity co ege, university, and gradu-
ate students rom various backgrounds
or more than three decades. H e has
earned severa citations or teaching
anatomy and physio ogy (A&P), in-
c uding the Missouri Governors
Award or Exce ence in eaching. H is
teaching experience has he ped him
produce a text that wi be easier to
understand or a students. One thing Ive earned, says
Kevin, is that most o us earn scientif c concepts more easi y
when we can see whats going on. H is ta ent or using imag-
ery to teach is evident throughout this edition, with its im-
proved i ustration program.
Kevin ound that the work that ed him to a PhD in ver-
tebrate anatomy and physio ogy insti ed in him an apprecia-
tion or the big picture o human structure and unction. H e
a so has a keen interest in the science o earning, which is
re ected in the enhanced pedagogica design o this edition.
Kevins interest in promoting exce ence in teaching anat-
omy and physio ogy has ed him to take an active ro e in the
H uman Anatomy and Physio ogy Society (H APS). H e serves
as H APS President Emeritus and was the ounding Director
o H APS Institute (H APS-I), a pro essiona continuing edu-
cation program or anatomy and physio ogy teachers. As a
ounding acu ty member o a Master o Science in Anatomy
& Physio ogy Instruction, he current y mentors those who are
preparing to teach A&P or improve their ski s. Kevin a so
produces severa on ine resources or A&P students and
teachers, inc uding theAPstudent.org and theAPpro essor.org.
Kevin is a so a eader among textbook authors, serving
many ro es in the extbook & Academic Authors Association
( AA) and mentoring other textbook authors in a variety o
discip ines. In 2016, AA recognized Kevins service to the
pro ession with the Norma H ood Award.
o my amily and riends, who never let me orget the joys o
discovery, adventure, and good humor.
o the many teachers who taught me more by who they were
than by what they said.
o my students, who help me keep the joy o learning resh and
exciting.
Kevin . Patton
Gary Thibo de au has been teach-
ing anatomy and physio ogy or more
than three decades. T is new edition
o T e Human Body in Health & Disease
is a ogica extension o his interest
and commitment to education. Garys
teaching sty e encourages active inter-
action with students using a variety o
teaching methodo ogies. H e is consid-
ered a pioneer in the introduction o
co aborative earning strategies to the
teaching o anatomy and physio ogy.
Gary has been active in numerous pro essiona organiza-
tions, inc uding the H uman Anatomy and Physio ogy Society
(H APS), the American Association o Anatomists, the Amer-
ican Association o C inica Anatomists, the American Phar-
maceutica Association, the American Society or Reproduc-
tive Medicine (ASRM), and the American Association or the
Advancement o Science (AAAS). H is biography is inc uded
in numerous pub ications, inc uding Whos Who in America,
Whos Who in American Education, Outstanding Educators in
America, American M en and Women o Science, and Whos Who in
M edicine and Healthcare.
W hi e earning masters degrees in both zoo ogy and phar-
maco ogy, and a PhD in physio ogy, Gary says that he became
ascinated by the connectedness o the i e sciences. T at
ascination has ed to this editions uni ying themes, which
ocus on how each concept f ts into the big picture o the
human body.
o my parents, M .A. T ibodeau and Florence T ibodeau, who
had a deep respect or education at all levels and who truly believed
that you never give up being a student.
o my wi e, Emogene, an ever-generous and uncommonly
discerning critic, or her love, support, and encouragement over the
years.
o my children, Douglas and Beth, or making it all
worthwhile.
o my grandchildren, Allan Gary Foster and Johanna Lorraine
Foster, or proving to me that you really can learn something new
every day.
Gary A. T ibodeau
v
 CONTRIBUTOR PANEL
Le a d C o n t r ib u t o r s C o n t r ib u t o r s
Rhonda J. Gamble, PhD Ed Calcaterra, BS, MEd
Pro essor o Physio ogy and Li e Sciences Instructor
Minera Area Co ege DeSmet Jesuit H igh Schoo
Park H i s, Missouri Creve Coeur, Missouri

Linda Swisher, RN, EdD Jef Kingsbury, MD

Suncoast echnica Co ege Pro essor, Li e Sciences
Chair o H ea th Sciences Division (retired) Mohave Community Co ege
Advanced rauma Li e Support Associate Pro essor, Department o Bio ogica Sciences
Instructor Northern Arizona University
Course Educator or the American Co ege o Surgeons F agsta , Arizona
Sarasota, F orida
D aniel J. Matusiak, Ed D
Li e Science Instructor
St. Dominic H igh Schoo
OFa on, Missouri
Adjunct Pro essor
St. Char es Community Co ege
Cott evi e, Missouri

Amy L. Way, PhD

Pro essor o H ea th Science
Lock H aven University o Pennsy vania
C earf e d, Pennsy vania

vi
SCIENTIFIC REVIEW PANEL
Re v ie w e r s o C u r r e n t Ed it io n Re v ie w e r s o P r e v io u s Ed it io n s
Frank Bell, D C, MSHAPI Bert Atsma
SUNY Adirondack Union County Co ege
Q ueensbury, New York Cran ord, New Jersey
Angela Erickson, MSN, RN Janis A. Baker
Minera Area Co ege Schoo o Vocationa Nursing
Park H i s, Missouri H ar ingen, exas
Elizabeth G. F. Granier, PhD Rachel Venn Beecham
St. Louis Community Co ege Mississippi Va ey State University
St. Louis, Missouri Itta Bena, Mississippi
Heiko Heisermann, PhD Christi A. Blair
W inona State University H o mes Community Co ege
W inona, Minnesota Goodman, Mississippi
Ann L. Henninger, PhD Andrew Case
Wartburg Co ege Southeast Community Co ege
Waver y, Iowa Linco n, Nebraska
Virginia Johnson, MSHAPI, RN, LM D eborah Cipale
Stark State Co ege Des Moines Area Community Co ege
North Canton, Ohio Ankeny, Iowa
Fiona A. Murray, PhD, BSc (hons) Erin Clason
Swedish Institute Spokane Community Co ege
New York, New York Spokane, Washington
ina K. Putman, CS , CRS Virginia Clevenger
Lord Fair ax Community Co ege Mercer County Vocationa Schoo
Midd etown, Virginia renton, New Jersey
Paula D. Silver, BS, PharmD Mentor D avid
ECPI University Barton County Community Co ege
Newport News, Virginia Great Bend, Kansas
Jenni er Swann, PhD Leslie D ay
Lehigh University Northeastern University
Beth ehem, Pennsy vania Boston, Massachusetts
Barbara L. Westrick, AAS, CPC, CMA (AAMA) Judith D iehl
Ross Medica Education Center Reid State echnica Campus
Brighton, Michigan Atmore, A abama
Peggie Williamson, MS, MSHAPI Paul Ellis
Centra exas Co ege St. Louis Co ege o H ea th Careers
Ki een, exas Saint Louis, Missouri
D awn Zuidgeest-Cra t, RN Judy Fair
Grand Rapids Community Co ege Sandusky Schoo o Practica Nursing
Grand Rapids, Michigan Sandusky, Ohio

vii
viii SCIENTIFIC REVIEW PANEL

John Finnegan Caleb Makukutu

Cortiva Institute Kingwood Junior Co ege
Somerset, New Jersey Kingwood, exas
Beth A. Forshee Susan Caley Opsal
Freeman H ea th System I inois Va ey Community Co ege
Jop in, Missouri Og esby, I inois
Linda Fulton D arrell Pietarila
North H i s Schoo o H ea th Occupations F int H i s echnica Schoo
Pittsburgh, Pennsy vania Emporia, Kansas
Christy Gee Henry M. Seidel
South Co ege T e Johns H opkins University Schoo o Medicine
Ashevi e, North Caro ina Ba timore, Mary and
Natalie Greene D onna Silsbee
Macoupin County H ea th Department SUNY Institute o echno ogy
Car invi e, I inois Utica, New York
Sharon Harris-Pelliccia, BS, RPA Gerry Silverstein
Mi dred E ey Co ege University o Vermont
A bany, New York Bur ington, Vermont
Beulah Hof man Greg K. Sitorius
Indiana Vocationa echnica Co ege Minden H igh Schoo
erre H aute, Indiana Minden, Nebraska
Rita Hoots Sharon Spalding
Yuba Co ege Mary Ba dwin Co ege
Wood and, Ca i ornia Staunton, Virginia
Marilyn Hunter William Sproat
Daytona Beach Community Co ege Wa ters State Community Co ege
Daytona Beach, F orida Morristown, ennessee
Jon-Phillippe Hyatt D eborah Sulkowski
Georgetown University Pittsburg echnica Institute
Washington, D C Oakda e, Pennsy vania
Pablo Irusta Karen vedten
Georgetown University Schoo o Radio ogic echno ogy
Washington, D C Madison, W isconsin
anys Gene James Patricia A. West
North Centra exas Co ege Independent A&P and Massage T erapy Consu tant
Gainesvi e, exas Watervi e, Ohio
Michelle Kennedy Rebecca S. Wiggins
Morgan County H igh Schoo West F orida H igh Schoo o Advanced echno ogy
Madison, Georgia Pensaco a, F orida
Brian H. Kipp Shirley Yeargin
Grand Va ey State University Rend Lake Co ege
A enda e, Michigan Ina, I inois
Kathy Korona Nina Zanetti
Community Co ege o A egheny County Siena Co ege
West Mi in, Pennsy vania Loudonvi e, New York
Anne Lilly
Santa Rosa Junior Co ege
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PREFACE
This book about the human body represents the atest
and best in ormation avai ab e. T e Human Body
in Health & Disease is a guide or uture hea th pro essiona s
who are just beginning their exp oration o the comp ex hu-
man organism. It not on y presents introductory materia on
the e egance and e ciency o the hea thy human body but a so
shows what happens when things go wrong. o tru y under-
stand the human body, one must appreciate both norma and
abnorma structure and unction.
As we prepared this newest edition, each decision regard-
ing how concepts were to be presented in our book was eva u-
ated by teachers actua y working in the f e dteachers cur-
rent y he ping students earn about human structure, unction,
and disease or the f rst time. We a so consu ted c ose y with
working hea th pro essiona s and medica writers to ensure
that our re erences to disease processes and re ated topics are
current, accurate, and c ear y summarized. We a so paid care-
u attention to what research te s us about how the brain
reads, processes, and earns new in ormation, enab ing us to
present in ormation in a way the promotes student success.
T e resu t is a text that students wi read with enthusiasm
one designed to he p the teacher teach and the student earn.
T is book is particu ar y suited to introductory courses
about the human body in re ation to various hea th pro essions.
T e Human Body in Health & Disease emphasizes concepts that
are required know edge or entry into more advanced courses,
comp etion o pro essiona icensing examinations, and success
in a practica , work-re ated environment.
In s t r u c t io n a l D e s ig n
U n i y in g Th e m e s
Anatomy, physio ogy, and introductory patho ogy encompass
a body o know edge that, because o its sheer magnitude, can
easi y discourage and overwhe m the new student. T ere is no
question, however, that competency in these f e ds is essentia
or student success in a most every hea th-re ated or science
curricu um. I a textbook is to be success u as a teaching too
in such a comp ex and important earning environment, it
must he p uni y in ormation, stimu ate critica thinking, and
motivate students to master a new vocabu ary as they earn
about the beauty and connectedness o human structure and
unction and the disjointedness o human disease.
T e Human Body in Health & Disease is dominated by two
uni ying conceptua themes: the complementarity o normal
structure and unction and homeostasis. In every chapter o the
book the student is shown how organized anatomica struc-
tures o a particu ar size, shape, orm, or p acement serve
specif c unctions. Emphasis o this princip e encourages
students to integrate otherwise iso ated actua in ormation
into a cohesive and understandab e who e. T e breakdown o
norma integration o orm and unction is identif ed as the
basis or many disease processes.
T e integrating princip e o homeostasis is used to show
how norma structure and unction are maintained by dy-
namic counterba ancing o orces within the body. Fai ures o
homeostasis are shown as basic mechanisms o diseasea
concept that rein orces understanding o the regu atory sys-
tems o the human body.
T e Human Body in Health & Disease is dominated by two
uni ying pedagogica themes: the language o science and medi-
cine and a multisensory approach to earning.
o success u y earn and app y the concepts o human
science, students must f rst master the comp ex termino ogy
and usage o scientif c anguage. T is edition again eatures
expanded word ists that start at the beginning o each chap-
ter to assist both native speakers and Eng ish anguage
earners. Embedded hints encourage students to read and
say new terms out oud be ore encountering them in the
context o earning conceptsa proven reading strategy
based on how we natura y earn new anguage and process
reading in the brain. Inc uded pronunciation guides he p
students get it right without guessing and inc uded trans-
ations o word parts he p students see how scientif c an-
guage is constructed. O n ine audio chapter summaries and
an audio g ossary add an auditory dimension to the proper
pronunciation and usage o essentia scientif c anguage,
whi e the suggested saying terms out oud provides a he p-
u kinesthetic/motor experience.
O ur mu tisensory approach is urther enhanced by the
many intriguing visua e ements such as detai ed drawings,
photographs, medica imaging, and ow charts that he p stu-
dents picture the concepts described in the text. Unique
anatomica compass rosettes he p students deve op a sense o
anatomica direction. Expanded egends and embedded steps
provide a wa kthrough o key diagrams that rein orce es-
sentia concepts o each chapter. T e digita co oring activities
on the Evo ve website rein orce visua earning with kines-
thetic experiences.
O r g a n iz a t io n a n d C o n t e n t
T e 25 chapters o T e Human Body in Health & Disease pre-
sent the core materia o anatomy, physio ogy, and patho ogy
most important or introductory students.
T e sequence o chapters in the book o ows that most
common y used in courses taught at the undergraduate eve .
Basic concepts o human bio ogyanatomy, physio ogy, bio-
chemistry, cyto ogy, histo ogy, and patho ogyare presented
ix
x PREFACE

in Chapters 1 through 6. Chapters 7 through 25 present ma-

teria on more specia ized topics, such as individua organs or
C le a r Vie w o t h e Hu m a n Bo d y
systems, the senses (Chapter 11), immunity (Chapter 16), and Uppe r Arm - Trans ve rs e Se c tio n

genetics and genetic diseases (Chapter 25). Because each b.

Po s te rio r Vie w

Cranial region (upper skull) b

b
B
A

chapter is se -contained, instructors are given the exibi ity

c. Facial region 2
1 D
d. Pinna of ear d
e. Cervical (neck) region c 1 4
E
D
f. Axilla (armpit) A
153
i. Brachial region (arm) e L R
154
j. Antebrachial region (forearm)
P
k. Carpal region (wrist)

to a ter the sequence o materia to f t persona teaching pre -

154 155
m. Digital or phalangeal region (fingers) A. Biceps brachii m.
t. Femoral region (thigh) 155 121 B. Brachialis m.
u. Crural region (leg) 156
31
C. Humerus
v. Tarsal region (ankle) 156 D. Triceps brachii m., medial
31 121
157 E. Triceps brachii m., lateral
w. Olecranal (back of elbow) 157
x. Dorsal region (back) f 158

erences or the specia content or time constraints o their

y. Gluteal region (buttock) f 158
i
z. Popliteal region (back of knee) 160 162a
162a 160 Po s te rio r Vie w
aa. Plantar region (sole) i
127 161 127
162 162
161 1. Epicranius m.
x x 2. Temporalis m.
w 15 15
w 4. Masseter m.

courses.
159 15. Abdominal oblique m., external
166 159 31. Deltoid m.
166 167
j 167 163
121. Trapezius m.
j 168
168 163 164 127. Triceps m.
164 171 163
163 153. Platysma m.
171 172
154. Splenius capitis m.
172

In this edition, we continue deve oping our popu ar con-

164 164 173
174
155. Levator scapulae m.
173
k
169 175 169 156. Rhomboideus m.
k 170 174
y 175 176 170 157. Infraspinatus m.
y 176 158. Teres major m.
165 165 159. Lumbodorsal fascia
165 165 160. Erector spinae m.
m m
161. Serratus post. inf. m.

versationa sty e o narrative with additiona chunking o

162. Latissimus dorsi m.
S t S 162a. Latissimus dorsi m. (cut)
L R t L R 163. Gluteus medius m.
I
177 177
I 164. Gluteus maximus m.
177 177 165. Iliotibial tract
166. Flexor carpi ulnaris m.

content or better comprehension. We broke apart onger

z
167. Extensor carpi ulnaris m.
168. Extensor digitorum m.
z 169. Carpal ligament, dorsal
170. Interosseous m.
171. Gluteus minimus m.
172. Piriformis m.
178 178 173. Gemellus sup. m.

sentences and paragraphs and abe ed subtopics with addi-

178 178
u u 174. Obturator internus m.
175. Gemellus inf. m.
176. Quadratus femoris m.
177. Biceps femoris m.
178. Gastrocnemius m.
179 179 179. Calcaneal (Achilles) tendon

tiona descriptive headings.

179 179 180. Calcaneus bone
v v 180
180

aa aa

An equa y important goa or us in designing this text is

to present in ormation using a conceptua ramework on
which the student can bui d an understanding o the human
body. Rather than simp y isting a set o acts, each chapter
out ines the broad concepts that a ow students to re ate the
acts to one another in a meaning u way. For examp e, rather
than presenting diseases in a disjointed scattering o def ni-
tions or descriptions typica y seen in other texts, we exp ain
disease conditions within a ramework o patterns that aci i-
tates a more comp ete understanding o the process o disease
and a ows the student to compare and contrast re ated dis-
orders easi y.
Instructors who teach courses with ess emphasis on con-
cepts o patho ogy may wish to examine an a ternate text with
a simi ar instructiona design: Structure & Function o the Body,
a so avai ab e rom E sevier.
Illu s t r a t io n s a n d P a g e D e s ig n
A major strength o T e Human Body in Health & Disease is
the exceptiona qua ity, accuracy, and beauty o the i ustration
program and page design. Many i ustrations have been re-
vised or updated and severa new i ustrations have been
added. We have continued to use a consistent co or scheme
and i ustration sty e to enhance student understanding.
O ur popu ar directiona rosettes appear inconspicuous y in
a anatomica i ustrations. T ese rosettes, ike the compass
rosettes ound on a modern maps, orient the user, pointing
which way is e t and which way is rightdirections that in
anatomy may appear backward to the beginning student.
Many i ustrations eature expanded egends and embedded
steps that provide a he p u wa k through describing the chapter at the major concept eve be ore embarking on the
concepts represented and pointing out important e ements o
the i ustration.
Advancing an approach to page design f rst attempted in
the previous two editions, we have made additiona improve-
ments in our intuitive interna design that integrates the i -
ustrations and other earning too s more c ose y with the
text narrative. Summary tab es are used extensive y to visu-
a y organize concepts in a way that he p students compare
and contrast them to better understand the re ationships
among structures and unctions o the body. T is has pro-
duced a more usab e and more attractive p at orm or stu-
dent earning.
A u -co or, semitransparent mode o the body ca ed the
Clear View o the Human Body is ocated between Chapters 3
and 4 in the textbook. T is revised eature provides a handy
a ways on virtua dissection o ma e and ema e human bod-
ies a ong severa di erent p anes. A student avorite, this too
he ps earners use both visua and kinesthetic experiences to
assimi ate their know edge o the comp ex, three-dimensiona
nature o the human body. It a so he ps students visua ize hu-
man anatomy in the manner o todays c inica and ath etic
body-imaging techno ogy.
Em b e d d e d Le a r n in g To o ls
T e Human Body in Health & Disease is a student-oriented
text. Written in a riend y sty e accessib e to both expert and
cha enged students, it has many earning aids within the text
that maintain interest and motivation. Every chapter contains
the o owing e ements, each o which aci itates teaching and
earning.
Hints: H ints embedded within earning aids
marked with a bo d iconhigh ight strategies in
using the provided earning too s e ective y. T ese hints are
based on strategies recommended by earning and reading
experts.
Chapter Outline: An overview out ine introduces each chapter
and enab es the student to preview the content and ow o the
detai ed reading.
Chapter Objectives: Each chapter opening page contains sev-
era measurab e earning objectives. Each c ear y identif es or
the student, be ore he or she reads the chapter, what the key
goa s shou d be and what concepts shou d be mastered.
Language o Science and Medicine: Key terms (bo d ace in
the text) are isted starting at the beginning o each chapter so
that students can say them out oud using the provided pro-
nunciation guidesa strategy based on how the brain pro-
cesses reading and recommended by reading experts. Word

parts that orm each term are identif ed and trans ated to he p
students s ow y bui d a oundation in understanding the
structure o scientif c anguage and medica termino ogy.
Quick Check questions: Brie sets o QUICK CHECK
questions appearing at interva s through-
out each chapter encourage students to pause and re ect on
what they just read. T is strategy improves reading compre-
hension and retention by practicing the retrieva o recent y
earned in ormation and ideasa so preparing them or an
eventua end-o -chapter retrieva practice. Answers to a
Q uick Check questions are on Evo ve.
Active Concept Maps: New to this edition are animated,
narrated ow charts o se ected concepts that many students
f nd di cu t to understand are now avai ab e at the Evo ve
website. Ca ed out at appropriate ocations within the chap-
ters, they use sight and sound to virtua y wa k students
through conceptua re ationships.
Boxed sidebars: Brie boxed sidebars appear in every chapter.
T ese boxes inc ude in ormation ranging rom c inica app i-
cations o the in ormation to high ights o recent research or
re ated topics to re evant discussions o exercise and f tness.
Patho ogica conditions are sometimes exp ained in essay or-
mat to he p students better understand the re ationship be-
tween norma structure and unction. A sidebars are high-
ighted with an easi y recognized symbo so that students can
see at a g ance whether the box contains we ness, c inica ,
research, or science app ication in ormation. In this edition,
the eatured boxes cover our categories:
Health & Well-Being boxes contain
in ormation about we ness, f tness and
exercise, ath etics, pub ic hea th, and re-
ated issues and prob ems.
Clinical Application boxes emphasize
interesting acts and trends re ated to dis-
ease processes and therapies.
Research, Issues, & rends sidebars
i ustrate the dynamic nature o human
science today, as we as the importance
o ethica and ega issues in app ying
new research in ormation.
Science Applications boxes summa-
rize a ew o the pro essions that make use o
the concepts in the chapter to improve our
qua ity o i e. T ese essays a so eature sig-
nif cant individua s who have contributed to
human science and medicine. T us they he p p ace
the study o the human body in a historica , g oba ,
and socia context.
Connect It! online articles: New to this edition are a co ec-
tion o brie artic es that i ustrate, c ari y, and app y concepts
encountered in the text. Embedded within the text narrative,
sma boxes connect students with specif c i ustrated artic es
PREFACE xi
avai ab e on ine at evolve.elsevier.com. T ese artic es stimu ate
thinking, satis y the natura curiosity o students, and he p
integrate concepts, so that each student better understands
the big picture o human structure, unction, and disease.
AnimationDirect: Each chapter has sma boxes that point the
reader to animations o important princip es. T ese are avai -
ab e in AnimationDirect, which is inc uded on Evo ve. T e
brie animated sequences are designed to demonstrate con-
cepts that are not easi y i ustrated in static diagrams. In e ect
they he p put a students understanding in motion and thus
he p so idi y earning using a mu tisensory approach.
Outline Summaries: Many students are ow structure bui d-
ers, meaning they have troub e bui ding a comp ex concep-
tua ramework on their own. Extensive and detai ed end-o -
chapter summaries in out ine ormat provide exce ent guides
or students as they bui d the conceptua structures needed to
understand the content o each chapter. T ey a so he p review
the text materia s when preparing or examinations. Many
students a so f nd these detai ed guides to be use u as a chap-
ter previewthe conceptua b ueprintin conjunction with
the chapter out ine.
Audio Chapter Summary boxes: Found at the Evo ve website
and ca ed out with an icon at the start o each chap-
ter out ine summary, brie audio (mp3) summaries
can be p ayed on a variety o digita devices. T ese
summaries are use u or both previews and reviews o chapter
content, enab ing students to use mu tip e sensory moda ities
in their earning.
Active Learning tools: A comp ete set o end-o -chapter cha -
enges a ow students to test their own earning to f nd weak
spots that require additiona study and provide opportunities
to try their hand at ana yzing and eva uating questions and
cases to app y the concepts they have earned.
Study ips. A ist o specif c active study strategies
to most e ective y study the concepts presented in
the chapter. By participating in suggested study
activities, students not on y master the concepts o
a specif c chapter but a so bui d their overa com-
petence as se -directed earners.
Review Questions. Subjective review questions at
the end o each chapter a ow students to use a nar-
rative ormat to discuss concepts and a so serve to
synthesize important chapter in ormation that can
then be reviewed to assess comprehension o the
materia .
Critical T inking Questions. Review questions that en-
courage students to use critica thinking ski s are high-
ighted at the end o the Review Q uestions section.
Chapter ests. O bjective-type Chapter est questions
inc uded at the end o each chapter serve as se -tests
or the reca and mastery o important subject matter.
T ey a so provide practice needed to increase the re-
xii PREFACE
tention o in ormation and bui d conf dence be ore
an in-c ass quiz or test.
Case Studies. Each chapter ends with a ew case stud-
ies that ask students to practice their ski s o ana ysis,
eva uation, and app ication by so ving specif c, practi-
ca prob ems.
Answers or a Active Learning sections are on the
Evo ve website.
Glossary: An extensive isting o key terms, pronunciations,
and def nitions serves as a handy re erence or students as they
progress through the course.
Index: A comprehensive index aids in ocating in ormation
anywhere in the book quick y and easi y.
D ig it a l Le a r n in g To o ls
A wide variety o mu tisensory earning too s are avai ab e at
evolve.elsevier.com/PattonT ibodeau/humanbody:
Audio chapter summaries or each chapter in the
book are a student avorite. T ese concise, narrated
overviews are ca ed out at the start o each chapter
O ut ine Summary and can be accessed on the
Evo ve website. Some students f nd that these audio
reviews improve their retention o chapter concepts
when used immediate y a ter reading the chapter.
Active
Concept Map and AnimationD irect eatures that
are ound on Evo ve. T ese provide audio and visua
coverage o a wide range o topics and body systems.
Connect It! artic es, which are ca ed out through-
out the text, expand on topics in the text to stimu-
ate thinking beyond the coverage o the textbook.
Body Spectrum Electronic Anatomy Coloring
Book is one o our most popu ar interactive eatures
on Evo ve. Using a visua -kinesthetic approach, this
too simp if es the way students earn anatomy and
medica termino ogy by o ering more than 70 de-
tai ed anatomy i ustrations that can be co ored on-
ine or printed out to co or and study o ine.
proper pronunciation with the Audio Glossary!
FAQsFrequent y Asked Q uestionsby stu-
dents, a ong with answers rom the authors.
Sel - est and Matching Exercises activities
on Evo ve a ow or interactive practice with im-
mediate eedback, providing an exce ent too or
gauging comprehension.
Appendixes that were ormer y in the print book
have been moved to the Evo ve site or easier re er-
ence on ine. T ese provide detai ed in ormation on
se ected patho ogica conditions, medica termino -
ogy, and c inica and aboratory va ues and conver-
sion actors.
O n lin e Re s o u r c e s o r In s t r u c t o r s
TEAC H In s t r u c t o r Re s o u r c e M a n u a l
EACH has been updated and revised or this edition.
T e EACH esson p ans he p instructors prepare or c ass
and make u use o the rich array o anci aries and re-
sources that come with the textbook. T e content covered
in each textbook chapter is divided across one or more
esson p ans, each designed to occupy 50 minutes o
c ass time. Lesson p ans are organized into easi y under-
standab e sections that are each tied to the chapter earning
objectives:
Instructor Preparation: T is section provides a
check ist o a the things you need to do to prepare
or c ass, inc uding a ist o a the items that you
need to bring to c ass to per orm any activity or
demonstration inc uded in the esson p an, and a
pertinent key terms covered in that esson.
Student Preparation: extbook readings, study
guide exercises, on ine activities, and other app i-
cab e homework assignments or each esson are
provided here a ong with an overa estimated
comp etion time.
T e 50-Minute Lesson Plan: A ecture out ine
that re ects the chapter ecture s ides that come as
part o EACH is inc uded, as we as c assroom
activities and on ine activities, one or more critica
thinking questions, and time estimates or the
c assroom ecture and activities.
Assessment Plan: o ensure that your students
have mastered a the objectives, the new EACH
inc udes a separate Assessment P an section. An
easy-to-use tab e maps each assessment too to the
esson p ans and chapter objectives so you can see
a your assessment optionsby chapter, by esson,
and by objectiveand choose according y.
Te s t Ba n k
An e ectronic test bank o more than 3,600 questions with
answersrevised and updated or this editiongives
instructors an easy way to test students comprehension
o text materia and create comprehensive exams or stu-
dents. T e test bank questions are avai ab e on the Evo ve
website.
Im a g e C o lle c t io n
T e image co ection inc udes more than 500 anatomy and
physio ogy images rom the text, avai ab e in jpeg and
PowerPoint ormats, with and without abe s and with
and without ead ines. Use these images to enhance the
visua e ements o your ectures, discussions, case studies,
quizzes, tests, handouts, and more. T e image co ection is
avai ab e on the Evo ve website.

U p d a t e G u id e
Compi ed by the ead author during the revision process
o this textbook, the Changes to the 7th Edition document is
a detai ed ist inc uding updates in the textbook since the
ast edition. T ese inc ude g oba , chapter-by-chapter, and
section-by-section changes. T is document wi he p in
p anning as you upgrade rom the 6th edition to the new
7th edition o T e Human Body in Health & Disease. Updates
and teaching tips are a so posted at PattonHD.org.
S u p p le m e n t s
T e supp ements package has been care u y p anned and de-
ve oped to assist instructors and to enhance their use o the
text. Each supp ement has been thorough y reviewed by many
o the same instructors who reviewed the text.
Study Guide. Written by Linda Swisher, it provides
students with additiona se -study aids, inc uding
chapter overviews, topic reviews, and app ication
and abe ing exercises (such as matching, crossword
puzz es, f in the b ank, and mu tip e choice), as
we as answers in the back o the guide.
Anatomy and Physiology Online or T e Human Body in
Health & Disease. T is optiona too is a 24-modu e
on ine course that brings A&P to i e and he ps you
understand the most important concepts presented
in T e Human Body in Health & Disease. It inc udes
over 125 animations, 300 interactive exercises, and
quizzes and exams to assess student comprehension.
Avai ab e at the Evo ve website.
Elsevier Adaptive Learning (EAL). T is persona -
ized and interactive too enab es students to earn
aster and remember onger. Its un; its engaging;
and its constant y tracking student per ormance
and adapting to de iver content precise y when its
needed to ensure in ormation is trans ormed into
asting know edge.
Survival Guide or Anatomy & Physiology. An en-
tertaining and easy-to-read set o tips, shortcuts,
and advice, this surviva kit he ps students achieve
success in anatomy and physio ogy.
S u m m a ry o C h a n g e s
t o t h e S e ve n t h Ed it io n
A comprehensive detai ed ist o changes appears in the Changes
to 7th Edition guide. Look or it in the Instructor Resources on
Evo ve. A ew se ected revisions or this edition are isted here.
or c arity
Connect It! boxes embedded in the text point
students to i ustration artic es that he p them inte-
grate and app y concepts.
PREFACE xiii
chunking and reorganization o sec-
tions, paragraphs, and sentences to improve read-
ing comprehension.
Active Concept M aps have
been added to the Evo ve website resources and
ca ed out where appropriate in each chapter
Language o Science and Language o M edicine word
ists now start on each chapter-opener page, then
continue in the end-o -chapter resources. Each
bo d ace term rom the text narrative is isted with
a pronunciation guide and word parts (with itera
trans ations).
ists. Most y words that a ready appear in the
book, the additions to the word ists ensure that
students have immediate access to pronunciation
guides and trans ation o word parts.
-
ing he p with standard vocabu ary that may be
cha enging to Eng ish anguage earners and
underprepared students. Pronunciations or un-
usua p ura s orms have a so been added.
Clear View o the Human
Body and to the appendixes on Evo ve have been
embedded in the text to assist student earning
Hints throughout each chapter te
students how best to use the inc uded earning
too s have been c arif ed or ease o use.
Science Appli-
cations boxes are now emphasized in bo d ace or
ita ic and have been added to the word ists, a ong
with pronunciations and word part trans ations;
photographs o hea th pro essiona s in action a so
have been added to some boxes.
previous i ustrations
-
vised to inc ude exp anatory step boxes, o ten
with matching numera s embedded within an
i ustrations detai , he p wa k students through
comp ex concepts.
c arity.
Clear View o the Human Body has additiona
new ayers. Some existing ayers have additiona
structures abe ed.
microbiomean emerging concept o
rapid y growing importance in hea th careis now
introduced in Chapter 1 and integrated into many
o the remaining chapters.
with the more precise terms orearm and arm.
and osmosis) has been reorganized and osmosis
def nition c arif ed to distinguish it rom di usion.
xiv PREFACE
students better understand the ske eton.
- ing many o the Connect It! artic es and editing a o them.
c es move joints.
and revised.
- ing earning too s on the Evo ve website; Jenni er Bertucci or
tion system revised or c arity.
ow o any uid is a pressure gradient.
better rame the discussion o the ro e o b ood pres-
sure in b ood circu ation.
(ABGs) to i ustrate how acid/base ba ance can be
assessed.
intake.
A Wo r d o Th a n k s
Many peop e have contributed to the deve opment and suc-
cess o T e Human Body in Health & Disease. We extend our
thanks and deep appreciation to the various students and
c assroom instructors who have provided us with he p u sug-
gestions o owing their use o the ear ier editions o this text.
For this edition, we wou d ike to thank the o owing ex-
perts or their contributions: Rhonda Gamb e, or contribut-
Linda Swisher, who he ped us improve the earning opportu-
nities in every chapter o the bookas we as producing a
very use u Study Guide. Janie Corbitt, Virginia Johnson, and
Ange a Pa mier or their exce ent work reviewing and updat-
the EACH Instructor Resource M anual; Dan Matusiak
or reviewing and revising the on ine course; and Peggie
W i iamson or updating the test bank on Evo ve. We are
grate u or the prior contributions o Ed Ca caterra, Je
Kingsbury, and Amy Way.
At E sevier, thanks are due to a on the ta ented and cre-
ative team that produced this 7th edition. We wish especia y
to acknow edge the support, e ort, and occasiona crisis man-
agement o Ke ie W hite, executive content strategist; Karen
urner and H eather Bays, content deve opment specia ists;
Je rey Patterson, pub ishing services manager; Caro
OConne , book production specia ist; Doris Cadd, copy edi-
tor; and Ash ey Miner, book designer, a o whom were in-
strumenta in bringing this edition to success u comp etion.
We a so wish to thank a the many others o the E sevier
ami y who support our ongoing e orts, rom animation cre-
ation, to on ine resource creation and support, to the hard-
working marketing and sa es pro essiona s.
Kevin . Patton
Gary A. T ibodeau
HOW TO USE THIS BOOK
You might think that it s obvious how to use a
textbookyou just open it up and read it! But
that wont get you very ar in your earning. You need a
textbook strategy to make the best use o this too . H ere, we
out ine a three-step p an that you can adapt to your own
earning goa s and study pre erences.
1. G e t Yo u r He a d In t o It
Regularly think about how you learn bestand
notice what is working or you and what is not.
Learning coaches ca this metacognition, a term that
means thinking about your thinking. Surprising y,
this a one wi improve your success! T e many Hints
embedded in each chapter wi he p you ocus on how
you are thinking about your reading.
Avoid distractions while your use your book. T is
means a quiet environment and no interruptions. T is
inc udes turning of your music. Even i you think its
he ping you, research shows that istening to music
near y a ways reduces your abi ity to ocus u y on
what you are reading.
Realize that deep learning takes time and ef ort.
T is recommended strategy wi not work i you dont
put signif cant work into it. So make sure youve
schedu ed a ot o short study sessions (20-45 min-
utes) to get it a done. Space out your study sessions,
interspersing other activities between them, or your
study time wi be wasted.
3 . S e e k M a s t e ry
2 . G a in Fa m ilia r it y
Familiarity is recognition o the terminology and
basic ideas in each chapter. T is is on y the f rst step
to earning, but its the necessary oundation or ater
mastery o the content.
First, take a look at the Chapter O bjectives. T is
te s you what you need to master by the time youve
f nished earning the chapter. T at wi he p you ocus
on the big ideas as you read.
T en slowly read through the Chapter Outline at the
beginning o each chapter to get your brain ami iar
with how the story o the chapter is aid out. T is
he ps you sort out the ideas in a chapter as you read
and bui d a menta ramework o new concepts.
Next, read each term in the Language o Science and
Language o Medicine out loud. T is book has as
many new words as a oreign- anguage textbook, so
recognizing that you must learn a new language is an
important step to success. As you say each term a oud,
use the provided pronunciation guideso you wont
trip over comp ex terms when you read the chapter.
ake a moment to g ance at the word parts that make
up each term. T is he ps you start recognizing how
scientif c termino ogy worksthere ore, it he ps you
earn additiona new terms aster and more accurate y.
More than one pass at this step works even better.
Read the chapter. Read each section separate y,
skimming the subheadings be ore you begin your
readingto he p you bui d your menta ramework o
concepts. By reading in sections, it wont matter that
you cant read the who e chapter in one sitting.
Answer the embedded Quick Check questions be-
ore you move ahead in your reading. T is he ps you
make sure you have paused to think about what
youve read. And it he ps you see i you have rea y
understood the main ideas. I you cant correct y an-
swer the Quick Check, consider reading that part o
the chapter again, so you get it be ore moving to the
next section.
Use the embedded resources to help you understand
the text narrative. ake the time to study the i ustra-
tions ca ed out in the reading. I there are Animation-
Direct videos or Active Concept M aps, watch and isten
to them. Read a the re ated Connect It! artic es and
boxed sidebars.
Move beyond amiliarity to mastery. Many students
dont rea ize that amiliaritywhich is incomp ete
and easi y orgottenis not the same as mastery.
Mastery is a more comp ete understanding o the
concepts, how they re ate to one another, and how
they can be app ied to rea wor d situations. Mastery
is something that stays with you or yearswhen you
rea y need itrather than being orgotten in a ew
days or weeks.
Review the O utline Summary. Start thinking about
how it a f ts together and consider how ami iar you
are with each major idea. You may need to go back
and review a section that you have orgotten.
Work through the Active Learning process. Work
through the Review Questions, then Critical T inking
items, the Chapter est, and Case Studies at the end o
the chapter. Write out your answersdont just an-
swer them in your head. Check your answers and
correct any weaknesses be ore moving on to the next
xv
xvi HOW TO USE THIS BOOK
set o items. T en do this again in a ew days.
You have orgotten some things, but thats ex-
pectedand thats why continuing, spaced repetition
o know edge-retrieva practice is so important!
Use your Evolve Resources or additional retrieval
practice. Your Evo ve resources inc ude practice
questions in the Prepare or Exams section.
Combine this textbook strategy with the other
course components. Your instructor has care u y
p anned a who e course around the textbookso this
strategy is just a part o what you must be doing to
earn and master a the essentia concepts. Make sure
you participate ully in your course and use e ective
study strategies to maximize your earning.
CONTENTS
1 Introduction to the Body, 2 4 Tissues, 70
S cie ntif c Me tho d, 4 Intro ductio n to Tis s ue s , 71
Le ve ls o Organizatio n, 6 Tis s u e Typ e s , 71
Anato m ical Po s itio n, 7 Ma trix, 72
Anato m ical Dire ctio ns , 7 Epithe lial Tis s ue s , 72
Plane s o the Bo dy, 8 In tro d u ctio n to Ep ith e lia l Tis s u e s , 72
Bo dy Cavitie s , 9 S q u a m o u s Ep ith e liu m , 73
Bo dy Re g io ns , 11 Cu b o id a l Ep ith e liu m , 75
Balance o Bo dy Functio ns , 14 S im p le Co lu m n a r Ep ith e liu m , 75
Ps e u d o s tra tif e d Ep ith e liu m , 76

2 Tra n s itio n a l Ep ith e liu m , 76

Chemistry o Li e, 24 Co nne ctive Tis s ue , 76
In tro d u ctio n to Co n n e ctive Tis s u e , 76
Le ve ls o Che m ical Organizatio n, 25 Fib ro u s Co n n e ctive Tis s u e , 78
Ato m s , 25 Bo n e , 80
Ele m e n ts , Mo le cu le s , a n d Co m p o u n d s , 26 Ca rtila g e , 80
Che m ical Bo nding , 27 Ep ith e lia l Tis s u e , 73
Io n ic Bo n d s , 27 Blo o d Tis s u e , 80
Cova le n t Bo n d s , 27 He m a to p o ie tic Tis s u e , 81
Hyd ro g e n Bo n d s , 28 Mus cle Tis s ue , 81
Ino rganic Che m is try, 29 In tro d u ctio n to Mu s cle Tis s u e , 81
Wa te r, 29 S ke le ta l Mu s cle Tis s u e , 81
Acid s , Ba s e s , a n d Sa lts , 30 Ca rd ia c Mu s cle Tis s u e , 82
Organic Che m is try, 31 S m o o th Mu s cle Tis s u e , 82
Ca rb o hyd ra te s , 31 Ne rvo us Tis s ue , 83
Lip id s , 31 Tis s ue Re pair, 83
Pro te in s , 33
Nu cle ic Acid s , 35
Clinical Applicatio ns o Che m is try, 35 5 Organ Systems, 92

3 Organ Sys te m s o the Bo dy, 93

Cells, 42 In te g u m e n ta ry Sys te m , 93
S ke le ta l Sys te m , 94
Ove rvie w o Ce lls , 43 Mu s cu la r Sys te m , 94
S ize a n d S h a p e , 43 Ne rvo u s Sys te m , 95
Co m p o s itio n , 44 En d o crin e Sys te m , 96
Pa rts o th e Ce ll, 44 Ca rd iova s cu la r Sys te m , 96
Re latio ns hip o Ce ll S tructure and Functio n, 50 Lym p h a tic a n d Im m u n e Sys te m s , 97
Move m e nt o S ubs tance s Thro ug h Ce ll Re s p ira to ry Sys te m , 98
Me m brane s , 50 Dig e s tive Sys te m , 98
Typ e s o Me m b ra n e Tra n s p o rt, 50 Urin a ry Sys te m , 99
Pa s s ive Tra n s p o rt Pro ce s s e s , 51 Re p ro d u ctive Sys te m s , 99
Active Tra n s p o rt Pro ce s s e s , 53 Bo dy as a Who le , 101
Ce ll Tra n s p o rt a n d Dis e a s e , 55 Ho m e o s ta s is , 101
Ce ll Grow th and Re pro ductio n, 56 Ap p lyin g Orga n Sys te m Co n ce p ts , 101
Ce ll Gro w th , 56 Organ Re place m e nt, 101
Ce ll Re p ro d u ctio n , 59 Vita l a n d No nvita l Orga n s , 101
Ch a n g e s in Ce ll Gro w th a n d Re p ro d u ctio n , 60 Artif cia l Orga n s , 101
Orga n Tra n s p la n ta tio n , 104

xvii
xviii CONTENTS

6 Mechanisms o Disease, 112 8 Skeletal System, 174

S tudying Dis e as e , 113 Functio ns o the S ke le tal Sys te m , 175
Dis e a s e Te rm in o lo g y, 113 S u p p o rt, 175
Pa tte rn s o Dis e a s e , 114 Pro te ctio n , 176
Patho phys io lo gy, 115 Move m e n t, 176
Me ch a n is m s o Dis e a s e , 115 S to ra g e , 176
Ris k Fa cto rs , 117 He m a to p o ie s is , 176
Patho ge nic Organis m s and Particle s , 117 Gro s s S tructure o Bo ne s , 176
Viru s e s , 118 Typ e s o Bo n e s , 176
Prio n s , 120 S tru ctu re o Lo n g Bo n e s , 176
Ba cte ria , 120 S tru ctu re o Fla t Bo n e s , 177
Fu n g i, 123 Micro s co pic S tructure o Bo ne , 177
Pro to zo a , 123 Bo n e Tis s u e S tru ctu re , 177
Pa th o g e n ic An im a ls , 124 Ca rtila g e Tis s u e S tru ctu re , 177
Pre ve ntio n and Co ntro l, 124 Bo ne De ve lo pm e nt, 177
Me ch a n is m s o Tra n s m is s io n , 125 Ma kin g a n d Re m o d e lin g Bo n e , 177
Pre ve n tio n a n d Tre a tm e n t S tra te g ie s , 126 En d o ch o n d ra l Os s if ca tio n , 179
Dru g Th e ra p y, 127 In tra m e m b ra n o u s Os s if ca tio n , 179
Tum o rs and Cance r, 128 Axial S ke le to n, 180
Ne o p la s m s , 128 S ku ll, 181
Ca u s e s o Ca n ce r, 130 Hyo id Bo n e , 185
Pa th o g e n e s is o Ca n ce r, 131 Ve te b ra l Co lu m n (S p in e ), 186
In am m atio n, 134 Th o ra x, 189
In a m m a to ry Re s p o n s e , 134 Appe ndicular S ke le to n, 190
In a m m a to ry Dis e a s e , 135 Up p e r Extre m ity, 190
Lo w e r Extre m ity, 191

7
S ke le to n Variatio ns , 194
Skin and Membranes, 144 Ma le -Fe m a le S ke le ta l Di e re n ce s , 194
Ag e Di e re n ce s , 195
Bo dy Me m brane s , 145 Enviro n m e n ta l Fa cto rs , 195
Cla s s if ca tio n o Me m b ra n e s , 145 Jo ints , 196
Ep ith e lia l Me m b ra n e s , 146 Articu la tio n o Bo n e s , 196
Co n n e ctive Tis s u e Me m b ra n e s , 147 Kin d s o J o in t, 196
S kin S tructure , 148 Syn a rth ro s e s , 196
Ove rvie w o S kin S tru ctu re , 148 Am p h ia rth ro s e s , 196
Ep id e rm is , 149 Dia rth ro s e s , 197
De rm is , 150 S ke le tal Dis o rde rs , 200
S u b cu ta n e o u s Tis s u e , 151 Tu m o rs , 200
Ha ir, Na ils , a n d S kin Re ce p to rs , 151 Me ta b o lic Bo n e Dis e a s e s , 201
S kin Gla n d s , 154 Bo n e In e ctio n , 202
Functio ns o the S kin, 155 Bo n e Fra ctu re s , 203
Pro te ctio n , 155 J o in t Dis o rd e rs , 204
Te m p e ra tu re Re g u la tio n , 155
Se n s a tio n , 156
Excre tio n , 156
Syn th e s is o Vita m in D, 156
9 Muscular System, 218
Dis o rde rs o the S kin, 156 Mus cle Tis s ue , 220
S kin Le s io n s , 156 S ke le ta l Mu s cle , 220
Bu rn s , 157 Ca rd ia c Mu s cle , 220
S kin In e ctio n s , 161 S m o o th Mu s cle , 220
Va s cu la r a n d In a m m a to ry S kin Dis o rd e rs , 161 S tructure o S ke le tal Mus cle , 220
S kin Ca n ce r, 163 Mu s cle Orga n s , 220
Mu s cle Fib e rs , 221
 CONTENTS xix

Functio n o S ke le tal Mus cle , 222

Move m e n t, 223
11 Senses, 290
Po s tu re , 224 Clas s if catio n o S e ns e s , 291
He a t Pro d u ctio n , 224 Ge n e ra l Se n s e s , 291
Fa tig u e , 224 S p e cia l Se n s e s , 292
Mo to r Unit, 225 Se n s o ry Re ce p to r Typ e s , 292
Mus cle S tim ulus , 225 S e ns o ry Pathw ays , 293
Type s o Mus cle Co ntractio n, 225 Ge ne ral S e ns e s , 293
Tw itch a n d Te ta n ic Co n tra ctio n s , 225 Dis trib u tio n o Ge n e ra l Se n s e Re ce p to rs , 293
Is o to n ic Co n tra ctio n , 26 Mo d e s o Se n s a tio n , 293
Is o m e tric Co n tra ctio n , 226 Dis o rd e rs Invo lvin g Ge n e ra l Se n s e s , 294
E e cts o Exe rcis e o n S ke le tal Mus cle s , 226 S pe cial S e ns e s , 294
Move m e nts Pro duce d by Mus cle s , 228 Vis io n , 294
An g u la r Mo ve m e n ts , 228 Dis o rd e rs o Vis io n , 297
Circu la r Move m e n ts , 228 He a rin g a n d Eq u ilib riu m , 302
S p e cia l Mo ve m e n ts , 229 He a rin g a n d Eq u ilib riu m Dis o rd e rs , 307
S ke le tal Mus cle Gro ups , 230 Ta s te , 307
Mu s cle s o th e He a d a n d Ne ck, 232 S m e ll, 308
Mu s cle s o th e Up p e r Extre m itie s , 232 Inte g ratio n o S e ns e s , 309
Mu s cle s o th e Tru n k, 232

12
Mu s cle s o th e Lo w e r Extre m itie s , 234
Mus cular Dis o rde rs , 235 Endocrine System, 318
Mu s cle In ju ry, 235
Mu s cle In e ctio n s , 235 Endo crine Glands , 320
Mu s cu la r Dys tro p hy, 236 Me chanis m s o Ho rm o ne Actio n, 320
Mya s th e n ia Gra vis , 237 No n s te ro id Ho rm o n e s , 320
S te ro id Ho rm o n e s , 321
Re g ulatio n o Ho rm o ne S e cre tio n, 324
10 Nervous System, 248 Ne ga tive Fe e d b a ck, 324
Po s itive Fe e d b a ck, 324
Organs and Divis io ns o the Ne rvo us Sys te m , 249 Le ve ls o Re g u la tio n , 324
Ce lls o the Ne rvo us Sys te m , 250 Me chanis m s o Endo crine Dis e as e , 325
Ne u ro n s , 250 Pro s tag landins , 325
Glia , 250 Pituitary Gland, 326
Dis o rd e rs o Ne rve Tis s u e , 252 S tru ctu re o th e Pitu ita ry Gla n d , 326
Ne rve s and Tracts , 253 An te rio r Pitu ita ry Gla n d Ho rm o n e s , 326
Ne rve S ig nals , 253 Po s te rio r Pitu ita ry Gla n d Ho rm o n e s , 328
Re e x Arcs , 253 Hypo thalam us , 328
Ne rve Im p u ls e s , 255 Thyro id Gland, 329
Syn a p s e s , 256 Thyro id Ho rm o n e , 329
Ce ntral Ne rvo us Sys te m , 259 Ca lcito n in , 330
Bra in , 260 Parathyro id Glands , 331
Bra in Dis o rd e rs , 264 Adre nal Glands , 331
S p in a l Co rd , 266 Lo ca tio n o Ad re n a l Gla n d s , 331
Cove rin g s a n d Flu id S p a ce s , 268 Ad re n a l Co rte x, 331
Pe riphe ral Ne rvo us Sys te m , 270 Ad re n a l Me d u lla , 333
Cra n ia l Ne rve s , 270 Ad re n a l Ab n o rm a litie s , 334
S p in a l Ne rve s , 270 Pancre atic Is le ts , 334
Pe rip h e ra l Ne rve Dis o rd e rs , 273 S e x Glands , 336
Auto no m ic Ne rvo us Sys te m , 274 Fe m a le Se x Gla n d s , 336
Ove rvie w, 274 Fe m a le Se x Gla n d s , 336
Fu n ctio n a l An a to m y, 275 Thym us , 337
Au to n o m ic Co n d u ctio n Pa th s , 276 Place nta, 337
Sym p a th e tic Divis io n , 276 Pine al Gland, 338
Pa ra s ym p a th e tic Divis io n , 277 Endo crine Functio ns Thro ug ho ut the Bo dy, 338
Au to n o m ic Ne u ro tra n s m itte rs , 277 Oth e r En d o crin e S tru ctu re s , 338
Au to n o m ic Ne rvo u s Sys te m a s a Wh o le , 278 Ho rm o n e Actio n s in Eve ry Orga n , 339
Dis o rd e rs o th e Au to n o m ic Ne rvo u s Sys te m , 278
xx CONTENTS
13 Blood, 348
Blo o d Co m po s itio n, 349
Blo o d Tis s u e , 349
Blo o d Pla s m a , 350
Fo rm e d Ele m e n ts , 351
He m a to p o ie s is , 352
Me chanis m s o Blo o d Dis e as e , 352
Re d Blo o d Ce lls , 352
RBC S tru ctu re a n d Fu n ctio n , 352
RBC Co u n t, 353
He m o g lo b in , 354
RBC Ab n o rm a litie s , 354
Blo o d Typ e s , 355
Re d Blo o d Ce ll Dis o rde rs , 358
Po lycyth e m ia , 358
An e m ia , 358
White Blo o d Ce lls , 361
In tro d u ctio n to WBCs , 361
WBC Co u n t, 362
WBC Typ e s , 362
White Blo o d Ce ll Dis o rde rs , 363
Mu ltip le Mye lo m a , 363
Le u ke m ia , 363
In e ctio u s Mo n o n u cle o s is , 364
Plate le ts and Blo o d Clo tting , 365
Pla te le ts , 365
Blo o d Clo ttin g , 365
Clo tting Dis o rde rs , 365
Ab n o rm a l Blo o d Clo ts , 365
He m o p h ilia , 366
Th ro m b o cyto p e n ia , 368
Vita m in K De f cie n cy, 368
14 Heart, 378
Lo catio n o the He art, 389
Functio nal Anato my o the He art, 380
He a rt Ch a m b e rs , 380
Pe rica rd iu m , 381
He a rt Actio n , 383
He a rt Va lve s , 383
He art S o unds , 384
Blo o d Flow Thro ug h the He art, 384
Blo o d S upply to He art Mus cle , 385
Cardiac Cycle , 387
Ele ctrical Activity o the He art, 388
Co n d u ctio n Sys te m , 388
Ele ctro ca rd io g ra p hy, 388
Ca rd ia c Dys rhyth m ia , 389
Cardiac Output, 392
De f n itio n o Ca rd ia c Ou tp u t, 392
He a rt Ra te , 393
S tro ke Vo lu m e , 393
He art Failure , 394
15 Circulation o Blood, 402
Blo o d Ve s s e ls , 403
Typ e s , 403
S tru ctu re , 404
Fu n ctio n s , 405
Dis o rde rs o Blo o d Ve s s e ls , 406
Dis o rd e rs o Arte rie s , 406
Dis o rd e rs o Ve in s , 408
Ro ute s o Circulatio n, 408
Sys te m ic a n d Pu lm o n a ry Circu la tio n , 408
He p a tic Po rta l Circu la tio n , 409
Fe ta l Circu la tio n , 412
He m o dynam ics , 414
De f n in g Blo o d Pre s s u re , 414
Fa cto rs Th a t In u e n ce Blo o d Pre s s u re , 414
Flu ctu a tio n s in Arte ria l Blo o d Pre s s u re , 417
Puls e , 419
Hype rte ns io n, 419
De f n itio n , 419
Ris k Fa cto rs , 420
Circulato ry S ho ck, 421
Ca rd io g e n ic S h o ck, 421
Hyp ovo le m ic S h o ck, 421
Ne u ro g e n ic S h o ck, 421
An a p hyla ctic S h o ck, 421
Se p tic S h o ck, 421
16
Lymphatic System and Immunity, 428
Lym phatic Sys te m , 429
Orga n iza tio n o th e Lym p h a tic Sys te m , 429
Lym p h , 430
Lym p h a tic Ve s s e ls , 431
Lym p h e d e m a , 432
Lym p h o id Orga n s , 432
Im m une Sys te m , 436
Fu n ctio n o th e Im m u n e Sys te m , 436
In n a te Im m u n ity, 436
Ad a p tive Im m u n ity, 437
Im m une Sys te m Mo le cule s , 438
Cyto kin e s , 438
An tib o d ie s , 439
Co m p le m e n t Pro te in s , 440
Im m une Sys te m Ce lls , 440
Ph a g o cyte s , 440
Lym p h o cyte s , 441
Hype rs e ns itivity o the Im m une Sys te m , 444
Alle rg y, 445
Au to im m u n ity, 445
Allo im m u n ity, 446
Im m une Sys te m De f cie ncy, 447
Co n g e n ita l Im m u n e De f cie n cy, 447
Acq u ire d Im m u n e De f cie n cy, 448
 CONTENTS xxi

17 Respiratory System, 458 Live r and Gallbladde r, 509

S tru ctu re , 509
S tructural Plan, 460 Fu n ctio n , 509
Ove rvie w, 460 Dis o rd e rs o th e Live r a n d Ga llb la d d e r, 509
Re s p ira to ry Tra ct, 460 Pancre as , 511
Re s p ira to ry Mu co s a , 461 S tru ctu re a n d Fu n ctio n , 511
Uppe r Re s pirato ry Tract, 462 Dis o rd e rs o th e Pa n cre a s , 511
No s e , 462 Large Inte s tine , 512
Ph a ryn x, 462 S tru ctu re , 512
La ryn x, 464 Fu n ctio n , 513
Dis o rd e rs o th e Up p e r Re s p ira to ry Tra ct, 464 Dis o rd e rs o th e La rg e In te s tin e , 514
Low e r Re s pirato ry Tract, 466 Appe ndix and Appe ndicitis , 515
Tra ch e a , 466 S tru ctu re a n d Fu n ctio n , 515
Bro n ch ia l Tre e , 466 Ap p e n d icitis , 516
Alve o li, 467 Pe rito ne um , 516
Re s p ira to ry Dis tre s s , 468 Lo ca tio n , 516
Lu n g s , 469 Exte n s io n s , 516
Ple u ra e , 469 Pe rito n itis , 517
Dis o rd e rs o th e Lo w e r Re s p ira to ry Tra ct, 470 As cite s , 517
Re s piratio n, 473 Dige s tio n, 517
Pulm o nary Ve ntilatio n, 473 Ove rvie w o Dig e s tio n s , 517
Me ch a n ics o Bre a th in g , 473 En zym e s a n d Ch e m ica l Dig e s tio n , 517
Pu lm o n a ry Vo lu m e s , 473 Ca rb o hyd ra te Dig e s tio n , 518
Re g u la tio n o Ve n tila tio n , 475 Pro te in Dig e s tio n , 518
Bre a th in g Pa tte rn s , 477 Pro te in Dig e s tio n , 518
Gas Exchange and Trans po rt, 478 Lip id Dig e s tio n , 519
Pu lm o n a ry Ga s Exch a n g e , 478 En d Pro d u cts o Dig e s tio n , 519
Sys te m ic Ga s Exch a n g e , 480 Abs o rptio n, 519
Blo o d Tra n s p o rta tio n o Ga s e s , 480 Me ch a n is m s o Ab s o rp tio n , 519
S u r a ce Are a a n d Ab s o rp tio n , 520

18 Digestive System, 492

19 Nutrition and Metabolism, 532
Ove rvie w o Dige s tio n, 494
Wall o the Dige s tive Tract, 495 Macro nutrie nts , 534
Mo uth, 496 Die ta ry So u rce s o Nu trie n ts , 534
S tru ctu re o th e Ora l Ca vity, 496 Ca rb o hyd ra te Me ta b o lis m , 535
Te e th , 497 Fa t Me ta b o lis m , 537
Sa liva ry Gla n d s , 498 Pro te in Me ta b o lis m , 538
Dis o rd e rs o th e Mo u th , 499 Micro nutrie nts , 538
Pharynx, 497 Vita m in s , 538
S tru ctu re , 501 Min e ra ls , 540
Fu n ctio n , 502 Re g ulating Fo o d Intake , 541
Es o phag us , 502 Me tabo lic Rate s , 541
S tru ctu re a n d Fu n ctio n , 502 Me tabo lic and Eating Dis o rde rs , 542
Re u x, 503 Me ta b o lic Im b a la n ce s , 542
S to m ach, 504 Ea tin g Dis o rd e rs , 543
S tru ctu re , 504 Bo dy Te m pe rature , 544
Fu n ctio n , 505 Th e rm o re g u la tio n , 544
Dis o rd e rs o th e S to m a ch , 505 Ab n o rm a l Bo d y Te m p e ra tu re , 545
Ca n ce r, 506
S m all Inte s tine , 506
S tru ctu re , 506
Fu n ctio n , 508
Dis o rd e rs o th e S m a ll In te s tin e , 508
xxii CONTENTS
20 Urinary System, 544
Kidneys , 556
Lo ca tio n o th e Kid n e ys , 556
Gro s s S tru ctu re o th e Kid n e y, 556
Micro s co p ic S tru ctu re o th e Kid n e y, 557
Ove rvie w o Kid n e y Fu n ctio n , 559
Fo rm atio n o Urine , 560
Filtra tio n , 560
Re a b s o rp tio n , 561
Se cre tio n , 562
S u m m a ry o Urin e Fo rm a tio n , 562
Co ntro l o Urine Vo lum e , 563
An tid iu re tic Ho rm o n e , 563
Ald o s te ro n e , 563
Atria l Na triu re tic Ho rm o n e , 563
Ab n o rm a litie s o Urin e Vo lu m e , 563
Elim inatio n o Urine , 564
Ure te rs , 564
Urin a ry Bla d d e r, 565
Ure th ra , 565
Mictu ritio n , 565
Ab n o rm a litie s o Urin e Ou tp u t, 566
Urinalys is , 567
Re nal and Urinary Dis o rde rs , 567
Ob s tru ctive Dis o rd e rs , 567
Urin a ry Tra ct In e ctio n s , 569
Glo m e ru la r Dis o rd e rs , 570
Kid n e y Fa ilu re , 571
21 Fluid and Electrolyte Balance, 584
Bo dy Fluid Co m partm e nts , 584
Extra ce llu la r Flu id , 585
In tra ce llu la r Flu id , 585
Me chanis m s That Maintain Fluid Balance , 585
Ove rvie w o Flu id Ba la n ce , 585
Re g u la tio n o Flu id Ou tp u t, 586
Re g u la tio n o Flu id In ta ke , 587
Exch a n g e o Flu id s b y Blo o d , 588
Fluid Im balance s , 588
De hyd ra tio n , 588
Ove rhyd ra tio n , 589
Im po rtance o Ele ctro lyte s in Bo dy Fluids , 589
Ele ctro lyte s , 589
Io n s , 589
Ele ctro lyte Fu n ctio n s , 589
Ele ctro lyte Im balance s , 591
Ho m e o s ta s is o Ele ctro lyte s , 591
So d iu m Im b a la n ce , 592
Po ta s s iu m Im b a la n ce , 592
Ca lciu m Im b a la n ce , 592
22 Acid-Base Balance, 600
pH o Bo dy Fluids , 601
Us in g th e p H Sca le , 601
Th e p H Un it, 602
Me chanis m s That Co ntro l pH o Bo dy Fluids , 602
Ove rvie w o p H Co n tro l Me ch a n is m s , 602
In te g ra tio n o p H Co n tro l, 603
Bu e rs , 603
Re s p ira to ry Me ch a n is m o p H Co n tro l, 606
Urin a ry Me ch a n is m o p H Co n tro l, 606
pH Im balance s , 607
Acid o s is a n d Alka lo s is , 607
Me ta b o lic a n d Re s p ira to ry Dis tu rb a n ce s , 607
Co m p e n s a tio n o p H Im b a la n ce s , 609
23
Reproductive Systems, 616
S e xual Re pro ductio n, 617
Pro d u cin g O s p rin g , 617
Ma le a n d Fe m a le Sys te m s , 618
Ma le Re p ro d u ctive Sys te m , 618
S tru ctu ra l Pla n , 618
Te s te s , 619
Re p ro d u ctive Du cts , 622
Acce s s o ry Gla n d s , 623
Exte rn a l Ge n ita ls , 623
Dis o rde rs o the Male Re pro ductive Sys te m , 624
In e rtility a n d S te rility, 624
Dis o rd e rs o th e Te s te s , 625
Dis o rd e rs o th e Pro s ta te , 625
Dis o rd e rs o th e Pe n is a n d Scro tu m , 625
Fe m ale Re pro ductive Sys te m , 627
S tru ctu ra l Pla n , 627
Ova rie s , 627
Re p ro d u ctive Du cts , 630
Acce s s o ry Gla n d s , 631
Exte rn a l Ge n ita ls , 632
Me n s tru a l Cycle , 633
Dis o rde rs o the Fe m ale Re pro ductive Sys te m , 635
Ho rm o n a l a n d Me n s tru a l Dis o rd e rs , 635
In e ctio n a n d In a m m a tio n , 636
Tu m o rs a n d Re la te d Co n d itio n s , 637
In e rtility, 638
S um m ary o Male and Fe m ale Re pro ductive
Sys te m s , 639
S e xually Trans m itte d Dis e as e s , 639
 CONTENTS xxiii

24 Growth, Development, and Aging, 652 Ge ne Expre s s io n, 682

He re d ita ry Tra its , 682
Pre natal Pe rio d, 654 Se x-Lin ke d Tra its , 683
Fe rtiliza tio n to Im p la n ta tio n , 654 Ge n e tic Mu ta tio n s , 684
Am n io tic Ca vity a n d Pla ce n ta , 654 Ge ne tic Dis e as e s , 684
Pe rio d s o De ve lo p m e n t, 656 Me ch a n is m s o Ge n e tic Dis e a s e , 684
Fo rm a tio n o th e Prim a ry Ge rm La ye rs , 657 S in g le -Ge n e Dis e a s e s , 686
His to g e n e s is a n d Orga n o g e n e s is , 658 Ep ig e n e tic Co n d itio n s , 688
Birth, 658 Ch ro m o s o m a l Dis e a s e s , 688
Pa rtu ritio n , 658 Pre ve ntio n and Tre atm e nt o Ge ne tic Dis e as e s , 689
S ta g e s o La b o r, 661 Ge n e tic Co u n s e lin g , 689
Mu ltip le Birth s , 661 Tre a tin g Ge n e tic Dis e a s e s , 692
Dis o rd e rs o Pre g n a n cy, 662
Im p la n ta tio n Dis o rd e rs , 662
Pre e cla m p s ia , 662 Glossary, 700
Ge s ta tio n a l Dia b e te s , 662
Fe ta l De a th , 662
Birth De e cts , 663
Po s tp a rtu m Dis o rd e rs , 663 Appendixes (only available on Evolve)
Po s tnatal Pe rio d, 664
Appe ndix A
Gro w th , De ve lo p m e n t, a n d Ag in g , 664
Exa m p le s o Pa th o lo g ica l Co n d itio n s
In a n cy, 665
Appe ndix B
Ch ild h o o d , 666
Me d ica l Te rm in o lo g y
Ad o le s ce n ce , 666
Hin ts o r Le a rn in g a n d Us in g Me d ica l Te rm s
Ad u lth o o d , 666
Appe ndix C
Old e r Ad u lth o o d , 667
Clin ica l a n d La b o ra to ry Va lu e s
Ag ing , 667
Co nve rs io n Fa cto rs to In te rn a tio n a l Sys te m o Un its
Me ch a n is m s o Ag in g , 667
(S I Un its )
E e cts o Ag in g , 668

25 Genetics and Genetic Diseases, 678 Index, I-1

Ge ne tics and Hum an Dis e as e , 679

Chro m o s o m e s and Ge ne s , 680
Me ch a n is m s o Ge n e Fu n ctio n , 680
Hu m a n Ge n o m e , 680
Dis trib u tio n o Ch ro m o s o m e s to O s p rin g , 681
This pa ge inte ntiona lly le ft bla nk
THE
HUMANBODY
HEALTH
IN

&DISEASE
Introduction to the Body
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Scientif c Method, 4 Body Regions, 11

Levels o Organization, 4 Balance o Body Functions, 14
Anatomical Position, 7 Homeostasis, 14
Anatomical Directions, 7 Feedback Control, 14
Directional Terms, 7 Negative Feedback, 15
,8 Positive Feedback, 15
Planes o the Body, 8 Normal Fluctuations, 16
Body Cavities, 9
Dorsal Cavities, 9
Ventral Cavities, 9

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you 6. Do the ollowing related to body cavities
should be able to: and body regions:
anatomy, physiology,
and pathology. the body and the subdivisions o
- each.

the body.
anatomical position,
supine, and prone. anatomical regions in each area.
7. Do the ollowing related to the balance
o body unctions:
homeostasis.
 HAPTER 1
Th e r e are many wonders in our wor d, but none is more wondrous than LANGUAGE OF
the human body. T is is a textbook about that incomparab e structure. It dea s S C IEN C E
with two very distinct and yet interre ated sciences: anatomy and physiology.
Be o re re ading the
As a science, anatomy is o ten def ned as the study
chapte r, s ay e ach o
o the structure o an organism and the re ation- the s e te rm s o ut lo ud. This w ill
ships o its parts. T e word anatomy is derived he lp yo u to avo id s tum bling ove r
rom two word parts that mean cutting the m as yo u re ad.
apart. Anatomists earn about the structure
o the human body by cutting it apart. T is
abdominal
process, ca ed dissection, is sti the principa
technique used to iso ate and study the structura [abdomin- belly, -al relating to]
components or parts o the human body. abdominal cavity

Physio ogy, on the other hand, is the study o the unctions o [abdomin- belly, -al relating to,
iving organisms and their parts. Physio ogists use scientif c ex- cav- hollow, -ity state]
perimentation to tease out how each activity o the body works, how abdominopelvic cavity
it is regu ated, and how it f ts into the comp ex, coordinated operation
o the who e human organism.
[abdomin- belly, -pelv- basin,
In the chapters that o ow, you wi see again and again that anatomica parts cav- hollow, -ity state]
have structures exact y suited to per orm specif c unctions. Each has a particu- abdominopelvic quadrant
ar size, shape, orm, or position in the body re ated direct y to its abi ity to
per orm a unique and specia ized activity. T is princip ethat structure ts
unctionis the key to understanding a o human bio ogy. [abdomin- belly, -pelv- basin,
quadran- ourth part]

A though an understanding o the norma structure and unction o the body is abdominopelvic region
important, it is a so important to know the mechanisms o disease. Disease
[abdomin- belly, -pelv- basin,
conditions resu t rom abnorma ities o body structure or unction that prevent
-ic relating to]
the body rom maintaining the interna stabi ity that keeps us a ive and hea thy.
anatomical position
Pathology, the scientif c study o disease, uses princip es o anatomy and physi-
o ogy to determine the nature o particu ar diseases. T e term pathology comes [ana- apart, -tom- cut, -ical- relating
rom pathos, the Greek word or disease. Chapter 6 provides an overview o to, posit- place, -tion state]
the basic mechanisms o disease, such as in ection and cancer. anatomist

T roughout the rest o this textbook, exp anations o norma structure and [ana- apart, -tom- cut, -ist agent]
unction are supp emented by discussions o re ated disease processes. By anatomy
knowing the structure and unction o the hea thy body, you wi be
better prepared to understand what can go wrong to cause [ana- apart, -tom- cut, -y action]
disease. At the same time, having know edge o antebrachial
disease states wi enhance your under-
standing o norma structure and [ante- ront -brachi- arm,
unction. -al relating to]
anterior

[ante- ront, -er- more, -or quality]

Continued on p. 17

3
 4 CHAPTER 1 Introduction to the Body
S c ie n t if c M e t h o d
W hat we o ten ca the scienti c method is mere y a system-
1 atic approach to discovery. A though there is no sing e
method or scientif c discovery, some scientists o ow the
steps out ined in Figure 1-1 to discover the concepts o human
bio ogy discussed in this textbook.
First, one makes a tentative exp anation, ca ed a hypothesis.
A hypothesis is a reasonab e guess based on previous in orma
observations or on previous y tested exp anations.
A ter a hypothesis has been proposed, it must be testeda
process ca ed experimentation. Scientif c experiments are
designed to be as simp e as possib e to avoid the possibi ity o
errors. O ten, experimental controls are used to ensure that
the test situation itse is not a ecting the resu ts.
For examp e, i a new cancer drug is being tested, ha the
test subjects wi get the drug and ha the subjects wi be
given a harm ess substitute. T e group getting the drug is
ca ed the test group, and the group getting the substitute is
ca ed the control group. I both groups improve, or i on y the
contro group improves, the drugs e ectiveness has not been
demonstrated. I the test group improves, but the contro
group does not, the hypothesis that the drug works is tenta-
tive y accepted as true. Experimentation requires accurate
measurement and recording o data.
I the resu ts o experimentation support the origina hy-
pothesis, it is tentative y accepted as true, and the researcher
moves on to the next step. I the data do not support the hy-
pothesis, the researcher tentative y rejects the hypothesis.
Obs e rva tions a nd previous expe rime nts
P ropos e a lte rna te
hypothe s is
P ropos e hypothe s is
Re de s ign
expe rime nt
De s ign expe rime nt
Colle ct a nd a na lyze da ta
YES
De te rmine whe the r da ta a re bia s e d
NO
Re fine hypothe s is
Re s ults not
re pe a ta ble
Re pe a t expe rime nts
If re s ults a re cons is te nt
Ac c e pt as the o ry
If unus ua lly high leve l of confide nce
Ac c e pt as law
FIGURE 1-1 Scientif c method. In this classic example, initial observa-
tions or results rom other experiments may lead to ormation o a new hy-
pothesis. As more testing is done to ensure that outside inf uences and bi-
ases are eliminated, results become more consistent and scientists begin to
have more con dence in the tested principle, which can then be called a
theory or law.
RES EA RC H, IS S U ES ,
AND TREN D S
METRIC SYSTEM
Scie ntis ts , m any gove rnm e nt age ncie s , and incre as ing
num be rs o Am e rican indus trie s are us ing or m oving to-
ward the conve rs ion o our s ys te m o Englis h m e as ure -
m e nts to the m e tric s ys te m . The m e tric s ys te m is a de ci-
m al s ys te m in w hich m e as ure m e nt o le ngth is bas e d on
the m e te r (39.37 inche s ) and we ight or m as s is bas e d
on the gram (about 454 gram s e qual a pound).
A m icrom e te r is one m illionth o a m e te r. (Micron is
anothe r nam e or m icrom e te r.) In the m e tric s ys te m s , the
units o le ngth are as ollow s :
1 kilom e te r 1000 m e te rs
1 m e te r (m ) 39.37 inche s
1 ce ntim e te r (cm ) 1/100 m
1 m illim e te r (m m ) 1/1000 m
1 m icrom e te r ( m ) or m icron ( ) 1/1,000,000 m
1 nanom e te r (nm ) 1/1,000,000,000 m
1 Angs trom () 1/10,000,000,000 m
Approxim ate ly e qual to 1 inch:
m
Knowing which hypotheses are incorrect is as va uab e as
knowing which hypotheses are va id. Scientists can thus ocus
on the ideas shown to have merit and avoid wasting time with
disproven hypotheses.
Initia experimenta resu ts are pub ished in scientif c jour-
na s so that other researchers can benef t rom them and veri y
them. I experimenta resu ts cannot be reproduced by other
scientists, then the hypothesis is not wide y accepted. I a
hypothesis withstands this rigorous retesting, the eve o con-
f dence in the hypothesis increases. A hypothesis that has
gained a high eve o conf dence is ca ed a theory or law.
W hy is it important to know the steps o experimentation
and deve oping theories i your main interest is a career in sci-
ence app icationssuch as a hea th career? I you do not un-
derstand how concepts are discovered and how they can change
a ter additiona experimentation, it is hard to u y grasp them.
T e acts presented in this textbook are among the atest
theories o how the body is bui t and how it unctions. As
methods o imaging the body and measuring unctiona pro-
cesses improve, we f nd new data that cause us to rep ace o d
theories with newer ones.
Le ve ls o O r g a n iz a t io n
Be ore you begin the study o the structure and unction o
the human body and its many parts, it is important to think
about how those parts are organized and how they might
ogica y f t together into a unctioning who e.
 CHAPTER 1 Introduction to the Body 5

Examine Figure 1-2. It i ustrates the di ering levels o
organization that in uence body structure and unction.
Note that the eve s o organization progress rom the east
comp ex (chemica eve ) to the most comp ex (organism
eve ).
Because you a ready know that structure f ts unction, it
shou d not surprise you that the high y comp ex and coordi-
nated unctions o the who e body can be understood by dis-
covering the many basic processes that occur in the sma er
parts, such as organs, tissues, and ce s.
Organization is one o the most important characteristics
o body structure. Even the word organism, used to denote a
iving thing, imp ies organization. 1
A though the body itse is considered a sing e structure, it is
made up o tri ions o sma er structures. Atoms and mo ecu es
are o ten re erred to as the chemical level o organization. T e
existence o i e depends on the proper eve s and proportions
o many chemica substances in the ce s o the body.
Many o the physica and chemica phenomena that p ay
important ro es in the i e process are reviewed in Chapter 2.

Atom
Mole cule
Ve s icle s
Ne uron
s
l
e
v
e
l
c
i
p
o
Che mic al leve l Group of ne urons
c
s
(Chapte r 2) a nd s upport ce lls
o
r
c
i
M
Org ane lle le ve ls
(Chapte r 3)

Ce llular le ve l
(Chapte r 3)

Inte gume nta ry Tis s ue leve l

(Chapte rs 4, 13)
S ke le ta l
Mus cula r Org an leve l
Org an s ys te m leve l (Chapte r 5) Bra in
(Chapte rs 5-23) Ca rdiova s cula r

Endocrine
s
l
e
v
e
l
s
s
o
r
G
Re productive

Urina ry

Dige s tive Ne rvous

Re s pira tory
Org anis m leve l
(Chapte rs 19, Lympha tic/Immune
21, 22, 24, 25)

FIGURE 1-2 Levels o organization in the body. Atoms, molecules, and cells ordinarily can be seen only
with a microscope, but the gross (large) structures o tissues, organs, systems, and the whole organism can be
seen easily with the unaided eye.
 6 CHAPTER 1 Introduction to the Body

Such in ormation provides an understanding o the physica
basis or i e and or the study o the remaining eve s o orga-
1 nization that are so important in the study o anatomy and
physio ogyce s, tissues, organs, and systems.
Cells are considered to be the sma est iving units o
structure and unction in our bodies. A though ong recog-
nized as the simp est units o iving matter, ce s are ar rom
simp e. T ey are extreme y comp ex, a act you wi discover in
Chapter 3.
issues are somewhat more comp ex than ce s. By def ni-
tion a tissue is an organization o many ce s that act together
to per orm a common unction. T e ce s o a tissue may be o
severa types, but a work together in some way to produce
the structura and unctiona qua ities o the tissue. Ce s o a
tissue are o ten he d together and surrounded by varying
amounts and varieties o g ue ike, non iving interce u ar sub-
stances. T e varied properties o di erent tissues are exp ored
in Chapter 4.
Organs are arger and even more comp ex than tissues. An
organ is a group o severa di erent kinds o tissues arranged
in a way that a ows them to act together as a unit to per orm
a specia unction. For instance, the brain shown in Figure 1-2
is an examp e o organization at the organ eve . Un ike mi-
croscopic mo ecu es and ce s, some tissues and most organs
are gross ( arge) structures that can be seen easi y without a
microscope.
Systems are the most comp ex units that make up the
body. A system is an organization o varying numbers and
kinds o organs arranged in ways that a ow them to work
together to per orm comp ex unctions or the body. T e or-
gans o the nervous system shown in Figure 1-2 unction to
monitor and regu ate the overa unctioning o the body.
T e body as a whole the human organismis a the at-
oms, mo ecu es, ce s, tissues, organs, and systems that you wi
study in subsequent chapters o this text. A though capab e o
being dissected or broken down into many parts, the body is
a unif ed and comp ex assemb y o structura y and unction-
a y interactive components, each working together to ensure
hea thy surviva .
microbial systems
o the body, or human microbiome, have come
in our body with each other, and with our own
critical to maintaining normal structure and unc-
tion o the body. To learn more, check out the
article The Human Microbiome at Connect It! at
evolve.elsevier.com.
For a brie 3-D tour o each o the bodys
organ systems, go to AnimationDirect at
evolve.elsevier.com.
QUICK CHECK
1. Wh a t is a n a to m y? Wh a t is p hys io lo g y? Wh a t is p a th o lo g y?
2. Wh a t a re th e ch a ra cte ris tic s te p s o th e s cie n tif c m e th o d ?
3. Wh a t a re th e m a jo r le ve ls o o rga n iza tio n in th e b o d y?
4. Ho w d o e s a tis s u e d i e r ro m a n o rga n ?
5. Ho w d o e s th e p rin cip le s tru ctu re f ts u n ctio n re la te to
th e b o d y?

S C IEN C E APPLICATIONS
MODERN ANATOMY
Anato m is ts s tudy the s tructure o
the hum an body. Mode rn anatomy
Mus cle
s tarte d during the Re nais s ance in
Europe w ith the Fle m is h s cie ntis t
Andre as Ve s alius (s how n at le t)
and his conte m porarie s . Ve s alius
was the f rs t to apply a s cie ntif c Fa t
m e thod (s e e p. 4) to the s tudy o
the hum an body. Bone
Most anatomis ts still disse ct ca-
Andreas Vesalius dave rs (pre s erve d human re mains).
(15141564) Howeve r, today m any anatom ists
also use im aging te chnologie s s uch Horizontal section o the human arm

digitized photographs o thin s lice s o the body as you can s e e Applications o m ode rn anatomy are als o ound in the f e lds
in the f gure at right rom the National Library o Me dicines Vis - o o re ns ic s cie nce , anthro po lo gy, m e dicine and allie d
ible Human Project. Such digitize d image s can be re constructe d he alth pro e s s io ns , he alth e ducation, s ports and athle tics ,
into dis se ctible , thre e -dim ens ional body view s by com pute rs. dance , and eve n art and com pute rize d anim ation.
 CHAPTER 1 Introduction to the Body 7

A n a t o m ic a l P o s it io n A n a t o m ic a l D ir e c t io n s
Discussions about the body, the way it moves, its posture, or
the re ationship o one area to another assume that the body
D ir e c t io n a l Te r m s 1
as a who e is in a specif c position ca ed the anatomical W hen studying the body, it is o ten he p u to know where an
position. In this re erence position (Figure 1-3), the body is in organ is in re ation to other structures. T e o owing direc-
an erect, or standing, posture with the arms at the sides and tiona terms are used in describing re ative positions o body
pa ms turned orward. T e head a so points orward, as do the parts. o he p you understand them better, they are isted here
eet, which are a igned at the toe and set s ight y apart. in sets o opposite pairs:
T e broken ine a ong the midd e, or median, o the body
demonstrates that the body has externa bilateral symmetry 1. Superior and in erior (Figure 1-4). Superior means
that is, the e t and right sides o the body rough y mirror toward the head, and in erior means toward the
each other. eet. Superior a so means upper or above, and
T e anatomica position is a re erence position that gives in erior means ower or be ow. For examp e, the
meaning to the directiona terms used to describe the body ungs are ocated superior to the diaphragm, whereas
parts and regions. In other words, you need to know the ana- the stomach is ocated in erior to the diaphragm
tomica position so that you know how to app y directional (re er to Figure 1-8 i you are not sure where these
terms correct y regard ess o the particu ar position o the organs are ocated). T e simp e terms upper and lower
body being described. are sometimes used in pro essiona anguage as we .
Supine and prone are terms used to describe the position For examp e, the term upper respiratory tract and
o the body when it is not in the anatomica position. In the ower gastrointestina tract are used common y by
supine position the body is ying ace upward, and in the anatomists and hea th pro essiona s.
prone position the body is ying ace downward. 2. Anterior and posterior (see Figure 1-4). Anterior
means ront or in ront o . Posterior means back
FIGURE 1-3 Anatomical
t mical position. or in back o . In humans, who wa k in an upright
The body is in an erect or standing position, ventral (toward the be y) can be used in
posture with the arms
rms at the sides p ace o anterior, and dorsal (toward the back) can be
and the palms orward.
rd. The head and used or posterior. For examp e, the nose is on the
eet also point orward.
ard. The dashe
dashed anterior sur ace o the body, and the shou der b ades
median line shows the axis o the
bodys external bilateral
ateral sym- are on its posterior sur ace.
metry, in which the right and 3. Medial and lateral (see Figure 1-4). M edial means
le t sides o the body are toward the mid ine o the body. Lateral means to-
mirror images o eachch other. ward the side o the body or away rom its mid ine.
The anatomical compass
pass ro- For examp e, the great toe is at the media side o the
sette is explained in a later
section o this chapter.
ter. oot, and the itt e toe is at its atera side. T e heart
ies media to the ungs, and the ungs ie atera to
the heart.
4. Proximal and distal (see Figure 1-4). Proximal means
toward or nearest the trunk o the body, or nearest
the point o origin o one o its parts. Distal means
away rom or arthest rom the trunk or the point
o origin o a body part. For examp e, the e bow
ies at the proxima end o the orearm, whereas the
hand ies at its dista end. Likewise, the dista por-
tion o a kidney tubu e is more distant rom the
tubu e origin than is the proxima part o the kid-
ney tubu e.
5. Super cial and deep. Super cial means nearer the
sur ace. Deep means arther away rom the body sur-
ace. For examp e, the skin o the arm is superf cia to
the musc es be ow it, and the bone o the arm is deep
to the musc es that surround and cover it.
S

R L
Anatomical Directions at
I evolve.elsevier.com.
 8 CHAPTER 1 Introduction to the Body

S upe rior

Pos te rior Ante rior

P roxima l

Mids a gitta l

S a gitta l pla ne s Fronta l pla ne s

Dis ta l

l
e ra
La t

te ra l
La
P roxima l

S
Dis ta l n ta
l L
r o
F ne R
p la
I
S
l
d ia
P A e
lM
Infe rior ia
ed
I M Tra ns ve rs e pla ne s Oblique pla ne s

FIGURE 1-4 Directions and planes o the body. The arrows show anatomical directions and the blue
plates show examples o body planes along which cuts or sections are made in visualizing the structure o
the body.

A n a t o m ic a l C o m p a s s Ro s e t t e QUICK CHECK
o make the reading o anatomica f gures a itt e easier or 1. Wh a t is th e a n a to m ica l p o s itio n ?
you, we have used an anatomica compass rosette throughout 2. Wh a t is b ila te ra l s ym m e try?
this book. O n many f gures, you wi see a sma compass ro- 3. Wh a t a re tw o te rm s th a t a re u s e d to d e s crib e th e b o d y
w h e n lyin g d o w n ?
sette ike you might see on a geographica map. Instead o 4. Why a re th e a n a to m ica l d ire ctio n s lis te d in p a irs ?
being abe ed N, S, E, or W, the anatomica compass rosette
is abe ed with abbreviated anatomica directions.
For examp e, in Figure 1-3 (p. 7), the rosette is abe ed S
( or superior) on top and I ( or in erior) on the bottom. Notice
P la n e s o t h e Bo d y
that in Figure 1-3 the rosette shows R (right) on the subjects o aci itate the study o individua organs or the body as a
rightnot your right. Now ook at the rosettes in Figure 1-4 who e, it is o ten use u to f rst subdivide or cut it into
and compare them to the body positions shown. sma er segments. T is can be done with actua cuts in a
H ere are the directiona abbreviations used with the ro- dissection, or it can be done virtua y, as in medica imaging
settes in this book: in sonography (ultrasound images), computed tomography (C )
A Anterior scans, or magnetic resonance imaging (M RI) scans (see M edi-
D Dista cal Imaging o the Body in Chapter 6 on p. 132). o under-
I In erior stand such a cuta so ca ed a sectionone must imagine
(opposite R) L Le t a body being divided by an imaginary at p ate ca ed a
(opposite M) L Latera p ane.
M Media Because many anatomica sections, cut a ong specif c
(opposite A) P Posterior p anes o the body, are used in anatomica studies and medica
(opposite D) P Proxima imaging, we describe them here. As you read the o owing
R Right descriptions, identi y each type o p ane in Figure 1-4.
S Superior T is chapter continues on p. 10, ollowing the Clear View insert.
 CHAPTER 1 Introduction to the Body 9

1. Sagittal planea sagitta cut or section that runs a ong a S

engthwise p ane running rom anterior to posterior. It Cra nia l

1
R L
divides the body or any o its parts into right and e t cavity
I
sides. T e midsagittal plane shown in Figure 1-4 is a
unique type o sagitta p ane that divides the body into
S pina l
two equal halves. cavity
2. Frontal planea ronta p ane (coronal plane) is a ength-
Thora cic
wise p ane running rom side to side. As you can see in cavity
Figure 1-4, a ronta p ane divides the body or any o its parts
into anterior and posterior ( ront and back) portions. P le ura l
3. ransverse planea transverse p ane is a crosswise or hori- cavitie s
zontal plane. Such a p ane (see Figure 1-4) divides the body Me dia s tinum
or any o its parts into superior and in erior portions.
Dia phra gm
Understanding p anes o the body is essentia to being ab e to
interpret medica images. Abdomina l
cavity
Sometimes it is he p u to make a cut a ong a p ane that is
not para e to the p anes we have a ready mentioned. Such Abdominope lvic
diagona cuts are made a ong oblique planes, which you can cavity
see i ustrated in Figure 1-4.
Pe lvic
Besides using p anes to cut the body into various sections, cavity
we sometimes use p anes to describe movement. For examp e,
one rotates the head in a transverse p ane, and one can move
S
a f nger a ong both a sagitta p ane and a ong a ronta p ane. Dors a l body cavitie s
Ve ntra l body cavitie s
Exp ore the Clear View o the Human Body insert ocated A P

just prior to this page. Note that the arger transparency im-
ages show the body and its organs sectioned a ong ronta
p anes. H owever, the sma er images in the margins show
transverse sections at specif c ocations in the body.
I
FIGURE 1-5 Body cavities. Location and subdivisions o the dorsal and
ventral body cavities as viewed rom the ront (anterior) and rom the side
(lateral).

images that use sectional views o the body, Th o r a c ic a n d A b d o m in o p e lv ic C a v it ie s

see the article Medical Imaging o the Body at
Connect It! at evolve.elsevier.com.
Bo d y C a v it ie s
Contrary to its externa appearance, the body is not a so id
structure. It is made up o open spaces or cavities that in turn
contain compact, we -ordered arrangements o interna or-
gans. T e major body cavities are categorized as the
dorsal body cavities and ventral body cavities. T e ocation
and out ines o the major body cavities are i ustrated in
Figure 1-5.
D o r s a l C a v it ie s
T e dorsa cavities shown in Figure 1-5 inc ude the space inside
the sku that contains the brain. It is ca ed the cranial cavity.
T e space inside the spina co umn is ca ed the spinal cavity.
It contains the spina cord. T e crania and spina cavities are
dorsal cavities because they are located in a dorsal position in the
body.
Ve n t r a l C a v it ie s
T e ventral cavities are ocated in a ventra position in the
body.
T e upper ventra cavities inc ude the thoracic cavity, a space
that you may think o as your chest cavity. Its midportion is a
subdivision o the thoracic cavity, ca ed the mediastinum.
T e atera subdivisions o the thoracic cavity are ca ed the
right and e t pleural cavities.
T e ower ventra cavities in Figure 1-5 inc ude an abdominal
cavity and a pelvic cavity. Actua y, they orm on y one cavity,
the abdominopelvic cavity, because no physica partition sepa-
rates them. In Figure 1-5 a aint ine shows the approximate point
o separation between the abdomina and pe vic subdivisions.
Notice, however, that an actua physica partition separates the
thoracic cavity above rom the abdominope vic cavity be ow.
T is muscu ar sheet is the diaphragm. It is dome-shaped and is
the most important musc e or breathing.
A b d o m in o p e lv ic Q u a d r a n t s a n d Re g io n s
Abdominopelvic Quadrants
o make it easier to ocate organs in the arge abdominope vic
cavity, anatomists have divided the abdominope vic cavity into
our abdominopelvic quadrants:
1. Right upper quadrant or RUQ (right superior
quadrant)
2. Right lower quadrant or RLQ (right in erior quadrant)
3. Le t upper quadrant or LUQ ( e t superior quadrant)
4. Le t lower quadrant or LLQ ( e t in erior quadrant)
 10 CHAPTER 1 Introduction to the Body

1
Rig ht Le ft
p
hypo c ho ndriac hypo c ho ndriac
re i n
re g io n re g io n
Rig ht uppe r Le ft uppe r
quadrant quadrant
(RUQ) (LUQ)
Rig ht lumbar Le ft lumbar
(flank) Umbilic al (flank)
re g io n re g io n re g io n

Rig ht lowe r Le ft lo we r
quadrant quadrant Rig ht iliac Hypo g as tric Le ft iliac
(RLQ) (LLQ) (ing uinal) (pubic ) (ing uinal)
re g io n re g io n re g io n

S S

R L R L

I I

FIGURE 1-6 Abdominopelvic quadrants. Diagram showing location o FIGURE 1-7 Abdominopelvic regions. The most super cial organs are
internal organs within our abdominal quadrants. shown. Look at Figure 1-8 (p. ***)can you identi y the deeper structures
in each region?

As you can see in Figure 1-6, the midsagitta and transverse 3. Lower abdominopelvic regionsthe right iliac region,
p anes, which were described in the previous section, pass le t iliac region (a so ca ed inguinal regions), and
through the nave (umbi icus) and divide the abdominope vic the hypogastric region ie be ow an imaginary ine
region into the our quadrants. T is method o subdividing across the abdomen at the eve o the top o the hip
the abdominope vic cavity is requent y used by hea th pro es- bones.
siona s and is use u or ocating the origin o pain or describ-
ing the ocation o a tumor or other abnorma ity. Some o the organs in the argest body cavities are visib e
You may notice that terms ike upper and lower are o ten in Figure 1-8 and are isted in Table 1-1. Find each body cavity
used to name quadrants, which may seem over y in orma in a mode o the human body i you have access to one. ry
compared with the more technica terms superior and in erior.
H owever, this practice re ects the usage ound in many c ini-
ca environments, where one common y encounters a mix o
in orma and orma termino ogy. TABLE 1-1 Body Cavities
BODY CAVITIES ORGAN(S )
Abdominopelvic Regions
Do rs al Bo dy Cavitie s
Another and perhaps more precise way to divide the abdomi-
Cranial cavity Brain
nope vic cavity is shown in Figure 1-7. H ere, the abdominope -
vic cavity is subdivided into nine abdominopelvic regions Spinal cavity Spinal cord
def ned as o ows: Ve ntral Bo dy Cavitie s
Th o ra cic Ca vity
1. Upper abdominopelvic regionsthe right hypochon- Me dias tinum He art, trache a, e s ophagus , thym us ,
driac region, le t hypochondriac region, and the blood ve s s e ls
epigastric region ie above an imaginary ine across Ple ural cavitie s Lungs
the abdomen at the eve o the ninth rib carti ages.
Ab d o m in o p e lvic Ca vity
2. M iddle abdominopelvic regionsthe right lumbar
region, le t lumbar region, and the umbilical Abdom inal cavity Live r, gallbladde r, s tom ach, s ple e n,
region ie be ow an imaginary ine across the abdo- pancre as , s m all inte s tine , parts o
large inte s tine
men at the eve o the ninth rib carti ages and above
an imaginary ine across the abdomen at the top o Pe lvic cavity Lowe r (s igm oid) colon, re ctum , urinary
bladde r, re productive organs
the hip bones.
 CHAPTER 1 Introduction to the Body 11

to identi y the organs in each cavity, and try to visua ize their
Bo d y Re g io n s
ocations in your own body. Study Figure 1-5 and Figure 1-8 and o recognize an object, you usua y f rst notice its overa
exp ore the ayers o the Clear View o the Human Body insert structure and orm. For examp e, a car is recognized as a car 1
ocated in this book a ter p. 8. be ore the specif c detai s o its tires, gri , or whee covers are
noted. Recognition o the human orm a so occurs as you f rst
identi y overa shape and basic out ine. H owever, or more
QUICK CHECK specif c identif cation to occur, detai s o size, shape, and ap-
1. Wh a t is m e a n t b y a s e ctio n o th e b o d y? pearance o individua body areas must be described. Indi-
2. Wh a t a re th e tw o m a jo r s e ts o ca vitie s o th e b o d y? vidua s di er in overa appearance because specif c body areas
3. Wh a t is th e d i e re n ce b e tw e e n th e a b d o m in a l ca vity a n d such as the ace or torso have unique identi ying characteris-
th e a b d o m in o p e lvic ca vity?
4. Wh a t is th e d i e re n ce b e tw e e n rig h t u p p e r q u a d ra n t a n d
tics. Detai ed descriptions o the human orm require that
rig h t s u p e rio r q u a d ra n t? specif c regions be identif ed and appropriate terms be used to
describe them.
T e abi ity to identi y and correct y describe specif c body
areas is particu ar y important in the hea th sciences. For a
S pina l cord patient to comp ain o pain in the head is not as specif c, and
Bra in there ore not as use u to a hea th pro essiona , as a more
specif c and oca ized description wou d be. Saying that the
Es opha gus pain is acia provides additiona in ormation and he ps to
more specif ca y identi y the area o pain. By using correct
Lung La rynx anatomica terms such as orehead, cheek, or chin to describe
the area o pain, attention can be ocused even more quick y
Tra che a on the specif c anatomica area that may need attention.
He a rt
Fami iarize yourse with the more common terms
Live r used to describe
de specif c body regions identif ed
Dia phra gm in Figur
Figure 1-9 and isted in Table 1-2. Exp ore the
Ga llbla dde r
Clea
Clear View o the Human Body insert ocated
Kidney S ple en (be hind stomach) in this book a ter p. 8 to f nd the major
(be hind live r) body regions.
S toma ch
Pa ncre a s Kidney (be hind stoma ch)

S ma ll inte s tine S
Ure te r
(be hind s ma ll inte s tine ) La rge inte s tine R L

Urina ry bla dde r I

A Ure thra Pos te rior

S pinal c avity
Ve rte bra S pina l cord

Ple ural c avity

Right lung
Le ft lung
Prima ry bronchus
P le ura l me mbra ne s
Pulmona ry a rte ry

Pulmona ry ve in Intra ple ura l s pa ce

Aorta

Pulmona ry trunk

He a rt
P
S te rnum
R L

Me dias tinum A

B Ante rior

FIGURE 1-8 Organs o the major body cavities. A, A view rom the ront. B, Transverse section viewed rom above.
 12 CHAPTER 1 Introduction to the Body

1 C LIN ICA L APPLICATION

AUTOPSY
Know le dge o hum an anatomy is im portant in conducting an be gins . It is a m icros copic exam ination o tis s ue s colle cte d
auto ps y or pos tm orte m exam ination. The te rm autops y is built during the f rs t two phas e s . Te s ts to analyze the che m ical con-
rom the words auto (m e aning s e l ) and ops is (m e aning te nt o body uids or to de te rm ine the pre s e nce o in e ctious
view ). Autops ie s are proce dure s in w hich a hum an body is organis m s als o m ay be pe r orm e d.
exam ine d a te r de ath to accurate ly de te rm ine the caus e o
de ath, to conf rm the accuracy o diagnos tic te s ts , to dis cove r
previous ly unde te cte d proble m s , and to as s e s s the e e ctive -
ne s s o s urge rie s or othe r tre atm e nts . Me dical and allie d
he alth s tude nts o te n atte nd autops ie s to im prove the ir know l-
e dge o hum an anatomy and pathology.
Autops ie s are us ually pe r orm e d in thre e s tage s . In the f rs t
s tage , the exte rior o the body is exam ine d or abnorm alitie s
s uch as wounds or s cars rom injurie s or s urge rie s . In the
s e cond s tage , the ve ntral body cavity is ope ne d by a de e p,
Y-s hape d incis ion. The arm s o the Y s tart at the ante rior s ur-
ace o the s houlde rs and join at the in e rior point o the bre as t-
bone (s te rnum ) to orm a s ingle cut that exte nds to the pubic
are a. A te r the rib cage is s aw n through, the walls o the tho-
racic and abdom inope lvic cavitie s can be ope ne d like hinge d
doors to expos e the inte rnal organs .
The s e cond s tage o the autops y include s care ul dis s e c-
tion o m any or all o the inte rnal organs . I the brain is to be
exam ine d, a portion o the s kull m us t be re m ove d. The ace ,
arm s , and le gs are us ually not dis s e cte d unle s s the re is a s pe -
cif c re as on or doing s o.
A te r the organs are re turne d to the ir re s pe ctive body cavi-
tie s , and the body is s ew n up, the third phas e o the autops y

TABLE 1-2
BODY REGION AREA OR EXAMPLE BODY REGION AREA OR EXAMPLE
Abdo m inal re g io n Ante rior tors o be low diaphragm Mam m ary re g io n Bre as t
Ante brachial re g io n Fore arm Nas al re g io n Nos e
Axillary re g io n Arm pit Occipital re g io n Back o lowe r s kull
Brachial re g io n Arm Ole cranal re g io n Back o e lbow
Buccal re g io n Che e k Oral re g io n Mouth
Carpal re g io n Wris t Orbital re g io n or Eye s
Ce phalic re g io n He ad o phthalm ic re g io n

Ce rvical re g io n Ne ck Palm ar re g io n Palm o hand

Cranial re g io n Skull Pe dal re g io n Foot

Crural re g io n Le g Pe lvic re g io n Lowe r portion o tors o

Cubital re g io n* Elbow Pe rine al re g io n Are a (pe rine um ) be twe e n anus and

ge nitals
Cutane o us Skin (or body s ur ace )
Plantar re g io n Sole o oot
Dig ital re g io n Finge rs or toe s
Po plite al re g io n Are a be hind kne e
Do rs al re g io n Back
S upraclavicular re g io n Are a above clavicle (collar bone )
Facial re g io n Face
Tars al re g io n Ankle
Fe m o ral re g io n Thigh
Te m po ral re g io n Side o s kull
Fro ntal re g io n Fore he ad
Tho racic re g io n Entire che s t
Glute al re g io n Buttock
Um bilical re g io n Are a around nave l or um bilicus
Ing uinal re g io n Groin
Vo lar re g io n Palm or s ole
Lum bar re g io n Lowe r back be twe e n ribs and pe lvis
Zygo m atic re g io n Uppe r che e k
*The te rm cubital m ay als o re e r to the ore arm .
 CHAPTER 1 Introduction to the Body 13

Fronta l (fore he a d)
Cra nia l Orbita l (eye ba ll)
Ce pha lic
(he a d)
(uppe r s kull)
Na s a l (nos e )
Te mpora l
(s ide of s kull) Ce pha lic (he a d) 1
Fa cia l (fa ce ) Zygoma tic (uppe r che e k)
Bucca l (lowe r che e k)
S upra clavicula r Ora l (mouth) Ce rvica l (ne ck)
(a re a a bove clavicle )
Axilla ry (a rmpit)
Ma mma ry (bre a s t) Thora cic Dors a l (ba ck)
Bra chia l (a rm) (che s t)
Ole cra na l
Cubita l (e lbow) (ba ck of e lbow)

Abdomina l Trunk Fla nk Uppe r

(a bdome n) (la te ra l re gion) extre mity
Umbilica l (nave l)
Lumba r (loin)
Ante bra chia l
Pe lvic
(fore a rm)
(pe lvis ) Glute a l
Ca rpa l (wris t)
(buttock)
Digita l or
pha la nge a l Pa lma r or vola r
(finge rs ) (a nte rior s urfa ce
of ha nd)
Fe mora l (thigh) Inguina l (groin)
Poplite a l
(ba ck of kne e ) Lowe r
extre mity

Crura l (le g)
S S
Axia l s ke le ton
Appe ndicula r s ke le ton
R L L R

I I
Ta rs a l (a nkle )
P la nta r
Digita l (toe ) Pe da l (foot) (s ole of foot)

FIGURE 1-9 Axial and appendicular divisions o the body. Speci c body regions are labeled (examples
in parentheses). For example, the cephalic region includes the head. Notice how the axial and appendicular
regions o the body rame are distinguished by contrasting colors.

T e body as a who e can be subdivided into two major por-
tions or components: axial and appendicular. T e axia por-
tion o the body consists o the head, neck, and torso or trunk.
T e appendicu ar portion consists o the upper and ower ex-
tremities (or imbs). Each major axia and appendicu ar area is
subdivided as shown in Figure 1-9. Note, or examp e, that the
torso is composed o thoracic, abdomina , and pe vic areas,
and the upper extremity is divided into arm, orearm, wrist,
and hand components.
A though most terms used to describe gross body regions
are we understood, misuse is common. T e word leg is a good
examp e: it re ers to the area o the ower extremity between
the knee and ank e and not to the entire ower extremity.
T e structure o each persons body is unique. Even identi-
ca twins have some variations in the size, shape, and texture
o various tissues and organs.
T e structure o the body a so changes in many ways and
at varying rates during a i etime. Be ore young adu thood, the
body deve ops and grows. A ter young adu thood, the body
gradua y undergoes changes re ated to aging. For examp e,
with the reduced activity o the body as one advances through
o der adu thood, body organs and tissues decrease in size and
there ore change in their unctions. A degenerative process
that resu ts rom disuse is ca ed atrophy. In many cases, atro-
phy can be reversed with therapy. Some tissues simp y ose
their e asticity or abi ity to regenerate as we get o der. Near y
every chapter o this book re ers to a ew o the changes that
occur through the i e cyc e.
Be ore moving ahead, we pause to consider what seems
ike an overwhe ming number o scientif c terms introduced
in the preceding sections. It is important to know that such
termino ogy is a new anguage that you must earn as you
continue your studies. Now is a good time to review the intro-
duction to this new anguage in Appendix B at evolve.elsevier
.com. T en, in upcoming chapters, make it a habit to read
through the new terms in the chapter word istspausing
to pronounce each term out oud and g ance at its word
partsbe ore starting your reading. Such a strategy wi he p
you s ow y and com ortab y bui d a mastery o scientif c
anguage.
 14 CHAPTER 1 Introduction to the Body

QUICK CHECK ca the relative constancy o the interna environment. T e

ce s o the body ive in an interna environment made up
1 1. Wh a t is th e d i e re n ce b e tw e e n th e a xia l p o rtio n o th e
b o d y a n d th e a p p e n d icu la r p o rtio n o th e b o d y? most y o water combined with sa ts and other disso ved
2. Wh a t a re s o m e o th e re g io n s o th e u p p e r e xtre m ity a n d substances.
lo w e r e xtre m ity? Like f sh in a f shbow , the ce s are ab e to survive on y i
3. Wh a t is m e a n t b y th e te rm a tro p hy? the conditions o their watery environment remain re ative y
stab ethat is, on y i conditions stay within a narrow range.
T e temperature, sa t content, acid eve (pH ), uid vo ume
Ba la n c e o Bo d y Fu n c t io n s and pressure, oxygen concentration, and other vita conditions
must remain within acceptab e imits. o maintain a narrow
Ho m e o s t a s is range o water conditions in a f shbow , one may add a heater,
A though structura y di erent rom one another, a iving an air pump, and f ters. Likewise, the body has mechanisms
organisms maintain mechanisms that ensure surviva o the that act as heaters, air pumps, and the ike to maintain the
body and success in propagating its genes through its re ative y stab e conditions o its interna uid environment
o spring. (Figure 1-10).
Surviva depends on maintaining re ative y constant con- Because externa disturbances and the activities o ce s
ditions within the body. H omeostasis is what physio ogists themse ves cause requent uctuations inside the body, condi-
tions are continuous y dri ting away rom homeostasis. T ere-
Nutrie nts ore, the body must constant y work to maintain or re-
S a lts store stabi ity, or homeostasis. For examp e, the heat
Wa te r O2 CO 2
Exte rnal generated by musc e activity during exercise may cause
S kin
e nviro nme nt the bodys temperature to rise above norma . T e body
must then re ease sweat, which evaporates and coo s the
Inte rnal body back to a norma temperature.
e nviro nme nt
Re s pirato ry
s ys te m
Fe e d b a c k C o n t ro l
Dig e s tive
s ys te m
o accomp ish such se -regu ation, a high y comp ex and
integrated communication contro system is required. T e
basic type o contro system in the body is ca ed a
Ce ll eedback loop.
T e idea o a eedback oop is borrowed rom engi-
He a rt neering. Figure 1-11, A, shows how an engineer wou d
describe the eedback oop that maintains stabi ity o
temperature in a bui ding. Co d winds outside a bui ding
Cardiovas c ular
s ys te m
may cause the bui ding temperature to drop be ow nor-
Blood ma . A sensor, in this case a thermometer, detects the
(ce lls a nd pla s ma ) change in temperature. In ormation rom the sensor eeds
Inte rs titia l
fluid back to a control centera thermostat in this examp e
that compares the actua temperature to the norma
temperature and responds by activating the bui dings
Urinary urnace. T e urnace is ca ed an ef ector because it has an
s ys te m
e ect on the contro ed condition (temperature). Because
the sensor continua y eeds in ormation back to the con-
tro center, the urnace wi be automatica y shut o
when the temperature has returned to norma .
As you can see in Figure 1-11, B, the body uses a simi ar
eedback oop to restore body temperature when we be-
Una bs orbe d S a lts come chi ed. Nerve endings that act as temperature sen-
ma tte r Wa te r sors eed in ormation to a contro center in the brain that
Orga nic wa s te Nitroge nous wa s te
compares actua body temperature to norma body tem-
FIGURE 1-10 Diagram o the bodys internal environment. The human body perature. In response to a chi , the brain sends nerve
is like a bag o f uid separated rom the external environment. Tubes, such as the signa s to musc es that cause rapid y repeated contrac-
digestive tract and respiratory tract, bring the external environment to deeper parts tions. T is shivering produces heat that increases our
o the bag where substances can be absorbed into the internal f uid environment or
excreted into the external environment. All the organs and systems somehow help body temperature. We stop shivering when eedback in-
maintain a constant environment inside the bag that allows survival o the cells that ormation te s the brain that body temperature has in-
live there. creased to norma .
 CHAPTER 1 Introduction to the Body 15

Dis turbanc e Feedback Dis turbanc e

1
loop
Co ld Ro o m Co ld Bo dy
wind te mpe rature wind te mpe rature
de c re as e s de c re as e s

Te mpe rta ure Te mpe ra ture

De te cte d by De te cte d by
incre a s e s incre a s e s
Co ntro lle d Co ntro lle d
c o nditio n c o nditio n

Mus cle s Cold

Furna ce The rmome te r (s hive r) re ce ptors
Effe c to r S e ns o r Effe c to r S e ns o r

Corre ction Fe e ds Corre ction Fe e ds

s igna ls ba ck to s igna ls ba ck to

Norma l room The rmo s tat Actua l room Norma l body Brain Actua l body
te mpe ra ture Inte g rato r te mpe ra ture te mpe ra ture Inte g rato r te mpe ra ture
A B

FIGURE 1-11 Negative eedback loops. A, An engineers diagram showing how relatively constant room
temperature (controlled condition) can be maintained. A thermostat (control center) receives eedback in orma-
tion rom a thermometer (sensor) and responds by counteracting change rom normal by activating a urnace
(e ector). B, A physiologists diagram showing how a relatively constant body temperature (controlled condi-
tion) can be maintained. The brain (control center) receives eedback in ormation rom nerve endings called cold
receptors (sensors) and responds by counteracting a change rom normal by activating shivering by muscles
(e ectors).

N e g a t ive Fe e d b a c k an increase in breathing rate that brings the b ood CO 2 eve

Feedback oops such as those shown in Figure 1-11 are ca ed
negative eedback oops because they oppose, or negate, a
change in a contro ed condition. M ost homeostatic contro
oops in the body invo ve negative eedback because revers-
ing changes back toward a norma va ue tends to stabi ize
conditionsexact y what homeostasis is a about.
T ink about the opposite circumstance o that shown in
Figure 1-11, as when we become overheated during hot weather.
emperature receptors detect a body temperature higher than
norma , and the brain sends signa s to the sweat g ands to coo
us down through evaporation. T us the conditions are re-
versed and ba ance is restored.
Another examp e o a negative eedback oop occurs dur-
ing exercise. As musc es contract, they produce additiona
CO 2 that is transported by b ood. T is increase in b ood CO 2
eve s is detected by sensory receptors that transmit the in or-
mation to respiratory contro centers in the brain. T is triggers
back down toward norma .
An additiona examp e is the excretion o arger than usua
vo umes o urine when the vo ume o uid in the body is
greater than the norma , idea amount.
P o s it ive Fe e d b a c k
A though not common, positive eedback oops do exist in
the body and are sometimes a so invo ved in norma unction.
Positive eedback contro oops are stimu atory. Instead o op-
posing a change in the interna environment and causing a
return to norma , positive eedback oops temporari y am-
p i y or rein orce the change that is occurring. T is type o
eedback oop causes an ever-increasing rate o events to occur
unti something stops the process. An examp e o a positive
eedback oop inc udes the events that cause rapid increases in
uterine contractions be ore the birth o a baby (Figure 1-12).
 16 CHAPTER 1 Introduction to the Body

Variable Un ortunate y, this increases the oss o b ood, which causes a

Feedback urther drop in b ood pressure and an even aster heart rate.
1 loop S tre tch T e response is acce erated, and the amp if cation o
incre a s e
b ood oss caused by this positive eedback oop can
rapid y turn dead y. App ying pressure to the
S tre tch wound can stop or s ow the oss o b ood and
De te cte d by
incre a s e stop the positive eedback oop.

Fe tus move s
into birth ca na l N o r m a l Flu c t u a t io n s
S tronge r, more fre que nt
la bor contra ctions S tre tch re ce ptors It is important to rea ize that norma homeo-
static contro mechanisms can maintain on y
a relative constancy. A homeostatica y con-
tro ed conditions in the body do not remain
Ute rine abso ute y constant. Rather, conditions nor-
mus cle ma y uctuate near a norma , idea va ue.
T us body temperature, or examp e, rare y
Effe c to r S e ns o r remains exact y the same or very ong
Hypotha la mus instead it uctuates up and down near a per-
P ituita ry
sons norma body temperature.
ake a moment to scan Appendix C at
Fe e ds informa tion evolve.elsevier.com. It ists some o the norma
Corre ction via ne rve fibe rs
s igna ls via oxytocin ba ck to bra in ranges o physio ogica variab es o ten mea-
sured when assessing a patients hea th. Notice
that near y every norma va ue isted is shown
as a range instead o a sing e number. Ranges
are used because di erent peop e may have
Norma l Inte g rato r S tre tche d s ight y di erent set points, some set points
FIGURE 1-12 Positive eedback loop. An example o positive eedback occurs when a baby change under di erent circumstances, and the
is born. As the baby is pushed rom the womb (uterus) into the birth canal (vagina), stretch recep- va ues norma y uctuate c ose to (but not ex-
tors detect the movement o the baby. Stretch in ormation is ed back to the brain, triggering the act y at) the set point va ue.
pituitary gland to secrete a hormone called oxytocin (OT). OT travels through the bloodstream to Because a organs unction to he p main-
the uterus, where it stimulates stronger contractions. Stronger contractions push the baby arther tain homeostatic ba ance, we discuss negative
along the birth canal, thereby increasing stretch and stimulating the release o more OT. Uterine
contractions quickly get stronger and stronger until the baby is pushed out o the body, and the and positive eedback mechanisms o ten
positive eedback loop is broken. OT also can be injected therapeutically by a physician to stimu- throughout the remaining chapters o this
late labor contractions. book.
Be ore eaving this brie introduction to
physio ogy, we must pause to state an im-
Another examp e o norma positive eedback regu ation in portant princip e: the abi ity to maintain the ba ance o
the body is the activity o b ood ce s ca ed platelets, which body unctions is re ated to age. D uring chi dhood, homeo-
become increasing y sticky in response to damage to a b ood static unctions gradua y become more and more e cient
vesse . Circu ating p ate ets rapid y c ing to the damaged area and e ective. T ey operate with maximum e ciency and
and re ease chemica s that attract additiona p ate ets that ac- e ectiveness during young adu thood. D uring ate adu t-
cumu ate at the site o damage to orm a b ood c ot. T e b ood hood and o d age, they gradua y become ess and ess e -
c ot orms to contro b eeding. cient and e ective.
In each o these cases, the process rapid y increases unti Changes and unctions occurring during the ear y years are
the positive eedback oop is stopped sudden y by the birth o ca ed developmental processes. Changes occurring a ter young
a baby or the ormation o a c ot. In the ong run, such norma adu thood are ca ed aging processes. In genera , deve opmenta
positive eedback events a so he p maintain constancy o the processes improve e ciency o unctions. Aging processes, on
interna environment. the other hand, o ten diminish e ciency o body unctions.
H owever, negative eedback can abnorma y turn into posi-
tive eedback, possib y causing a dead y shi t in body unction. QUICK CHECK
For examp e, consider the ro e o b ood pressure and the e - 1. Why is h o m e o s ta s is a ls o ca lle d b a la n ce o b o d y
ect that severe b eeding may have on b ood pressure. A norma u n ctio n ?
b ood pressure is necessary to ensure that b ood ows through 2. Wh a t is a e e d b a ck lo o p a n d h o w d o e s it w o rk?
b ood vesse s at an appropriate rate. W hen b ood is ost, as oc- 3. Ho w d o e s n e ga tive e e d b a ck d i e r ro m p o s itive e e d b a ck?
curs with severe b eeding, b ood pressure drops. o compensate, 4. Ho w ca n n e ga tive e e d b a ck a b n o rm a lly tu rn in to p o s itive
e e d b a ck?
the heart beats aster to try to restore norma pressure.
 CHAPTER 1 Introduction to the Body 17

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 3)

1
anthropology cubital rontal plane

[anthropo- human, -log- words (study o ), [cubit- elbow, -al relating to] [ ront- orehead, -al relating to, plan- at
-y activity] cutaneous sur ace]
appendicular gluteal
[cut- skin, -aneous relating to]
[append- hang upon, -ic- relating to, -ul- little, deep [glut- buttocks, -al relating to]
-ar relating to] diaphragm homeostasis
axial
[dia- across, -phrag- enclose] [homeo- same or equal, -stasis standing still]
[axi- axis, -al relating to] hypochondriac region
digital
axillary
[digit- f nger or toe, -al relating to] [hypo- under or below, -chondr- cartilage, -ac
[axilla- wing, -ary relating to] relating to]
directional term
bilateral symmetry hypogastric region
dissection
[bi- two, -later- side, -al relating to, sym- [hypo- under or below, gastr- stomach, -ic
together, -metr- measure, -ry condition o ] relating to]
[dis- apart, -sect- cut, -tion process]
brachial distal hypothesis

[brachi- arm, -al relating to] [dist- distance, -al relating to]
pl.,
buccal dorsal
[hypo- under or below, -thesis placing or
[bucca- cheek, -al relating to] proposition]
[dors- back, -al relating to]
carpal iliac region
dorsal cavity

[carp- wrist, -al relating to] [ilia- loin or gut (ileum), -ac relating to]
[dors- back, -al relating to, cav- hollow, -ity
cavity state] in erior
e ector
[cav- hollow, -ity state] [in er- lower, -or quality]
cell [e ect- accomplish, -or agent] inguinal
epigastric region
[cell storeroom] [inguin- groin, -al relating to]
cephalic [epi- upon, gastr- stomach, -ic relating to] lateral
experimental control
[cephal- head, -ic relating to] [later- side, -al relating to]
cervical [ex- out o , -peri- tested, -ment- thing, -al law
relating to] levels o organization
[cervic- neck, -al relating to] experimentation
chemical level lumbar
[ex- out o , -peri- tested, -ment- thing, -tion
[chem- alchemy, -ical relating to] process] [lumb- loin, -ar relating to]
control center acial lumbar region

cranial [ aci- ace, -al relating to] [lumb- loin, -ar relating to]
eedback loop mammary
[crani- skull, -al relating to]
cranial cavity emoral [mamma- breast, -ry relating to]
medial
[crani- skull, -al relating to, cav- hollow, -ity [ emor- thigh, -al relating to]
state] [media- middle, -al relating to]
rontal
crural mediastinum
[ ront- orehead, -al relating to]
[crur- leg, -al relating to] [mediastin- midway, -um thing]

Continued on p. 18
 18 CHAPTER 1 Introduction to the Body

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 17)

1
microbiome physiology supine

[micro- small, -bio- li e, -ome entire collection] [physio- nature ( unction), -o- combining vowel, [supin- lying on the back]
midsagittal plane -log- words (study o ), -y activity] supraclavicular
plane
[mid- middle, -sagitta- arrow, -al relating to] [supra- above or over, -clavi- key, -ul- little, -ar
nasal [plan- at sur ace] relating to]
plantar system
[nas- nose, -al relating to]
negative eedback [planta- sole o oot, -ar relating to] [sy(n)- together, -stem standing]
pleural tarsal
[nega- deny, -tive relating to]
oblique plane [pleura- rib, -al relating to] [tars- ankle, -al relating to]
pleural cavity temporal
[obliq- slanted, plan- at sur ace]
occipital [pleura- rib, -al relating to, cav- hollow, -ity [tempora- temple (o head), -al relating to]
state] theory
[occipit- back o head, -al relating to] popliteal
olecranal [theor- look at, -y act o ]
[poplit- back o knee, -al relating to] thoracic
[olecran- elbow, -al relating to] positive eedback
ophthalmic [thorac- chest (thorax), -ic relating to]
[posit- to place or ampli y, -tive relating to] thoracic cavity
[oph- eye or vision, -thalm- inner chamber, -ic posterior
relating to] [thorac- chest (thorax), -ic relating to, cav-
oral [poster- behind, -or quality] hollow, -ity state]
prone tissue
[or- mouth, -al relating to] [prone lying ace down]
orbital proximal [tissu- abric]
transverse plane
[orbi- circle, -al relating to] [proxima- near, -al relating to]
organ sagittal plane [trans- across or through, -vers turn, plan- at
sur ace]
[organ tool or instrument] [sagitta- arrow, -al relating to, plan- at umbilical
organism sur ace]
scientif c method [umbilic- navel, -al relating to]
[organ- instrument, -ism condition] ventral
palmar section
[ventr- belly, -al relating to]
[palm- palm o hand, -ar relating to] [sect- cut, -ion process or state] ventral cavity
pedal sensor
[ventr- belly, -al relating to, cav- hollow, -ity
[ped- oot, -al relating to] [sens- eel, -or relating to] state]
pelvic spinal cavity volar

[pelvi- basin, -ic relating to] [spin- backbone, -al relating to, cav- hollow, -ity [vola- hollow o hand, -ar relating to]
pelvic cavity state] zygomatic
superf cial
[pelvi- basin, -ic relating to, cav- hollow, -ity [zygo- union or yoke, -ic relating to]
state] [super- over or above, -f ci- ace, -al relating to]
perineal superior

[peri- around, -ine- excrete (perineum), -al [super- over or above, -or quality]
relating to]

LANGUAGE OF M ED IC IN E
allied health pro essions disease
atrophy [dis- without, -ease com ort]
orensic science
[a- without, -troph- nourishment, -y state]
autopsy [ orens- public orum, -ic relating to, scienc-
knowledge]
[auto- sel , -ops- view, -y procedure]
OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
S cie ntif c Me tho d
A. Science invo ves ogica inquiry based on experimenta-
tion and can use a variety o methods (Figure 1-1)
1. H ypothesisidea or princip e to be tested in
experiments
2. Experimentseries o tests o a hypothesis; a con-
tro ed experiment e iminates biases or outside
in uences
3. T eory or awa hypothesis that has been supported
by experiments and thus shown to have a high degree
o conf dence
B. T e process o science is active and changing as new
experiments add new know edge
Le ve ls o Organizatio n
A. O rganization is the most important characteristic o
body structure
B. T e body as a who e (organism) is a unit constructed o
the o owing sma er units (Figure 1-2):
1. Atoms and mo ecu eschemica eve
2. Ce sthe sma est structura units; organizations o
various chemica s
3. issuesorganizations o simi ar ce s
4. O rgansorganizations o di erent kinds o tissues
5. Systemsorganizations o many di erent kinds o
organs
CHAPTER 1 Introduction to the Body 19
1
medicine
[med- heal, -ic- relating to, -ine o or like]
pathology
[patho- disease, -o- combining vowel, -log-
words (study o ), -y activity]
6. O rganismorganization o a systems together,
orming a who e body
C. Microbiomeset o interacting communities o bacteria
and other microorganisms that inhabit the human body;
in uences norma body unction
Anato m ical Po s itio n
A. Re erence position in which the body is standing erect
with the eet s ight y apart and arms at the sides with
pa ms turned orward (Figure 1-3)
B. Anatomica position gives meaning to directiona terms
C. erms that describe the body not in anatomica position
1. Supine ying ace upward
2. Prone ying ace downward
Anato m ical Dire ctio ns
A. Common y used directiona terms
1. Superiortoward the head, upper, above
2. In eriortoward the eet, ower, be ow
3. Anterior ront, in ront o (same as ventra in
humans)
4. Posteriorback, in back o (same as dorsa in
humans)
5. Media toward the mid ine o a structure
6. Latera away rom the mid ine or toward the side
o a structure
7. Proxima toward or nearest the trunk, or nearest
the point o origin o a structure
8. Dista away rom or arthest rom the trunk, or
arthest rom a structures point o origin
9. Superf cia nearer the body sur ace
10. Deep arther away rom the body sur ace
B. Anatomica compass rosetteindicator o anatomica
directions in an i ustration that uses abbreviated direc-
tiona terms
 20 CHAPTER 1 Introduction to the Body
Plane s o the Bo dy (Figure 1-4)
1 A. Sagitta p ane engthwise p ane that divides a structure
into right and e t sections
B. Midsagitta sagitta p ane that divides the body into
two equa ha ves
C. Fronta (corona ) p ane engthwise p ane that divides a
structure into anterior and posterior sections
D. ransverse p anehorizonta p ane that divides a struc-
ture into upper and ower sections
E. O b ique p aneany p ane that is not para e to any o
the p anes isted above, thus producing a s anted section
Bo dy Cavitie s (Figure 1-5, Table 1-1)
A. Dorsa cavities
1. Crania cavity contains brain
2. Spina cavity contains spina cord
B. Ventra cavities
1. T oracic cavity
a. Mediastinummidportion o thoracic cavity; heart
and trachea ocated in mediastinum
b. P eura cavitiesright ung ocated in right p eura
cavity, e t ung in e t p eura cavity
2. Abdominope vic cavity
a. Abdomina cavity contains stomach, intestines,
iver, ga b adder, pancreas, and sp een
b. Pe vic cavity contains reproductive organs, urinary
b adder, and owest part o intestine
c. Abdominope vic subdivisions
(1) Four abdominope vic quadrants (Figure 1-6)
(2) Nine abdominope vic regions (Figure 1-7)
C. O rgans o the major body cavities can be seen in
Figure 1-8 and are a so re erenced in ab e 1.1
Bo dy Re g io ns (Figure 1-9, Table 1-2)
A. Axia regionhead, neck, and torso or trunk
B. Appendicu ar regionupper and ower extremities
( imbs)
C. Body structure and unction vary among individua s and
a so throughout an individua s i espan; atrophy
(decrease in size) occurs when an organ is not used
Balance o Bo dy Functio ns
A. Surviva o the individua and o the genes that make up
the body is o the utmost importance
B. Surviva depends on the maintenance or restoration o
homeostasis (re ative constancy o the interna
environment)
1. T e interna environment is a uid that must be kept
stab e by the operation o various organ systems
(Figure 1-10)
2. T e body uses stabi izing negative eedback oops
(Figure 1-11) and, ess o ten, amp i ying positive eed-
back oops (Figure 1-12) to maintain or restore
homeostasis
3. Feedback oops invo ve a sensor, a contro center, and
an e ector
4. Negative eedback oops can turn into positive eed-
back oops during injury or disease, possib y causing a
dead y shi t in body unction
C. A organs unction to maintain homeostasis
D. Abi ity to maintain ba ance o body unctions is re ated
to age; peak e ciency occurs during young adu thood,
diminishing e ciency occurs a ter young adu thood

ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
1. A number o topics are introduced in this chapter that
wi be important throughout the rest o the course.
2. One o your f rst steps shou d be mastering the new ter-
mino ogy o each chapter. Read the new terms isted at
the beginning o each chapter out oud be ore attempting
to read or earn each new topic. Use the pronunciation
guides provided, saying each term severa times to get it
into your working memory. Pay attention to word parts,
toothey he p you master the termino ogy o science
and medicine more quick y. (For more termino ogy tips,
see my-ap.us/ sboS2.)
3. T e most important concept is probab y homeostasis.
T e word itse te s you what it means: homeo means
the same, stasis means staying. H omeostasis is the 7. In your study group, try to come up with examp es o
ba ance the body tries to maintain by making sure its
interna environment stays the same. M ake sure you
understand this concept. (For more tips on homeostasis,
see my-ap.us/rs3KqV.)
4. Another important topic introduced in this chapter is the
structura eve s o organization. T e ower eve s are the
bui ding b ocks on which the upper eve s depend. As
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne anatomy, physio ogy, and patho ogy.
2. Disease resu ts rom what genera conditions in the
body?
3. Describe the process used to orm scientif c theories.
4. List and exp ain the eve s o organization in the human
body.
5. Describe the anatomica position.
6. Name and describe the three p anes or sections o the
body.
CHAPTER 1 Introduction to the Body 21
1
various disease processes are exp ained in ater chapters,
notice how many o these processes cause ai ure at the
chemica or ce u ar eve and how this ai ure a ects
organs, systems, and even the body as a who e.
5. Become ami iar with the directiona termsyou wi see
them in a most every diagram in the text. T e terms a so
are used in naming severa body structures ( or examp e,
superior vena cava, dista convo uted tubu e). T e terms
are air y easy to earn because they are presented in
opposite pairs, so i you earn one term, you a most a ways
automatica y know its opposite. F ash cards wi he p you
earn them. (For more on using ash cards e ective y, see
my-ap.us/LzuowE. See my-ap.us/K9GtVc or more tips on
earning directions.)
6. Table 1-2 and Appendix B (at evolve.elsevier.com) are
he p u resources to keep in mind when you see an un a-
mi iar term.
negative eedback oops that he p maintain a ba ance. Be
creativeand try to use something other than the urnace
examp e. Go over your directiona -term ash cards or
photocopy Figure 1-4 and then b acken out the terms so
you and your e ow students can use the i ustration to
quiz each other. Go over the questions at the end o the
chapter and discuss possib e test questions.
7. List two organs o the mediastinum, two organs o the
abdomina cavity, and two organs o the pe vic cavity.
8. List the nine regions o the abdominope vic cavity,
beginning at the upper e t region and ending at the
ower right region.
9. Name the main areas o the axia ske eton.
10. Name the two subdivisions o the dorsa cavity. W hat
structure does each contain?
11. Exp ain the di erence between the terms ower extrem-
ity, thigh, and eg.
12. List our conditions in the ce that must be kept in
homeostatic ba ance.
13. List the three parts o a negative eedback oop and give
the unction o each.
 22 CHAPTER 1 Introduction to the Body

13. ________ is the term used to describe the act that the
Critical Thinking e t and right sides o the body appear a ike or mirror
1 A te r f nis hing the Review Que s tions , w rite out each other.
the ans we rs to the s e m ore in-de pth que s tions to 14. An ________ p ane is an imaginary at p ane that runs
he lp you apply your new know le dge . Go back to diagona y to an axis o the body or one o its parts, pro-
s e ctions o the chapte r that re late to conce pts ducing a s anted section or cut.
that you f nd di f cult. 15. T e two major cavities o the body are the:
a. thoracic and abdomina
14. Identi y a structure that is in erior to the heart, superior b. abdomina and pe vic
to the heart, anterior to the heart, posterior to the heart, c. dorsa and ventra
and atera to the heart. d. anterior and posterior
15. T e maintenance o body temperature and the birth o a 16. T e structure that divides the thoracic cavity rom the
baby are two body unctions that are regu ated by eed- abdomina cavity is the:
back oops. Exp ain the di erent eedback oops that a. mediastinum
regu ate each process. b. diaphragm
16. I a person comp ained o pain in the epigastric region, c. ungs
what organs cou d be invo ved? d. stomach
17. Give an examp e o a negative eedback oop that occurs 17. T e epigastric region o the abdominope vic cavity is:
during exercise. Exp ain the physio ogy invo ved during a. in erior to the umbi ica region
the process. b. atera to the umbi ica region
c. media to the umbi ica region
d. none o the above
Chapte r Te s t 18. T e hypogastric region o the abdominope vic cavity is:
A te r s tudying the chapte r, te s t your m as te ry by a. in erior to the umbi ica region
re s ponding to the s e ite m s . Try to ans we r the m b. atera to the e t i iac region
w ithout looking up the ans we rs . c. media to the right i iac region
d. both a and c
1. ________ is a term derived rom two Greek words 19. W hich o the o owing is an examp e o a positive eed-
meaning cutting apart. back oop?
2. ________ means the study o the unction o iving a. Maintaining a constant body temperature
organisms and their parts. b. Contractions o the uterus during chi dbirth
3. ________ is the scientif c study o disease. c. Maintaining a constant vo ume o water in the body
4. A hypothesis that has been rigorous y tested and has d. Both a and c
gained a high eve o conf dence is ca ed a ________ or 20. W hich o the o owing is an examp e o a negative
________. eedback oop?
5. ________, ________, ________, ________, and a. Maintaining a constant body temperature
________ are the f ve eve s o organization in a iving b. Contractions o the uterus during chi dbirth
thing. c. Maintaining a constant vo ume o water in the body
6. ________ and ________ are terms used to describe the d. Both a and c
body position when it is not in anatomica position.
7. A ________ section cuts the body or any o its parts Match each directional term in column B with its opposite term
into upper and ower portions. in column A.
8. A ________ section cuts the body or any o its parts
into ront and back portions. Column A Column B
9. A ________ section cuts the body or any o its parts 21. ________ superior a. posterior
into e t and right portions. 22. ________ dista b. superf cia
10. I the body is cut into equa right and e t sides, the cut 23. ________ anterior c. media
is ca ed a ________ section or p ane. 24. ________ atera d. proxima
11. T e body portion that consists o the head, neck, and 25. ________ deep e. in erior
torso is ca ed the ________ portion.
12. T e body portion that consists o the upper and ower
extremities is ca ed the ________ portion.

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Mrs. Mi er was re erred to the c inic by her regu ar phy-
sician to have a mo e on her skin examined. T e re erra
orm states that the mo e is on the e t upper quadrant o
her abdomen. Give a more detai ed description o its
ocation. In preparing Mrs. Mi er or the examination,
how wou d you position her? Shou d you ask her to
assume a supine or prone position? D uring the examina-
tion, the physician notices that the re erra orm states
that Mrs. Mi er has a simi ar mo e in the occipita region.
W hat position shou d she assume so that the physician
can examine that mo e?
2. Mr. Sanchez has just severed the dista tip o the ourth
digit on his upper extremity. Describe in aymans terms
which body part he has injured. As b ood poured out o
CHAPTER 1 Introduction to the Body 23
the injured tissue, his b ood pressure dropped. H is heart
then pumped aster to restore norma pressure. W hat
e ect wou d this response have on Mr. Sanchezs homeo- 1
stasis? Wou d such a response be an examp e o negative
or positive eedback?
3. Mrs. ipps is a high schoo a gebra teacher who thinks
that she might have high b ood pressure (hypertension).
She a so thinks that it might be stress re ated. She experi-
ences symptoms such as a ushing o her ace and head-
aches at certain times during the day. She notices them
particu ar y during her f th period c ass, which has been
particu ar y cha enging. She a so seems to be symptom
ree on the weekends. She has a regu ar appointment
a ready schedu ed with her doctor in 3 weeks. W hat data
cou d she take with her that might he p her doctor with a
diagnosis and possib y a rm her thinking?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Chemistry o Li e
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Levels o Chemical Organization, 25

Atoms, 25
Elements, Molecules, and Compounds, 26
Chemical Bonding, 27
Ionic Bonds, 27
Covalent Bonds, 27
Hydrogen Bonds, 28
Inorganic Chemistry, 29
Water, 29
Acids, Bases, and Salts, 30
Organic Chemistry, 31
Carbohydrates, 31
Lipids, 31
Proteins, 33
Nucleic Acids, 35
Clinical Applications o Chemistry, 35

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Describe the structure o an atom.
2. Def ne and discuss the terms element, molecule, and
compound.
3. Compare and contrast the major types o chemical
bonding.
4. Do the ollowing related to inorganic chemistry:
-
cal compounds.

5. Discuss the structure and unction o the ollowing

types o organic molecules: carbohydrate, lipid,
protein, and nucleic acid.
 HAPTER 2
Li e is u o chemistry and the more we earn about chemica s and their LANGUAGE OF
structures, the better we can understand chemica processes in the human body. S C IEN C E
T e digestion o ood, the ormation o bone tissue, and the contraction o a
musc e are a chemica processes. T us the basic princip es o anatomy and
Be o re re ading the
physio ogy are u timate y based on princip es o chemistry. A who e f e d o
chapte r, s ay e ach o
science, biochemistry, is devoted to studying the chemica aspects o i e. o the s e te rm s o ut lo ud. This w ill
tru y understand the human body, it is important to understand a ew basic he lp yo u to avo id s tum bling ove r
acts about biochemistry, the chemistry o i e. T e best p ace to begin is with the m as yo u re ad.
the bui ding b ocks o matter.
acid
Le ve ls o C h e m ic a l O r g a n iz a t io n (AS-id)
adenine
Matter is anything that occupies space and has mass. Biochemists c assi y (AD-eh-neen)
matter into severa eve s o organization or easier study. T e sma est [aden- gland]
unit o matter is the atom. Atoms are used to bui d more com- adenosine diphosphate (ADP)
p icated substances in the body. In the body, most chemi- (ah-DEN-oh-seen dye-FAHS- ayt
ca s are in the orm o mo ecu es. Molecules are [ay dee pee])
partic es o matter that are composed o one [adenos- shortened rom adenine-
or more atoms. Atoms are considered to ribose, -ine chemical, di- two,
be the basic units o matter. So a good -phosph- phosphorus, -ate oxygen]
p ace to start is with the atom. adenosine triphosphate (ATP)
(ah-DEN-oh-seen try-FOS- ayt
[ay tee pee])
At o m s [adenos- shortened rom adenine-
Atoms are so sma they can be observed on y ribose, -ine chemical, tri- three,
-phosph- phosphorus, -ate oxygen]
with very sophisticated equipment. For exam-
p e, tunneling microscopes and atomic orce micro- alkaline
(AL-kah-lin)
scopes (AFM ) can produce pictures o individua
[alkal- ashes, -ine relating to]
atoms (Figure 2-1). Atoms are composed o severa
amino acid
kinds o subatomic particles: protons, electrons, and
(ah-MEE-no AS-id)
neutrons.
[amino NH2, acid sour]
At the core o each atom is a nucleus composed o
aqueous solution
positive y charged protons and uncharged neutrons. T e
(AY-kwee-us suh-LOO-shun)
number o protons in the nuc eus is an atoms atomic number. [aqu- water, -ous relating to,
T e number o protons and neutrons combined is the atoms solut- dissolved, -ion process]
atomic mass. atom
Negative y charged e ectrons surround the nuc eus at a dis- (AT-om)
tance. I an atom is neutra (carries no e ectrica charge), there is [atom indivisible unit]
one e ectron or every proton. E ectrons do not stay sti . Instead, atomic mass
e ectrons keep darting about within certain imits ca ed orbitals. (ah-TOM-ik mas)
Each orbita can ho d two e ectrons. Even though atomic mode s and [atom- indivisible unit, -ic relating to]
the name orbita imp y that e ectrons move around in conf ned e iptica atomic number
orbits, e ectrons actua y move about in chaotic, unpredictab e paths. (ah-TOM-ik NUM-ber)
O rbita s are arranged into energy levels (she s), depending on [atom- indivisible unit, -ic relating to]
their distance rom the nuc eus. T e arther an orbita extends base
rom the nuc eus, the higher its energy eve . T e energy eve (bays)
[base oundation]

Continued on p. 36

25
 26 CHAPTER 2 Chemistry o Li e
FIGURE 2-1 Atoms. A group o cloudlike
atoms in a crystal as pictured by atomic
orce microscopy (AFM). Added colors high-
light di erent kinds o atoms.
c osest to the nuc eus has one or-
bita , so it can ho d two e ectrons.
T e next energy eve has up to our
orbita s, so it can ho d eight e ectrons.
Figure 2-2 shows a carbon (C) atom. Notice that the f rst
energy eve (the innermost she ) contains two e ectrons, and
the outer energy eve contains our e ectrons. T e outer en-
ergy eve o a carbon atom cou d ho d up to our more e ec-
2 trons ( or a tota o eight). T e number o e ectrons in the
outer energy eve o an atom determines how it behaves
chemica y (that is, how it might interact with other atoms).
T is behavior, ca ed chemical bonding, is discussed ater.
Ele m e n t s , M o le c u le s , a n d C o m p o u n d s
Substances can be c assif ed as elements or compounds. E e-
ments are pure substances, composed o on y one o more
than a hundred types o atoms that exist in nature. On y our
kinds o atoms (oxygen, carbon, hydrogen, and nitrogen)
make up about 96% o the human body. T ere are traces o
about 20 other e ements in the body. Table 2-1 ists some o the
C LIN ICA L APPLICATION
RADIOACTIVE IS OTOPES
Each e le m e nt is unique be caus e o the num be r o protons it
has . In s hort, e ach e le m e nt has its ow n atom ic num be r. How-
eve r, atom s o the s am e e le m e nt can have di e re nt num be rs
o ne utrons . Two atom s that have the s am e atom ic num be r but
di e re nt atom ic m as s e s are is o to pe s o the s am e e le m e nt.
An exam ple is hydroge n. Hydroge n has thre e is otope s : 1 H
(the m os t com m on is otope ), 2 H, and 3 H. The accom panying
f gure s how s that e ach di e re nt is otope has only one proton
but di e re nt num be rs o ne utrons .
Som e is otope s have uns table nucle i that radiate (give o )
particle s . Radiation particle s include protons , ne utrons , e le c-
trons , and alte re d ve rs ions o the s e norm al s ubatom ic parti-
cle s . An is otope that e m its radiation is calle d a radio active
is o to pe .
Radioactive is otope s o com m on e le m e nts are s om e tim e s
us e d to evaluate the unction o body parts . Radioactive iodine
; made with radiation techniques check out
; : ; : :
1H 2H 3H
Ene rgy
Nucle us Ele ctron leve ls
(s he lls )
FIGURE 2-2 A model o the atom. The nucleusprotons ( ) and
neutronsis at the core. Electrons inhabit outer regions called energy lev-
els. This is a carbon atom, a act that is determined by the number o its
protons. All carbon atoms (and only carbon atoms) have six protons. Be-
cause there are only our electrons in the outer energy level, which can hold
up to eight electrons, this carbon atom will share electrons with other atoms
so that its outer energy level becomes ull. (One proton and two neutrons in
the nucleus are not visible in this illustration.)
e ements in the body and a so gives their universa chemica
symbolsthe abbreviations used by chemists wor dwide.
Atoms usua y unite with each other to orm arger chemi-
ca units ca ed molecules. Some mo ecu es are made o severa
atoms o the same e ement. Compounds are substances
whose mo ecu es have more than one e ement in them.
(125 I) that is put into the body and the n take n up by the thyroid
gland give s o radiation that can be e as ily m e as ure d. Thus the
rate o thyroid activity can be de te rm ine d us ing this m e thod.
Im age s o inte rnal organs can be cre ate d by radiation s can-
ne rs that plot out the location o inje cte d or inge s te d radioac-
tive is otope s . For exam ple , radioactive te chne tium (99 Tc) is
com m only us e d to im age the live r and s ple e n. The radioactive
is otope s 13 N, 15 O, and 11 C are o te n us e d to s tudy the brain by
way o a te chnique calle d the PET (pos itron e m is s ion tom ogra-
phy) s can.
Radiation can dam age ce lls . Expos ure to high leve ls o radia-
tion m ay caus e ce lls to deve lop into cance r ce lls . Highe r leve ls
o radiation com ple te ly de s troy tis s ue s , caus ing radiatio n
s ickne s s . Low dos e s o radioactive s ubs tance s are s om e tim e s
give n to cance r patie nts to de s troy cance r ce lls . The s ide e -
e cts o the s e tre atm e nts re s ult rom the unavoidable de s truc-
tion o norm al ce lls along w ith the cance r ce lls .
To learn more about the health applications
o nuclear radiation and to see medical images
the articles Radiation, Medical Imaging o
the Body, and Bone Scans at Connect It! at
evolve.elsevier.com.
 CHAPTER 2 Chemistry o Li e 27

wou d be as an atom. T is is an examp e o

TABLE 2-1 Important Elements in the Human Body
how atoms bond to orm mo ecu es. O ther
NUMBER OF NUMBER OF atoms may instead donate or borrow e ectrons
PROTONS IN ELECTRONS IN unti the outermost energy eve is u and
ELEMENT SYMBOL NUCLEUS OUTER S HELL* then orm crysta s.
Majo r Ele m e nts (Gre ate r Than 96% o Bo dy We ig ht)
Oxyge n O 8 6
Io n ic b o n d s
Carbon C 6 4
Hydroge n H 1 1 One common way in which atoms make their
outermost energy eve u is to orm ionic
Nitroge n N 7 5
bonds with other atoms. Such a bond orms
Trace Ele m e nts (Exam ple s o Mo re Than 20 Trace Ele m e nts Fo und in between an atom that has on y one or two
the Bo dy)
e ectrons in the outermost eve (which wou d
Calcium Ca 20 2 norma y ho d eight) and an atom that needs 2
Phos phorus P 15 5 on y one or two e ectrons to f its outer eve .
Sodium (Latin natrium ) Na 11 1 T e atom with one or two e ectrons simp y
Potas s ium (Latin kalium ) K 19 1 donates its outer she e ectrons to the one
Chlorine Cl 17 7 that needs one or two.
For examp e, as you can see in Table 2-1, the
Iodine I 53 7
sodium (Na) atom has one e ectron in its outer
*Maxim um is e ight, exce pt or hydroge n. The m axim um or that e le m e nt is two. eve and the ch orine (C ) atom has seven.
Both need to have eight e ectrons to f their
In order to describe which atoms are present in a com- outer she . Figure 2-3 shows how sodium and ch orine orm an
pound, a chemica ormula is used. T e ormu a or a com- ionic bond when sodium donates the e ectron in its outer
pound contains symbo s that represent each e ement in the she to ch orine. Now both atoms have u outer she s (a -
mo ecu e. T e number o atoms o each e ement in the mo - though sodiums outer she is now one energy eve ower).
ecu e is expressed as a subscript a ter the e ementa symbo . Because the sodium atom ost an e ectron, it now has one
For examp e, each mo ecu e o the compound carbon dioxide more proton than it has e ectrons. T is makes it a positive ion,
has one carbon (C) atom and two oxygen (O) atomsthus its an e ectrica y charged atom. Ch orine has borrowed an
mo ecu ar ormu a is CO 2. e ectron to become a negative ion ca ed the chloride ion. Be-
cause opposite y charged partic es attract one another, the
To learn more about molecule ormation, go to sodium and ch oride ions are drawn together to orm a so-
AnimationDirect at evolve.elsevier.com. dium ch oride (NaC ) crysta common tab e sa t (Figure 2-3, B).
T e crysta is he d together by ionic bonds.
Ionic compounds usua y disso ve easi y in water because
QUICK CHECK water mo ecu es are attracted to ions and wedge between the
1. Wh a t a re th e th re e m a in s u b a to m ic p a rticle s o a n a to m ? ionsthus orcing them apart. W hen this happens, we say
2. Wh a t is m a tte r? the compounds dissociate to orm ree ions. Compounds that
3. De s crib e a n e n e rg y le ve l. orm ions when disso ved in water are ca ed electrolytes.
4. Wh a t is a co m p o u n d ? An e le m e n t? A m o le cu le ?
T e ormu a o an ion a ways shows its charge by a or
superscript a ter the chemica symbo . T us the sodium
ion is Na , and the ch oride ion is C . Ca cium (Ca) atoms
C h e m ic a l Bo n d in g ose two e ectrons when they orm ions, so the ca cium ion is
Chemica bonds orm to make atoms more stab e. An atom is written as Ca .
said to be chemica y stab e when its outer energy eve is u Because the bodys interna environment is most y water, we
(that is, when its energy she s have the maximum number o f nd many disso ved ions in the body. Specif c ions have impor-
e ectrons they can ho d). A but a hand u o atoms have tant ro es to p ay in musc e contraction, nerve signa ing, and
room or more e ectrons in their outermost energy eve . A other vita unctions. Table 2-2 ists some o the more important
basic chemica princip e states that atoms react with one an- ions present in body uids. Many o these ions are discussed in
other in ways that make their outermost energy eve u . o ater chapters. Chapter 21 describes mechanisms that maintain
create this u energy eve , atoms can share, donate, or borrow the homeostasis o the e ectro ytes throughout the body.
e ectrons.
For examp e, a hydrogen atom has one e ectron and one
C o va le n t Bo n d s
proton. Its sing e energy she has one e ectron but can ho d
twoso it is not u . I two hydrogen atoms share their Atoms a so may f their energy eve s by sharing e ectrons
sing e e ectrons with each other, then both wi have u en- rather than donating or receiving them. W hen atoms share
ergy she s, making them more stab e as a molecule than either e ectrons, a covalent bond orms. Figure 2-4 shows how two
 28 CHAPTER 2 Chemistry o Li e

TABLE 2-2 Important Ions in Body Fluids

NAME SYMBOL
Sodium (Latin natrium ) Na
11 17
Chloride Cl
Potas s ium (Latin kalium ) K
Calcium Ca
Hydroge n H
S odium a tom (Na ) Chlorine a tom (Cl)
Magne s ium Mg
Hydroxide OH
Phos phate PO 4 q

2 Bicarbonate HCO 3

11 17
hydrogen atoms may move to-
gether c ose y so that their energy
eve s over ap. Each energy eve
contributes its one e ectron to the
S odium ion (Na ) Chloride ion (Cl ) sharing re ationship. T at way, both
Na +
outer eve s have access to both
Cl e ectrons.
Ionic bond Because atoms invo ved in a
cova ent bond must stay c ose to
each other, it is not surprising that
cova ent bonds are not easi y bro-
11 17
ken. Cova ent bonds norma y do
not break apart in water.
Carbon, nitrogen, oxygen, and
hydrogen a most a ways share
A S odium chloride (Na Cl) B e ectrons to orm cova ent bonds,
making this type o bonding im-
FIGURE 2-3 Ionic bonding. A, The sodium atom donates the single electron in its outer energy level to a
chlorine atom having seven electrons in its outer level. Then both have eight electrons in their outer shells. portant in the human body. Cova-
Because the electron/proton ratio changes, the sodium atom becomes a positive sodium ion. The chlorine atom ent bonding is used to orm a
becomes a negative chloride ion. The positive-negative attraction between these oppositely charged ions is o the major organic compounds
called an ionic bond. B, A cube-shaped crystal o sodium chloride (table salt). ound in the body.

Hyd ro g e n Bo n d s
:

: ; ; A kind o weak attraction that he ps ho d your bodys sub-

stance together is the hydrogen bond. S ight e ectrica charges
may deve op in di erent regions o a mo ecu e when tiny hy-
Hydroge n Hydroge n
drogen atoms are not ab e to equa y share their e ectrons in a
a tom (H) a tom (H) cova ent bond. Opposite y charged ends o various mo ecu es
then e ectrica y attract one another (Figure 2-5).
Cova le nt H ydrogen bonds do not orm new mo ecu es, but instead
bond provide subt e orces that he p a arge mo ecu e stay in a par-
ticu ar shape. T ey a so may he p ho d together neighboring
:
mo ecu es. For examp e, hydrogen bonds he p maintain the
; : ; comp ex o ded shapes o proteins (see Figure 2-12 on p. 34).
H ydrogen bonds a so keep water mo ecu es oose y joined
togethergiving water a weak g ue ike qua ity that he ps ho d
Hydroge n your body together (see Figure 2-5).
mole cule (H2 )

FIGURE 2-4 Covalent bonding. Two hydrogen atoms move together, To learn more about chemical bonding, go to
overlapping their energy levels. Although neither gains nor loses an elec- AnimationDirect at evolve.elsevier.com.
tron, the atoms share the electrons, thereby orming a covalent bond.
 CHAPTER 2 Chemistry o Li e 29

Wa t e r
Wa te r T ough water is an inorganic compound, it is
mole cule essentia to i e. Found in and around each ce ,
water is the most abundant compound in the
Hydroge n body. Its s ight y g ue ike properties he p ho d
Oxyge n the tissues o the body together.
Hydroge n
bonds S o lu t io n s
Water is the solvent in which most other com-
pounds or solutes are disso ved. W hen water is
the so vent or a mixture (a b end o two or
more kinds o mo ecu es), the mixture is ca ed
an aqueous solution.
FIGURE 2-5 Hydrogen bonds. Because the tiny hydrogen atoms in water cannot share their An aqueous so ution containing common 2
electrons equally with a large oxygen atom, the water molecule develops slightly di erent sa t (NaC ) and other mo ecu es orms the
charges at each end. Like weak magnets, the water molecules orm temporary attachments
(hydrogen bonds) that give liquid water its slightly gluelike properties.
interna sea o the body. Water mo ecu es not
on y compose the basic interna environment
o the body but a so participate in many im-
portant chemical reactions. Chemica reactions
QUICK CHECK are interactions among mo ecu es in which atoms regroup
into new combinations.
1. Wh a t is a n io n ic b o n d ? Wh a t is a cova le n t b o n d ?
2. Wh a t is m e a n t b y a n e le ctro lyte d is s o cia tin g in wa te r?
3. Ho w d o e s hyd ro g e n b o n d in g d i e r ro m io n ic a n d cova -
Wa t e r C h e m is t ry
le n t b o n d in g ? D ehydration synthesis is a common type o chemica reac-
4. Why is th e s ym b o l o r ca lciu m e xp re s s e d C ? tion in the body. In any kind o synthesis reaction, the
reactants combine to orm a arger product. In dehydration
synthesis, reactants combine on y a ter hydrogen (H ) and oxy-
In o r g a n ic C h e m is t ry gen (O) atoms are removed. T ese removed H and O atoms
A compounds in iving organisms can be c assif ed as either combine to orm H 2O, or water. As Figure 2-6 shows, the resu t
organic or inorganic. O rganic compounds are composed o o a dehydration synthesis reaction is both the arge product
mo ecu es that contain carbon-carbon (C O C) cova ent bonds mo ecu e and a water mo ecu e.
or carbon-hydrogen (C O H ) cova ent bondsor both kinds Just as dehydration o a ce is a oss o water rom the ce
o bonds. Few inorganic compounds have carbon atoms in and dehydration o the body is oss o uid rom the entire
them and none have C O C or C O H bonds. O rganic mo e- interna environment, dehydration synthesis is a reaction in
cu es are genera y arger and more comp ex than inorganic which water is ost rom the reactants.
mo ecu es. T e human body has both kinds o compounds Hydrolysis is another common reaction in the body that
because both are equa y important to the chemistry o i e. invo ves water. In this reaction, water (hydro) disrupts the
We wi discuss the chemistry o inorganic compounds f rst, bonds in arge mo ecu es, breaking them down into sma er
and then move on to some o the important types o organic mo ecu es (lysis). H ydro ysis is virtua y the reverse o dehy-
compounds. dration synthesis, as Figure 2-6 shows.

Polyme r Polyme r
HO H HO H

De hydratio n H2 O Hydro lys is H2 O

s ynthe s is

HO H OH H HO H OH H

FIGURE 2-6 Water-based chemistry. Dehydration synthesis (on the le t) is a reaction in which small
molecules are assembled into large molecules by removing water (H and O atoms). Hydrolysis (on the right)
operates in the reverse directionH and O rom water are added as large molecules are broken down into
small molecules.
 30 CHAPTER 2 Chemistry o Li e

Not on y is water the medium in which a major types o reactions in the body, and as such are c ose y regu ated. As
organic compounds are ormed and broken down; it is a so a exp ained in more detai at the beginning o Chapter 22, a ew
product (dehydration synthesis) or reactant (hydro ysis) in water mo ecu es dissociate to orm the H and the OH
these types o reactions. C ear y, water is an important sub- (hydroxide ion):
stance in the body!
Chemica reactions a ways invo ve energy trans ers. En- H 2O H OH
ergy is required to bui d the mo ecu es. Some o that energy
is stored as potentia energy in the chemica bonds. T e stored Ac id s
energy can then be re eased when the chemica bonds in the In pure water, the ba ance o H and OH is equa . H owever,
mo ecu e are ater broken apart. For examp e, a mo ecu e when an acid such as hydroch oric acid (H C ) dissociates into
ca ed adenosine triphosphate (A P) breaks apart in the musc e H and C , it shi ts this ba ance in avor o excess H ions.
ce s to yie d the energy needed or musc e contraction (see In the b ood, carbon dioxide (CO 2) orms carbonic acid
Figure 2-15 on p. 35). (H 2CO 3) when it disso ves in water. Some o the carbonic
2 Chemists o ten use a chemical equation to represent a acid then dissociates to orm H ions and H CO 3 (bicarbon-
chemica reaction. In a chemica equation, the reactants are ate) ions, producing an excess o H ions in the b ood. T us
separated rom the products by an arrow () showing the high CO 2 eve s in the b ood make the b ood more acidic.
direction o the reaction. Reactants are separated rom each
other, and products are separated rom each other by addition, Ba s e s
or p us, signs ( ). T us the reaction potassium and chloride Bases, or alkaline compounds, on the other hand, shi t the
combined to orm potassium chloride can be expressed as the o - ba ance in the opposite direction. For examp e, sodium hy-
owing equation: droxide (NaOH ) is a base that orms OH but not H .
Looking at it simp y, acids are compounds that produce an
K C KC excess o H ions, and bases are compounds that produce an
excess o OH . Since O H can bind to H , bases actua y
T e sing e arrow is used or equations that occur in on y decrease H concentration o a so ution.
one direction. For examp e, when hydroch oric acid (H C ) is
disso ved in water, a o it dissociates to orm H and C . pH
T e re ative H concentration is a measure o how acidic or
HC H C basic a so ution is. T e H concentration is usua y expressed
in units o pH. T e ormu a used to ca cu ate pH units assigns
T e doub e arrow is used or reactions that happen in a va ue o 7 to pure water. A higher pH va ue indicates a ow
both directions at the same time. W hen carbonic acid re ative concentration o H a base. A ower pH va ue indi-
(H 2CO 3) disso ves in water, some o it dissociates into H cates a higher H concentrationan acid.
(hydrogen ion) and H CO 3 (bicarbonate), but not a o it. As Figure 2-7 shows a sca e o pH rom 0 to 14. Notice that
additiona ions dissociate, previous y dissociated ions bond when the pH o a so ution is ess than 7, the sca e tips toward
together again, orming H 2CO 3. the side marked high H . W hen the pH is more than 7, the
sca e tips toward the side marked ow H . pH units increase
H 2CO 3 H H CO 3 or decrease by actors o 10. T us a pH 5 so ution has 10 times
the H concentration o a pH 6 so ution. A pH 4 so ution has
In short, the doub e arrow indicates that at any instant in 100 times the H concentration o a pH 6 so ution.
time both reactants and products are present in the so ution A strong acid is an acid that comp ete y, or a most com-
at the same time. p ete y, dissociates to orm H ions. Strong acids are indicated
by very ow pH va ues ar be ow pH 7. A weak acid, on the
Ac id s , Ba s e s , a n d S a lt s
Besides water, many other inorganic Acidic Ba s ic
compounds are important in the 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
chemistry o i e. For examp e,
acids and bases are compounds
that pro ound y a ect chemica High H Low H
(High OH )
Cytopla s m
S toma ch Va gina l Milk of
s e cre tions 7.0 Ma gne s ia
a cid
0.8 4.1 10.5
FIGURE 2-7 The pH scale. The H concentra- Urine Blood
tion is balanced with the OH concentration at pH 7. 6.0 7.4
At values above 7 (low H ), the scale tips in the basic direc- Ora nge Bla ck Pa ncre a tic Hous e hold
tion. At values below 7 (high H ), the scale tips toward the juice coffe e S e me n juice a mmonia
acidic side. Examples given are normal, average values. 2.8 5.0 7.8 8.0 11.9

other hand, dissociates very itt e and there ore produces ew
excess H ions in so ution. Weak acids have a pH va ue just
be ow 7.
Likewise, strong bases produce a very ow re ative H con-
centration and have a very high pH va ue ar above 7. Weak
bases produce a H concentration a bit ower than pure water
and thus have a pH va ue just a bit higher than 7.
To better understand this concept, use the Active
Concept Map Concept o pH at evolve.elsevier.com.
S a lt s
W hen a strong acid and a strong base mix, excess H may
combine with the excess OH to orm water. T at is, they
may neutralize each other. T e remaining ions usua y orm
neutra ionic compounds ca ed salts. For examp e:
H Cl NaOH H Cl Na OH H 2O
acid base w ater
Ho m e o s t a s is o p H
T e pH o body uids a ects body chemistry so great y that
norma body unction can be maintained on y within a narrow
range o pH o about 7.35 to 7.45. Acidosis ( ow b ood pH )
and alkalosis (high b ood pH ) are equa y dangerous and
thank u y rare y occur because o the homeostatic mecha-
nisms o the body.
T e body can remove excess H ions by excreting them in
the urine (see Chapter 22). Another way to remove acid is by
increasing the oss o CO 2 (an acid) by way o the respiratory
system (see Chapter 17).
A third way to adjust the bodys pH is by using buf ers
chemica s in the b ood that maintain pH . Bu ers maintain pH
ba ance by preventing sudden changes in the H ion concentra-
tion. Bu ers do this by orming a chemica system that neutra -
izes acids and bases as they are added to a so ution.
T e mechanisms by which the body maintains pH homeo-
stasis, or acid-base ba ance, are discussed urther in Chapter 22.
QUICK CHECK
1. De f n e a n o rga n ic co m p o u n d .
2. Wh a t is th e d i e re n ce b e tw e e n d e hyd ra tio n s yn th e s is a n d
hyd ro lys is ?
3. Wh a t d e te rm in e s w h e th e r a s o lu tio n is a n a cid , a b a s e , o r
n e u tra l?
4. Ho w d o b u e rs a d ju s t th e b o d ys p H?
5. Wh a t a re th e ch e m ica l ch a ra cte ris tics o wa te r?
O r g a n ic C h e m is t ry
O rganic compounds are much more comp ex than inorganic
compounds. In this section, we describe the basic structure and
unction o each major type o organic compound ound in the
body: carbohydrates, lipids ( ats), proteins, and nucleic acids.
Table 2-3 summarizes the structure and the unction o each
major type o organic compound in the body. Re er to this
tab e as you read through the descriptions that o ow.
CHAPTER 2 Chemistry o Li e 31
A our o these organic compounds are ormed by dehy-
dration synthesis reactions. Converse y, their bonds can be
broken by hydro ysis.
C a r b o h yd r a t e s
T e name carbohydrate itera y means carbon (C) and water
(H 2O), signi ying the types o atoms that orm carbohydrate
mo ecu es.
T e basic unit o many carbohydrate mo ecu es is ca ed a
monosaccharide (Figure 2-8). G ucose (dextrose) is an impor-
tant monosaccharide in the bodyce s use it as their primary
source o energy (see Chapter 19).
A mo ecu e made o two saccharide units is a doub e sugar, 2
or disaccharide. T e disaccharides sucrose (tab e sugar) and
actose (mi k sugar) are important dietary carbohydrates. A -
ter they are eaten, the body breaks them down, or digests
them, to orm monosaccharides that can be used as ce u ar
NaCl ue .
salt Many saccharide units joined together orm poly-
saccharides. Examp es o po ysaccharides are glycogen and
starch. G ycogen is the po ysaccharide o g ucose that the hu-
man body stores. P ants store g ucose as starch. Each g ycogen
mo ecu e is a chain o g ucose mo ecu es joined together.
W hen there is excess g ucose in the b ood, iver ce s and
musc e ce s pu g ucose out o the b ood and store it as g y-
cogen or ater use. W hen we eat p ants, we can break apart
their starch mo ecu es to get g ucose.
Carbohydrates have potentia energy stored in their bonds.
W hen the bonds are broken in ce s, they re ease energy that
can then be used to do work. Chapter 19 exp ains more about
the process by which the body extracts energy rom carbohy-
drates and other nutrient mo ecu es.
To better understand this concept, use the Active
Concept Map Metabolism o Glucose to Generate
ATP at evolve.elsevier.com.
CH2 OH
C O
Monos a ccha ride H H
H
C C
OH H
OH OH
C C
Dis a ccha ride
H OH
Polys a ccha ride
FIGURE 2-8 Carbohydrates. Monosaccharides are single carbohydrate
units joined by dehydration synthesis to orm disaccharides and polysac-
charides. The detailed chemical structure o the monosaccharide glucose is
shown in the inset.
 32 CHAPTER 2 Chemistry o Li e

TABLE 2-3 Major Types o Organic Compounds

EXAMPLE COMPONENTS FUNCTIONS
Carbo hydrate
Monos accharide (glucos e , galactos e , Single m onos accharide unit Us e d as s ource o e ne rgy
ructos e ) Unit us e d to build othe r carbohydrate s
Dis accharide (s ucros e , lactos e , m altos e ) Two m onos accharide units Can be broke n into m onos accharide s
Polys accharide (glycoge n, s tarch) Many m onos accharide units Us e d to s tore m onos accharide s (thus to s tore
e ne rgy)
Lipid
Triglyce ride One glyce rol he ad, thre e atty acid tails Store s e ne rgy
Provide s prote ctive or s tructural padding
2 Phos pholipid One glyce rol/phos phate he ad, two atty
acid tails
Form s ce ll m e m brane s

Ste roid Four carbon rings at core Stabilize s ce ll m e m brane s

Pro te in
Structural prote ins (f be rs )
Functional prote ins (e nzym e s , horm one s )
Nucle ic Acid
De oxyribonucle ic acid (DNA)
Ribonucle ic acid (RNA)
Ade nos ine triphos phate (ATP)
Am ino acids
Am ino acids
Nucle otide s (contain de oxyribos e )
Nucle otide s (contain ribos e )
Modif e d nucle otide (ribos e , ade nine , and
thre e phos phate s )
Cate gory o horm one s
Form s tructure s o the body
Facilitate che m ical re actions
Carry s ignals
Re gulate unctions
Contains in orm ation (ge ne tic code ) or m aking
prote ins
Se rve s as a copy o a portion o the ge ne tic code
during prote in s ynthe s is
Trans e rs e ne rgy rom nutrie nt m ole cule s to powe r
work in the ce ll

(Figure 2-9). T e atty acid components can be c assif ed as

saturated or unsaturated. Saturated atty acids tend to be so id
at room temperature and are ound in butter and ard. Un-
Glyce rol
saturated atty acids tend to be iquids and are ound in oi s
Fa tty ike corn oi and o ive oi .
a cids Like carbohydrates, the bonds in trig ycerides can be bro-
ken to yie d energy (see Chapter 19). T us trig ycerides are
use u in storing energy in ce s or ater use.
rig ycerides stored in at tissue a so provide he p u pad-
FIGURE 2-9 Triglyceride. Each triglyc- ding around organs and under the skin to stabi ize and pro-
eride is composed o three atty acid units tect body structures.
attached to a glycerol unit.
P h o s p h o lip id s
Phospholipids are simi ar in structure to trig ycerides but
instead o having three atty acid chains attached to a g ycero ,
Lip id s they have two atty acid chains and a phosphorus-containing
Lipids inc ude a diverse group o at-so ub e mo ecu es that unit ca ed a phosphate attached to a g ycero . T e phosphate at
inc ude triglycerides, phospholipids, and steroids. T e most the base o the g ycero head attracts water. T e two atty
abundant ipids in the body are the trig yceridesthe ipids acid tai s repe water.
that we common y re er to as ats. T e o owing sections Figure 2-10, A shows the head and tai o the phospho ipid
provide more detai s about the three major groups o ipids. mo ecu e. T is structure a ows them to orm a stab e doub e
ayera bilayerin water. A phospho ipid bi ayer orms the
Tr ig lyc e r id e s oundation or the ce membrane. In Figure 2-10, B the water-
riglycerides, or ats, are ipid mo ecu es ormed by a attracting heads ace the water and the water-repe ing tai s
glycerol unit or head joined to three atty acid tai s ace away rom the water (and toward each other).
 CHAPTER 2 Chemistry o Li e 33

Glyce rol

P hos pha te C LIN ICA L APPLICATION

BLOOD LIPOPROTEINS
A lipid s uch as chole s te rol can trave l in the blood only a te r
it attache s to triglyce ride s and is w rappe d w ith a laye r o
He a d
(a ttra cts phos pholipids s tudde d w ith prote in m ole cule s (s e e f gure ).
wa te r) This large , com plex lipo pro te in caps ule thus be com e s a
trans port ve hicle or chole s te rol in the blood.
Som e o the s e lipoprote in s tructure s are calle d high-
de ns ity lipoprote ins (HDLs ) be caus e they have a high de n-
Ta il Fa tty s ity o prote in (m ore prote in than lipid). Anothe r type o
A (re pe ls wa te r) a cids m ole cule contains le s s prote in (and m ore lipid), s o it is
calle d low-de ns ity lipoprote in (LDL).
LDL carrie s chole s te rol to ce lls , including the ce lls that
2
line blood ve s s e ls . I a large am ount o chole s te rol builds up
in arte ry walls , a condition calle d athe ro s cle ro s is m ay de -
ve lop. Athe ros cle ros is m ay progre s s to li e -thre ate ning ar-
te rial blockage s , e s pe cially w he n they occur in the he art or
brain (s e e Figure 15-5 on p. 407).
HDL, on the othe r hand, carrie s chole s te rol away rom
Wa te r Wa te r ce lls and toward the live r or e lim ination rom the body. A
high proportion o HDL in the blood is as s ociate d w ith a low
ris k o deve loping athe ros cle ros is and m ay eve n re duce
exis ting buildup o chole s te rol in arte rial walls .
Factors s uch as cigare tte s m oking de cre as e HDL leve ls
and thus contribute to the ris k o athe ros cle ros is . Factors
s uch as exe rcis e incre as e HDL leve ls and thus de cre as e
the ris k o athe ros cle ros is .
B
FIGURE 2-10 Phospholipids. A, Each phospholipid molecule has a
phosphorus-containing head that attracts water and a lipid tail that re- Triglyce ride s
pels water. B, Because the tails repel water, phospholipid molecules o ten
arrange themselves so that their tails ace away rom water. The stable
P rote in
structure that results is a bilayer sheet orming a small bubble. The mem-
brane around each cell o the body is ormed o such a structure.
P hos pholipids

S t e ro id s
Fre e chole s te rol
Steroid mo ecu es have mu tip e-ring structures, as shown in
Figure 2-11. Chole s te rol bound
Cholesterol is an important steroid ipid that per orms to fa tty a cids
severa critica unctions in the body. For examp e, it is embed-
ded within the ce s to he p stabi ize its bi ayer structure. As
Chapter 12 exp ains, the body a so uses cho estero as a start-
ing point in making steroid hormones such as estrogen, testos-
terone, and cortisone.
P ro t e in s
CH2 OH Proteins are very arge mo ecu es composed o basic units
CH3
CH3 ca ed amino acids. In addition to carbon, hydrogen, and oxy-
CH CH2 CH2 CH2 CH C O gen, a amino acids contain nitrogen (N). Many di erent
CH3 CH3
CH3 HO OH amino acids are inked together in a particu ar sequence to
CH3 CH3 orm a o the proteins in ce s. T e process that joins amino
acids by peptide bonds is u y discussed in Chapter 3.
HO
O Attractions between positive y charged and negative y
Chole s te rol Cortis ol charged regions a ong the ong amino acid chain cause it to
(a s te roid hormone ) o d over on itse and maintain its unique shape. T e comp ex,
FIGURE 2-11 Steroids. Cholesterol (le t) has a steroid structure, repre- three-dimensiona mo ecu e that resu ts is a protein mo ecu e
sented here as our colored rings. Changes to the side groups can convert (Figure 2-12). T e o ded shape o a protein mo ecu e deter-
cholesterol to cortisol (shown) or other steroid hormones. mines its ro e in body chemistry.
 34 CHAPTER 2 Chemistry o Li e

Structural proteins have shapes that a ow them to orm

Primary (firs t leve l)
Prote in s tructure is a s e que nce of a mino a cids in a cha in. essentia structures o the body. Co agen, a protein with a f -
ber shape, ho ds most o the body tissues together. Keratin,
R another structura protein, orms a network o waterproo f -
One a mino a cid bers in the outer ayer o the skin.
Functional proteins have o ded shapes that a ow them to
participate in chemica processes o the body. Functiona pro-
teins inc ude some o the hormones, growth actors, ce
membrane channe s and receptors, and enzymes.
Enzymes are chemica cata ysts. T is means that they
he p a chemica reaction occur but are not reactants or
Amino a cid cha in
products themse ves. T ey participate in chemica reactions
but are not changed by the reactions. Enzymes are vita to
2 body chemistry. No reaction in the body occurs ast enough
S e c o ndary (s e c o nd leve l) un ess the specif c enzymes needed or that reaction are
Prote in s tructure is forme d by folding a nd twis ting of a mino
a cid cha in. present.
Figure 2-13 i ustrates how enzyme unction depends on
enzyme shape. Each enzyme has a shape that f ts the specif c
substrate mo ecu es it works on, much as a key f ts specif c
ocks. T is exp anation o enzyme action is sometimes ca ed
the lock-and-key model. Notice that, un ike most keys, the
enzyme is dynamic, so it changes shape to ensure a better f t
when it encounters one or more substrates.
Proteins can bond with other organic compounds and
Folde d s he e t Twis te d he lix orm mixed mo ecu es. For examp e, glycoproteins (de-
scribed in Chapter 3) embedded in ce membranes and
proteoglycans between ce s (described in Chapter 4) are
Te rtiary (third leve l) proteins with sugars attached. Lipoproteins are ipid-protein
Prote in s tructure is forme d whe n the
twis ts a nd folds of the s e conda ry combinations, as described in the C inica App ication box
s tructure fold a ga in to form a la rge r on p. 33.
3-dime ns iona l s tructure.

Mole cule B Mole cule A

Folde d s he e t
+

+
Enzyme
Twis te d he lix

+
Quate rnary (fo urth leve l)
Prote in s tructure is a prote in +
cons is ting of more tha n one
folde d a mino a cid cha in.

+
+

FIGURE 2-12 Protein. Protein New mole cule AB

molecules are large, complex mole-
cules ormed by one or more strands o
amino acids. Each amino acid is connected
to the next by a type o covalent bond called a peptide bond. Additional
weak orces between atoms o the larger molecule then cause the strand to
twist or old into a secondary (second-level) protein structure. New relation-
ships among the atoms then cause the molecule to old again on itsel to
orm a three-dimensional tertiary (third-level) protein structure. Several ter-
tiary proteins may join to orm a quaternary ( ourth-level) protein structure.
+
+
FIGURE 2-13 Enzyme action. Enzymes are unctional proteins whose
molecular shape and ability to alter shape allow them to catalyze chemical
reactions. Substrate molecules A and B are brought together by the enzyme
to orm a larger molecule, AB.
 CHAPTER 2 Chemistry o Li e 35

Each nuc eotide consists o a phosphate unit, a sugar (ribose

TABLE 2-4 Components o Nucleotides
or deoxyribose), and a nitrogen base. DNA nuc eotide bases
NUCLEOTIDE DNA RNA inc ude adenine, thymine, guanine, and cytosine. RNA uses
Sugar De oxyribos e Ribos e the same set o bases, except or the substitution o uracil or
Phos phate Phos phate Phos phate thymine (Table 2-4).
Nitroge n bas e Cytos ine Cytos ine Nuc eotides bind to one another to orm strands or other
structures. In the DNA mo ecu e, nuc eotides are arranged in
Guanine Guanine
a twisted, doub e strand ca ed a double helix (Figure 2-14).
Ade nine Ade nine
T e sequence o di erent nuc eotides a ong the DNA
Thym ine Uracil doub e he ix is the master code or assemb ing proteins and
other nuc eic acids. M essenger RNA (mRNA) mo ecu es have
a sequence that orms a temporary working copy o a por-
N u c le ic Ac id s tion o the DNA code ca ed a gene. T e genetic code in
T e two orms o nucleic acid are deoxyribonucleic acid nuc eic acids u timate y directs the entire symphony o iv- 2
(D NA) and ribonucleic acid (RNA). As out ined in Chap- ing chemistry.
ter 3, the basic bui ding b ocks o nuc eic acids are ca ed A modif ed nuc eotide ca ed adenosine triphosphate
nucleotides. (A P) p ays an important energy-trans er ro e in the body.
As Figure 2-15 shows, adenosine (a base and a sugar) has not
Nucle otide Ade nine (A) Cytos ine (C) just one phosphate, as in a standard nuc eotide, but instead
P hos pha te
has three phosphates. T e extra phosphates are attached to
Nitroge n P Gua nine (G) Thymine (T)
the mo ecu e with unstab e high-energy bonds that require
ba s e A DNA a great amount o energy ( rom nutrients) to orm. T ere-
5-Ca rbon s uga r
ore, they re ease a arge amount o energy when broken.
D
(de oxyribos e [D]) W hen a phosphate breaks o o A P orming adenosine
diphosphate (AD P)the energy re eased is used to do
P
work in ce s.
P T A A P thus acts as a sort o energy-trans er battery that
D picks up energy rom nutrients and then quick y makes the
D
P energy avai ab e to ce u ar processes. Chapter 19 out ines
P C
G detai s o how A P works in the ce s.
D Hydroge n D
bonds
P P
A T
To learn more about how energy in the body is

content o ood and the energy cost o common

FIGURE 2-14 DNA. Deoxyribonucleic acid (DNA), like all nucleic acids, activities, check out the article Measuring Energy
is composed o units called nucleotides. Each nucleotide has a phosphate, a at Connect It! at evolve.elsevier.com.
sugar, and a nitrogen base. In DNA, the nucleotides are arranged in a double
helix ormation.

P hos pha te FIGURE 2-15 ATP. A, Structure o adenosine triphosphate (ATP). Because the adenosine
Ade nos ine groups group is made up o a sugar (ribose) and a base (adenine), ATP is really a nucleotide with
added phosphates. B, The role o ATP in trans erring energy rom nutrient molecules to cel-
ATP A P P P lular processes. ADP, Adenosine diphosphate.

A High-e ne rgy bonds

ATP
A P P P

Ene rgy High-e ne rgy bonds Ene rgy

ADP
From A P P P To
nutrie nt ce llula r
B bre a kdown proce s s e s
 36 CHAPTER 2 Chemistry o Li e

C lin ic a l A p p lic a t io n s
S C IEN C E APPLICATIONS o C h e m is t ry
BIOCHEMISTRY In addition to the c inica app ications a ready mentioned in
Britis h s cie ntis t Ros alind Frank- this chaptersuch as pH imba ancesthere are many yet to
lin was one o the le ading come as we move through each remaining chapter. ake a
bio che m is ts o the m ode rn moment to scan through Appendix C (at evolve.elsevier.com),
age . Franklin us e d x-rays to cas t which ists norma concentrations o various chemica s ound in
s hadow s through DNA to ana- the b ood, urine, or other body uids o a hea thy person. You
lyze its s tructure . Whe n s he was can see that our bodies are, in a way, chemica systems where
only 32 ye ars old, s he dis cov- each chemica must be maintained in a hea thy ba ance.
e re d the unus ual he lical (s piral)
Continue to watch or the important ro es p ayed by water,
s tructure o the DNA m ole cule
oxygen, carbon dioxide, ions, pH , carbohydrates, ipids, pro-
2 Rosalind Franklin
and how the s ugars and phos -
phate s orm an oute r backbone
teins, and nuc eic acids as you progress through your course.
(19201958) or the m ole cule (Figure 2-14). T is wi he p you understand the big picture o human
He r bre akthrough he lpe d structure and unction. Do not hesitate to return to this chap-
Jam e s Wats on, Francis Crick, ter ater on in your studies when you need a quick re resher
and Maurice Wilkins to f nally work out the s tructure and on one o these chemistry topics.
unction o DNA in 1953 and thus crack the code o li e .
The thre e m e n re ce ive d a Nobe l Prize or the ir achieve m e nt To learn how principles o chemistry are involved
in 1962, but Franklins e arly de ath rom cance r in 1958 pre - in human nutrition, check out the articles Func-
ve nte d he r rom s haring in the cre dit or one o the gre ate s t tional Foods and Measuring Energy at Connect It!
dis cove rie s o all tim e .
at evolve.elsevier.com.
Bioche m is ts continue to m ake im portant dis cove rie s
that incre as e our unde rs tanding o hum an s tructure and
unction. Aide d by labo rato ry te chnicians and lab as s is -
tants , bioche m is ts als o f nd ways to he lp othe r pro e s s ion- QUICK CHECK
als apply bioche m is try to s olve eve ryday proble m s . For ex- 1. Wh ich typ e s o o rga n ic m o le cu le s d o th e o llo w in g s u b -
am ple , clinical labo rato ry te chnicians analyze s am ple s u n its o rm : Mo n o s a cch a rid e s ? Fa tty a cid s ? Am in o a cid s ?
rom the bodie s o patie nts or s igns o he alth or dis e as e . Nu cle o tid e s ?
Othe rs w ho us e bioche m is try as a bas is or the ir work in- 2. Why is th e s tru ctu re o a p ro te in m o le cu le im p o rta n t?
clude nucle ar m e dicine te chno lo g is ts , pharm acis ts and 3. Wh a t a re e n zym e s a n d h o w d o th e y u n ctio n in th e b o d y?
pharm acy te chnicians , die titians , ore ns ic inve s tigators , 4. Wh a t is a s u b s tra te ?
ge ne tic co uns e lo rs , and eve n s cie nce journalis ts . 5. Wh a t is th e ro le o DNA in th e b o d y?
6. Wh a t is th e ro le o ATP in th e b o d y?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 25)

bilayer carbon dehydration synthesis

(BYE-lay-er) (KAR-bun) (dee-hye-DRAY-shun SIN-the-sis)
[bi- two, layer] [carbon coal] [de- rom, -hydrat- water, -tion process,
biochemist carbon dioxide (CO2) synthesis putting together]
(bye-oh-KEM-ist) (KAR-bun dye-AHK-syde [see oh too]) deoxyribonucleic acid (DNA)
[bio- li e, -chem- alchemy, -ist agent] [carbon coal, di- two, -ox- sharp (oxygen), (dee-ok-see-rye-boh-nook-lay-ik AS-id
biochemistry -ide chemical] [dee en ay])
(bye-oh-KEM-is-tree) cholesterol [de- removed, -oxy- oxygen, -ribo- ribose
[bio- li e, -chem- alchemy, -ist agent, (koh-LES-ter-ol) (sugar), -nucle- nucleus (kernel), -ic relating
-ry practice o ] [chole- bile, -stero- solid, -ol oil] to, acid sour]

bond compound disaccharide

[bond band] (KOM-pound) (dye-SAK-ah-ryde)
[compound put together] [di- two, -sacchar- sugar, -ide chemical]
bu er
(BUF-er) covalent bond dissociate
[bu e- cushion, -er actor] (koh-VAYL-ent) (dih-SOH-see-ayt)
[co- with, -valen power, bond band] [dis- apart, -socia- unite, -ate action]
carbohydrate
(kar-boh-HYE-drayt) cytosine
[carbo- carbon, -hydr- hydrogen, -ate oxygen] (SYE-toh-seen)
[cyto- cell, -os- sugar, -ine like]
 CHAPTER 2 Chemistry o Li e 37

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 36)

double helix ionic bond pH

(aye-ON-ik bond) (pee aych)
pl., helices [ion to go, -ic- relating to, bond band] [abbreviation or potenz power, hydrogen
(HEE-lis-eez) isotope hydrogen]
[helix spiral] (AYE-soh-tohp) phospholipid
electrolyte [iso- equal, -tope place] ( oys- oh-LIP-id)
(eh-LEK-troh-lyte) lipid [phospho- phosphorus, -lip- at, -id orm]
[electro- electricity, -lyt loosening] (LIP-id) polysaccharide
electron [lip- at, -id orm] (pahl-ee-SAK-ah-ryde)
(eh-LEK-tron)
[electr- electric, -on unit]
lipoprotein
(lip-oh-PROH-teen)
[poly- many, -sacchar- sugar, -ide chemical]
product
2
element [lipo- at, prote- primary, -in substance] (PROD-ukt)
(EL-eh-ment) lock-and-key model protein
[element f rst principle] (lok and kee MAHD-el) (PROH-teen)
energy level matter [prote- primary, -in substance]
(EN-er-gee LEV-el) (MAT-er) proton
[en- in, -erg- work, -y state] [matter something rom which something is (PROH-ton)
enzyme made] [proto- f rst, -on unit]
(EN-zyme) molecule radioactive isotope
[en- in, -zyme erment] (MOL-eh-kyool) (ray-dee-oh-AK-tiv AYE-soh-tohp)
atty acid [mole- mass, -cul small] [radio- send out rays, iso- equal, -tope place]
(FAT-tee AS-id) monosaccharide reactant
[ at- at, -ty state, acid sour] (mon-oh-SAK-ah-ryde) (ree-AK-tant)
ormula [mono- one, -sacchar- sugar, -ide chemical] [re- again, -act- act, -ant agent]
(FOR-myoo-lah) neutron ribonucleic acid (RNA)
[ orm- orm, -ula little] (NOO-tron) (rye-boh-noo-KLAY-ik AS-id [ar en ay])
unctional protein [neuter- neither, -on unit] [ribo- ribose (sugar), -nucle- nucleus,
(FUNK-shen-al PROH-teen) nitrogen -ic relating to, acid sour]
[ unction- per orm, -al relating to, (NYE-troh-jen) salt
prote- primary, -in substance] [nitro- soda, -gen produce] (sawlt)
glycerol nucleic acid solute
(GLIS-er-ol) (noo-KLAY-ik AS-id) (SOL-yoot)
[glyce- sweet, -ol alcohol] [nucle- kernel, -ic relating to, acid sour] [solut dissolved]
glycogen nucleotide solvent
(GLYE-koh-jen) (NOO-klee-oh-tyde) (SOL-vent)
[glyco- sweet, -gen produce] [nucleo- nut or kernel, -ide chemical] [solv- dissolve, -ent agent]
guanine nucleus steroid
(GWAH-neen) (NOO-klee-us) (STAYR-oid)
[guan- guano, -ine like] pl., nuclei [ster- sterol, -oid like]
hydrogen (NOO-klee-aye) structural protein
(HYE-droh-jen) [nucleus kernel] (STRUK-shur-al PROH-teen)
[hydro- water, -gen produce] orbital [structura- arrangement, -al relating to,
hydrogen bond (OR-bih-tal) prote- primary, -in substance]
(HYE-droh-jen bond) [orb- circle, disk ring, -al relating to] thymine
[hydro- water, -gen produce, bond band] organic compound (THYE-meen)
hydrolysis (or-GAN-ik KOM-pownd) [thym- thymus, -ine like]
(hye-DROHL-ih-sis) [organ- tool or instrument, -ic relating to, triglyceride
[hydro- water, -lysis loosening] compound to assemble] (try-GLIH-ser-ayed)
inorganic compound oxygen (O2) [tri- three, -glycer- sweet, -ide chemical]
(in-or-GAN-ik KOM-pownd) (AHK-sih-jen [oh too]) uracil
[in- not, -organic natural, compound to [oxy- sharp, -gen produce] (YOOR-ah-sil)
assemble] peptide bond [ura- urea, -il chemical]
ion (PEP-tyde) water
(AYE-on) [pept- digest, -ide chemical, bond band] (WAyT-er)
[ion to go]
 38 CHAPTER 2 Chemistry o Li e

LANGUAGE OF M ED IC IN E

acidosis dietitian pharmacist

(as-ih-DOH-sis) (dye-eh-TISH-en) (FAR-mah-sist)
[acid- sour, -osis condition] [diet- way o living, -itian practitioner] [pharmac- drug, -ist agent]
alkalosis genetic counselor pharmacy technician
(al-kah-LOH-sis) (jeh-NET-ik KOWN-se-ler) (FAR-mah-see tek-NISH-en)
[alkal- ashes, -osis condition] [gene- produce, -ic relating to, counsel- advise [pharmac- drug, -y location o activity,
atherosclerosis or plan, -or agent] techn- art or skill, -ic relating to,
(ath-er-oh-skleh-ROH-sis) laboratory technician -ian practitioner]
[ather- porridge, -sclero- harden, (LAB-rah-tor-ee tek-NISH-en) radiation sickness

2 -osis condition]
clinical laboratory technician
(KLIN-ih-kal LAB-rah-tor-ee tek-NISH-en)
[clin- sickbed, -ic relating to, -al relating to,
labor- work, -tory place o activity,
techn- art or skill, -ic relating to,
-ian practitioner]
[labor- work, -tory place o activity, techn- art
or skill, -ic relating to, -ian practitioner]
(ray-dee-AY-shun SIK-nes)
[radiat- send out rays, -ion process]
nuclear medicine technologist
(NOO-klee-ar MED-ih-sin tek-NOL-oh-jist)
[nucle- nut or kernel, -ar relating to,
techn- art or skill, -log- words (study o ),
-ist agent]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Le ve ls o Che m ical Organizatio n
A. Atoms (Figures 2-1 and 2-2)
1. Nuc euscentra core o atom
a. Protonpositive y charged partic e in nuc eus
b. Neutronuncharged partic e in nuc eus
c. Atomic numbernumber o protons in nuc eus
d. Atomic massnumber o protons and neutrons
combined
2. Energy eve sorbita regions surrounding atomic
nuc eus that contain e ectrons
a. E ectronnegative y charged partic e
b. May contain up to eight e ectrons in each eve
c. Energy eve increases the arther it is rom the
nuc eus
B. E ements, mo ecu es, and compounds
1. E ementa pure substance; made up o on y one kind
o atom
2. Mo ecu ea group o atoms bound together in a
group
3. Compoundsubstances whose mo ecu es have more
than one kind o atom
Che m ical Bo nding
A. Chemica bonds orm to make atoms more stab e
1. Atoms react with one another in ways that make their
outermost energy eve u
2. Atoms may share e ectrons or donate or borrow them
to become stab e
B. Ionic bonds (Figure 2-3)
1. Ions orm when an atom gains or oses e ectrons in its
outer energy eve to become stab e
a. Positive ionhas ost e ectrons; indicated by super-
script positive sign(s), as in Na or Ca
b. Negative ionhas gained e ectrons; indicated by
superscript negative sign(s), as in C
2. Ionic bonds orm when positive and negative (oppo-
site y charged) ions attract each other
3. E ectro ytecompound that dissociates (breaks apart)
in water to orm individua ions; an ionic compound
C. Cova ent bonds (Figure 2-4)
1. Cova ent bonds orm when atoms try to comp ete
their outer energy eve s by sharing e ectrons
2. Cova ent bonds do not easi y dissociate in water
3. Cova ent bonding is used to orm a o the major
organic compounds ound in the body
D. H ydrogen bonds (Figure 2-5)
1. H ydrogen bonds are re ative y weak bonds that do not
create new mo ecu es
2. H ydrogen bonds orm when partia y charged regions
o neighboring mo ecu es attract one another
3. H ydrogen bonds are present in water, DNA, and
proteins

Ino rganic Che m is try
A. Organic mo ecu es contain carbon-carbon cova ent bonds
and/or carbon-hydrogen cova ent bonds; inorganic mo e-
cu es do not
B. O rganic mo ecu es are genera y arger and more comp ex
than inorganic mo ecu es
C. Water
1. Water is essentia to i e
2. Water is a so vent ( iquid in which so utes are dis-
so ved), orming aqueous so utions in the body
3. Water is invo ved in chemica reactions (Figure 2-6)
a. Dehydration synthesischemica reaction in which
water is removed rom sma mo ecu es so they can
be strung together to orm a arger mo ecu e
b. H ydro ysischemica reaction in which water is
added to a arge mo ecu e to break it into sma er
mo ecu es
c. A the major organic mo ecu es are ormed through
dehydration synthesis and broken apart by hydro ysis
d. Chemica reactions a ways invo ve energy trans ers,
as when energy is used to bui d A P mo ecu es
e. Chemica equations show how reactants interact to
orm products; arrows separate the reactants rom
the products
D. Acids, bases, and sa ts
1. Water mo ecu es dissociate to orm equa amounts o
H (hydrogen ion) and OH (hydroxide ion)
2. Acidsubstance that shi ts the H /OH ba ance in
avor o H ; opposite o base
3. Basesubstance that shi ts the H /OH ba ance
against H ; a so known as an alkaline; opposite o acid
4. pH mathematica expression o re ative H concen-
tration in an aqueous so ution (Figure 2-7)
a. A pH va ue o 7 is neutra (neither acid nor base)
b. pH va ues above 7 are basic; pH va ues be ow 7 are
acidic
5. Neutra ization occurs when acids and bases mix and
orm sa ts
6. pH imba ance occurs when b ood pH is too high
(a ka osis) or too ow (acidosis); homeostasis restores
and maintains pH ba ance in the body
7. Bu ers orm chemica systems that neutra ize excess
acids or bases and thus maintain a re ative y stab e pH
Organic Che m is try
A. Carbohydratessugars and comp ex carbohydrates
(Figure 2-8)
1. Contain carbon (C), hydrogen (H ), oxygen (O )
2. Monosaccharidebasic unit o carbohydrate mo e-
cu es (e.g., g ucose)
3. Disaccharidedoub e sugar made up o two mono-
saccharide units (e.g., sucrose, actose)
4. Po ysaccharidecomp ex carbohydrate made up o
many monosaccharide units (e.g., g ycogen; stored by
the body)
5. Function o carbohydrates is to store energy or ater use
CHAPTER 2 Chemistry o Li e 39
B. Lipidsdiverse group o at-so ub e mo ecu es
1. rig ycerides (Figure 2-9)
a. Formed by a g ycero unit joined to three atty acids
(1) Saturated atty acids are usua y so id at room
temperature
(2) Unsaturated atty acids are usua y iquid at
room temperature
b. Store energy or ater use
c. Provide padding around organs and under the skin
2. Phospho ipids
a. Simi ar to trig yceride structure, but have
phosphorus-containing unitseach with a head
and two tai s (Figure 2-10)
b. T e head attracts water and the doub e tai does 2
not, thus orming stab e doub e ayers (bi ayers) in
water
c. Form membranes o ce s
3. Steroids
a. Mo ecu es have a structure made up o mu tip e
rings (Figure 2-11)
b. Cho estero is an important steroid
c. Cho estero stabi izes the phospho ipid tai s in ce -
u ar membranes and is a so converted into steroid
hormones by the body
C. Proteins
1. Very arge mo ecu es made up o amino acids he d
together in ong, o ded chains by peptide bonds
(Figure 2-12)
2. Structura proteins
a. Form various structures o the body
(1) Co agen is a f brous protein that ho ds many
tissues together
(2) Keratin orms tough, waterproo f bers in the
outer ayer o the skin
3. Functiona proteins
a. Participate in chemica processes o the body
b. Examp es inc ude hormones, ce membrane chan-
ne s and receptors, and enzymes
4. Enzymeschemica cata ysts
a. H e p chemica reactions occur
b. Enzyme action sometimes ca ed ock-and-key
mode because enzymes f t their substrates much
ike a key f ts into a ock (Figure 2-13)
5. Proteins can combine with other organic mo ecu es to
orm mixed mo ecu es such as g ycoproteins or
ipoproteins
D. Nuc eic acids
1. Made up o nuc eotides that inc ude:
a. A phosphate unit
b. A sugar (ribose or deoxyribose)
c. A nitrogen base (adenine [A], thymine [ ] or
uraci [U], guanine [G], cytosine [C])
2. DNA (deoxyribonuc eic acid)
a. Used as the ce s master code or assemb ing
proteins
b. Uses deoxyribose as the sugar and A, (not U), C,
and G as bases
c. Forms a doub e he ix shape (Figure 2-14)
 40 CHAPTER 2 Chemistry o Li e
3. RNA (ribonuc eic acid)
a. Used as a temporary working copy o a gene
(portion o the DNA code)
b. Uses ribose as the sugar and A, U (not ), C, and
G as bases
4. By directing the ormation o structura and unc-
tiona proteins, nuc eic acids u timate y direct overa
body structure and unction
5. A P (adenosine triphosphate) is a modif ed nuc eo-
tide used to trans er energy rom nutrients to ce u ar
2 ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
This chapte r introduce s you to s om e bas ic che m ical conce pts
that are us e d late r in othe r chapte rs to de s cribe s tructure s and
unctions o the body. Firs t o all, it is im portant that you can
re ad and unde rs tand a hand ul o im portant che m ical s ym bols
and e quations .
1. Practice by putting the chemica symbo s ound in Tables 2-1
and 2-2 on ash cards, and then pair up with a c assmate
and quiz each other on what the symbo s stand or. A so
earn to identi y whether each one is or is not an ion.
2. I your instructor requires you to know the parts o the
atom, make your own abe ed diagram o an atom or
make a three-dimensiona mode out o househo d items
such as marshma ows, toothpicks, and string. T ere are
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne the terms element, compound, atom, and molecule.
2. Name and def ne three kinds o partic es within an
atom.
3. W hat is an energy eve ?
4. W hat is a chemica bond?
5. W hat are the major types o chemica bonds?
6. W hat is an e ectro yte? An ion?
7. Def ne the terms organic compound and inorganic
compound.
8. W hat is a so vent? A so ute?
9. Exp ain the concept o pH .
10. W hat is an acid? A base?
processes, thus acting as an energy-trans er battery
(Figure 2-15)
Clinical Applicatio ns o Che m is try
A. Appendix C (at evolve.elsevier.com) i ustrates the norma
va ues o various chemica s in the body
B. T e human body is a chemica system in which a
chemica s must remain in a hea thy ba ance
a so many on ine resources that i ustrate the parts o the
atom. Using mu tip e senses wi he p you earn and
remember the in ormation.
3. It is important that you earn the concept o pH va ue,
which wi be an integra part o ater discussions.
Deve op a -chart that ists the pH va ues (1 to 14) and
give examp es (besides those isted in your text) o sub-
stances and their appropriate pH va ue. ( o earn about
-charts, go to my-ap.us/Lzxuko).
4. Table 2-3 summarizes some important concepts o the
structure and unction o the major organic compounds
that you wi be using ater in the course. Make your own
version o the tab e on a poster-sized piece o paper and
add simp e pictures o the di erent mo ecu es. T en make
ash cards or use on ine ash cards and practice identi y-
ing which category di erent mo ecu es be ong to: protein,
carbohydrate, ipid, or nuc eic acid. Practice identi ying
which unction each compound per orms.
11. Brie y describe the structure o each o the o owing:
protein, ipid, carbohydrate, nuc eic acid.
12. Brie y state the principa unctions o each o the o -
owing: carbohydrate, protein, ipid, nuc eic acid.
13. W hat are the three main parts o nuc eotides?
14. W hat is a ka osis?
15. W hat organic compound is associated with
atherosc erosis?
16. Describe atherosc erosis and give an examp e o a habit
that may increase and one that can decrease your risk o
deve oping atherosc erosis.
17. W hat is an aqueous so ution?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
 CHAPTER 2 Chemistry o Li e 41

18. Compare and contrast how ionic bonds and cova ent 21. An ion is ormed when:
bonds so ve the prob em o achieving stabi ity in atoms. a. e ectrons are shared
19. A particu ar protein mo ecu e is hydro yzed by an b. e ectrons remain in p ace
enzyme. H ow wou d you exp ain that process to c. e ectrons are gained or ost
someone un ami iar with chemica termino ogy? d. neutrons are added to the nuc eus
20. Your b ood norma y has a pH o around 7.4. Is your 22. In the equation H 2O CO 2 H H CO 3 , which
b ood a ka ine, acid, or neutra ? o the compounds is a reactant?
21. I a new y discovered protein was ound to regu ate how a. CO 2
hormones in uence the unctions o ce s in the body, b. H CO 3
wou d the protein be a structura protein or a unctiona c. O 2
protein? d.
22. Describe how DNA regu ates a o the bodys structures 23. W hich o these chemica subunits is ound in DNA?
and unctions? a. Uraci
23. H ow wou d you exp ain the di erence between 1H , 2H , b. Ribose 2
and 3H ? c. Amino acid
d. Deoxyribose
24. W hich o these va ues represents an acid?
Chapte r Te s t a. pH 7.5
A te r s tudying the chapte r, te s t your m as te ry by b. pH 6.1
re s ponding to the s e ite m s . Try to ans we r the m c. pH 9.0
w ithout looking up the ans we rs . d. pH 7.0
25. Steroid hormones are:
1. ________ is anything that occupies space and has mass. a. carbohydrates
2. Mo ecu es are made up o partic es ca ed ________. b. proteins
3. Positive y charged partic es within the nuc eus o an c. ipids
atom are ca ed ________. d. nuc eic acids
4. E ectrons inhabit regions o the atoms ca ed ________
eve s.
5. Substances with mo ecu es having more than one kind
Cas e S tudie s
o atom are ca ed ________. To s olve a cas e s tudy, you m ay have to re e r to
6. A(n) ________ chemica bond occurs when atoms share the glos s ary or index, othe r chapte rs in this text-
e ectrons. book, and othe r re s ource s .
7. T e symbo K represents the potassium ________.
8. A compound that dissociates in water to orm ions is 1. Grania knows that the pH o b ood is norma y 7.35 to
ca ed a(n) ________. 7.45. She sees that her b ood test resu ts show 7.57 as her
9. Mo ecu es that have a carbon-carbon bond in them are b ood p asma pH . Is Granias b ood too acid or too
c assif ed as ________ compounds. a ka ineor is her b ood pH within norma range?
10. In sa t water, sa t is the so ute and water is the 2. Baraka has adopted a high carb dieting strategy to he p
________. him prepare or an upcoming ath etic event. W hat cate-
11. W hen water is used to bui d up sma mo ecu es into gory o organic compound wi Baraka be eating in higher
arger mo ecu es, the process is ca ed ________. proportions than usua ? W hat are some examp es o this
12. ________ are so utions that have an excess o hydrogen type o compound that might be ound in Barakas ood?
ions. W hat ro e does this type o organic compound p ay in
13. T e b ood contains chemica s ca ed ________ that Barakas body? W hy might this be an advantage in an
maintain a stab e pH . ath etic event?
3. Sineads husband, Shane OShaunessey, just received the
Match each term in column B with its related term in column A. resu ts rom his annua physica examination. Shane
sheepish y reported to Sinead that his H DL cho estero
Column A Column B eve s have increased signif cant y. Sinead smi ed and to d
14. ________ g ycogen a. sa t Shane not to worry. W hy wou d Sinead not be troub ed
15. ________ co agen b. acid by this increase in Shanes H DL eve ?
16. ________ RNA c. base
17. ________ cho estero d. carbohydrate Answers to Active Learning Questions can be ound online
18. ________ NaC e. ipid at evolve.elsevier.com.
19. ________ NaOH . protein
20. ________ H C g. nuc eic acid
Cells
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Overview o Cells, 43
Size and Shape, 43
Composition, 44
Parts o the Cell, 44
Relationship o Cell Structure and Function, 50
Movement o Substances Through Cell Membranes, 50
Types o Membrane Transport, 50
Passive Transport Processes, 51
Active Transport Processes, 53
Cell Transport and Disease, 55
Cell Growth and Reproduction, 56
Cell Growth, 56
Cell Reproduction, 59
Changes in Cell Growth and Reproduction, 60

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Identi y three major components o a cell and discuss
the basic structure and unction o the plasma mem-
brane and cytoplasm.
2. List and brie y discuss the unctions o the primary
cellular organelles.
3. Discuss the basic structure and unction o the
nucleus.
4. Compare the major passive and active transport pro-
cesses that act to move substances through cell
membranes, as well as discuss the relationship o
cell transport to diseases.
5. Compare and discuss DNA and RNA and their unc-
tions in protein synthesis.
6. Discuss the stages o mitotic cell division and explain
the importance o normal cellular reproduction.
7. Explain how changes in cell growth and reproduction
allow the cell to adapt to its ever-changing
environment.
 3
Ab o u t 350 years ago, Robert H ooke ooked through his microscope LANGUAGE OF
one o the very ear y, somewhat primitive onesat some p ant materia . W hat S C IEN C E
he saw must have surprised him. Instead o a sing e magnif ed piece o p ant
materia , he saw many sma pieces. Because they reminded him o miniature
Be o re re ading the
monastery ce s, that is what he ca ed themce s. Since H ookes time, thou-
chapte r, s ay e ach o
sands o individua s have examined thousands o p ant and anima specimens the s e te rm s o ut lo ud. This w ill
and ound them a , without exception, to be composed o ce s. he lp yo u to avo id s tum bling ove r
the m as yo u re ad.
T is act, that ce s are the sma est structura units o iving things, has become
the oundation o modern bio ogy. Many iving things are so simp e that they
active transport
consist o just one ce . T e human body, however, is so comp ex that it (AK-tiv TRANZ-port)
consists not o a ew thousand or mi ions or even bi ions o ce s [act- move, -ive relating to,
but o many tri ions o them. T is chapter exp ores the struc- trans- across, -port carry]
ture and unction o ce s. adenosine triphosphate (ATP)
(ah-DEN-oh-seen try-FOS- ayt
[ay tee pee])
O ve r v ie w o C e lls [adenos- shortened rom adenine-
ribose, -ine chemical, tri- three,
S ize a n d S h a p e -phosph- phosphorus, -ate oxygen]
H uman ce s are microscopic in size anaphase
that is, they can be seen on y when (AN-ah- ayz)
magnif ed by a microscope. H ow- [ana- apart, -phase stage]
ever, the di erent types o hu- apoptosis
man ce s vary considerab y in (ap-oh-TOH-sis or ap-op-TOH-sis)
[apo- away, -ptosis alling]
centriole
(SEN-tree-ohl)
[centr- center, -ole small]
centromere
(SEN-troh-meer)
[centr- center, -mere part]
centrosome
(SEN-troh-sohm)
[centr- center, -som body]
chromatid
(KROH-mah-tid)
[chrom- color, -id structure or body]
chromatin granule
(KROH-mah-tin GRAN-yool)
[chrom- color, -in substance,
gran- grain, -ule little]
chromosome
(KROH-meh-sohm)
[chrom- color, -som- body]
cilium
(SIL-ee-um)
pl., cilia
(SIL-ee-ah)
[cili- eyelid, -um thing]

Continued on p. 63

43
 44 CHAPTER 3 Cells
size. An ovum ( ema e sex ce ), or examp e, has a diameter o
about 150 micrometers, but red b ood ce s have a diameter o
on y 7.5 micrometers.
Ce s di er even more notab y in shape than in size. Some
are at, some are brick shaped, some are thread ike, and some
have irregu ar shapes.
Advanced microscopes can picture human cells
and their internal structures with detail never
be ore possible. Check out these methods and
the dramatic images they produce in the article
Tools o Microscopic Anatomy at Connect It! at
evolve.elsevier.com.
C o m p o s it io n
Ce s contain cytoplasmthe iving substance that exists
on y in ce s. T e term cyto- is a word part that means ce .
Each ce in the body is surrounded by a thin membrane, the
plasma membrane. T is membrane separates the ce con-
tents rom the sa ty so ution ca ed interstitial uid (IF), or
simp y tissue uid, that bathes every ce in the body. Numer-
ous specia ized structures ca ed organelles, which are de-
3 scribed in subsequent sections, are contained within the cyto-
p asm o each ce . A sma , circu ar body ca ed the nucleus is
a so inside the ce .
Important in ormation re ated to body composition is in-
c uded in Chapter 2. You are encouraged to review this mate-
ria , which inc udes a discussion o the chemica e ements and
compounds important to body structure and unction.
P hos pholipid
bilaye r
Chole s te rol
P rote ins
FIGURE 3-1 Structure o the plasma membrane. Note that protein molecules may penetrate completely
through the two layers o phospholipid molecules.
P a r t s o t h e C e ll
T e three main parts o a ce are
1. P asma membrane
2. Cytop asm
3. Nuc eus
T e p asma membrane surrounds the entire ce , orming its
outer boundary. T e cytop asm is a the iving materia in-
side the ce (except the nuc eus). T e nuc eus is a arge,
membrane-bound structure in most ce s that contains the
genetic code.
P la s m a M e m b r a n e
As the name suggests, the plasma membrane is the mem-
brane that enc oses the cytop asm and orms the outer bound-
ary o the ce . It is an incredib y de icate structureon y
about 7 nm (nanometers) or 3/10,000,000 o an inch thick!
Yet it has a precise, order y structure (Figure 3-1).
wo ayers o phosphate-containing ipid mo ecu es ca ed
phospholipids orm a uid ramework or the p asma mem-
brane. Another kind o ipid mo ecu e ca ed cholesterol is a so
a component o the p asma membrane. Cho estero he ps
stabi ize the phospho ipid mo ecu es to prevent breakage o
the p asma membrane.
Note in Figure 3-1 that protein mo ecu es dot the sur aces
o the membrane. Some proteins extend a the way through
the phospho ipid ramework and others do not. T ese mem-
brane proteins have a variety o unctions in transport, signa -
ing, se -identif cation, anchoring o f bers, chemica process-
ing (enzymes), and more.
Ca rbohydra te
cha ins
 CHAPTER 3 Cells 45

Nucle us Nucle a r Nucle olus

e nve lope Nucle opla s m Nucle a r pore

Fla ge llum Microtubule s Chroma tin gra nule s

Rough e ndopla s mic
re ticulum
Ribos ome (a tta che d)

Cytopla s m

Microfila ments

Cilia

S mooth
endoplasmic
re ticulum
Microvilli

Lys os ome
P la s ma 3
me mbra ne
(cut)
Fre e ribos ome s
Ce ntriole s (ins ide ce ll)

Ce ntros ome
Mitochondrion
Golgi a ppa ra tus

FIGURE 3-2 Structure o the cell. Sketch o typical cell structure shows simpli ed drawings o major organelles. Some o these
structures, such as a f agellum or groups o cilia, are present only in certain types o cells.

Despite its seeming ragi ity, the p asma
membrane is strong enough to keep the ce
who e and intact and a so per orms other
i e-preserving unctions or the ce . It serves
as a we -guarded gateway between the uid
inside the ce and the uid around it. Certain
substances can move through the membrane
by way o transporter channe s and carriers, but
other substances are barred rom entry.
T e p asma membrane even unctions as a
communication mechanism. In what way, you
may wonder? Some o the proteins on the mem-
branes outer sur ace serve as receptors or certain
other mo ecu es when these other mo ecu es con-
tact the proteins. In other words, certain mo ecu es
bind to certain receptor proteins. For examp e,
some hormones (chemica s secreted into b ood
rom duct ess g ands) bind to membrane receptors, and a change
in ce unctions o ows. We might there ore think o such hor-
mones as carriers o chemica messages that are communicated
to ce s by way o binding to their receptors in the membrane.
T e p asma membrane a so identif es a ce as being part o
one particu ar individua . Some o the sur ace proteins serve
as positive identif cation tags because they occur on y in the
ce s o that individua . Carbohydrate chains and hybrid mo -
ecu es attached to the sur ace o ce s a so may p ay a ro e in
the identif cation o ce types. A practica app ication o this
act is made in tissue typing, a procedure per ormed be ore an
organ rom one individua is transp anted into another.
Cy t o p la s m
Cytop asm is the interna iving materia o ce s. It f s the
space between the p asma membrane and the nuc eus, which
can be seen in Figure 3-2 as a round or spherica structure in
 46 CHAPTER 3 Cells

the center o the ce . Numerous sma structures are part o cytoske eton. W hen a ce movesor when organe es within
the cytop asm, a ong with the uid that serves as the interior a ce moveparts o the cytoske eton are actua y pu ing or
environment o each ce . As a group, the sma structures pushing membranes and organe es.
that make up much o the cytop asm are ca ed organelles. Look again at Figure 3-2. Notice how many di erent kinds
T is name means itt e organs, an appropriate name be- o structures you can see in the cytop asm o this ce . A itt e
cause they unction or the ce ike organs unction or the more than a generation ago, a most a o these organe es
body. were unknown. T ey are so sma that they are sti invisib e
Another unction o membrane proteins is as transporters even when magnif ed 1000 times by a ight microscope. T e
that move various substances across the membrane. Such advent o e ectron microscopes in the midd e o the twentieth
movement across ce u ar membranes is discussed in detai century f na y brought them into view by magni ying them
ater in this chapter (see p. 50). many thousands o times.
In Figure 3-2 you can see sma thread ike structures scat- Next we brie y discuss the o owing organe es, a o
tered around in the cytop asm. You can see on y a ew o the which are ound in cytop asm (Table 3-1):
very many threads that make up the cytoskeleton or ce
ske eton. T in thread ike f aments in this ramework are 1. Ribosomes
ca ed microf aments. iny, ho ow tubes ca ed microtubu es 2. Endop asmic reticu um
a so are important. 3. Go gi apparatus
Like the bodys ramework o bones and musc es, the cyto- 4. Mitochondria
ske eton provides support and movement. T e various organ- 5. Lysosomes
e es are not just oating around random y. Instead, they are 6. Centrosome
he d (or moved) by the f bers and mo ecu ar motors o the 7. Ce extensions

3 TABLE 3-1 Structures and Function o Some Major Cell Parts

CELL PART STRUCTURE FUNCTION(S )
Plas m a m e m brane Phos pholipid bilaye r s tudde d w ith prote ins Se rve s as the boundary o the ce ll
Prote in and carbohydrate m ole cule s on oute r s ur ace o
plas m a m e m brane pe r orm various unctions or exam ple ,
they s e rve as m arke rs that ide nti y ce lls as be ing rom a
particular individual, re ce ptor m ole cule s or ce rtain hor-
m one s , or trans porte rs to m ove s ubs tance s through the
m e m brane
Ribos om e s Tiny particle s , e ach m ade up o rRNA s ubunits Synthe s ize prote ins a ce lls prote in actorie s
Endoplas m ic Me m branous ne twork o inte rconne cte d canals and Rough ER re ce ive s and trans ports s ynthe s ize d prote ins ( rom
re ticulum (ER) s acs , s om e w ith ribos om e s attache d (rough ER) ribos om e s )
and s om e w ithout attachm e nts (s m ooth ER) Sm ooth ER s ynthe s ize s lipids and ce rtain carbohydrate s
Golgi apparatus Stack o atte ne d, m e m branous s acs Che m ically proce s s e s , the n package s s ubs tance s rom the ER
Mitochondria Me m branous caps ule containing a large , olde d inte r- Ade nos ine triphos phate (ATP) s ynthe s is a ce lls powe r
nal m e m brane e m be dde d w ith e nzym e s ; contains plant or batte ry charge r
its ow n DNA m ole cule
Lys os om e Bubble o hydrolys is e nzym e s e ncas e d by A ce lls dige s tive bag, it bre aks apart large m ole cule s
m e m brane
Ce ntriole s Pair o hollow cylinde rs at right angle s to e ach othe r, He lp organize and m ove chrom os om e s during ce ll
e ach m ade up o tiny tubule s w ithin the re production
ce ntros om e
Cilia Hairlike ce ll s ur ace exte ns ions s upporte d by an Se ns ory ante nnae to de te ct conditions outs ide the ce ll;
inte rnal cylinde r m ade o m icrotubule s (longe r s om e cilia als o m ove s ubs tance s ove r s ur ace o the ce ll
than m icrovilli)
Flage lla Long w hiplike proje ction on the s pe rm ; s im ilar to a The only exam ple in hum ans is the tail o a s pe rm ce ll, pro-
cilium but m uch longe r pe lling the s pe rm through uids
Nucle us Double -m e m brane d, s phe rical e nve lope containing Contains DNA, w hich dictate s prote in s ynthe s is , the re by
DNA s trands playing an e s s e ntial role in othe r ce ll activitie s s uch as
trans port, m e tabolis m , grow th, and he re dity
Nucle olus De ns e re gion o the nucle us Make s s ubunits that orm ribos om e s

rDNA, Ribos om al RNA.


Ribosomes
O rgane es ca ed ribosomes, shown as dots in Figure 3-2, are
very tiny partic es ound throughout the ce . T ey are each
made up o two tiny subunits constructed most y o a specia
kind o RNA ca ed ribosomal RNA (rRNA).
Some ribosomes are ound temporari y attached to a net-
work o membranous cana s ca ed endoplasmic reticulum (ER).
Ribosomes a so may be ree- oating in the cytop asm. Ribo-
somes per orm a very comp ex unctionthey make enzymes
and other protein compounds. T us they are apt y nicknamed
protein actories.
Endoplasmic Reticulum
An endoplasmic reticulum (ER) is a system o membranes
orming a network o connecting sacs and cana s that wind back
and orth through a ce s cytop asm. T e ER extends rom the
nuc eus a most to the p asma membrane. T e tubu ar passage-
ways or cana s in the ER carry proteins and other substances
through the cytop asm o the ce rom one area to another.
T ere are two types o ER: rough and smooth.
Rough ER gets its name rom the many ribosomes that are
attached to its outer sur ace, which gives it a rough texture
simi ar to sandpaper. As they make their proteins, some ribo-
somes attach to the rough ER and insert the protein into the
interior o the ER.
As the proteins begin o ding insides, the ER transports
them to areas where chemica processing takes p ace. T ese
areas o the ER are so u o enzymes and other mo ecu es
that ribosomes have no room into which they can pass their
proteins, and so they do not attach. T e absence o attached
ribosomes gives this type o ER a smooth texture. Fats, carbo-
hydrates, and proteins that make up ce u ar membrane mate-
ria are manu actured in smooth ER. T us the smooth ER
makes new membrane or the ce .
o sum up: rough ER receives, o ds, and transports new y
made proteins, and smooth ER manu actures new membrane.
Golgi Apparatus
T e Golgi apparatus consists o tiny, attened sacs stacked on
one another near the nuc eus. Litt e bubb es, or sacs, pinch o
the ER and carry new proteins and other compounds to the
sacs o the Go gi apparatus (Figure 3-3). T ese itt e sacs, a so
ca ed vesicles, use with the Go gi sacs and a ow the con-
tents o both to ming e.
T e Go gi apparatus chemica y processes the mo ecu es
rom the ER by urther o ding, sorting, and modi ying pro-
teins and combining them with other mo ecu es to orm
quaternary proteins (see Figure 2-12 on p. 34) or combinations
such as g ycoproteins (carbohydrate/protein mo ecu es).
T e Go gi apparatus then packages the processed mo e-
cu es into new itt e vesic es that pinch o and pu away rom
the Go gi apparatus, moving s ow y outward to the p asma
membrane. Each vesic e then uses with the p asma mem-
brane, opens to the outside o the ce , and re eases its con-
tents. T e wa o each vesic e then becomes incorporated into
the p asma membranea mechanism or adding new mem-
brane components.
CHAPTER 3 Cells 47
An examp e o a Go gi apparatus product is the s ippery
substance ca ed mucus. I we wanted to nickname the Go gi
apparatus, we might ca it the ce s chemica processing and
packaging center.
Mitochondria
T e mitochondrion is another kind o organe e ound in a
ce s except red b ood ce s. Mitochondria are so tiny that a
ineup o 15,000 or more o them wou d f a space on y about
2.5 cm (1 inch) ong.
wo membranous sacs, one o ded tight y inside the other,
compose a sing e mitochondrion. T e o ds o the inner mem-
brane ook ike incomp ete partitions. W ithin a mitochon-
drions ragi e membranes, comp ex, energy-re easing chemi-
ca reactions occur continuous y. Because these reactions
supp y most o the power or ce u ar work, mitochondria have
been nicknamed the ce s power p ants.
Enzymes (mo ecu es that promote specif c chemica reac-
tions), ound in mitochondria membranes and the mito-
chondria uids, break down products o g ucose and other
nutrients to re ease energy. T e mitochondrion uses this re-
eased energy to recharge A P (adenosine triphosphate)
mo ecu esthe batteries required or ce u ar work. T is
process, which requires oxygen and re eases carbon dioxide,
is ca ed cellular respiration. 3
Each mitochondrion has its own tiny, ring-shaped DNA mo -
ecu e, sometimes ca ed a mitochondrial chromosome, that contains
in ormation or bui ding and running the mitochondrion.
To better understand this concept, use the Active
Concept Map Metabolism o Glucose to Generate
ATP at evolve.elsevier.com.
To learn more about how energy in the body is
measured, including examples o the energy
content o ood and the energy cost o common
activities, review the article Measuring Energy at
Connect It! at evolve.elsevier.com.
Lysosomes
T e lysosomes are membrane-wa ed organe es that in their
active stage ook ike sma sacs, o ten with tiny partic es in
them (see Figure 3-2). Because ysosomes contain enzymes that
promote hydro ysis, they can break apart (digest) arge nutrient
mo ecu es. T ere ore, they have the nickname digestive bags.
Lysosoma enzymes can a so digest substances other than
nutrients. For examp e, they can digest and thereby destroy
microbes that invade the ce . T us ysosomes can protect ce s
against destruction by microbes.
Former y, scientists thought ysosomes were invo ved in
programmed ce death. Now, however, we know a di erent
set o mechanisms is responsib e or ce suicide,or apoptosis,
which makes space or newer ce s. W hen apoptosis does not
occur norma y, the ce may remain and cause overgrowth o
the tissuepossib y producing a tumor.
 48 CHAPTER 3 Cells

T ey are arranged so that they ie at right ang es to each other

Why learn about organelles and their unctions? In
addition to helping us learn about normal body
structure and unction, these concepts help us
understand disease mechanisms that involve
organelles. To learn about some o these diseases,
check out the article Organelle Diseases at
Connect It! at evolve.elsevier.com.
Centrosome
T e centrosome is a region o cytop asm near the nuc eus o
each ce . It serves as the microtubule-organizing center o the
ce , thus p aying an important ro e in organizing and moving
the structures within the ce .
Centrioles are paired organe es ound within the centro-
some. wo o these rod-shaped structures exist in every ce .
(see Figure 3-2). Each centrio e is composed o microtubu es that
orm a tapered ramework or spind e that moves chromo-
somes during ce division, as we sha see ater in this chapter.
T e centrosome a so p ays a ro e in orming and organizing
the ce s cytoske eton, inc uding some o a ce s outward
extensions.
Cell Extensions
Most ce s have various indentations and extensions that serve
many di erent unctions. H ere we describe three o the major
types o ce extensions (Figure 3-4).
Microvilli
Microvilli are sma , f nger ike projections o the p asma
membrane o some ce s (Figure 3-4, A). T ese projections

FIGURE 3-3 The cells protein export system. The Golgi apparatus processes and packages protein molecules delivered rom the endoplasmic reticulum
(ER) by small vesicles. Some vesicles migrate to the plasma membrane to secrete the nal products, and other vesicles remain inside the cell or a time and
serve as storage vessels or the substance to be secreted.

1
P rote ins a s s e mble d by ribos ome s
3 a re folde d in the ER a nd pinch off in
me mbra ne ve s icle s.

2
Nucle us
ER ve s icle s move to the Golgi
a ppa ra tus for proce s s ing a nd 3
pa cka ging.
Ente ring the Golgi cha mbe r, a
prote in unde rgoe s che mica l
modifica tions a nd move s by a
ve s icle from cha mbe r to
3 chamber for further proce ssing.

Golgi
1
cha mbe rs
4
P roce s s e d mole cule s a re
Ribos ome s pa cka ge d in a me mbra nous
ve s icle tha t pinche s off a nd is
pulle d to the s urface of the cell.

Endopla s mic 2
P rote ins
re ticulum S e cre tory
ve s icle
Ve s icle
4 5
The ve s icle pops ope n a t
the ce ll s urfa ce to re le a s e
Cytopla s m Golgi its conte nts into the s pa ce
a ppa ra tus Ve s icle conta ining pla s ma outs ide the ce ll.
me mbra ne compone nts
5

P la s ma Me mbra ne
me mbra ne prote ins

Cilia Microvilli Fla ge llum
A B
FIGURE 3-4 Cell extensions. A, Microvilli (light blue) are small, nger-
like extensions o the plasma membrane that increase the sur ace area or
absorption. Cilia (darker blue) are longer than microvilli and move back and
orth, pushing f uids along the sur ace. B, The tail-like f agellum that propels
each sperm cell is so long that it does not t into the photograph at this
magni cation.
increase the sur ace area o the ce and thus increase its abi ity
to absorb substances. For examp e, ce s that ine the sma
intestine are covered with microvi i that increase the absorp-
tion rate o nutrients into the b ood. Microvi i have microf a-
ments inside them that produce wobb y movement and thus
make absorption more e cient.
Cilia
Cilia are extreme y f ne, hair ike extensions on the exposed or
ree sur aces o ce s (see Figure 3-4, A). Ci ia are arger than
microvi i and possess inner microtubu es that support and
enab e them to move. Every ce has at east one ci ium.
A ci ia act ike an insects antennae, a owing the ce to
sense its surroundings. For examp e, the hair ike ci ia in the
Cilia ry motion
Effe ctive
s troke
Extra ce llula r
move me nt
Re cove ry
s troke
Ce ll
Cilium Cilia
FIGURE 3-5 Movement patterns. In humans, cilia (le t and middle) ound in groups on stationary cells beat
in a coordinated oarlike pattern to push f uid and particles in the extracellular f uid along the outer cell sur ace.
A f agellum (right) produces wavelike movements, which propels a sperm cell orwardlike the tail o an eel.
CHAPTER 3 Cells 49
taste buds o the mouth can detect di erent chemica s dis-
so ved in sa iva.
Some ce s have hundreds o ci ia capab e o moving to-
gether in a wave ike ashion over the sur ace o a ce
(Figure 3-5). By moving as a group in one direction, they prope
mucus over the ce s that ine the respiratory or reproductive
tubes.
Cilia make one o the most important mechanisms
helping protect the delicate tissues o the bodys
airways. To preview these strategies, check out
the article Protective Strategies o the Respiratory
Tract at Connect It! at evolve.elsevier.com.
Flagella
A agellum is a sing e projection extending rom the ce
sur ace. F age a are structura y simi ar to ci ia but much on-
ger. Like ci ia, age a can move. T e cy inder o microtubu es
inside the age um moves in a way that whips the age um
around a owing it to act ike a prope er that pushes the ce
orward (see Figure 3-5).
In the human, the on y examp e o a age um is the tai
o the ma e sperm ce (see Figure 3-4, B). W igg ing move-
ments o the age um make it possib e or sperm to swim or 3
move toward the ovum a ter they are deposited in the ema e
reproductive tract.
N u c le u s
Central Structure o a Cell
Viewed under a ight microscope, the nuc eus o a ce ooks
ike a very simp e structurejust a sma sphere usua y near
the center o the ce . In certain specia ized ce s, the nuc eus
may be pushed to one side and perhaps s ight y compressed
into a more attened shape.
H owever, its simp e appearance be ies the comp ex and
critica ro e the nuc eus p ays in ce unction. T e nuc eus
contains most o the ce s genetic in ormation, which u ti-
mate y contro s every organe e in the cytop asm. It a so con-
tro s the comp ex process o ce reproduction. In other words,
Ce ll
motion
Fla ge lla r
motion
Ce ll
Flag e llum
 50 CHAPTER 3 Cells
the nuc eus must unction proper y or a ce to accomp ish its
norma activities and be ab e to dup icate itse .
Note that the ce nuc eus in Figure 3-2 is surrounded by
a nuclear envelope, a structure made up o two separate
membranes. T e nuc ear enve ope has many tiny openings
ca ed nuclear pores that permit arge mo ecu es to move
into and out o the nuc eus. T e nuc ear enve ope enc oses
a specia type o ce materia within the nuc eus ca ed
nucleoplasm.
Nuc eop asm contains a number o structures. wo o the
most important structures are the nucleolus and the chromatin
granules both pictured in Figure 3-2.
Nucleolus
T e nucleolus is a dense region o the nuc ear materia that is
critica in protein ormation because it is where the ce makes
the subunits that orm ribosomes. T e ribosome subunits then
migrate through the pores o the nuc ear enve ope into the
cytop asm o the ce where they assemb e into ribosomes, the
protein-making machinery o the ce .
Chromatin and Chromosomes
Chromatin granules in the nuc eus are made o proteins
around which are wound segments o the ong, thread ike
3 mo ecu es ca ed D NA, or deoxyribonucleic acid. DNA is
the genetic materia o ten described as the chemica cook-
book o the body. Because it contains the code or bui ding
both structura proteins and unctiona proteins, DNA deter-
mines everything rom gender and metabo ic rate to body
bui d and hair co or in every human being.
D uring ce division, DNA mo ecu es become tight y
coi ed. T ey then ook ike short, rod ike structures and are
ca ed chromosomes.
Each ce o the body contains a tota o 46 di erent DNA
mo ecu es in its nuc eus and one copy o a 47th DNA mo e-
cu e in each o its mitochondria. T e importance and unction
o DNA are exp ained in greater detai in the section on ce
reproduction ater in this chapter.
Re la t io n s h ip o C e ll S t r u c t u r e
a n d Fu n c t io n
Every human ce per orms certain unctionssome maintain
the ce s surviva , and others he p maintain the bodys surviva .
In many instances, the number and type o organe es within
ce s cause ce s to di er dramatica y in terms o their specia -
ized unctions.
For examp e, ce s that contain arge numbers o mitochon-
dria, such as heart musc e ce s, are capab e o sustained work.
W hy? Because the numerous mitochondria ound in these
ce s supp y the necessary energy required or rhythmic and
ongoing contractions o the heart.
Movement o the age um o a sperm ce is another ex-
amp e o how each type o organe e has a particu ar unction.
T e sperms age um prope s it through the reproductive tract
o the ema e, thus increasing the chances o success u
erti ization.
T is is how and why organizationa structure at the ce -
u ar eve is so important or unction in iving organisms.
Examp es in every chapter o the text i ustrate how structure
and unction are intimate y re ated at every eve o body
organization.
QUICK CHECK
1. Wh a t a re th e th re e m a jo r co m p o n e n ts o a ce ll?
2. Wh a t is th e m o le cu la r s tru ctu re o th e ce ll p la s m a
m e m b ra n e ?
3. Wh a t is cyto p la s m ? Ho w d o e s it s e rve th e b o d y?
4. Wh a t a re th e p rim a ry o rga n e lle s o th e ce ll? Wh a t a re th e
u n ctio n s o th e s e o rga n e lle s ?
5. Wh ich tw o ce ll s tru ctu re s co n ta in DNA?
M o ve m e n t o S u b s t a n c e s
Th ro u g h C e ll M e m b r a n e s
Ty p e s o M e m b r a n e Tr a n s p o r t
T e p asma membrane in every hea thy ce separates the
contents o the ce rom the tissue uid that surrounds it. At
the same time, the membrane must permit certain substances
to enter the ce and a ow others to eave. H eavy tra c
moves continuous y in both directions through ce mem-
branes. Mo ecu es o water, nutrients, gases, wastes, and many
other substances stream in and out o a ce s in end ess
procession.
A number o di erent transport processes a ow this mass
movement o substances into and out o ce s. T ese transport
processes are c assif ed under two genera headings:
1. Passive transport processes
2. Active transport processes
As imp ied by the name, active transport processes require
the expenditure o energy by the ce , and passive transport
processes do not. T e energy required or active transport
processes is obtained rom A P. A P is produced by the ce
using energy rom nutrients and is capab e o re easing that
energy to do work in the ce . For active transport processes to
occur, the breakdown o A P and the use o the re eased en-
ergy are required.
T e detai s o active and passive transport o substances
across ce membranes are much easier to understand i you
keep in mind the o owing two key acts:
1. In passive transport processes, no ce u ar energy is
required to move substances rom a high concentra-
tion to a ow concentration.
2. In active transport processes, ce u ar energy is re-
quired to move substances rom a ow concentration
to a high concentration.

P a s s ive Tr a n s p o r t P ro c e s s e s
T e primary passive transport processes that move sub-
stances through the ce membranes inc ude the o owing:
1. Di usion
2. Osmosis
3. Dia ysis
4. Fi tration
Scientists describe the movement o substances in passive
systems as going down a concentration gradient.T is means
that substances in passive systems move rom a region o high
concentration to a region o ow concentration unti they
reach equa proportions on both sides o the membrane. As
you read the next ew paragraphs, re er to Table 3-2, which
summarizes important in ormation about passive transport
processes.
D i u s io n
D if usiona good examp e o a passive transport processis
the process by which substances scatter themse ves even y
throughout an avai ab e space. T e system does not require
additiona energy or this movement. Di usion can thus be
described as a trend o movement o partic es down a concen-
tration gradientthat is, net movement rom an area o high
concentration toward an area o ower concentration.
TABLE 3-2 Passive Transport
PROCES S ES DES CRIPTION
Di us ion Move m e nt o particle s through a m e m -
brane rom an are a o high conce ntration
to an are a o low conce ntrationthat is ,
dow n the conce ntration gradie nt
Os m os is Pas s ive m ove m e nt o wate r through a
s e le ctive ly pe rm e able m e m brane in the
pre s e nce o at le as t one nonpe ne trating
s olute
Filtration Move m e nt o wate r and s m all s olute parti-
cle s , but not large r particle s , through a
f ltration m e m brane ; m ove m e nt occurs
rom are a o high pre s s ure to are a o
low pre s s ure
High
pre s s ure
CHAPTER 3 Cells 51
Lump
of s uga r
Time
FIGURE 3-6 Di usion. The molecules o a lump o sugar are very
densely packed when they enter the water. As sugar molecules collide re-
quently in the area o high concentration, they gradually spread away rom
each othertoward the area o lower concentration. Eventually, the sugar
molecules become evenly distributed.
o demonstrate di usion o partic es throughout a uid,
per orm this simp e experiment the next time you pour your-
se a cup o co ee or tea (Figure 3-6). P ace some sugar on a
teaspoon and ower it gent y to the bottom o the cup. Let it
stand or 2 or 3 minutes, and then, ho ding the cup steady,
take a sip o the top. It wi taste sweet. W hy? Because some
o the sugar mo ecu es wi have di used rom the area o high
concentration near the mound o sugar at the bottom o the 3
EXAMPLES
Move m e nt o carbon dioxide out o all ce lls ;
m ove m e nt o s odium ions into ne rve
ce lls as they conduct an im puls e
Move m e nt o wate r into and out o ce lls to
corre ct im balance s in wate r
conce ntration
In the kidney, wate r and s m all s olute s
m ove rom blood ve s s e ls but blood pro-
te ins and blood ce lls do not, thus be gin-
ning the orm ation o urine
Low
pre s s ure
 52 CHAPTER 3 Cells
cup to the area o ow concentration at the top o the
cupthus sweetening the entire so ution.
Assume that the tea is brewed using a tea bag made o
shredded tea eaves inside a pouch o porous f ter paper..
One can easi y watch the di usion o dark pigment parti-
c es rom a concentrated area inside the tea bag to the esss
concentrated area in the water outside the tea bag. T us,,
the pigment partic es moved through a membrane (the
paper) by di usionthe tendency to spread out and create
a uni orm concentration or equilibrium.
T e key to di usion across a membrane is the presence
o pores big enough or the partic es to pass through. In
ce membranes, most mo ecu es cannot pass through the
membrane un ess there are gateways that permit it. Various
protein channe s act as gated doorways that permit certain
mo ecu es to di use through them. O ther protein struc-
tures act as carriers that bind to the partic es and carry
them through to the other side o the membrane. W ithout
these transporters, most solutes (substances disso ved in
the water) cou d not di use through ce membranes.
T e process o di usion is shown in Figure 3-7. Note that
both substances di use rapid y through the porous membrane
in both directions. H owever, as indicated by the purp e arrows,
more o the so ute (disso ved substance) moves out o the 20%
3 so ution, where the concentration is higher, into the 10% so u-
tion, where the concentration is ower, than in the opposite
direction. T is is an examp e o movement down a concentra-
tion gradient.
T e resu t? Equilibration or ba ancing o the concentra-
tions o the two so utions a ter an interva o time. A ter this
equi ibrium is reached, equa amounts o so ute wi di use in
both directions.
T e p asma membrane o a ce is said to be selectively per-
meable because it permits the passage o certain substances but
not others. Put another way, the membrane has specif c chan-
nels and carriers to a ow di usion o specif c kinds o
Me mbra ne
(pe rme a ble to H2 O a nd s olute )
10% s olute 20% s olute 15% s olute 15% s olute
S olute S olute
H2 O
H2 O
Diffus ion Equilibrium
Time
FIGURE 3-7 Di usion through a membrane. Note that the membrane is
permeable to solute and water and that it separates a 10% solution o solute
particles rom a 20% solution. The container on the le t shows the two solutions
separated by the membrane at the start o di usion. The container on the right
shows the result o di usion a ter some time has passed.
Me mbra ne 7.5%
5% 10% (pe rme a ble a lbumin
a lbumin a lbumin to H2 O, 7.5%
not a lbumin) a lbumin
H 2O H 2O
Ne t os mos is Equilibrium
Time
FIGURE 3-8 Osmosis. The solute albumin cannot cross the semipermeable
membrane, but water can. The resulting movement o water (only) produces
equilibration o the solutions, as water moves away rom the side where it is
most abundant and toward the solution with more solute particles. Osmosis also
causes a shi t in f uid volume and pressure (osmotic pressure).
mo ecu es. T is necessary property permits some substances,
such as nutrients, to gain entrance to the ce whi e exc uding
others.
O s m o s is
Osmosis is a specia case o passive transport. It is in many
ways simi ar to di usion, but is thought to invo ve unique
mechanisms at the pores o ce membranes.
Osmosis is the passive movement o water molecules
through water channe s in a se ective y permeab e membrane
when some o the solute cannot cross the membrane (because
there are no open channe s or carriers or that so ute).
Figure 3-8 shows that osmosis moves water in a direction that
resu ts in di ution o so ution to a type o equi ibrium ca ed
osmotic balance.
In osmosis, because water moves into a space but there is
no exchange o so utes, a change in uid pressure may resu t.
Such uid pressure is ca ed osmotic pressure.
D ia ly s is
In a process ca ed dialysis, some so utes move across a
se ective y permeab e membrane by di usion and other
so utes do not (Figure 3-9). T us, dia ysis resu ts in an un-
even distribution o various so utes.
eve
Dia ysis is o ten used as a medica procedure in which
b oood is pumped through membranous tubing bathed in a
so ution that mimics norma body uids. Because the
sma waste mo ecu es norma y removed by the kidney
di use into the bath so ution, but the arger proteins in the
b ood cannot di use, such dia ysis can sa e y c ean the
b ood o waste.
Another strategy is to instead pump the bath so ution
into the uid space o the abdominope vic cavity to accept
the b oods wastes by dia ysis. A ter some time, the dirty
so ution is then pumped back out o the body.
T ese dia ysis procedures can be used when the kidney
is not unctioning e cient y.

C LIN ICA L APPLICATION
OS MOTIC BALANCE
The inte rnal uid e nvironm e nt o the body is m os tly a we ak
s olution o s alts s uch as NaCl and othe r s olute s as is the
s olution ins ide e ach ce ll o the body. Os m otic balance is m ain-
taine d through hom e os tas is . Howeve r, dis ruptions o hom e o-
s tas is can caus e pote ntially dange rous m ove m e nt o wate r
and re s ulting s hi ts in pre s s ure . He re , we explore exam ple s o
w hat can go w rong.
A NaCl solution is said to be isotonic (iso equal) i it con-
tains the same concentration o salt normally ound in a living red
blood cell, which measures 0.9% NaCl. Salt particles (Na and
Cl ions) do not cross the plasma membrane easily, so salt solu-
tions that di er in concentration rom the cells uid will promote
the osmosis o water one way or the other. A solution that con-
tains a higher level o salt than the cell (above 0.9% ) is said to be
hypertonic (hyper above) to the cell and one containing less
(below 0.9% ) is hypotonic (hypo below) to the cell.
With w hat you now know about f ltration, di us ion, and
os m os is , can you pre dict w hat would occur i re d blood ce lls
we re place d in is otonic, hypotonic, and hype rtonic s olutions ?
Examine the f gure s. Note that re d blood ce lls place d in iso-
tonic solution rem ain unchange d be caus e the re is no e ective
di ere nce in s alt or wate r conce ntrations . The movem e nt o
water into and out o the ce lls is about e qual. This is not the case
w hen red ce lls are place d in hype rtonic salt solution. In this
case , the ce lls imm ediate ly lose wate r rom their cytoplas m into
Filt r a t io n
Filtration is the movement o water and so utes through a
membrane as a resu t o a pushing orce that is greater on one
side o the membrane than on the other side. T e orce is
ca ed hydrostatic pressure, which is simp y the orce or weight
o a uid pushing against some sur ace (an examp e is b ood
pressure, in which b ood pushes against vesse wa s).
Dia lys is
ba g
Glucos e
Albumin
Wa te r
Time
FIGURE 3-9 Dialysis. A membrane bag containing glucose, water, and
albumin (protein) molecules is suspended in pure water. Over time, the smaller
solute molecules (glucose) di use out o the bag. The larger solute molecules
(albumin) remain trapped in the bag because the bag is impermeable to them.
Thus dialysis results in separation o small and large solute particles.
CHAPTER 3 Cells 53
H2 O
Hypotonic s olution
(ce lls lys e )
Is otonic s olution
the surrounding salty solutionand
the ce lls s hrink. This proce ss is called
crenatio n be cause unde r a micros cope ,
Hype rtonic s olution
the se shrive le d ce lls appear to have a (ce lls cre na te )
cre nate d (scallope d) borde r.
The oppos ite occurs i re d ce lls are
place d in a hypotonic s olutionthe ce lls s we ll as wate r e nte rs
rom the s urrounding dilute s olution. Eve ntually the ce lls bre ak
3
or lys e , and the he m oglobin they contain is re le as e d into the
s urrounding s olution.
A princip e concerning f tration that is o great physio og-
ica importance is that it a ways occurs down a hydrostatic
pressure gradient. T is means that when two uids have un-
equa hydrostatic pressures and are separated by a membrane,
water and di usib e so utes or partic es (those to which the
membrane is permeab e) wi f ter out o the so ution that has
the higher hydrostatic pressure into the so ution that has the
ower hydrostatic pressure.
Fi tration is part y responsib e or moving water and sma
so utes rom b ood into the uid spaces o the bodys tissues.
Fi tration is one o the processes responsib e or urine orma-
tion in the kidney. Disso ved waste partic es are f tered out o
the b ood into the kidney tubu es because o a di erence in
hydrostatic pressure.
Ac t ive Tr a n s p o r t P ro c e s s e s
Active transport is the uphi movement o a substance
through a iving ce membrane. Uphill means up a concen-
tration gradient (that is, rom a ower to a higher concentra-
tion). T e energy required or this movement is obtained
rom A P. Because the ormation and breakdown o A P
require ce activity, active transport mechanisms occur on y
through iving membranes. Table 3-3 summarizes active trans-
port processes.
 54 CHAPTER 3 Cells

TABLE 3-3 Active Transport Processes

PROCES S DES CRIPTION EXAMPLES
Ion pum p Move m e nt o s olute particle s rom an are a o In m us cle ce lls , pum ping o ne arly all
low conce ntration to an are a o high conce n- calcium ions to s pe cial com partm e nts
tration (up the conce ntration gradie nt) by or out o the ce ll
m e ans o a carrie r prote in s tructure

ATP

Phagocytos is Move m e nt o a ce ll or othe r large particle into a Trapping o bacte rial ce lls by phagocytic
ce ll by trapping it in a s e ction o plas m a m e m - w hite blood ce lls
brane that pinche s o ins ide the ce ll

Pinocytos is Move m e nt o uid and dis s olve d m ole cule s into Trapping o large prote in m ole cule s by s om e
a ce ll by trapping the m in a s e ction o plas m a body ce lls
m e m brane that pinche s o ins ide the ce ll

3 Io n P u m p s Greek word meaning to eat.T e word is appropriate because

A comp ex membrane component ca ed the ion pump makes this process permits a ce to engu and itera y eat re ative y
possib e a number o active transport mechanisms. An ion arge partic es.
pump is a protein structure in the ce membrane ca ed a Certain white b ood ce s can use phagocytosis to destroy
carrier. T e ion pump uses energy rom A P to active y move invading bacteria and chunks o debris rom tissue damage.
ions across ce membranes against their concentration gradi- D uring this process the cytoske eton extends the ce s p asma
ents. Pump is an appropriate term because it suggests that membrane to orm a pocket around the partic es to be moved
active transport moves a substance in an uphi direction just
as a water pump does, that is, moves water uphi . Extrac e llular
An ion pump is specif c to one particu ar ion. T ere ore, S odium-pota s s ium K; K;
di erent ion pumps are required to move di erent types o ATP a s e
ions. For examp e, sodium pumps move sodium ions on y.
Likewise, ca cium pumps move ca cium ions and potassium
pumps move potassium ions.
Some ion pumps are coup ed to one another so that two
or more di erent substances may be moved through the ce ATP
Na+ P
membrane at one time. For examp e, the sodium-potassium Na+ Na+ ADP
Intrac e llular
pump shown in Figure 3-10 pumps sodium ions out o a ce
whi e it pumps potassium ions into the ce . Because both ions
are moved against their concentration gradients, this pump
Na+ Na+
creates a high sodium concentration outside the ce and a
high potassium concentration inside the ce . Such a pump is Na+
required to remove sodium rom the inside o a nerve ce a ter
it has rushed in as a resu t o the passage o a nerve impu se.
Some ion pumps are coup ed with other specif c carriers
that transport g ucose, amino acids, and other substances.
P
H owever, there are no transporter pumps or moving water P
it can move on y passive y by osmosis.

P h a g o c y t o s is FIGURE 3-10 Sodium-potassium pump. Three sodium ions (Na ) are

pumped out o the cell and two potassium ions (K ) are pumped into the cell
Phagocytosis is another examp e o how a ce can active y during one pumping cycle o this carrier molecule. Adenosine triphosphate
move an object or substance through the p asma membrane (ATP) is broken down in the process so that the energy reed rom ATP can
and into the cytop asm. T e term phagocytosis comes rom a be used to pump the ions. ADP, Adenosine diphosphate.
 CHAPTER 3 Cells 55

Golgi
a ppa ra tus

Pa rticle

Me mbra ne -
bound
ve s icle

Lys os ome
Fus ion of FIGURE 3-11 Phagocytosis. Phagocytosis
ve s icle with is an active transport mechanism that requires
lys os ome expenditure o energy. Note how an extension o
cytoplasm envelops the particles, which are drawn
through the cell membrane and into the cytoplasm,
where they are digested.
Dige s tion
by e nzyme s

3
transport o C out o ce s resu ts in the re ease o water as
we . In CF, the mucus and other watery secretions o ce s get
very thick because they contain very itt e water. In the ungs,
this thick mucus impairs norma breathing and requent y
into the ce and thus enc oses the materia in a vesic e. Move- eads to recurring ung in ections.
ments o the cytoske eton pu the vesic e deeper into the ce . Figure 3-12 shows a newborn with severe CF. Because o the
Once inside the cytop asm, the phagocytic vesic e uses di cu ty with breathing and digestion and other prob ems
with a ysosome containing digestive enzymes and the parti- caused by the disease, the a ected chi d has not deve oped
c es are broken apart (Figure 3-11). norma y and has a b oated ab-
domen. Digestion is compro-
P in o c y t o s is mised by thick pancreatic secre-
Pinocytosis is an active transport mechanism used to incor- tions that may p ug the duct
porate uids or disso ved substances into ce s by trapping eading rom the pancreas and
them in a pocket o p asma membrane that pinches o inside thereby prevent important di-
the ce . Again, the term is appropriate because the word part gestive juices rom owing into
pino comes rom the Greek word meaning drink. the intestines. T ickened mucus
Because the cytoske eton uses energy rom A P to pro- can a so cause intestina b ock-
duce the movements o both pinocytosis and phagocytosis, age and disrupt norma absorp-
these processes are active transport mechanisms. tion o nutrients.

C e ll Tr a n s p o r t a n d D is e a s e FIGURE 3-12 Cystic f brosis. In

Considering the importance o active and passive transport cystic brosis (CF), the absence o chlo-
ride ion pumps causes thickening o
processes to ce surviva , you can imagine the prob ems that watery secretions in the body. Because
arise when one o these processes ai s. Severa very severe thickened secretions block airways, in-
diseases resu t rom damage to ce transport processes. testines, and digestive ducts, children
Cystic brosis (CF), or examp e, is an inherited condition born with this disease o ten become
in which ch oride ion (C ) pumps in the p asma membrane weakened and bloatedand, without
S
treatment, may die be ore adulthood.
are mis o ded and not unctioning proper y. Movement o Recent availability o advanced CF ther- R L
negative C ions attracts positive sodium ions (Na ), which apies has increased the quality and
in turn osmotica y attract water mo ecu es. T ere ore, length o li e in CF patients. I
 56 CHAPTER 3 Cells

Advances in treatment o CF have great y improved sur-

Ea ch DNA mole cule
vivabi ity and qua ity o i e in many CF patients. As our un-
derstanding o CFs ce u ar mechanisms increases, there is
Ma de up of
rea hope or even more improvements in the near uture
perhaps inc uding gene therapy (see Chapter 25).
Cholera is a bacteria in ection that causes ce s ining the Ge ne s
intestines to eak C . In cho era, water o ows C out o the
ce s by osmosis, causing severe diarrhea and the resu ting oss Copie d a s RNA tra ns cripts
o water by the body. Death can occur in a ew hours i treat- (tra ns cription)
ment is not received.
As you can see, a working know edge o ce transport is
needed to understand the mechanisms o a number o medica
conditions. Coding RNA Noncoding RNA

(tra ns la tion)
QUICK CHECK
Dicta te s prote in
1. Wh a t a re th e d i e re n ce s b e tw e e n p a s s ive a n d a ctive s ynthe s is, S upports
tra n s p o rt p ro ce s s e s ? which de te rmine s or re gula te s
2. Wh a t is d i u s io n ? Wh a t is o s m o s is ? s tructure of
3. Ho w d o e s a n io n p u m p w o rk? Ho w d o a u lty io n p u m p s
ca u s e d is e a s e ?
4. Ho w d o p h a g o cyto s is a n d p in o cyto s is d i e r?

S tructura l Functiona l
prote ins of ce ll prote ins of ce ll

C e ll G ro w t h a n d Re p ro d u c t io n
3 C e ll G ro w t h
De te rmine De te rmine

For norma growth and maintenance, the ce must continu-

a y produce the many diverse structura and unctiona pro-
teins needed or human i e. T e unctiona proteins then
synthesize carbohydrates and ipids and he p regu ate a ce
unctions.
T e two nucleic acids deoxyribonucleic acid (D NA) and
ribonucleic acid (RNA) p ay crucia ro es in directing protein
synthesis in each ce . We start our story o ce growth and
reproduction with these amazing mo ecu es.
S tructure of ce ll Functions of ce ll
FIGURE 3-13 Function o genes. Genes copied rom deoxyribonucleic
acid (DNA) are copied to ribonucleic acid (RNA) in a process called transcrip-
tion. The RNA transcripts are then used in a process called translation, in
which a code that determines the sequence o amino acids is translated to
orm a protein. The structure o the resulting protein determines the role o
the protein in body structure and unctionand ultimately, the structure and
unction o the body.

DNA
Chromosomes, which are composed arge y o DNA, contain
the in ormation needed to make a the proteins o the ce s
the in ormation that a ows a ce to ive and unction nor-
ma y. T e genetic code contained in segments o the DNA
mo ecu es that are ca ed genes u timate y determines the
structure and unction o a ce s (Figure 3-13). T is coded in-
ormation can be transmitted to generations o ce s and
eventua y to o spring.
Structura y, the DNA mo ecu e resemb es a ong, narrow
adder made o a p iab e materia . It is twisted round and
round its axis, taking on the shape o a doub e he ix (see
Figure 2-14, p. 35).
Each DNA mo ecu e is made o many sma er units ca ed
nucleotides. Each nuc eotide is made up o a sugar, a phosphate,
and a base (see Table 2-4 on p. 35). T e bases are adenine,
thymine, guanine, and cytosine. T ese nitrogen-containing
chemica s are ca ed bases because by themse ves they have a
high pH and chemica s with a high pH are ca ed bases (see
p. 30 or a discussion o acids and bases).
As you can see in Figure 2-14 (p. 35), each step in the
D NA adder consists o a pair o bases. O n y two combina-
tions o bases occur, and the same two bases always pair o
with each other in a D NA mo ecu e. Adenine a ways binds
to thymine, and cytosine a ways binds to guanine. T is
characteristic o D NA structure is ca ed complementary
base pairing.
A gene is a specif c segment o base pairs in a chromosome.
A though the types o base pairs in a chromosomes are the
same, the order or sequence o base pairs is not the same. T is
act has tremendous unctiona importance because it is the
sequence o base pairs in each gene o each chromosome that
determines the genetic code.
Most genes direct the synthesis o at east one kind o
protein mo ecu e. Each protein may unction, or examp e, as
an enzyme, a structura component o a ce , or a specif c hor-
mone. O r it may combine with other protein mo ecu esor
even with carbohydrates or ipidsto orm any number o
arge, comp ex mo ecu es such as quaternary proteins, g yco-
proteins, proteog ycans, or ipoproteins.

T e enzymes and other unctiona mo ecu es produced by
protein synthesis aci itate and regu ate ce u ar chemica reac-
tions that drive a the unctions o ce sand thereby a the
unctions o the body.
In humans having 46 nuc ear chromosomes and one kind
o mitochondria chromosome in each body ce , DNA has a
content o genetic in ormation tota ing about 3 billion base
pairs in perhaps 19,000 or so protein-coding genes. Sections
o DNA that do not code or protein structure have other
unctions, which inc ude regu ation o turning genes on and
o and regu ating protein synthesis. T is means that over a
bi ion bits o in ormation are inherited rom each o our two
bio ogica parents. Is it any wonder, then, with a o this ge-
netic in ormation packed into each o our ce s, that we are
such comp ex organisms?
RN A
T e genetic in ormation contained in protein-coding genes is
capab e o directing the synthesis o a specif c protein. Some
genes instead contain in ormation needed to bui d regu atory
types o RNA mo ecu es.
Regu atory RNA mo ecu es act as unctiona mo ecu es that
a ect some o the chemica processes in a ce . For examp e,
ribosomal RNA (rRNA) mo ecu es orm most o the ribosomes
protein-synthesizing structure and other RNA mo ecu es that
serve as temporary working copies o genetic code.
Most o the DNA, with its genetic code that dictates di-
rections or protein synthesis, is contained in the nuc eus o
the ce . T e actua process o protein synthesis, however, oc-
curs at ribosomes in the cytop asm and on ER. Another nu-
c eic acid, RNA, copies this genetic in ormation rom the
nuc eus and carries it to the cytop asm. RNA a so may be an
end product ormed in the nuc eus using the DNA code and
transported out to the cytop asm, where it regu ates various
unctions o the ce .
Both RNA and DNA are composed o nuc eotide sub-
units made up o a sugar, a phosphate, and one o our bases.
RNA subunits, however, contain a di erent sugar and base
TABLE 3-4 Types o RNA*
ACRONYM NAME DES CRIPTION
m RNA Me s s e nge r Single , un olde d s trand Se rve s as working copy o
RNA o nucle otide s
rRNA Ribos om al Single , olde d s trand
RNA o nucle otide s
tRNA Trans e r Single , olde d s trand
RNA o nucle otide s ; has
an anticodon at one
e nd and an am ino
acidbinding s ite at
the othe r e nd
*Ce lls contain othe r type s o RNA that pe r orm com plex unctions beyond the s cope o this book.
CHAPTER 3 Cells 57
component. In RNA nuc eotide subunits, the base uraci
substitutes or the base thymine. T e types o RNA discussed
here are a sing e-stranded mo ecu esnot doub e-stranded
ike DNA. H owever, short doub e-stranded RNA mo ecu es
a so exist in nature.
Table 3-4 ists the major types o RNA invo ved in protein
synthesis.
P ro t e in S y n t h e s is
T e process o trans erring genetic in ormation rom the nu-
c eus into the cytop asm, where proteins are actua y pro-
duced, requires comp etion o two steps ca ed transcription
and translation.
Transcription
D uring transcription the doub e-stranded DNA mo ecu e
separates or unwinds, and a specia type o RNA ca ed
messenger RNA (mRNA) is ormed (Figure 3-14, Step 1).
Each strand o mRNA is a comp ementary copy o a particu-
ar gene sequence a ong one o the new y separated DNA
spira s. T e messenger RNA is said to have been transcribed
or copied rom its DNA mo d or temp ate. T e mRNA then
unctions as a temporary working copy o the genetic in or-
mation in a gene rom DNA.
T e mRNA transcripts pass rom the nuc eus to the cyto- 3
p asm to direct protein synthesis in the ribosomes (Figure 3-14,
Step 2).
Translation
ranslation is the process o trans ating the genetic code in
the mRNA transcript to synthesize a protein. rans ation oc-
curs within ribosomes, which attach around the mRNA
strands in the cytop asm. T e ribosomes move a ong the
mRNA transcript and read the in ormation encoded there
to direct the choice and sequencing o the appropriate chemi-
ca bui ding b ocks ca ed amino acids.
First, the two subunits o a ribosome attach at the begin-
ning o the mRNA mo ecu e (Figure 3-14, Step 3). Reca that
ribosomes are themse ves made most y o
RNAribosoma RNA (rRNA). T e ribo-
some then moves down the mRNA strand
ROLE IN CELL as amino acids are assemb ed into their
FUNCTION proper sequence (Figure 3-14, Step 4).
rans er RNA (tRNA) mo ecu es assist
one prote in-coding ge ne the process by bringing specif c amino acids
Com pone nt o the ribos om e in to dockat each codon a ong the mRNA
(along w ith prote ins ); strand. A codon is a series o three nuc eo-
attache s to m RNA and tide basesa trip etthat acts as a code
participate s in trans lation representing a specif c amino acid. Each
Carrie s a s pe cif c am ino gene encoded in the mRNA is made up o
acid to a s pe cif c codon a series o codons that te the ce the se-
o m RNA at the ribos om e quence o amino acids to string together to
during trans lation orm a protein strand. Each tRNA inc udes
an anticodon segment at one end, which is
a comp ementary sequence o three bases
that a ows the tRNA to recognize the
 58 CHAPTER 3 Cells

1 particu ar codon or the type o amino

T
r
P rote in s ynthe s is be gins with acid carried by that tRNA mo ecu e (see

a
n
Nucle us transcription, a process in which an

s
Figure 3-14, inset).

c
(s ite of 1 mRNA mole cule forms a long one

r
i
T e strand o amino acids ormed

p
tra ns cription) gene se que nce of a DNA molecule

t
i
o
within the ce lls nucle us. As it is during trans ation then o ds on itse

n
mRNA forme d, the mRNA mole cule
DNA and perhaps even combines with another
s e pa ra te s from the DNA mole cule.
strand to orm a comp ete protein mo -
ecu e (see Figure 2-12, p. 34). T e specif c,
2 Nucle a r e nve lope
comp ex shape o each type o protein
The mRNA tra ns cript the n mo ecu e a ows the mo ecu e to per orm
le ave s the nucle us through 2 specif c unctions in the ce . It is c ear
the la rge nucle a r pore s. mRNA tra ns porte d that because DNA directs the shape o

T
r
a
out of nucle us

n
each protein, DNA a so directs the unc-

s
l
a
3 tion o each protein in a ce (see

t
i
S ma ll

o
Figure 3-13).

n
ribos ome
Nucle a r unit
pore s Protein Synthesis and Disease
3 Many diseases have a ce u ar basis. T at
La rge ribos ome unit
Outs ide the
nucle us, ribos ome
is, they are basica y ce prob ems even
Growing s ubunits a tta ch to though they may a ect the entire body.
polype ptide cha in the be ginning of Because individua ce s are members o
the mRNA
mole cule a nd
an interacting community o ce s, it is
Anticodon be gin the proce s s no wonder that a prob em in just a ew
(mRNA binding s ite ) of tra ns la tion. ce s can have a ripp e e ect that in u-
3 Pe ptide
bonds ences the entire body. Most o these ce
prob ems can be traced to abnorma ities
Cytopla s m
(s ite of tra ns la tion) in the DNA itse or in the process by
Amino a cid which DNA in ormation is transcribed
U

tRNA binding s ite

U

and trans ated into proteins.

C

In individua s with inherited diseases,

A
G
A

4 abnorma DNA rom one or both par-

Pe ptide ents may cause production o dys unc-
G

bond
A

tiona proteins in certain ce s or prevent

U
G

forming
C

a vita protein rom being synthesized.

A
C

U
C

Amino For examp e, DNA may contain a mis-

G
G

a cids
G

take in its genetic code that prevents

C

Codon
production o norma b ood-c otting
G

proteins. Def ciency o these essentia

U
G

C
A proteins resu ts in excessive, uncontro -
A

C
ab e b eedinga condition ca ed hemo-
C

Dire ction of
philia (see Chapters 13 and 25).
U

ribos ome
a dva nce
G

4 Chemica or mechanica irritants, ra-

C

In tra ns la tion, tRNA mole cule s diation, bacteria, viruses, and other actors
C

bring s pe cific a mino a cids, C

e ncode d by e a ch mRNA codon, U can direct y damage DNA mo ecu es and
G
into pla ce a t the ribos ome s ite . As U
G
thus disrupt a ce s norma unction. For
the a mino a cids a re brought into examp e, the human immunode ciency vi-
the prope r s e que nce, they a re
joine d toge the r by pe ptide bonds
rus (HIV) eventua y inserts its own ge-
to form long s tra nds ca lle d netic codes into the DNA o certain ce s.
polype ptide s. T e vira codes trigger synthesis o vira
mo ecu es, detouring raw materia s in-
tended or use in bui ding norma human
products. T is does two things: it prevents
FIGURE 3-14 Protein synthesis. Steps show transcription o the DNA code to mRNA and subse-
quent translation o the mRNA at the ribosome to assemble a polypeptide. Several polypeptide chains human white b ood ce s rom per orm-
may be needed to make a complete protein molecule. DNA, Deoxyribonucleic acid; mRNA, messenger ing their norma unctions, and it pro-
RNA (ribonucleic acid); tRNA, trans er RNA. vides a mechanism by which the virus can

RES EA RC H, IS S U ES , AND TREN D S
HUMAN GENOME
The s um total o all o the DNA in e ach ce ll o the body is calle d
the ge no m e . Inte ns e , coordinate d e orts by s cie ntis ts re -
ce ntly m appe d all o the ge ne locations in the hum an ge nom e .
E orts at re ading the di e re nt ge ne tic code s pos s ible at e ach
location are s till unde rway.
Much o the work o m apping the hum an ge nom e was
done as part o the Hum an Ge nom e Proje ct (HGP), w hich was
s tarte d in 1990. Be s ide s producing a hum an ge ne tic m ap and
deve loping tools o ge ne tic m apping, a f e ld calle d ge nom ics ,
the HGP als o addre s s e s the e thical, le gal, and s ocial is s ue s
that m ay aris e a notable f rs t or s uch a m as s ive s cie ntif c
re s e arch e ort.
reproduce itse and spread to other ce s. W hen enough ce s o
the human immune system are a ected, they can no onger
protect us rom in ections and cancera condition that may
eventua y ead to death.
T e genetic basis or disease discussed brie y in Chapter 6
is more u y exp ained in Chapter 25.
C e ll Re p ro d u c t io n
C e ll Li e Cyc le
T e process o ce reproduction is one part o the ce s i e
cyc e. It invo ves the division o the ce into two genetica y
identica daughter ce s. Ce reproduction thus requires divi-
sion o the nuc eusa process ca ed mitosisand division o
the cytop asm.
As you can see in Figure 3-15, when a ce is not dividing, but
instead going about its usua unctions, it is in a period o its
i e cyc e ca ed interphase.
Interphase inc udes the initia growing stages o a new y
ormed ce , in which a ce is busy with protein synthesis and
other growth and maintenance unctions. T is initia growth
period o interphase is o owed by a period during which the
ce prepares or possib e ce division.
D uring interphase, the ce is said to be resting. H owever,
it is resting on y rom the standpoint o active ce division. In
a other aspects it is exceeding y active. D uring interphase
and just be ore mitosis begins, the DNA o each chromosome
makes an identica copy o itse . T e ce then enters another
growth period o interphase be ore it begins to active y
divide.
D N A Re p lic a t io n
D NA mo ecu es are somewhat unusua in that, un ike most
mo ecu es in nature, they can make identica copies o
themse vesa process ca ed D NA replication. Be ore a
ce divides to orm two new ce s, each D NA mo ecu e in
its nuc eus orms another D NA mo ecu e just ike itse .
CHAPTER 3 Cells 59
With the hum an ge nom e alre ady m appe d, m any s cie ntis ts
are working now to f ll in the de tails conce rning the m any
ge ne s and ge ne variants ound in the hum an ge nom e . An o -
s hoot o the HGP is ENCODE, The Encyclope dia o DNA Ele -
m e nts . ENCODE s cie ntis ts have m appe d large re gions o DNA
be twe e n the ge ne s that contain a rich and com plex as s ort-
m e nt o s w itche s that re gulate ge ne activity.
Many s cie ntis ts are als o working in the e m e rging f e ld o
prote om ics the s tudy o all the prote ins e ncode d by e ach o
the ge ne s o the hum an ge nom e .
W hen a DNA mo ecu e is not rep icating, it has the shape
o a tight y coi ed doub e he ix. As it begins rep ication, short
segments o the DNA mo ecu e uncoi and the two strands o
the mo ecu e pu apart between their base pairs. T e sepa-
rated strands there ore contain unpaired bases.
Each unpaired base in each o the two separated strands
attracts its comp ementary base (in the nuc eop asm) and 3
binds to it. Specif ca y, each adenine attracts and binds to a
thymine, and each cytosine attracts and binds to a guanine.
T ese steps are repeated over and over throughout the ength
o the DNA mo ecu e. T us each ha o a DNA mo ecu e
becomes a who e DNA mo ecu e identica to the origina
DNA mo ecu e.
A ter DNA rep ication is comp ete, the ce continues to
grow unti it is ready or the f rst phase o mitosis.
M it o s is
Mitosis is the process o dividing the rep icated genetic
materia the DNAo the nuc eus in an order y way so that
each resu ting daughter ce has a comp ete identica set.
Prophase
Look at Figure 3-15 and note the changes that identi y the f rst
stage o mitosis, prophase. T e chromatin becomes orga-
nized. Chromosomes in the nuc eus have ormed two strands
ca ed chromatids. Note that the two chromatids are he d
together by a bead ike structure ca ed the centromere. In the
cytop asm the centrio es are moving away rom each other as
a network o tubu es ca ed spindle bers orms between
them. T ese spind e f bers serve as guidewires and assist the
chromosomes to move toward opposite ends o the ce ater
in mitosis.
Metaphase
By the time metaphase begins, the nuc ear enve ope and nu-
c eo us have disappeared. Note in Figure 3-15 that the chromo-
somes have a igned themse ves across the center o the ce .
 60 CHAPTER 3 Cells

1 Nucle olus
INTERPHAS E Mitochondrion
2
Ce ll growth Nucle us Chroma tin PROPHAS E
Re plica tion of chromos ome s
Ce ll not a ctive ly dividing Ce ntriole The chromatin
Golgi condenses into visible
a ppa ra tus chromos ome s
Nucle olus Chromos ome s Chroma tids become
1 a tta che d a t the
ce ntrome re
S pindle fibe rs a ppe a r
Ce ntrome re The nucle olus a nd
(Early) nucle a r e nve lope
dis a ppe a r
Daug hte r c e lls
2
CELL
5 Chroma tids
LIFE
TELOPHAS E 5 CYCLE
The nucle a r (Late )
e nve lope a nd both Ce ntriole S pindle
nucle i a ppe a r be rs
The cytopla s m a nd
orga ne lle s divide
3
e qua lly
Cle ava ge
The proce s s of ce ll
divis ion is furrow 4
comple te d Ce ntriole
Chromos ome s

3
S pindle fibe rs
METAPHAS E
3 S pindle fibe rs a tta ch to e a ch
chroma tid
4 Chromos ome s a lign a cros s
FIGURE 3-15 Cell li e cycle. Inter- the ce nte r of the ce ll
ANAPHAS E
phase is ollowed by the our phases o
Ce ntrome re s bre a k a pa rt
mitosis, at the end o which the result- Chromos ome s move away
ing daughter cells enter interphase. For from the ce nte r of the ce ll
simplicity, only our chromosomes per The cle ava ge furrow a ppe a rs
cell are shown in the diagram.

A so, the centrio es have migrated to opposite ends o the ce ,
and spind e f bers are attached to each chromatid.
Anaphase
As anaphase begins, the bead ike centromeres, which were
ho ding the paired chromatids together, break apart. As a re-
su t, the individua chromatids, identif ed once again as chro-
mosomes, move away rom the center o the ce . Movement
o chromosomes occurs a ong spind e f bers toward the cen-
trio es. Note in Figure 3-15 that chromosomes are being pu ed
to opposite ends o the ce .
A cleavage urrow that begins to divide the ce into two
daughter ce s can be seen or the f rst time at the end o
anaphase.
Telophase
D uring telophase, ce division is comp eted. wo nuc ei ap-
pear, and chromosomes become ess distinct and appear to
break up. As the nuc ear enve ope orms around the chroma-
tin, the c eavage urrow comp ete y divides the ce into two
parts. T e division o the p asma membrane and cytop asm
surrounding the nuc eus is ca ed cytokinesis.
Be ore division is comp ete, each nuc eus is surrounded by
cytop asm in which organe es have been equa y distributed.
By the end o te ophase, two separate daughter ce s, each
having identica genetic characteristics, are ormed. Each
daughter ce is now in interphase, is u y unctiona , and wi
perhaps itse undergo mitotic ce division (ce reproduction)
in the uture.
Now is a good time to review again the stages o mitosis
summarized in Figure 3-15.
Re s u lt s o C e ll D iv is io n
Mitotic ce division resu ts in the production o identica
new ce s. D uring deve opmenta years, the addition o ce s
he ps tissues and organs grow in size. D uring such periods o
body growth, mitosis a so a ows groups o simi ar ce s to
dif erentiate or deve op into di erent tissues. T e next chap-
ter exp ores the major types o tissues in the human body that
resu t rom di erentiation.
In the adu t, mitosis rep aces ce s that have become ost or
ess unctiona with age, as we as ce s damaged or destroyed
by i ness or injury.
C h a n g e s in C e ll G ro w t h
a n d Re p ro d u c t io n
Ce s have the abi ity to adapt to changing conditions.
Ce s may a ter their size, reproductive rate, or other char-
acteristics to adapt to changes in the interna environment.
 CHAPTER 3 Cells 61

C LIN ICA L APPLICATION

STEM CELLS
Scie ntis ts all ove r the world are curre ntly e n- S te m
gage d in inte ns ive re s e arch e orts to unrave l the ce ll
biological s e cre ts o a s pe cial kind o undi e re nti-
ate d ce ll calle d a s te m ce ll. As the illus tration
s how s , s te m ce lls produce daughte r ce lls w ith
s pe cif c characte ris tics during the proce s s o
di e re ntiatio n. Ste m ce lls m ay als o pro-
duce additional daughte r s te m ce lls ,
w hich m ay the n late r produce di e re nti-
ate d daughte r ce lls .
Em bryonic s te m ce lls , w hich are ob- Da ughte r
s te m ce lls
taine d rom a deve loping e m bryo, can be
is olate d and culture d in the laboratory. Us ing
com plex re s e arch m e thods , the s e prim itive ce lls
can the n be s tim ulate d to produce additional s te m ce lls or be
dire cte d to produce m any di e re nt kinds o di e re ntiate d
daughte r ce ll type s including ne rve , blood, m us cle , and vari-
ous type s o glandular tis s ue .
Adult s te m ce lls are undi e re ntiate d ce lls ound s cat-
te re d w ithin m ature tis s ue s throughout the body. Curre nt
re s e arch s ugge s ts that all adult tis s ue s have s om e o
the s e undi e re ntiate d ce lls that are capable o
producing any o the s pe cialize d ce ll
type s w ithin its particular tis s ue .
Diffe re ntia tion Inje cting adult bone m arrow
s te m ce lls is a the rapy now be -
ing us e d to tre at patie nts w ith
le uke m ia or bone m arrow dam -
age d by toxins or high-dos e
Diffe re ntia te d
da ughte r ce lls x-ray. Curre nt re s e arch s ugge s ts
that s om e adult s te m ce lls , like
e m bryonic s te m ce lls , can be
coaxe d into producing a varie ty o di -
e re nt type s o ce lls .
We w ill revis it the role o s te m ce lls in the body
and in the rapyin late r chapte rs .

Such adaptations usua y a ow ce s to work more e - period, musc es that move the arm o ten atrophy. Because the
cient y. H owever, sometimes ce s a ter their characteristics musc es are temporari y out o use, musc e ce s decrease in 3
abnorma ydecreasing their e ciency and threatening size. Atrophy a so may occur in tissues whose nutrient or oxy-
the hea th o the body. gen supp y is diminished.
Common types o changes in ce growth and reproduction Sometimes ce s respond to changes in the interna envi-
are summarized in Figure 3-16, and in Table 3-5. ronment by increasing their rate o reproductiona process
Ce s may respond to changes in unction, hormone sig- ca ed hyperplasia. T e word part -plasia comes rom a Greek
na s, or avai abi ity o nutrients by increasing or decreasing in word that means ormationre erring to ormation o new
size. T e term hypertrophy re ers to an increase in ce size, ce s. Because hyper means excessive, hyperplasia means ex-
and the term atrophy re ers to a decrease in ce size. cessive ce reproduction.
Either hypertrophy or atrophy can occur easi y in musc e
tissue. W hen a person continua y uses musc e ce s to pu
against heavy resistance, as in weight training, the ce s re-
spond by increasing in size. Bodybui ders thus increase the Alterations in Cell Growth and
size o their musc es by hypertrophyincreasing the size o TABLE 3-5
Reproduction
musc e ce s.
TERM DEFINITION EXAMPLE
Atrophy o ten occurs in underused musc e ce s. For ex-
amp e, when a broken arm is immobi ized in a cast or a ong Change s in Grow th o Individual Ce lls
Hype rtrophy Incre as e in s ize o Stre ngth training s tim u-
individual ce lls late s incre as e in s ize o
Nucle us s ke le tal m us cle f be rs
Atrophy De cre as e in s ize o Im m obility o lim bs
Ba s e me nt me mbra ne
Norma l individual ce lls caus e s s ke le tal
m us cle s that m ove
lim bs to de cre as e in
s ize
Change s in Ce ll Re pro ductio n
Atrophy Hype rpla s ia
Hype rplas ia Incre as e in ce ll Skin tum or caus e s thick-
re production e ning o s kin by ove r-
production o s kin ce lls
Anaplas ia Production o abnor- Lung cance r caus e s pro-
m al, undi e re nti- duction o abnorm al
Hype rtrophy Ana pla s ia
ate d ce lls ce lls that do not unc-
tion prope rly
FIGURE 3-16 Alterations in cell growth and reproduction.
 62 CHAPTER 3 Cells
FIGURE 3-17 Cancer. This depic-
tion o an abnormal mass o proli -
erating cells in the lining o lung
airways is a malignant tumor
lung cancer. Notice how some
cancer cells are leaving the
tumor and entering the blood
and lymph vessels.
Re s pira tory e pithe lium Lung
(ps e udos tra tifie d cilia te d) ca nce r
3 1. Ho w d o g e n e s d e te rm in e th e s tru ctu re a n d u n ctio n o th e
S mooth Conne ctive Blood Ca nce r Lympha tic
mus cle tis s ue ve s s e l ce lls ve s s e l
S C IEN C E APPLICATIONS
CELL BIOLOGY
Re cognize d as a biologis t o un-
us ual s kill and ge nius in the de -
s ign o expe rim e nts , A rican-
Am e rican Erne s t Eve re tt Jus t was
a pione e r in dis cove ring the role o
the ce ll m e m brane in ce ll divis ion,
e rtilization, and othe r deve lopm e n-
tal proce s s e s . For exam ple , he was
the f rs t to de m ons trate that the
point w he re a s pe rm e nte rs an e gg
Ernest Everett Just ce ll be com e s the cle avage point
(1883-1941) obs e rve d as the e rtilize d e gg s plits
during cytokine s is . One o the f rs t
re s e arche rs to s ucce s s ully s tudy groups o living and deve lop-
ing ce lls not jus t s ingle , is olate d ce lls Jus t laid the ground-
work or uture bre akthroughs in cyto lo gy (the s tudy o ce lls ).
As todays s cie ntis ts continue to work out the m any com -
plex role s o the plas m a m e m brane and the m e chanis m s o
Like hypertrophy, hyperp asia causes an increase in the
size o a tissue or organ. H owever, hyperp asia is an increase
in the number o cells rather than an increase in the size o
each ce . A common examp e o hyperp asia occurs in the
mi k-producing g ands o the ema e breast during preg-
nancy. In response to hormone signa s, the g andu ar ce s
reproduce rapid y, preparing the breast or nursing.
I the body oses its abi ity to contro the ce i e cyc ece
growth, reproduction, di erentiation, and deathabnorma
hyperp asia may occur. T e new mass o ce s thus ormed is a
tumor or neoplasm.
Many neop asms a so exhibit a characteristic ca ed
anaplasia. Anap asia is a condition in which ce s change in
orientation to each other and ai to mature norma ythat is,
they ai to di erentiate into a specia ized ce type and appear
disorganized.
Neop asms may be re ative y harm ess growths ca ed
benign tumors. I tumor ce s can break away and trave
through the b ood or ymphatic vesse s to other parts o the
body (Figure 3-17), the neop asm is a malignant tumor or
cancer. Neop asms are discussed urther in Chapter 6.
QUICK CHECK
b o d y?
2. Wh a t a re th e m a in s te p s in m a kin g p ro te in s in th e ce ll?
3. Wh a t a re th e o u r p h a s e s o m ito tic ce ll d ivis io n ?
4. De s crib e hyp e rtro p hy, hyp e rp la s ia , a n d a tro p hy.
ce ll divis ion, they provide clue s to the preve ntion and tre at-
m e nt o dis e as e . For exam ple , pharm aco lo g is ts s tudy the
role o m e m brane re ce ptors that re gulate ce ll unctions and
us e that in orm ation to de s ign drugs that can s tim ulate , block,
or othe rw is e in ue nce the re ce ptors and the re by a e ct ce ll
unction. The s tudy o o nco lo gy (cance r biology) involve s ana-
lyzing the proce s s e s o m itotic ce ll divis ion that o te n ail to
unction prope rly in cance r. Pro e s s ionals w ho s pe cialize in
m e dical ge ne tics he lp s ort out the m e chanis m s o cance r and
m any othe r dis orde rs by s tudying how ge ne s in the nucle us
and m itochondria a e ct ce ll s tructure and unction.
The holis tic view o biology cham pione d a ce ntury ago by
Dr. Jus t re cognize d eve n the n that ne arly eve ry unction we
s tudy and tre at in the he alth pro e s s ions is ce ll unction. Thus ,
ne arly eve ry he alth pro e s s ion dire ctly or indire ctly re lie s on
unde rs tanding the bas ic principle s o ce ll biology.
 CHAPTER 3 Cells 63

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 43)

cleavage urrow agellum mitosis

(KLEE-vij FUR-oh) ( ah-J EL-um) (my-TOH-sis)
[cleav- split, -age state, urrow trench] pl., agella [mitos- thread, -osis process]
codon ( ah-J EL-ah) nuclear envelope
(KOH-don) [ agellum whip] (NOO-klee-ar)
[cod- book, -on thing] gene [nucle- nucleus (kernel), -ar relating to]
complementary base pairing (jeen) nucleolus
(kom-pleh-MEN-tah-ree bays PAYR-ing) [gen- produce or generate] (noo-KLEE-oh-lus)
[comple- complete, -ment- process, genetics [nucleo- nucleus (kernel), -olus little]
-ary relating to] (jeh-NET-iks) nucleoplasm
cytokinesis [gene- produce, -ic relating to] (NOO-klee-oh-plaz-em)
(sye-toh-kin-EE-sis) genome [nucleo- nucleus (kernel), -plasm substance]
[cyto- cell, -kinesis movement] (J EE-nohm) nucleus
cytology [gen- produce (gene), -ome entire collection] (NOO-klee-us)
(sye-TOL-oh-jee) Golgi apparatus [nucleus kernel]
[cyto- cell, -log- words (study o ), -y activity] (GOL-jee ap-ah-RA-tus) organelle
cytoplasm [Camillo Golgi Italian histologist] (or-gah-NELL)
(SYE-toh-plaz-em) hypertonic [organ- tool or instrument, -elle small]
[cyto- cell, -plasm to mold] (hye-per-TON-ik) osmosis
cytoskeleton [hyper- excessive, -ton- tension, -ic relating to] (os-MOH-sis)
(sye-toh-SKEL-eh-ton) hypotonic [osmos- push, -osis process]
[cyto- cell, -skeleto- dried body] (hye-poh-TON-ik) passive transport 3
deoxyribonucleic acid (DNA) [hypo- under or below, -ton- tension, (PAS-iv TRANZ-port)
(dee-ok-see-rye-boh-nook-lay-ik AS-id -ic relating to] [pass- submit, -ive relating to, trans- across,
[dee en ay]) interphase -port carry]
[de- removed, -oxy- oxygen, -nucle- nucleus (IN-ter- ayz) phagocytosis
(kernel), -ic relating to, acid sour] [inter- between, -phase stage] ( ag-oh-sye-TOH-sis)
dialysis interstitial uid [phago- eat, -cyte- cell, -osis process]
(dye-AL-ih-sis) (in-ter-STISH-al FLOO-id) phospholipid
[dia- apart, -lysis loosening] [inter- between, -stit- stand, -al relating to] ( os- oh-LIP-id)
di erentiate isotonic [phospho- phosphorus, -lip- at, -id orm]
(di -er-EN-shee-ayt) (aye-soh-TON-ik) pinocytosis
[di erent- di erence, -ate action] [iso- equal, -ton- tension, -ic relating to] (pin-oh-sye-TOH-sis)
di erentiation lyse [pino- drink, -cyto- cell, -osis process]
(di -er-EN-shee-AY-shun) (lyze) plasma membrane
[di erent- di erence, -ation process] [lysis loosening] (PLAZ-mah MEM-brayn)
di usion lysosome [plasma substance, membrane thin skin]
(dih-FYOO-zhun) (LYE-soh-sohm) prophase
[dis- apart, - us- ow, -tion process] [lyso- dissolution, -som body] (PROH- ayz)
DNA replication messenger RNA (mRNA) [pro- f rst, -phase stage]
(D N A rep-lih-KAY-shun) (MES-en-jer ar en ay [em ar en ay]) ribonucleic acid (RNA)
[re- again, -plic- old, -ation process] [RNA- ribonucleic acid] (rye-boh-noo-KLAY-ik AS-id [ar en ay])
endoplasmic reticulum (ER) metaphase [ribo- ribose (sugar), nucle- nucleus, -ic relating
(en-doh-PLAZ-mik reh-TIK-yoo-lum [ee ar]) (MET-ah- ayz) to, acid sour]
[endo- inward or within, -plasm- to mold, [meta- change (place), -phase stage] ribosome
-ic relating to, ret- net, -ic- relating to, microvillus (RYE-boh-sohm)
-ul- little, -um thing] (my-kroh-VIL-us) [ribo- ribose or RNA, -som- body]
equilibrium pl., microvilli sodium-potassium pump
(ee-kwih-LIB-ree-um) (my-kroh-VIL-aye or my-kroh-VIL-ee) (SOH-dee-um poh-TAS-ee-um)
[equi- equal, -libr- balance, -um, thing] [micro- small, -villus shaggy hair] [sod- soda, -um thing or substance,
f ltration mitochondrion potas- potash, -um thing or substance]
(f l-TRAY-shun) (my-toh-KON-dree-on)
[f ltr- strain, -ation process] pl., mitochondria
(my-toh-KON-dree-ah)
[mito- thread, -chondrion granule] Continued on p. 64
 64 CHAPTER 3 Cells

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 63)

solute tissue translation

(SOL-yoot) (TISH-yoo) (trans-LAY-shun)
[solut dissolved] [tissu abric] [translat- bring over, -tion process]
spindle f ber transcription transport process
(SPIN-dul FYE-ber) (trans-KRIP-shun) (TRANS-port PROH-ses)
stem cell [trans- across, -script- write, -tion process] [trans- across, -port carry]
(stem sel) trans er RNA (tRNA) vesicle
[stem tree trunk, cell storeroom] (TRANS- er ar en ay [tee ar en ay]) (VES-ih-kul)
telophase [RNA- ribonucleic acid] [vesic- blister, -cle little]
(TEL-oh- ayz or TEE-loh- ayz)
[telo- end, -phase stage]

LANGUAGE OF M ED IC IN E

anaplasia cholera neoplasm

(an-ah-PLAY-zhah) (KAHL-er-ah) (NEE-oh-plaz-em)
[ana- without, -plasia shape] [chole- bile, -a state] [neo- new, -plasm ormation]
3 atrophy crenation oncology
(AT-roh- ee) (kreh-NAY-shun) (ong-KAHL-oh-jee)
[a- without, -troph- nourishment, -y state] [crenat- scalloped or notched, -ation process] [onco- tumor, -log- words (study o ), -y activity]
benign tumor hyperplasia pharmacologist
(bee-NYNE TOO-mer) (hye-per-PLAY-zhah) ( ar-mah-KAHL-oh-jist)
[benign kind] [hyper- excessive, -plasia shape] [pharmaco- drug, -log- words (study o ),
cancer malignant tumor -ist agent]
(KAN-ser) (mah-LIG-nant TOO-mer)
[cancer crab or malignant tumor] [malign bad, -ant state; tumor swelling]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary B. Composition
or us e w ith your device , acce s s the Au d io Ch a p te r 1. Ce s contain cytop asmsubstance ound on y in
S u m m a rie s online at evolve .e ls evie r.com . ce s
2. O rgane es are specia ized structures within the
Scan this s um m ary a te r re ading the chapte r to cytop asm
he lp you re in orce the key conce pts . Late r, us e 3. Ce interior is surrounded by a p asma membrane
the s um m ary as a quick review be ore your clas s C. Parts o the ce
or be ore a te s t. 1. P asma membrane (Figure 3-1)
a. Forms outer boundary o ce
b. Composed o a thin, two- ayered membrane o
Ce lls phospho ipids containing proteins
A. Size and shape c. Proteins and other mo ecu es embedded in mem-
1. H uman ce s vary considerab y in size brane can unction in transport, signa ing, se -
2. A are microscopic identif cation, anchoring o f bers, chemica
3. Ce s di er notab y in shape processing (enzymes), and more

2. Cytop asm (Figure 3-2)interna ce uid and numer-
ous organe es
a. Ribosomes
(1) Made o two tiny subunits o most y ribosoma
RNA
(2) May attach to rough ER or ie ree in
cytop asm
(3) Manu acture enzymes and other protein
compounds
(4) O ten ca ed protein actories
b. Endop asmic reticu um (ER)
(1) Network o connecting sacs and cana s
(2) Carry substances through uid cytop asm
(3) wo typesrough and smooth
(4) Rough ER co ects, o ds, and transports pro-
teins made by ribosomes
(5) Smooth ER synthesizes chemica s; makes new
membrane
c. Go gi apparatus (Figure 3-3)
(1) Group o attened sacs near nuc eus
(2) Co ect chemica s into vesic es that move rom
the smooth ER outward to p asma membrane
(3) Ca ed the chemical processing and packaging
center
d. Mitochondria
(1) Composed o inner and outer membranous
sacs
(2) Invo ved with energy-re easing chemica
reactions
(3) O ten ca ed power plants o the ce
(4) Contain one DNA mo ecu e
e. Lysosomes
(1) Membranous-wa ed organe es
(2) Contain digestive enzymes
(3) H ave protective unction (engu and destroy
microbes)
. Centrio es
(1) Paired organe es that ie at right ang es to each
other near the nuc eus
(2) Function in ce reproduction
g. Microvi i (Figure 3-4)
(1) Sma , f nger ike extensions o the p asma
membrane
(2) Increase absorptive sur ace area o the ce
h. Ci ia (Figure 3-4)
(1) Fine, hair ike extensions ound on ree or
exposed sur aces o some ce s
(2) Some are ound in groups and capab e o
moving in unison in a wave ike ashion
(Figure 3-5)
(3) Sing e, nonmoving ci ia in some ce s serve
sensory unctions
i. F age a (Figure 3-4)
(1) Sing e projections extending rom ce sur ace;
much arger than ci ia
(2) Prope a ce through its uid environment
(Figure 3-5)
CHAPTER 3 Cells 65
(3) ai s o sperm ce s on y examp e o age a
in humans
3. Nuc eus
a. Contro s ce because it contains DNA, the genetic
codeinstructions or making proteins, which in
turn determine ce structure and unction
b. Component structures inc ude nuc ear enve ope,
nuc eop asm, nuc eo us, and chromatin granu es
c. DNA mo ecu es become tight y coi ed chromo-
somes during ce division
d. Each ce has 46 chromosomes in the nuc eus
D. Re ationship o ce structure and unction
1. Every human ce has a designated unctionsome
he p maintain the ce ; others regu ate i e processes o
the body itse
2. Specia ized unctions o a ce di er depending on
number and type o organe es
Move m e nts o S ubs tance s Thro ug h
Ce ll Me m brane s
A. ypes o membrane transport
1. ransport processes move substances into and out o
ce s
2. ypes o transport 3
a. Passive transportdoes not require the ce to
expend energy
b. Active transportrequires the ce to expend
energy ( rom A P)
B. Passive transport processes
1. Passive transport processes do not require added
energy and resu t in movement down a concentration
gradient
2. Di usion
a. Substances scatter themse ves even y throughout an
avai ab e space, the partic es moving rom high to
ow concentration (Figure 3-6)
b. So ute partic es may thus move through channe s
or carriers in a membrane to reach an equi ibrium
(equa ity o concentration) o so ution on both
sides o the membrane (Figure 3-7)
c. Passive processit is unnecessary to add energy to
the system
3. O smosis (Figure 3-8)
a. Passive movement o water mo ecu es when some
so utes cannot cross the membrane
b. Simi ar to di usion, water moves in a direction that
produces an equi ibrium
c. Because water moves, but not a the so utes,
osmotic pressure may change across the membrane
4. Dia ysissome so utes move across a se ective y per-
meab e membrane by di usion and other so utes do
not, thus resu ting in uneven distribution o so ute
types (Figure 3-9)
5. Fi trationmovement o water and so utes caused by
hydrostatic pressure on one side o membrane
 66 CHAPTER 3 Cells
C. Active transport processes
1. Active transport processes occur on y in iving ce s;
movement o substances is up the concentration gra-
dient; requires energy rom A P
2. Ion pumps (Figure 3-10)
a. An ion pump is protein comp ex in ce membrane
b. Ion pumps use energy rom A P to move sub-
stances across ce membranes against their concen-
tration gradients
c. Examp es: sodium-potassium pump; ca cium pump
d. Some ion pumps work with other carriers so that
g ucose or amino acids are transported a ong with
ions
3. Phagocytosis and pinocytosis
a. Both are active transport mechanisms because they
require ce energy
b. Phagocytosis is a protective mechanism o ten used
to destroy bacteria (Figure 3-11)
c. Pinocytosis is used to incorporate uids or dis-
so ved substances into ce s
D. Ce transport and disease
1. Cystic f brosis, characterized by abnorma y thick
secretions in the airways and digestive ducts, resu ts
rom ai ed C transport (Figure 3-12)
3 2. Cho era is a bacteria in ection that causes C and
water to eak rom ce s ining the intestines, resu ting
in severe diarrhea and water oss
Ce ll Grow th and Re pro ductio n
A. Ce growth
1. Proteins determine the structure and unction o ce s
2. Protein synthesis is directed by two nuc eic acids:
deoxyribonuc eic acid (DNA) and ribonuc eic acid
(RNA)
3. DNA
a. Make up 46 chromosomes contained in ce
nuc eus
b. Large mo ecu e shaped ike a spira staircase; sugar
(deoxyribose) and phosphate units compose sides
o the mo ecu e; base pairs (adenine-thymine or
guanine-cytosine) compose steps (see Figure 2-14,
p. 35)
c. Base pairings a ways the same (comp ementary
base pairing), but the sequence o base pairs di ers
in di erent DNA mo ecu e
d. A gene is a specif c sequence o base pairs within a
DNA mo ecu e
e. Genes dictate ormation o enzymes and other pro-
teins by ribosomes, thereby indirect y determining a
ce s structure and unctions (Figure 3-13)
4. RNA (Table 3-4)
a. RNA mo ecu es are made rom genes that do not
code direct y or proteins
b. RNA mo ecu es regu ate ce processes, such as
protein synthesis
c. RNA subunits are made up o nuc eotides, but have
ribose as their sugar and have the base uraci
instead o thymine
(1) mRNAmessenger RNA; transcribed working
copy o one gene
(2) rRNAribosoma RNA; component o
ribosome
(3) tRNAtrans er RNA; carries specif c amino
acid to its ocation on a ribosome during
trans ation
5. Protein synthesisoccurs in cytop asm; thus genetic
in ormation must pass rom the nuc eus to the cyto-
p asm (Figure 3-14)
a. ranscription
(1) Doub e-stranded DNA separates, and one
strand copied to orm messenger RNA
(mRNA)
(2) Each strand o mRNA is a copy (transcript) o
a particu ar gene (base-pair sequence) rom a
segment o DNA
b. mRNA mo ecu es pass rom the nuc eus to the
cytop asm where they direct protein synthesis in
ribosomes and ER
c. rans ation
(1) rans ation o code in mRNA transcript a ows
ribosomes to synthesize proteins
(2) Codona series o three nuc eotide bases in
mRNA that acts as a code or a specif c amino
acid
(3) tRNAcarries a specif c amino acid and has
an anticodon, which is a three-base sequence
that comp ements the mRNA codon that sig-
nif es that amino acid
(4) tRNA brings amino acids into p ace a ong the
mRNA strand where it is he d by a ribosome,
thus orming a strand o amino acids
B. Protein synthesis and disease
1. Abnorma DNA that is inherited or that resu ts rom
damage is o ten the basis o disease
2. Factors that cause damage to DNA mo ecu es inc ude
chemica or mechanica irritants, radiation, bacteria,
and viruses
C. Ce reproduction
1. Ce i e cyc einc udes reproduction o ce invo ving
division o the nuc eus (mitosis) and the cytop asm
(Figure 3-15)
a. wo daughter ce s resu t rom the division
b. Interphaseperiod o i e cyc e when the ce is
not active y dividing
2. DNA rep icationprocess by which each ha o a
DNA mo ecu e becomes a who e mo ecu e identica to
the origina DNA mo ecu e; precedes mitosis

3. Mitosisprocess in ce division that distributes iden-
tica nuc ear chromosomes (DNA mo ecu es) to each
new ce ormed when the origina ce divides
(Figure 3-15)
a. Prophasef rst stage
(1) Chromatin granu es become organized
(2) Chromosomes (pairs o inked chromatids)
appear
(3) Centrio es move away rom nuc eus
(4) Nuc ear enve ope disappears, reeing genetic
materia
(5) Spind e f bers appear
b. Metaphasesecond stage
(1) Chromosomes a ign across center o ce
(2) Spind e f bers attach themse ves to each
chromatid
c. Anaphasethird stage
(1) Centromeres break apart
(2) Separated chromatids now ca ed chromosomes
(3) Chromosomes are pu ed to opposite ends o
ce
(4) C eavage urrow deve ops at end o anaphase
d. e ophase ourth stage
(1) Ce division is comp eted
(2) Nuc ei appear in daughter ce s
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Chapte r 3 s hould be a review o your ge ne ral biology cours e
m os t o w hat is in this chapte r s hould be am iliar.
1. T e section on ce structure begins with the p asma
membrane. It is made up most y o phospho ipids, but
the most important part o the membrane structure is
the proteins embedded in the phospho ipids. T ey p ay
important ro es in a number o systems in the body such
as the nervous and endocrine systems.
2. T e organe es may seem to have strange-sounding
names. Use the vocabu ary ist with the word origins in
this chapter to he p you determine the meaning o each
organe e name. F ash cards wou d be he p u in earning
these new terms.
3. T e transport processes o osmosis and dia ysis are
specia cases o di usionosmosis with water and dia y-
sis with so utes. Fi tration uses a pressure rather than a
concentration di erence to move substances.
4. Phagocytosis and pinocytosis are descriptions o what
the ce is doing. Phago means to eat, pino means to
drink, cyto means ce , and -sis means condition.
CHAPTER 3 Cells 67
(3) Nuc ear enve ope and nuc eo i appear
(4) Cytop asm is divided (cytokinesis)
e. Mitosis ends as daughter ce s become u y unc-
tiona and enter interphase
4. Resu ts o ce division
a. wo identica ce s resu t rom ce division,
growing tissues or rep acing o d or damaged ce s
b. Di erentiationprocess by which daughter ce s
can specia ize and orm di erent kinds o tissue
D. Changes in ce growth and reproduction (Figure 3-16 and
Table 3-5)
1. H ypertrophyincrease in size o individua ce s;
increasing size o tissue
2. Atrophydecrease in size o individua ce s; decreas-
ing size o tissue
3. H yperp asiaincrease in ce reproduction, increasing
size o tissue
4. Anap asiaproduction o abnorma , undi erentiated
ce s
5. Uncontro ed ce reproduction resu ts in ormation o
a benign or ma ignant neop asm (tumor) (Figure 3-17)
3
5. W hen studying protein synthesis, keep the goa o the
process in mind. T e ce wants a protein made, the
DNA has the p ans, but the ribosome is the actory. T e
DNA needs to te the ribosome what to bui d (tran-
scription), and the actory needs to put the protein
together in the correct order (trans ation).
6. Use ash cards to study the phases o mitosisremember
that the phases are based on what is happening to the
chromosomes. T ere are many on ine resources that i us-
trate the phases o mitosis. T ese resources inc ude anima-
tions that can he p you better understand what occurs in
each phase o mitosis.
7. Make and use ash cards to earn the terms used to
describe changes in ce growth and reproduction.
8. Link the diseases or conditions described in the chapter
by constructing a -chart with the ce structure or unc-
tion that is abnorma .
9. In your study group, review the ash cards or the
organe es, mitosis, and changes in ce growth and
reproduction. Be sure to discuss steps in protein synthe-
sis and the ce transport processes. Go over the ques-
tions at the end o the chapter and discuss possib e test
questions.
10. Check my-ap.us/JEdgo or the atest tips on studying
ce s.
 68 CHAPTER 3 Cells

Re vie w Que s tio ns Chapte r Te s t

Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Describe the structure o the p asma membrane, cyto-
p asm, and nuc eus.
2. List the unctions o the p asma membrane, cytop asm,
and nuc eus.
3. List the unctions o each o the o owing organe es:
ribosome, endop asmic reticu um, Go gi apparatus, mito-
chondria, ysosome, centrosome, centrio es, microvi i,
ci ia, and age a.
4. Exp ain the unction o the nuc eus and nuc eo us.
5. Exp ain the di erence between chromatin and
chromosomes.
6. Describe the processes o di usion and f tration.
7. Describe the unctioning o the ion pump.
8. Exp ain the process o phagocytosis.
9. Describe the process o transcription.
3 10. Describe the process o trans ation.
11. List the our stages in active ce division (mitosis) and
brie y describe what occurs in each stage.
12. W hat important event in mitosis occurs during
interphase?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
13. Exp ain what wou d happen i a ce containing 97%
water were p aced in a 10% sa t so ution.
14. I one side o a DNA mo ecu e had the o owing base
sequence: adenine-adenine-guanine cytosine-thymine-
cytosine-thymine, what wou d the sequence o bases on
the opposite side o the mo ecu e be?
15. I a mo ecu e o mRNA was made rom the DNA base
sequence in question 14, what wou d the sequence o
bases be in the RNA?
16. I an intravenous so ution contains 1.1% sa t, wou d it be
hypertonic, hypotonic, or isotonic to ce s?
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________ and ________ are two ipid-based mo ecu es
that make up part o the structure o the p asma
membrane.
2. ________ is a term that re ers to sma structures inside
the ce it means itt e organs.
3. ________ is the movement o substances across a ce
membrane using ce energy, whereas ________ is the
movement o substances across a ce membrane without
using ce energy.
4. ________ re ers to the movement o uids or disso ved
mo ecu es into the ce by trapping them in the p asma
membrane.
5. ________ is a disease caused by the inabi ity o ce s to
transport C ions.
6. ________ occurs when enzymes in the mitochondria use
oxygen to break down g ucose and other nutrients to
re ease energy needed or ce u ar work.
7. ________ is the process in protein synthesis that orms
the mRNA mo ecu e.
8. A ________ is a segment o base pairs in a chromosome.
9. ________ is the tota genetic in ormation packaged in a
ce .
10. rans ation occurs within the ________.
11. Another name or ce suicide is ________.
12. T e disease caused by an inherited mistake in the
genetic code that prevents production o norma b ood
c otting proteins is:
a. cystic f brosis
b. hemophi ia
c. D uchenne muscu ar dystrophy
d. AIDS
13. T e synthesis o a protein by ribosomes begins with:
a. trans ation
b. transcription
c. trans er RNA
d. comp ementary base pairing
14. D uring what stage o mitosis do the chromosomes move
away rom the center o the ce ?
a. Interphase
b. Metaphase
c. Anaphase
d. e ophase
15. Atrophy re ers to a(n):
a. increase in ce size
b. decrease in ce size
c. increase in use
d. condition that resu ts rom overextending a musc e
 CHAPTER 3 Cells 69

16. D uring what stage o mitosis do the chromosomes a ign 19. W hich o the o owing terms re ers to an increase in
in the center o the ce ? ce size?
a. Interphase a. H yperp asia
b. Metaphase b. H ypertrophy
c. Prophase c. Anap asia
d. e ophase d. Atrophy
17. D uring what stage o mitosis does the chromatin con- 20. W hich o the o owing terms does not be ong?
dense into chromosomes? a. Sugar
a. Interphase b. Phosphate
b. Metaphase c. Nitrogen base
c. Prophase d. Lipid
d. e ophase
18. D uring what stage o mitosis do the nuc ear enve ope
and nuc ei reappear?
a. Interphase
b. Prophase
c. Anaphase
d. e ophase

Match the cell structure in column A with its corresponding description in column B.

Column A Column B
21. ________ ribosome a. ong ce projections used to prope sperm ce s
22. ________ endop asmic reticu um b. bags o digestive enzymes in the ce 3
23. ________ Go gi apparatus c. tube ike passages that carry substances throughout the ce
24. ________ mitochondria d. short hair ike structures on the ree sur aces o some ce s
25. ________ ysosomes e. chemica y processes and packages substances rom the endop asmic reticu um
26. ________ age a . directs protein synthesis, contains DNAthe brain o the ce
27. ________ ci ia g. protein actories in the ce , made o RNA
28. ________ nuc eus h. sma structure in the nuc eus that he ps in the ormation o ribosomes
29. ________ nuc eo us i. powerhouse o the ce where most o the ce s A P is ormed

cancer ce s. wo such drugs, vincristine su ate and vin-

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. O ne orm o the inherited condition glycogen storage
diseasea orm ca ed Pompe diseaseresu ts in accumu a-
tion o excessive g ycogen in ce s o the heart, iver, and
other organs. T e accumu ation o g ycogen can disrupt
ce unction, causing heart and other prob ems that can
progress to death. G ycogen is a arge carbohydrate mo e-
cu e ormed by inking numerous g ucose mo ecu es into a
branched chain (see Chapter 2). G ycogen ormation is
norma in the a ected ce s. T e accumu ation o excessive
g ycogen resu ts rom the ai ure o enzymes that are sup-
posed to break apart the g ycogen so that the ce can use
the g ucose subunits. In what organe e wou d you expect
to f nd these g ycogen-digesting enzymes? Exp ain how
the presence o non unctiona enzymes cou d have been
inherited.
2. M a ignant tumors are sometimes treated with drugs
that ha t mitosis, and thus stop the production o new
b astine su ate, inter ere with the ormation o spind e
f bers. H ow cou d this action ha t mitosis? Antibiotics
such as mitomycin C and inorganic compounds such as
cis-p atinum a so can be used to stop the growth o
tumors. T ese drugs inter ere with D NA synthesis in
treated ce s. H ow cou d this action ha t mitosis?
3. Lauren is a 2-year-o d gir with cystic f brosis (CF).
Because Lauren has this condition, her mother requent y
turns her over, cups her hand, and quick y but f rm y pats
her sharp y on the back between the shou der b ades.
H ow cou d this he p Laurens condition?
4. E izabeth is a senior in high schoo and has se ected the
f e d o proteomics to study when she enters co ege. She
has been accepted at a prestigious institution and has
even received scho arship money. You are excited or her
and are p anning to contact her and congratu ate her on
her choice. W hen discussing E izabeths se ection and
good ortune with your parents, they ask you questions
such as: W hat is the f e d o proteomics? W hat are
ENCODE scientists? H ow do you answer them?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Tissues
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Introduction to Tissues, 71
Tissue Types, 71
Matrix, 72
Epithelial Tissue, 72
Introduction to Epithelial Tissues, 72
Squamous Epithelium, 73
Cuboidal Epithelium, 75
Simple Columnar Epithelium, 75
Pseudostratif ed Epithelium, 76
Transitional Epithelium, 76
Connective Tissue, 76
Introduction to Connective Tissue, 76
Fibrous Connective Tissue, 78
Bone, 80
Cartilage, 80
Blood Tissue, 80
Hematopoietic Tissue, 81
Muscle Tissue, 81
Introduction to Muscle Tissue, 81
Skeletal Muscle Tissue, 81
Cardiac Muscle Tissue, 82
Smooth Muscle Tissue, 82
Nervous Tissue, 83
Tissue Repair, 83

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Explain how epithelial tissue is grouped according to
shape and arrangement o cells.
2. List and brie y discuss the major types o connective
and muscle tissue.
3. Discuss nervous tissue and list the three structural
components o a neuron.
4. Describe how injured tissues regenerate in each o
the our major types o tissue.
 APTER 4
We exp ored ce s in the previous chapter and now LANGUAGE OF
we turn our attention to the various groups o ce s S C IEN C E
ca ed tissues. T e arrangement o ce s in one tissue
may orm a thin sheet on y one ce deep, whereas the
Be o re re ading the
ce s o another tissue may orm huge masses con-
chapte r, s ay e ach o
taining mi ions o ce s. issues are the abric o the s e te rm s o ut lo ud. This w ill
the body, and ike the various abrics that make up a he lp yo u to avo id s tum bling ove r
garment, each tissue o an organ specia izes in per- the m as yo u re ad.
orming unique unctions that he p the organ do its
job. T is co aborative unctioning o tissues within
adipose
our bodys organs maintains homeostatic ba ance and (AD-ih-pohs)
thus is vita to our surviva . [adipo- at, -ose ull o ]
antigen
In this chapter, we brie y survey the major kinds o tis- (AN-tih-jen)
sues that orm the organs o the body. As we progress [anti- against, -gen produce]
through ater chapters, we wi revisit each o these tissue areolar tissue
types and exp ore more detai about their ocations, struc- (ah-REE-oh-lar TISH-yoo)
tures, and unctions. [are- open space, -ola- little,
-ar relating to, tissue abric]
axon
In t ro d u c t io n t o Tis s u e s (AK-son)
[axon axle]
Tis s u e Ty p e s
basement membrane
issues di er rom each other in the size and shape o their [base- base, -ment thing,
ce s, in the amount and kind o materia between the ce s, membrane thin skin]
and in the specia unctions they per orm to he p maintain the blood
bodys surviva . In Tables 4-1 through Table 4-3, you wi f nd a (blud)
isting o the our major tissues and the various subtypes o bone
each. T e tab es a so inc ude the structure o each subtype a ong (bohn)
with examp es o the ocation o the tissues and a primary unc- cardiac muscle tissue
tion o each tissue type. (KAR-dee-ak MUS-el TISH-yoo)
T e our main kinds o tissues that compose the bodys many [cardi- heart, -ac relating to,
organs o ow: mus- mouse, -cle small,
tissue abric]
1. Epithe ia tissue orms sheets that cover or ine the cell body
body (sel BOD-ee)
2. Connective tissueprovides structura and unctiona [cell storeroom, body body]
support chondrocyte
3. Musc e tissuecontracts to produce movement (KON-droh-syte)
4. Nervous tissuesenses, conducts, and processes [chondro- cartilage, -cyte cell]
in ormation collagen
(KAHL-ah-jen)
To learn more about how the various body tissues [colla- glue, -gen produce]
develop, check out the article Embryonic Develop- columnar
ment o Tissues at Connect It! at evolve.elsevier.com. (koh-LUM-nar)
[column- column, -ar relating to]

Continued on p. 85

71
 72 CHAPTER 4 Tissues

TABLE 4-1 Epithelial Tissues

TIS S UE STRUCTURE LOCATION(S ) FUNCTION(S )
Sim ple s quam ous Single laye r o atte ne d ce lls Alve oli o lungs Di us ion o re s piratory gas e s
Lining o blood and lym phatic ve s s e ls be twe e n alve olar air and blood
Di us ion, f ltration, and os m os is
Stratif e d s quam ous Many laye rs ; oute rm os t laye r(s ) is Sur ace o lining o m outh and e s ophagus Prote ction
atte ne d ce lls
Sim ple cuboidal Single laye r o ce lls that are as tall Glands ; kidney tubule s Se cre tion, abs orption
as they are w ide Sur ace o s kin (e pide rm is ) Prote ction
Sim ple colum nar Single laye r o tall, narrow ce lls Sur ace laye r o lining o s tom ach, inte s - Prote ction; s e cre tion; trans port
tine s , parts o re s piratory tract; lining (abs orption)
o ute rine ( allopian) tube s
Ps e udos tratif e d Single laye r o tall ce lls that we dge Lining o portions o the re s piratory tract; Prote ction
toge the r to appe ar as i the re portion o the m ale re productive tract
are two or m ore laye rs
Stratif e d trans itional Many laye rs o varying s hape s , Urinary bladde r Prote ction
capable o s tre tching

M a t r ix
Reca rom Chapter 1 that a centra princip e o human physi-
o ogy is homeostasisthe re ative constancy o the interna
uid environment. T is uid environment f s the spaces be-
tween the ce s o the body. issues di er in the amount and
kind o uid materia between the ce sthe matrix. It is a so
ca ed the extracellular matrix (ECM ) to emphasize its ocation
between ce s.
T e matrix varies in amount and composition among the
various tissueswhich re ects the variety o unctions among
tissue types. Epithe ia tissues have very itt e matrix because
P rote oglyca ns
Colla ge n fibrils Polys a ccha ride
ba ckbone
4 ib e strength. Elastin is present in some tissues, and its rub-
the ce s are so c ose y connected to each other. Connective
tissues, on the other hand, are most y matrixwith the ce s
ew and ar between.
Matrix is ike je y, made up o most y water with various
inter ocking f bers that thicken it (Figure 4-1). T e kinds and
amounts o f bers can produce a variety o matrix typesa
with di erent unctions.
T e thin watery matrix o b oodp asmahas no f bers at
a (except when orming a b ood c ot), which a ows it to re-
main ree- owing. T e tissue o tendons and igaments is dense
with strong, twisted f bers that give the matrix a thick, rope ike
qua ity. Bones matrix f bers are encrusted with minera crysta s
to give it the characteristics o rein orced concrete.
Collagen is a protein that orms microscopic twisted ropes
within the matrix o many tissues. Co agen gives a tissue ex-
bery qua ity gives tissues the abi ity to stretch and rebound
easi y.
T e matrix contains various polysaccharides and proteoglycans
that provide tissues with specia ized properties. For examp e,
these mo ecu es ink ce s, absorb shock, regu ate unction, and
o er ubrication.

FIGURE 4-1 Extracellular matrix. The matrix is outside o cells, orm-
ing a connecting gel that contributes to the overall unction o the tissue.
This example illustrates thick, ropelike collagen brils interspersed with
proteoglycan (protein-carbohydrate) structures attached to polysaccharide
backbonesall surrounded by water. The collagen gives tissue strength,
and the polysaccharide-proteoglycan structures absorb shocks. (Collagen is
naturally white, but is o ten stained pink to make it more visible in micro-
scopic studies.)
Ep it h e lia l Tis s u e
In t ro d u c t io n t o Ep it h e lia l Tis s u e s
O ve r v ie w
Epithelial tissue orms sheets that cover the body and many
o its parts (Table 4-1). It a so ines various parts o the body
and orms ducts or tubes.
Protein connectors in the p asma membranes o adjacent
ce s f rm y ho d epithe ia ce s together. Because epithe ia
ce s are packed c ose together with itt e or no interstitial
uid or other matrix between them, they orm continuous
sheets that contain no b ood vesse s.
 CHAPTER 4 Tissues 73

CELL S HAP ES S IMP LE S TRATIFIED

S qua mous
(S imple
s qua mous )

(S tra tifie d s qua mous )

Cuboida l (S imple
cuboida l)

(S imple
Cilia (Tra ns itiona l, re la xe d)
columna r)
Columna r

Ba s e me nt
me mbra ne

Conne ctive tis s ue

(P s e udos tra tifie d) (Tra ns itiona l, s tre tche d)

FIGURE 4-2 Classif cation o epithelial tissues. The tissues are classi ed according to the shape and
arrangement o cells.

Because epithe ium acks b ood vesse s, epithe ia ce s

must get their oxygen and nutrients rom nearby b ood vesse s
in the connective tissue that a ways under ies sheets o epithe-
ia ce s. A g ue ike ayer ca ed the basement membrane
connects epithe ia tissue to its connective tissue oundation.
Examine Figure 4-2. It i ustrates how this arge group o
tissues can be subdivided according to the shape and arrange-
ment o the ce s ound in each type.
S h a p e o C e lls
I c assif ed according to shape, epithe ia ce s are identi-
f ed as:
1. Squamous at and sca e ike
2. Cuboidalcube-shaped
3. Columnarta er than they are wide
4. ransitionalvarying shapes that can stretch
A r r a n g e m e n t o C e lls
I c assif ed according to arrangement o ce s, epithe ia tissue
can be abe ed as one o the o owing:
1. Simplea sing e ayer o ce s o the same shape
2. Strati edmany ayers o ce s, named or the
shape o ce s in the outer ayer
Severa types o epithe ium are described in the paragraphs
that o ow and are i ustrated in Figures 4-2 to 4-8.
The translucent, microscopic structures that dis-
tinguish di erent types o epithelial tissue are
visible in light microscopes only when stained.
Many o the pink and purple colors in many o the
micrographs in this chapter re ect common stains
used to visualize tissues. For more on microscopic 4
tools, review the article Tools o Microscopic
Anatomy at Connect It! at evolve.elsevier.com.
S q u a m o u s Ep it h e liu m
S im p le S q u a m o u s Ep it h e liu m
Simple squamous epithelium consists o a sing e ayer o
very thin and irregu ar y shaped ce s. Because o its structure,
substances can readi y pass through simp e squamous epithe-
ia tissue, making transport its specia unction. Absorption o
oxygen into the b ood, or examp e, takes p ace through the
simp e squamous epithe ium that orms the tiny air sacs in the
ungs (Figure 4-3).
S t r a t if e d S q u a m o u s Ep it h e liu m
Strati ed squamous epithelium (Figure 4-4) consists o severa
ayers o c ose y packed ce s, an arrangement that makes this
tissue especia y adept at protection. For instance, stratif ed
squamous epithe ia tissue protects the body against invasion
by microorganisms. Most microbes cannot work their way
 74 CHAPTER 4 Tissues

S imple s qua mous S imple cuboida l Ba s e me nt

e pithe lia l ce ll e pithe lia l ce ll me mbra ne

Fre e
e dge

Nucle us

A B
FIGURE 4-3 Simple squamous and simple cuboidal epithelium. A, Photomicrograph shows thin simple
squamous epithelium orming some tubules (arrows) and simple cuboidal epithelium orming the walls o other
tubules. B, Sketch o photomicrograph.

through a barrier o stratif ed squamous tissue such as that

Knowledge o the tissues that make up the skin is
composing the sur ace o skin and o mucous membranes.
critical to understanding the di erent types o skin
One way o preventing in ections, there ore, is to take good
cancer. Check out the article Skin Cancer at
care o your skin. Prevent it rom becoming cracked rom
Connect It! at evolve.elsevier.com.
chapping, and guard against cuts and scratches.

S upe rficia l s qua mous Ba s a l Ba s e me nt

e pithe lia l ce ll e pithe lia l ce ll me mbra ne
A B
FIGURE 4-4 Stratif ed squamous epithelium. A, Photomicrograph. B, Sketch o the photomicrograph.
Note the many layers o epithelial cells and the f attened (squamous) cells in the outer layers.
 CHAPTER 4 Tissues 75

C u b o id a l Ep it h e liu m
Simple cuboidal epithelium is a sing e ayer o ce s that are
typica y about as ta as they are widethus resemb ing a
cube shape. T is tissue does not orm protective coverings.
Instead, it orms tubu es or other groupings adapted or secre-
tory activity (Figure 4-5), which is why they appear to orm
ring ike arrangements in cross section (see Figure 4-3). T ese
secretory cuboida ce s usua y unction in tubes or c usters o
secretory ce s common y ca ed glands.
G ands o the body may be c assif ed as exocrine i they
re ease their secretion through a duct or as endocrine i they
re ease their secretion direct y by di usion into the b ood-
stream. Examp es o g andu ar secretions inc ude sa iva, diges-
tive juices, sweat, and hormones such as those secreted by the
pituitary or thyroid g ands. Simp e cuboida epithe ium a so
orms the tubu es that orm urine in the kidneys.
In some g ands, cuboida epithe ium occurs in more than
one ayer. Such strati ed cuboidal epithelium may be ound in
the sweat g and ducts.

S im p le C o lu m n a r Ep it h e liu m
Simple columnar epithelium can be ound ining the inner
Tubula r gla nd Cuboida l ce lls
sur ace o the stomach, intestines, and some areas o the res-
forming wa ll piratory and reproductive tracts. In Figure 4-6 the simp e co-
of gla nd umnar ce s are arranged in a sing e ayer ining the inner
sur ace o the co on or arge intestine. T ese epithe ia ce s are
FIGURE 4-5 Simple cuboidal epithelium. This scanning electron mi-
crograph shows how a single layer o cuboidal cells can orm glands. The ta er than they are wide, and the nuc ei are ocated toward the
secreting cells arrange themselves into single or branched tubules that open bottom o each ce . T e open spaces seen among the ce s
onto a sur acethe lining o the stomach in this case. are specia ized goblet cells that produce mucus. T e regu ar
co umnar-shaped ce s specia ize in absorption.

Columna r
Goble t ce ll e pithe lia l ce lls

A B
FIGURE 4-6 Simple columnar epithelium. A, Photomicrograph. B, Sketch o the photomicrograph. Note
the oblong nuclei in all the cells and the goblet or mucus-producing cells that are present.
 76 CHAPTER 4 Tissues

P s e u d o s t r a t if e d Ep it h e liu m
Pseudostrati ed epithelium, i ustrated in Figures 4-2 and 4-7,
is typica o that which ines the trachea or windpipe. Look
care u y at the i ustrations. Note that each ce actua y
touches the g ue ike basement membrane that ies under a
epithe ia tissues. A though the epithe ium in Figure 4-7 ap-
pears to be severa ce ayers thick, it is not. T is is the reason
it is ca ed pseudo (or a se) stratif ed epithe ium.
T e ci ia that extend rom the ce s are capab e o moving
in unison (see Figure 3-5, p. 49). As they do so, they move mu-
cus a ong the ining o the trachea, thus protecting the ungs
against entry o dust or other oreign partic es.
In the wa o the urinary b adder, the abi ity o transitiona
epithe ium to stretch easi y without damage keeps the b adder
wa rom tearing as urine f s the space inside. Stratif ed
transitiona epithe ium is shown in Figures 4-2 and 4-8.
QUICK CHECK
1. Lis t th e o u r m a in typ e s o tis s u e s o u n d in th e b o d y.
2. Wh a t is m a trix?
3. Na m e th e typ e s o e p ith e lia l tis s u e a cco rd in g to th e ir
shape.
4. Wh a t is th e d i e re n ce b e tw e e n s im p le e p ith e liu m a n d
s tra tif e d e p ith e liu m ?
5. Wh ich typ e o e p ith e lia l tis s u e is o u n d in th e wa ll o th e
u rin a ry b la d d e r?

Tr a n s it io n a l Ep it h e liu m
Strati ed transitional epithelium is typica y ound in body
areas subjected to stress and must be ab e to stretch. An ex-
amp e wou d be the ining o the urinary b adder. In many
instances, up to 10 ayers o di erent y shaped ce s o varying
sizes are present when the tissue is not stretched. W hen
stretching occurs, the epithe ia sheet expands, the number o
ce ayers decreases, and ce shape changes rom rough y cu-
boida to near y squamous ( at) in appearance.
C o n n e c t ive Tis s u e
In t ro d u c t io n t o C o n n e c t ive Tis s u e
O ve r v ie w
Connective tissue is the most abundant and wide y distributed
tissue in the body. It a so exists in more varied orms than any
o the other tissue types. It is ound in skin, membranes, mus-
c es, bones, nerves, and a interna organs. Connective tissue

S C IEN C E APPLICATIONS
MICROS COPY
Until the very hour o his death in rie ty o pro e s s ions have ound practical applications or m i-
1723, the Dutch drapery merchant cros copy. Mos t he alth pro e s s ionals us e m icros cope s , or the
Antonie van Leeuwenhoek (le t) im age s produce d w ith m icros cope s , to pe r orm routine dutie s .
spent most o his 91 years pursuing For exam ple , clinical laboratory te chnicians and patho lo g is ts
adventures w ith the hundreds o us e m icros cope s to as s e s s the he alth o hum an ce lls and tis -
4 microscopes he had built or col-
lected. Using what were, even then,
s ue s . Outs ide o the he alth s cie nce s , pro e s s ionals s uch as
law e n orce m e nt inve s tigators , archae ologis ts , anthropolo-
very simple lenses or combinations gis ts , and pale o nto lo g is ts o te n us e m icros cope s to urthe r
o lenses, van Leeuwenhoek discov- the ir s tudy o hum an and anim al tis s ue s .
ere d a whole world o tiny struc-
Antonie van Leeuwenhoek tures he called animalcules in
(1632-1723) body uids. Although scientists a
century later would declare that Lig ht mic ro s c o pe
Ocula r le ns
all living organisms are made up o cells, van Leeuwenhoek Eye
was the f rst to see and describe human blood cells (see Ocula r Obje ctive
le ns le ns
Figure 4-15 on p. 81), human sperm cells (see Figure 3-4, B),
S pe cime n
and many other cells and tissues o the body. He was also the (on s lide )
f rst to observe many microscopic organisms that live on or
Obje ctive S ta ge
in the human bodymany o which are capable o producing le ns
disease. Conde ns e r
S pe cime n le ns
Scie ntis ts today us e light m icros cope s that are m uch m ore
Conde ns e r Conde ns e r le ns
advance d than thos e o van Le e uwe nhoe ks tim e . Som e o the
le ns focus
m os t m ode rn m icros cope s , calle d e le ctron m icros cope s , us e Coa rs e focus
e le ctron be am s ins te ad o light to produce im age s o ve ry Fine focus
Light
high m agnif cation (s e e Figure 3-4). Both ce ll biologis ts and Light
his to lo g is ts (tis s ue biologis ts ) us e m icros cope s to re s e arch s ource
the f ne s tructure and unction o the hum an body. A w ide va- Modern compound light microscope.
 CHAPTER 4 Tissues 77

Columna r ce lls Goble t ce lls Cilia

A B Ba s e me nt me mbra ne

FIGURE 4-7 Pseudostratif ed columnar epithelium. A, Photomicrograph. The arrangement o nuclei

makes this specimen seem strati ed, but it is not because each cell reaches the basement membrane, thus
orming just one layer. B, Sketch o the micrograph. Note the presence o goblet cells and cilia.

exists as de icate, paper-thin webs that ho d interna organs
together and give them shape. It a so exists as strong and tough
cords, rigid bones, and even in the orm o a uidb ood.
T e unctions o connective tissue are as varied as its
structure and appearance. It connects tissues to each other
and orms a supporting ramework or the body as a who e
and or its individua organs. As b ood, it transports sub-
stances throughout the body. Severa other kinds o connec-
tive tissue unction to de end us against microbes and other
invaders.

Ba s e me nt Binucle a te S tra tifie d tra ns itiona l

me mbra ne ce ll e pithe lia l ce lls

Conne ctive tis s ue

A B
FIGURE 4-8 Stratif ed transitional epithelium. A, Photomicrograph o tissue lining the urinary bladder
wall. B, Sketch o the photomicrograph. Note the many layers o epithelial cells o various shapes in this re-
laxed (unstretched) specimen.
 78 CHAPTER 4 Tissues

C e lls a n d M a t r ix Fib ro u s C o n n e c t ive Tis s u e

Connective tissue di ers rom epithe ia tissue in the arrange-
ment and variety o its ce s and in the amount and kinds o
interce u ar materia , or matrix, ound between its ce s. In
addition to the re ative y ew ce s embedded in the matrix o
most types o connective tissue, varying numbers and kinds o
f bers are a so present.
T e structura qua ity and appearance o the matrix and
f bers determine the qua ities o each type o connective tissue.
T e matrix o b ood, or examp e, is a iquid, but other types
o connective tissue, such as carti age, have the consistency o
f rm rubber. T e matrix o bone is hard and rigid, whi e the
matrix o connective tissues such as tendons and igaments is
strong and exib e.
Lo o s e Fib ro u s C o n n e c t ive Tis s u e (A r e o la r )
Loose brous connective tissue is the most wide y distrib-
uted o a connective tissue types. It is the g ue that he ps
keep the organs o the body together. A so ca ed areolar tissue,
it consists o webs o f bers and o a variety o ce s embedded
in a oose matrix o so t, sticky ge (Figure 4-9).
Some o the f bers are made o collagen, a strong but ex-
ib e f brous protein. Some are stretchy f bers made o rubbery
elastin proteins. T ese elastic bers he p tissues return to
their origina ength a ter having been stretched.
T e ascia o the body is primari y composed o areo ar
tissue. Fascia is the f brous materia that he ps bind the skin,
musc es, bones, and other organs o the body together.

Ty p e s o C o n n e c t ive Tis s u e Ad ip o s e Tis s u e

T e o owing ist identif es severa major types o connective W hen it begins to store ipids, areo ar tissue can deve op into
tissue in the body. Notice that the ist is organized by category. adipose tissue, or at tissue. In Figure 4-10, numerous vesic es
Photomicrographs o representative types are provided in the have ormed inside the adipose ce s where arge quantities o
o owing pages. trig yceride ipids accumu ate. T ese c ear ipid-storage vesi-
c es scatter ight ike so many snow akes, giving ordinary adi-
A. Fibrous (connective tissue proper) pose tissue a whitish appearance. T is is why it is sometimes
1. Loose f brous (areo ar) ca ed white at. Excess trig ycerides move into storage a ter a
2. Adipose ( at) mea and out o storage as energy-producing nutrients are
a. W hite needed by other tissues.
b. Brown A specia kind o adipose tissue ca ed brown at actua y
3. Reticu ar burns its ue when the body is co d to produce heat. T is heat,
4. Dense f brous a ong with shivering by musc es, he ps restore homeostasis o
a. Regu ar body temperature (see Figure 1-11, p. 15).
b. Irregu ar A types o adipose tissue a so secrete hormones that he p
B. Bone regu ate metabo ism and ue storage in the body.
1. Compact
2. Cance ous Re t ic u la r Tis s u e
C. Carti age Another type o f brous connective tissue ca ed reticular tissue
1. H ya ine has thin, de icate webs o co agen f bers ca ed reticular bers.
4 2. Fibrocarti age T e word reticular means net ike, and it apt y describes the
3. E astic net ike structure o this tissue, as you can see in Figure 4-11.
D. B ood Reticu ar tissue is ound in bone marrow, or examp e, where
E. H ematopoietic tissue it he ps support ce s o the b ood- orming hematopoietic tissue.

Colla ge nous
Ela s tic fibe rs bundle s S tora ge P la s ma
a re a for fa t me mbra ne

Ca pilla ry Ma s t ce lls

FIGURE 4-9 Loose f brous (areolar) connective tissue. Notice how Nucle us of a dipos e ce ll
the staining used renders the bundles o collagen pink and the elastin bers
dark purple. Compare the loose arrangement o bers here with those in FIGURE 4-10 Adipose tissue. Photomicrograph showing the large lipid
Figure 4-12. storage spaces inside the adipose cells o white at.
 CHAPTER 4 Tissues 79

TABLE 4-2 Connective Tissues

TIS S UE STRUCTURE LOCATION(S ) FUNCTION(S )
Loos e f brous Loos e arrange m e nt o collage n Are a be twe e n othe r tis s ue s and organs Conne ction
(are olar) f be rs , e las tic f be rs , and ce lls ( as cia)
Adipos e (w hite and Ce lls contain triglyce ride ve s icle s White Fat
brow n at) Are a unde r s kin; padding at various Prote ction, ins ulation, s upport,
points nutrie nt re s e rve , re gulation
Brow n Fat
Pocke ts w ithin w hite at o ne ck and He at production, re gulation
tors o
Re ticular Ne twork o f ne collage n (re ticular) Bone m arrow, s ple e n, lym ph node s , can- Supports blood-producing ce lls
f be rs ce llous bone cavitie s and im m une ce lls
De ns e f brous (re gular De ns e arrange m e nt o collage n f be r Te ndons , ligam e nts , s kin (de e p laye r), Flexible but s trong conne ction
and irre gular) bundle s orm ing s traps or s he e ts as cia, s car tis s ue
Bone (com pact and Hard, calcif e d m atrix arrange d in Ske le ton Support, prote ction
cance llous ) os te ons (com pact) or ne twork o
be am s (cance llous )
Cartilage (hyaline , Hard but s om ew hat exible ge l Hyaline
f brocartilage , and m atrix w ith e m be dde d Part o nas al s e ptum , are a cove ring s ur- Firm but exible s upport
e las tic) chondrocyte s ace s o bone s at joints , larynx wall,
rings in trache a, and bronchi
Fibro cartilage
Disks betwe en vertebrae and in kne e joint Withs tands pre s s ure
Elas tic
Exte rnal e ar Flexible s upport
Blood Liquid m atrix w ith ow ing re d and Blood ve s s e ls Trans portation
w hite ce lls
He m atopoie tic Liquid m atrix w ith de ns e arrange - Re d bone m arrow Blood ce ll orm ation
m e nt o blood ce llproducing ce lls

It is a so ound in the sp een and ymph nodes, where it sup-
ports deve oping ce s o the immune system.
D e n s e Fib ro u s C o n n e c t ive Tis s u e
D ense brous connective tissue consists main y o thick
bund es o strong, white collagen f bers that are packed c ose y
together. A ew f ber-producing ce s are scattered among the
bund es.
Regular dense brous connective tissue has its co agen f ber 4
bund es arranged in rough y para e rows (Figure 4-12). T is
type o connective tissue makes up tendonsthe strong straps
that connect musc e to bone. It provides great strength and

Blood-forming cells Re ticula r fibe rs Nucle i of Bundle s of

fibe r-producing ce lls colla ge nous fibe rs

FIGURE 4-11 Reticular connective tissue. The supportive ramework

o reticular bers is stained black in this section o a lymph node. Note also FIGURE 4-12 Dense f brous connective tissue. Bundles o wavy col-
the aint blood cells and blood- orming (hematopoietic) cells within the lagen bers are roughly parallel to one another in dense regular tissue. Dark
network o bers. nuclei o ber-producing cells are also visible in this sample rom a tendon.
 80 CHAPTER 4 Tissues
exibi ity, but it cannot stretch. Such characteristics are idea
or these structures that anchor our musc es to our bones.
Irregular dense brous connective tissue has its co agen ar-
ranged in a chaotic swir o tang ed bund es. T is type o tis-
sue orms the tough sheets in the deepest ayer o the skin. It
orms a tough, exib e support to the epithe ia superf cia
ayer o the skin. A though the swir ed pattern o f ber bun-
d es a ows the skin to stretch a itt e, overstretching the skin
o ten causes tears in the irregu ar f brous tissue ca ed stretch
marks.
Bo n e
T e matrix o bone is hard because it has a dense packing o
co agen bund es encrusted with minera crysta s containing
ca cium. Bones are a storage area or ca cium and provide sup-
port and protection or the body.
Compact bone is the so id orm o bone that makes up the
outer wa s o bones in the ske eton. Compact bone is made
up o numerous structura bui ding b ocks ca ed osteons or
haversian systems. W hen compact bone is viewed under a
microscope, we can see these circu ar arrangements o ca ci-
f ed matrix and ce s that give bone its characteristic appear-
ance (Figure 4-13).
Inside each bone is a type o tissue ca ed cancellous bone or
spongy bone. T e term cancellous re ers to something that is
made up o a attice. T e term app ies to this bone type be-
cause it is a chaotic attice o branching beams. Like a bath
sponge, the attice orms many, interconnected ho ow
spacesgiving this bone type the name spongy. T ese beams
are near y as hard as compact bone, but spongy bone cannot
be compressed ike a wet bath sponge. In act, the crisscross-
ing pattern o the bony attice adds rigidityjust ike the
crossed beams that o ten support roo s o bui dings.
T e spaces within cance ous bone are f ed with b ood-
4 orming hematopoietic tissue or adipose tissue.
Os te on
FIGURE 4-13 Bone tissue. Photomicrograph o a chip o compact bone.
A cylindrical structural unit o bone, known as an osteon (haversian system),
is seen in this cross section.
Ma trix Chondrocyte
in a la cuna
FIGURE 4-14 Cartilage. Photomicrograph showing the chondrocytes
distributed throughout the gel-like matrix o hyaline cartilage.
C a r t ila g e
O ve r v ie w
Un ike bone, the co agen bund es o the carti age matrix are
not encrusted with hard minera s. Instead, carti age matrix has
the consistency o a f rm p astic or a grist e ike ge . Carti age
ce s, which are ca ed chondrocytes, are ocated in many tiny
spaces distributed throughout the matrixgiving this tissue
the appearance o Swiss cheese (Figure 4-14). T ere are three
major types o carti age.
Hya lin e C a r t ila g e
Hyaline cartilage has on y a moderate amount o co agen in
its ge matrix, giving it a trans ucent, g ass ike appearance. T e
name hyaline means g assy.T is is the most common type o
carti age in the body. It is ound in the support rings o the
respiratory tubes and covering the ends o bones that orm
movab e joints.
Fib ro c a r t ila g e
Fibrocartilage is the strongest and most durab e type o car-
ti age. T e matrix is rigid and f ed with a dense packing o
strong co agen f bers. Fibrocarti age disks serve as shock ab-
sorbers between adjacent vertebrae and in the knee joint.
Ela s t ic C a r t ila g e
Elastic cartilage contains ew co agen f bers but arge num-
bers o very f ne e astic f bers that give the matrix materia a
high degree o exibi ity. T is type o carti age is ound in the
externa ear and in one o the components o the voice box, or
arynx.
Blo o d Tis s u e
B ood is perhaps the most unusua orm o connective tissue
because its matrixb ood plasmais iquid. It has transpor-
tation and protective unctions in the body. B ood contains red
blood cells, white blood cells, and platelets (Figure 4-15).

Ma trix White Re d
(liquid) blood ce ll blood ce lls
FIGURE 4-15 Blood. Photomicrograph o a human blood smear. This
smear shows a white blood cell surrounded by a number o smaller red blood
cells and tiny platelets. The liquid matrix o this tissue is also called plasma.
He m a t o p o ie t ic Tis s u e
Hematopoietic tissue is the b ood ike connective tissue
ound in the red marrow cavities o bones and in organs such
as the sp een, tonsi s, and ymph nodes (see Figure 4-11). T is
type o tissue is responsib e or the ormation o b ood ce s
and ymphatic system ce s important in our de ense against
disease (Table 4-2).
C LIN ICA L APPLICATION
S CREENING DONATED ORGANS AND TIS S UES
Tis s ue typing is a s cre e ning proce s s in w hich ce ll m arke rs in
a donate d organ or tis s ue are ide ntif e d s o that they can be
m atche d to re cipie nts w ith s im ilar ce ll m arke rs . Ce ll m arke rs
are s pe cif c prote in m ole cule s (calle d antige ns [s e e Chapte r
16]) on the s ur ace o plas m a m e m brane s . I the ce ll m arke rs
in donate d tis s ue are di e re nt rom thos e in the re cipie nts
norm al tis s ue , the re cipie nts im m une s ys te m w ill re cognize
the tis s ue as ore ign. Whe n the im m une s ys te m m ounts a
s ignif cant attack agains t the donate d tis s ue , a re je ctio n re actio n
occurs . The in am m ation and tis s ue de s truction that occur in
a re je ction re action not only de s troy or re je ct the donate d
tis s ue but als o m ay thre ate n the li e o the re cipie nt. Although
drugs s uch as cyclos porine can be us e d to inhibit the im m une
s ys te m s attack agains t donate d tis s ue , cros s m atching o tis -
s ue s by the ir ce ll m arke rs is the prim ary m e thod o preve nting
re je ction re actions .
I you know your blood type , you alre ady know s om e o
your tis s ue m arke rs . In the ABO s ys te m (s e e Chapte r 13), type
A blood has the A m arke r, type B blood has the B m arke r, type
AB blood has both A and B m arke rs , and type O blood has
ne ithe r A nor B m arke rs . It is im portant to type and cros s -
m atch blood be ore a blood trans us ion take s place to preve nt
a re je ction re action that could kill the re cipie nt. The Am e rican
Re d Cros s and othe r age ncie s that coordinate procure m e nt o
organs and tis s ue s or trans plantation are deve loping com pute r
CHAPTER 4 Tissues 81
QUICK CHECK
1. Wh a t a re th e u n ctio n s o co n n e ctive tis s u e ?
2. Lis t th e f ve m a jo r cla s s if ca tio n s o co n n e ctive tis s u e .
3. Wh ich typ e o co n n e ctive tis s u e co m p o s e s te n d o n s ?
4. Ho w d o e s ca rtila g e d i e r ro m b o n e ?
M u s c le Tis s u e
In t ro d u c t io n t o M u s c le Tis s u e
Musc e ce s are the movement specia ists o the body. T ey have
a higher degree o contracti ity (abi ity to generate orce or con-
tract) than any other tissue ce s. Besides producing movement,
musc e tissue can a so provide stabi ityand even produce body
heat. Un ortunate y, injured musc e ce s are sometimes s ow to
hea and o ten rep aced by f brous scar tissue i injured.
T ere are three kinds o musc e tissue: ske eta musc e tis-
sue, cardiac musc e tissue, and smooth musc e tissue (Table 4-3).
S k e le t a l M u s c le Tis s u e
Skeletal muscle or striated muscle is ca ed vo untary because
wi ed or voluntary contro o ske eta musc e contractions is
possib e. Note in Figure 4-16 that, when viewed under a micro-
scope, ske eta musc e is characterized by many cross striations
and many nuc ei per ce . Individua ce s are ong and thread-
ike and are o ten ca ed bers.
ne tworks to m onitor availability o organs w ith s pe cif c ce ll
m arke rs . Such high-s pe e d com pute r ne tworks allow phys i-
cians to im m e diate ly locate organs or tis s ue s or e m e rge ncy 4
trans plants or trans us ions .
Anothe r proce dure us e d to s cre e n pote ntial donor organs
and tis s ue s involve s che cking or the pre s e nce o in e ctious
age nts , e s pe cially virus e s . Be caus e virus e s are di f cult to f nd,
m os t s cre e ning te s ts s cre e n or the pre s e nce o s pe cif c anti-
bodie s . Antibodie s are prote in m ole cule s produce d by s om e
w hite blood ce lls upon expos ure to a virus or othe r in e ctious
age nt. Each type o virus trigge rs production o a s pe cif c kind
o antibody, s o the pre s e nce o a s pe cif c antibody type m e ans
that the tis s ue m ay have the corre s ponding virus . For exam ple ,
a te s t calle d ELISA (e nzym e -linke d im m unos orbe nt as s ay) is
us e d to te s t or the pre s e nce o antibodie s produce d in re -
s pons e to HIV (hum an im m unode f cie ncy virus ). HIV m ay
progre s s to acquire d im m unode f cie ncy s yndrom e (AIDS), a
atal dis e as e that can be trans m itte d through HIV-contam inate d
tis s ue s or body uids . Routine s cre e ning or viral he patitis an-
tige ns and othe r viral antibodie s is als o done by m os t tis s ue
and blood banks . Be caus e the re is s om e lag tim e be twe e n
in e ction by a virus and the re s ulting production o antibodie s ,
s uch s cre e ning te s ts m ay ail to ide nti y a virus -contam inate d
tis s ue rom a re ce ntly in e cte d donor.
 82 CHAPTER 4 Tissues

TABLE 4-3 Muscle and Nervous Tissue

TIS S UE STRUCTURE
MUS CLE
Ske le tal (s triate d Long, thre adlike ce lls w ith m ulti-
voluntary) ple nucle i and s triations
Cardiac (s triate d Branching, inte rconne cte d cylin-
involuntary) de rs w ith aint s triations
Sm ooth (nons triate d Thre adlike ce lls w ith s ingle
involuntary or vis ce ral) nucle i and no s triations
NERVOUS
Ne rve ce lls w ith large ce ll bodie s
and thin f be rlike exte ns ions ;
s upportive glial ce lls als o
pre s e nt
LOCATION(S )
Mus cle s that attach to bone s
Eye ball m us cle s
Uppe r third o e s ophagus
Wall o he art
Walls o tubular vis ce ra o dige s tive ,
re s piratory, and ge nitourinary
tracts
Walls o blood ve s s e ls and large lym -
phatic ve s s e ls
Ducts o glands
Intrins ic eye m us cle s (iris and ciliary
body)
Arre ctor m us cle s o hairs
Brain; s pinal cord; ne rve s
FUNCTION(S )
Mainte nance o pos ture ; m ove m e nt
o bone s ; produce s body he at
Eye m ove m e nts
Involve d in f rs t part o s wallow ing
Contraction o he art
Move m e nt o s ubs tance s along
re s pe ctive tracts
Changing o diam e te r o ve s s e ls
Move m e nt o s ubs tance s along
ducts
Changing o diam e te r o pupils and
s hape o le ns
Ere ction o hairs (goos e pim ple s )
Irritability; conduction

Ske eta musc es are common y attached to bones and,
when contracted, can produce vo untary and contro ed body
movements.
C a r d ia c M u s c le Tis s u e
Cardiac muscle orms the wa s o the heart, and the regu ar
but invo untary contractions o cardiac musc e produce the
heartbeat. Under the ight microscope (Figure 4-17), cardiac
musc e f bers have aint cross striations ( ike ske eta musc e)
4 and thicker dark bands ca ed intercalated disks.
Cardiac musc e f bers branch and connect to various
other cardiac f ber branches to produce a three-dimensiona ,
inter ocking mass o contracti e tissue. ube ike membrane
proteins ink the musc e f bers end-to-end and thus a ow
them to unction as i they are one arge unit. T is arrange-
ment a ows the impu se that triggers contraction to move
a ong a the f bers quick yproducing a near y simu tane-
ous contraction in the wa o heart chambers.
S m o o t h M u s c le Tis s u e
Smooth muscle (visceral muscle) is said to be invo untary
because it is not under conscious or wi u contro . Under a
microscope (Figure 4-18), smooth musc e ce s are seen as
ong, narrow f bers but not near y as ong as ske eta f bers.

S tria tions

A B Nucle i of mus cle fibe rs Mus cle fibe r

FIGURE 4-16 Skeletal muscle. A, Photomicrograph. B, Sketch o the photomicrograph. Note the striations
o the muscle cell bers seen in this longitudinal section.
 CHAPTER 4 Tissues 83

Nucle us of mus cle ce ll

A B Inte rca la te d dis ks

FIGURE 4-17 Cardiac muscle. A, Photomicrograph. B, Sketch o the photomicrograph. Note the branched,
lightly striated bers. The darker bands, called intercalated disks, which are characteristic o cardiac muscle,
are easily identi ed in this tissue section.

S mooth mus cle ce lls Nucle i of s mooth mus cle ce lls

A B
FIGURE 4-18 Smooth muscle. A, Photomicrograph. B, Sketch o the photomicrograph. Note the central 4
placement o nuclei in the spindle-shaped smooth muscle bers in this longitudinal section.

Individua smooth musc e ce s appear smooth (that is, with-

out cross striations) and have on y one nuc eus per f ber.
Smooth musc e he ps orm the wa s o b ood vesse s and
ho ow organs such as the intestines and other tube-shaped
structures in the body. Contractions o smooth (viscera )
musc e prope materia through the digestive tract and he p
regu ate the diameter o b ood vesse s. Contraction o smooth
musc e in the tubes o the respiratory system, such as the
bronchio es in the ungs, can impair breathing and resu t in
asthma attacks and abored respiration.
N e r vo u s Tis s u e
Nervous tissue contro s body unctions and coordinates rapid
communication between body structures (see Table 4-3). Ner-
vous tissue consists o two kinds o ce s: neurons are the
impu se conducting units o the system, whi e glia or neuroglia
are specia connecting and supporting ce s.
A neurons are characterized by a cell body and two types
o processes: (1) one axon, which transmits a nerve impu se
away rom the ce body, and (2) one or more dendrites, which
carry impu ses toward the ce body. T e arge neurons in
Figure 4-19 have many dendrites extending rom the ce body.

QUICK CHECK
1. Na m e th e th re e m a jo r cla s s if ca tio n s o m u s cle tis s u e .
Tis s u e Re p a ir
2. Wh ich typ e s o m u s cle tis s u e a re u n d e r invo lu n ta ry W hen damaged by mechanica or other injuries, tissues have
co n tro l?
a varying capacity to repair themse ves. Damaged tissue wi
3. Wh e re w o u ld yo u f n d s m o o th m u s cle tis s u e in th e b o d y?
either regenerate or be rep aced by tissue known as scars.
 84 CHAPTER 4 Tissues

HEA LTH AND WELL-BEIN G

TIS S UES AND FITNES S
Achieving and m aintaining an ide al body we ight is a he alth-cons cious goal. Howeve r, a be tte r
indicator o he alth and f tne s s is body com pos ition. Exe rcis e phys iologis ts as s e s s body com -
pos ition to ide nti y the pe rce ntage o the body m ade o le an tis s ue and the pe rce ntage m ade
o at. Body- at pe rce ntage is o te n de te rm ine d by us ing calipe rs to m e as ure the thickne s s o
s kin olds at ce rtain place s on the body (s e e f gure ).
A pe rs on w ith low body we ight m ay s till have a high ratio o at to m us cle , an unhe althy
condition. In this cas e the individual is unde rwe ight but ove r at. In othe r words , f tne s s
de pe nds m ore on the pe rce ntage and ratio o s pe cif c tis s ue type s than the ove rall am ount
o tis s ue pre s e nt.
One goal o a good f tne s s program is a de s irable body- at pe rce ntage . For m e n, the ide al
is 12% to 18% , and or wom e n, the ide al is 18% to 24% . The s e range s can vary as a re s ult
o various othe r he alth actors and s hould be dis cus s e d w ith a phys ician.
Be caus e at contains s tore d e ne rgy (m e as ure d in calorie s ), a low at pe rce ntage m e ans a
low e ne rgy re s e rve . High body- at pe rce ntage s are as s ociate d w ith s eve ral li e -thre ate ning
conditions , including diabe te s and cardiovas cular dis e as e . A balance d die t and an exe rcis e
program can e ns ure that the ratio o at to m us cle tis s ue s tays at a leve l appropriate or m ain-
taining hom e os tas is .

Ne rve ce ll body

4
De ndrite s Axon Glia l ce lls

FIGURE 4-19 Nervous tissue. Photomicrograph o neurons and glia in

a smear o the spinal cord. The neurons in this slide display characteristic
cell bodies and multiple cell processes. Nuclei o glia are visible as dark dots
surrounding the neuron.

D uring repair, phagocytic ce s remove dead or injured ce s

and a ow new tissue ce s to f in the gaps that are e t. T is
growth o new tissue is ca ed regeneration.
Epithe ia and connective tissues have the greatest capacity
to regenerate. W hen a break in an epithe ia membrane oc-
curs, as in a cut, ce s quick y divide to orm daughter ce s that
f the wound.
In connective tissues, ce s that orm co agen f bers be-
come active a ter an injury and f in a gap with an unusua y
dense mass o f brous connective tissue. I this dense mass o
f brous tissue is sma , it may be rep aced by norma tissue
ater. I the mass is deep or arge, or i ce damage was
FIGURE 4-20 Keloid. Keloids are thick scars that orm in the lower layer
o the skin in predisposed individuals.
extensive, it may remain a dense f brous mass ca ed a scar. An
unusua y thick scar that deve ops in the ower ayer o the
skin, such as that shown in Figure 4-20, is ca ed a keloid.
Ske eta musc e tissue o ten regenerates itse when in-
jured. Cardiac and smooth musc e seem to have ess abi ity to
regenerateespecia y when the damage is severe.
 CHAPTER 4 Tissues 85

occurs i certain neurog ia are present to pave the way. In the

Crushing injuries o skeletal muscle can release
norma adu t brain and spina cord, neurons may not a ways
massive amounts o intracellular substances into
grow back when injured. T us brain and spina cord injuries
the bloodstream that can have li e-threatening
o ten resu t in permanent damage. Fortunate y, the discovery
consequences. Learn more in the article Rhabdo-
o nerve growth actors produced by neurog ia o ers the prom-
myolysis at Connect It! at evolve.elsevier.com.
ise o treating brain damage by stimu ating re ease o these
actors.
Nerve tissue had been viewed as having a imited capacity
to regenerate, but accumu ating evidence shows that these
imitations are not as great as once thought. QUICK CHECK
Neurons outside the brain and spina cord can sometimes 1. Wh a t a re th e tw o m a in ce ll typ e s o u n d in n e rvo u s tis s u e ?
regenerate on their own, but the process is very s ow and on y 2. Wh a t is m e a n t b y th e te rm re g e n e ra tio n o tis s u e ?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 71)

connective tissue gland neuron

(koh-NEK-tiv TISH-yoo) (gland) (NOO-ron)
[con- together, -nect- bind, -ive relating to, [gland acorn] [neur- string or nerve, -on unit]
tissue abric] glia osteon
cuboidal (GLEE-ah) (AHS-tee-on)
(KYOO-boyd-al) [glia glue] [osteo- bone, -on unit]
[cub- cube, -oid like, -al relating to] goblet cell proteoglycan
dendrite (GOB-let sel) (PRO-tee-oh-GLYE-kan)
(DEN-dryte) [goblet small bowl, cell storeroom] [proteo- protein, -glycan polysaccharide
[dendr- tree, -ite part (branch) o ] haversian system ( rom -glyc- sweet)]
dense f brous connective tissue (hah-VER-zhun or HAV-er-zhun SIS-tem) pseudostratif ed epithelium
(dens FYE-brus koh-NEK-tiv TISH-yoo) [Clopton Havers English physician, (SOOD-oh-STRAT-ih- yed ep-ih-THEE-
[dense thick, f bro- f ber, -ous relating to, -ian relating to] lee-um)
con- together, -nect- bind, -ive relating to, hematopoietic tissue [pseudo- alse, -strati- layer, -f ed made,
tissue abric] (hee-mah-toh-poy-ET-ik TISH yoo) epi- on or upon, theli- nipple, -um thing]
elastic cartilage [hema- blood, -poie- to make, -ic relating to, reticular tissue
(eh-LAS-tik KAR-tih-lij) tissue abric] (reh-TIK-yoo-lar TISH-yoo)
[elast- drive or propel, -ic relating to, hyaline cartilage [ret- net, -ic- relating to, -ul- little,
cartilag- cartilage] (HYE-ah-lin KAR-tih-lij) -ar characterized by, tissue abric] 4
elastin [hyal- glass, -ine o or like, cartilag- cartilage] simple
(e-LAS-tin) interstitial (SIM-pel)
[elast- strike or beat out, -in substance] (in-ter-STISH-al) [simple not mixed]
endocrine [inter- between, -stit- stand, -al relating to] simple columnar epithelium
(EN-doh-krin) loose f brous connective tissue (SIM-pel koh-LUM-nar ep-ih-THEE-lee-um)
[endo- within, -crin secrete] (LOOS FYE-brus kon-NEK-tiv TISH-yoo) [simple not mixed, column- column, -ar relating
epithelial tissue [f br- thread or f ber, -ous relating to, to, epi- on, -theli- nipple, -um thing]
(ep-ih-THEE-lee-al TISH-yoo) con- together, -nect- bind, -ive relating to, simple cuboidal epithelium
[epi- on or upon, -theli- nipple, -al relating to, tissu- abric] (SIM-pel KYOO-boyd-al ep-ih-THEE-
tissue abric] matrix lee-um)
exocrine (MAY-triks) [simple not mixed, cub- cube, -oid like,
(EK-soh-krin) [matrix womb] -al relating to, epi- on, -theli- nipple,
[exo- outside or outward, -crin secrete] -um thing]
nervous tissue
ascia (NER-vus TISH-yoo) simple squamous epithelium
(FASH-ee-ah) [nerv- nerves, -ous relating to, tissue abric] (SIM-pel SKWAY-mus ep-ih-THEE-lee-um)
[ ascia band or bundle] [simple not mixed, squam- scale,
neuroglia
(noo-ROG-lee-ah or noo-roh-GLEE-ah) -ous characterized by, epi- on, -theli- nipple,
at tissue
( at TISH-yoo) sing., neuroglial cell -um thing]
[tissue abric] (noo-ROG-lee-al or noo-roh-GLEE-al sel) skeletal muscle tissue
f brocartilage [neuro- nerve, -glia glue] (SKEL-et-tal MUS-el TISH-yoo)
( ye-broh-KAR-tih-lij) [skelet- dried body, -al relating to, mus- mouse,
-cle small, tissue abric]
[f br- thread or f ber, -cartilag- cartilage]
Continued on p. 86
 86 CHAPTER 4 Tissues

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 85)

smooth muscle tissue stratif ed squamous epithelium tissue

(smoothe MUS-el TISH-yoo) (STRAT-ih- yde SKWAY-mus (TISH-yoo)
[smooth smooth, mus- mouse, -cle small, ep-ih-THEE-lee-um) [tissue abric]
tissue abric] [strati- layer, -f ed made, squam- scale, transitional
squamous -ous characterized by, epi- on, -theli- nipple, (tranz-IH-shen-al)
(SKWAY-mus) -um thing] [trans- across, -tion- process, -al relating to]
[squam- scale, -ous characterized by] stratif ed transitional epithelium
stratif ed (STRAT-ih- yde tran-ZISH-en-al ep-ih-
(STRAT-ih- yde) THEE-lee-um)
[strati- layer, -f ed made] [strati- layer, -f ed made, trans- across,
-tion- process, -al relating to, epi- on,
-theli- nipple, -um thing]

LANGUAGE OF M ED IC IN E

histologist pathologist rhabdomyolysis

(hih-STOL-oh-jist) (pah-THOL-oh-jist) (RAB-doh-mye-OL-ih-sis)
[histo- tissue, -log- words (study o ), -ist agent] [patho- disease, -log- words (study o ), [rabdo- rod, -myo- muscle, -lysis loosening]
keloid -ist agent] scar
(KEE-loyd) regeneration (skahr)
[kel- claw, -oid like] (ree-jen-er-AY-shun) [scar scab]
paleontologist [re- again, generat- produce, -tion process] tissue typing
(pay-lee-un-TOL-oh-jist) rejection reaction (TISH-yoo TYE-ping)
[paleo- ancient, -onto- being, -log- words (reh-J EK-shun ree-AK-shun) [tissue abric, type- kind]
(study o ), -ist agent] [re- again, -ject to throw, -tion process o ,
re- again, -act- to do, -tion process o ]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
B. Matrixa so ca ed extrace u ar matrix (ECM)
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Intro ductio n to Tis s ue s
A. Four main tissue types
1. Epithe ia tissue orms sheets that cover or ine the
body
2. Connective tissueprovides structura and unctiona
support
3. Musc e tissuecontracts to produce movement
4. Nervous tissuesenses, conducts, and processes
in ormation
1. Interna uid environment o the body, surrounding
ce s o each tissue
2. Most y water, but a so o ten contains f bers and other
substances that give it thick, je y ike consistency
(Figure 4-1)
a. Co agenprotein that orms twisted rope ike
f bers that provide exib e strength to tissue
b. E astinrubbery protein that provides e astic
stretch and recoi in tissues
c. Po ysaccharides and proteog ycans he p ink ce s,
absorb shock, regu ate unction, and ubricate

Epithe lial Tis s ue
A. Introduction to epithe ia tissue (Table 4-1)
1. Covers body and ines body cavities; orms tubes and
ducts
2. Strong y connected ce s are packed c ose y together
with itt e matrix; contains no b ood vesse s
3. G ue ike basement membrane ho ds epithe ium to
under ying connective tissue
4. C assif ed by shape o ce s (Figure 4-2)
a. Squamous at and sca e ike
b. Cuboida cube-shaped
c. Co umnarta er than they are wide
d. ransitiona varying shapes that can stretch
5. A so c assif ed by arrangement o ce s into one or
more ayers: simp e or stratif ed
B. Squamous epithe ium
1. Simp e squamous epithe iumsing e ayer o sca e ike
ce s adapted or transport (e.g., absorption)
(Figure 4-3)
2. Stratif ed squamous epithe iumsevera ayers o
c ose y packed ce s specia izing in protection
(Figure 4-4)
C. Cuboida epithe ium
1. Simp e cuboida epithe iumsing e ayer o cube ike
ce s o ten specia ized or secretory activity; may
secrete into ducts, direct y into b ood, and on body
sur ace (Figure 4-3 and Figure 4-5)
2. Stratif ed cuboida epithe iumtwo or more ayers o
cube ike ce s, sometimes ound in sweat g ands and
other ocations
D. Co umnar epithe ium
1. Simp e co umnar epithe iumta , co umn ike ce s
arranged in a sing e ayer; contain mucus-producing
gob et ce s; specia ized or absorption (Figure 4-6)
2. Pseudostratif ed epithe iumsing e ayer o distorted
co umnar ce s; each ce touches basement membrane
(Figure 4-7)
E. ransitiona epithe ium
1. Stratif ed transitiona epithe iumup to 10 ayers o
rough y cuboida ce s that distort to squamous shape
when stretched (Figure 4-8)
2. Found in body areas that stretch, such as urinary
b adder
Co nne ctive Tis s ue
A. Introduction to connective tissue (Table 4-2)
1. Most abundant and wide y distributed tissue in body,
with many di erent types, appearances, and unctions
2. Re ative y ew ce s in extrace u ar matrix between
tissue ce s
3. ypes
a. Fibrous oose f brous (areo ar), adipose ( at),
reticu ar, dense f brous
CHAPTER 4 Tissues 87
b. Bonecompact and cance ous (spongy)
c. Carti agehya ine, f brocarti age, e astic
d. B ood
e. H ematopoietic tissue
B. Fibrous connective tissue
1. Loose f brous connective tissue (areo ar)f brous g ue
( ascia) that ho ds organs together; co agenous and
e astic f bers, p us a variety o ce types (Figure 4-9)
2. Adipose ( at) tissuewhite at stores ipids (trig ycer-
ides); brown at produces heat; both types regu ate
metabo ism (Figure 4-10)
3. Reticu ar tissuede icate net o co agen f bers, as in
bone marrow (Figure 4-11)
4. Dense f brous tissuebund es o strong co agen
f bers, dense y packed
a. Regu arpara e co agen bund es; examp e is
tendon (Figure 4-12)
b. Irregu archaotic, swir ing co agen bund es;
examp e is deep ayer o skin
C. Bone tissuematrix is co agen bund es encrusted with
ca cium minera crysta s
1. Compact bonemade up o cy indrica osteons
(haversian systems); orms outer wa s o bones
2. Cance ous bonemade up o thin, crisscrossing
beams o bone; ound inside bones; a so ca ed spongy
bone
3. Bone unctions in support and protection (Figure 4-13)
D. Carti age tissuematrix has consistency o grist e ike
ge ; chondrocyte is ce type (Figure 4-14)
1. H ya ine carti agemoderate amount o co agen in
matrix; orms a exib e ge
2. Fibrocarti agematrix is very dense with co agen;
orms very tough, hard ge
3. E astic carti agematrix has some co agen with
e astin; orms a so t, e astic ge
E. B ood tissuematrix is uid p asma; contains red b ood 4
ce s, white b ood ce s, and p ate ets; unctions are trans-
portation and protection (Figure 4-15)
F. H ematopoietic tissueb ood- orming tissue with a
iquid matrix
Mus cle Tis s ue
A. Musc e tissue contracts to provide movement or stabi ity;
produces body heat (Table 4-3)
B. Ske eta musc e tissueattaches to bones; a so ca ed
striated or voluntary; contro is vo untary; striations
apparent when viewed under a microscope (Figure 4-16)
C. Cardiac musc e tissuea so ca ed striated involuntary;
composes heart wa ; ordinari y cannot contro contrac-
tions (Figure 4-17)
D. Smooth musc e tissuea so ca ed nonstriated (visceral)
or involuntary; no cross striations; ound in b ood vesse s
and other tube-shaped organs (Figure 4-18)
 88 CHAPTER 4 Tissues
Ne rvo us Tis s ue
A. Functionrapid communication between body struc-
tures and contro o body unctions (Table 4-3)
B. Neurons (Figure 4-19)
1. Conduction ce s
2. A neurons have ce body and two types o processes:
axon and dendrite
a. Axon (one) carries nerve impu se away rom ce
body
b. Dendrites (one or more) carry nerve impu se
toward the ce body
C. G ia (neurog ia)supportive and connecting ce s
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
1. issue identif cation may seem a bit overwhe ming at f rst
g ance. But i you ook or key characteristics as you
study each one, it becomes easier. See my-ap.us/learntissues
or advice.
2. issue types are additiona topics that cou d be earned
using ash cards. It may be he p u to remember that epi-
the ia tissues are covering and protective tissues, and the
important thing about connective tissue is the matrix sur-
rounding the ce s.
3. o understand the shape o epithe ia ce s, you can use a
soda can ana ogy. Imagine a soda can that has been com-
p ete y smashed. T is wou d represent a squamous-shaped
4 ce . A soda can that has on y been smashed ha way
wou d represent a cuboida -shaped ce . A soda can that
has not been smashed wou d represent a co umnar-shaped
ce . Fina y, soda cans arranged in a o these shapes
wou d represent stratif ed transitiona epithe ium.
4. Because membranous epithe ium covers the body or ines
a cavity, there is a ways an exposed space. A ter you have
identif ed the exposed space, c assi y the shape (squamous,
cuboida , or co umnar) o the ce s. T en determine the
number o ayers (simp e or stratif ed). Deve op a concept
map that depicts the di erent epithe ia tissues. Use
Tis s ue Re pair
A. Usua y accomp ished by means o regeneration o tissue
B. Epithe ia and connective tissues have greatest capacity
or se -repair
1. Scardense f brous mass sometimes orms i damage
was extensive
2. Ke oid scars are unusua y thick (Figure 4-20)
C. Musc e and nervous tissue can regenerate under avor-
ab e conditions
Table 4-1 and inc ude the ocations o these tissues in the
body.
5. W hen c assi ying connective tissues, pay c ose attention
to the matrix. Identi y whether the matrix is f brous
protein, protein that is ground substance, or uid. Use
avai ab e resources (textbook, ab manua , at as, or Internet
sources) to ami iarize yourse with the di erence among
these matrices. Deve op a concept map that depicts the di -
erent connective tissues. Use Table 4-2 and inc ude the
ocations o these tissues in the body. ( o earn about
concept mapping, go to my-ap.us/M ExHC .)
6. Fami iarize yourse with the unique characteristics that
def ne each type o musc e tissue. Re er to Table 4-3. Con-
struct a -chart that ists the di erent musc e tissues and
their ocations.
7. T e use o ash cards or review cards is an exce ent strat-
egy to earn the various types o tissues. T ere are many
on ine sources that have tissue images. O btain photos or
i ustrations o the di erent types o tissues. P ace the
photo or i ustration on one side o an index card. On the
opposite side o the card, put the name o the tissue. You
can a so add additiona in ormation such as unique char-
acteristics or ocation in the body.
8. Check out the o owing websites or interactive strategies
that wi enhance your understanding o the di erent
tissues: my-ap.us/JuM 3p3 and my-ap.us/KR4tvs.

Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne the term tissue and identi y the our principa
tissue types.
2. Name and describe three epithe ia tissues.
3. C assi y epithe ium according to the ayers o ce s
present.
4. W here can stratif ed squamous ce s be ound?
5. W hat is the specia unction o simp e co umnar
epithe ium?
6. H ow does pseudostratif ed epithe ium di er rom strati-
f ed epithe ium?
7. W hat are some examp es o substances secreted through
g ands or tubu es made up o simp e cuboida epithe ia
ce s?
8. Name and describe three connective tissues.
9. W here is connective tissue ound?
10. W hat type o connective tissue is the most wide y dis-
tributed throughout the body?
11. W hat type o connective tissue provides great strength
and exibi ity, but no stretch?
12. W hat is the unction o hematopoietic tissue?
13. Name and describe two musc e tissues.
14. Describe the structure and distinctive traits o ske eta
musc e.
15. Give some examp es o smooth musc e tissue.
16. Name the two types o nervous tissue. W hich is unc-
tiona nerve tissue and which is support tissue?
17. Give a genera description o a neuron.
18. W hat is the unction o an axon? H ow do dendrites
serve the nervous system?
19. W hat tissues have the greatest capacity to regenerate?
20. Name the tissues that do not regenerate.
21. W hat is the uid materia between ce s?
22. W hat is brown at?
23. W hat is cance ous bone?
24. Name three types o carti age.
CHAPTER 4 Tissues 89
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
25. Exp ain what is meant by tissue typing. W hy has this
become so important in recent years?
26. You are working in a patho ogy ab and have been given
an epithe ia tissue samp e to identi y. W hat steps wou d
you take to determine what type o epithe ia tissue you
are examining?
27. I a sma , but deep cut invo ving skin and musc e occurs,
predict which tissue wi probab y hea f rst and which
wi hea more comp ete y. Exp ain your answer.
28. Compare and contrast tissue repair in epithe ia , connec-
tive, musc e, and nervous tissue.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________, ________, ________, and ________ are the
our main tissues in the body.
2. ________ tissue covers the body and many o its parts.
3. Epithe ia ce s that vary in shape that can stretch are
c assif ed as ________ epithe ium.
4. T e open spaces seen among epithe ia ce s are specia -
ized ________ ce s that produce mucus.
5. T e most abundant and wide y distributed tissue in the
body is ________ tissue.
6. Connective tissue di ers rom epithe ia tissue in the 4
arrangement and variety o its ce s and in the amount
and kinds o interce u ar materia , ca ed ________.
7. Cardiac musc e f bers have aint cross striations and
thicker dark bands ca ed ________.
8. A neurons are characterized by a ________ ________
and two processes: one ________ and one or more
________.
9. T e growth o new tissue is ca ed ________.
10. An unusua y thick scar that deve ops in the ower ayer
o the skin is ca ed a ________.
 90 CHAPTER 4 Tissues

11. Epithe ia tissue that contains ce s that are at and 16. endons are examp es o which connective tissue type?
sca e ike are c assif ed as: a. Dense f brous
a. stratif ed transitiona b. Areo ar
b. squamous c. Adipose
c. cuboida d. Reticu ar
d. co umnar 17. W hich o the musc e tissue types are invo untary?
12. T e type o epithe ia tissue that protects the body rom a. Ske eta
invasion by microorganisms is: b. Smooth
a. simp e squamous c. Cardiac
b. stratif ed squamous d. Both b and c
c. pseudostratif ed 18. T is type o musc e tissue can be ound in the wa s o
d. simp e co umnar b ood vesse s and intestines.
e. stratif ed transitiona a. Ske eta
13. W hich epithe ia tissue orms tubu es or other groupings b. Smooth
or secretory activity? c. Cardiac
a. Simp e squamous d. Both a and b
b. Pseudostratif ed 19. A neuron process that carries the impu se away rom the
c. Stratif ed transitiona ce body is ca ed a(n):
d. Cuboida a. axon
14. W hat are the unctions o connective tissue? b. dendrite
a. Connects tissue to each other c. g ia
b. Forms a supporting ramework or the body d. neurog ia
c. ransports substances throughout the body 20. W hich tissue is east ike y to regenerate itse ?
d. A o these choices are correct a. Simp e squamous epithe ium
15. W hat type o tissue is the most wide y distributed o a b. Dense f brous connective tissue
connective tissue? c. Smooth musc e tissue
a. Areo ar d. Stratif ed squamous epithe ium
b. Adipose
c. Dense f brous
d. Reticu ar

Match the tissue type in column A with its corresponding description in column B.

Column A Column B
4 21. ________ Simp e squamous epithe ium a. Found in the wa s o the intestines
22. ________ Pseudostratif ed epithe ium b. G ia ce s
23. ________ Dense f brous connective tissue c. Absorption o oxygen into the b ood
24. ________ Carti age d. Interca ated disks
25. ________ Adipose e. Lines the trachea
26. ________ Reticu ar . Composes tendons
27. ________ Ske eta musc e tissue g. Fat tissue
28. ________ Smooth musc e tissue h. De icate webs o co agen f bers
29. ________ Cardiac musc e tissue i. Chondrocytes
30. ________ Nervous tissue j. Striated, vo untary

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Faye was brought to the hea th c inic by her granddaugh-
ter. Faye sustained a burn on her right oot rom burning
trash. T e area is b istered, swo en, hot, and tender to the
touch. T e area surrounding the burn has an increased
redness. Based on the structure and unction o types o
tissue, what type o injury do you suspect Faye has sus-
tained? Because the basement membrane was not com-
p ete y destroyed in Fayes injury, what type o tissue
repair wou d you expect to occur?
CHAPTER 4 Tissues 91
2. Lauren is a bodybui der who is obsessed with her phy-
sique. She exercises dai y and eats a very ow- at diet. H er
sister E en is a persona f tness trainer and she assessed
Laurens body at at 12%. Determine whether Lauren is
too ean or too at. Exp ain the re ationship between her
body- at percentage and i esty e.
3. Dennis is a sedentary, midd e-aged smoker who is com-
p aining o chest pain. U timate y, he is diagnosed with
ung cancer. W hat type o tissues wou d be invo ved?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
4
Organ Systems
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Organ Systems o the Body, 93

Integumentary System, 93
Skeletal System, 94
Muscular System, 94
Nervous System, 95
Endocrine System, 96
Cardiovascular System, 96
Lymphatic and Immune Systems, 97
Respiratory System, 98
Digestive System, 98
Urinary System, 99
Reproductive Systems, 99
Body as a Whole, 101
Homeostasis, 101
Applying Organ System Concepts, 101
Organ Replacement, 101
Vital and Nonvital Organs, 101
Artif cial Organs, 101
Organ Transplantation, 104

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Def ne and contrast the terms organ and organ
system.
2. Identi y and locate the major organs o the integu-
mentary, skeletal, and muscular systems, and brie y
describe their major unctions.
3. Identi y and locate the major organs o the nervous,
endocrine, and cardiovascular systems, and brie y
describe their major unctions.
4. Identi y and locate the major organs o the lymphatic
and immune, respiratory, digestive, and urinary
systems, and brie y describe their major unctions.
5. Identi y and locate the major organs and subdivisions
o the male and emale reproductive systems, and
brie y describe their major unctions.
6. Describe the body as a whole, including listing the
major organ systems o the body, discussing homeo-
stasis, and applying organ system concepts.
7. Describe current approaches to organ replacement.
 5
LANGUAGE OF
S C IEN C E

Be o re re ading the
chapte r, s ay e ach o
the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
the m as yo u re ad.
A t e r exp oring ce s and
tissues in the previous chapters,
adrenal gland
we are ready to ook at the organs (ah-DREE-nal gland)
and systems o the body. An organ is [ad- toward, -ren- kidney, -al relating
a structure made up o two or more kinds to, gland acorn]
o tissue and is organized to per orm a alimentary canal
more comp ex unction compared to a sing e (al-eh-MEN-tar-ee kah-NAL)
tissue. A system is a group o organs that [aliment- nourishment, -ary relating
together per orm a more comp ex unction than to, canal channel]
does one organ. T is chapter gives a brie overview o alveolus
the major organ systems o the body. (al-VEE-oh-lus)
pl., alveoli
An overview o body systems provides the oundation needed to (al-VEE-oh-lye)
see the big picture o human structure and unction as we ater revea [alve- hollow, -olus little]
the detai s o each system. As you progress through your detai ed study o the antibody
major organ systems in the chapters that o ow, it wi be possib e to view the (AN-tih-bod-ee)
body not just as an assemb y o individua parts but as an integrated and unc- [anti- against, -body body]
tioning who e. artery
(AR-ter-ee)
[arteri vessel]

O r g a n S y s t e m s o t h e Bo d y bronchus
(BRONG-kus)
In t e g u m e n t a ry S y s t e m pl., bronchi
(BRONG-kye)
T e integumentary system inc udes on y one organ: the skin (Figure 5-1). In [bronchus windpipe]
most adu ts, the skin a one weighs 20 pounds or moreaccounting or about
capillary
16% o tota body weight and making it the bodys heaviest organ. (KAP-ih-layr-ee)
A though the integumentary system has on y one organ, that one organ, the [capill- hair, -ary relating to]
skin or integument, has many mi ions o appendages (structures attached to a cardiac muscle
main part) and g ands. T ese skin structures inc ude the hair, nai s, and sweat- (KAR-dee-ak MUS-el)
and oi -producing g ands. T e skin inc udes many microscopic sense receptors, [cardi- heart, -ic relating to,
making it the argest sensory organ o the body. Skin sense receptors permit the mus- mouse, -cle little]
body to respond to pain, pressure, touch, texture, vibration, and changes in cardiovascular system
temperature. (kar-dee-oh-VAS-kyoo-lar
SIS-tem)
[cardio- heart, -vas- vessel,
-ular relating to, system organized
whole]

Continued on p. 106

93
 94 CHAPTER 5 Organ Systems

Ha ir
Pa rie ta l bone Fronta l bone

Occipita l bone
Ma xilla
Ve rte bra Ma ndible

Clavicle
S ca pula
S kin
S te rnum
Rib
Hume rus

Cos ta l
ca rtila ge Ve rte bra e
Hip
(coxa l)
Ra dius
Ulna

Ca rpa l bone s
Me ta ca rpa l
bone s
P ha la nge s

Fe mur

Na ils

Pa te lla

S Tibia
R L
Fibula
I

FIGURE 5-1 Integumentary system. Ta rs a l bone s

T e integumentary system is crucia to surviva . Its primary
unction is protection. T e skin protects under ying tissue
against invasion by harm u bacteria, bars entry o most
chemica s, and minimizes the chances o mechanica injury to
under ying structures. In addition, the skin regu ates body
temperature by sweating and by contro ing b ood ow and
there ore heat oss at the body sur ace. T e skin a so synthe-
sizes important chemica s, such as vitamin D, and unctions as
a sophisticated sense organ or temperature, touch, pressure,
pain, vibration, and more.
5 S k e le t a l S y s t e m
Bones are the primary organs o the ske eta system. Figure 5-2
shows examp es o the 206 individua y named bones ound in
the skeletal system. Each individua a so has some variab e
bones that di er rom person to person and do not have spe-
cif c names.
T e ske eta system inc udes not on y bone but a so re ated
tissues such as carti age. Carti age can cushion bones that are
inked together and can act as the connection between one
bone and another. Look at the arge carti age bands (costa
carti age) that connect the ribs to the sternum in Figure 5-2.
S
Me ta ta rs a l
bone s R L
I
FIGURE 5-2 Skeletal system.
Ligaments are bands o f brous connective tissue that he p
ho d bones together. Connections between two or more bones
are ca ed joints. T e moveab e joints between bones make
various movements o individua body parts possib e. W ithout
movab e joints, our bodies wou d be rigid, immobi e hu ks.
T e ske eton provides protection and a supporting rame-
work or the brain and other interna organs. Bones a so serve
as storage areas or important minera s such as ca cium and
phosphorus.
T e ormation o b ood ce s in the red marrow o certain
bones is another crucia unction o the ske eta system.
M u s c u la r S y s t e m
S k e le t a l M u s c le s
Individua ske eta musc es are the organs o the muscular
system. Musc es are made up o most y skeletal muscle

tissue. A so ca ed voluntary muscle, this tissue has the abi ity
to contract when stimu ated by conscious nerve regu ation.
A though movement o the body is the primary unction o
the muscu ar system, it a so maintains stabi ity o our posture
(body position) and provides heat to maintain our body
temperature.
A tendon is a dense strap or sheet o regu ar dense f brous
connective tissue. A tendon is part o a musc e organ that at-
taches the musc e to a bone (or to another musc e). T e ante-
rior tibia is tendon o the eg abe ed in Figure 5-3 shows how
tendons attach musc es to bones.
W hen stimu ated by a nervous impu se, ske eta musc e
tissue shortens or contracts. Vo untary movement occurs
when ske eta musc es shortena unction o the way musc es
S te rnocle idoma s toid
De ltoid
Pe ctora lis
ma jor
Bice ps
bra chii
Exte rna l
a bdomina l
oblique
Re ctus
a bdominis
S a rtorius
Re ctus fe moris
Tibia lis a nte rior
Tibia lis a nte rior te ndon
S In addition, e ements o the periphera nervous system
R L
I ated, these sense organs (discussed in Chapter 11) generate
FIGURE 5-3 Muscular system.
CHAPTER 5 Organ Systems 95
are attached to bones and the way bones articu ate (join) with
one another in joints. Sometimes it is use u to think o this
cooperative unctioning o the bones and musc es as the skel-
etomuscular system or musculoskeletal system.
M u s c le s o O t h e r S y s t e m s
In addition to organs o the muscu ar system, the body con-
tains other types o musc e tissue that orm parts o organs in
other body systems.
For examp e, smooth muscle tissue is ound in the wa s o
ho ow organs such as the stomach and sma intestine.
Smooth musc es he p move uids through organs and o ten
orm va ves that regu ate when uids may move rom one sec-
tion o a ho ow organ to another.
A third type o musc e tissue is the cardiac muscle in the
wa o the heart. By contracting, it pumps b ood through the
circu atory system. Some cardiac musc e ce s in the heart
generate the rhythm o the heartbeat.
Smooth and cardiac musc e tissues are involuntary be-
cause they are regu ated by subconscious mechanisms.
N e r vo u s S y s t e m
T e brain, spina cord, and nerves are the organs o the
nervous system (Figure 5-4). T e brain and spina cord make
up the central nervous system (CNS). T ese two organs
provide the centra contro o the who e nervous system.
T e cranial nerves extend rom the brain and the spinal
nerves extend rom the spina cord. T e crania and spina
nerves, and a their branches, make up the peripheral
nervous system (PNS). T e word peripheral means around
the boundary, an apt term or the nerve branches that extend
a the way to the arthest boundaries o the body.
T e extensive networking o the components o the ner-
vous system makes it possib e or this comp ex system to
per orm its primary unctions. T ese inc ude the o owing:
1. Communication between body organs
2. Integration o body unctions
3. Contro o body unctions
4. Recognition o sensory stimu i
T ese unctions are per ormed by signa s ca ed nerve
impulses. In genera , the unctions o the nervous system
resu t in rapid activity that asts usua y or a short duration.
For examp e, we can chew our ood norma y, wa k, and per-
orm coordinated muscu ar movements on y i our nervous
system unctions proper y. T e nerve impu ses permit the 5
rapid and precise contro o diverse body unctions. O ther
types o nerve impu ses cause g ands to secrete hormones or
other uids.
can recognize certain stimuli, such as heat, ight, sound,
pressure, or temperature, that a ect the body. W hen stimu-
nerve impu ses that trave to the brain or spina cord where
ana ysis or re ay occurs and, i needed, appropriate action is
initiated.
 96 CHAPTER 5 Organ Systems

Bra in
P ine a l Hypotha la mus
Eye
(s e ns e orga n) P ituita ry
Cra nia l ne rve s Pa ra thyroids
S pina l cord Thyroid

S pina l
ne rve s Thymus

Adre na ls

Pa ncre a tic
is le ts

Ova rie s
(fe ma le )
Te s te s
(ma le )

R L

Centra l nervous FIGURE 5-5 Endocrine system.

s yste m (CNS)
Pe riphe ra l ne rvous
system (P NS )
S ties. T ey p ay important ro es in uid and e ectro yte ba ance
R L
I As you can see in Figure 5-5, endocrine g ands are wide y
FIGURE 5-4 Nervous system.
En d o c r in e S y s t e m
T e endocrine system is composed o g ands that secrete
chemica s known as hormones direct y into the b ood.
Sometimes ca ed ductless glands, the organs o the endo-
crine system per orm the same genera unctions as the
5 nervous system: communication, integration, and contro .
T e nervous system provides rapid, brie contro by ast-
trave ing nerve impu ses. T e endocrine system provides
s ower but onger- asting contro by hormone secretion. For
examp e, secretion o growth hormone contro s the rate o
deve opment over ong periods o gradua growth.
Because o their in uence over activities throughout the
body, it is no wonder that the nervous and endocrine systems
are sometimes thought o as one arge regu atory systemthe
neuroendocrine system.
In addition to contro ing growth, hormones are the main
regu ators o metabo ism, reproduction, and other body activi-
and acid-base ba ance. T e various ro es o major hormones are
integrated into discussions throughout the rest o this book.
distributed throughout the body. But this is not the comp ete
pictureendocrine g ands are ar more numerous and wide-
spread than is shown here. We consider just a ew o the major
endocrine g ands.
T e pituitary gland, pineal gland, and hypothalamus are
ocated in the sku . T e thyroid gland and parathyroid glands
are in the neck, and the thymus gland is in the thoracic cavity,
specif ca y in the mediastinum (see Figure 1-5, p. 9). T e
adrenal glands and pancreas are ound in the abdomina
cavity.
Note in Figure 5-5 that some reproductive organs (ovaries in
the ema e and the testes in the ma e) a so unction as endo-
crine g ands.
C a r d io va s c u la r S y s t e m
T e cardiovascular system consists o the heart and a c osed
system o vesse s made up o arteries, veins, and capillaries
(Figure 5-6). As the name imp ies, b ood contained in this
 CHAPTER 5 Organ Systems 97

QUICK CHECK
1. Wh a t is th e in te g u m e n t, a n d w h a t a re its u n ctio n s ?
2. Give e xa m p le s o o rga n s o th e s ke le ta l s ys te m .
S upe rior ve na 3. Wh a t a re th e m a jo r u n ctio n s o th e n e rvo u s s ys te m ?
cava (ve in) 4. Wh a t o rga n s m a ke u p th e ca rd iova s cu la r s ys te m ?
S ubclavia n ve in
S ubclavia n
a rte ry Aorta (a rte ry)
P ulmona ry Ly m p h a t ic a n d Im m u n e S y s t e m s
a rte ry
T e two systems we describe next work as partners to provide
He a rt de ense o the bodys interna environment against harm u
Infe rior ve na agents such as pathogens and cancer.
cava (ve in)
Ly m p h a t ic S y s t e m
T e lymphatic system is composed o lymphatic vessels to-
gether with other ymphatic organs made up o masses o
Common
ilia c a rte ry
de ensive ce s o ten ca ed lymphoid tissue. T ese ymphoid
organs inc ude the lymph nodes, tonsils, thymus gland, and
spleen (Figure 5-7). Note that the thymus unctions as an en-
docrine g and and as a ymphatic organ. A though it is part o
the ske eta system, red bone marrow is a so o ten considered
to be a ymphoid structure.
Fe mora l ve in Instead o containing b ood, the ymphatic vesse s are f ed
with lymph, a watery uid that contains ymphocytes, pro-
Fe mora l a rte ry
teins, and some atty mo ecu es, but no red b ood ce s. T e
ymph is ormed rom the uid around the body ce s that
di uses into the ymph vesse s.
Poplite a l a rte ry
Un ike b ood, ymph does not circu ate repeated y through
a c osed circuit, or oop, o vesse s. Instead, ymph owing
through ymphatic vesse s eventua y enters the cardiovascu ar,
or circu atory, system by passing through arge ducts, such as
the thoracic duct, which in turn connect with veins in the
upper thoracic cavity. Many bio ogists consider the ymphatic
system to be part o the cardiovascu ar system.
S T e unctions o the ymphatic system inc ude moving
interstitia uids and sma partic es back into b ood vesse s
R L
and transporting ats absorbed rom the digestive tract to the
I b ood.
FIGURE 5-6 Cardiovascular system. Lymph nodes and other ymphoid structures act as sma
f ters that trap and destroy bacteria ce s, cancerous ce s, and
other debris that are carried by the ymph uid as it ows
system is pumped by the heart around a c osed circ e, or cir- through the tissues. As such, the organs o the ymphatic sys-
cuit, o vesse s as it passes through the body. T e cardiovascu- tem p ay a ro e in immunity. Because o this over ap o unc-
ar system is sometimes ca ed the circulatory system. tions, the ymphatic system and immune system are o ten
T e primary unction o the cardiovascu ar or circu atory discussed together.
system is transportation. T e need or an e cient transporta- Figure 5-7 shows groupings o ymph nodes in the axi ary
tion system in the body is critica . ransportation needs in- (armpit) and in the inguina (groin) areas o the body.
c ude continuous movement o oxygen (O 2) and carbon diox- 5
ide (CO 2), nutrients, hormones, and other important Im m u n e S y s t e m
substances. Wastes produced by the ce s are re eased into the A o the bodys de ense systems together make up the
b oodstream on an ongoing basis and are transported by the immune system. It protects us rom disease-causing microor-
b ood to the excretory organs. ganisms, harm u toxins, transp anted tissue ce s, and any o
T e cardiovascu ar system a so he ps regu ate body tempera- our own ce s that have turned ma ignant or cancerous.
ture by distributing heat throughout the body and by assisting T e immune system is composed o protective ce s (such
in retaining or re easing heat rom the body by regu ating b ood as phagocytes) and various types o de ensive protein mo e-
ow near the body sur ace. Some ce s o the cardiovascu ar cu es (produced by secretory immune ce s). Some immune
system a so unction in de ense by way o immunity. system ce s have the abi ity to attack, engu , and destroy
 98 CHAPTER 5 Organ Systems

Na s a l cavity
(nos e )
Tons ils
P ha rynx (throa t) Ora l cavity

Bronchi La rynx
Right (voice box)
lympha tic duct
Tra che a
Thymus (wind pipe )

Thora cic duct

Lungs

S ple e n Dia phra gm

S

R L

Re d bone FIGURE 5-8 Respiratory system.

ma rrow
In the a veo i, oxygen rom the air is exchanged or un-
needed CO 2. CO 2 is carried to the ungs by the b ood so it can
be e iminated rom the body. Figure 5-8 a so shows the
diaphragm, which is a sheet o musc e that p ays a major ro e
Lymph ve s s e ls
in in ating the ungs during breathing.
T e organs o the respiratory system per orm a number o
Lymph node
unctions in addition to permitting movement o air into the
a veo i. For examp e, i you ive in a co d or dry environment,
incoming air can be warmed and humidif ed as it passes over
S
the ining o the respiratory air passages. In addition, inha ed
irritants such as po en or dust passing through the respira-
R L
tory tubes can be trapped in the sticky mucus that covers the
I ining o many respiratory passages and then e iminated rom
the body.
T e respiratory system a so is invo ved in regu ating the
acid-base ba ance o the bodya unction that is discussed in
Chapter 22.

To protect the delicate, vital alveoli deep inside

FIGURE 5-7 Lymphatic and immune systems.
harm u bacteria direct y by phagocytosis. O ther more numer-
ous immune system ce s secrete protein compounds ca ed
antibodies and complements. T ese substances produce
chemica reactions that he p protect the body rom many
harm u agents.
T e ymphatic and immune systems, which are inked to
5 each other and to the cardiovascu ar system, are discussed in
Chapter 16.
Re s p ir a t o ry S y s t e m
T e major organs o the respiratory system inc ude the nose,
pharynx (throat), larynx (voice box), trachea (windpipe),
bronchi, and lungs (Figure 5-8). ogether these organs aci i-
tate the movement o air into the tiny, thin-wa ed sacs o the
ungs ca ed alveoli.
the lungs, the respiratory tract has many complex
mechanisms that guard against injury and disease.
Check out the article Protective Strategies o
the Respiratory Tract at Connect It! at
evolve.elsevier.com.
D ig e s t ive S y s t e m
T e organs o the digestive system (Figure 5-9) are o ten sepa-
rated into two groups: the primary organs and the secondary or
accessory organs. T ey work together to ensure proper digestion
and absorption o nutrientsand e imination o waste.
T e primary organs o digestion orm the digestive tract.
T ey inc ude the mouth, pharynx, esophagus, stomach, sma
intestine, arge intestine, rectum, and ana cana . T e accessory
organs o digestion may attach to the digestive tract (or be
inside it). Accessory digestive organs inc ude the teeth, sa ivary
g ands, tongue, iver, ga b adder, pancreas, and appendix.
 CHAPTER 5 Organ Systems 99

Tongue
S a liva ry gla nd Mouth
P ha rynx (throa t)
S a liva ry gla nds

Es opha gus

Live r

S toma ch
Ga llbla dde r Kidney
Pa ncre a s
Ure te r
La rge
inte s tine
S ma ll
inte s tine

Re ctum Urina ry bla dde r

Ure thra
Appe ndix Anus
S

R L
S
I
R L
FIGURE 5-9 Digestive system.
I

T e digestive tract is a tube, open at both ends. It is a so

ca ed the alimentary canal, a major part o which is the
gastrointestinal (GI) tract. Food that enters the a imentary
cana is digested, its nutrients are absorbed, and the undi-
gested residue is e iminated rom the body as waste materia
ca ed eces.
U r in a ry S y s t e m
T e organs o the urinary system inc ude the kidneys,
ureters, urinary bladder, and urethra.
T e kidneys (Figure 5-10) f ter out, or c ear, the b ood o
the waste products continua y produced by the metabo ism o
nutrients in the body ce s. T e kidneys a so p ay an important
ro e in maintaining the e ectro yte, water, and acid-base ba -
ances in the body.
T e waste product produced by the kidneys is ca ed urine.
A ter it is produced by the kidneys, urine ows out o the
kidneys, through the ureters, and into the urinary b adder
where it is temporari y stored. Urine passes rom the b adder
to the outside o the body through the urethra.
In the ma e the urethra passes through the penis and has a
doub e unctionit transports both urine and semen (semina
uid). T ere ore it has urinary and reproductive purposes. In
the ema e the urinary and reproductive passages are comp ete y
separate, so the urethra per orms on y a urinary unction.
FIGURE 5-10 Urinary system.
In addition to the organs o the urinary system, other or-
gans a so he p e iminate body wastes. Undigested ood resi-
dues and metabo ic wastes are e iminated rom the intestina
tract as eces, and the ungs rid the body o carbon dioxide.
T e skin a so serves an excretory unction by e iminating wa-
ter and some sa ts in sweat.
Re p ro d u c t ive S y s t e m s
Hu m a n Re p ro d u c t io n
T e norma unction o the reproductive system is di erent 5
rom the norma unction o other organ systems o the body.
T e proper unctioning o the reproductive systems ensures
surviva , not o the individua but o the genes. In addition,
production o the hormones that permit the deve opment o
sexua characteristics a so a ects other structures and unc-
tions o the body.
H umans reproduce sexua y (two-parent reproduction) so
the ma e and the ema e reproductive systems must work to-
gether to produce o spring. Both systems have gonads that
 100 CHAPTER 5 Organ Systems

produce sex ce s and hormones necessary or producing o - mammary glands, which produce mi k to nurture o spring.
spring and regu ation o reproductive unctions. T ey are present in both ma es and ema es, but norma y on y
produce mi k in ema es. Because o their ro e in supporting
M a le Re p ro d u c t ive S y s t e m deve opment o o spring, mammary g ands usua y are c assi-
T e ma e reproductive structures shown in Figure 5-11 inc ude f ed as accessory sex organs, rather than as skin g ands.
the testes, which produce the sex ce s and thus serve as the T e reproductive organs in the ema e unction to
ma e gonads. T e testes produce sperm as we as the ma e
hormone testosterone. A tube ca ed the vas de erens extends
rom each testis and eads to the urethra. Surrounding the
upper urethra is the prostate, which is an exocrine g and or
the uterus
ducted g and.
T e penis and scrotum are externa structures and to-
o o spring
gether are known as the externa genitalia. T e urethra, which
is identif ed in Figure 5-10 as part o the urinary system, passes
QUICK CHECK
through the penis. It carries sperm to the exterior and acts as
a passageway or the e imination o urine. 1. Wh a t a re th e u n ctio n s o th e lym p h a tic s ys te m ?
2. Wh a t a re th re e wa ys th a t th e im m u n e s ys te m f g h ts
Functioning together, the ma e reproductive structures
d is e a s e -ca u s in g m icro o rga n is m s ?
produce sperm and introduce them into the ema e repro- 3. Wh a t u n ctio n s b e s id e s ga s e xch a n g e a re p e r o rm e d b y
ductive tract, where erti ization can occur. Sperm produced th e re s p ira to ry s ys te m ?
by the testes trave through a number o ducts, inc uding the 4. Wh a t a re s o m e o th e a cce s s o ry o rga n s o th e d ig e s tive
vas de erens, to exit the body. T e prostate and other acces- s ys te m ?
5. Wh a t o rga n in m a le s is s h a re d b y b o th th e u rin a ry s ys te m
sory organs, which add uid and nutrients to the sex ce s as
a n d th e re p ro d u ctive s ys te m ?
they pass through the ducts and the supporting structures
(especia y the penis), aci itate trans er o
sex ce s into the ema e reproductive
tract.

Fe m a le Re p ro d u c t ive
S ys t e m
T e ema e gonads are the
ovaries. O ther reproductive Bre a s ts
organs shown in Figure 5-12 (ma mma ry
gla nds )
inc ude the uterus, uterine
tubes or allopian tubes,
and the vagina. In the e-
ma e the term vulva is used
to describe the externa
genita ia. Va s
Eggs, or ova, are sex de fe re ns
ce s produced by the ova- Ute rine
P ros ta te tube
ries. O va trave through
the uterine tubes, where
they may be erti ized by
Ova ry
sperm. As the o spring
ormed by the union o Ute rus
sperm and ovum matures, it
5 moves down the uterine tube
Te s tis
Ure thra
S crotum Exte rna l
Pe nis ge nita lia
to the uterus, where it im- Va gina Vulva
p ants and orms a connection (exte rna l
ge nita lia )
with the mothers b ood vesse s.
S
A ter about 9 months, the o - S
spring is de ivered through the R L
R L
cervix (neck) o the uterus and I
I
through the vagina.
T e breasts are atty exten-
sions o the skin that house the FIGURE 5-11 Male reproductive system. FIGURE 5-12 Female reproductive system.

HEA LTH AND WELL-BEIN G
CANCER S CREENING
Know le dge o the s tructure and unction o the organ s ys te m s
is a critically im portant f rs t s te p in unde rs tanding and us ing
in orm ation that e m powe rs us to be com e m ore s ophis ticate d
guardians o our ow n he alth and we ll-be ing.
For example, a better understanding o the reproductive sys-
tem helps individuals participate in a more direct and personal
way in cancer screening. Breast and testicular sel -examinations
to detect cancer are two important ways that women and men
can participate directly in protecting their own health.
Bo d y a s a Wh o le
As you study the structure and unction o the various organ
systems in the chapters that o ow, it is important that you
ocus on how each system and its component organs re ate to
other systems and to the body as a who e.
Ho m e o s t a s is
Table 5-1 ists major organs o each system and identif es the
unction o each system in the context o homeostasis. T e
concept o homeostasis, introduced in Chapter 1, exp ains
how the body maintains or is ab e to restore re ative constancy
to its interna environment even when aced with changing
externa surroundings or interna needs.
For examp e, musc e contraction can produce a specif c
body movement on y i it is attached appropriate y to a bone
in the ske eta system. In order or contraction to begin,
musc es must f rst be stimu ated by nerve impu ses generated
in the nervous system. T en, in order to continue contracting,
musc es must receive both oxygen rom the respiratory system
and nutrients absorbed rom the digestive system. Numerous
wastes produced by contracting musc es must be e iminated
by the urinary and respiratory systems. T e cardiovascu ar
system provides transportation or the respiratory gases, nu-
trients, and waste products o metabo ism.
No one body system unctions entire y independent y o
other systems. Instead, you wi f nd that they are structura y
and unctiona y interre ated and interdependent. H omeosta-
sis can be maintained on y by the coordinated and care u y
regu ated unctioning o a body organ systems.
A p p ly in g O r g a n S y s t e m C o n c e p t s
Notice that Table 5-1 groups the major organ systems into arger
systems or divides some o them into sma er systems. We
group or sp it the major organ systems when it makes a particu-
ar situation easier to understandor in certain c inica app i-
cations where it he ps c ari y pro essiona communication.
For examp e, physica therapists sometimes f nd it most
use u to use the concept o a skeletomuscular system rather than
CHAPTER 5 Organ Systems 101
Likew is e , aware ne s s o norm al ne rvous s ys te m unctions
can ale rt a pe rs on o a pos s ible brain tum or w he n expe rie ncing
unexplaine d he adache s or change s in vis ion or othe r s e ns e s .
Unus ual im m une s ys te m unctions , s uch as night s we ats , als o
can ale rt phys icians to the pos s ibility o cance r.
In orm ation on cance r s cre e ning is available rom the
Am e rican Cance r Socie ty and rom m os t hos pitals , clinics , and
he alth care provide rs .
thinking o the ske eta and muscu ar systems separate y. T e
nervous system is so comp ex that o ten it is easier to under-
stand i it is sp it into central and peripheral nervous systems.
Notice a so in the tab e that some organs be ong to more
than one system. For examp e, the hypotha amus is part o the
brain and there ore is in the nervous system, but it a so se-
cretes hormones, so it is in the endocrine system as we .
O r g a n Re p la c e m e n t
Vit a l a n d N o n v it a l O r g a n s
As we a know, disease and injury are sometimes unavoidab e.
T ere ore it is common to su er damage that renders an or-
gan incapab e o proper unction.
By def nition, a nonvita organ is not required or i e to
continuea vita organ is. I a nonvital organ is damaged, a
persons hea th may be in some peri , but even permanent oss
o that organ wi not resu t in death. For examp e, we can
survive easi y without the use o our sp een, appendix, and
tonsi s. We can a so survive, a though ess easi y, without the
use o our eyes, arms, and egs. H owever, i the unctions o a
vital organ are ost, we are in immediate danger o dying. For
examp e, when the heart or brain ceases to unction, death wi
resu t.
O ver the past ew decades, hea th science pro essiona s
have made great advances in the abi ity to rep ace or repair
ost or damaged organs. In the case o nonvita organs, these
techniques have improved the qua ity o i e or many pa-
tients. In the case o vita organs, these techniques have saved
and extended i e. 5
A r t if c ia l O r g a n s
N o n v it a l O r g a n Re p la c e m e n t
A nonvita organ is o ten success u y rep aced or enhanced by
an artif cia organ or prosthesis. T e term prosthesis, in the
broadest sense, re ers to any device used to rep ace a body part
or improve its unction. Figure 5-13 shows examp es o many
types o prostheses now in use.
 102 CHAPTER 5 Organ Systems

TABLE 5-1 Organ Systems o the Body

MAJOR BODY
GROUPED SYSTEMS S PLIT
SYSTEM* (by chapte r) GENERAL FUNCTIONS SYSTEM* PRINCIPAL ORGANS
Ske le tom us cular Inte gum e ntary Se parate s inte rnal e nvironm e nt Skin (include s hair, nails , glands )
(m us culo- (7) rom exte rnal e nvironm e nt
s ke le tal) Ske le tal Supports , prote cts , and m ove s Axial Bone s o s kull, Ligam e nts and joints
(8) body s pine , thorax o s kull, s pine ,
Store s m ine rals (m any) thorax (m any)
Appe ndicular Bone s o extre m itie s Ligam e nts and joints
(m any) o extre m itie s
(m any)
Mus cular Powe rs and dire cts s ke le tal Mus cle s (m any)
(9) m ove m e nt
Stabilize s the s ke le ton to m ain-
tain pos ture
Ge ne rate s he at
Ne uroe ndocrine Ne rvous Major re gulatory s ys te m o the Ce ntral Brain Spinal cord
(10, 11) inte rnal e nvironm e nt Pe riphe ral Cranial ne rve s (and Se ns e organs (m any)
Se ns e s change s , inte grate s in or- branche s )
m ation, and s e nds s ignals to Pe riphe ral ne rve s
e e ctors (m us cular organs , (and branche s )
glands )
Endocrine Re gulate s inte rnal e nvironm e nt Pituitary gland Pancre atic is le ts
(12) by s e cre ting horm one s that Pine al gland Ovarie s
trave l through bloods tre am to Hypothalam us Te s te s
targe t are as Thyroid gland Othe r glands
Adre nal glands
Circulatory Cardiovas cular Trans ports nutrie nts , wate r, He art Ve ins (m any)
(13-15) oxyge n, horm one s , was te s , Arte rie s (m any) Capillarie s (m any)
and othe r m ate rials w ithin the
inte rnal e nvironm e nt
Lym phatic/im m une Drains exce s s uid rom tis s ue s , Lym phatic Lym ph node s Sple e n
(16) cle ans it, and re turns it to the Lym ph ve s s e ls Tons ils
blood Thym us
De e nds inte rnal e nvironm e nt Im m une Lym ph node s All othe r lym phoid
rom injury by abnorm al ce lls , organs
ore ign particle s , and othe r
irritants
Re s piratory Exchange s O 2 and CO 2 be twe e n Nos e Trache a
(17) the inte rnal and exte rnal Pharynx Bronchi
e nvironm e nt Larynx Lungs
Dige s tive Bre aks apart nutrie nts rom the PRIMARY ACCESSORY
(18, 19) exte rnal e nvironm e nt and Mouth Te e th
abs orbs the m into the inte rnal Pharynx Salivary glands
e nvironm e nt Es ophagus Tongue

5 Stom ach
Sm all inte s tine
Live r
Gallbladde r
Large inte s tine Pancre as
Re ctum Appe ndix
Anal canal
*Som e s ys te m s are groupe d or s plit into othe r s ys te m s w he n ne e de d; a ew exam ple s are give n he re .
Num e rals in pare nthe s e s a te r e ach s ys te m nam e re e r to the chapte r num be rs w he re that s ys te m is dis cus s e d.
The ne rvous s ys te m o te n is s plit in othe r ways , s uch as s e ns ory/m otor or s om atic/autonom ic.
The lym phatic s ys te m include s both lym phoid organs and an exte ns ive ne twork o lym ph ve s s e ls , w he re as the im m une s ys te m include s only lym phoid
organs w ith de e ns ive unctions .
 CHAPTER 5 Organ Systems 103

TABLE 5-1 Organ Systems o the Bodycont'd

MAJOR BODY
GROUPED SYSTEMS S PLIT
SYSTEM* (by chapte r) GENERAL FUNCTIONS SYSTEM* PRINCIPAL ORGANS
Uroge nital Urinary Adjus ts inte rnal e nvironm e nt by Kidneys Urinary bladde r
(20-22) excre ting exce s s wate r, s alt, Ure te rs Ure thra
was te s , acids , and othe r
s ubs tance s
Re productive Produce s s ex ce lls that orm o - Male Te s te s (gonads ) Pros tate
(23-25) s pring, e ns uring s urvival o Vas de e re ns Pe nis
ge ne s Ure thra Scrotum
Fe m ale s ys te m is als o s ite o e r- Fe m ale Ovarie s (gonads ) Vagina
tilization and e arly o s pring Ute rus Vulva
deve lopm e nt Ute rine ( allopian) Mam m ary glands
tube s (bre as ts )

FIGURE 5-13 Examples o prostheses. Damaged organs or

tissues o ten can be replaced or repaired by using arti cial materi-
als or devices.

Crude artif cia imbs have been

used or centuries, but the avai abi -
ity o new materia s and advanced Cochle a r impla nt Conta ct le ns
engineering have made more e - (a rtificia l e a r)
cient types possib e. For examp e,
new computer-assisted arm and
hand rep acements can manipu-
ate sma objects with amazing
dexterity. Artif cia sense organs
have even been ab e to restore Artificia l a rm a nd ha nd Pa ce ma ke r
sight to the b ind and hearing to
the dea .
For examp e, many peop e su -
ering rom dea ness have had
their hearing partia y restored by
artif cia ears ca ed
cochlear implants. In coch ear
imp ants, a miniature microphone
is surgica y imp anted under the Dia lys is ma chine Artificia l he a rt
skin near the outer ear and wired to (a rtificia l kidney) pumps
an e ectrode in the inner ear, or cochlea.
Sound picked up by the microphone is S
converted to e ectrica signa s that are re ayed
direct y to the auditory nerve in the coch ea.
R L
5
I
I you would like to see diagrams that show Artificia l joint Ins ulin infus ion device
how cochlear implants work, check out the (hip) (a rtificia l pa ncre a s )
article Cochlear Implants at Connect It! at
evolve.elsevier.com. rep ace vita organs or to augment their unctions is occurring
more and more requent y in modern medica practice.

Vit a l O r g a n Re p la c e m e n t Medical Machines

T e use o artif cia materia stransp anted anima or human One o the ear iest devices to augment vita unctions was
tissues or mechanica devicesto partia y or comp ete y the artif cia kidney, or dialysis machine (see Chapter 20).
 104 CHAPTER 5 Organ Systems

O r g a n Tr a n s p la n t a t io n
FIGURE 5-14 Tissue-engineered human
ear cartilage. Photo showing cartilage tis- S u r g ic a l Tr a n s p la n t s
sue grown rom human cells on an engineered One approach that o ers the hope o
rame in a lab.
a permanent so ution to oss o vita
organ unction is organ transplanta-
Kidney dialysis machines pump tion. In this technique, a norma iv-
b ood through permeab e tubes in an ing organ rom a donor is surgica y
externa apparatus, a owing waste transp anted into the recipient. Kid-
products to di use out o the b ood ney, iver, pancreas, ung, sma intes-
and into a sa t-water type o e ectro- tine, and heart transp ants are now
yte uid that surrounds the semi- done at many hospita s throughout
the wor d.
with kidney ai ure must be hooked W hen a new organ is trans-
up to the machine, genera y or 2- S
p anted into the body, the o d organ
to 4-hour periods 2 or 3 times each may or may not be removed. For
M L examp e, ai ed kidneys are o ten e t
week. A though ongoing machine-
based dia ysis treatments can extend I in p ace at the posterior o the ven-
the ives o kidney ai ure patients tra body cavity. As Figure 5-15 shows,
or ong periods, this process is gen- the new kidney is nest ed in erior
era y considered an interim so ution whi e awaiting kidney to the o d kidneyin the curve o the pe vic bone, where it
transp antation. is attached to major b ood vesse s and to the b adder. Using
T e f rst permanent artif cia heart was imp anted in a hu- this strategy, the trauma o removing the damaged kidneys is
man in 1982. Since that time, great progress has been made in avoided and the transp anted kidney can sti process b ood
the deve opment o sma er and much more e cient e ectro- e cient y.
mechanica devices that he p keep b ood pumping in patients
su ering rom end-stage heart disease. A number o these Im m u n e Re je c t io n o Tr a n s p la n t s
devices, ca ed le t ventricular assist systems (LVAS), are im- Despite its many successes, organ transp antation sti has
p anted in the abdomen and connected to the heart. T ey are some prob ems. One is that a recipients immune system o ten
regu ated and contro ed by a battery pack. LVAS devices have rejects a transp anted organ. T e immune response may be re a-
been used by patients wor dwide or extended periods unti a tive y minor, but can become i e-threatening in some cases.
heart transp ant becomes possib e. Some immunosuppressive drugs that suppress the im-
Un ortunate y, because o the critica shortage o donor mune system and inhibit rejection reactions a so increase
organs, on y about 2500 heart transp ants occur in the United the risk o severe in ection. Cyc osporine is an immunosup-
States each year, a though the need is much greater. In addi- pressive drug that so ves this prob em to some degree by
tion to LVAS devices, cardiovascu ar surgeons have a wide
array o heart va ve rep acement and repair products avai ab e.
Some cardiac rep acement va ves are tota y mechanica ,
whereas others are abricated rom porcine (pig), bovine Re na l
(cow), or human tissues. Dis e a s e d a rte ry
kidney Re na l
Engineered Tissues and Organs ve in
Exciting advances in the abi ity to grow human tissues and Infe rior Re cipie nt
organs in a ab using ce -cu turing techniques is rapid y in- ve na kidneys
cava Aorta
creasing medica options or rep acing both vita and nonvita
organs.
Donor
For examp e, Figure 5-14 shows carti age tissue grown on an
5 engineered rame in a ab. Various techniques or growing
kidney
Inte rna l
Common
ilia c
skin, membranes, organs, and parts o organs rom human ilia c ve in
a rte ry
ce s have been deve oped. W hen grown rom a patients own
Ure te rs
ce s, these engineered tissues and organs have a better chance Inte rna l
ilia c S
o success than structures received rom donors. a rte ry
A though new materia s and bioengineering advances are R L
encouraging, many cha enges remain or success u , ong- I
term transp antation o many organs. ota artif cia rep ace-
ment or vital organs, i possib e at a , is genera y emp oyed FIGURE 5-15 Kidney transplantation. In kidney transplantations, the
on y to ensure surviva unti a more permanent so ution (most diseased organs are le t in place, and the donated organ is nestled in an-
o ten organ transp antation) can occur. other part o the body.

suppressing rejection reactions without severe y inhibiting
in ection contro .
In addition, better tissue-typing procedures, continued
deve opment o new and more e ective antirejection drugs,
and the possibi ity o using a patients own ce s to bui d an
engineered organ, a so o er hope o reducing organ-rejection
prob ems.
Another way to so ve the rejection prob em is to bui d
new organs rom a patients own tissues. For examp e, in a
method ca ed ree- ap surgery, pieces o tissue rom one part
o the body are surgica y remode ed and then gra ted to a
new part o the body.
A ter cancerous breasts are removed, new breasts can be
ormed rom skin and musc e tissue taken rom the thighs,
repair the urinary b adder. oes can even be transp anted to
the hand to rep ace missing f ngers. T e advantage o using a
patients own tissues is that the possibi ity o rejection is
great y reduced.
Another major prob em with organ transp ants is the im-
ited avai abi ity o donor organs. O ne so ution is to e iminate
S C IEN C E APPLICATIONS
RADIOGRAPHY
In 1895, the Ge rm an phys icis t
Wilhe lm Rntge n (RENT-gun) m ade
one o the m os t im portant m e dical
dis cove rie s o the m ode rn age : ra-
diographic im aging o the body.
Radio g raphy, or x-ray photogra-
phy, e arne d Rntge n a Nobe l Prize
and is the olde s t and m os t w ide ly
us e d m e thod o noninvas ive im ag-
ing o inte rnal body. While s tudying
Wilhelm Rntgen the e e cts o e le ctricity pas s ing
(18451923) through gas unde r low pre s s ure s ,
Rntge n accide ntally dis cove re d
x-rays w he n they caus e d a plate coate d w ith s pe cial che m icals
to glow. Not long a te r that, he s howe d that they could pro-
duce s hadow s o inte rnal organs s uch as bone s on photo-
graphic f lm . His f rs t, and m os t am ous , radiograph was o his
w i e Be rthas hand. Although a little uzzy, it cle arly s howe d
Be rthas f nge r bone s and the outline o he r ring. Whe n this
radiograph was publis he d by a Vie nna new s pape r, the e ntire
world be cam e ins tantly aware o his bre akthrough dis cove ry.
The f gure at the right s how s how radiography works . A
s ource o wave s in the x band o the radiation s pe ctrum be am s
the x-rays through a body and to a pie ce o photographic f lm
or phos phore s ce nt s cre e n. The re s ulting im age s how s the
outline s o bone s and othe r de ns e s tructure s that abs orb the
x-rays . As the f gure s how s , one way to m ake s o t, hollow
s tructure s s uch as dige s tive organs m ore vis ible is to us e radi-
opaque contras t m ate rial. For exam ple , barium s ul ate (w hich
CHAPTER 5 Organ Systems 105
or reduce the need or human donors. Researchers are now
working on a variety o methods by which new organs or tis-
sues can be grown in a tissue cu ture or in a patients body.
For examp e, it is hoped that one day, norma iver ce s can be
sa e y removed rom a hea thy donor and imp anted in a p as-
tic sponge that wi be p aced in the recipients body. T e
transp anted ce s may then reproduce and orm a mass ca-
pab e o per orming some iver unction. Researchers are a so
cu turing co onies o hea thy nervous tissue in aboratory
dishes in the hope that it can someday be used to repair dam-
aged sections o the brain or spina cord.
QUICK CHECK
1. Ho w is a n o nvita l o rga n o te n re p la ce d ?
2. Wh a t a re tw o e xa m p le s o m e d ica l m a ch in e s th a t a re u s e d
w h e n o rga n tra n s p la n ta tio n is n o t a va ila b le o r a n o p tio n ?
3. Wh a t is th e g re a te s t co n ce rn re ga rd in g o rga n tra n s p la n ta -
tio n ? Wh a t a re s o m e p o s s ib le o p tio n s to a vo id th is
p ro b le m ?
4. Wh a t is re e - a p s u rg e ry?
abs orbs x-rays ) can be introduce d into the colon to m ake it
m ore vis ible in a radiograph.
Today, m any variations o Rntge ns inve ntion are us e d to
s tudy inte rnal organs w ithout having to cut into the body.
For exam ple , com pute d tom ography (CT) s canning is a m od-
e rn, com pute rize d type o x-ray photography. Radio lo g ical
te chno lo g is ts are he alth pro e s s ionals w hos e chie re s pons i-
bility is to m ake radiographs , and radio lo g is ts are re s pons ible
or inte rpre ting the s e im age s . Many m e dical, ve te rinary, and
de ntal pro e s s ionals re ly on the s e im age s and inte rpre tations
in the ir diagnos is , as s e s s m e nt, and tre atm e nt o patie nts . In
addition, radiography is us e d in m any indus trial and inve s tiga-
tive s e ttings eve n by archae ologis ts s tudying m um m ie s .
P hotogra phic film or
phos phore s ce nt s cre e n
5
X-ray
s ource
Radiography
 106 CHAPTER 5 Organ Systems

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 93)

central nervous system (CNS) integumentary system ovary

(SEN-tral NER-vus SIS-tem [see en es]) (in-teg-yoo-MEN-tar-ee SIS-tem) (OH-var-ee)
[centr- center, -al relating to, nerv- nerves, [in- on, -teg- cover, -ment- result o action, [ov- egg, -ar- relating to, -y location o process]
-ous relating to, system organized whole] -ary relating to, system organized whole] ovum
circulatory system involuntary (smooth) muscle (OH-vum)
(SER-kyoo-lah-tor-ee SIS-tem) (in-VOL-un-tayr-ee MUS-el) pl., ova
[circulat- go around, -ory relating to, [in- not, volunt- will, mus- mouse, -cle little] (OH-vah)
system organized whole] joint [ovum egg]
complement (joynt) pancreas
(KOM-pleh-ment) kidney (PAN-kree-as)
[comple- complete, -ment result o action] (KID-nee) [pan- all, -creas esh]
diaphragm [kidney womb (shape)] parathyroid gland
(DYE-ah- ram) larynx (payr-ah-THYE-royd gland)
[dia- across, -phrag- enclose, -(u)m thing] (LAYR-inks) [para- beside, -thyr- shield, -oid like,
digestive system [larynx voice box] gland acorn]
(dye-J ES-tiv SIS-tem) ligament penis
[digest- break apart, -tive relating to] (LIG-ah-ment) (PEE-nis)
endocrine system [liga- bind, -ment result o action] [penis male sex organ]
(EN-doh-krin SIS-tem) lung peripheral nervous system (PNS)
[endo- inward or within, -crin secrete, (lung) (peh-RIF-er-al NER-vus SIS-tem
system organized whole] lymph [pee en es])
allopian tube (lim ) [peri- around, -phera- boundary, -al relating to,
( al-LOH-pee-an toob) nerv- nerves, -ous relating to,
[lymph water]
[Gabriele Fallopio Italian anatomist] system organized whole]
lymph node
eces (lim nohd) pharynx
(FEE-seez) [lymph water, nod knot]
(FAYR-inks)
[ eces waste] [pharynx throat]
lymphatic system
gastrointestinal tract (GI tract) (lim-FAT-ik SIS-tem) pineal gland
(gas-troh-in-TES-tih-nal trakt [lymph- water, -atic relating to,
(PIN-ee-al gland)
[jee aye trakt]) [pine- pine, -al relating to, gland acorn]
system organized whole]
[gastr- stomach, -intestin- intestine, -al relating lymphatic vessel pituitary gland
to, tract trail] (lim-FAT-ik VES-el) (pih-TOO-ih-tayr-ee gland)
genitalia [pituit- phlegm, -ary relating to, gland acorn]
[lymph- water, -atic relating to,
(jen-ih-TAYL-yah) vessel container] prostate (gland)
sing., genital mammary gland (PROS-tayt gland)
(J EN-ih-tul) (MAM-mah-ree gland) [pro- be ore, -stat- set or place, gland acorn]
[gen- produce, -al relating to] [mamma- breast, -ry relating to, gland acorn] reproductive system
gonad muscular system (ree-proh-DUK-tiv SIS-tem)
(GOH-nad) (MUS-kyoo-lar SIS-tem) [re- again, -produc- bring orth, -tive relating to,
[gon- o spring, -ad relating to] system organized whole]
[mus- mouse, -cul- little, -ar relating to,
hormone system organized whole] respiratory system
(HOR-mohn) nerve impulse (RES-pih-rah-tor-ee SIS-tem)
[hormon excite] (nerv IM-puls) [re- again, -spir- breathe, -tory relating to,
hypothalamus system organized whole]
5 (hye-poh-THAL-ah-mus)
[nervus nerve, impulse to drive]
nervous system scrotum
[hypo- under or below, -thalamus inner (NER-vus SIS-tem) (SKROH-tum)
chamber] [scrotum bag]
[nerv- nerves, -ous relating to, system organized
immune system whole] sense organ
(ih-MYOON SIS-tem) nose (sens OR-gan)
[immun ree (immunity), system organized (nohz) [organ tool or instrument]
whole] [nose something obvious] skeletal system
integument organ (SKEL-eh-tal SIS-tem)
(in-TEG-yoo-ment) (OR-gan) [skeleto- dried body, -al relating to, system
[in- on, -teg- cover, -ment result o action] organized whole]
[organ tool or instrument]
 CHAPTER 5 Organ Systems 107

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 106)

smooth muscle thymus gland urine

(smoothe MUS-el) (THY-mus gland) (YOOR-in)
[smooth smooth, mus- mouse, -cle small] [thymus thyme ower, gland acorn] [ur- urine, -ine chemical]
sperm thyroid gland uterine tube
(spurm) (THY-royd gland) (YOO-ter-in toob)
[sperm seed] [thyro- shield, -oid like, gland acorn] [uter- womb, -ine relating to, tube pipe]
spleen tissue uterus
(spleen) (TISH-yoo) (YOO-ter-us)
stem cell [tissue abric] [uterus womb]
(stem sel) tonsil vagina
[stem tree trunk, cell storeroom] (TAHN-sil) (vah-J YE-nah)
stimulus [tons- goiter, -il little] [vagina sheath]
(STIM-yoo-lus) trachea vas de erens
pl., stimuli (TRAY-kee-ah) (vas DEF-er-enz)
(STIM-yoo-lye) [trachea rough duct] pl., vasa de erentia
[stimulus incitement] ureter (VAS-ah de -er-EN-chah)
system (YOOR-eh-ter) [vas duct or vessel, de erens carrying away]
(SIS-tem) [ure- urine, -ter agent or channel] vein
[system organized whole] urethra (vayn)
tendon (yoo-REE-thrah) [vena blood vessel]
(TEN-don) [ure- urine, -thr- agent or channel] voluntary (skeletal) muscle
[tend- pulled tight, -on unit] urinary bladder (VOL-un-tayr-ee MUS-el)
testis (YOOR-ih-nayr-ee BLAD-er) [volunt- will, mus- mouse, -cle little]
(TES-tis) [urin- urine, -ary relating to, bladder blister, vulva
pl., testes pimple] (VUL-vah)
(TES-teez) urinary system [vulva wrapper]
[testis witness (male gonad)] (YOOR-ih-nayr-ee SIS-tem)
thoracic duct [urin- urine, -ary relating to, system organized
(thoh-RAS-ik dukt) whole]
[thorac- chest (thorax), -ic relating to,
duct to lead]

LANGUAGE OF M ED IC IN E

cochlear implant kidney dialysis radiological technologist

(KOHK-lee-ar IM-plant) (KID-nee dye-AL-ih-sis) (ray-dee-oh-LOJ -ih-kul tek-NOL-oh-jist)
[cochlea- snail shell, -ar relating to, im- into, [dia- apart, -lysis loosening] [radi(at)- emit rays, -log- words (study o ),
-plant plant] radiography -ic- relating to, -al relating to, techn- art or
immunosuppressive drug (ray-dee-OG-rah- ee) skill, -log- words (study o ), -ist agent]
(ih-myoo-noh-soo-PRES-iv drug) [radio- ray, requency, -graphy drawing] radiologist 5
[immuno- ree (immunity), -suppress- press (ray-dee-AHL-oh-jist)
down, -ive relating to] [radi(at)- emit rays, -log- words (study o ),
-ist agent]
 108 CHAPTER 5 Organ Systems

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary d. Storage o minera s
or us e w ith your device , acce s s the Au d io Ch a p te r e. Formation o b ood ce s
S u m m a rie s online at evolve .e ls evie r.com . C. Muscu ar system (Figure 5-3)
1. Structure
Scan this s um m ary a te r re ading the chapte r to a. Musc es are the primary organs
he lp you re in orce the key conce pts . Late r, us e (1) Vo untary or striated ske eta musc e
the s um m ary as a quick review be ore your clas s (2) Invo untary or smooth musc e tissue in wa s o
or be ore a te s t. some organs
(3) Cardiac musc e in wa o the heart
2. Functions
De f nitio ns and Co nce pts a. Movement
A. O rgana structure made up o two or more kinds o b. Maintenance o body posture
tissues that can together per orm a more comp ex unc-
tion than a sing e tissue 3. Ske etomuscu ar systemcombination o the ske eta
B. O rgan systema group o organs that per orm a more and muscu ar systems; a so ca ed musculoskeletal system
comp ex unction than can any organ a one D. Nervous system (Figure 5-4)
C. Know edge o individua organs and how they are orga- 1. Structure
nized into groups improves the understanding o how a a. Centra nervous system (CNS)
particu ar organ system unctions as a who e (1) Brain
(2) Spina cord
Organ Sys te m s o the Bo dy (1) Crania nerves and their branches
A. Integumentary system (Figure 5-1) (2) Spina nerves and their branches
1. Structure (3) Sense organs
a. O n y one organ, the skin, but has many appendages 2. Functions
(attached structures) a. Communication between body organs
b. Skin appendages b. Integration o body unctions
(1) H air c. Contro o body unctions
(2) Nai s d. Recognition o sensory stimu i
(3) Microscopic sense receptors E. Endocrine system (Figure 5-5)
(4) Sweat g ands 1. Structureduct ess g ands that secrete signa ing hor-
(5) O i g ands mones direct y into the b ood
2. Functions 2. Functions
a. Same as nervous systemcommunication, integra-
b. Regu ation o body temperature tion, contro
c. Synthesis o chemica s b. Contro is s ow and o ong duration
d. Sense organ c. Neuroendocrine systemcombination o nervous
B. Ske eta system (Figure 5-2) and endocrine systems
1. Structure d. Examp es o unctions regu ated by hormones
a. Bonesorgans o the ske eta system (1) Growth
(1) 206 named bones in the ske eton (2) Metabo ism
5 (2) Additiona variab e bones occur in each (3) Reproduction
individua (4) F uid and e ectro yte ba ance
b. Carti age connects and cushions joined bones F. Cardiovascu ar system (a so ca ed circulatory system)
c. Ligamentsbands o f brous tissue that ho d bones (Figure 5-6)
together 1. Structure
d. Jointsconnections between bones that make a. H eart
movement possib e b. B ood vesse s
2. Functions 2. Functions
a. Supporting ramework or entire body a. ransportation o substances throughout the body
b. Regu ation o body temperature
c. Movement (with joints and musc es) c. Immunity (body de ense)
 CHAPTER 5 Organ Systems 109

G. Lymphatic and immune systems (Figure 5-7) c. Urinary b adder

1. Lymphatic system d. Urethra (part o both urinary and reproductive
a. Structure systems in ma es)
(1) Lymphatic vesse s 2. Functions
(2) Lymph nodes and tonsi s a. C earing, or c eaning, b ood o waste products
(3) T ymus excreted rom the body as urine
(4) Sp een b. E ectro yte ba ance
b. Functions c. Water ba ance
(1) ransportation o ymph d. Acid-base ba ance
(2) Immunity K. Reproductive systems
2. Immune system 1. Structure
a. Structure a. Ma e (Figure 5-11)
(1) Unique ce s (1) Gonadstestes
(2) O ther structuresvas de erens, urethra, pros-
(b) Secretory ce s tate, externa genita ia (penis and scrotum)
(2) De ensive protein compounds b. Fema e (Figure 5-12)
(a) Antibodies (1) Gonadsovaries
(b) Comp ements (2) O ther structuresuterus, uterine ( a opian)
b. Functions tubes, vagina, externa genita ia (vu va),
mammary g ands (breasts)
(2) Chemica reactions that provide protection 2. Functions
rom harm u agents a. Surviva o genes
H . Respiratory system (Figure 5-8)
1. Structure c. rans er and erti ization o sex ce s
a. Nose d. Deve opment and birth o o spring
e. Nourishment o o spring
c. Larynx
d. rachea
e. Bronchi
. Lungs
Bo dy as a Who le
2. Functions A. H omeostasis
a. Exchange o waste gas (carbon dioxide or CO 2) or 1. No one body system unctions entire y independent y
oxygen (O 2) in the a veo i o the ungs o other systems (Table 5-1)
b. Fi tration o irritants rom inspired air 2. A body systems are structura y and unctiona y
c. Regu ation o acid-base ba ance interre ated and interdependent
I. Digestive system (Figure 5-9) B. App ying organ system concepts
1. Structure 1. Systems can be grouped or sp it or better understand-
ing (Table 5-1)
(1) Form a tube ca ed the a imentary cana , or GI a. Ske etomuscu ar system made up o both ske eta
tract and muscu ar systems
(2) Inc ude mouth, pharynx, esophagus, stomach, b. Nervous system can be sp it into centra and
sma intestine, arge intestine, rectum, ana periphera nervous systems
cana 2. Some organs, such as the hypotha amus, can be in
b. Accessory organs more than one system
(1) Assist the digestive process
(2) Inc ude teeth, sa ivary g ands, tongue, iver,
ga b adder, pancreas, appendix
Organ Re place m e nt 5
2. Functions A. Vita and nonvita organs
a. Mechanica and chemica breakdown (digestion) o 1. Loss o unction in nonvita organs is not immediate y
nutrients i e-threatening
b. Absorption o nutrients 2. Loss o unction in vita organs is immediate y
c. E imination o undigested waste productre erred i e-threatening
to as eces 3. Loss o unction in organs can be treated by organ
J. Urinary system (Figure 5-10) rep acement
1. Structure
a. Kidneys
b. Ureters
 110 CHAPTER 5 Organ Systems
B. Artif cia organs (Figure 5-13)
1. Nonvita organ rep acement
improves its unction
b. Examp ecoch ear imp ant to improve hearing
2. Vita organ rep acement
a. Medica machines or examp e, kidney dia ysis
(artif cia kidney) machine, artif cia heart pumps
b. Engineered tissues and organs or examp e,
trachea (windpipe) grown rom cu tured human
ce s (Figure 5-14)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Chapte r 5 is the big picture chapte r. It is a preview o the
s ys te m s dis cus s e d in the re m aining chapte rs .
and the unctions o the systems and their organs on the
other side. Notice how each organ contributes to the
unctioning o the system. Use Table 5-1 as a resource.
2. Review the various types o artif cia organs, transp ants,
and some o the prob ems in transp antation.
3. Be ore you begin the chapter dea ing with a particu ar
system, it wou d be he p u to get an overview o that
system by reviewing the synopsis o that system in this
chapter. T at wi give you a quick ook at its major unc-
tions and the organs in that system.
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne organ and organ system.
5 2. W hat is the unction o skin sense receptors?
3. H ow is the skin ab e to assist in the bodys abi ity to
regu ate temperature?
4. W hat is the costa carti age?
5. W hat is a tendon and describe what unction it serves.
6. W hat structure is part o the ske eta system, but is o ten
considered to a so be a ymphoid structure?
C. O rgan transp antation
1. Surgica transp antsorgans rom donors are surgi-
ca y trans erred to a recipient; sometimes the origina
is e t in p ace (Figure 5-15)
2. Immune rejection o transp ants is sometimes treated
with immunosuppressive drugs; new organs engi-
neered with compatib e ce s may avoid rejection
4. In your study group, review the body system ash cards
you have made. Discuss how severa systems need to be
invo ved in accomp ishing one unction in the body, such
as getting nutrients or oxygen to the ce s. Go over the
questions at the back o the chapter and discuss possib e
test questions.
5. Consider starting some running concept lists or each o
the systems and organs that you wi encounter in this
course. T en, each time you earn something new about
each one, you can add your new know edge to the appro-
priate concept ist. See my-ap.us/JlLFb6 to earn more
about how to use running concept lists.
6. Make use o the many on ine resources that provide an
overview o the bodys systems. Examp es inc ude:
my-ap.us/JmM kpi, my-ap.us/K9GtVc, and my-ap.us/Lzv45j.
7. Name the organs that he p rid the body o waste. W hat
type o waste does each organ remove?
8. W ith the exception o bone, what other types o tissue
are inc uded in the ske eta system, and what unction do
they serve or the body?
9. List the e even organ systems discussed in this chapter.
10. Most o the organ systems have more than one unction.
List two unctions or the o owing systems: integu-
mentary, ske eta , muscu ar, ymphatic and immune, res-
piratory, and urinary.
11. W hat is unique about the reproductive system?
12. Name three artif cia organs or prostheses. W hat organs
do they rep ace or assist?
13. W hat is the ro e o drugs such as cyc osporine in organ
transp antation?
 CHAPTER 5 Organ Systems 111

Critical Thinking Chapte r Te s t

A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
14. Exp ain the di erence between the nervous and endo-
crine systems. Inc ude what types o unctions are regu-
ated and the message carriers or each system.
15. T e term balance is used throughout this chapter. T is is
another term or homeostasis. Review the unctions o the
body systems and ist the homeostatic unctions o each.
16. W hat exp anation wou d you give to a riend who has
recent y had a kidney transp antation but cant be ieve it
when a nurse to d him that his o d kidneys were e t in
p ace?
17. Exp ain how the use o stem ce s wi have a pro ound
impact on human hea th.
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e primary organs o the digestive system make up a
ong tube ca ed the ________.
2. ________ is another name or vo untary musc e.
3. ________ is another name or invo untary musc e.
4. T e nervous system can generate specia e ectrochemica
signa s ca ed ________.
5. T e ________, ________, and ________ are ca ed
accessory structures o the skin.
6. T e ________ g and is part o both the ymphatic and
endocrine systems.
7. T e ________ is part o both the ma e reproductive
system and urinary system.
8. T e gonads or the ma e reproductive system are the
________; the gonads or the ema e reproductive
system are the ________.
9. T e ske eta system is composed o bone and what two
re ated tissues: ________ and ________.
10. A ________ is an artif cia ear used to improve hearing.
11. ________ are undi erentiated ce s taken rom embry-
onic tissue or cord b ood and can be used in organ
engineering.

Match each system in column A with its corresponding unction in column B.

Column A Column B
12. ________ integumentary
13. ________ ske eta b. Uses hormones to regu ate body unction
14. ________ muscu ar c. ransports atty nutrients rom the digestive system into the b ood
15. ________ nervous d. Causes physica and chemica changes in nutrients so they can be absorbed into the b ood
16. ________ endocrine e. C eans the b ood o metabo ic waste and regu ates water and e ectro yte ba ance
17. ________ cardiovascu ar
18. ________ ymphatic g. Responsib e or the transport o substances rom one part o the body to another
19. ________ respiratory h. Ensures the surviva o the species rather than the individua
20. ________ digestive i. Uses e ectrochemica signa s to integrate and contro body unctions
21. ________ urinary j. Exchanges oxygen and carbon dioxide and he ps regu ate acid-base ba ance
22. ________ reproductive

3. om comp ained o pain in his abdomen one night and

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. ommy has been diagnosed as having irreversib e kidney
ai ure. W hich system o the body is invo ved in this con-
dition? W hat unctions has ommy ost? W hat options
do his physicians have in treating ommys condition?
2. Mr. Davidson was re erred to a uro ogist or diagnosis and
treatment o an obstruction in his urethra. W hat bodi y
unctions may be a ected by Mr. Davidsons conditions?
decided to go to the emergency department. H is b ood
work was negative and a at screen x-ray o his abdomen 5
revea ed nothing abnorma . T e doctor, however, sti sug-
gested that om be admitted to the hospita . H e advised
om that he wou d be ordering some additiona tests and
x-rays. W hat are some x-ray options that the doctor
might order, and what are the individua advantages o
these x-rays?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Mechanisms o Disease
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Studying Disease, 113

Disease Terminology, 113
Patterns o Disease, 114
Pathophysiology, 115
Mechanisms o Disease, 115
Risk Factors, 117
Pathogenic Organisms and Particles, 117
Viruses, 118
Prions, 120
Bacteria, 120
Fungi, 123
Protozoa, 123
Pathogenic Animals, 124
Prevention and Control, 125
Mechanisms o Transmission, 125
Prevention and Treatment Strategies, 126
Drug Therapy, 127
Tumors and Cancer, 128
Neoplasms, 128
Causes o Cancer, 130
Pathogenesis o Cancer, 131
In ammation, 134
In ammatory Response, 134
In ammatory Disease, 135

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Explain the study o disease, including disease termi-
nology and patterns o disease.
2. List and describe the basic mechanisms o disease
and risk actors associated with disease.
3. List and describe six categories o pathogenic organ-
isms and explain how they cause disease.
4. List and describe the ways pathogens can be spread,
as well as prevention and control measures.
5. Do the ollowing related to tumors and cancer:
benign and
malignant.

6. Outline the events o the in ammatory response and

explain its role in disease.
 6
Th e tit e o this book uses the words health and disease. We use these words LANGUAGE OF
a the time, but what do they rea y mean? In scientif c study, hea th is def ned S C IEN C E
as physica , menta , and socia we -beingnot mere y the absence o disease.
Disease can be described itera y as ack o ease, or a physio ogica distur-
Be o re re ading the
bance that threatens we -being. A named disease is a specif c set o structura
chapte r, s ay e ach o
or unctiona abnorma ities, as def ned by characteristic signs and symptoms. the s e te rm s o ut lo ud. This w ill
In this chapter we exp ore these basic ideas about disease and how disease he lp yo u to avo id s tum bling ove r
disrupts norma unction. the m as yo u re ad.

S t u d y in g D is e a s e age
(ayj)
D is e a s e Te r m in o lo g y ameba
(ah-MEE-bah)
S ig n s , S y m p t o m s ,
pl., amebas or amebae
a n d D is e a s e (ah-MEE-bahz or ah-MEE-bee)
Pathology is the study o disease. [amoeba change]
Researchers want to know the archaea
scientif c basis o abnorma (ARK-ee-ah)
conditions. H ea th practitio- sing., archaeon
ners want to know how to (ARK-ee-ahn)
prevent and treat a wide vari- [archae ancient]
ety o diseases. W hen we su - arthropod
er rom the inevitab e co d (AR-throh-pod)
or something more serious, we [arthro- jointed, -pod oot]
a want to know what is going autoimmunity
on and how best to dea with it. (aw-toh-ih-MYOO-nih-tee)
Patho ogy has its own termi- [auto- sel , -immun- ree, -ity state]
no ogy, as in any specia ized f e d. bacillus
Most o these terms are de- (bah-SIL-us)
pl., bacilli
rived rom Latin and
(bah-SIL-aye)
Greek word parts.
[bac- sta , -ill- small, -us thing]
bacterium
(bak-TEER-ee-um)
pl., bak-TEER-ee-ah
[bacter- rod, -ium thing]
chemotaxis
(kee-moh-TAK-sis)
[chemo- chemical, -taxis movement
or reaction]
ciliate
(SIL-ee-at)
[cili- eyelid, -ate o or like]
coccus
(KOK-kus)
pl., cocci
(KOK-sye or KOK-see)
[coccus grain, berry]

Continued on p. 136

113
 114 CHAPTER 6 Mechanisms o Disease

For examp e, patho- comes rom the Greek word or disease undetermined causes are said to be idiopathic. Communicable,
(pathos) and is used to orm many terms, inc uding pathology or in ectious, diseases can be transmitted rom one individua
6 itse . I you are un ami iar with word parts common y used in to another.
medica science, re er to Appendix B at evolve.elsevier.com. T e term etiology re ers to the theory o a diseases cause,
Many disease-causing organisms are known by their scien- but the actua mechanism o a diseases deve opment is ca ed
tif c names, which are Latin names that are o ten ita icized to its pathogenesis. T e common co d, or examp e, begins with
show that they are non-Eng ish terms. a latent, or hidden, stage during which the co d virus estab-
Disease conditions are usua y diagnosed or identif ed by ishes itse in the patient. No signs o the co d are yet evident
signs and symptoms. Signs are objective abnorma ities that at this stage. In in ectious diseases, the atent stage is a so
can be seen or measured by someone other than the patient, ca ed incubation. A ter incubating, the co d may then mani-
whereas symptoms are the subjective abnorma ities e t on y est itse as a mi d nasa drip, triggering a ew sneezes. It then
by the patient. progresses to its u ury and continues or a ew days. A ter
A though sign and symptom are distinct terms, we o ten use the co d has run its course, convalescence, or recovery, occurs.
them interchangeab y. A syndrome is a co ection o di erent D uring this stage, body unctions return to norma .
signs and symptoms, usua y with a common cause that pre- T ose who deve op a chronic disease such as cancer may
sents a distinct picture o a patho ogica condition. T e condi- exhibit a temporary reversa o signs and symptoms that
tion or syndrome, as def ned by a characteristic set o signs seems to be a recovery. Such reversa o a chronic disease is
and symptoms, is what we common y re er to as a disease. ca ed a remission. I a remission is comp ete and permanent,
we say that the person is cured.
D is e a s e P ro g r e s s io n
W hen signs and symptoms appear sudden y, persist or a
P a t t e r n s o D is e a s e
short time, then disappear, we say that the disease is acute.
In t ro d u c t io n t o Ep id e m io lo g y
On the other hand, diseases that deve op s ow y and ast or a
ong time (perhaps or i e) are abe ed chronic diseases. T e
Epidemiology is the study o the occurrence, distribution,
term subacute re ers to diseases with characteristics some-
and transmission o diseases in humans. Epidemio ogists are
where between acute and chronic. physicians or medica scientists who study patterns o disease
T e study o a actors invo ved in causing a disease is re-
occurrence in specif c groups o peop e. For examp e, a hospi-
erred to as etiology. T e etio ogy (causes or origin) o a skin
ta may emp oy a sta epidemio ogist who is responsib e or
in ection o ten invo ves a cut or abrasion and subsequent inva-
in ection-contro programs within the hospita . Many gov-
sion and growth o a bacteria popu ation. Diseases with ernments and other agencies emp oy epidemio ogists who
track the spread o disease through
a oca community or even the wor d
at arge.
RES EA RC H, IS S U ES , AND TREN D S A disease that is native to a oca
CENTERS FOR DIS EAS E CONTROL AND PREVENTION region is ca ed an endemic disease.
I the disease spreads to many indi-
Epide m iology is a m ajor conce rn o the vidua s at the same time within a
Ce nte rs or Dis e as e Control and Pre - def ned geographic region, the situ-
ve ntion (CDC). Scie ntis ts and he alth
ation is ca ed an epidemic.
pro e s s ionals at CDC he adquarte rs
Pandemics are epidemics that
in Atlanta, Ge orgia, and around the
world continually track the incide nce spread throughout the wor d. H IV
and s pre ad o dis e as e in this country (human immunodef ciency virus) is
and w orldw ide . now considered a pandemic because
Much o the CDCs tracking in orm a- it is ound wor dwide. Because o
tion is publis he d in the Morbidity and the speed and avai abi ity o modern
Mortality We e kly Re port (MMWR). air trave , pandemics are more com-
Available to phys icians and othe r he alth mon than they once were. A most
pro e s s ionals , this re port provide s re - every u season, we see a new strain
ce nt in orm ation on dis e as e rate s in o in uenza virus quick y spreading
s pe cif c populations (m o rbidity) and
rom continent to continent.
the num be rs o de aths caus e d by s pe -
cif c dis e as e s (m o rtality). Tr a c k in g D is e a s e
Much o the in orm ation in the
MMWR conce rns notif able dis e as e s racking the cause o a disease and
dis e as e s that phys icians m us t re port its pattern o spread through a pop-
cas e s o to the U.S. Public He alth Se rvice . Gonorrhe a, m e as le s , HIV, Zika virus , Lym e u ation can be very di cu t. O ne
dis e as e , anthrax, tube rculos is , and te tanus are exam ple s o notif able dis e as e s . reason is that there are so many di -
erent actors invo ved in the spread

o disease. Nutrition, age, gender, sanitation
practices, and socioeconomic conditions may
p ay a ro e in the spread o disease.
In ectious agents, or examp e, can spread
quick y and easi y through an unsanitary wa-
ter supp y. Likewise, accumu ation o un-
treated sewage or garbage can harbor disease-
causing organisms or chemica s. In ectious
agents or other contaminants in ood a so
may spread disease to a arge number o
peop e. Crowded conditions may o ten p ay a
ro e in spreading disease because more peop e
come in c ose contact with one another. In
crowded regions with poor sanitation and
ood-hand ing practices, disease may spread
quick y.
T e pattern o a diseases spread may be
di cu t to exp ain because o the di erent
kinds o agents that can cause disease. For
examp e, imagine that the majority o students in your c ass
became i with headaches and nausea (upset stomach) at
about the same time. One wou d have to investigate many
possib e causes and modes o transmission be ore an exp ana-
tion cou d be o ered. Is it ood poisoning? Is it an outbreak o
the u or another virus? Is the water supp y or the drinking
ountain contaminated? Is there a eak o toxic umes in the
bui ding? Is there radioactive materia nearby? Because any o
these can cause the situation that is described, a thorough
investigation is needed to distinguish the causal re ationships
rom the coincidental re ationships.
Causa re ationships estab ish the cause o a disease out-
break (any o the possibi ities isted in the previous paragraph
are potentia y causa ). Coincidenta re ationships are events
that coincide by chance. Using the examp e above, the pro es-
sor may have worn a particu ar y unattractive sweater on the
day the students became i . H owever, it is much more ike y
that is a coincidenta re ationship, than a causa one. On y
when a possib e causa actors have been investigated can a
reasonab e answer be proposed that wou d exp ain the etio -
ogy o the disease outbreak.
S t o p p in g t h e S p r e a d o D is e a s e
Epidemio ogists study the spread o disease so that ways o
stopping it can be ound. T e two most obvious strategies or
combating disease are prevention and therapy.
T erapy or treatment o diseases was perhaps the f rst
strategy used by humans to f ght disease. T e continued
search or therapeutic treatments or a most a known dis-
eases is evidence that we sti va ue this strategy.
H owever, we have a ways known that an even more e ec-
tive disease-f ghting strategy is prevention. On y recent y have
we understood many diseases we enough to know how to
prevent them.
A though the war on human disease wi probab y never
end, we have had some dramatic successes. T e o ten ata
vira in ection, smallpox, once caused catastrophic epidemics,
but natura outbreaks have been e iminated at this point in
CHAPTER 6 Mechanisms o Disease 115
FIGURE 6-1 The last smallpox patient. Ali Maow
Maalin o Somalia contracted the last known naturally
occurring case o smallpox in 1977. Success ul disease
prevention techniques completely eradicated natural
6
outbreaks o this disease that once killed millions world-
wide and dramatically a ected human history. The
World Health Organization (WHO) considers naturally
occurring cases to be eradicatedthus the vaccine or
smallpox is no longer required in the United States. Un-
ortunately, the potential o smallpox being used as a
biological weapon remains a threat.
history because o success u prevention strat-
egies such as wor dwide vaccination and edu-
cation (Figure 6-1).
Un ortunate y, sma pox and other patho-
gens that rare y i ever now produce natura
outbreaks o disease may nonethe ess become
avai ab e or use as weapons. Such bio ogica
weapons cou d produce epidemics in oca
regions and wou d thus not on y generate a arm but a so
wou d severe y burden pub ic hea th resources. See the Re-
search, Issues, and rends box on the acing page.
QUICK CHECK
1. Wh a t is th e d i e re n ce b e tw e e n a s ig n a n d a s ym p to m ?
2. Ho w d o e s a n a cu te d is e a s e d i e r ro m a ch ro n ic d is e a s e ?
3. De f n e p a th o g e n e s is . Wh a t a re th e s ta g e s o a co ld viru s ?
4. Wh a t is th e d i e re n ce b e tw e e n a n e p id e m ic a n d a
p a n d e m ic?
5. Ho w d o m o rb id ity a n d m o rta lity d i e r?
6. Wh a t a re th e tw o p rim a ry s tra te g ie s o r co m b a tin g
d is e a s e ?
P a t h o p h y s io lo g y
M e c h a n is m s o D is e a s e
D is t u r b a n c e s o Ho m e o s t a s is
Pathophysiology is the study o the under ying physio ogica
processes associated with disease. Pathophysio ogy is a branch
o patho ogy, the genera study o disease. Pathophysio ogists
attempt to understand the mechanisms o a disease and its
pathogenesis. A though pathophysio ogists uncover in orma-
tion that eads to the discovery o strategies o prevention and
treatment, deve oping and app ying these strategies is e t to
other pro essiona s.
Many diseases are best understood as disturbances o ho-
meostasis, the re ative constancy o the bodys interna envi-
ronment. Under norma physio ogica conditions, i homeo-
stasis is disturbed, a variety o eedback mechanisms returns
the body to norma . Negative and positive eedback, or eed-
back oops, were introduced in Chapter 1. W hen a distur-
bance o homeostasis goes beyond norma uctuations, a dis-
ease condition exists.
In acute conditions, the body recovers its homeostatic ba -
ance quick y. In chronic diseases, a norma state o ba ance
may never be restored. I the disturbance keeps the bodys
 116 CHAPTER 6 Mechanisms o Disease
Dis turba nce Dis turba nce
6
De a th Abnorma l Ide a l norma l va lue Abnorma l De a th
FIGURE 6-2 Model o homeostatic balance. Movement o the param-
eter in question, away rom the ideal normal value, is depicted as normal
f uctuations. Sometimes a physiological disturbance pushes the body be-
yond its capacity to maintain homeostasis and into the abnormal range or
a given physiological parametera disordered condition. Disturbances in
the extreme range may result in death.
interna environment too ar rom norma or too ong, death
may resu t (Figure 6-2).
Disturbance o homeostasis and the bodys responses to
that disturbance are the basic mechanisms o disease. Because
o the variety o disease mechanisms, they are easier to study
i categorized as in the o owing subsections.
Ty p e s o D is e a s e M e c h a n is m s
Genetic Mechanisms
A genetic mechanism occurs when a tered or mutated genes
cause production o abnorma proteins. T ese abnorma pro-
teins o ten simp y do not per orm their origina y intended
unction, resu ting in the absence o an essentia unction. On
the other hand, such proteins may per orm an abnorma , dis-
ruptive unction instead. Either case may be a threat to the
constancy o the bodys interna environment.
T e basis or genetic diseases is discussed in Chapter 25,
and important genetic conditions are summarized in Ap-
pendix A at evolve.elsevier.com.
In ectious Mechanisms
An in ectious mechanism occurs when pathogenic (disease-
causing) organisms or partic es damage the body in some way.
An organism that ives in or on another organism to obtain
its nutrients is ca ed a parasite. T e presence o microscopic-
size or arger parasites may inter ere with norma body unc-
tions o the host and thereby cause disease. O rganisms other
than parasites can poison or otherwise damage the human
body to cause disease.
Some o the major pathogenic organisms are isted ater in
this chapter and in Appendix A at evolve.elsevier.com.
Neoplastic Mechanisms
A neoplastic mechanism occurs when abnorma tissue growths
or neoplasms deve op. Neop asms such as benign tumors or
cancers (ma ignant) can cause a variety o physio ogica distur-
bances. Many such mechanisms are described ater in this
chapter.
Traumatic Mechanisms
A traumatic mechanism invo ves injury by physica or chemi-
ca agents such as toxic or destructive chemica s, extreme heat
or co d, mechanica injury (trauma), or radiation that can a -
ect the norma homeostasis o the body.
Examp es o patho ogica conditions caused by physica
agents are summarized in Appendix A at evolve.elsevier.com.
T ese conditions inc ude injuries such as ractures and acera-
tions caused by physica trauma or poisoning caused by chemi-
ca agents.
Trauma to skeletal musclesespecially crushing
injuriescan have catastrophic bodywide e ects.
Review the article Rhabdomyolysis at Connect It!
at evolve.elsevier.com.
Metabolic Mechanisms
Metabolic mechanisms inc ude ma nutrition or endocrine
imba ances that cause insu cient or imba anced intake o
nutrients.
A variety o diseases caused by metabo ic mechanisms are
out ined in Chapters 12, 19, 22, and other chapters. Some are
a so described in Appendix A at evolve.elsevier.com.
Inf ammatory Mechanisms
In ammatory mechanisms are common y occurring disease
mechanisms that can be invo ved a ong with other mechanisms
to produce diseaseor it may be the primary mechanism o a
disease. In ammation re ers to the set o reactions o the im-
mune system that o ten inc udes pain, redness, swe ing, and
warmth. It is a common response o the body to disturbances.
T e in ammatory response is a norma mechanism that usu-
a y speeds recovery rom an in ection or injury. H owever,
when the in ammatory response occurs at inappropriate
times or is abnorma y pro onged or severe, norma tissues
may be damaged. T us some disease symptoms are caused by
the in ammatory response.
Autoimmunity is a au ty response or overreaction o the
immune system that causes it to attack the body. Autoimmunity,
itera y se -immunity, is discussed in Chapter 16 a ong with
other immune system disturbances. Examp es o autoimmune
conditions are isted in Appendix A at evolve.elsevier.com.
Degeneration
Breaking apart, or degeneration, o tissues occurs by means
o many sti unknown processes. A though an expected

consequence o aging, degeneration o one or more tissues
resu ting rom disease can occur at any time. T e degeneration
o tissues associated with aging is discussed in Chapter 24.
Ris k Fa c t o r s
Other than direct causes or disease mechanisms, certain predis-
posing conditions may make the deve opment o a disease more
ike y to occur. Usua y ca ed risk actors, they o ten do not ac-
tua y cause a disease but may put one at risk or deve oping it.
Ty p e s o Ris k Fa c t o r s
T ere are many di erent types o risk actors. We describe some
o the major categories o risk actors in the o owing sections.
Genetic Factors
T ere are severa types o genetic actors that increase risk o
certain diseases. In such a case, an inherited trait puts a person
at a greater-than-norma risk or deve oping a specif c disease.
For examp e, ight-skinned peop e are more at risk or de-
ve oping certain orms o skin cancer than are dark-skinned
peop e. T is occurs because ight-skinned peop e have ess
pigment in their skin to protect them rom cancer-causing
u travio et radiation (see Chapter 7).
Membership in a certain ethnic group or gene pool invo ves
the risk o inheriting a disease-causing gene that is common
in that gene poo . For examp e, certain A ricans and their
descendants are at a greater-than-average risk o inheriting
sickle cell anemiaa dead y b ood disorder (see Chapter 13).
Age
A persons age can be a risk actor or certain diseases. Bio-
ogica and behaviora variations inherent during di erent
phases o the human i e cyc e put us at greater risk or deve -
oping certain diseases at certain times in i e.
For examp e, midd e ear in ections are more common in
in ants than in adu ts because o the di erence in ear structure
at di erent ages. A person is at a higher risk or certain types
o arthritis and bone ractures during the ater adu t years.
Li estyle
T e way we ive and workour li estylecan put us at risk
or some diseases. For examp e, peop e whose work or persona
activity puts them in direct sun ight or ong periods have a
greater chance o deve oping skin cancer because they experi-
ence more exposure to u travio et radiation rom the sun.
Research has shown that the high- at, ow-f ber diet com-
mon among peop e in deve oped nations increases their risk o
deve oping certain cancers such as co on cancer. O besity is
another risk actor or disease and has been shown to ead to
increased incidence in type 2 diabetes and high b ood pressure.
Using tobacco is another important risk actor or disease.
Stress
Physica , psycho ogica , or emotiona stress can put one at risk
o deve oping prob ems such as headaches, chronic high b ood
pressure (hypertension), depression, heart disease, and cancer.
CHAPTER 6 Mechanisms o Disease 117
Conditions caused by psycho ogica actors are sometimes
ca ed psychogenic (mind-caused) disorders.
6
Environmental Factors
A though environmental actors such as c imate and po u-
tion can cause injury or disease, some environmenta situa-
tions simp y put us at greater risk or getting certain diseases.
For examp e, because some parasites survive on y in tropica
environments, we are at risk or diseases caused by those par-
ticu ar organisms on y i we ive in or trave to that c imate.
Preexisting Conditions
A preexisting condition, such as an in ection, can adverse y
a ect our capacity to de end ourse ves against urther attack.
T us a primary (preexisting) condition can put a person at risk
o deve oping a secondary condition. For examp e, b isters rom
a preexisting burn may break open and thus increase the risk
o a bacteria in ection o the skin.
C o m b in e d Ris k Fa c t o r s
Combined risk actors can increase a persons chances o de-
ve oping a specif c disease even more. For examp e, a ight-
skinned person can add to the genetic risk o deve oping skin
cancer by spending a ong time in the sun without skin
protectiona i esty e risk added to a genetic risk.
As you may have guessed, many o these categories o risk
actors over ap. For examp e, stress can be a component o
i esty e, or it cou d be considered a preexisting condition.
Sometimes a high-risk group is identif ed by epidemio ogists,
but the exact mechanism that puts them at high risk may be
uncertain. For examp e, a high incidence o heart disease in a
sma ethnic group may point to a genetic risk actor but a so
cou d resu t rom some aspect o a shared i esty e.
Avo id in g Ris k o D is e a s e
Risk actors or many dead y diseases can be reduced or
avoided. For examp e, risk o heart disease, diabetes, cancer,
in ections, and other types o disease can be decreased by
making in ormed choices about i esty e and persona hea th
management. Such choices may in uence diet and exercise,
stress management, the environment, and treatment o preex-
isting conditions.
QUICK CHECK
1. De f n e p a th o p hys io lo g y.
2. Lis t s e ve n g e n e ra l m e ch a n is m s th a t m a y ca u s e d is e a s e .
3. Lis t s ix ris k a cto rs th a t m a y ca u s e d is e a s e .
4. Ho w d o e s a p rim a ry co n d itio n d i e r ro m a s e co n d a ry
co n d itio n ?
P a t h o g e n ic O r g a n is m s
a n d P a r t ic le s
Many kinds o organisms and partic es can cause disease in
humans. Even humans can cause human disease through ac-
cidenta or intentiona injury to themse ves or others. In
 118 CHAPTER 6 Mechanisms o Disease

pathophysio ogy, the pathogenic organisms most o ten stud-
ied are microscopic or just bare y visib e to the unaided eye.
6 Microscopic organisms, a so ca ed microbes, inc ude bacteria,
ungi, and protozoa. Larger organisms, the pathogenic ani-
mals, are a so medica y important.
T e sma est o a pathogens, microscopic non iving par-
tic es ca ed viruses and prions, ead our ist o important
disease-causing agents.
Vir u s e s
In t ro d u c t io n t o Vir u s e s
Viruses are intrace u ar parasites that consist o a nuc eic acid
(DNA or RNA) core surrounded by a protein coat and some-
times a ipoprotein enve ope.
Bio ogists ho d that viruses are not technica y iving or-
ganisms because they are not made up o ce s. H owever, be-
cause they in ect iving ce s and contain their own unique
genetic code, they remain the subject o bio ogica study and
are c assif ed into groups as i they are organisms.
Virus partic es can mu tip ybut on y by using the mech-
anisms o their host ce . T ey invade ce s and insert their
own genetic code into the host ce s genetic processes, causing
the host ce to produce vira DNA or RNA and protein coats.
T ey thus pirate the host ce s nutrients and organe es to
produce more virus partic es. T ese new y ormed viruses
may eave the ce to in ect other ce s by way o vesic es or
by bursting the ce membrane (Figure 6-3).
T e symptoms o vira in ections may not appear right
away. T e vira genetic code may not become active or some
time, or vira mu tip ication may not immediate y cause sig-
nif cant ce u ar damage. In any case, the e ects o the intra-
ce u ar vira parasite may eventua y take their to and thus
produce symptoms o disease.
Viruses are a very diverse group, as i ustrated in Figure 6-4.
T ey are usua y c assif ed according to their shape, DNA or
RNA content, and their method o mu tip ying. Some exam-
p es o medica y important viruses are isted in Table 6-1.
Many o these and some other vira diseases are discussed in
detai in ater chapters.
Ex a m p le s o Vir u s e s
T ere are many types o viruses that in ect humansand
more are being discovered or are new y appearing in the hu-
man popu ation a the time. H ere, we discuss just a ew o the
many interesting examp es o human viruses.
Human Immunode ciency Virus
T e most discussed virus in recent history is human
immunode ciency virus (HIV). H IV is an RNA-containing
retrovirus. A retrovirus uses its RNA to transcribe backward
DNA
RNA

RNA

FIGURE 6-3 HIV. The human immunode ciency virus, or HIV (blue in
this electron micrograph), is released rom in ected white blood cells and
soon spreads over neighboring cells, in ecting them in turn. The individ-
ual viruses are very smallmore than 200 million would t on the period Pa ra myxovirus
Va ccinia virus (mumps )
at the end o this sentence. (cowpox)
He rpe s
s implex virus
(feve r blis te r)

0.5 mm (micron)

RNA

HIV
DNA (AIDS )

RNA
RNA

Ade novirus
Rhinovirus (re s pira tory virus )
Poliovirus (common cold)
(polio)

FIGURE 6-4 Diversity o pathogenic viruses. Some viruses are rela-

tively large; others are extremely tiny. A human hair would be 8 meters (over
26 eet) thick i drawn at the same scale as the particles depicted here.

TABLE 6-1 Examples o Pathogenic Viruses
VIRAL TYPE VIRUS
DNA virus Hum an papillom avirus (HPV)
He patitis B
He rpe s s im plex 1 and 2
Eps te in-Barr virus (EBV)
RNA virus In ue nza A, B, and C
Hum an im m unode f cie ncy virus (HIV)
Flavivirus
Paramyxovirus
Rhinovirus
Coronavirus (CoV)
He patitis A and C
Ebolavirus
Se e Table 2 in Appe ndix A at evolve .e ls evie r.com or a lis t o viral dis e as e s and the ir de s criptions .
to produce the viruss primary genetic code and insert it into
the hosts DNA genome.
H IV attacks the immune system, thus rendering the host
organism susceptib e to a variety o in ections. T e immune
system gives our bodies the abi ity to f ght in ections. H IV
f nds and destroys a type o white b ood ce (a variety o
ce s ca ed CD4 ce s) that the immune system must have to
f ght disease (see Figure 6-3). I untreated, an H IV in ection
may progress to stage 3, more common y known as acquired
immunode ciency syndrome (AID S).
H IV in ection was f rst identif ed in the United States in
1981 a ter a number o homosexua men started getting sick
with a rare type o cancer. It took severa years or scientists to
deve op a test or the virus, to understand how H IV was
transmitted between humans, and to determine what peop e
cou d do to protect themse ves against being in ected. D uring
the ear y 1980s, as many as 150,000 peop e became in ected
with H IV each year in the United States. By the ear y 1990s,
this rate had dropped to about 40,000 to 50,000 each year,
where it remains today.
T e spread o H IV in ection in regions o the wor d that
are economica y disadvantaged remains a major g oba hea th
concern. T is persists as a consequence o ack o education
about disease prevention and ack o resources needed to treat
the in ected individua s with antivira therapy.
It is a so important to note that antivira therapy prevents
the immune system co apse characteristic o AIDS, but does
not e iminate H IV rom the in ected individua , who thus
remains contagious. H IV is a ragi e virus, and cannot ive or
very ong outside the body. T e virus is not transmitted
through day-to-day activities such as shaking hands, hugging,
or a casua kiss. H IV is not spread rom a toi et seat, drinking
ountain, doorknob, dishes, drinking g asses, ood, or pets.
Un ike other in ections discussed ater, H IV in ection is not
an arthropod-borne disease and cannot be spread by mosqui-
toes or other biting arthropods.
CHAPTER 6 Mechanisms o Disease 119
DIS EAS ES CAUS ED 6
Warts
He patitis B (viral live r in e ction)
Feve r blis te rs and ge nital he rpe s
Mononucle os is
Various in ue nza in e ctions
Acquire d im m unode f cie ncy s yndrom e (AIDS)
We s t Nile virus (WNV), ye llow eve r, de ngue , Zika, St. Louis e nce phalitis
Me as le s , m um ps , and parain ue nza
Com m on cold and uppe r re s piratory in e ctions
Re s piratory in e ctions , including com m on cold, s eve re acute re s piratory
s yndrom e (SARS), and Middle Eas t re s piratory s yndrom e (MERS)
He patitis A and C (viral live r in e ctions )
Ebola virus dis e as e (EVD or Ebola he m orrhagic eve r)
H IV is primari y ound in the b ood, semen, or vagina
uid o an in ected person. H IV is transmitted in three main
ways:
in ected with H IV
with H IV
during birth or through breast eeding
Coronaviruses
Coronaviruses are RNA viruses characterized by a crown o
sur ace projections when viewed under an e ectron micro-
scope. T e word part corona- means crown. T ey use their
RNA in host ce s to produce their own vira enzymes and
structura proteins needed to rep icate.
Coronaviruses are ound near y everywhere in our environ-
ment and are the second eading cause o the common co d
a ter rhinoviruses (see Table 6-1). Coronavirus in ections are
spread when virus partic es are shed by an in ected body by
way o respiratory uids or other body uids, and these par-
tic es then come in contact with another persons body uids.
A person is most ike y to pick up shed viruses in the moist
mucous membranes o the mouth, nose, eyes, or genita s.
Some coronavirus in ections can be very serious. An ex-
amp e is in ection by the SARS-associated coronavirus
(SARSCoV), the cause o severe acute respiratory syndrome
(SARS).
Flaviviruses
Flaviviruses are RNA viruses that are transmitted ess di-
rect y than coronaviruses. F aviviruses move rom an in ected
bird or other anima to a mosquito or other biting insect and
then f na y to the human host. Such viruses cannot move
direct y rom an in ected bird to a humanthey require the
 120 CHAPTER 6 Mechanisms o Disease
insect to carry the virus to humans. T is ro e o anima s, in-
c uding biting insects, in disease transmission is discussed
6 ater in this chapter.
Various types o aviviruses ( itera y ye ow viruses) cause
yellow ever, dengue, West Nile virus (WNV) in ection,
Zika virus disease, and other potentia y serious in ections.
T ere are many types o viruses that a ect humans. Review
Table 6-1 or more examp es.
To learn more about virus replication, go to
AnimationDirect online at evolve.elsevier.com.
P r io n s
T e word prion is a shortened orm o the phrase PRO tein-
aceous IN ectious partic e. Prions are pathogenic protein
mo ecu es that can cause mis o ding o other proteins in the
in ected ce . Review norma protein o ding in Figure 2-12
on p. 34.
T e mis o ding induced by prions converts norma proteins
o the body into abnorma proteins, causing abnorma ities o
FIGURE 6-5 Prion. A, This
oddly olded protein particle is
the pathogen that causes variant
Creutz eldt-Jakob disease (vCJD),
a degenerative, atal condition o
the brain. B, Photomicrograph o a slice
o brain rom an individual with Variant Creutz eldt-
Jakob disease (vCJD). Arrows show where abnor-
mal, tangled proteins have built up in the brain
tissue. Later in the disease, these areas will de-
velop open spaces in the brain.
A B
unction (Figure 6-5, A). T e abnorma orm o the protein a so
may be inherited by o spring o an a ected person.
We do know that prions can a ect proteins in the ner-
vous system and cause diseases such as bovine spongi orm
encephalopathy (BSE or mad cow disease) and variant
Creutz eldt-Jakob disease (vCJD ) (Figure 6-5, B). Both o
these diseases are very rare, ata conditions characterized by
degeneration o brain tissue and progressive oss o nervous
system unction.
Many scientists be ieve that prions rom in ected catt e
were consumed as bee by humans with these diseases, but
there are many unanswered questions about the exact mecha-
nisms o transmission o prion diseases.
Ba c t e r ia
A bacterium (pl., bacteria) is a tiny, primitive ce without a
nuc eus. Bacteria produce disease in a variety o ways. T ey can
secrete toxic substances that damage human tissues, they may
become parasites inside human ce s, or they may orm popu a-
tions in the host body that disrupt norma human unction.
Like viruses, bacteria a so are a diverse group o patho-
gens (disease-producers). T ere are severa ways to c as-
si y bacteria:
1. Growth requirementsBacteria can be catego-
rized according to whether they need oxygen to
grow. For examp e, they can be categorized as
aerobic (requiring oxygen or their metabo ism)
or anaerobic (requiring an absence o oxygen).
2. Staining propertiesBacteria stain di erent y,
depending on the compounds in their wa s. For
examp e, gram-positive bacteria are stained pur-
p e by the Gram staining technique, whereas
 CHAPTER 6 Mechanisms o Disease 121

TABLE 6-2 Examples o Pathogenic Bacteria

STRUCTURAL GRAM STAIN 6
CLAS S IFICATION CLAS S IFICATION BACTERIUM DIS EAS ES CAUS ED
Bacillus (rod) Gram -pos itive Bacillus organis m s Anthrax and gas troe nte ritis
Gram -pos itive Clos tridium organis m s Botulis m , te tanus , and s o t tis s ue in e ctions
Gram -ne gative Ente robacte riace ae Salm one lla dis e as e s and gas troe nte ritis
organis m s
Gram -ne gative Ps e udom onas organis m s Exte rnal otitis (s w im m e rs e ar), e ndocarditis , and pulm o-
nary in e ctions

Coccus (s phe re ) Gram -pos itive Staphylococcus organis m s Staphylococci in e ctions , ood pois oning, urinary tract
in e ctions , and toxic s hock s yndrom e
Gram -pos itive Stre ptococcus organis m s Throat in e ctions , pne um onia, s inus itis , otitis m e dia, rhe u-
m atic eve r, and de ntal carie s
Gram -ne gative Ne is s e ria organis m s Me ningitis , gonorrhe a, and pe lvic in am m atory dis e as e

Curve d or s piral rod Gram -ne gative Vibrio organis m s Chole ra, gas troe nte ritis , and wound in e ctions
Gram -ne gative Cam pylobacte r organis m s Diarrhe a
Gram -ne gative Spiroche te s Syphilis and Lym e dis e as e

Sm all bacte rium Gram -ne gative Ricke tts ia organis m s Rocky Mountain s potte d eve r and Q eve r
Gram -ne gative Chlamydia organis m s Ge nital in e ctions , lym phogranulom a ve ne re um , pe lvic
in am m atory dis e as e , conjunctivitis , and parrot eve r

gram-negative bacteria are not (see C inica App ica-

tion box on p. 122).
3. Shape and sizeBacteria are most common y c assi-
f ed by their varied shapes (Table 6-2). Medica y sig-
nif cant bacteria range in size rom ess than 0.5 m
to more than 5 m, making size a use u characteristic
or c assif cation. T e abbreviation m represents
micrometers or microns, one mi ionth o a meter. Some
major groupings based on shape and size o ow:
a. Bacilli arge, rod-shaped ce s ound sing y or in
groups.
b. Cocci arge, round bacteria ound sing y, in
pairs (diplococci), in strings (streptococci) as shown
in Figure 6-6, or in c usters (staphylococci).
c. Curved or spira rodscurved rods arranged
sing y or in strands, or arge curved or spira ce s
arranged sing y or in ce co onies.
d. Sma bacteriaround or ova bacteria that are
so sma that some o them were once thought to
be viruses. T ey can reproduce on y inside other
iving ce s, so they are sometimes ca ed obligate FIGURE 6-6 Bacteria. As the scanning electron micrograph and draw-
intracellular parasites. Rickettsia and Chlamydia ing show, individual spherical bacteria (cocci) may adhere to each other to
are two types o sma bacteria. orm chains.
 122 CHAPTER 6 Mechanisms o Disease
6 C LIN ICA L APPLICATION
LABORATORY IDENTIFICATION OF PATHOGENS
O te n the evide nt s igns or s ym ptom s o a dis e as e caus e d by
bacte ria or othe r pathoge ns provide e nough in orm ation or a
he alth pro e s s ional to m ake a diagnos is . To be s ure that the
corre ct cours e o tre atm e nt is give n, laboratory te s ts are o te n
re quire d to pos itive ly ide nti y a pathoge n.
Som e tim e s pathoge ns can be obs e rve d in s pe cim e ns o
blood, e ce s (s tool), ce re bros pinal uid (CSF), m ucus , urine , or
othe r s ubs tance s rom the body. To view a m icros copic patho-
ge n, a portion o the colle cte d s pe cim e n is s m e are d on a m i-
cros cope s lide and the n s taine d to e nhance vis ibility.
Ce rtain s tains color only ce rtain type s o ce lls . For exam ple ,
only gram -pos itive bacte ria re tain the viole t s tain us e d in the
Gram s taining te chnique (Figure s A and B). Gram -ne gative
bacte ria do not re tain the viole t s tain; they re tain only a re d
counte rs tain (Figure s C and D). Thus gram -pos itive (viole t)
bacte ria can be dis tinguis he d rom gram -ne gative (re d) bacte ria
Gra m-pos itive (Lis te ria ) Gra m-pos itive (S tre ptoccus )
A B
Gra m-ne ga tive (E. coli) Gra m-ne ga tive (Ne is s e ria )
C D
Table 6-2 summarizes bacteria types and some o the diseases
each group causes.
Some bacteria can deve op into resistant dormant orms
ca ed spores when subjected to adverse environmenta con-
ditions. Spores are resistant to chemica s, heat, and dry
conditions. W hen environmenta conditions become more
suitab e or i e processes such as reproduction, the spores
revert back to the active orm o bacterium. A though ad-
vantageous or the bacterium, this trans ormation abi ity
o ten makes it di cu t or humans to destroy pathogenic
bacteria.
Microbes o another type that are simi ar to bacteria are
the archaea. T ey di er rom bacteria in their chemica
us ing the Gram m e thod. The s taining prope rtie s , s hape , and
s ize o a pathoge n are a ew o the characte ris tics s om e tim e s
us e d to ide nti y pathoge ns in s pe cim e n s am ple s .
Pathoge ns are s om e tim e s ide ntif e d by culture s (propaga-
tion o m icroorganis m s in s pe cial m e dia conducive to the ir
grow th) that originate rom s pe cim e ns take n rom a patie nt.
The s e populations o bacte ria can be grow n only on ce rtain
m e dia (liquid or agar ge lcontaining nutrie nts ). Thus patho-
ge nic bacte ria are o te n ide ntif e d by the type o m e dium in
w hich they grow be s t.
For exam ple , m ucus s wabbe d rom a s ore throat and
place d in a m e dium that contains blood m ay produce pinpoint-
s ize d colonie s o pathoge nic s tre ptococci bacte ria. The s tre p-
tococci bacte ria that caus e s tre p throat typically have a dis -
tinct, trans pare nt ring around e ach colony. The rings re s ult
rom he m olys is burs ting o re d blood ce lls in the s urrounding
m e dium . A ew virus e s als o can be cultivate d but only
w ithin living ce lls .
Som e in e ctions can be diagnos e d on the bas is o im -
m unological te s ts that che ck or antibodie s agains t a par-
ticular pathoge n. I antibodie s are ound, it is as s um e d
that the patie nt has be e n expos e d to a pathoge n; a large
num be r o antibodie s us ually indicate s an active in e ction.
An exam ple is the te s t or anti-HIV antibodie s us e d to
ide nti y HIV in e ctions . Re call rom Chapte r 5 that s uch
te s ts are o te n us e d to s cre e n donate d tis s ue s and organs
or pathoge nic organis m s .
Eve n new e r te s ts us e rapid biological s e ns ors that bor-
row the re cognition m e chanis m s rom im m une ce lls
s e ns itive to particular pathoge ns and link the m to s pe cial
prote ins rom je llyf s h that caus e the s e ns or to glow
w he n the pathoge n is pre s e nt. A w ide varie ty o di e re nt
im m unological te s ts are now available or bacte rial and
viral in e ctions and othe r new te chnologie s are on the
horizon.
The re ce nt explos ion o know le dge in ge ne tics and
ge nom ics (s e e Chapte r 25) has le d to m any newe r m e th-
ods o rapidly and accurate ly ide nti ying a varie ty o patho-
ge ns . For exam ple , patte rns o DNA or RNA code that are
unique to a particular virus , bacte rium , or othe r pathoge n
can be de te cte d by s pe cial s e ns ors or laboratory te s ts .
makeup and metabo ism. A so, un ike bacteria, many archaea
thrive in extreme y harsh environments that are very hot, very
acid, or very sa ty. A though archaea are ound as norma resi-
dents in the human body, in the mouth or examp e, none
have yet been proven to cause disease. H owever, they may p ay
an important ro e in the human microbiome.
The presence o bacteria and other microorgan-
isms in and on the body is normal and necessary
or normal unction. To learn more, review the
article The Human Microbiome at Connect It! at
evolve.elsevier.com.
 CHAPTER 6 Mechanisms o Disease 123

TABLE 6-3 Examples o Pathogenic Fungi

Ye a s t Mold
FUNGUS
Candida organis m s
Epide rm ophyton and
Micros porum organis m s
His toplas m a organis m s
As pe rgillus organis m s
Coccidioide s organis m s
Se e Table 4 in Appe ndix A at evolve .e ls evie r.com or a lis t o mycotic dis -
e as e s and the ir de s criptions .
A B
DIS EAS ES CAUS ED 6
Thrus h and m ucous m e m brane
in e ctions (including vaginal
ye as t in e ctions )
Tine a in e ctions : ringworm , jock
itch, and athle tes oot
His toplas m os is
As pe rgillos is and pne um onia
Coccidioidomycos is (San Joaquin
eve r)

FIGURE 6-7 Examples o pathogenic ungi. Electron

micrographs and drawings. A, Scanning electron micrograph TABLE 6-4 Examples o Pathogenic Protozoa
o yeast cells. Yeasts commonly in ect the urinary and repro-
ductive tracts. B, This electron micrograph shows Aspergillus CLAS S IFICATION PROTOZOAN DIS EAS ES CAUS ED
organisms, a mold that can in ect di erent parts o the body Am e ba Entam oe ba organis m s Diarrhe a, am e bic dys e n-
where it orms characteristic ungus balls. te ry, and live r and lung
in e ctions
Nae gle ria ow le ri Brain in e ctions
Fu n g i
Fungi (sing., ungus) are simp e organisms that
are simi ar to p ants but without ch orophy Flage llate Giardia organis m s Giardias is , diarrhe a, and
(green pigment). W ithout ch orophy , pathogenic m alabs orption s yndrom e
ungi cannot produce their own ood, so they must Trichom onas organis m s Trichom onias is , vaginitis ,
consume or parasitize other organisms. and urinary tract
Most pathogenic ungi parasitize tissue on or in e ctions
near the skin or mucous membranes, as in ath-
etes oot and vagina yeast in ections. A ew
Ciliate Balantidium organis m s Gas trointe s tinal dis tur-
systemic (body-wide) unga in ections, such as
bance s , including pain,
San Joaquin ever, can disrupt the entire body.
naus e a, and anorexia
Figure 6-7 shows that yeasts are sma , sing e-
ce ed ungi and molds are arge, mu tice u ar
ungi. Funga in ections, or mycotic in ections,
o ten resist treatment, so they can become a quite
serious hea th prob em. Table 6-3 ists some o the
important pathogenic ungi and the diseases that
Sporozoan (coccidium ) Is os pora organis m s Is os porias is in e ction o
they cause. gas trointe s tinal tract,
diarrhe a, and m alabs orp-
P ro t o zo a tion s yndrom e
Plas m odium organis m s Malaria
Protozoa are protists, one-ce ed organisms that
Toxoplas m a organis m s Toxoplas m os is and conge n-
are arger than bacteria and whose DNA is orga- ital dam age to e tus
nized in a nuc eus. Table 6-4 i ustrates some o the
pathogenic protozoa. Protozoa can in ect human Se e Table 5 in Appe ndix A at evolve .e ls evie r.com or a lis t o dis e as e s caus e d by protozoa.

uids and cause disease by parasitizing ce s or

direct y destroying them (Figure 6-8). 2. Flagellatesprotozoa that are simi ar to amebas but
Some major groups o pathogenic protozoa inc ude the move by wigg ing ong, whip ike extensions ca ed
o owing: agella.
3. Ciliatesprotozoa that move by means o many
1. Amebas arge ce s o changing shape; amebas ex- short, hair ike projections ca ed ci ia.
tend their membranes to orm pseudopodia ( a se 4. Sporozoaprotozoa with unusua organe es at their
eet) that pu themse ves a ong. tips that a ow them to enter host ce s; a so ca ed
 124 CHAPTER 6 Mechanisms o Disease

Table 6-5 i ustrates some anima s that cause disease. T e

6 1. Nematodes arge parasites, a so ca ed roundworms,
FIGURE 6-8 Pathogenic amebas. The Naegleria owleri organism
seen in this light micrograph is an emerging pathogen in the southern United
States. It is an ameba ound in warm, resh-water ponds, lakes, streams,
and warm springs. The organism enters the body by swimming up the nose
and invading the brain through the thin ethmoid bone. It can cause a atal
central nervous system in ection.
major groups o pathogenic anima s inc ude the o owing:
that in est a variety o di erent human tissues. T ey
are o ten transmitted by ood or by ies that bite.
2. Platyhelminths arge parasites, otherwise known
as atworms and ukes, that can in est severa di er-
ent human organs. T e Schistosoma ukes shown in
Figure 6-9 cause snai ever, or schistosomiasis.
3. Arthropodsgroup o parasites that inc ude mites,
ticks, lice, and eas. A so inc uded are biting or sting-
ing wasps, bees, mosquitoes, and spiders. A are capab e
o causing injury or in estation themse ves but a so
can carry other pathogenic organisms. An organism
that spreads disease to other organisms is ca ed a
vector o the disease.
Table 6-5 summarizes some o the major hea th prob ems as-
sociated with se ected pathogenic anima s.

coccidia. T ey o ten osci ate between two di erent QUICK CHECK

hosts, having two di erent stages in their i e cyc e.
T e sporozoa that cause ma aria exhibit this pattern.
P a t h o g e n ic A n im a ls
Pathogenic anima s sometimes ca ed metazoa are arge, mu -
tice u ar organisms. Anima s can cause disease by parasitizing
humans or causing injury in some other way.
1. Na m e a d is e a s e ca u s e d b y a viru s a n d a d is e a s e ca u s e d
b y a p rio n .
2. Wh a t is a re troviru s ? Na m e a d is e a s e th a t is ca u s e d b y a
re tro viru s .
3. Ho w d o b a cte ria ca u s e d is e a s e ?
4. Na m e a co m m o n u n ga l in e ctio n .
5. Wh a t a re p ro to zo a , a n d h o w d o th e y ca u s e d is e a s e ?
6. Lis t th e m a jo r g ro u p s o p a th o g e n ic a n im a ls .

TABLE 6-5 Examples o Pathogenic Animals

CLAS S IFICATION ANIMAL
Ne m atode As caris organis m s
Ente robius organis m s
Trichine lla organis m s
DIS EAS ES CAUS ED
Inte s tinal roundworm in e s tation, gas trointe s tinal obs truction, and bronchial dam age
Pinworm in e s tation o the lowe r gas trointe s tinal tract, itching around the anus , and
ins om nia
Trichinos is , eve r, and m us cle pain

Platyhe lm inth Schis tos om a organis m s Schis tos om ias is (s nail eve r)
Fas ciola organis m s Live r uke in e s tation
Tae nia organis m s Pork and be e tapeworm in e s tation

Arthropod Arachnida organis m s In e s tation by m ite s and ticks ; toxic bite s by s pide rs , s corpions ; and trans m is s ion o
othe r pathoge ns
Ins e cta In e s tation by e as and lice ; toxic bite s by was ps , m os quitoe s , and be e s ; and trans m is -
s ion o othe r pathoge ns ; ticks (Lym e dis e as e )

Se e Table 6 in Appe ndix A at evolve .e ls evie r.com or a lis t o dis e as e s caus e d by pathoge nic anim als .

FIGURE 6-9 Pathogenic animals. This light
micrograph shows both male and emale
Schistosoma f ukes mating in the human
bloodstream (the male is the larger o
the two).
P r e ve n t io n
a n d C o n t ro l
T e key to preventing many diseases caused by
pathogenic organisms is stopping them rom
entering the human body. T is sounds simp e
enough but is o ten very di cu t to accomp ish.
M e c h a n is m s o Tr a n s m is s io n
A key to stopping pathogens is to understand the mecha-
nisms by which they spreadmechanisms that potentia y
can be disrupted. T e o owing sections can be used as a
partia ist o the ways in which pathogens can spread.
P e r s o n -t o -P e r s o n C o n t a c t
Sma pathogens o ten can be carried in the air rom one
person to another. A so, direct contact with an in ected person
or with contaminated materia s hand ed by the in ected per-
son is a common mode o transmission. T e rhinoviruses and
coronaviruses that cause the common co d are o ten transmit-
ted in these ways.
Some viruses, such as those that cause hepatitis B,
hepatitis C, and AIDS, are instead transmitted when in-
ected b ood, semen, or another body uid enters a persons
b oodstream.
Preventing the spread o these diseases o ten invo ves edu-
cating peop e about avoiding certain types o contact with
individua s known or suspected o carrying the disease. An-
other strategy, ca ed aseptic technique, invo ves ki ing or
disab ing pathogens on sur aces be ore they can spread to
other peop e. Table 6-6 summarizes the major approaches
TABLE 6-6 Common Aseptic Methods That Prevent the Spread o Pathogens*
METHOD ACTION
Ste rilization De s truction o all living organis m s ; doe s not
us ually a e ct prions
Dis in e ction De s truction o m os t or all pathoge ns on
inanim ate obje cts but not ne ce s s arily all
harm le s s m icrobe s
Antis e ps is Inhibition or inactivation o pathoge ns
Is olation Se paration o pote ntially in e ctious pe ople or
m ate rials rom nonin e cte d pe ople
*Spore s (s pe cial bacte rial orm s ) m ay re s is t m e thods that would ordinarily kill active bacte rial ce lls .
CHAPTER 6 Mechanisms o Disease 125
taken when using aseptic
technique.
6
En v iro n m e n t a l
Co n t a c t
Many pathogens are ound
throughout the oca envi-
ronmentin ood, water,
soi , and on assorted sur-
aces. Under norma condi-
tions, these pathogens in ect
on y individua s who happen
to come across them or
who are a ready weakened by
some other condition. I im-
proper sanitation practices create an environment that pro-
motes increased growth and spread o pathogens, an epidemic
cou d resu t.
Disease caused by environmenta pathogens can o ten be
prevented by avoiding contact with certain materia s and by
maintaining sa e sanitation practices.
O p p o r t u n is t ic In va s io n
Some potentia y pathogenic organisms are ound on the skin
and mucous membranes o near y everyone. H owever, they do
not cause disease unti they have the opportunity. T at is, they
do not create a prob em unti and un ess conditions change or
they enter the bodys interna environment.
For examp e, the ungi that cause ath etes oot are o ten
present on the skin o peop e who do not have symptoms o
this in ection. On y when the skin is kept warm and moist or
pro onged periods can the ungus reproduce and create an
in ection.
Preventing opportunistic in ection invo ves avoiding con-
ditions that cou d promote in ections. Changes in the pH
(acidity), moisture, temperature, or other characteristics o
skin and mucous membranes o ten promote opportunistic
in ections. C eansing and aseptic treatment o accidenta or
surgica wounds a so can prevent these in ections.
EXAMPLES
Pre s s urize d s te am bath, extre m e te m pe rature , gas (e thyle ne oxide ), or radia-
tion us e d to s te rilize s urgical ins trum e nts and garm e nts or othe r s ur ace s
Che m icals s uch as iodine , chlorine , alcohol, phe nol, and s oaps
Che m icals s uch as alcohol, iodine , quate rnary am m onium com pounds
(quats ), and dye s
Quarantine o a e cte d patie nts ; prote ctive appare l worn w hile giving tre at-
m e nts ; and s anitary trans port, s torage , and dis pos al o body uids ,
tis s ue s , and othe r m ate rials
 126 CHAPTER 6 Mechanisms o Disease
6 S C IEN C E APPLICATIONS
PUBLIC HEALTH
Robe rt Koch as tounde d his pare nts
w he n, at the age o 5 (in 1848), he
s howe d his pare nts that he had
taught him s e l to re ad. His de te r-
m ination and his m e thodical us e o
new s pape rs in his hom e not only
he lpe d young Robe rt te ach him s e l
to re ad, it als o ore s hadowe d a
brilliant care e r as an inve s tigative
s cie ntis t.
Robert Koch (18431910) Koch be cam e a phys ician, and
w hile s till a young m an, he prove d
that the anthrax bacillus (bacte rium ) caus e s the anthrax in e c-
tion (s e e Dis e as e as a We apon box, p. 128). Thus he was the
f rs t to prove that s pe cif c bacte ria caus e s pe cif c dis e as e s . He
late r we nt on to do s im ilar ground-bre aking work w ith wound
in e ctions , tube rculos is , chole ra, and m any othe r in e ctions .
Pe rhaps m ore im portantly, he laid the groundwork or the labo-
ratory s tudy o bacte ria and the control o individual in e ctions
as we ll as e pide m ics . In s o doing, Robe rt Koch laid the ground-
work or m ode rn public he alth, the f e ld that s trive s to pre -
ve nt and control dis e as e and prom ote good he alth in the hu-
m an population.
Public he alth is a f e ld that include s m any di e re nt e nde av-
ors , all aim e d at prom oting the he alth and we llne s s o us all.
For exam ple , m e dical and allie d he alth pro e s s ionals tre at dis -
e as e and work to preve nt and control e pide m ics . Pathologis ts
and laboratory te chnicians he lp us be tte r unde rs tand dis e as e s
Tr a n s m is s io n b y a Ve c t o r
As stated previous y, a vector such as an arthropod acts as a
carrier o a pathogenic organism. For examp e, the spirochete
bacterium that causes Lyme disease is not usua y transmitted
direct y rom human to human. Instead, a vector such as the
deer tick carries it rom one person to another or between ani-
ma s and humans. Table 6-7 gives examp es o severa tick-
borne i nesses.
T e most e ective way to stop vector-borne diseases rom
spreading is a combination o reducing the popu ation o vectors
and reducing the number o contacts with vectors. Malaria, sti
a major ki er in some parts o the wor d, was virtua y e imi-
nated rom North America in this way. Many mosquitoes that
transmit the ma aria organism were destroyed with pesticides,
and at the same time, peop e were educated about ways to pre-
vent mosquito bites. Consistent use o both strategies resu ted in
the co apse o the pathogen popu ation in the vector and host.
T e act that sporadic cases o ma aria sti occur in
North Americaand the emergence o other vector-borne
diseasesdemonstrates the need or ongoing monitoring o
vector popu ations and the incidence o each disease.
that a e ct the hum an population, and re s e arche rs he lp de -
ve lop e e ctive preve ntion and tre atm e nt.
Many public he alth advis ors , e nviro nm e ntal he alth
s cie ntis ts , and public he alth activis ts work to he lp us unde r-
s tand and re s olve is s ue s re late d to expos ure to pollutants , the
e e cts o our li e s tyle , te chnological advance s , and s ocial
choice s that a e ct our he alth. Public he alth adm inis trators and
s ta , including volunte e rs , he lp organize and s upport the
worldw ide e ort to prom ote public he alth. The photo s how s a
nurs e in the com m is s ione d corps o the Unite d State s Public
He alth Se rvice (USPHS) as s e s s ing a patie nt.
P r e ve n t io n a n d Tr e a t m e n t S t r a t e g ie s
Va c c in a t io n
A prevention strategy that has worked with some bacteria
and vira pathogens has been the vaccine. A vaccine is a ki ed
or attenuated (weakened) pathogen or part o a pathogen that
is given to a person to stimu ate immunity. Vaccination is a
preventive method that stimu ates a persons own immune
system in a way that promotes deve opment o resistance to a
particu ar pathogen.
A though vaccines are very sa e, they can cause mi d side
e ects such as temporary u- ike symptoms, mi d pain, and
ainting; they rare y cause more severe side e ects such as a -
ergic reactions or ebri e seizures. T orough research has
disproven a wide y he d be ie that chi dhood vaccines (in-
c uding preservatives) causes autism spectrum disorder (ASD), a
di erence in brain unction. T is dangerous myth sti persists,
however, reducing vaccination rates and increasing the inci-
dence o dangerous chi dhood diseases such as measles, mumps,
rubella, whooping cough, and polio.
More discussion o vaccination and other immune system
strategies o disease prevention is ound in Chapter 16.
 CHAPTER 6 Mechanisms o Disease 127

this occurs as a natura consequence o bacteria adaptation.

To learn more about vaccination, go to
AnimationDirect online at evolve.elsevier.com.
D r u g Th e r a p y
A ter an in ection has begun, there are severa ways to treat
the patient and attempt to gain contro o the disease. One
common approach is the use o drug therapy to destroy
pathogens or inhibit their growth.
A n t ib io t ic D r u g s
Antibiotics are compounds produced by certain iving organ-
isms or in a aboratory that ki or inhibit bacteria pathogens.
Penicillinproduced by a ungusand streptomycinproduced
by a bacteriumare we -known antibiotics. A ew synthetic
chemica s are now a so used to treat bacteria in ections.
Antibiotic resistance is an important consideration in the
treatment o in ectious diseases today. As we continue to use
antibiotics to treat bacteria disease, new generations o bacte-
ria eventua y deve op resistance to antibiotic drugs. Some o
H owever, we acce erate this process by prescribing antibiotics
or diseases that are not o bacteria etio ogy or by using the 6
medications inappropriate y a ter they are prescribed.
New antibiotics are needed when bacteria deve op resis-
tance to the drug or when the drug treatment cyc e is di cu t
to comp ete. A bacteria disease ca ed tubercu osis ( B) gives
us an examp e o both o these issues. Current B drugs are
taken over a 6- to 9-month period, and there are strains o the
B bacteria that have become resistant to those drugs.
Severa new drug combinations to treat B are current y in
c inica tria s. Adding one o the newer anti- B drugs to the
standard therapy may reduce the usua treatment time re-
quired by current B antibiotics and may be ab e to ki drug-
resistant strains o B.
T e Wor d H ea th O rganization (W H O) estimates that
around one f th o the wor ds popu ation is in ected with
Band that 1.5 mi ion peop e died o the disease in 2014.
T e good news is that this is an 18% reduction in B morta -
ity rate since the start o this century.

TABLE 6-7 Examples o Tick-Borne Diseases

BACTERIAL PATHOGEN
(DIS EAS E) VECTOR S IGNS AND SYMPTOMS *
Ehrlichia ew ingii (Ehrlichios is or Am blyom m a am e ricanum Feve r, he adache , m us cle pain, naus e a, and vom iting
hum an granulocytic e hrlichios is ) (Lone Star tick) Ras h is rare
Low w hite blood ce ll count, low plate le t count, ane m ia, e levate d
live r e nzym e s , kidney ailure , and re s piratory ins u f cie ncy

Borre lia burgdor e ri Ixode s s capularis (de e r tick or Feve r, he adache , m us cle pain, joint pain (arthritis ), and s wolle n
(Lym e dis e as e ) blackle gge d tick) lym ph node s
Re d, expanding ras h calle d e rythe m a m igrans (EM) or bulls eye
ras h in about 70% o cas e s
Arthritis (pain and s we lling) in the large joints (s uch as kne e s )

Bulls eye ras h.

Ricke tts ia ricke tts ii De rm ace ntor variabilis Feve r, he adache , m us cle pain, naus e a, vom iting, and los s o appe tite
(Rocky Mountain s potte d eve r) (Am e rican dog tick) Ras h a te r eve r in 50% o adults and 90% o childre n
Ras h m ay involve palm s and s ole s

*Sym ptom s vary am ong individual patie nts .

 128 CHAPTER 6 Mechanisms o Disease
Antibiotic resistance occurs when some patho-
6 genic bacteria in our microbiome survive antibiotic
therapy and then reproduce. Over time, this shi ts
the ecological balance in avor o antibiotic-
resistant strains. In a person with a well-
unctioning microbiome, antibiotic use can also
cause short-term imbalances o pathogenic and
nonpathogenic organisms that disrupt our micro-
bial ecosystem and cause some o the side
e ects o antibiotics, including indigestion,
opportunistic in ection, and in ammation. Please
review the article The Human Microbiome at
Connect It! at evolve.elsevier.com.
A n t iv ir a l D r u g s
Antiviral drugs, especia y when used in care u y ormu ated
combinations (o ten ca ed drug cocktai s), do not stop vira
in ections entire y. Instead, they inhibit vira reproduction and
thus s ow down the progression o vira in ections. T is strat-
egy may reduce acute episodes o some virus in ections or
prevent the deve opment o serious, perhaps i e-threatening,
vira disease and other comp ications.
Among the growing ist o synthetic antivira agents are
oseltamivir ( ami u) or treating in uenza A and B, acyclovir
RES EA RC H, IS S U ES , AND TREN D S
DIS EAS E AS A WEAPON
World eve nts have s how n us that the inte ntional trans m is s ion
o dis e as e can be us e d as a we apon o te rror. Anthrax, a bac-
te rial in e ction caus e d by Bacillus anthracis , is an exam ple o a
pathoge n that has be e n inte ntionally dis tribute d to othe rw is e
he althy pe ople in acts o bio te rro ris m .
The anthrax bacte rium ordinarily a e cts m ainly plant-e ating
anim als s uch as s he e p, cattle , and goats , o te n re s ulting in
the ir de ath.
The anthrax bacte rium can as s um e the orm o a s po re that
is re s is tant to he at, drying, and che m i-
cals and the n late r be com e s active to
caus e in e ction. Rare ly, hum ans inhale
s om e anthrax s pore s or ge t the s pore s in
an ope n cut w he n handling in e cte d ani-
m als or the ir hide s . The inhale d orm m ay
be atal i not tre ate d quickly w ith antibi-
otics . The cutane ous (s kin) orm is le s s
s e rious , characte rize d by a re ddis h brow n
patch on the s kin that ulce rate s and the n
orm s a dark, ne arly black s cab (s e e f g-
ure ), ollowe d by m us cle pain, inte rnal
he m orrhage (ble e ding), he adache , eve r,
naus e a, and vom iting.
Anthrax caus e s dis e as e by re le as ing a
toxin that latche s onto re ce ptors on the Cutaneous anthrax
(ACV) or treating herpes in ections, and e avirenz or treat-
ing H IV in ections.
Antivira agents used against H IVespecia y when used
in care u y ormu ated combinations ca ed drug cocktai s
may inhibit vira activity enough to s ow or prevent H IV in-
ection rom progressing to stage 3 (AIDS).
QUICK CHECK
1. Wh a t a re o u r wa ys th a t a d is e a s e ca n b e tra n s m itte d ?
2. Wh a t is a s e p tic te ch n iq u e ?
3. Ho w is a n a n tib io tic d ru g d i e re n t ro m a n a n tivira l d ru g ?
4. Why a re n e w a n tib io tics o te n n e e d e d in th e tre a tm e n t o
b a cte ria l d is e a s e ?
Tu m o r s a n d C a n c e r
N e o p la s m s
Be n ig n a n d M a lig n a n t Tu m o r s
T e term neoplasm itera y means new matter and re ers to
an abnorma growth o ce s. Neop asms, a so ca ed tumors,
can take the orm o distinct umps o abnorma ce s or, in
b ood tissue, can be di use.
Neop asms are o ten c assif ed as benign or malignant
(Table 6-8). Benign tumors remain oca ized within the tissue
rom which they arose. Ma ignant tumors tend to spread to
ce lls o the hos t, the n punching a hole in the ce lls m e m brane ,
and ins e rting a portion o the toxin calle d le thal actor that
de s troys prote ins in the ce ll and kills it.
I the in e ction is dis cove re d be ore the anthrax bacte ria
have tim e to m ake large am ounts o toxin, antibiotics s uch as
doxycycline and cipro oxacin can cure anthrax. Scie ntis ts als o
are working to pe r e ct drugs that im itate the ce lls re ce ptors
and would thus gum up the toxin on ake re ce ptors be ore
it can attack ce lls . Vaccine s are available , but the s e m us t be
give n long be ore pos s ible expos ure to
the s pore s .
Anthrax spores have bee n re f ned or
military purpose s, eve n though this is
outlawe d by various global tre atie s , and
have be e n use d by te rrorists to atte mpt to
intimidate or disrupt civilian populations .
Such a situation occurred in the Unite d
State s w he n anthrax-contaminated pack-
age s we re se nt through the mail in the
all o 2001.
Othe r bacte ria s uch as Ye rs inia pe s tis
(plague ), virus e s s uch as s m allpox, and a
varie ty o ge ne tically e ngine e re d orm s o
know n pathoge ns continue to be adde d
to the pote ntial ars e nal o te rroris ts .
 CHAPTER 6 Mechanisms o Disease 129

other regions o the body. Cancer is

TABLE 6-8 Comparison o Benign and Malignant Tumors
another term or a ma ignant tumor.
Benign tumors are ca ed such be- CHARACTERISTIC BENIGN TUMOR MALIGNANT TUMOR 6
cause they do not spread to other tissues Rate o grow th Slow Rapid
and they usua y grow very s ow y. T eir Structure Encaps ulate d None ncaps ulate d (inf ltrate s
ce s are o ten we di erentiated, un ike s urrounding tis s ue )
the undi erentiated ce s typica o ma- Patte rn o grow th Expanding but not s pre ading to Me tas tas izing (s pre ading) to
ignant tumors. Ce s in a benign tumor othe r tis s ue s othe r tis s ue s
tend to stay together, and they are o ten Ce ll type We ll di e re ntiate d (s im ilar to Undi e re ntiate d (abnorm al in
surrounded by a capsu e o dense tissue. norm al tis s ue ce lls ) s tructure and unction)
Benign tumors are usua y not i e Mortality rate Low High i condition re m ains
threatening but can be i they disrupt untre ate d
the norma unction o a vita organ
(Figure 6-10).
Ma ignant tumors, on the other
hand, are not encapsu ated and do not
stay in one p ace. T eir ce s tend to a
Be nign Ma ligna nt
away rom the origina neop asm and
may start new tumors in other parts o
the body. For examp e, ce s rom ma ig-
nant breast tumors usua y orm new
(secondary) tumors in bone, brain, and
ung tissues. T e ce s migrate by way o
ymphatic or b ood vesse s. T is manner
o spreading is ca ed metastasis. Ce s
that do not metastasize sti can spread,
but in another way: they grow rapid y A B
and extend the tumor into nearby tis-
FIGURE 6-10 Types o neoplasms. A, Benign neoplasms (tumors) are usually encapsulated and
sues. Ma ignant tumors may rep ace part grow slowly. B, Malignant neoplasms or cancers are not encapsulated. They grow rapidly, extending into
o a vita organ with abnorma , undi - surrounding tissues. Some cells metastasize, that is, they all away rom the original tumor and orm
erentiated tissuea i e-threatening tumors in other parts o the body.
situation (Figures 6-10 and 6-11).

3. Ma ignant tumors that arise rom epithe ia tissues,

For more about process o metastasis, see the
illustrated article Metastasis at Connect It! at
evolve.elsevier.com.
Ty p e s o Tu m o r s
Benign and ma ignant neop asms are c assif ed into sub-
groups, depending on appearance and the ocation where they
originate. Benign and ma ignant tumors can be divided into
three typesepithe ia tissue, connective tissue, and misce -
aneous tumors. Some examp es o each o ow:
1. Benign tumors that arise rom epithe ia tissues
a. Papillomaa type o tumor that orms a f nger-
ike projection, as in a wart
b. Adenomaa genera term or benign tumors
o g andu ar epithe ium
c. Nevusa variety o sma , pigmented tumors o
the skin, such as mo es
2. Benign tumors that arise rom connective tissues
a. Lipomaa tumor arising rom adipose ( at) tissue
b. Osteomaa tumor that invo ves bone tissues
c. Chondromaa tumor o carti age tissue
genera y ca ed carcinomas
a. Melanomaa type o cancer that invo ves me a-
nocytes, the pigment-producing ce s o the skin
b. Adenocarcinomathe genera term or ma ig-
nant tumor o g andu ar epithe ium
4. Ma ignant tumors that arise rom connective tissues,
genera y ca ed sarcomas
a. Lymphomaa term used to describe a cancer o
ymphatic tissue
b. Osteosarcomaa term that re ers to a ma ignant
tumor o bone tissue
c. Myelomaa type o ma ignant bone marrow
tumor
d. Fibrosarcomaa genera term used to describe
cancers invo ving f brous connective tissues.
Misce aneous tumors do not f t any o the other categories. For
examp e, an adeno broma is a benign neop asm ormed by epi-
the ia and connective tissues.Another examp e is neuroblastoma,
a ma ignant tumor that arises rom nerve tissue.
Cancers can be urther c assif ed by their ocation. For ex-
amp e, ma ignant tumors may be abe ed skin cancer, stomach
cancer, or lung cancer according to the ocation o the a ected
 130 CHAPTER 6 Mechanisms o Disease

Origina l tumor
TABLE 6-9 Common Forms o Cancer*
6 NEW CAS ES DEATHS
TYPE (by lo catio n) (pe r ye ar) (pe r ye ar)
Lung 224,390 158,080
Colore ctal 134,490 49,190
Pancre atic 53,070 41,780
Bre as t 249,260 40,890
Fe m ale 246,660 40,450
Male 2,600 440
Pros tate 180,890 26,120
Le uke m ia (blood cance r) 60,140 24,400
Non-Hodgkin lym phom a 72,580 20,150
(lym phoid tis s ue cance r)
Me ta s ta s is Bladde r 76,960 16,390
Blood
ve s s e l Kidney 62,700 14,240
Endom e trial (ute rus ) 60,050 10,470
Me lanom a (s kin) 76,380 10,130
Thyroid 64,300 1,980

*2016 annual e s tim ate s in the Unite d State s , lis te d in orde r o de ath rate .

Ma ligna nt ce lls
re produce to
form new tumors
Lympha tic
ve s s e l
FIGURE 6-11 Metastasis. Abnormal cells rom malignant tumors all
away rom the original neoplasm and travel along lymphatic vessels,
through which they can enter and exit easily. Malignant cells also can travel
through the bloodstream and burrow through a blood vessel wall to invade
other tissues.
tissues. T e more common cancer types (by ocation) in the
United States are isted in Table 6-9 and are described in ater
chapters.
Ca u s e s o Ca n c e r
A b n o r m a l C e ll D iv is io n
T e etio ogies o various orms o cancer puzz e researchers no
ess today than they did 100 years ago. T e more we know
about how cancer deve ops, the more questions we have. Cur-
rent y, the best answer to the question W hat causes cancer?
is Many di erent things.
We know that cancer is a type o neop asm, which means
that it invo ves uncontro ed ce division. A process ca ed
hyperplasia produces too many ce s. A so, abnorma , undi -
erentiated tumor ce s are o ten produced by a process ca ed
anaplasia. T us the mechanism o a cancers is a mistake or
prob em in ce division. H owever, science remains uncertain
o a the possib e triggers o the abnorma ce division.
Current y, the actors isted in the o owing sections are
known to p ay a ro e.
G e n e t ic Fa c t o r s
More than a dozen orms o cancer are known to be direct y
inherited, perhaps invo ving abnorma cancer genes ca ed
oncogenes. T e way in which every known oncogene works
is not yet c ear y understood and is ike y to invo ve a number
o di erent mechanisms.
O ther cancers may deve op primari y in those peop e with
genetic predispositions to specif c orms o cancer. Cancers
with known genetic risk actors inc ude basal cell carcinoma (a
type o skin cancer), breast cancer, and neuroblastoma (a cancer
o nerve tissue). T ese cancers probab y require a combination
o the at risk version o a gene p us one or more environmen-
ta actors.
C a r c in o g e n s
Carcinogens (cancer makers) are chemica s that a ect genetic
activity in some way, causing abnorma ce reproduction. Some
carcinogens are mutagens (mutation makers). Mutagens cause
changes in a ce s DNA structure. A though many industria
products such as benzene are known to be carcinogens, a wide
variety o natura vegetab e and anima materia s are a so carci-
nogenic. obacco, or examp e, contains carcinogens.
Ag e
Certain cancers are ound primari y in young peop e ( or ex-
amp e, eukemia) and others primari y in o der adu ts ( or
examp e, co on cancer). T e age actor may resu t rom
changes in the genetic activity o ce s over time or rom ac-
cumu ated e ects o ce damage.
En v iro n m e n t
Exposure to damaging types o radiation or chronic mechani-
ca injury can cause cancer. For examp e, sun ight can cause
 CHAPTER 6 Mechanisms o Disease 131

and the deve opment o secondary tumors has begun, cancer

TABLE 6-10 The Warning Signs o Cancer*
Sore s that do not he al
Unus ual ble e ding
A change in a wart or m ole
A lum p or thicke ning in any tis s ue
Pe rs is te nt hoars e ne s s or cough
Chronic indige s tion or di f culty s wallow ing
A change in bowe l or bladde r unction
Bone pain that wake s one at night and is locate d on only one s ide
*Any chronic change in body s tructure or unction could be a s ign o cance r
and s hould be inve s tigate d by a phys ician.
skin cancer, and breathing asbestos f bers can cause ung can-
cer. A so, exposure to high concentrations o certain meta s
such as nicke or chromium can cause tumors to deve op.
Vir u s e s
Severa cancers have now been identif ed as having a vira ori-
gin. T is makes sense because we know that viruses o ten
change the genetic machinery o in ected ce s. For examp e,
human papillomaviruses (HPVs) have been ound to have a
causa re ationship in some cases o cervica cancer in women
and peni e cancer in men. T us, H PV vaccines can prevent
both the vira in ections and the resu ting cancers.
P a t h o g e n e s is o C a n c e r
D e t e c t in g C a n c e r
Signs o cancer inc ude those a person wou d expect o a ma-
ignant neop asmthe appearance o abnorma , rapid y
growing tissue. Cancer specia ists, or oncologists, have sum-
marized some major signs o ear y stages o cancer. T ese
signs are isted in Table 6-10.
Ear y detection o cancer is important because in the ear y
stages o deve opment o primary tumors, be ore metastasis
is most treatab e. Some methods current y used to detect the
presence o cancer inc ude those described in the o owing 6
sections.
Sel -Examination
Examining ones se or the ear y signs o cancer is a surpris-
ing y e ective method o detection. For examp e, women are
encouraged to per orm a month y breast se -examination.
Likewise, men are encouraged to per orm a month y testicu ar
se -examination. Se -examination o the skin and other
accessib e organs or tissues is a so recommended by cancer
specia ists.
I an abnorma ity is ound, it can be urther investigated
with one o the methods described ater.
Diagnostic Imaging
A variety o methods are avai ab e or orming images o
interna body organs to detect tumors without exp oratory
surgery.
Radiography is the o dest and sti the most wide y used
method o noninvasive imaging o interna body structures.
Radiography is the use o x-rays to orm a sti or moving
picture o some o the interna tissues o the body. A mam-
mogram, or examp e, is an x-ray photograph o a breast. Po-
tentia y cancerous umps show up as sma , white areas on the
mammogram (Figure 6-12, A).
Computed tomography (C ) scanning is a type o radi-
ography in which x-rays produce a cross-sectiona image o
body regions (Figure 6-12, B).
Magnetic resonance imaging (MRI) is a type o scanning
that uses a magnetic f e d to induce tissues to emit radio
waves. Di erent tissues can be distinguished because each
emits di erent signa s. W ith MRI, tumors can then be visua -
ized on a computer screen in cross sections simi ar to those
produced in C scanning (Figure 6-12, C). MRI is a so some-
times ca ed nuclear magnetic resonance (NM R) imaging.

X-ray ima ge (ma mmogra m) CT s ca n MRI S onogram

L R L

RK

IVC
R L R L R

A B C D
FIGURE 6-12 Medical images o tumors. A, A mammogram (x-ray image) showing carcinoma o a breast
duct. B, CTscan o the brain showing a tumor in the le t hemisphere. C, MRimage o the brain showing a tumor
in the le t hemisphere. D, Sonogram showing a transverse view o an abdominal tumor. L, Le t; R, right; IVC,
in erior vena cava; L, liver; M, mass; RK, right kidney.
 132 CHAPTER 6 Mechanisms o Disease
In ultrasonography, high- requency sound waves can be
re ected o interna tissues to produce images, or sonograms,
6 o tumors (Figure 6-12, D). For more detai ed in ormation re-
garding medica imaging, re er to the C inica App ication
box be ow.
Review additional in ormation and examples o
medical images in the article Medical Imaging o
the Body at Connect It! at evolve.elsevier.com.
Biopsy
A ter a neop asm has been identif ed with one o the previ-
ous y mentioned techniques, a biopsy o the tumor may be
done. Biopsy o an accessib e tumor may precede or even
e iminate the need or extensive medica imaging.
A biopsy is the remova and examination o iving tissue.
Microscopic examination o tumor tissue removed surgica y
C LIN ICA L APPLICATION
MEDICAL IMAGING OF THE BODY
Cadave rs (pre s e rve d hum an bodie s us e d or s cie ntif c s tudy)
can be cut into s agittal, rontal, or trans ve rs e s e ctions or e as y
view ing o inte rnal s tructure s , but living bodie s , o cours e , can-
not. This lim itation has ham pe re d m e dical pro e s s ionals w ho
s trive to de te rm ine w he the r inte rnal organs are injure d or dis -
e as e d. In s om e cas e s , the only s ure way to de te ct a le s ion or
variation rom norm al is by pe r orm ing exte ns ive exploratory
s urge ry. Fortunate ly, advance s in m e dical im aging allow phys i-
cians to vis ualize inte rnal s tructure s o the body w ithout ris king
the traum a or othe r com plications as s ociate d w ith exte ns ive
s urge ry. Som e o the m ore w ide ly us e d te chnique s are brie y
de s cribe d he re .
Radiography
Radio g raphy, or x-ray photography, is the olde s t and s till m os t
w ide ly us e d m e thod o noninvas ive im aging o inte rnal body
s tructure s . The boxe d e s s ay Radiography on p. 105 dis cus s e s
the origins o radiography.
With this m e thod, e ne rgy in the x band o the radiation
s pe ctrum is be am e d through the body and onto photographic
f lm (Figure A). The x-ray photograph s how s the outline s o the
P hotogra phic film or
phosphorescent
s cre e n
X-ray
s ource
A B
or through a need e sometimes revea s whether the tissue is
ma ignant or benign.
A very simp e, noninvasive type o biopsy used to detect
some types o cancer invo ves simp y scraping or brushing
ce s rom an exposed sur ace and smearing them on a g ass
microscope s ide. For examp e, the Papanicolaou test or
Pap smear is a common screening procedure in which ce s
rom the neck o the uterus (cervix) are examined (see
Chapter 23).
To see an example o a needle biopsy, see
the article Kidney Biopsy at Connect It! at
evolve.elsevier.com.
Blood Test
Changes in the concentration o norma b ood components,
such as ions or enzymes, sometimes can indicate cancer.
bone s and othe r de ns e s tructure s that partially abs orb the
x-rays .
In uoros copy, a phos phore s ce nt s cre e n s e ns itive to x-rays
is us e d ins te ad o photographic f lm . A vis ible im age is orm e d
on the s cre e n as x-rays pas s ing through the s ubje ct caus e the
s cre e n to glow. Fluoros copy allow s a m e dical pro e s s ional to
view the inte rnal s tructure s o the s ubje cts body in re al tim e
as it m ove s .
Without e nhance m e nt aids , radiography works be s t as a
tool to view s olid obje cts s uch as bone s . One way to m ake
s o t, hollow s tructure s s uch as blood ve s s e ls or dige s tive or-
gans m ore vis ible is to us e radiopaque contras t m e dia. Sub-
s tance s s uch as barium s ul ate that abs orb x-rays are inje cte d
into or s wallowe d by the patie nt to f ll the hollow organ o in-
te re s t. As the s cre e n in Figure A s how s , the hollow organ the n
s how s up as dis tinctly as a de ns e bone .
Computed Tomography
A variation o traditional x-ray photography is co m pute d
to m o g raphy (CT) or com pute d axial tom ography (CAT) s can-
ning. In this m e thod, a device w ith an x-ray s ource on one s ide
X-ray s ource
s
e
t
a
Pa th of
r
r
x-rays t
o
X- ra y e tec
d
Compute r
Vide o monitor

Cancer ce s a so may produce or trigger production o ab-
norma substancessubstances o ten re erred to as tumor mark-
ers. For examp e, bone cancer and some other ma ignancies can
e evate the b ood concentration o ca cium ions (Ca ) above
norma eve s. B ood tests to he p detect tumor markers o pros-
tate and other cancers are being deve oped and introduced.
S t a g e s a n d Gra d e s o Ca n c e r
T e in ormation gained rom these and other techniques can
be used to stage and grade ma ignant tumors. Staging invo ves
c assi ying a tumor based on its size and the extent o its
spread. Grading is an assessment o what the tumor is ike y to
do, based on the degree o ce abnorma ity. Grading is a use u
basis or making a prognosis, or statement o the probab e
outcome o the disease.
W ithout treatment, cancer may resu t in death. T e progress
o a particu ar type o cancer depends on the type o cancer
and its ocation. Many cancer patients su er rom cachexia, a
o the body and an x-ray de te ctor on the othe r s ide is rotate d
around a ce ntral axis o the s ubje cts body (Figure B). In orm a-
tion rom the x-ray de te ctors is inte rpre te d by a com pute r,
w hich ge ne rate s a vide o im age o the body as i it we re cut
into anatom ical s e ctions .
The te rm com pute d tom ography lite rally m e ans picturing
a cut us ing a com pute r. Be caus e CT s canning and othe r re -
ce nt advance s in diagnos tic im aging produce im age s o the
body as i it we re actually cut into s e ctions , it has be com e
e s pe cially im portant or s tude nts o the he alth s cie nce s to
be com e am iliar w ith s e ctional anatomy, w hich is the s tudy o
the s tructural re lations hips vis ible in anatom ical s e ctions . Find
exam ple s o s e ctional anatomy in m argins o the Cle ar View o
the Hum an Body ( ollow s p. 8).
Magnetic Resonance Imaging
Mag ne tic re s o nance im ag ing (MRI) is a type o s canning
that us e s a m agne tic f e ld to induce tis s ue s to e m it radio re -
que ncy (RF) wave s . An RF de te ctor coil s e ns e s the wave s and
s e nds the in orm ation to a com pute r that cons tructs s e ctional
im age s s im ilar to thos e produce d in CT s canning (Figure C).
Ma gne t (ma gne tic fie ld)
(purple
a rrows )
Ra dio-
fre que ncy
(gre e n
a rrows )
de te ctor
coil
Compute r
Vide o monitor
C D
CHAPTER 6 Mechanisms o Disease 133
syndrome invo ving oss o appetite, severe weight oss, and
genera weakness. T e cause o cachexia in cancer patients is
uncertain. A variety o anatomica or unctiona abnorma ities 6
may arise as a resu t o damage to particu ar organs. T e u timate
causes o death in cancer patients inc ude secondary in ection by
pathogenic microbes, organ ai ure, hemorrhage (b ood oss),
and in some cases, undetermined actors.
C a n c e r Tr e a t m e n t
O course, a ter cancer has been identif ed, staged, and graded,
every e ort is made to treat it and thus prevent or de ay its
deve opment.
Surgical removal o cancerous tumors is pre erab e; a -
though or anatomic reasons, that is not a ways possib e. Even
with surgica remova , the possibi ity that ma ignant ce s have
been e t behind must be addressed.
Chemotherapy, or chemica therapy, using cytotoxic
(ce -ki ing) compounds or antineoplastic drugs can be used
Di e re nt tis s ue s can be dis tinguis he d rom e ach othe r be -
caus e e ach e m its di e re nt radio s ignals . MRI, als o calle d nu-
cle ar m agne tic re s onance (NMR) im aging, avoids the us e o
pote ntially harm ul x radiation and o te n produce s s harpe r im -
age s o s o t tis s ue s than othe r im aging m e thods .
Ultrasonography
During ultras o no g raphy, high- re que ncy (ultras onic) wave s
are re e cte d o inte rnal tis s ue s to produce an im age calle d a
s onogram (Figure D).
Be caus e it doe s not involve x radiation, and be caus e it is
re lative ly inexpe ns ive and e as y to us e , ultras onography has
be e n us e d exte ns ive lye s pe cially in s tudying m ate rnal or e -
tal s tructure s in pre gnant wom e n. Howeve r, the im age pro-
duce d is not as cle ar or s harp as thos e produce d by MRI, CT
s canning, or traditional radiography.
Variations o the s e and othe r te chnological advance s that
have im prove d the ability to s tudy the s tructure and unctions
o the hum an body are dis cus s e d m ore in late r chapte rs .
Ultra s ound Ultra s ound
s ource de te ctor
Vide o monitor
 134 CHAPTER 6 Mechanisms o Disease

a ter surgery to destroy any remaining ma ignant ce s. A injuries such as cuts and burns or damage caused by many
more recent approach is the use o rational drugs in chemo- other irritants such as chemica s, radiation, or toxins re eased
6 therapy. Rationa drugs are those that target on y specif c by bacteria. T e processes o in ammation eventua y e imi-
mo ecu es, enzymes, or receptors unique to cancer ce s or nate the irritant, a ter which tissue repair can begin.
tumor growth, thereby a ecting on y the cancer and sparing As you earned in Chapter 4, tissue repair is the rep ace-
the norma ce s. Rationa drugs thus increase the e ciency o ment o dead ce s with iving ce s. In a type o tissue repair
chemotherapy and reduce its side e ects. ca ed regeneration, the new ce s are simi ar to those that they
Radiation therapy, a so ca ed radiotherapy, using destruc- rep ace. Another type o tissue repair is replacement. In re-
tive x-ray or gamma radiation may be used a one or with p acement, the new ce s are di erent rom those that they
chemotherapy to destroy remaining cancer ce s. Chemo- rep ace, resu ting in a scar. O ten, brous tissue rep aces the o d
therapy and radiation therapy may have severe side e ects tissue, a condition ca ed brosis. Most tissue repairs are a
because norma ce s are o ten ki ed a ong with the cancer combination o regeneration and rep acement.
ce s. In ammation a so may accompany specif c immune sys-
Laser therapy, in which an intense beam o ight destroys tem reactions (which are discussed in Chapter 16). First de-
a tumor, is a so sometimes per ormed in addition to chemo- scribed by a Roman physician a most 2000 years ago, the in-
therapy or radiation therapy. ammatory response has our primary signsredness, heat,
Immunotherapy, a newer type o cancer treatment, bo - swe ing, and pain. T ese signs are indicators o a comp ex
sters the bodys own de enses against cancer ce s. Because process that is summarized in the o owing paragraphs and in
viruses cause some types o cancer, onco ogists hope that vac- Figures 6-13 and 6-14.
cines against certain orms o cancer wi be deve oped.
T ere has been some success with the treatment o peop e M e c h a n is m s o In a m m a t io n
with cancers such as advanced chronic lymphocytic leukemia As tissue ce s are damaged, they re ease in ammation
(CLL) by using genetica y engineered versions o their own mediators such as histamine, prostaglandins (PGs), and
ce s. T e new y programmed ce s have been shown to compounds ca ed kinins.
remove specia y targeted cancerous ce s throughout the pa-
tients bodies or severa months. Genetic engineering o the
host immune system is hoped to provide ongoing protection Irrita nt e nte rs tis s ue
against recurrence o severa types o cancers.
A though new and di erent approaches to cancer treat- Ce ll da ma ge occurs
ment are being investigated, many researchers are concentrat-
ing on improving existing methods and promoting cancer
prevention. Despite progress in reducing cancers in deve oped Infla mma tion me dia tors a re re le a s e d
countries, the steep rise in smoking in deve oping regions
threatens to make cancer the major ki er wor dwide.
Blood ve s s e ls Incre a s e d
Che mota xis
dila te, incre a s ing pe rme a bility of
loca l blood flow blood ve s s e l wa lls
QUICK CHECK
1. Wh a t is m e ta s ta s is ?
2. Give e xa m p le s o b e n ig n a n d m a lig n a n t
tu m o rs th a t a ris e ro m e p ith e lia l tis s u e a n d Ede ma Blood prote ins
Re dne s s He a t
(swe lling) form fibrous
b e n ig n a n d m a lig n a n t tu m o rs th a t a ris e ro m
ca ps ule a round
co n n e ctive tis s u e . injury s ite
3. Na m e f ve g e n e ra l ca u s e s o ca n ce r.
4. Wh a t a re o u r m e th o d s th a t a re u s e d to d e te ct Pa in
ca n ce r?
5. Ho w is ca n ce r tre a te d ?
6. De s crib e th e u s e o g e n e tica lly e n g in e e re d Incre a s e d numbe r of
ve rs io n s o T ce lls in th e tre a tm e n t o ca n ce r. white blood ce lls a t
injury s ite

In a m m a t io n
In a m m a t o ry Re s p o n s e
In t ro d u c t io n t o In a m m a t io n
T e in ammatory response is a combination o
processes that attempts to minimize injury to tis-
sues, thus maintaining homeostasis. In ammation may occur
as a response to any tissue injury, inc uding mechanica
P ha gocytos is of irrita nt
(for exa mple, ba cte ria
a nd da ma ge d ce lls )
FIGURE 6-13 In ammatory response. Starting at the top, ollow the
typical progression o inf ammation. The photo shows the redness and
swelling o inf ammation in the skin o the ear.

S plinte r
Ba cte ria
Epide rmis
introduce d De rmis
Blood
ve s s e l
A sume damaged ce s and pathogenic bacteria by means o
Ba cte ria
prolife ra ting
B
White blood ce ll White blood ce ll
migra ting through pha gocytizing
blood ve s s e l wa ll ba cte ria
FIGURE 6-14 Typical in ammatory response to a mechanical in-
jury. A, A splinter damages tissue and carries bacteria into the body. Blood
vessels dilate and begin leaking f uids, causing swelling and redness.
B, White blood cells are attracted to the injury site and begin to consume
bacteria and damaged tissue cells. A brous capsule separates the injury
site rom surrounding tissue.
Some in ammation mediators cause b ood vesse s to di ate
(widen), increasing b ood vo ume in the tissue. Increased
b ood vo ume produces the redness and heat o in ammation.
T is response is important because it a ows immune system
ce s (white b ood ce s) in the b ood to trave quick y and eas-
i y to the site o injury.
Some in ammation mediators increase the permeabi ity o
b ood vesse wa s. T is a ows immune system ce s and other
b ood components to move out o the b ood vesse s easi y
where they can dea direct y with injured tissue. As water eaks
out o the vesse , tissue swe ing, or edema, resu ts. T e pres-
sure caused by edema triggers pain receptors, conscious y
a erting an individua o the damage. T e excess uid o ten
has the benef cia e ect o di uting the irritant.
T e uid that accumu ates in in amed tissue is ca ed
in ammatory exudate. B ood proteins that eak into tissue
spaces begin to c ot within a ew minutes. T e c ot orms a
f brous capsu e around the injury site, preventing the irritant
rom spreading to nearby tissues.
CHAPTER 6 Mechanisms o Disease 135
In ammatory exudate is s ow y removed by ymphatic ves-
se s and is carried to ymph nodes, which act as f ters. Bacte-
ria and damaged ce s trapped in the ymph nodes are acted 6
on by white b ood ce s in each ymph node. In some cases,
ymph nodes en arge when they are processing a arge amount
o in ectious materia .
In ammation mediators a so can act as signa s that attract
white b ood ce s to the injury site. T e movement o white
b ood ce s in response to chemica attractants is ca ed
chemotaxis.
Once in the a ected tissue, white b ood ce s o ten con-
phagocytosis. W hen the in ammatory exudate becomes thick
with the accumu ation o white b ood ce s, dead tissue and
bacteria ce s, and other debris, pus is ormed.
Occasiona y, the in ammatory response is more intense or
pro onged than desirab e. In such a case, in ammation can be
suppressed by drugs such as antihistamines or aspirin.
Antihistamines b ock the action o histamine, as their name
imp ies. Aspirin disrupts the bodys synthesis o PGs, a group
o in ammation mediators.
To learn more about the in ammatory response,
check out the article In ammation at Connect It!
at evolve.elsevier.com.
To learn more about acute in ammatory
response, go to AnimationDirect online at
evolve.elsevier.com.
In a m m a t o ry D is e a s e
Lo c a l a n d S y s t e m ic In a m m a t io n
A though many in ammation events are local, some a ect the
entire body, producing systemic in ammation. Loca in am-
mation occurs when damage caused by an irritant remains
iso ated in a imited area, as in a sma cut that becomes in-
ected. Systemic in ammation occurs when the irritant
spreads wide y throughout the body or when in ammation
mediators cause changes throughout the body.
Fe ve r
One examp e o a systemic (body-wide) mani estation o the
in ammatory response is a ever. T e irritant or in ammation
mediators can cause the thermostat o the brain to reset at a
higher temperature. Instead o the norma body temperature,
the body achieves and maintains a new, higher temperature.
Increased temperature o ten ki s or inhibits pathogenic
microbes. Some pathophysio ogists a so be ieve that the
higher temperature enhances the activity o the immune sys-
tem. Fevers usua y subside or break a ter the irritant has
been e iminated. Fevers a so can be reduced by drugs that
b ock the ever-producing agents.
T e ever response in chi dren and in the e der y o ten di -
ers rom that in the norma adu t. Young chi dren o ten de-
ve op very high temperatures in response to mi d in ections as
 136 CHAPTER 6 Mechanisms o Disease

compared with adu ts, sometimes causing ebrile seizures
abnorma brain activity caused by ever.
6 E der y peop e o ten have reduced or absent ever re-
sponses during in ections, which may reduce their abi ity to
resist the in ectious agent.
Ac u t e a n d C h ro n ic In a m m a t io n
Acute in ammation is an immediate, protective response that
promotes e imination o an irritant and subsequent tissue re-
pair. See the photo inset in Figure 6-13.
O ccasiona y, chronic in ammatory conditions occur.
Chronic in ammation, whether oca or systemic, is a ways
damaging to a ected tissues.
Conditions invo ving chronic in ammation are c assif ed
as in ammatory diseases. A though some in ammatory dis-
eases are caused by known pathogens or by an abnorma im-
mune response (a ergy or autoimmunity), the causes o many
o them are uncertain. In ammatory conditions such as ar-
thritis, asthma, eczema, and chronic bronchitis are among the
most common chronic diseases in the wor d.
QUICK CHECK
1. Wh a t a re th e o u r p rin cip a l s ig n s o in a m m a tio n ?
2. Wh a t is th e ro le o a n in a m m a tio n m e d ia to r?
3. Wh a t h a p p e n s in th e b o d y to ca u s e a e ve r?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 113)

coronavirus in ammatory response prion

(koh-ROHN-ah-vye-rus) (in-FLAM-ah-toh-ree ree-SPONS) (PREE-ahn)
[corona- crown, -virus poison] [in am- set af re, -ory relating to, re- back, [condensed rom proteinaceous in ectious
epidemiology -sponse answer] particle]
(EP-ih-dee-mee-OL-oh-jee) kinin prostaglandin (PG)
[epi- upon, -dem- people, -log- words (study o ), (KYE-nin) (pros-tah-GLAN-din)
-y activity] [kin- move, -in substance] [pro- be ore, -stat- set or place (prostate),
agellate metabolic -gland- acorn (gland), -in substance]
(FLAJ -eh-lat) (met-ah-BOL-ik) protozoan
[ agell- whip, -ate o or like] [meta- over, -bol- throw, -ic relating to] (proh-toh-ZOH-an)
agellum metazoan pl., protozoa
( ah-J EL-um) (met-uh-ZOH-an) (proh-toh-ZOH-ah)
pl., agella pl., metazoa [proto- f rst, -zoan animal]
( ah-J EL-ah) (met-uh -ZOH-ah) psychogenic
[ agellum whip] [meta- over, -zoan animal] (sye-koh-J EN-ik)
avivirus microbe [psycho- the mind, -gen- production,
(FLAY-vih-vye-rus) (MY-krobe) -ic relating to]
[ av- yellow, -virus poison] [micro- small, -b(io) li e] pus
ungus nematode (pus)
(FUNG-gus) (NEM-ah-tohd) [pus rotten]
pl., ungi or unguses [nema- thread, -ode like] retrovirus
(FUN-jye or FUN-gye or FUN-gus-ez) oncogene (ret-roh-VYE-rus)
[ ungus mushroom] (ON-koh-jeen) [retro- backward, -virus poison]
Gram staining technique [onco- swelling or mass (cancer), risk actor
(gram STAYN-ing tek-NEEK) -gen- produce or generate] (risk FAK-tor)
[Hans Christian J oachim Gram Danish parasite [risk run into danger, actor agent]
pathologist] (PAYR-ah-syte) spore
histamine [para- beside, -site ood] (spor)
(HIS-tah-meen) pathogenesis [spore seed]
[hist- tissue, -amine ammonia compound] (path-oh-J EN-e-sis) sporozoan
in ammation [patho- disease, -genesis origin] (spor-oh-ZOH-an)
(in- ah-MAY-shun) pathophysiology pl., sporozoa
[in am- set af re, -tion process] (path-oh-f z-ee-OL-oh-jee) (spor-oh-ZOH-ah)
in ammation mediator [patho- disease, -physio- nature ( unction), [spor- seed, -zoan animal]
(in- ah-MAY-shun MEE-dee-ay-tor) -log- words (study o ), -y activity] vector
[in am- set af re, -tion process, platyhelminth (VEK-tor)
mediat- intervene, -or condition] (plat-ih-HEL-minth) [vector carrier]
in ammatory exudate [platy- broad, at, -helminth worm] virus
(in-FLAM-ah-toh-ree EK-soo-dayt) (VYE-rus)
[in am- set af re, -ory relating to, exud- sweat [virus poison]
out, -ate thing]
 CHAPTER 6 Mechanisms o Disease 137

LANGUAGE OF M ED IC IN E
6
acquired immune def ciency syndrome cachexia environmental health
(AIDS) (kah-KEKS-ee-ah) (en-VYE-ron-ment-al helth)
(ah-KWY-erd ih-MYOON deh-FISH-en-see [cache- bad, -(h)exia state] [environ- surround, -ment- condition,
SIN-drohm [aydz]) cancer -al relating to]
[immun- ree, -de- down, -f c- per orm, (KAN-ser) epidemic
-ency state, syn- together, -drome running or [cancer crab or malignant tumor] (ep-ih-DEM-ik)
(race) course] [epi- upon, -dem- people, -ic relating to]
carcinogen
acute (kar-SIN-oh-jen) etiology
(ah-KYOOT) [carcino- cancer, -gen produce] (ee-tee-AHL-oh-jee)
[acut- sharp] [eti- cause, -o- combining vowel, -log- words
carcinoma
adenocarcinoma (kar-sih-NOH-mah) (study o ), -y activity]
(ad-eh-noh-kar-sih-NOH-mah) [carcin- cancer, -oma tumor] ebrile seizure
[adeno- gland, -carcin- cancer, -oma tumor] (FEB-ril SEE-zhur)
chemotherapy
adenof broma (kee-moh-THAYR-ah-pee) [ ebri- ever, -ile characterized by, seiz- grasp
(ad-eh-noh- ye-BROH-mah) [chemo- chemical, -therapy treatment] suddenly, -ure action]
[adeno- gland, -f br- f ber, -oma tumor] ever
Chlamydia
adenoma (klah-MID-ee-ah) (FEE-ver)
(ad-eh-NOH-mah) [chlamyd- short mantle, -ia condition] [ ev- heat]
[adeno- gland, -oma tumor] f brosarcoma
chondroma
anaplasia (kon-DROH-mah) ( ye-broh-sar-KOH-mah)
(an-ah-PLAY-zhah or an-ah-PLAY-zee-ah) [chondr- cartilage, -oma tumor] [f bro- f ber, -sarco- esh, -oma tumor]
[ana- without, -plasia shape] f brosis
chronic
anthrax (KRON-ik) ( ye-BROH-sis)
(AN-thraks) [chron- time, -ic relating to] [f br- f ber, -osis condition]
[anthrax boil] genetic
communicable
antibiotic (kom-MYOO-nih-kah-bil) (jeh-NET-iks)
(an-tih-by-OT-ik) [communic- share, -able capacity] [gene- produce, -ic relating to]
[anti- against, -bio li e, -ic relating to] human immunodef ciency virus (HIV)
computed tomography (CT)
antihistamine (kom-PYOO-ted toh-MOG-rah- ee (HYOO-mon ih-myoo-noh-deh-FISH-en-see
(an-tih-HIS-tah-meen) [see tee]) VYE-rus [aych aye vee])
[anti- against, -histo- tissue, [com- together, -pute- think, tomo- cut, [immuno- ree (immunity), -de- down,
-amine ammonia compound] -graph- draw, -y process] -f c- per orm, -ency state, virus poison]
antiviral drug culture hyperplasia
(an-tee-VYE-ral [or an-tih-VYE-ral] drug) (KULT-chur) (hye-per-PLAY-zhah or
[anti- against, -vir- poison, -al relating to] [cultur- till land] hye-per-PLAY-zee-ah)
aseptic technique [hyper- excessive, -plasia shape]
degeneration
(ay-SEP-tik tek-NEEK) (dih-jen-uh-RAY-shun) idiopathic
[a- without, -septi- putrid, -ic relating to, [de- down, -generat- produce, -tion condition] (id-ee-oh-PATH-ik)
techn- method] [idio- peculiar, -path- disease, -ic relating to]
dengue
benign (DENG-gay or DENG-gee) immunotherapy
(bee-NYNE) [dengue seizure or cramp] (im-yoo-noh-THAYR-ah-pee)
[benign kind] [immuno- ree, -therapy treatment]
disease
biopsy (dih-ZEEZ) incubation
(BYE-op-see) [dis- opposite o , -ease com ort] (in-kyoo-BAY-shun)
[bio- li e, -ops- view, -y act o ] [in- in or on, -cubat- lie, -tion process]
edema
bioterrorism (eh-DEE-mah) in ectious
(bye-oh-TAYR-or-iz-em) [edema swelling] (in-FEK-shus)
[bio- li e, -terror- ear, -ism condition] [in ect- stain, -ous relating to]
endemic
bovine spongi orm encephalopathy (BSE) (en-DEM-ik) in ammatory
(BOH-vyne SPUN-jeh- orm [en- in, -dem- people, -ic relating to] (in-FLAM-ah-toh-ree)
en-se -uh-LOP-uh-thee [bee es ee]) environmental actor [in am- set af re, -ory relating to]
[bovi- ox or cow, -ine o or like, spongi- sponge, (en-VYE-ron-ment-al FAK-tor)
- orm shape, -en- within, -cephalo- head, [environ- surround, -ment- condition,
-path- disease, -y state] -al relating to, actor agent]
Continued on p. 138
 138 CHAPTER 6 Mechanisms o Disease

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 137)

6
laser therapy nevus SARS-associated coronavirus (SARSCoV)
(LAY-zer THAYR-ah-pee) (NEE-vus) (SARZ-as-ohs-ee-AYT-ed
[laser acronym or light amplif cation by [nevus birthmark] koh-ROHN-ah-vye-us [sarz koh vee])
stimulated emission o radiation] osteoma [SARS- severe acute respiratory syndrome,
li estyle (os-tee-OH-mah) associa- unite, -ate- process, corona- crown,
(LYFE-style) [oste- bone, -oma tumor] -virus poison]
lipoma osteosarcoma severe acute respiratory syndrome (SARS)
(lih-POH-mah) (os-tee-oh-sar-KOH-mah) (seh-VEER ah-KYOOT res-pir-ah-TOR-ee
[lip- at, -oma tumor] [osteo- bone, -sarc- esh, -oma tumor] SIN-drohm [sarz])
[acut- sharp, re- again, -spir- breathe,
lymphoma pandemic
-tory relating to, syn- together,
(lim-FOH-mah) (pan-DEM-ik)
-drome running or (race) course]
[lymph- water, -oma tumor] [pan- all, -dem- people, -ic relating to]
magnetic resonance imaging (MRI) Papanicolaou test sign
(mag-NET-ik REZ-ah-nens IM-ah-jing (pah-peh-nik-oh-LAH-oo) (syne)
[em ar aye]) [George N. Papanicolaou Greek physician] stress
[magnet- lodestone, -ic relating to, re- again, papilloma (stres)
-sona- sound, -ance state] [stress tighten]
(pap-ih-LOH-mah)
malignant [papill- nipple, -oma tumor] symptom
(mah-LIG-nant) preexisting condition (SIMP-tum)
[malign- bad -ant state] [sym- together, -tom all]
(pree-ig-ZIST-ing kon-DISH-un)
melanoma [pre- be ore, -existing being] syndrome
(mel-ah-NOH-mah) prognosis (SIN-drohm)
[melan- black, -oma tumor] [syn- together, -drome running or (race) course]
(prog-NOH-sis)
metastasis [pro- be ore, -gnosis knowledge] traumatic
(meh-TAS-tah-sis) pathology (truh-MAT-ik)
[meta- change, -stasis standing] [trauma- wound, -atic relating to]
(pah-THOL-oh-jee)
morbidity [patho- disease, -o- combining vowel, tumor
(mor-BID-ih-tee) -log- words (study o ), -y activity] (TOO-mer)
[morbid- sick, -ity condition] [tumor swelling]
psychogenic
mortality (sye-koh-J EN-ik) ultrasonography
(mor-TAL-ih-tee) [psycho- the mind, -gen- production, (ul-trah-son-OG-rah- ee)
[mortal- subject to death, -ity condition] -ic relating to] [ultra- beyond, -sono- sound, -graph- draw,
-y process]
mutagen public health
(MYOO-tah-jen) (PUB-lik helth) vaccine
[mutat- change, -gen producer] radiation therapy (VAK-seen)
[vaccin- cow (cowpox), -ine relating to]
mycotic in ection (ray-dee-AY-shun THAYR-ah-pee)
(my-KOT-ik in-FEK-shun) [radiat- send out rays, -ion process, variant Creutz eldt-J akob disease (vCJ D)
[myco- ungus, -ic relating to, in ect- stain, therapy treatment] (VAYR-ee-ant KROYTS- elt YAH-kohb
-tion process] radiography dih-ZEEZ)
[Hans G. Creutz eldt German neurologist,
myeloma (ray-dee-OG-rah- ee)
Al ons M. J akob German neurologist,
(my-eh-LOH-mah) [radi- rays, requency, -graphy drawing]
dis- opposite o , -ease com ort]
[myel- marrow, -oma tumor] remission
neoplasm (ree-MISH-un) West Nile virus (WNV)
(NEE-oh-plaz-em) [re- back or again, -miss- send, (west nyle VY-rus [DUB-el-yoo en vee])
[West Nile region o A rica, virus poison]
[neo- new, -plasm ormation] -sion condition o ]
neoplastic Rickettsia yellow ever
(nee-oh-PLAS-tik) (rih-KET-see-ah) (YEL-oh FEE-ver)
[ ev- heat]
[neo- new, -plas(m)- ormation, -ic relating to] [H.T. Ricketts U.S. pathologist, -ia condition]
neuroblastoma sarcoma Zika virus
(noo-roh-blas-TOH-mah) (SAR-koh-mah) (ZEE-kah VYE-rus)
[Zika orest in Uganda, virus poison]
[neuro- nerve, -blast- germ, -oma tumor] [sarco- esh, -oma tumor]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
S tudying Dis e as e
A. Disease termino ogy
1. H ea thphysica , menta , and socia we -beingnot
mere y the absence o disease
2. Diseasean abnorma ity in body unction that
threatens hea th
3. Etio ogythe study o the actors that cause a disease
4. Idiopathicre ers to a disease with an unknown cause
5. Signs and symptomsthe objective and subjective
abnorma ities associated with a disease
6. Pathogenesisthe pattern o a diseases deve opment
B. Patterns o disease
1. Epidemio ogy is the study o occurrence, distribution,
and transmission o diseases in human popu ations
2. Endemic diseases are native to a oca region
3. Epidemics occur when a disease a ects many peop e
at the same time
4. Pandemics are widespread, perhaps g oba , epidemics
5. Discovering the cause o a disease is di cu t because
many actors a ect disease transmission
6. Disease can be ought through prevention and therapy
(treatment) (Figure 6-1)
Patho phys io lo gy
A. Mechanisms o disease
1. Pathophysio ogythe study o under ying physio ogi-
ca aspects o disease
2. Many diseases are best understood as disturbances o
homeostasis (Figure 6-2)
3. Genetic mechanism
4. In ectious mechanism (pathogenic organisms and
partic es)
5. Neop astic mechanism (tumors and cancer)
6. raumatic mechanism (physica and chemica agents)
7. Metabo ic mechanism (endocrine imba ances or
ma nutrition)
8. In ammatory mechanism
a. In ammation
b. Autoimmunity
9. Degeneration
B. Risk actors (predisposing conditions)
1. ypes
a. Genetic actors
b. Age
CHAPTER 6 Mechanisms o Disease 139
6
c. Li esty e
d. Stress
e. Environmenta actors
. Preexisting conditions
2. Some risk actors can combine or over ap
3. Risk can be managed in some cases
Patho ge nic Organis m s and Particle s
A. Viruses (Table 6-1 and Figure 6-4)
1. Introduction
a. Not a ive because they are not made o ce s, but
are sti studied by bio ogists because they in ect
ce s and have a genetic code; viruses are c assif ed
into groups ike iving organisms
b. Virus partic es are microscopic, intrace u ar para-
sites that consist o a nuc eic acid core with a
protein coat
c. Invade host ce s and pirate organe es and raw
materia s
d. May be transmitted direct y rom human to
human, or may be transmitted indirect y through a
biting insect
e. C assif ed by shape, nuc eic acid type, and method
o reproduction
2. Examp es o viruses
a. H uman immunodef ciency virus (H IV) (Figure 6-3)
(1) Retrovirus that can transcribe its RNA back-
wards to produce DNA that becomes part o
the host ce s genome
(2) I untreated, can progress to acquired immune
def ciency syndrome (AIDS)
b. Coronaviruses
(1) RNA viruses that have a crown o sur ace
projections and make their own proteins inside
the host ce
(2) Found everywhere; second- eading (a ter rhi-
noviruses) cause o common co d
(3) Some can cause serious in ections such as
severe acute respiratory syndrome (SARS)
c. F aviviruses
(1) RNA viruses transmitted by mosquitoes
(2) Cause ye ow ever, dengue, West Ni e virus
(W NV) in ection, Z ika virus disease, and other
potentia y serious in ections
B. Prions (Figure 6-5)
1. Pathogenic protein mo ecu es
2. Convert norma proteins to abnorma proteins by
inducing mis o ding, causing abnorma unctions that
produce disease; may be passed on to o spring
3. Cause rare, degenerative disorders o the nervous
system such as BSE (bovine spongi orm encepha opa-
thy) and vCJD (variant Creutz e dt-Jakob disease)
 140 CHAPTER 6 Mechanisms o Disease
C. Bacteria (Table 6-2 and Figure 6-6)
1. iny ce s without nuc ei
6 2. Secrete toxins, parasitize host ce s, or orm co onies
3. C assif cation
a. By growth requirements
(1) Aerobicrequire oxygen
(2) Anaerobicrequire no oxygen
b. By staining properties (depend on composition o
ce wa )
(1) Gram-positive
(2) Gram-negative
c. By shape and size
(1) Baci irod-shaped ce s
(2) Cocciround ce s
(3) Curved or spira rods
(4) Sma bacteriaob igate parasites
d. Sporesnonreproducing orms o bacteria that
resist un avorab e environmenta conditions
e. Archaea are simi ar to bacteria but have a di erent
chemica makeup and di erent metabo ism (a ow-
ing them to survive harsh conditions); none ound
that in ect humans, but are nonpathogenic resi-
dents ound in the human body
D. Fungi (Table 6-3 and Figure 6-7)
1. Simp e organisms simi ar to p ants but acking
ch orophy
2. Yeastssma , sing e-ce ed ungi
3. Mo ds arge, mu tice u ar ungi
4. Mycotic in ectionso ten resist treatment
E. Protozoa (Table 6-4 and Figure 6-8)
1. Large, one-ce ed organisms having organized nuc ei
2. May in est human uids and parasitize or destroy ce s
3. Major groups
a. Amebaspossess pseudopodia
b. F age atespossess age a
c. Ci iatespossess ci ia
d. Sporozoa (coccidia)enter ce s during one phase
o a two-part i e cyc e; borne by vectors (transmit-
ters) during the other phase
F. Pathogenic anima s (Table 6-5)
1. Large, comp ex mu tice u ar organisms
2. Parasitize or otherwise damage human tissues or organs
3. Major groups
a. Nematodesroundworms
b. P atyhe minths atworms and ukes (Figure 6-9)
c. Arthropods
(1) Parasitic mites, ticks, ice, eas
(2) Biting or stinging wasps, bees, mosquitoes,
spiders
(3) Are o ten vectors o disease (Table 6-7)
Pre ve ntio n and Co ntro l
A. Mechanisms o transmission
1. Person-to-person contact
a. Can be prevented by education
b. Can be prevented by using aseptic technique
(Table 6-6)
2. Environmenta contact
a. Can be prevented by avoiding contact
b. Can be prevented by sa e sanitation practices
3. O pportunistic invasion
a. Can be prevented by avoiding changes in skin and
mucous membranes
b. Can be prevented by c eansing o wounds
4. ransmission by a vector
a. Can be prevented by reducing the popu ation o
vectors and reducing contact with vectors
B. Prevention and treatment strategies
1. Vaccinationstimu ates immunity; may produce mi d
side e ects, but does not cause autism (ASD)
2. Drug therapydestroy or inhibit pathogens
a. Antibioticsnatura compounds derived rom
iving organisms; synthetic antibacteria drugs are
a so avai ab e
b. Antivira drugssynthetic compounds such as
ami u, ACV, and e avirenz; s ow progression o
vira in ections, but do not cure them; may be given
in combination (drug cocktai s)
Tum o rs and Cance r
A. Neop asms (tumors)abnorma growths o ce s
(Table 6-8 and Figure 6-10)
1. Benign tumors remain oca ized
2. Ma ignant tumors spread, orming secondary tumors
3. Metastasisce s eave a primary tumor and start a
secondary tumor at a new ocation (Figure 6-11)
4. C assif cation o tumors
a. Benign, epithe ia tumors
(1) Papi omaf nger ike projection
(2) Adenomag andu ar tumor
(3) Nevussma , pigmented tumor
b. Benign, connective tissue tumors
(1) Lipomaadipose ( at) tumor
(2) Osteomabone tumor
(3) Chondromacarti age tumor
c. Carcinomas (ma ignant epithe ia tumors)
(1) Me anomainvo ves me anocytes
(2) Adenocarcinomag andu ar cancer
d. Sarcomas (connective tissue cancers)
(1) Lymphoma ymphatic cancer
(2) Osteosarcomabone cancer
(3) Mye omabone marrow tumor
(4) Fibrosarcomacancer o f brous tissue
e. Can a so be c assif ed by ocation in the body
(Table 6-9)
B. Causes o cancervaried and sti not c ear y understood
1. Cancer invo ves hyperp asia (growth o too many ce s)
and anap asia (deve opment o undi erentiated ce s)
2. Factors known to p ay a ro e in causing cancer
a. Genetic actors ( or examp e, oncogenescancer
genes)
b. Carcinogenschemica s that a ter genetic activity
c. Agechanges in ce activity over time or accumu-
ated e ects o ce damage

d. Environmentchronic exposure to damaging
substances
e. Virusescause change in genetic machinery
C. Pathogenesis o cancer
1. Signs o cancer (Table 6-10)
2. Methods o detecting cancers (Figure 6-12)
a. Se -examination
b. Diagnostic imagingradiography ( or examp e,
mammogram and C scan), magnetic resonance
imaging (MRI), u trasonography
c. Biopsy ( or examp e, Pap smear)
d. B ood tests
3. Stagingc assi ying tumors by size and extent o
spread
4. Gradingassessing the ike y pattern o a tumors
deve opment
5. Cachexiasyndrome inc uding appetite oss, weight
oss, and genera weakness
6. Causes o death by cancersecondary in ections,
organ ai ure, hemorrhage, and undetermined actors
7. reatments
a. Surgery
b. Chemotherapy (chemica therapy)
c. Radiation therapy (radiotherapy)
d. Laser therapy
e. Immunotherapy
. New strategies ( or examp e, rationa drugs that
target specif c mo ecu es, enzymes, or receptors)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
This is a ve ry challe nging chapte r. It pre s e nts a gre at de al o
in orm ation, m uch o w hich m ay be new to you.
1. Divide the chapter into parts: disease termino ogy, mech-
anisms and risk actors, pathogenic organisms, tumors and
cancer, and in ammation. In each o these sections, go
over the terms in bo d print. You may be surprised at how
many you a ready know. Put the ones you do not know on
ash cards.
2. Use ash cards to earn the mechanisms o disease; most
o them are se -exp anatory. Divide the pathogenic
organisms into viruses, bacteria, ungi, protozoa, and
pathogenic anima s. Use ash cards or each group. Write
a brie description o each type o organism.
3. Methods o disease spread are air y se -exp anatory.
Make sure you know the distinction between prevention
(e.g., vaccination) and treatment (e.g., antibiotic). In the
CHAPTER 6 Mechanisms o Disease 141
In am m atio n
A. In ammatory responsereduces injury to tissues, thus 6
maintaining homeostasis (Figures 6-13 and 6-14)
1. Signsredness, heat, swe ing, and pain
2. In ammation mediators (histamine, prostag andins,
and kinins)
a. Some cause b ood vesse s to di ate, increasing b ood
vo ume (redness and heat)white b ood ce s trave
quick y to injury site
b. Some increase b ood vesse permeabi ity (causing
swe ing, or edema, and pain)white b ood ce s
move easi y out o vesse s, irritant is di uted, and
exudate accumu ates
c. Some attract white b ood ce s to injury site
(chemotaxis)
B. In ammatory diseases
1. In ammation can be oca or systemic (body-wide)
2. Feverhigh body temperature caused by a resetting
o the bodys thermostatdestroys pathogens and
enhances immunity
3. Acute in ammation is an immediate response that
o ten rids the body o an irritant
4. Chronic in ammation can constitute a disease itse
because it causes damage to tissues
cancer section, be sure you understand the di erence
between a carcinoma and a sarcoma.
4. Check out the Centers or Disease Control and Prevention
website: cdc.gov. T is site contains in ormation on a
variety o diseases.
5. T e causes o cancer are a so se -exp anatory, as are the
methods o detection and types o treatment. W hen study-
ing the types o treatment, do not orget about surgery; it is
not in bo d type and there ore cou d be missed.
6. As you study in ammation, make ash cards or the our
primary signs and their causes. Be sure you understand
what chemotaxis is. Learn the positive e ects o ever and
the di erent e ects ever has on the young and the e der y.
7. Meet with your study group ear y and o ten. T is is not
materia you can master in one night. You may want to go
over on y one or two parts o the chapter per session.
Review def nitions, ash cards, major concepts, on ine
resources, questions at the end o the chapter, and possib e
test questions. Keep your study materia or this chapter
handy; you may wish to re er to it as you study uture
chapters.
 142 CHAPTER 6 Mechanisms o Disease
Re vie w Que s tio ns
6 Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne or exp ain the o owing terms: etio ogy, idio-
pathic, communicab e, and atent or incubation period.
2. W hat is the di erence between an epidemic and a pan-
demic? W hat actor makes pandemics increasing y
common in modern times?
3. List our actors invo ved in the spread o disease.
4. List seven mechanisms o disease.
5. W hat is a risk actor?
6. List the six risk actors discussed in the chapter.
7. Describe a virus. H ow does a virus damage a ce ?
8. Def ne a avivirus. List our examp es o aviviruses.
9. Brie y describe a bacterium. List the ways in which bac-
teria produce disease.
10. List three ways to c assi y bacteria.
11. Distinguish between anaerobic and aerobic bacteria.
12. Name the shapes and sizes used to c assi y bacteria.
W hich o these inc ude the ob igate parasites?
13. Describe a spore.
14. Describe ungi. Distinguish between yeasts and mo ds.
15. Describe protozoa. List the our major groups o
protozoa.
16. Name and give an examp e o each o the pathogenic
anima s. W hich o the arthropods are parasitic? W hat is
a vector?
17. List the our ways disease can be spread.
18. Distinguish between malignant and benign tumors.
19. List the three benign tumors that arise rom epithe ia
tissue.
20. List the three benign tumors that arise rom connective
tissue.
21. W hat are sarcomas? List the our sarcomas discussed in
the chapter.
22. List the f ve actors that are known to p ay a ro e in the
deve opment o cancer. W hat is a mutagen?
23. List the our methods used to detect the presence o
cancer.
24. List six methods o cancer treatment.
25. W hat are the our primary signs o in ammation? W hat
causes each o them?
26. W hat is chemotaxis?
27. W hat are two positive e ects o ever?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
28. T e doctor noticed a rash on a boys arm. T e boy com-
p ained that the rash itched. W hich o these was a sign?
W hich was a symptom? W hat is the di erence between
the two?
29. O the risk actors isted in the text, which can you
change, and which cant you change?
30. W hy do bacteria that orm spores present a greater
hea th risk than those that do not orm spores?
31. You have been given an antibiotic as a treatment or a
disease. W hy were you not given a vaccine instead o the
antibiotic?
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________ are objective abnorma ities that can be seen or
measured.
2. ________ are subjective abnorma ities e t on y by the
patient.
3. A disease with an undetermined cause is said to be
________.
4. A ________ a ects a arger geographica region than
does an epidemic.
5. A ________ is an attenuated pathogen given to a person
to stimu ate immunity.
6. A ________ tumor tends to spread to other regions o
the body.
7. ________ is a process by which cancer ce s are spread
by ymphatic or b ood vesse s.
8. ________ are ma ignant tumors that arise rom connec-
tive tissue.
9. ________ are ma ignant tumors that arise rom epithe-
ia tissue.
10. A ________ is a cause o cancer that damages or
changes DNA structure.
11. T e our primary signs o in ammation are ________,
________, ________, and ________.
12. ________ are not technica y iving organisms because
they are not made up o ce s. T ey do, however, in ect
iving ce s.
13. Stage 3 H IV in ection is a so known as ________.
14. T e Zika virus is in a category o viruses known as
________ that move rom an in ected bird or other
anima to a mosquito or biting insect and then to a
human.
 CHAPTER 6 Mechanisms o Disease 143

15. W hich o the o owing is not a risk actor or disease?

a. Stress
Cas e S tudie s
b. Genetic actors To s olve a cas e s tudy, you m ay have to re e r to 6
c. Age the glos s ary or index, othe r chapte rs in this text-
d. Autoimmunity book, and othe r re s ource s .
16. W hich o the o owing is not a means by which patho-
gens can spread? 1. W ithout warning, Mr. Lee begins to ee sick. H is most
a. Environmenta contact obvious symptom is a high ever. W ithin 24 hours, every-
b. Vectors one in the Lee househo d a so ee s sick and has a high
c. Person-to-person contact temperature. Be ore ong, nearby househo ds have the
d. A o the above can spread pathogens same experiencemany peop e in the community are
17. reatment or cancer inc udes everything except: now sick. T e oca hea th department wou d probab y ca
a. biopsy on what type o hea th pro essiona to investigate this sit-
b. surgery uation? Wou d the hea th pro essiona abe this situation
c. chemotherapy an epidemic or a pandemic? I the symptoms are caused
d. genetic engineering by a bacteria in ection, ist some ways the pathogen cou d
18. W hich o the o owing is not an in ammation have been transmitted to so many peop e within a short
mediator? span o time.
a. Prostag andins 2. Sandy is a nurse at the oca university hospita . One o
b. Edema her patients has a severe staphy ococca in ection. W hat
c. H istamine wou d the pathogen responsib e or this in ection ook
d. Kinins ike under a microscope? Sandys patient is taking a new y
deve oped antibiotic in the hope that it wi cure the
Match the descriptions in Column A with the corresponding in ection. Do you think that this drug is natura or
pathogenic organism in Column B. Some items in Column B synthetic?
will be used more than once. 3. Fred is a f rst-year medica student. H e received a minor
scrape during a basketba game on the parking ot
Column A Column B outside his dorm. H e has c eansed the wound and app ied
19. ________ intrace u ar parasites a. virus an antibiotic as a preventive measure. T e a ected area is
made up o DNA or b. bacteria red, swo en, and mi d y pain u . H ow do you exp ain
RNA and surrounded c. ungus these symptoms? Freds roommate suggested app ying an
by a protein coat d. protozoa anti-in ammatory drug to the wound, but Fred re uses.
20. ________ causes mycotic e. nematodes W hat advantage might Fred see in avoiding such
in ections . p atyhe minths treatment?
21. ________ roundworms g. arthropods 4. Lo a came home rom preschoo and was not ee ing we .
22. ________ can be gram-positive or She had not been ee ing we or the past ew days. H er
gram-negative mother noticed that she had not been s eeping we and
23. ________ causes ma aria she comp ained about itching in the region o her anus.
24. ________ vector or Lyme disease She was not eating we and cou d not even be tempted
25. ________ insert their genetic code with her avorite oods. H er mother took her to the pedi-
into the hosts genetic atrician who to d Mrs. Byers that it was possib e that
code Lo a had a round worm. W ith the in ormation that you
26. ________ one-ce ed organism have rom your text, cou d you be more specif c with that
with a nuc eus; can be a possib e diagnosis?
ci iate
27. ________ simi ar to p ants but Answers to Active Learning Questions can be ound online
with no ch orophy at evolve.elsevier.com.
28. ________ mites, ice, and eas
29. ________ tiny primitive ce s
without nuc ei; can be
rod shaped
30. ________ atworms and ukes
31. ________ can be baci i or cocci
shaped
Skin and Membranes
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Body Membranes, 145

Classif cation o Membranes, 145
Epithelial Membranes, 146
Connective Tissue Membranes, 147
Skin Structure, 148
Overview o Skin Structure, 148
Epidermis, 149
Dermis, 150
Subcutaneous Tissue, 151
Hair, Nails, and Skin Receptors, 151
Skin Glands, 154
Functions o the Skin, 155
Protection, 155
Temperature Regulation, 155
Sensation, 156
Excretion, 156
Synthesis o Vitamin D, 156
Disorders o the Skin, 156
Skin Lesions, 156
Burns, 157
Skin In ections, 161
Vascular and In ammatory Skin Disorders, 161
Skin Cancer, 163

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Classi y, compare the structure o , and give examples
o each type o body membrane.
2. Describe the structure and unction o the epidermis
and dermis.
3. List and brie y describe each accessory organ o the
skin.
4. List and discuss the f ve primary unctions o the skin.
5. Do the ollowing related to disorders o the skin:
-
ders, and give examples o each.

types o skin cancer.

 7
In Chapter 1 the concept o progressive organization o body structures rom LANGUAGE OF
simp e to comp ex was estab ished. Comp exity in body structure and unction S C IEN C E
progresses rom ce s to tissues and then to organs and organ systems. T is
chapter discusses the skin and its appendagesthe hair, the nai s, and
Be o re re ading the
the skin g andsas an organ system. T is system is ca ed the
chapte r, s ay e ach o
integumentary system. Integument is another name or the skin, the s e te rm s o ut lo ud. This w ill
and the skin itse is the principa organ o the integumentary he lp yo u to avo id s tum bling ove r
system. T e skin is one o a group o anatomica y simp e but the m as yo u re ad.
unctiona y important sheet ike structures ca ed membranes.
T is chapter begins with c assif cation and discussion o the
apocrine
important body membranes. Study o the integument o ows (AP-oh-krin)
our f rst exp oration o how the structure and unction o a body [apo- rom, crin- secrete]
system are interre ated. apocrine sweat gland
(AP-oh-krin swet gland)
To get an overview o the integumentary system, go to [apo- rom, -crin- secrete, gland acorn]
AnimationDirect online at evolve.elsevier.com. appendage

[append- hang upon, -age related to]

Bo d y M e m b r a n e s areola
(ah-REE-oh-lah)
C la s s if c a t io n o M e m b r a n e s
pl., areolae
T e term membrane re ers to a thin, sheet ike structure that may have (ah-REE-oh-lee)
many important unctions in the body. Membranes cover and protect [are- area or space, -ola little]
the body sur ace, ine body cavities, and cover the inner sur aces o arrector pili
the ho ow organs such as the digestive, reproductive, and respiratory (ah-REK-tor PYE-lye)
passageways. [arrector raiser, pili o hair]
Some membranes anchor organs to each other or to bones, and basement membrane
others cover the interna organs. In certain areas o the body, (BAYS-ment MEM-brayn)
membranes secrete ubricating uids that reduce ric- [base- base, -ment thing,
membrane thin skin]
tion during organ movements such as the
beating o the heart or ung expansion bursa
(BER-sah)
and contraction. M embrane u-
pl., bursae
bricants a so decrease riction
(BER-see or BER-say)
between bones in joints. [bursa purse]
connective tissue membrane
(kon-NEK-tiv TISH-yoo MEM-
brayn)
[con- together, -nect- bind,
-ive relating to, tissu- abric,
membran- thin skin]
cutaneous membrane
(kyoo-TAYN-ee-us MEM-brayn)
[cut- skin, -aneous relating to,
membrane thin skin]
cuticle
(KYOO-tih-kul)
[cut- skin, -icle little]

Continued on p. 165

145
 146 CHAPTER 7 Skin and Membranes

T ere are two major categories or types o body

membranes:
Epithe lial
1. Epithelial membranes are composed o epithe ia me mbrane s
tissue and an under ying ayer o f brous connective Mucous
tissue me mbra ne s
2. Connective tissue membranes are composed exc u- Cuta ne ous
sive y o various types o connective tissue; no epi- me mbra ne Vis ce ra l ple ura
(s kin)
the ia ce s are present in this type o membrane
S e rous
Pa rie ta l ple ura
me mbra ne s
Ep it h e lia l M e m b r a n e s Pa rie ta l
Dia phra gm
laye r
Ty p e s o Ep it h e lia l M e m b r a n e
Vis ce ra l Vis ce ra l
7 T ere are three types o epithe ia tissue membranes in the
body:
laye r pe ritone um

Pa rie ta l
1. Cutaneous membrane pe ritone um
2. Serous membranes
3. Mucous membranes

Cu t a n e o u s Me m b ra n e
T e cutaneous membrane, or skin, is the primary organ o
the integumentary system. It is one o the most important and
one o the argest and most visib e organs o the body. In most
individua s the skin composes some 16% o the body weight.
T e skin u f s the requirements necessary or an epithe-
ia tissue membrane in that it has a superf cia ayer o epithe-
ia ce s and an under ying ayer o supportive connective
tissue. Its structure is unique y suited to its many unctions.
T e skin is discussed in depth ater in the chapter.
S e ro u s M e m b r a n e s
Serous membranes are ound on y on sur aces within c osed
cavities. Like a epithe ia membranes, a serous membrane is
composed o two distinct ayers o tissue. T e epithe ia sheet
is a thin ayer o simp e squamous epithe ium. T e connective
tissue ayer orms a very thin, g ue ike basement membrane
that ho ds and supports the epithe ia ce s.
T e serous membrane that ines body cavities and covers
the sur aces o organs in those cavities is in rea ity a sing e,
continuous sheet o tissue covering two di erent sur aces. T is
arrangement resu ts in two distinct ayers o serous mem-
branes. One serous membrane ayer ines body cavities and the
other ayer covers the organs within those cavities.
T e serous membrane ayer that ines the wa s o a body
cavity, much ike wa paper covers the wa s o a room, is ca ed
the parietal ayer. T e other serous membrane ayer instead
o ds inward to cover the sur ace o organs ound within a
body cavity and is ca ed the visceral ayer.
wo serous membranes o the thoracic and abdomina
cavities are identif ed in Figure 7-1. In the thoracic cavity the
serous membranes are ca ed pleura, and in the abdomina
cavity, they are ca ed peritoneum.
Look again at Figure 7-1 to note the p acement o the
parietal pleura and visceral pleura and the parietal
peritoneum and visceral peritoneum. In both cases the pa-
rieta ayer orms the ining o the body cavity, and the viscera
ayer covers the organs ound in that cavity.
Co nne c tive tis s ue
me mbrane s
B
S
R L
S ynovia l
me mbra ne
I A
FIGURE 7-1 Types o body membranes. A, Epithelial membranes, in-
cluding cutaneous membrane (skin), serous membranes (parietal and vis-
ceral pleura and peritoneum), and mucous membranes. B, Connective tissue
membranes, including synovial membranes.
Serous membranes secrete a thin, watery uid that he ps
reduce riction and serves as a ubricant when organs rub
against one another and against the wa s o the cavities that
contain them.
T e heart is surrounded by a f brous sac ined with a thin,
s ippery membrane that doub es back on itse to orm a u-
bricating, uid-f ed pocket around the heart. Figure 7-2
shows how the serous membrane around the heartthe
pericardiumresemb es a water-f ed ba oon with a f st
thrust into it.
Pleurisy or pleuritis is a very pain u patho ogica condition
characterized by in ammation o a serous membrane (p eura)
that ines one side o the chest cavity and covers a ung. Pain
is caused by irritation rom riction as the viscera p eura on
the ungs rub against the parieta p eura ining the wa s o the
chest cavity. T e parieta p eura is much more sensitive to pain
than the viscera p eura. In severe cases the in amed sur aces
o the p eura use, and permanent damage may deve op.

Oute r
(pa rie ta l)
wa ll
Inne r
(vis ce ra l)
wa ll
Wa te r
Fis t
A B
FIGURE 7-2 Serous membranes. A, The analogy o a st thrust into a water- lled balloon demonstrates
how a serous membrane orms a double-walled structure containing a thin pocket o f uid. B, The heart is sur-
rounded by the serous pericardium, which orms a parietal and visceral layer lled with lubricating serous f uid
called pericardial f uid.
T e term peritonitis is used to describe in ammation o
the serous membranes in the abdomina cavity. Peritonitis is
sometimes a serious comp ication o an in ected appendix.
To learn more about serous membranes, go to
AnimationDirect online at evolve.elsevier.com.
Mu c o u s Me m b ra n e s
Mucous membranes are epithe ia membranes that contain
both an epithe ia ayer and a f brous or connective tissue ayer.
T ese membranes ine body sur aces opening direct y to the
exterior o the body.
Examp es o mucous membranes inc ude those ining the
respiratory, digestive, urinary, and reproductive tracts. T e epi-
the ia component o a mucous membrane varies, depending
on its ocation and unction. In most cases the ce composi-
tion is either stratif ed squamous, simp e co umnar, or pseu-
dostratif ed epithe ia.
In the esophagus, or examp e, a tough, abrasion-resistant
stratif ed squamous epithe ium is ound. T is is a good ex-
amp e o the structure f ts unction princip e. W ithout the
protection o a tough epithe ia ining, ingested ood that is
coarse, ike popcorn, might cause injury to the esophagea wa
when swa owed, resu ting in irritation or even in ection and
hemorrhage.
A thin ayer o simp e co umnar epithe ium ines the wa s
o the ower segments o the digestive tract. In the stomach
and sma intestine, ingested ood undergoes digestion and is
changed into a smooth, iquef ed materia that is no onger
abrasive. T e sing e ayer o ining epithe ia ce s in these seg-
ments o the intestina tract is we suited to a primary unc-
tion: nutrient and water absorption.
T e epithe ia ce s o most mucous membranes secrete a
thick, s imy materia ca ed mucus that keeps the membranes
moist and so t. T e f brous connective tissue under ying
CHAPTER 7 Skin and Membranes 147
R L
I
Oute r Pa rie ta l
(pa rie ta l) pe rica rdium
wa ll
Vis ce ra l
Inne r
pe rica rdium
(vis ce ra l)
wa ll
Wa te r-fille d Pe rica rdia l
cavity cavity with
pe rica rdia l
fluid
7
the epithe ium in mucous membranes is ca ed the lamina
propria.
Note that the term mucous identif es the type o membrane
whi e mucus re ers to the secretion produced by that membrane.
T e term mucocutaneous junction is used to describe the
transitiona area that serves as a point o usion where skin
and mucous membranes meet. Such junctions ack accessory
organs such as hair or sweat g ands that characterize the skin.
T ese transitiona areas are genera y moistened by mucous
g ands within the body orif ces, or openings, where these
junctions are ocated. T e eye ids, ips, nasa openings, vu va,
and anus have mucocutaneous junctions that may become
sites o in ection or irritation.
To learn more about mucous membranes, go to
AnimationDirect online at evolve.elsevier.com.
C o n n e c t ive Tis s u e M e m b r a n e s
Un ike cutaneous, serous, and mucous membranes, connective
tissue membranes do not contain epithe ia components. T e
synovial membranes ining the joint capsu es that surround
and attach the ends o articu ating bones in movab e joints are
c assif ed as connective tissue membranes (see Figure 7-1, B,
and Figure 8-28 on p. 198).
T ese membranes are smooth and s ick and secrete a thick
and co or ess ubricating uid ca ed synovial uid. T e
membrane itse , with its uid that resemb es egg white, he ps
reduce riction between the opposing sur aces o bones in
movab e joints. Synovia membranes a so ine the sma , cush-
ion ike sacs ca ed bursae ound between moving body parts.
To learn more about connective tissue and syno-
vial membrane, go to AnimationDirect online at
evolve.elsevier.com.
 148 CHAPTER 7 Skin and Membranes

QUICK CHECK sebaceous glands (oi g ands)

1. Wh a t a re th e o u r m a in typ e s o m e m b ra n e s in th e b o d y?
2. Wh ich o th e b o d ys m e m b ra n e s a re typ e s o e p ith e lia l
m e m b ra n e s ?
3. Wh a t u id s a re p ro d u ce d b y e a ch o th e o u r m a in m e m -
b ra n e typ e s ? Wh a t is th e u n ctio n o e a ch u id ?
4. Ho w d o e s th e in n e r lin in g o th e e s o p h a g u s d i e r ro m
th e in n e r lin in g o th e s m a ll in te s tin e ?
S k in S t r u c t u r e
O ve r v ie w o S k in S t r u c t u r e
7 T e brie description o the skin in Chapter 5 (see p. 93) iden-
tif ed it as not on y the primary organ o the integumentary
system but a so as the argest and one o the most impor-
tant organs o the body. Architectura y, the skin is a
marve . Consider the incredib e number o structures
f tting into 1 square inch (6.5 cm 2) o skin:
T e skin, or cutaneous membrane, is a sheet ike organ that
covers the body and acts as a barrier between the interna and
externa environment. Find the major sur ace structures and
regions o the skin in the Clear View o the Human Body
( o ows p. 8).
T e skin is composed o two main ayers (Figure 7-3):
1. T e epidermis is the superf cia , outermost ayer o
the skin. It is a re ative y thin sheet o stratif ed squa-
mous epithe ium.
2. T e dermis is the deeper o the two ayers. It is
thicker than the epidermis and is made up most y o
connective tissue.
FIGURE 7-3 Microscopic view
o the skin. The epidermis, shown
in longitudinal section, is raised at
one corner to reveal the ridges in
the dermis.

Ha ir s ha ft
De rma l pa pilla
S e ba ce ous
(oil) gla nd

S tra tum corne um

Epide rmis
S tra tum germina tivum
De rma l-e pide rma l
junction

Ope nings of
De rmis swe a t ducts

S ubcuta ne ous
tis s ue

Swe a t gla nd

Ta ctile
(Me is s ne r) Cuta ne ous ne rve
corpus cle Arre ctor
pili mus cle
La me lla r
Ha ir follicle (Pa cini) Pa pilla of ha ir
corpus cle

As you can see in Figure 7-3, the ayers o the skin are sup-
ported by a thick ayer o oose connective tissue and adipose
tissue ca ed subcutaneous tissue, or the hypodermis.
Fat in the adipose tissue o the subcutaneous ayer insu ates
the body rom extremes o heat and co d. It a so serves as a
stored source o energy or the body and can be used as a
nutrient source i required. In addition, the subcutaneous tis-
sue acts as a shock-absorbing pad and he ps protect under y-
ing tissues rom injury caused by bumps and b ows to the
body sur ace.
Ep id e r m is
Ep id e r m a l S t r u c t u r e
T e tight y packed epithe ia ce s o the epidermis are ar-
ranged in up to f ve distinct ayers.
T e basa ce s o the innermost ayer, ca ed the stratum
germinativum, undergo mitosis and reproduce themse ves
(see Figure 7-3). As new ce s are produced in the deep ayer o
the epidermis, they are pushed upward through additiona
ayers, or strata, o ce s.
As they approach the sur ace, the epiderma ce s die and
their cytop asm is rep aced by one o natures most unique
proteins, a substance ca ed keratin. Keratin is a tough, water-
proo materia that provides ce s in the outer ayer o the skin
with a horny, abrasion-resistant, and protective qua ity. T e
tough, keratinized outer ayer o the epidermis is ca ed the
stratum corneum.
In the photomicrograph o the skin shown in Figure 7-4,
many o the sur ace ce s o the stratum corneum have been
dis odged. T ese dry, dead ce s f ed with keratin ake o
by the thousands onto our c othes and bedding, into our bath-
water, and onto things we hand e. Mi ions o epithe ia ce s
reproduce dai y to rep ace the mi ions shedjust one exam-
p e o the work our bodies do without our know edge, even
when we seem to be resting.
Fla ke d ce lls from
Epide rmis s tra tum corne um De rmis
FIGURE 7-4 Photomicrograph o the skin. Many dead cells o the
stratum corneum have f aked o rom the sur ace o the epidermis. Note
that the epidermis is very cellular. The dermis has ewer cells and more
connective tissue.
CHAPTER 7 Skin and Membranes 149
S k in P ig m e n t
Melanin
T e deepest ce ayer o the stratum germinativum identif ed
in Figure 7-3 is responsib e or the production o a pigment
that gives co or to the skin. T e term pigment comes rom a
Latin word meaning paint.
T e brown pigment melanin is produced by ce s in the
basa ayer ca ed melanocytes. Me anocytes package the
me anin in vesic es and distribute it to the surrounding epi-
the ia ce s, making them a darker co or. T e higher the con-
centration o me anin distributed in the ayers o epithe ia
ce s, the deeper is the co or o skin. T e primary unction o
me anin is to absorb harm u u travio et (UV) radiation rom
sun ight be ore it reaches tissues be ow the outer ayers o the 7
epidermis.
Skin Color Changes
T e amount and type o me anin in your skin depends f rst on
the skin co or genes you have inherited. T at is, heredity de-
termines how dark or ight your basic skin co or is. H owever,
other actors such as sun ight exposure can modi y this he-
reditary e ect. Pro onged exposure to sun ight in ight-
skinned peop e darkens the exposed area because it eads to
increased me anin deposits in the epidermisa protective
mechanism that keeps deeper tissues sa e rom UV radiation.
I the skin contains itt e me anin, as under the nai s where
there is no me anin at a , a change in co or can occur i the
vo ume o b ood in the skin changes signif cant y or i the
amount o oxygen in the b ood is increased or decreased. In
these individua s, increased b ood ow to the skin or increased
b ood oxygen eve s can cause a pink ush to appear. H owever,
i b ood oxygen eve s decrease or i actua b ood ow is re-
duced dramatica y, the skin turns a b ue-gray co ora condi-
tion ca ed cyanosis.
In genera , the ess abundant the me anin deposits in the
skin are, the more visib e wi be the changes in co or caused
by the change in skin b ood vo ume or oxygen eve . Con-
verse y, the richer the skins pigmentation is, the ess notice-
ab e such changes wi be.
T e term vitiligo is used to describe a condition character-
ized by patchy ooking areas o ight skin resu ting rom the
acquired oss o epiderma me anocytes. T e term vitiligo is
derived rom the Greek word or ca . Ear y physicians com-
pared the white spots caused by the oss o pigment to the
ight patches o ten seen on ca ves.
A though not as apparent in ight-skinned individua s,
viti igo may be very obvious in those with darker skin. About
period o years. T e hands, ace, genita ia, and body o ds, in-
c uding the axi ae are o ten invo ved (Figure 7-5).
Most cases o viti igo are apparent y genetic in origin and
occur in individua s who have no other associated f ndings.
Occasiona y, the condition is re ated to autoimmune- or
endocrine-re ated diseases, especia y thyroid disorders. Some
success has been achieved in darkening depigmented skin ar-
eas by using drugs and steroid hormones and by transp anta-
tion o skin epidermis containing me anocytes.
 150 CHAPTER 7 Skin and Membranes
7 5. Wh a t is th e d e rm a l-e p id e rm a l ju n ctio n ?
FIGURE 7-5 Vitiligo. Note the patchy loss o pigment on the orehead.
A hereditary condition ca ed albinism is characterized by
a partia or tota ack o me anin pigment in the skin and eyes
(see Chapter 25, pp. 682683). A ected individua s are sub-
ject to eye damage and sunburn i exposed to direct sun ight.
A norma increase in skin pigmentation caused by hor-
mona changes is a most universa in pregnant women. It is
most common in the genita area, nipp es, and the areola sur-
- f bers), and others are stretchab e and e astic (e astic or ye ow
nant women deve op b otchy areas o brown pigmentation
over the orehead, cheeks, nose, upper ip, and chin. It is
sometimes ca ed the mask o pregnancy. T e pigmented
areas gradua y ade a ter de ivery.
One common variant o norma skin pigmentation is the
sma ight brown or red reckle ( ook ahead to Table 7-1 on
p. 158). Freck es are sma at macules that most o ten occur
as a genetic trait in ight-skinned individua s and are usua y
conf ned to the ace, upper extremities, and back.
In chronica y sun-exposed areas o the skin, especia y in
o der adu ts, brown-co ored age spots are common. Incorrect y
ca ed iver spots, these at, pigmented esions become more
numerous with advancing age. T ey may deve op into ma ig-
nant esions and shou d be monitored care u y or changes in
size and appearance.
D e r m a l-Ep id e r m a l J u n c t io n
T e junction that exists between the thin epiderma ayer o
skin above and the derma ayer be ow orms a type o base-
ment membrane ca ed the dermal-epidermal junction.
T e deeper ce s o the epidermis are packed tight y to-
gether. T ey are he d f rm y to one another by ce u ar junctions
between the membranes o adjacent ce s, sometimes described
as spot we ds. T ey are a so he d f rm y to the dermis be ow
by a unique type o ge that serves to g ue the two ayers o
the skin together. T e thick dermis is thus ab e to provide sup-
port or the thin epidermis attached to its upper sur ace.
Sma nipp e ike bumps that project upward rom the der-
mis into the epidermis, ca ed dermal papillaewhich are
discussed in the next sectiona so p ay an important ro e in
stabi izing the derma -epiderma junction (see Figure 7-3).
I the derma -epiderma junction is weakened or destroyed,
the skin a s apart. W hen this occurs over a imited area be-
cause o burns, riction injuries, or exposure to irritants,
blisters may resu t. Any widespread detachment o a arge area
o epidermis rom the dermis is an extreme y serious condition
that may resu t in overwhe ming in ection and death.
QUICK CHECK
1. Wh a t a re th e tw o m a jo r la ye rs o th e s kin ?
2. Wh a t is ke ra tin a n d w h e re is it lo ca te d ?
3. Ho w is th e co n d itio n kn o w n a s vitilig o re la te d to m e la n in ?
4. Give tw o e xa m p le s e a ch o e le va te d , a t, a n d d e p re s s e d
s kin le s io n s .
6. Wh a t is th e p rim a ry u n ctio n o m e la n in ?
D e r m is
O ve r v ie w o D e r m is
T e dermis is the deeper o the two primary skin ayers and is
much thicker than the epidermis.
T e mechanica strength o the skin is in the dermis. It is
composed arge y o connective tissue. Instead o ce s being
crowded c ose together ike the epithe ia ce s o the epider-
mis, they are scattered ar apart, with many f bers in between.
Some o the f bers are tough and strong (co agen or white
f bers).
P a p illa ry La ye r
Dermal Papillae
T e upper region, or papillary layer, o the dermis is character-
ized by para e rows o peg ike projections ca ed dermal pa-
pillae, which are visib e in Figure 7-3. T e papi ary ayer takes
its name rom the papi ae on its sur ace.
T e papi ary ayer and its papi ae are composed essentia y
o oose connective tissue e ements and a f ne network o thin
co agenous and e astic f bers. T e derma papi ae increase the
sur ace area o the g ue ike derma -epiderma junction that
he ps bind the skin ayers to each other. You may a ready know
that g ue ho ds rough sur aces together much more strong y
than it binds smooth sur aces.
T e pa ms and so es (and pa mar sur aces o f ngers and
toes) possess thick skin, which is a specia category o skin that
is thick, hair ess, and deep y ridged (Figure 7-6, A). H owever,
most o the skin is thin skin, which has hair and irregu ar, sha -
ow grooves (Figure 7-6, B).
Dermal Ridges
T e thick skin on the pa ms and so es have arge, distinct rows
o derma papi ae that he p orm the rough y para e riction
ridges seen in Figure 7-6, A. Friction ridges he p us to wa k up-
right without s ipping and to make and ho d too s. T ese ridges
a so he p us sense textures on sur aces in our environment.
You can observe these ridges on the tips o the f ngers and
on the skin covering the pa ms o your hands. O bserve in
Figure 7-3 how the epidermis o ows the contours o the der-
ma papi ae. T ese ridges deve op sometime be ore birth. Not
 CHAPTER 7 Skin and Membranes 151

o di ated vesse s that may initia y appear as a bruise at birth

and then grow rapid y during the f rst year into a bright red
nodu e ca ed a strawberry hemangioma.
A majority o these birthmarks shrink, ade, and disappear

pigmented vascu ar birthmarks, such as the port-wine stain,

are permanent and do not ade with age. In these cases severa
types o aser-based therapy or use o opaque makeup can
o ten provide e ective cosmetic treatment.
Di ation o derma capi aries at the nape o the neck in a
baby that occur during deve opment resu ts in a birthmark
A Thick s kin B Thin s kin ca ed a stork bite
FIGURE 7-6 Thick and thin skin. A, Thick skin is hairless and has they o ten persist or i e, these birthmarks genera y are cov-
roughly parallel riction ridges. B, Thin skin has hairs and shallow, irregular ered by hair and are inconspicuous. 7
grooves.

S u b c u t a n e o u s Tis s u e
on y is the pattern unique in each individua but a so it never
changes except to grow argertwo acts that exp ain why our T e subcutaneous tissue (hypodermis) is o ten ca ed the
f ngerprints or ootprints positive y identi y us. Many hospita s super cial ascia by anatomists. It is not a ayer o the skin.
identi y newborn babies by ootprinting them soon a ter birth. Instead, it ies deep to the dermis and orms a connection
between the skin and the under ying structures o the body
Re t ic u la r La ye r such as musc e and bone.
Fibrous Network Loose f brous and adipose tissues are prominent in subcu-
T e deeper area, or reticular layer, o the dermis is f ed with taneous tissue, and in obese individua s, at content in this
a dense network o inter acing f bers. Most o the f bers in this
area are co agen that gives toughness to the skin. H owever, p. 84). T e oose, spongy nature o subcutaneous tissue a ows
e astic f bers are a so present. T ese make the skin stretchab e s iding movement o the skin over the musc es and bones as
and e astic (ab e to rebound). our body parts move. I not or this s iding, our skin wou d
D uring pregnancy, the skin over a womans abdomen may tear when we move our arms or egs.
stretch beyond the abi ity o the e astic and connective tissue Liquid medicines such as insu in are o ten administered by
e ements in the dermis to rebound. T e resu t is creation o subcutaneous injection with a hypodermic need e into this area
stretch marks ca ed striae. A though they ade a ter de iv- (see the C inica App ication box).
ery, they never comp ete y disappear (see Table 7-1 on p. 158).
As we age, the number o e astic f bers in the dermis de-
creases, and the amount o at stored in the subcutaneous
Ha ir, N a ils , a n d S k in Re c e p t o r s
tissue is reduced. Wrink es deve op as the skin oses e asticity, Ha ir
sags, and becomes ess so t and p iant. Location o Hair
In addition to connective tissue e ements, the dermis con- T e human body is covered with mi ions o hairs. Indeed, at
tains an extensive network o nerves and nerve endings to de- the time o birth most o the pocket ike ollicles that are re-
tect sensory in ormation such as pain, pressure, touch, and quired or hair growth are a ready present. T ey deve op ear y in
temperature. At various eve s o eta i e and by birth are present
the dermis, there are musc e f - in most parts o the skin.
bers, hair o ic es, sweat and oi T e hair o a newborn in ant
g ands, and many b ood vesse s. is extreme y f ne and so t; it is
ca ed lanugo rom the Latin
Birthmarks
word meaning down. In pre-
D eve opmenta ma ormation mature in ants, anugo may be
o derma b ood vesse s can noticeab e over most o the
resu t in pigmented birthmarks body, but soon a ter birth the
in signif cant numbers o new- anugo is ost and rep aced by
borns. O ne o the most com- new hair that is stronger and
mon (Figure 7-7) is a co ection more pigmented.
A though on y a ew areas o
S the skin are hair essnotab y
FIGURE 7-7 Strawberry heman- the ips, the pa ms o the hands,
R L
gioma. This birthmark resembles a and the so es o the eetmost
strawberry because o a mass o di- I body hair remains a most invis-
lated dermal blood vessels. ib e. H air is most denseand
 152 CHAPTER 7 Skin and Membranes

C LIN ICA L APPLICATION

S ubcuta ne ous
S UBCUTANEOUS INJ ECTION inje ction Hypode rmic
s yringe
Although the s ubcutane ous laye r is not part o the s kin, it carrie s the m ajor 45
blood ve s s e ls and ne rve s that s upply the s kin above it. The rich blood s upply S kin
and loos e , s pongy texture o the s ubcutane ous laye r m ake it an ide al s ite or
S ubcuta ne ous
the rapid and re lative ly pain- re e abs orption o inje cte d m ate rial. Liquid m e di-
tis s ue (hypode rmis )
cine s s uch as ins ulin and pe lle te d im plant m ate rials s uch as s ynthe tic hor-
m one s are o te n adm inis te re d by s ubcutane o us inje ctio n into this s pongy Mus cle
and porous laye r be ne ath the s kin. Ne e dle s us e d to inje ct m ate rials into the
hypode rm is are calle d hypode rm ic ne e dle s .

7
there ore, most visib eon the sca p, eye ids, and eyebrows.
T e coarse hair that f rst appears in the pubic and axi ary
regions at the time o puberty deve ops in response to the
secretion o hormones.
Hair Growth
H air growth begins when ce s o the epiderma ayer o the
skin grow down into the dermis, orming a sma tube ca ed
the hair ollicle. T e re ationship o a hair o ic e and its re-
ated structures to the epiderma and derma ayers o the skin
is shown in Figure 7-8. Note in Figure 7-8 that part o the hair,
name y the hair root, ies hidden in the o ic e. T e visib e part
o a hair is ca ed the sha t.
H air growth begins rom a sma bump ca ed the hair
papilla, which is ocated at the base o the o ic e. T e papi a
is nourished by derma b ood vesse s and covered with a orm
o stratum germinativumthe epiderma growth ayer. As in
other areas o the skin, when new ce s are ormed, the o der
FIGURE 7-8 Hair ollicle. Struc-
ture o a hair ollicle and its rela-
tionship to nearby structures.
Epide rmis
De rma l-e pide rma l
junction
De rmis
De rma l root
s he a th
ce s are pushed outward and become f ed with keratin
producing a strong, keratinized cy inder o hair. T e type o
keratin in hair is a bit more rigid than the so ter, more exib e
keratin o stratum corneum.
As ong as stem ce s in the papi a o the hair o ic e re-
main a ive, new hair wi rep ace any that is cut or p ucked.
Contrary to popu ar be ie , requent cutting or shaving does
not make hair grow aster or become coarser. W hy? It is be-
cause neither process a ects the epithe ia growth ce s that
orm the hairs.
Hair Loss
H air oss o any kind is ca ed alopecia. Some orms o a ope-
cia, such as male pattern baldness, are not diseases but are
simp y inherited traits. A opecia a so may be a norma conse-
quence o aging. Sudden oss o hair in round or ova exc a-
mation point patches on the sca p, such as that seen in
Figure 7-9, is ca ed alopecia areata (AA). Areata means ba d
spot.
A opecia can occur without a known cause but is some-
times associated with certain metabo ic or endocrine diseases.
Sca p in ections, chemotherapy, radiation treatment, severe
emotiona or physica stress, and reactions to various types o
Ha ir s ha ft drugs a so can cause rapid hair oss. In most cases, regrowth o
hair begins in 1 to 3 months, and the condition genera y
c ears comp ete y in 1 year without treatment.
Me dulla A signif cant number o women experience hair oss, espe-
cia y on the ront and sides o the sca p, 1 to 4 months a ter
Cortex
Cuticle
Ha ir root
Arre ctor
pili mus cle
S e ba ce ous gla nd

Inte rna l e pithe lia l Exte rna l e pithe lia l

root s he a th root s he a th

Ge rmina l ma trix Ha ir bulb S

Pa pilla Ve in P A

Arte ry I

Fat FIGURE 7-9 Alopecia areata (AA). A sudden, abnormal loss

o a patch o hair, o ten o unknown cause.
 CHAPTER 7 Skin and Membranes 153

chi dbirth. T e condition is ca ed postpartum alopecia (post-, Fre e e dge

a ter; -partum, birth). As in a opecia areata, u regrowth o Na il body
hair genera y occurs in ess than a year.
O ccasiona y, and most o ten in young peop e, tota oss o Lunula D
sca p hair occurs without apparent cause and in the absence o Cuticle
Na il root L R
other f ndings. T e condition, ca ed alopecia totalis may be
accompanied by cyc es o partia hair regrowth and oss, but A P
the chances or signif cant ong-term regrowth are poor. Cuticle Na il body
Na il be d
Arrector Pili Muscle Na il
A tiny, smooth (invo untary) musc e can be seen in Figure 7-8. root Fre e e dge
It is ca ed an arrector pili musc e. It is attached to the base P
Bone
o a derma papi a above and to the side o a hair o ic e
be ow. Genera y, these musc es contract on y when we are P D 7
rightened or co d. A
W hen contraction occurs, each musc e simu taneous y pu s B
on its two points o attachment (that is, up on a hair o ic e FIGURE 7-10 Structure o nails. A, Posterior view o ngernail. B, Sag-
but down on a part o the skin). T is produces itt e raised ittal section o ngernail and associated structures.
p aces, ca ed goose pimples, between the depressed points o the
skin and at the same time pu s the hairs up unti they are more through the trans ucent nai bodies. I b ood oxygen eve s
or ess straight. T e name arrector pili describes the unction o drop and cyanosis deve ops, the nai bed wi turn b ue.
these musc es. It is Latin or erectors o the hair.
We subconscious y recognize these acts in expressions Variations in Nail Structure
such as I was so rightened my hair stood on end. Age and ethnicity can in uence the norma shape and appear-
ance o the nai s. For examp e, ongitudina ridges are com-
QUICK CHECK mon in those with ight skin o a ages and are especia y
1. Wh a t a re d e rm a l p a p illa e ? Why a re th e y im p o rta n t? prominent in the e der y, whereas pigmented bands are a
2. Wh a t a re b irth m a rks ? Lis t th re e typ e s . norma f nding in dark-skinned individua s (Figure 7-11).
3. Id e n ti y th e p ro m in e n t tis s u e s th a t co m p o s e s u b cu ta n e o u s Patho ogic changes in the appearance o the nai s o ten
tis s u e (s u p e rf cia l a s cia ).
4. Ho w is h a ir o rm e d ?
occur as a resu t o certain diseases and because o trauma. For
5. Wh a t is a lo p e cia ?
6. Wh a t ca u s e s g o o s e p im p le s ?

N a ils
Nail Growth and Structure
Nai s are c assif ed as accessory organs o the skin and are
produced by ce s in the epidermis. T ey deve op when epider-
ma ce s over the termina ends o the f ngers and toes f
with keratin and become hard and p ate ike.
T e components o a typica f ngernai and its associated
structures are shown in Figure 7-10. In this i ustration the
f ngernai o the index f nger is shown in a posterior view and
in a sagitta section. (Reca that a sagitta section divides a
body part into right and e t portions.) A
Look f rst at the posterior view o the nai in Figure 7-10, A.
T e visib e part o the nai is ca ed the nail body. T e rest o
the nai , name y, the root, ies in a groove and is hidden by a
o d o skin ca ed the cuticle. In the sagitta section you can
see the nai root rom the side and note its re ationship to the
cutic e, which is o ded back over its upper sur ace.
T e nai body nearest the root has a crescent-shaped white
area known as the lunula, or itt e moon. You shou d be ab e
to identi y this area easi y on your own nai s; it is most notice-
ab e on the thumbnai . B
Now ook at the sagitta section o the nai in Figure 7-10, B. FIGURE 7-11 Normal variations in nail structure. A, Longitudinal
Under the nai ies a ayer o epithe ium ca ed the nail bed. ridges in light-skinned people are common. B, Pigmented bands are a nor-
Because it contains abundant b ood vesse s, it appears pink mal nding in dark-skinned individuals.
 154 CHAPTER 7 Skin and Membranes
A Onycholys is
7 o secretion and ocation.
B P itting
FIGURE 7-12 Abnormal nail structure. A, Onycholysis. Separation o
nail rom the nail bed begins at the ree edge. B, Nail pitting. A common
nding in persons with psoriasis.
examp e, even minor trauma to ong f ngernai s can some-
times resu t in a oosening o the nai rom the nai bed with
a resu ting separation that starts at the dista or ree edge o
the a ected nai (Figure 7-12, A). T e condition, ca ed
onycholysis, is common. Figure 7-12, B, shows pitting o the
nai . Nai pitting o ten occurs in individua s with psoriasis, a
skin disorder described ater in the chapter (see p. 162).
Cyanosis and nai pitting are examp es o how distinctive
changes in the appearance o the skin or its appendages can
point to disease in other areas o the body. Many o the patho-
ogic conditions isted in Appendix A at evolve.elsevier.com
and described throughout the text, inc uding in ectious and
interna diseases, congenita syndromes, and tumors, have
symptoms that appear as changes in appearance o the integu-
mentary system and body membranes.
S k in Re c e p t o r s
Receptors in the skin make it possib e or the body sur ace to
act as a sense organ, re aying messages to the brain concerning
sensations such as touch, pain, temperature, and pressure. Sen-
sory receptors, which di er in structure rom the high y com-
p ex to the very simp e, are discussed in detai in Chapter 11.
wo skin receptors are visib e in Figure 7-3. O ne is a
lamellar corpuscle (Pacini corpuscle), which detects pres-
sure deep in the dermis. T e other is the more superf cia
tactile corpuscle (Meissner corpuscle), which detects ight
touch. O ther receptors mediate sensations such as crude
touch, vibration, temperature, and pain.
Burn injuries, which are discussed ater in the chapter, de-
stroy skin receptors. By doing so, they a so may destroy the
abi ity o the burned skin to unction as a sense organ.
S k in G la n d s
T e skin g ands inc ude the two varieties o sweat glands and
the tiny sebaceous glands.
S w e a t G la n d s
Sweat g ands, a so ca ed sudori erous glands, are the most
numerous o the skin g ands (see Figure 7-3). T ey can be c as-
sif ed into two groupseccrine and apocrinebased on type
Eccrine Glands
Eccrine sweat glands are by ar the more numerous, impor-
tant, and widespread sweat g ands in the body. T ey are quite
sma and, with ew exceptions, are distributed over the tota
body sur ace. T roughout i e they produce a transparent,
watery iquid ca ed perspiration, or sweat.
Sweat assists in the e imination o waste products such as
ammonia and uric acid. In addition to e imination o waste,
sweat p ays a critica ro e in he ping the body maintain a con-
stant temperature.
Anatomists estimate that a sing e square inch o skin on
g ands. W ith a magni ying g ass you can ocate the pinpoint-
size openings on the skin that you probab y ca pores. T e
pores are out ets o sma ducts rom the eccrine sweat g ands.
Apocrine Glands
Apocrine sweat glands are ound primari y in the skin o the
axi a (armpit) and in the pigmented skin areas around the
genita s. T ey are arger than the eccrine g ands, and instead
o watery sweat, they secrete a thicker, mi ky secretion.
T e odor associated with apocrine g and secretion is not
caused by the secretion itse . Instead, it is caused by the
contamination and decomposition o the secretion by skin
bacteria. Apocrine g ands en arge and begin to unction at
puberty.
S e b a c e o u s G la n d s
Sebum
Sebaceous g ands secrete oi or the hair and skin. Oi g ands,
or sebaceous g ands, are ound where hairs grow. T eir tiny
ducts open into hair o ic es (see Figure 7-3) so that their se-
cretion, ca ed sebum, ubricates the hair and skin. Someone
apt y described sebum as natures skin cream because it pre-
vents drying and cracking o the skin.
Sebum secretion increases during ado escence, stimu ated
by the increased b ood eve s o the sex hormones. Frequent y
sebum accumu ates in and en arges some o the ducts o the
sebaceous g ands, orming white pimp es. T is sebum o ten
darkens, orming a blackhead or comedo. Sebum secretion
decreases in ate adu thood, contributing to increased wrin-
k ing and cracking o the skin.

R L
FIGURE 7-13 Acne. Acne vulgaris results rom blocked sebaceous
glands that become inf amed or in ected.
Acne
T e most common kind o acne, acne vulgaris (Figure 7-13),
occurs most requent y during ado escence. T is condition
resu ts rom the more than f ve o d increase in sebum secre-
T e oversecretion o sebum resu ts in b ockage o the seba-
ceous g and ducts with sebum, skin ce s, and bacteria. T e
in amed esions that resu t are ca ed papules. Pus-f ed
pimp es ca ed pustules o ten deve op and then rupture, re-
su ting in secondary in ections in the surrounding skin.
Formation o acne esions can be minimized by care u
c eansing o the skin to remove sebaceous p ugs and to inhibit
anaerobic skin bacteria.
Combinations o topica (externa ) medications are now
used to e ective y treat many types o acne. opica use o vi-
tamin A acid (tretinoin) speeds up mitosis in the hair o ic e,
thus preventing sebum rom bui ding up as the hair moves
quick y out o the o ic e. It is o ten combined with drying and
pee ing agents such as benzoy peroxide and externa y app ied
antibiotics. In addition, physicians or other trained hea th pro-
essiona s may use a specia surgica instrument ca ed an ex-
tractor to remove compacted sebum (b ackheads) and the
contents o acne pustu es (whiteheads) to hasten hea ing.
More severe cases o acne may require additiona treatment
with ora antibiotics, which reduce in ection and in ammation.
Fu n c t io n s o t h e S k in
T e skin, or cutaneous membrane, serves many important
unctions that contribute to surviva . T e most important
unctions are as o ows:
1. Protection
2. emperature regu ation
3. Sense organ activity
4. Excretion
5. Synthesis o vitamin D
P ro t e c t io n
T e skin as a who e is o ten described as our f rst ine o
de ense against a mu titude o hazards. It protects us
against the dai y invasion o dead y microbes. T e tough,
keratin-f ed ce s o the stratum corneum a so resist the
CHAPTER 7 Skin and Membranes 155
Bruis ing
Re le a s e of
re d blood ce lls
S
P ha gocytos is of
re d ce lls by
ma cropha ge s
I
He mos ide rin Bile
pigme nts
FIGURE 7-14 Bruising. Color changes caused by the deoxygenation, clot-
ting, and breakdown o blood are easily seen in light-skinned individuals.
7
entry o harm u chemica s and protect against physica tears
and cuts. Because it is waterproo , keratin a so protects the
body rom excessive uid oss. Me anin in the pigment ayer
o the skin prevents the suns harm u UV rays rom penetrat-
ing the interior o the body.
Physica damage can cause bruising o the skin when b ood
vesse s in the skin break open (Figure 7-14). Re ease o red b ood
ce s initia y produces a reddish co or in the skin. It then be-
gins to darken and produce b uish co ors when hemog obin
oses oxygen. As the b ood c ots, it may begin to appear darker
b ue or even b ack. Ce s break down the hemog obin into
iron-containing hemosiderin (a ye ow-brownish pigment) and
severa iron- ree bile pigments that are greenish and ye owish.
Skin gra ts may be required to provide some degree o
protection to areas o the body that are no onger covered by
skin because o burns or to rep ace skin destroyed by disease or
trauma. Figure 7-15 shows a skin gra t covering a burned hand.
Te m p e r a t u r e Re g u la t io n
T e skin p ays a key ro e in regu ating the bodys temperature.
Incredib e as it seems, on a hot and humid day the skin can
L
D P
M
FIGURE 7-15 Skin gra t. Photograph shows a skin gra t covering a severe burn
to the hand. Multiple slits allow the gra ted piece o skin to stretch over a larger
area than would otherwise be possible.
 156 CHAPTER 7 Skin and Membranes

HEA LTH AND WELL-BEIN G

EXERCIS E AND THE S KIN S mooth He a t
mus cle los s a cros s
Exce s s he at produce d by the s ke le tal m us cle s during exe rcis e controls e pide rmis S we a t
blood flow
incre as e s the core body te m pe rature ar beyond the norm al
range . Be caus e blood in ve s s e ls ne ar the s kins s ur ace dis s i-

s
pate s he at we ll, the bodys control ce nte rs adjus t blood ow s o

i
m
r
that m ore warm blood rom the bodys core is s e nt to the s kin

e
d
i
or cooling (s e e illus tration). During exe rcis e , blood ow in the

p
E
s kin can be s o high that the s kin take s on a re dde r coloration.
To he lp dis s ipate eve n m ore he at, s we at production in-
cre as e s to as high as 3 lite rs pe r hour during exe rcis e . Al-
7

s
i
though e ach s we at gland produce s ve ry little o this total,

m
r
m ore than 3 m illion individual s we at glands are ound through-

out the s kin.
Swe at evaporation is e s s e ntial to ke e ping body te m pe ra-
ture in balance , but exce s s ive s we ating can le ad to a dange r-
ous los s o uid. Be caus e norm al am ounts o drinking m ay not
re place the wate r los t through s we ating, it is im portant to in-
cre as e uid cons um ption during and a te r any type o exe rcis e
to avoid de hydratio nexce s s ive wate r los s that dis rupts
hom e os tas is .
e
D
Heat loss during exercise. Excess heat produced by working muscles
can be lost rom blood through the skin to the air. Sweat on the skin can
also absorb some o the heat and evaporatecooling the body urther.
These mechanisms help maintain homeostasis o body temperature.

- Synthesis o vitamin D is another important unction o the
ter! It accomp ishes this eat by regu ating sweat secretion and
by regu ating the ow o b ood c ose to the body sur ace.
W hen sweat evaporates rom the body sur ace, heat is a so
ost. T e princip e o heat oss through evaporation is basic to
many coo ing systems.
W hen increased quantities o b ood are a owed to f the
vesse s c ose to the skin, heat is a so ost by radiation. B ood
supp y to the skin ar exceeds the amount needed by the skin.
T e overabundant b ood supp y primari y enab es the regu a-
tion o body temperature.
S e n s a t io n
S y n t h e s is o Vit a m in D
skin. It occurs when the skin is exposed to UV lightusua y
rom the sun. W hen UV ight penetrates the skin, a precursor
substance in skin ce s orms, then is transported to the iver
and kidneys where it is converted into an active orm o vita-
min D. Research shows that vitamin D a ects many di erent
unctions in the body, thus emphasizing the importance o
this skin unction.
QUICK CHECK
1. Id e n ti y th e s tru ctu ra l co m p o n e n ts o a n a il.
2. Ho w d o e ccrin e a n d a p o crin e s w e a t g la n d s d i e r?
3. Ho w is s e b a ce o u s g la n d u n ctio n re la te d to a cn e ?
4. Lis t th e m a jo r u n ctio n s o th e s kin .

T e skin unctions as an enormous sense organ. Its mi ions

o nerve endings serve as antennas or receivers or the body,
keeping it in ormed o changes in its environment. T e sen-
sory receptor types shown in Figure 7-3 make it possib e or
the body to detect sensations o ight touch (tacti e corpus-
c es) and pressures ( ame ar corpusc es). O ther receptors
make it possib e or us to respond to the sensations o pain,
heat, and co d.
Exc r e t io n
T e term excretion re ers to any process in which the body rids
itse o waste or surp us substances. Excretion o substances
in sweat can in uence the amounts o certain ions (such as
sodium) and waste products (such as uric acid, ammonia, and
urea) that are present in the b ood. Excess vitamins, drugs, and
even hormones in the b ood can a so be excreted onto the skin
by sweat.
D is o r d e r s o t h e S k in
Any disorder o the skin can be ca ed a dermatosis, which
simp y means skin condition. Many dermatoses invo ve in-
ammation o the skin, or dermatitis. On y a ew o the many
disorders o the skin are discussed here.
Review concepts o the in ammatory response
in the article In ammation at Connect It! at
evolve.elsevier.com.
S k in Le s io n s
A lesion is any measurab e variation rom the norma struc-
ture o a tissue. Lesions are not necessari y signs o disease
they instead may be benign, ordinary variations. For examp e,
reck es are considered esions but are not signs o disease.

A most a diseases a ecting the skin are discovered and
diagnosed a ter observing the nature o the esions present.
Lighting the skin rom the side with a pen ight is a method
used to determine the category o a esion: e evated, at, or
depressed. E evated esions cast shadows outside their edges;
at esions do not cast shadows, and depressed esions cast
shadows inside their edges.
Important examp es o each type o esion are summarized
in Table 7-1.
Lesions are o ten distinguished by abnorma density o
tissue or abnorma co oration. O vergrowth or def cient growth
o skin ce s, ca cif cation, and edema can cause changes in
skin density. Disco oration can resu t rom overproduction or
underproduction o skin pigments such as the increase in
me anin seen in a mo e. A decrease in b ood ow or oxygen
content can give the skin a b uish cast (cyanosis), whereas an
increased b ood ow or oxygen content can give a red or
darker hue to the skin. Disco oration o the a ected area is
associated with most skin esions.
Some o the most common esions resu t rom scrapes and
cuts that our skin o ten endures in its ro e o protection.
Figure 7-16 shows the way in which such injuries typica y
repair themse ves. First, c otting o b ood stops b ood oss.
T en ce s o the stratum germinativum produce more epithe-
ia ce s to rebui d the epidermis as the c ot disso ves. At the
same time, f ber-producing ce s o the dermis rep ace torn
co agen f bers.
O ten, the f brous tissue rep aced during skin repair is
denser than the origina tissueproviding extra strength in
the case o urther injury but a so sometimes producing a scar.
Bu r n s
Burns constitute one o the most serious and requent prob-
ems that a ect the skin. ypica y, we think o a burn as
an injury caused by f re or by contact o the skin with a hot
1 2
Blood clots, quickly
s topping blood los s.
Blood clot S kin
1 4
Conne ctive Epithe lium
tis s ue
FIGURE 7-16 Skin repair. A minor skin injury is ollowed
by blood clotting and sel -repair o the damaged epidermis and
dermis.
CHAPTER 7 Skin and Membranes 157
sur ace. H owever, overexposure to UV ight (sunburn) or con-
tact o the skin with an e ectric current or a harm u chemica
such as an acid a so can cause burns.
S e ve r it y o Bu r n s
T e seriousness o a burn injury, as we as appropriate treat-
ment and the possibi ity or recovery, are determined by three
major actors:
1. Depth and number o tissue ayers invo ved
2. ota body sur ace area a ected
3. ype o homeostatic mechanisms that are damaged
or destroyed, such as respiratory and b ood pressure
contro or uid and e ectro yte ba ance
7
T e age and genera state o hea th o the individua at the
time o injury a so are important. A moderate y severe burn
in an otherwise hea thy young adu t may become a i e-
threatening major burn in an in ant or an e der y individua
with preexisting respiratory prob ems or heart disease.
D e p t h C la s s if c a t io n o Bu r n s
Burns can be c assif ed in a variety o ways, inc uding how
deep y the tissues are damaged (Figure 7-17).
First-degree Burns
A rst-degree burn ( or examp e, a typica sunburn) causes
minor discom ort and some reddening o the skin. A -
though the sur ace ayers o the epidermis may pee in 1 to
3 days, no b istering occurs, and actua tissue destruction is
minima .
Second-degree Burns
A second-degree burn (Figure 7-18, A) invo ves the deep epi-
derma ayers and a ways causes injury to the upper ayers o
the dermis. A though deep second-degree burns damage
sweat g ands, hair o ic es, and sebaceous g ands, comp ete
4
Ge rmina tivum ce lls grow Clot dis s olve s, le aving
la te ra lly to clos e the ga p re pa ire d e pide rmis a nd
a nd re s tore e pide rmis. thicke ne d de rmis.
Clot Fre s hly he a le d e pithe lium
2
Fibrobla s ts Epithe lium New conne ctive tis s ue s ca r
3
Fibe r-producing ce lls in
de rmis re pa ir da ma ge d
ne twork of fibe rs.
 158 CHAPTER 7 Skin and Membranes

TABLE 7-1 Common Skin Lesions

LES ION DES CRIPTION EXAMPLE
Ele vate d
Papule Firm , rais e d le s ion (le s s than 1 cm in Warts
diam e te r)

7 Plaque Large , rais e d le s ion (gre ate r than 1 cm in Plaque caus e d by

diam e te r) riction

Ve s icle Thin-walle d blis te r f lle d w ith uid that is Non-ge nital he rpe s
s m alle r than 1 cm (a ve s icle large r ve s icle s
than 1 cm is a bulla)

Pus tule Elevate d le s ion f lle d w ith pus Acne

Crus t Scab; are a w ith drie d blood or exudate Scab

Whe al (hive ) Firm , rais e d are a o irre gular s hape w ith Drug-s e ns itivity hive s
a light ce nte r
 CHAPTER 7 Skin and Membranes 159

TABLE 7-1 Common Skin Lesionscont'd

LES ION DES CRIPTION EXAMPLE
Flat
Macule Are a dis tinguis he d rom s urrounding s kin Fre ckle
by color

Patch Macule s large r than 1 cm Vitiligo 7

De pre s s e d
Excoriation Are a in w hich e pide rm is is m is s ing, Scratch
expos ing the de rm is

Atrophy Skin leve l de pre s s e d, s how ing los s o Striae

tis s ue

Ulce r Crate rlike le s ion caus e d by dis inte gration Be ds ore or pre s s ure
o s kin s ore

Fis s ure Line ar crack or bre ak rom e pide rm is to Athle tes oot
de rm is
 160 CHAPTER 7 Skin and Membranes

FIGURE 7-17 Depth classif cation o burns. First- and second-

degree burns are classi ed as partial-thickness burns and third- and
ourth-degree burns as ull-thickness burns.

Ca pilla ry
S e ba ce ous
gla nd

FIRS T
DEGREE S ECOND
Epide rmis DEGREE
(pa rtia l THIRD
thickne s s ) DEGREE
(full
thickne s s ) FOURTH

7 De rmis Ne rve e ndings DEGREE

(full
thickne s s
re a ching
mus cle or
Ha ir follicle bone )
S ubcuta ne ous
tis s ue S we a t gla nd

Mus cle

Bone

Third-degree Burns
Blood ve s s e l
A third-degree burn is characterized by comp ete destruction
o the epidermis and dermis. In addition, tissue death extends
destruction o the dermis does not occur. B isters, severe pain, be ow the primary skin ayers into the subcutaneous tissue. A
genera ized swe ing, and uid oss characterize this type o third-degree burn is a type o ull-thickness burn.
burn. Scarring is common. One distinction between second- and third-degree burns is
First- and second-degree burns are ca ed partial-thickness that third-degree esions are insensitive to pain immediate y
burns. a ter injury because o the de-
struction o nerve endings. H ow-
FIGURE 7-18 Partial- and ull-thickness burns. A, Second- ever, intense pain occurs soon a -
degree (partial-thickness) burn showing a scald injury in a young ter the injury. T e uid oss that
child. B, Fourth-degree ( ull-thickness) high-voltage electrical burn resu ts rom third-degree burns is
resulting in underlying muscle and bone damage. a very serious prob em. Another
serious prob em with third-degree
burns is the great risk o in ection
because the protective unctions
o the skin are ost.

Fourth-Degree Burns
T e term ourth-degree burn
(Figure 7-18, B) is used to de-
scribe a u -thickness burn that
extends be ow the subcutaneous
tissue to reach musc e or bone.
Such injuries may occur as a re-
su t o high-vo tage e ectrica
P L burns or rom exposure to very
P A P D
intense heat over time. reat-
ment may require extensive skin
D M
gra ting and even amputation o
A B imbs.

4.5% 4.5%
4.5% 4.5% 4.5%
18% 18%
1%
9% 9% 9% 9%
S S
R L L R
I I
FIGURE 7-19 Rule o nines. Dividing the adult body into 11 areas o 9%
each helps in estimating the amount o skin sur ace burned in an adult.
Es t im a t in g Bo d y S u r a c e A r e a
W hen burns invo ve arge areas o the skin, treatment and the
possibi ity or recovery depend in arge part on the total area
involved and the severity o the burn. T e severity o a burn is
determined by the depth o the injury, as we as by the
amount o body sur ace area a ected.
T e rule o nines is one o the most requent y used
methods o determining the extent o a burn injury in adu ts.
W ith this technique (Figure 7-19), the body is divided into
11 areas o 9% each, with the area around the genita s repre-
senting the additiona 1% o body sur ace area.
As you can see in Figure 7-19, in the adu t 9% o the skin
covers the head and each upper extremity, inc uding anterior
and posterior sur aces. wice as much, or 18%, o the tota
skin area covers the anterior and posterior o the trunk and
each ower extremity, inc uding a sur aces.
To learn more about burns, go to AnimationDirect
online at evolve.elsevier.com.
S k in In e c t io n s
T e skin is the f rst ine o de ense against microbes that
might otherwise invade the bodys interna environment. So
the skin is a common site o in ection. Viruses, bacteria, ungi,
or arger parasites cause skin conditions such as those isted
here. Re er to Appendix A at evolve.elsevier.com or more in-
ormation on these and other skin in ections.
Im p e t ig o
Impetigo is a high y contagious condition that resu ts rom
staphy ococca or streptococca in ection and occurs most o -
ten in young chi dren. It starts as a reddish disco oration, or
erythema, but soon deve ops into vesic es and ye owish
CHAPTER 7 Skin and Membranes 161
crusts (Figure 7-20, A). Occasiona y, impetigo becomes sys-
temic (body-wide) and thus i e threatening.
Tin e a
inea is the genera name or many di erent mycoses ( unga
in ections) o the skin. Ringworm, jock itch, and ath etes oot
are c assif ed as tinea.
Signs o tinea inc ude erythema, sca ing, and crusting. Oc-
casiona y, ssures, or cracks, deve op at creases in the epider-
mis. Figure 7-20, B, shows a case o ringworm, a tinea in ection
that typica y orms a round rash that hea s in the center to
orm a ring.
Anti unga agents usua y stop the acute in ection. Recur-
rence can be avoided by keeping the skin dry because ungi 7
require a moist environment to grow.
Wa r t s
Caused by a papi omavirus, warts are a type o benign neo-
p asm o the skin. H owever, some warts do trans orm and
become ma ignant.
T e nipp e ike projections characteristic o this contagious
condition are shown in Table 7-1, p. 158. ransmission o warts
genera y occurs through direct contact with esions on the
skin o an in ected person. Warts can be removed by reezing,
drying, aser therapy, or app ication o chemica s.
Bo ils
A so ca ed uruncles, boi s are most o ten oca staphy ococ-
ca in ections o hair o ic es and are characterized by arge,
in amed pustu es (Figure 7-20, C). A group o untreated boi s
may use into even arger pus-f ed esions ca ed carbuncles.
S c a b ie s
Scabies is a contagious skin condition caused by the itch mite
(Sarcoptes scabiei).
ransmitted by skin-to-skin contact, as in sexua activity,
the ema e mite digs under the hard stratum corneum and
orms a short, winding burrow where she deposits her eggs
(Figure 7-20, D). Young mites ca ed larvae hatch, orming tiny,
red papu es. A ter a month or so, a hypersensitivity reaction
(see Chapter 16) may cause a rash characterized by erythema
and numerous papu es.
As the name o the cu prit indicates, in estation o the skin
by itch mites causes intense itching. Excoriation that resu ts
rom scratching the itchy in ested areas may ead to secondary
bacteria in ections.
Va s c u la r a n d In a m m a t o ry
S k in D is o r d e r s
Just a ew examp es o the many vascu ar and in ammatory
skin disorders are described in the o owing sections.
D e c u b it u s U lc e r s
Every caregiver shou d be aware o the causes and nature o
pressure sores or decubitus ulcers (Figure 7-21, A). Decubitus
means ying down, a name that hints at a common cause o
 162 CHAPTER 7 Skin and Membranes

L S

S I R L

R I

7 A Impe tigo B Tine a (ringworm)

C Furuncle (boil) D S ca bie s

FIGURE 7-20 Skin in ections.

pressure sores: ying in one position or ong periods. A so
ca ed bedsores, these esions appear a ter b ood ow to a oca
area o skin s ows or is obstructed because o pressure on skin
covering bony prominences such as the hee . U cers orm and
in ections deve op because ack o b ood ow causes tissue
damage or death.
Frequent changes in body position and so t support cush-
ions he p prevent decubitus u cers.
Hive s
Hives, or urticaria, is a common condition characterized by
raised red esions ca ed wheals (Figure 7-21, B). Urticaria is
o ten associated with severe itching. H ives are genera y short
ived, asting rom a ew hours to a ew weeks.
T e esions are caused by eakage o uid rom the skins
b ood vesse s. T ey change in size and shape over time; new
esions erupt as o d ones disappear when uid in the raised
whea s is reabsorbed by the body. H ypersensitivity or a ergic
reactions to drugs or ood, physica irritants, and systemic
diseases are common causes o urticaria.
S c le ro d e r m a
Scleroderma is an autoimmune disease that a ects the b ood
vesse s and connective tissues o the skin.
T e name scleroderma comes rom the word parts sclera,
which means hard, and derma, which means skin. H ard
skin is a good description o the esions characteristic o sc ero-
derma. Sc eroderma begins as an area o mi d in ammation
that ater deve ops into a patch o ye owish, hardened skin.
Sc eroderma most common y remains a mi d, oca ized
condition. Very rare y, oca ized sc eroderma progresses to a
systemic orm, a ecting arge areas o the skin and other or-
gans. Persons with advanced systemic sc eroderma seem to be
wearing a mask because skin hardening prevents them rom
moving their mouths ree y. Both orms o sc eroderma occur
more common y in women than in men.
P s o r ia s is
Psoriasis is a common, chronic, and o ten i e ong skin dis-
ease that a ects 1% to 3% o the popu ation. It is character-
ized by si very white, sca e ike plaques that may remain f xed
on the skin or months (Figure 7-21, C).
Psoriasis is thought to have a genetic basis and tends to
a ect skin on the e bows, knees, and sca p most o ten. Indi-
vidua s with psoriasis o ten show pitting o the nai s (see
Figure 7-12, B). T e sca es or p aques associated with the dis-
ease deve op rom an excessive rate o epithe ia ce growth.
Ec ze m a
Eczema is the most common in ammatory disorder o the
skin. T is condition is characterized by in ammation that is
o ten accompanied by papu es, vesic es, and crusts.
 CHAPTER 7 Skin and Membranes 163

D P

L
A De cubitus ulce r

7
C P s oria s is

S D

P A L M

I P
B Hive s D Conta ct de rma titis

FIGURE 7-21 Vascular and in ammatory skin disorders.

Eczema is not a distinct disease but rather a sign or symp-
tom o an under ying condition. For examp e, an a ergic reac-
tion ca ed contact dermatitis can progress to become eczema-
tous. T e b isters and marked redness on the arm shown in
Figure 7-21, D are the resu t o contact dermatitis caused by soap
used in aundering a ong-s eeved shirt.
Skin ce s have a natura abi ity to repair UV damage to the
DNA, but in some peop e, this inherent mechanism may not be
ab e to dea with a massive amount o damage. Peop e with the
rare, inherited condition xeroderma pigmentosum cannot re-
pair UV damage at a and a most a ways deve op skin cancer.

S k in C a n c e r
Ro le o U lt r a v io le t Ra d ia t io n
O the many types o skin cancer, the most
common are squamous cell carcinoma,
basal cell carcinoma, and ma ignant
melanoma.
A though genetic predisposition a so
p ays a ro e, many pathophysio ogists be-
ieve that exposure to the suns UV radia-
tion is the most important causa actor in
the three most common skin cancers. UV
radiation damages the DNA in skin ce s,
causing the mistakes in mitosis that pro-
duce cancer.
HEA LTH AND WELL-BEIN G
S UNBURN AND S KIN CANCER
Burns caus e d by expos ure to harm ul ultraviole t (UV) radiation in s unlight are com -
m only calle d s unburns . As w ith any burn, s e rious s unburns can caus e tis s ue
dam age and le ad to s e condary in e ctions and uid los s . Cance r re s e arche rs have
re ce ntly the orize d that blis te ring (s e cond-de gre e ) s unburns during childhood m ay
trigge r the deve lopm e nt o m alignant m e lanom a late r in li e . Epide m iologic s tud-
ie s now s how that adults w ho had m ore than two blis te ring s unburns be ore the
age o 20 have a m uch gre ate r ris k o deve loping m e lanom a than s om e one w ho
expe rie nce d no s uch burns . This the ory he lps explain the dram atic incre as e in s kin
cance r rate s in the Unite d State s obs e rve d in re ce nt ye ars . Thos e w ho grew up
s unbathing and expe rie nce d s unburns in the ir youth are now, as olde r adults , ex-
hibiting m e lanom a at a m uch highe r rate than thos e in previous ge ne rations .
 164 CHAPTER 7 Skin and Membranes
7 A S qua mous ce ll ca rcinoma
C Ma ligna nt me la noma
FIGURE 7-22 Examples o skin cancer lesions.
S q u a m o u s C e ll C a r c in o m a
Squamous cell carcinoma is a s ow-growing ma ignant tu-
mor o the epidermis. It is the most common type o skin
cancer. Lesions typica o this orm o skin cancer are hard,
raised nodu es that are usua y pain ess (Figure 7-22, A). I not
treated, squamous ce carcinoma wi metastasize, invading
other organs.
Ba s a l C e ll C a r c in o m a
As its name imp ies, basal cell carcinoma be- TABLE 7-2
gins in ce s at the base o the epidermis (the
ABCDE
basa ayer o stratum germinativum). Usua y
As ym m e try
occurring on the upper ace, this type o skin
cancer is much ess ike y to metastasize than
other types. Basa ce carcinoma esions typi- Borde r
ca y begin as papu es that erode in the center to
orm a b eeding, crusted crater (Figure 7-22, B). Color
M e la n o m a
Ma ignant melanoma is the most serious Diam e te r
orm o skin cancer. Un ortunate y, the inci-
dence o me anoma in the U.S. popu ation is Evolving
increasing. In the absence o ear y treatment, it
causes death in about one in every our cases.
B Ba s a l ce ll ca rcinoma
D Ka pos i s a rcoma
T is type o cancer sometimes deve ops rom a pigmented
nevus (mole) and trans orms into a dark, spreading esion
(Figure 7-22, C). Benign mo es shou d be checked regu ar y or
warning signs o me anoma because ear y detection and re-
mova are essentia in treating this rapid y spreading cancer.
T e ABCDE ru e o se -examination o mo es is summa-
rized in Table 7-2.
Warning Signs o Malignant Melanoma
RULE
Be nign m ole s are us ually s ym m e trical; the ir halve s are m irror im age s
o e ach othe r. Me lanom a le s ions are as ym m e trical or lops ide d.
Be nign m ole s are outline d by a dis tinct borde r, but m alignant m e la-
nom a le s ions are o te n irre gular or indis tinct in s hape .
Be nign m ole s m ay be any s hade o brow n but are re lative ly eve nly
colore d; m e lanom a le s ions te nd to be uneve nly colore d, exhibiting
a m ixture o s hade s or colors .
By the tim e a m e lanom a le s ion exhibits characte ris tics A, B, and C, it
als o is probably large r than 6 m m ( inch)
Mole s that continue to evolve , or change ove r tim e , m ay be cance r-
ous . Be s ide s the change s note d above , m e lanom a le s ions m ay
be gin to itch, orm an ulce r, or ble e d.
 CHAPTER 7 Skin and Membranes 165

Ka p o s i S a r c o m a
For more in ormation, including additional
Kaposi sarcoma (KS) is caused by Kaposi sarcomaassociated
photographs, review the article Skin Cancer at
herpes virus (KSHV), a so known as human herpes virus 8
Connect It! at evolve.elsevier.com.
(HHV8). Once associated main y with certain ethnic groups,
a orm o this cancer now a so appears in many cases o AIDS
and other immune def ciencies. QUICK CHECK
Kaposi sarcoma, f rst appearing as purp e papu es (Figure 7-22, 1. Ho w a re b u rn s cla s s if e d ?
D), quick y spreads to the ymph nodes and interna organs. 2. Ho w ca n th e s kin s u r a ce a re a d a m a g e d b y a b u rn b e
e s tim a te d ?
3. Id e n ti y f ve s kin in e ctio n s a n d o u r va s cu la r a n d in a m -
m a to ry s kin d is o rd e rs .
4. Lis t th e th re e m a jo r typ e s o s kin ca n ce r.
5. Wh a t a re th e wa rn in g s ig n s o m a lig n a n t m e la n o m a ?

7
S C IEN C E APPLICATIONS
S ECRETS OF THE S KIN
The s kin is our m os t vis ible organ, othe r s kin, nail, and hair tre atm e nts . For exam ple , indus trial
s o it is no wonde r that obs e rving re s e arche rs , product deve lope rs , co s m e ticians , s pa s pe cial-
the s tructure and unction o s kin is ts , and hair s tylis ts all re quire s om e know le dge o curre nt
has ge ne rate d s parks that have lit s kin s cie nce to do the ir jobs e e ctive ly.
the f re s o s cie ntif c dis cove ry The photo s how s a phys ician and m e dical as s is tant us ing a
through the age s . The ancie nt Ro- m e dical las e r to re m ove a tattoo rom the s kin o a patie nt.
m ans outline d the proce s s o in-
am m ation in de tail a te r obs e rving
it f rs t in the s kin. In the twe ntie th
ce ntury, Jos e ph Murray (s e e f g-
Dr. Joseph E. Murray ure ) notice d that s kin he gra te d
(1919-2012) onto burne d s oldie rs he tre ate d
during World War II would eve ntu-
ally be re je cte d by the body (s e e Figure 7-15 on p. 155).
A te r the war, Murray trie d to unde rs tand the bodys im -
m une re actions to trans plante d tis s ue s and his work le d to the
f rs t s ucce s s ul kidney trans plants . His bre akthroughs in trans -
planting kidneys not only e arne d him a Nobe l Prize in 1990, it
als o pave d the way or all the di e re nt type s o tis s ue and or-
gan trans plantation that we s e e today.
Many s cie ntis ts continue to s tudy the s e cre ts o the s kin,
and m any phys icians and othe r he alth-care pro e s s ionals are
als o pione e rs in deve loping new m e thods o s kin care and
tre atm e nt in the f e lds o de rm ato lo gy, alle rgy, im m uno lo gy,
burn m e dicine , re co ns tructive s urge ry, and co s m e tic s urge ry.
Additional practical applications o s om e o this s kin s ci-
e nce are practice d by pe ople working w ith cos m e tics and

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 145)

dermal papilla dermal-epidermal junction eccrine

(DER-mal pah-PIL-ah) (DER-mal EP-ih-der-mal J UNK-shun) (EK-rin)
pl., papillae [derma- skin, -al relating to, epi- on or upon, [ec- out, -crin- secrete]
(pah-PIL-ee) -derma- skin, -al relating to, junc- join, eccrine sweat gland
[derma- skin, -al relating to, papilla nipple] -tion condition] (EK-rin swet gland)
dermis [ec- out, -crin- secrete, gland acorn]
(DER-mis)
[dermis skin] Continued on p. 166
 166 CHAPTER 7 Skin and Membranes

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 165)

epidermis melanocyte root

(ep-ih-DER-mis) (MEL-ah-noh-syte) sebaceous gland
[epi- on or upon, -dermis skin] [melan- black, -cyte cell] (seh-BAY-shus gland)
epithelial membrane membrane [seb- tallow (hard animal at), -ous relating to,
(ep-ih-THEE-lee-al MEM-brayn) (MEM-brayn) gland acorn]
[epi- on or upon, -theli- nipple, -al relating to, [membran- thin skin] sebum
membran- thin skin] mucocutaneous junction (SEE-bum)
ollicle (myoo-koh-kyoo-TAY-nee-us J UNK-shun) [sebum grease]
(FOL-lih-kul) [muco- slime or mucus, -cut- skin, serous membrane
7 [ oll- bag, -icle little]
reckle
-aneous relating to, junc- join,
-tion condition]
(SEE-rus MEM-brayn)
[sero- watery body uid, -ous characterized by,
(FREK-uhl) mucous membrane membran- thin skin]
hair ollicle (MYOO-kus MEM-brayn) stratum corneum
(hayr FOL-lih-kul) [muc- slime, -ous characterized by, (STRAH-tum KOR-nee-um)
[ oll- bag, -icle little] membran- thin skin] [stratum layer, corneum horn]
hair papilla mucus stratum germinativum
(hayr pah-PIL-ah) (MYOO-kus)
[papilla nipple] [mucus slime] [stratum layer, germinativum something that
hypodermis nail body sprouts]
(hye-poh-DER-mis) (nayl BOD-ee) subcutaneous tissue
[hypo- under or below, -dermis skin] Pacini corpuscle (sub-kyoo-TAY-nee-us TISH-yoo)
integument (pah-CHEE-nee KOR-pus-ul) [sub- beneath, -cut- skin, -ous relating to,
(in-TEG-yoo-ment) [Filippo Pacini Italian anatomist, corpus- body, tissu- abric]
[in- on, -teg- cover, -ment result o action] -cle little] sudori erous gland
integumentary system parietal (soo-doh-RIF-er-us gland)
(in-teg-yoo-MEN-tar-ee SIS-tem) (pah-RYE-ih-tal) [sudo- sweat, - er- bear or carry, -ous relating
[in- on, -teg- cover, -ment- result o action, [pariet- wall, -al relating to] to, gland acorn]
-ary relating to] parietal peritoneum superf cial ascia
keratin (pah-RYE-ih-tal payr-ih-TOH-nee-um) (soo-per-FISH-al FAH-shah)
(KER-ah-tin) [parie- wall, -al relating to, peri- around, [super- over or above, -f ci- ace, -al relating to,
[kera- horn, -in substance] -tone- stretched, -um thing] ascia band]
lamellar corpuscle pericardium sweat gland
(lah-MEL-ar KOR-pus-ul) (pair-ih-KAR-dee-um) (swet gland)
[lam- plate, -ella- little, -ar relating to, pl., pericardia [gland acorn]
corpus- body, -cle little] (pair-ih-KAR-dee-ah) synovial uid
[peri- around, -cardi- heart, -um thing] (sih-NOH-vee-al FLOO-id)
lamina propria
(LAM-in-ah PROH-pree-ah) peritoneum [syn- together, -ovi- egg (white), -al relating to]
[lamina thin plate, propria proper] (payr-ih-toh-NEE-um) synovial membrane
[peri- around, -tone- stretched, -um thing] (sih-NOH-vee-al MEM-brayn)
lanugo
(lah-NOO-go) perspiration (sweat) [syn- together, -ovi- egg (white), -al relating to,
[lanugo down] (per-spih-RAY-shun [swet]) membran- thin skin]
[per- through, -spire breathe, -ation process] tactile corpuscle
lunula
(LOO-nyoo-lah) pigment (TAK-tyle KOR-pus-ul)
[luna- moon, -ula small] (PIG-ment) [tact- touch, -ile relating to, corpus- body,
[pigment paint] -cle little]
Meissner corpuscle
(MYZ-ner KOR-pus-ul) pleura visceral
[George Meissner German physiologist, (PLOO-rah) (VIS-er-al)
corpus- body, -cle little] pl., pleurae [viscer- internal organ, -al relating to]
melanin (PLOO-ree) visceral peritoneum
(MEL-ah-nin) [pleura side o body (rib)] (VIS-er-al payr-ih-TOHN-ee um)
[melan- black, -in substance] pore [viscer- internal organ, -al relating to,
(por) peri- around, -tone- stretched, -um thing]
 CHAPTER 7 Skin and Membranes 167

LANGUAGE OF M ED IC IN E

acne vulgaris dermatosis partial-thickness burn

(AK-nee vul-GAR-is) (der-mah-TOH-sis) (PAR-shal THIK-nis bern)
[acne point, vulgaris common] [derma- skin, -osis condition] peritonitis
albinism eczema (payr-ih-toh-NYE-tis)
(AL-bih-niz-em) (EK-zeh-mah) [peri- around, -ton- stretch (peritoneum),
[alb- white, -in- characterized by, -ism state] [eczema to boil over] -itis in ammation]
allergy erythema plaque
(er-ih-THEE-mah) (plak)
[all- other, -erg- work, -y state] [erythem- become red, -a condition] [plaque patch]
alopecia
(al-oh-PEE-sha)
excoriation
(eks-koh-ree-AY-shun)
pleurisy
(PLOOR-ih-see)
7
[alopec- ox, -ia condition] [ex- o , -cori- skin, -ation process] [pleur- side o body (rib), -isy condition]
basal cell carcinoma f rst-degree burn port-wine stain
(BAY-sal sel kar-sih-NOH-mah) ( urst dih-GREE bern) (port wyne stayn)
[bas- base, -al relating to, cell storeroom, f ssure [port wine type o dark red wine]
carcin- cancer, -oma tumor] (FISH-ur) psoriasis
blackhead [f ss- split, -ure thing] (soh-RYE-ah-sis)
(BLAK-hed) ourth-degree burn [psor- itching, -iasis condition]
blister ( ohrth dih-GREE bern) pustule
(BLIS-ter) ull-thickness burn (PUS-tyool)
burn ( ul THIK-nis bern) [pus- pus (rotten), -ule little]
(bern) uruncle (boil) reconstructive surgery
carbuncle (FUR-un-kul [boyl])
(KAR-bung-kul) [ ur- thie , -uncle little] [re- again, -con- with, -struct- build,
[carbun- coal, -cle little] -ive relating to, surger- hand, -y activity]
immunology
comedo rule o nines
(KOM-ee-doh) [immuno- ree (immunity), -logy study o ] (rool ov nahynz)
[comedo glutton (secretions resemble body- impetigo scabies
devouring worms)] (im-peh-TYE-go) (SKAY-beez)
cosmetic surgery [impet- attack] [scabies mange or itch]
kaposi sarcoma (KS) scleroderma
[cosmet- adorned, -ic relating to, surger- hand, (KAH-poh-see sar-KOH-mah [kay es]) (skleer-oh-DER-mah)
-y activity] [Moritz K. Kaposi Hungarian dermatologist, [sclero- hard, -derma skin]
cosmetician sarco- esh, -oma tumor] second-degree burn
(koz-meh-TISH-un) lesion (SEK-und dih-GREE bern)
[cosmet- adorned, -ic relating to] (LEE-zhun) skin gra t
crust [les- hurt, -ion condition] (skin grah t)
(krust) macule [gra t shoot inserted into another plant]
cyanosis (MAK-yool) squamous cell carcinoma
(sye-ah-NOH-sis) [macul(a)- spot] (SKWAY-mus sel kar-sih-NOH-mah)
[cyan- blue, -osis condition] melanoma [squam- scale, -ous characterized by,
decubitus ulcer (mel-ah-NOH-mah) cell storeroom, carcin- cancer, -oma tumor]
(deh-KYOO-bih-tus UL-ser) [melan- black, -oma tumor] stork bite
[decubitus lying-down position, ulcer sore] nevus (stork byte)
dehydration (NEE-vus) [stork large bird related to birth mythology]
(dee-hye-DRAY-shun) pl., nevi strawberry hemangioma
[de- remove, -hydro water, -ation process] (NEE-vye)
dermatitis [nevus birthmark] [hem- blood, -angi- vessel, -oma tumor]
(der-mah-TYE-tis) onycholysis striae
[derma- skin, -itis in ammation] (ahn-ik-oh-LYE-sis) (STRYE-ee)
dermatology [onycho- nail, -lysis loosen] sing., stria
papule (STRYE-ah)
[derma- skin, -log- words (study o ), -y activity] (PAP-yool) [stria- urrow or ute o a column]
[papul(a) pimple]
Continued on p. 168
 168 CHAPTER 7 Skin and Membranes

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 167)

subcutaneous injection urticaria (hives) wheal

(sub-kyoo-TAY-nee-us in-J EK-shun) (er-tih-KAYR-ee-ah [hyvez]) (weel)
[sub- under, cut- skin, -aneous relating to, [urtica- nettle, -ia condition] [wheal welt or whip mark]
in- in, -ject- throw, -tion process] vitiligo xeroderma pigmentosum
third-degree burn (vit-ih-LYE-go) (zeer-oh-DER-mah pig-men-TOH-sum)
(third dih-GREE bern) [vitiligo blemish] [xero- dry, -derma skin, pigment- paint,
tinea wart -osum characterized by]
(TIN-ee-ah) (wort)
[tinea gnawing worm] [wart swelling]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Bo dy Me m brane s
A. C assif cation o body membranes (Figure 7-1)
1. Epithe ia membranescomposed o epithe ia tissue
and an under ying ayer o connective tissue
2. Connective tissue membranescomposed exc usive y
o various types o connective tissue
B. Epithe ia membranes
1. Cutaneous membranethe skin
2. Serous membranessimp e squamous epithe ium on
a connective tissue basement membrane
a. Layers (Figure 7-2)
(1) Parieta ine wa s o body cavities
(2) Viscera cover organs ound in body cavities
b. Examp es
(1) P euraparieta and viscera ayers ine wa s o
thoracic cavity and cover the ungs
(2) Peritoneumparieta and viscera ayers ine
wa s o abdomina cavity and cover the organs
in that cavity
(3) Pericardiumparieta and viscera ayers ine a
f brous sac around the heart and a viscera ayer
covers the heart wa
c. Diseases
(1) P eurisyin ammation o the serous mem-
branes that ine the chest cavity and cover the
ungs
(2) Peritonitisin ammation o the serous mem-
branes in the abdomina cavity that ine the
wa s and cover the abdomina organs
3. Mucous membranes
a. Line body sur aces that open direct y to the
exterior
b. Produce mucus, a thick secretion that keeps the
membranes so t and moist
C. Connective tissue membranes
1. Do not contain epithe ia components
2. Produce a ubricant ca ed synovial uid
3. Examp es are the synovia membranes in the spaces
between joints and in the ining o the bursa sacs
S kin S tructure
A. O verview (Figure 7-3)two primary ayers
1. Epidermissuperf cia ayer
2. Dermisdeep ayer
B. Epidermis
1. Epiderma structure
a. O utermost and thinnest primary ayer o skin
b. Composed o severa ayers o stratif ed squamous
epithe ium
c. Stratum germinativuminnermost (deepest) ayers
o ce s; basa ayer continua y reproduces, pushing
o der ce s toward the sur ace
d. As ce s approach the sur ace, they become f ed
with a tough, waterproo protein ca ed keratin and
eventua y ake o (Figure 7-4)
e. Stratum corneumoutermost ayer o keratin-
f ed ce s

2. Skin pigment
a. Me aninbrown skin pigment
(1) Basa ayer o stratum germinativum has
pigment-producing me anocyte ce s
(2) T e brown pigment me anin produced by
me anocytes is distributed to other epithe ia
ce s, giving skin a darker co or
(3) Amount and type o me anin, determined by
genes, he ps determine basic skin co or
b. Skin co or changes
(1) Sun ight promotes additiona pigmentation
(2) Pink ush indicates increased b ood vo ume or
increased b ood oxygen
(3) Cyanosisb uish co or o skin indicates
decreased b ood oxygen eve
(4) Viti igopatchy ight skin areas resu ting rom
acquired oss o epiderma me anocytes
(Figure 7-5)
(5) Increased skin pigmentation caused by hor-
mona changes in pregnant women
(6) Freck essma , at macu es; common norma
skin pigment variation
C. Derma -epiderma junction
1. G ue ike ayer between the dermis and epidermis
2. Sma bumps ca ed dermal papillae he p stabi ize the
junction
3. B isterscaused by breakdown o union between ce s
or primary ayers o skin
D. Dermis
1. Deeper and thicker o the two primary skin ayers;
composed arge y o connective tissue
2. Papi ary ayer
a. Derma papi aepara e rows o tiny bumps that
characterize the upper area o dermis
(1) T ick skin has para e riction ridges in dermis
and no hairs (Figure 7-6)
(2) T in skin has irregu ar, sha ow grooves and
hair
b. Derma ridges
(1) Ridges and grooves in dermis orm pattern
unique to each individua
(2) Improves grip or too use and wa king; he ps
in sensing textures on sur aces
(3) Basis o f ngerprint identif cation
3. Reticu ar ayerdeeper area o dermis is f ed with
network o tough co agenous and stretchab e e astic
f bers
a. Number o e astic f bers decreases with age and
contributes to wrink e ormation
b. Striaestretch marks; e ongated marks caused by
overstretching o skin
c. Dermis a so contains nerve endings, musc e f bers,
hair o ic es, sweat and sebaceous g ands, and many
b ood vesse s
CHAPTER 7 Skin and Membranes 169
d. Birthmarksma ormation o derma b ood vesse s
(1) Strawberry hemangioma (Figure 7-7)
(2) Port-wine stain
(3) Stork bite
E. Subcutaneous tissue
1. A so ca ed hypodermis or super cial ascia
2. Most y oose f brous connective tissue and adipose
tissue
3. Connecting ayer
a. Deep to dermis, between the skin and the under y-
ing structures such as bone and musc e
b. Not part o the skin
c. A ows s iding movement o skin as body parts
move 7
F. H air, nai s, and skin receptors
1. H air (Figure 7-8)
a. Location o hair
(1) H air grows rom pocket ike hair o ic es in the
epidermis
(2) So t hair o etus and newborn ca ed lanugo
(3) H air is distributed wide y (except ips, pa ms,
so es) but varies in density and coarseness
b. H air growth
(1) H air growth occurs within the tube o the hair
o ic e
(2) H air- orming ce s reproduce on bump at the
bottom o each o ic e ca ed the hair papilla
(3) H air ce s become keratinized ike the epider-
mis, but in a cy inder orm and having a
tougher type o keratin
(4) H air root ies hidden in o ic e; visib e part o
hair ca ed sha t
c. H air oss
(1) A opecia (Figure 7-9)any type o hair oss
(2) Can resu t rom norma aging, various disorders
or treatments, pregnancy, or have unknown
causes
d. Arrector pi ismooth musc e o the skin that pro-
duces goose pimp es and causes hair to stand up
straight
2. Nai s (Figure 7-10)
a. Produced by epiderma ce s over termina ends o
f ngers and toes
b. Visib e part ca ed nail body
c. Root ies in a groove and is hidden by cutic e
d. Crescent-shaped area nearest root ca ed lunula
e. Nai bed may change co or with change in b ood
ow
. Norma variations in nai structure (Figure 7-11)
(1) Longitudina ridges in ight-skinned
individua s
(2) Pigmented bands in dark-skinned individua s
g. Abnorma variations in nai structure (Figure 7-12)
(1) O nycho ysisseparation o nai rom nai bed
(2) Pittingcommon in psoriasis
 170 CHAPTER 7 Skin and Membranes
3. Receptors (Figure 7-3)
a. Sensory nerve endingsmake it possib e or skin
to act as a sense organ
b. acti e (Meissner) corpusc ecapab e o detecting
ight touch
c. Lame ar (Pacini) corpusc ecapab e o detecting
pressure
G. Skin g andstwo main types: sweat and sebaceous
g ands
1. Sweat g ands; a so ca ed sudori erous glands
a. Eccrine sweat g ands
(1) Most numerous, important, and wide-spread o
the sweat g ands
7 (2) Produce perspiration or sweat, which ows out
through pores on skin sur ace
(3) Function throughout i e and assist in body
heat regu ation
b. Apocrine sweat g ands
(1) Found primari y in axi a and around genita ia
(2) Secrete a thicker, mi ky secretion quite di erent
rom eccrine perspiration
(3) Breakdown o secretion by skin bacteria pro-
duces odor
2. Sebaceous g ands
a. Sebum
(1) Oi y secretion or hair and skin, ubricates and
prevents drying, cracking
(2) Leve o secretion increases during ado escence
(3) Amount o secretion regu ated by sex
hormones
(4) Sebum in sebaceous g and ducts may darken to
orm a b ackhead (comedo)
(5) Acne vu garis (Figure 7-13)in ammation o
sebaceous g and ducts
Functio ns o the S kin
A. Protectionf rst ine o de ense
1. Against in ection by microbes
2. Against u travio et (UV) rays rom sun
3. Against harm u chemica s
4. Against cuts and tears
5. Bruising can cause disco oration o skin as b ood
re ease rom damaged vesse s breaks down (Figure 7-14)
6. Skin gra ts may be needed to rep ace skin destroyed
by disease or trauma (Figure 7-15)
B. emperature regu ation
day
2. Mechanisms o temperature regu ation
a. Regu ation o sweat secretion
b. Regu ation o ow o b ood c ose to the body
sur ace
C. Sensation
1. Receptors serve as receivers or the body, keeping it
in ormed o changes in its environment
a. Skin can detect sensations o ight touch, pressure,
pain, heat, and co or
D. Excretionsweat excretes waste products such as uric
acid, ammonia, urea
E. Synthesis o vitamin D, which requires UV ight avai -
ab e in the skin
Dis o rde rs o the S kin
A. Skin esions (Table 7-1)any measurab e variation rom
the norma structure
1. E evated esionscast a shadow outside their edges
a. Papu esma , f rm raised esion
b. P aque arge raised esion
c. Vesic eb ister
d. Pustu epus-f ed esion
e. Crustscab
. W hea (hive)raised, f rm esion with a ight
center
2. F at esionsdo not cast a shadow
a. Macu e at, disco ored region
3. Depressed esions cast a shadow within their edges
a. Excoriationmissing epidermis, as in a scratch
wound
b. U cercrater ike esion
c. Fissuredeep crack or break
4. Some esions are produced by scrapes and cutsthe
skin can repair itse (Figure 7-16)
B. Burns
1. reatment and recovery or surviva depends on tota
area invo ved and severity or depth o the burn
2. Depth c assif cation o burns (Figure 7-17)
a. First-degree (partia -thickness) burnson y sur ace
ayers o epidermis invo ved
b. Second-degree (partia -thickness) burnsinvo ve
the deep epiderma ayers and a ways cause injury
to the upper ayers o the dermis
c. T ird-degree ( u -thickness) burns (Figure 7-18)
characterized by comp ete destruction o the epi-
dermis and dermis
(1) Lesion is insensitive to pain because o
destruction o nerve endings immediate y a ter
injuryintense pain is experienced a ter the
initia injury
(2) Risk o in ection is increased
d. Fourth-degree burns u -thickness burns that
extend to musc e or bone
3. Estimating body sur ace area using the ru e o nines
(Figure 7-19) in adu ts
a. Body divided into 11 areas o 9% each
b. Additiona 1% o body sur ace area around genita s
C. Skin in ections (Figure 7-20)
1. Impetigohigh y contagious staphy ococca or strep-
tococca in ection
2. inea unga in ection (mycosis) o the skin; severa
orms occur
3. Wartsbenign neop asm caused by papi omavirus
4. Boi s urunc es; staphy ococca in ection in hair
o ic es
5. Scabiesparasitic in ection

D. Vascu ar and in ammatory skin disorders (Figure 7-21)
1. Decubitus u cers (bedsores) deve op when pressure
s ows down b ood ow to oca areas o the skin
2. Urticaria or hivesred esions caused by uid oss
rom b ood vesse s
3. Sc erodermadisorder o vesse s and connective
tissue characterized by hardening o the skin; two
types: oca ized and systemic
4. Psoriasischronic in ammatory condition accompa-
nied by sca y p aques
5. Eczemacommon in ammatory condition character-
ized by papu es, vesic es, and crusts; not a disease itse
but a symptom o an under ying condition
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
1. T e body membranes are either epithe ia or connective.
T e epithe ia membranes cover or protect. T e di erence
between mucous and serous membranes is their ocation
in the body. I the membrane is exposed to the environ-
ment, it is a mucous membrane. Connective tissue mem-
branes cover joints.
2. T e skin is divided into two parts: epidermis and dermis.
Epi- means on, so the epidermis is on the dermis. T e
job o the epidermis is protection. T e dermis contains
most o the skin appendages: nai s, sense receptors, hair,
and g ands.
3. T e unctions o the skin are re ated to its ocation: pro-
tection, sensation, heat regu ation, excretion, and synthesis
o vitamin. Deve op a concept map that detai s the spe-
cif c unctions o the skin.
4. Burns are c assif ed by how much damage has been done
and how deep the damage goes.
5. ake a photocopy or use your mobi e phone to take a
photo o the i ustrations o the membranes, the micro-
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Def ne membrane.
2. List the two major categories o body membranes.
3. Exp ain the structure o a serous membrane, inc uding
the di erence between the viscera and parieta
membranes.
CHAPTER 7 Skin and Membranes 171
E. Skin cancer (Figure 7-22, Table 7-2)
1. T e most important causative actor in common skin
cancers is exposure to sun ight
2. T ree common types
a. Squamous ce carcinomathe most common type,
characterized by hard, raised tumors
b. Basa ce carcinomacharacterized by papu es
with a centra crater; rare y spreads
c. Me anomama ignancy in a nevus (mo e); the
most serious type o skin cancer
3. Kaposi sarcomacaused by a virus and characterized
by purp e esions, is associated with certain ethnic
groups, as we as AIDS and other immune
def ciencies 7
scopic view o the skin, the hair, and the nai s. B acken
out the abe s on the photocopy and quiz each other in
your study group on the ocation and unction o various
structures.
6. Make a -chart o the di erent types o skin disorders.
Your chart wi be most he p u i you organize it accord-
ing to mechanisms. Group the diseases by pathogenic
organisms and by interna or externa conditions.
discuss possib e test questions with your study group. Use
on ine resources that provide tutoria s and diagrams. One
examp e is studyblue.com. T is is a ree on ine site that
a ows you to create ash cards, and down oad apps or a
academic discip ines. O ther ash card sites and tips are
ound at my-ap.us/LzuowE
8. Review the Language o Science and Language o Medi-
cine terms and their word origins to he p you better
understand the meaning o the terms in this chapter.
9. Review the out ine at the end o this chapter. T is out ine
provides an overview o the materia and wou d he p you
understand the genera concepts o the chapter.
4. W hat is responsib e or the pigment o the skin?
5. Exp ain the structure o a mucous membrane, inc uding
an exp anation o the mucocutaneous junction.
6. Exp ain the structure o a synovia membrane. W hat is
the unction o synovia uid?
8. Exp ain the structure o the dermis.
9. W hat is the structura advantage o the oose, spongy
nature o subcutaneous tissue?
the hair sha t.
11. Exp ain what happens when the arrector pi i contracts.
 172 CHAPTER 7 Skin and Membranes
12. Name two receptors o the skin. o what stimu i does
each respond?
13. Give the ocation o eccrine g ands, their unction, and
what type o uid they produce.
14. Give the ocation o apocrine g ands, their unction, and
what type o uid they produce.
15. Give the ocation o sebaceous g ands, their unction,
and what type o uid they produce.
16. W hat is sebum? W hy is sebum sometimes described as
natures skin cream?
burns. W hich is considered a u -thickness burn?
18. List the three most common orms o skin cancer and
7 exp ain the actors invo ved in their deve opment.
19. List the f ve types o skin in ections and ist the cause as
vira , bacteria , unga , or arthropod.
methods o prevention?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
21. An individua running a marathon expends a great dea
o energy. Much o this energy generates heat. W hat is
the ro e o the skin in ba ancing body temperature
during this strenuous exercise?
22. Concern about skin cancer is reducing the amount o
time peop e spend in the sun. I this caution is carried to
the extreme, how wou d you exp ain the impact on skin
unction?
23. I a person burned a o his back, the posterior o his
right arm, and the posterior o his right thigh, approxi-
mate y what percent o his body sur ace area wou d be
invo ved? H ow did you determine this?
24. A coroner was discussing a recent autopsy and cause o
death to a group o students. H e re ated to the group
that the organ o trauma was ined with tough, abrasive-
resistant stratif ed squamous epithe ium that had been
destroyed in areas throughout the ining o the organ.
W hat most ike y was the organ? Can you suggest a pos-
sib e exp anation or the areas o destruction?
25. W hy are subcutaneous injections given by a hypodermic
need e?
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________, ________, and ________ are the three types
o epithe ia membranes.
2. Epithe ia membranes are usua y composed o two dis-
tinct ayers: the epithe ia ayer and a supportive ayer
ca ed the ________.
3. T e membrane ining the interior o the chest wa is
ca ed the ________.
4. T e membrane covering the organs o the abdomen is
ca ed the ________.
5. T e connective tissue membrane that ines the space
between bone and joint capsu e is ca ed ________.
6. T e two main ayers o the epidermis o the skin are the
________ and the ________.
cytop asm is rep aced by a unique waterproo protein
ca ed ________.
8. T e upper region o the dermis orms projections ca ed
________ that orm unique f ngerprints.
9. T e ________ are the sweat g ands ound in armpits;
they produce a thicker secretion.
________ are the sweat g ands ound a over the
body; they produce a transparent, watery iquid.
11. Sebaceous g ands secrete an oi ca ed ________.
12. ________, ________, ________, ________, and
________ are the f ve primary unctions o the skin.
13. T e ru e o nines is used to estimate body sur ace
invo ved in ________.
14. ________ are pressure sores caused by reduced b ood
ow to oca areas o the skin.
15. T e most common type o skin cancer is ________
carcinoma.
16. ________ o ten resu ts rom a f ve o d increase in sebum
 CHAPTER 7 Skin and Membranes 173

19. T e f ne, so t hair o a newborn is re erred to as:

dermis are the: a. a opecia
a. Meissner corpusc es b. anugo
b. ame ar corpusc es c. viti igo
c. ree nerve endings d. striae
d. Krause end bu bs not a birthmark?
18. T e receptors in the skin that respond to ight touch are: a. Strawberry hemangioma
a. Meissner corpusc es b. Port wine stain
b. ame ar corpusc es c. inea
c. ree nerve endings d. Stork bite
d. Krause end bu bs

Match each structure in column A with its description o the part o the hair in column B. 7
Column A Column B
21. ________ hair o ic e a. the part o the hair hidden in the o ic e
22. ________ hair papi a b. the growth o the epiderma ce s into the dermis orming a sma tube
23. ________ hair root c. the part o the hair that is visib e
24. ________ hair sha t d. a bump at the base o the o ic e where hair growth begins

Match each skin condition in column A with its description in column B.

Column A
25. ________ urunc e
26. ________ urticaria
________ excoriation
28. ________ me anoma
29. ________ sc eroderma
________ Kaposi sarcoma
Column B
a. an autoimmune skin condition
b. skin cancer that can deve op rom a mo e; the most serious orm o skin cancer
c. another name or hives
d. skin esion caused by a sha ow scratch
e. another name or a skin boi
. a virus-caused skin cancer that sometimes deve ops in immune-def cient individua s

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Dana is an intern who has just been assigned to the burn
unit at Mercy H ospita . One patient in the unit has burns
covering the ower ha o each arm ( ront and back).
W hat is Danas estimate o the tota percent o skin
sur ace area a ected by the burn?
2. Unc e Ed, a ight-skinned o der man, has just earned
rom his physician that the spot on his orehead is skin
cancer. O course, dark-skinned Aunt Gina is very upset.
Be ore Unc e Ed exp ains to the ami y what type o skin
cancer he has, you examine the esion and notice that it is
a papu e with an u cer in the center. W hat type o skin
cancer do you think Unc e Ed has? W hat do you know
about this type o cancer that may he p com ort Aunt
Gina?
3. D uring your shi t at the c inic, a young man arrives with
a red, sca y rash ormed into rings. W hat is this patients
diagnosis ike y to be? W hat causes this condition? H ow
can he avoid this rash in the uture?
4. Christy is at high risk or me anoma. She wants to be
proactive. W hat measures wou d you suggest that she
inc ude in her dai y routine?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Skeletal System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Functions o the Skeletal System, 175 Thorax, 189

Support, 175 Appendicular Skeleton, 190
Protection, 176 Upper Extremity, 190
Movement, 176 Lower Extremity, 191
Storage, 176 Skeletal Variations, 194
Hematopoiesis, 176 Male-Female Skeletal Di erences,
Gross Structure o Bones, 176 194
Types o Bones, 176 Age Di erences, 195
Structure o Long Bones, 176 Environmental Factors, 195
Structure o Flat Bones, 177 J oints, 196
Microscopic Structure o Bones, 177 Articulation o Bones, 196
Bone Tissue Structure, 177 Kinds o J oints, 196
Cartilage Tissue Structure, 177 Synarthroses, 196
Bone Development, 177 Amphiarthroses, 196
Making and Remodeling Bone, 177 Diarthroses, 197
Endochondral Ossif cation, 179 Skeletal Disorders, 200
Intramembranous Ossif cation, 179 Tumors, 200
Axial Skeleton, 180 Metabolic Bone Diseases, 201
Skull, 181 Bone In ection, 202
Hyoid Bone, 185 Bone Fractures, 203
Vertebral Column (Spine), 186 J oint Disorders, 204

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you 6. Do the ollowing related to skeletal
should be able to: variations:
1. List and discuss the generalized unc- -
tions o the skeletal system. ences between a mans and a
2. Identi y the types o bones, the major womans skeleton.
anatomical structures ound in a typical -
long bone, and the structure o at mental actors.
bones. 7. List and compare the major types o
3. Discuss the microscopic structure o joints in the body and give an example
bone and cartilage, including the identi- o each.
f cation o specif c cell types and struc- 8. Name and describe major disorders o
tural eatures. bones and joints.
4. Explain how bones are ormed, how
they grow, and how they are remodeled.
5. Identi y the two major subdivisions o
the skeleton and list the bones ound in
each area.
 HAPTER 8
Th e primary organs o the ske eta system, that is, bones, ie buried beneath LANGUAGE OF
the musc es and other so t tissues, providing a rigid ramework and support S C IEN C E
structure or the who e body. In this respect the ske eta system unctions ike
stee girders in a bui ding; however, un ike stee girders, bones can be moved.
Be o re re ading the
Bones are a so iving organs. T ey can change and he p the body respond to a
chapte r, s ay e ach o
changing environment. T is abi ity o bones to change a ows our bodies to the s e te rm s o ut lo ud. This w ill
grow and change. he lp yo u to avo id s tum bling ove r
the m as yo u re ad.
O ur study o the ske eta system begins with an overview o its unction. T e
bones are c assif ed by their structure and described by identi ying characteris-
abduct
tics o a typica bone. A ter discussing the microscopic structure o ske eta (ab-DUKT)
tissues, we brie y out ine bone growth and ormation. H aving this in ormation [ab- away, -duct lead]
makes the study o specif c bones and the way they are assemb ed in the ske - abduction
eton more meaning u . T e chapter ends with a discussion o ske eta variations (ab-DUK-shun)
and disorders and an overview o joints between bones. [ab- away, -duct- lead, -tion process]
acetabulum
An understanding o how bones articu ate with one another in joints and how (as-eh-TAB-yoo-lum)
they re ate to other body structures provides a basis or understanding the [acetabulum vinegar cup]
unctions o many other organ systems. Coordinated movement, or examp e, adduct
is possib e on y because o the way bones are joined to one another and because (ad-DUKT)
o the way musc es are attached to those bones. In addition, knowing where [ad- toward, -duct lead]
specif c bones are in the body wi assist you in ocating other body structures adduction
that are discussed in ater chapters. (ad-DUK-shun)
[ad- toward, -duct- lead,
-tion process]
Fu n c t io n s o t h e S k e le t a l S y s t e m amphiarthrosis
(am- ee-ar-THROH-sis)
Support pl., amphiarthroses
T e ske eton provides the interna ramework o the body much ike tent po es (am- ee-ar-THROH-seez)
[amphi- both sides, -arthr- joint,
he p maintain the structure o a tent. Ske eta musc es are attached to the
-osis condition]
bones, and interna organs are ound in the cavities surrounded by
appendicular skeleton
the bones and ske eta musc es. T e ske eta system can provide
(ah-pen-DIK-yoo-lar SKEL-eh-ton)
this support on y when the composition o the bone is strong
[append- hang upon, -ic- relating to,
enough to ho d the body weight and yet exib e enough to -ul- little, -ar relating to,
withstand twisting orces. skeleton dried body]
arch
articular cartilage
(ar-TIK-yoo-lar KAR-tih-lij)
[artic- joint, -ul- little, -ar relating to,
cartilage gristle]
articulation
(ar-tik-yoo-LAY-shun)
[artic- joint, -ul- little, -ation state]
athletic trainer
(ath-LET-ik TRAY-ner)
[athlet- prize contender,
-ic relating to]

Continued on p. 209

175
 176 CHAPTER 8 Skeletal System

Flat bones or examp e, ronta or sku bone

P ro t e c t io n Irregular bones or examp e, vertebrae or spina
T e ske eta system protects the so t tissues that are ocated bones
inside o bony cavities. T e sku protects the brain, and the
ribs and breastbone protect vita organs in the chest (heart Some scientists recognize an additiona category ca ed
and ungs). Bone a so protects the vita b ood ce orming sesamoid ( ike a sesame seed), or round, bones. T ese sma
tissue inside the bones themse ves. T e bones o the extremi- bones may deve op within a tendon. An examp e o a arge
ties can a so be moved and used in the de ense o the body sesamoid bone is the kneecap (pate a), which deve ops within
rom outside orces. the pate ar tendon.
Many important bones in the ske eton are c assif ed as ong
bones, and a have severa common characteristics. By study-
M o ve m e n t ing a typica ong bone, you can become ami iar with the
T e f rm attachments between bones and musc es make body structura eatures o the entire group o bones.
movement possib e. As musc es contract and shorten, they
pu on bones and thereby move them.
S t r u c t u r e o Lo n g Bo n e s
Figure 8-1 wi he p you earn the names o the main parts o a
S t o ra g e ong bone. Identi y each o the o owing:
Bones p ay an important part in maintaining homeostasis o
1. D iaphysis or sha tho ow tube made o hard com-
b ood ca cium, a vita substance required or norma nerve and
pact bone, hence a rigid and strong structure ight
musc e unction. T ey serve as a sa ety-deposit box or ca -
enough in weight to permit easy movement
cium. W hen the amount o ca cium in b ood increases above
norma , ca cium moves out o the b ood and into the bones or
storage. Converse y, when b ood ca cium decreases be ow nor-
8 ma , ca cium moves in the opposite direction. It comes out o
storage in bones and enters the b ood. Articula r ca rtila ge
T e ba ance o ca cium deposits and withdrawa s to and Epiphys is Ca nce llous (s pongy)
bone
rom the ske eton is regu ated by a ba ance o hormones. For
Epiphys e a l line
examp e, calcitonin (C ) rom the thyroid g and increases
Re d ma rrow
minera ization o bone and thus reduces b ood ca cium. cavitie s
Parathyroid hormone (P H) rom the parathyroid glands
counterba ances the e ects o ca citonin by decreasing ca -
cium in the bone and thus increasing b ood ca cium.
Compa ct bone
T e medu ary cavities inside o ong bones a so store at.
Me dulla ry
cavity
He m a t o p o ie s is
T e term hematopoiesis is used to describe the process o
Endos te um
b ood ce ormation. It is a combination o two word parts:
hemato meaning b ood and poiesis meaning making. B ood
ce ormation is a vita process carried on in red bone marrow. Dia phys is Ye llow ma rrow
Red bone marrow is so t connective tissue surrounded by the
hard wa s o some bones that produces both red and white
b ood ce s.
Pe rios te um

To see exactly where in the skeleton hemato-

poiesis takes place, check out the images in
Sites o Hematopoiesis at Connect It! at
evolve.elsevier.com.

G ro s s S t r u c t u r e o Bo n e s
Ty p e s o Bo n e s P

T ere are our types o bones. T eir names suggest their shapes: L M
Epiphys is
D
Long bones or examp e, humerus or arm bone
Short bones or examp e, carpa s or wrist bones FIGURE 8-1 Long bone. Frontal section (partial) o a tibia.

2. Medullary cavityho ow area in-
side the diaphysis o a bone; con-
tains so t, yellow bone marrow,
an inactive, atty orm o mar- Compa ct
row ound in the adu t ske eton bone
3. Epiphysesthe ends o a ong
bone; red bone marrow f s in Ca nce llous bone
(diploe )
sma spaces in the spongy bone in-
side the epiphyses; some ye ow marrow
may appear as a person ages
4. Articular cartilagethin ayer o hya ine carti age
covering each epiphysis; unctions ike a thin, smooth
rubber cushion wou d i it were p aced over the ends
o bones where they orm a joint
5. Periosteumstrong membrane o dense f brous tis-
sue covering a ong bone everywhere except at joint
sur aces, where it is covered by articu ar carti age
6. Endosteumthin membrane that ines the medu -
ary cavity
QUICK CHECK
1. Na m e s o m e o th e o rga n s o th e s ke le ta l s ys te m .
2. Wh a t a re th e f ve m a jo r u n ctio n s o th e s ke le ta l s ys te m ?
3. Wh a t a re th e o u r ca te g o rie s o b o n e s in th e s ke le to n ?
4. De s crib e th e m a in e a tu re s o a lo n g b o n e .
S t r u c t u r e o Fla t Bo n e s
F at bones, such as the sternum (breastbone), the ribs, and
many o the sku bones have a simp er structure than most
ong bones. As Figure 8-2 shows, at bones have a ayer o
cance ous bone between outer ayers o compact bone. T e
cance ous bone ayer is ca ed the diploe.
M ic ro s c o p ic S t r u c t u r e o Bo n e s
T e bones o the ske eta system contain two major types o
connective tissue: bone and cartilage.
Bo n e Tis s u e S t r u c t u r e
Bone tissue has di erent microscopic structures, depending
on its ocation and unction. In Figure 8-3, A, the outer ayer o
bone is hard and dense. Bone o this type is ca ed compact
bone. Compact bone appears so id to the naked eye. T e po-
rous bone tissue on the inside o individua bones is ca ed
cancellous bone or spongy bone.
C a n c e llo u s Bo n e (S p o n g y Bo n e )
As the name imp ies, spongy bone contains many spaces
ike a bath sponge. T e cavities are f ed with red or ye ow
marrow. T e beams that orm the attice o spongy bone are
ca ed trabeculae. Figure 8-3, B, shows the microscopic appear-
ance o cance ous bone.
C o m p a c t Bo n e
As you can see in Figure 8-3 and Figure 8-4, compact bone does
not contain a network o open spaces. Instead, the extrace u ar
CHAPTER 8 Skeletal System 177
FIGURE 8-2 Flat bone. Portion o a
skull bone. The outer layers o compact
bone surround the inner cancellous bone
called diploe.
matrix is organized into numerous structura units ca ed
osteons or haversian systems. Each circu ar and tube ike os-
teon is composed o ca cif ed matrix arranged in mu tip e ay-
ers that resemb e the rings o an onion. Each ring is ca ed a
concentric lamella.
T e circu ar ame ae surround the central canal, or haver-
sian canal, which contains b ood vesse s and nerves. T e cen-
tra cana s are connected to each other by transverse canals,
sometimes ca ed Volkmann canals.
Bones are not i e ess structures. W ithin their hard, seem-
ing y i e ess matrix are many iving bone ce s ca ed
osteocytes. Osteocytes are mature bone ce s that were or-
mer y active bone-making osteob ast ce s, but which have
now become dormant. T ese osteocytes ie between the hard
ayers o the ame ae in itt e spaces ca ed lacunae.
In Figure 8-3, B, and Figure 8-4, note that tiny passageways, 8
or cana s, ca ed canaliculi connect the acunae with one an-
other and with the centra cana in each osteon. Nutrients pass
a ong ce extensions o the osteocytes rom the b ood vesse
in the centra cana through the cana icu i and are distributed
to a osteocytes o the osteon.
Note a so in Figure 8-3, B, that numerous b ood vesse s rom
the outer periosteum enter the bone and eventua y pass
through transverse cana sand eventua y to centra cana s.
C a r t ila g e Tis s u e S t r u c t u r e
Cartilage both resemb es and di ers rom bone. As with
bone, it consists more o interce u ar substance than o ce s.
Innumerab e co agenous f bers rein orce the matrix o both
tissues. H owever, in carti age the f bers are embedded in a
f rm ge instead o in a ca cif ed cement substance ike they are
in bone. As a resu t, carti age has the exibi ity o a f rm p as-
tic rather than the rigidity o bone.
Carti age ce s, ca ed chondrocytes, as with the osteocytes
o bone, are ocated in acunae (Figure 8-5). In carti age, acunae
are suspended in the carti age matrix much ike air bubb es in
a b ock o Swiss cheese. Because there are no b ood vesse s in
carti age, nutrients must di use through the matrix to reach
the ce s. Because o this ack o b ood vesse s, carti age re-
bui ds itse very s ow y a ter an injury.
Bo n e D e ve lo p m e n t
M a k in g a n d Re m o d e lin g Bo n e
W hen the ske eton begins to orm in a baby be ore its birth, it
consists not o bones but o carti age and f brous structures
shaped ike bones. Gradua y these carti age mode s become
 178 CHAPTER 8 Skeletal System

Conce ntric la me lla e

Ce ntra l ca na l La cuna Blood ve s s e ls

a nd ne rve
in ce ntra l ca na l
Ca na liculi Os te ocyte in la cuna e
Pe rios te um

Os te on
Tra be cula e
Tra ns ve rs e
ca na l

Pe rfora ting
fibe rs

S pongy
bone

Tra be cula e

8 A B

Os te ocyte s
in la cuna e
Compa ct
bone
FIGURE 8-3 Microscopic structure o bone. The longitudinal section o a
long bone (A) shows the location o the microscopic section illustrated in B. Note P
that the compact bone orming the hard shell o the bone is constructed o cylindri- L M
cal units called osteons. Cancellous (spongy) bone is constructed o thin bony
branches called trabeculae. D

Os te on (have rs ia n s ys te m) Ca na liculi

Chondrocyte s (in la cuna e ) Ma trix

Ce ntra l
(have rs ia n)
ca na l
La cuna e
(conta ining
os te ocyte s )

FIGURE 8-4 Compact bone. Photomicrograph shows circular cross section o FIGURE 8-5 Cartilage tissue. Photomicrograph shows chondro-
a cylindrical osteon. cytes scattered around the tissue matrix in spaces called lacunae.

Os te ocla s ts dis s olve
exis ting bone tis s ue
A
Os te obla s ts form new bone
B endochondral ossi cation, meaning ormed in carti age.
New bone
Os te ocyte s
C o ossif cation have used together.
FIGURE 8-6 Bone remodeling. During remodeling o bone, bone-
dissolving osteoclasts remove the hard calcium salts in bone matrix (A).
Osteoblasts then orm new bone matrix in the area (B) until they eventually
become surrounded and trapped by hard bone and are then called osteo-
cytes (C).
trans ormed into rea bones when the carti age is rep aced with
ca cif ed bone matrix. T is process o constant y remode ing a
growing bone as it changes rom a sma carti age mode to the
characteristic shape and proportion o the adu t bone requires
continuous activity by bone- orming ce s ca ed osteoblasts and
bone-disso ving ce s ca ed osteoclasts, both seen in Figure 8-6.
T e aying down o bone matrix is an ongoing process.
O steob asts f rst ay down organic co agen f bers i needed.
T ey a so re ease a so ution o inorganic ca cium sa ts that
crysta ize on the f bers. T e f bers rein orce the matrix to
withstand twisting orces, and the minera crysta s ca ci y the
bone to make it as hard as bone.
W hen osteob asts eventua y become trapped between
ame ae o hard bone matrix, they stop orming bone and are
ca ed osteocytes. Osteocytes resume their bone-making activity
when osteoc asts (or an injury) remove the surrounding bone.
O steoc asts re ease acids that disso ve the ca cium crysta s.
T is has two e ects: the hard bone matrix is removed, and the
CHAPTER 8 Skeletal System 179
ca cium ions are re eased rom bone tissue to di use into the
b oodstream.
T e combined breaking-bui ding actions o the osteo-
b asts and osteoc asts remode bones into their adu t shapes
(Figure 8-7). T e process o scu pting by the bone- orming
and bone-reabsorbing ce s a ows bones to respond to stress
or injury by changing size, shape, and density.
W hen a bone is mechanica y stressed rom the pu o a
musc e, the osteob asts are stimu ated to strengthen the bone
at that ocation to resist the stress o pu ing musc e. For this
reason, ath etes or dancers may have denser, stronger bones
than ess active peop e.
To learn more about bone remodeling, go to
AnimationDirect online at evolve.elsevier.com.
En d o c h o n d r a l O s s if c a t io n
Many bones o the body are ormed rom carti age mode s, as
i ustrated in Figure 8-7 and Figure 8-8. T is process is ca ed
As you can see in Figure 8-7, a ong bone grows and u ti-
mate y becomes ossif ed rom sma centers within a deve -
oping bone. T ese centers o ossif cation are ocated in the
epiphyses at the ends o a ong bone and rom a arger center 8
ocated in the diaphysis (sha t) o the bone.
An area o carti age ca ed an epiphyseal plate or growth
p ate remains between the epiphyses and the diaphysis as
ong as growth continues. Growth ceases when a epiphysea
carti age is trans ormed into bone. A that remains is a aint
epiphyseal line that marks the ocation where the two centers
Physicians sometimes use concepts o bone deve opment to
determine whether a chi d is going to grow any more. T ey
have an x-ray study per ormed on the chi ds wrist. I it shows
a ayer o epiphysea carti age, they know that additiona growth
wi occur. H owever, i it shows no epiphysea carti age, they
know that growth has stopped and that the individua has at-
tained adu t height.
In t r a m e m b r a n o u s O s s if c a t io n
Some bones, such as the sku bones i ustrated in Figure 8-8,
are ormed by ca cif cation o f brous membranes in a process
ca ed intramembranous ossi cation.
T e so t spots, or ontanels, on a newborn babys sku are
areas o f brous membrane that have not yet u y ossif ed (see
Figure 8-8). As intramembranous ossif cation progresses, a hard
bone p ate orms a comp ete at bone.
QUICK CHECK
1. Wh a t is th e b a s ic s tru ctu ra l u n it o co m p a ct b o n e tis s u e
ca lle d ?
2. Wh a t a re o s te o cyte s ? Wh e re w o u ld yo u f n d th e m in b o n e
tis s u e ?
3. Ho w d o e s ca rtila g e d i e r ro m b o n e ?
4. Wh a t is o s s if ca tio n ? Wh a t is th e ro le o th e o s te o b la s t?
 180 CHAPTER 8 Skeletal System

Ca rtila ge P
Ca lcifie d ca rtila ge
Bone L M
Pe rios te um
Blood ve s s e l D

Os te obla s ts
Blood ve s s e ls ca lcify ca rtila ge
exte nd into a a nd os te ocla s ts
ca rtila ge be gin to hollow Bone grows a s
mode l to be gin out a ce ntra l expa nding ca rtila ge
os s ifica tion. cavity. be come s os s ifie d.

A B C D

FIGURE 8-7 Endochondral ossif cation. As the cartilage o an immature long bone expands by normal
growth, it is invaded by blood vessels carrying bone cells. Osteoblasts calci y cartilage as it becomes avail-
able. As the bone grows, osteoclasts hollow out the medullary cavity. Eventually, ossi cation overtakes carti-
8 lage expansion and urther growth is not possible.

Parie tal bo ne To learn more about bone ormation and

Fonta ne ls
(s oft s pots ) growth, go to AnimationDirect online at
Oc c ipital bo ne
evolve.elsevier.com.

Maxilla
Mandible
A x ia l S k e le t o n
Clavicle T e human ske eton has two divisions: the axial skeleton and
the appendicular skeleton. Go back to Figure 1-9 on p. 13 to
Hume rus S te rnum review the axia -appendicu ar division o body regions.
Bones o the center, or axis, o the body make up the axia
ske eton. T e bones o the sku , spine, and chest and the hyoid
Radius bone in the neck are a in the axia ske eton. T e bones o the
Ulna upper and ower extremities or appendages make up the ap-
pendicu ar ske eton. T e appendicu ar ske eton consists o the
bones o the upper extremities (shou der or pectora gird e,
arms, orearms, wrists, and hands) and the ower extremities
(hip or pe vic gird e, thighs, egs, ank es, and eet) (Table 8-1).
S ac rum Fe mur Locate the various parts o the axia ske eton and the ap-
pendicu ar ske eton in Figure 8-9.
Pe lvic Ilium
bone s Is chium Tibia To better understand this concept, use the
Pubis Fibula Active Concept Map Organization o the Skeleton
at evolve.elsevier.com.
S

Bone R L
Ca rtila ge or FIGURE 8-8 Bone development in a newborn. An in ants skeleton has
me mbra ne I many bones that are not yet completely ossi ed.
 CHAPTER 8 Skeletal System 181

Epiphys e a l
Epiphys e a l line
pla te

L M

D
Bone grows Ce nte rs of
in le ngth a nd os s ifica tion fus e ,
dia me te r a s s topping growth
os s ifica tion and leaving only a
continue s. faint epiphyseal line.

E F G

TABLE 8-1 Main Parts o the Skeleton (206 bones)

8
AXIAL S KELETON (80 bo ne s ) APPENDICULAR S KELETON (126 bo ne s )
Skull Uppe r extre m itie s
Cranial bone s Pe ctoral girdle
Ear bone s Arm and ore arm bone s
Face bone s Wris t bone s
Spine Hand bone s
Ve rte brae Lowe r extre m itie s
Thorax Pe lvic girdle
Ribs Thigh and le g bone s
Ste rnum Ankle bone s
Hyoid bone Foot bone s

S k u ll
Re g io n s o t h e S k u ll
T e skull consists o 8 bones that orm the cranium, 14 bones
that orm the ace, and 6 tiny bones in the middle ear. You
can earn the names and ocations o these bones by studying
Table 8-2. Find as many o them as you can on Figure 8-10. Fee
their out ines in your own body where possib e. Examine
them on a medica ske eton or sku mode i you have access
to one.
S in u s e s
Sinuses are spaces or cavities inside some o the crania bones.
Four pairs o them (those in the rontal, maxilla, sphenoid,
and ethmoid bones) have openings into the nose and thus are
re erred to as paranasal sinuses (Figure 8-11).
My sinuses give me so much troub e. H ave you ever
heard this comp aint or perhaps uttered it yourse ? Sinuses
cause troub e when the mucous membrane that ines them
becomes in amed, swo en, and pain u . For examp e, in am-
mation in the ronta sinus ( rontal sinusitis) o ten begins as a
resu t o a nasa in ection. T e word part -itis added to a word
means in ammation o .
Mastoiditis, in ammation o the air spaces within the
mastoid portion o the temporal bone, can produce very seri-
ous medica prob ems i not treated prompt y (Figure 8-12).
Locate the mastoid process in Figure 8-10, A.
 182 CHAPTER 8 Skeletal System

Fro ntal bo ne
Parie tal bo ne
Nas al bo ne
Oc c ipital bo ne
Zyg o matic Maxilla
bo ne
Mandible Ce rvic al ve rte brae (7)

Clavicle Clavicle
Gle no id
c avity

S te rnum S c apula S c apula

Co s tal c artilag e Tho rac ic
Ribs Ribs ve rte brae (12)

Hume rus Hume rus

Ve rte brae

Radius Lumbar
Ulna
Ulna ve rte brae (5)

Ilium Radius

8 S ac rum

Carpals
Me tac arpals
Co c c yx
Phalang e s

Is chium Ilium
Coxal Fe mur
P ubis bo ne Is chium
Fe mur
P ubis

Pate lla

Tibia Tibia

S Fibula S
Fibula
R L L R

I Axia l s ke le ton I
Tars als
Appe ndicula r
Tars als s ke le ton
Me tatars als Phalang e s
Me tatars al bo ne s
Phalang e s
A B Calc ane us
(a ta rs a l bone )

FIGURE 8-9 Human skeleton. The axial skeleton is distinguished by a blue tint. A, Anterior view. B, Pos-
terior view.
 CHAPTER 8 Skeletal System 183

TABLE 8-2 Bones o the Skull

NAME NUMBER DES CRIPTION
Cranial Bo ne s
Frontal 1 Fore he ad bone ; als o orm s ront part o oor o cranium and m os t o uppe r part o eye s ocke ts ;
cavity ins ide bone above uppe r m argins o eye s ocke ts (orbits ) calle d rontal s inus ; line d w ith
m ucous m e m brane
Parie tal 2 Form bulging tops ide s o cranium
Te m poral 2 Form lowe r s ide s o cranium ; contain m iddle and inne r e ar s tructure s ; m as toid s inus e s are m ucos a-
line d s pace s in m as toid proce s s , the protube rance be hind e ar; exte rnal auditory canal is a tube
le ading into te m poral bone ; m us cle s attach to s tyloid proce s s
Occipital 1 Form s pos te rior o s kull; s pinal cord e nte rs cranium through large hole ( oram e n m agnum ) in occipital
bone
Sphe noid 1 Form s ce ntral part o oor o cranium ; pituitary gland locate d in s m all de pre s s ion in s phe noid calle d
s e lla turcica (Turkis h s addle ); m us cle s attach to pte rygoid proce s s
Ethm oid 1 Com plicate d bone that he lps orm oor o cranium , s ide walls and roo o nos e and part o its m iddle
partition (nas al s e ptum m ade up o the e thm oids pe rpe ndicular plate and the vom e r bone ), and 8
part o orbit; contains honeycom blike s pace s , the e thm oid s inus e s ; s upe rior and m iddle conchae
are proje ctions o e thm oid bone ; orm le dge s alongs ide wall o e ach nas al cavity
Face Bo ne s
Nas al 2 Sm all bone s that orm uppe r part o bridge o nos e
Maxilla 2 Uppe r jaw bone s ; als o he lp orm roo o m outh, oor, and s ide walls o nas al cavity and oor o orbit;
large cavity in m axillary bone is m axillary s inus
Zygom atic 2 Che e k bone s ; als o he lp orm orbit
Mandible 1 Lowe r jaw bone articulate s w ith te m poral bone at condyloid proce s s ; s m all ante rior hole or pas s age
o ne rve s and ve s s e ls is the m e ntal oram e n
Lacrim al 2 Sm all bone s ; he lp orm m e dial wall o eye s ocke t and s ide wall o nas al cavity
Palatine 2 Form pos te rior part o roo o m outh and oor and s ide walls o nos e and part o oor o orbit
In e rior nas al concha 2 Form curve d le dge along ins ide o s ide wall o nos e , be low m iddle concha
Vom e r 1 Form s lowe r pos te rior part o nas al s e ptum
Ear Bo ne s
Malle us 2 Malle us , incus , and s tape s are tiny bone s in m iddle e ar cavity in te m poral bone ; m alle us m e ans
ham m e r s hape o bone
Incus 2 Incus m e ans anvil s hape o bone
Stape s 2 Stape s m e ans s tirrup s hape o bone
Hyo id Bo ne
Hyoid bone 1 U-s hape d bone in ne ck; not joine d to any othe r bone (not part o s kull); be twe e n m andible and uppe r
e dge o larynx
 184 CHAPTER 8 Skeletal System

S qua mous s uture Corona l s uture

Fro ntal bo ne
Parie tal bo ne

La mbdoida l Nas al
s uture bo ne

Oc c ipital
bo ne Ethmo id
Exte rna l bo ne
auditory canal Lac rimal
bo ne
Parie tal
Condyloid S phe no id bo ne
proce s s of ma ndible bo ne
Te mpo ral
Te mpo ral bo ne Zyg o matic bo ne
Ma s toid proce s s bo ne
Middle concha
S tyloid proce s s of te mpora l of e thmoid
S
Pe rpe ndicula r
P te rygoid proce s s of s phe noid pla te of
P A Maxilla e thmoid
I Inferior
Mandible nas al
A RIGHT LATERAL VIEW conchae
Me nta l fora me n Vo me r
of ma ndible
S
Cris ta ga lli of
R L
e thmoid bone
8 Cribriform pla te Fro ntal bo ne I
Ethmo id bo ne B ANTERIOR VIEW
S upe rior
orbita l fis s ure
Le s s e r wing
Optic fora me n Gre a te r wing S phe no id
Foramen ovale S e lla turcica bo ne
Fora me n
la ce rum Te mpo ral bo ne
Fora me n Pe trous pa rt
s pinos um of te mpora l bone

Internal acoustic Parie tal bo ne

me a tus
Oc c ipital bo ne
Jugula r fora me n
A
Fora me n ma gnum
L R

P Pa la tine proce s s
of ma xilla
Ha rd
C CRANIAL FLOOR S UPERIOR VIEW
Zygoma tic a rch
Horizonta l pla te pa la te
of pa la tine bone

Te mpo ral bo ne Vo me r
S tyloid proce s s
Jugula r fora me n
Fora me n ova le
Occipita l condyle
Ma s toid proce s s
Fora me n ma gnum
Oc c ipital bo ne
Parie tal bo ne

A
FIGURE 8-10 Skull. A, Right side. B, Anterior.
C, Floor o cranial cavity, as viewed rom above a - R L
ter the top o the skull is removed. D, Base o the
skull, as viewed rom below. D P
INFERIOR VIEW
 CHAPTER 8 Skeletal System 185

S phe noid Fronta l s inus S phe noid s inus

s inus
Ethmoid a ir ce lls
La crima l s a c

Na s a l S upe rior
concha e Middle
(turbina te s ) Infe rio r
Ma xilla ry s inus Ora l cavity

S S

R L R L

A I B I

FIGURE 8-11 Paranasal sinuses. A, Lateral view o the ace shows the position o the paranasal sinuses.
B, Anterior view shows the relationship o the sinuses to each other and the nasal cavity.

Coronal suturejoins the anterior margins o parieta

bones with the posterior margin o the rontal bone
Sagittal suturejoins the media margins o the pa-
rieta margins to each other (not visib e in Figure 8-10)

You may be ami iar with the so t spots on a babys sku .

T e so t areas are six ontanels, or areas where intramembra- 8
nous ossif cation remains incomp ete at birth. You can see
them depicted in Figure 8-8. Fontane s a ow some compression
o the sku during birth without much risk o breaking the
S sku bones. T ey a so may be identif ed by a c inician as an
important diagnostic indication o the position o the babys
A P
head be ore de ivery.
I T e ontane s use to orm sutures be ore a baby is 2 years o d.
FIGURE 8-12 Mastoiditis. Note the redness and swelling over the
mastoid process o the temporal bone behind the le t ear. Hyo id Bo n e
T e odd itt e hyoid bone resemb es the Greek etter upsi on
In ectious materia rom midd e ear in ections sometimes ( or ). Un ike other bones, it does not orm a joint with any
f nds its way into the mastoid air ce s. T ese air ce s do not other bone o the ske eton. As you can see in Figure 8-13, the
drain into the nose ike the paranasa sinuses do. T us in ec- hyoid bone is ocated in the neck, where it serves as an anchor
tious materia that accumu ates may damage the thin, bony or tongue musc es and he ps support the arynx (voice box).
partition that separates the air ce s rom the brain. I this
occurs, the in ection may spread to the brain or the mem-
branes covering the brain, a i e-threatening situation.
I antibiotic therapy ai s, chronic mastoiditis may be treated
by surgica y removing the a ected tissue, inc uding interna
parts o the earrendering the individua dea in the a ected ear.
S
S u t u r e s a n d Fo n t a n e ls
R L
Note in Figure 8-10 that two parietal bones, which give shape
to the bu ging topside o the sku , orm immovab e joints I
ca ed sutures with severa bones.
Hyo id bo ne
Lambdoidal suturejoins posterior margins o pari-
La rynx (voice box)
eta bones to the occipital bone
Squamous sutures joins atera margin o each pari-
eta bone with the superior margin o the tempora FIGURE 8-13 Hyoid bone. The U-shaped hyoid bone is unique because
bone and to the atera part o the sphenoid bone it does not attach to any other bone o the skeleton.
 186 CHAPTER 8 Skeletal System

Ve r t e b r a l C o lu m n (S p in e )
vertebras ong, orked spinous process. T e seven cervica
Ve r t e b r a e vertebrae orm the supporting ramework o the neck.
T e term vertebral column may conjure up a menta picture o At the top o Figure 8-14, C, you can see that the f rst two
the spine as a sing e ong bone shaped ike a co umn in a cervica vertebrae have an unusua structure compared to the
bui ding, but this is ar rom true. T e vertebra co umn con- rest o the vertebrae. Figure 8-16 shows that the f rst cervica
sists o a series o 24 separate bones, or vertebrae, connected vertebraca ed the atlasis a ring made up o an anterior
in such a way that they orm a exib e curved rod (Figure 8-14). arch and posterior arch. T e superior articu ar processes join
Di erent sections o the vertebra co umn have di erent with the processes ca ed occipital condyles on the base o the
names: cervical region, thoracic region, and lumbar region. sku (see Figure 8-10, D).
A though individua vertebrae are sma bones that are ir- T e second cervica vertebra is the axis. T e axis has a
regu ar in shape, they have severa we -def ned parts. Note, pointed dens (meaning tooth) that extends up into the curve
or examp e, in Figure 8-15, the body o the umbar vertebra, its o the at ass anterior arch to act as pivot around which the
spinous process (or spine), its two transverse processes, and the at as (and the sku ) can swive e t and right. T is is yet an-
ho e in its center, ca ed the vertebral oramen. T e superior and other examp e o structure ts unction because rotation o the
in erior articular processes permit imited and contro ed move- neck wou d be very imited without this unique structure.
ment between adjacent vertebrae.
o ee the tip o the spinous process o one o your verte- S a c ru m a n d Co c c yx
brae, simp y bend your head orward and run your f ngers T e sacrum and coccyx are two additiona bones o the ver-
down the back o your neck unti you ee a projection o bone tebra co umn ocated just be ow the 24 vertebrae. In in ants,
at shou der eve . T is is the tip o the seventh cervica the sacrum exists as f ve separate vertebrae that start to use

Rig ht late ral view Ante rio r view Po s te rio r vie w

8 S
Atlas Axis S S

P A R L L R
C
c u

I I I
r

r
v

Ce rvic al
a

i
c
t
er u

ve rte brae
a
l

(7 )
re
tu
a
v
r

u
c
c

Tho rac ic
i
c
ar

ve rte brae
o

(12)
h
T

L
u
m
b
a
r
c
u
rv

Inte r-
a
tu

ve rte bra l
r

Lumbar
e

fora mina
ve rte brae
(5)
re
a
tu
u
rv
cl

a
r
c

S ac rum
a
S

A B Co c cyx C

FIGURE 8-14 The vertebral column.

 CHAPTER 8 Skeletal System 187

S upe rior S pinous proce s s Tra ns ve rs e S upe rior

a rticula r proce s s a rticula r
proce s s Ve rte bra l proce s s
fora me n
Tra ns ve rs e
proce s s Body

S pinous
proce s s
Body

P Infe rior a rticula r S

proce s s
R L P A

A A B I

FIGURE 8-15 Typical vertebra. Third lumbar vertebra. A, From above (superior view). B, From the side
(lateral view).

Atlas and axis

S upe rior a rticula r together about age 18 and are comp ete y used by
s urfa ce (for De ns 25 to 33 years o age. Likewise, three to f ve tiny
occipita l condyle ) Pos te rior a rch
(of a tla s ) tai vertebrae use to orm a sing e coccyx by ear y 8
adu thood.
Atlas A 26 bones o the vertebra co umn are i us-
trated in Figure 8-14 and described in Table 8-3.
Ante rior a rch
(of a xis )
S p in a l C u r va t u r e s
H ave you ever noticed the our curves in your spine?
Axis Tra nsve rs e
proce s s e s Your neck and the sma o your back curve s ight y
P inward or orward, whereas the chest region o the
L spine and the owermost portion curve in the op-
R posite direction (see Figure 8-14).
A

FIGURE 8-16 Atlas and axis. The toothlike dens o the axis (second Convex and Concave Curvatures
cervical vertebra) extends along the inside o the anterior arch o the atlas W hen you ook at the spine rom the rear, you wi see the
( rst cervical vertebra) to act as a pivot. Because the atlas supports the en- thoracic and sacra curves, ca ed convex curvatures because
tire skull, this arrangement allows the head to rotate.
they round outward. T e cervica and umbar curves o
the spine are ca ed concave curvatures because they curve
inward.
TABLE 8-3 Bones o the Vertebral Column T is is not true, however, o a newborn babys spine. It orms
a continuous convex curveca ed the primary curvature
NAME NUMBER DES CRIPTION
rom top to bottom (Figure 8-17). Gradua y, as the baby earns
Ce rvical 7 Uppe r 7 ve rte brae , in ne ck re gion;
to ho d up his or her head, a reverse or concave curve deve ops
f rs t ce rvical ve rte bra calle d
atlas ; s e cond, axis
in the neck (cervica region). Later, as the baby earns to stand,
the umbar region o his or her spine a so becomes concave. T e
Thoracic 12 Next 12 ve rte brae ; ribs attach to
concave cervica and umber curvatures are sometimes ca ed
ve rte brae the s e
secondary curvatures because they appear ater in deve opment
Lum bar 5 Next 5 ve rte brae ; in s m all o back
than the primary (convex) curvatures.
ve rte brae
T e norma curves o the spine have important unctions.
Sacrum 1 In child, 5 s e parate ve rte brae ; in T ey give it enough strength to support the weight o the rest
adult, us e d into one
o the body. T ese curves a so make it possib e to ba ance the
Coccyx 1 In child, 3 to 5 s e parate ve rte brae ; weight o the body, which is necessary or us to stand and
in adult, us e d into one wa k on two eet instead o having to craw on a ours. A
 188 CHAPTER 8 Skeletal System

S
curved structure has more strength than a straight one o the
same size and materia s. (T e next time you pass a bridge, ook
A P to see whether or not its supports orm a curve.)
I C ear y the spine needs to be a strong structure. It supports
the head that is ba anced on top o it, the ribs and interna
organs that are suspended rom it in ront, and the hips and
egs that are attached to it be ow.

Abnormal Spinal Curvatures

FIGURE 8-17 Spinal curvature o an in ant. The spine o the newborn
baby orms a continuous convex curve.
Poor posture, genetics, or disease may cause abnorma curva-
tures (Figure 8-18) that inter ere with norma breathing and
other vita unctions. I the umbar curve is abnorma y exag-
gerated, the condition may be ca ed swayback or lordosis.
Abnorma thoracic curvature is kyphosis or hunchback.
T is termino ogy is not universa . Some re er to the norma
umbar curve as ordosis and to excessive curvature as hyper-
lordosis. Likewise, kyphosis may re er to the norma thoracic
curve and hyperkyphosis to excessive curvature.
Abnorma side-to-side curvature is scoliosis. Sco iosis is a
re ative y common condition that appears be ore ado escence,
usua y o unknown cause.

8 C LIN ICA L APPLICATION

VERTEBROPLASTY
Ve rte bro plas ty is an orthope dic proce dure that involve s the
inje ction o a s upe r glue type o bone ce m e nt to re pair
racture d and com pre s s e d (collaps e d) ve rte brae (s e e illus tra-
tion). In the s e patie nts the body o one or m ore ve rte brae
(ge ne rally lowe r thoracic and/or lum bar s e gm e nts ) has unde r-
gone a com pre s s ion racture due to os te o-
poros is , traum a, tum ors , or prolonge d
us e o s te roid drugs .
A balloon is in ate d to re s tore the ve rte bras he ight; the n
bone ce m e nt is inje cte d by ne e dle into the are a o com pre s -
s ion, w he re it quickly harde ns and thus s tabilize s and s e als
the racture .
Ve rtebroplasty is cost e e ctive , has a short re cove ry pe riod,
and in many cas es may e liminate the ne e d or di f cult and ex-
pe nsive spinal s urge ry. The procedure is not inte nded or tre at-
me nt o herniate d dis ks and othe r type s o ve rte bral pathology.

Fra cture d
ve rte bra Ne e dle

Inje ction of bone ce me nt into fra cture

Re pa ire d
ve rte bra
S

P A

I
 CHAPTER 8 Skeletal System 189

Lordos is Kyphos is S colios is S colios is Corre cte d s colios is

A B C D E

FIGURE 8-18 Abnormal spinal curvatures. A, Lordosis (hyperlordosis). B, Kyphosis (hyperkyphosis).

C, Scoliosis. D, An x-ray showing pronounced scoliosis and E, an x-ray o an 11-year-old girl a ter corrective
surgery or scoliosis.

Sco iosis treatments vary depending on the degree o atera
curvature and resu ting de ormity o individua vertebrae. radi-
tiona treatments or sco iosis inc ude ong-term use o support-
ive braces, transcutaneous (through-the-skin) musc e stimu a-
tion, and surgery. E ectrica stimu ation o musc es on one side
o the spine over time he ps pu the vertebrae into a more nor-
ma position. Surgica procedures to straighten the spine may
invo ve bone gra ts and the insertion o interna meta rods.
Th o r a x
we ve pairs o ribs, the sternum (breastbone), and the thoracic
vertebrae orm the bony cage known as the thorax or chest.
Each o the 12 pairs o ribs is attached posterior y to a
vertebra. A so, a the ribs except the ower two pairs are at-
tached to the sternum and so have anterior and posterior 8
anchors.
Look c ose y at Figure 8-19 and you can see that the f rst
seven pairs o ribs (sometimes re erred to as the true ribs) are
attached to the sternum by costal cartilage. T e remaining ribs
are ca ed alse ribs because they do not attach direct y to the
sternum.
Fa se rib pairs 8, 9, and 10 attach to the carti ages o rib
pair 7. T e ast two pairs o a se ribs, in contrast, are not at-
tached to any costa carti age but seem to oat ree in ront,
hence their descriptive name, oating ribs (Table 8-4).

Cos tos te rna l a rticula tion Clavicle

C7
T1
1
S te rnoclavicula r
2 joint
3 Ma nubrium
True ribs 4 Body S te rnum

5 Xiphoid
proce s s
6
7
Cos ta l
8 11 ca rtila ge
Fals e ribs 9 12 S
L1
10 R L

Flo ating ribs I

FIGURE 8-19 Thorax. Rib pairs 1 through 7, the true ribs, are attached by cartilage to the sternum. Rib pairs
8 through 10, the alse ribs, are attached to the cartilage o the seventh pair. Rib pairs 11 and 12 are called
f oating ribs because they have no anterior cartilage attachments.
 190 CHAPTER 8 Skeletal System

T e on y direct point o attachment between bones o the

TABLE 8-4 Bones o the Thorax
upper extremity and thorax occurs at the sternoclavicular
NAME NUMBER DES CRIPTION joint between the c avic e and the sternum or breastbone. As
True ribs 14 Uppe r s eve n pairs ; attache d to you can see in Figures 8-9 and 8-19, this joint is very sma .
s te rnum by cos tal cartilage s Because the upper extremity is capab e o a wide range o mo-
Fals e ribs 10 Lowe r f ve pairs ; lowe s t two pairs tion, great pressures can occur at or near the joint. As a resu t,
do not attach to s te rnum ; the re - ractures o the c avic e are very common.
ore , calle d oating ribs ; next T e humerus is the ong bone o the arm and the second
thre e pairs attache d to s te rnum ongest bone in the body. It is attached to the scapu a at its
by cos tal cartilage o s eve nth ribs proxima end, where it is he d in p ace and permitted to move
Ste rnum 1 Bre as tbone ; s hape d like a dagge r; primari y by a group o musc es that are together ca ed the
pie ce o cartilage at lowe r e nd o rotator cuf .
bone calle d xiphoid proce s s ; T e dista end o the humerus articu ates with the two
s upe rior portion calle d the
bones o the orearm at the e bow joint. T e bones o the
m anubrium
orearm are the radius and the ulna.
T e anatomy o the e bow is a good examp e o how struc-
ture is re ated to unction. Note in Figure 8-20 that the rounded
A p p e n d ic u la r S k e le t o n trochlea o the humerus f ts into the trochlear notch o the u na
O the 206 bones that orm the ske eton as a who e, 126 are to orm a hinge ike structure that a ows the e bow to bend
contained in the appendicu ar subdivision (see Figure 8-9). or ex.
Note that the bones in the shou der, or pectoral girdle, con- Notice a so that the arge bony process o the u na, ca ed
nect the bones o the arm, orearm, wrist, and hands to the the olecranon, f ts nice y into a arge depression on the pos-
axia ske eton o the thorax, and the hip, or pelvic girdle, con- terior sur ace o the humerus, ca ed the olecranon ossa. T is
nects the bones o the thigh, eg, ank e, and oot to the axia arrangement prevents the hinge o the e bow rom extend-
8 ske eton o the pe vis. ing beyond a straight-arm positiona stabi ity needed to
ho d objects e cient y.
QUICK CHECK T e radius and the u na o the orearm articu ate with each
other and with the dista end o the humerus at the e bow
1. Wh a t is th e d i e re n ce b e tw e e n th e a xia l s ke le to n a n d th e
a p p e n d icu la r s ke le to n ? joint. In addition, they a so touch each another dista y where
2. Wh a t is a s u tu re ? A o n ta n e l? A s in u s ? they articu ate with the bones o the wrist. In the anatomica
3. Wh a t is th e hyo id b o n e a n d w h e re is it lo ca te d ? position, with the arm at the side and the pa m acing or-
4. Na m e th e s e ctio n s o th e ve rte b ra e ? Ho w m a ny b o n e s a re ward, the radius runs a ong the atera side o the orearm, and
in e a ch s e ctio n ? the u na is ocated a ong the media side o the orearm.
5. Ho w d o e s a a ls e rib d i e r ro m a tru e rib ?
T e wrist and the hand have more bones in them or their
size than any other part o the body8 carpal or wrist bones,
5 metacarpal bones that orm the support structure or the
U p p e r Ex t r e m it y pa m o the hand, and 14 phalanges, or f nger, bones
T e scapula, or shou der b ade, and the clavicle, or co ar 27 bones in a (Table 8-5). T is composition is very important
bone, compose the shoulder girdle, or pectoral girdle. T is structura y. T e presence o many sma bones in the hand
structure connects the upper extremity to the axia ske eton. and wrist and the many movab e joints between them makes

TABLE 8-5 Bones o the Upper Extremities

NAME NUMBER DES CRIPTION
Clavicle 2 Collar bone s ; only joints be twe e n s houlde r girdle and axial s ke le ton are thos e be twe e n e ach clavicle and
s te rnum (s te rnoclavicular joints )
Scapula 2 Shoulde r blade s ; s capula plus clavicle orm s s houlde r girdle ; acrom ion proce s s tip o s houlde r that orm s
joint w ith clavicle ; gle noid cavityarm s ocke t
Hum e rus 2 Arm bone (m us cle s are attache d to the gre ate r tube rcle and to the m e dial and late ral e picondyle s ; the troch-
le a articulate s w ith the ulna; the s urgical ne ck is a com m on racture s ite )
Radius 2 Bone on thum b s ide o ore arm (m us cle s are attache d to the radial tube ros ity and to the s tyloid proce s s )
Ulna 2 Bone on little f nge r s ide o ore arm ; ole cranon proce s s proje ction o ulna know n as e lbow or unny bone
(m us cle s are attache d to the coronoid proce s s and to the s tyloid proce s s )
Carpal bone s 16 Irre gular bone s at uppe r e nd o hand; anatom ical w ris t
Me tacarpals 10 Form ram ework o palm o hand
Phalange s 28 Finge r bone s ; thre e in e ach f nge r, two in e ach thum b
 CHAPTER 8 Skeletal System 191

Gre a te r He a d Trochle a r
tube rcle notch Ole cra non
Le s s e r proce s s
tube rcle He a d of Coronoid Hume rus
ra dius proce s s
Inte rtube rcula r Ra dia l
groove tube ros ity Ra dia l Coronoid
fos s a fos s a
De ltoid
tube ros ity Nutrie nt La te ra l
A Me dia l
fora me n e picondyle
C e picondyle
B Ca pitulum Trochle a
Radius Ulna
He a d of
Hume rus ra dius Coronoid
proce s s
Radius
Coronoid
fos s a Ulna
Ra dia l fos s a
ANTERIOR C
La te ra l Me dia l
S tyloid VIEW
e picondyle e picondyle
S tyloid proce s s
proce s s of ulna
of ra dius S
Ca pitulum
Trochle a B L M
A
I

He a d
Gre a te r
tube rcle
Ole cra non
proce s s
8
Coronoid
He a d of ra dius Hume rus
proce s s
Ana tomica l
ne ck Ne ck
Ole cra non
Ra dia l Me dia l fos s a
S urgica l ne ck tube ros ity e picondyle La te ra l
D e picondyle
F Ole cra non
Coronoid proce s s
Ulna Radius E
Hume rus proce s s

Ulna
Ole cra non Radius
POSTERIOR
fos s a La te ra l VIEW
e picondyle S tyloid F
S tyloid proce s s
proce s s of ra dius
Me dia l S
of ulna
e picondyle
E M L
Trochle a
D I FIGURE 8-20 Right arm and orearm.

the human hand high y maneuverab ea owing us to easi y
make and use too s.
Figure 8-21 shows the re ationships between the bones o
the wrist and hand.
Lo w e r Ex t r e m it y
T e hip girdle, or pelvic girdle, is the part o the ower ex-
tremity that connects to the trunk. T e pe vic gird e as a who e
consists o two arge coxal bones, one ocated on each side o
the pe vis, attached in erior y to the sacrum o the vertebra
co umn. T is ring ike arrangement o bones provides a strong
base o support or the torso and connects the ower extremi-
ties to the axia ske eton.
In an in ants body, each coxa bone consists o three sepa-
rate bonesthe ilium, the ischium, and the pubis (see
Figure 8-8). T ese bones grow together to become one bone in
an adu t (see Figures 8-9 and 8-25 on pp. 182 and 195.
Just as the humerus is the on y bone in the arm, the emur
is the on y bone in the thigh (Figure 8-22). It is the ongest bone
 192 CHAPTER 8 Skeletal System

D
III
II IV L M
Dis tal
III P
phalanx
II Middle
IV
V
phalanx

III IV V Proximal
II
I phalanx
V Me tac arpal
bo ne
I
II III IV Hamate
V
I Capitate
Hamate
Trape zo id Trape zo id
Pis ifo rm Trique trum
Trape zium Trape zium
Capitate Lunate
S c apho id S c apho id
Trique trum
S tyloid proce s s
Lunate of ulna
S tyloid proce s s
of ra dius
Radius Ulna Ulna r he a d

POSTERIOR VIEWS

FIGURE 8-21 Right hand and wrist. Note that the phalanges o each respective nger are designated with
8 a Roman numeral.

C LIN ICA L APPLICATION

PALPABLE BONY LANDMARKS Zygoma tic bone
He alth pro e s s ionals o te n ide nti y exte rnally palpable bony land- Angle of ma ndible
m arks w he n de aling w ith the s ick and injure d. Palpable bony ony Acromion proce s s of s ca pula
landm arks are bone s that can be touche d and ide ntif e d through gh
the s kin. They s e rve as re e re nce points in ide nti ying othe r body
dy Clavicle
s tructure s .
Try to ide nti y as m any o the e xte rnally palpable bone s o
the s ke le ton as pos s ible on your ow n body. Us ing the s e ass La te ra l e picondyle of hume rus
points o re e re nce w ill m ake it e as ie r or you to vis ualize the Me dia l e picondyle of hume rus
place m e nt o othe r bone s that cannot be touche d or palpate d
through the s kin. Ilia c cre s t

S tyloid proce s s of ra dius

S tyloid proce s s of ulna

Pa te lla

Ante rior borde r of tibia

Me dia l ma lle olus of tibia S

La te ra l ma lle olus of fibula R L
Me ta ta rs a ls
I
 CHAPTER 8 Skeletal System 193

Ne ck FIGURE 8-22 Right thigh, knee joint, and leg. A, B, and C are anterior views.
D is a posterior view.
He a d
Gre a te r
trocha nte r
Inte rtrocha nte ric
line

Le s s e r
trocha nte r Me dia l
e picondyle
Fe mur
Pate lla
La te ra l
Fe mur e picondyle
S Me dia l
condyle
L M La te ra l
condyle Tibia l
La te ra l I tube ros ity
e picondyle
Adductor He a d of
fibula Tibia
tube rcle
La te ra l
condyle Me dia l
Me dia l Fibula
e picondyle
B s urfa ce
of tibia
Pa te lla r S
s urfa ce Me dia l
A condyle L M

Inte rcondyla r Poplite a l

I
8
La te ra l e mine nce s urfa ce
condyle of fe mur
Me dia l La te ra l
condyle e picondyle

He a d of La te ra l condyle
fibula Tibia l
tube ros ity Me dia l
condyle
Inte rcondyla r fos s a
Cre s t
Me dia l La te ra l condyle
condyle
He a d of fibula
Pos te rior S
Pos te rior
s urfa ce
Tibia S D s urfa ce
Fibula of tibia
of fibula M L

L M I

A s ender, nonweight-bearing, and rather ragi e bone named

La te ra l
ma lle olus Me dia l
ma lle olus
C that might surprise you because toes are shorter than f ngers.
in the body and articu ates proxima y (toward the hip) with
the coxa bone in a deep, cup-shaped socket ca ed the
acetabulum. T e articu ation o the head o the emur in the
acetabu um is more stab e than the articu ation o the head o
the humerus with the scapu a in the upper extremity. As a re-
su t, dis ocation o the hip occurs ess o ten than does disar-
ticu ation o the shou der. Dista y, the emur articu ates with
the kneecap, or patella, and the tibia, or shinbone. T e tibia
orms a rather sharp edge or crest a ong the anterior o the eg.
the bula ies a ong the outer or atera border o the eg.
oe bones have the same name as f nger bonesphalanges.
T ere is the same number o toe bones as f nger bones, a act
Foot bones comparab e to the metacarpa s and carpa s o
the hand have s ight y di erent names. T ey are ca ed
metatarsals and tarsals in the oot (Figure 8-23). Just as each
hand contains f ve metacarpa bones, each oot contains f ve
metatarsa bones. H owever, the oot has on y seven tarsa
bones, in contrast to the hands eight carpa s. T e argest tarsa
bone is the calcaneus, or hee bone. T e talus is the second
argest tarsa bone and articu ates with the tibia at the ank e
joint. T e bones o the ower extremities are summarized in
Table 8-6.
 194 CHAPTER 8 Skeletal System

Dis tal phalanx You stand on your eet, so it is important that certain ea-
Middle phalanx tures o their structure make them ab e to support the bodys
weight. T e great toe, or examp e, is considerab y more so id
and ess mobi e than the thumb. T e oot bones are he d to-
Phalang e s gether in such a way as to orm springy engthwise and cross-
Proximal
phalanx wise arches.
wo arches extend in a engthwise direction in the oot
(Figure 8-24, A). O ne ies on the inside part o the oot
and is ca ed the medial longitudinal arch. T e other ies
a ong the outer edge o the oot and is named the lateral
longitudinal arch. Another arch extends across the ba o
Me tatars als
the oot; this arch is ca ed the transverse arch, or metatarsal
I
arch (Figure 8-24, C).
II III T ese arches provide great supporting strength and a
IV
V Cune ifo rm
high y stab e base. Strong igaments and eg musc e tendons
I II III bo ne s norma y ho d the oot bones f rm y in their arched positions.
Frequent y, however, the oot igaments and tendons weaken.
T e arches then atten, a condition appropriate y ca ed allen
Cubo id bo ne
arches or at eet (Figure 8-24, B).
Navic ular bo ne
Tars als
A
S k e le t a l Va r ia t io n s
M L
Many di erent actors cause each individua s ske eton to vary
Talus P rom a other human ske etons. In this section, we exp ore a
8 Calc ane us bo ne ew o those actors.

M a le -Fe m a le S k e le t a l D i e r e n c e s
FIGURE 8-23 Right oot. Compare the names and numbers o oot
bones (viewed here rom above) with those o the hand bones shown in A mans ske eton and a womans ske eton di er in severa ways.
Figure 8-21. I you were to examine a ma e ske eton and a ema e ske eton
p aced side by side, you wou d
probab y f rst notice the di er-
TABLE 8-6 Bones o the Lower Extremities
ence in their sizes. Most ma e
NAME NUMBER DES CRIPTION ske etons have bones that are
Coxal bone 2 Hipbone s ; ilium uppe r aring part o pe lvic bone ; is chium lowe r arger, with more distinct bumps
pos te rior part; pubic bone lowe r ront part; ace tabulum hip and other markings, than most
s ocke t; s ym phys is pubis joint in m idline be twe e n two pubic ema e ske etons. T is di erence
bone s ; pe lvic inle tope ning into true pe lvis or pe lvic cavity; i resu ts part y rom the di erence
pe lvic inle t is m is s hape n or too s m all, in ant s kull cannot e nte r
in musc e tension on bonesthe
true pe lvis or natural birth
more tension on bone, the bigger
Fe m ur 2 Thigh bone s ; he ad o e m urball-s hape d uppe r e nd o bone ; f ts and denser the bone gets at the
into ace tabulum (m us cle s are attache d to the gre ate r and le s s e r
points o musc e attachment.
trochante rs and to the late ral and m e dial e picondyle s ; the late ral
T ese ma e- ema e distinc-
and m e dial condyle s orm articulations at the kne e )
tions are visib e in near y every
Pate lla 2 Kne e cap
bone o the body, so it is no
Tibia 2 Shinbone ; m e dial m alle olus rounde d proje ction at lowe r e nd o wonder that orensic scientists
tibia com m only calle d inne r ankle bone ; m us cle s are attache d to
can o ten accurate y determine
the tibial tube ros ity
the sex o human remains using
Fibula 2 Long s le nde r bone o late ral s ide o le g; late ral m alle olus rounde d just a ew bones. Sex di erences
proje ction at lowe r e nd o f bula com m only calle d oute r ankle bone
are a so important in sports
Tars al bone s 14 Form he e l and pos te rior part o oot; anatom ical ankle ; large s t is the physio ogy and medicine, where
calcane us it is use u in improving ath etic
Me tatars als 10 Form part o oot to w hich toe s are attache d; tars al and m e tatars al per ormance in some sports and
bone s arrange d s o that they orm thre e arche s in oot; m e dial in avoiding certain injuries.
(inne r) longitudinal arch and late ral (oute r) longitudinal arch, w hich Perhaps the most obvious o
exte nd rom ront to back o oot, and trans ve rs e or m e tatars al
the many structura di erences
arch, w hich exte nds acros s oot
between the ma e and ema e
Phalange s 28 Toe bone s ; thre e in e ach toe , two in e ach gre at toe ske etons are in the pelvic girdle
 CHAPTER 8 Skeletal System 195

or pelvisthe ring ormed by the Me dia l longitudina l a rch

two coxa bones and sacrum. T e Tibia
La te ra l longitudina l a rch Fibula
word pelvis means basin.T e wide
structure o the ema e pe vis a ows Talus
the body o a etus to be crad ed in Navic ular
Tars al bo ne Cubo id bo ne
it be ore birth, and its wide opening bo ne s
Cune ifo rm
a ows the baby to pass through it A No rmal lo ng itudinal arc h bo ne Me tatars al
during birth. bo ne s
Calc ane us
A though the individua ma e Phalang e s
coxa bones are genera y arger than
the individua ema e coxa bones,
together the ma e coxa bones orm
a narrower structure than do the C Trans ve rs e arch
ema e coxa bones. A mans pe vis is
shaped more ike a unne than the B Flatfo o t
broad, sha ow basin o the ema e
pe vis (Figure 8-25). FIGURE 8-24 Arches o the oot. A, Medial and lateral longitudinal arches. (Arrows show direction o
orce.) B, Flat oot occurs when tendons and ligaments weaken and the arches all. C, Transverse arch.
You can a so see in Figure 8-25
that the openings rom the abdo-
men into and through the pe visthe pe vic in et and pe vic the ma e. T is e ect is part y because the ang e at the ront o
out etare both norma y much wider in the ema e than in the ema e pe vis where the two pubic bones join is wider than
in the ma e. Such an arrangement a ows more room or a
etuss head to move through during chi dbirth.
Find the major structures o the ske eta system in the Clear

Coxal
View o the Human Body ( o ows p. 8) and compare the ma e 8
S acrum Pe lvic inle t and ema e structures, which are i ustrated side-by-side.
bo ne
S a cra l
promontory
Pe lvic Ag e D i e r e n c e s
inle t
Pubis
Pe lvic As we earned ear ier in the chapter, during chi dhood and
outle t ado escence the bones o the ske eton en arge and become
Symphys is more ossif ed. T e human ske eton is considered to reach its
pubis
mature state around age 25. From then unti about age 50 or
so, the ske eton is in a state o active maintenance, continua y
Pubic a ngle remode ingdisso ving and rebui dingbone tissue.
Male A ter age 50, the density o bone o ten decreases s ow y
because o a shi t in the remode ing activity. An e der y per-
sons ske eton o ten weighs much ess than it did when they
were in their 30s.

Coxal S acrum En v iro n m e n t a l Fa c t o r s

bo ne
Among the many actors that can cause variations in ones
Pe lvic Pe lvic o utle t ske eton is nutrition. W ithout enough ca cium and vitamin D,
inle t especia y during the deve opmenta years, the ske eton may
Is chia l s pine
Pe lvic not reach its u potentia o growth or it may show signs o
outle t Co c cyx
ear y degeneration.
Symphys is
pubis Load-bearing, or mechanica stress, o using the ske eton
a ects how bone tissue is remode ed. Exercise has a pro ound
S
Pubic a ngle
e ect on the ske eton. An active o der person can reverse
Fe male R L much or a o the bone oss associated with aging. Scientists
can sometimes te a persons occupation by which bonesor
I
which parts o bonesare more deve oped. For examp e, a
person who works with heavy oads on their right arm every
day wi have denser bones in the right arm and shou der than
FIGURE 8-25 Comparison o the male and emale pelvis. Notice the in the e t arm.
narrower width o the male pelvis, giving it a more unnel-like shape than Breaks and repairs simi ar y cause individua variations in
the emale pelvis. The pubic angle is narrower in males than emales. the ske eton.
 196 CHAPTER 8 Skeletal System

C LIN ICA L APPLICATION

EPIPHYS EAL AND AVULS ION FRACTURES Dia phys is
(of fe mur)
The point o articulation be twe e n the e piphys is and diaphys is
o a grow ing long bone is s us ce ptible to injury i ove rs tre s s e d,
e s pe cially in the young child or pre adole s ce nt athle te . In the s e Epiphys e a l
fra cture
individuals the e piphys e al plate can be s e parate d rom the di-
aphys is or e piphys is , caus ing an e piphys e al racture . This x-ray
s tudy s how s s uch a racture in a young boy. Without s ucce s s ul Epiphys is
(of fe mur)
tre atm e nt, an e piphys e al racture m ay inhibit norm al grow th.
Stunte d bone grow th in turn m ay caus e the a e cte d lim b to be
Kne e joint
s horte r than the norm al lim b.
In addition to e piphys e al racture s , viole nt contraction or
ove rs tre tching o a m us cle in s ke le tally im m ature individuals P Epiphys e a l pla te
als o can caus e a ragm e nt o bone unde r the point o attach- M L Tibia
m e nt to bre ak away rom the bone as a w hole . The re s ult is
calle d an avuls io n racture (s e e p. 205). D Fibula

at the anatomy, do you understand why you cannot move your

To see images o skeletal variations, check out
the article Skeletal Variations at Connect It! at
evolve.elsevier.com.
8 Kin d s o J o in t s
QUICK CHECK
1. Na m e s o m e o th e b o n e s o th e u p p e r a n d lo w e r
e xtre m itie s .
2. Id e n ti y th e th re e b o n e s th a t u s e to g e th e r to o rm th e
coxa l b o n e o a n a d u lt.
3. Na m e th e a rch e s th a t o rm th e o o t a n d e xp la in th e ir
s ig n if ca n ce .
4. Ho w d o e s th e e m a le p e lvis d i e r ro m th e m a le p e lvis ?
J o in t s
A r t ic u la t io n o Bo n e s
T e term joint is borrowed rom carpentry, where it re ers to
the structure ormed when pieces o wood are joined together.
In anatomy, a joint is the structure ormed when bones join
together. Joints are a so ca ed articulationsa term based on
the word part arthro, which means joint.
Every bone in the body, except one, connects to at east one
other bone. In other words, every bone but one orms a joint
with some other bone. T e exception is the hyoid bone in the
neck, to which the tongue anchors. Most o us probab y never
think much about our joints un ess something goes wrong
with them, and they do not unction proper y. T en their tre-
mendous importance becomes pain u y c ear.
Joints ho d our bones together secure y and at the same
time make it possib e or movement to occur between the
bonesbetween most o them, that is. W ithout joints we
cou d not move our arms, egs, or any other o our body parts.
O ur bodies wou d, in short, be rigid, immobi e hu ks.
ry, or examp e, to move your arm at your shou der joint
in as many directions as you can. ry to do the same thing at
your e bow joint. Now examine the shape o the bones at each
o these joints on a ske eton or in Figures 8-9 and 8-20. Looking
arm at your e bow in near y as many directions as you can at
your shou der?
One method c assif es joints into three types according to the
degree o movement they a ow:
1. Synarthrosesno movement
2. Amphiarthrosess ight movement
3. Diarthroses ree movement
Di erences in joint structure account or di erences in the
degree o movement that is possib e.
To better understand this concept, use the
Active Concept Map Classif cation o J oints at
evolve.elsevier.com.
S y n a r t h ro s e s
A synarthrosis is a joint in which no signif cant movement
occurs. T is unctiona characteristic is produced by the f -
brous connective tissue ( igaments) between the articu ating
(joining) bones, ho ding them tight y together. T e joints be-
tween crania bones are synarthroses, common y ca ed sutures
(Figure 8-26, A).
A m p h ia r t h ro s e s
An amphiarthrosis is a joint in which on y s ight movement
is possib e. Amphiarthroses are usua y made up o f brocarti-
age, which joins the bones tight ybut o ten with s ight
exibi ity.
T e symphysis pubis, the joint between the two pubic
bones, is an amphiarthrosis (Figure 8-26, B). It norma y on y
exes ate in pregnancy when movement o the pe vic gird e
is he p u during de ivery o an in ant.
 CHAPTER 8 Skeletal System 197

SYNARTHROS IS FIGURE 8-26 J oints. Two o the three major classes o

joints. A, Synarthrotic joint. B, Amphiarthrotic joint.

S
AMPHIARTHROS IS
P A

Corona l
s uture

S
Pubic
R L symphys is

A B I

Another examp e is the vertebral disk that connects each

vertebra body to the next in the spina co umn. Damage to a
disk caused by the pressure o sudden exertion or injury may
push its wa into the spina cana (Figure 8-27). Severe pain
may resu t i the disk presses on the spina cord or spina
nerve. Popu ar y known as a slipped disk, this condition is
known to hea th pro essiona s as a herniated disk.
D ia r t h ro s e s
T e vast majority o our joints are diarthroses. Such joints a -
ow considerab e movement, sometimes in many directions
and sometimes in on y one or two directions.
S t r u c t u r e o D ia r t h ro s e s 8
D iarthroses ( ree y movab e joints) are made a ike in certain
ways. A have a joint capsu e, a joint cavity, and a ayer o hya-
ine carti age (articu ar carti age) over the ends o two joining
bones (Figure 8-28).
T e joint capsule is made o the bodys strongest and
toughest materia , f brous connective tissue, and is ined with
a smooth, s ippery synovia membrane. T e capsu e f ts over
the ends o the two bones somewhat ike a s eeve. Because it
attaches f rm y to the sha t o each bone to orm its covering
(periosteum), the joint capsu e ho ds the bones secure y to-
gether but at the same time permits movement at the joint.

P re s s ure on P re s s ure
Ve rte bra l Cavity for Ve rte bra l s pina l cord (body we ight)
s pine s pina l cord body a nd ne rve
root

Fibrous
He rnia te d dis k
ca rtila ge Ve rte bra l
P ulpy dis k
tis s ue

P A

I
A B
FIGURE 8-27 Herniated disk. Sagittal section o vertebrae showing (A) normal and (B) herniated disks.
 198 CHAPTER 8 Skeletal System

T e ayer o articular cartilage over the joint ends o bones

acts ike a rubber hee on a shoeit absorbs jo ts. T e articu ar
carti age a so provides a smooth sur ace that enab es the
bones o the joint to move with itt e riction. T e synovial
Bone
membrane secretes a ubricating uid (synovial uid) that
Pe rios te um a ows easier movement with ess riction.
In some joints, the synovia membrane orms a pocket ike
extension or a pouch f ed a ongside a joint. Ca ed a bursa,
Blood ve s s e l this pocket o uid acts as a shock-absorbing cushion around
Ne rve
the bones o the joint. Irritation, injury, or in ection o a bursa
can cause in ammationa condition ca ed bursitis.

Fu n c t io n o D ia r t h ro s e s
Articula r
ca rtila ge T ere are severa types o diarthroses: ball-and-socket, hinge,
J oint pivot, saddle, gliding, and condyloid joints (Figure 8-29). Because
cavity they di er in structure, they di er a so in their possib e range
J oint
o movement.
ca ps ule
Ball-and-Socket J oints
Articula r
ca rtila ge In a ball-and-socket joint, a ba -shaped head o one bone
f ts into a concave socket o another bone. Shou der and hip
S ynovia l
me mbra ne joints, or examp e, are ba -and-socket joints. O a the joints
P
in our bodies, these permit the widest range o movements.
T ink or a moment about how many ways you can move your
8 L M arms. You can move them orward, backward, away rom the
D sides o your body, and back down to your sides. You can a so
move them around so as to make a circ e in the air with your
FIGURE 8-28 Diarthrotic joint structure. Each diarthrosis has a joint hands.
capsule, a joint cavity, and a layer o cartilage over the ends o the joined bones.
Hinge J oints
T e structure o the joint capsu e, in other words, he ps make Hinge joints, ike the hinges on a door, a ow movements in
possib e the joints unction. on y two directions, name y, exion and extension. Flexion is
Ligaments (cords or bands made o the same strong f brous bending a joint; extension is straightening it out (Table 8-7).
connective tissue as the joint capsu e) a so grow out o the E bow and knee joints and the joints in the f ngers are hinge
periosteum and ash the two bones together even more f rm y. joints.

A HINGE JOINT B PIVOT JOINT

D De ns of a xis
B rota ting a ga ins t
a tla s
E Elbow joint He a d of ra dius
rota ting a ga ins t
ulna

A
C C S ADDLE JOINT D CONDYLOID JOINT
B

F Ca rpome ta ca rpa l
joint of thumb Atla ntooccipita l
joint

E
E BALL-AND-S OCKET JOINT F GLIDING JOINT

S houlde r joint Articula r

Hip joint proce s s e s
FIGURE 8-29 Diarthrotic joint types. Notice that the structure o be twe e n
each type indicates its unction (movement). The mechanical diagrams ve rte bra e
represent the type o action at the highlighted anatomical joints.

TABLE 8-7 Types o J oint Movements
MOVEMENT EXAMPLE
Fle xio n (to ex a joint) Flexion
Re duce s the angle o the joint, as in
be nding the e lbow
Abductio n (to abduct a joint)
Abduction
Incre as e s the angle o a joint to
m ove a part away rom the
m idline , as in m oving the arm to
the s ide and away rom the body
Ro tatio n (to rotate a joint) Rota tion
Spins one bone re lative to anothe r,
as in rotating the he ad at the ne ck
joint
Pivot J oints
Pivot joints are those in which a sma projection o one bone
pivots in an arch o another bone. For examp e, reca rom
Figure 8-16 (on p. 187) that a projection o the axis (second
cervica vertebra) is a point around which an arch o the atlas
(f rst cervica vertebra) can pivot. T is pivoting motion is re-
erred to as rotation. Because the sku rests on the at as, this
action rotates the head.
Saddle J oints
On y one pair o saddle joints exists in the bodybetween the
metacarpa bone o each thumb and a carpa bone o the wrist
(the name o this carpa bone is the trapezium). Because the
articu ating sur aces o these bones are sadd e-shaped, they
make possib e the human thumbs great mobi ity, a mobi ity no
anima s thumb possesses. We can ex, extend, abduct, adduct,
and circumduct our thumbs, and most important o a , we can
move our thumbs to touch the tip o any one o our f ngers.
(T is movement is ca ed opposing the thumb to the ngers.)
CHAPTER 8 Skeletal System 199
MOVEMENT EXAMPLE
Exte ns io n (to exte nd a joint) Exte ns ion
Incre as e s the angle o a joint, as in
s traighte ning a be nt e lbow
Adductio n (to adduct a joint) Adduction
De cre as e s the angle o a joint to
m ove a part toward the m idline ,
as in m oving the arm in and
dow n rom the s ide
8
Circum ductio n (to circum duct a Circumduction
joint)
Move s the dis tal e nd o a bone in a
circle , w hile circum ducting a
joint, ke e ping the proxim al e nd
re lative ly s table , as in m oving
the arm in a circle and thus cir-
cum ducting the s houlde r joint
W ithout the sadd e joints, we cou d not do simp e acts
such as picking up a pin or grasping a penci between thumb
and oref nger.
Gliding J oints
Gliding joints are the east movab e diarthrotic joints. T eir
at articu ating sur aces a ow imited g iding movements,
such as that at the superior and in erior articu ating processes
between successive vertebrae.
Condyloid J oints
Condyloid joints are those in which a condy e (an ova pro-
jection) f ts into an e iptica socket. An examp e is the f t o
the dista end o the radius into depressions in the carpa
bones.
To learn more about types o joint movement, go to
AnimationDirect online at evolve.elsevier.com.
 200 CHAPTER 8 Skeletal System

C LIN ICA L APPLICATION

TOTAL HIP REPLACEMENT
Be caus e total hip re place m e nt (THR) is one o the m ore com m on ortho-
pe dic ope rations pe r orm e d on olde r pe rs ons (m ore than 300,000 pro-
ce dure s pe r ye ar in the Unite d State s ), hom e he alth care pro e s s ionals
o te n are e ngage d to work w ith patie nts re cove ring rom THR s urge ry. It
is a type o arthro plas tythat is , a proce dure that partially or totally
re place s a dis e as e d joint w ith an artif cial device (pros the s is ).
The THR proce dure involve s re place m e nt o the e m oral he ad by a
m e tal pros the s is and the ace tabular s ocke t by a polye thyle ne cup. The
pros the s is is us ually coate d w ith a porous m ate rial that allow s natural
grow th o bone to m e s h w ith the artif cial m ate rial. Such m e s hing o
tis s ue and pros the s is e ns ure s s tability o the parts w ithout the loos e n-
ing that the us e o glue s in the pas t o te n allowe d.
Firs t introduce d in 1953, THR te chnique has advance d to the s tate
that it is now one o the m os t s ucce s s ul s urgical proce dure s in adults .
As patie nts re cove r at hom e a te r THR s urge ry, they can expe ct to
progre s s through norm al s urgical he aling and re cove ry, w hich include s
s tabilization o the pros the s is as new tis s ue grow s into the porous coat-
ing that was applie d to the pros the s is . Typically, THR patie nts als o can
expe ct alm os t im m e diate pain re lie and to re gain s om e previous ly los t
unction in the a e cte d hipincluding im prove d we ight-be aring and
walking m ove m e nts .
8

QUICK CHECK T ese tumors are characterized by severe, unre enting pain.
reatment invo ves surgica remova o the tumor and both
1. Id e n ti y th e th re e m a jo r typ e s o jo in ts in th e s ke le to n .
Na m e a n e xa m p le o e a ch . presurgica and postsurgica chemotherapy.
2. Wh a t m e m b ra n e in a d ia rth ro tic jo in t p ro vid e s lu b rica tio n
o r m ove m e n t? C a r t ila g e Tu m o r s
3. Wh a t is a liga m e n t? Chondrosarcoma is cancer o ske eta hya ine carti age tissue
4. Na m e th re e e xa m p le s o a h in g e jo in t a n d d e s crib e th e
and is the second most common type o cancer a ecting bones.
m ove m e n t a h in g e jo in t a llo w s .

S k e le t a l D is o r d e r s L M

Tu m o r s P

wo o the most serious ske eta disorders invo ve ma ignant

tumors o bone tissue and carti age.

Bo n e Tu m o r s
T e most common and devastating ma ignant neop asm o
bone is ca ed osteosarcoma. wenty-f ve years ago near y a P
patients diagnosed with this disease died within 3 years. A -
L M
though sti considered a very aggressive and destructive type
o cancer, ear ier diagnosis and newer treatment options are D
increasing surviva rates and decreasing the need or immedi- A Os te os a rcoma B Chondros a rcoma
ate and comp ete amputation o a ected imbs.
Osteosarcomas occur most o ten in the dista emur FIGURE 8-30 Tumors. Surgical specimens sectioned longitudinally.
A, Osteosarcoma o distal emur. The tumor has broken out o the medullary
(Figure 8-30, A) and proxima areas o the tibia and humerus. cavity and is growing on the sur ace o the bone. B, Chondrosarcoma o
Near y twice as many ma es are a ected as ema es and most proximal humerus. Note the glistening appearance o the hyaline cartilage
cases occur between 20 and 40 years o age. tumor in the medullary cavity.
 CHAPTER 8 Skeletal System 201

FIGURE 8-31 Osteoporosis. Scanning electron micrograph (SEM) o

(A) normal bone and (B) bone with osteoporosis. Note the loss o tra-
beculae and appearance o enlarged spaces in the osteoporotic bone.

T e most common tumor sites invo ve the medu ary cavity

o the humerus, emur, ribs, and pe vic bones (Figure 8-30, B).
Chondrosarcomas occur most o ten in adu ts between
40 and 70 years o age. Incidence is s ight y higher in ma es.
Pain is a common but not a universa symptom and
when present is genera y ess severe than in osteosarcoma.
reatment is surgica remova o the esion. Chemotherapy
is not e ective in treating chondrosarcoma.

Tumors and cancers o bone and cartilage are

A Norma l B Os te oporos is
o ten di f cult to detect early. Medical imaging
can helpcheck out the article Bone Scans at
Connect It! at evolve.elsevier.com. Rickets invo ves deminera ization o deve oping bones in
in ants and young chi dren be ore ske eta maturity. In osteo-
ma acia, minera content is ost rom bones that have a ready
M e t a b o lic Bo n e D is e a s e s
matured.
O s t e o p o ro s is In rickets, the ack o rigidity caused by deminera ization
Osteoporosis is the name o the disorder in which bones ose o deve oping bones resu ts in gross ske eta changes inc uding
minera s and become ess dense, as evidenced on scanning a c assic bowing o the egs symptom (Figure 8-32). T e
e ectron micrograph studies (Figure 8-31). It is one o the most
common and serious bone diseases. 8
A though the cause remains unknown, genetics p ay a part in
the etio ogy, as do ow estrogen eve s and postmenopausa status
in women. Certain drugs, a diet ow in ca cium-containing
oods, ack o weight-bearing exercise, and smoking are a so risk
actors. Osteoporosis occurs most o ten in e der y white women.
T e disease is characterized by excessive oss o ca cif ed
bone matrix. A reduction in the number o branching trabecu-
ae in spongy bone is particu ar y noticeab e. T e name osteopo-
rosis means condition o bone pores re erring to the ho es or
pores ormed as bone tissue is ost. Compare the appearance o
norma and osteoporotic bone specimens in Figure 8-31.
A progressive increase in bone porosity causes the bones in
peop e with osteoporosis to become britt e and easi y broken.
Fractures may be comp ete y spontaneous or occur with even
minor trauma or during routine activities. T e most common
racture sites are the wrists, hips, and vertebrae. Compression
ractures o the vertebrae resu t in a shortened stature and the
c assic kyphosis o the thoracic spine ca ed dowagers hump
in e der y women su ering rom the disease. S
reatment or preventive measures may inc ude drug ther-
apy, weight-bearing exercise, and dietary supp ements o ca - L R

cium and vitamin D to rep ace def ciencies or to o set intes- I

tina ma absorption.

Ric k e t s a n d O s t e o m a la c ia
Rickets in young chi dren and osteomalacia in adu ts are
metabo ic ske eta diseases that a ect signif cant numbers o
individua s wor dwide. Both diseases are characterized by
deminera ization, or oss o minera s, rom bone re ated to
vitamin D def ciency. Vitamin D he ps the intestines absorb
ca cium rom the diet. T e oss o minera s is coup ed to an FIGURE 8-32 Rickets. Bowing o legs in this toddler is due to poorly
increased production o unminera ized matrix. mineralized bones
 202 CHAPTER 8 Skeletal System
deminera ization o bones in osteoma acia does not genera y
a ect overa ske eta contours but does resu t in increased
susceptibi ity to ractures, especia y in the vertebra bodies
and emora necks.
Vitamin D is produced by the body when sun ight strikes
the skin and its production is reduced during winter months
where peop e wear warmer c othing that covers more o their
bodies. Vitamin D is added to some oods (mi k and some
juices) to he p reduce this def ciency.
P a g e t D is e a s e
Paget disease o bone, a so ca ed osteitis de ormans, was
f rst described by British surgeon Sir James Paget in 1882. H is
remarkab y detai ed observations o a patient he treated re-
peated y over a 20-year period or a de orming bone disease
are considered c assic in the anna s o surgery.
T e disease Paget described is characterized by oca ized,
intermittent, and uncontro ed episodes o a most renzied
osteoc astic (bone resorbing) and osteob astic (bone orming)
activity. T e au ty remode ing process resu ts in bones that are
de ormed, unstab e, and easi y ractured (Figure 8-33).
Paget disease is o ten asymptomatic ear y in its course but
becomes pain u as the weak but o ten thickened areas o
de ective bone cause de ormity, arthritic symptoms, and rac-
8 ture injuries. T e disease may invo ve one or many bones. T e
spine, sku , pe vis, and ong bones o the extremities are com-
mon sites.
In addition to pain, the ocation o the esion may produce
additiona unique symptoms. For examp e, de ormity o sku
P decreases b ood ow, and in time wi cause necrosis or death
L M
D Severe cases o osteomye itis are o ten treated with inten-
FIGURE 8-33 Paget disease (osteitis de ormans). The uzzy, disorga-
nized appearance o this emur results rom weakened and irregular cancel-
lous bone overgrowth.
bones may compress crania nerves causing dea ness, b ind-
ness, headaches, and acia para ysis. Un ortunate y, areas o
diseased bone deve op into osteosarcomas in about 1% o a -
ected individua s.
Paget disease a ects about 3% o peop e over 50 years o
age. T e disease has a genetic tendency and may be triggered
by vira in ections. Disease treatment inc udes most y pain
contro and drugs that improve the strength o the bone.
O s t e o g e n e s is Im p e r e c t a
Osteogenesis imper ecta is a genetic disease that can a ect
1 in 30,000 births and is a so ca ed brittle-bone disease. T e
bones are britt e as the resu t o a ack o production o the
f brous matrix o bone.
T e f brous materia (most y co agen) in bone gives it
the abi ity to withstand twisting and compression orces
without breaking. T e same concept app ies to the practice
o p acing meta rods inside o concrete in bridge or road
construction. A bridge without meta rods wou d not be
ab e to withstand the weight and vibration o tra c. Bones
without organic f brous materia are thus very ragi e and
easi y ractured.
T e diagnosis o osteogenesis imper ecta usua y o ows
increased racture rates and a b ood test or the enzyme a ka-
ine phosphatase. reatment may inc ude sp inting o the
bone to reduce racture during growth and treatment with
drugs that decrease the activity o ce s that break down bone
(Figure 8-34).
Bo n e In e c t io n
Osteomyelitis is the genera name or bacteria in ections o
bone and marrow tissue. Staphylococcus bacteria are the most
common pathogens ound in this condition. T ey may reach
bone via the b oodstream or rom an adjacent so t tissue in ec-
tion such as an abscess, or be introduced direct y into the bone
as a resu t o open ractures, penetrating wounds, or by awed
surgica aseptic techniques.
On rare occasions, in ections a so may occur a ter insertion
o in ected donor tissues into bones or joints or by contami-
nated joint prostheses. Besides bacteria in ections, bone tissue
is a so susceptib e to damage by viruses, ungi, and other
pathogens.
Any bone in ection is di cu t to treat because o the den-
sity o the bone and the s owness o the hea ing process com-
pared with that o other tissues. Osteomye itis produces per-
sistent and severe pain, musc e spasm, swe ing, and ever. Pus
co ecting in the conf ned space o the bone increases pressure,
o bone tissue. Figure 8-35 shows a segment o in ected bone in
a severe case o chronic osteomye itis.
sive and repeated drug therapy inc uding parenteralthat is,
intravenous (IV)administration o antibiotics. Di cu t
cases o osteomye itis may become chronic and reappear
months or years a ter an assumed cure.
 CHAPTER 8 Skeletal System 203

QUICK CHECK
1. Na m e tw o typ e s o m a lig n a n t tu m o rs th a t a e ct b o n e s .
2. Wh a t m e ta b o lic b o n e d is e a s e is ch a ra cte rize d b y kyp h o s is
o th e th o ra cic s p in e ca lle d d o wa g e rs h u m p ?
3. Id e n ti y th e m e ta b o lic b o n e d is e a s e ch a ra cte rize d b y lo s s
o b o n e m in e ra ls a n d vita m in D d e f cie n cy in ch ild re n .
Wh a t is th e d is e a s e ca lle d in a d u lts ?
4. Wh a t is th e g e n e ra l n a m e o r b a cte ria l in e ctio n s o b o n e
a n d m a rro w tis s u e ?
pierce the skin and so do not pose an immediate danger o
bone in ection.
In complete ractures the bone ragments separate com-
p ete y, whereas in incomp ete ractures the bone ragments
are sti partia y joined. Incomplete ractures in which a
bone is bent but broken on y on the outer curve o the bend
are o ten ca ed greenstick ractures. Greenstick ractures, com-
mon in chi dren, usua y hea rapid y.

Bo n e Fr a c t u r e s
Excessive mechanica stress on bones can resu t in breaks or
ractures. Sometimes bone cancer or metabo ic bone disorders
weaken a bone to the point that it ractures with very itt e
stress. Figure 8-36 shows some o the major types o ractures
summarized in the o owing paragraphs.
Open ractures, or compound ractures, in which bone
pierces the skin, invite the possibi ity o in ection or osteomy-
e itis. Closed ractures, a so known as simple ractures, do not

FIGURE 8-34 Osteogenesis imper ecta. These x-ray studies S

show the progression o treatment o emurs in the same individual
L R
8
with brittle-bone disease. A telescoping rod is inserted into each
medullary cavity to provide rigidity, lengthening as the individual I
grows. A, Shows original x-ray lm; B, same individual with the rods
in place; C, x-ray lm o the same person 4 years later. A

B C
 204 CHAPTER 8 Skeletal System

O blique racture racture ine is diagona to the

bones ong axis. I the ob ique racture ine seems to
spira around a bone ike the stripe on a candy cane,
the racture may be ca ed a spiral racture.
A ter a racture occurs, a bone usua y b eeds, becomes in-
amed, and then orms a bony ramework ca ed a callus
around the injury (Figure 8-37). T e ca us tissue stabi izes the
bone ragments and thus aids in the ong hea ing and remod-
e ing process.

X-rays are commonly used in diagnosing bone

ractures. To see examples and get a new visual
perspective on skeletal anatomy, check out the
article Skeletal Radiography at Connect It! at
evolve.elsevier.com.

To learn more about bone racture and repair, go

P to AnimationDirect online at evolve.elsevier.com.
L M

D
J o in t D is o r d e r s
Joint disorders can be c assif ed as nonin ammatory joint
8 FIGURE 8-35 Osteomyelitis. Segment o emur rom a patient with
chronic osteomyelitis showing extensive damage rom in ection.
disease or in ammatory joint disease.

Comminuted ractures are breaks that produce many
ragments. Impacted ractures occur when bone ragments
are driven into each other.
Sometimes the ang e o the racture ine or crack is used in
abe ing racture types:
Linear racture racture ine is para e to the
bones ong axis.
ransverse racture racture ine is at a right ang e
to the bones ong axis.
N o n in a m m a t o ry J o in t D is e a s e
Nonin ammatory joint disease is distinguished rom other
joint conditions because it does not invo ve in ammation o
the synovia membrane and does not produce systemic signs
or symptoms.
Osteoarthritis, known a so as degenerative joint disease
(DJD), is the most common nonin ammatory disorder o
movab e joints. Abnorma ormation o new bone (bone spurs)
at joint sur aces and degeneration o articu ar carti age are
characteristic eatures o osteoarthritis. Weight-bearing joints,
such as the hips, umbar spine, and knees are o ten invo ved.

Line a r

Clos e d Incomple te
Ope n Tra ns ve rs e

Comple te
P Oblique

L M

A B C D
FIGURE 8-36 Bone ractures. A, Open. B, Closed. C, Incomplete and complete. D, Linear, transverse, and
oblique.

Afte r a fra cture,
ble e ding a nd
infla mma tion
deve lop in the
a ffe cte d a re a .
S
L M
I Ca llus
Fra cture
Ble e ding
A B
FIGURE 8-37 Bone repair. A ter a racture (A), there is bleeding and inf ammation around the a ected
area (B). Special tissue orms a bony ramework called a callus (C) that stabilizes the bone until the repair is
complete (D).
Loca ized tenderness over a ected joints, morning sti ness,
and pain on movement are requent symptoms.
Figure 8-38, A, shows another common sign o osteoarthritis
at the interphalangeal joints o the f ngersthe joints be-
tween pha anges. T e f ngers o individua s with this orm o
DJD o ten show bony bumps (nodes) at both the proxima
interpha angea joints (Bouchard nodes) and the dista inter-
pha angea joints (Heberden nodes).
T e etio ogy o most cases o DJD is unknown, but ad-
vanced age, joint damage caused by wear and tear, and obe-
sity are known risk actors. Advanced cases o osteoarthritis
are the most common cause or partia or tota hip and knee
rep acements.
raumatic injury is o ten the cause o nonin ammatory
joint prob ems. D islocation occurs when the articu ar sur-
aces o bones orming the joint are no onger in proper con-
tact with each other. A subluxation is a partia or minor dis-
ocation in which the bones are s ight y misa igned. A sprain
is an acute injury to the igaments around a joint. A common
cause o sprains is a twisting or wrenching movement o ten
associated with whip ash-type injuries.
T e term strain is used to describe an injury invo ving the
musculotendinous unit and may invo ve the musc e, the
tendon, and the junction between the two, as we as their at-
tachments to bone. Most strains occur in musc e tissue, o ten
because o overstretching, or vio ent types o musc e contrac-
tion (see Chapter 9, p. 235).
H owever, the portion o the muscu otendinous unit in-
jured depends on which component is weakest. In preado-
escent ath etes with incomp ete y ossif ed bones, the musc e
component o the unit or the point o attachment o the
musc e to the bone may be stronger than the deve oping
CHAPTER 8 Skeletal System 205
A bony fra mework Os te obla s ts a nd
ca lle d a ca llus os te ocla s ts
forms, s ta bilizing continue
the bone during re mode ling the
re pa ir. tis s ue until a
re pa ir is a chieve d.
Re pa ire d
bone
C D
8
bone itse or the union between its epiphysis and diaphysis.
In these cases, vio ent musc e contractions can cause an
avulsion racture (o ten near a joint), in which a piece o
bone is pu ed ree, or an epiphyseal racture between the
epiphysis and diaphysis o the invo ved bone (see box on
p. 196).
In a m m a t o ry J o in t D is e a s e (A r t h r it is )
Arthritis is a genera name or many di erent in ammatory
joint diseases. Arthritis can be caused by a variety o actors,
inc uding in ection, injury, genetic actors, and autoimmunity.
We now exp ore a brie ist o major types o arthritis.
Rheumatoid arthritis
Be ieved to be a type o autoimmune disease, rheumatoid
arthritis (RA), invo ves chronic in ammation o connective
tissues. It begins in the synovia membrane and spreads to
carti age and other tissues, o ten causing severe cripp ing.
A characteristic de ormity o the hands in rheumatoid ar-
thritis is ulnar deviation o the f ngers. As you can see in
Figure 8-38, B u nar deviation invo ves an e bow- ike bending
o the f nger joints.
T e autoimmune nature o the disease may cause damage
to many body organs, such as the b ood vesse s, eyes, ungs,
and heart. Because it is a systemic disease, ever, anemia,
weight oss, and pro ound atigue are common.
Juvenile rheumatoid arthritis ( JRA) is usua y more se-
vere than the adu t orm but invo ves simi ar deterioration and
de ormity o joints. T e joint in ammatory process o ten de-
stroys growth o carti age, and growth o ong bones is ar-
rested. T is orm begins during chi dhood and is more com-
mon in gir s.
 206 CHAPTER 8 Skeletal System

A Os te oa rthritis B Rhe uma toid a rthritis C Gouty a rthritis

FIGURE 8-38 Types o arthritis. A, Osteoarthritis. Note the presence o nodes in the proximal interphalan-
geal joints (Bouchard nodes) and distal interphalangeal joints (Heberden nodes). B, Rheumatoid arthritis. Note
the marked ulnar (elbow-like) deviation o the wrists. C, Gouty arthritis. Note tophi (stones) containing sodium
urate crystals.

Gouty Arthritis Sometimes, gout f rst appears as nodu es ca ed tophi with or

Gouty arthritis is a chronic type o joint in ammation that
can progress rom gout. Gout is a metabo ic condition in
which uric acid, a nitrogenous waste, increases in the b ood.
Excess uric acid is deposited as sodium urate crysta s in dista
joints and other tissues, causing in ammation.
without in ammation (Figure 8-38, C). T ese bumps are gritty
accumu ations o urate crysta s in the so t tissues o a joint. T ese
crysta s can trigger occasiona , acute episodes o severe arthritis.
H owever, without treatment it may progress to the chronic in-
ammation and tissue damage characteristic o gouty arthritis.

8
HEA LTH AND WELL-BEIN G
KNEE J OINT INJ URY
The kne e is the large s t m ovable joint in the bodybut als o
Pos te rior
one o the m os t vulne rable to injury. Be caus e the kne e is Fe mur
crucia te
ve ry m oblie , but als o o te n s ubje cte d to s udde n, s trong liga me nt
(P CL) Inte rcondyla r
orce s during athle tic activity, kne e injurie s are am ong the notch
m os t com m on type o athle tic injury.
Som e tim e s , the concave dis ks o articular cartilage Torn crucia te
liga me nts
calle d m e nis ci on the tibia te ar w he n the kne e tw is ts
w hile be aring we ight. The ligam e nts holding the tibia and Torn me nis cus
Torn
e m ur toge the r can als o be injure d in this way. liga me nts
Figure A s how s te ars in the late ral and m e dial liga-
Force
m e nts outs ide the joint cavity, as we ll as te ars in the
cros s e d cruciate ligam e nts ins ide the joint. Kne e injurie s
m ay als o occur w he n a we ight-be aring kne e is hit by an-
othe r pe rs on or a m oving obje ct.
Ante rior
Wom e n have a highe r ris k o kne e injurie s than m e n. crucia te
The re have be e n s eve ral propos e d caus e s , including the P liga me nt
ollow ing: (ACL)
L M
Tibia Fibula
D
toward the knee at a gre ate r angle , calle d the Q angle
(Figure B). This re sults in the pull on the pate lla (kne e cap) A
by ante rior late ral m uscle s o the thigh, w hich pulls the
patella out o alignme nt and may we ake n the kne e .
inte rcondylar notch o the e mur is narrow in e male s quadrice ps (ante rior thigh
compare d to the male s . This narrow notch m ay rub and m us cle s ) than ham s trings (pos te rior thigh m us cle s ). The
we ake n the ante rior cruciate ligame nt (ACL) that stabilize s ham s tring m us cle s ke e p the tibia in place in the kne e w he n
the knee . jum ping or m aking s udde n s tops .
In orde r to avoid injury to the kne e , it is re com m e nde d that
the ligam e nts to be m ore exible and m ore prone to ove r-
wom e n
s tre tching and rupturing. This m ay incre as e exibility o liga-
m e nts w he n e s troge n leve ls are highe r, as occurs during
ovulation or pre gnancy. kne e

Acute episodes o gout are o ten success u y treated with
nonsteroidal anti-in ammatory drugs (NSAIDs) such as ibupro-
en or naproxen. H owever, aspirin can make the gout worse by
changing uric acid eve s in the b ood. I the episodes become
requent, gout may be treated with allopurinol, which reduces
the production o uric acid in the bodythus preventing or
essening acute episodes.
Review the article In ammation at Connect It! at
evolve.elsevier.com.
In ectious Arthritis
A variety o pathogens can in ect synovia membrane and
other joint tissues and thereby cause in ectious arthritis.
One orm o in ectious arthritis, Lyme arthritis, or Lyme
disease, has become a prob em throughout most o the United
States in on y the ast ew decades. Lyme disease was identif ed
in O d Lyme, Connecticut, in 1975 and is caused by a spirochete
bacterium carried by deer ticks (Figure 8-39). T is condition is
characterized by in ammation in the knees or other joints ac-
companied by a variety o systemic signs and symptoms.
Q a ngle Q a ngle
ave ra ge : ave ra ge :
18 13
de gre e s de gre e s
R L
B Fe ma le Ma le
m us cle s
the m how to land a te r jum ping and how to m ake quick
turns w ithout tw is ting the kne e .
CHAPTER 8 Skeletal System 207
Another group o bacteria ca ed Ehrlichia is a so carried
by ticks and inc udes the agents that cause the various orms
o ehrlichiosis. T is bacteria in ection has some o the same
symptoms as Lyme disease, but is more preva ent than Lyme
arthritis in some parts o the United States. O ne orm o
ehr ichiosis is more preva ent in the midwestern United
States and another orm is ound most y in the southern
United States.
Both Lyme arthritis and ehr ichiosis are treated by the use
o antibiotics. See Table 6-7, p. 127, or more on tick-borne
i ness.
QUICK CHECK
1. Wh a t typ e o b o n e ra ctu re is m o s t like ly to re s u lt in in e c-
tio n o r o s te o m ye litis ?
2. Wh a t is th e m o s t co m m o n n o n in a m m a to ry d is o rd e r o
m ova b le jo in ts ?
3. Uln a r d e via tio n o th e f n g e rs is a co m m o n s ig n in w h a t
typ e o in a m m a to ry jo in t d is e a s e ?
4. Wh a t o rm o a rth ritis is a m e ta b o lic co n d itio n ch a ra cte r-
ize d b y a n in cre a s e in u ric a cid in th e b lo o d ?
D P
A
B
FIGURE 8-39 Lyme disease. A, Circular, expanding rash resembling a
bulls-eye target caused by the spirochete bacteria Borrelia burgdor eri.
B, Deer tick, vector or transmission o Lyme disease.
 208 CHAPTER 8 Skeletal System

S C IEN C E APPLICATIONS
BONES AND J OINTS
Ever s ince 400 B.C.E., w he n he alth. The photo s how s a s ports phys ician and athle tic traine r
Hippocrate s (the Gre ek physician as s e s s ing an injure d athle te on the f e ld.
o ten regarde d as a ounde r o the Radiographic te chnologis ts and radiologis ts are o te n calle d
m edical pro e s sion) f rs t de scribe d upon to m ake m e dical im age s o the bone s and joints and in-
tre atm e nts o human bone and joint te rpre t the m e aning o the s e im age s .
dis orde rs and injurie s, many ap-
proache s to tre ating the hum an
s keleton have be e n take n. Physical
therapis ts and occupatio nal ther-
apists he lp patie nts re gain move -
Hippocrates (460-377 BC) m ent in joints through phys ical exe r-
cises and ortho pe dic surge ons
he lp the ir patie nts by m e ans o s urgical ope rations.
Be caus e the s ke le ton, w ith its m any bone s and joints , is
the ram ework o the e ntire body, it is not s urpris ing to le arn
that m any di e re nt he alth pro e s s ionals work dire ctly w ith the
s ke le ton. Po diatris ts work w ith the bone s and joints o the
oot and ankle , athle tic traine rs and s po rts phys icians work
w ith m any parts o the s ke le ton, and chiro practo rs o te n work
to align the ve rte bral colum n and othe r bone s to m aintain

C LIN ICA L APPLICATION

ARTHROS COPY
Arthro s co py is an im aging te chnique that allow s a phys ician
to exam ine the inte rnal s tructure o a joint w ithout the us e o
exte ns ive s urge ry. The photos s how arthros copy o the le t
kne e . As Figure A s how s , a narrow tube w ith le ns e s and a
f be r-optic light s ource is ins e rte d into the joint s pace through
a s m all puncture . Is otonic s aline (s alt) s olution is inje cte d
through a ne e dle or cannula (tube ) to expand the volum e o the
s ynovial s pace . This s pre ads the joint s tructure s and m ake s
view ing e as ie r (B).
Although arthros copy is o te n us e d as a diagnos tic proce -
dure , it als o can be us e d to pe r orm joint s urge ry. While the
s urge on view s the inte rnal s tructure o the joint through the
arthros cope or on an attache d vide o m onitor, ins trum e nts can
be ins e rte d through puncture hole s and us e d to re pair or re -
m ove dam age d tis s ue . Arthros copic s urge ry is m uch le s s
traum atic than previous m e thods in w hich the joint cavity was
com ple te ly ope ne d.

Articula r
ca rtila ge

Ante rior
Arthro s c o pe crucia te
liga me nt
(ACL)

Articula r
ca rtila ge

A B
 CHAPTER 8 Skeletal System 209

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 175)

atlas clavicle epiphyseal line

(AT-lis) (KLAV-ih-kul) (ep-ih-FEEZ-ee-al lyne)
[Atlas, Greek mythical f gure who supports the [clavi- key, -cle little] [epi- upon, -phys- growth, -al relating to]
world] coccyx epiphyseal plate
axial skeleton (KOK-sis) (ep-ih-FEEZ-ee-al playt)
(AK-see-al SKEL-eh-ton) [coccyx cuckoo (beak)] [epi- upon, -phys- growth, -al relating to,
[axi- axis, -al relating to, skeleton dried body] compact bone plate at]
axis (kom-PAKT bohn) epiphysis
(AK-sis) concave curvature (eh-PIF-ih-sis)
pl., axes (kon-KAYV KUR-vah-chur) pl., epiphyses
(AK-seez) [con- together, -cave hollow, curvat- bend, (eh-PIF-ih-seez)
ball-and-socket joint -ure state] [epi- upon, -physis growth]
bursa concentric lamella ethmoid bone
(BER-sah) (kon-SEN-trik lah-MEL-ah) (ETH-moyd bohn)
pl., bursae pl., lamellae [ethmo- sieve, -oid like]
(BER-see or BER-say) (lah-MEL-ee) extend
[bursa purse] [con- together, -centr- center, -ic relating to, (ek-STEND)
calcaneus lam- plate, -ella little] [ex- outward, -tend- stretch]
(kal-KAY-nee-us) condyloid joint extension
[calcane- heel, -ous having to do with] (KON-dih-loyd joynt) (ek-STEN-shun)
calcitonin (CT) [condylo- knuckle, -oid like] [extend to stretch out, -ion process]
(kal-sih-TOH-nin) convex curvature ace 8
[calci- lime (calcium), -ton- tone, -in substance] (kon-VEKS KUR-vah-chur) ( ays)
canaliculus [con- together, -vex convey, curvat- bend, emur
(kan-ah-LIK-yoo-lus) -ure state] (FEE-mur)
pl., canaliculi coxal bone [ emur thigh]
(kan-ah-LIK-yoo-lye) (kok-SAL bohn) f bula
[canal- channel, -uculus little] [coxa- hip, -al relating to] (FIB-yoo-lah)
cancellous bone cranium [f bula clasp]
(KAN-seh-lus bohn) (KRAY-nee-um) ex
[cancel- lattice, -ous characterized by] [cranium skull] (FLEKS)
carpal cruciate ligament [ ex bend]
(KAR-pul) (KRU-shee-ayt) exion
[carp- wrist, -al relating to] [cruci- cross, -ate o or like] (FLEK-shun)
cartilage diaphysis [ ex- bend, -ion process]
(KAR-tih-lij) (dye-AF-ih-sis) ontanel
[cartilage gristle] pl., diaphyses (FON-tah-nel)
central canal (dye-AF-ih-seez) [ ontan- ountain or source, -el little]
(SEN-tral kah-NAL) [dia- through or apart, -physis growth] rontal bone
[centr- center, -al relating to, canal channel] diarthrosis (FRUNT-al bohn)
chest (dye-ar-THROH-sis) [ ront- orehead, -al relating to]
chiropractor pl., diarthroses gliding joint
(KYE-roh-prak-ter) (dye-ar-THROH-seez) (GLY-ding joynt)
[dia- between, -arthr- joint, -osis condition]
[chiro- hand, -pract- practical, -or agent] hematopoiesis
chondrocyte diploe (hee-mah-toh-poy-EE-sis)
(KON-droh-syte) (DIP-loh-EE) [hemo- blood, -poiesis making]
[diploe olded over (doubled)]
[chondro- cartilage, -cyte cell] hinge joint
circumduct endochondral ossif cation (hinj joynt)
(ser-kum-DUKT) (en-doh-KON-dral os-ih-f h-KAY-shun)
humerus
[endo- inward or within, -chondr- cartilage,
[circum- around, -duct lead] (HYOO-mer-us)
-al relating to, oss- bone, -f cation to make]
circumduction [humerus arm]
(ser-kum-DUK-shun) endosteum
hyoid bone
[circum- around, -duct- lead, -tion process]
(en-DOS-tee-um)
(HYE-oyd bohn)
[endo- within, -osteum bone]
[hy- Greek letter upsilon ( or ), -oid like]

Continued on p. 210
 210 CHAPTER 8 Skeletal System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 209)

ilium middle ear pectoral girdle

(IL-ee-um) (MID-ul eer) (PEK-toh-ral GIRD-el)
[ilium ank] musculotendinous unit [pector- breast, -al relating to, girdle belt]
interphalangeal joint (mus-kyoo-loh-TEN-din-us YOO-nit) pelvic girdle
(in-ter- ah-LAN-jee-al joynt) [mus- mouse, -cul- little, -tend- pulled tight, (PEL-vic GIRD-el)
[inter- between, -phalang- rows o soldiers -in- unit, -ous relating to] [pelvi- basin, -ic relating to, girdle belt]
(f nger bones), -al relating to] occipital bone pelvis
intramembranous ossif cation (ok-SIP-it-al bohn) (PEL-vis)
(in-trah-MEM-brah-nus [occipit- back o head, -al relating to] pl., pelves or pelvises
os-ih-f h-KAY-shun) occupational therapist (PEL-veez or PEL-vis-ez)
[intra- within, -membran- thin skin, (ak-yoo-PAY-shun-al THAYR-ah-pist) [pelvis basin]
-ous characterized by, os- bone, -f c- make, [occup- occupy, -tion- process, -al relating to, periosteum
-ation process] therap- treatment, -ist agent] (payr-ee-OS-tee-um)
ischium olecranon [peri- around, -osteum bone]
(IS-kee-um) (oh-LEK-rah-nohn) phalanges
[ischium hip joint] [ole- elbow, -cran- head, -on unit] ( ah-LAN-jeez)
joint capsule olecranon ossa sing., phalanx
(joynt CAP-sool) (oh-LEK-rah-non FOS-ah) ( ah-LANKS)
lacuna [ole- elbow, -cran- head, -on unit, ossa ditch] [phalanx ormation o soldiers in rows]
(lah-KOO-nah) orthopedic surgeon physical therapist
pl., lacunae (or-thoh-PEE-dik SUR-jen) (FIS-ik-al THAYR-ah-pist)
8 (lah-KOO-nee) [ortho- straight or normal, -ped- eet, [physic- medicine, -al relating to,
[lacuna pit] -ic relating to, surg- hand, -eon practitioner] therap- treatment, -ist agent]
lateral longitudinal arch osteoblast pivot joint
(LAT-er-al lawnj-ih-TOOD-in-al) (OS-tee-oh-blast) (PIV-it joynt)
[later- side, -al relating to, longitud- length, [osteo- bone, -blast bud or sprout] podiatrist
-al relating to] (poh-DYE-ah-trist)
osteoclast
ligament (OS-tee-oh-klast) [pod- oot, -iatr- treatment, -ist agent]
(LIG-ah-ment) [osteo- bone, -clast break] pubis
[liga- bind, -ment result o action] (PYOO-bis)
osteocyte
maxilla (OS-tee-oh-syte) [pubis groin]
(mak-SIH-lah) [osteo- bone, -cyte cell] radius
pl., maxillae osteon (haversian system) (RAY-dee-us)
(mak-SIH-lee) (AHS-tee-on [hah-VER-zhun or [radius ray]
[maxilla upper jaw] HAV-er-zhun SIS-tem]) red bone marrow
medial longitudinal arch [osteo- bone, -on unit, Clopton Havers, English (red bohn MAR-oh)
(MEE-dee-al lon-jih-TOO-dih-nal) physician] rib
[medi- middle, -al relating to, longitud- length, palpable rotation
-al relating to] (PAL-pah-bul) (roh-TAY-shun)
medullary cavity [palp- touch gently, -able capable] [rot- turn, -ation process]
(MED-oo-lar-ee KAV-ih-tee) paranasal sinus sacrum
[medulla- marrow, -y related to, cav- hollow, (payr-ah-NAY-zal SYE-nus) (SAY-krum)
-ity state] [para- beside, -nas- nose, -al relating to, [sacr- holy, -um thing]
meniscus sinus hollow] saddle joint
(meh-NIS-kus) parathyroid hormone (PTH) (SAD-el joynt)
pl., menisci (pair-ah-THYE-royd HOR-mohn)
(meh-NIS-aye or meh-NIS-kye) scapula
[para- besides, -thyr- shield, -oid like, (SKAP-yoo-lah)
[meniscus crescent] hormon- excite] [scapula shoulder blade]
metacarpal parietal bone
(met-ah-KAR-pal) sha t
(pah-RYE-ih-tal bohn)
[meta- beyond, -carp- wrist, -al relating to] sinus
[parie- wall, -al relating to]
metatarsal (SYE-nus)
patella [sinus hollow]
(met-ah-TAR-sal) (pah-TEL-ah)
[meta- beyond, -tars- ankle, -al relating to] skull
[pat- dish, -ella small]
(skuhl)
[skull head]
 CHAPTER 8 Skeletal System 211

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 210)

sphenoid bone synarthrosis tibia

(SFEE-noyd bohn) (sin-ar-THROH-sis) (TIB-ee-ah)
[spheno- wedge, -oid like] pl., synarthroses [tibia shin bone]
spine (sin-ar-THROH-seez) trabecula
(spyne) [syn- together, -arthr- joint, -osis condition] (trah-BEK-yoo-lah)
[spine thorn] synovial uid pl., trabeculae
spongy bone (sih-NOH-vee-al FLOO-id) (trah-BEK-yoo-lee)
(SPUN-jee bohn) [syn- together, -ovi- egg (white), -al relating to] [trab- beam, -ula little]
[spong- sponge, -y characterized by] synovial membrane transverse arch (metatarsal arch)
sports physician (sih-NOH-vee-al MEM-brayn) (TRANS-vers arch [met-ah-TAR-sal])
(sports f h-ZISH-un) [syn- together, -ovi- egg (white), -al relating to, [trans- across or through, -vers- turn
[physic- medicine, -ian practitioner] membran- thin skin] (meta- beyond, -tars- ankle, -al relating to)]
sternoclavicular joint talus transverse canal (Volkmann canal)
(ster-noh-klah-VIK-yoo-lar joynt) (TAY-lus) (tranz-VERS kah-NAL [VOLK-man])
[sterno- breastbone (sternum), -clavi- key, pl., tali [trans- across, -vers- turn, Richard von
-ular relating to] (TAY-lye) Volkmann, German surgeon]
[talus ankle] ulna
sternum
(STER-num) tarsal (UHL-nah)
pl., sterna or sternums (TAR-sal) [ulna elbow]
(STER-nah or STER-numz) [tars- ankle, -al relating to] vertebra
[sternum breastbone] temporal bone (VER-teh-bra)
suture (TEM-poh-ral bohn) pl., vertebrae 8
(SOO-chur) [tempora- temple (o head), -al relating to] (VER-teh-bree or VER-teh-bray)
[suture seam] thorax [vertebra joint or turning part]
(THOR-aks) yellow bone marrow
[thorax chest] (YEL-oh bohn MAR-oh)

LANGUAGE OF M ED IC IN E

arthritis chondrosarcoma epiphyseal racture

(ar-THRY-tis) (KON-droh-sar-KOH-mah) (ep-ih-FEEZ-ee-al FRAK-chur)
[arthr- joint, -itis in ammation] [chondro- cartilage, -sarco- esh, -oma tumor] [epi- on, -phys- growth, -al relating to,
arthroplasty closed racture racture to break]
(AR-throh-plas-tee) (klohzd FRAK-chur) at eet
[arthr- joint, -plasty surgical repair] [ racture a breaking] ( at FEET)
arthroscopy comminuted racture gout
(ar-THROS-skah-pee) (kom-ih-NOO-ted FRAK-chur) (gowt)
[arthr- joint, -scop- see, -y activity] [commin- break into pieces, -ute per orm [gout drop]
avulsion racture action, racture a breaking] gouty arthritis
(ah-VUL-shun FRAK-chur) complete racture (gow-TEE ar-THRY-tis)
[avuls- pull away, -ion process, (kom-PLEET FRAK-chur) [gout- drop, -y o or like, arthr- joint,
racture a breaking] [ racture a breaking] -itis in ammation]
Bouchard node dislocation Heberden node
(boo-SHAR nohd) (dis-loh-KAY-shun) (HEB-er-den nohd)
[Charles J . Bouchard French physician, [dis- apart, -locat- locate, -tion condition] [William Heberden English physician, nod- knot]
nod- knot] dowagers hump herniated disk
bursitis (DOW-ah-jerz hump) (HER-nee-ayt-ed disk)
(ber-SYE-tis) [dowager widow with a dower (gi t or wealth)] [hernia- rupture, -ate act o ]
[burs- purse, -itis in ammation] ehrlichiosis impacted racture
callus (ur-lik-ee-OH-sis) (im-PAK-ted FRAK-chur)
(KAL-us) [Paul Ehrlich German microbiologist] [impact- push into, racture a breaking]
[callus hard skin]
Continued on p. 212
 212 CHAPTER 8 Skeletal System

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 211)

incomplete racture open racture rheumatoid arthritis (RA)

(in-kom-PLEET FRAK-chur) (OH-pen FRAK-chur) (ROO-mah-toyd ar-THRY-tis [ar ay])
[ racture a breaking] [ racture a breaking] [rheuma- ow, -oid like, arthr- joint,
in ectious arthritis osteoarthritis -itis in ammation]
(in-FEK-shus ar-THRY-tis) (os-tee-oh-ar-THRY-tis) rickets
[in ect- stain, -ous relating to, arthr- joint, [osteo- bone, -arthr- joint, -itis in ammation] (RIK-ets)
-itis in ammation] osteogenesis imper ecta [unknown origin]
intravenous (os-tee-oh-J EN-eh-sis im-per-FEK-tah) scoliosis
(in-trah-VEE-nus) [osteo- bone, -gen- produce, -esis process, (skoh-lee-OH-sis)
[intra- within, -ven- vein, -ous relating to] im- not, -per ecta per ect] [scolio- twisted or crooked, -osis condition]
juvenile rheumatoid arthritis (J RA) osteitis de ormans sprain
(J OO-veh-ney-el ROO-mah-toyd (os-tee-AYE-tis deh-FOR-manz) (sprayn)
ar-THRY-tis) [oste- bone, -itis in ammation, de ormans [unknown origin]
[juven- youth, -ile o or like, rheuma- ow, de orming] strain
-oid like, arthr- joint, -itis in ammation] osteomalacia (strayn)
kyphosis (os-tee-oh-mah-LAY-shah) [strain stretch]
(kye-FOH-sis) [osteo- bone, -malacia so tening] subluxation
[kypho- hump, -osis condition] osteomyelitis (sub-luks-AY-shun)
linear racture (os-tee-oh-my-eh-LYE-tis) [sub- below or near, -luxat- locate,
(LIN-ee-ar FRAK-chur) [osteo- bone, myel- marrow, -itis in ammation] -tion condition]
[linea- line, -ar relating to, racture a breaking] osteoporosis tophus
8 lordosis (os-tee-oh-poh-ROH-sis) (TOH- us)
(lor-DOH-sis) [osteo- bone, -poro- pore, -osis condition] pl., tophi
[lordos- bent backward, -osis condition] osteosarcoma (TOH- ye)
Lyme arthritis (os-tee-oh-sar-KOH-mah) [tophus porous rock]
(lyme ar-THRY-tis) [osteo- bone, -sarc- esh, -oma tumor] transverse racture
[Lyme city in Connecticut, arthr- joint, Paget disease (TRANS-vers FRAK-chur)
-itis in ammation] (PAJ -et dih-ZEEZ) [trans- across, -verse turn, racture a breaking]
mastoiditis [Sir J ames Paget British surgeon and ulnar deviation
(mas-toyd-AYE-tis) pathologist, dis- without, -ease com ort] (UL-nur dee-vee-AY-shun)
[mast- breast, -oid- like, -itis in ammation] parenteral [ulna- elbow, -ar relating to, de- out o ,
oblique racture (pah-REN-ter-al) -via- road or path, -ation process]
(oh-BLEEK FRAK-chur) [par- beside, -enter- intestine, -al relating to] vertebroplasty
[obliq- slanted, racture a breaking] (ver-tee-broh-PLAS-tee)
[vertebr- joint or backbone, -plasty surgical
repair]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Functio ns o the S ke le tal Sys te m
A. Provides interna ramework that supports and gives
shape to the body
B. Protects interna organs and tissues
C. Makes movement possib e when bones at movab e joints
are pu ed by musc es
D. Storage o vita substances
1. Ca ciumhormones regu ate ca cium storage: ca cito-
nin (C ) increases storage and parathyroid hormone
(P H ) reduces stores o ca cium
2. Fatstored in cavities o some bones

E. H ematopoiesisb ood ce ormation in the red bone
marrow
Gro s s S tructure o Bo ne s
A. Four major types, according to overa shape o the bone
1. Longexamp e: humerus (arm)
2. Shortexamp e: carpa s (wrist)
3. F atexamp e: ronta (sku )
4. Irregu arexamp e: vertebrae (spina bones)
5. Some a so recognize a sesamoid (round) bone
categoryexamp e: pate a (kneecap)
B. Structure o ong bones (Figure 8-1)
1. Diaphysis, or sha tho ow tube o hard compact bone
2. Medu ary cavityho ow space inside the diaphysis
that contains ye ow marrow
3. Epiphysesends o the bones made o spongy bone
that contains red bone marrow
4. Articu ar carti agethin ayer o hya ine carti age that
covers each epiphysis; provides a smooth cushion
5. Periosteumstrong, f brous membrane covering bone
everywhere except at joint sur aces
6. Endosteumthin membrane that ines medu ary
cavity
C. Structure o at bones (Figure 8-2)
1. Spongy bone ayer sandwiched between two compact
bone ayers
2. Dip oespongy bone ayer o a at bone
Micro s co pic S tructure o Bo ne s
A. Bone tissue structure (Figure 8-3)
1. Cance ous (spongy) bone
a. exture resu ts rom need e ike threads o bone
ca ed trabeculae surrounded by a network o open
spaces
b. Found in epiphyses o bones
c. Spaces contain red bone marrow
2. Compact bone
a. Structura unit is an osteonca cif ed matrix
arranged in mu tip e ayers or rings ca ed concen-
tric ame a (Figure 8-4)
b. Bone ce s are ca ed osteocytes and are ound inside
spaces ca ed lacunae, which are connected by tiny
tubes ca ed canaliculi
B. Carti age (Figure 8-5)
1. Ce type ca ed chondrocyte
2. Matrix is ge - ike and acks b ood vesse s
Bo ne De ve lo pm e nt
A. Making and remode ing bone tissue (Figure 8-6)
1. Ear y bone deve opment (be ore birth) consists o car-
ti age and f brous structures
2. O steob asts
a. Form new bone matrix by encrusting co agen
f bers with ca cium crysta s
b. O steocytes are inactive osteob asts
CHAPTER 8 Skeletal System 213
3. O steoc asts disso ve bone, re easing ca cium ions or
reabsorption into the b oodstream
4. Remode ing is a combined action o making and dis-
so ving bone matrix that eventua y scu pts bone into
the adu t shape
B. Endochondra ossif cationcarti age mode s gradua y
rep aced by ca cif ed bone (Figure 8-7 and Figure 8-8)
C. Intramembranous ossif cationf brous membranes are
ossif ed into hard bone p ates; ontane s are so t, not-yet-
ossif ed regions
Axial S ke le to n
A. Ske eton can be divided into centra axial and periphera
appendicular regions (Figure 8-9 and Table 8-1)
B. Axia ske eton inc udes 80 bones:
1. Sku (Figure 8-10 and Table 8-2)
a. Bones o the cranium (8), ace (14), and midd e
ear (6)
b. Inc udes spaces ca ed paranasal sinuses (Figure 8-11)
c. Mastoiditis is in ammation o mastoid process o
tempora bone (Figure 8-12)
2. H yoid bone (Figure 8-13)
3. Vertebra co umn (spine) (Figure 8-14 and Table 8-3)
a. 24 vertebrae: cervica (7), thoracic (12), umbar (5), 8
sacrum, coccyx
b. Vertebrae are irregu ar bones with we -def ned
parts, such as body, spine, transverse process, verte-
bra oramen, and articu ar processes (Figure 8-15)
c. At as and axisf rst two cervica vertebrae orm a
unique pivoting structure (Figure 8-16)
d. Spina curvatures support the body, but can become
abnorma y exaggerated (Figure 8-17 and Figure 8-18)
4. T oraxribs (24), sternum (Figure 8-19 and Table 8-4)
Appe ndicular S ke le to n
A. Bones o the upper and ower extremities (126)
B. Upper extremity (64) (Table 8-5)
1. Pectora (shou der) gird escapu a (2), c avic e (2)
2. Arm and orearmhumerus (2), radius (2), u na (2)
(Figure 8-20)
3. Wrist and handcarpa bones (16), metacarpa bones
(10), pha anges (28) (Figure 8-21)
C. Lower extremity (62) (Table 8-6)
1. Pe vic (hip) gird ecoxa bone (2) (Figure 8-25)
2. T igh and eg emur (2), pate a (2), tibia (2), f bu a
(2) (Figure 8-22)
3. Ank e and oot
a. arsa bones (14), metatarsa bones (10), pha anges
(28) (Figure 8-23)
b. Arched structure o oot provides dynamic support
or entire ske eton (Figure 8-24)
 214 CHAPTER 8 Skeletal System
S ke le tal Variatio ns
A. Ma e and ema e ske eta di erences
1. Sizema e ske eton genera y arger
2. Shape o pe visma e pe vis deep and narrow, ema e
pe vis sha ow and broad
3. Size o pe vic in et ema e pe vic in et genera y
wider, norma y arge enough or babys head to pass
through it (Figure 8-25)
4. Pubic ang eang e between pubic bones o ema e
genera y wider
B. Age di erences
1. Bones en arge and become more ossif ed unti matu-
rity at age 25
2. Bones active y remode (disso ve and rebui d) in
midd e adu thood
3. Bones become ess dense during e der y years
C. Environmenta actors
1. Nutrition a ects growth and maintenance o bone
tissue
2. Mechanica stress, inc uding exercise, a ects bone
remode ing
8 Jo ints
A. Articu ationa joint between two or more bones
B. Every bone except the hyoid (which anchors the tongue)
connects to at east one other bone.
C. Kinds o joints
1. Synarthroses (no movement)f brous connective
tissue ( igaments) grows between articu ating bones;
or examp e, sutures o sku (Figure 8-26)
2. Amphiarthroses (s ight movement)
a. Fibrocarti age connects articu ating bones; or
examp e, symphysis pubis (Figure 8-26)
b. Another examp e is the vertebra disk orming each
joint between vertebra bodies, which can become
herniated (Figure 8-27)
3. Diarthroses ( ree movement)most joints be ong to
this c ass
a. Structure (Figure 8-28)
(1) Structures o ree y movab e jointsjoint
capsu e and igaments ho d adjoining bones
together but permit movement at joint
(2) Articu ar carti agehya ine carti age covers
joint ends o bones where they orm joints with
other bones
(3) Synovia membrane ines joint capsu e and
secretes ubricating synovia uid
(4) Joint cavityspace between joint ends o bones
(5) Bursa uid-f ed pouch that absorbs shock;
in ammation o bursa is ca ed bursitis
b. Functions o ree y movab e jointsba -and-socket,
hinge, pivot, sadd e, g iding, and condy oida ow
di erent kinds o movements determined by the
structure o each joint (Figure 8-29 and Table 8-7)
S ke le tal Dis o rde rs
A. umors
1. Bone tumorsosteosarcoma (Figure 8-30, A)
a. Most common and serious type o ma ignant bone
neop asm
b. Frequent sites inc ude dista emur and proxima
tibia and humerus
2. Carti age tumorschondrosarcoma (Figure 8-30, B)
a. Cancer o ske eta hya ine carti age
b. Second most common cancer o ske eta tissues
c. Frequent sites inc ude medu ary cavity o humerus,
emur, ribs, and pe vic bones
B. Metabo ic bone diseases
1. Osteoporosis (Figure 8-31)
a. Characterized by oss o ca cif ed bone matrix and
reduction in number o trabecu ae in spongy bone
b. Bones racture easi yespecia y in wrists, hips, and
vertebrae
c. reatment inc udes drug therapy, exercise, and
dietary supp ements o ca cium and vitamin D
2. Rickets and osteoma aciaboth diseases characterized
by oss o bone minera s re ated to vitamin D
def ciency
a. Rickets (Figure 8-32)
(1) Loss o bone minera s occurs in in ants and
young chi dren be ore ske eta maturity
(2) Lack o bone rigidity causes gross ske eta
changes (bowing o egs)
(3) reated with vitamin D
b. O steoma acia
(1) Minera content is ost rom bones that have
a ready matured
(2) Increases susceptibi ity to ractures
(3) reated with vitamin D
3. Paget disease (osteitis de ormans) (Figure 8-33)
a. Fau ty remode ing resu ts in de ormed bones that
racture easi y
b. Cause may be genetic or triggered by vira
in ections
4. Osteogenesis imper ecta (a so ca ed brittle-bone
disease) (Figure 8-34)
a. Bones are britt e because o a ack o organic
matrix
b. reatment may inc ude sp inting to reduce racture
and drugs that decrease ce activity
C. Bone in ection
1. O steomye itis (Figure 8-35)
a. Genera term or bacteria (usua y staphy ococca )
in ection o bone
b. reatment may invo ve surgery, drainage o pus,
and parentera (IV) antibiotic treatmento ten
over pro onged periods
D. Bone ractures (Figure 8-36)
1. Open (compound) ractures pierce the skin and c osed
(simp e) ractures do not

2. Fracture types inc ude comp ete and incomp ete,
inear, transverse, and ob ique
3. Bone repairb eeding and in ammation, o owed by
ormation o a ca us (supportive ramework), and
f na y remode ing o bone (Figure 8-37)
E. Joint disorders
1. Nonin ammatory joint disordersdo not usua y
invo ve in ammation o the synovia membrane;
symptoms tend to be oca and not systemic
a. Osteoarthritis, or degenerative joint disease (DJD)
(Figure 8-38, A)
(1) Most common nonin ammatory disorder o
movab e jointso ten ca ed wear and tear
arthritis
(2) Symptoms inc ude joint pain, morning sti -
ness, and appearance o Bouchard nodes (at
proxima interpha angea joints) and H eberden
nodes (at dista interpha angea joints) o the
f ngers
(3) Most common cause or partia and tota hip
and knee rep acements
b. raumatic injury
(1) Dis ocationarticu ar sur aces o bones in
joint are no onger in proper contact; sublux-
ation is a minor dis ocation or misa ignment
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Be ore s tarting your s tudy o Chapte r 8, go back to Chapte r 5
and review the s ynops is o the s ke le tal s ys te m .
1. T ere are severa terms in this chapter that use pref xes or
su xes that he p exp ain their meaning. T e pref xes epi-
(upon) and endo- (within) were discussed ear ier. Peri-
means around, osteo- or os- re ers to bone, chondro- re ers
to carti age, -cyte means ce , -blast means young ce or
bui ding ce , and -clast means to destroy. Knowing the
meaning o these pref xes or su xes makes most o the
terms se -exp anatory.
2. W hen studying the microscopic structure o the ske eta
system, remember that bone tissue hea s air y we ,
whereas carti age does not. T is is because there are many
b ood vesse s throughout the bone; this is not so in carti-
age. T e ce s must have a way o receiving nutrients and
oxygen and a way to get rid o waste products. T e struc-
ture o the osteon a ows this to occur.
3. Reviewing the f gures o the u ske eton and the sku
may be the best way to earn the bones o the ske eton.
Use ash cards or on ine resources to supp ement the text
materia . One such on ine resource is: getbodysmart.com.
CHAPTER 8 Skeletal System 215
(2) Sprainacute injury to ligaments around joints
(examp e: whip ash-type injuries)
(3) Strainacute injury to any part o the musculo-
tendinous unit (musc e, tendon, junction
between the two, and attachments to bone)
2. In ammatory joint disordersthe term arthritis is a
genera name or severa types o in ammatory joint
diseases that may be caused by in ection, injury,
genetic actors, and autoimmunity. In ammation o
the synovia membrane occurs, o ten with systemic
signs and symptoms.
a. Rheumatoid arthritis (Figure 8-38, B)systemic
autoimmune diseasechronic in ammation o
synovia membrane with invo vement o other
tissues such as b ood vesse s, eyes, heart, and ungs
b. Gouty arthritis (Figure 8-38, C)synovia in am-
mation caused by chronic gout, a condition in
which sodium urate crysta s orm in joints and
other tissues, sometimes orming accumu ations
ca ed tophi
c. In ectious arthritis (Figure 8-39)arthritis resu ting
rom in ection by a pathogen, as in Lyme arthritis
and ehr ichiosis, caused by two di erent types o
bacteria that are transmitted to humans by tick
bites. 8
T is site has exce ent i ustrations, tutoria s, and quizzes.
Additiona on ine tips are ound at my-ap.us/JJEEM F.
4. T e joints are named based on the amount o movement
they a ow (arthro means joint). T e joint capsu e is an
examp e o a synovia membrane discussed in Chapter 7.
5. In your study group you can use ash cards to earn the
terms in the bone structure and joints. Discuss the orma-
tion and structure o the osteon. A photocopy or a ce -
phone picture o the ske eton f gures with the abe s
b ackened out wi he p you earn the names and charac-
teristics o the bones. T ere is no rea shortcut to earning
the names and ocations o the bones, it is simp y a mem-
orization task, but quizzing each other wi he p you earn
them aster.
6. Construct a tab e to he p yourse earn the bone and joint
disorders. Again, as in previous chapters, it wou d be
he p u to organize them by mechanism or cause. T e
bone cancers shou d be easy to remember because they
use the pref xes; osteo- or bone and chondro- or carti age.
7. Review the Language o Science and Language o Medi-
cine terms and their word origins to he p you better
understand the meaning o the names o the bones.
8. Review the out ine at the end o this chapter. T is out ine
provides an overview o the materia and wou d he p you
understand the genera concepts to the chapter.
 216 CHAPTER 8 Skeletal System
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. List and brie y describe the f ve unctions o the ske eta
system.
2. Describe the structure o the osteon.
3. Describe the structure o carti age.
4. Exp ain brie y the process o endochondra ossif cation,
inc uding the unction o the osteob asts and osteoc asts.
5. Exp ain the importance o the epiphysea p ate.
6. In genera , what bones are inc uded in the axia ske e-
ton? T e appendicu ar ske eton?
7. T e vertebra co umn is divided into f ve sections based
on ocation. Name the sections and give the number o
vertebrae in each section.
8. Distinguish between true, a se, and oating ribs. H ow
many o each is in the human body?
9. Describe and give an examp e o a synarthrotic joint.
10. Describe and give an examp e o an amphiarthrotic joint.
8 11. Describe and give two examp es o a diarthrotic joint.
12. Brie y describe a joint capsu e.
13. Describe open, c osed, and comminuted ractures.
14. Describe the three types o arthritis.
15. Describe bursa and def ne bursitis.
16. Describe an avu sion racture.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
17. W hen a patient receives a bone marrow transp ant, what
vita process is being restored?
18. Exp ain how the cana icu i a ow bone to hea more e -
cient y than carti age.
19. Based upon what you know, what wou d happen to bone
tissue i one o the three types o bone ce s were
missing, but the other types o bone ce s were present in
the tissue?
20. W hat e ect does the task o chi dbearing have on the
di erence between the ma e and ema e ske eton?
21. Exp ain why a bone racture a ong the epiphysea p ate may
have serious imp ications in chi dren and young adu ts.
22. Compare and contrast the causes and changes associated
with osteoporosis, osteoma acia, and Paget disease.
23. W hy is mastoiditis potentia y more dangerous than a
paranasa sinus in ection?
24. Exp ain how the anatomy o the e bow is a good
examp e o how structure f ts unction.
25. Exp ain how pa pab e bony andmarks are used in the
medica pro essions.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e thin ayer o carti age on the ends o bones where
they orm joints is ca ed the ________.
2. T e ho ow area in the sha t o a ong bone where
marrow is stored is ca ed the ________.
3. T e need e ike threads o spongy bone are ca ed
________.
4. T e structura units o compact bone are ca ed either
osteons or ________.
5. Osteocytes and chondrocytes ive in sma spaces in the
matrix ca ed ________.
6. Bone-resorbing ce s are ca ed ________.
7. Bone- orming ce s are ca ed ________.
8. T e process o orming bone rom carti age is ca ed
________.
9. I an ________ remains between the epiphysis and
diaphysis, bone growth can continue.
10. T e two major divisions o the human ske eton are the
________ ske eton and the ________ ske eton.
11. T e three types o joints, named or the amount o move-
ment they a ow are ________, ________, and ________.
12. T e ________ are cords or bands made o strong con-
nective tissue that ho d bones together.
13. Abnorma side-to-side curvature o the vertebra co umn
is ca ed ________.
14. T e ske eta disorder, common in e der y white women
and characterized by excessive oss o ca cif ed matrix
and co agen f bers is ca ed ________.
15. Microbia in ection o the bone is ca ed ________.
16. A ________ racture invites the possibi ity o in ection
because the skin is pierced.
17. Degenerative joint disease, or ________, invo ves
wearing away o articu ar carti age.
18. T e ________ bone serves as an anchor or tongue
musc es and he ps support the arynx.
19. T e cervica and umbar curves o the spine are ca ed
________ curvatures.
20. A ________ is an orthopedic procedure that invo ves the
injection o a bone cement to repair ractured and com-
pressed vertebrae or those who have experienced a com-
pression racture due to osteoporosis, trauma, tumors, or
pro onged use o steroid drugs.
21. ophi are o ten the f rst indication o ________
arthritis.
22. W hich o the o owing is not a unction o the ske eton?
a. Minera storage
b. B ood ormation
c. H eat production
d. Protection
 CHAPTER 8 Skeletal System 217

23. T e strong f brous membrane covering a o a ong bone Cas e S tudie s

except the joint is ca ed the:
a. endosteum To s olve a cas e s tudy, you m ay have to re e r to
b. periosteum the glos s ary or index, othe r chapte rs in this text-
c. igament book, and othe r re s ource s .
d. tendon
24. T e f brous ining o the ho ow cavity in the ong bone 1. Andrew is a young boy who oves to c imb trees. W hi e
is ca ed the: attempting to c imb his avorite oak tree, Andrew e and
a. endosteum ractured his humerus. T e radio ogist described Andrews
b. periosteum injury as a greenstick racture. W hat does this abe te
c. medu ary cavity you about the appearance o the racture? I given proper
d. igament medica care, is the injury ike y to hea rapid y or s ow y?
25. T e end o a ong bone is ca ed the: 2. Christine is a young music student at the oca co ege.
a. endosteum One o her pro essors suggested that she ana yze her con-
b. periosteum ducting technique by videotaping herse as she conducts
c. diaphysis the choir. As she rep ays the tape, Christine notices that
d. epiphysis her hips and shou ders seem awkward y benteven when
26. T e sha t o a ong bone is ca ed the: she is in a orma standing position. W hat condition
a. endosteum might cause this abnorma curve o the trunk? W hat are
b. periosteum some ways o treating this condition?
c. diaphysis 3. Agnes is an e der y woman with osteoporosis. She
d. epiphysis recent y sustained a severe bone racture or no apparent
27. Cancer o the carti age is ca ed: reason (she did not a or otherwise injure herse ). T e
a. osteosarcoma racture was not treated or some time, and as a resu t,
b. chondrosarcoma Agnes deve oped osteomye itis. Based on what you know 8
c. f brosarcoma o osteoporosis, how do you exp ain her mysterious rac-
d. osteoma acia ture? H ow can a racture progress to osteomye itis?
28. T e in ammatory joint disease that is caused by an 4. A ice is 10 years o d and over the past ew years has had
increase o uric acid is: severa ractures even though she is not an active chi d. A
a. osteoarthritis recent b ood test indicated that her a ka ine phosphatase
b. rheumatoid arthritis eve was high y e evated. W hat diagnosis is possib e with
c. gouty arthritis her history and ab va ues? W hat are some treatment
d. in ectious arthritis options i your diagnosis is correct?

Match the bones in Column A with their locations in Column B. Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Column A Column B
29. ________ u na a. sku
30. ________ mandib e b. upper extremity
31. ________ humerus (arm, orearm,
32. ________ metatarsa s wrist, and hand)
33. ________ tibia c. trunk
34. ________ rib d. ower extremity
35. ________ f bu a (thigh, eg, ank e,
36. ________ sternum and oot)
37. ________ scapu a
38. ________ emur
39. ________ metacarpa s
40. ________ ronta bone
41. ________ pate a
42. ________ zygomatic bone
43. ________ c avic e
44. ________ occipita bone
45. ________ carpa s
46. ________ maxi a
Muscular System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Muscle Tissue, 220 E ects o Exercise, 226

Skeletal Muscle, 220 Movements Produced by Muscles, 228
Cardiac Muscle, 220 Angular Movements, 228
Smooth Muscle, 220 Circular Movements, 228
Structure o Skeletal Muscle, 220 Special Movements, 229
Muscle Organs, 220 Skeletal Muscle Groups, 230
Muscle Fibers, 221 Muscles o the Head and Neck, 232
Function o Skeletal Muscle, 222 Muscles o the Upper Extremities,
Movement, 223 232
Posture, 224 Muscles o the Trunk, 233
Heat Production, 224 Muscles o the Lower Extremities,
Fatigue, 224 234
Integration with Other Body Systems, Muscular Disorders, 235
225 Muscle Injury, 235
Motor Unit, 225 Muscle In ections, 235
Muscle Stimulus, 225 Muscular Dystrophy, 236
Types o Muscle Contraction, 225 Myasthenia Gravis, 237
Twitch and Tetanic Contractions, 225
Isotonic Contraction, 226
Isometric Contraction, 226

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. List, locate in the body, and compare
the structure and unction o the three
major types o muscle tissue.
2. Discuss the structure and unction o
skeletal muscle.
3. Describe the role o other body systems
in movement.
4. Discuss the role o the motor unit in
muscle stimulation and how a muscle
f ber contracts.
5. Compare the major types o skeletal
muscle contractions.
6. Describe the primary e ects o exercise
on skeletal muscle.
7. List and explain the most common types
o movement produced by skeletal
muscles.
8. Name, identi y on a model or diagram,
and give the unction o the major
muscles o the body.
9. Name and describe the major disorders
o skeletal muscles.
 9
A lt h o u g h we initia y review three types o musc e tis- LANGUAGE OF
sue introduced ear ier (see Chapter 4), the p an or this chapter S C IEN C E
is to ocus on ske eta , or vo untary, musc ethose musc e
masses that attach to bones and actua y move them about
Be o re re ading the
when contraction or shortening o musc e ce s, or musc e
chapte r, s ay e ach o
f bers, occurs. the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
I you weigh 120 pounds, about 50 pounds o your weight the m as yo u re ad.
comes rom your ske eta musc es, the red meat o the body
that is attached to your bones. T e so t muscu ar tissue that
abduct
ies between your skin and your bones is o ten ca ed esh (ab-DUKT)
the site o injury in a esh wound. [ab- away, -duct lead]
abduction
Muscu ar movement occurs when chemica energy rom nutrient (ab-DUK-shun)
mo ecu es is trans erred to protein f aments in each musc e f ber and [ab- away, -duct- lead, -tion process]
converted to mechanica energy that shortens (contracts) the acetylcholine (ACh)
musc e. As the musc e f bers in a musc e contract, they pu on (as-ee-til-KOH-leen [ay see aych])
the bones to which they are attached and thus produce move- [acetyl- vinegar, -chole- bile,
ment o the body. -ine made o ]
actin
Movements caused by ske eta musc e contraction vary in (AK-tin)
comp exity rom b inking an eye to the coordinated, pow- [act- act or do, -in substance]
er u , and uid movements o a gi ted ath ete. Not many o adduct
our body structures can c aim as great an importance or (ad-DUKT)
happy, active iving as can our vo untary musc es, and on y [ad- toward, -duct lead]
a ew can boast o greater importance or i e itse . O ur adduction
abi ity to survive o ten depends on our abi ity to adjust to (ad-DUK-shun)
the changing conditions o our environment to maintain [ad- toward, -duct- lead,
homeostasis. Movements requent y constitute a major -tion process]
part o this homeostatic adjustment. adductor muscle
(ad-DUK-tor MUS-el)
[ad- toward, -duct- lead,
-or condition, mus- mouse,
-cle small]
antagonist
(an-TAG-oh-nist)
[ant- against, -agon- struggle,
-ist agent]
biceps brachii
(BYE-seps BRAY-kee-aye)
[bi- two, -cep head,
brachii related to the arm]
brachialis
(bray-kee-AL-is)
[brachi arm, -al- relating to, -is thing]

Continued on p. 238

219
 220 CHAPTER 9 Muscular System
M u s c le Tis s u e
S k e le t a l M u s c le
Under the microscope, thread ike and cy indrica skeletal
muscle ce s appear in bund es. T ey are characterized by
many crosswise stripes and mu tip e nuc ei (Figure 9-1, A).
Each f ne thread is a musc e ce usua y ca ed a muscle ber.
T is type o musc e tissue has three names: skeletal muscle,
because it attaches to bone; striated muscle, because o its cross
stripes or striations; and voluntary muscle, because its contrac-
tions can be contro ed vo untari y.
C a r d ia c M u s c le
In addition to ske eta musc e, the body a so contains two
other types o musc e tissue: cardiac muscle and smooth muscle.
Cardiac muscle composes the bu k o the heart. Ce s in
this type o musc e tissue are a so cy indrica , branch re-
quent y (Figure 9-1, B), and then recombine into a continuous
mass o interconnected tissue. As with ske eta musc e ce s,
they have cross striations. T ey a so have unique dark bands
ca ed intercalated disks where the p asma membranes o
adjacent cardiac f bers come in contact with each other.
Cardiac musc e tissue demonstrates the princip e that
structure f ts unction. T e interconnected nature o cardiac
musc e f bers he ps the tissue contract as a unit and increases
the e ciency o the heart musc e in pumping b ood.
S m o o t h M u s c le
Smooth muscle f bers are tapered at each end and have a
sing e nuc eus (Figure 9-1, C). Because they ack cross stripes,
S ke le tal mus cle fibe rs
9 S tria tions
Nucle i
Cardiac mus cle fibe rs
A
S tria tions
Inte rca la te d
dis ks Nucle us
B
S mo o th mus cle fibe rs
Nucle us
FIGURE 9-1 Muscle tissue.
A, Skeletal muscle. B, Cardiac
C muscle. C, Smooth muscle.
or striations, they are sometimes ca ed nonstriated musc e
ce s. T ey have a smooth, even appearance when viewed
through a microscope. T ey are ca ed involuntary because we
norma y do not have contro over their contractions.
Smooth, or invo untary, musc e orms an important part o
b ood vesse wa s and o many ho ow interna organs (vis-
cera) such as the gut, urethra, and ureters. Because o its oca-
tion in many viscera structures, it is sometimes a so ca ed
visceral muscle.
A though we cannot wi u y contro the action o smooth
musc e, its contractions are high y regu ated, which aci itates,
or examp e, the passage o nutrients through the digestive
tract or urine through the ureters into the b adder.
A three musc e ce typesske eta , cardiac, and smooth
specia ize in contraction or shortening. Every movement we
make is produced by contractions o ske eta musc e ce s.
Contractions o cardiac musc e ce s pump b ood through the
heart, and smooth musc e contractions he p pump b ood and
other substances through our other ho ow organs.
S t r u c t u r e o S k e le t a l M u s c le
M u s c le O r g a n s
A ske eta musc e is an organ composed main y o ske eta
musc e f bers and connective tissue.
Fibrous connective tissue wraps around each individua
musc e f ber. T e tissue continues as it wraps around groups o
musc e f bers ca ed ascicles and f na y orms a wrapper
around the entire musc e organ.
Fascia is the oose connective tissue outside the musc e
organs that orms a exib e, sticky packing materia between
musc es, bones, and the skin.
Most ske eta musc es attach to two bones that have a mov-
ab e joint between them. In other words, most musc es extend
rom one bone across one or more joints to another bone. A so,
one o the two bones is usua y more stationary during a given
movement than the other. T e musc es attachment to this
more stationary bone is ca ed its origin. Its attachment to the
more movab e bone is ca ed the musc es insertion.
T e rest o the musc e (a except its two ends) is ca ed the
body o the musc e (Figure 9-2).
endons anchor musc es f rm y to bones, being made o
dense, f brous connective tissue that extends rom the musc e
wrappers described ear ier. In the shape o heavy cords or
broad sheets, tendons have great strength. T ey do not tear or
pu away rom bone easi y. Yet any emergency room nurse or
physician sees many tendon injuriessevered tendons and
tendons torn oose rom bones.
Sma uid-f ed sacs ca ed bursae ie between some ten-
dons and the bones beneath them. T ese sma sacs are made
o connective tissue and are ined with synovial membrane.
T e synovia membrane secretes a s ippery ubricating uid
synovial uidthat f s the bursa. Like a sma , exib e
cushion, a bursa makes it easier or a tendon to s ide over a
bone when the tendons musc e shortens.
endon sheaths enc ose some tendons. Because these
tube-shaped structures are a so ined with synovia membrane
 Origin CHAPTER 9 Muscular System 221
Te ndons

Mus cle
body
Te ndon
Bone
Ins e rtion
Fa s cia
Te ndon

Conne ctive
Fa s cicle s tis s ue
(bundle s of
mus cle fibe rs )

FIGURE 9-2 Attachments o

a skeletal muscle. A muscle MUS CLE
originates at a relatively stable part o FIBER
the skeleton (origin) and inserts at the skel-
etal part that is moved when the muscle con-
tracts (insertion).

and are moistened with synovia uid, they, ike the bursae, S a rcome re
aci itate body movement.

M u s c le Fib e r s
S t r u c t u r e o M u s c le Fib e r s
Thick myofila me nt (myos in)
Ske eta musc e tissue consists o e ongated contracti e ce s, Z line Z line
or musc e f bers, that ook ike ong, tapered cy inders. T eir A Thin myofila me nt (mos tly a ctin)
exib e connective tissue wrappings ho d them together in
para e groups, a owing the musc e f bers to a pu together
in the same directionas a team.
Thick fila me nts Thin fila me nts
Each ske eta musc e f ber has a very unique cytoske eton
structure. T e f bers interna ramework is organized into many
Re la xe d
ong cy inders, each made up o two kinds o thread ike micro-
f aments ca ed thick and thin myo laments. T e thick myo-
f aments are ormed rom a protein ca ed myosin, and the Z line Z line Z line
thin myof aments are composed main y o the protein actin. 9
Each sha t ike myosin mo ecu e has a head that sticks out Contra cte d
toward the actin mo ecu es. At rest, the actin is b ocked rom
connecting with the myosin heads by sma proteins attached
to the actin. D uring contraction, however, the b ocking pro-
Ma xima lly
teins re ease actin and the myosin heads connect to orm contra cte d
crossbridges between the thick and thin f aments.
Find the abe sarcomere in Figure 9-3. T ink o the sarco-
B S a rcome re
mere as the basic unctiona , or contractile, unit o ske eta
musc e. T e submicroscopic structure o a sarcomere consists
o numerous thick and thin myof aments arranged so that
when viewed under a microscope, dark and ight stripes or

FIGURE 9-3 Structure o skeletal muscle. A, Each muscle organ has

many muscle bers, each containing many bundles o thick and thin myo la-
ments. The diagrams show the overlapping thick and thin laments arranged
to orm adjacent segments called sarcomeres. B, During contraction, the
thin laments are pulled toward the center o each sarcomere, thereby
shortening the whole muscle. C, This electron micrograph shows that the
overlapping thick and thin laments within each sarcomere create a pattern
o dark striations in the muscle. The extreme magni cation allowed by
electron microscopy has revolutionized our concept o the structure and
unction o skeletal muscle and other tissues. C Z line S a rcome re Z line
 222 CHAPTER 9 Muscular System

striations are seen. T e repeating units, or sarcomeres, are sepa-
rated rom each other by dark bands ca ed Z lines or Z disks.
A though the sarcomeres in the upper portions (Figure 9-3, B)
and in the e ectron micrograph (EM) o Figure 9-3, C, are in a
re axed state, the thick and thin myof aments, which are ying
para e to each other, sti over ap. Now ook at the diagrams in
the midd e portion o Figure 9-3, A. Note that contraction o the
musc e causes the two types o myof aments to s ide toward
each other and shorten the sarcomere, thus shortening the entire
musc e. W hen the musc e re axes, the sarcomeres can return to
resting ength, and the f aments resume their resting positions.
C o n t r a c t io n o M u s c le Fib e r s
An exp anation o how a ske eta musc e contracts is provided
by the sliding lament model. According to this mode , dur-
ing contraction, the thick and thin myof aments in a musc e
f ber f rst attach to one another by orming crossbridges that
then act as evers to ratchet or pu the myof aments past
each other.
T e connecting bridges between the myof aments orm
on y i ca cium is present. D uring the re axed state, ca cium
ions (Ca ) are stored within the endop asmic reticu um (ER)
in the musc e ce . W hen a nerve signa stimu ates the musc e
f ber, Ca are re eased rom the ER into the cytop asm.
T ere, the Ca bind to the thin f aments and re ease
actin to react with myosin. T e myosin heads connect to
actin, pu , re ease, and then pu again. T is ratcheting o
myosin heads thus pu s the thin f aments toward the cen-
ter o the sarcomereproducing the musc e contraction
(Figure 9-4).
Ca cium ion pumps in the membrane o the ER quick y
pu most o the ree Ca back out o the cytop asm and back
into the ER. Because Ca are no onger avai ab e to bind to
the thin f aments, the actin-myosin reactions stoprestoring
re axation in the musc e f ber.
T e contraction process o a musc e ce requires energy.
T is energy is supp ied by g ucose and other nutrients.
T e energy must be trans erred to myosin heads by adenos-
ine triphosphate (A P) mo ecu es, the energy-trans er mo e-
cu es o the ce (see Figure 2-15 on p. 35). O xygen is required
to trans er energy rom g ucose to A P and make it avai ab e
to the myosin heads, so it is not surprising that many musc es
have high oxygen requirements.
o supp ement the oxygen carried to musc e f bers by the
hemoglobin o b ood, musc e f bers contain myoglobina red,
oxygen-storing pigment simi ar to hemog obin. D uring rest,
oxygen carried to musc es by hemog obin in the b ood is taken
up by myog obin within musc e f bers. As oxygen is used up
quick y during musc e contractions, oxygen rom myog obin
adds to the oxygen rom hemog obinthereby a owing maxi-
mum recharging o energy-containing A P mo ecu es.
We discuss the processes o trans erring energy to A P to
ce u ar processes in Chapter 19.
To learn more about how energy in the body is
measured, including examples the energy cost
o common muscular activities, check out the
article Measuring Energy at Connect It! at
evolve.elsevier.com.

QUICK CHECK
FIGURE 9-4 Mechanism o 1. Wh a t a re th e th re e m a in typ e s
Ne rve impuls e P la s ma me mbra ne
muscle contraction.
Motor ne uron of mus cula r fibe r o m u s cle tis s u e ? Ho w d o th e y
Ne uromus cula r Ele ctrica l d i e r?
9 junction (NMJ ) impuls e 2. Dis tin g u is h b e tw e e n a s cicle s
a n d a s cia .
1 3. Wh a t is a m u s cles o rig in ? Its
A ne rve impuls e trave ls to a in s e rtio n ?
mus cle fibe r through a motor Ca 4. Ho w d o a m u s cles m yo f la -
ne uron, trigge ring a n m e n ts p rovid e th e m e ch a n is m
e le ctrica l impuls e tha t o r m ove m e n t?
trave ls a long the mus cle
fibe r me mbra ne.

To better understand
2 this concept, use the
The impuls e trigge rs the S mooth e ndopla s mic
re le a s e of ca lcium ions
Active Concept Map
re ticulum
(Ca ) from the Ca How a Skeletal Muscle
e ndopla s mic re ticulum a nd Fiber Contracts at
into the cytopla s m.
evolve.elsevier.com.

3
The Ca ions bind to thin Fu n c t io n o
fila me nts a nd pe rmit a ctin to
re a ct with myos in. Myos in S k e le t a l M u s c le
he a ds form ra tche ting
cros s bridge s with a ctin, T e unctions o the muscu ar sys-
which pull the thin fila me nts tem are many. Most obvious y, this
towa rd the middle of the
s a rcome rethus producing
system produces movement o the
Thick Cros s -
a contra ction. Z dis k fila me nt bridge Z dis k ske eton and permits us to move
Thin fila me nt Myos in he a ds our who e body, as we as our
 CHAPTER 9 Muscular System 223

teams, not individua y. Severa musc es contract whi e others

C LIN ICA L APPLICATION re ax to produce a most any movement that you can imagine.
O a the musc es contracting simu taneous y, the one that
RIGOR MORTIS is main y responsib e or producing a particu ar movement is
The te rm rigo r m o rtis is a Latin phras e that m e ans s ti - ca ed the prime mover or that movement. T e other musc es
ne s s o de ath. In a m e dical context, the te rm rigor m ortis that he p in producing the movement are ca ed synergists.
re e rs to the s ti ne s s o s ke le tal m us cle s s om e tim e s ob- As prime movers and synergist musc es at a joint contract,
s e rve d s hortly a te r de ath. other musc es, ca ed antagonists, re ax. W hen antagonist
What caus e s rigor m ortis ? At the tim e o de ath, s tim ula- musc es contract, they produce a movement opposite to that
tion o m us cle ce lls ce as e s . Howeve r, s om e m us cle f be rs o the prime movers and their synergist musc es.
m ay have be e n in m id-contraction at the tim e o de ath Locate the biceps brachii, brachia is, and triceps brachii
w he n the myos in-actin cros s bridge s are s till intact. ATP is
musc es in Figure 9-10 on p. 231. A o these musc es are in-
re quire d to re le as e the cros s bridge s and e ne rgize the m
vo ved in bending and straightening the orearm at the e bow
or the ir next attachm e nt. Be caus e the las t o a ce lls ATP
s upply is us e d up at the tim e it die s , m any cros s bridge s
joint. Each may p ay a di erent ro e, depending on the start-
m ay be le t s tuck in the contracte d pos ition. Thus m us - ing positions o the bones and rom which direction the oad
cle s in a de ad body m ay be s ti be caus e individual m us cle is resisting the movement.
f be rs ran out o the ATP re quire d to turn o a m us cle Imagine the e bow is s ight y exed and orearm is s ight y
contraction. twisted so that the hand is thumb up, as in ho ding a arge
bott e o water upright. T e biceps brachii may act as the
prime mover as you ex the e bow to i t the bott e to drink.
In this case, the brachia is may act as its he per or synergist
individua imbs. By producing continuous tension on the musc e.
ske etonmuscle tonethis system a so he ps maintain a I you instead i ted a heavy object rom a pa m-up posi-
stab e body position, or posture. As we earned in Chapter 1, tion, the brachia is and biceps brachii musc es wou d ike y
ske eta musc es a so produce heat and thus he p us maintain reverse ro es, with the brachia is becoming the prime mover.
homeostatic ba ance o body temperature. T is happens because the direction o the oad has changed
so musc e contro wi adapt according y.
M o ve m e n t
Musc es move bones by pu ing on them. Be-
cause the ength o a ske eta musc e becomes
shorter as its f bers contract, the bones to S C IEN C E APPLICATIONS
which the musc e attaches move c oser to-
MUS CLE FUNCTION
gether. As a ru e, on y the insertion bone
moves. Look again at Figure 9-2. As the ba is The Britis h phys iologis t Andrew F. Huxley is large ly
i ted, the shortening o the musc e body pu s re s pons ible or explaining how m us cle f be rs con- 9
the insertion bone toward the origin bone. T e tract. A te r m aking pione e ring dis cove rie s in how
origin bone stays put, ho ding f rm, whi e the ne rve s conduct im puls e s , a e at or w hich he
insertion bone moves toward it. Remember s hare d the 1963 Nobe l Prize in Me dicine or Phys i-
ology, Huxley turne d his atte ntion to m us cle f be rs .
this simp e ru e: a musc es insertion bone
It was he w ho, in the 1950s , propos e d the s liding
moves toward its origin bone. It can he p you f lam e nt m ode l along w ith its m e chanical explana-
understand musc e actions. tion o m us cle contraction.
Shortening o a musc e is the primary ex- Today, e xe rcis e phys io lo g is ts and othe r re -
amp e o musc e action in this chapter, but it is Andrew Huxley s e arche rs continue to f nd out m ore about how
important to remember that musc es can a so (19172012) m us cle f be rs and m us cle organs work. The s e
produce tension as they extend. T is occurs dis cove rie s are be ing applie d in m any di e re nt
when musc es engthen under tension, as the pro e s s ions . For exam ple , nutritio nis ts us e this in orm ation in advis ing ath-
musc e insertion is pu ed by a oad away rom le te s and othe rs conce rning w hat and w he n to e at to m axim ize m us cular
the origin. For examp e, when you ower a s tre ngth and e ndurance . Athle te s the m s e lve s , along w ith the ir coache s and
heavy bow ing ba rom your shou der the athle tic traine rs , us e curre nt conce pts o m us cle s cie nce in he lping the m
im prove the ir pe r orm ance .
musc es in your arm produce tension as they
He alth pro e s s ionals s uch as phys icians , nurs e s , phys ical the rapis ts , and
engthen and a ow you to gent y ower it occupational the rapis ts us e in orm ation about m us cular proble m s s uch as
otherwise the ba wou d sudden y a and pos- myas the nia gravis and m us cular dys trophy to he lp clie nts im prove the ir m o-
sib y cause injury. ension during musc e bility and quality o li e . Many othe r pro e s s ions s uch as chiro practic,
engthening is o ten ca ed eccentric contraction. m as s age the rapy, e rgo no m ics , phys ical e ducatio n, f tne s s , dance , art,
Vo untary muscu ar movement is norma y and bio m e chanical e ng ine e ring als o re ly on up-to-date in orm ation on
smooth and ree o jerks and tremors because m us cle s tructure and unction or optim al pe r orm ance .
ske eta musc es genera y work in coordinated
 224 CHAPTER 9 Muscular System

In either case, when the biceps brachii and brachia is
musc es i t the orearm, the triceps brachii re axes to a ow
the movementthus acting as the antagonistic musc e.
W hen the orearm straightens, these three musc es con-
tinue to work as a team. H owever, during straightening, the
triceps brachii becomes the prime mover and the biceps
brachii and brachia is become the antagonistic musc es. T is
combined and coordinated team ike activity is what makes
our muscu ar movements smooth and grace u .
To learn more about movement o the muscles, go
to AnimationDirect online at evolve.elsevier.com.
Po s t u re
We are ab e to maintain our body position because o a spe-
cif c type o ske eta musc e contraction ca ed muscle tone or
tonic contraction. Because re ative y ew o a musc es f bers
shorten at one time in a tonic contraction, the musc e as a
who e does not shorten, and no movement occurs. Conse-
quent y, tonic contractions do not move any body parts. T ey
do ho d musc es in position, however. In other words, musc e
tone maintains posture.
Good posture is the def nition o body positioning that
avors best unctioning o a body parts. Such positioning
ba ances the distribution o weight and there ore puts the
east strain on musc es, tendons, igaments, and bones.
Ske eta musc e tone maintains posture by counteract-
ing the pu o gravity. G ravity tends to pu the head and
trunk downward and orward, but the tone in certain back
and neck musc es pu s just hard enough in the opposite
direction to overcome the orce o gravity and ho d the head
and trunk erect.
He a t P ro d u c t io n
H ea thy surviva depends on our abi ity to maintain a con-
stant body temperature. A ever, or e evation in body tempera-
ture, o on y a degree or two above 37 C (98.6 F) is a most
a ways a sign o i ness. Just as serious is a a in body tem-
perature. Any decrease be ow norma , a condition ca ed
hypothermia, drastica y a ects ce u ar activity and norma
body unction. T e contraction o musc e f bers produces most
o the heat required to maintain body temperature.
Energy required to produce a musc e contraction is ob-
tained rom A P. Some o the energy trans erred to A P and
re eased during a muscu ar contraction is used to shorten the
musc e f bers; however, much o the energy is ost as heat dur-
ing its trans er to A P. T is heat he ps us to maintain our
body temperature at a constant eve .
Sometimes the heat rom generating A P during heavy
musc e use can produce too much heat, and we have to sweat
or shed ayers o c othing to coo back down to our setpoint
temperature.
Fa t ig u e
I musc e f bers are stimu ated repeated y without adequate
periods o rest, the strength o the musc e contraction de-
creases, resu ting in atigue. I repeated stimu ation occurs,
the strength o the contraction continues to decrease, and
eventua y the musc e oses its abi ity to contract.

9 HEA LTH AND WELL-BEIN G

S LOW AND FAST MUS CLE FIBERS
Sports phys iologis ts know the re are thre e bas ic s ke le tal m us cle f be r type s in the
body: s low, as t, and inte rm e diate f be rs . Each type is be s t s uite d to a particular s tyle
o m us cular contractiona act that is us e ul w he n cons ide ring how di e re nt m us -
cle s are us e d in various athle tic activitie s .
Slow f be rs are als o calle d re d f be rs be caus e they have a high conte nt o
oxyge n-s toring m yoglobin (a re d pigm e nt s im ilar to he m oglobin). Slow f be rs are
be s t s uite d to e ndurance activitie s s uch as long-dis tance running (picture d) be -
caus e the y do not atigue e as ily. Mus cle s that m aintain body pos itionpos ture
have a high proportion o s low f be rs .
Fas t f be rs are als o calle d w hite f be rs be caus e they have a low re d myoglobin
conte nt. Fas t f be rs are be s t s uite d or quick, powe r ul contractions be caus e eve n
though they atigue quickly they can produce a gre at am ount o ATP ve ry quickly. Fas t
f be rs are we ll s uite d to s printing and we ight-li ting eve nts . Mus cle s that m ove the
f nge rs have a high proportion o as t f be rs a big he lp w he n playing com pute r
gam e s or m us ical ins trum e nts .
Inte rm e diate f be rs have characte ris tics be twe e n the extre m e s o s low and as t
f be rs . This m us cle type is ound in m us cle s s uch as the cal m us cle (gas trocne m ius )
that is us e d both or pos ture and occas ional brie , powe r ul contractions s uch as
jum ping.
Each m us cle o the body is a m ixture o varying proportions o s low, as t, and in-
te rm e diate f be rs .

D uring exercise, the stored A P required or musc e con-
traction becomes dep eted. Formation o more A P resu ts in
rapid consumption o oxygen and nutrients, o ten outstripping
the abi ity o the musc es b ood supp y to rep enish them.
W hen oxygen supp ies run ow, the musc e f bers switch to a
type o energy conversion that does not require oxygen. T is
process produces actic acid that may contribute to a burning
sensation in musc e during exercise.
T e simp e term oxygen debt describes the continued in-
creased metabo ism that must occur in a ce to remove excess
actic acid that accumu ates during pro onged exercise. T us
the dep eted energy reserves are rep aced. Labored breathing
a ter the cessation o exercise is required to pay the debt o
oxygen required or the metabo ic e ort.
T e technica name or oxygen debt used by exercise physi-
o ogists is excess post-exercise oxygen consumption (EPOC), a
term that more direct y describes what happens a ter exercise.
T e oxygen debt mechanism is a good examp e o homeo-
stasis at work. T e body returns the ce s energy and oxygen
reserves to norma , resting eve s.
Interested in learning more about EPOC?
Check out the illustrated article Oxygen Debt at
Connect It! at evolve.elsevier.com.
In t e g r a t io n w it h O t h e r Bo d y S y s t e m s
Remember that musc es do not unction a one. O ther struc-
tures such as bones and joints must unction a ong with them.
Most ske eta musc es cause movements by pu ing on bones
across movab e joints.
H owever, the respiratory, cardiovascu ar, nervous, muscu ar,
and ske eta systems a p ay essentia ro es in producing norma
movements. T is act has great practica importance. For ex-
amp e, a person might have per ect y norma musc es and sti
not be ab e to move norma y. H e or she might have a nervous
system disorder that shuts o impu ses to certain ske eta
musc es, which resu ts in paralysis. Multiple sclerosis (MS) cre-
ates para ysis in this way, but so do some other conditions such
as a brain hemorrhage, a brain tumor, or a spina cord injury.
Ske eta system disorders, especia y arthritis, have dis-
ab ing e ects on body movement.
Musc e unctioning, then, depends on the unctioning o
many other parts o the body. T is act i ustrates a princip e
that is repeated o ten in this book. It can be simp y stated:
Each part o the body is one o many components in a arge,
interactive system that maintains homeostasis. T e norma
unction o one part depends on the norma unction o the
other parts.
QUICK CHECK
1. Wh a t a re th e th re e p rim a ry u n ctio n s o th e m u s cu la r
s ys te m ?
2. Wh e n a p rim e m ove r m u s cle co n tra cts , w h a t d o e s its
a n ta g o n is t d o ?
3. Ho w w o u ld yo u d e f n e th e te rm p o s tu re ?
4. Ho w d o e s m u s cle u n ctio n a e ct b o d y te m p e ra tu re ?
5. Wh a t is oxyg e n d e b t?
CHAPTER 9 Muscular System 225
M o t o r U n it
Be ore a ske eta musc e can contract and pu on a bone to
move it, the musc e must f rst be stimu ated by nerve impu ses.
Musc e ce s are stimu ated by a nerve f ber ca ed a motor
neuron (see Figures 9-4 and 9-5). T e junction between the
nerve ending and the musc e f ber is ca ed a neuromuscular
junction (NMJ).
Signa chemica s ca ed neurotransmitters are re eased by
the motor neuron in response to a nervous impu se. T e type
o neurotransmitter operating in each NMJ is ca ed
acetylcholine (ACh). T e re eased ACh di uses across a tiny
gap at the NMJ and triggers events within the musc e ce that
stimu ate the contraction process i ustrated in Figure 9-4. A
sing e motor neuron, with the musc e ce s it innervates, is
ca ed a motor unit (see Figure 9-5).
M u s c le S t im u lu s
In a aboratory setting, a sing e musc e f ber can be iso ated
and subjected to stimu i o varying intensities so that it can be
studied. Such experiments show that a musc e f ber does not
contract unti an app ied stimu us reaches a certain eve o
intensity. T e minima eve o stimu ation required to cause a
f ber to contract is ca ed the threshold stimulus.
A musc e is composed o many musc e ce s that are con-
tro ed by di erent motor units and that have di erent
thresho d-stimu us eve s. Consider a so that di erent num-
bers o motor units can be activated simu taneous y, thus a -
ecting the overa strength o contraction. T is act has tre-
mendous importance in everyday i e. It a ows you to pick up
either a sma bott e o water or a two-ga on jug because
di erent numbers o motor units can be activated or di erent
oads.
Ty p e s o M u s c le C o n t r a c t io n 9
In addition to the tonic contraction o musc e that maintains
musc e tone and posture, other types o contraction occur as
we . T ese additiona types o musc e contraction inc ude the
o owing:
1. witch contraction
2. etanic contraction
3. Isotonic contraction
4. Isometric contraction
Tw it c h a n d Te t a n ic C o n t r a c t io n s
A twitch is a quick, jerky response to a stimu us. witch con-
tractions can be seen in iso ated musc es during research, but
they p ay a minima ro e in norma musc e activity. o accom-
p ish the coordinated and uid muscu ar movements needed
or most dai y tasks, musc es must contract in a smooth and
sustained waynot in the jerky manner o a twitch.
A tetanic contraction is a more sustained and steady re-
sponse than a twitch. It is produced by a series o stimu i
bombarding the musc e in rapid succession. Contractions
 226 CHAPTER 9 Muscular System

Motor ne uron Ne uromus cula r

Mus cle fibe r junction

S chwa nn
ce ll
Mye lin s he a th

Motor
ne uron

Ne uromus cula r junction

Nucle us
Mus cle be rs
me t together to produce a sus-
tained contraction or tetanus. About Myo brils
30 stimu i per second, or examp e, evoke a B
tetanic contraction in certain types o ske eta
musc e. etanic contraction is not necessari y a maxima con-
traction in which each musc e f ber responds at the same time. S pina l cord
In most cases, on y a ew motor units undergo contractions at
any one time.

Is o t o n ic C o n t r a c t io n
In most cases, isotonic contraction o musc e produces
movement at a joint. W ith this type o contraction, the mus-
c e changes ength, and the insertion end moves re ative to the
point o origin (Figure 9-6, A).
T ere are two types o isotonic contraction. One is
9 concentric contraction, in which the musc e shortens. T e
other is eccentric contraction, in which the musc e engthens
but sti provides work.
For examp e, i ting this book requires concentric con-
traction o the biceps musc e that exes your e bow. Lower-
ing the book s ow y and sa e y requires eccentric contraction
o the biceps musc e. T us, what we ca musc e contraction
rea y means any pu ing o the musc e whether it shortens
or not.
Wa king, running, breathing, i ting, twisting, and most
body movements are examp es o isotonic contraction.
Is o m e t r ic C o n t r a c t io n
Contraction o a ske eta musc e does not a ways produce
movement. Sometimes, it increases the tension within a mus-
c e but does not change the ength o the musc e. W hen the
musc e contracts and no movement resu ts, it is ca ed an
isometric contraction. T e word isometric comes rom Greek
words that mean equa measure. In other words, a musc es
ength during an isometric contraction and during re axation is
about equa .
Motor unit 1
Motor unit 2
Motor unit 3
C
FIGURE 9-5 Motor unit. A, A motor unit consists o one motor neuron
and the muscle bers supplied by its branches. B, Micrograph o a motor
unit. C, Diagram o several motor units, each controlled by its own motor
neuron.
A though musc es do not shorten (and thus produce no
movement) during isometric contractions, tension within
them increases (Figure 9-6, B). Because o this, repeated iso-
metric contractions make musc es grow arger and stronger.
Pushing against a wa or other immovab e object is a good
examp e o isometric exercise. A though no movement occurs
and the musc e does not shorten, its interna tension increases
dramatica y.
E e c t s o Exe r c is e
We know that exercise is good or us. Some o the benef ts o
regu ar, proper y practiced exercise are great y improved mus-
c e tone, better posture, more e cient heart and ung unc-
tion, ess atigue, and ooking and ee ing better.
 CHAPTER 9 Muscular System 227

IS OTONIC IS OMETRIC
S a me te ns ion; cha nging le ngth S a me le ngth; cha nging te ns ion

Mus cle Re la xe d
le ngthe ns

Ec c e ntric c o ntrac tio n

Contra cting
Mus cle
s horte ns

Co nc e ntric c o ntrac tio n

A B
FIGURE 9-6 Types o muscle contraction. A, In isotonic contraction the muscle changes length, produc-
ing movement either by eccentric contraction (muscle lengthens) or concentric contraction (muscle shortens).
B, In isometric contraction the muscle pulls orce ully against a load but does not shorten.

RES EA RC H, IS S U ES , AND TREN D S

ENHANCING MUS CLE STRENGTH
The m os t obvious and e e ctive way o incre as ing s ke le tal
m us cle s tre ngth is by s tre ngth training, that is , re gularly pulling
agains t he avy re s is tance . The m axim al am ount o m us cular
s tre ngth one can achieve is de te rm ine d m ainly by ge ne tics .
Howeve r, the re are a num be r o che m ical e nhance m e nts ath-
le te s have trie d ove r the ce nturie s to im prove s tre ngth. An
e arly ad am ong athle te s in the twe ntie th ce ntury was the
ove rus e o vitam in s upple m e nts . Although m ode rate vitam in
s upple m e ntation w ill e ns ure ade quate intake o vitam ins ne c-
e s s ary or good m us cle unction, ove rus e m ay le ad to hype rvi-
tam inos is and pos s ibly s e rious cons e que nce s .
Anothe r type o che m ical o te n abus e d by athle te s is ana-
bolic s te roids . Anabolic s te roids are us ually s ynthe tic de riva-
tive s o the m ale horm one te s tos te rone . As w ith te s tos te rone ,
they do in act s tim ulate an incre as e in m us cle s ize and
s tre ngth, m aking the m dange rous ly attractive to coache s and
athle te s wanting to w in the ir eve nts . Howeve r, us e o the s e
horm one s can caus e s e rious , eve n li e -thre ate ning, horm onal
im balance s . For this re as on, anabolic s te roids are s trictly
banne d rom organize d s ports .
Sports phys iologis ts are now inve s tigating a w hole varie ty
o che m icals s uch as cre atine phos phate and various coe n-
zym e s (e nzym e he lpe rs ) that are re porte d to e nhance s tre ngth
or e ndurance . Always care ully review the late s t re s e arch f nd-
ings on s uch s ubs tance s w ith the he lp o your re e re nce librar-
ian and dis cus s the m w ith your phys ician be ore us ing the m
yours e l , or you m ay s u e r s e rious he alth cons e que nce s .
 228 CHAPTER 9 Muscular System

Ske eta musc es undergo changes that correspond to the

amount o work that they norma y do. D uring pro onged HEA LTH AND WELL-BEIN G
inactivity, musc es usua y shrink in mass, a condition ca ed
disuse atrophy. Exercise, on the other hand, may cause an MUS CLE MAS SAGE
increase in musc e size ca ed hypertrophy. Re s e arch s how s that m as s aging m us cle s a te r exe rcis e
Musc e hypertrophy can be enhanced by strength training, re duce s the in am m ation that can caus e s ore ne s s a te r a
which invo ves contracting musc es against heavy resistance. workout or athle tic com pe tition. Mas s aging m us cle s or
Isometric exercises and weight i ting are common strength- jus t 10 m inute s im m e diate ly a te r exe rcis e can de cre as e
training activities. T is type o training resu ts in increased the che m icals that trigge r the pain and s we lling that s om e -
numbers o myof aments in each musc e f ber. A though the tim e s ollow s vigorous us e o s ke le tal m us cle s . Mas s aging
number o musc e f bers stays the same, the increased number m us cle s als o incre as e s the num be r o m itochondria in e ach
m us cle f be rre s ulting in m ore e ne rgy be ing available or
o myof aments great y increases the mass o the musc e.
uture contractions .
Endurance training, o ten ca ed aerobic training, does
not usua y resu t in musc e hypertrophy. Instead, this type o
exercise program increases a musc es abi ity to sustain moder-
ate exercise over a ong period. Aerobic activities such as run-
ning, bicyc ing, or other primari y isotonic movements in-
crease the number o b ood vesse s in a musc e without
signif cant y increasing its size. T e increased b ood ow a -
ows a more e cient de ivery o oxygen and g ucose to musc e
f bers during exercise.
Aerobic training a so causes an increase in the number o
mitochondria in musc e f bers. T is a ows production o more
A P as a rapid energy source.

QUICK CHECK
1. Wh a t is th e ro le o a ce tylch o lin e a t th e n e u ro m u s cu la r
ju n ctio n ?
2. Wh a t is a m o to r u n it?
3. Ho w d o e s a m u s cle p ro d u ce d i e re n t le ve ls o s tre n g th ?
4. Wh a t is th e d i e re n ce b e tw e e n is o to n ic a n d is o m e tric
m u s cle co n tra ctio n ?
5. Ho w d o e s s tre n g th tra in in g d i e r ro m e n d u ra n ce
tra in in g ?
9 M o ve m e n t s P ro d u c e d
b y M u s c le s
T e particu ar type o movement that may occur at any joint
depends on the musc es acting at that joint, on their origin
and insertion points, on the shapes o the bones invo ved, and
the joint type (see Chapter 8). Musc es acting on some joints
produce movement in severa directions, whereas on y imited
movement is possib e at other joints. T e terms most o ten
used to describe body movements are described in the o ow-
ing sections.
A n g u la r M o ve m e n t s
Flexion is a movement that makes the ang e between two
bones at their joint sma er than it was at the beginning o the
movement. Most exions are movements common y de-
scribed as bending. I you bend your e bow or your knee, you
ex it.
Extension movements are the opposite o exions. T ey
make the ang e between two bones at their joint arger than it
was at the beginning o the movement. T ere ore, extensions
are straightening or stretching movements rather than bend-
ing movements. W hen you straighten your e bow or knee, you
extend it.
Figure 9-7 and Figure 9-9, A, show exion and extension o the
e bow. Figure 9-8 i ustrates exion and extension o the knee.
Abduction means moving a part away rom the mid ine o
the body, such as moving your arm out to the side.
Adduction means moving a part toward the mid ine, such
as bringing your arms down to your sides rom an e evated
position. W hen you move your arm to the side to wave, you
abduct it. W hen you move your arm back toward your body,
you adduct it. Figure 9-9, B, shows abduction and adduction.
C ir c u la r M o ve m e n t s
Rotation is movement around a ongitudina axis. You rotate
your head and neck by moving your sku rom side to side as
in shaking your head no (Figure 9-9, C).
Circumduction moves a part so that its dista end moves
in a circ e (Figure 9-9, D). W hen a pitcher winds up to throw a
ba , she circumducts her arm.
Supination and pronation re er to hand positions that
resu t rom rotation o the orearm. (T e term prone re ers to
the body as a who e ying ace down. Supine means ying ace
up.) Supination resu ts in a hand position with the pa m
turned to the anterior position (as in the anatomica position)
and pronation occurs when you turn the pa m o your hand so
that it aces posterior y (Figure 9-9, E).
 CHAPTER 9 Muscular System 229

Flexio n Exte ns io n
Flexio n
Bra chia lis a nd Bra chia lis a nd
bice ps bra chii bice ps bra chii
(contra cte d) S (re la xe d)
Exte ns io n
P D

I
Trice ps bra chii Trice ps bra chii
(re la xe d) (contra cte d)

A B C
FIGURE 9-7 Flexion and extension o the orearm. A and B, When the orearm is f exed at the elbow,
the brachialis and biceps brachii contract while an antagonist, the triceps brachii, relaxes. B and C, When the
orearm is extended, the brachialis and biceps brachii relax while the triceps brachii contracts.

Qua drice ps fe moris group

Qua drice ps fe moris (contra cte d)
group (re la xe d)

Exte ns io n
Ha ms tring group Ha ms tring group S
(contra cte d) (re la xe d)
P D
Flexio n
I
Flexio n Exte ns io n

A B C
FIGURE 9-8 Flexion and extension o the leg. A and B, When the leg f exes at the knee, muscles o the
hamstring group contract while their antagonists in the quadriceps emoris group relax. B and C, When the leg
extends, the hamstring muscles relax while the quadriceps emoris muscle contracts.

W hen you ask or change, you supinate as you twist the your oot when the so e moves inward. Eversion turns the
orearm outward and you pronate as you twist the orearm ank e in the opposite direction, so that the bottom o the oot
inward to put the change in your pocket. aces toward the side o the body (Figure 9-9, H). You evert
your oot when your so e moves outward.
S p e c ia l M o ve m e n t s As you study the i ustrations and earn to recognize the 9
musc es discussed in this chapter, you shou d attempt to group
Some body parts, such as the oot, are di cu t to describe them according to unction, as in Table 9-1. Some musc e
with ordinary terms, so specia terms are o ten used to de- names inc ude the type o movement the musc e produces,
scribe their unique movements. such as the musc e named adductor longus. You wi note,
D orsi exion and plantar exion re er to ank e movements. or examp e, that exors produce many o the movements
o dorsi ex the ank e, the dorsum or top o the oot is e evated used or wa king, sitting, swimming, typing, and many other
with the toes pointing
upwardas when stand-
ing on your hee . o TABLE 9-1 Muscles Grouped According to Function
plantar ex the ank e, the PART
bottom o the oot is di- MOVED FLEXORS EXTENS ORS ABDUCTORS ADDUCTORS
rected downward so that Arm Pe ctoralis m ajor Latis s im us dors i De ltoid Pe ctoralis m ajor and latis s im us
you are in e ect standing dors i contracting toge the r
on your toes (Figure 9-9, F).
Fore arm Bice ps brachii Trice ps brachii None None
Inversion and eversion
Thigh Iliops oas Glute us m axim us Glute us m e dius Adductor group
are a so ank e movements.
Sartorius Ham s trings
Inversion moves turn the
Re ctus e m oris
ank e so that the bottom
Le g Ham s trings Quadrice ps group None None
o the oot aces toward
the mid ine o the body Foot Tibialis ante rior Gas trocne m ius Fibularis longus Tibialis ante rior
Sole us Fibularis brevis Fibularis te rtius
(Figure 9-9, G). You invert
 230 CHAPTER 9 Muscular System

ANGULAR activities. Extensors a so unction in these ac-

tivities but perhaps p ay their most important
ro e in maintaining an upright posture.

QUICK CHECK
1. Ho w d o e s th e a n g le b e tw e e n tw o b o n e s

A
b
d i e r in e xio n a n d e xte n s io n ?

d
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io n

n oi
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l
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3. Ho w is d o rs i e xio n o th e o o t p e r o rm e d ?
4. Fle xo rs a n d e xte n s o rs u n ctio n in m a ny o
th e s a m e a ctivitie s ; h o w e ve r, th e e xte n s o rs

A
d

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et
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tions, go to AnimationDirect online

at evolve.elsevier.com.
S S

A P R L
S k e le t a l M u s c le G ro u p s
I I In the paragraphs that o ow, representative
A B musc es rom the most important ske eta mus-
c e groups are discussed. Re er to Figure 9-10
o ten so that you wi be ab e to see a musc e as
CIRCULAR you read about its p acement on the body and
its unction.
R

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h
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tio tr ot
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Dors iflexion P
P la nta r flexion
L M

P D

A P FIGURE 9-9 Examples o body movements.

A, Flexion and extension. B, Adduction and abduc-
D tion. C, Rotation. D, Circumduction. E, Pronation
Inve rs ion Eve rs ion and supination. F, Dorsif exion and plantar f exion.
F G H G, Inversion. H, Eversion.
 CHAPTER 9 Muscular System 231

Table 9-2 through Table 9-5 identi y and group musc es ac-
Muscles o the body do not work as isolated
cording to unction and provide in ormation about musc e
engines o movement, but instead act in unctional
action and points o origin and insertion. Keep in mind that
teams to produce e ective movement. Check out
musc es move bones, and the bones that they move are their
the illustrated article Whole Body Muscle
insertion bones.
Mechanics at Connect It! at evolve.elsevier.com.
As you study the major musc es o the body, try to f nd
them in the Clear View o the Human Body ( o ows p. 8).

FIGURE 9-10 Overview o muscles o the body. A, Anterior view. B, Posterior view. Both views show an
adult emale.
 232 CHAPTER 9 Muscular System

TABLE 9-2 Muscles o the Head and Neck

MUS CLE FUNCTION INS ERTION ORIGIN
Frontal Rais e s eye brow Skin o eye brow Occipital bone
Orbicularis oculi Clos e s eye Maxilla and rontal bone Maxilla and rontal bone (e ncircle s eye )
Orbicularis oris Draw s lips toge the r Encircle s lips Encircle s lips
Zygom aticus Elevate s corne rs o m outh and lips Angle o m outh and uppe r lip Zygom atic
Mas s e te r Clos e s jaw s Mandible Zygom atic arch
Te m poral Clos e s jaw s Mandible Te m poral re gion o the s kull
Ste rnocle idom as toid Rotate s and exe s he ad and ne ck Mas toid proce s s Ste rnum and clavicle
Trape zius Exte nds he ad and ne ck Scapula Skull and uppe r ve rte brae
Move s or s tabilize s s capula

M u s c le s o t h e He a d a n d N e c k musc es are ocated on the anterior sur ace o the neck. T ey

T e muscles o acial expression (Figure 9-11) a ow us to com-
municate many di erent emotions nonverba y. Contraction
o the rontal muscle, or examp e, a ows you to raise your
eyebrows in surprise and urrow the skin o your orehead into
a rown. T e orbicularis oris, ca ed the kissing muscle, puckers
the ips. T e zygomaticus e evates the corners o the mouth
and ips and has been ca ed the smiling muscle.
T e musc es o mastication are responsib e or c osing the
mouth and producing chewing movements. As a group, they
are among the strongest musc es in the body. T e two argest
musc es o the group, identif ed in Figure 9-11, are the masseter,
which e evates the mandib e, and the temporal, which assists
the masseter in c osing the jaw.
T e sternocleidomastoid and trapezius musc es are easi y
identif ed in Figures 9-10 and 9-11. T e two sternoc eidomastoid
Te mpora l
9 Fronta l
Orbicula ris oculi
Zygoma ticus minor
Zygoma ticus ma jor
Ma s s e te r
Orbicula ris oris
S te rnocle idoma s toid
S and inserts into the o ecranon process o the u na. T e triceps
Tra pe zius
P A
I Many o the musc es acting on the wrist and hand are o-
FIGURE 9-11 Muscles o the head and neck. Muscles that produce
most acial expressions surround the eyes, nose, and mouth. Large muscles
o mastication stretch rom the upper skull to the lower jaw. These power ul
muscles produce chewing movements. The neck muscles connect the skull
to the trunk o the body, rotating the head or bending the neck.
originate on the sternum and then pass up and cross the neck
to insert on the mastoid process o the sku . Working together,
they ex the head on the chest. I on y one contracts, the head
is both exed and ti ted to the opposite side.
T e triangu ar-shaped trapezius musc es orm the ine
rom each shou der to the neck on its posterior sur ace. T ey
have a wide ine o origin extending rom the base o the sku
down the spina co umn to the ast thoracic vertebra. W hen
contracted, the trapezius musc es he p e evate the shou ders
and extend the head backward.
Table 9-2 summarizes important acts about the major
musc es o the head and neck.
M u s c le s o t h e U p p e r Ex t r e m it ie s
T e upper extremity is attached to the thorax by the an-
shaped pectoralis major musc e, which covers the upper chest,
and by the latissimus dorsi musc e, which takes its origin rom
structures over the ower back (see Figures 9-10 and 9-12). Both
musc es insert on the humerus. T e pectora is major is a exor,
and the atissimus dorsi is an extensor o the arm.
T e deltoid musc e orms the thick, rounded prominence
over the shou der and arm (see Figure 9-10). T e musc e takes
its origin rom the scapu a and c avic e and inserts on the
humerus. It is a power u abductor o the arm.
As the name imp ies, the biceps brachii is a two-headed
musc e. A ong with the brachialis musc e, it serves as a exor
o the orearm (see Figure 9-10). It originates rom the bones o
the shou der gird e and inserts on the radius in the orearm.
T e triceps brachii is on the posterior or back sur ace o
the arm. It has three heads o origin rom the shou der gird e
is an extensor o the e bow and thus per orms a straightening
unction.
cated on the orearm. In most instances, the anterior orearm
musc es are exors and the posterior orearm musc es are ex-
tensors (see Figure 9-10).
Table 9-3 summarizes important acts about musc es o the
upper extremities.
 CHAPTER 9 Muscular System 233

Pe ctora lis ma jor Pe ctora lis ma jor

La tis s imus dors i
Re ctus a bdominis
Re ctus a bdominis
(cut)
Re ctus a bdominis
(cove re d by s he a th)
S
Re ctus s he a th
Re ctus s he a th (cut)
R L
(cut e dge s )
I
Tra ns ve rs us
a bdominis
Exte rna l oblique
Umbilicus Umbilicus
Inte rna l oblique

Inguina l ca na l
A B

FIGURE 9-12 Muscles o the trunk. A, Anterior view showing super cial muscles. B, Anterior view show-
ing deeper muscles.

TABLE 9-3 Muscles o the Upper Extremities

MUS CLE FUNCTION INS ERTION ORIGIN
Pe ctoralis m ajor Flexe s and he lps adduct arm Hum e rus Ste rnum , clavicle , and uppe r rib cartilage s
Latis s im us dors i Exte nds and he lps adduct arm Hum e rus Ve rte brae and ilium
De ltoid Abducts arm Hum e rus Clavicle and s capula
Brachialis Flexe s e lbow Hum e rus Ulna
Bice ps brachii Flexe s e lbow ; pronate s /s upinate s w ris t Radius Scapula
Trice ps brachii Exte nds e lbow Ulna Scapula and hum e rus

these sheet ike musc es, the band- or strap-shaped rectus

M u s c le s o t h e Tr u n k
T e musc es o the anterior, or ront, side o the abdomen are
arranged in three ayers, with the f bers in each ayer running
in di erent directions much ike the ayers o wood in a sheet
o p ywood (Figure 9-12). T e resu t is a very strong gird e o
musc e that covers and supports the abdomina cavity and its
interna organs.
T e three ayers o musc e in the antero atera (side) ab-
domina wa s are arranged as o ows: the outermost ayer or
external oblique; a midd e ayer or internal oblique; and the
innermost ayer or transversus abdominis. In addition to
abdominis musc e runs down the mid ine o the abdomen
rom the thorax to the pubis. In addition to protecting the 9
abdomina viscera, the rectus abdominis exes the spina co -
umn. T e musc es o the trunk can be seen in Figure 9-12.
T e respiratory muscles are discussed in Chapter 17.
Intercostal muscles, ocated between the ribs, and the sheet-
ike diaphragm separating the thoracic and abdomina cavi-
ties change the size and shape o the chest during breathing.
As a resu t, air is moved into or out o the ungs.
Table 9-4 summarizes important acts about musc es o the
trunk.

TABLE 9-4 Muscles o the Trunk

MUS CLE FUNCTION INS ERTION ORIGIN
Exte rnal oblique Com pre s s e s abdom e n Midline o abdom e n Lowe r thoracic cage
Inte rnal oblique Com pre s s e s abdom e n Midline o abdom e n Pe lvis
Trans ve rs us abdom inis Com pre s s e s abdom e n Midline o abdom e n Ribs , ve rte brae , and pe lvis
Re ctus abdom inis Flexe s trunk Lowe r rib cage Pubis
Diaphragm Expands thoracic cavity during Circum e re nce o lowe r rib cage Fibrous tis s ue (ce ntral te ndon) at ce nte r
ins piration o diaphragm
 234 CHAPTER 9 Muscular System

M u s c le s o t h e Lo w e r Ex t r e m it ie s
T e iliopsoas originates rom deep within the pe vis and the
ower vertebrae to insert on the esser trochanter o the emur
and capsu e o the hip joint. It is genera y c assif ed as a exor
o the thigh and an important postura musc e that stabi izes
and keeps the trunk rom a ing over backward when you
stand. H owever, i the thigh is f xed so that it cannot move, the
i iopsoas exes the trunk. An examp e wou d be doing sit-ups.
T e gluteus maximus orms the outer contour and much
o the substance o the buttock. It is an important extensor o
the thigh (see Figure 9-10) and supports the torso in the erect
position.
T e adductor muscles originate on the bony pe vis and
insert on the emur. T ey are ocated on the inner or media
side o the thighs. T ese musc es adduct or press the thighs
together.
T e three hamstring muscles are ca ed the semimembra-
nosus, semitendinosus, and biceps emoris. Acting together, they
serve as power u exors o the eg and extensors o the thigh
(see Figure 9-10). T ey originate on the ischium and insert on
the tibia or f bu a.
T e quadriceps emoris musc e group covers the upper
thigh. T e our thigh musc esthe rectus emoris and three
vastus musc esextend the eg (see Figure 9-10 and Table 9-2).
O ne component o the quadriceps group has its origin on the
pe vis, and the remaining three originate on the emur; a our
insert on the tibia. On y two o the vastus musc es are visib e
in Figure 9-10. T e vastus intermedius is covered by the rectus
emoris and is not visib e. Functiona y, the hamstrings ( ex-
ors) and quadriceps (extensors) act as power u antagonists in
movement o the eg.
T e tibialis anterior musc e (see Figure 9-10) is ocated on
the anterior, or ront, sur ace o the eg. It dorsi exes the oot.
T e gastrocnemius is the primary ca musc e. Note in
Figure 9-10 that it has two eshy components arising rom both
sides o the emur. It inserts through the ca canea (Achi es)
tendon into the hee bone or ca caneus. T e gastrocnemius is
responsib e or p antar exion o the oot; because it is used to
stand on tiptoe, it is sometimes ca ed the toe dancers muscle.
A group o three musc es ca ed the bularis group or
peroneus group (see Figure 9-10) is ound a ong the sides o
the eg. As a group, these musc es p antar ex the oot. A ong
tendon rom one component o the groupthe bularis lon-
gus musc e tendon orms a support arch or the oot (see
Figure 8-24).
Table 9-5 summarizes important acts about musc es o the
ower extremities.
QUICK CHECK
1. Wh a t u n ctio n d o th e m u s cle s o m a s tica tio n m a ke
p o s s ib le ?
2. Wh a t m u s cle s a re re s p o n s ib le o r ch a n g in g th e s ize a n d
s h a p e o th e ch e s t d u rin g b re a th in g ?
3. Wh a t th re e m u s cle s co m p o s e th e a n te ro la te ra l (s id e )
a b d o m in a l wa lls ?
4. Wh a t a ctio n d o th e h a m s trin g m u s cle s p e r o rm ?

TABLE 9-5 Muscles o the Lower Extremities

MUS CLE FUNCTION INS ERTION ORIGIN
Iliops oas Flexe s thigh or trunk Fe m ur Ilium and ve rte brae
Sartorius Flexe s thigh and rotate s le g Tibia Ilium

9 Glute us m axim us
Adducto r Gro up
Exte nds thigh Fe m ur Ilium , s acrum , and coccyx

Adductor longus Adducts thigh Fe m ur Pubis

Gracilis Adducts thigh Tibia Pubis
Pe ctine us Adducts thigh Fe m ur Pubis
Ham s tring Gro up
Se m im e m branos us Flexe s kne e ; exte nds thigh Tibia Is chium
Se m ite ndinos us Flexe s kne e ; exte nds thigh Tibia Is chium
Bice ps e m oris Flexe s kne e ; exte nds thigh Fibula Is chium and e m ur
Quadrice ps Gro up
Re ctus e m oris Exte nds kne e Tibia Ilium
Vas tus late ralis Exte nd kne e Tibia Fe m ur
Vas tus inte rm e dius
Vas tus m e dialis
Tibialis ante rior Dors i exe s ankle Me tatars als ( oot) Tibia
Gas trocne m ius Plantar exe s ankle Calcane us (he e l) Fe m ur
Sole us Plantar exe s ankle Calcane us (he e l) Tibia and f bula
Fibularis Gro up
Fibularis longus Eve rts and plantar exe s ankle Tars al and m e tatars als Tibia and f bula
Fibularis brevis (te rtius dors i exe s ankle ) (ankle and oot)
Fibularis te rtius

Torn mus cle
Bice ps bra chii
Bra chia lis
S
P A
Trice ps
bra chii I
FIGURE 9-13 Muscle strain. Severe strain o the biceps brachii mus-
cle. When a muscle is severely strained, it may break in two pieces, causing
a visible gap in muscle tissue under the skin. Notice how the broken ends o
the muscle ref exively contract (spasm) to orm a knot o tissue.
M u s c u la r D is o r d e r s
As you might expect, musc e disorders, or myopathies, gener-
a y disrupt the norma movement o the body. In mi d cases,
these disorders vary in degree o discom ort rom mere y in-
convenient to s ight y troub esome. Severe musc e disorders,
however, can impair the musc es used in breathinga i e-
threatening situation.
M u s c le In ju ry
Injuries to ske eta musc es resu ting rom overexertion or
trauma usua y resu t in a muscle strain (Figure 9-13). Musc e
strains are characterized by musc e pain, or myalgia, and in-
vo ve overstretching or tearing o musc e f bers. I an injury
occurs in the area o a joint and a igament is damaged, the
injury may be ca ed a sprain.
Any musc e in ammation, inc uding that caused by a
musc e strain, is termed myositis. I tendon in ammation
occurs with myositis, as when one experiences a charley horse,
the condition is termed bromyositis. A though in amma-
tion may subside in a ew hours or days, it usua y takes severa
weeks or damaged musc e f bers to repair themse ves. Some
damaged musc e ce s may be rep aced by f brous tissue, orm-
ing scars. Occasiona y, hard ca cium is deposited in the scar
tissue.
Cramps are pain u musc e spasms (invo untary twitches).
Cramps o ten resu t rom mi d myositis or f bromyositis, but
can be a symptom o any irritation or o an ion and water
imba ance.
Minor trauma to the body, especia y a imb, may cause a
musc e bruise or contusion. Musc e contusions invo ve oca
interna b eeding and in ammation. Severe trauma to a ske -
eta musc e may cause a crush injury. Crush injuries not on y
great y damage the a ected musc e tissue but a so cause the
re ease o musc e f ber contents into the b oodstream, which
CHAPTER 9 Muscular System 235
can be i e threatening. For examp e, the reddish musc e pig-
ment myoglobin can accumu ate in the b ood and cause kidney
ai ure.
Review the article Rhabdomyolysis at Connect It!
at evolve.elsevier.com.
Stress-induced musc e tension can resu t in mya gia and
sti ness in the neck and back and is thought to be one cause
o stress headaches. H eadache and back-pain c inics use a
variety o strategies to treat stress-induced musc e tension.
T ese treatments inc ude massage, bio eedback, and re ax-
ation training.
M u s c le In e c t io n s
Severa bacteria, viruses, and parasites are known to in ect
musc e tissueo ten producing oca or widespread myositis.
For examp e, in trichinosis (see Appendix A at evolve.elsevier
.com), widespread myositis is common. T e musc e pain and
sti ness that sometimes accompany in uenza is another
examp e.
O nce a tragica y common disease, poliomyelitis is a
vira in ection o the nerves that contro ske eta musc e
movement. A though the disease can be asymptomatic, it
o ten causes para ysis that may progress to death. E imi-
nated in the United States as a resu t o a comprehensive
vaccination program, it sti a ects individua s in other parts
o the wor d.
Another in ection that a ects musc e and is e ective y
prevented by vaccination is in ection by the Clostridium tetani
bacterium, which is ound near y everywhere in our environ-
ment. T is condition is o ten ca ed tetanus because the toxin
re eased into the body by C. tetani bacteria can produce invo -
untary, sustained (tetanic) contractions throughout the body
(Figure 9-14). I not success u y treated, tetanus in ections can 9
be ata . etanus vaccinations, usua y combined with other
vaccines, are recommended throughout ones i etime to re-
main protected.
A
S I
P
FIGURE 9-14 Tetanus in ection. Severe muscle cramping caused by
the involuntary, sustained (tetanic) contractions caused by toxins released
into the body rom C. tetani bacteria can produce this tense, twisted body
posture.
 236 CHAPTER 9 Muscular System
C LIN ICA L APPLICATION
OCCUPATIONAL HEALTH PROBLEMS
Som e e pide m iologis ts s pe cialize in the f e ld o occupational
he alth, the s tudy o he alth m atte rs re late d to work or the work-
place . Many proble m s s e e n by occupational he alth expe rts are
caus e d by re pe titive m otions o the w ris ts or othe r joints .
Word proce s s ors (typis ts ) and m e at cutte rs , or exam ple , are
at ris k o deve loping conditions caus e d by re pe titive m otion
injurie s .
One com m on proble m o te n caus e d by s uch re pe titive m o-
tion is te no s ynovitis in am m ation o a te ndon s he ath. Te no-
s ynovitis can be pain ul, and the s we lling characte ris tic o this
condition can lim it m ove m e nt in a e cte d parts o the body. For
exam ple , s we lling o the te ndon s he ath around te ndons in an
are a o the w ris t know n as the carpal tunne l can lim it m ove -
m e nt o the w ris t, hand, and f nge rs .
The f gure s how s the re lative pos itions o the te ndon
s he ath and m e dian ne rve w ithin the carpal tunne l. I this s we ll-
ing, or any othe r le s ion in the carpal tunne l, pre s s e s on the
Te ndons of
flexors of finge rs
Ca rpa l tunne l
Flexor
re tina culum
Ca rpa l a rch
9 Ca rpa l tunne l
Te ndons of exte ns ors of finge rs
The median nerve and tendons o f exor muscles pass through a concavity called the carpal tunnel.
M u s c u la r D y s t ro p h y
Muscular dystrophy (MD ) is not a sing e disorder but a
group o genetic diseases characterized by atrophy (wasting)
o ske eta musc e tissues. Some, but not a , orms o muscu ar
dystrophy can be ata .
T e most common orm o muscu ar dystrophy is D uchenne
muscular dystrophy (D MD ). T is orm o the disease is a so
ca ed pseudohypertrophy (meaning a se musc e growth) be-
cause the atrophy o musc e is masked by excessive rep acement
o musc e by at and f brous tissue.
DMD is characterized by mi d eg musc e weakness that
progresses rapid y to inc ude the shou der musc es. T e f rst
signs o DMD are apparent at about 3 years o age, and the
stricken chi d is usua y severe y a ected within 10 to 12 years.
m e dian ne rve , a condition calle d carpal tunne l s yndro m e
m ay re s ult. Be caus e the m e dian ne rve conne cts to the palm
and radial s ide (thum b s ide ) o the hand, carpal tunne l s yn-
drom e is characte rize d by we akne s s , pain, and tingling in that
part o the hand. The pain and tingling als o m ay radiate to the
ore arm and s houlde r. The m e dian ne rve and m us cle s that ex
the f nge rs pas s through a concavity calle d the carpal tunne l.
Prolonge d or s eve re cas e s o carpal tunne l s yndrom e m ay
be re lieve d by inje ction o anti-in am m atory age nts . A pe rm a-
ne nt cure is s om e tim e s accom plis he d by s urgically cutting the
f brous band calle d the exor re tinaculum e nclos ing the carpal
tunne lthus re lieving pre s s ure on the m e dian ne rve .
Re pe titive m otion and othe r type s o traum a als o m ay
caus e in am m ation o a burs a, know n as burs itis . For exam -
ple , carpe t laye rs , roo e rs , and othe rs w ho work on the ir kne e s
are prone to burs itis involving the kne e joints . Burs itis is m os t
o te n tre ate d w ith anti-in am m atory age nts .
Me dia n ne rve
Flexor
re tina culum
Te ndon s he a th
A
M
P
L
Severe respiratory or cardiac musc e weakness o ten occurs by
the time the patient is in their 20s.
DMD is caused by a missing gene in the X chromosome.
DMD occurs primari y in boys. Because gir s have two
X chromosomes and boys on y one, genetic diseases invo ving
X chromosome abnorma ities are more ike y to occur in boys
than in gir s.
T is is true because gir s with one damaged X chromosome
may not exhibit an X- inked disease i their other X chromo-
some is norma (see Chapter 25). T e missing gene codes or a
ce protein ca ed dystrophin. In DMD, dystrophin is missing
rom musc e ce s, which then become too weak to ho d to-
gether during musc e contraction. Immune system responses
may add to the damage. Gene therapy (see Chapter 25) is
now being tested or use in DMD patients, with the hope
 CHAPTER 9 Muscular System 237

C LIN ICA L APPLICATION

Tra pe zius Acromion
INTRAMUS CULAR INJ ECTIONS proce s s
of s ca pula
Many drugs are adm inis te re d by intram us cular inje ctio n
(IM)that is , into the s ke le tal m us cle tis s ue .
I the am ount to be inje cte d is 2 m L or le s s , the de l- De ltoid
toid m us cle is o te n s e le cte d as the s ite o inje ction. Note
in Figure A that the ne e dle is ins e rte d into the m us cle
about two f nge rs bre adth be low the acrom ion proce s s
o the s capula and late ral to the tip o the acrom ion.
I the am ount o m e dication to be inje cte d is 2 to 3 m L,
the glute al are a s how n in Figure B is o te n us e d. Inje ctions
S
are m ade into the glute us m e dius m us cle ne ar the ce nte r
o the uppe r oute r quadrants om e tim e s calle d the ve n- M L
troglute al (VG) s ite as s how n in the illus tration.
I
Anothe r te chnique o locating the VG s ite is to place
the bas e o the palm ove r the patie nts gre ate r trochante r
A
( e m ur) us ing your le t palm on the patie nts right thigh
(and vice ve rs a). The n e e l or the ante rior s upe rior iliac Ilia c cre s t Glute us
s pine at the e nd o the iliac cre s t w ith the tip o your in- Pos te rior s upe rior me dius
ilia c s pine
dex f nge r. Se parate your next f nge r to orm a V or
pe ace s ign and inje ct into the are a in the m iddle o the
V (s e e Figure B, photo ins e t). It is im portant that the s ci-
S upe rior glute a l
atic ne rve and the s upe rior glute al blood ve s s e ls be a rte ry a nd ve in Glute us
avoide d during the inje ction. Prope r te chnique re quire s ma ximus
know le dge o the unde rlying anatomy.
The vas tus late ralis m us cle o the thigh is anothe r S cia tic ne rve
Gre a te r
com m on s ite or IM inje ctions . trocha nte r
In addition to intram us cular inje ctions , w hich are ge n-
e rally adm inis te re d by a he alth care provide r in an ins titu-
S
tional s e tting, m any individuals m us t s e l -adm inis te r inje c-
tions o ne e de d m e dications on a re gular bas is in the ir M L
hom e s . Educating the s e patie nts or the ir care give rs on
I
how to corre ctly adm inis te r m e dication by inje ction is an
im portant is s ue in the de live ry o hom e he alth care s e r-
vice s . Topics that m us t be cove re d include ins truction on
prope r inje ction te chnique s , s e le ction o ne e dle le ngth
and gauge , ide ntif cation o im portant anatom ical land-
9
m arks w he n m aking inje ction s ite s e le ctions , and the
pre paration and rotation o s e le cte d inje ction s ite s . B

that the gene or dystrophin can be rep aced by ce s rom a
hea thy donor.
M ya s t h e n ia G r a v is
Myasthenia gravis (MG) is a chronic disease characterized by
musc e weakness, especia y in the ace and throat. Most orms
o this disease begin with mi d weakness and chronic musc e
atigue in the ace, then progress to wider musc e invo vement.
W hen severe musc e weakness causes immobi ity in a
our imbs, a myasthenic crisis is said to have occurred. A
person in myasthenic crisis is in danger o dying rom respira-
tory ai ure because o weakness in the respiratory musc es.
Myasthenia gravis is an autoimmune disease in which the
immune system attacks ACh receptors on musc e ce s at the
NMJ (see Figure 9-4). Nerve impu ses rom motor neurons are
then unab e to u y stimu ate the a ected musc e. reatment
is individua ized or each patient, but may inc ude drugs that
b ock the breakdown o ACh (so more is avai ab e at the
NMJ) and immunosuppressant drugs that reduce the autoim-
mune damage to the NMJ.
QUICK CHECK
1. Ho w d o e s m yo s itis d i e r ro m f b ro m yo s itis ?
2. Wh a t is p o lio m ye litis a n d w h a t e e ct d o e s it h a ve o n s ke l-
e ta l m u s cle ?
3. Wh a t is th e ca u s e o Du ch e n n e m u s cu la r d ys tro p hy
(DMD)?
4. De s crib e th e ch a ra cte ris tics o m ya s th e n ia g ra vis .
 238 CHAPTER 9 Muscular System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 219)

bursa f bularis group isotonic contraction

(BER-sah) (f b-YOO-lay-ris groop) (aye-soh-TON-ik kon-TRAK-shun)
pl., bursae [f bula- clasp (f bula bone), -aris relating to] [iso- equal, -ton- tension, -ic relating to,
(BER-see or BER-say) ex con- together, -tract- drag or draw,
[bursa purse] ( eks) -tion process]
cardiac muscle [ ex bend] latissimus dorsi
(KAR-dee-ak MUS-el) exion (lah-TIS-ih-mus DOR-sye)
[cardi- heart, -ac relating to, mus- mouse, (FLEK-shun) [latissimus broadest, dorsi relating to back]
-cle small] [ ex- bend, -ion process] masseter
circumduct rontal muscle (mah-SEE-ter)
(SER-kum-DUKT) (FRUN-tal MUS-el) [masseter chewer]
[circum- around, -duct lead] [ ront- orehead, -al relating to, mus- mouse, mastication
circumduction -cle small] (mas-tih-KAY-shun)
(ser-kum-DUK-shun) gastrocnemius [mastica- chew, -ation process]
[circum- around, -duct- lead, -tion process] (GAS-trok-NEE-mee-us) motor neuron
concentric contraction [gastro- belly, -cnemius leg] (MOH-ter NOO-ron)
(kon-SEN-trik kon-TRAK-shun) gluteus maximus [mot- movement, -or agent, neuron nerve]
[con- together, -centr- center, -ic relating to, (GLOO-tee-us MAX-ih-mus) motor unit
con- together, -tract- drag or draw, [gluteus buttocks, maximus greatest] (MOH-ter YOO-nit)
-tion process] [mot- movement, -or agent, unit single]
hamstring muscle
deltoid (HAM-string MUS-el) muscle f ber
(DEL-toyd) [ham- hollow o knee, -string (tendon), (MUS-el FYE-ber)
[delta- triangle, -oid like] mus- mouse, -cle small] [mus- mouse, -cle little, f br- thread]
diaphragm hypertrophy muscle tone
(DYE-ah- ram) (hye-PER-troh- ee) (MUS-el tohn)
[dia- across, -phrag- enclose, -(u)m thing] [hyper- excessive, -troph- nourishment, -y state] [mus- mouse, -cle little, tone stretching]
dorsi ex iliopsoas myof lament
(dor-sih-FLEKS) (il-ee-oh-SOH-as) (my-oh-FIL-ah-ment)
[dorsi- back, - ex bend] [ilio- loin or gut, -psoas loin muscle] [myo- muscle, -f la- thread, -ment thing]
dorsi exion insertion myoglobin
(dor-sih-FLEK-shun) (in-SER-shun) (my-oh-GLOH-bin)
[dorsi- back, - ex- bend, -ion process] [in- in, -ser- join, -tion process] [myo- muscle, -glob- ball, -in substance]
9 eccentric contraction
(ek-SENT-rik kon-TRAK-shun)
intercalated disk
(in-TER-kah-lay-ted disk)
myosin
(MY-oh-sin)
[ec- out o , -centr- center, -ic relating to, [inter- between, -cala- calendar, -ate act o ] [myos- muscle, -in substance]
con- together, -tract- drag or draw, intercostal muscle neuromuscular junction (NMJ )
-tion process] (in-ter-KOS-tal MUS-el) (noo-roh-MUS-kyoo-lar J UNK-shun
eversion [inter- between, -costa- rib, -al relating to, [en em jay])
(ee-VER-shun) mus- mouse, -cle small] [neuro- nerve, -mus- mouse, -cul- little,
[e(x)- outward, -ver- turn, -sion process] -ar relating to, -junc- join, -tion condition]
internal oblique muscle
evert (in-TER-nal oh-BLEEK MUS-el) orbicularis oris
(ee-VERT) [intern- inside, -al relating to, obliq- slanted, (or-bik-yoo-LAYR-is OR-is)
[e(x)- outward, -ver- turn] mus- mouse, -cle little] [orbi- circle, -cul- little, -aris relating to,
extend inversion oris relating to mouth]
(ek-STEND) (in-VER-shun) origin
[ex- outward, -ten stretch] [in- in, -ver- turn, -sion process] (OR-ih-jin)
extension invert [origin source]
(ek-STEN-shun) (in-VERT) oxygen debt
[ex- outward, -tens- stretch, -sion process] [in- in, -ver- turn] (AHK-sih-jen det)
external oblique isometric contraction [oxy- sharp, -gen produce, debt thing owed]
(eks-TER-nal oh-BLEEK) (aye-soh-MET-rik kon-TRAK-shun) pectoralis major
[extern- outside, -al relating to, obliq- slanted] [iso- equal, metric relating to measure, (pek-teh-RAH-liss MAY-jor)
atigue con- together, -tract- drag or draw, [pector- breast, -alis relating to, major greater]
( ah-TEEG) -tion process]
 CHAPTER 9 Muscular System 239

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 238)

peroneus group sarcomere tendon

(per-on-EE-uss groop) (SAR-koh-meer) (TEN-don)
[pero- boot, -us thing] [sarco- esh, -mere part] [tend- pulled tight, -on unit]
plantar ex skeletal muscle tendon sheath
(PLAN-tar eks) (SKEL-et-al MUS-el) (TEN-don sheeth)
[planta- sole, -ar relating to, ex bend] [skelet- dried body, -al relating to, mus- mouse, [tend- pulled tight, -on unit]
plantar exion -cle small] tetanic contraction
(PLAN-tar FLEK-shun) sliding f lament model (teh-TAN-ik kon-TRAK-shun)
[planta- sole, -ar relating to, ex- bend, (SLY-ding FIL-ah-ment MAH-del) [tetanus tension, -ic relating to, con- together,
-ion process] [slide- glide, -ing action, f la- thread, -tract- drag or draw, -tion process]
posture -ment thing, model standard] tetanus
(POS-chur) smooth muscle (TET-ah-nus)
[postur- position] (smoothe MUS-el) [tetanus tension]
prime mover [smooth smooth, mus- mouse, -cle small] threshold stimulus
(pryme MOO-ver) sternocleidomastoid (THRESH-hold STIM-yoo-lus)
[prime f rst order] (STERN-oh-KLYE-doh-MAS-toyd) [stimul- to excite, -us thing]
pronate [sterno- breastbone (sternum), -cleid- key tibialis anterior
(PROH-nayt) (clavicle), -masto- breast (mastoid process), (tib-ee-AL-is an-TEER-ee-or)
[prona- bend orward, -ate process] -oid like] [tibia- shinbone, -alis relating to, ante- ront,
pronation supinate -er- more, -or quality]
(PROH-nay-shun) (soo-pih-NAYT) tonic contraction
[prona- bend orward, -ation process] [supin- turned backward (belly up), (TAHN-ik kon-TRAK-shun)
-ate process] [ton- to stretch, -ic relating to, con- together,
quadriceps emoris
(KWOD-reh-seps eh-MOR-is) supination -tract- drag or draw, -tion process]
[quadri- our, -ceps head, emoris related to the (soo-pih-NAY-shun) transversus abdominis
thigh ( emur)] [supin- turned backward (belly up), (tranz-VERS-us ab-DAH-min-us)
-ation process] [trans- across, -vers- turn, abdomin- belly]
rectus abdominis
(REK-tus ab-DOM-ih-nus) synergist trapezius
[rectus straight, abdominis related to the (SIN-er-jist) (trah-PEE-zee-us)
abdomen] [syn- together, -erg- to work, -ist agent] [trapezius small table (irregular 4-sided shape)]
rigor mortis synovial uid triceps brachii
(RIG-or MOR-tis) (sih-NOH-vee-al FLOO-id) (TRY-seps BRAY-kee-aye)
[rigor sti ness, mortis o death]
rotate
[syn- together, -ovi- egg (white), -al relating to]
synovial membrane
[tri- three, -ceps head, brachii related to
the arm]
9
(roh-TAYT) (sih-NOH-vee-al MEM-brayn) twitch
[rot- turn, -ate process] [syn- together, -ovi- egg (white), -al relating to, (twich)
membran- thin skin] [twitch quick jerk]
rotation
(roh-TAY-shun) temporal zygomaticus
[rot- turn, -ation process] (TEM-poh-ral) (zye-goh-MAT-ik-us)
[tempora- temple (o head), -al relating to] [zygo- union or yoke, -ic- relating to, -us thing]

LANGUAGE OF M ED IC IN E

aerobic training bursitis chiropractic

(ayr-OH-bik TRAYN-ing) (ber-SYE-tis) (kye-roh-PRAK-tik)
[aer- air, -bi- li e, -ic relating to] [burs- purse, -itis in ammation] [chiro- hand, -practic practical]
biomechanical engineering carpal tunnel syndrome contusion
(bye-oh-meh-KAN-ik-al en-juh-NEER-ing) (KAR-pul TUN-el SIN-drohm) (kon-TOO-zhun)
[bio- li e, -mechan- machine, -ic- relating to, [carp- wrist, -al relating to, syn- together, [contus- bruise, -sion result]
-al relating to, engin- devise or design, -drome running or (race) course] cramps
-eer practitioner] (kramps)
Continued on p. 240
 240 CHAPTER 9 Muscular System

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 239)

disuse atrophy hypothermia nurse

(DIS-yoos AT-roh- ee) (hye-poh-THER-mee-ah) (nurs)
[dis- absence o , a- without, [hypo- under or below, -therm- heat, [nurs- nourish or nurture]
-troph- nourishment] -ia abnormal condition] nutritionist
Duchenne muscular dystrophy (DMD) massage therapy (noo-TRISH-en-ist)
(doo-SHEN MUS-kyoo-lar DIS-troh- ee) (mah-SAHJ THAYR-ah-pee) [nutri- nourish, -tion- process, -ist agent]
[Guillaume B.A. Duchenne de Boulogne French [mass- handle, -age process, therap- treatment, paralysis
neurologist, muscul- little mouse (muscle), -y activity] (pah-RAL-ih-sis)
-ar relating to, dys- bad, -troph- nourishment, muscle strain [para- beside, -lysis loosening]
-y state] (MUS-el strayn) physical education
endurance training [mus- mouse, -cle small, strain stretch] (FIS-ik-al ed-yoo-KAY-shun)
(en-DUR-ance TRAYN-ing) muscular dystrophy (MD) [physic- medicine, -al relating to]
[en- in, -dur- harden, -ance state] (MUS-kyoo-lar DIS-troh- ee [em dee]) physician
ergonomics [muscul- little mouse (muscle), -ar relating to, (f h-ZISH-en)
(er-go-NOM-iks) dys- bad, -troph- nourishment, -y state] [physic- medicine, -ian practitioner]
[ergo- work, -nom- arrangement, -ic relating to] myalgia poliomyelitis
exercise physiologist (my-AL-jee-ah) (pol-ee-oh-my-eh-LYE-tis)
(EK-ser-syze f z-ee-OL-oh-jist) [my- muscle, -algia pain] [polio- gray, -mye- marrow, -itis in ammation]
f bromyositis myasthenia gravis sprain
( ye-broh-my-oh-SYE-tis) (my-es-THEE-nee-ah GRAH-vis) (sprayn)
[f bro- f ber, -myos- muscle, -itis in ammation] [my- muscle, -asthenia weakness, strength training
intramuscular injection (IM) gravis severe] (strengkth TRAYN-ing)
(in-trah-MUS-kyoo-lar in-J EK-shun) myopathy [strength power, train- instruct, -ing action]
[intra- within, mus- mouse, -cle little, (my-OP-ah-thee) tenosynovitis
-ar relating to, in- in, -ject- throw, [myo- muscle, -path- disease, -y state] (ten-oh-sin-oh-VYE-tis)
-tion process] myositis [teno- pulled tight (tendon), -syn- together,
(my-oh-SYE-tis) -ovi- egg white (joint uid),
[myos- muscle, -itis in ammation] -itis in ammation]

9
OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Intro ductio n
A. Muscu ar tissue enab es the body and its parts to move
1. Movement caused by abi ity o musc e ce s (ca ed
bers) to shorten or contract
2. Musc e ce s shorten by converting chemica energy
(obtained rom nutrients) into mechanica energy,
which causes movement
3. T ree types o musc e tissue exist in the body (see
Chapter 4)

Mus cle Tis s ue
A. Ske eta musc ea so ca ed striated or voluntary musc e
(Figure 9-1, A)
1. Is 40% to 50% o body weight (red meat attached to
bones)
2. Microscope revea s crosswise stripes, or striations
3. Contractions can be vo untari y contro ed
B. Cardiac musc ecomposes bu k o heart (Figure 9-1, B)
1. Cardiac musc e ce s branch requent y
2. Characterized by unique dark bands ca ed intercalated
disks
3. Interconnected nature o cardiac musc e ce s a ows
heart to contract e cient y as a unit
C. Smooth musc ea so ca ed nonstriated, involuntary, or
visceral musc e (Figure 9-1, C)
1. Lacks cross stripes, or striations, when seen under a
microscope; appears smooth
2. Found in wa s o ho ow viscera structures such as
digestive tract, b ood vesse s, and ureters
3. Contractions not under vo untary contro ; movement
caused by contraction is invo untary
D. Functiona musc e ce s specia ize in contraction
(shortening)
S tructure o S ke le tal Mus cle
A. Musc e organsmain y ske eta musc e ce s and connec-
tive tissue
1. Connective tissue orms wrappers around each
musc e f ber, around ascic es (groups) o musc e f bers,
and around the entire musc e; ascia surrounds musc e
organs and nearby structures
2. Most ske eta musc es extend rom one bone across a
joint to another bone
3. Regions o a ske eta musc e (Figure 9-2)
a. O riginattachment to the bone that remains re a-
tive y stationary or f xed when movement at the
joint occurs
b. Insertionpoint o attachment to the bone that
moves when a musc e contracts
c. Bodymain part o the musc e
4. Musc es attach to bone by tendonsstrong cords o
f brous connective tissue; some tendons are enc osed
in synovia - ined tubes and are ubricated by synovia
uid; tubes are ca ed tendon sheaths
5. Bursaesma synovia - ined sacs containing a sma
amount o synovia uid; ocated between some
tendons and under ying bones
CHAPTER 9 Muscular System 241
B. Musc e f bers (Figure 9-3)
1. Contracti e ce s, or musc e f bersgrouped into
bund es and intricate y arranged
2. Fibers o the cytoske eton orm cy inders made up o
myof aments
a. T ick myof aments contain myosin
b. T in myof aments contain main y actin
c. Basic unctiona (contracti e) units ca ed sarcomeres,
separated rom each other by dark bands ca ed
Z lines
3. S iding f ament mode exp ains mechanism o musc e
f ber contraction
a. T ick and thin myof aments s ide past each other
as a musc e contracts
b. Contraction requires ca cium and energy-rich A P
mo ecu es (Figure 9-4)
Functio n o S ke le tal Mus cle
A. Movement
1. Musc es produce movement by pu ing on bones as a
musc e contracts
a. T e insertion bone is pu ed c oser to the origin
bone
b. Movement occurs at the joint between the origin
and the insertion
2. Groups o musc es usua y contract to produce a sing e
movement
a. Prime movermusc e whose contraction is main y
responsib e or producing a given movement
b. Synergistmusc e whose contraction he ps the
prime mover produce a given movement
c. Antagonistmusc e whose action opposes the
action o a prime mover in any given movement
B. Posture
1. A type o musc e contraction, ca ed tonic contraction, 9
enab es us to maintain body position
a. In tonic contraction, on y a ew o a musc es f bers
shorten at one time
b. onic contractions produce no movement o body
parts
c. onic contractions maintain musc e tone ca ed
posture
2. Good posture (optimum body positioning) avors best
body unctioning
3. Ske eta musc e tone maintains posture by counteract-
ing the pu o gravity
 242 CHAPTER 9 Muscular System
C. H eat production
1. Surviva depends on the bodys abi ity to maintain a
constant body temperature
a. Feveran e evated body temperatureo ten a sign
o i ness
b. H ypothermiabody temperature be ow norma
2. Contraction o musc e f bers produces most o the
heat required to maintain norma body temperature
D. Fatigue
1. Reduced strength o musc e contraction
2. Caused by repeated musc e stimu ation without ade-
quate periods o rest
3. Repeated muscu ar contraction dep etes ce u ar A P
stores and outstrips the abi ity o the b ood supp y to
rep enish oxygen and nutrients
4. Contraction in the absence o adequate oxygen pro-
duces actic acid, which contributes to musc e burning
5. Oxygen debtterm used to describe the metabo ic
e ort required to burn excess actic acid that may
accumu ate during pro onged periods o exercise
a. Labored breathing a ter strenuous exercise is
required to pay the debt
b. T is increased metabo ism he ps restore energy and
oxygen reserves to pre-exercise eve s
E. Integration with other body systems
1. Musc e unctioning depends on the unctioning o
many other parts o the body
a. Most musc es cause movements by pu ing on
bones across movab e joints
b. Respiratory, cardiovascu ar, nervous, muscu ar, and
ske eta systems p ay essentia ro es in producing
norma movements
2. Mu tip e sc erosis, brain hemorrhage, and spina cord
injury are examp es o how patho ogica conditions in
other body organ systems can dramatica y a ect
9 movement
Mo to r Unit
A. Stimu ation o a musc e by a nerve impu se is required
be ore a musc e can shorten and produce movement
B. A motor neuron is the nerve ce that transmits an
impu se to a musc e, causing contraction
C. A neuromuscu ar junction (NMJ)
1. Junction between a nerve ending and the musc e f ber
it innervates
2. Chemica s ca ed neurotransmitters cross a sma gap
at the NMJ to trigger contraction in the musc e
3. Acety cho ine (ACh) is the neurotransmitter operat-
ing at each NMJ
D. Motor unitcombination o a motor neuron and the
musc e ce or ce s it innervates (Figure 9-5)
Mus cle S tim ulus
A. A musc e wi contract on y i an app ied stimu us
reaches a certain minima eve o intensityca ed a
threshold stimulus
B. Di erent musc e f bers in a musc e are contro ed by di -
erent motor units having di erent thresho d-stimu us
eve s
C. Di ering numbers o motor units can be activated simu -
taneous y to execute contractions o graded orce
Type s o Mus cle Co ntractio n
A. witch and tetanic contractions
1. witch contractionsquick, jerky responses to a
stimu usare aboratory phenomena and do not p ay
a signif cant ro e in norma muscu ar activity
2. etanic contractions are sustained and steady muscu-
ar contractions caused by a series o stimu i bombard-
ing a musc e in rapid succession
B. Isotonic contractions (Figure 9-6)
1. Contraction o a musc e that produces movement at a
joint
2. D uring isotonic contractions, the musc e changes
ength, causing the insertion end o the musc e to
move re ative to the point o origin
3. Concentric contractions shorten musc es
4. Eccentric contractions a ow musc es to increase in
ength
5. Most types o body movements such as wa king and
running are caused by isotonic contractions
C. Isometric contractions (Figure 9-6)
1. Isometric contractions are musc e contractions that do
not produce movement; the musc e as a who e does
not shorten
2. A though no movement occurs during isometric con-
tractions, tension within the musc e increases
E e cts o Exe rcis e
A. Exercise, i regu ar and proper y practiced, improves
musc e tone and posture, resu ts in more e cient heart
and ung unctioning, and reduces atigue
B. Specif c e ects o exercise on ske eta musc es
1. Musc es undergo changes re ated to the amount o
work they norma y do
a. Pro onged inactivity causes disuse atrophy
b. Regu ar exercise increases musc e size, ca ed
hypertrophy
 CHAPTER 9 Muscular System 243

2. Strength training invo ves contraction o musc es B. Musc es o the upper extremities (Table 9-3)
against heavy resistance 1. Pectora is major exes arm
a. Strength training increases the numbers o myof a- 2. Latissimus dorsiextends arm
ments in each musc e f ber, and as a resu t, the tota 3. De toidabducts arm
mass o the musc e increases 4. Biceps brachii exes orearm at e bow
b. Strength training does not increase the number o 5. Brachia is exes orearm at e bow
musc e f bers 6. riceps brachiiextends orearm
3. Endurance training increases a musc es abi ity to 7. F exor musc es in orearm ex wrist and hand
sustain moderate exercise over a ong period; it is 8. Extensor musc es in orearmextend wrist and hand
sometimes ca ed aerobic training C. Musc es o the trunk (Figure 9-12 and Table 9-4)
a. Endurance training a ows more e cient de ivery 1. Abdomina musc es
o oxygen and nutrients to a musc e via increased a. Rectus abdominis
b ood ow b. Externa ob ique
b. Endurance training does not usua y resu t in c. Interna ob ique
musc e hypertrophy d. ransversus abdominis
2. Respiratory musc es
Move m e nts Pro duce d by Mus cle s a. Intercosta musc es
b. Diaphragm
(Figures 9-7 through 9-9)
D. Musc es o the ower extremities (Table 9-5)
A. Angu ar movements 1. I iopsoas exes thigh
1. F exiondecreases an ang e 2. G uteus maximusextends thigh
2. Extensionincreases an ang e 3. Adductor musc esadduct thighs
3. Abductionaway rom the mid ine 4. H amstring musc es ex eg and extend thigh
4. Adductiontoward the mid ine a. Semimembranosus
B. Circu ar movements b. Semitendinosus
1. Rotationaround an axis c. Biceps emoris
2. Circumductionmove dista end o a part in a circ e 5. Q uadriceps emoris groupextend eg
3. Supination and pronationhand positions that resu t a. Rectus emoris
rom twisting o the orearm b. Vastus musc es
C. Specia movementsthose not easi y described with 6. ibia is anteriordorsi exes oot
genera terms 7. Gastrocnemiusp antar exes oot
1. Dorsi exion and p antar exion oot movements 8. Fibu aris (peroneus) group exes oot
(upward and downward ank e movement)
2. Inversion and eversion oot movements (sideways)
D. Musc es can be named or grouped according to unction
Mus cular Dis o rde rs
(movement) (Table 9-1) A. Myopathiesmusc e disorders; can range rom mi d to 9
i e threatening
B. Musc e injury
S ke le tal Mus cle Gro ups (Table 9-2)
1. Straininjury rom overexertion or trauma; invo ves
A. Musc es o the head and neck (Figures 9-10 and 9-11; stretching or tearing o musc e f bers (Figure 9-13)
Table 9-2) a. O ten accompanied by mya gia (musc e pain)
1. Facia musc es b. May resu t in in ammation o musc e (myositis) or
a. O rbicu aris ocu i o musc e and tendon (f bromyositis)
b. O rbicu aris oris c. I injury is near a joint and invo ves igament
c. Zygomaticus damage, it may be ca ed a sprain
2. Musc es o mastication 2. Cramps are pain u musc e spasms (invo untary
a. Masseter twitches)
b. empora 3. Crush injuries resu t rom severe musc e trauma and
3. Sternoc eidomastoid exes head may re ease ce contents that u timate y cause kidney
4. rapeziuse evates shou ders and extends head ai ure
4. Stress-induced musc e tension can cause headaches
and back pain
 244 CHAPTER 9 Muscular System
C. Musc e in ections
1. Severa bacteria, viruses, and parasites can in ect
musc es
2. Po iomye itis is a vira in ection o motor nerves that
ranges rom mi d to i e threatening
3. etanus in ections are caused by C. tetani bacteria,
which are ound everywhere in our environment and
re ease into the body a toxin that causes invo untary,
sustained (tetanic) musc e contractions; can be ata
(Figure 9-14)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Go back to Chapte r 5 and review the s ynops is o the m us cular
s ys te m . The thre e type s o m us cle tis s ue we re cove re d in
Chapte r 4.
1. T ere are two pref xes that re er to musc e. O ne is myo-
which means musc e and the other is sarco-, which
means esh (the so t muscu ar tissue between skin and
bone). Severa terms in this chapter have one or the other
o these pref xes.
2. Movement is one o the unctions o the muscu ar system.
In order to create movement, musc e ce s must get
shorter. T e sarcomere is the structure in the musc e that
actua y shortens. T e s iding f ament mode exp ains
how this shortening occurs. T e shortening o the sarco-
9 mere requires energy. A P supp ies this energy. Check
on ine resources with animations o musc e contraction.
3. T e names o the musc es are probab y ess ami iar to
you than the names o the bones. But musc e names can
give you in ormation about the musc e. Musc es are
named or their shape: deltoid, trapezius. T ey are named
or the number o origins they have: triceps brachii, their
points o attachment: sternocleidomastoid, their size:
g uteus maximus, and the direction o the musc e f bers:
rectus abdominis (rectus means the musc e has f bers
running para e to the mid ine o the body). W hen you
D. Muscu ar dystrophy (MD)
1. A group o genetic disorders characterized by musc e
atrophy
2. D uchenne muscu ar dystrophy (DMD) is the most
common type; a so ca ed pseudohypertrophic
a. Characterized by rapid progression o weakness
and atrophy
b. X- inked inherited disease, a ecting most y boys
E. Myasthenia gravisautoimmune musc e disease charac-
terized by weakness and chronic atigue
are earning the musc es, try to ook or meaning in the
musc e names. Review the Language o Science and Lan-
guage o Medicine terms and their word origins to he p
you better understand the meaning o the musc e names.
Check out tips on ine at my-ap.us/LnDZ 2U
4. Most o the terms or musc e movement are air y
straight orward. O ne way to remember the di erence
between supination and pronation is to picture your hand
ho ding a bow o soupthats supination (si y, but an
e ective memory aid).
5. Draw a chart showing the mechanisms o muscu ar disor-
ders by type: injury, in ection, dystrophy, and myasthenia
gravis.
6. Prepare ash cards and re er to on ine resources to he p
you earn the terms in this chapter. Review them in your
study group. A so discuss the process o contraction and
atigue, and be sure you understand the movement terms.
I you are asked to earn the names and ocations o the
musc es, a photocopy o the musc e f gures with the abe s
b ackened out can be used to quiz each other. T ere are
many on ine abe ing exercises (getbodysmart.com) that you
can use as tutoria s. I you are asked to earn the unction,
origin, and insertion o the musc es, prepare and use ash
cards a ong with the f gures.
7. Go over the questions at the end o the chapter and
discuss possib e test questions in your study group.
Review the out ine at the end o this chapter. T is out ine
provides an overview o the materia and wou d he p you
understand the genera concepts to the chapter.

Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Brie y describe the structure o cardiac musc e.
2. Brie y describe the structure o smooth musc e.
3. Describe the unction o tendons, bursae, and synovia
membranes.
4. Exp ain the s iding f ament mode o musc e
contraction.
5. Exp ain why it is necessary to maintain good posture.
6. Suggest an examp e o how two body systems other than
the muscu ar system contribute to the movement o the
body.
7. Exp ain twitch and tetanic contractions.
8. Exp ain isotonic contractions.
9. Exp ain isometric contractions.
10. Describe the o owing movements: exion, extension,
abduction, adduction, and rotation.
11. Name two musc es in the head or neck and give the
origin, insertion, and unction o each.
12. Name two musc es that move the upper extremity and
give the origin, insertion, and unction o each.
13. Name two musc es o the trunk and give the origin,
insertion, and unction o each.
14. Name three musc es o the ower extremity and give the
origin, insertion, and unction o each.
15. W hat signs and symptoms are ike y to accompany a
moderate musc e strain?
16. W hat causes the signs and symptoms o myasthenia
gravis?
CHAPTER 9 Muscular System 245
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
17. Exp ain the ro e o the biceps brachii and triceps brachii
in terms o prime mover and antagonist in exion and
extension.
18. Exp ain the interaction o the prime mover, the syner-
gist, and the antagonist in e cient movement.
19. Describe the condition that causes a musc e to deve op
an oxygen debt. H ow is this debt paid o ?
20. W hy can a spina cord injury be o owed by musc e
para ysis?
21. Can a musc e contract very ong i its b ood supp y is
shut o ? Give a reason or your answer.
22. Brie y exp ain changes that gradua y take p ace in
bones, joints, and musc es in a person who habitua y
gets too itt e exercise.
23. Using f ber types, describe a musc e best suited or a
marathon runner and di erent musc e or a 100-meter-
dash sprinter. Exp ain your choices.
24. Brie y exp ain the progression o D uchenne muscu ar
dystrophy.
25. Exp ain the need or myog obin, in addition to hemo-
g obin, when oxygenating musc e f bers.
26. Exp ain how cardiac tissue demonstrates the princip e
that structure f ts unction.
9
 246 CHAPTER 9 Muscular System

18. Excessive stretching or tearing o musc e f bers is ca ed

Chapte r Te s t ________.
A te r s tudying the chapte r, te s t your m as te ry by 19. In ammation o musc e and tendon is termed
re s ponding to the s e ite m s . Try to ans we r the m ________.
w ithout looking up the ans we rs . 20. ________ is a vira in ection o motor nerves that may
progress to i e-threatening para ysis o the respiratory
1. ________ is another name or musc e ce . musc es.
2. Cardiac musc e makes up the bu k o the tissue o the 21. ________ is a group o musc e disorders characterized
________. by musc e atrophy and that o ten progresses to death
3. T e musc e attachment to the more movab e bone is be ore age 21.
ca ed the ________. 22. ________ is an autoimmune musc e disease character-
4. T e musc e attachment to the more stationary bone is ized by weakness and chronic atigue.
ca ed the ________. 23. Ske eta musc es can a so be ca ed:
5. ________ is the protein that makes up the thin a. viscera musc e
myof ament. b. vo untary musc e
6. ________ is the protein that makes up the thick c. cardiac musc e
myof ament. d. a o the above
7. T e ________ is the basic unctiona unit o contraction 24. Smooth musc e can a so be ca ed:
in a ske eta musc e. a. viscera musc e
8. T e three unctions o the musc e system are ________, b. vo untary musc e
________, and ________. c. cardiac musc e
9. T e mo ecu e ________ supp ies energy or musc e d. a o the above
contraction. 25. W hat action does the hamstring group provide?
10. ________ is the waste product produced when the a. F exion
musc e must switch to an energy-supp ying process that b. Adduction
does not require oxygen. c. Abduction
11. A sing e motor neuron with a the musc e ce s it inner- d. Eversion
vates is ca ed a ________. 26. W hich o the o owing is not a type o musc e f ber?
12. ________ is the minima eve o stimu ation required to a. Red f bers
cause a musc e to contract. b. Fast f bers
13. ________ is a type o musc e contraction that produces c. W hite f bers
movement in a joint and a ows the musc e to shorten. d. Gray f bers
14. ________ is a type o musc e contraction that does not 27. Acety cho ine:
produce movement and does not a ow the musc e to a. stimu ates musc e ce contraction
shorten but increases musc e tension. b. a ows musc e ce s to re ax
9 15. ________ is a term that describes movement o a body c. is the uid within bursae
part away rom the mid ine o the body. d. is an oxygen-storing pigment simi ar to hemog obin
16. ________ is a term used to describe the movement that 28. Wa king, running, and breathing are examp es o :
is opposite inversion. a. isometric contraction
17. ________ describes the hand position when the body is b. isotonic contraction
in anatomica position. c. tetanic contraction
d. twitch contraction
 CHAPTER 9 Muscular System 247

Match each muscle in Column A with its corresponding location egs is typica or this orm o muscu ar dystrophy. Can
or unction in Column B. you exp ain this apparent contradiction?
2. Your riend E ena is su ering rom a strain o her gas-
Column A Column B trocnemius musc e. W hat type o injury is this, and where
29. ________ tempora musc e a. musc es o the head in E enas body is it ocated? W hat symptoms are ike y to
30. ________ biceps brachii or neck accompany E enas injury? W hat movements shou d
31. ________ sartorius b. musc es that move E ena avoid to prevent urther injury to the gastrocne-
32. ________ masseter the upper extremity mius musc e?
33. ________ gastrocnemius c. musc es o the trunk 3. Robert has decided to improve his appearance by exercis-
34. ________ pectora is major d. musc es that move ing. H e wou d ike to bui d up his chest and shou der
35. ________ externa ob ique the ower extremity musc es so that he ooks better in the -shirts he is so
36. ________ g uteus maximus ond o wearing. H e has decided to p ay racquetba every
37. ________ sternoc eidomastoid day as his primary training program because he knows
38. ________ rectus abdominis that he uses his upper body musc es in this sport. A ter
39. ________ rectus emoris his f rst game o racquetba , you ask him how he ikes his
40. ________ triceps brachii new sport and he can hard y answer youhe seems out
o breath. Is Roberts p an ike y to he p him meet his
goa ? H ow do you exp ain his breathing di cu ties?
Cas e S tudie s 4. Jessica was in the hospita or an extended period with a
To s olve a cas e s tudy, you m ay have to re e r to severe respiratory in ection. D uring that period she
the glos s ary or index, othe r chapte rs in this text- received mu tip e IM injections and was discharged with
book, and othe r re s ource s . orders to continue the injections dai y unti the doctor
advised her to discontinue them. T e nursing sta had
1. Your 3-year-o d nephew, om, has just been diagnosed been injecting the medication into the g utea area, but
with pseudohypertrophic muscular dystrophy. H ow did he this area was becoming sore rom a o the prior injec-
get this disease? Is his twin sister, Geri, ike y to deve op tions. W hat options might she use or the uture to avoid
the same condition? Are you ike y to get this disease? pain in the area o the injections?
(H IN : See Chapter 25.) You know that muscu ar dys-
trophy typica y causes atrophy or wasting o musc e Answers to Active Learning Questions can be ound online
tissue, yet oms eg musc es seem particu ar y we deve - at evolve.elsevier.com.
oped. oms physician said that the appearance o oms

9
Nervous System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Organs and Divisions o the Nervous Peripheral Nervous System, 270

System, 249 Cranial Nerves, 270
Cells o the Nervous System, 250 Spinal Nerves, 270
Neurons, 250 Peripheral Nerve Disorders, 273
Glia, 250 Autonomic Nervous System, 274
Disorders o Nerve Tissue, 252 Overview, 274
Nerves and Tracts, 253 Functional Anatomy, 275
Nerve Signals, 253 Autonomic Conduction Paths, 276
Re ex Arcs, 253 Sympathetic Division, 276
Nerve Impulses, 255 Parasympathetic Division, 277
Synapses, 256 Autonomic Neurotransmitters, 277
Central Nervous System, 259 Autonomic Nervous System as a
Brain, 260 Whole, 278
Brain Disorders, 264 Disorders o the Autonomic Nervous
Spinal Cord, 266 System, 278
Coverings and Fluid Spaces, 268

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. List the organs and divisions o the
nervous system and describe the gener-
alized unctions o the nervous system
as a whole.
2. Do the ollowing related to the cells o
the nervous system:
the nervous system and discuss the
unction o each.
shape o glia.
tissue.
3. Identi y the structure o a nerve.
4. Identi y the anatomical components o a
re ex arc and explains its unction.
5. Explain the mechanisms o transmission
o a nerve impulse along a nerve f ber
and across a synapse.
-
cal components o the brain and spinal
cord, their unctions, and brain
disorders.
7. Identi y and discuss the coverings and
uid spaces o the brain and spinal
cord.
8. Compare and contrast cranial nerves
and spinal nerves, and identi y periph-
eral nerve disorders.
9. Discuss the structure and unction o
the two divisions o the autonomic
nervous system, and identi y disorders
o these two divisions.
 10
Th e human body must accomp ish a gigantic and enormous y comp ex LANGUAGE OF
jobkeeping itse a ive and hea thy. Each one o its tri ions o ce s per orms S C IEN C E
some activity that is a part o this unction. Contro o the bodys tri ions o
ce s is accomp ished main y by two communication systems: the nervous sys-
Be o re re ading the
tem and the endocrine system. Both systems transmit in ormation rom one
chapte r, s ay e ach o
part o the body to another, but they do it in di erent ways. T e nervous system the s e te rm s o ut lo ud. This w ill
transmits in ormation very rapid y by nerve impu ses conducted rom one body he lp yo u to avo id s tum bling ove r
area to another. T e endocrine system transmits in ormation more s ow y by the m as yo u re ad.
chemica s secreted by duct ess g ands into the b oodstream and then circu ated
to other parts o the body.
acetylcholine (ACh)
(as-ee-til-KOH-leen [ay see aych])
Nerve impu ses and hormones communicate in ormation to body structures, [acetyl- vinegar, -chole- bile,
increasing or decreasing their activities as needed or hea thy surviva . In other -ine made o ]
words, the communication systems o the body are a so its contro and inte- action potential
grating systems. T ey combine the bodys hundreds o unctions into its one (AK-shun poh-TEN-shal)
overa unction o keeping itse a ive and hea thy. [act- moving, -ion condition,
poten- power, -ial relating to]
Reca that homeostasis is the ba anced and contro ed interna environment adrenergic f ber
o the body that is basic to i e itse . H omeostasis is possib e on y i our
physio ogica contro and integration systems unction proper y. O ur p an [ad- toward, -ren- kidney, -erg- work,
or this chapter is to name the ce s, organs, and divisions o the nervous -ic relating to, f br- thread]
system and then exp ain how these impu ses move between one area o the a erent neuron
body and another. We not on y discuss the (AF- er-ent NOO-ron)
major structures o the nervous system, such [a[d]- toward, - er- carry, -ent relating
as the brain, spina cord, and nerves, but to, neur- string or nerve, -on unit]
a so earn how they unction to maintain antidiuretic hormone (ADH)
and regu ate homeostasis. In Chapter 11,
mohn [ay dee aych])
we consider the senses.
[anti- against, -dia- through,
-uret- urination, -ic relating to,
hormon- excite]
O r g a n s a n d D iv is io n s arachnoid mater
o t h e N e r vo u s S y s t e m (ah-RAK-noyd MAH-ter)
[arachn- spider(web), -oid like,
T e organs o the nervous system as a who e inc ude the brain and mater mother]
spina cord, the numerous nerves o the body, the specia sense organs such astrocyte
as the eyes and ears, and the microscopic sense organs such as those ound in (AS-troh-syte)
the skin. T e system as a who e consists o two principa divisions: the centra [astro- star shaped, -cyte cell]
nervous system and the periphera nervous system (Figure 10-1). Because the autonomic e ector
brain and spina cord occupy a mid ine or centra ocation in the body, together
they are ca ed the central nervous system, or CNS. Simi ar y, the usua des- [auto- sel , -nom- rule, -ic relating to,
ignation or the nerves o the body is the peripheral nervous system, or PNS. e ect- accomplish, -or agent]
T e term peripheral is appropriate because nerves extend to out ying or periph- autonomic nervous system (ANS)
era parts o the body. A subdivision o the periphera nervous system, ca ed
the autonomic nervous system, or ANS, consists o structures that regu ate SIS-tem [ay en es])
the bodys automatic or invo untary unctions ( or examp e, the heart rate, the [auto- sel , -nom- rule, -ic relating to,
nerv- nerve, -ous, relating to]

Continued on p. 280

249
 250 CHAPTER 10 Nervous System
CENTRAL NERVOUS S YS TEM
Bra in S pina l cord
PERIPHERAL NERVOUS S YS TEM
Cra nia l ne rve s S pina l ne rve s
Autonomic (involunta ry)
motor ne rve s
S oma tic (volunta ry)
motor ne rve s
S e ns ory ne rve s
FIGURE 10-1 Divisions o the nervous system.
contractions o the stomach and intestines, and the secretion
o chemica compounds by g ands).
As you study the brain spina cord, and nerves, try to f nd
their ocation in the Clear View o the Human Body ( o ows
p. 8) and note their re ationships to surrounding structures.
To better understand this concept, use the Active
Concept Map Organization o the Nervous System
at evolve.elsevier.com.
To get an overview o the nervous system, go to
AnimationDirect online at evolve.elsevier.com.
C e lls o t h e N e r vo u s S y s t e m
In Chapter 4, we earned that nervous tissue is the major
component o the nervous system. And we earned two major
types o ce s are ound in nervous tissue: neurons or nerve
ce s and glia, which are support ce s (see Figure 4-19 on p. 84).
10 Neurons conduct impu ses, whereas g ia support neurons.
N e u ro n s
N e u ro n S t r u c t u r e
Each neuron consists o three parts: a main part ca ed the
neuron cell body, one or more branching projections ca ed
dendrites, and one e ongated projection known as an axon.
T e axon shown in Figure 10-2, B, is surrounded by a seg-
mented wrapping o a materia ca ed myelin. Mye in is a
white, atty substance ormed by Schwann cells that wrap
around some axons outside the centra nervous system. Such
f bers are ca ed myelinated bers. In Figure 10-2, B, one such
axon has been en arged to show additiona detai . Nodes o
Ranvier are gaps between adjacent Schwann ce s.
T e outer wrapped ayer o a Schwann ce is ca ed the
neurilemma. It is c inica y signif cant that axons in the brain
and spina cord have no neuri emma, because neuri emma p ays
an essentia part in the regeneration o cut and injured axons.
T ere ore, the potentia or regeneration in the brain and spina
cord is ar ess than it is in the periphera nervous system.
Identi y each part on the neuron shown in Figure 10-2.
Dendrites are the processes or projections that carry impu ses
to the neuron ce bodies, and axons are the processes that
carry impu ses away rom the neuron ce bodies.
Ty p e s o N e u ro n s
T ere are three major types o neurons c assif ed according to
the direction in which they carry impu ses.
Sensory Neurons
Sensory neurons carry impu ses to the spina cord and brain
rom a parts o the body. Sensory neurons are a so ca ed
af erent neurons.
Motor Neurons
Motor neurons carry impu ses in the opposite directionaway
rom the brain and spina cord. T ey do not conduct impu ses
to a parts o the bodyon y to two kinds o tissuemusc e
and g andu ar epithe ia tissue. Motor neurons are a so ca ed
ef erent neurons.
Interneurons
Interneurons conduct impu ses rom sensory neurons to mo-
tor neurons. T ey a so o ten connect with each other to orm
comp ex, centra networks o nerve f bers. Interneurons are
sometimes ca ed central or connecting neurons.
G lia
Fu n c t io n o G lia
G iaor neurogliado not specia ize in transmitting im-
pu ses. Instead, they are specia types o supporting ce s. T eir
name is appropriate because it is derived rom the Greek word
glia meaning g ue. One unction o g ia ce s is to ho d the
unctioning neurons together and protect them.
We now know that g ia per orm many di erent unctions,
inc uding the regu ation o neuron unction. T ere ore, they
not on y act as g ue in the physica sense but a so he p bring
the various unctions o nervous tissue together into a coordi-
nated who e.
An important reason or discussing g ia is that one o the
most common types o brain tumorca ed gliomadeve ops
rom them.
C e n t r a l G lia
G ia vary in size and shape (Figure 10-3). Some are re ative y arge
ce s that ook somewhat ike stars because o the thread ike
 CHAPTER 10 Nervous System 251

extensions that jut out rom their sur aces. T ese g ia ce s are
ca ed astrocytes, a word that means star ce s (see Figure 10-3,
De ndrite
A). T eir thread ike branches attach to neurons and to sma
b ood vesse s, ho ding these structures c ose to each other.
A ong with the wa s o the b ood vesse s, astrocyte
branches orm a two- ayer structure ca ed the blood-brain
Ce ll body barrier (BBB). As its name imp ies, the BBB separates the
b ood tissue and nervous tissue to protect vita brain tissue
rom harm u chemica s that might be in the b ood.
Mitochondrion
Microglia are sma er than astrocytes (see Figure 10-3, B).
T ey usua y remain stationary, but in in amed or degenerat-
Nucle us
ing brain tissue, they en arge, move about, and act as microbe-
eating scavengers. T ey surround the microbes, draw them
into their cytop asm, and digest them. T ey ikewise he p

Axon

Node of Ra nvie r
S chwa nn ce ll Nucle us of S chwa nn ce ll

Mye lin
s he a th

Axon

Ne urile mma
(s he a th of S chwa nn ce ll)
Ce ll me mbra ne
B of a xon

FIGURE 10-2 Structure o a neuron. A, Diagram o a typical neuron showing

dendrites, a cell body, and an axon. B, Segment o a myelinated axon cut to show detail
A o the concentric layers o the Schwann cell lled with myelin.

CENTRAL NERVOUS S YS TEM NEUROGLIA

Foot Oligode ndrocyte

proce s s e s

10
Ca pilla ry As trocyte s

Microglia
Ne rve be r
A B C Mye lin s he a th

FIGURE 10-3 Central glia. A, Astrocytes have extensions attached to blood vessels in the brain. B, Microglia
within the central nervous system can enlarge and consume microbes by phagocytosis. C, Oligodendrocytes have
extensions that orm myelin sheaths around axons in the central nervous system. Glia are not shown to scale.
 252 CHAPTER 10 Nervous System

No rmal mye lin Mye lin partially de s troye d by MS

Oligode ndrocyte ce ll Oligode ndrocyte ce ll

Mye lin Axon Mye lin De mye lina te d a xon

A B
FIGURE 10-4 Myelin disorders. Diagram showing e ects o multiple sclerosis (MS). A, A normal myelin
sheath allows rapid conduction. B, In those with MS, the myelin sheath is damaged, disrupting normal nerve
conduction.

c ean up ce damage resu ting rom injury or disease. Reca
rom Chapter 3 that phagocytosis is the scientif c name or
this important ce u ar process.
T e oligodendrocytes he p ho d nerve f bers together in
the CNS. T ey a so serve another and probab y more impor-
tant unction: they produce the atty mye in sheath that enve -
ops nerve f bers ocated in the brain and spina cord. T e
mye in sheath in uences nerve conduction speed, which in
turn a ects the coordination and e ectiveness o nerve signa -
ing. We return to this concept ater in the chapter.
P e r ip h e r a l G lia
Schwann cells are g ia ce s that a so orm mye in sheaths
but do so on y in the periphera nervous system. Notice in
Figure 10-3, C, that each o igodendrocyte can orm part o the
mye in sheath around severa axons but Schwann ce s wrap
entire y around on y one axon.
p aque ike esions rep ace the destroyed mye in, and a ected
areas are invaded by in ammatory ce s. As the mye in around
the axons is ost, nerve conduction is impaired, potentia y re-
su ting in weakness, incoordination, visua impairment, and
speech disturbances. A though the disease occurs in both sexes
and a age-groups, it is most common in women between the
ages o 20 and 40 years.
T e cause o MS is thought to be re ated to autoimmunity
and to vira in ections in some individua s. MS is characteris-
tica y re apsing and chronic in nature, but some cases o acute
and unremitting disease have been reported. In most instances
the disease is pro onged, with remissions and re apses occur-
ring over many years.
e evision persona ity and author Monte W i iams reports
that he ived with recurring episodes o MS or 20 years be ore
he rea ized that he has the condition. A though there is not yet

QUICK CHECK FIGURE 10-5 Multiple neurof bromatosis. This photo shows multiple
1. Wh a t is th e d i e re n ce b e tw e e n th e ce n tra l n e rvo u s s ys te m tumors o Schwann cells in the nerves o the skin that are characteristic o
a n d th e p e rip h e ra l n e rvo u s s ys te m ? this inherited condition.
2. Wh a t a re th e m a jo r e a tu re s o a n e u ro n ?
3. Na m e a n d d e s crib e th e th re e typ e s o n e u ro n s b a s e d
u p o n th e d ire ctio n th e y co nve y im p u ls e s .
4. Ho w a re g lia d i e re n t ro m n e u ro n s ?
5. Wh a t a re th re e typ e s o g lia ?

10 D is o r d e r s o N e r vo u s Tis s u e
M u lt ip le S c le ro s is
A number o diseases are associated with disorders o the
o igodendrocytes. Because these g ia ce s are invo ved in
mye in ormation, the diseases as a group are ca ed myelin
disorders. T e most common primary disease o the CNS is a
mye in disorder ca ed multiple sclerosis, or MS.
MS is an autoimmune condition characterized by mye in
oss and destruction accompanied by varying degrees o o igo-
dendrocyte injury and death (Figure 10-4). T e resu t is areas o
demye ination throughout the white matter o the CNS. H ard,

Epine urium
a cure or MS, ear y diag-
nosis and treatment can s ow
or stop its progression.
Tu m o r s
T e genera name or tumors arising in
nervous system structures is neuroma. umors
do not usua y deve op direct y rom neurons but instead
rom g ia, membrane tissues, and b ood vesse s.
As stated ear ier, a common type o brain tumor
gliomaoccurs in g ia. G iomas are usua y benign but may
sti be i e threatening. Patients usua y show def cits re ect-
ing damaged unction o the area in which the tumor is o-
cated (Figure 10-4, B). Because these tumors o ten deve op in
deep areas o the brain, they are di cu t to treat. Untreated
g iomas may grow to a size that disrupts norma brain unc-
tion, perhaps eading to death.
Multiple neuro bromatosis is an inherited disease char-
acterized by numerous f brous neuromas throughout the
body (Figure 10-5). T e tumors are benign, appearing f rst as
sma nodu es in the Schwann ce s o cutaneous nerves. In
some cases, invo vement spreads as arge, disf guring f brous
tumors appear in many areas o the body, inc uding musc es,
bones, and interna organs.
Most ma ignant tumors o g ia and other nervous tissues
do not originate there but instead are secondary tumors re-
su ting rom metastasis o cancer ce s rom the breast, ung,
or other organs.
QUICK CHECK
1. Wh a t is a m ye lin d is o rd e r? Ho w d o e s a m ye lin d is o rd e r
d is ru p t n e rvo u s s ys te m u n ctio n ?
2. Wh a t is a n e u ro m a ?
3. Wh a t is a co m m o n d is o rd e r th a t is ch a ra cte rize d b y
m ye lin lo s s a n d d e s tru ctio n o va ryin g d e g re e s o th e
o lig o d e n d ro cyte s ?
N e r ve s a n d Tr a c t s
A nerve is a group o periphera nerve f bers (axons) bund ed
together ike the strands o a cab e. Periphera nerve f bers
usua y have a mye in sheath and because mye in is white,
periphera nerves o ten ook white.
CHAPTER 10 Nervous System 253
FIGURE 10-6 Nerve. Each nerve contains axons
bundled into ascicles. A connective tissue epineu-
rium wraps the entire nerve. Perineurium surrounds
each ascicle and endoneurium surrounds each axon.
Lymph
s pa ce
Fa t
Arte ry
a nd ve in
Fa s cicle
S chwa nn
ce ll
Pe rine urium Axon
Endone urium
Figure 10-6 shows that each axon in a nerve is surrounded
by a thin wrapping o f brous connective tissue ca ed the
endoneurium. Groups o these wrapped axons are ca ed
ascicles. Each ascic e is surrounded by a thin, f brous
perineurium. A tough, f brous sheath ca ed the epineurium
covers the who e nerve.
Bund es o axons in the CNS, ca ed tracts, a so may be
mye inated and thus orm the white matter o the brain and
cord. Brain and cord tissue composed o ce bodies and un-
mye inated axons and dendrites is ca ed gray matter because
o its characteristic gray appearance.
N e r ve S ig n a ls
Re e x A r c s
N e u ro n P a t h w a y s
D uring every moment o our ives, nerve impu ses speed over
neurons to and rom our spina cords and brains. I a impu se
conduction ceases, i e itse ceases.
On y neurons can provide the rapid communication be-
tween ce s that is necessary or maintaining i e. H ormones
are the on y other kind o signa the body can send, and they
trave much more s ow y than nerve signa s. H ormones can 10
move rom one part o the body to another on y via circu ating
b ood. Compared with nerve impu se conduction, hormone
circu ation is a very s ow process.
Nerve impu ses, o ten ca ed action potentials, can trave
over tri ions o routesroutes made up o neurons because
they are the ce s that conduct impu ses. H ence the routes
trave ed by nerve impu ses are sometimes spoken o as neuron
pathways.
A basic type o neuron pathway, ca ed a re ex arc, is im-
portant to nervous system unctioning. T e simp est kind o
 254 CHAPTER 10 Nervous System
Gray
ma tte r
Dors a l root ga nglion
S yna ps e
S pinal c o rd
Motor ne uron
re ex arc is a two-neuron arc, so ca ed because it con-
Qua drice ps
sists o on y two neurons: one sensory neuron and one
motor neuron. T ree-neuron arcs are the next simp est
kind. A three-neuron arc, o course, consists o a three
kinds o neurons: a sensory neuron, an interneuron, and a
motor neuron.
S t r u c t u r e o Re e x A r c s
Re ex arcs are ike one-way streets; they a ow impu se con-
duction in on y one direction. T e next paragraph describes
this direction in detai . Look requent y at Figure 10-7 as you
read it.
Impu se conduction norma y starts in receptors. Receptors
are the beginnings o dendrites o sensory neurons. T ey are
o ten ocated ar rom the spina cord (in tendons, skin, or
mucous membranes, or examp e).
In Figure 10-7 the sensory receptors are ocated in the quad-
riceps musc e groupwhich acts to extend the eg. In the
re ex that is i ustrated there, stretch receptors are stimu ated
when musc es are stretched as a resu t o a tap on the pate ar
igament rom a rubber hammer used by a physician to e icit
a re ex during a physica examination. T e nerve impu se that
is generated, its neuro ogica pathway, and its u timate knee-
jerk e ect provide an examp e o the simp est orm o a two-
neuron re ex arc.
In the knee-jerk re ex, on y sensory and motor neurons
are invo ved. T e nerve impu se that is generated by stimu-
ation o the stretch receptors trave s a ong the ength o the
sensory neurons dendrite to its ce body ocated in the
dorsal root ganglion. A ganglion is a group o nerve-ce
10 bodies ocated in the PNS. T is gang ion is ocated near the
spina cord. Each dorsa root gang ion contains not one
sensory neuron ce body as shown in Figure 10-7, but hun-
dreds o them.
T e axon o the sensory neuron trave s rom the ce body
in the dorsa root gang ion and ends near the dendrites o
another neuron ocated in the gray matter o the spina cord.
A microscopic space separates the axon ending o one neuron
rom the dendrites o another neuron. T is gap serves as a
junction between nerve ce s ca ed a synapse. T e nerve im-
pu se stops at the synapse, chemica signa s are sent across the
FIGURE 10-7 Knee-jerk re ex. The neural pathway
involved in the knee-jerk (patellar) ref ex.
S e ns ory ne uron
S tre tch re ce ptor
Te ndon
Pa te lla
Pa te lla r liga me nt
mus cle
(e ffe ctor)
P
P A
D
gap, and then the new impu se continues a ong the dendrites,
ce body, and axon o the motor neuron.
T e motor neuron axon orms a synapse with a structure
ca ed an ef ector, an organ that puts nerve signa s into e -
ect. E ectors are usua y musc es or g ands, and musc e
contractions and g and secretion are the kinds o re exes op-
erated by these e ectors.
Re e x Re s p o n s e s
An invo untary response to impu se conduction over a re ex
arc is ca ed a re ex. In short, impu se conduction by a re ex
arc causes a re ex to occur. In our examp e re ex, the nerve
impu ses that reach the quadriceps musc e (the e ector) resu t
in the knee-jerk response.
Some re exes invo ve three rather than two neurons. In
these more comp ex types o responses, an interneuron, in ad-
dition to the sensory and motor neurons, is invo ved. In three-
neuron re exes, the end o the sensory neurons axon synapses
f rst with an interneuron be ore chemica signa s are sent
across a second synapse, resu ting in conduction through the
motor neuron.
For examp e, app ication o an irritating stimu us to the
skin o the thigh initiates a three-neuron re ex response that
causes contraction o exor musc es to pu the eg away rom
the irritanta three-neuron arc reaction ca ed the withdrawal
re ex.
A interneurons ie entire y within the gray matter o the
brain or spina cord. Gray matter orms the H -shaped inner
core o the spina cord. Because o the presence o an inter-
neuron, three-neuron re ex arcs have two synapses. A two-
neuron re ex arc, however, has on y a sensory neuron and a
motor neuron with one synapse between them.
 CHAPTER 10 Nervous System 255

Identi y the motor neuron in Figure 10-7. O bserve that its N e r ve Im p u ls e s

dendrites and ce body, ike those o an interneuron, are o-
cated in the spina cords gray matter. T e axon o this motor
neuron, however, runs through the ventra root o the spina
nerve and terminates in a musc e.
To explore applications o neural pathway con-
Pain Control Areas at
Connect It! at evolve.elsevier.com.
QUICK CHECK
1. Ho w is w h ite m a tte r d i e re n t ro m g ra y m a tte r?
2. Ca n yo u e xp la in th e u n ctio n o a re e x a rc?
3. Wh a t is a s e n s o ry re ce p to r? Ho w d o e s it re la te to th e
re e x a rc?
4. Wh a t is a n e e cto r? Ho w d o e s it re la te to th e re e x a rc?
5. Wh a t is a ga n g lio n ?
D e f n it io n o a N e r ve Im p u ls e
W hat are nerve impu ses? H ere is one wide y accepted def ni-
tion: a nerve impu se is a se -propagating wave o e ectrica
disturbance that trave s a ong the sur ace o a neurons p asma
membrane. You might visua ize this as a tiny spark sizz ing its
way a ong a use.
Nerve impu ses do not continua y race a ong every nerve
ce s sur ace. First they have to be initiated by a stimu us, a
change in the neurons environment. Pressure, temperature,
and chemica changes are the usua stimu i.
M e c h a n is m o a N e r ve Im p u ls e
Figure 10-8 depicts a simp if ed summary o the mechanism o
a nerve impu se.
T e membrane o each resting neuron has a s ight positive
charge on the outside and a negative charge on the inside, a state

Voltme te r
Sodium ion

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+
1
An exce s s of
s odium ions (Na +)
on the outs ide of
the me mbra ne
pola rize s the a xon.

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+
Pola rize d
(re s ting)

2 Na+ Na+ Na+ Na+ Na+ Na+

S timula tion of the
me mbra ne trigge rs
inwa rd diffus ion of Na+ Na+ Na+ Na+ Na+ Na+
Na +, de pola rizing
the me mbra ne by Na+ Na+ Na+ Na+ Na+ Na+
ba la ncing the
cha rge d ions.
Na+ Na+ Na+ Na+ Na+ Na+
De pola riza tion

Na+ Na+ Na+ Na+ Na+ Na+

10
3
Me mbra ne Na+ Na+ Na+ Na+
Na+ Na+
re pola rize s a s
origina l s ta te is
a chieve d. Na+ Na+ Na+ Na+ Na+ Na+

Na+ Na+ Na+ Na+ Na+ Na+

Re pola riza tion

FIGURE 10-8 Mechanism o the nerve impulse. A voltmeter (right) shows how the charge di erence
across the membrane f uctuates as the balance o positive ions (Na ) changes.
 256 CHAPTER 10 Nervous System
ca ed polarization. T is occurs because there is norma y an ex-
cess o sodium ions (Na ) on the outside o the membrane.
W hen a section o the membrane is stimu ated, its Na
channe s sudden y open, and Na ions rush inward. T e inside
o the membrane temporari y becomes positive, and the out-
side becomes negativea process ca ed depolarization.
T e depo arized section o the membrane then immedi-
ate y recoversa process ca ed repolarization. H owever, the
depo arization has a ready stimu ated Na channe s in the
next section o the membrane to open.
C o n d u c t io n o N e r ve Im p u ls e s
T e impu seor action potentialcannot go backward dur-
ing the brie moment o repo arization and recovery o the
previous section o membrane. T us a se -propagating wave o
e ectrica disturbancea nerve impu setrave s continuous y
in one direction across the neurons sur ace (Figure 10-9, A).
Nerve impu ses are a so ca ed action potentials because
each one is a di erence in charge (ca ed e ectrica potentia )
that usua y triggers an action by the ce in this case, trans-
mission o the impu se itse .
I the trave ing impu se encounters a section o membrane
covered with insu ating mye in, it simp y jumps around the
mye in rom one gap to the next. Ca ed saltatory conduction,
this type o impu se trave is much aster than is possib e in
nonmye inated sections. Sa tatory conduction is i ustrated in
Figure 10-9, B.
To learn more about nerve impulses, go to
AnimationDirect online at evolve.elsevier.com.
Syn a p s e s
S t r u c t u r e a n d Fu n c t io n o a S y n a p s e
ransmission o signa s rom one neuron to the nextacross
the synapseis an important part o the nerve conduction
process. By def nition, a synapse is the p ace where impu ses
are transmitted rom one neuron, ca ed the presynaptic
neuron, to another neuron, ca ed the postsynaptic neuron.
T ree structures make up a synapse: a synaptic knob, a
synaptic c e t, and the p asma membrane o a postsynaptic
neuron.
A synaptic knob is a tiny bu ge at the end o a termina
branch o a presynaptic neurons axon (Figure 10-10). Each
synaptic knob contains many sma sacs or vesic es. Each
vesic e contains a very sma quantity o a chemica compound
10 ca ed a neurotransmitter. W hen a nerve impu se arrives at the
synaptic knob, neurotransmitter mo ecu es are re eased rom
the vesic es into the synaptic cle t.
T e synaptic cle t is the space between a synaptic knob
and the p asma membrane o a postsynaptic neuron. It is an
incredib y narrow spaceon y about two mi ionths o a cen-
timeter in width. T e synaptic c e t is f ed with extrace u ar
matrix that ho ds the synaptic structure in p ace. Identi y the
synaptic c e t in Figure 10-10.
T e p asma membrane o a postsynaptic neuron has protein
mo ecu es embedded in it opposite each synaptic knob. T ese
serve as receptors to which neurotransmitter mo ecu es bind.
T is binding can initiate an impu se in the postsynaptic neu-
ron by opening ion channe s in the postsynaptic membrane.
A ter impu se conduction by postsynaptic neurons is initi-
ated, neurotransmitter activity is rapid y terminated. Either
one or both o two mechanisms cause this: reuptake or en-
zyme breakdown.
Some neurotransmitter mo ecu es are transported out o
the synaptic c e t and back into synaptic knobs in a process
ca ed reuptake. Like taking the key out o the ignition switch
and returning it to your pocket, the receptor stops unctioning
when the neurotransmitters are taken back. T ere, they are
repackaged into vesic es to be used again atera mechanism
ca ed recycling.
T e neurotransmitters may instead be broken apart by
specif c enzymes in the extrace u ar matrix o the synaptic
c e t. T e neurotransmitters may a so be transported into a
C LIN ICA L APPLICATION
THE BLOOD-BRAIN BARRIER
As trocyte s have an im portant unction othe r than s upport-
ing ne urons and blood ve s s e ls . Notice in the f gure that the
e e t o the as trocyte s orm a wall around the outs ide o
blood ve s s e ls in the ne rvous s ys te m . This as trocyte wall,
along w ith the ve s s e l wall, orm s a s tructure know n as the
blo o d-brain barrie r (BBB).
The BBB allow s wate r, oxyge n, carbon dioxide , and a
ew othe r s ubs tance s s uch as alcoholto m ove be twe e n
the blood and the tis s ue o the brain. Howeve r, m any toxins
and pathoge ns that can e nte r othe r tis s ue s through blood
ve s s e l walls cannot e nte r ne rvous tis s ue be caus e o this
barrie r. This adaptation e nhance s s urvival be caus e it pro-
te cts vital brain and ne rve tis s ue s rom dam age .
This prote ctive unction o the BBB has gre at clinical
s ignif cance . Drugs us e d in othe r parts o the body to tre at
in e ctions , cance r, and othe r dis orde rs o te n cannot pas s
through the BBB. For exam ple , pe nicillin and othe r antibiot-
ics cannot e nte r the inte rs titial uid o brain tis s ue rom the
blood. Obvious ly, this m ake s deve lopm e nt o tre atm e nts
or brain dis orde rs s om e tim e s ve ry di f cult.
As dis cus s e d in the text (p. 259), parkins onis m re s ulting
rom a lack o dopam ine in the brain cannot be tre ate d w ith
dopam ine be caus e it cannot cros s the BBB. Howeve r, the
dopam ine pre curs or L-dopa can cros s the BBB and be con-
ve rte d to dopam ine in the brain in s om e patie nts .
Bra in inte rs titia l uid
As trocyte
Blood-bra in Wa ll of
ba rrie r blood
Blood ve s s e l
Wa te r Oxyge n L-Dopa Dopa mine
 CHAPTER 10 Nervous System 257

CONTINUOUS CONDUCTION

A S timulus

Action
Unmye lina te d pote ntia l
ne rve fibe r

Re cove ry
pe riod

2
FIGURE 10-9 Conduction o
nerve impulses. A, In an unmyelin-
ated ber, a nerve impulse (action
potential, shown with yellow glow) is
a continuous, sel -propagating wave
o electrical disturbance. The dark Mye lina te d
blue area o recovery during repo- ne rve fibe r
larization cannot be restimulated,
preventing backward conduction. 3
B, In a myelinated ber, the action
potential jumps around the insulat-
ing myelin in a rapid type o conduc-
tion called saltatory conduction.

S timulus B S ALTATORY CONDUCTION

+ + + +
+
+
+ + + +
1
Action pote ntia l

+ + + +
+
+
+ + + +
2
Re cove ry pe riod Action pote ntia l

+ +
+
+
3
+ +
nearby g ia ce and broken apart by enzymes there. In either
case, the pieces e t a ter enzyme breakdown are returned to
the presynaptic neuron to be recyc ed into new neurotrans-
mitter mo ecu es.
N e u ro t r a n s m it t e r s a n d Re c e p t o r s
Neurotransmitters
Neurotransmitters are chemica s by which neurons commu-
nicate. As previous y noted, at tri ions o synapses in the
CNS, presynaptic neurons re ease neurotransmitters that assist,
+ +
+ +
10
stimu ate, or inhibit postsynaptic neurons. At east 30 di erent
compounds have been identif ed as neurotransmitters. T ey are
not distributed random y through the spina cord and brain.
Instead, specif c neurotransmitters are oca ized in discrete
groups o neurons and re eased in specif c pathways.
For examp e, the substance named acetylcholine (ACh) is
re eased at some o the synapses in the spina cord and at neu-
romuscu ar (nerve-musc e) junctions. O ther we -known neu-
rotransmitters inc ude norepinephrine (NE), dopamine, and
serotonin. T ese three neurotransmitters be ong to a group o
 258 CHAPTER 10 Nervous System

1 pain ki ers. Research shows that

Action pote ntia l conducte d Axon
a long a xon re a che s the
the re ease o endorphins in-
a xon knob creases during heavy exercise.
Norma y, pain is a warning signa
2 that ca s attention to injuries or
Action pote ntia l trigge rs re le a s e of dangerous circumstances. H ow-
P la s ma me mbra ne
ne urotra ns mitte rs from ve s icle s
1 of pre s yna ptic ne uron ever, it is better to inhibit moder-
ate pain i it wou d stop us rom
3 S yna ptic continuing an activity that may
Ne urotra ns mitte rs Ve s icle s conta ining
knob be necessary or surviva .
cros s s yna ptic ne urotra ns mitte r
cle ft a nd bind to S yna ptic mole cule s Very sma mo ecu es such as
pos ts yna ptic cle ft 2
re ce ptors
nitric oxide (NO) a so have an
important ro e as neurotransmit-
3
4
ters. Un ike most other neuro-
P la s ma transmitters, NO di uses direct y
Activa te d re ce ptors me mbra ne of
trigge r ope ning of ion 4 across the p asma membrane o
pos ts yna ptic Ne urotra ns mitte r
cha nne ls, initia ting a Ion cha nne ls
pos ts yna ptic impuls e
ne uron mole cule s neurons rather than being re-
with re ce ptors
eased rom vesic es.
NO is important during the
ma e sexua response in regu-
FIGURE 10-10 Synapse. Diagram shows synaptic knob or axon terminal o presynaptic neuron, the plasma ating smooth musc es in the
membrane o a postsynaptic neuron, and a synaptic cle t. Boxed steps summarize the process o synaptic transmis- b ood vesse s o the penis to
sion o a nerve signal. a ow or peni e erection. T e
drug si denaf (Viagra) treats
compounds ca ed catecholamines, which p ay a ro e in s eep, male erectile dys unction (M ED) by promoting the same re-
motor unction, mood, and p easure recognition. sponse in the penis as NO.
wo morphine ike neurotransmitters ca ed endorphins
and enkephalins are re eased at various spina cord and brain Receptors
synapses in the pain conduction pathway. T ese neurotrans- Look again at Figure 10-10 and ocate the receptors to which
mitters inhibit conduction o pain impu ses. T ey are natura neurotransmitters bind during synaptic transmission o a

C LIN ICA L APPLICATION

ANTIDEPRES SANTS
Antide pre s s ant drugs are pre s cribe d w ide ly or outpatie nts type s o antide pre s s ants incre as e s e rotonin leve ls in othe r
s u e ring rom de pre s s ion as s ociate d w ith the ir ongoing ill- ways or a e ct othe r ne urotrans m itte rs , s uch as dopam ine or
ne s s . De pre s s ion als o can be a dis tinct m e ntal illne s s that can nore pine phrine , w hich are als o active in m ood
be caus e d by a varie ty o actors . pathways as s ociate d w ith de pre s s ion.
The exact m e chanis m s o s eve re de pre s s ion re m ain incom - Re se archers continue to study
ple te ly explaine d. A clas s ic explanation s tate s that a de f cit o othe r drugs, such as the an-
s e rotonin or anothe r ne urotrans m itte r exis ts at ce rtain s yn- es the tic ketamine , that
aps e s in parts o the brain that a e ct ones m ood. More re ce nt more rapidly e rase de -
explanations propos e that it is a lack o s u f cie nt s ynaptic con- pre ss ion by incre asing
ne ctions in the m ood pathways o the brain that are to blam e . synaptic com munica-
10 Som e o the m ore com m only us e d antide pre s s ants today tion am ong existing
are paroxe tine (Paxil), uoxe tine (Prozac), and s e rtraline (Zolo t). ne urons in the brains
The s e drugs produce the ir e e cts by blocking the uptake o mood pathways.
s e rotonin back into pre s ynaptic ne urons . Drugs in this clas s o
antide pre s s ants are calle d s e rotonin-s pe cif c re uptake inhibi-
tors (SSRIs ).
Se rotonin-uptake inhibition caus e s an incre as e in the
am ount o s e rotonin in the s ynaps e , the re by reve rs ing the
s e rotonin de f cit that m ay contribute to e e lings o de pre s s ion.
Howeve r, it m ay be the s e drugs ability to produce new ne u-
rons that produce s m os t o the antide pre s s ant e e ct. Othe r
 CHAPTER 10 Nervous System 259

nerve signa . Notice that those shown are a component o

the ion channe s that produce a postsynaptic impu se when
they open in response to activation o their receptors. Recep-
tors can a so be separate membrane structures that send a
chemica signa to nearby ion channe s to trigger their
opening.
Each type o neurotransmitter can bind on y to a receptor
that chemica y f ts with it. T us dopamine can on y bind to
a dopamine receptor and not to an acety cho ine receptor.
H owever, there are s ight y di erent kinds o dopamine
receptorseach responding on y to dopamine. T e di erent
kinds o dopamine receptors are ound in di erent ocations
in the body.
T e characteristics o neurotransmitter and receptors a ow
or very precise contro o body unctions. T ey a so give an
opportunity or deve oping e ective drugs. For examp e, some
asthma drugs target certain catecho amine receptors in the
airways o ung and trigger them to di ate and a ow a person
to breathe more easi y. H owever, such drugs can have un-
wanted side e ects in other parts o the body that a so have
catecho amine receptors. So researchers attempt to f nd a drug
that wi trigger just the specif c kind o catecho amine recep-
tors ound in the airwaysand thus have ewer unwanted
side e ects.
To learn more about synapses, go to
AnimationDirect online at evolve.elsevier.com.
Parkinson Disease
Parkinson disease (PD ) is a chronic, progressive nervous
disorder resu ting rom a def ciency o the neurotransmitter
dopamine in certain parts o the brain.
T e group o signs associated with this disorder, a syn-
drome ca ed parkinsonism, inc udes rigidity and tremb ing
o the head and extremities, a orward ti t o the trunk, and
a shu ing manner o wa king (Figure 10-11). You may have
noticed these signs in ormer boxing champion M uhammad
A i, the actor M ichae J. Fox, or in others you may know
with PD. A o these characteristics resu t rom ack o
dopamine, eading to misin ormation in the parts o the
brain that norma y prevents the ske eta musc es rom be-
ing overstimu ated.
Dopamine injections and dopamine pi s are not e ective
treatments or PD because dopamine cannot cross the b ood-
brain barrier (see box on p. 256).
A breakthrough in the treatment o Parkinson disease
came when the drug levodopa or l -dopa (Sinemet) was ound
to increase the dopamine eve s in a icted patients. Neurons
use l -dopa, which can cross the b ood-brain barrier, to make
dopamine. For some reason, l -dopa does not a ways have the
desired e ects in individua patients or its e ect may wear o
over time, so a number o a ternative treatments have been
deve oped. For examp e, the drug apomorphine (Apokyn) has
proved use u in treating individua s who no onger respond to
l -dopa.
A treatment option that has shown some success is surgica
gra ting o norma dopamine-secreting neurons into the
Forwa rd tilt
of trunk
Rigidity a nd
tre mbling of
he a d
Re duce d a rm
swinging
Rigidity a nd
tre mbling of
extre mitie s
S huffling ga it
with s hort s te ps
FIGURE 10-11 Parkinsonism. Parkinsonism is a syndrome typically
ound in individuals with Parkinson disease (PD). The signs include (but are not
limited to) rigidity and trembling o the head and extremities, a orward tilt o
the trunk, and a shu f ing gait with short steps and reduced arm swinging.
brains o individua s with PD. Another experimenta option
is an artif cia imp ant that gives e ectrica stimu ation to the
brain, causing it to produce more dopamine.
QUICK CHECK
1. Why a re n e rve im p u ls e s o te n re e rre d to a s a ctio n
p o te n tia ls ?
2. Ho w d o e s m ye lin in cre a s e th e s p e e d o n e rve im p u ls e
co n d u ctio n ?
3. Ho w d o n e u ro tra n s m itte rs tra n s m it s ig n a ls a cro s s th e
s yn a p s e ?
4. Wh a t a re th e ch a ra cte ris tics o p a rkin s o n is m ?
5. Ho w a re th e te rm s re u p ta ke a n d re cycle u s e d w h e n d is -
cu s s in g th e s yn a p s e ?
10
C e n t r a l N e r vo u s S y s t e m
T e CNS, as its name imp ies, is centra y ocated. Its two
major structures, the brain and spina cord, are axia ound
in the centra axis o the body (Figure 10-12). T e brain is pro-
tected in the crania cavity o the sku , and the spina cord is
surrounded in the spina cavity by the vertebra co umn. In
addition, the brain and spina cord are a so covered by protec-
tive membranes ca ed meninges, which are discussed in a ater
section o the chapter.
 260 CHAPTER 10 Nervous System

III. Diencepha on
Bra in A. H ypotha amus
Eye B. T a amus
(s e ns e orga n) C. Pinea g and
Cra nia l ne rve s IV. Cerebrum
S pina l cord
O bserve in Figure 10-13 the ocation and re ative sizes o the
di erent divisions o the brain.
S pina l
ne rve s Br a in s t e m
T e owest part o the brainstem is the medu a ob ongata.
Immediate y above the medu a ies the pons and above that
the midbrain. ogether these three structures are ca ed the
brainstem (see Figure 10-13).
T e medulla oblongata is an en arged, upward extension
o the spina cord. It ies just inside the crania cavity above
the arge ho e in the occipita bone ca ed the oramen mag-
num. T e pons bu ges out a bit more than medu a, orming a
bridge to the narrower midbrain.
In the brainstem, sma bits o gray matter mix c ose y and
intricate y with white matter to orm the reticular ormation
(reticular means net ike). In the spina cord, gray and white
matter do not interming e; gray matter orms the interior core
o the cord, and white matter surrounds it.
A three parts o the brainstem unction as two-way con-
duction paths. Sensory f bers conduct impu ses up rom the
spina cord to other parts o the brain, and motor f bers con-
duct impu ses down rom the brain to the spina cord.
In addition, many important re ex centers ie in the brain-
stem. T e cardiac, respiratory, and vasomotor centers (co ec-
Central ne rvous tive y ca ed the vital centers), or examp e, are ocated in the
sys tem (CNS )
medu a. Impu ses rom these centers contro heartbeat, respi-
Pe riphe ra l ne rvous rations, and b ood vesse diameter (which is important in
s ys te m (PNS)
regu ating b ood pressure).
S
C e r e b e llu m
R L
Structure
I Look at Figure 10-13 to f nd the ocation, appearance, and size
o the cerebe um.
T e cerebellum is the second argest part o the human
FIGURE 10-12 Nervous system. The brain and spinal cord (highlighted brain. It ies under the occipita obe o the cerebrum. In the
green) constitute the central nervous system (CNS), and the nerves (yellow) cerebe um, o ded gray matter composes the thin outer ayer,
make up the peripheral nervous system (PNS). orming a arge sur ace area o nervous connections that a ow
or a huge amount o in ormation processing.
W hite matter tracts orm most o the interior. Notice that
these tracts branch in a tree ike pattern ca ed the arbor vitae
10 Br a in ( itera y, iving tree).
D iv is io n s o t h e Br a in
T e brain, one o our argest organs, consists o the o owing Function
major divisions, named in ascending order beginning with the Most o our previous know edge about cerebe ar unctions
most in erior part: has come rom observing patients who have some sort o
disease o the cerebe um and rom anima s that have had the
I. Brainstem cerebe um removed. From such observations, we know that
A. Medu a ob ongata the cerebe um p ays an essentia part in the production o
B. Pons norma movements.
C. Midbrain Perhaps a ew examp es wi make this c ear. A patient who
II. Cerebe um has a tumor o the cerebe um requent y oses his ba ance and
 CHAPTER 10 Nervous System 261

topp es over; he may ee ike a drunken man when he wa ks. D ie n c e p h a lo n

H e cannot coordinate his musc es norma y. H e may com-
p ain, or instance, that he is c umsy about everything he
doesthat he cannot even drive a nai or draw a straight ine.
W ith the oss o norma cerebe ar unctioning, he has ost the
abi ity to make precise movements.
T e most obvious unctions o the cerebe um, then, are to
produce smooth coordinated movements, maintain equi ib-
rium, and sustain norma postures.
Recent studies using new brain imaging methods show
that the cerebe um may have ar more unctions than ear ier
observed. T e cerebe um may assist the cerebrum and other
parts o the brain, perhaps having an overa coordinating
unction or the who e brain.
T e diencephalon is a sma but important part o the brain
ocated between the midbrain be ow and the cerebrum above.
It consists o three major structures: the hypotha amus, tha a-
mus, and pinea g and. Find these structures in Figure 10-13
be ore reading urther.
Hypothalamus
T e hypothalamus, as its name suggests, is ocated be ow the
tha amus. T e posterior pituitary g and, the sta k that attaches
it to the undersur ace o the brain, and areas o gray matter
ocated in the side wa s o a uid-f ed space ca ed the third
ventricle are extensions o the hypotha amus. Identi y the pi-
tuitary g and and the hypotha amus in Figure 10-13.

FIGURE 10-13 Central nervous

system. A, Sagittal section o the
brain and spinal cord. B, Sagittal sec-
Tha la mus tion o preserved brain.

Ce re bra l cortex Corpus

ca llos um
(of ce re brum)

S kull Ce re brum
Die nce pha lon
Hypotha la mus
P ine a l gla nd Midbra in
Pons
Arbor vita e Ce re be llum
(of ce re be llum) Me dulla
S pina l cord
Ce re be llum

Midbra in
P ituita ry gla nd
Pons
S pina l cord
Re ticula r forma tion
A Me dulla

Ce re bra l cortex

Tha la mus

Hypotha la mus
Corpus ca llos um
(of ce re brum) 10
P ine a l gla nd

Midbra in

Ce re be llum
Bra ins te m Pons
Arbor vita e
(of ce re be llum)
S
Me dulla
A P

B I
 262 CHAPTER 10 Nervous System
T e o d adage, Dont judge by appearances, app ies we
to appraising the importance o the hypotha amus. Measured
by size, it is one o the east signif cant parts o the brain, but
measured by its contribution to hea thy surviva , it is one o
the most important brain structures.
Impu ses rom neurons whose dendrites and ce bodies ie
in the hypotha amus are conducted by their axons to neurons
ocated in the spina cord, and many o these impu ses are
then re ayed to musc es and g ands a over the body. T us the
hypotha amus exerts major contro over virtua y a interna
organs. Among the vita unctions that it he ps contro are the
heartbeat, constriction and di ation o b ood vesse s, and con-
tractions o the stomach and intestines.
Some neurons in the hypotha amus unction in a surprising
way; they make the hormones that the posterior pituitary g and
secretes into the b ood. Because one o these hormones
antidiuretic hormone (AD H)a ects the vo ume o urine
excreted, the hypotha amus p ays an essentia ro e in maintain-
ing the bodys water ba ance.
Some o the neurons in the hypotha amus unction as en-
docrine (duct ess) g ands. T eir axons secrete chemica s ca ed
releasing hormones into the b ood, which then carries them to
the anterior pituitary g and. Re easing hormones, as their
name suggests, contro the re ease o certain anterior pituitary
hormones. T ese in turn in uence the hormone secretion o
other endocrine g ands. T us the hypotha amus indirect y
he ps contro the unctioning o every ce in the body.
T e hypotha amus is a crucia part o the mechanism or
maintaining body temperature. T ere ore marked e evation in
body temperature in the absence o disease o ten characterizes
injuries or other abnorma ities o the hypotha amus. In addi-
tion, this important center is invo ved in unctions such as the
regu ation o water ba ance, s eep cyc es, and the contro o
appetite and many emotions invo ved in p easure, ear, anger,
sexua arousa , and pain.
Thalamus
Just above the hypotha amus is a dumbbe -shaped section o
gray matter ca ed the thalamus. Each en arged end o the
dumbbe ies in a atera wa o the third ventricle. T e thin
center section o the tha amus passes rom e t to right
through the third ventric e, which we discuss in more detai
ater in this chapter.
T e tha amus is composed chie y o dendrites and ce
bodies o neurons that have axons extending up toward the
sensory areas o the cerebrum.
10 T e tha amus per orms the o owing primary unctions:
1. Relays sensory in ormation. Its neurons re ay im-
pu ses to the cerebra cortex rom the sense organs
o the body.
2. Associates sensations with emotions. A most a sen-
sations are accompanied by a ee ing o some de-
gree o p easantness or unp easantness. T e way
that these p easant and unp easant ee ings are
produced is unknown except that they seem to be
associated with the arriva o sensory impu ses in
the tha amus.
3. Regulates level o consciousness. It p ays a part in the
so-ca ed arousal or a erting mechanism that keeps us
awake.
4. Participates in motor re exes. It p ays a ro e in mecha-
nisms that produce comp ex re ex movements.
Pineal gland
Posterior to the tha amus is a tiny mass protruding rom the
back o the diencepha on ca ed the pineal gland or pineal
body. It resemb es a sma pine nut or kerne o corn.
T e pinea g and receives sensory in ormation about the
strength o ight seen by the eyes and adjusts its output o the
hormone melatonin. Me atonin is known as the timekeeping
hormone because it he ps keep the bodys c ock on time
with the dai y, month y, and seasona cyc es o sun ight and
moon ight.
We return to this amazing itt e organ in Chapter 12
(p. 338).
Ce re b ru m
Structure o the Cerebrum
T e cerebrum is the argest and uppermost part o the brain.
I you were to ook at the outer sur ace o the cerebrum, the
f rst eatures you wou d notice might be its many ridges and
grooves. T e ridges are ca ed convolutions, or gyri, and the
grooves are ca ed sulci.
T e deepest su ci are ca ed ssures. T e ongitudina f ssure
divides the cerebrum into right and e t ha ves or hemi-
spheres. T ese ha ves are a most separate structures except or
an in erior centra band ca ed the corpus callosum, which is
made up o white matter tracts (see Figure 10-13).
wo deep su ci subdivide each cerebra hemisphere into
our major obes and each obe into numerous convo utions.
T e obes are named or the bones that ie over them: the
rontal lobe, the parietal lobe, the temporal lobe, and the occipital
lobe. Identi y these in Figure 10-14, A. T ere is a so a hidden
obe ca ed the insula (meaning is and) o ded behind the
atera f ssure a ong the top o the tempora obe.
A thin ayer o gray matter ca ed the cerebral cortex is
made up o neuron dendrites and ce bodies; this makes up
the sur ace o the cerebrum.
W hite matter, made up o bund es o nerve f bers (tracts),
composes most o the interior o the cerebrum. W ithin this
white matter, however, are a ew is ands o gray matter known
as the basal nuclei, or basal ganglia, whose unctioning is es-
sentia or producing automatic movements and postures.
Parkinson disease (PD) is a disease o the basa nuc ei.
Because shaking or tremors are common symptoms o PD, it
has a so been ca ed shaking pa sy (see discussion on p. 259).
Brain Wrinkles at Connect It! at evolve.elsevier.com.
Function o the Cerebrum
W hat unctions does the cerebrum per orm? T is is a hard ques-
tion to answer brie y because the neurons o the cerebrum do
not unction a one. T ey unction with many other neurons in
 CHAPTER 10 Nervous System 263

Ce ntra l s ulcus FIGURE 10-14 Cerebrum. A, The lobes o the cere-

brum. The insula lobe is hidden rom view, as it olds
behind the lateral ssure. B, Functional regions o the
cerebral cortex. Association areas are so named be-
cause they put together (associate) in ormation rom
many di erent parts o the brain.

Fronta l lobe Pa rie ta l lobe

La te ra l Occipita l
s s ure lobe
Te mpora l lobe

Ce ntra l s ulcus P rima ry s oma tic

P re ce ntra l gyrus
s e ns ory a re a
(prima ry s oma tic motor a re a )
(body s e ns e pe rce ption)

P rima ry ta s te a re a
P re motor a re a
(mus cle coordina tion) S oma tic s e ns ory
a s s ocia tion a re a
(body s e ns e pe rce ption)
P re fronta l Vis ua l a s s ocia tion a re a
a s s ocia tion a re a
(cons cious thought)

Broca a re a Vis ua l cortex

(motor s pe e ch a re a )

We rnicke a re a
Auditory a s s ocia tion a re a (s e ns ory s pe e ch a re a )

P rima ry a uditory a re a
S
10
A P

B I

many other parts o the brain and in the spina cord. Neurons o
these various structures continua y bring impu ses to cerebra
neurons and a so continua y transmit impu ses away rom them.
I a other neurons were unctioning norma y and on y ce-
rebra neurons were not unctioning, here are some o the things
that you cou d not do: You cou d not think or use your wi . You
cou d not remember anything that has ever happened to you.
You cou d not decide to make the sma est movement, nor cou d
you make it. You wou d not see or hear. You cou d not experience
any o the sensations that make i e so rich and varied. Nothing
wou d anger or righten you, and nothing wou d bring you joy
or sorrow. You wou d, in short, be unconscious.
 264 CHAPTER 10 Nervous System

TABLE 10-1 Br a in D is o r d e r s
BRAIN AREA FUNCTION D e s t r u c t io n o Br a in
Tis s u e
Brains te m
Me dulla oblongata Two-way conduction pathway be twe e n the s pinal cord and highe r
Physical Injury
brain ce nte rs ; cardiac, re s piratory, and vas om otor control ce nte r Injury or disease can destroy neurons
Pons Two-way conduction pathway be twe e n are as o the brain and othe r in the brain. A common examp e is a
re gions o the body; in ue nce s re s piration concussion, a type o traumatic brain
Midbrain Two-way conduction pathway; re lay or vis ual and auditory im puls e s injury ( BI) resu ting rom a jo t to
Ce re be llum Mus cle coordination; m ainte nance o e quilibrium and pos ture ; as s is ts
the head that bends the brainstem and
ce re brum causes temporary chemica changes in
the brain. A concussion can be charac-
Die nce phalon
terized by changes in thinking or con-
Hypothalam us Re gulation o body te m pe rature , wate r balance , s le e p-cycle control,
centration; physica symptoms ike
appe tite , and s exual arous al
headache, nausea, or ight sensitivity; a
Thalam us Se ns ory re lay s tation rom various body are as to ce re bral cortex; change in mood; and/or changes in
e m otions and ale rting or arous al m e chanis m s
s eep. Sometimes symptoms appear
Pine al gland Adjus ts output o m e latonin in re s pons e to change s in exte rnal light, immediate y but sometimes they de-
to ke e p the bodys inte rnal clock on tim e
ve op over days or even months, as in
Ce re brum Se ns ory pe rce ption, e m otions , w ille d m ove m e nts , cons cious ne s s , postconcussion syndrome. I severe, or i
and m e m ory a second jo t occurs, b eeding or swe -
ing o brain a so may occur, which
may be i e-threatening.
T ese terms sum up the major cerebra unctions: con- Most concussions (and the symptoms) are re ative y mi d,
sciousness, thinking, memory, sensations, emotions, and wi ed however, and with rest and other precautions may eventua y
movements. Figure 10-14, B, shows the areas o the cerebra hea without permanent e ects. Studies show that the inci-
cortex essentia or wi ed movements, genera sensations, vi- dence o concussions can be great y reduced with appropriate
sion, hearing, and norma speech. head protection, such as sports he mets, and avoiding certain
It is important to understand that very specif c areas o the types o movements that put the head at risk.
cortex have very specif c unctions. For examp e, the tempora
obes auditory areas interpret incoming nervous signa s rom
the ear as very specif c sounds. T e visua area o the cortex in medical imaging used to assess brain damage and
the occipita obe he ps you identi y and understand specif c other disorders, see the article Brain Studies at
images. Connect It! at evolve.elsevier.com.
T e localization o unction exp ains the very specif c
symptoms associated with an injury to oca ized areas o the
cerebra cortex a ter a stroke or traumatic injury to the head. Stroke
Table 10-1 summarizes the major components o the brain and Another common examp e is the destruction o neurons o the
their main unctions. motor area o the cerebrum that resu ts rom a cerebrovascular
accident (CVA). A CVA, or stroke, is a hemorrhage rom or
To explore how the two hemispheres o the cere- cessation o b ood ow through cerebra b ood vesse s. W hen
this happens, the oxygen supp y to portions o the brain is
article Specialization o Cerebral Hemispheres at disrupted, and neurons cease unctioning. I the ack o oxygen
Connect It! at evolve.elsevier.com. is pro onged, the neurons die.
I the damage rom a CVA occurs in a motor contro area
o the brain (see Figure 10-14, B), the patient can no onger
10 To learn more about parts o the brain that control
body unctions, go to AnimationDirect online at
vo untari y move the parts o the body contro ed by the a -
ected areas. Because the paths o most motor neurons in the
evolve.elsevier.com.
cerebrum cross over in the brainstem, para ysis appears most y
on the side o the body opposite to the side o the brain on
QUICK CHECK which the CVA occurred.
1. Wh a t a re th e o u r m a in d ivis io n s o th e b ra in ? Cerebral Palsy
2. Wh a t re g io n s m a ke u p th e b ra in s te m ?
3. Wh a t is th e co rp u s ca llo s u m ? One o the most common cripp ing diseases that can appear
4. Wh a t s tru ctu re in th e d ie n ce p h a lo n co n tro ls th e h o rm o n e during chi dhood, cerebral palsy (CP), a so resu ts rom dam-
m e la to n in ? age to brain tissue. Cerebra pa sy invo ves permanent, non-
5. Why is th e hyp o th a la m u s s a id to b e a lin k b e tw e e n th e
progressive damage to motor contro areas o the brain, which
n e rvo u s s ys te m a n d th e e n d o crin e s ys te m ?
in turn causes abnorma musc e tension (spasticity) that
 S
R L
I para ysis may a ect most o one side o the body (hemiplegia),
FIGURE 10-15 Cerebral palsy (CP). This patient requires crutches to
walk because abnormal tension (spasticity) in muscles prevents normal
walking movements.
hinders movement (Figure 10-15). Such damage is present at
birth or occurs short y a ter birth and remains throughout i e.
Possib e causes o brain damage inc ude prenata in ections
or diseases o the mother; mechanica trauma to the head
be ore, during, or a ter birth; nerve-damaging poisons; and
reduced oxygen supp y to the brain. T e resu ting impairment
to vo untary musc e contro can mani est itse in a variety o
ways. Many peop e with cerebra pa sy exhibit spastic
paralysis, a type o para ysis characterized by invo untary
contractions o a ected musc es. In cerebra pa sy, spastic
No rmal
R L
FIGURE 10-16 Alzheimer disease (AD). The CT scan on the le t shows a horizontal section o a normal
brain. In the CT scan on the right, however, you can see the dark patches in the cerebral cortex that show dam-
age to brain tissue typical o AD.
CHAPTER 10 Nervous System 265
both egs (paraplegia), both egs and one arm (triplegia), or
a our extremities (quadriplegia).
Degenerative Disease
A variety o degenerative diseases can resu t in destruction o
neurons in the brain. T is degeneration can progress to ad-
verse y a ect memory, attention span, inte ectua capacity,
persona ity, and motor contro . T e genera term or this syn-
drome is dementia.
Dementia is characteristic o Alzheimer disease (AD ). Its
characteristic esions deve op in the cortex during the midd e
to ate adu t years (Figure 10-16). Exact y what makes dementia-
causing esions deve op in the brains o individua s with AD is
not known. T ere is some evidence that this disease has a ge-
netic basisat east in some ami ies. O ther evidence indicates
that environmenta actors may p ay a ro e. T ese various trig-
gers apparent y cause accumu ation o improper y o ded pro-
teins in brain ce s, which in turn causes oss o unction.
Once AD starts, the tang ed proteins are ab e to move to
nearby ce s and trigger protein mis o ding there. T is is simi ar
to the way prions can spread their damaging properties to other
ce s in the brain (see Chapter 6, p. 120). Because a the vari-
ous mechanisms o AD are sti not comp ete y known, deve -
opment o an e ective treatment has proved di cu t.
Current y, peop e diagnosed with AD are o ten treated
with drugs such as donepezi (Aricept) or mi d to moderate
AD or with the drug memantine (Namenda) or moderate to
advanced AD. T ese drugs cause therapeutic shi ts in base ine
neurotransmitter eve s at synapses in the brain. In addition,
treatment inc udes he ping patients maintain their remaining
menta abi ities and ooking a ter their hygiene, nutrition, and
other aspects o persona hea th management.
Alzhe ime r dis e as e
10
 266 CHAPTER 10 Nervous System
A B
FIGURE 10-17 Electroencephalography. A, Photograph o a person with voltage-sensitive electrodes at-
tached to his skull. In ormation rom these electrodes is used to produce a graphic recording o brain activityan
electroencephalogram (EEG). B, An EEG tracing showing activity in our di erent places in the brain (obtained
rom our sets o electrodes). Compare the moderate chaotic activity identi ed as normal with the explosive activ-
ity that occurs during a seizure.
Chronic traumatic encephalopathy (C E) simi ar y in-
vo ves accumu ation o abnorma proteins in the brain and
memory oss. H owever, it is a so characterized by parkinson-
ism (see Figure 10-11 on p. 259), disordered thinking, and other
neuro ogica symptoms. As its name imp ies, C E resu ts
rom repeated trauma to the brain, inc uding BIs, as occurs
in some sports, physica abuse, and those with seizure disor-
ders or head-banging behavior.
Huntington disease (H D ) is an inherited disease charac-
terized by chorea (invo untary, purpose ess movements) that
progresses to severe dementia and death. T e initia symp-
toms o this disease f rst appear between ages 30 and 40, with
death occurring by age 55. Now that the gene responsib e or
H untington disease has been ocated, researchers hope that
an e ective treatment wi be ound (see Chapter 25). T e
discovery o the H D gene poses an interesting question: i
you cou d earn ear y in i e that you wi get H D, wou d you
want to know?
T e human immunodef ciency virus (H IV) that causes
acquired immunode ciency syndrome (AIDS) a so can cause de-
mentia. T e immune def ciency characteristic o AIDS resu ts
rom H IV in ection o white b ood ce s critica to the proper
unction o the immune system (see Chapter 16). H owever,
H IV a so in ects neurons and can cause progressive degenera-
tion and shrinkage o the brain, resu ting in dementia.
10 S e iz u r e D is o r d e r s
Some o the most common nervous system abnorma ities
be ong to the group o conditions ca ed seizure disorders.
T ese disorders are characterized by seizuressudden bursts
o abnorma neuron activity that resu t in temporary changes
in brain unction. Seizures may be very mi d, causing subt e
changes in the eve o consciousness, motor contro , or sen-
sory perception. On the other hand, seizures may be quite
severe, resu ting in jerky, invo untary musc e contractions
ca ed convulsions or even unconsciousness.
Recurring or chronic seizure episodes constitute a condi-
tion ca ed epilepsy. A though some cases o epi epsy can be
Norma l EEG S e izure
1
e
g
a
t
l
o
V
3
4
1 s e cond
traced to specif c causes such as tumors, trauma, or chemica
imba ances, most epi epsy is idiopathic (o unknown cause).
T ose with epi epsy are o ten treated with we -known
anticonvu sive drugs such as phenobarbital, phenytoin (Dilan-
tin), or valproic acid (Depakene) that b ock neurotransmitters
in a ected areas o the brain. By thus b ocking synaptic trans-
mission, such drugs inhibit the exp osive bursts o neuron
activity associated with seizures.
Continuing research has resu ted in the re ease o severa
new epi epsy drugs that have provided improved treatment
options or many patients. Newer drugs inc ude gabapentin
(Neurontin) and amotrigine (Lamicta ). W ith proper medi-
cation, many peop e with epi epsy ead norma ives without
the ear o experiencing uncontro ab e seizures.
Diagnosis and eva uation o epi epsy or any seizure disor-
der o ten re y on a graphic representation o brain activity
ca ed an electroencephalogram (EEG). In Figure 10-17, B, a
norma EEG shows the chaotic rise and a o the e ectrica
activity in di erent parts o the brain as a series o wavy ines
(the so-ca ed brain waves). A seizure mani ests itse as an
exp osive increase in the size and requency o wavesas seen
on the right side o Figure 10-17, B. C assif cations o epi epsy
are based on the ocations in the brain and the duration o
these changes in brain activity.
QUICK CHECK
1. Id e n ti y th e ch a ra cte ris tics o r s ym p to m s o a co n cu s s io n .
2. Wh a t is a CVA? Ho w d o e s it a e ct th e b ra in ?
3. Wh a t d is o rd e rs a re ch a ra cte rize d b y d e m e n tia ?
4. Wh a t is e p ile p s y? Ho w is e p ile p s y d ia g n o s e d a n d
e va lu a te d ?
S p in a l C o r d
S t ru c t u re
I you are o average height, your spina cord is about 42 cm to
45 cm (17 or 18 inches) ong (Figure 10-18). It ies inside the
spina co umn in the spina cavity and extends rom the occipita
 CHAPTER 10 Nervous System 267

Pos te rior me dia n Dors a l roots of

s ulcus of s pina l cord C2, C3, a nd C4 ne rve s
C1
C1
C2
C2
Ce rvica l C3
ve rte bra e C4 C3
C5 C4

l
a
s
C6 Ce rvica l

c
xu
C5 Inte rve rte bra l

vi
C7 ne rve s

e
r
fora me n

l
e
C6

p
C
C7
l
a
s
C8
i
xu
h
c
e
a
l
r
p
B
T1 T1 S
Tra ns ve rs e
T2 T2 L R proce s s e s
T3 T3 of ve rte bra e
I (cut)
T4 T4
T5 T5
Thora cic T6 T6
ve rte bra e T7 Thora cic
T7
ne rve s
T8 T8
T9 T9
T1 0 T1 0
T11 T11
T1 2 Dors a l root
T1 2
Dura ma te r ga nglion
Ca uda e quina
L1 L1
L2 L2
Lumba r
r
s
L3 L3
a
ve rte bra e Lumba r
xu
b
m
ne rve s
e
L4 L4
l
u
p
L
L5 L5

S a crum

S1
S2
l
s
S a cra l
a
S3
xu
r
c
ne rve s
e
a
l
S
S4
p
Coccyx S5 FIGURE 10-18 Spinal cord and spinal nerves.
The diagram shows that spinal nerves are named simi-
larly to vertebrae. Note that the spinal cord ends at
Coccyge a l
ne rve
about the level o vertebra T12 or L1. Inset is a dissec-
tion o the cervical segment o the spinal cord showing
emerging cervical nerves. The spinal cord is viewed
Filum te rmina le rom behind (posterior aspect).

bone down to the bottom o the f rst umbar vertebra. P ace your
hands on your hips, and they wi ine up with your ourth um-
bar vertebra. Your spina cord ends just above this eve .
Look now at Figure 10-19. Notice the H -shaped core o the
spina cord. It consists o gray matter and thus is composed
main y o dendrites and ce bodies o neurons. T is part o the
spina cord contains many synapses and interneurons, which
enab e it to be invo ved in many important re ex arcs.
Co umns o white matter orm the outer portion o the
spina cord, and bund es o mye inated nerve f bersthe
spinal tractsmake up the white co umns.
10
Spina cord tracts provide two-way conduction paths to
and rom the brain. Ascending tracts conduct impu ses up the
spina cord to the brain. Descending tracts conduct impu ses
down the spina cord rom the brain.
racts are unctiona organizations in that a axons com-
posing one tract serve one genera unction. For instance, f -
bers o the spinotha amic tracts serve a sensory unction. T ey
carry impu ses that produce sensations o crude touch, pain,
and temperature. O ther ascending tracts shown in Figure 10-19
inc ude the graci is and cuneatus tracts, which transmit sensa-
tions o touch and pressure up to the brain, and the anterior
 268 CHAPTER 10 Nervous System
Cune a tus
Pos te rior s pinoce re be lla r
La te ra l s pinotha la mic
Ante rior s pinoce re be lla r
S pinote cta l
Ve ntra l s pinotha la mic
As ce nding pa thways
De s ce nding pa thways
FIGURE 10-19 Spinal cord cross section. Cross section o the spinal
cord showing some o the major pathways. The ascending tracts are shown
in blue and the descending tracts are shown in red. You can also see the
gray matter in the center o the spinal cord (brown) and the nerve roots (yel-
low) attached to the spinal cord.
and posterior spinocerebe ar tracts, which transmit in orma-
tion about musc e ength to the cerebe um.
Descending tracts inc ude the atera and ventra cortico-
spina tracts, which carry impu ses contro ing many vo untary
movements.
Fu n c t io n s
o try to understand spina cord unctions, think about a hote
te ephone switching system. Suppose a guest in Room 108
ca s the switching system and keys in the extension number
or Room 520, and in a second or so, someone in that room
answers. Very brie y, three events took p ace: a message trav-
e ed into the switching system, the system routed the message
a ong the proper path, and the message trave ed out rom the
switching system toward Room 520. T e te ephone switching
system provided the network o connections that made pos-
sib e the comp etion o the ca . We might say that the switch-
ing system trans erred the incoming ca to an outgoing ine.
T e spina cord unctions simi ar y. It contains the centers
or thousands and thousands o re ex arcs. Look back at
10 Figure 10-7. T e interneuron shown there is an examp e o a
spina cord re ex center. It switches or trans ers incoming
sensory impu ses to outgoing motor impu ses, thereby making
it possib e or a re ex to occur.
Re exes that resu t rom conduction over arcs whose cen-
ters ie in the spina cord are ca ed spinal cord re exes. wo
common kinds o spina cord re exes are withdrawal and jerk
re exes. An examp e o a withdrawa re ex is pu ing ones
hand away rom a hot sur ace. T e ami iar knee jerk is an
examp e o a jerk re ex.
In addition to unctioning as the primary re ex center o
the body, the spina cord tracts, as previous y noted, carry
Gra cilis Dors a l root
ga nglion
Ce ntra l
ca na l
La te ra l corticos pina l
Rubros pina l
Gray ma tte r
Ante rior corticos pina l
Re ticulos pina l
Ve s tibulos pina l
Ve ntra l root
P
Te ctos pina l R L
Ve ntra l corticos pina l A
impu ses to and rom the brain. Sensory impu ses trave up to
the brain in ascending tracts, and motor impu ses trave down
rom the brain in descending tracts.
I an injury cuts the spina cord a the way across, impu ses
can no onger trave to the brain rom any part o the body
ocated be ow the injury, nor can they trave rom the brain
down to these parts. In short, this kind o spina cord injury
produces a oss o sensation, which is ca ed anesthesia, and a
oss o the abi ity to make vo untary movements, which is
ca ed paralysis.
C o ve r in g s a n d Flu id S p a c e s
M e n in g e s a n d Bo n e
Nervous tissue is not a sturdy tissue. Even moderate pressure
can ki nerve ce s, so nature sa eguards the chie organs made
o this tissuethe spina cord and the brainby surrounding
them with severa protective ayers.
A tough, uid-cushioned set o membranes ca ed the
meninges make up the inner ayers o protection or the CNS.
T e spina meninges orm a tube ike covering around the
spina cord and ine the bony vertebra oramen o the verte-
brae that surround the cord. Look at Figure 10-20, and you can
identi y the three ayers o the spina meninges. T ey are the
dura mater, which is the tough outer ayer that ines the ver-
tebra cana , the pia mater, which is the innermost membrane
covering the spina cord itse , and the arachnoid mater,
which is the membrane between the dura and the pia mater.
T e arachnoid mater resemb es a cobweb with uid in its
spaces. T e word arachnoid means cobweb ike. It comes rom
arachne, the Greek word or spider.
T e meninges that orm the protective covering around the
spina cord a so extend up and around the brain to enc ose it
comp ete y (peek ahead to Figure 10-22).
 Gray ma tte r Ce ntra l
White ma tte r ca na l
Ve ntra l root
Dors a l root
P ia ma te r
Ara chnoid
ma te r
Dura ma te r
FIGURE 10-20 Spinal cord and its coverings. The meninges, spinal
nerves, and sympathetic trunk are all depicted in a posterior view.
In ection or in ammation o the meninges is termed
meningitis. T is condition is most common y caused by bac-
teria such as Neisseria meningitidis (meningococcus), Strepto-
coccus pneumoniae, or Haemophilus in uenzae (see Appendix A
at evolve.elsevier.com). H owever, vira in ections, mycoses ( un-
ga in ections), and tumors a so may cause in ammation o the
meninges.
Patients with meningitis usua y comp ain o severe head-
aches and neck pain. T ose experiencing symptoms shou d
seek immediate attention to get the prob em under contro .
Depending on the primary cause, meningitis may be mi d
and se - imiting or may progress to a severe, perhaps ata ,
condition. I on y the spina meninges are invo ved, the condi-
tion is ca ed spinal meningitis.
CHAPTER 10 Nervous System 269
Dors a l root
ga nglion
T e meninges are inner, so t coverings o the CNS. T ey
are, in turn, surrounded by the hard bone o the sku and
S pina l vertebrae orming a high y protective shie d rom injury.
ne rve
C e r e b ro s p in a l Flu id S p a c e s
F uid f s the subarachnoid spaces between the pia mater and
arachnoid in the brain and spina cord. T is uid is ca ed
S ympa the tic cerebrospinal uid (CSF).
ga nglion CSF a so f s spaces in the brain ca ed cerebra ventricles.
In Figure 10-21, you can see the irregu ar shapes o the ventri-
c es o the brain. T ese i ustrations a so can he p you visua ize
the ocation o the ventric es i you remember that these arge
spaces ie deep inside the brain and that there are two atera
ventric es. One ies inside the right ha o the cerebrum (the
argest part o the human brain), and the other ies inside the
e t ha .
CSF orms continua y rom uid f tering out o the b ood
in a network o brain capi aries known as the choroid plexus
and into the ventric es.
S CSF is one o the bodys circu ating uids. CSF seeps rom
L R the atera ventric es into the third ventric e and ows down
through the cerebra aqueduct (f nd this in Figures 10-21 and
I
10-22) into the ourth ventric e. Most o the CSF moves
through tiny openings rom the ourth ventric e into the sub-
arachnoid space near the cerebe um. Some o it moves into
the sma , tube ike central canal o the spina cord and then out
into the subarachnoid spaces. T en CSF moves eisure y down
and around the spina cord and up and around the brain (in
the subarachnoid spaces o their meninges) and returns to the
b ood (in the veins o the brain).
Remembering that this uid orms continua y rom b ood,
circu ates, and is resorbed into b ood can be use u . It can he p
you understand certain abnorma ities. Suppose a person has a
brain tumor that presses on the cerebra aqueduct. T is b ocks
the way or the return o CSF to the b ood. Because the uid
continues to orm but cannot drain away, it accumu ates in the
ventric es or in the meninges, creating enough pressure to
damage or de orm the nearby so t nervous tissue.
O ther conditions can cause an accumu ation o CSF in the
ventric es. An examp e is hydrocephalus, or water on the

S A

A P L R
Ce re bra l
I Ante rior he mis phe re P
horn of
la te ra l Pos te rior 10
ve ntricle horn
of la te ra l
Inte rve ntricula r ve ntricle
fora me n Ce re bra l
a que duct
Third ve ntricle
Fourth
Infe rior horn of ve ntricle
la te ra l ve ntricle Pons Ce re be llum
A Ce ntra l ca na l of s pina l cord B

FIGURE 10-21 Fluid spaces o the brain. A, The ventricles are highlighted within the brain in a le t lateral
view. B, The ventricles shown rom above.
 270 CHAPTER 10 Nervous System
Ve nous blood
Choroid
plexus of
la te ra l ve ntricle
S uba ra chnoid
s pa ce
S
A P
I
Choroid plexus of fourth ve ntricle
Ce ntra l ca na l of s pina l cord
Dura ma te r
FIGURE 10-22 Flow o cerebrospinal uid (CSF). The fuid produced by
ltration o blood by the choroid plexus o each ventricle fows in eriorly
through the lateral ventricles, interventricular oramen, third ventricle, cere-
bral aqueduct, ourth ventricle, and subarachnoid space and then to the blood.
brain. O ne orm o treatment invo ves surgica p acement o
a ho ow tube or catheter through the b ocked channe so that
CSF can drain into another ocation in the body (Figure 10-23).
The uid spaces o the brain are better under-
stood when one realizes that the CNS develops
rom a uid-f lled tube during embryonic develop-
ment. To see a diagram and brie description o
Embryonic
Development o Tissues at Connect It! at
evolve.elsevier.com.
QUICK CHECK
10 1. Wh a t a re th e m a jo r u n ctio n s o th e s p in a l co rd ?
2. Na m e th e th re e m e n in g e s th a t cove r th e b ra in a n d s p in a l
co rd .
3. Wh a t is CS F? Wh a t is its u n ctio n ?
P e r ip h e r a l N e r vo u s S y s t e m
T e nerves connecting the brain and spina cord to other parts
o the body constitute the periphera nervous system (PNS).
T is system inc udes cranial and spinal nerves that connect the
brain and spina cord, respective y, to periphera structures
such as the skin sur ace and the ske eta musc es.
Ve nous blood
Ce re bra l
cortex
Choroid
plexus of Dura
third ve ntricle ma te r
Ce re bra l a que duct
P ia ma te r Ara chnoid
ma te r
S uba ra chnoid s pa ce
(with ce re bros pina l fluid)
In addition, other structures in the autonomic nervous
system (ANS) are considered part o the PNS. T ese connect
the brain and spina cord to various g ands in the body and to
the cardiac and smooth musc e in the thorax and abdomen.
C r a n ia l N e r ve s
we ve pairs o cranial nerves (CN) emerge rom the under-
sur ace o the brain. Figure 10-24 shows the attachments o
these nerves to the brainstem and diencepha on. T eir f bers
conduct impu ses between the brain and structures in the
head and neck and in the thoracic and abdomina cavities.
For examp e, the second crania nerve (CN II or optic
nerve) conducts impu ses rom the eye to the brain, where
these impu ses produce vision. T e third crania nerve (CN III
or oculomotor nerve) conducts impu ses rom the brain to
musc es in the eye, where they cause contractions that move
the eye. T e tenth crania nerve (CN X or vagus nerve) con-
ducts impu ses between the medu a ob ongata and structures
in the neck and thoracic and abdomina cavities.
T e names o each crania nerve and a brie description o
their unctions are isted in Table 10-2.
To learn more about cranial nerves, go to
AnimationDirect online at evolve.elsevier.com.
S p in a l N e r ve s
S t ru c t u re
T irty-one pairs o spinal nerves emerge rom the spina
cord in the o owing descending order:
 CHAPTER 10 Nervous System 271

Enla rge d
ve ntricle s

Ca the te r tip
in ve ntricle
Blocke d Va lve
a que duct
S hunt

A P

A HYDROCEP HALUS B NORMAL I

Enla rge d Blocke d S

ve ntricle s a que duct S hunt
L R

I
FIGURE 10-23 Hydrocephalus. A, Hydrocephalus is caused by narrowing or blockage o the pathways or
CSF, causing the retention o CSF in the ventricles. B, This condition can be treated by surgical placement o a
shunt or tube to drain the excess f uid. Notice in the cross sections o the brain how the ventricles and surround-
ing tissue return to their normal shapes and size a ter shunt placement.

TABLE 10-2 Cranial Nerves

NERVE* IMPULS ES FUNCTIONS
I Ol actory From nos e to brain Se ns e o s m e ll
II Optic From eye to brain Vis ion
III Oculom otor From brain to eye m us cle s Eye m ove m e nts
IV Trochle ar From brain to exte rnal eye m us cle s Eye m ove m e nts
V Trige m inal From s kin and m ucous m e m brane o he ad and rom te e th Se ns ations o ace , s calp, and te e th; chew ing
to brain; als o rom brain to chew ing m us cle s m ove m e nts
VI Abduce ns From brain to exte rnal eye m us cle s Eye m ove m e nts
VII Facial From tas te buds o tongue to brain; rom brain to ace Se ns e o tas te ; contraction o m us cle s o acial
m us cle s expre s s ion
VIII Ve s tibulocochle ar From e ar to brain He aring; s e ns e o balance 10
IX Glos s opharynge al From throat and tas te buds o tongue to brain; als o rom Se ns ations o throat, tas te , s wallow ing m ove -
brain to throat m us cle s and s alivary glands m e nts , s e cre tion o s aliva
X Vagus From throat, larynx, and organs in thoracic and abdom inal Se ns ations o throat and larynx and o thoracic and
cavitie s to brain; als o rom brain to m us cle s o throat abdom inal organs ; s wallow ing, voice production,
and to organs in thoracic and abdom inal cavitie s s low ing o he artbe at, acce le ration o pe ris tals is
(gut m ove m e nts )
XI Acce s s ory From brain to ce rtain s houlde r and ne ck m us cle s Shoulde r m ove m e nts ; turning m ove m e nts o he ad
XII Hypoglos s al From brain to m us cle s o tongue Tongue m ove m e nts

* The f rs t le tte r o e ach word in the ollow ing s e nte nce corre s ponds to the f rs t le tte r o e ach o the cranial ne rve s , in as ce nding orde r rom I to XII. Many
anatomy s tude nts f nd that us ing this m e m ory aid, or one like it, he lps in m e m orizing the nam e s and num be rs o the cranial ne rve s . It is On Old Olym pus
Tiny Tops , A Frie ndly Viking Grew Vine s And Hops .
 272 CHAPTER 10 Nervous System

Trochle a r ne rve Olfa ctory ne rve

(CN IV) (CN I)

Optic ne rve (CN II)

Oculomotor ne rve
(CN III)
Abduce ns
ne rve (CN VI)
Trige mina l
ne rve (CN V)
Fa cia l ne rve
(CN VII)

Ve s tibulocochle a r
ne rve (CN VIII)
Glos s opha rynge a l
ne rve (CN IX)

Va gus Acce s s ory

ne rve (CN X) ne rve (CN XI)

Hypoglos s a l
ne rve (CN XII)

FIGURE 10-24 Cranial nerves.

View o the undersur ace o the
brain shows attachments o the cra-
nial nerves.

Un ike crania nerves, spina nerves have no specia names.
Instead, a etter and number identi y each one (see Figure 10-18).
C1, or examp e, indicates the pair o spina nerves attached to
the f rst segment o the cervica part o the cord, and 8 indi-
cates nerves attached to the eighth segment o the thoracic part
o the spina cord.
In Figure 10-18 the cervica area o the spine has been dis-
sected to show the emerging spina nerves in that area. A ter
spina nerves exit rom the spina cord, they branch to orm
the many periphera nerves o the trunk and imbs.
Sometimes, nerve f bers rom severa spina nerves are reor-
ganized to orm a sing e periphera nerve. T is reorganization

C LIN ICA L APPLICATION

10 LUMBAR PUNCTURE
The m e ninge s , the uid-containing m e m brane s s urrounding
the brain and s pinal cord, exte nd beyond the s pinal cord, an
anatom ical act that is m os t conve nie nt in re gard to be ing able
to pe r orm lum bar puncture s w ithout putting the s pinal cord at
ris k o injury. A lum bar puncture , or s pinal tap, is the w ith-
drawal o s om e ce re bros pinal uid (CSF) rom the s ubarach-
noid s pace in the lum bar re gion o the s pinal cord.
The phys ician ins e rts a ne e dle jus t above or be low the
ourth lum bar ve rte bra, know ing that the s pinal cord e nds an
inch or m ore above this leve l. The ourth lum bar ve rte bra can
be e as ily locate d be caus e it lie s on a line w ith the iliac cre s t.
Placing an adult patie nt on his s ide and having him arch his
back by draw ing the kne e s and che s t toge the r s e parate s the
ve rte brae s u f cie ntly to introduce the ne e dle .
Lum bar puncture s are o te n pe r orm ed w he n CSF is ne e ded
or analysis or w he n it is ne ces sary to re duce pre s sure caus ed
by swe lling o the brain or spinal cord a te r injury or dise as e . The
normal sam ple o CSF rom a lumbar puncture show n he re is
slightly ye llow ish and clear but the re d color in the abnormal
sam ple indicates ble eding (in this cas e, a he m orrhage in the
subarachnoid s pace ).

can be seen as a network o intersecting or braided branches
ca ed a plexus. Figure 10-18 shows severa p exuses.
Fu n c t io n s
Spina nerves conduct impu ses between the spina cord and
the parts o the body not supp ied by crania nerves. T e spina
nerves shown in Figure 10-18 contain, as do a spina nerves,
sensory and motor f bers. Spina nerves there ore unction to
make possib e a range o sensations and movements. A disease
or injury that prevents conduction by a spina nerve thus re-
su ts in a oss o ee ing and a oss o movement in the part
supp ied by that nerve.
Detai ed mapping o the skins sur ace revea s a c ose re a-
tionship between the source on the spina cord o each spina
nerve and the part o the body that it innervates (Figure 10-25).
Know edge o the segmenta arrangement o spina nerves is
use u to physicians. For instance, a neuro ogist can identi y the
site o a spina cord or nerve abnorma ity by determining which
area o the body is insensitive to a pinprick. Skin sur ace areas
that are supp ied by a sing e spina nerve are ca ed dermatomes.
A dermatome map o the body is shown in Figure 10-25.
QUICK CHECK
1. Wh a t d ivis io n o th e n e rvo u s s ys te m in clu d e s th e cra n ia l
n e rve s a n d s p in a l n e rve s ?
2. Wh ich cra n ia l n e rve co n d u cts im p u ls e s ro m th e b ra in to
m u s cle s in th e e ye ?
3. Wh a t is a s p in a l n e rve p le xu s ?
4. Wh a t is a d e rm a to m e ? Wh a t is th e im p o rta n ce o a d e rm a -
to m e m a p ?
P e r ip h e r a l N e r ve D is o r d e r s
Many a ictions o periphera nerves, or their branches, invo ve
in ammationor neuritis. You may know someone who su -
ers rom a orm o neuritis ca ed sciatica. T is is a pain u
in ammation o the spina nerve branch in the thigh ca ed the
sciatic nervethe argest nerve in the body. T is condition is
characterized by nerve pain, or neuralgia. In some cases, this
condition may ead to atrophy o the eg musc es.
Compression or degeneration o the f th crania nerve, the
trigemina nerve, may resu t in a condition ca ed trigeminal
Third S pina l
lumba r
ve rte bra
cord
S pina l
ne rve
Hollow root
ne e dle (of ca uda
e quina )
S uba ra chnoid s pa ce
S (conta ins CS F)
Ne e dle ins e rtion s ite
P A
I Clinic al applic atio n
lumbar punc ture
CHAPTER 10 Nervous System 273
neuralgia, or tic douloureux. T is condition is characterized
by recurring episodes o stabbing pain radiating rom the an-
g e o the jaw a ong a branch o the trigemina nerve. Neura -
gia o one branch occurs over the orehead and around the
eyes. Pain a ong another branch is e t in the cheek, nose, and
upper ip. Neura gia o the third branch resu ts in stabbing
pains in the tongue and ower ip.
Compression, degeneration, or in ection o CN VII, the a-
cial nerve, may resu t in Bell palsy. Be pa sy is characterized by
para ysis o some or a o the acia eatures innervated by the
acia nerve, inc uding the eye ids and mouth. T is condition is
o ten temporary but in some cases is irreversib e. P astic surgery
is sometimes used to correct permanent disf gurement.
H erpes zoster, or shingles, is a unique vira in ection
that a most a ways a ects the skin o a sing e dermatome
(Figure 10-26). It is caused by a varice a zoster virus (VZV)
o chickenpox. Near y 15% o the popu ation wi su er rom
shing es at east once by the time they reach the age o 80.
In most cases, shing es resu ts rom reactivation o the vari-
ce a virus. T e virus probab y trave s through a cutaneous
nerve and remains dormant in a dorsa root gang ion or years
a ter an episode o the chickenpox. I the bodys immuno ogi-
ca protective mechanism becomes diminished in the e der y,
a ter stress, or in individua s undergoing radiation therapy or
taking immunosuppressive drugs, the virus may reactivate. I
this occurs, the virus trave s over the sensory nerve to the skin
o a sing e dermatome. T e resu t is a pain u eruption o red,
swo en p aques or vesic es that eventua y rupture and crust
be ore c earing in 2 to 3 weeks.
In severe cases o shing es, extensive in ammation, hemor-
rhagic b isters, and secondary bacteria in ection may ead to
permanent scarring. In most cases, the eruption o vesic es is
preceded by 4 to 5 days o pre-eruptive pain, burning, and
itching in the a ected dermatome. A though an attack o
herpes zoster does not con er asting immunity, on y 5% o
cases are recurrences.
Some hea th o cia s are concerned about a possib e shin-
g es epidemic among adu ts caused by widespread use o
chickenpox vaccines in chi dren. Apparent y, adu ts who have
not had occasiona immune-boosting exposures to chi dren
with chickenpox have an increased risk o deve oping shing es.
10
Norma l Abnorma l
CS F CS F
 274 CHAPTER 10 Nervous System

Ante rio r view Po s te rio r view

C2 S pina l cord
V1 s e gme nts C2
Trige mina l C3
C3 V2 cra nia l C1 C4
V3 ne rve (V) C2 C5
C4 C3 C6
C4 C7
T1 C5 C8 T1
C5
T2 C6 T2
T3 T1 T3
C7 T2 T4
T4 C8 T5
T5 T3 T6
T1
T6 T4 T7
C6 T1 T8
T7 C6 T5 C6
T6 T9
T8 T7 T10
T11
T9 T8 T12
T10 C5 T9 L1
C5 T10
T11 L1 L2
T11 L3
T12 L2
T12 L4
S2 L1 L3
S3 L4 S1 S3
L5 C8 CX L5
S2
L2 L2
C8 S3 C7 S4
S4 S1
S2 S5
CX S5
L1
L2
L3
L3
L3

L4 L4

L5 L5

L4
S
S2 S
S1
R L L R S2 S2
L5
I I S1

FIGURE 10-25 Dermatomes. Segmental dermatome distribution o spinal nerves to the ront and
back o the body. C, Cervical segments; T, thoracic segments; L, lumbar segments; S, sacral segments;
CX, coccygeal segment.

A shing es vaccine is recommended or adu ts at risk, inc ud-

ing peop e 60 and o der who have had chickenpox.

QUICK CHECK
1. Wh a t is n e u ra lg ia ?
2. Wh a t a re th e ch a ra cte ris tic s ym p to m s o Be ll p a ls y?
3. Wh a t ca u s e s s h in g le s ?
10
Au t o n o m ic N e r vo u s S y s t e m
O ve r v ie w
S
T e autonomic nervous system (ANS) consists o certain mo-
R L
tor neurons that conduct impu ses rom the spina cord or
I brainstem to the o owing kinds o tissues:

1. Cardiac musc e tissue

FIGURE 10-26 Herpes zoster (shingles). Photograph o a 13-year-old 2. Smooth musc e tissue
boy with eruptions involving dermatome T4 (see Figure 10-25). 3. G andu ar epithe ia tissue
 CHAPTER 10 Nervous System 275

T e ANS inc udes the parts o the nervous system that
regu ate invo untary unctions ( or examp e, the heartbeat,
contractions o the stomach and intestines, and secretions by
g ands). On the other hand, motor nerves that contro the
vo untary actions o ske eta musc es are sometimes ca ed the
somatic nervous system (SNS).
T e autonomic nervous system consists o two main divi-
sions: the sympathetic division and the parasympathetic
division (Figure 10-27).
Fu n c t io n a l A n a t o m y
Autonomic neurons are the motor neurons that make up the
ANS. T e dendrites and ce bodies o some autonomic neu-
rons are ocated in the gray matter o the spina cord or
brainstem. T eir axons extend rom these structures and termi-
nate in periphera junction boxes ca ed ganglia. T ese auto-
nomic neurons are ca ed preganglionic neurons because they
conduct impu ses between the spina cord and a gang ion.
In the autonomic gang ia, the axon endings o pregang i-
onic neurons synapse with the dendrites or ce bodies o
postgang ionic neurons. Postganglionic neurons, as their
name suggests, conduct impu ses rom a gang ion to cardiac
musc e, smooth musc e, or g andu ar epithe ia tissue.
Autonomic ef ectors, or visceral ef ectors, are the tissues
to which autonomic neurons conduct impu ses. Specif ca y, a
viscera e ector is cardiac musc e that makes up the wa o
the heart, smooth musc e that partia y makes up the wa s o
b ood vesse s and other ho ow interna organs, and g andu ar
epithe ia tissue that makes up the secreting part o g ands.

FIGURE 10-27 Innervation o tar-

get organs by the autonomic ner-
vous system. The sympathetic path-
Cons trict
ways are highlighted with orange, and
the parasympathetic pathways are
Dila te highlighted with green.

S e cre te s a liva

S pina l cord PARAS YMPATHETIC

S top s e cre tion

S YMPATHETIC

Cons trict
Dila te bronchiole s bronchiole s

S low down
he a rtbe a t
S pe e d up he a rtbe a t

S ympa the tic

ga nglion
S e cre te e pine phrine Adre na l
cha in Incre a s e
gla nd S toma ch
s e cre tion
De cre a s e s e cre tion

La rge inte s tine

Incre a s e
S ma ll
inte s tine
motility
10
De cre a s e motility

Empty
colon
Re ta in colon conte nts Empty
Bla dde r bla dde r
De lay e mptying
 276 CHAPTER 10 Nervous System
Au t o n o m ic C o n d u c t io n P a t h s
Conduction paths to viscera and somatic e ectors rom the
CNS (spina cord or brainstem) di er somewhat. Autonomic
paths to viscera e ectors, as the right side o Figure 10-28, A
shows, consist o two-neuron re ays. Impu ses trave over pre-
gang ionic neurons rom the spina cord or brainstem to auto-
nomic gang ia. T ere, they are re ayed across synapses to
postgang ionic neurons, which then conduct the impu ses
rom the gang ia to viscera e ectors.
Compare the autonomic conduction path with the somatic
conduction path i ustrated on the e t side o Figure 10-28, A.
A sing e somatic motor neuron, ike the one shown here, con-
ducts impu ses a the way rom the spina cord or brainstem
to somatic e ectors, with no intervening synapses.
To learn more about the di erence between auto-
nomic and somatic conduction paths, go to
AnimationDirect online at evolve.elsevier.com.
S y m p a t h e t ic D iv is io n
S t ru c t u re
Sympathetic preganglionic neurons have dendrites and ce
bodies in the gray matter o the thoracic and upper umbar
segments o the spina cord. For this reason, the sympathetic
division a so has been re erred to as the thoracolumbar system.
Ce ll body of s oma tic S pina l cord
motor ne uron
Axon
of s oma tic
motor ne uron
Axon of pre ga nglionic
s ympa the tic ne uron
Pos tga nglionic
ne uron's a xon
To s o matic e ffe c to r
(s ke le tal mus cle )
To vis c e ral e ffe c to rs Colla te ra l
10 (s mo o th mus cle ,
c ardiac mus cle , g lands )
ga nglion
A B
FIGURE 10-28 Autonomic conduction paths. A, One somatic motor neuron conducts impulses all the
way rom the spinal cord to a somatic e ector. Conduction rom the spinal cord to any visceral e ector, how-
ever, requires a relay o at least two autonomic motor neuronsa preganglionic and a postganglionic neuron.
B, Location o the sympathetic chain ganglia.
Look now at the right side o Figure 10-28, A. Fo ow the
course o the axon o the sympathetic pregang ionic neuron
shown there. It eaves the spina cord in the anterior (ventra )
root o a spina nerve. It next enters the spina nerve but soon
eaves it to extend to and through a sympathetic gang ion and
terminate in a co atera gang ion. T ere, it synapses with sev-
era postgang ionic neurons whose axons extend to terminate
in viscera e ectors.
A so shown in Figure 10-28, A, branches o the pregang i-
onic axon may ascend or descend to terminate in gang ia
above and be ow their point o origin. A sympathetic pre-
gang ionic axons there ore synapse with many postgang ionic
neurons, and these requent y terminate in wide y separated
organs. H ence sympathetic responses are usua y widespread,
invo ving many organs rather than just one.
Sympathetic postganglionic neurons have dendrites and
ce bodies in sympathetic gang ia. Sympathetic gang ia are
ocated anterior to and at each side o the spina co umn. Be-
cause short f bers extend between the sympathetic gang ia,
they ook a itt e ike two chains o beads and are o ten re-
erred to as the sympathetic chain ganglia (Figure 10-28, B).
Axons o sympathetic postgang ionic neurons trave in
spina nerves to b ood vesse s, sweat g ands, and arrector hair
musc es a over the body. Separate autonomic nerves distrib-
ute many sympathetic postgang ionic axons to various inter-
na organs.
Ce ll body of
pre ga nglionic ne uron
Middle ce rvica l
ga nglion
Ce rvicothora cic
ga nglion
Thora cic ca rdia c
bra nche s
Pos tga nglionic
ne urons a xon
Thora cic ga nglia
Gre a te r
s pla nchnic ne rve
S ympa the tic
ga nglion
De s ce nding a orta
Colla te ra l ga nglia
S
Re na l a rte ry
R L
 CHAPTER 10 Nervous System 277

Fu n c t io n ocated in the head and in the thoracic and abdomina cavities

T e sympathetic division unctions as an emergency system.
Impu ses over sympathetic f bers take contro o many inter-
na organs when we exercise strenuous y and when strong
emotionsanger, ear, hate, anxietyare e icited. In short,
when we must cope with stress o any kind, sympathetic im-
pu ses increase to many viscera e ectors and rapid y produce
widespread changes within our bodies.
T e midd e co umn o Table 10-3 ists many o the possib e
sympathetic responses. T e heart beats aster. Most b ood
vesse s constrict, causing b ood pressure to increase. B ood
vesse s in ske eta musc es di ate, supp ying the musc es with
more b ood. Sweat g ands and adrena g ands secrete more
abundant y. Sa ivary and other digestive g ands secrete more
sparing y. Digestive tract contractions (perista sis) become
s uggish, hampering digestion.
ogether, a these varied sympathetic responses make us
ready or strenuous muscu ar work. We need such physio ogi-
ca preparation when acing a threatwe must be ready to
either resist (f ght) the threat or to avoid ( y rom) the threat.
T ere ore, this group o changes induced by sympathetic con-
tro is known as the ght-or- ight response.
P a r a s y m p a t h e t ic D iv is io n
S t ru c t u re
T e dendrites and ce bodies o parasympathetic
preganglionic neurons are ocated in the gray matter o the
brainstem and the sacra segments o the spina cord. For
this reason, the parasympathetic division a so has been re-
erred to as the craniosacral system.
T e parasympathetic pregang ionic axons extend some
distance be ore terminating in the parasympathetic gang ia
c ose to the viscera e ectors that they contro .
T e dendrites and ce bodies o parasympathetic post-
ganglionic neurons ie in these out ying parasympathetic gan-
g ia, and their short axons extend into the nearby structures.
T ere ore, each parasympathetic pregang ionic neuron synapses
on y with postgang ionic neurons to a sing e e ector.
For this reason, parasympathetic stimu ation requent y
invo ves response by on y one organ. T is is in stark contrast
to sympathetic responses, which invo ve numerous organs.
Fu n c t io n
T e parasympathetic system dominates contro o many viscera
e ectors under norma , everyday conditions. Impu ses carried by
parasympathetic f bers, or examp e, tend to s ow heartbeat, in-
crease perista sis, and increase secretion o digestive juices and
insu in (see Table 10-3). T us, we can think o parasympathetic
unction as counterba ancing sympathetic unction.
Recent evidence suggests that the sacral portion
o the autonomic pathways may be sympathetic
not parasympathetic as f rst described over a
century ago. Find out more at New Model o ANS
Pathways at Connect It! at evolve.elsevier.com.
Au t o n o m ic N e u ro t r a n s m it t e r s
urn your attention now to Figure 10-29. It i ustrates in orma-
tion regarding autonomic neurotransmitters, the chemica
compounds re eased rom the axon termina s o autonomic
neurons.
O bserve that three o the axons shown in Figure 10-29
the sympathetic pregang ionic axon, the parasympathetic

TABLE 10-3 Autonomic Functions

VIS CERAL EFFECTORS SYMPATHETIC CONTROL PARASYMPATHETIC CONTROL
He art m us cle Acce le rate s he artbe at Slow s he artbe at
Sm ooth m us cle
O m os t blood ve s s e ls Cons tricts blood ve s s e ls None
O blood ve s s e ls in s ke le tal m us cle s Dilate s blood ve s s e ls None
O the dige s tive tract De cre as e s pe ris tals is ; inhibits de e cation Incre as e s pe ris tals is
O the anal s phincte r Stim ulate s clos e s s phincte r Inhibits ope ns s phincte r or de e cation
O the urinary bladde r Inhibits re laxe s bladde r Stim ulate s contracts bladde r
O the urinary s phincte rs Stim ulate s clos e s s phincte r Inhibits ope ns s phincte r or urination
10
O the eye
Iris Stim ulate s radial f be rs dilation o pupil Stim ulate s circular f be rs cons triction o pupil
Ciliary Inhibits accom m odation or ar vis ion ( atte n- Stim ulate s accom m odation or ne ar vis ion
ing o le ns ) (bulging o le ns )
O hairs (pilom otor m us cle s ) Stim ulate s goos e pim ple s No paras ym pathe tic f be rs
Glands
Adre nal m e dulla Incre as e s e pine phrine s e cre tion None
Swe at glands Incre as e s s we at s e cre tion None
Dige s tive glands De cre as e s s e cre tion o dige s tive juice s Incre as e s s e cre tion o dige s tive juice s
 278 CHAPTER 10 Nervous System
pregang ionic axon, and the parasympathetic postgang ionic
axonre ease acety cho ine. T ese axons are there ore c as-
sif ed as cholinergic bers.
On y one type o autonomic axon re eases the neurotrans-
mitter norepinephrine (noradrena ine). T is is the axon o a
sympathetic postgang ionic neuron, and such neurons are
c assif ed as adrenergic bers.
T at each division o the ANS signa s its e ectors with a
di erent neurotransmitter exp ains how an organ can te
which division is stimu ating it. T e heart, or examp e, re-
sponds to acety cho ine rom the parasympathetic division by
s owing down. T e presence o norepinephrine in the heart,
on the other hand, is a signa rom the sympathetic division,
and the response is an increase in heart activity.
Au t o n o m ic N e r vo u s S y s t e m
a s a Wh o le
T e unction o the autonomic nervous system is to regu ate
the bodys automatic, invo untary unctions in ways that
maintain or quick y restore homeostasis.
Many interna organs are dually innervated by the ANS. In
other words, they receive f bers rom parasympathetic and
sympathetic divisions. Parasympathetic and sympathetic im-
pu ses continua y bombard them and, as Table 10-3 indicates,
in uence their unction in opposite or antagonistic ways.
For examp e, the heart continua y receives sympathetic
impu ses that make it beat aster and parasympathetic im-
pu ses that s ow it down. T e ratio between these two
S ympa the tic
ga nglion
S ympathe tic
P re ga nglionic
ACh
Ce ntra l
ne rvous
s ys te m
Paras ympathe tic
10
P re ga nglionic
FIGURE 10-29 Autonomic neurotransmitters. Three o the our ber types are cholinergic, secreting the
neurotransmitter acetylcholine (ACh) into a synapse. Only the sympathetic postganglionic ber is adrenergic,
secreting norepinephrine (NE) into a synapse.
antagonistic orces, determined by the ratio between the two
di erent autonomic neurotransmitters, determines the actua
heart rate.
T e term autonomic nervous system is something o a
misnomer. Autonomy seems to imp y that this part o the
nervous system is independent rom other parts. But this is
not true. D endrites and ce bodies o pregang ionic neu-
rons are ocated, as observed in Figure 10-29, in the spina
cord and brainstem. T ey are continua y in uenced direct y
or indirect y by impu ses rom neurons ocated above them,
notab y by some in the hypotha amus and in the parts o
the cerebra cortex ca ed the limbic system, or emotional
brain. T rough conduction paths rom these areas, emo-
tions can produce widespread changes in the automatic
unctions o our bodies, in cardiac and smooth musc e con-
tractions, and in secretion by g ands. Anger and ear, or
examp e, ead to increased sympathetic activity and the
f ght-or- ight response.
According to some physio ogists, the s ight y a tered state
o consciousness known as meditation eads to decreased sym-
pathetic activity and a group o changes opposite those o the
f ght-or- ight response.
D is o r d e r s o t h e Au t o n o m ic
N e r vo u s S y s t e m
S t r e s s -In d u c e d D is e a s e
Considering the variety and number o e ectors innervated
by the autonomic nervous system, it is no wonder that
Cholinergic fibers
Adrenergic fiber
Effe ctor
Pos tga nglionic
NE
Pa ra s ympa the tic
ga nglion
Effe ctor
Pos tga nglionic
ACh
ACh

autonomic disorders have varied and ar-reaching conse-
quences. T is is especia y true o stress-induced diseases.
Pro onged or excessive physio ogica response to stress, the
f ght-or- ight response, can disrupt norma unctioning
throughout the body.
Stress has been cited as an indirect cause or an important
risk actor in a number o conditions. On y a ew o those are
isted here.
1. Heart diseaseA though an extreme episode o
stress can precipitate heart ai ure even in hea thy
peop e, chronic stress is known to increase the risk o
certain heart disorders. One such condition is stress-
induced high b ood pressure, or hypertension, that
can weaken the heart and b ood vesse s.
2. D igestive problemsColitis (co on in ammation)
and gastric u cers, or examp e, may be precipitated
by the changes in digestive secretion and movement,
a ong with increased susceptibi ity to in ection, that
occur during pro onged or repeated stress responses.
3. Reduced resistance to diseaseH ormones ca ed
glucocorticoids that are re eased by the adrena g ands
during pro onged or repeated stress episodes depress
the activity o the immune system. Depressed im-
mune unction eads to increased risk o in ection
and cancer.
S C IEN C E APPLICATIONS
NEUROS CIENCE
The Aus trian s cie ntis t Otto Loew i
s tarte d his s tudie s in the hum ani-
tie s , not s cie nce . Eve n a te r he did
f nally be gin unive rs ity s tudie s in
m e dicine , he o te n s kippe d his s ci-
e nce clas s e s to atte nd le cture s in
philos ophy ins te ad. But a te r Dr.
Loew i turne d his atte ntion to hu-
m an biology, his brilliance be cam e
evide nt. In 1921, w hile working to
Otto Loewi (18731961) de s ign an expe rim e nt that would
unlock the mys te ry o how ne urons
com m unicate w ith othe r ce lls , he had a dre am in w hich the
ans we r was reve ale d to him . He rus he d to his lab and pe r-
orm e d a now am ous expe rim e nt in w hich he dis cove re d
w hat we know as ace tylcholine .
For his work that s howe d that it is ne urotrans m itte rs that
carry s ignals rom ne urons , Loew i s hare d a Nobe l Prize in
CHAPTER 10 Nervous System 279
4. Spread o cancerT e chronica y e evated eve s o
norepinephrine caused by stress can speed up the ow
o cancer ce s out o tissues by way o the ymphatic
system, possib y resu ting in metastasis (see Figure 6-11
on p. 130).
Because both the nervous system and endocrine system are
invo ved in stress disorders, they are usua y thought o as
neuroendocrine disorders.
N e u ro b la s t o m a
Neuroblastoma is a ma ignant tumor o the sympathetic divi-
sion. It most o ten occurs in the deve oping nervous systems
o young chi dren and metastasizes rapid y to other parts o
the body. Symptoms o ten inc ude exaggerated or inappropri-
ate sympathetic e ects, inc uding increased heart rate, sweat-
ing, and high b ood pressure. As with some other orms o
cancer, spontaneous remissions may occur.
QUICK CHECK
1. Wh a t a re th e tw o m a in d ivis io n s o th e ANS ?
2. De s crib e th e u n ctio n o th e p a ra s ym p a th e tic n e rvo u s
d ivis io n .
3. Wh ich tw o n e u ro tra n s m itte rs a re u s e d b y th e a u to n o m ic
n e rve p a th wa ys ?
4. Wh a t p ro b le m s in th e b o d y a ris e ro m ANS m a l u n ctio n s ?
1936. Not s urpris ingly, Loew i late r s pe nt s om e o his tim e
s tudying how dre am s m ay he lp us unde rs tand s ubcons cious
thoughts .
Many pro e s s ions de pe nd on ne uro s cie ntis ts like Otto
Loew i to provide in orm ation they ne e d to he lp us im prove
our live s . For e xam ple , ne uro lo g is ts , ps ychiatris ts , and
othe r m e dical pro e s s ionals us e this in orm ation to tre at dis -
orde rs o the ne rvous s ys te m . Pharm aco lo g is ts us e the s e
ide as to de ve lop drug tre atm e nts that a e ct the ne rvous
s ys te m and pharm acis ts and pharm acy te chnicians s up-
ply the s e tre atm e nts .
Me ntal he alth pro e s s ionals s uch as ps ycho lo g is ts and
couns e lors us e conce pts de rive d rom ne uros cie nce to be tte r
unde rs tand hum an e m otions and be havior. Eve n pe ople w ho
s pe cialize in bus ine s s and m arke ting us e s om e o the ne uro- 10
s cie nce dis cove rie s the ir ocus is le arning how to e ntice
buye rs to buy ce rtain products or, pe rhaps , to pre dict the be -
havior o crowds .
 280 CHAPTER 10 Nervous System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 249)

autonomic neuron cranial nerve (CN) gray matter

(gray MAT-ter)
[auto- sel , -nom- rule, -ic relating to, [crani- skull, -al relating to, nerv- string or gyri
neuron nerve] nerve]
axon dendrite sing., gyrus
(AK-son) (DEN-dryte)
[axon axle] [dendr- tree, -ite part (branch)] [gyrus circle]
basal nuclei (basal ganglia) dermatome hypothalamus
(DER-mah-tohm) (hye-poh-THAL-ah-mus)
sing., basal nucleus or ganglion [derma- skin, -tome cut (segment)] [hypo- under or below, -thalamus inner
diencephalon chamber]
[bas- oundation, -al relating to, nucle- nut or (dye-en-SEF-ah-lon) interneuron
kernel (ganglion knot)] [di- between, -en- within, -cephalon head] (in-ter-NOO-ron)
blood-brain barrier (BBB) dopamine [inter- between, -neuron nerve]
(DOH-pah-meen) limbic system
catecholamine [dopa- amino acid, -amine ammonia]
dura mater [limb- edge, -ic relating to]
[catech- melt, -ol- alcohol, -amine ammonia (DOO-rah MAH-ter) medulla oblongata
compound] [dura hard, mater mother] (meh-DUL-ah ob-long-GAH-tah)
cell body e ector [medulla marrow or pith, oblongata oblong]
(sell BOD-ee) (e -FEK-tor) meninges
[cell storeroom] [e ect- accomplish, -or agent]
central nervous system (CNS) e erent neuron sing., meninx
(SEN-tral NER-vus SIS-tem [see en es]) (EF- er-ent NOO-ron) (meh-NINKS)
[centr- center, -al relating to, nerv- nerve, [e- away, - er- carry, -ent relating to, [meninx membrane]
-ous relating to] neur- string or nerve, -on unit] microglia
cerebellum endoneurium (my-KROG-lee-ah)
(sayr-eh-BEL-um) (en-doh-NOO-ree-um) sing., microglial cell
pl., cerebella or cerebellums [endo- inward, -neuri- nerve, -um thing] (my-KROG-lee-al sel)
(sayr-eh-BEL-ah or sayr-eh-BEL-umz) endorphin [micro- small, -glia glue]
[cereb- brain, -ell- small, -um thing] (en-DOR-f n) midbrain
cerebral cortex [endo- within, -(m)orph- Morpheus (Roman god (MID-brayn)
o dreams), -in substance] [mid- middle, -brain skull]
[cerebr- brain (cerebrum), -al relating to, motor neuron
enkephalin
cortex bark] (en-KEF-ah-lin) (MOH-ter NOO-ron)
cerebrospinal uid (CSF) [en- within, -kephalo- head, -in substance] [mot- movement, -or agent, neuron nerve]
epineurium myelin
[cerebr- brain, -spin- backbone, -al relating to] (ep-ih-NOO-ree-um)
cerebrum [epi- upon, -neuri- nerve, -um thing] [myel- marrow, -in substance]
ascicle myelinated f ber
[cerebrum brain]
cholinergic f ber [ asci- band or bundle, -cle small] [myel- marrow, -in- substance, -ate act o ,
f br- thread]
f ght-or- ight response
[chole- bile, -erg- work, -ic relating to, nerve
10 f br- thread]
( yte or yte ree-SPAHNS)
ganglion (nerv)
choroid plexus (GANG-lee-on) [nerv- string or nerve]
(KOH-royd PLEK-sus) pl., ganglia neurilemma
pl., choroid plexuses (GANG-lee-ah) (noo-rih-LEM-mah)
(KOH-royd PLEK-sus-ez) [gangli- knot, -on unit] [neuri- neuron, -lemma sheath]
[chorio- skin, -oid like, plexus braid or network]
glia neuroglia
corpus callosum (GLEE-ah) (noo-ROH-glee-ah or noo-roh-GLEE-ah)
sing., glial cell sing., neuroglial cell
pl., corpora callosa (GLEE-al sel) (noo-ROH-glee-al sel)
[glia glue] [neur- nerve, -glia glue]
[corpus body, callosum callous or tough]
 CHAPTER 10 Nervous System 281

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 280)

neuron plexus spinal nerve

(NOO-ron) (PLEK-sus)
[neur- string or nerve, -on unit] [plexus braid or network] [spin- backbone, -al relating to, nerv- string or
neurotransmitter pl., plexuses nerve]
(noo-roh-trans-MIT-ter) (PLEK-sus-ez) spinal tract
[neuro- nerve, -trans- across, -mitt- send, pons
-er agent] (ponz) [spin- backbone, -al relating to, trac- course or
nitric oxide (NO) [pons bridge] trail]
postganglionic neuron sulci
[nitr- nitrogen, -ic relating to, ox- oxygen,
-ide chemical] [post- a ter, -ganglion- knot, -ic relating to, sing., sulcus
node o Ranvier neuron nerve] [sulcus urrow]
postsynaptic neuron sympathetic division
[nod- knot, Louis A. Ranvier French pathologist]
norepinephrine (NE) [post- a ter, -syn- together, -apt- join, [sym- together, -pathe- eel, -ic relating to]
(nor-ep-ih-NEF-rin [en ee]) -ic relating to, neuron nerve] sympathetic postganglionic neuron
[nor- chemical pref x (unbranched C chain), preganglionic neuron
-epi- upon, -nephr- kidney, -ine substance] NOO-ron)
oligodendrocyte [pre- be ore, -ganglion- knot, -ic relating to, [sym- together, -pathe- eel, -ic relating to,
(ohl-ih-goh-DEN-droh-syte) neuron nerve] post- a ter, -ganglion- knot, -ic relating to,
[oligo- ew, -dendr- part (branch) o , -cyte cell] presynaptic neuron neur- string or nerve, -on unit]
parasympathetic division sympathetic preganglionic neuron
[pre- be ore, -syn- together, -apt- join,
[para- beside, -sym- together, -pathe- eel, -ic relating to, neuron nerve] NOO-ron)
-ic relating to] receptor [sym- together, -pathe- eel, -ic relating to,
(ree-SEP-tor) pre- be ore, -ganglion- knot, -ic relating to,
parasympathetic postganglionic neuron
[recept- receive, -or agent] neur- string or nerve, -on unit]
re ex synapse
[para- beside, -sym- together, -pathe- eel, (SIN-aps)
-ic relating to, post- a ter, -ganglion- knot, [re- again, - ex bend] [syn- together, -aps- join]
-ic relating to, neur- string or nerve, -on unit] re ex arc synaptic cle t
parasympathetic preganglionic neuron
[re- back or again, - ex bend, arc curve] [syn- together, -apt- join, -ic relating to]
reticular ormation synaptic knob
[para- beside, -sym- together, -pathe- eel,
-ic relating to, pre- be ore, -ganglion- knot, [ret- net, -ic- relating to, -ul- little, [syn- together, -apt- join, -ic relating to]
-ic relating to, neur- string or nerve, -on unit] -ar characterized by, orm- shape, thalamus
perineurium -ation state] (THAL-ah-mus)
(payr-ih-NOO-ree-um) saltatory conduction [thalamus inner chamber]
[peri- around, -neur- nerve, -um thing] tract
peripheral nervous system (PNS) [salta- leap, -ory relating to, con- with,
(peh-RIF-er-al NER-vus SIS-tem -duct- lead, -ion process] [trac- course or trail]
[pee en es]) Schwann cell ventricle
[peri- around, -phera- boundary, -al relating to, (shwon or shvon sell)
nerv- nerve, -ous relating to,
system organized whole]
[Theodor Schwann German anatomist, [ventr- belly, -icle little] 10
cell storeroom] visceral e ector
pia mater sensory neuron
(PEE-ah MAH-ter) (SEN-sor-ee NOO-ron) [viscer- internal organ, -al relating to,
[pia tender, mater mother] [sens- eel, -ory relating to, neur- string or e ect- accomplish, -or agent]
pineal gland nerve, -on unit] white matter
(PIN-ee-al gland) serotonin withdrawal re ex
[pine- pine, -al relating to, gland acorn] (sayr-oh-TOH-nin)
[sero- watery body uid, -ton- tension, [with- away, -draw- draw, -al relating to,
-in substance] re- again, - ex bend]
 282 CHAPTER 10 Nervous System

LANGUAGE OF M ED IC IN E

Alzheimer disease (AD) herpes zoster Parkinson disease (PD)

[Alois Alzheimer German neurologist, [herpe- creep, zoster belt or girdle] [J ames Parkinson English physician,
dis- opposite o , -ease com ort] Huntington disease (HD) dis- opposite o , -ease com ort]
anesthesia pharmacist
(an-es-THEE-zhah) [George S. Huntington American physician, (FAR-mah-sist)
[an- absence, -esthesia eeling] dis- opposite o , -ease com ort] [pharmac- drug, -ist agent]
antidepressant hydrocephalus pharmacologist
(an-tee-deh-PRESS-ant) (hye-droh-SEF-ah-lus)
[anti- against, -de- down, -press- press, [hydro- water, -cephalus head] [pharmaco- drug, -log- words (study o ),
-ant agent] lumbar puncture -ist agent]
Bell palsy (LUM-bar PUNK-chur) pharmacy technician
(bell PAWL-zee) [lumb- loin, -ar relating to]
[Charles Bell Scots anatomist, palsy paralysis] meningitis [pharmac- drug, -y location o activity,
cerebral palsy (CP) techn- art or skill, -ic relating to,
(seh-REE-bral PAWL-zee [see pee]) [mening- membrane, -itis in ammation] -ian practitioner]
[cerebr- brain, -al relating to, palsy paralysis] multiple neurof bromatosis psychiatrist
cerebrovascular accident (CVA) (MUL-tih-pul noo-roh- ye-broh-
mah-TOH-sis) [psych- mind, -iatr- treatment, -ist agent]
AK-sih-dent [see vee ay]) [multi- many, -pl- old, neuro- nerve, -f br- f ber, psychologist
[cerebr- brain, -vas- vessel, -cul- little, -oma- tumor, -osis condition]
-ar relating to] multiple sclerosis (MS) [psych- mind, -log- words (study o ), -ist agent]
chronic traumatic encephalopathy (CTE) quadriplegia
[multi- many, -pl- old, scler- hard,
en-se -al-OP-path-ee [see tee ee]) -osis condition] [quadri- our old, -pleg- stricken, -ia condition]
[chron- time, -ic relating to, trauma- wound, neuralgia sciatica
-atic relating to, encephal- brain,
-pathy disease] [neur- nerve, -algia pain] [sciatica pain in the hip]
concussion neuritis seizure
(SEE-zhur)
[concuss- shake violently, -ion condition] [neur- nerve, -itis in ammation] shingles
dementia neuroblastoma (SHING-guls)
(de-MEN-shah) (noo-roh-blas-TOH-mah) [ rom cingulum belt or girdle]
[de- o , -ment- mind, -ia condition o ] [neuro- nerve, -blast germ, -oma tumor] spastic paralysis
electroencephalogram (EEG) neurologist
[spast- pull, -ic relating to, para- beyond,
[neuro- nerve, -log- words (study o ), -ist agent] -lysis loosening]
[electro- electricity, -en- within, -cephal- head, neuroma tic douloureux
-gram drawing] (noo-ROH-mah)
epilepsy [neur- nerve, -oma tumor] [tic spasm, douloureux pain ul spasm]
(EP-ih-lep-see) neuroscientist trigeminal neuralgia
[epi- upon, -leps- seizure, -y state]
glioma [neuro- nerve, -scien- knowledge, -ist agent] [tri- three, -gemina- twins or pair, -al relating to,
(glee-OH-mah) neur- nerve, -algia pain]
10 [gli- neuroglia, -oma tumor]
paralysis
(pah-RAL-ih-sis) triplegia
hemiplegia [para- beyond, -lysis loosening]
paraplegia [tri- three, -pleg- stricken, -ia condition]
[hemi- hal , -pleg- stricken, -ia condition]
[para- beside, -pleg- stricken, -ia condition]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Intro ductio n
A. Both the nervous system and the endocrine system
contro various unctions o the body by transmitting
in ormation
B. H omeostasis is possib e on y i contro and integration
systems unction proper y
Organizatio n o the Ne rvo us Sys te m
(Figure 10-1)
A. Centra nervous system (CNS)brain and spina cord
B. Periphera nervous system (PNS)a nerves
C. Autonomic nervous system (ANS)
Ce lls o the Ne rvo us Sys te m
A. Neurons
1. Neuron structure
a. Consist o three main partsdendrites, ce body
o neuron, and axon (Figure 10-2)
b. Dendritesbranching projections that conduct
impu ses to ce body o neuron
c. Axone ongated projection that conducts impu ses
away rom ce body o neuron
(1) Mye inwhite, atty substance ormed by g ia,
surrounding some axons as a sheath
(2) Nodes o Ranviergaps in the mye in sheath
(3) Neuri emmaouter ayer o mye in sheath
needed or repair o damaged axons
2. Neuron types are c assif ed according to unction
a. Sensory neurons: conduct impu ses to the spina
cord and brain; a so ca ed af erent neurons
b. Motor neurons: conduct impu ses away rom brain
and spina cord to musc es and g ands; a so ca ed
ef erent neurons
c. Interneurons: conduct impu ses rom sensory
neurons to motor neurons or among a network o
interneurons; a so ca ed central or connecting
neurons
CHAPTER 10 Nervous System 283
B. G ia (neurog ia)
1. Functionsupport ce s, bringing the ce s o nervous
tissue together structura y and unctiona y
2. Centra g iathree main types o g ia ce s o the
CNS (Figure 10-3)
a. Astrocytesstar-shaped ce s that anchor sma
b ood vesse s to neurons
b. Microg iasma ce s that move in in amed brain
tissue carrying on phagocytosis
c. O igodendrocytes orm mye in sheaths on axons
in the CNS (Schwann ce s orm mye in sheaths in
PNS on y)
3. Periphera g iaSchwann ce s orm mye in sheaths
on axons o the PNS (Figure 10-2)
C. Disorders o nervous tissue
1. Mu tip e sc erosischaracterized by mye in oss in
centra nerve f bers and resu ting conduction impair-
ments (Figure 10-4)
2. umors
a. Genera name or nervous system tumors is neuroma
b. Most neuromas are g iomas (g ia tumors)
c. Mu tip e neurof bromatosischaracterized by
numerous benign tumors (Figure 10-5)
Ne rve s and Tracts
A. Nervebund e o periphera axons (Figure 10-6)
1. Nerve coveringsf brous connective tissue
a. Endoneuriumsurrounds individua f bers within
a nerve
b. Perineuriumsurrounds a group ( ascic e) o nerve
f bers
c. Epineuriumsurrounds the entire nerve
B. ractbund e o centra axons
1. W hite mattertissue composed primari y o mye in-
ated axons (tracts)
2. Gray mattercomposed primari y o ce bodies and
unmye inated f bers
Ne rve S ig nals
A. Re ex Arcs 10
1. Nerve impu ses are conducted rom receptors to e ec-
tors over neuron pathways or re ex arcs; conduction
by a re ex arc resu ts in a re ex (that is, contraction by
a musc e or secretion by a g and)
2. T e simp est re ex arcs are two-neuron arcs
consisting o sensory neurons synapsing in the spina
cord with motor neurons
3. T ree-neuron arcs consist o sensory neurons synaps-
ing in the spina cord with interneurons that synapse
with motor neurons (Figure 10-7)
 284 CHAPTER 10 Nervous System
B. Nerve Impu ses
1. Def nitionse -propagating wave o e ectrica distur-
bance that trave s a ong the sur ace o a neuron mem-
brane (o ten ca ed action potentials)
2. Mechanism (Figure 10-8)
a. At rest, the neurons membrane is s ight y positive
on the outsidepo arized rom a s ight excess o
Na on the outside
b. A stimu us triggers the opening o Na channe s in
the p asma membrane o the neuron
c. Inward movement o Na depo arizes the mem-
brane by making the inside more positive than the
outside at the stimu ated point; this depo arization
is a nerve impu se (action potentia )
3. Conduction o nerve impu ses (Figure 10-9)
a. Continuous conductionthe stimu ated section o
membrane immediate y repo arizes, but by that
time the depo arization has a ready triggered the
next section o membrane to depo arize, thus prop-
agating a wave o e ectrica disturbances (depo ar-
izations) a the way down the membrane
b. Sa tatory conductionin mye inated f bers, con-
duction can jump rom gap to gap and thus
great y speed up the rate o conduction
C. T e Synapse
1. Def nitionthe p ace where impu ses are transmitted
rom one neuron to another (the postsynaptic neuron)
(Figure 10-10)
2. Synapse made o three structuressynaptic knob,
synaptic c e t, and p asma membrane
3. Neurotransmitters bind to specif c receptor mo ecu es
in the membrane o a postsynaptic neuron, opening
ion channe s and thereby stimu ating impu se conduc-
tion by the membrane
4. ransmission stops when neurotransmitters are
removed rom receptors
a. Reuptake o neurotransmitters into presynaptic
neurons, with repackaging and recyc ing or ater
use
b. Breakdown o neurotransmitters in extrace u ar
matrix (ECM) o synaptic c e t
c. G ia may break down neurotransmitters and return
pieces to the presynaptic neuron or recyc ing
5. Examp es o neurotransmittersacety cho ine, cate-
cho amines (norepinephrine, dopamine, and sero-
tonin), endorphins, enkepha ins, nitric oxide (NO),
10 and other compounds
6. Receptorsspecif c to a particu ar neurotransmitter;
possib e to have severa versions o receptors or a
sing e neurotransmitter, each ound in a di erent body
ocation
7. Parkinson disease (PD)characterized by abnorma y
ow eve s o dopamine in motor contro areas o the
brain; patients usua y exhibit invo untary tremb ing
and musc e rigidity (parkinsonism; Figure 10-11)
Ce ntral Ne rvo us Sys te m
A. CNS is made up o the brain and spina cord; centra
axis ocation; protected by hard bones and so t meninges
(Figure 10-12)
B. Brain (Figure 10-13 and Table 10-1)
1. Brainstem
a. Consists o , named in ascending order, the medu a
ob ongata, pons, and midbrain
b. Structurewhite matter with bits o gray matter
scattered through it
c. Functions
(1) A three parts o brainstem are two-way con-
duction paths
(a) Sensory tracts in the brainstem conduct
impu ses to the higher parts o the brain
(b) Motor tracts conduct rom the higher parts
o the brain to the spina cord
(2) Gray matter areas in the brainstem unction as
important re ex centers
2. Cerebe um
a. Structure
(1) Second argest part o the human brain
(2) Gray matter outer ayer is thin but high y
o ded, orming a arge sur ace area or process-
ing in ormation
(3) Arbor vitaeinterna , tree ike network o
white matter tracts
b. Function
(1) H e ps contro musc e contractions to produce
coordinated movements so that we can main-
tain ba ance, move smooth y, and sustain
norma postures
(2) Variety o additiona coordinating e ects, assist-
ing the cerebrum and other regions o the brain
3. Diencepha on
a. H ypotha amus
(1) Consists main y o the posterior pituitary
g and, pituitary sta k, and gray matter
(2) Acts as the major center or contro ing the
ANS; there ore he ps contro the unctioning
o most interna organs
(3) Contro s hormone secretion by anterior and
posterior pituitary g ands; there ore it indirect y
he ps contro hormone secretion by most other
endocrine g ands
(4) Contains centers or contro ing appetite,
wake u ness, p easure, etc.
b. T a amus
(1) D umbbe -shaped mass o gray matter extend-
ing toward each cerebra hemisphere
(2) Primary unctions:
(a) Re ays sensory impu ses to cerebra cortex
sensory areas
(b) In some way produces the emotions o
p easantness or unp easantness associated
with sensations

(c) H e ps regu ate eve o consciousness by
participating in arousa mechanism
(d) P ays a ro e in comp ex re ex movements
c. Pinea g and (pinea body)
(1) Sma body resemb ing pine nut behind the
tha amus
(2) Adjusts output o timekeeping hormone me -
atonin in response to changing eve s o exter-
na ight (sun ight and moon ight)
4. Cerebrum (Figure 10-14)
a. Largest part o the human brain
b. O uter ayer o gray matter is the cerebra cortex;
made up o obes; composed main y o dendrites
and ce bodies o neurons
c. Interior o the cerebrum composed main y o white
matter
(1) ractsnerve f bers arranged in bund es
(2) Basa nuc eiis ands o gray matter regu ate
automatic movements and postures
d. Functions o the cerebrummenta processes o a
types, inc uding sensations, consciousness, memory,
and vo untary contro o movements; many unc-
tions are oca ized to specif c areas o cortex
C. Brain disorders
1. Damage to brain tissue
a. Concussiontype o traumatic brain injury ( BI)
caused by a jo t to the head and resu ting changes
in brain chemica s (or even b eeding or swe ing)
and characterized by changes in thinking, physica
symptoms such as nausea, and mood or s eep
changes; symptoms may deve op months a ter an
injury (postconcussion syndrome)
b. Cerebrovascu ar accident (CVA)hemorrhage
rom or cessation o b ood ow through cerebra
b ood vesse s; a stroke
c. Cerebra pa sy (CP)condition in which damage
to motor contro areas o the brain be ore, during,
or short y a ter birth causes para ysis (usua y
spastic) o one or more imbs (Figure 10-15)
2. Dementiasyndrome that inc udes progressive oss o
memory, shortened attention span, persona ity
changes, reduced inte ectua capacity, and motor
contro def cit
a. A zheimer disease (AD)brain disorder o the
midd e and ate adu t years characterized by
dementia (Figure 10-16)
b. Chronic traumatic encepha opathy (C E)resu ts
rom repeated head trauma and characterized by
memory oss, parkinsonism, disordered thinking
c. H untington disease (H D)inherited disorder
characterized by chorea (purpose ess movement)
progressing to severe dementia
d. H IV (a so causes AIDS) can in ect neurons and
thus cause dementia
CHAPTER 10 Nervous System 285
3. Seizure disorders
a. Seizuresudden burst o abnorma neuron activity
that resu ts in temporary changes in brain unction
b. Epi epsymany orms, a characterized by recur-
ring seizures
c. E ectroencepha ogramgraphic representation o
vo tage changes in the brain used to eva uate brain
activity (Figure 10-17)
D. Spina cord (Figure 10-18)
1. Co umns o white matter, composed o bund es o
mye inated nerve f bers, orm the outer portion o the
H -shaped core o the spina cord; bund es o axons
ca ed tracts
2. Interior composed o gray matter made up main y o
neuron dendrites and ce bodies (Figure 10-19)
3. Spina cord tracts provide two-way conduction
pathsascending and descending
4. Spina cord unctions as the primary center or a
spina cord re exes; sensory tracts conduct impu ses to
the brain, and motor tracts conduct impu ses rom the
brain
E. Coverings and uid spaces o the brain and spina cord
1. Meninges and bone (Figure 10-20)
a. Cerebra and spina meninges
(1) D ura matertough outer membrane
(2) Arachnoid matercobweb ike midd e ayer
(3) Pia materde icate inner ayer; adheres to
CNS tissue
b. Crania bones and vertebrae orm hard outer
covering
2. Cerebrospina uid (CSF) spaces (Figures 10-21 and
10-22)
a. Subarachnoid spaces o meninges
b. Centra cana inside cord
c. Ventric es in brain
d. H ydrocepha us can resu t rom b ocked CSF circu-
ation (Figure 10-23)
Pe riphe ral Ne rvo us Sys te m
A. Crania nerves (Figure 10-24 and Table 10-2)
1. we ve pairsattached to undersur ace o the brain
2. Connect brain with the neck and structures in the
thorax and abdomen
B. Spina nerves
1. T irty-one pairscontain dendrites o sensory
neurons and axons o motor neurons 10
2. Conduct impu ses necessary or sensations and vo un-
tary movements
3. Dermatomeskin sur ace area supp ied by a sing e
crania or spina nerve (Figure 10-25)
 286 CHAPTER 10 Nervous System
C. Periphera nerve disorders
1. Neuritisgenera term re erring to nerve
in ammation
a. Sciaticain ammation o the sciatic nerve that
innervates the egs
b. Neura gia, or musc e pain, o ten accompanies
neuritis
2. rigemina neura giarecurring episodes o stabbing
pain a ong one or more branches o the trigemina
(f th crania ) nerve in the head
3. Be pa sypara ysis o acia eatures resu ting rom
damage to the acia (seventh crania ) nerve
4. H erpes zoster, or shing es (Figure 10-26)
a. Vira in ection caused by chickenpox virus that has
invaded the dorsa root gang ion and remained
dormant unti stress or reduced immunity precipi-
tates an episode o shing es
b. Usua y a ects a sing e dermatome, producing
characteristic pain u p aques or vesic es
Auto no m ic Ne rvo us Sys te m
A. Functiona anatomy
1. Autonomic nervous system
a. Motor neurons that conduct impu ses rom the
CNS to cardiac musc e, smooth musc e, and g an-
du ar epithe ia tissue
b. Regu ates the bodys automatic, or invo untary,
unctions (Figure 10-27)
c. Distinct rom the somatic nervous system, which
instead regu ates vo untary somatic e ectors (ske e-
ta musc es)
2. Autonomic neuronspregang ionic autonomic
neurons conduct rom spina cord or brainstem to an
autonomic gang ion; postgang ionic neurons conduct
rom autonomic gang ia to cardiac musc e, smooth
musc e, and g andu ar epithe ia tissue
3. Autonomic or viscera e ectorstissues to which
autonomic neurons conduct impu ses (that is, cardiac
and smooth musc e and g andu ar epithe ia tissue)
4. Composed o two divisionsthe sympathetic system
and the parasympathetic system
B. Autonomic conduction paths (Figure 10-28)
1. Consist o two-neuron re ays (that is, pregang ionic
neurons rom the CNS to autonomic gang ia, syn-
apses, postgang ionic neurons rom gang ia to viscera
10 e ectors)
2. In contrast, somatic motor neurons conduct a the
way rom the CNS to somatic e ectors with no inter-
vening synapses
C. Sympathetic division
1. Dendrites and ce bodies o sympathetic pregang i-
onic neurons are ocated in the gray matter o the tho-
racic and upper umbar segments o the spina cord
2. Axons eave the spina cord in the ventra roots o
spina nerves, extend to sympathetic, or co atera ,
gang ia and synapse with severa postgang ionic
neurons whose axons extend to spina or autonomic
nerves to terminate in viscera e ectors
3. A chain o sympathetic gang ia is in anterior and at
each side o the spina co umn
4. Functions o the sympathetic division
a. Serves as the emergency or stress system, contro -
ing viscera e ectors during strenuous exercise and
when strong emotions (anger, ear, hate, or anxiety)
are triggered
b. Group o changes induced by sympathetic contro
is ca ed the ght-or- ight response
D. Parasympathetic division
1. Structure
a. Parasympathetic pregang ionic neurons have den-
drites and ce bodies in the gray matter o the
brainstem and the sacra segments o the spina
cord
b. Parasympathetic pregang ionic neurons terminate
in parasympathetic gang ia ocated in the head and
the thoracic and abdomina cavities c ose to viscera
e ectors
c. Each parasympathetic pregang ionic neuron syn-
apses with postgang ionic neurons to on y one
e ector
2. Functiondominates contro o many viscera e ec-
tors under norma , everyday conditions; counterba -
ances sympathetic unction
E. Autonomic neurotransmitters (Figure 10-29)
1. Cho inergic f berspregang ionic axons o parasym-
pathetic and sympathetic systems and parasympathetic
postgang ionic axons re ease acety cho ine
2. Adrenergic f bersaxons o sympathetic postgang i-
onic neurons re ease norepinephrine (noradrena ine)
F. Autonomic nervous system as a who e
1. Regu ates the bodys automatic unctions in ways that
maintain or quick y restore homeostasis
2. Many viscera e ectors are doub y innervated (that is,
they receive f bers rom parasympathetic and sympa-
thetic divisions and are in uenced in opposite ways by
the two divisions)
G. Disorders o the autonomic nervous system
1. Stress-induced disease
a. Pro onged or excessive response to stress can
disrupt norma unctioning throughout the body
b. Examp es o stress-induced conditions inc ude
heart disease, digestive prob ems, reduced resistance
to disease, and spread o cancer
2. Neurob astomahigh y ma ignant tumor o the sym-
pathetic division, primari y a ecting young chi dren

ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the ne rvous s ys te m in Chapte r 5. The
am ount o m ate rial pre s e nte d in Chapte r 10 m ay be ove r-
w he lm ing at f rs t, but it can be s om ew hat e as ie r to le arn i you
divide the chapte r into thre e parts : the m icros copic s tructure
and unction o the ne rvous s ys te m , the ce ntral ne rvous s ys -
te m , and the pe riphe ral ne rvous s ys te m .
1. Keep in mind that the nervous system unctions as one
organized system. T e unction o the nervous system is
accomp ished by two processes: conduction o nerve
impu ses and passing o the nerve impu se across a
synapse. Nerve impu ses are an exchange o ions between
the interior and exterior o the neuron.
2. T e synapse requires the production, re ease, and deacti-
vation o neurotransmitters. Neurotransmitters unction
by stimu ating receptors in the neuron on the other side
o the synapse.
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. List the three types o neurons c assif ed according to
the direction in which the impu se is being transmitted.
Def ne or exp ain each o them.
2. Def ne or exp ain the o owing terms: mye in, nodes o
Ranvier, and neuri emma.
3. List and give the unction o the three types o g ia ce s.
4. W hat occurs at the ce u ar eve in mu tip e sc erosis?
W hat e ect does this have on the body?
5. Neuromas usua y deve op rom what type o ce s or
tissues?
6. Def ne or exp ain the o owing terms: epineurium, peri-
neurium, and endoneurium.
7. W hat causes gray matter to be gray and white matter to
be white?
8. Exp ain how a re ex arc unctions. W hat are two types
o re ex arcs?
9. Exp ain what occurs during a nerve impu se. W hat is
sa tatory conduction?
CHAPTER 10 Nervous System 287
3. T e materia on the centra nervous system can be earned
best by using ash cards that match up the structure and
unction. Use on ine resources that provide tutoria s and
animations ( or examp e, getbodysmart.com).
4. Make a chart showing the disorders o the nervous
system. O rganize them by type: mye in disorder, brain
disorder, etc. Describe the damage done by the disorder
and the e ect it has on the body.
5. In your study group, you shou d go over the terms pre-
sented in the f rst part o the chapter. Review the Lan-
guage o Science and Language o Medicine terms and
their word origins to he p you better understand the
meaning o the nervous system terms. Discuss the pro-
cesses o nerve impu se transmission and what occurs at
the synapse. Review the ash cards with the names and
unctions o the parts o the centra nervous system.
Remember that most o the structures in the centra
nervous system have more than one unction. Go over the
disorder chart. I you remember the genera unctions o
the sympathetic and parasympathetic divisions, the spe-
cif c e ects wi be easier to remember. A so review the
questions and out ine summary at the end o the chapter.
10. Exp ain what occurs at a synapse. W hat are the two
ways that neurotransmitter activity is terminated?
11. W hat is the cause o Parkinson disease? W hat are some
treatment options?
12. Def ne dementia.
13. W hat is a seizure?
14. List two possib e causes o A zheimer disease.
15. List and describe the unctions o the medu a ob ongata.
16. List and describe the unctions o the hypotha amus.
17. List and describe the unctions o the tha amus.
18. Describe the unction o the pinea g and (body).
19. List and describe the unctions o the cerebe um.
20. List the genera unctions o the cerebrum. W hat are the
specif c unctions o the occipita and tempora obes?
21. W hat is a concussion? Describe its symptoms.
22. List and describe the unctions o the spina cord.
23. List and exp ain the three ayers o the meninges. 10
24. W hat is the unction o cerebrospina uid? W here and
how is cerebrospina uid produced?
25. H ow many nerve pairs are generated rom the spina
cord? H ow many nerve pairs are generated rom each
section o the spina cord? H ow are these nerves named?
W hat is a p exus?
26. Def ne neuritis and neura gia.
 288 CHAPTER 10 Nervous System

27. W hat is the cause o tic dou oureux? W hat is the cause
o Be pa sy?
28. Exp ain the structure and unction o the sympathetic
nervous division.
29. Exp ain the structure and unction o the parasympa-
thetic nervous division.
30. W here is the hidden obe ocated on the brain?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
31. Can you e aborate on why po ice o cers use sobriety
tests such as wa king a ong a straight ine, touching the
tip o the nose with one f nger, or maintaining ba ance
with the eyes c osed?
32. H ow wou d you exp ain why a person is more ike y to
survive damage to the cerebrum than damage to the
brainstem?
33. T ere is a type o medication that inhibits the unction-
ing o acety cho inesterase (the enzyme that deactivates
acety cho ine). Exp ain the e ect this medication wou d
have on the viscera e ectors.
34. T e body conserves everything it possib y can or ater
use. Each system attempts to be prudent with its
resources. Can you give an examp e o how the nervous
system demonstrates this concept with neurotransmitter
mo ecu es?
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________ is the name o the nervous system division
that inc udes the nerves that extend to the out ying parts
o the body.
2. ________ is the name o the nervous system division
that inc udes the brain and spina cord.
3. A group o periphera axons bund ed together in an epi-
neurium is ca ed a ________.
4. T e two types o ce s ound in the nervous system are
________ and ________.
5. T e knee-jerk re ex is a type o neura pathway ca ed a
________.
6. A ________ is a se -propagating wave o e ectrica dis-
turbance that trave s a ong the sur ace o a neurons
p asma membrane.
7. ________ conduction is the term that describes the
impu se as it jumps around the mye in.
8. T e ________ is a p ace where impu ses are passed rom
one neuron to another.
9. Acety cho ine and dopamine are examp es o ________,
which are chemica s used by neurons to communicate.
10. ________, ________, and ________ are the three mem-
branes that make up the meninges.
11. W hen too much CSF accumu ates in the ventric es, it
may ead to a condition ca ed ________ or water on
the brain.
12. T e two hemispheres o the brain are a most separate
structures except or their ower midportions, which are
connected by a structure ca ed the ________ ________.
13. T ere are ________ pairs o crania nerves and
________ pairs o nerves that come rom the spina
cord.
14. ________ are skin sur ace areas supp ied by a sing e
spina nerve.
15. ________ is the part o the autonomic nervous system
that regu ates e ectors during nonstress conditions.
16. ________ is the part o the autonomic nervous system
that regu ates e ectors during the f ght-or- ight
response.
17. T e pregang ionic axons o the parasympathetic nervous
system re ease the neurotransmitter ________. T e post-
gang ionic axons re ease ________.
18. T e pregang ionic axons o the sympathetic nervous
system re ease the neurotransmitter ________. T e post-
gang ionic axons re ease ________.
19. A ter impu se conduction by postsynaptic neurons is ini-
tiated, neurotransmitter activity is rapid y terminated.
wo mechanisms that cause this are ________ and
________.
20. T e cerebrum has many ridges and grooves. T e grooves
are ca ed ________.

10
Match each term in Column A with its corresponding unction or description in Column B.

Column A
21. ________ dendrite
22. ________ axon
23. ________ mye in
24. ________ Schwann ce s
25. ________ astrocyte
26. ________ microg ia
27. ________ o igodendrocyte
Column B
a. ce s that make mye in or axons outside the CNS
b. g ia ce s that he p orm the b ood-brain barrier
c. a sing e projection that carries nerve impu ses away rom the ce body
d. ce s that make mye in or axons inside the CNS
e. a white atty substance that surrounds and insu ates the axon
. ce s that act as microbe-eating scavengers in the CNS
g. a high y branched part o the neuron that carries impu ses toward the ce body
 CHAPTER 10 Nervous System 289

Match each part o the central nervous system in Column A with its corresponding unction in Column B.

Column A Column B
28. ________ medu a ob ongata a. part o the brainstem that is a conduction pathway between the brain and body;
29. ________ pons in uences respiration
30. ________ midbrain b. sensory re ay station rom various body areas to the cerebra cortex; a so invo ved
31. ________ hypotha amus with emotion and a erting and arousa mechanisms
32. ________ tha amus c. carries messages to and rom the brain and the rest o the body; a so mediates
33. ________ cerebe um re exes
34. ________ cerebrum d. part o the brainstem that contains cardiac, respiratory, and vasomotor centers
35. ________ spina cord e. sensory perception, wi ed movements, consciousness, and memory are mediated
here
. regu ates body temperature, water ba ance, s eep-wake cyc e, and sexua arousa
g. regu ates musc e coordination, maintenance o equi ibrium and posture
h. part o the brainstem that contains re ays or visua and auditory impu ses

Match each disorder or disease in Column A with its description or cause in Column B.

Column A Column B
36. ________ mu tip e sc erosis a. inherited condition causing mu tip e benign tumors
37. ________ neuroma b. cessation o b ood ow to the brain; a stroke
38. ________ mu tip e neurof bromatosis c. syndrome that inc udes memory oss, short attention span, and reduced
39. ________ Parkinson disease inte ectua capacity
40. ________ CVA d. recurring or chronic seizure disorder
41. ________ dementia e. compression or degeneration o the seventh crania nerve
42. ________ epi epsy . disorder caused by the oss o mye in
43. ________ meningitis g. a ma ignant tumor o the sympathetic nervous division
44. ________ tic dou oureux h. compression or degeneration o the f th crania nerve
45. ________ Be pa sy i. in ection or in ammation o the meninges
46. ________ neurob astoma j. genera term or a tumor in the nervous system
k. disease characterized by an abnorma y ow eve o dopamine

3. Baraka oves to dance. H owever, he and his riends notice

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. onys teachers describe him as a daydreamer. T e teach-
ers o ten f nd him staring o into space when they are
trying to get his attention. W hen onys parents men-
tioned this to their ami y physician, the physician brings
up the possibi ity o epi epsy. Cou d onys daydreaming
be a sign o epi epsy? W hat test cou d he p conf rm such
a diagnosis? W hat signs wou d one ook or in such a test
i epi epsy is present?
2. O ver the ast ew years, your riend Ange a has deve oped
f brous nodu es in many areas o her skin. She recent y
conf ded that she has an inherited disorder o the nervous
system that causes these bumps. W hat disease might
Ange a have? H ow can a nervous disorder cause skin
esions?
that he misses easy steps more and more o ten. In act,
Baraka a most seems intoxicated because his coordination
is so bad y a ected. Barakas physicians te him that he
has a mye in disorder. H ow wou d such a disorder cause
Barakas symptoms? Name a specif c mye in disorder and
exp ain how this disease causes simi ar prob ems.
4. Matt has just returned home rom his doctors o ce. H e
has a kidney in ection and his doctor has prescribed med-
ication or it. Matt was concerned that he might not be
ab e to drive whi e taking the medication, but his doctor
reassured him that it wou d not a ect his brain. W hat
did the doctor mean by that remark? Can you o er a
more comp ete exp anation? 10
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Senses
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Classif cation o Senses, 291

General Senses, 291
Special Senses, 292
Sensory Receptor Types, 292
Sensory Pathways, 293
General Senses, 293
Distribution o General Sense Receptors, 293
Modes o Sensation, 293
Disorders Involving General Senses, 294
Special Senses, 294
Vision, 294
Disorders o Vision, 297
Hearing and Equilibrium, 302
Hearing and Equilibrium Disorders, 307
Taste, 307
Smell, 308
Integration o Senses, 309

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Classi y sense organs as general or special and
explain the basic di erences between the two
groups.
2. Discuss how a stimulus is converted into a sensa-
tion, as well as disorders involving general senses.
3. Discuss the general sense organs and their
unctions.
4. Describe the structure o the eye and the unctions
o its components.
5. Name and describe the major visual disorders.
6. Discuss the anatomy o the ear and its sensory unc-
tion in hearing and equilibrium.
7. Name and describe the major orms o hearing
impairment.
8. Describe the anatomy o the tongue and its sensory
unction in taste.
9. Describe the anatomy o the nasal cavity and its
sensory unction in smell.
10. Discuss how senses are integrated in the brain.
 11
I you were asked to name the sense organs, what organs wou d you LANGUAGE OF
name? Can you think o any besides the eyes, ears, nose, and taste S C IEN C E
buds? Actua y there are mi ions o other sense organs through-
out the body in our skin, interna organs, and musc es. T ey
Be o re re ading the
constitute the many sensory receptors that a ow us to respond
chapte r, s ay e ach o
to stimu i such as touch, pressure, temperature, and pain. T ese the s e te rm s o ut lo ud. This w ill
microscopic receptors are ocated at the tips o dendrites o he lp yo u to avo id s tum bling ove r
sensory neurons. the m as yo u re ad.

O ur abi ity to detect changes in our externa and interna

adaptation
environments is a requirement or maintaining homeostasis (ad-ap-TAY-shun)
and or surviva itse . We can initiate protective re exes impor- [adapt- f t to, -tion process]
tant to homeostasis on y i we can sense a change or danger. aqueous humor
(AY-kwee-us HYOO-mor)
Externa dangers may be detected by sight or hearing. I the danger is [aqu- water, -ous relating to,
interna , such as overstretching a musc e, detecting an increase in body humor body uid]
temperature ( ever), or sensing the pain caused by an u cer, we have other auditory tube
receptors that make us aware o the prob em, which makes it possib e or us (AW-dih-toh-ree toob)
to then take appropriate action to maintain homeostasis. [audit- hear, -ory relating to]
auricle
(AW-rih-kul)
C la s s if c a t io n o S e n s e s [auri- ear, -icle little]
T e senses are o ten c assif ed as either general senses or special senses. bony labyrinth
(BOHN-ee LAB-eh-rinth)
[labyrinth maze]
Ge n e ra l S e n s e s cerumen
T e general senses are those detected by rather simp e, microscopic recep- (seh-ROO-men)
tors that are wide y distributed throughout the body in the skin, [cer(a)- wax, -men ormed o ]
musc es, tendons, joints, and other interna organs o the ceruminous gland
body. T ey are responsib e or such sensations as (seh-ROO-mih-nus gland)
pain, temperature, touch, pressure, and [cer(a)- wax, -min- ormed o ,
-ous relating to, gland acorn]
body position.
chemoreceptor
(kee-moh-ree-SEP-tor)
[chemo- chemical, -recept- receive,
-or agent]
choroid
(KOH-royd)
[chor- skin, -oid like]
ciliary muscle
(SIL-ee-ayr-ee)
[ciliary eyelids or eyelashes,
mus- mouse, -cle little]

Continued on p. 310

291
 292 CHAPTER 11 Senses

S p e c ia l S e n s e s
T e specia senses are those detected by receptors that are
11 grouped in specif c areas and associated with comp ex struc-
tures that aci itate these senses. T e senses o sme , taste,
vision, hearing, and equi ibrium are considered specia senses
because their receptors are grouped within distinct structures
that enhance their unction.
S e n s o ry Re c e p t o r Ty p e s
Individua receptor ce s are o ten identif ed structura y ac-
cording to whether they are encapsulated or unencapsulated,
that is, whether they are covered by some sort o capsu e or are
ree or naked o any such covering.
Sensory receptor ce s are a so c assif ed unctiona y by the
types, or modes, o stimu i that activate them:
1. Photoreceptorssensitive to change in intensity or
co or o ight, as in vision
2. Chemoreceptorssensitive to presence o certain
chemica s, as in taste or sme
3. Pain receptorssensitive to physica injury
4. T ermoreceptorssensitive to changes in
temperature
5. Mechanoreceptorssensitive to mechanica stimu i
that change their position or shape
Table 11-1 identif es the genera sense organs as either ree
nerve endings or one o the six types o encapsu ated nerve

TABLE 11-1 General Sense Organs

TYPE MAIN LOCATIONS GENERAL S ENS ES
Fre e Ne rve Ending s
Nake d ne rve e nding Skin and m ucos a (e pithe lial laye rs ) Pain, dis crim inative touch, tickle , and
(s eve ral type s te m pe rature
exis t)

Encaps ulate d Ne rve Ending s

Bulboid corpus cle Skin (de rm al laye r), s ubcutane ous tis s ue , Touch and pos s ibly cold
(Kraus e corpus cle ) m ucos a o lips and eye lids , and exte rnal
ge nitals

Lam e llar corpus cle Subcutane ous , s ubm ucous , and s ubs e rous Pre s s ure and high- re que ncy vibration
(Pacini corpus cle ) tis s ue s ; around joints ; in m am m ary glands
and exte rnal ge nitals o both s exe s

Tactile corpus cle Skin (in papillae o de rm is ) and f nge rtips and Fine touch and low- re que ncy vibration
(Me is s ne r lips (num e rous )
corpus cle )

Bulbous corpus cle s Skin (de rm al laye r) and s ubcutane ous tis s ue o Touch and pre s s ure
(Ru f ni corpus cle ) f nge rs

Golgi te ndon organ Ne ar junction o te ndons and m us cle s Proprioce ption (s e ns e o m us cle te ns ion)

Mus cle s pindle Intra fus a l Ske le tal m us cle s Proprioce ption (s e ns e o m us cle le ngth)
fibe rs

TABLE 11-2 Special Sense Organs
S ENS E TYPE OF
ORGAN S PECIFIC RECEPTOR RECEPTOR
Eye Rods and cone s Photore ce ptor
Ear Organ o Corti (s piral organ) Me chanore ce ptor
Cris tae am pullare s Me chanore ce ptor
Maculae Me chanore ce ptor
Nos e Ol actory ce lls Che m ore ce ptor
Tas te buds Gus tatory ce lls Che m ore ce ptor
endings, whereas Table 11-2 identif es the type o receptor ce s
in the specia sense organs that are stimu ated by specif c types
o stimu i.
S e n s o ry P a t h w a y s
A sense organs, regard ess o size, type, or ocation, have in
common some important unctiona characteristics. First, they
must be ab e to sense or detect a stimu us or a change in the
qua ity or intensity o a particu ar stimu us in their environment.
Next, detection o a stimu us must be converted into a nerve
impu se. T is signa is then conducted over a nervous system
pathway to the brain, where the incoming in ormation is f -
tered and sortedo ten comparing it to in ormation coming in
a ong other sensory pathways. On y a ter a o this processing
o in ormation is the sensation actua y perceived in the brain.
T e sensory pathway or the genera senses typica y in-
vo ves conduction o action potentia s generated in the recep-
tors through the spina cord to the tha amus (cutaneous or
skin receptors) or cerebe um (proprioceptors) where they
synapse, and impu ses are then re ayed to specif c areas o the
cerebra cortex or conscious sensory interpretation.
T e sensory pathways or the specia senses are varied, but
a so u timate y end in specif c sensory areas o the cerebra
cortex.
Ge n e ra l S e n s e s
D is t r ib u t io n o G e n e r a l
S e n s e Re c e p t o r s
Microscopic genera sense organ receptors are ound in a most
every part o the body, but they are most concentrated in the
skin (Figure 11-1). H owever, these receptors are not even y
distributed over the body sur ace or in the interna organs.
A so, they do not a respond to the same type o stimu us. o
demonstrate this, try touching any point o your skin on a
f ngertip with the tip o a toothpick. You can hard y miss
stimu ating at east one receptor and a most instantaneous y
experiencing a sensation o touch.
T e abi ity to distinguish one touch stimu us rom two is
ca ed two-point discrimination. A neuro ogica test that mea-
sures this unction invo ves simu taneous y touching two
points on the skin over one area o the body to determine
CHAPTER 11 Senses 293
whether the abi ity to ee the two separate
stimu i is present. T e skin over di erent
parts o the body wi respond di erent y 11
S ENS E because o the di ering numbers o touch
Vis ion receptors that are present.
He aring ouch receptors are distributed c ose y
Dynam ic e quilibrium together over the f ngertips (2 to 8 mm
Static e quilibrium apart), re ative y c ose together over the
pa ms (8 to 12 mm), and quite ar apart over
Sm e ll
the back o the torso (40 to 60 mm). Lesions
Tas te
to the parieta obe o the brain wi impair
two-point discrimination.
M o d e s o S e n s a t io n
Stimu ation o genera sensory receptors can ead to a variety
o sensations. T e di erence in what kind o stimu i is de-
tected is ca ed the mode o the sensation. Di erent genera
sensory receptors can detect vibration, deep pressure, ight
pressure, pain, stretch, or temperature.
Examp es o genera sensory receptors o various modes are
isted in Table 11-1 and i ustrated in Figure 11-1.
Some genera sensory receptors ound near the point o
junction between tendons and musc es and others ound deep
within ske eta musc e tissue are ca ed proprioceptors. W hen
stimu ated by stretch, these mechanoreceptors provide us with
in ormation concerning the position or movement o the di -
erent parts o the body as we as the ength and the extent o
contraction o our musc es.
T e Go gi tendon receptors and musc e spind es identif ed
in Table 11-1 are important proprioceptors.
Many genera sensory receptors are ound in the skin, but
some are present deep in the body. For examp e, there are
stretch receptors in your stomach that signa you when it is
Fre e ne rve
e ndings
Bulboid
(Kra us e )
Ta ctile
(Me is s ne r)
corpus cle corpus cle
La me lla r
(Pa cini)
corpus cle
Bulbous
(Ruf ni)
corpus cle
FIGURE 11-1 General sense receptors. This section o skin shows the
placement o some o the receptors described in Table 11-1.
 294 CHAPTER 11 Senses

u . T ere are a so stretch (pressure) receptors in most other
ho ow organs such as the stomach and intestines, arteries,
11 vagina (birth cana ), and urinary b adder that enab e the nor-
ma unctioning o those organs.
T ere are a so important chemoreceptors in the aorta and
other arteries that detect changes in pH and carbon dioxide
eve s in the b oodimportant in ormation or regu ating
breathing and heart rate.
D is o r d e r s In vo lv in g G e n e r a l S e n s e s
Disruption o genera sense organs can occur by means o a
variety o mechanisms. For examp e, third-degree burns can
comp ete y destroy genera sense receptors throughout the
a ected arearesu ting in oss o pain and touch sensations.
emporary impairment o genera sense receptors occurs
when the b ood ow to them is s owed. T is common y occurs
when you put your egs in a position (such as crossing them
above the knee or o ding a eg under yourse as you sit) that
causes pressure to be app ied to your egs in a way that reduces
b ood ow. W hen you try to stand up, you cannot ee your
egs because the genera sense organs are temporari y im-
paired. You may not even be ab e to wa k at f rst because you
cannot te where your egs are without ooking at them. As
b ood ow returns, reactivation o the sense organs may pro-
duce a ting ing sensation.
Disruption in the unctioning o the genera sense organs
a so can occur as a resu t o diabetes, cardiovascu ar disease,
stroke, and spina cord or brain injury or disease.
QUICK CHECK
1. Wh a t a re tw o ca te g o rie s th a t th e s e n s e s a re o te n cla s s i-
f e d in to w h e n d is cu s s in g th e s tru ctu re a n d u n ctio n o th e
s ys te m ?
2. De s crib e th e s e n s o ry p a th wa y o th e g e n e ra l s e n s e
o rga n s .
3. Wh a t is th e u n ctio n o a p ro p rio ce p to r?
4. Wh a t is tw o -p o in t d is crim in a tio n ?
S p e c ia l S e n s e s
Vis io n
Vision detects the co or and intensity o ight in our externa
environment. But when ocused by the eyes and processed by
the brain, it can do much more. For examp e, we can recognize
the out ines and depth o objects, ana yze movement, and
determine distances. In this section, we discuss that comp ex
and amazing too o visionthe eye.

Vis ua l (optic) a xis Ante rior cha mbe r (conta ins a que ous humor)
Corne a P upil
(tra ns pa re nt)
Iris
Le ns

Lowe r lid
La crima l ca runcle

Cilia ry mus cle

S cle ra
Choroid
Inne r
Re tina Va s cula r Laye rs
Fibrous

Pos te rior cha mbe r

(conta ins vitre ous humor)
Optic dis k
Ce ntra l a rte ry
A
a nd ve in
M L
Optic ne rve
Fove a Ma cula
P

FIGURE 11-2 Eye. This transverse (horizontal) section through the le t eyeball is shown as i viewed rom
above.
 CHAPTER 11 Senses 295

S t r u c t u r e a n d Fu n c t io n o t h e Eye Severa invo untary musc es make up the anterior part o

W hen you ook at a persons eye, you see on y a sma part o
the who e eye. As you can see in Figure 11-2, the eyeba is a
uid-f ed sphere having a wa o three ayers:
1. Fibrous ayer
2. Vascu ar ayer
3. Inner ayer
Fibrous Layer
T e brous layer o the eyeba consists o tough f brous
tissue.
T e white o the eye is part o the f brous ayer ca ed the
sclera. T e sc era, made white by its dense bund es o co agen
f bers, orms most o the f brous ayer.
T e transparent circ e on the anterior o the f brous ayer is
ca ed the cornea. T e cornea is sometimes spoken o as the
window o the eye because o its transparency.
In ammation o the cornea is ca ed keratitis. In addition to
possib e oss o transparency that may resu t rom in amma-
tion, any change in the shape o the cornea can dramatica y
change the abi ity o the eye to ocus an image on the retina.
T e act that the shape o the cornea a ects the eyes ocus
exp ains the popu arity o surgica procedures that use asers
or other specia ty instruments to scu pt and change the
shape o the cornea. T e resu t is improvement o many visua
prob ems without the use o eyeg asses or contact enses.
A mucous membrane known as the conjunctiva ines the
eye ids and covers the f brous ayer in ront. T e b ood vesse s
you see on the sur ace o the sc era actua y be ong to the
conjunctiva. T e conjunctiva is kept moist by tears secreted by
the lacrimal gland.
the choroid. Some are in the iris, the co ored structure seen
through the cornea. T e iris may appear b ue, green, brown, 11
gray, or some combination o these co ors when seen through
the transparent cornea because o the pigments in this ayer o
the eyeba .
T e b ack center o the iris is rea y a ho e in this doughnut-
shaped musc eit is the pupil o the eye. Some o the f bers
o the iris are arranged ike spokes in a whee . W hen they
contract, the pupi s di ate, etting in more ight rays. O ther
f bers are circu ar. W hen they contract, the pupi s constrict,
etting in ewer ight rays. Norma y, the pupi s constrict in
bright ight and di ate in dim ight. Figure 11-3 shows how these
musc es work under the contro o autonomic nerves.
T e lens o the eye ies direct y behind the pupi . It is he d
in p ace by a igament attached to an invo untary musc e
ca ed the ciliary muscle (see Figure 11-2) W hen we ook at
distant objects, the ci iary musc e is re axed, and the ens has
Dim light
Pos tga nglionic
s ympa the tic
fibe r
From s upe rior
ce rvica l ga nglion
Norma l light
Ra dia l s mooth
mus cle
Circula r s mooth
mus cle
P upil
Iris

Several strategies are available or replacing Bright light

Bright light
damaged corneas, as described in the
article Corneal Transplants at Connect It! Cilia ry ga nglion
at evolve.elsevier.com.

Vascular Layer
T e midd e ayer o the eyeba is ca ed the vascular layer be-
cause it has a dense network o tiny b ood vesse s.
Most o the vascu ar ayer is made up o the choroid,
which contains a arge amount o the dark pigment melanin.
T is a most-b ack ayer absorbs ight and thus he ps prevent
the scattering o incoming ight rays, which cou d make it
hard or the eye to ocus an image.
Pos tga nglionic
pa ra s ympa the tic
fibe r
FIGURE 11-3 Control o pupil. This diagram o the muscular parts o
the iris shows autonomic nerves stimulating radial muscles to dilate the
pupil (top) and stimulating circular muscle to constrict the pupil (bottom).
 296 CHAPTER 11 Senses
on y a s ight y curved shape. o ocus on near objects, the ci i-
ary musc e must contract. As it contracts, it pu s the choroid
11 coat orward toward the ens, thus causing the ens to bu ge
and curve even more.
Inner Layer
T e retina makes up most o the inner layer o the eyeba . It
contains microscopic photoreceptor ce s to detect ight
(Figure 11-4). Most o these receptor ce s are ca ed rods and
cones because o their shapes. Dim ight o various wave-
engthsor co orscan stimu ate the rods, giving us mono-
chrome (co or ess) vision when ighting is ow. H owever, air y
bright ight is necessary to stimu ate the cones. In other
words, rods are the receptors or night vision and cones are
the receptors or daytime vision.
T ere are three kinds o cones; each is sensitive to a di er-
ent co or: red, green, or b ue. Scattered throughout the centra
portion o the retina, these three types o cones a ow us to
distinguish between di erent co orsbut on y in bright ight.
T ere is a ye owish area near the center o the retina
ca ed the macula luteaa term that means ye ow spot. It
surrounds a sma depression, ca ed the ovea centralis,
which contains the greatest concentration o cones o any
area o the retina. T ese structures are identif ed in Figure 11-2
C LIN ICA L APPLICATION
REFERRED PAIN
The stim ulation o pain re ce ptors in de e p s tructures m ay be e lt
as pain in the skin that lie s ove r the a e cte d organ or in an are a
o skin on the body sur ace ar re move d rom the site o dise as e
or injury. Re e rre d pain is the term or this phenom enon.
The caus e o re e rre d pain is re -
late d to a conve rge nce o s e ns ory
ne rve im puls e s rom both the
dis e as e d organ and the s kin in S kin in which
the are a o re e rre d pain. For ex- pa in is
pe rce ive d
am ple , pain originating in an or-
gan de e p in the abdom inal cavity
is o te n inte rpre te d as com ing
rom an are a o s kin w hos e s e n-
s ory f be rs e nte r the s am e s e g-
m e nt o the s pinal cord as the
s e ns ory f be rs rom the de e p
s tructure .
A clas s ic e xam ple is the re -
e rre d pain o te n as s ociate d pa in fibe r
w ith a he art attack. Se ns ory f -
be rs rom the s kin on the che s t
ove r the he art and rom the tis -
s ue o the he art its e l e nte r the
S ite of
f rs t to the f th thoracic s pinal injury
cord s e gm e nts and s o do s e n-
s ory f be rs rom the s kin are as
ove r the le t s houlde r and inne r A
but can a so be seen using a common medica device ca ed
an ophthalmoscope, shown in Figure 11-5.
In good ight, greater visua acuity, or sharpness o visua
perception, can be obtained i we ook direct y at an object and
ocus the image on the ovea. But in dim ight or darkness, we
see an object better i we ook s ight y to the side o it, thereby
ocusing the image nearer the periphery o the retina, where
the rods are more p enti u .
Figure 11-4 a so shows ganglion cells, which are a so sensi-
tive to ight. Gang ion ce s, ike rods, are sensitive to various
wave engths (co ors) o ight, but they are not used to orm
visua images. Instead, in ormation rom gang ion ce s he ps
the body determine whether it is day or night, as we as the
eve o moon ight (month y phases). T is he ps our bodys
internal clock mechanisms synchronize themse ves to the dai y,
month y, and seasona rhythms o our externa environment.
Fluids o the Eyeball
F uids f the ho ow spaces inside the eyeba . T ey maintain
the norma shape o the eyeba and he p re ract ight rays;
that is, the uids bend ight rays to bring them to ocus on the
retina.
Aqueous humor is the name o the watery uid in ront o
the ens (in the anterior chamber o the eye), and vitreous
s ur ace o the le t arm . Part A o the f gure s how s the pri-
m ary s e ns ory f be rs rom both the s kin and he art conve rging
in the s pinal cord. Se ns ory im puls e s rom both the s e are as
trave l to the brain ove r a com m on pathw aythe s e condary
s e ns ory f be r. Thus the brain m ay locate the pain o a he art
attack in the s houlde r or arm (part B o the f gure ).
Mis inte rpre tation in the brain in re gard to the
true location o s e ns ory ne urons be ing s tim u-
late d caus e s re e rre d pain. In clinical m e dicine ,
an unde rs tanding o re e rre d pain can be an im -
To bra in
P rima ry
S e conda ry
pa in fibe r
 CHAPTER 11 Senses 297

humor is the name o the je y ike uid behind the ens (in the
posterior chamber). Aqueous humor is constant y being
ormed, drained, and rep aced in the anterior chamber. I
drainage is b ocked or any reason, the interna pressure
within the eye wi increase, and damage that cou d ead to
b indness wi occur. T is condition is ca ed glaucoma, which
we discuss ater in this chapter.
QUICK CHECK
1. Id e n ti y th e th re e la ye rs o tis s u e s th a t o rm th e e ye b a ll.
2. Ho w d o e s th e iris re g u la te th e s ize o th e p u p il?
3. Wh a t is th e w in d o w o th e e ye ?
4. Wh a t is th e u n ctio n o m e la n in in th e e ye ? Wh e re is it
lo ca te d ?
5. Wh a t a re th e h u m o rs o th e e ye ? De s crib e th e u n ctio n o
th e h u m o rs .
6. Ho w a re ro d s a n d co n e s u s e d in vis io n ?
C LIN ICA L APPLICATION
11
FINDING YOUR BLIND S POT
You can de m ons trate the location o the blind s pot in your
vis ual f e ld by cove ring your le t eye and looking at the ob-
je cts be low. Be gin by pos itioning your ace about 35 cm
(12 in) away rom this page . Cove r your le t eye and s tare
continuous ly at the s quare w ith your right eye w hile s low ly
bringing your ace clos e r and clos e r to the im age . At one
point, the circle w ill s e e m to dis appe ar be caus e its im age
has alle n on the blind s pot.

To learn more about the structures o the eye, go

to AnimationDirect online at evolve.elsevier.com.

Vis u a l P a t h w a y detecting intensity (brightness) and wave ength (co or) o

Light is the stimu us that resu ts in vision (that is, our abi ity
to see objects as they exist in our environment). Besides
portant de te rm inant in w he the r the corre ct diagnos is o
dis e as e is m ade (s e e f gure ).
These concepts also relate to those
explored in the article Pain Control Areas at
Connect It! at evolve.elsevier.com.
He a rt
ight, we can a so perceive images and their movements.
Light enters the eye through the pupi and is re racted, or
bent, so that it is ocused on the retina. Re raction occurs as
ight passes through the cornea, the aqueous humor, the ens,
and the vitreous humor on its way to the retina.
T e innermost ayer o the retina contains the rods and
cones, which are the photoreceptor cells o the eye (see
Figure 11-4). T ey respond to a ight stimu us by producing a
nervous impu se. T e rod and cone photoreceptor ce s synapse
with neurons in the bipo ar and gang ionic ayers o the retina.
Nervous signa s eventua y eave the retina and exit the eye
through the optic nerve on the posterior sur ace o the eyeba .
No rods or cones are present in the area o the retina where
the optic nerve f bers exit. T e resu t is a b ind spot known
as the optic disk (see Figure 11-2).
A ter eaving the eye, the optic nerves enter the brain and
trave to the visua cortex o the occipita obe (Figure 11-6).
Eventua y, visual interpretation o the nervous impu ses gen-
erated by ight striking the retina resu ts in seeing.

D is o r d e r s o Vis io n
S toma ch H ea thy vision requires three basic processes: ormation o an
Live r a nd image on the retina (re raction), stimu ation o rods and cones,
ga llbla dde r and conduction o nerve impu ses to the brain. Ma unction
Appe ndix a nd o any o these processes can disrupt this chain o processes,
s ma ll inte s tine producing a visua disorder.
Right a nd le ft
kidneys Re r a c t io n D is o r d e r s
Colon Common Focusing Problems
Ure te r S
Focusing a c ear image on the retina is essentia or good vi-
R L
sion. In the norma eye, ight rays enter the eye and are ocused
B I into a c ear, upside-down image on the retina (Figure 11-7, A).
T e brain can easi y right the upside-down image in our
 298 CHAPTER 11 Senses Rods
Cone

Pig me nte d
re tina
11
P hotore ce ptor
ce lls

Bipola r
ce lls S e ns o ry
re tina

Ga nglion
ce lls

Fibe rs to
optic ne rve

S urfac e o f re tina
L
ig
h
t

FIGURE 11-4 Cells o the retina. Photoreceptors called rods

and cones (notice their shapes) detect changes in light and relay
the in ormation to bipolar neurons. The bipolar cells, in turn,
conduct the in ormation to ganglion cells. The in ormation leaves
the eye by way o the optic nerve.

C LIN ICA L APPLICATION

VIS UAL ACUITY
Vis ual acuity is the cle arne s s or s harpne s s o vis ual pe rce ption. Acuity is
a e cte d by our ocus ing ability, the e f cie ncy o the re tina, and the
prope r unction o the vis ual pathway and proce s s ing ce nte rs in the
brain.
One com m on way to m e as ure vis ual acuity is to us e the am iliar
te s t chart on w hich le tte rs or othe r obje cts o various s ize s and s hape s
are printe d. The s ubje ct is as ke d to ide nti y the s m alle s t obje ct that he
or s he can s e e rom a dis tance o 20 e e t (6.1 m ). The re s ulting de te rm i-
nation o vis ual acuity is expre s s e d as a double num be r s uch as 20-20.
The f rs t num be r re pre s e nts the dis tance (in e e t) be twe e n the s ubje ct
and the te s t chartthe s tandard be ing 20. The s e cond num be r re pre s e nts
the num be r o e e t a pe rs on w ith norm al acuity would have to s tand away
rom the chart to s e e the s am e obje cts cle arly.
Thus a f nding o 20-20 is norm al be caus e the s ubje ct can s e e at 20 e e t w hat
a pe rs on w ith norm al acuity can s e e at 20 e e t. A pe rs on w ith 20-100 vis ion can s e e
obje cts at 20 e e t that a pe rs on w ith norm al vis ion can s e e at 100 e e t away.
Pe ople w hos e acuity is wors e than 20-200 a te r corre ction are cons ide re d to be
le gally blind. Le gal blindne s s is the de s ignation us e d to ide nti y the s eve rity o a w ide
varie ty o vis ual dis orde rs s o that law s that involve vis ual acuity can be e n orce d. For
exam ple , law s that gove rn the awarding o driving lice ns e s re quire that drive rs have a
m inim um leve l o vis ual acuity.
Sm alle r charts , s uch as the one s how n in the f gure , can be us e d to te s t ne ar vis ion
acuity.
 CHAPTER 11 Senses 299

FIGURE 11-5 Examining the eye. A, Using Optic dis k Fove a ce ntra lis
S
an ophthalmoscope to view the retina. B, Oph-
thalmoscopic view o the retina, as seen through
the pupil. C, A case o retinal tear and detach-
L M 11
ment. D, Diabetes can produce abnormal blood I
vessels and bleeding o the retina.

conscious perception but cannot correct

an image that is not sharp y ocused.
S
I our eyeba s are e ongated, the im-
age ocuses somewhere in ront o the M L
retina rather than direct y on it. T e I
retina receives on y a uzzy image. T is Re tina l blood Ma cula lute a
ve s s e ls
condition, ca ed myopia or nearsighted- A B
ness, can be corrected by re ractive eye Re tina l blood Optic
Torn e dge s He morrha ge ve s s e l dis k
surgery or by using contact enses or
g asses (Figure 11-7, B and C).
I our eyeba s are shorter (as mea-
sured rom anterior to posterior) than
norma , the image ocuses behind the
retina, a so producing a uzzy image.
T is condition, ca ed hyperopia or
arsightedness, a so can be corrected by
eye surgery or enses (Figure 11-7, D
and E).
An irregu arity (unequa curvature)
in the cornea or ens, a condition ca ed
C D
astigmatism that distorts vision, a so
can be corrected with g asses or contact Re tina l te a r a nd de ta chme nt Dia be tic re tinopa thy
enses.

For brie descriptions o some surgical options to

treat re raction issues, such as radial keratotomy LEFT EYE RIGHT EYE
(RK) and laser-assisted in situ keratomileusis
(LASIK), see the article Re ractive Eye Surgery at Optic
Connect It! at evolve.elsevier.com. ne rve

Fronta l
In most young peop e, the ens is both transparent and Optic lobe
somewhat e astic, making it capab e o easi y changing shape. chia s ma
As we grow o der, however, most o us become more ar- Optic
sighted as we ose the abi ity to ocus on c ose objects because tra ct
our enses ose their e asticity and can no onger bu ge enough Te mpora l
to bring near objects into ocus. Presbyopia, itera y o d- lobe
sightedness, is the name or this condition. O der individua s

La te ra l
Optic ge nicula te
ra dia tion body
FIGURE 11-6 The visual pathway. Transverse section o the brain and A
eyes (in erior view). Note that the pathway rom the retina o the le t eye is
color-coded blue and the pathway rom the right eye is color-coded green. R L Occipita l
lobe
Identi y the point at which hal the in ormation rom each eye crosses over P
to the other side o the brain. Vis ua l cortex
 300 CHAPTER 11 Senses

NORMAL

11
S

P A

S
A
M L
MYOPIA FIGURE 11-9 Conjunctivitis. In this case o acute
bacterial in ection, notice the discharge o mucous I
Unc o rre c te d Co rre c te d
pus characteristic o this highly contagious in ection
o the conjunctiva.

ight cannot pass through the c oudy spots the way some
brighter ight can. T is act accounts or the troub e many
o der adu ts have with their night vision.
B C T e tendency to deve op cataracts is inherited. Formation
o cataracts may occur in one or both eyes, tends to be pro-
HYPEROPIA gressive, and may eventua y resu t in b indness. Cataracts can
Unc o rre c te d Co rre c te d be removed surgica y and the de ective ens rep aced with an
artif cia imp ant.

D E
FIGURE 11-7 Re raction. A, Shows how light is re racted in the normal
eye to orm a well- ocused image on the retina. B and C, The abnormal and
corrected re raction observed in patients with myopia, or nearsightedness.
D and E, Abnormal and corrected re raction in patients with hyperopia, or
arsightedness.
can compensate or presbyopia by using reading g asses
when near vision is needed.
Cataracts
Un ortunate y, in some individua s, ongtime exposure to u -
travio et (UV) radiation in sun ight may cause the ens to
become hard, ose its transparency, and have regions that be-
come mi ky in appearance.T is condition is ca ed a cataract
(Figure 11-8). Cataracts o ten inter ere with ocusing. Cataracts
are especia y troub esome in dim ight because weak beams o
S Chapter 16. rauma to the eye may cause b eeding be ow the
R L
Conjunctivitis
A variety o other conditions can prevent the ormation o a
c ear image on the retina. For examp e, in ections o the eye
and its associated structures a so have the potentia to impair
vision, sometimes permanent y.
M ost eye in ections start out in the conjunctiva, produc-
ing an in ammation response known as pink eye or
conjunctivitis. You may reca rom Chapter 6 that a variety
o di erent pathogens can cause conjunctivitis. For examp e,
the bacterium Chlamydia trachomatis that common y in ects
the reproductive tract can cause a chronic in ection ca ed
chlamydial conjunctivitis or trachoma. Because ch amydia
and other pathogens o ten inhabit the birth cana , antibiot-
ics are routine y app ied to the eyes o newborns to prevent
conjunctivitis.
H igh y contagious acute bacterial conjunctivitis, characterized
by drainage o a mucous pus (Figure 11-9), is most common y
caused by bacteria such as Staphylococcus and Haemophilus.
Conjunctivitis may produce esions on the inside o the eye-
id that can damage the cornea and thus impair vision. Occa-
siona y in ections o the conjunctiva spread to the tissues o the
eye proper and cause permanent injuryeven tota b indness.
In addition to in ection, conjunctivitis a so may be caused
by a ergies. T e red, itchy, watery eyes common y associated
with a ergic reactions to po en and other substances resu t
rom an a ergic in ammation response o the conjunctiva.
A ergy and hypersensitivity reactions are discussed urther in
conjunctiva resu ting in a subconjunctival hemorrhage.

I Strabismus
FIGURE 11-8 Cataract. Notice the cloudiness o the le t eye character- Yet another manner in which re raction can be disrupted oc-
istic o advanced cataracts. The normal right eye is not cloudy. curs when one eye does not ocus on the same object as the

S cause tota b indness in the a ected eye.
R L
I
FIGURE 11-10 Strabismus. This child exhibits convergent le t eye
strabismus.
other eye. Norma y, we use binocular (two-eyed) vision in
which both eyes aim toward the same object at the same time.
Because the eyes are separated by a short distance, the images
ormed in each eye do not match exact ya act that a ows
depth perception.
I the positioning o the eyes cannot be coordinated, a
condition ca ed strabismus or squint resu ts. In some cases,
the eyes may diverge outward to the side, a condition ca ed
divergent squint. I one or both eyes converge toward the nose,
the condition is ca ed convergent squint or cross-eye. T e
photo in Figure 11-10 shows a chi d with convergent e t eye
strabismus.
Usua y the brain compensates or missing or unusua e e-
ments in the visua f e d. H owever, in severe cases o strabis-
mus, the eyes may be so ar o in their center o ocus that the
brain cannot mesh the two resu ting images into a sing e
picture.
Strabismus is usua y caused by para ysis, weakness, or an-
other abnorma ity a ecting the externa musc es o the eye.
W hatever the cause, strabismus o ten can be corrected by
treatment in ear y chi dhood that orces the eyes to ocus to-
gether, by means o therapeutic training, corrective enses, or
by corrective surgery. I e t untreated, by about 6 years o age
the visua centers in the brain wi earn to ignore in ormation
rom one eyecausing a decrease in visua acuity and perma-
nent b indness in the a ected eye.
QUICK CHECK
1. Ho w d o m yo p ia a n d hyp e ro p ia d i e r in te rm s o o cu s in g
a n im a g e o n th e re tin a ?
2. Wh a t is s tra b is m u s ? Ho w is it tre a te d ?
3. Wh a t is p in k e ye ?
4. Wh a t p a rt o th e e ye is a e cte d w h e n a n in d ivid u a l h a s
ca ta ra cts ?
D is o r d e r s o t h e Re t in a
Damage to the retina impairs vision because even a we -
ocused image cannot be perceived i some or a o the ight
receptors do not unction proper y.
Retinal Detachment
For examp e, in a condition ca ed retinal detachment, part o
the retina a s away rom the tissue supporting it (see
Figure 11-5, C). T is condition o ten resu ts rom norma aging,
eye tumors, or rom sudden b ows to the headas in a
CHAPTER 11 Senses 301
sporting injury. Common warning signs inc ude the sudden
appearance o oating spots that may decrease over a period
o weeks and odd ashes o ight that appear when the eye 11
moves. I e t untreated, the retina may detach comp ete y and
A number o treatments are avai ab e or correcting retina
detachment. A traditiona approach is the use o aser therapy.
Another approach invo ves p acing a tight co ar around the
eyeba to increase pressure within the eye. T e high pressure
o the je y ike vitreous humor ho ds the retina in p ace against
the rear o the eyeba .
Diabetic Retinopathy
Diabetes mellitus, a disorder invo ving the hormone insu in,
may cause a condition known as diabetic retinopathy. In this
disorder, diabetes causes sma hemorrhages in retina b ood
vesse s that disrupt the oxygen supp y to the photoreceptors
(see Figure 11-5, D). T e eye responds by bui ding new but
abnorma vesse s that b ock vision and may cause detachment
o the retina.
Diabetic retinopathy is considered one o the eading
causes o b indness in the United States. Fortunate y, treat-
ments deve oped over the ast two decades have improved the
out ook in this regard. For examp e, a type o aser therapy in
which aser beams are used to sea o hemorrhaging retina
vesse s has been used success u y in many cases.
Glaucoma
Another common condition that can damage the retina is
glaucoma. intraocular
pressure caused by abnorma accumu ation o aqueous humor.
As uid pressure against the retina increases above norma ,
causes degeneration o the retina and thus a oss o vision.
A though acute orms o g aucoma can occur, most cases
deve op s ow y over a period o years. T is chronic orm may
not produce symptoms, especia y in its ear y stages. For this
reason, routine eye examinations typica y inc ude a screening
test or g aucoma.
As chronic g aucoma progresses, damage f rst appears at
the edges o the retina, causing a gradua oss o periphera
vision resu ting in a condition known common y as tunne
vision. B urred vision and headaches a so may occur. As the
damage becomes more extensive, ha os are seen around
bright ights. I untreated, g aucoma eventua y produces tota ,
permanent b indness.
Retinal Degeneration
Degeneration o the retina can cause di cu ty seeing at night
or in dim ight. T is condition is ca ed nyctalopia or night
b indness.
Nycta opia a so can be caused by a def ciency o vitamin A.
Vitamin A is needed to make photopigment in rod ce s.
Photopigment is a ight-sensitive chemica that triggers
stimu ation o the visua nerve pathway. A ack o vitamin A
may resu t in a ack o photopigment in rods, a condition that
impairs dim- ight vision.
 302 CHAPTER 11 Senses
T e eading cause o permanent b indness in the e der y
is progressive degeneration o the centra part o the retina.
11 Ca ed age-related macular degeneration (AMD ), this
condition a ects the part o the retina that is most essentia
to good visionthe centra region ca ed the macula. T e
exact cause o the degeneration is unknown, but the risk or
deve oping this condition increases with age a ter reaching
50. O ther known risk actors inc ude cigarette smoking and
a ami y history o the disorder.
Learn more about wet and dry orms o AMD
and how lasers or injections may be used to treat
them in the article Therapy or Macular Degenera-
tion at Connect It! at evolve.elsevier.com.
Color Blindness
color blindness are caused by genes on the X chromosome
that produce abnorma photopigments in the cones. Each o
three photopigments in cones is sensitive to one o the pri-
mary co ors o ight: green, b ue, and red. In many co or-b ind
individua s, the green-sensitive photopigment is missing or
def cient; at other times, the red-sensitive photopigment is
abnorma . Def ciency o the b ue-sensitive photopigment is
very rare.
Co or-b ind individua s see co ors, but they cannot distin-
guish among a o them norma y. Because co or b indness is
an X- inked genetic trait, more men than women have this
condition (see Chapter 25). A though co or b indness is an
abnorma ity, it is not usua y considered a c inica disease.
Co ored f gures are o ten used to screen individua s or
co or b indness (Figure 11-11). A person with red-green co or
b indness cannot see the number 74 in Figure 11-11, A, whereas
a person with norma co or vision can.
o determine which photopigment is def cient, red or
green, a co or-b ind person may be eva uated using a f gure
simi ar to Figure 11-11, B. Persons with a def ciency o red-
sensitive photopigment can distinguish on y the number 2;
those def cient in green-sensitive photopigment can see on y
the number 4.
A B
FIGURE 11-11 Color vision screening. A, People with normal color
vision can see 74 in this mosaic; people with red-green color blindness can-
not. B, This mosaic is used to classi y the type o red-green color blindness
a patient has. I the patient sees only the 2, the red-sensitive cones are
abnormal. I only the 4 is seen, the green-sensitive cones are abnormal.
QUICK CHECK
1. Ho w d o th e va rio u s typ e s o re ra cto ry e ye s u rg e ry
im p rove e ye s ig h t? Wh a t is LAS IK?
2. Ho w d o e s g la u co m a h a rm th e re tin a ?
3. Wh a t is nycta lo p ia ? Wh a t typ e o vita m in d e f cie n cy is
a s s o cia te d w ith th is co n d itio n ?
D is o r d e r s o t h e Vis u a l P a t h w a y
Damage or degeneration in the optic nerve, the brain, or any
part o the visua pathway between them can impair vision
(see Figure 11-6). For examp e, the pressure associated with
g aucoma a so can damage the optic nerve. Diabetes, a ready
cited as a cause o retina damage, a so can cause degeneration
o the optic nerve.
Damage to the visua pathway does not a ways resu t in
tota oss o sight. Depending on where the damage occurs,
on y a part o the visua f e d may be a ected. For examp e, a
certain orm o neuritis o ten associated with mu tip e sc ero-
sis can cause oss o on y the center o the visua f e da
condition ca ed scotoma.
A cerebrovascu ar accident (CVA), or stroke, can cause vi-
sion impairment when the resu ting tissue damage occurs in
one o the regions o the brain that process visua in ormation
(see Figure 10-14). For examp e, damage to an area that pro-
cesses in ormation about co ors may resu t in a rare condition
ca ed acquired cortical color blindness. T is condition is charac-
terized by di cu ty in distinguishing any co ornot just one
or two co ors as in the more common inherited orms o reti-
na co or b indness.
He a r in g a n d Eq u ilib r iu m
In addition to its ro e in hearing, the ear a so unctions as the
sense organ o ba ance, or equilibrium. T e stimu ation, or
trigger, that activates receptors invo ved with hearing and
equi ibrium is mechanica , and the receptors themse ves are
ca ed mechanoreceptors. In hearing, sound vibrations trig-
ger nervous impu ses that are eventua y perceived in the brain
as sound. In equi ibrium, changes in position or movement o
the body trigger impu ses that ead to sensations o ba ance.
Ea r
T e ear is more than an appendage on the side o the head. A
arge part o the ear and its most important part ie hidden
rom view deep inside the tempora bone. T e ear is divided
into the o owing anatomica areas (Figure 11-12):
1. Externa ear
2. Midd e ear
3. Inner (interna ) ear
External Ear
T e externa ear has two parts: the auricle, or pinna, and the
external acoustic canal. T e auric e is the appendage on the
side o the head surrounding the opening o the externa
acoustic cana . A number o the anatomica andmarks o the
externa ear are identif ed in Figure 11-12.
 CHAPTER 11 Senses 303

Middle
Exte rnal e ar e ar Inne r e ar

(Not to s ca le ) 11
Auditory os s icle s
Auricle S e micircula r ca na ls
(pinna ) Ma lle us Ova l window
Te mpora l Incus
bone Fa cia l ne rve
S ta pe s
Ve s tibula r
ne rve
Ve s tibulo-
cochle a r
He lix Cochle a r
ne rve
ne rve
(CN VIII)
Antihe lix
Ve s tibule
Tra gus

Cochle a

Exte rna l Tympa nic

a cous tic me mbra ne
ca na l
Auditory
tube
Antitra gus
Lobule (e a rlobe )
FIGURE 11-12 Ear. External, middle, and inner
ear structures. Structures not shown to scale.

Because it ies exposed against the bony sur ace o the In peop e who su er rom gout, sma nodu es made up o
sku , the auric e is requent y injured by b unt trauma. Bruis- urate crysta s and ca ed tophi, o ten appear on the upper
ing may then cause an accumu ation o b ood and tissue uid edge o the helix. Another type o nodu e that may appear on
between the skin and under ying carti age. I e t untreated, the he ix is ca ed a Darwin tubercle. It is considered a varia-
the c assic swe ing o cau i ower ear may deve op and be- tion o norma and requires no treatment.
come permanent. T e skin behind the ear is rich in sebaceous A though controversia , there is some evidence to suggest
g ands. And, i they become in ected, pain u cysts deve op that the presence o ob ique ear obe creases (Franks sign) in
that must be drained. individua s over the age o 50 may be re ated to coronary ar-
tery disease.
Note in Figure 11-12 that the tragus o the auric e ies just
anterior to the opening to the acoustic cana . T e cana itse is
HEA LTH AND WELL-BEIN G a curving tube about 2.5 cm (1 inch) in ength. It extends into
the tempora bone and ends at the tympanic membrane, or
S WIMMERS EAR eardrum, which is a partition between the externa and mid-
Exte rnal otitis , or s w im m e rs e ar, is a com m on in e ction o d e ear. Sound waves trave ing through the externa acoustic
the exte rnal e ar in athle te s . It can be bacte rial or cana strike the tympanic membrane and cause it to vibrate.
ungal in origin and is us ually as s ociate d T e skin o the acoustic cana , especia y in its outer one
w ith prolonge d expos ure to wate r. The third, contains many short hairs and ceruminous glands that
in e ction ge ne rally involve s , at le as t produce a waxy substance ca ed cerumen. Cerumen, or
to s om e exte nt, the acous tic canal earwax, he ps keep the cana s skin rom drying and
and auricle . The e ar as a w hole is aking. It a so traps dust that enters the cana and is
te nde r, re d, and s wolle n. Tre at-
then carried toward the exterior as the epithe ium
m e nt o s w im m e rs e ar us ually
grows outward rom the inner cana . H owever, ceru-
involve s antibiotic the rapy and
pre s cription analge s ics . men may co ect in excess and impair hearing by ab-
sorbing or b ocking the passage o sound waves.
S Just as an ophtha moscope is used to view the in-
terior o the eyeba and examine the retina, a ighted
A P
instrument ca ed an otoscope is used to examine the
I externa ear cana and outer sur ace o the tympanic
 304 CHAPTER 11 Senses

S Ha ndle of ma lle us
(s e e n through me mbra ne ) S we lling Ce rume n
11 A

I
P

B C D
A
Tympa nic me mbra ne

FIGURE 11-13 Examining the external ear. A, Using a lighted otoscope to view the external ear canal
and tympanic membrane. B, Note the translucent, pearly-gray appearance o a normal tympanic membrane
(with a bit o white glare rom the otoscope light in the lower right). The handle o the malleus can be seen
attaching near the center o the inner sur ace o the membrane. C, Acute otitis media. Note the red, thickened,
and bulging tympanic membrane. D, Cerumen (earwax) in ear canal.

membrane (Figure 11-13, A and B). Changes in the appearance
o the ear cana and tympanic membrane can provide a ski ed
observer with a great dea o in ormation.
For examp e, midd e ear in ections cause the eardrum to
become red and in amed and to bu ge outward into the ear
cana as pus and other uids accumu ate in the midd e ear
(Figure 11-13, C). Foreign objects or excess cerumen in the
ear cana , in ammation o the ining o the cana caused by
pro onged exposure to moisture or bacteria in ection (swim-
mers ear), and per oration o the eardrum itse are a so easi y
observed using an otoscope (Figure 11-13, D).
Middle Ear
T e midd e ear is a tiny and very thin epithe ium- ined cavity
ho owed out o the tempora bone (Figure 11-12). It is an air-
f ed space housing three very sma bones. T e names o
these ear bones, ca ed ossicles, describe their shapes
malleus (hammer), incus (anvi ), and stapes (stirrup).
T e hand e o the ma eus attaches to the inside o the
tympanic membrane, and the head attaches to the incus (see
Figure 11-13, B). T e incus attaches to the stapes, and the stapes
presses against a membrane that covers a sma opening, the
oval window. T e ova window separates the midd e ear rom
the inner ear.
W hen sound waves cause the eardrum to vibrate, that
movement is transmitted and amp if ed by the ear ossic es as it
passes through the midd e ear. Movement o the stapes against
the ova window causes movement o uid in the inner ear.
A point worth mentioning, because it exp ains the requent
spread o in ection rom the throat to the ear, is that a tube
the auditory tube, or eustachian tubeconnects the throat
with the midd e ear. T e epithe ia ining o the midd e ears,
auditory tubes, and throat are extensions o one continuous
membrane. Consequent y, in ection causing a sore throat may
spread to produce a midd e ear in ection ca ed otitis media
(see Figure 11-13, C).
T e unction o a hea thy auditory tube is to equa ize air
pressure between the midd e ear and the outside environment.
W hen air pressures are unequa , the tympanic membrane may
remain stretchedsometimes becoming quite pain u and
reducing its abi ity to vibrate.
Inner Ear
Anatomica y, the inner ear consists o three spaces in the
tempora bone, assemb ed in a comp ex maze ca ed the bony
labyrinth. T is odd-shaped bony space is f ed with a watery
uid ca ed perilymph and is divided into the o owing parts:
vestibule, semicircular canals, and cochlea. T e vestibu e is
adjacent to the ova window between the semicircu ar cana s
and the coch ea (Figure 11-14).
Note in Figure 11-14 that a ba oon ike membranous sac is
suspended in the peri ymph and o ows the shape o the bony
abyrinth much ike a tube within a tube. T is is the
membranous labyrinth, and it is f ed with a thicker uid
ca ed endolymph.
He a r in g
H earing is the sensation o the intensity and requency (tone)
o sounds in our environment.
Sound waves are simp y pressure waves in the air. Such
waves can be unne ed by the auric e into the externa acoustic
cana and strike the tympanic membrane. Sound waves cause
the eardrum to vibrate, and that movement is then transmit-
ted and amp if ed by the ear ossic es as it passes through the
midd e ear. Movement o the stapes against the ova window
causes movement o peri ymph uid in the inner ear, which in
turn triggers vibrations o the endo ymph.
T e vibration waves now trave through the uid o the
inner ear to the organ o hearingthe organ o Corti
which ies within the cur ing, snai -shaped coch ea. A so
ca ed the spiral organ, it is surrounded by endo ymph, f ing
the membranous abyrinth, which is the membranous tube
within the bony coch ea. Ci iated hair ce s on the organ o
Corti generate nerve impu ses when they are bent by the
movement o endo ymph set in motion by sound waves (see
Figure 11-14 and Figure 11-15).
 CHAPTER 11 Senses 305

S e micircula r Pe rilymph s pa ce
ca na ls
Endolymph s pa ce
(within me mbra ne ) 11
Ve s tibulocochle a r ne rve
(cra nia l ne rve VIII)
Ampulla

Ve s tibula r
ne rve

Cochle a r
ne rve

Ve s tibule

Ova l window
S

L M
S e ns ory Orga n of Corti
Cochle a I ha ir ce lls
A B
FIGURE 11-14 Inner ear. A, The bony labyrinth is the hard outer wall o the entire inner ear and includes semicir-
cular canals, vestibule, and cochlea. Within the bony labyrinth is the membranous labyrinth (purple), which is sur-
rounded by perilymph and lled with endolymph. Each ampulla in the vestibule contains a crista ampullaris that detects
changes in head position and sends sensory impulses through the vestibular nerve to the brain. B, The inset shows a
section o the membranous cochlea. Hair cells in the organ o Corti detect sound and send the in ormation through the
cochlear nerve. The vestibular and cochlear nerves join to orm the vestibulocochlear nerve, or cranial nerve VIII.

Ma lle us
Cochle a r ne rve
Incus
Tympa nic S ta pe s Cochle a r
me mbra ne duct

Exte rna l
a cous tic
ca na l

Ha ir ce lls on
Ova l window orga n of Corti
(s pira l orga n)

S
Auditory tube
L M
Ba s ila r me mbra ne
(s pira l me mbra ne ) I

FIGURE 11-15 E ect o sound waves in the ear. Sound waves strike the tympanic membrane and cause it to
vibrate. This vibration causes the membrane o the oval window to vibrate. Vibration o the oval window causes the
perilymph in the bony labyrinth o the cochlea to move, which causes the endolymph in the membranous labyrinth o
the cochlea or cochlear duct to move. This movement o endolymph stimulates hair cells on the organ o Corti (spiral
organ) to generate a nerve impulse. The nerve impulse travels over the cochlear nerve, which becomes a part o cranial
nerve VIII. Eventually, nerve impulses reach the auditory cortex and are interpreted as sound.
 306 CHAPTER 11 Senses
11
Ma cula e
Ve s tibule
S a nd cupula
L M
A I
Ma cula
B C
FIGURE 11-16 Static equilibrium. A, Structure o vestibule showing
placement o the maculae, which have mechanoreceptors that detect our
sense o gravity or static equilibrium. B, Macula stationary in upright posi-
tion. C, Macula displaced by gravity as person bends over.
T is activation o mechanoreceptors in the organ o Corti
inside the coch ea o the inner ear generates nervous impu ses
that trave through the cochlear nerve to the brain and resu ts
in hearing.
I you would like to learn how cochlear
implants or artif cial ears work, check out
the article Cochlear Implants at Connect It! at
evolve.elsevier.com.
To better understand this concept, use the
Active Concept Map Mechanism o Hearing
at evolve.elsevier.com.
Eq u ilib r iu m
T e mechanoreceptors or our sense o ba ance, or equilibrium,
are ocated in the sac ike vestibu e and the three semicircu ar
cana s o the inner ear.
W ithin the vestibu e are two structures, each made up o a
patch o sensory hairs coated with a thick g ob o heavy ge .
Each o these structures is ca ed a macula. W hen you bend
your head, gravity acts on the heavy ge to pu it one way or
the other (Figure 11-16). T is, in turn, bends the ci ia o the hair
ce s and thus produces a nerve signa . T is signa is interpreted
by the brain as our sense o gravity or static equilibrium.
S e micircula r
ducts
Ampulla e
Ve s tibula r
ne rve
Cris ta a mpulla ris
S
Ve s tibula r ne rve L M
A bra nch
I
Cupula
B Cris ta C
FIGURE 11-17 Dynamic equilibrium. A, Semicircular ducts showing
location o the crista ampullaris and cupula in ampullae. B, When a person
is at rest, the crista ampullaris and cupula do not move. C, As a person be-
gins to spin, the cupula bends and the crista ampullaris is displaced by the
endolymph in a direction opposite to the direction o spin. This produces the
sensation o dynamic equilibrium.
T e three semicircu ar cana s are ha -circ es oriented at
right ang es to one another (Figure 11-17). W ithin each cana is
a di ated area ca ed the ampulla that contains a sensory struc-
ture ca ed a crista ampullaris, which generates a nerve im-
pu se when the speed or direction o movement o your head
changes. T is sense o motionis ca ed dynamic equilibrium.
T e sensory ce s in the cristae ampu ares have hair ike
ci ia that are embedded in a ap ike cupula, which sways back
and orth within the endo ymph. T e sensory ce s are stimu-
ated when a change in movement o the head causes the
endo ymph to move di erent y, thus causing the crista ampu -
aris to sway with more or ess orce. Because each semicircu-
ar cana is ang ed in a di erent p ane o the body, the brain
can compare in ormation rom each crista ampu aris to de-
termine direction o movement.
Nerves rom mechanoreceptors in the vestibu e join those
rom the semicircu ar cana s to orm the vestibular nerve. T e
vestibu ar nerve then joins with the coch ear nerve to orm the
vestibulocochlear nerve (CN VIII) (see Figure 11-12). Eventua y,
nervous impu ses passing through this nerve reach the cerebe -
um and medu au timate y reaching the cerebra cortex.

QUICK CHECK
1. Wh a t s tru ctu re in th e e a r vib ra te s w h e n s o u n d wa ve s
tra ve l th ro u g h th e a co u s tic ca n a l?
2. Why d o e s a n in e ctio n o th e th ro a t o te n s p re a d a n d
ca u s e a m id d le e a r in e ctio n ca lle d o titis m e d ia ?
3. Wh a t u id f lls th e m e m b ra n o u s la b yrin th ? th e o rga n o
Co rti?
4. Wh e re a re th e m e ch a n o re ce p to rs o r b a la n ce a n d e q u ilib -
riu m lo ca te d ?
To learn more about the process o hearing, go to
AnimationDirect online at evolve.elsevier.com.
He a r in g a n d Eq u ilib r iu m D is o r d e r s
He a r in g D is o r d e r s
H earing prob ems can be divided into two basic categories:
conduction impairment and nerve impairment. Conduction
impairment re ers to the b ocking o sound waves as they
trave through the externa and midd e ear to the sensory re-
ceptors o the inner ear (the conduction pathway). Nerve
impairment resu ts in insensitivity to sound because o inher-
ited or acquired nerve damage.
T e most obvious cause o conduction impairment is
b ockage o the externa auditory cana . Waxy bui dup o ceru-
men common y b ocks conduction o sound toward the tym-
panic membrane (see Figure 11-13, D). Foreign objects, tumors,
and other matter can b ock conduction in the externa or
midd e ear.
An inherited bone disorder ca ed otosclerosis impairs
conduction by causing structura irregu arities in the stapes.
O tosc erosis usua y f rst appears during chi dhood or ear y
adu thood as tinnitus, or ringing in the ear.
emporary conduction impairment o ten resu ts rom ear
in ection, or otitis. As stated ear ier, the structure o the audi-
tory tube makes the midd e ear prone to bacteria or vira otitis
media. O titis media o ten produces swe ing and pus orma-
tion that b ocks the conduction o sound through the midd e
ear. Permanent damage to structures o the midd e ear occa-
siona y occurs in severe cases. In ectious organisms rom a
midd e ear in ection that invade the mastoid bone are o ten
di cu t to treat (see discussion in Chapter 8 on p. 185). T ey
cause redness, in ammation, and swe ing o the mastoid pro-
cess that may push the auric e away rom the sku . H earing
oss may be a comp ication in severe cases.
H earing oss caused by nerve impairment is common in
the e der y. Ca ed presbycusis, this progressive hearing oss
associated with aging resu ts rom degeneration o nerve tis-
sue in the ear and the vestibu ococh ear nerve.
A simi ar type o hearing oss occurs a ter chronic exposure
to oud noises that damages receptors in the organ o Corti.
Because di erent sound requencies (tones) stimu ate di erent
regions o the organ o Corti, hearing impairment is imited
to on y requencies associated with the damaged portion o
the organ o Corti. For examp e, the portion o the organ
o Corti that degenerates f rst in presbycusis is norma y
CHAPTER 11 Senses 307
stimu ated by high- requency sounds. T us the inabi ity to
hear high-pitched sounds is common among the e der y.
W hether a person is young or o d, research shows that 11
protecting onese rom oud noises and constant noises can
reduce hearing oss over time.
Eq u ilib r iu m D is o r d e r s
Equi ibrium disorders are o ten characterized by vertigo
(sensation o spinning), disorientation, a ing (or ee ing o
a ing), dizziness, and/or ightheadedness. Some anxiety dis-
orders can a so cause these symptoms, but are not true equi-
ibrium disorders.
Some equi ibrium disorders are caused by in ection or in-
ammation o the inner ear, others by head injuries, nerve
damage, or unknown causes. emporary equi ibrium impair-
ment sometimes occurs when the brain receives con icting
sensory in ormation about body movement rom mu tip e
senses (vision, ba ance, proprioception, etc.)as in motion
sickness.
Mnire disease is a chronic inner ear disease o unknown
cause. Mnire disease is characterized by tinnitus, progressive
nerve dea ness, and vertigo.
QUICK CHECK
1. Wh a t is tin n itu s ?
2. Wh a t is th e p ro g re s s ive h e a rin g lo s s ca u s e d b y n e rve
im p a irm e n t th a t is co m m o n in th e e ld e rly?
3. Wh a t a re th e tw o b a s ic ca te g o rie s o h e a rin g p ro b le m s ?
Ta s t e
O ur sense o tasteor gustationa ows us to chemica y
ana yze ood be ore we bite or swa ow it.
T e taste buds are the sense organs o taste. T ey contain
both supporting ce s and chemoreceptors ca ed gustatory
cells. T ese ce s generate the nervous impu ses u timate y
interpreted by the brain as taste (Figure 11-18).
Nervous impu ses that are generated by stimu ation o taste
buds trave primari y through two crania nerves (CN VII and
CN IX) to end in the taste area o the cerebra cortex.
A though a ew taste buds are ocated in the ining o the
mouth and on the so t pa ate, most are ocated on the sides o
much arger and di ering shaped bumps scattered across the
tongue ca ed papillae. About 10 to 15 arge circumvallate
papillae orm an inverted V pattern at the back o the
tongue and contain the most taste buds.
Each taste bud, as you can see in Figure 11-18, C, opens
through an opening into a trench ike moat that surrounds the
papi a and is f ed with sa iva. Chemica s disso ved in the
sa iva stimu ate the chemoreceptor gustatory ce s. A tastes
can be detected in a areas o the tongue that contain taste
buds.
Physio ogists origina y counted on y our primary taste
sensationssweet, sour, bitter, and saltythat permit us to
detect sugars, acids, a ka ines, and sodium ions disso ved in our
sa iva. H owever, the ist o primary taste sensations has ex-
panded to inc ude severa others present in most individua s.
 308 CHAPTER 11 Senses

Pa la tine Circumva lla te Lingua l tons il FIGURE 11-18 Tongue. A, Dorsal sur ace o the tongue. B, Section
tons il pa pilla e through a papilla with taste buds on the side. C, Enlarged view o a section
11 through a taste bud.

Ne rve Gus ta tory Gus ta tory

fibe rs ce ll ha irs
Ta s te buds Ora l S upporting
e pithe lium ce ll

Folia te
pa pilla e

Ta s te
pore

Fungiform
pa pilla e
P

R L

A
A B C

Current y, metallic taste (to detect meta ions) and a sa-
vory, meaty taste ca ed umami (to detect the amino acid
g utamate) have been added to the ist o primary tastes. T e
ist continues to grow. O course, some individua s are ab e to
sense a arger number o tastes than others. Notab e examp es
inc ude experts and supertasters who, it is said, can detect
itera y dozens o discrete and di erent tastes in wine, co ee,
tea, and other oods and beverages.
S m e ll
T e chemoreceptors responsib e or sme or ol action are
ocated in a sma area o epithe ia tissue in the upper part o
the nasa cavity (Figure 11-19). T e ocation o the ol actory
receptors is somewhat hidden, and we o ten have to orce u y
sni air to sme de icate odors.
Each o actory ce has a number o sensory ci ia that detect
di erent chemica s and cause the ce to respond by generating

Olfa ctory Olfa ctory Olfa ctory Olfa ctory Olfa ctory Olfa ctory Tha la mic
e pithe lium bulb ne rve s tra ct bulb tra ct ce nte r

Olfa ctory
e pithe lium
Na s a l
cavity

A P

Na s a l cavity I

Odor Olfa ctory Olfa ctory

mole cule s cilia ce lls

FIGURE 11-19 Ol actory structures. Gas molecules

stimulate ol actory cells in the nasal epithelium. Sensory
in ormation is then conducted along nerves in the ol ac-
tory bulb and ol actory tract to sensory processing cen-
ters in the brain.

a nervous impu se. o be detected by o actory receptors,
chemica s must be disso ved in the watery mucus that ines the
nasa cavity.
T e o actory receptors are extreme y sensitive and respond
quick y to even very s ight odors. H owever, they are a so easi y
atigueda act that exp ains why odors that are at f rst very
noticeab e are not sensed at a a ter a short time. T is de-
crease in receptor sensitivity is ca ed adaptation.
A ter the o actory ce s are stimu ated by odor-causing
chemica s, the resu ting nerve impu se trave s through the o ac-
tory nerves in the o actory bu b and tract and then enters the
tha amic and o actory centers o the brain, where the nervous
impu ses are interpreted as specif c odors. T e pathways taken by
o actory nerve impu ses and the areas where these impu ses are
interpreted are c ose y associated with areas o the brain impor-
tant in memory and emotion. For this reason, we may retain
vivid and ong- asting memories o particu ar sme s and odors.
QUICK CHECK
1. Id e n ti y th e p rim a ry ta s te s th a t h u m a n s ca n p e rce ive .
2. Why a re o d o rs th a t a re ve ry n o tice a b le a t f rs t, n o t s e n s e d
a t a ll a te r a s h o rt tim e ?
3. Tra ce th e p a th wa y o s m e ll ro m th e o l a cto ry ce lls to th e
b ra in .
To learn more about how the brain interprets odors,
go to AnimationDirect online at evolve.elsevier.com.
In t e g r a t io n o S e n s e s
Looking at the big picture o sensation, we shou d remind
ourse ves that sensations are a perceived in the brainnot at
the individua receptors scattered throughout the body. Some
sensory signa s never get to the brain, others are amp if ed or
mu ed in the brain. A incoming signa s are integrated with
other sensory signa s and even memories to produce our per-
ceptions, which are rea y a combined sensation o our wor d
at that moment.
S C IEN C E APPLICATIONS
S ENS ES
Santiago Ramn y Cajal is consid-
ered by many to be the originator o
the modern view o the nervous
systems organization. He not only
uncovered much about sensory cen-
ters o the cortex and the structure
o the retina but also made impor-
tant discoveries about nearly every
part o the nervous system. Most o
this Spanish researchers ideas
Santiago Ramn y Cajal about the nervous system are intact
(1852-1934) today. Although Santiago wanted to
be an artist, his ather convinced
him to ollow in his ootsteps and become an anatomista
choice that led to his receiving a Nobel Prize in 1906.
CHAPTER 11 Senses 309
For examp e, most o what we think o as avor sensations
resu t rom a combination o sensory stimu i detected by gus-
tatory ce s, o actory receptors, and even touch and pain re- 11
ceptors. In other words, the myriad unique avors we recog-
nize are not just tastes a one but are a combined sensation
based on tastes, odors, touch, temperature, and pain.
For this reason, severe nasa congestion can inter ere with
the stimu ation o the o actory receptors by odors rom oods
in the mouth, which can marked y du avor sensations (see
Figure 11-19). Some oods seem to have a di erent avor i they
are crispy or warm or co d. And some spicy oods stimu ate
pain or temperature receptors to produce a hot avor. Some
mints can produce a sensation o coo ness that adds to our
experience o avor.
Sme sensations, even more than other modes o sensa-
tion, are o ten power u triggers o memory. Yet a sensations
are compared to our earned memories, which he p us accu-
rate y interpret what we are sensing at any one moment.
We o ten combine the senses o equi ibrium with vision and
proprioception to maintain our posture and ba ancethus
maintaining a sa e body position under changing circumstances.
We shou d a so remind ourse ves that some sensory in or-
mation is processed and perceived subconscious y. You cannot
ee your b ood pH go up or down, but your brain is con-
stant y aware o such changes. Likewise, you cannot state your
current b ood oxygen saturationbut your subconscious
mind is aware o the precise eve .
W ith a the senses, advancing age o ten brings a structura
degeneration that resu ts in reduced unction. Mechanorecep-
tors in our ears become ess sensitive, our enses become ess
ab e to adjust our visua ocus, and we s ow y ose taste and
sme unction. T is may exp ain why some oods just dont
taste the same as they did when we were younger. It is no
wonder that some o der adu ts become iso ated and depressed
when their contact with the outside wor d, through the senses,
is gradua y ost. Caring hea th pro essiona s recognize these
signs o aging and provide assistance needed by their aged
patients to once again enjoy i e.
The s tudy o the s e ns ory as pe ct o the ne rvous s ys te m and
its re lations hips w ith the re s t o the body is us e ul in m any
di e re nt f e lds . For exam ple , the ide as us e d by o pto m e tris ts
and o phthalm o lo g is ts , o to lo g is ts and audio lo g is ts , and
othe r pro e s s ionals w ho as s e s s and tre at s e ns ory dis orde rs
are bas e d on ne uros cie nce .
Many othe r f e lds m ake indire ct us e o ne uros cie nce as
we ll. For exam ple , artis ts us e w hat we know o vis ual pe rce p-
tion in cre ating the ir works , m us icians and archite cts m ake us e
o our know le dge o s ound pe rce ption w he n pe r orm ing in or
de s igning conce rt halls , and ae ros pace pro e s s ionals can us e
w hat we know o e quilibrium and how it is pe rce ive d in the
brain to unde rs tand s patial orie ntation and m otion s ickne s s .
 310 CHAPTER 11 Senses

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 291)

11
circumvallate papilla ganglion cell mode
(ser-kum-VAL-ayt pah-PIL-ah) (GANG-lee-on sell) (mohd)
pl., papillae [gangli- knot, -on unit, cell storeroom] ol action
(pah-PIL-ee) general senses (ohl-FAK-shun)
[circum- around, -vall- post or stake, (J EN-er-al SEN-sez) [ol act- smell, -ion process]
-ate relating to, papilla nipple] gustation ol actory receptor
cochlea (GUS-tay-shun) (ohl-FAK-tor-ee ree-SEP-tor)
(KOHK-lee-ah) [gusta- taste, -tion process] [ol act- smell, -ory relating to, recept- receive,
[cochlea snail shell] -or agent]
gustatory cell
cochlear duct (GUS-tah-tor-ee sell) optic disk
(KOHK-lee-ar dukt) [gusta- taste, -ory relating to, cell storeroom] (OP-tic disk)
[cochlea- snail shell, -ar relating to] [opti- vision, -ic relating to]
helix
cochlear nerve (HEE-liks) organ o Corti
(KOHK-lee-ar nerv) pl., helices (OR-gan ov KOR-tee)
[cochlea- snail shell, -ar relating to, (HEE-lis-eez) [organ tool or instrument, Al onso Corti Italian
nerv- string or nerve] [helix spiral] anatomist]
cone incus ossicle
(cohn) (IN-kus) (OS-sih-kul)
conjunctiva [incus anvil] [os- bone, -icle little]
(kon-junk-TIH-vah) intraocular pressure pain receptor
[con- together, -junct join] (in-trah-OK-yoo-lar PRESH-ur) (payn ree-SEP-tor)
cornea [intra- within, -ocul- eye, -ar relating to] [recept- receive, -or agent]
(KOR-nee-ah) iris papilla
[corn- horn, -a thing] (AYE-ris) (pah-PIL-ah)
crista ampullaris [iris rainbow] pl., papillae
(KRIS-tah am-pyoo-LAYR-is) lacrimal gland (pah-PIL-ee)
[crista ridge, ampu- ask, -ulla- little, (LAK-rih-mal gland) [papilla nipple]
-aris relating to] [lacrima- tear, -al relating to, gland- acorn] perilymph
cupula lens (PAYR-ih-lim )
(KYOO-pyoo-lah) (lenz) [peri- around, -lymph water]
pl., cupulae [lens lentil] photopigment
(KYOO-pyoo-lee) macula ( oh-toh-PIG-ment)
[cup- tub, -ula little] (MAK-yoo-lah) [photo- light, -pigment paint]
dynamic equilibrium pl., maculae or maculas photoreceptor
(dye-NAM-ik ee-kwi-LIB-ree-um) (MAK-yoo-lee or MAK-yoo-lahz) (FOH-toh-ree-sep-tor)
[dynam- moving orce, -ic relating to, [macula spot] [photo- light, -recept- receive, -or agent]
equi- equal, -libr- balance] macula lutea pinna
eardrum (MAK-yoo-lah LOO-tee-ah) (PIN-nah)
(EAR-drum) [macula spot, lutea yellow] [pinna wing or f n]
endolymph malleus proprioceptor
(EN-doh-lim ) (MAL-ee-us) (proh-pree-oh-SEP-tor)
[endo- within, -lymph water] [malleus hammer] [propri- ones own, -(re)cept- receive, -or agent]
eustachian tube mechanoreceptor pupil
(yoo-STAY-shun) (mek-an-oh-ree-SEP-tor) (PYOO-pill)
[Bartolomeo Eustachio Italian anatomist, [mechano- machine (mechanical), [pup- doll, -il little]
-an relating to] -recept- receive, -or agent] re erred pain
external acoustic canal membranous labyrinth (re-FERD payn)
(eks-TER-nal ah-KOO-stik kah-NAL) (MEM-brah-nus LAB-eh-rinth) re raction
[extern- outside, -al relating to, acoust- hearing, [membran- thin skin, -ous characterized by, (ree-FRAK-shun)
-ic relating to] labyrinth maze] [re- back or again, - ract- break, -tion process]
ovea centralis metallic retina
(FOH-vee-ah sen-TRAL-is) (meh-TAL-ik) (RET-ih-nah)
[ ovea pit, centralis in the center] [metal- metal, -ic relating to] [ret- net, -ina relating to]
 CHAPTER 11 Senses 311

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 310)

11
rod stapes tympanic membrane
(rod) (STAY-peez) (tim-PAN-ik MEM-brayn)
sclera [stapes stirrup] [tympan- drum, -ic relating to,
(SKLEH-rah) static equilibrium membran- thin skin]
[sclera hard] (ee-kwih-LIB-ree-um) umami
semicircular canal [stat- stand, -ic relating to, equi- equal, (oo-MAH-mee)
(sem-ih-SIR-kyoo-lar kah-nal) -libr- balance] [umami savory]
[semi- hal , -circul-circle, -ar relating to] taste bud vestibular nerve
sensory receptor (tayst bud) (ves-TIB-yoo-lar nerv)
(SEN-soh-ree ree-sep-tohr) thermoreceptor [vestibul- entrance hall, -ar relating to,
[sens- eel, -ory relating to, recept- receive, (ther-moh-ree-SEP-tor) nerv- string or nerve]
-or agent] [thermo- heat, -cept- receive, -or agent] vestibule
special senses tragus (VES-tih-byool)
(SPESH-ul SEN-sez) (TRAY-gus) [vestibul- entrance hall]
spiral organ [tragus male goat] vitreous humor
(SPY-rel OR-gun) (VIT-ree-us HYOO-mer)
[spir- coiled, -al relating to, organ tool or [vitre- glassy, -ous o or like, humor uid]
instrument]

LANGUAGE OF M ED IC IN E

age-related macular degeneration (AMD) hyperopia optometrist

(ayj ree-LAYT-ed MAK-yoo-lar (hye-per-OH-pee-ah) (op-TOM-eh-trist)
dih-jen-uh-RAY-shun) [hyper- excessive or above, -op- vision, [opti- vision, -metr- measure, -ist agent]
[macula- spot, -ar relating to, de- down, -ia condition] otitis
-generat- produce, -tion condition] laser-assisted in situ keratomileusis (LASIK) (oh-TYE-tis)
astigmatism (LAY-zer ah-SIS-ted in- SYE-too [ot- ear, -itis in ammation]
(ah-STIG-mah-tiz-em) kayr-at-oh-mil-YOO-sis) otitis media
[a- not, -stigma- point, -ism condition] [laser- shortened light amplif cation by (oh-TYE-tis MEE-dee-ah)
audiologist stimulated emission o radiation, in in, [ot- ear, -itis in ammation, media middle]
(aw-dee-OL-oh-jist) situ place, kera- horn, -mileusis carving] otosclerosis
[audio- hear, -log- words (study o ), -ist agent] Mnire disease (oh-toh-skleh-ROH-sis)
cataract (men-ee-AYR dih-ZEEZ) [oto- ear, -sclero- hard, -sis condition]
(KAT-ah-rakt) [Prosper Mnire French physician, otologist
[cataract broken water] dis- opposite o , -ease com ort] (oh-TOL-o-jist)
color blindness myopia [oto- ear, -log- words (study o ), -ist agent]
(KUL-or BLIND-nes) (my-OH-pee-ah) otoscope
[my- shut, -op- vision, -ia condition]
conjunctivitis (OH-toh-skohp)
(kon-junk-tih-VYE-tis) nyctalopia [oto- ear, -scop- see]
[con- together, -junct- join, -iv- relating to, (nik-tah-LOH-pee-ah) presbycusis
-itis in ammation] [nyct- night, -op- vision, -ia condition] (pres-bih-KYOO-sis)
diabetic retinopathy ophthalmologist [presby- elderly, -cusis hearing]
(dye-ah-BET-ik ret-in-AH-path-ee) (o -thal-MOL-eh-jist) presbyopia
[diabet- siphon (diabetes), -ic relating to, [oph- eye or vision, -thalm- inner chamber, (pres-bee-OH-pee-ah)
ret- net, -in- relating to, -path- disease, -o- combining vowel, -log- words (study o ), [presby- aging, -op- vision, -ia condition]
-y state] -ist agent]
radial keratotomy (RK)
glaucoma ophthalmoscope (RAY-dee-al KAR-ah-tah-toh-mee)
(glaw-KOH-mah) (o -THAL-mah-skohp) [radi- ray, -al relating to, kera- horn, -tom- cut,
[glauco- gray or silver, -oma tumor (growth)] [oph- eye or vision, -thalmo- inner chamber, -y action]
-scop- see]
 312 CHAPTER 11 Senses

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 311)

11
retinal detachment tinnitus trachoma
(RET-in-al deh-TACH-ment) (tih-NYE-tus or TIN-nit-us) (trah-KOH-mah)
[ret- net, -in- relating to, -al relating to, [tinnitis ringing or tinkling] [trach- rough, -oma tumor]
de- remove, -tach- attach, -ment condition] tophus vertigo
scotoma (TOH- us) (VER-tih-go)
(skoh-TOH-mah) pl., tophi [vertigo turning]
[scoto- darkness, -oma tumor] (TOH- ye)
strabismus [tophus porous rock]
(strah-BIS-mus)
[strab- squinting, -ismus condition]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S e ns o ry Pathw ays
S u m m a rie s online at evolve .e ls evie r.com . A. A sense organs have common unctiona characteristics
1. A are ab e to detect a particu ar stimu us
Scan this s um m ary a te r re ading the chapte r to 2. A stimu us resu ts in generation o a nerve impu se
he lp you re in orce the key conce pts . Late r, us e 3. A nerve impu se is processed and perceived as a sensa-
the s um m ary as a quick review be ore your clas s tion in the centra nervous system
or be ore a te s t.

Ge ne ral S e ns e s
Clas s if catio n o S e ns e s A. Distribution is widespread; sing e-ce receptors are
A. Genera senses common
1. Detected by sensory organs that exist as individua B. Modethe kind o stimu us or change a receptor or
ce s or receptor units (Table 11-1) sense is ab e to detect
2. W ide y distributed throughout the body C. Examp es o genera sensory receptors and their modes
B. Specia senses (Table 11-2) (Figure 11-1, Table 11-1)
1. Detected by arge and comp ex organs, or oca ized 1. Skin receptors
grouping o sensory receptors a. Free nerve endings (severa types)pain, discrimi-
C. Sensory receptor types native touch, tick e, and temperature
1. C assif ed by presence or absence o covering capsu e b. acti e (Meissner) corpusc ef ne touch and
a. Encapsu ated vibration
b. Unencapsu ated ( ree or naked)
2. C assif ed by type o stimu i (mode) required to acti- d. Lame ar (Pacini) corpusc epressure and
vate receptors vibration
a. Photoreceptors ( ight) e. Bu boid (Krause) corpusc etouch
b. Chemoreceptors (chemica s) 2. Musc e receptors
c. Pain receptors (injury) a. Go gi tendon receptorproprioception
d. T ermoreceptors (temperature change) b. Musc e spind eproprioception
e. Mechanoreceptors (movement or shape change) 3. Deep receptors
a. Stretch (pressure) receptors in ho ow organs
b. Chemica receptorsdetect pH , carbon dioxide,
other chemica s

S pe cial S e ns e s
A. Vision
1. Eye (Figure 11-2)
a. Layers o eyeba
(1) Fibrous ayertough outer coat
(a) Sc erawhite o eye
(b) Corneatransparent part over iris
(c) Conjunctivamucous membrane that
covers ront o f brous ayer and extends to
inside o eye ids
(d) Lacrima g andsecretes tears that
moisten conjunctiva
(2) Vascu ar ayerhas dense network o b ood
vesse s
(a) Choroidpigmented, me anin-rich ayer
prevents scattering o ight
(b) Iristhe co ored part o the eye; the pupi
is the ho e in the center o the iris; con-
traction o smooth musc e di ates or con-
stricts pupi (Figure 11-3)
(c) Lenstransparent body behind the pupi ;
ocuses or re racts ight rays on the retina
(d) Ci iary musc enear ront o vascu ar
ayer, just outside the edge o the iris; con-
traction a ects shape o ens just behind
the iris, thus a tering ocus or near objects
(3) Inner ayerinnermost sensory ayer
- b.
ceptors (Figure 11-4 and Figure 11-5)
periphera vision
ii. Conesreceptors or day vision and
co or vision
iii. Gang ion ce sreceptors or changing
ight patterns o days, months, seasons
b. Eye uids
(1) Aqueous humorin the anterior chamber in
ront o the ens
(2) Vitreous humorin the posterior chamber
behind the ens
2. Visua pathway
a. Vision detects intensity (brightness) and wave-
ength (co or) o ight, as we as images and
motion
b. Light must be re racted ( ocused) by the eye to
orm a detectab e image
c. Innermost ayer o retina contains rods and cones
d. Impu se trave s rom the rods and cones through
the bipo ar and gang ionic ayers o retina
(Figure 11-4)
e. Nerve impu se eaves the eye at the optic disk and
continues through the optic nerve; the point o exit
(optic disk) is ree o receptors and is there ore a so
ca ed a blind spot (Figure 11-5)
. Visua interpretation occurs in the visua cortex o
the cerebrum (Figure 11-6)
CHAPTER 11 Senses 313
B. Visua disorders
a. Common ocusing prob ems (Figure 11-7) 11
(1) Myopia (nearsightedness) is o ten caused by
e ongation o the eyeba
(2) H yperopia ( arsightedness) is o ten caused by a
shortened eyeba
(3) Astigmatism is distortion caused by an irregu-
arity o the cornea or ens
(4) Presbyopia is arsightedness that occurs in ate
adu thood due to reduced e asticity
b. Cataracts i etime exposure to UV radiation can
trigger ormation o hard, mi ky spots in the ens
(Figure 11-8)
c. Conjunctivitis (in ammation o the conjunctiva)
can inter ere with re raction
(1) rachomachronic ch amydia in ection
(2) Acute bacteria conjunctivitishigh y conta-
gious in ection that produces a discharge o
mucous pus (Figure 11-9)
(3) Conjunctivitis can be caused by a ergies
d. Strabismusimproper a ignment o eyes
(Figure 11-10)
(1) Eyes can converge (cross) or diverge
(2) I not corrected, can cause b indness
2. Disorders o the retina
eye tumors, or head trauma
Diabetic retinopathydamage to retina rom hem-
orrhages and growth o abnorma vesse s associated
with diabetes me itus
c. G aucomaincreased intraocu ar pressure
decreases b ood ow in retina and thus causes
retina degeneration
d. Nycta opia (night b indness) or the inabi ity to see
in dim ight is caused by retina degeneration or
ack o vitamin A
e. Macu ar degenerationprogressive degeneration o
centra part o retina; eading cause o permanent
b indness in e der y
condition invo ving the inabi ity to perceive certain
co ors; it is caused by an abnorma ity in the cones
photopigments (Figure 11-11)
3. Disorders o the visua pathway
a. Degeneration o the optic nerve resu ting rom dia-
betes, g aucoma, and other causes can impair vision
b. Scotoma is the oss o on y the centra visua f e d
when on y certain nerve pathways are damaged
c. Cerebrovascu ar accidents (CVAs) can damage
visua processing centers; examp e is acquired corti-
ca co or b indness
C. H earing and Equi ibrium
1. T e ear unctions in hearing and in equi ibrium using
receptors ca ed mechanoreceptors
 314 CHAPTER 11 Senses
2. Ear (Figure 11-12)
a. Externa ear
11 (1) Auric e (pinna)
(2) Externa acoustic cana
(a) Curving cana 2.5 cm (1 inch) in ength
(b) Contains ceruminous g ands
(c) Ends at the tympanic membrane
(Figure 11-13)
b. Midd e ear
(1) H ouses ear ossic esma eus, incus, and stapes
(2) Ends in the ova window
(3) T e auditory (eustachian) tube connects the
midd e ear to the throat
(4) In ammation ca ed otitis media
c. Inner ear (Figure 11-14)
(1) Bony abyrinth f ed with peri ymph
(2) Subdivided into the vestibu e, semicircu ar
cana s, and coch ea
(3) Membranous abyrinth f ed with endo ymph
3. H earing (Figure 11-15)
a. H earing detects changes in intensity and requency
(tone) o sound waves, which are pressure waves
b. Sound waves unne ed by auric e into externa
acoustic cana and vibrate the tympanic membrane
c. Vibrations o tympanic membrane are amp if ed by
auditory ossic es and transmitted to the ova window
d. Vibrations o the ova window trigger vibrations o
peri ymph, which in turn vibrates the endo ymph
e. Sensory hair ce s on the organ o Corti (spira
organ) respond when bent by the movement o sur-
rounding endo ymph set in motion by sound waves;
can become damaged by chronic exposure to oud
noise
4. Equi ibriumtwo types o ba ance: static and
dynamic
a. Static equi ibriumsense o gravity (Figure 11-16)
(1) Detected by ci iated hair ce s (mechanorecep-
tors) o the two macu ae in the vestibu e
(2) W hen the head ti ts, gravity pu s the heavy ge
o each macu a, bending the sensory ci ia and
producing a nerve signa
b. D ynamic equi ibriumsense o speed and direc-
tion o movement (Figure 11-17)
(1) Detected by ci iated hair ce s (mechanorecep-
tors) o the crista ampu aris (with ap ike
cupu a) in the ampu a o each semicircu ar cana
(2) W hen speed or direction o movement o head
changes, the ow o endo ymph in semicircu ar
cana s is a tered, which causes change in bending
o sensory ci ia (producing a nerve signa )
c. Vestibu ar nerve carries nerve impu ses rom the
equi ibrium receptors o the vestibu e; joins with
coch ear nerve to orm vestibu ococh ear nerve
(CN VIII)
D. H earing and equi ibrium disorders
1. H earing Disorders
a. Conduction impairment
(1) Can be caused by b ockage o the externa or
midd e ear ( or examp e, by cerumen and
tumors)
(2) O tosc erosisinherited bone disorder invo ving
irregu arity o the stapes; it f rst appears as tin-
nitus (ringing), then progresses to hearing oss
(3) O titisear in ammation caused by in ection;
can produce swe ing and uids that b ock
sound conduction
b. Nerve impairment
(1) Presbycusisprogressive nerve dea ness associ-
ated with aging
(2) Progressive nerve dea ness a so can resu t rom
chronic exposure to oud noise
2. Equi ibrium disorders
a. Characterized by vertigo, disorientation, a ing (or
a ing ee ing), dizziness, and/or ightheadedness
b. Motion sicknesstemporary equi ibrium prob em
caused by mismatch o senses in the brain regard-
ing body movement
c. Mnire diseasechronic inner ear disorder o
unknown cause; characterized by tinnitus, nerve
dea ness, and vertigo
E. aste
1. Sense o taste is a so ca ed gustation
ocated in taste buds (Figure 11-18)
3. Crania nerves VII and IX carry gustatory impu ses
4. Primary taste modes
a. Sweetdetects sugars
b. Sourdetects acids
c. Bitterdetects a ka ine so utions
d. Sa tydetects sodium ions
e. Meta icdetects meta ions
. Umami (savory)detects g utamate (an amino acid)
F. Sme (o action)
1. O actory receptorssensory f bers o o actory or
crania nerve I ie in o actory mucosa o nasa cavity
(Figure 11-19)
2. O actory receptors are extreme y sensitive but easi y
adapt (become atigued)
3. Odor-causing chemica s initiate a nervous signa that
is interpreted as a specif c odor by the brain
4. O action has a strong re ationship with emotions and
memory

Inte g ratio n o S e ns e s
1. A senses are processed and f na y perceived in the
brain (not receptors)
2. Sensory in ormation is combined to orm an overa
sensory perception o our wor d
a. F avor
(1) Combination o gustatory and o actory senses;
can be a ected by other senses, such as touch,
pain, or temperature
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Each o the bodys s e ns e s m us t go through the ollow ing pro-
ce s s e s to pe r orm its unction: (1) de te ct the phys ical s tim ulus
to w hich it re s ponds and (2) conve rt that s tim ulus into a ne rve
im puls e . For exam ple , the eye m us t le t light in and ocus it on
a s pe cif c point; the re ce ptors conve rt that s tim ulus into a
ne rve im puls e and s e nd it to the brain.
1. W hen you study structures and their specif c unction in a
sensory system, ocus on how they contribute to one o
these two processes. Use ash cards and other on ine
resources to earn the specif c structures and their unc-
tions in each sensory system. Link the disorders in the
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Name the genera senses ound in the skin or subcutane-
ous tissue and ist the type o stimu i to which each o
them responds.
2. List the two genera senses o proprioception and give
the ocation o each.
3. W ith what type o in ormation do proprioceptors
provide us?
4. Describe how the iris changes the size o the pupi .
5. Exp ain how the ci iary musc es a ow the eye to ocus
on near and ar objects.
6. W hat is presbyopia and what is its cause?
7. List the three types o receptor ce s in the retina.
Exp ain the di erences between the three receptors.
CHAPTER 11 Senses 315
(2) Nasa congestion inter eres with stimu ation o
o actory receptors and thereby du s avor
sensations 11
b. Posture and ba anceboth senses o equi ibrium
with vision and proprioceptioncombine to he p
us maintain a sa e body position
3. Some sensory in ormation is processed subconscious y
4. O ur senses may dec ine as we age
sensory system to their cause or mechanism. In the eye,
these are re raction, retina damage, or pathway damage.
In the ear, conduction, in ection, or nerve damage may
cause disorders. A chart may be the best way to organize
this in ormation.
2. In your study group, discuss how each o the sensory
systems detect and respond to a stimu us. Photocopy the
f gures o the sense organs, b acken out the abe s, and
quiz each other on the name, ocation, and unction o
each structure. Use on ine abe ing exercises (www
.getbodysmart.com) as a resource.
-
the end o the chapter and discuss possib e test questions
in your study group.
8. Def ne g aucoma and exp ain the cause o this condition.
9. W hat are cataracts? W hat causes cataracts and how can
they be prevented?
10. W hat is meant by the visual pathway? W here is the
blind spot and what causes it?
11. Exp ain how the disorder strabismus a ects vision.
12. W hat causes diabetic retinopathy?
13. Brie y exp ain the structure o the externa ear.
14. Exp ain how sound waves are transmitted through the
midd e ear.
15. Exp ain how sound waves are converted to an auditory
impu se.
16. Exp ain how the structures in the inner ear he p main-
tain ba ance or equi ibrium.
17. W hat is Mnire disease?
18. W here are the gustatory ce s ocated, and to what
primary tastes do they respond?
19. Exp ain how the sense o sme is stimu ated.
20. Describe how gang ion ce s di er rom rods and cones
 316 CHAPTER 11 Senses

Critical Thinking Chapte r Te s t

11 A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
21. Exp ain why ood oses some o its taste when you have
a bad co d or stu y nose.
22. Exp ain why the onger you are in a new y painted room
the ess ab e you are to sme the paint.
23. Exp ain why the sme o a doctors o ce or the sme
o turkey cooking on T anksgiving can easi y generate
an emotiona response?
24. H ow is sensory response re ated to age?
high- requency tones; exp ain how this can happen.
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e eye can be c assif ed as a photoreceptor. aste and
sme can be c assif ed as ________, and Go gi tendon
receptors and musc e spind es can be c assif ed as
________.
2. T e specif c mechanoreceptor or ba ance is the
________.
3. T e gustatory ce s are invo ved with the sense o
________.
4. T e our primary taste sensations that resu t rom the
stimu ation o the taste buds are ________, ________,
________, and ________.
5. aste buds can be ound on much arger structures on
the tongue ca ed ________.
6. T e chemoreceptors responsib e or the sense o sme
are the ________.
7. ________ is the gradua reduction in sensitivity to an
odor a ter initia contact.
8. T e ________ is a so known as the blind spot.
9. ________ keeps the acoustic cana rom drying and
aking.
10. ________ is used to examine the externa ear cana and
tympanic membrane

Match each structure o the eye in Column A with its corresponding unction or description in Column B.

Column A Column B
11. ________ sc era a. g and in which tears are ormed
12. ________ cornea b. ho e in the eye that ets ight in
13. ________ iris c. receptors or night vision or dim ight
14. ________ pupi d. thick je y ike uid o the eye
15. ________ acrima e. tough, white outer ayer o the eye
16. ________ ens . receptors or red, b ue, and green co or vision
17. ________ rods g. structure on which ci iary musc es pu to he p the eye ocus
18. ________ cones h. dark pigmented midd e ayer o the eye that prevents the scattering o incoming ight
19. ________ choroid coat i. transparent part o the sc era, the window o the eye
20. ________ vitreous body j. co ored part o the anterior o the eye
21. ________ aqueous humor k. thin, watery uid o the eye
 CHAPTER 11 Senses 317

Match each structure o the ear in Column A with its corresponding unction or description in Column B.

Column A Column B 11
22. ________ tympanic membrane a. tube connecting the midd e ear and the throat
23. ________ ossic es b. watery uid that f s the bony abyrinth
24. ________ auditory tube c. snai -shaped structure in the inner ear
25. ________ peri ymph d. organ o hearing
26. ________ endo ymph e. thick uid in the membranous abyrinth
27. ________ coch ea . another term or eardrum
28. ________ organ o Corti g. co ective name or the incus, ma eus, and stapes

Match each disorder in Column A with its description in Column B.

Column A
29. ________ myopia
30. ________ astigmatism
31. ________ conjunctivitis
32. ________ strabismus
33. ________ diabetic retinopathy
34. ________ g aucoma
35. ________ age-re ated macu ar
degeneration
36. ________ co or b indness
37. ________ otitis media
38. ________ Mnire disease
Column B
a. caused by increased uid pressure in the eye
b. an in ammation o the conjunctiva, pink eye
c. progressive degeneration o the centra part o the retina
d. nearsightedness caused by the e ongation o the eyeba
e. an in ection o the midd e ear
. an improper a ignment o the eyes; can cause them to converge (cross)
g. chronic inner ear disorder o unknown cause; characterized by tinnitus, dea ness,
and vertigo
h. an X- inked genetic condition invo ving inabi ity to perceive some co ors
i. damage to the retina caused by hemorrhage and abnorma vesse growth
j. distortion o the image in the eye caused by irregu arities o the cornea or ens

b ack and white movie. She cannot distinguish ye ows,

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
- this condition?
cation o diabetes me itus. Can you describe what struc-
As you were he ping him cross the street, a e ow pedes-
trian sudden y stumb ed into your path. W ithout any
this way?
2. As a chi d, Mrs. Stark was tested or co or b indness and
to d that she had norma co or vision. She never had any
prob ems distinguishing co ors unti short y a ter her
retirement, when sudden y she ost her sense o co or. She
describes her perception o the wor d as being ike a
oranges, b ues, greens, reds, or any other co ors. W hat
might have caused Mrs. Starks prob ems?
3. You have just been diagnosed with otitis media. Describe
what has happened to your body to produce this condi-
tion. I e t untreated, what are the possib e outcomes o
4. Sharon went to the doctor comp aining o abdomina
pain in the right i iac region. A ter examination, the
doctor advised Sharon that he suspected a spina cord
prob em. H e re erred her to a neuro ogist and ordered
pre iminary tests o the spine to be sent to the doctors
o ce in preparation or her visit. Sharon is con used. H er
pain is in her abdomen. W hy is he sending her to a
neuro ogist?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Endocrine System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Endocrine Glands, 320 Parathyroid Glands, 331

Mechanisms o Hormone Action, 320 Adrenal Glands, 331
Nonsteroid Hormones, 320 Location o Adrenal Glands, 331
Steroid Hormones, 321 Adrenal Cortex, 331
Regulation o Hormone Secretion, 324 Adrenal Medulla, 333
Negative Feedback, 324 Adrenal Abnormalities, 334
Positive Feedback, 324 Pancreatic Islets, 334
Levels o Regulation, 324 Sex Glands, 336
Mechanisms o Endocrine Disease, 325 Female Sex Glands, 336
Prostaglandins, 325 Male Sex Glands, 336
Pituitary Gland, 326 Thymus, 337
Structure o the Pituitary Gland, 326 Placenta, 337
Anterior Pituitary Gland Hormones, Pineal Gland, 338
326 Endocrine Functions Throughout the Body,
Posterior Pituitary Gland Hormones, 338
328 Other Endocrine Structures, 338
Hypothalamus, 328 Hormone Actions in Every Organ, 339
Thyroid Gland, 329
Thyroid Hormone, 329
Calcitonin, 330

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you -

should be able to: back mechanisms regulate the secre-
1. Do the ollowing related to endocrine tion o endocrine hormones.
glands:
endocrine disorders.
exocrine glands.
hormone.
-
each major endocrine hormone and crine glands, list the major hormones
describe the conditions that may
- disorders o the endocrine system.
secretion.
2. Describe the mechanisms o steroid and
nonsteroid hormone action.
 12
Ha ve you ever known anyone with thyroid prob- LANGUAGE OF
ems or diabetes? Sure y you have seen the dramatic S C IEN C E
changes that happen to a persons body as he or she
goes through puberty. T ese are a proo o the
Be o re re ading the
importance o the endocrine system in norma
chapte r, s ay e ach o
deve opment and hea th. the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
T e endocrine system per orms the same genera the m as yo u re ad.
unctions as the nervous system: communication
and contro . T e nervous system provides rapid,
adenohypophysis
brie contro by way o ast-trave ing nerve im-
pu ses. T e endocrine system provides s ower but [adeno- gland, -hypo- under or below,
onger- asting contro by way o hormones (chem- -physis growth]
ica s) secreted into and circu ated by the b ood. adrenal cortex

T e main organs o the endocrine system are ocated in [ad- toward, -ren- kidney, -al relating
wide y separated parts o the body, as you can see in to, cortex bark]
Figure 12-1. adrenal medulla

In this chapter you wi read about the unctions o the main [ad- toward, -ren- kidney, -al relating
endocrine g ands and discover why their importance is a most im- to, medulla marrow or pith]
possib e to exaggerate. H ormones are the main regu ators o adrenocorticotropic hormone
metabo ism, growth and deve opment, reproduction, and (ACTH)
many other body activities. T ey p ay important
ro es in maintaining homeostasis uid and
e ectro yte, acid-base, and energy ba ances,
[adreno- gland, -cortic- bark,
or examp e. H ormones make the
-trop- nourish, -ic relating to,
di erence between norma cy and hormon- excite]
aldosterone
or

[aldo- aldehyde, -stero- solid or

steroid derivative, -one chemical]
anabolic steroid

[anabol- build up, -ic relating to,

stero- solid, -oid like]
anabolism

[anabol- build up, -ism action]

androgen

[andro- male, -gen produce]

Continued on p. 339

319
 320 CHAPTER 12 Endocrine System
Hypotha la mus
P ituita ry
P ine a l
Pa ra thyroids
Thyroid
Thymus
Adre na ls
12
Pa ncre a tic
is le ts
Ova rie s S acts as a f rst messenger (that is, it de ivers its chemica mes-
(fe ma le )
R L
Te s te s
(ma le ) I
FIGURE 12-1 Location o endocrine glands. Some o the major endo-
crine structures are shown. Thymus gland is shown at maximum size at
puberty.
many kinds o abnorma ities such as dwarf sm, gigantism, and
steri ity. T ey are important not on y or the hea thy surviva o
each one o us but a so or the surviva o the human species.
En d o c r in e G la n d s
A organs o the endocrine system are g ands, but not a
g ands are organs o the endocrine system. O the two types
o g ands in the bodyexocrine glands and endocrine
glandson y endocrine g ands be ong to this system.
You may reca rom Chapters 4 and 5 that exocrine g ands
secrete their products into ducts that empty onto a sur ace or
into a cavity. For examp e, sweat g ands produce a watery secre-
tion that empties onto the sur ace o the skin. Sa ivary g ands are
a so exocrine g ands, secreting sa iva that ows into the mouth.
Endocrine g ands, on the other hand, are duct ess g ands.
T ey secrete chemica s known as hormones into interce u ar
spaces. From there, the hormones di use direct y into the
b ood and are carried throughout the body. Each hormone
mo ecu e may then bind to a ce that has specif c receptors or
that hormone, triggering a reaction in the ce . Such a ce is
ca ed a target cell.
T e ist o endocrine g ands and the organs in which their
target ce s are ound (target organs) continues to grow. T e
names, ocations, and unctions o the we -known endocrine
g ands are given in Figure 12-1 and Table 12-1.
To get an overview o the endocrine system, go to
AnimationDirect online at evolve.elsevier.com.
M e c h a n is m s o Ho r m o n e Ac t io n
A hormone causes its target ce s to respond in particu ar
ways; this has been the subject o intense interest and research.
T e two major c asses o hormonesnonsteroid hormones
and steroid hormonesdi er in the mechanisms by which
they in uence target ce s.
Active
Hormones at evolve.elsevier.com.
N o n s t e ro id Ho r m o n e s
Nonsteroid hormones are who e proteins, shorter chains o
amino acids, or simp y versions o sing e amino acids. Nonste-
roid hormones typica y work according to the second-
messenger mechanism. According to this concept, a nonste-
roid protein hormone, such as thyroid-stimu ating hormone,
sage rom the ce s o an endocrine g and to high y specif c
RES EA RC H, IS S U ES ,
AND TREN D S
S ECOND-MES S ENGER SYSTEMS
Rapid and revolutionary dis cove rie s about how nons te roid
horm one s act on the ir targe t ce lls be gan w ith the pione e r-
ing work o Earl Suthe rland, w ho re ce ive d the 1971 Nobe l
Prize or orm ulating the s e cond-m e s s e nge r hypothe s is ,
and new dis cove rie s continue to be m ade eve n today.
Late r, the im portant role o the s o-calle d G pro te in in
ge tting the s ignal rom the re ce ptor to the e nzym e that
orm s cyclic AMP (cAMP) was dis cove re d. Look or the G
prote in in Figure 12-2. More re ce ntly, the role o nitric oxide
(NO) in s e cond-m e s s e nge r s ys te m s has be e n worke d out.
All o these discoveries resulted in Nobel Prizes, which
shows the importance the scientif c community has placed
on them. Why? By working out the details o how hormones
work, we can more clearly understand how and why things
can go wrong that a ect endocrine disorders. Perhaps we
may even gain new know ledge about disorders that we pre-
viously did not even know involved hormone mechanisms.
Once the proce s s e s o dis e as e m e chanis m s are f gure d
out, we hope s cie ntis ts w ill be able to de s ign te s ts that can
s cre e n or s uch proble m s . Or pe rhaps they can deve lop
drugs that w ill f x the broke n m e chanis m s and cure the
dis e as e . A te r re ading this chapte r, you w ill dis cove r that
unde rs tanding how horm one s act on targe t ce lls the con-
ce pt o s ig nal trans ductio nw ill pre pare you or the revo-
lution in m e dicine that is now upon us .
 CHAPTER 12 Endocrine System 321

membrane receptor sites on the

P rote in hormone
ce s o a target organ). T is inter- Firs t me s s e ng e r
action between a hormone and its
specif c receptor site on the ce
membrane o a target ce is o ten
compared to the f tting o a unique
key into a ock. T is idea is the lock-
and-key model o chemica activity.
G Enzyme
A ter the hormone attaches to
its specif c receptor site, a number Me mbra ne
re ce ptor
ATP
S e c o nd
o chemica reactions occur. T ese cAMP
me s s e ng e r
reactions activate mo ecu es within GTP
the ce ca ed second messengers.
One examp e o this mechanism
Activa te s
othe r e nzyme s 12
occurs when the hormone-receptor Targ e t c e ll
interaction changes energy-rich Re gula te s ce llula r a ctivity
A P mo ecu es inside the ce into
cyclic AMP (adenosine mono-
FIGURE 12-2 Mechanism o protein hormone action. The hormone acts as rst messenger, delivering
phosphate). Cyc ic AMP serves as its message via the bloodstream to a membrane receptor in the target cell much like a key ts into a lock. The
the second messenger, de ivering second messenger is cyclic AMP (cAMP), which orms in response to the rst messengers signaling actions.
in ormation inside the ce that cAMP causes the cell to respond and per orm the unction triggered by the hormone. Variations o this mecha-
regu ates the ce s activity. For ex- nism also exist.
amp e, cyc ic AMP causes thyroid
ce s to respond to thyroid-stimu ating hormone by secreting a Figure 12-3 summarizes this mechanism o steroid hormone
thyroid hormone such as thyroxine. Cyc ic AMP is on y one o action. Because it takes some time to accomp ish a o the
severa second messengers that have been discovered. steps i ustrated in the diagram, steroid hormone responses
In summary, nonsteroid hormones serve as f rst messen- typica y are s ow compared with responses triggered by non-
gers, providing communication between endocrine g ands steroid hormones.
and target organs. Another mo ecu e, such as cyc ic AMP, Besides the primary e ects o steroids produced by the
then acts as the second messenger, providing communication DNA-triggering mechanism just described, steroid hormones
within a hormones target ce s. Figure 12-2 summarizes the a so may trigger membrane receptors to produce a variety o
mechanism o nonsteroid hormone action. secondary e ects. T ese secondary e ects usua y appear much
more rapid y than do the primary steroid e ects.
S t e ro id Ho r m o n e s
T e primary actions o sma , ipid-so ub e steroid hormones
such as estrogen do not occur by the second-messenger
mechanism. Because they are ipid so ub e, steroid hormones
can pass intact direct y through the ce membrane o the
target ce .
Once inside the ce , steroid hormones pass through the Blood
cytop asm and enter the nuc eus, where they bind with a recep- ve s s e l
tor (according to the ock-and-key mode ) to orm a hormone-
receptor comp ex. T is comp ex acts on DNA, which u ti- Ta rge t ce ll
mate y causes the ormation o a new protein in the
cytop asm that then produces specif c e ects in S te roid
the target ce . In the case o estrogen, or ex- hormone
Re ce ptor (e s troge n)
amp e, that e ect might be breast deve op-
ment in the ema e ado escent.
Hormone -
re ce ptor
complex
FIGURE 12-3 Mechanism o steroid hor- Newly forme d prote in
mone action. Steroid hormones pass through produce s s pe cific
the plasma membrane and enter the nucleus to e ffe cts in ta rge t ce ll
DNA
orm a hormone receptor complex that acts on
P la s ma me mbra ne
DNA. As a result, a new protein is ormed in the
cytoplasm that produces speci c e ects in the Nucle us Cyto plas m Extrac e llular fluid
target cell.
 322 CHAPTER 12 Endocrine System

TABLE 12-1 Endocrine Glands, Hormones, and Their Functions

GLAND/ HORMONE FUNCTION DYS FUNCTION*
Ante rio r Pituitary
Thyroid-s tim ulating Tropic horm one Hype rs e cre tion: ove rs tim ulation o thyroid
horm one (TSH) Stim ulate s s e cre tion o thyroid horm one s Hypos e cre tion: unde rs tim ulation o thyroid
Adre nocorticotropic Tropic horm one Hype rs e cre tion: ove rs tim ulation o adre nal cortex
horm one (ACTH) Stim ulate s s e cre tion o adre nal cortex horm one s
Follicle -s tim ulating Tropic horm one Hypos e cre tion: unde rs tim ulation o adre nal cortex
horm one (FSH) Fe m ale : s tim ulate s deve lopm e nt o ovarian ollicle s and horm one s
s e cre tion o e s troge ns Hypos e cre tion: lack o s exual deve lopm e nt and
Male : s tim ulate s s e m ini e rous tubule s o te s te s to s te rility
grow and produce s pe rm
12 Lute inizing horm one (LH) Tropic horm one Hypos e cre tion: lack o s exual deve lopm e nt and
Fe m ale : s tim ulate s m aturation o ovarian ollicle and s te rility
ovum ; s tim ulate s s e cre tion o e s troge n; trigge rs ovu-
lation; s tim ulate s deve lopm e nt o corpus lute um
(lute inization)
Male : s tim ulate s inte rs titial ce lls o the te s te s to
s e cre te te s tos te rone
Grow th horm one (GH) Stim ulate s grow th in all organs ; m obilize s nutrie nt m ol- Hype rs e cre tion: gigantis m (pre -adult); acrom e galy
e cule s , caus ing an incre as e in blood glucos e (m ature adult)
conce ntration Hypos e cre tion: dwarf s m (pre -adult)
Prolactin (PRL or lactoge nic Stim ulate s bre as t deve lopm e nt during pre gnancy and Hype rs e cre tion: inappropriate lactation in m e n or
horm one ) m ilk s e cre tion (m ilk le tdow n) a te r pre gnancy non-nurs ing wom e n
Hypos e cre tion: ins u f cie nt lactation in nurs ing
wom e n
Po s te rio r Pituitary
Antidiure tic horm one Stim ulate s re te ntion o wate r by the kidneys Hype rs e cre tion: abnorm al wate r re te ntion
(ADH) Hypos e cre tion: diabe te s ins ipidus
Oxytocin (OT) Stim ulate s ute rine contractions at the e nd o pre g- Hype rs e cre tion: inappropriate e je ction o m ilk in
nancy; s tim ulate s the re le as e o m ilk into the bre as t lactating wom e n
ducts Hypos e cre tion: prolonge d or di f cult labor and
de live ry (unce rtain)
Hypo thalam us
Re le as ing horm one s (RHs ) Stim ulate the ante rior pituitary to re le as e horm one s Hype rs e cre tion: hype rs e cre tion by ante rior
(s eve ral) pituitary
Hypos e cre tion: hypos e cre tion by ante rior pituitary
Inhibiting horm one s (IHs ) Inhibit the ante rior pituitarys s e cre tion o horm one s Hype rs e cre tion: hypos e cre tion by ante rior pituitary
(s eve ral) Hypos e cre tion: hype rs e cre tion by ante rior pituitary
Thyro id
Thyroxine (T4 ) and Stim ulate the e ne rgy m e tabolis m o all ce lls Hype rs e cre tion: hype rthyroidis m , Grave s dis e as e
triiodothyronine (T3 ) Hypos e cre tion: hypothyroidis m , cre tinis m (pre -
adult); myxe de m a (adult); goite r
Calcitonin (CT) Inhibits the bre akdow n o bone ; caus e s a de cre as e in Hype rs e cre tion: pos s ible hypocalce m ia
blood calcium conce ntration Hypos e cre tion: pos s ible hype rcalce m ia
Parathyro id
Parathyroid horm one (PTH) Stim ulate s the bre akdow n o bone ; caus e s an incre as e Hype rs e cre tion: pos s ible hype rcalce m ia
in blood calcium conce ntration Hypos e cre tion: pos s ible hypocalce m ia
*In s om e cas e s , s igns o hypos e cre tion re s ult rom targe t ce ll abnorm ality rathe r than rom actual hypos e cre tion o a horm one .

Pos te rior pituitary horm one s are s ynthe s ize d in the hypothalam us but re le as e d rom axon te rm inals in the pos te rior pituitary.
 CHAPTER 12 Endocrine System 323

TABLE 12-1 Endocrine Glands, Hormones, and Their Functionscont'd

GLAND/ HORMONE FUNCTION DYS FUNCTION*
Adre nal Co rte x
Mine ralocorticoids : Re gulate e le ctrolyte and uid hom e os tas is Hype rs e cre tion: incre as e d wate r re te ntion
aldos te rone Hypos e cre tion: abnorm al wate r los s (de hydration)
Glucocorticoids : Stim ulate glucone oge ne s is , caus ing an incre as e in blood Hype rs e cre tion: Cus hing s yndrom e
cortis ol (hydrocortis one ) glucos e conce ntration; als o have anti-in am m atory, Hypos e cre tion: Addis on dis e as e
anti-im m unity, and antialle rgy e e cts
Androge ns Stim ulate s exual drive in the e m ale but have ne gligible Hype rs e cre tion: pre m ature s exual (androge ns )
e e cts in the m ale deve lopm e nt; m as culinization o e m ale
Hypos e cre tion: no s ignif cant e e ct
Adre nal/ Me dulla
Epine phrine (Epi) and Prolong and inte ns i y the s ym pathe tic ne rvous Hype rs e cre tion: s tre s s e e cts (adre naline )
12
nore pine phrine (NE) re s pons e during s tre s s Hypos e cre tion: no s ignif cant e e ct
Pancre atic Is le ts
Glucagon Stim ulate s glycoge nolys is in live r, caus ing an incre as e (Unce rtain)
in blood glucos e conce ntration
Ins ulin Prom ote s glucos e e ntry into all ce lls , caus ing a Hype rs e cre tion: s eve re hypoglyce m ia (ins ulin
de cre as e in blood glucos e conce ntration s hock)
Hypos e cre tion: diabe te s m e llitus
Ovary
Es troge ns Prom ote deve lopm e nt and m ainte nance o e m ale Hype rs e cre tion: pre m ature s exual deve lopm e nt
s exual characte ris tics (s e e Chapte r 23) ( e m ale ) and in e rtility
Hypos e cre tion: lack o s exual deve lopm e nt
( e m ale ), in e rtility, and os te oporos is
Proge s te rone Prom ote s conditions re quire d or pre gnancy (s e e Hypos e cre tion: s te rility
Chapte r 23)
Te s tis
Te s tos te rone Prom ote s deve lopm e nt and m ainte nance o m ale Hype rs e cre tion: pre m ature s exual deve lopm e nt
s exual characte ris tics (m ale ); m us cle hype rtrophy
Hypos e cre tion: lack o s exual deve lopm e nt (m ale )
Thym us
Thym os in Prom ote s deve lopm e nt o im m une -s ys te m ce lls Hypos e cre tion: de pre s s ion o im m une s ys te m
unctions
Place nta
Chorionic gonadotropin, Prom ote conditions re quire d during e arly pre gnancy Hypos e cre tion: s pontane ous abortion (m is carriage )
e s troge ns , proge s te rone
Pine al
Me latonin Inhibits tropic horm one s that a e ct the ovarie s ; he lps Hype rs e cre tion: w inte r de pre s s ion, s le e p dis or-
re gulate the bodys inte rnal clock and s le e p cycle s de rs , and othe r pos s ible e e cts
He art (Atria)
Atrial natriure tic horm one Re gulate s uid and e le ctrolyte hom e os tas is Hypos e cre tion: uid or e le ctrolyte im balance s ;
(ANH) pos s ible blood pre s s ure proble m s
Gas tro inte s tinal (GI) Tract
Ghre lin A e cts e ne rgy balance (m e tabolis m ) Hype rs e cre tion: incre as e in hunge r and s uppre s -
s ion o at utilization; pos s ible obe s ity
Fat-S to ring Ce lls
Le ptin Controls how hungry or ull we e e l Hypos e cre tion: pos s ible obe s ity, othe r m e tabolic
dis orde rs
 324 CHAPTER 12 Endocrine System

QUICK CHECK As b ood g ucose concentration drops, the endocrine ce s

1. Wh a t is th e ch e m ica l m e s s e n g e r u s e d b y th e e n d o crin e
s ys te m ?
2. Ho w d o n o n s te ro id h o rm o n e s a n d s te ro id h o rm o n e s
d i e r?
3. Wh a t is a s e co n d -m e s s e n g e r s ys te m ?
Re g u la t io n o Ho r m o n e
S e c r e t io n
N e g a t ive Fe e d b a c k
Regu ation o hormone eve s in the b ood depends on a ho-
12 meostatic mechanism ca ed negative eedbacka concept f rst
introduced in Chapter 1.
T e princip e o negative eedback in the endocrine sys-
tem can be i ustrated by using the hormone insu in as an
examp e. W hen re eased rom endocrine ce s in the pan-
creas, insu in owers b ood sugar eve s or g ucose
concentration in the b ood. Norma y, e evated
b ood g ucose occurs a ter a mea , a ter the ab-
sorption o g ucose rom the digestive tract
takes p ace. T e e evated b ood g ucose stimu-
ates the re ease o insu in rom the pancreas.
Insu in then assists in the trans er o g ucose
rom the b ood into ce s, causing b ood g ucose
to drop back toward the norma set point.
in the pancreas s ow their production and re ease o insu in.
T ese responses are negative because they reverse the direction o
a disturbance to the stability o the internal environment o the
body. T ere ore, this homeostatic mechanism is ca ed a nega-
tive eedback control mechanism because it reverses the change
in b ood g ucose (Figure 12-4).
P o s it ive Fe e d b a c k
Positive eedback mechanisms, which are uncommon, am-
p i y changes rather than reverse them. Usua y, such amp if -
cation threatens homeostasis, but in some situations it can
he p the body maintain its stabi ity.
For examp e, during abor, the musc e contractions that push
the baby through the birth cana become stronger and stronger
by means o a positive eedback mechanism that regu ates se-
cretion o the hormone oxytocin (see Figure 1-12 on p. 16).
Le ve ls o Re g u la t io n
T e endocrine system provides a good examp e o
the concept o di erent eve s o homeostatic regu-
ation. Regu ating the secretion o a particu ar
hormone is one eve o contro , but that in turn
regu ates specif c unctions in the target ce s, which
in turn changes some particu ar unction o the body.

Inte s tine s a bs orb

glucos e a fte r a me a l
Glucos e
Feedback
Inc re as ing
loop g luc o s e leve l

Pa ncre a s
re s ponds to
high glucos e
leve l by
NORMAL s e cre ting ins ulin
GLUCOS E
LEVEL

NEGATIVE FEEDBACK
LOOP
Ins ulin

HIGH
Ho me o s tas is
GLUCOS E
re s to re d
LEVEL
Ins ulin ca us e s
live r, s ke le ta l mus cle,
a nd othe r tis s ue s to Glucos e
ta ke up more glucos e
Bloods tre a m

FIGURE 12-4 Negative eedback. The secretion o most hormones is regulated by negative eedback
mechanisms that tend to reverse any deviations rom normal. In this example, an increase in blood glucose
triggers secretion o insulin. Because insulin promotes glucose uptake by cells, the blood glucose level is re-
stored to its lower, normal level.

HEA LTH AND WELL-BEIN G
STEROID ABUS E
Som e s te roid horm one s are calle d anabo lic s te ro ids be -
caus e they s tim ulate the building o large m ole cule s (anabo-
lis m ). Spe cif cally, they s tim ulate the building o prote ins in
m us cle and bone . Ste roids s uch as te s tos te rone and its s yn-
the tic de rivative s are o te n abus e d by athle te s and othe rs
w ho want to incre as e the ir athle tic pe r orm ance . The anabolic
e e cts o the horm one s incre as e the m as s and s tre ngth o
s ke le tal m us cle s .
ypica y, additiona eve s o contro are invo ved in main-
taining homeostasis. For examp e, eedback may trigger the
secretion o a re easing hormone that targets another g and
and triggers the secretion o that second g ands hormone.
Feedback may instead trigger autonomic nervous stimu a-
tion o a g and, which then secretes a re easing hormone. In
turn, the re easing hormone triggers the re ease o another
hormone that regu ates its target ce s, which change their
unctions to produce an e ect that changes a variab e to move
back toward its set point.
O ten, all the eve s o contro are receiving and reacting to
eedbackthus providing extra e ciency and precision to the
homeostatic contro o body unction.
M e c h a n is m s o En d o c r in e
D is e a s e
Diseases o the endocrine system are numerous, varied, and
sometimes catastrophic. umors or other abnorma ities re-
quent y cause the g ands to secrete too much or too itt e o
their hormones. Production o too much hormone by a dis-
eased g and is ca ed hypersecretion. I too itt e hormone is
produced, the condition is ca ed hyposecretion.
A variety o endocrine disorders that appear to resu t
rom hyposecretion are actua y caused by a prob em in the
target ce s. I the usua target ce s o a particu ar hormone
have damaged receptors, too ew receptors, or some other
abnorma ity, they wi not respond to that hormone proper y.
In other words, ack o target ce response cou d be a sign o
hyposecretion or a sign o target ce insensitivity. Diabetes
mellitus (DM ), or examp e, can resu t rom insu in hypose-
cretion or rom the target ce s insensitivity to insu in
or both.
Imba ances o one type o hormone o ten a ect other hor-
mones as we . Disorders that resu t rom the hypersecretion
or hyposecretion o severa hormones are o ten ca ed
polyendocrine disorders.
Endocrinologists, scientists who specia ize in endocrine
unction, or endocrinology, have deve oped a variety o strat-
egies or treating endocrine disorders. Surgica or chemica
treatment o tumors or damaged tissue is use u in some cases.
CHAPTER 12 Endocrine System 325
Un ortunate ly, s te roid abus e has othe r cons e que nce s that
are not de s irable . It dis rupts the norm al ne gative e e dback
control o horm one s throughout the body and m ay re s ult in
tis s ue dam age , s te rility, m e ntal im balance , and m any li e -
thre ate ning m e tabolic proble m s . Abus e o s te roids , othe r
pe r orm ance -e nhancing drugs , or blood products in athle tics is
calle d doping. Such practice s are outlawe d in s ports world-
w ide (s e e als o the box Blood Doping on p. 354).
12
Another common strategy is the use o pharmaco ogica
preparations o hormones. For examp e, insu in injections are
used in treating some orms o diabetes me itus.
T e avai abi ity o synthetic hormones produced with ge-
netic engineering techno ogy has revo utionized the treat-
ment o many endocrine disorders. Synthetic hormones are
cheaper and more wide y avai ab e than natura human hor-
mones, and they do not carry the same risk o possib e con-
tamination with viruses or other dangerous substances (see
box on p. 354).
Table 12-1 summarizes some o the major disorders o the
endocrine system. Re er to this tab e o ten as you study the
individua g ands and hormones o the endocrine system. You
may a so want to re er to Appendix A at evolve.elsevier.com,
which a so contains a tab e isting major endocrine disorders.
P ro s t a g la n d in s
Prostaglandins (PGs), or tissue hormones, are important and
extreme y power u substances ound in a wide variety o tis-
sues. PGs are modif ed versions o atty acids. PGs p ay an
important ro e in communication and in the contro o many
body unctions but do not meet the def nition o a typica
hormone.
T e term tissue hormone is appropriate because in many
instances a prostag andin is produced in a tissue and then di -
uses on y a short distance to act on ce s within that tissue.
ypica hormones in uence and contro activities o wide y
separated organs; typica PGs in uence activities o neighbor-
ing ce s.
PGs, a ong with severa other tissue hormones such as
leukotrienes and thromboxane, are sometimes ca ed paracrine
agents. T e term paracrine itera y means secrete besidean
apt description or a regu atory agent re eased right next to its
target ce .
T e prostag andins in the body can be divided into severa
groups. T ree c asses o prostag andinsprostaglandin A
(PGA), prostaglandin E (PGE), and prostaglandin F (PGF)
are among the best known.
PGs have pro ound e ects on many body unctions. T ey
in uence respiration, b ood pressure, gastrointestina secre-
tions, in ammation, and the reproductive system. Researchers
 326 CHAPTER 12 Endocrine System
RES EA RC H, IS S U ES , AND TREN D S
PROSTAGLANDIN THERAPY
Although much research is yet to be done, prostaglandins are already playing an
important role in the treatment o diverse conditions such as glaucoma, high blood
pressure, asthma, and ulcers. Because some prostaglandins have local muscle-
relaxing e ects, they can relax muscles in the walls o blood vessels to reduce
blood pressure. In asthma, prostaglandins administered in a nebulizer (mist applica-
tor) relax the muscles that constrict air ow during an asthma attack. Some gastric
ulcers can be treated with prostaglandins that decrease stomach acid secretion.
Pharm acologis ts , s cie ntis ts w ho s tudy drug actions , or pharm aco lo gy, have
dis cove re d that pros taglandins are involve d in s om e traditional the rapie s . For
exam ple , as pirin and its de rivative s (s alicylate s ) produce s om e o the ir e e cts by
12 blocking pros taglandins involve d in the in am m ation re s pons e .
be ieve that most PGs regu ate ce s by in uencing the pro-
duction o cyc ic AMP.
PGs are a ready p aying an important ro e in the treat-
ment o conditions such as g aucoma, high b ood pressure,
asthma, and u cersas described in the box above. In act,
many common treatments such as aspirin create their e ects
by a tering the unctions o PGs in the body.
QUICK CHECK
1. Ho w d o e s n e ga tive e e d b a ck a e ct h o rm o n e le ve ls in th e
b lo o d ?
2. Wh a t m a y o ccu r i th e u s u a l ta rg e t ce lls o a p a rticu la r
h o rm o n e h a ve d a m a g e d re ce p to rs , to o e w re ce p to rs , o r
s o m e o th e r a b n o rm a lity?
3. Id e n ti y th e s tra te g ie s in tre a tin g e n d o crin e d is o rd e rs .
4. Why a re p ro s ta g la n d in s ca lle d tis s u e h o rm o n e s ?
P it u it a ry G la n d
S t r u c t u r e o t h e P it u it a ry G la n d
T e pituitary gland is a sma but mighty structure. A -
though no arger than a pea, it is rea y two endocrine g ands.
O ne is ca ed the anterior pituitary g and or adenohypophysis,
and the other is ca ed the posterior pituitary g and or
neurohypophysis.
Di erences between the two g ands are indicated by their
namesadeno means g and, and neuro means nervous. tion, LH is sometimes ca ed the ovulating hormone.
T e adenohypophysis has the structure o an endocrine
g and, whereas the neurohypophysis has the structure o
nervous tissue. H ormones secreted by the adenohypophysis
serve very di erent unctions rom those re eased rom the
neurohypophysis.
T e protected ocation o this dua g and suggests its im-
portance. T e pituitary g and ies buried deep in the crania
cavity, in a we -protected ocation. It sits secure y within a
seat ca ed the sella turcica ormed by two bony projections
at the top o the sphenoid bone (see Figure 8-10, C, on p. 184).
A stem- ike structure, the pituitary stalk, attaches the g and
to the undersur ace o the brain. More specif ca y, the sta k
attaches the pituitary body to the hypotha amus.
A n t e r io r P it u it a ry G la n d
Ho r m o n e s
T e anterior pituitary g and secretes severa
major hormones. Each o the our hor-
mones isted as a tropic hormone in
Table 12-1 stimu ates another endocrine
g and to grow and secrete its hormones.
Because the anterior pituitary g and ex-
erts this tropic contro over the structure
and unction o the thyroid g and, the adre-
na cortex, the ovarian o ic es, and the
corpus uteum, in the past it was sometimes
ca ed the master gland. H owever, because
its secretions are in turn contro ed by the
hypotha amus and other mechanisms, the
anterior pituitary is hard y the master o
body unction it was once thought to be.
Th y ro id -s t im u la t in g Ho r m o n e
T yroid-stimulating hormone ( SH) acts on the thyroid
g and. As its name suggests, it stimu ates the thyroid g and to
increase secretion o thyroid hormone.
Ad r e n o c o r t ic o t ro p ic Ho r m o n e
T e adrenocorticotropic hormone (AC H) acts on the ad-
rena cortex. It stimu ates the adrena cortex to increase in size
and to secrete arger amounts o its hormones, especia y
arger amounts o cortiso (hydrocortisone).
Fo llic le -s t im u la t in g Ho r m o n e
Follicle-stimulating hormone (FSH) stimu ates the primary
ovarian o ic es in an ovary to start growing and to continue
deve oping to maturity (that is, to the point o ovu ation).
FSH a so stimu ates o ic e ce s to secrete estrogens. In the
ma e, FSH stimu ates the semini erous tubu es to grow and
orm sperm.
Lu t e in iz in g Ho r m o n e
Luteinizing hormone (LH) acts with FSH to per orm sev-
era unctions. It stimu ates a o ic e and ovum to comp ete
their growth to maturity, it stimu ates o ic e ce s to secrete
estrogens, and it causes ovu ation (rupturing o the mature
o ic e with expu sion o its ripe ovum). Because o this unc-
LH a so stimu ates the ormation o a go den body, the
corpus uteum, rom the ruptured o ic e. T is processca ed
luteinization is the one that earned LH its tit e o luteiniz-
ing hormone. As it promotes uteinization, LH stimu ates the
corpus uteum to produce the hormone progesterone.
T e ma e pituitary g and a so secretes LH . In ma es, LH
stimu ates interstitia ce s in the testes to deve op and secrete
testosterone, the ma e sex hormone.
G ro w t h Ho r m o n e
Another important hormone secreted by the anterior pituitary
g and is growth hormone (GH). GH speeds up the movement
o digested proteins (amino acids) out o the b ood and into the

ce s, and this acce erates the ce s anabolism (bui ding up) o
amino acids to orm tissue proteins (see Chapter 19). T is ana-
bo ic action promotes norma growth.
Growth hormone a so a ects at and carbohydrate me-
tabo ism. It acce erates at catabo ism (breakdown) but s ows
g ucose catabo ism. T is means that ess g ucose eaves the
b ood to enter ce s, and there ore the amount o g ucose in
the b ood increases.
T us growth hormone and insu in have opposite e ects on
b ood g ucose. Insu in decreases b ood g ucose, and growth
hormone increases it. oo much insu in in the b ood produces
hypoglycemia ( ower than norma b ood g ucose concentra-
tion). oo much growth hormone produces hyperglycemia
(higher than norma b ood g ucose concentration).
A so ca ed human growth hormone (hGH), this hormone is
used by some peop e to keep themse ves youth u or to boost
ath etic per ormance. T ese unapproved uses can have dan-
gerous side e ects by disrupting norma hormone ba ances in
the body.
H ypersecretion o growth hormone during the ear y years
o i e produces a condition ca ed gigantism. T e name sug-
gests the obvious characteristics o this condition. T e chi d
grows to a giant size.
I the anterior pituitary g and secretes too much growth
hormone a ter the norma growth years, the disease ca ed
acromegaly deve ops. Characteristics o this disease are en-
argement o the bones o the hands, eet, jaws, and cheeks.
T e acia appearance that is typica o acromega y resu ts
rom the combination o bone and so t tissue overgrowth. A
prominent orehead and arge nose are characteristic. In addi-
tion, patients with acromega y may have en arged skin pores
R L
I
A B
CHAPTER 12 Endocrine System 327
and an overgrown mandib e. Figure 12-5 i ustrates the major
characteristics o gigantism and acromega y.
H yposecretion o growth hormone during the growth
years o ten produces pituitary dwar sm. Peop e with this
condition usua y have a body rame o norma proportions
but are much sma er in overa size. D warf sm caused by
other conditions may produce an odd y proportioned body
rame. Pituitary dwarf sm can be treated with injections o
synthetic growth hormone as the ske eton deve ops.
P ro la c t in
T e anterior pituitary g and a so secretes prolactin (PRL), or
lactogenic hormone. D uring pregnancy, PRL stimu ates the
breast deve opment necessary or eventua actation (mi k se- 12
cretion). A so, soon a ter de ivery o a baby, PRL stimu ates
the breasts to start secreting mi k, a unction suggested by
pro actins other name, lactogenic hormone.
One o the most common types o pituitary tumor is
prolactinoma, a noncancerous adenoma that produces hyper-
secretion o PRL. Most pro actinomas are sma and occur
most y in women. A patient may have symptoms typica o
crania tumors, such as headache, vision and other sensory
changes, ethargy, and nausea. T e excess PRL can cause
changes in reproductive unction inc uding breast tenderness
or en argement, abnorma mi k production, in erti ity, and oss
o sexua interest or unction.
For those who need treatment or pro actinoma, medica-
tions are usua y e ective. H owever, sometimes radiation
therapy or surgery is required.
For a brie summary o anterior pituitary hormone target
organs and unctions, see Figure 12-6.
FIGURE 12-5 Growth hormone abnormalities.
A, The 22-year-old man on the le t with gigantism is
much taller than his identical twin on the right. B, Ac-
romegaly. Notice the large head, exaggerated projec-
tion o the lower jaw, and protrusion o the ridge above
the eye orbits.
S
A P
I
 328 CHAPTER 12 Endocrine System

Hypotha la mic S
ne uros e cre tory ce ll
A P

Bone I Kidney
tubule s
Ante rior pituita ry
Growth Pos te rior
Adre na l pituita ry
cortex hormone (GH)
Antidiure tic
hormone
Adre nocorticotropic (ADH)
hormone (ACTH)

Thyroid-
12 Thyroid
gla nd
s timula ting
hormone (TS H)

Oxytocin
P rola ctin (OT) Ute rus
Gona dotropic s mooth
hormone s (P RL)
mus cle
(FS H a nd LH)

Te s tis

Ova ry Ma mma ry
gla nds
Ma mma ry gla nds

FIGURE 12-6 Pituitary hormones. Principal anterior and posterior pituitary hormones and their target
organs.

P o s t e r io r P it u it a ry G la n d Ho r m o n e s
T e posterior pituitary g and stores and re eases two
hormonesantidiuretic hormone and oxytocin. Both hor-
mones are produced in ce bodies that are ocated in the
hypotha amus but are re eased rom the ends o axons that
are ocated in the posterior pituitary.
A n t id iu r e t ic Ho r m o n e
Antidiuretic hormone (AD H) is a major regu ator o uid
ba ance in the human body. ADH acce erates the reabsorp-
tion o water rom urine in kidney tubu es back into the b ood
when the body needs to conserve water. W ith more water
moving out o the tubu es into the b ood, ess water remains
in the tubu es, and there ore ess urine eaves the body.
T e term antidiuretic is appropriate because anti- means
against and diuretic means increasing the vo ume o urine
excreted. T ere ore, antidiuretic means acting against an in-
crease in urine vo umein other words, ADH acts to de-
crease urine vo umeand thus prevent dehydration.
H yposecretion o ADH resu ts in diabetes insipidus, a
condition in which arge vo umes o urine are ormed. Dehy-
dration and e ectro yte imba ances may cause serious prob-
ems. A though increased water intake can re ieve mi d symp-
toms, many cases a so require administering a synthetic orm
o ADH .
O x y t o c in
T e posterior pituitary hormone oxytocin (O ) is secreted at
high eve s by a womans body be ore and a ter she has a baby.
O xytocin stimu ates contraction o the smooth musc e o the
pregnant uterus and is be ieved to initiate and maintain abor.
T is is why physicians sometimes prescribe oxytocin injec-
tions to induce or increase abor.
O xytocin a so per orms a unction important to a newborn
baby. It causes the g andu ar ce s o the breast to re ease mi k
into ducts rom which a baby can obtain it by sucking. In
short, oxytocin stimu ates mi k etdown.
O xytocin is a so thought to enhance socia bondinga
unction he p u in supporting the mother-in ant bond.
T e right side o Figure 12-6 summarizes posterior pituitary
unctions. Disorders o the anterior and posterior pituitary are
summarized in Table 12-1.
Hy p o t h a la m u s
In discussing ADH and oxytocin, we noted that these hor-
mones were released rom the posterior obe o the pituitary.
As we a so stated, actua production o these two hormones
occurs in the hypotha amus. wo groups o secretory neurons
in the hypotha amus synthesize the posterior pituitary hor-
mones, which then pass down a ong axons into the pituitary
g and. Re ease o ADH and oxytocin into the b ood is con-
tro ed by nervous stimu ation.
In addition to oxytocin and ADH , the hypotha amus a so
produces substances ca ed releasing hormones (RHs) and
inhibiting hormones (IHs). T ese substances are produced in
the hypotha amus and then re eased direct y into a connected
b ood capi ary system. T is system carries the hormones to the
 CHAPTER 12 Endocrine System 329

anterior pituitary g and, where they stimu ate or inhibit the

re ease o anterior pituitary hormones into the genera b ood
circu ation. Thyroid
T e combined nervous and endocrine unctions o the follicle
hypotha amus a ow the nervous system to in uence many
endocrine unctions. T ere ore, the hypotha amus p ays a
dominant ro e in the regu ation o many body unctions re-
ated to homeostasis. Examp es inc ude the regu ation o body
temperature, appetite, and thirst.

QUICK CHECK
1. Ho w a re th e a n te rio r p itu ita ry a n d p o s te rio r p itu ita ry d i - Colloid
e re n t? Ho w a re th e y a like ? in follicle
2. Wh a t m a ke s a h o rm o n e a tro p ic h o rm o n e ?
3. Wh a t a re th e e e cts o a p ro la ctin o m a ?
12
4. Ho w d o e s th e hyp o th a la m u s co n tro l th e p itu ita ry g la n d ? CT ce ll

FIGURE 12-8 Thyroid gland tissue. Thyroid hormone is produced by

Th y ro id G la n d ollicular cells in the walls o the thyroid ollicles. Note that each o the
ollicles is lled with colloida f uid with ne, suspended particles. The
T e thyroid g and ies in the neck just be ow the arynx colloid serves as a storage medium or the thyroid hormones. Another type
(Figure 12-7). T e thyroid g and secretes two thyroid hormones o thyroid gland cells, called CT cells, are outside the ollicles and secrete
and the hormone calcitonin (C ). calcitonin (CT).
As Figure 12-8 shows, thyroid tissue is organized into many
chambers ca ed thyroid ollicles. Each thyroid o ic e is
f ed with a thick uid having many f ne, suspended partic es O the two thyroid hormones, 4 is the more abundant.
ca ed colloid. H owever, 3 is the more potent and is considered by physi-
o ogists to be the principa thyroid hormone. One mo ecu e o
4 contains our atoms o iodine, and one mo ecu e o 3, as
Th y ro id Ho r m o n e its name suggests, contains three iodine atoms. For thyroid
W hat was once thought o as a sing e thyroid hormone is hormones to be produced in adequate amounts, the diet must
actua y two simi ar hormones: triiodothyronine ( 3) and contain su cient iodine.
thyroxine ( 4). Most endocrine g ands do not store their hormones but
instead secrete them direct y into the b ood as they are pro-
Epiglottis duced. T e thyroid g and is di erent in that it stores consider-
ab e amounts o the thyroid hormones in the
orm o mo ecu es suspended in a uid as a
Hyoid bone co oid, as seen in Figure 12-8. T e co oid
materia is stored in the o ic es o the
g and, and when the thyroid hormones are
needed, they are re eased rom the co oid
La rynx and secreted into the b ood.
(thyroid ca rtila ge )
4 and 3 are sma , nonsteroid hor-

S upe rior
mones that are ab e to enter their target
pa ra thyroid gla nd ce to f nd their receptors. T is is an
exception to the genera mode o non-
steroid action requiring an interna
Thyroid gla nd
second messenger.
4 and 3 in uence every one o
the tri ions o ce s in our bodies.
Infe rior
pa ra thyroid gla nd T ey make them speed up their
S S
re ease o energy rom nutrients.
In other words, these thyroid hor-
R L L R
Tra che a mones stimu ate ce u ar metabo-
I I ism. T is has ar-reaching e ects.
Because a body unctions de-
A B pend on a norma supp y o en-
FIGURE 12-7 Thyroid and parathyroid glands. Note their relationship to each other and to the larynx ergy, they a depend on norma
(voice box) and trachea. A, Anterior view. B, Posterior view. thyroid secretion. Even norma
 330 CHAPTER 12 Endocrine System
12 S
R L
I
FIGURE 12-9 Hyperthyroidism. Note the prominent, protruding eyes
(exophthalmos) o this woman with Graves disease.
menta and physica growth and deve opment depend on
norma thyroid unctioning.
Hyperthyroidism, or oversecretion o the thyroid hor-
mones, dramatica y increases the metabo ic rate. Nutrients
are consumed by the ce s at an excessive rate, and individua s
who su er rom this condition ose weight, have an increased
appetite, and show signs o nervous irritabi ity. T ey appear
rest ess, jumpy, and excessive y active.
M any patients with hyperthyroidism a so have very
prominent, a most protruding eyesa condition ca ed
exophthalmos (Figure 12-9). H yperthyroidism with exoph-
tha mos is characteristic o Graves disease, an inherited
autoimmune condition that occurs f ve times more re-
quent y in women than in men.
S
R L
I Calcitonin (C ) is secreted by thyroid g and ce ssometimes
FIGURE 12-10 Goiter. The enlarged thyroid gland appears as a swelling
o the neck. This conditiona simple goiterresults rom a low dietary
intake o iodine.
S
R L
I
FIGURE 12-11 Myxedema. This condition results rom hyposecretion o
the thyroid gland during the adult years. Note the edema around the eyes,
acial pu ness, prominent tongue, coarse hair, and dull yellowish skin.
Hypothyroidism, or undersecretion o thyroid hormones,
can be caused by and resu t in a number o di erent condi-
tions. Low dietary intake o iodine causes a pain ess en arge-
ment o the thyroid g and ca ed a simple goiter, shown in
Figure 12-10.
T is condition was once common in areas o the United
States where the iodine content o the soi and water was in-
adequate. T e use o iodized sa t has dramatica y reduced the
incidence o goiters caused by ow iodine intake. o produce a
goiter, the g and en arges in an attempt to compensate or the
ack o iodine in the diet necessary or the synthesis o thyroid
hormones.
H yposecretion o thyroid hormones during the ormative
years eads to a condition ca ed cretinism. It is characterized
by a ow metabo ic rate, retarded growth and sexua deve op-
ment, and o ten, menta retardation. Fortunate y, hea th
screening or ow thyroid unction can ead to treatment be-
ore cretinism deve ops.
Later in i e, def cient thyroid hormone secretion pro-
duces the disease ca ed myxedema. T e ow metabo ic rate
that characterizes myxedema eads to essened menta and
physica vigor, weight gain, dry and sca y skin, oss o hair,
and an accumu ation o thick, mucus ike uid in the subcu-
taneous tissue that is o ten most noticeab e around the ace
(Figure 12-11).
Disorders o thyroid hormone secretion are summarized in
Table 12-1.
C a lc it o n in
ca ed C cellsthat ie outside the thyroid o ic es.
Ca citonin decreases the concentration o ca cium in the
b ood by f rst acting on bone to inhibit its breakdown. W ith
 CHAPTER 12 Endocrine System 331

ess bone being resorbed, ess ca cium moves out o bone into
b ood, and, as a resu t, the concentration o ca cium in b ood Feedback
decreases. loop
An increase in ca citonin secretion quick y o ows any
increase in b ood ca cium concentration, even i it is a s ight
one. T is causes b ood ca cium concentration to decrease to Pa ra thyroids
its norma eve . Ca citonin thus he ps maintain homeosta- High blood Low blood
sis o b ood ca cium. It prevents a harm u excess o ca cium ca lcium leve l ca lcium leve l
in the b ood, a condition ca ed hypercalcemia, rom
deve oping.
Ca lcitonin Pa ra thyroid
P a r a t h y ro id G la n d s s e cre tion
(from thyroid)
hormone
s e cre tion
T e parathyroid glands are sma umps o g andu ar epithe- incre a s e s
Thyroid
incre a s e s 12
ium. T ere are usua y our o them, and they are ound on the
posterior sur ace o the thyroid g and (see Figure 12-7).
T e parathyroid g ands secrete parathyroid hormone Bre a kdown of Bre a kdown of
(P H). bone ma trix bone ma trix
P H increases the concentration o ca cium in the b ood de cre a s e s incre a s e s
the opposite e ect o the thyroid g ands ca citonin. W hereas
ca citonin acts to decrease the amount o ca cium being dis-
so ved and reabsorped rom bone, P H acts to increase it.
P H stimu ates minera -disso ving osteoc ast ce s in bone Ca ++ leve l Bone Ca ++ leve l
in blood conta ining Ca ++ in blood
tissue to increase their breakdown o bones hard matrix, a
de cre a s e s ris e s
process that rees the ca cium stored in the matrix. T e re-
eased ca cium then moves out o bone into b ood, and this in
turn increases the b oods ca cium concentration. P H a so
promotes absorption o ca cium rom ood and reduces oss o
ca cium in the urine.
Norma l blood
Figure 12-12 provides a summary o the antagonistic e ects ca lcium leve l
o ca citonin and parathyroid hormone. T is ca cium-contro
mechanism is a matter o i e-and-death importance because
our ce s are extreme y sensitive to changing amounts o b ood FIGURE 12-12 Regulation o blood calcium levels. Calcitonin and
ca cium. T ey cannot unction norma y with either too much parathyroid hormones have antagonistic (opposite) e ects on calcium con-
centration in the blood. Both are negative eedback e ects because they
or too itt e ca cium. reverse a trend away rom normal blood calcium levels.
For examp e, with too much b ood ca cium, brain ce s
and heart ce s soon do not unction norma y; a person be-
comes menta y disturbed, and the heart may stop a together. Ad r e n a l G la n d s
H owever, with too itt e b ood ca cium, nerve ce s become
overactive, sometimes to such a degree that they bombard
Lo c a t io n o Ad r e n a l G la n d s
musc es with so many impu ses that the musc es go into As you can see in Figure 12-1 and Figure 12-13, an adrena g and
spasms. curves over the superior sur ace o each kidney.
Disorders o parathyroid secretion are summarized in From the sur ace an adrena g and appears to be on y one
Table 12-1. organ, but it is actua y two separate endocrine g ands: the
adrenal cortex and the adrenal medulla. Does this two-g ands-
in-one structure remind you o another endocrine organ? (See
glands, go to AnimationDirect online at evolve p. 326.)
.elsevier.com. T e adrena cortex is the outer part o an adrena g and and
is made up o g andu ar epithe ium. T e adrena medu a is the
inner part and it is made up o secretory nervous tissuemuch
ike the secretory nervous tissue o the posterior pituitary. Each
QUICK CHECK part re eases a di erent set o hormones, as you might expect.
1. Wh e re a re th e thyro id a n d p a ra thyro id g la n d s lo ca te d ?
2. Wh a t is th e d a n g e r o a hyp o s e cre tio n o thyro id h o r- Ad r e n a l C o r t e x
m o n e s d u rin g th e o rm a tive ye a rs ?
3. Wh a t is a g o ite r a n d h o w d o e s it d e ve lo p ? T ree di erent zones or ayers o ce s make up the adrenal
4. Ca lcito n in a n d p a ra thyro id h o rm o n e b o th re g u la te th e cortex as you can see in Figure 12-13. Fo ow this diagram
b lo o d co n ce n tra tio n o w h a t im p o rta n t io n ?
care u y as you read the o owing paragraph, and you wi
 332 CHAPTER 12 Endocrine System
FIGURE 12-13 Adrenal gland. The three cell layers o the adrenal cortex are easily seen
here. The outer zone cells secrete mineralocorticoids (aldosterone). The middle zone cells
secrete glucocorticoids (cortisol). The inner zone cells secrete sex hormones (androgens).
Adre na l Ca ps ule
gla nd
Cortex
Me dulla
12
S Inne r zone
R L
Kidney
I
easi y see the specia unction o each ayer o the adrena
cortex.
Zo n e s o Ad r e n a l C o r t e x
H ormones secreted by the three ce ayers, or zones, o the
adrena cortex are ca ed corticoids, a o which are steroid
hormones.
T e outer zone o adrena cortex ce s secretes hormones
ca ed mineralocorticoids (MCs). T e main minera ocorti-
coid is the hormone aldosterone.
T e midd e zone secretes glucocorticoids (GCs). Cortisol
is the chie g ucocorticoid.
T e innermost or deepest zone o the cortex secretes sma
amounts o sex hormones. Sex hormones secreted by the
adrena cortex resemb e testosterone and are c assif ed as an-
drogens (ma e sex hormones).
We now discuss brie y the unctions o the main cortica
hormones.
A ld o s t e ro n e
As their name suggests, mineralocorticoids he p contro the
amount o certain minera sa ts (main y sodium ch oride) in
the b ood.
Aldosterone is the chie minera ocorticoid. Remember its
main unctionsto increase the amount o sodium and de-
crease the amount o potassium in the b oodbecause these
changes ead to other pro ound changes.
A dosterone increases b ood sodium and decreases b ood
potassium by in uencing the kidney tubu es. It causes the
kidney tubu es to speed up their reabsorption o sodium back
into the b ood so that ess o it wi be ost in the urine. At the
same time, a dosterone causes the tubu es to increase their
secretion o potassium so that more o this minera wi be ost
in the urine. T e e ects o a dosterone speed up kidney reab-
sorption o water.
C o r t is o l
An important unction o g ucocorticoids is to he p main-
tain norma b ood g ucose concentration. Cortisolca ed
Ca ps ule
Oute r zone
Middle zone
Me dulla
hydrocortisone when used as medica therapyis the chie
g ucocorticoid produced by the adrena cortex.
Cortiso and other g ucocorticoids increase gluco-
neogenesis, a process in iver ce s that converts amino acids
or g ycero to g ucose. G ucocorticoids act in severa ways to
increase g uconeogenesis. T ey promote the breakdown o tis-
sue proteins to amino acids, especia y in musc e ce s. Amino
acids thus ormed move out o the tissue ce s into b ood and
circu ate to the iver. Liver ce s then change them to g ucose
by the process o g uconeogenesis. T e new y ormed g ucose
eaves the iver ce s and enters the b ood. T is action increases
b ood g ucose concentration.
In addition to per orming unctionswhich are neces-
sary or maintaining norma b ood g ucose concentration
g ucocorticoids such as cortiso a so p ay an essentia part in
maintaining norma b ood pressure. T ey act in a comp i-
cated way to make it possib e or two other hormones se-
creted by the adrena medu a to partia y constrict b ood
vesse s, a condition necessary or maintaining norma b ood
pressure.
A so, g ucocorticoids act with these hormones rom the
adrena medu a to produce an anti-in ammatory e ect. T ey
bring about a norma recovery rom in ammations produced
by many kinds o agents. T e use o hydrocortisone to re ieve
skin rashes, or examp e, is based on the anti-in ammatory
e ect o g ucocorticoids.
In ammation at
at evolve.elsevier.com.
Another e ect produced by g ucocorticoids is ca ed their
anti-immunity, antiallergy ef ect. G ucocorticoids bring about
a decrease in the number o certain ce s that produce anti-
bodies, substances that make us immune to some actors and
a ergic to others.
W hen extreme stimu i act on the body, they produce an
interna state or condition known as stress. Surgery, hemor-
rhage, in ections, severe burns, and intense emotions are

examp es o extreme stimu i that bring on stress. T e norma
adrena cortex responds to the condition o stress by quick y
increasing its secretion o g ucocorticoids.
Increased g ucocorticoid secretion is on y one o many
ways in which the body responds to stress. H owever, it is one
o the f rst stress responses and it brings about many o the
other stress responses. Examine Figure 12-14 to discover some
o the e ects o g ucocorticoids in the b ood.
W hen resisting (or avoiding) a threat, the increased b ood
g ucose can he p improve our ske eta musc e unction. Re-
duced in ammation may he p keep us ess swo enand thus
more mobi ewhi e we dea with the threat. Decreased im-
munity may he p us ocus a our resources on the more im-
mediate threat. Immunity resumes a ter a threatening en-
counter to dea with any damage.
Frequent or pro onged stress responses cou d cause meta-
bo ic prob ems by disturbing norma mechanisms keeping
b ood g ucose and stored ats in ba ance. Chronic stress may
a so increase our susceptibi ity to cancer and in ections by
reducing our immunity. Pro onging the anti-in ammatory
e ects may cause constriction o b ood vesse spossib y rais-
ing our b ood pressure.
Ad r e n a l S e x Ho r m o n e s
T e sex hormones that are secreted by the inner zone o the
adrena cortex are ma e hormonesandrogenssimi ar to
testosterone. T ese hormones are secreted in very sma
amounts in both adu t ma es and adu t ema es. H owever, they
p ay an ear y ro e in the deve opment o reproductive organs.
In women, these androgens may stimu ate the ema e sexua
drive. In men, so much testosterone is secreted by the testes that
adrena androgens are usua y not very important in adu ts.
High blood glucocorticoid conce ntra tion
Incre a s e d mobiliza tion
of fa ts a nd tis s ue
prote ins
Incre a s e d live r glucone oge ne s is De cre a s e d
from mobilize d fa ts a nd numbe r of
prote ins ; a ls o de cre a s e d glucos e lymphocyte s
ca ta bolis m but incre a s e d fa t
ca ta bolis m
(te nd to produce )
Hype rglyce mia De cre a s e d
immunity
FIGURE 12-14 Stress responses. Stress may trigger elevated secretion o glucocorticoids (GCs) into the
blood. This f ow chart shows the possible e ects induced by high blood GC concentration.
CHAPTER 12 Endocrine System 333
Ad r e n a l M e d u lla
T e adrenal medulla, or inner portion o the adrena g and
shown in Figure 12-13, secretes the hormones epinephrine
(Epi) and norepinephrine (NE). Epinephrine is a so known
as adrenaline.
O ur bodies have many ways to de end themse ves against
enemies that threaten their we -being. A physio ogist might
say that the body resists stress by producing a coordinated set
o stress responses. We have just discussed increased g ucocor-
ticoid secretion. An even aster-acting stress response is in-
creased hormone secretion by the adrena medu a.
T e adrena medu a responds very rapid y to stress because
nerve impu ses conducted by sympathetic nerve f bers stimu-
ate the adrena medu a. W hen stimu ated, it itera y squirts 12
epinephrine and norepinephrine into the b ood. As with g u-
cocorticoids, these hormones may he p the body resist or
avoid stress. In other words, these hormones produce the
bodys f ght-or- ight response to danger (stress).
Suppose you sudden y ace some threatening situation.
Imagine encountering a arge anima that is threatening you
with bared teeth. A most instant y, the medu a o each adre-
na g and wou d be thrust into everish activity. T ey wou d
quick y secrete arge amounts o epinephrine (adrena ine) into
your b ood. Many o your body unctions wou d seem to be
supercharged. Your heart wou d beat aster, your b ood pres-
sure wou d rise, more b ood wou d be pumped to your ske eta
musc es, your b ood wou d contain increased g ucose or more
energy, and so on. In short, you wou d be geared or strenuous
activity to either resist or avoid the anima attackthus the
phrase, f ght or ight.
Epinephrine pro ongs and intensif es changes in body
unction brought about by the stimu ation o the sympathetic
Atrophy Inhibite d
of thymus infla mma tory
re s pons e
De cre a s e d Acce le ra te d
numbe r of re cove ry
e os inophils from
infla mma tion
De cre a s e d
a lle rgic re s pons e s
 334 CHAPTER 12 Endocrine System
subdivision o the autonomic nervous system. Reca rom
Chapter 10 that sympathetic, or adrenergic, f bers re ease epi-
nephrine and norepinephrine as neurotransmitters.
T e c ose unctiona re ationship between the nervous and
the endocrine systems is perhaps most noticeab e in the bodys
response to stress. In stress conditions, the hypotha amus acts
on the anterior pituitary g and to cause the re ease o AC H ,
which stimu ates the adrena cortex to secrete g ucocorticoids.
At the same time, the sympathetic subdivision o the auto-
nomic nervous system is stimu ated with the adrena medu a,
so the re ease o epinephrine and norepinephrine occurs to
assist the body in responding to the stress u stimu us.
12 To learn more about adrenal unction, go to
AnimationDirect online at evolve.elsevier.com.
Ad r e n a l A b n o r m a lit ie s
Injury, disease states, or ma unction o the adrena g ands can
resu t in hypersecretion or hyposecretion o severa di erent
hormones.
umors o the adrena cortex ocated in the midd e zone
o ten resu t in the production o abnorma y arge amounts o
g ucocorticoids. T e medica name or the co ection o symp-
toms that characterize hypersecretion o g ucocorticoids is
Cushing syndrome.
For some reason more women than men deve op Cushing
syndrome. Its most noticeab e eatures are the so-ca ed moon
ace (Figure 12-15) and the buf alo hump on the upper back that
deve op because o the redistribution o body at. Individua s
with Cushing syndrome a so have e evated b ood g ucose
eve s and su er requent in ections. Surgica remova o a
g ucocorticoid-producing tumor may resu t in dramatic im-
provement o the moon- ace symptom within on y 4 months.
umors that a ect the inner zone o the adrena cortex
o ten produce androgens. As a resu t, the symptoms o
hypersecretion o ten resemb e the ma e secondary sexua
S to be seen without a magni ying g ass. T e pancreatic
R L
I
A B
FIGURE 12-15 Cushing syndrome. This condition results rom hypersecretion
o glucocorticoid hormone by a tumor o the middle zone o the adrenal cortex.
A, Photo taken when patient was rst diagnosed with Cushing syndrome. B, Taken
4 months a ter treatment.
S
P A
I
FIGURE 12-16 Addison disease. Addison disease may produce excess
pigmentation o the skin and mucous membranes, as in the buccal (cheek)
sur ace shown here.
characteristics such as beard growth, deve opment o body
hair, and increased musc e mass. I these mascu inizing
symptoms appear in a woman, the cause is requent y a
virilizing tumor o the adrena cortex. T e term virile is
rom the Latin word virilis meaning ma e or mascu ine.
Def ciency or hyposecretion o adrena cortex hormones
resu ts in a condition ca ed Addison disease. President John
F. Kennedy su ered rom Addison disease, which causes re-
duced cortica hormone eve s that resu t in musc e weakness,
reduced b ood g ucose, nausea, oss o appetite, and weight
oss. Increased skin and mucous membrane pigmentation
sometimes characterizes Addison disease (Figure 12-16).
Disorders o adrena secretion are summarized in Table 12-1.
QUICK CHECK
1. Why is th e a d re n a l g la n d o te n th o u g h t o a s tw o s e p a ra te
g la n d s ?
2. Na m e th e h o rm o n e s p ro d u ce d b y th e a d re n a l g la n d .
3. Ho w d o e s th e p itu ita ry g la n d in u e n ce a d re n a l u n ctio n ?
4. Ad d is o n d is e a s e is ca u s e d b y hyp o s e cre tio n o w h ich
h o rm o n e ?
P a n c r e a t ic Is le t s
A the endocrine g ands discussed so ar are big enough
islets, or islets o Langerhans, in contrast, are too tiny
to be seen without a microscope. T ese g ands are mere y
itt e c umps o ce s scattered ike is ands in a sea among
the pancreatic ce s that secrete the pancreatic digestive
juice (Figure 12-17).
wo o the most important kinds o ce s in the pan-
creatic is ets are the alpha cells (or A cells) and beta cells (or
B cells). A pha ce s secrete a hormone ca ed glucagon,

Common bile duct
S ma ll inte s tine
FIGURE 12-17 Pancreas. Location and
structure o the pancreas (cut open). Inset
shows a pancreatic islet (o Langerhans)
in cross section, showing the glucagon-
producing alpha cells and insulin-producing
beta cells. Notice the many exocrine cells
surrounding the endocrine pancreatic islet.
Alpha ce lls
(s e cre te gluca gon)
whereas beta ce s secrete one
o the most we -known o a
hormones, insulin.
G ucagon acce erates a pro- Pa ncre a tic
cess ca ed glycogenolysis in is le t
the iver. G ycogeno ysis is a
chemica process by which the
g ucose stored in the iver ce s
in the orm o g ycogen is con- Ve in
verted to g ucose. T is g ucose
then eaves the iver ce s and
enters the b ood. G ucagon
there ore increases b ood g ucose concentration.
Insu in and g ucagon are antagonists. In other words, insu-
in decreases b ood g ucose concentration; g ucagon increases
it. Insu in is the on y hormone that can decrease b ood g ucose
concentration. Severa hormones, however, increase g ucose
concentration, inc uding g ucocorticoids, growth hormone,
and g ucagon. Insu in decreases b ood g ucose by acce erating
its movement out o the b ood, through ce membranes, and
into ce s. As g ucose enters the ce s at a aster rate, the ce s
increase their metabo ism o g ucose.
Brie y then, insu in decreases b ood g ucose and increases
g ucose metabo ism.
I the pancreatic is ets secrete a norma amount o insu in,
g ucose enters the ce s easi y, and a norma amount o g ucose
stays behind in the b ood. Norma b ood g ucose is about
70-100 mg o g ucose in every 100 mL (one deci iter or dL)
o b ood during asting.
I the pancreatic is ets secrete too much insu in, as they
rare y do when a person has a tumor o the pancreas, more
g ucose than usua eaves the b ood to enter the ce s, and
b ood g ucose decreases.
I the pancreatic is ets secrete too itt e insu in, as they do
in type 1 diabetes mellitus, ess g ucose eaves the b ood to
enter the ce s, so the b ood g ucose increases, sometimes to
even three or more times the norma amount.
Most cases o type 2 diabetes mellitus resu t rom an
abnorma ity o the insu in receptors or their signa ing
CHAPTER 12 Endocrine System 335
Pa ncre a tic duct
S
R L
I
12
Be ta ce lls
(s e cre te ins ulin)
Exocrine ce lls
(s e cre te e nzyme s )
Pa ncre a tic duct
(to duode num)
mechanism, preventing the norma e ects o insu in on its
target ce s and thus a so raising b ood g ucose eve s.
Screening tests or a types o diabetes mellitus (D M)
are based on the act that the b ood g ucose eve is e evated
in this condition. oday, most screening is done with a
simp e test that requires on y a drop o b ood. Subjects with
a high b ood g ucose eve are suspected o having diabetes
me itus.
HEA LTH AND WELL-BEIN G
EXERCIS E AND DIABETES MELLITUS
Type 1 diabe te s m e llitus is characte rize d by high blood glu-
cos e conce ntration be caus e the lack o s u f cie nt ins ulin
preve nts glucos e rom e nte ring ce lls . Howeve r, exe rcis e
phys iologis ts have ound that ae robic training incre as e s the
num be r o ins ulin re ce ptors in targe t ce lls and the ins ulin
a f nity (attraction) o the re ce ptors . Such training allow s a
s m all am ount o ins ulin to have a gre ate r e e ct than it
would have othe rw is e had. Thus exe rcis e re duce s the s e -
ve rity o the diabe tic condition.
All orm s o diabe te s be ne f t rom prope rly planne d ex-
e rcis e the rapy. Not only is this orm o tre atm e nt natural
and cos t-e e ctive , but it als o he lps re duce or preve nt othe r
proble m s s uch as obe s ity and he art dis e as e .
 336 CHAPTER 12 Endocrine System
C LIN ICA L APPLICATION
SYNTHETIC HUMAN INS ULIN
Advance s in biote chnology and ge ne tic e ngine e ring have
m ade s eve ral type s o s ynthe tic hum an ins ulin available or
tre atm e nt o diabe te s .
Ge ne tically e ngine e re d hum an ins ulin was one o the f rs t
artif cial horm one s deve lope d or us e in clinical m e dicine .
Be ore its re le as e , pork and be e pancre as e s we re harve s te d
rom anim als to produce the only orm o ins ulin available or
hum an us e . This orm o ins ulin is s till w ide ly us e d. Howeve r,
in s om e individuals , s m all but im portant di e re nce s in the
12 che m ical m ake up o anim al and hum an ins ulin (one to thre e
am ino acids ) re s ults in im m une s ys te m or alle rgic re actions .
For the s e individuals , deve lopm e nt o s ynthe tic hum an ins ulin
was a m ajor m e dical bre akthrough.
Today, s ynthe tic ins ulin is adm inis te re d in di e re nt ways ,
de pe nding on individual circum s tance s . For exam ple , it can be
inje cte d w ith s m all ne e dle s in various orm s , s uch as in a s m all
s yringe pe n. Or it can be inje cte d through an im plante d
ne e dle by a tim e d, exte rnal ins ulin pum p (picture d).
Othe r m e thods o ins ulin de live ry als o are available or be ing
inve s tigate d. For exam ple , s o-calle d s m art patche s contain-
ing ins ulin m ay be us e d to abs orb ins ulin through the s kin.
esting or g ucose in the urine is another common screen-
ing procedure. In diabetes me itus, excess g ucose is f tered
out o the b ood by the kidneys and ost in the urine, produc-
ing the condition glycosuria.
Figure 12-18 summarizes some o the many prob ems that
can be caused by diabetes me itus. A quick ook at these
prob ems underscores the importance o insu in and insu in
receptors in hea thy bodies.
Disorders o pancreatic is et secretion are summarized in
Table 12-1.
in the article Diabetes Mellitus at at
evolve.elsevier.com.
To learn more about insulin unction, go to
AnimationDirect online at evolve.elsevier.com.
QUICK CHECK
1. Na m e th e tw o p rim a ry h o rm o n e s o th e p a n cre a tic is le ts .
2. Wh a t e e ct d o e s in s u lin h a ve o n th e b lo o d s g lu co s e
co n ce n tra tio n ?
3. Ho w d o e s typ e 1 d ia b e te s d i e r ro m typ e 2 d ia b e te s ?
S e x G la n d s
Fe m a le S e x G la n d s
A womans primary sex g ands are her two ovaries. Each ovary
contains two di erent kinds o g andu ar structures: the ovar-
ian ollicles and the corpus luteum.
Re s e arche rs als o have deve lope d ins ulin pills that could
dram atically im prove diabe te s care or m illions i in the long
run they prove to be s a e and e e ctive .
S ubcuta ne ous
S kin tis s ue
Indwe lling
Ins ulin s ubcuta ne ous
pump ne e dle
S
L M
I
O varian ollicles are itt e pockets in which egg ce s,
or ova, deve op. O varian o ic es a so secrete estrogen,
the eminizing hormone. Estrogen is invo ved in the de-
ve opment and maturation o the breasts and externa geni-
ta s. T is hormone is a so responsib e or deve opment o
adu t ema e body contours and initiation o the menstrua
cyc e.
T e corpus luteum chie y secretes progesterone but a so
some estrogen.
We sha save our discussion o the structure o these en-
docrine g ands and the unctions o their hormones or
Chapter 23.
M a le S e x G la n d s
Some o the ce s o the testes produce the ma e sex ce s
ca ed sperm. O ther ce s in the testes, ma e reproductive
ducts, and g ands produce the iquid portion o the ma e re-
productive uid ca ed semen. T e interstitia ce s in the
testes secrete the ma e sex hormone ca ed testosterone di-
rect y into the b ood. T ese ce s o the testes are there ore the
ma e endocrine g ands.
estosterone is the mascu inizing hormone. It is respon-
sib e or the maturation o the externa genita s, beard growth,
changes in voice at puberty, and or the muscu ar deve opment
and body contours typica o the ma e.
Chapter 23 contains more in ormation about the structure
o the testes and the unctions o testosterone.
 CHAPTER 12 Endocrine System 337

Hypos e cre tion Ma lfunction of

Undis cove re d
of hormone s igna l
me cha nis ms
ins ulin in ta rge t ce lls

De cre a s e d
ins ulin
e ffe cts

Incre a s e d De cre a s e d
blood glucos e glucos e ava ila ble
leve l for ce llula r
(hype rglyce mia ) re s pira tion

12
Incre a s e d Kidneys Ne urons S hift from us ing
glucos e in a bility to s ta rve ca rbohydra te s
inte rs titia l cons e rve glucos e to us ing fa t
fluid is exce e de d

Coma Ne rve
dis e a s e s

Incre a s e d Wa te r
urine glucos e follows glucos e
P rovide s leve l into urine P roduction We ight Incre a s e d
nutrie nts for (glycos uria ) by os mos is of los s blood lipid
microorga nis ms ke tone bodie s leve ls
(hype rlipide mia )

Incre a s e d Incre a s e d Ne t Acidos is Ca rdiova s cula r Ga lls tone s

s us ce ptibility volume of wa te r los s dis orde rs
to infe ction urine from body
(polyuria )

Thirs t He a rt Ulce rs Kidney Eye (re tina )

(polydips ia ) dis e a s e a nd da ma ge da ma ge
ga ngre ne

Blindne s s

FIGURE 12-18 Diabetes mellitus. The signs and symptoms o this disorder (highlighted in yellow) all re-
sult rom decreased insulin e ects. Although this diagram may seem overwhelming at rst glance, it is easy to
ollow i you trace each o the pathways step-by-step through to the end. By doing so, you will begin to appreci-
ate how one event o ten triggers another in human physiology.

A though this structure is sma it weighs about

Th y m u s
T e thymus is ocated in the mediastinum (see Figure 12-1),
and in in ants it may extend up into the neck as ar as the
ower edge o the thyroid g and. Like the adrena g and, the
thymus has a cortex and medu a. Both portions are composed
arge y o ymphocytes (white b ood ce s).
T e thymus is the ocation where many o the bodys ce s
o immunity deve op. T e hormone thymosin is actua y a
group o severa hormones that together p ay an important
ro e in regu ating the deve opment and unction o ce s
an important category o immunity agents in the body. T e
unction o ce s is discussed in detai in Chapter 16.
20 gramsit p ays a critica part in the bodys de enses
against in ections and cancer.
P la c e n t a
T e p acenta unctions as a temporary endocrine g and.
D uring pregnancy, it produces chorionic gonadotropins,
so ca ed because they are tropic hormones secreted by ce s o
the chorion, the outermost membrane that surrounds the
embryo and etus during deve opment in the uterus. In addi-
tion to chorionic gonadotropins, the p acenta a so produces
estrogen and progesterone.
 338 CHAPTER 12 Endocrine System
D uring the ear iest weeks o pregnancy, the kidneys excrete
arge amounts o chorionic gonadotropins in the urine. T is
act, discovered near y a century ago, ed to the deve opment
o early pregnancy tests that are sti in common use today.
P in e a l G la n d
T e pinea g and is a sma g and near the roo o the third
ventric e o the brain (see Figure 10-13). It is named pinea
because it resemb es the pine nut (which ooks ike a sma
kerne o corn). T e pinea g and is easi y ocated in a chi d but
becomes f brous and encrusted with ca cium deposits as a
person ages.
12 T e pinea g and produces a number o hormones in very
sma quantities, with melatonin being the most signif cant.
Me atonin inhibits the tropic hormones that a ect the ova-
ries, and it is thought to be invo ved in regu ating the onset o
puberty and the menstrua cyc e in women.
Because the pinea g and receives and responds to sensory
in ormation rom the ight-sensitive gang ion ce s o the eyes
retina, it is sometimes ca ed the third eye. T e pinea g and
uses in ormation regarding changing ight eve s to adjust its
output o me atonin; me atonin eve s increase during the
night and decrease during the day. T is cyc ic variation is an
important timekeeping mechanism or the bodys interna
c ock and s eep cyc e.
Me atonin supp ements are now wide y used as an aid to
induce s eep or to reprogram the s eep cyc e as a treatment
or jet ag.
S C IEN C E APPLICATIONS
ENDOCRINOLOGY
The undis pute d he roe s o e ndo-
crinology are Canadian s urge on
Fre de rick Banting and his as s is tant
Charle s Be s t. Until the e arly tw e n-
tie th ce ntury, childre n w ith type 1
diabe te s m e llitus die d a s low, hor-
rible de ath as a re s ult o the ir ce lls
lite rally s tarving to de ath rom lack
o glucos e . Acting on Bantings
ide a or re m oving ins ulin rom
Frederick Banting the pancre atic is le ts o dogs , the
(18911941) tw o w e re the f rs t to s ucce s s ully
is olate this im portant horm one .
Che m is t Jam e s Collip w as able to puri y the ins ulin s u f -
cie ntly s o that in 1921 the ir colle ague , Scots phys iologis t
J ohn Macle od, could adm inis te r the ins ulin to a 14-ye ar-old
boy w ith diabe te s . It w orke d! The tre atm e nt not only re lieve d
the boys s u e ring, but it als o gave him a he althy, long li e .
The ir bre akthrough, or w hich Banting and Macle od re -
ce ive d the 1923 Nobe l Prize , was the s tart o a ce ntury o rapid
Abnorma secretion o or sensitivity to me atonin is imp i-
cated in a number o disorders. One dramatic examp e is sea-
sonal af ective disorder (SAD). Patients with this condition
exhibit signs o c inica depression on y during the winter
months, when nights are ong. Apparent y, unusua y high
me atonin eve s associated with ong winter nights cause
psycho ogica e ects in these patients.
A treatment that has been success u in some cases o this
winter depression invo ves the use o bright ights in the
persons indoor environment or a ew hours each day a ter
sundown. T e pinea g and seems to be tricked into respond-
ing as i the patient were experiencing a ong summer day,
thus secreting ess me atonin (see Table 12-1).
E ectronic screensmost o which have the b uish cast
that triggers retina gang ion ce so ten have the unwanted
e ect o disrupting s eep patterns when used ate at night.
W hen treating insomnia, many physicians suggest re raining
rom using such devices or at east an hour or so be ore
bedtime.
En d o c r in e Fu n c t io n s Th ro u g h o u t
t h e Bo d y
O t h e r En d o c r in e S t r u c t u r e s
Continuing research into the endocrine system has shown that
near y every organ and system has an endocrine unction.
issues in the kidneys, stomach, intestines, and other or-
gans secrete hormones that regu ate a variety o essentia
progre s s in unde rs tanding and
tre ating e ndocrine dis orde rs .
Be caus e horm one s a e ct s o
m any di e re nt body unctions ,
ne arly eve ry kind o he alth pro e s -
s ional, rom m e dical doctors to
nurs e s to die titians , ne e ds to be
aware o the ir unctions . O cours e ,
horm one s and che m icals that in u-
e nce horm one actions are o te n
us e d in tre atm e nts , s o pharm acol- Charles Best
ogis ts and pharm acis ts als o m us t (18991978)
have an exce lle nt know le dge o
e ndocrinology.
Som e s cie ntis ts have applie d principle s o e ndocrinology in
a varie ty o unexpe cte d ways , including the deve lopm e nt o
e arly pre gnancy te s t kits and ovulation te s t kits , to the us e o
s ynthe tic horm one s in he althy pe ople to he lp the m control
the ir e rtility.
 CHAPTER 12 Endocrine System 339

human unctions. For examp e, ghrelin is secreted by epithe-
ia ce s ining the stomach and boosts appetite, s ows me-
tabo ism, and reduces at burning. Ghre in may, there ore, be
invo ved in the deve opment o obesity.
Another examp e is atrial natriuretic hormone (ANH),
which is secreted by ce s in the wa o the hearts atria (upper
chambers). ANH is an important regu ator o uid and e ec-
tro yte homeostasis. ANH is an antagonist to a dosterone.
A dosterone stimu ates the kidney to retain sodium ions and
water, whereas ANH stimu ates oss o sodium ions and
water.
A more recent y discovered hormone is leptin, which is
secreted by at-storing ce s throughout the body. Leptin
seems to regu ate how hungry or u we ee and how at is
metabo ized by the body. Researchers are now ooking at how
eptin works with other hormones in the hopes o f nding
ways to treat patients with obesity, diabetes me itus, and
other disorders invo ving at storage.
In the Clear View o the Human Body ( o ows p. 8), try to
f nd as many endocrine organs as you can and note their posi-
tions re ative to other structures o the body.
Ho r m o n e Ac t io n s in Eve ry O r g a n
T is chapter has inc uded a ist o endocrine g ands and hor-
mones that may have seemed end ess. Yet it is on y a sma
raction o the known hormones and hormone-producing ce s.
We have mentioned the actions o hormones in previous
chapters, and we wi continue to discuss near y a the hor-
mones identif ed in this chapter as we proceed through the
rest o this book. W hy? H ormone actions are important regu-
ators o homeostasis throughout the body. T ey p ay critica
ro es in the unction o every organ o the body.
As you move orward in your course, a ways be on the ook-
out or the regu atory and coordinating ro es o hormones. By
doing so, you wi have a more comp ete picture o who e-body
unctiona view that wi serve you we in the uture. 12
QUICK CHECK
1. Wh ich h o rm o n e s a re p ro d u ce d b y th e m a le a n d e m a le
s e x g la n d s ?
2. Why is th e p la ce n ta co n s id e re d to b e a g la n d ?
3. Why is th e p in e a l g la n d s o m e tim e s ca lle d th e tim e -
ke e p e r o th e b o d y?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 319)

antidiuretic hormone (ADH) cortisol ollicle-stimulating hormone (FSH)

[cortis- cortex (bark), -ol alcohol]

[anti- against, -dia- through, -uret- urination,
-ic relating to, hormon- excite]
atrial natriuretic hormone (ANH)
[atria- entrance courtyard (atrium o heart),
-al relating to, natri- natrium (sodium),
-uret- urination, -ic relating to,
hormon- excite]
calcitonin (CT)
[calci- lime (calcium), -ton- tone, -in substance]
chorion
[chorion skin]
chorionic gonadotropin (hCG)
[chorion- skin, -ic relating to, gon- o spring,
-ad- relating to, -trop- nourish, -in substance]
corpus luteum
pl.,
[corpus body, lute- yellow, -um thing]
corticoid
cyclic AMP (cAMP) [ oll- bag, -icle little, stimulate- urge,
-ing action, hormon- excite]
[cycl- circle, -ic relating to] G protein
endocrine gland
[G or guanine-nucleotide binding,
[endo- inward or within, -crin- secrete, prote- f rst rank, -in substance]
gland acorn] ghrelin
endocrine system
[ghrel- grow (also acronym or growth
[endo- inward or within, -crin- secrete, hormone releasing), -in substance]
system organized whole] glucagon
endocrinology
[gluca- sweet (glucose), -agon lead or bring]
[endo- within, -crin- secrete, -o- combining glucocorticoid (GC)
vowel, -log- words (study o ), -y activity]
epinephrine (Epi) [gluco- sweet (glucose), -cortic- cortex (bark),
-oid like]
[epi- upon, -nephr- kidney, -ine substance] gluconeogenesis
estrogen
[gluco- sweet (glucose), -neo- new,
[estro- renzy, -gen produce] -gen- produce, -esis process]
exocrine gland glycogenolysis
[exo- outside or outward, -crin- secrete, [glyco- sweet (glucose), -gen- produce,
gland acorn] -o- combining vowel, -lysis loosening]
growth hormone (GH or hGH)

[cortic- cortex (bark), -oid like] [hormon- excite]

Continued on p. 340
 340 CHAPTER 12 Endocrine System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 339)

hormone oxytocin (OT) sex hormone

[hormon- excite] [oxy- sharp or quick, -toc- birth, -in substance] [hormon- excite]
inhibiting hormone (IH) pancreatic islet (islet o Langerhans) signal transduction

[inhib- restrain, -ing action, hormon- excite] [trans- across, -duc- trans er, -tion process]
insulin [pan- all, -creat- esh, -ic relating to, isl- island, sperm
-et little] [Paul Langerhans German
[insul- island, -in substance] pathologist] pl.,

12 leptin paracrine [sperm seed]

steroid hormone
[lept- thin, -in substance] [para- beside, -crin- secrete]
leukotriene parathyroid gland [ster- sterol, -oid like, hormon- excite]
stress
[leuko- white, -tri- three, -ene chemical] [para- beside, -thyr- shield, -oid like,
gland acorn] [stress tighten]
luteinization
parathyroid hormone (PTH) target cell
[lute- yellow, -ization process]
luteinizing hormone (LH) [cell storeroom]
[para- besides, -thyr- shield, -oid like, testosterone
hormon- excite]
[lute- yellow, -izing process, hormon- excite]
melatonin pituitary gland [testo- witness (testis), -stero- solid or steroid
derivative, -one chemical]
[pituit- phlegm, -ary relating to, gland acorn]
[mela- black, -ton- tone, -in substance] thromboxane
mineralocorticoid (MC) positive eedback
[thrombo- clot, -oxa- oxygen, -ane chemical]
[posit- put or place, -ive relating to,
[mineral- mine, -cortic- cortex (bark), -oid like] thymosin
eedback in ormation about the results o
negative eedback
a process] [thymos- thyme ower (thymus gland),
[negat- deny, -ive relating to, eedback progesterone -in substance]
in ormation about the results o a process] thyroid ollicle
[pro- be ore, -gester- bearing pregnancy
neurohypophysis
-stero- solid or steroid derivative, [thyro- shield thyroid gland -oid like, oll- bag,
-one chemical]
[neuro- nerve, -hypo- under or below, -icle little]
-physis growth] prolactin (PRL) thyroid-stimulating hormone (TSH)
nonsteroid hormone
[pro- be ore, -lact- milk, -in substance]

[non- not, -stero- solid, -oid like, prostaglandin (PG) [thyro- shield, -oid like, stimulate- urge,
hormon- excite] -ing action, hormon- excite]
[pro- be ore, -stat- set or place (prostate),
norepinephrine (NE) thyroxine (T4)
-gland- acorn (gland), -in substance]

[nor- chemical pref x (unbranched C chain), releasing hormone (RH) [thyro- shield (thyroid gland), -ox- oxygen,
-epi- upon, -nephr- kidney, -ine substance] -ine chemical]
[hormon- excite]
ova triiodothyronine (T3)
second-messenger mechanism
sing., ovum [tri- three, -iodo- violet (iodine), -thyro- shield
sella turcica (thyroid gland), -nine chemical]
[ovum egg] tropic hormone
[sella saddle or seat, turcica Turkish]
ovarian ollicle
semen [trop- turn or change, -ic relating to,
[ov- egg, -arian relating to, oll- bag, -icle little] hormon- excite]
[semen seed]
 CHAPTER 12 Endocrine System 341

LANGUAGE OF M ED IC IN E

acromegaly gigantism hyposecretion

[acro- extremities, -mega- great, -aly state] [gigant- great, -ism condition] [hypo- under or below, -secret- separate,
Addison disease glycosuria -tion process]
hypothyroidism
[Thomas Addison English physician, [glyco- sweet (glucose), -ur- urine,
dis- opposite o , -ease com ort] -ia condition] [hypo- under or below, -thyr- shield (thyroid
cretinism goiter gland), -oid- like, -ism condition]
myxedema
[cretin- idiot, -ism condition]
Cushing syndrome
[goiter throat]
Graves disease [myx- mucus, -edema swelling] 12
pharmacology
[Harvey W. Cushing American neurosurgeon, [Robert J . Graves Irish physician, dis- opposite
syn- together, -drome running or (race) o , -ease com ort] [pharmaco- medicine or poison, -log- words
course] hydrocortisone (study o ), -y activity]
diabetes insipidus polyendocrine disorder
[hydro- water, -cortisone cortex o adrenal
[diabetes siphon, insipidus without zest] gland] [poly- many, -endo- inward or within,
diabetes mellitus (DM) hypercalcemia -crin- secrete, dis- lack o ,
-order arrangement]
[diabetes pass-through or siphon, [hyper- excessive, calc- lime (calcium), prolactinoma
mellitus honey-sweet] -emia blood condition]
diuretic hyperglycemia [pro- be ore, -lact- milk, -in- substance,
-oma tumor]
[dia- through, -ure- urine, -ic relating to] [hyper- excessive, -glyc- sweet (glucose), simple goiter
dwarf sm -emia blood condition]
hypersecretion [goiter throat]
[dwar - something tiny, -ism condition] type 1 diabetes mellitus
endocrinologist [hyper- excessive, -secret- separate,
-tion process] [diabetes siphon, mellitus honey sweet]
[endo- within, -crin- secrete, -o- combining hyperthyroidism type 2 diabetes mellitus
vowel, -log- words (study o ), -ist agent]
exophthalmos [hyper- excessive, -thyr- shield (thyroid gland), [diabetes siphon, mellitus honey sweet]
-oid- like, -ism condition] virilizing tumor
[ex- outward, -oph- eye, -thalm- inner chamber, hypoglycemia
-os state] [viril- male or masculine, -izing making,
[hypo- under or below, -glyc- sweet (glucose), tumor swelling]
-emia blood condition]
 342 CHAPTER 12 Endocrine System
OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
12 Endo crine Glands
A. Exocrine g ands are ducted g ands and are not inc uded
in the endocrine system
B. Endocrine g ands are duct ess g ands that secrete chemi-
ca s (hormones) into the b ood (see Table 12-1)
1. arget ce ce that has specif c receptors or a par-
ticu ar hormone
2. Endocrine g ands are numerous and widespread in the
body (Figure 12-1)
Me chanis m s o Ho rm o ne Actio n
A. Endocrine g ands secrete chemica s (hormones) into the
b ood (Figure 12-1)
B. H ormones per orm genera unctions o communication
and contro but a s ower, onger- asting type o contro
than that provided by nerve impu ses
C. Ce s that respond to hormones are ca ed target cells
ound within target organs
D. Nonsteroid hormones (f rst messengers) bind to recep-
tors on the target ce membrane, triggering intrace u ar
second messengers such as cyc ic AMP to a ect the ce s
activities (Figure 12-2)
E. Steroid hormones
1. Primary e ects produced by binding to receptors
within the target ce nuc eus and in uence ce activ-
ity by acting on DNAa s ower process than nonste-
roid action (Figure 12-3)
2. Secondary e ects may occur when steroid hormones
bind to membrane receptors to rapid y trigger unc-
tiona changes in the target ce
Re g ulatio n o Ho rm o ne S e cre tio n
A. H ormone secretion is contro ed by homeostatic
eedback
B. Negative eedbackmechanisms that reverse the direc-
tion o a change in a physio ogica system (Figure 12-4)
C. Positive eedback(uncommon) mechanisms that
amp i y physio ogica changes
D. Leve s o regu ationendocrine regu ation o body unc-
tion usua y operates at mu tip e eve s o contro at the
same time or better e ciency and precision
Me chanis m s o Endo crine
Dis e as e (Table 12-1)
A. H ypersecretionexcess hormone secretion
B. H yposecretioninsu cient hormone secretion
C. Po yendocrine disordershyper- or hyposecretion o
more than one hormone
D. arget ce insensitivity produces resu ts simi ar to
hyposecretion
E. Endocrino ogists have deve oped many di erent strategies
or treatment ( or examp e, surgery and hormone therapy)
Pro s tag landins
A. Prostag andins (PGs) are power u ipid substances ound
in a wide variety o body tissues; PGs are modif ed atty
acids
B. PGs are typica y produced in a tissue and di use on y a
short distance to act on ce s in that tissue; o ten ca ed
tissue hormones or paracrine agents
C. Severa c asses o PGs inc ude prostag andin A (PGA),
prostag andin E (PGE), and prostag andin F (PGF)
D. PGs in uence many body unctions, inc uding respiration,
b ood pressure, gastrointestina secretions, and reproduction
Pituitary Gland
A. Structure o the pituitary g and (Figure 12-6)
1. Anterior pituitarya so ca ed adenohypophysis; made
up o g andu ar epithe ium
2. Posterior pituitarya so ca ed neurohypophysis; made
up o nervous tissue
3. Locationin bony depression (se a turcica) o sphe-
noid bone in sku ; connected to the hypotha amus by
a pituitary sta k
B. Anterior pituitary g and (adenohypophysis)
1. Names o major hormones
a. T yroid-stimu ating hormone ( SH )
b. Adrenocorticotropic hormone (AC H )
c. Fo ic e-stimu ating hormone (FSH )
d. Luteinizing hormone (LH )
e. Growth hormone (GH )
. Pro actin ( actogenic hormone)
2. Functions o major hormones
a. SH stimu ates growth o the thyroid g and; a so
stimu ates it to secrete thyroid hormone
b. AC H stimu ates growth o the adrena cortex
and stimu ates it to secrete g ucocorticoids (main y
cortiso )
c. FSH initiates growth o ovarian o ic es each
month in the ovary and stimu ates one or more o i-
c es to deve op to the stage o maturity and ovu ation;
FSH a so stimu ates estrogen secretion by deve oping
o ic es; stimu ates sperm production in the ma e

d. LH acts with FSH to stimu ate estrogen secre-
tion and o ic e growth to maturity; causes ovu a-
tion; causes uteinization o the ruptured o ic e
and stimu ates progesterone secretion by corpus
uteum; causes interstitia ce s in the testes to
secrete testosterone in the ma e
e. GH stimu ates growth by acce erating protein
anabo ism; a so acce erates at catabo ism and s ows
g ucose catabo ism; by s owing g ucose catabo ism,
tends to increase b ood g ucose to higher than
norma eve (hyperg ycemia)
(1) H ypersecretion during chi dhood resu ts in
gigantism and during adu thood resu ts in
acromega y (Figure 12-5)
(2) H yposecretion during chi dhood resu ts in
pituitary dwarf sm
. Pro actin (PRL) or actogenic hormonestimu ates
breast deve opment during pregnancy and secretion
o mi k a ter the de ivery o the baby
(1) Pro actinomabenign adenoma causing hyper-
secretion o PRL; occurs most requent y in
ema es
C. Posterior pituitary g and (neurohypophysis) (Figure 12-6)
1. Names o hormones
a. Antidiuretic hormone (ADH )
(1) H yposecretion causes diabetes insipidus, char-
acterized by excessive vo ume o urine
b. O xytocin (O )
2. Functions o hormones
a. ADH acce erates water reabsorption rom urine
in the kidney tubu es into the b ood, thereby
decreasing urine secretion
b. O xytocinstimu ates the pregnant uterus to con-
tract; may initiate abor; causes g andu ar ce s o
the breast to re ease mi k into ducts
Hypo thalam us
A. Produces posterior pituitary hormones
1. Actua production o ADH and oxytocin occurs in the
hypotha amus
2. A ter production in the hypotha amus, hormones pass
a ong axons into the pituitary g and
3. T e secretion and re ease o posterior pituitary hor-
mones are contro ed by nervous stimu ation
B. Regu ates anterior pituitary secretion
1. Re easing hormones (RH s) and inhibiting hormones
(IH s) contro secretion by anterior pituitary
2. RH s and IH s reach anterior pituitary through a direct
capi ary connection
C. T e hypotha amus contro s many body unctions re ated
to homeostasis (temperature, appetite, and thirst)
Thyro id Gland
A. Located in the neck, just in erior to the arynx
(Figure 12-7)
CHAPTER 12 Endocrine System 343
B. issue made up o thyroid o ic es f ed with co oid
(Figure 12-8)
C. Names o hormones
1. T yroid hormonesthyroxine ( 4) and triiodothyro-
nine ( 3); produced by o ic e ce s and stored in
co oid o o ic es
2. Ca citonin (C )made by C ce s outside the o i-
c e wa s
D. Functions o hormones
1. T yroid hormonesacce erate catabo ism and energy
production (increasing the bodys metabo ic rate)
2. C decreases the b ood ca cium concentration by
inhibiting breakdown o bone, which wou d re ease
ca cium into the b ood 12
E. H yperthyroidism (hypersecretion o thyroid hormones)
increases metabo ic rate
1. Characterized by rest essness and exophtha mos (pro-
truding eyes) (Figure 12-9)
2. Graves disease is an inherited orm o
hyperthyroidism
F. H ypothyroidism (hyposecretion o thyroid hormones)
1. May resu t rom di erent conditions
2. Simp e goiterpain ess en argement o thyroid
caused by dietary def ciency o iodine (Figure 12-10)
3. H yposecretion during ear y deve opment may resu t in
cretinism (retardation) and during adu thood in myx-
edema (characterized by edema, dry skin, and s ug-
gishness; Figure 12-11)
Parathyro id Glands
A. Sma umps o g andu ar tissue ocated on the posterior
sur ace o the thyroid g and (Figure 12-7)
B. Name o hormoneparathyroid hormone (P H )
1. Increases b ood ca cium concentration by increasing
the breakdown o bone with the re ease o ca cium
into the b ood; a so promotes ca cium absorption rom
ood and reduces ca cium oss in the urine
2. P H and C have antagonistic e ects that he p
maintain stab e b ood ca cium concentrations needed
or good hea th (Figure 12-12)
Adre nal Glands
A. Located on the superior end o each kidney; outer region
is g andu ar and inner region is secretory nervous tissue
(Figure 12-13)
B. Adrena cortex
1. Names o hormones (corticoids)
a. G ucocorticoids (GCs)chie y cortiso
(hydrocortisone)
b. Minera ocorticoids (MCs)chie y a dosterone
c. Sex hormonessma amounts o ma e hormones
(androgens) secreted by adrena cortex o both sexes
2. T ree ce ayers (zones)
a. O uter ayersecretes minera ocorticoids
b. Midd e ayersecretes g ucocorticoids
c. Inner ayersecretes sex hormones
 344 CHAPTER 12 Endocrine System
3. Minera ocorticoidsincrease b ood sodium and
decrease body potassium concentrations by acce erat-
ing kidney tubu e reabsorption o sodium and excre-
tion o potassium
4. Functions o g ucocorticoids
a. H e p maintain norma b ood g ucose concentration
by increasing g uconeogenesisthe ormation o
new g ucose rom amino acids produced by the
breakdown o proteins, main y those in musc e
tissue ce s; a so the conversion to g ucose o atty
acids produced by the breakdown o ats stored in
adipose tissue ce s
b. P ay an essentia part in maintaining norma b ood
12 pressuremake it possib e or epinephrine and
norepinephrine to maintain a norma degree o
vasoconstriction, a condition necessary or main-
taining norma b ood pressure
c. Act with epinephrine and norepinephrine to produce
an anti-in ammatory e ect, to bring about norma
recovery rom in ammations o various kinds
d. Produce anti-immunity, antia ergy e ect; bring
about a decrease in the number o ymphocytes and
p asma ce s and there ore a decrease in the amount
o antibodies ormed
e. Secretion o g ucocorticoid quick y increases when
the body is thrown into a condition o stress; high
b ood concentration o g ucocorticoids, in turn, brings
about many other stress responses (Figure 12-14)
. Chronic stress can disturb the bodys ba ance o
metabo ic and immune unctions
5. Sex hormonesma e androgens simi ar to testoster-
one are produced in both sexes; have a ro e in repro-
ductive deve opment
C. Adrena medu a
1. Names o hormonesepinephrine (Epi), or adrena-
ine, and norepinephrine (NE)
2. Functions o hormoneshe p the body resist stress by
intensi ying and pro onging the e ects o sympathetic
stimu ation; increased epinephrine secretion is the f rst
endocrine response to stress
D. Adrena abnorma ities
1. H ypersecretion o g ucocorticoids causes Cushing
syndrome: moon ace, hump on back, e evated b ood
g ucose eve s, requent in ections (Figure 12-15)
2. H ypersecretion o adrena androgens may resu t rom
a viri izing tumor and cause mascu inization o
a ected women
3. H yposecretion o cortica hormones may resu t in
Addison disease: increased pigmentation in skin and
mucous membranes, musc e weakness, reduced b ood
g ucose, nausea, oss o appetite, and weight oss
(Figure 12-16)
Pancre atic Is le ts
A. Is ands o endocrine tissue scattered within the exocrine
tissue o the pancreas, a digestive g and near the junction
o the stomach and sma intestine (Figure 12-17)
B. Names o hormones
1. G ucagonsecreted by a pha ce s
2. Insu insecreted by beta ce s
C. Functions o hormones
1. G ucagon increases the b ood g ucose eve by acce er-
ating g ycogeno ysis in iver (conversion o g ycogen to
g ucose)
2. Insu in decreases the b ood g ucose by acce erating the
movement o g ucose out o the b ood into ce s,
which increases g ucose metabo ism by ce s
D. Diabetes me itus (Figure 12-18)
1. ype 1 resu ts rom hyposecretion o insu in
2. ype 2 resu ts rom target ce insensitivity to insu in
3. G ucose cannot enter ce s and thus b ood g ucose
eve s rise, producing g ycosuria (g ucose in the urine)
S e x Glands
A. Fema e sex g ands
1. T e ovaries contain two structures that secrete
hormonesthe ovarian o ic es and the corpus
uteum; see Chapter 23
2. E ects o estrogen ( eminizing hormone)
a. Deve opment and maturation o breasts and exter-
na genita s
b. Deve opment o adu t ema e body contours
c. Initiation o menstrua cyc e
B. Ma e sex g ands
1. T e interstitia ce s o testes secrete the ma e
hormone testosterone; see Chapter 23
2. E ects o testosterone (mascu inizing hormone)
a. Maturation o externa genita s
b. Beard growth
c. Voice changes at puberty
d. Deve opment o muscu ature and body contours
typica o the ma e
Thym us
A. Name o hormonethymosin
B. Function o hormonep ays an important ro e in the
deve opment and unction o ce s (agents o the bodys
immune system)
Place nta
A. Name o hormoneschorionic gonadotropins, estrogens,
and progesterone
B. Functions o hormonesmaintain the corpus uteum
during pregnancy
Pine al Gland
A. A sma g and near the roo o the third ventric e o the
brain
1. G andu ar tissue predominates in chi dren and young
adu ts
2. Becomes f brous and ca cif ed with age

B. Ca ed third eye because its in uence on secretory activity
is re ated to the amount o ight entering the eyes
C. Secretes me atonin, which
1. Inhibits ovarian activity
2. Regu ates the bodys interna c ock
D. Abnorma secretion o (or sensitivity to) me atonin may
produce seasona a ective disorder (SAD) or winter
depression, a orm o depression that occurs when expo-
sure to sun ight is ow and me atonin eve s are high
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the e ndocrine s ys te m in Chapte r 5.
The unction o the e ndocrine s ys te m is the s am e as that o
the ne rvous s ys te m . The di e re nce s are in the m e thods us e d
and the exte nt o the ir e e cts . The e ndocrine s ys te m us e s
che m icals in the blood (horm one s ) rathe r than ne rve im -
puls e s . Horm one s can have a dire ct e e ct on alm os t eve ry
ce ll in the body, an im pos s ible tas k or the ne rvous s ys te m .
Ste roid horm one s can act dire ctly be caus e they can e nte r
the ce ll; prote in horm one s cannot, s o they ne e d a s e cond-
m e s s e nge r s ys te m .
1. Reviewing materia rom ear ier chapters such as receptor
proteins in the ce membrane, A P, homeostasis, and
negative eedback oops wi he p you understand the
materia in this chapter.
2. Use ash cards and on ine resources to earn the names o
the hormones, what they do, and the names and ocations
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Di erentiate between endocrine and exocrine g ands.
2. Def ne or exp ain the o owing terms: hormone, target
organ, hypersecretion, and hyposecretion.
3. Exp ain the mechanism o action o nonsteroid
hormones.
4. Exp ain the mechanism o action o steroid hormones.
CHAPTER 12 Endocrine System 345
Endo crine Functio ns
Thro ug ho ut the Bo dy
A. Many organs ( or examp e, the stomach, intestines, and
kidneys) produce endocrine hormones
1. Stomach ining produces ghre in, which a ects appe-
tite and metabo ism
2. T e atria wa o the heart secretes atria natriuretic
hormone (ANH ), which stimu ates sodium oss rom
the kidneys
3. Fat-storing ce s secrete eptin, which contro s how
u or hungry we ee
B. H ormone actions occur in every organ o the body and
are addressed throughout the rest o this book 12
o the g ands that produce them. Deve op a concept map
that inc udes the g and, hormones, and their unctions.
3. Remember that hormones re eased by the posterior pitu-
itary g and are made in the hypotha amus.
4. W hen studying the disorders o the endocrine system,
make a chart that identif es the disorders as a hyposecre-
tion or hypersecretion o a specif c g and. T is may be
more di cu t than you think because many o the disor-
ders are named a ter peop e, so the names themse ves are
not he p u in exp aining the disorders. Usua y, i you
know the norma unction o the hormone, you shou d be
ab e to f gure out what e ect on the body hyposecretion
or hypersecretion wou d have.
5. In your study group, discuss the hormone mechanisms
and negative eedback oops invo ved in hormone regu a-
tion. Review the hormone ash cards. Use your e ectronic
device to photocopy Table 12-1. T e photocopy and the
chapter out ine summary at the end o the chapter wou d
be a good way to organize a most a the in ormation in
the chapter. Go over the chart o endocrine disorders and
the questions at the end o the chapter, and discuss possi-
b e test questions.
5. Exp ain and give an examp e o a negative eedback oop
or the regu ation o hormone secretion.
6. Exp ain and give an examp e o a positive eedback oop
or the regu ation o hormone secretion.
7. Exp ain the di erence between prostag andins and hor-
mones. List some o the body unctions that can be
in uenced by prostag andins.
8. Describe the structure o the pituitary g and and where
it is ocated.
9. Name the our tropic hormones re eased by the anterior
pituitary g and and brie y exp ain their unctions.
10. Exp ain the unction o growth hormone.
 346 CHAPTER 12 Endocrine System

11. Gigantism and acromega y have the same cause. W hat is 3. T e two major c asses o hormones are ________ and
the cause o these two endocrine disorders and how do ________.
they di er? 4. A ce or body organ that has receptors or a hormone
12. Exp ain the unction o ADH . that triggers a reaction is ca ed a ________.
13. W hat is the cause o diabetes insipidus? W hat are the 5. O ne examp e o a second-messenger system invo ves the
signs and symptoms o the condition? conversion o A P into ________.
14. Exp ain the unction o pro actin and oxytocin. 6. T e hormone receptors or a nonsteroid hormone are
15. Exp ain the unction o the hypotha amus in the endo- ocated in the ________, whereas the receptors or a
crine system. steroid hormone are ocated in the ________.
16. Exp ain the di erence between 3 and 4. W hat is 7. issue hormones is another name or ________.
unique about the thyroid g and? 8. W hat part o the pituitary g and is made o nervous
17. Describe the antagonistic e ects o ca citonin and para- tissue? ________
thyroid hormone in the regu ation o ca cium. 9. W hat part o the pituitary g and is made o g andu ar
12 18. Distinguish between cretinism and myxedema. tissue? ________
19. Name the hormones produced by the zones or areas o 10. T e hormone oxytocin is re eased by the ________ but
the adrena cortex. is made in the ________.
20. W hat are the signs and symptoms o Cushing syn- 11. T e hormone hGH is a synonym or the________.
drome? O Addison disease? 12. T e ________ enters target ce s and does not require a
21. Exp ain the unction o a dosterone. second-messenger action. It is an exception to the
22. Exp ain the unction o g ucocorticoids. genera mode o nonsteroid action requiring an interna
second messenger.
13. Patients with ________ exhibit signs o c inica depres-
Critical Thinking sion on y during the winter months, when nights are
A te r f nis hing the Review Que s tions , w rite out ong.
the ans we rs to the s e m ore in-de pth que s tions to 14. A tropic hormone secreted by the anterior pituitary
he lp you apply your new know le dge . Go back to g and is:
s e ctions o the chapte r that re late to conce pts a. thyroid-stimu ating hormone
that you f nd di f cult. b. adrenocorticotropic hormone
c. uteinizing hormone
23. Exp ain why a secondary messenger system is needed or d. a o the above
nonsteroid hormones but not or steroid hormones. 15. Antidiuretic hormone (ADH ):
24. W hy is the ba ance o b ood ca cium eve s signif cant to a. is made in the posterior pituitary g and
homeostasis? b. acce erates water reabsorption in the kidney
25. W hy is a goiter usua y more o a dietary prob em rather c. in high concentration causes diabetes insipidus
than an endocrine prob em? d. a o the above
26. A doctor discovered a patient had very ow eve s o thy- 16. W hich o the o owing hormones is re eased by the
roxine by noting high eve s o SH . Is the patients anterior pituitary g and and stimu ates breast deve op-
prob em in the thyroid g and or the pituitary g and? ment during pregnancy necessary or eventua mi k
Exp ain your answer. production?
27. I a person diagnosed with diabetes me itus were ound a. Estrogen
to be producing a norma amount o insu in, what other b. O xytocin
cause cou d exp ain the diabetes? c. Pro actin
28. W hy is a program o regu ar exercise so important to a d. Progesterone
diabetic patient; especia y someone with a diagnosis o 17. W hich hormone re eased by the posterior pituitary
type 1 diabetes? g and stimu ates the contraction o the pregnant uterus?
a. Estrogen
b. O xytocin
Chapte r Te s t c. Pro actin
A te r s tudying the chapte r, te s t your m as te ry by d. Progesterone
re s ponding to the s e ite m s . Try to ans we r the m 18. A benign adenoma that causes a hypersecretion o pro-
w ithout looking up the ans we rs . actin (PRL) is ca ed:
a. viri izing tumor
1. ________ g ands secrete their products into ducts that b. exophtha mos
empty onto a sur ace or into a cavity. c. pro actinoma
2. ________ g ands are duct ess and secrete their products, d. myxedema
ca ed ________, into interce u ar space, where they
di use into the b ood.
 CHAPTER 12 Endocrine System 347

19. W hat is the chemica process by which the g ucose 20. W hich o the o owing is not a paracrine?
stored in the iver ce s in the orm o g ycogen is con- a. Prostag andin
verted to g ucose? b. Leukotriene
a. G yco ysis c. T romboxane
b. G uconeogenesis d. Ghre in
c. Second-messenger mechanism
d. G ycogeno ysis

Match each hormone in Column A with its unction or source in Column B.

Column A Column B
21. ________ parathyroid hormone a. re eased by the adrena medu a; pro ongs the e ect o the sympathetic
22. ________ minera ocorticoids nervous system
23. ________ g ucocorticoids b. made in the heart; he ps regu ate b ood sodium 12
24. ________ epinephrine c. made in the pancreatic is ets; decreases b ood g ucose eve s
25. ________ g ucagon d. has the opposite e ect o ca citonin in the b ood
26. ________ insu in e. made by the a pha ce s in the pancreatic is ets
27. ________ chorionic gonadotropins . made in the outermost ayer o the adrena cortex
28. ________ me atonin g. the most signif cant hormone re eased by the pinea g and
29. ________ atria natriuretic hormone h. the hormone made in the p acenta and detected by home pregnancy tests
i. made by the midd e ayer o the adrena cortex

Match each description or signs and symptoms in Column B with its corresponding endocrine disorder in Column A.

Column A Column B
30. ________ gigantism a. an inherited hyperthyroidism with exophtha mos
31. ________ acromega y b. hyposecretion o thyroid hormone in ater i e eading to essened physica and
32. ________ diabetes insipidus menta vigor
33. ________ Graves disease c. hyposecretion o insu in causing an increased b ood g ucose eve
34. ________ myxedema d. hypersecretion o growth hormone a ter the norma growth years
35. ________ goiter e. an en arged thyroid g and as a resu t o dietary def ciency o iodine
36. ________ cretinism . a condition caused by a hypersecretion o g ucocorticoids
37. ________ Cushing syndrome g. hypersecretion o growth hormone in the ear y years o i e
38. ________ diabetes me itus h. hyposecretion o thyroid hormone in the ormative years resu ting in physica ,
39. ________ seasona a ective menta , and sexua retardation
disorder i. a condition caused by high secretions o me atonin, causing depression in winter
j. hyposecretion o ADH , causing the production o a arge vo ume o urine

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. George, the chie executive o cer o a major institution,
was jogging around his summer home when he became
distressed at what seemed to be an irregu arity o his
heart rhythm. H is assistants immediate y rushed George
to a hospita , where he was diagnosed as having atria
f bri ation (uncoordinated contractions o the upper heart
chambers). George was even more distressed to hear that
he had a specif c heart condition, earing it might disrupt
his very active i esty e. H is physicians in ormed him that
the overactivity o his heartand perhaps other organs
was caused by hyperthyroidism. Exp ain how hyperthy-
roidism cou d cause Georges prob ems. W hat strategies
might his physicians have avai ab e or treating him?
2. In Georges case (see preceding case study), the attending
physicians chose to surgica y remove part o the thyroid
in an attempt to contro Georges hyperthyroidism. W hat
precautions ought Georges surgeons take in removing
this tissue? (H IN : W hat anatomica structures in the
thyroid area shou d they avoid cutting or removing?)
3. Your riend Lynn has type 1 diabetes me itus. W hat
therapy is ike y to he p her regain contro o her metabo-
ism and thus avoid possib e tissue or organ damage?
Lynn has to d you that her condition, i untreated, resu ts
in starvation o ce s in her body. T is condition is char-
acterized by hyperg ycemia (e evated b ood g ucose), so
you might wonder how the ce s cou d starve i they have
an excess o nutrients avai ab e. W hat is the exp anation
or this seeming y contradictory act?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Blood
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Blood Composition, 349 White Blood Cell Disorders, 363

Blood Tissue, 349 Multiple Myeloma, 363
Blood Plasma, 350 Leukemia, 363
Formed Elements, 351 In ectious Mononucleosis, 364
Hematopoiesis, 352 Platelets and Blood Clotting, 365
Mechanisms o Blood Disease, 352 Platelets, 365
Red Blood Cells, 352 Blood Clotting, 365
RBC Structure and Function, 352 Clotting Disorders, 365
RBC Count, 353 Abnormal Blood Clots, 365
Hemoglobin, 354 Hemophilia, 366
RBC Abnormalities, 354 Thrombocytopenia, 368
Blood Types, 355 Vitamin K Def ciency, 368
Red Blood Cell Disorders, 358
Polycythemia, 358
Anemia, 358
White Blood Cells, 361
Introduction to WBCs, 361
WBC Count, 362
WBC Types, 362

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. Describe the primary unctions and
composition o blood, including the
characteristics o blood tissue and
plasma, and identi y the most important
unction o each o the ormed elements
o blood.
2. Explain the mechanisms o blood
disease.
3. Explain the structure and unction o red
blood cells, the purpose o an RBC
count, the unction o hemoglobin, and
list RBC abnormalities.
4. Describe ABO and Rh systems or blood
typing.
5. Identi y and discuss common red blood
cell disorders.
6. Describe the structure and unction o
white blood cells.
7. State the purpose o per orming a WBC
count, and identi y WBC types.
8. Identi y and discuss common white
blood cell disorders.
9. Explain the steps involved in blood clot-
ting and describe clotting disorders.
 13
Th e next ew chapters dea with transportation LANGUAGE OF
and protection, two o the bodys most important S C IEN C E
unctions. H ave you ever thought o what wou d
happen i the transportation ceased in your
Be o re re ading the
city or town? Or what wou d happen i the po ice,
chapte r, s ay e ach o
f ref ghters, and armed services stopped doing the s e te rm s o ut lo ud. This w ill
their jobs? Food wou d become scarce, garbage he lp yo u to avo id s tum bling ove r
wou d pi e up, and no one wou d protect you the m as yo u re ad.
or your property. Stretch your imagina-
tion just a itt e, and you can imagine
ABO system
many disastrous resu ts. Simi ar y, (ay bee oh SIS-tem)
ack o transportation and protec-
agglutinate
tion or the ce sthe individu- (ah-GLOO-tin-ayt)
a s o the bodythreatens the [agglutin- glue, -ate process]
homeostasis o the body. T e agranular leukocyte
systems that provide these (ah-GRAN-yoo-lar LOO-koh-syte)
vita services or the body [a- without, -gran- grain, -ul- little,
are the cardiovascular system -ar relating to, leuko- white,
(circulatory system), lymphatic -cyte cell]
system, and immune system. albumin
(al-BYOO-min)
In this chapter, we discuss the primary [alb- white, -in substance]
transportation uidb ood. B ood not antibody
on y per orms vita pickup and de ivery (AN-tih-bod-ee)
services but a so provides much o the [anti- against, -body main part]
protection necessary to withstand oreign antigen
invaders.T e heart and b ood vesse s are (AN-tih-jen)
discussed in Chapters 14 and 15. T e ym- [anti- against, -gen produce]
phatic system and immunity are discussed basophil
in Chapter 16. (BAY-soh-f l)
[bas- base (high pH), -phil love]
bu y coat
Blo o d C o m p o s it io n (BUF-ee koht)
[bu - leather, -y characterized by]
Blo o d Tis s u e carbaminohemoglobin (HbCO2)
(kar-bah-MEE-noh-hee-moh-
B ood is a uid tissue that has many kinds
GLOH-bin [aych bee see
o chemica s disso ved in it and mi ions
oh too])
upon mi ions o ce s oating in it [carb- coal (carbon),
(Figure 13-1). T e iquid (extrace u ar) part -amino- ammonia compound
is ca ed plasma. Suspended in the p asma (amino acid), -hemo- blood,
are many di erent types o ce s and ce -glob- ball, -in substance]
ragments that make up the ormed elements cardiovascular system
o b ood. (kar-dee-oh-VAS-kyoo-lar
Many peop e are curious about just how SIS-tem)
much b ood they have. T e amount varies with [cardi- heart, -vas- vessel,
-ular relating to]

Continued on p. 368

349
 350 CHAPTER 13 Blood

PLAS MA PROTEINS
(pe rce nta ge by we ight)
WHOLE BLOOD Albumins 57%
(pe rce nta ge P rote ins
by volume ) 7% Globulins 38%
Fibrinoge n 4%
Ce ntrifuge d P rothrombin 1%
Blood 8% s a mple
of blood
ood Wa te r OTHER S OLUTES
91%
Ions
Nutrie nts
PLAS MA
55% Wa s te products
Othe r s olute s
2% Ga s e s
Othe r fluids
a nd tis s ue s Re gula tory s ubs ta nce s
92% Buffy coa t P la te le ts
140,000340,000
LEUKOCYTES
FORMED
ELEMENTS Le ukocyte s
50009000 Ne utrophils 60%70%
45%

Erythrocyte s Lymphocyte s 20%25%

4.26.2 millio n
TOTAL BODY WEIGHT
Monocyte s 3%8%

13 Eos inophils 2%4%

Ba s ophils 0.5%1%
FIGURE 13-1 Blood components. Approximate values FORMED ELEMENTS
or the components o blood in a normal adult. (numbe r pe r cubic mm)

how big they are and whether they are ma e or ema e. A big
person has more b ood than a sma person, and a man has
more b ood than a woman. But as a genera ru e, most adu ts
probab y have between 4 and 6 L o b ood. It norma y ac-
counts or about 7% to 9% o the tota body weight.
T e vo ume o the p asma part o b ood is usua y a itt e
more than ha the entire vo ume o who e b ood. An examp e
o norma b ood vo umes or a person o ows:
Plasma 2.6 L
Formed elements 2.4 L
W hole blood 5.0 L
B ood is s ight y a ka ine, with a pH between 7.35 and 7.45
a ways staying just above the chemica y neutra point o 7.00
(see Chapter 2). I the a ka inity o your b ood decreases to-
ward neutra , you are a very sick person; in act, you have
acidosis. But even in this condition, b ood a most never be-
comes the east bit acid; it just becomes ess a ka ine than
norma .
QUICK CHECK
1. Na m e th e liq u id (e xtra ce llu la r) ra ctio n o w h o le b lo o d .
2. Blo o d a cco u n ts o r w h a t p e rce n t (%) o to ta l b o d y w e ig h t?
3. Wh a t is th e n o rm a l b lo o d p H?
Blo o d P la s m a
B ood p asma is the iquid part o the b ood, or b ood minus
its ormed e ements. It consists o water with many substances
disso ved in it. A o the chemica s needed by ce s to stay
a ivenutrients, oxygen, and sa ts, or examp ehave to be
brought to them by the b ood.
Nutrients and sa ts are disso ved in p asma. About 1.5% o
the tota amount o oxygen (O2) transported in the b ood is
a so disso ved in p asma. Wastes that ce s must get rid o are
disso ved in p asma and transported to the excretory organs.
Approximate y 10% o the tota amount o the waste product
carbon dioxide (CO2) that is carried in the b ood is disso ved in
the p asma.
In addition to the re ative y sma amounts o O 2 and
CO 2 disso ved in p asma, other mechanisms are invo ved in
the transportation o these important gases in the b ood and
are described ater. T e hormones and other regu atory
chemica s that he p contro ce s activities are a so disso ved
in p asma.
As Figure 13-1 shows, the most abundant type o so ute in
the p asma is a group o plasma proteins that together make
up about 7% o the p asma by weight. T ese proteins inc ude
albumins, which he p retain water in the b ood by osmosis.
Globulins, which inc ude the antibodies that he p protect us
rom in ections, circu ate in the p asma. T e p asma a so carries
brinogen and prothrombin, which are necessary or b ood
c otting.
 CHAPTER 13 Blood 351

Intravenous administration o
albumin is sometimes used as a
plasma volume expander in peo-
ple with abnormally low blood
volume. T e injected albumin
will draw about three to our
times its volume o f uid into the
blood through the process o os-
mosis. T e result is an expansion
o blood volume that can be li e-
saving in cases o hemorrhage,
severe burns, or kidney disease.
Blood serum is plasma minus
its clotting actors, such as brin-
ogen and prothrombin. Serum is
obtained rom whole blood by
allowing the blood to rst clot in
the bottom o a tube; then the
liquid serum that remains at the
top is poured o . Serum still con-
tains antibodies, so it can be used
to treat patients who have a need
or speci c antibodies.
C LIN ICA L APPLICATION
CARDIAC BLOOD TESTS
Som e tim e s blood plas m a contains exce s s e s o norm al
s ubs tance s or low am ounts o abnorm al s ubs tance s
that m ay indicate dis e as e . For exam ple , w he n the he art
m us cle is dam age d, e nzym e s containe d w ithin the
m us cle ce lls are re le as e d into the bloods tre am , caus ing
incre as e d plas m a leve ls o the s e e nzym e s .
Blood te s ts or a num be r o cardiac e nzym e s , includ-
ing cre atine kinas e (CK), lactic de hydroge nas e (LD), and
s e rum glutam ic-oxaloace tic trans am inas e (SGOT), are
us e ul in conf rm ing a myocardial in arction (MI), or
he art attack.
The troponins te s t is anothe r ve ry valuable diagnos tic
aid. Rathe r than m aking an e nzym atic de te rm ination, it
ide ntif e s a s pe cif c bioche m ical m arke r pre s e nt in car-
diac dis e as e . The pre s e nce o cardiac troponins is par-
ticularly us e ul in di e re ntiating cardiac rom noncardiac
che s t pain.

Fo r m e d Ele m e n t s
13
T ere are three main types and several subtypes o ormed TABLE 13-1 Classes o Blood Cells
elements: BODY CELL FUNCTION
Erythrocyte Oxyge n and carbon dioxide
1. Red blood cells (RBCs), or erythrocytes
trans port
2. W hite blood cells (W BCs), or leukocytes
a. Granular leukocytes (have stained granules in
their cytoplasm)
Ne utrophil Im m une de e ns e (phagocytos is )
(1) Neutrophils
(2) Eosinophils
(3) Basophils
b. Agranular leukocytes (do not have stained gran-
ules in their cytoplasm) Eos inophil De e ns e agains t paras ite s
(1) Lymphocytes
(2) Monocytes
3. Platelets or thrombocytes
Bas ophil In am m atory re s pons e and
Figure 13-1 shows the breakdown o numbers and percent- he parin s e cre tion
ages o the ormed elements. Table 13-1 lists the unctions o
these ormed elements and shows what each looks like under
the microscope. B lym phocyte Antibody production (pre curs or
It is di cult to believe just how many blood cells and cell o plas m a ce lls )
ragments are in the human body. For instance, 5,000,000
RBCs, 7500 W BCs, and 300,000 platelets in 1 cubic milli-
T lym phocyte Ce llular im m une re s pons e
meter (mm3) o blood (a tiny raction o a drop) would be
considered normal counts. Because RBCs, W BCs, and plate-
lets are continually being destroyed, the body also must con-
tinually make new ones to take their place at a really stagger- Monocyte Im m une de e ns e s
ing rate; a ew million RBCs are manu actured each second! (phagocytos is )

To learn more about the types o blood cells, go to Throm bocyte Blood clotting
AnimationDirect online at evolve.elsevier.com.
 352 CHAPTER 13 Blood

He m a t o p o ie s is
Recall rom our previous discussion o bones in Chapter 8
that ormation o new blood cells is called hematopoiesis.
wo kinds o connective tissuemyeloid tissue and lymphoid
tissuemake blood cells or the body.
Myeloid tissue is better known as red bone marrow. In the
adult, it is ound chief y in the sternum, ribs, and coxal (hip)
bones. A ew other bones such as the vertebrae, clavicles, and
cranial bones also contain small amounts o this important
tissue.
Red bone marrow orms all types o blood cells except
lymphocytes, which are ormed in lymphoid tissue. Lymphoid
tissue is ound as white masses located chief y in the lymph
nodes, thymus, and spleen.
As blood cells mature, they move into the circulatory ves-
sels. Erythrocytes circulate up to 4 months be ore they break
apart and their components are removed rom the blood-
stream by the spleen and liver. Granular leukocytes o ten have
a li e span o only a ew days, but agranular leukocytes may
live or more than 6 months.
FIGURE 13-2 Red blood cells (RBCs). Color-enhanced scanning elec-
To see exactly where in the body hematopoiesis tron micrograph shows the detailed structure o normal RBCs. Note the bi-
takes place, review the images in Sites o Hemato- concave shape o each RBC.
poiesis at Connect It! at evolve.elsevier.com.
13 I the recipients immune system does not reject the new
tissue or stem cells, always a danger in transplant procedures,
QUICK CHECK
a new colony o healthy tissue may become established in the
1. Wh a t is th e m o s t a b u n d a n t typ e o s o lu te in p la s m a ? bone marrow. As a result, myeloid tissue destroyed by disease,
Na m e s o m e e xa m p le s .
2. Id e n ti y th e o rm e d e le m e n ts o b lo o d .
high-dose irradiation, or chemotherapy will be replaced and
3. Na m e th e tw o typ e s o co n n e ctive tis s u e th a t m a ke b lo o d begin again to produce normal, unctioning blood cells.
ce lls o r th e b o d y.
QUICK CHECK
1. Ho w d o e s th e p ro ce d u re ca lle d a s p ira tio n b io p s y cyto lo g y
(ABC) d i e r ro m a b o n e m a rro w tra n s p la n t?
M e c h a n is m s o Blo o d D is e a s e 2. Wh a t typ e o ce ll is invo lve d in a b o n e m a rro w tra n s p la n t?
Most blood diseases are disorders o the ormed elements.
T us it is not surprising that the basic mechanism o many
blood diseases is the ailure o the blood-producing myeloid Re d Blo o d C e lls
and lymphoid tissues to orm blood cells properly. In many
RBC S t r u c t u r e a n d Fu n c t io n
cases, this ailure is the result o damage by toxic chemicals or
radiation. In other cases, it results rom an inherited de ect, T e red blood cell (RBC) is an elegant example o how struc-
viral in ection, de ciency o nutrients, or even cancer. tural adaptation can impact biological unction. Note in
I bone marrow ailure is the suspected cause o a particular Figure 13-2 that the RBC, which is surrounded by a tough and
blood disorder, a sample o myeloid tissue may be drawn into f exible plasma membrane, is caved in on both sides so that
a syringe rom inside the pelvic bone (iliac crest) or the ster- each one has a thin center and thicker edges. T is biconcave
num. T is procedure, called aspiration biopsy cytology disk shape provides a large sur ace area or moving dissolved
(ABC), allows examination o the tissue that may help con- blood gases (O 2 and CO 2) and other solutes quickly in or out
rm or reject a tentative diagnosis. o the blood cell. It also helps keep the RBCs rom spinning
I the bone marrow is severely damaged, the choice o a wildly as they f ow through the bloodstream.
bone marrow transplant may be o ered to the patient. In this Mature RBCs have no nucleus or cytoplasmic organelles.
procedure, myeloid tissue rom a compatible donor is intro- Because o this they are unable to reproduce themselves or
duced into the recipient intravenously. replace lost or damaged cellular components. T e result is a
ransplantation also may involve in usion o hematopoietic relatively short li e span o about 80 to 120 days.
stem cells. T ese blood- orming cells are harvested rom the H owever, the additional intracellular space that becomes
individual being treated, rom a compatible donor, or rom available in each cell when the nucleus and cytoplasmic organ-
umbilical cord blood (see box on p. 659). elles are lost is lled to capacity with an important red pigment
 CHAPTER 13 Blood 353

called hemoglobin (H b). T e unique chemical No rmal Hc t Low Hc t Hig h Hc t Ce ntrifug e

properties o hemoglobin permit the RBC to per-
orm several critically important unctions required
or maintenance o homeostasis, such as carrying
oxygen and bu ering blood. Because RBCs are al-
most completely lled with hemoglobin, they are
o ten called erythrocytes (literally, red cells).
D uring hematopoiesis, RBCs lose their mito-
P la s ma
chondria. T us, any oxygen carried in RBCs by H b
is not used up by mitochondria to gen-
erate adenosine triphosphate (A P). WBCs
Buffy
D uring its short li e span, each RBC coa t a nd
travels around the entire cardiovascular pla te le ts
system more than 100,000 times! It is
the f exible plasma membrane that per- RBCs
mits each cell to de orm and undergo
drastic changes in shape as it repeatedly
passes through capillaries whose lumen
is smaller than the RBC cells diameter. A B C D
Because o the large numbers o RBCs
FIGURE 13-3 Hematocrit (Hct). Note the bu y coat located between the packed RBCs and the
and their unique biconcave shape, the plasma. A, Normal blood with the typical percent o RBCs. B, Anemia (a low percent o RBCs). C, Poly-
total sur ace area available or them cythemia (a high percent o RBCs). D, Centri uge that spins tubes o blood, causing RBCs to become
to per orm their biological unctions is densely packed into the bottom o the tubes.
enormous.
13
hemorrhaging, or other circumstances that a ect the RBC
RBC C o u n t
ratio. Normally about 45% o the blood volume consists o
T e CBC, or complete blood cell count, is a battery o tests RBCs (see Figure 13-1).
used to measure the amounts or levels o many blood con-
stituents and is o ten ordered as a routine part o the physical Another commonly used blood test ocusing on
examination (see box on this page). RBCs is summarized in the article Erythrocyte Sedi-
Measuring the numbers o circulating RBCs per unit o blood mentation Rate at Connect It! at evolve.elsevier.com.
volume is a valuable part o the CBC. Values listed in CBC re-
sults as normal will vary slightly between di erent laboratories
QUICK CHECK
and re erence texts. For RBCs, a range o 4.2 to 6.2 million per
cubic millimeter o blood (mm3), with males generally having a 1. Ho w d o e s th e b ico n ca ve d is k s h a p e o th e re d b lo o d ce ll
a llo w th e re d b lo o d ce ll to ca rry o u t its u n ctio n s ?
higher number than emales, is common. Normal deviations 2. Wh a t is th e CBC, o r co m p le te b lo o d ce ll co u n t?
rom average ranges o ten occur with age di erences, level o 3. Wh a t is th e im p o rta n ce o a h e m a to crit te s t?
hydration, altitude o residence, and other variables.
O riginally RBC counts were done with a hemocytometer, a
microscope slide with a counting grid etched on it. T e cur-
rent practice is to use a aster, more accurate automated blood
cell counter. C LIN ICA L APPLICATION
T e hematocrit (Hct) component o the CBC provides COMPLETE BLOOD CELL COUNT
in ormation about the volume o RBCs in a blood sample. I
whole blood is placed in a special centri uge tube and then One o the m os t us e ul and re que ntly pe r orm e d clinical
spun down, the heavier ormed elements will quickly settle blood te s ts is calle d the com ple te blood ce ll count, or s im -
to the bottom o the tube. ply the CBC. The CBC is a colle ction o te s ts w hos e re s ults ,
w he n inte rpre te d as a w hole , can yie ld an e norm ous
D uring the procedure, RBCs are orced to the bottom o the
am ount o in orm ation re garding a pe rs ons he alth. Stan-
tube rst. T e WBCs and platelets then settle out in a light- dard RBC, WBC, and throm bocyte counts , the di e re ntial
colored layer called the buf y coat. In Figure 13-3 the bu y coat WBC count, he m atocrit, he m oglobin conte nt, and othe r
can be seen between the packed RBCs on the bottom o the characte ris tics o the orm e d e le m e nts are us ually include d
hematocrit tube and the liquid layer o plasma above. in this batte ry o te s ts . Norm al range s or blood value s in-
T e hematocrit testalso called packed-cell volume (PCV) clude d in m os t CBC te s ts are ound in Appe ndix C at
testgives an estimate o the proportion o RBCs to whole evolve .e ls evie r.com .
blood. Such in ormation could help screen or dehydration,
 354 CHAPTER 13 Blood
Be ta ( ) polype ptide cha ins
O2
Iron-conta ining
he me groups
CO 2
Alpha ( ) polype ptide cha ins
FIGURE 13-4 Hemoglobin (Hb). This large molecule is composed o
our polypeptide subunitsthe alpha ( ) and beta ( ) chains. Carbon diox-
ide may be carried on the amino acids o these chains. Each olded chain
holds an iron-containing chemical group (red) at its core. The iron (Fe) gives
hemoglobin its oxygen-carrying capacity.
13 He m o g lo b in
T e hemoglobin molecules that ll the millions o RBCs are
critical in the transport and exchange o oxygen and carbon
dioxide between the blood and the bodys cells. T ey also play
a key role in maintenance o acid-base balance in the body.
H emoglobin is a quaternary protein made up o our
olded polypeptide chains, two alpha ( ) chains and two beta
( ) chains. As you can see in Figure 13-4, there is a chemical
structure called a heme group embedded within each olded
chain. An iron (Fe) atom within each heme group attracts
oxygen molecules to unite with hemoglobin and thus orm an
oxygen-hemoglobin complex called oxyhemoglobin (H bO 2).
HEA LTH AND WELL-BEIN G
BLOOD DOPING
A num be r o athle te s have re porte dly im prove d the ir pe r or-
m ance by a practice calle d blood boos ting or blo o d do ping .
A ew we e ks be ore an im portant eve nt, an athle te has
s om e blood draw n. The RBCs in this s am ple are s e parate d and
roze n. Jus t be ore com pe tition, the RBCs are thawe d and in-
je cte d back into the athle te . The incre as e d he m atocrit (Hct)
that re s ults s lightly im prove s the oxyge n-carrying capacity o
the blood, w hich the ore tically im prove s pe r orm ance . How-
eve r, in practice the e e cts are s light.
In addition to blood trans us ions , inje ction o s ubs tance s
s uch as horm one s that incre as e RBC leve ls in an atte m pt to
im prove athle tic pe r orm ance als o has be e n conde m ne d by
le ading authoritie s in the are a o s ports m e dicine and by ath-
le tic organizations around the w orld. Doping w ith e ithe r
the naturally occurring horm one e rythro po ie tin (EPO) or
O xyhemoglobin makes possible the e cient transport o
98.5% o all o the oxygen required or the body cells (1.5% is
dissolved in plasma).
Iron (Fe) is an essential nutrient needed to give hemoglo-
bin its oxygen-carrying ability. Vitamin B12 and olate (also a
B vitamin) are also among the critical nutrients needed by the
red bone marrow to manu acture enough hemoglobin to
maintain survival.
Carbon dioxide (CO 2) may attach to the amino acids
within hemoglobins alpha and beta chains to orm
carbaminohemoglobin (H bCO 2). T is molecule transports
about 20% o the carbon dioxide produced as a waste product
o cellular metabolism to the lungs or disposal into the exter-
nal environment. Recall that about 10% o CO 2 is transported
in the blood dissolved in plasma. T e majority o CO 2 (70%)
carried in the blood is converted in RBCs to bicarbonate or
its journey to the lungs or excretion (see Chapter 17).
To better understand these concepts, use the
Active Concept Map Transport o Oxygen and
Carbon Dioxide in the Blood at evolve.elsevier.com.
RBC A b n o r m a lit ie s
In peripheral blood smears, an RBC o normal size is about
7 to 9 m in diameter and is called a normocytic RBC (normo-
normal, -cyte cell). A normocytic RBC is approximately the
same size as the nucleus o a small lymphocyte (Figure 13-5).
Abnormally small RBCs are called microcytes (micro- small,
-cyte cell) and larger RBCs are called macrocytes (macro- large,
-cyte cell).
Figure 13-5 also compares the appearance o RBCs with
normal amounts o the red pigment hemoglobin, called
normochromic RBCs (normo- normal, -chromic color) with those
that are de cient in hemoglobin, called hypochromic RBCs (hypo-
low, -chromic color), and those that have an excess o hemoglo-
bin, called hyperchromic RBCs (hyper- high, -chromic color).
w ith s ynthe tic drugs that have s im ilar biological e e cts
s uch as Epoge n and Procritcan re s ult in devas tating m e di-
cal outcom e s .
Blood doping is judge d to be an un air and unw is e practice
in athle tics . Be s ide s the s ignif cant he alth ris ks com pare d w ith
only s light im prove m e nt in pe r orm ance , the re are the pe rs onal
and pro e s s ional ris ks o che ating. Wide ly re porte d blood dop-
ing s candals in pro e s s ional cycling com pe titions and Olym pic
s ports atte s t to the devas tating e e cts o s uch s candal.
An alte rnative to blood doping is high-altitude training. Ath-
le te s w ho train at m ode rate ly high altitude s us ually at a re -
duce d inte ns ityw ill naturally build up a s lightly highe r Hct in
a ne gative - e e dback re s pons e to the lowe r O 2 available in the
atm os phe re at thos e altitude s . This type o training m us t be
m anage d care ully to avoid the ris ks as s ociate d w ith high Hct.

NORMAL
Hypochromic RBCs Normochromic RBCs
Microcytic RBCs Normocytic RBCs
FIGURE 13-5 RBC abnormalities. Micrographs showing normal red blood cells (RBCs) in a smear com-
pared to abnormal RBCs. The cells with a large, dark nucleus shown in some o the images are lymphocytesa
type o white blood cell similar in size to an RBC.
Production o macrocytic hyperchromic RBCs during periods
o chronic blood loss is a good example o a negative eedback
response that helps maintain homeostasis. Because the body
is unable to produce adequate numbers o RBCs with normal
levels o hemoglobin in each cell to replace those lost by hem-
orrhage, the body increases the size and amount o hemoglo-
bin in those cells it can produce to help restore and maintain
the oxygen-carrying capacity o the blood.
Blo o d Ty p e s
S y s t e m s o Blo o d Ty p in g
Blood is o ten identi ed as a speci c type by using the ABO ABO system o typing:
system and Rh system o classi cation. O ther blood types
also occur, but usually do not have the signi cant clinical ap-
plications o the ABO and Rh systems.
Blood types are identi ed by certain antigens on the sur-
aces o RBCs (Figure 13-6). An antigen is a substance that can
stimulate the body to make antibodies. Almost all substances
that act as antigens are oreign proteins. T at is, they are not
the bodys own natural proteins but instead are proteins that
have entered the body rom the outside by means o in ection,
trans usion, or some other method.
T e word antibody can be de ned in terms o what causes
its ormation or in terms o how it unctions. De ned the rst
way, an antibody is a substance made by the body in response
CHAPTER 13 Blood 355
Hype rchromic RBCs
13
Ma crocytic RBCs
to stimulation by an antigen. De ned according to its unc-
tions, an antibody is a substance that reacts with the antigen
that stimulated its ormation.
Many antibodies react with their antigens to cause
clumpingthat is, they agglutinate the antigens. In other
words, the antibodies cause their targeted antigens to stick
together in little clusters, which disrupts the unctions o ag-
glutinated cells and makes them easy targets or the bodys
immune responses.
A BO S y s t e m
Every persons blood is one o the ollowing blood types in the
1. ype A
2. ype B
3. ype AB
4. ype O
Suppose that you have type A blood (as do about 41% o
Americans). T e letter A stands or a certain type o antigen
in the plasma membrane o your RBCs that has been present
since birth. Because you were born with type A antigen, your
body does not orm antibodies to react with it. In other words,
your blood plasma contains no anti-A antibodies. It does,
however, contain anti-B antibodies. For some unknown rea-
son, these antibodies are present naturally in type A blood
 356 CHAPTER 13 Blood

Re c ipie nts blo o d Re ac tio ns with do no rs blo o d

RBC P la s ma Donor type Donor type Donor type Donor type

a ntige ns a ntibodie s O A B AB

None Anti-A
(Type O) Anti-B

A
Anti-B
(Type A)

B
Anti-A
(Type B)

AB
(None )
(Type AB)

13
FIGURE 13-6 ABO blood typing. The le t columns show the re-
cipients blood characteristics and the top row shows the donors blood
type. Inset, Photo showing samples o agglutinated and nonaggluti-
nated blood. Norma l blood Agglutina te d blood

plasma. T e body did not orm them in response to the pres-
ence o the B antigenthey are simply part o the bodys
genetic makeup.
In summary, in type A blood the RBCs contain type A
antigen and the plasma contains anti-B antibodies.
Similarly, in type B blood, the RBCs contain type B anti-
gen, and the plasma contains anti-A antibodies. In type AB
blood, as its name indicates, the RBCs contain both type A
and type B antigens, and the plasma contains neither anti-A
nor anti-B antibodies.
T e opposite is true o type O bloodits RBCs contain
neither type A nor type B antigens, and its plasma contains
both anti-A and anti-B antibodies.
Figure 13-6 shows the results o di erent combinations o
donor and recipient blood.
Rh S y s t e m
You may be amiliar with the term Rh-positive blood. It
means that the RBCs o this blood type contain an antigen
called the Rh actor. I , or example, a person has type AB,
Rh-positive blood, his red blood cells contain type A antigen,
type B antigen, and the Rh actor antigen. T e term Rh is used
because this important blood cell antigen was rst discovered
in the blood o Rhesus monkeys.
In Rh-negative blood, the RBCs do not have the Rh an-
tigens on their sur aces. Plasma never naturally contains anti-
Rh antibodies. But i Rh-positive blood cells are introduced
into an Rh-negative persons body, anti-Rh antibodies soon
appear in the recipients blood plasma.
W ithout appropriate precautions, there could be some
danger or o spring born to an Rh-negative mother and an
Rh-positive ather. I the o spring inherits the Rh-positive
trait rom his ather, the Rh actor on his RBCs may stimulate
the mothers body to orm anti-Rh antibodies. T en, i she
later carries another Rh-positive etus, it may develop a type o
hemolytic anemia called erythroblastosis etalis, caused by the
mothers Rh antibodies reacting with the babys Rh-positive
cells (Figure 13-7).
All Rh-negative mothers who carry an Rh-positive o -
spring should be treated with an immunoglobulin (antibody)
serum, widely marketed under the brand name RhoGAM.
RhoGAM stops the mothers body rom orming anti-Rh
antibodies and thus prevents the possibility o harm to the
next Rh-positive o spring.
Likewise, a person with Rh-negative blood who receives a
trans usion o Rh-positive blood will also develop anti-Rh
antibodies and be at risk o an immune reaction i exposed to
Rh-positive blood again later.
 1 CHAPTER 13 Blood 357
Rh-pos itive blood ce lls
e nte r the mothe rs
bloods tre a m during Ma te rna l circula tion
de live ry of a n Rh- 1
pos itive ba by. If not Ma te rna l Rh-ne ga tive
tre a te d, the mothe rs re d blood ce lls
body will produce a nti-
Rh a ntibodie s .
Fe ta l Rh-pos itive re d
blood ce ll e nte rs ma te rna l
Rh-pos itive re d blood ce lls circula tion a t birth

Earlie r o ffs pring

Rh-po s itive
2 3
A la te r pre gna ncy A la te r pre gna ncy involving
involving a n Rh-ne ga tive a n Rh-pos itive ba by ma y
ba by is norma l be ca us e re s ult in e rythrobla s tos is fe ta lis .
the re a re no Rh A Anti-Rh a ntibodie s e nte r the
a ntige ns in the ba bys ba bys blood s ypply a nd ca us e
blood. a gglutina tion of RBCs with the
Rh a ntige n.

Fe ta l Rh-ne ga tive
re d blood ce lls

Ma te rna l circula tion Ma te rna l

circula tion
Ma te rna l Rh-ne ga tive
re d blood ce lls
13
Anti-Rh
2 Anti-Rh a ntibodie s a ntibodie s
3 cros s the
pla ce nta

Agglutina tion of fe ta l
Rh-pos itive re d blood
ce lls le a ds to
e rythrobla s tos is fe ta lis

Late r o ffs pring Late r o ffs pring

Rh-ne g ative Rh-po s itive

B C
FIGURE 13-7 Erythroblastosis etalis. Under certain conditions, anti-Rh antibodies may enter the o -
springs blood supply and cause agglutination o RBCs with the Rh antigen.

C o m b in e d A BO -Rh S y s t e m
Both the ABO and Rh systems are o ten used in combination
to identi y a persons blood type, as you can see in Table 13-2.
For example, the blood type AB re ers to the ABO type
AB and the Rh-positive type. Likewise, O identi es the
blood type o a person with the O version o ABO type and
the Rh-negative version o Rh type.
Knowing ones blood type can be li esaving in a medical
emergency or during surgery, when a blood trans usion may be
needed to maintain the total blood volume. H arm ul e ects or
even death can result rom a blood trans usion reaction i the
donors RBCs become agglutinated by antibodies in the recipi-
ents plasma.
I a donors RBCs do not contain any A, B, or Rh antigen,
they cannot be clumped by anti-A, anti-B, or anti-Rh anti-
bodies. For this reason, the type o blood that contains no A,
B, or Rh antigens, which is type O , can be used in an emer-
gency as donor blood. W ith type O , there is no danger o
anti-A, anti-B, or anti-Rh antibodies clumping its RBCs.
ype O blood has there ore been called universal donor
blood.
Similarly, blood type AB has been called universal
recipient blood because it contains no anti-A, anti-B, or anti-
Rh antibodies in its plasma. T ere ore, type AB blood does
not clump any donors RBCs containing A, B, or Rh antigens.
 358 CHAPTER 13 Blood

moving through vessels. T is high pressure can

TABLE 13-2 Blood Typing
cause dangerous stretching (distention) o
PERCENT OF blood vessels and even hemorrhaging when the
BLOOD TYPE ANTIGENS ANTIBODIES GENERAL pressure causes a vessel to rupture.
(ABO and Rh) PRES ENT* PRES ENT* POPULATION T e dense crowding o RBCs also can trig-
O Rh anti-A, anti-B 35% ger abnormal blood clots. T ese conditions
O None anti-A, anti-B, anti-Rh? 7% may put a person at risk or heart attack or
(unive rs al donor) stroke.
A A, Rh anti-B 35% In polycythemia, the hematocrit (RBC %)
A A anti-B, anti-Rh? 7% may reach 60%way above the normal 45%
average (see Figure 13-3, C). reatment involves
B B, Rh anti-A 8%
blood removal (bleeding), irradiation o bone
B B anti-A, anti-Rh? 2%
marrow, or chemotherapy treatment to sup-
AB A, B, Rh None 4% press RBC production.
(unive rs al re cipie nt)
AB A, B anti-Rh? 2%
A n e m ia
*Anti-Rh antibodie s m ay be pre s e nt, de pe nding on expos ure to Rh antige ns .
Adapte d rom Pagana KD, Pagana TJ : Mos bys m anual o diagnos tic and laboratory te s ts , e d 5, Anemia can result rom inadequate numbers
St Louis , 2014, Mos by.
o RBCs (see Figure 13-3, B), a de ciency in the
production o normal hemoglobin, or produc-
In a normal clinical setting, however, all blood intended or tion o hemoglobin that is in some way de ective. T us anemia
trans usion is not only matched care ully to the blood o the can occur i the hemoglobin in RBCs is inadequate or de ec-
recipient or ABO and Rh compatibility but also tested ur- tive, even i adequate numbers o RBCs are present.
ther in a process called crossmatching or a variety o so-called Many o the clinical signs and symptoms o anemia, regard-
13 minor antigens that may also cause certain types o trans u- less o type or cause, are related to low tissue oxygen levels.
sion reactions. Anemic individuals o ten eel atigued or tired all the time,
Review Figure 13-6, which shows the results o di erent and su er rom weakness, skin pallor, headache, and aintness.
combinations o donor and recipient blood in the ABO Some symptoms o anemia are caused by the bodys at-
system. tempts to increase or compensate or low tissue oxygen
levels by speeding up the heart and respiratory rates. T ese
Explore the illustrated article Blood Trans usions negative eedback mechanisms are examples o homeostasis
at Connect It! at evolve.elsevier.com. at workthe body attempting to return tissue oxygen levels
to normal despite the low oxygen-carrying capacity o the
blood in anemia.
QUICK CHECK
A number o the more common types o anemia are de-
1. Wh a t b lo o d typ e is ca lle d u n ive rs a l d o n o r b lo o d ? Wh a t scribed in the ollowing sections and in Table 13-3.
typ e b lo o d is th e u n ive rs a l re cip ie n t?
2. Why s h o u ld a ll m o th e rs w h o a re Rh p o s itive b e tre a te d
w ith Rh o Ga m ? To learn more about the clinical mani estations
o anemias, go to AnimationDirect online at
evolve.elsevier.com.
Re d Blo o d C e ll D is o r d e r s
RBC disorders most o ten involve either overproduction o He m o r r h a g ic A n e m ia
RBCs (polycythemia) or a condition that results in low oxygen- Hemorrhagic anemia is caused by an actual decrease in the
carrying capacity o the blood (anemia). number o circulating RBCs because o hemorrhage or bleed-
ing. It is re erred to as either acute blood-loss anemia resulting,
or example, rom extensive surgery or sudden trauma, or
P o lyc y t h e m ia chronic blood-loss anemia caused by slow but continuous loss o
Polycythemia is a serious blood disorder characterized by blood over time rom diseases such as cancer or ulcers.
dramatic increases in RBC numbers. One cause o this disor- As noted earlier, although ewer RBCs are present in
der is cancer o cells in the red bone marrow. Blood doping circulating blood because o the hemorrhage, those RBCs
also can cause temporary polycythemia (see box on p. 354). that are produced during this time are both macrocytic
In polycythemia, RBC counts may reach 10 million/mm3 and hyperchromican attempt to restore homeostasis by
or higher. Such high numbers o RBCs thicken the blood. compensating or the low oxygen-carrying capacity caused
T icker than normal blood resists f owjust as thicker than by the hemorrhagic anemia. O nce the actual bleeding is
normal ketchup resists f ow out o the bottle. T is increased stopped, trans usion o whole blood or red cells and suc-
f ow resistance (viscosity) o ten causes hypertension (high blood cess ul treatment o the underlying reason or chronic blood
pressure) because more pressure is needed to keep thick blood loss are curative.
 CHAPTER 13 Blood 359

A p la s t ic A n e m ia Vitamin B12 de ciency impairs the bone marrow and re-

Aplastic anemia is characterized by abnormally low RBC
counts and destruction o bone marrow. T e cause is o ten
related to high-dose exposure to certain toxic chemicals such
as benzene or mercury; irradiation; and in susceptible indi-
viduals, certain drugs including chloramphenicol.
Acute cases o aplastic anemia are very serious, with death
rates reaching 70% at 3 or 4 months a ter diagnosis. Bone
marrow or stem cell transplants provide the most e ective
treatment.
D e f c ie n c y A n e m ia s
Reduction o Normal Hemoglobin
De ciency anemias are caused by an inadequate supply o
some substance, such as vitamin B12 or iron, required or red
blood cell or hemoglobin production. In addition to adequate
numbers o normally unctioning RBCs, the amount and
quality o hemoglobin are critical actors in maintaining the
oxygen-carrying capacity o the blood.
Normal hemoglobin ranges rom 12 to 14 grams per
100 milliliters (g/100 mL) o whole blood or adult emales
and rom 14 to 17 g/100 mL or adult males. A hemoglobin
value less than 9 g/100 mL indicates anemia.
Figure 13-4 shows the relationship o the our iron-containing
groups and our protein subunits or chains in the hemoglobin
molecule. Chemical changes in the hemoglobin molecule can
result in development o de ective hemoglobin and red cells and
thus impair the ability o the blood to deliver adequate oxygen
to the body tissues.
Pernicious Anemia
Pernicious anemia results rom a dietary de ciency o vita-
min B12 or rom the ailure o the stomach lining to produce
intrinsic actorthe substance that allows vitamin B12 to be
absorbed.
G enetics plays a role in development o pernicious ane-
mia, and research evidence suggests that it is an autoimmune
disease.
sults in decreased RBC production, as well as a reduction in
W BC and platelet numbers. T e reduced number o red cells
that do enter the circulation are macrocytes and are much
larger than normal RBCs.
In addition to the classic symptoms o anemia caused by
low oxygen delivery to tissues, patients with pernicious anemia
develop numerous nervous system problems such as numbness,
tingling, and burning in the eet and hands. Mental impair-
ment, delusions, irritability, and depression are also common.
Pernicious anemia is success ully treated by repeated injec-
tions o vitamin B12.
Folate De ciency Anemia
Folate de ciency anemia is similar to pernicious anemia be-
cause it also causes a decrease in the RBC count resulting
rom a vitamin de ciency. In this condition, it is olic acid
(vitamin B9) that is de cient.
Folic acid de ciencies are common among individuals with
alcoholism and other malnourished individuals. reatment or
acute olate de ciency anemia involves taking vitamin supple-
ments until a balanced diet can be restored.
Iron De ciency Anemia
Iron de ciency anemia, as the name suggests, is caused by a 13
de ciency o iron, which is required or hemoglobin synthesis.
Although the body care ully protects its iron reserves, they
may be depleted through hemorrhage, increased requirements
such as wound healing or pregnancy, or by low intake.
Un ortunately, iron de ciency is the most common nutri-
tional de ciency in the world. T e tragic result is that an esti-
mated 10% o the population in some developed countries
and up to 50% in developing countries su er rom iron de -
ciency anemia.
In most cases o iron de ciency anemia, the RBC numbers
are only slightly below normal. H owever, the cells are small
(microcytic) and appear pale due to the reduction in hemo-
globin content (Figure 13-8).

TABLE 13-3 Laboratory Results or Types o Anemia

FOLATE IRON RBC S IZE VITAMIN B12
ANEMIA CONTENT HEMOGLOBIN HEMATOCRIT CONTENT (VOLUME) CONTENT
Aplas tic ane m ia Norm al Low to norm al Low to norm al High Norm al to Norm al
s lightly high
Pe rnicious ane m ia Norm al Low Low High High Low
He m orrhagic ane m ia
Acute blood-los s Norm al Low to norm al Low to norm al Norm al Slightly low Norm al
ane m ia
Chronic blood-los s Norm al Low Low Low Low to norm al Norm al
ane m ia
Folate de f cie ncy Low Low Low High High Norm al
ane m ia
Iron de f cie ncy ane m ia Norm al Low Low Low Low Norm al
He m olytic ane m ia Norm al Low Low Norm al to high Norm al to high Norm al
(s ickle ce ll ane m ia
and thalas s e m ia)
 360 CHAPTER 13 Blood
FIGURE 13-8 Iron def ciency anemia. Note the small (microcytic),
pale (hypochromic) red blood cells (RBCs). Lack o adequate color in the
RBCs is due to reduced hemoglobin content. Compare to RBCs in Figure 13-5
on p. 355.
A low hematocrit value is common in iron de ciency ane-
mia. Can you explain how this can be i the RBC numbers are
near normal? T e reason is that the size o the RBCs is small
13 (microcytic) so the red cell volume and there ore the hemato-
crit value are both decreased.
O ral administration o iron-containing compounds, such
as errous sul ate or errous gluconate, is very e ective in treat-
ing the basic iron de ciency seen in the disease. T e probabil-
ity o a complete cure is excellent i , in addition to administra-
tion o iron, any underlying causes such as chronic bleeding or
iron malabsorption problems are corrected.
Excess availability o iron in the blood can
also cause health problems, as in cases o
hemochromatosis or iron storage disease. Explore
this condition in the article Hemochromatosis at
Connect It! at evolve.elsevier.com.
He m o ly t ic A n e m ia s
RBC Destruction
Hemolytic anemias as a group are all associated with a de-
creased RBC li e span caused by an increased rate o destruc-
tion. Frequently, an abnormal hemoglobin will cause red
blood cells to become distorted and easily broken.
T e hemolytic anemias have some distinguishing symp-
toms in addition to those expected because o low oxygen de-
livery to tissues. Many are related to the
act that the body retains many o the
breakdown products o the excess numbers
o RBCs that are destroyed, including iron
and pigments. T e result may be jaundice,
a yellowing o skin and other tissues caused
by the breakdown o red hemoglobin into
yellowish bilirubin in the liver.
Swelling o the spleen, problems as-
sociated with excess iron storage, and
gallstone ormation are also common. Some symptoms are
unique to a particular type o hemolytic anemia, as discussed
later.
Sickle Cell Anemia
Sickle cell anemia is a genetic disease that results in the or-
mation o limited amounts o an abnormal type o hemoglo-
bin called sickle hemoglobin, or hemoglobin S (HbS). T e genetic
de ect produces an amino acid substitution in one o the beta
( ) polypeptide chains (see Figure 13-4), causing the resulting
H bS to be less stable and less soluble than normal hemoglo-
bin. T e de ective hemoglobin orms crystals and causes the
red cell to become ragile and assume a sickle (crescent) shape
when the blood oxygen level is low (Figure 13-9).
A person who inherits only one de ective gene develops
only a small amount o H bS and has a orm o the disease
called sickle cell trait. T ose with sickle cell trait most o ten
have no symptoms at all. H owever, in some stress ul or high-
exertion situations, a person with sickle cell trait could be-
come ill.
I two de ective genes are inherited (one rom each parent),
then more H bS is produced and a much more severe condition
called sickle cell disease develops. In addition to RBC sickling
and rupture, high levels o H bS may cause reduction in blood
f ow; blood clotting; and in episodes o crisis, severe pooling
o red cells, particularly in the spleen, causing sudden death.
reatment is primarily supportive because no e ective
anti-sickling drugs are currently available. H owever, patient
education, early diagnosis, preventive measures to reduce de-
hydration and in ection, and limited use o blood trans usions
to treat episodes o crisis are improving survival rates.
Sickle cell anemia is ound almost entirely in those o black
A rican descent, and in the United States nearly 1 in every
600 A rican-American newborns is a ected with sickle cell
trait or disease.
Check out the brie , illustrated article Sickle Cell
Anemia at Connect It! at evolve.elsevier.com.
Thalassemia
T alassemia re ers to a group o inherited hemolytic anemias.
T e most common type, which occurs most o ten in individu-
als o Mediterranean descent, is characterized by production o
abnormal hemoglobin and inadequate numbers o small (mi-
crocytic) and o ten oddly shaped RBCs that are short lived.
T alassemia, like sickle cell anemia, occurs in two orms,
mild and severe. In both orms, f awed protein synthesis in the
RBCs results in de ective hemoglobin
production and early hemolysis, or death,
o de ective red cells.
T alassemia minor, or thalassemia trait,
occurs when only one de ective gene is
FIGURE 13-9 Sickle cell. A sickle-shaped red
blood cell typical o sickle cell anemia.
 CHAPTER 13 Blood 361

inherited and is characterized by mild anemia, minimal RBC

To learn more about hemolytic disease o the
changes, and ew symptoms.
newborn, go to AnimationDirect online at
T alassemia major, which occurs when two de ective genes
evolve.elsevier.com.
are inherited, is a very serious and li e-threatening hemolytic
anemia. Red cells are quickly destroyed, hemoglobin levels
o ten all below 7 g/100 mL o blood, low blood and tissue
oxygen levels cause multiple problems, bone marrow mass Wh it e Blo o d C e lls
expands causing crippling and skeletal de ormities, and swell-
In t ro d u c t io n t o WBC s
ing o the spleen and liver occurs.
I adequate and ongoing treatment is not initiated, iron Recall rom the listing o ormed elements ound in the blood
released as a result o RBC hemolysis accumulates in patho- (see p. 351) that the white blood cells (WBCs) are also called
logical tissue deposits throughout the body. leukocytes.
Bone marrow and stem cell transplantation and experimen- T e W BC, when stained on a microscope slide, shows a
tal gene manipulation initiatives hold the most promise or prominent and sometimes oddly shaped nucleus ar di er-
long-term treatment success. Because thalassemia is a geneti- ent in appearance than the RBC, which has no nucleus.
cally transmitted disease, genetic counseling is appropriate. WBCs have no hemoglobin and thus are translucent when
unstained. A mass o W BCs looks whitish in appearance be-
Hemolytic Disease o the Newborn cause o the di usion o light, much as clear snowf akes ap-
Hemolytic disease o the newborn (H D N) begins during pear white when ound in a mass.
pregnancy i etal RBCs o a di erent blood type (see p. 356) Di erent types o WBCs are categorized by the presence
than the mother cross the placenta and enter the mothers or absence o stained granules in their cytoplasm. Granular
circulation. leukocytes (granulocytes) have stained granules and agranular
T e most common H DN is called etal-maternal ABO in- leukocytes (agranulocytes) do not. T e granulocytes include
compatibility. T is can start during delivery as blood cells leak the neutrophils, eosinophils, and basophils (Figure 13-10 A, B,
rom the placenta as it pulls away rom the lining o the uterus and C). T e lymphocytes and monocytes (Figure 13-10, D and E) 13
(womb). I this should occur, antibodies against them will be are agranulocytes.
ormed because antigens on the etal RBCs are oreign to
the mother. Problems or the etus begin i the maternal anti-
bodies against the oreign etal RBCs cross the placental
barrier and enter the etal circulation. I this occurs, the ma-
ternal antibodies will attack and destroy the etuss red cells, GRANULAR LEUKOCYTES
causing a hemolytic anemia to develop.
Rh incompatibility between an Rh-positive etus and its
Rh-negative mother results in hemolytic anemia called
erythroblastosis etalis. Review Figure 13-7 on p. 357.
Rh actor incompatibility is clinically more important than
ABO incompatibility because the hemolytic response, although A
it occurs less requently, is generally more severe. Fortunately, Ne utrophil
in ant mortality caused by Rh incompatibility has been drasti-
cally reduced ollowing introduction and widespread use o a
product called RhoGAM in Rh-negative mothers (see p. 356).
H DN caused by either ABO or Rh incompatibility may
occur early in pregnancy or become apparent only at birth.
Red cell numbers and hemoglobin levels decline. Jaundice,
intravascular coagulation, heart and lung damage, and swell- B C
ing o the liver and spleen are common. I problems are de- Eos inophil Ba s ophil
tected by laboratory tests o amniotic f uid or rom etal or
AGRANULAR LEUKOCYTES
maternal blood sampling be ore birth, in utero exchange
trans usions and early delivery may be needed to save the li e
o the in ant.

QUICK CHECK
1. Ho w d o e s p o lycyth e m ia d i e r ro m a n e m ia ?
2. De s crib e th e clin ica l s ig n s a n d s ym p to m s o a n e m ia .
D E
3. Give e xa m p le s o h e m o rrh a g ic, d e f cie n cy, a n d h e m o lytic Lymphocyte Monocyte
typ e s o a n e m ia s .
4. Wh a t is h e m o lytic d is e a s e o th e n e w b o rn ? Why d o e s it
d e ve lo p ? Ho w ca n it b e p re ve n te d ? FIGURE 13-10 Leukocytes. A-E, Each light micrograph shows a di er-
ent type o stained WBC.
 362 CHAPTER 13 Blood
All o the W BCs are involved in immunity. H owever, each
type and subtype o W BC has its own unique roles to play in
immunity, such as phagocytosis o oreign particles or virus-
in ected cells. Details o the roles o some W BCs are ound in
Chapter 16.
WBC C o u n t
Normally, the total number o W BCs per cubic millimeter o
whole blood (mm3) ranges between 5000 and 10,000.
T e term leukopenia is used to describe an abnormally low
W BC count (less than 5000 W BCs/mm3 o blood). Leuko-
penia does not occur o ten. H owever, mal unction o blood-
orming tissues and cells and some diseases a ecting the im-
mune system, such as AIDS (discussed in Chapter 16), may
lower W BC numbers.
Leukocytosis re ers to an abnormally high W BC count
(that is, more than 10,000 W BCs/mm3 o blood). It is a much
more common problem than leukopenia and almost always
accompanies bacterial in ections. In addition, leukocytosis is
also seen in many orms o blood cancer (described later),
which are o ten diagnosed when tremendous increases in
W BC numbers are detected in blood tests.
A special type o white blood cell count called a dif erential
13 WBC count reveals more in ormation than simply count-
ing the total number o all o the di erent types o W BCs
in a blood sample. In a di erential W BC count, a compo-
nent test in the CBC (see box, p. 353), the proportions o
each type o white blood cell are reported as percentages o
the total W BC count. Normal percentages are shown in
Figure 13-1.
Because all disorders do not a ect each W BC type the
same way, the di erential W BC count is a valuable diagnostic
tool. For example, although some parasite in estations do not
cause an increase in the total W BC count, they o ten do cause
an increase in the proportion o eosinophils that are present.
T e reason? T is type o W BC specializes in de ending
against parasites (see Table 13-1).
WBC Ty p e s
G r a n u la r Le u k o c y t e s
Neutrophils are the most numerous o the active WBCs,
called phagocytes, that protect the body rom invading micro-
organisms by actually taking them into their own cell bodies
and digesting them in the process o phagocytosis (Figure 13-11).
Eosinophils also serve as weak phagocytes. Perhaps one o
their most important unctions, as noted, involves protection
against in ections caused by certain parasites and parasitic
worms. T ey also are involved in regulating allergic reactions,
including asthma.
Basophils, in peripheral blood, and related mast cells
ound in the tissues, both secrete the chemical histamine,
which is released during inf ammatory reactions. Basophils
also produce a potent anticoagulant called heparin, which
helps prevent blood rom clotting as it f ows through the
blood vessels o the body.
White blood ce ll
1
Cytos ke le ton of ne utrophil
forms a n e xte ns ion tha t
tra ps a ba cte ria l ce ll.
Ba cte ria
2
Us ing mole cula r motors ,
the cytos ke le ton pulls the
e xte ns ion inwa rd, a ls o
pulling the tra ppe d
ba cte ria l ce ll.
3
The ba cte ria l ce ll
be come s comple te ly
e ngulfe d within the
ne utrophil, whe re it will be
de s troye d by lys os ome s .
FIGURE 13-11 Phagocytosis. Diagrammatic representation o phago-
cytosis by a neutrophil (note the multilobed nucleus). Extension o cytoplasm
envelopes the bacteria, which are drawn through the cell membrane and
into the cytoplasm. (also see Figure 16-13).
Ag r a n u la r le u k o c y t e s
Monocytes are the largest leukocytes. Like neutrophils, they
are aggressive phagocytes. Because o their size, they are ca-
pable o engul ng larger bacterial organisms and cancerous
cells. Macrophages (meaning large eater) are monocytes
that have grown to several times their original size a ter mi-
grating out o the bloodstream. T ey are discussed urther in
Chapter 16.
Lymphocytes help protect us against in ections, but they
do it by a process di erent rom phagocytosis. Lymphocytes
unction in the immune mechanism, the complex process that
makes us immune to in ectious diseases.
Lymphocytes called B lymphocytes develop within several
lymphoid organs o the body. B lymphocytes (B cells) secrete
plasma proteins called antibodies that attach to speci c mole-
cules related to bacteria, viruses, chemical toxins, or other
oreign substances. Active B lymphocytes, called plasma cells,
are ormed in unusually large numbers in a type o bone mar-
row cancer called multiple myeloma, which is described later.
O ther lymphocytes, called lymphocytes, develop in the
thymus. T ey do not secrete antibodies but instead protect us
by directly attacking bacteria, virus-in ected cells, or cancer
cells.
Details o the role o lymphocytes in the immune system
are discussed in Chapter 16.

P A
I
A
FIGURE 13-12 Multiple myeloma. A, X-ray lm o skull showing hon-
eycomb or punched-out bone de ects caused by diseased antibody rom
plasma cells. B, Malignant plasma cell. Vacuoles (arrowheads) contain de-
ective antibodies.
Wh it e Blo o d C e ll D is o r d e r s
wo major groups o disease conditions constitute a majority
o W BC and blood-related cancers, or neoplasms. Lymphoid
neoplasms arise rom lymphoid precursor cells that normally
produce B lymphocytes, lymphocytes, or their descendant
cell types. Myeloid neoplasms appear as a result o malignant
trans ormation o myeloid precursor cells that normally pro-
duce granulocytic W BCs, monocytes, RBCs, and platelets
(see Table 13-1).
M u lt ip le M ye lo m a
Multiple myeloma is cancer o mature, antibody-secreting B
lymphocytes called plasma cells (Figure 13-12). It is the most
common and one o the most deadly orms o blood-related
cancers in people older than 65 years o age.
T e cancerous trans ormation o plasma cells results in im-
pairment o bone marrow unction, production o de ective
antibodies, recurrent in ections, anemia, and the pain ul de-
struction and racture o bones in the skull, vertebrae, and
throughout the skeletal system. T e x-ray photo in Figure 13-12
shows typical honeycomb- or punched-outappearing de-
ects in skull bones caused by the de ective myeloma antibody.
reatment may lengthen li e and help relieve symptoms
but does not cure the disease. Chemotherapy, marrow and
stem cell transplantation, and certain drug and antibody treat-
ments are being used with varying degrees o success.
Le u k e m ia
Leukemia is the term used to describe a number o blood
cancers a ecting the W BCs. In almost every orm o leuke-
mia, marked leukocytosis, or elevated W BC levels, occur.
CHAPTER 13 Blood 363
FIGURE 13-13 Chronic lymphocytic leukemia (CLL). Periph-
eral blood smear showing large numbers o diseased B lymphocytes.
Leukocyte counts in excess o 100,000/mm 3 in circulating
blood are common.
T e di erent types o leukemia are identi ed as either acute
or chronic, based on how quickly symptoms appear a ter the
disease begins. Leukemias also can be identi ed as lymphocytic
or myeloid depending on the cell type involved.
Four o the most common leukemias are brief y described 13
subsequently.
C h ro n ic Ly m p h o c y t ic Le u k e m ia
Chronic lymphocytic leukemia (CLL) most o ten a ects older
adults and is rare in individuals younger than 30 years o age.
Average age o onset is about 65 years, appearing more o ten in
men than in women. In those with CLL, malignant precursor
B lymphocytes are produced in great numbers (Figure 13-13).
T ey are long lived but do not produce normal antibodies
and, as a result, some increase in in ections may occur. H ow-
ever, early in the disease ew symptoms are apparent, and
many patients are diagnosed inadvertently as part o routine
physical examinations when results o blood tests become
available. W hen symptoms do appear, they are o ten quite
mild. Anemia, atigue, and development o enlarged but gen-
erally painless lymph nodes are common.
Many patients with CLL live many years a ter diagnosis
with little or no treatment. More severe cases o ten bene t
rom chemotherapy and irradiation.
Ac u t e Ly m p h o c y t ic Le u k e m ia
Acute lymphocytic leukemia (ALL) is primarily a disease o
children and constitutes the most common orm o blood
cancer in children between 3 and 7 years o age (Figure 13-14).
Fully 80% o children who develop leukemia have this orm
o the disease. Although always a serious condition, it is
highly curable in children but less so when it occurs in adults.
Onset o ALL is sudden and o ten marked by ever, bone
pain, and increased rates o in ection. Cancerous cells crowd out
other bone marrow cells and decrease the production o RBCs,
platelets, and other nonmalignant lymphocyte precursor cells,
thereby producing anemia. As cancerous trans ormation o
 364 CHAPTER 13 Blood
FIGURE 13-14 Acute lymphocytic leukemia (ALL). Appearance o
B lymphocytes in acute lymphocytic leukemia.
B lymphocytes continues, their numbers increase in circulating
blood and swelling o ten occurs in lymph nodes, spleen, and
liver.
reatment may involve chemotherapy, irradiation, and
bone marrow or stem cell transplants.
13 C h ro n ic M ye lo id Le u k e m ia
Chronic myeloid leukemia (CML) accounts or about 20%
o all cases o leukemia and occurs most o ten in adults be-
tween 25 and 60 years o age. CML results rom cancerous
trans ormation o granulocytic (neutrophil, eosinophil, and
basophil) precursor cells in the bone marrow.
Onset o CML is slow and early symptoms, such as a-
tigue, weakness, and weight loss, tend to be nonspeci c. Once
established, the disease progresses slowly. Diagnosis is o ten
made by discovery o marked elevations o granulocytic
W BCs in peripheral blood (Figure 13-15) and by extreme
spleen enlargement.
Bone marrow transplants produce a cure in up to 70% o
cases. At the beginning o this century, introduction o a
FIGURE 13-15 Chronic myeloid leukemia (CML). Severe granulo-
cytic leukocytosis typical o CML.
new type o rational drug called Gleevec was a major ad-
vance in treatment o CM L. It speci cally seeks out and
blocks the f awed signals in CM L cancer cells that cause
runaway proli eration.
Ac u t e M ye lo id Le u k e m ia
T e pathological trans ormation o myeloid stem cells result-
ing in acute myeloid leukemia (AML) accounts or 80% o
all cases o acute leukemia in adults and 20% o acute leuke-
mia in children.
As the name suggests, onset is sudden, and once symptoms
appear, the disease progresses rapidly. Patients most o ten seek
help because o atigue, bone and joint pain, spongy bleeding
gums, symptoms o anemia, and recurrent in ections.
T e prognosis in AML is poor, with only about 50% o
children and 30% o adults achieving long-term survival. Ad-
vances in bone marrow and stem cell transplantation have
increased cure rates in selected patients.
In e c t io u s M o n o n u c le o s is
In ectious mononucleosis is a common noncancerous W BC
disorder appearing most o ten in adolescents and young
adults between 15 and 25 years o age.
T e disease is usually caused by the Epstein-Barr virus
(EBV), ound in the saliva o in ected individuals. Mono can
be spread by kissing or any other direct contact with an in-
ected persons saliva, such as sharing a straw, toothbrush, or
eating utensil.
Leukocytosis is common early in the disease, with total
WBC counts averaging between 12,000 to 18,000/mm3. More
than 60% o the leukocytes can be identi ed in a di erential
WBC count as large, atypical (abnormal) lymphocytes that have
abundant cytoplasm and a large nucleus (Figure 13-16).
Symptoms o mono vary greatly but, in addition to the
leukocytosis and atypical lymphocytes seen in peripheral
blood, ever, sore throat, rash, severe atigue, and enlargement
o lymph nodes and the spleen are common ndings.
FIGURE 13-16 In ectious mononucleosis. The cell on the le t is a
typical small lymphocyte with its nucleus almost lling the cell. O ten seen
in in ectious mononucleosis is the larger atypical lymphocyte on the right,
which has much more cytoplasm and a larger nucleus.

In ectious mononucleosis is generally sel -limited and re-
solves without complications in about 4 to 6 weeks, although
atigue may last or longer periods. Occasionally, severe com-
plications a ecting almost any body organ system may occur
in individuals with weakened immune systems.
QUICK CHECK
1. Wh a t a re th e tw o ca te g o rie s o w h ite b lo o d ce lls ? Wh a t
d e te rm in e s h o w th e w h ite b lo o d ce lls a re ca te g o rize d ?
2. De f n e th e te rm s le u ko p e n ia a n d le u ko cyto s is .
3. Na m e o n e u n ctio n o r e a ch o th e le u ko cyte ce ll typ e s .
4. Ho w d o B lym p h o cyte s d i e r ro m T lym p h o cyte s ?
5. Wh a t typ e o le u ke m ia is p rim a rily a d is e a s e o ch ild re n ?
O o ld e r a d u lts ?
P la t e le t s a n d Blo o d C lo t t in g
P la t e le t s
T e platelet, the third main type o ormed element, plays an
essential part in blood clotting or coagulation. Your li e might
someday be saved just because your blood can clot. A clot
plugs up torn or cut vessels and stops bleeding that otherwise
might prove atal. Platelets also are called thrombocytes rom
thrombus meaning clot.
Much smaller than RBCs, platelets are tiny cell ragments
that have broken away rom a much larger precursor cell. Each
tiny platelet is lled with chemicals necessary or triggering
the ormation o a blood clot.
Blo o d C lo t t in g
T e story o how we stop bleeding when an injury occursa
process called hemostasisis the story o a chain o rapid-
re reactions. All these reactions culminate in the ormation
o a blood clot.
W hen an injury occurs, smooth muscles around the wall o
the vessel may ref exively contract and thereby constrict the
diameter o the vessela process called vasoconstriction.
T e resulting pressure helps temporarily close any gaps in the
vessel wall and reduces local blood f ow until other measures
come into play. Pressure applied rom outside the wound by a
rst responder o ten enhances this e ect.
As vessels constrict, damaged tissue cells release various
clotting actors into the plasma. T ese actors rapidly react
with other actors already present in the plasma to orm
prothrombin activator.
Normally the lining o blood vessels is extremely smooth,
but an injury makes a rough spot with exposed collagen
bers. T is attracts platelets to the site, which become sticky
at the point o injury and rapidly accumulate near the break
in the blood vessel, orming a so t, temporary platelet plug.
As the platelets accumulate, they release additional clotting
actors, orming even more prothrombin activatora kind o
sel -ampli ying, positive- eedback response.
I the normal amount o blood calcium is present, pro-
thrombin activator triggers the next step o clotting by con-
verting prothrombin (a protein in normal blood) to thrombin.
CHAPTER 13 Blood 365
In the last step, thrombin reacts with brinogen (a normal
plasma protein) to change it to a brous gel called brin.
Under the microscope, brin looks like a tangle o ne threads
with RBCs caught in the tangle. Figure 13-17 illustrates the
steps in the blood-clotting mechanism.
T e clotting mechanism contains clues or ways to stop
bleeding by speeding up blood clotting. For example, you
might simply apply gauze to a bleeding sur ace. Its slight
roughness would cause more platelets to stick together and
release more clotting actors. T ese additional actors would
then make the blood clot more quickly.
Physicians sometimes prescribe vitamin K be ore surgery
to make sure that the patients blood will clot ast enough to
prevent hemorrhage. Vitamin K stimulates liver cells to in-
crease the synthesis o prothrombin. More prothrombin in
blood allows aster production o thrombin during clotting
and thus aster clot ormation.
To learn more about hemostasis, go to
AnimationDirect online at evolve.elsevier.com.
C lo t t in g D is o r d e r s
A b n o r m a l Blo o d C lo t s
13
Ty p e s o A b n o r m a l C lo t s
Un ortunately, clots sometimes orm in unbroken blood ves-
sels o the heart, brain, lungs, or some other organa dreaded
thing because clots may produce sudden death by shutting o
the blood supply to a vital organ. W hen a clot stays in the
place where it ormed, it is called a thrombus and the condi-
tion is spoken o as thrombosis.
I part o the clot dislodges and circulates through the
bloodstream, the dislodged part is then called an embolus,
and the condition is called an embolism. For example, a clot
ragment that lodges in the lung is called a pulmonary
embolisma situation that may prove atal (Figure 13-18).
Suppose that your doctor told you that you had a clot in
one o your coronary arteries. W hich diagnosis would she
makecoronary thrombosis or coronary embolismi she
thought that the clot had ormed originally in the coronary
artery as a result o the accumulation o atty material in the
vessel wall?
Crushing injuries o skeletal muscle can
cause widespread abnormal clotting. Review
the article Rhabdomyolysis at Connect It! at
evolve.elsevier.com.
A n t ic o a g u la n t Th e r a p y
A number o drugs are now available to help dissolve abnor-
mal clots. Streptokinase and recombinant tissue plasminogen
activator ( PA or tPA) are drugs requently used in a variety
o conditions, including treatment o clot-induced strokes,
heart attacks, and other thrombus-induced and embolus-
induced medical emergencies.
 366 CHAPTER 13 Blood

FIGURE 13-17 Blood clotting. A, The extremely complex clotting mechanism can be distilled into three 2
basic steps outlined in the boxes. B, Color-enhanced scanning electron micrograph shows RBCs and WBCs
S e rie s of che mica l re a ctions
entrapped in a brin (yellow) mesh during clot ormation (platelets are blue).
tha t eve ntua lly re s ult in the
forma tion of thrombin.
Injury

Da ma ge d tis s ue ce lls
2
P rothrombin

Ve s s e l cons tricts, P rothrombin

he lping to Clotting a ctiva tor
clos e ga ps fa ctors
Ca lcium

Thrombin

Fibrinoge n
A 1

1 S ticky pla te le ts
Re le a s e of clotting fa ctors from both
injure d tis s ue ce lls a nd s ticky pla te le ts a t

13 the injury s ite (which form a te mpora ry

pla te le t plug).
Plate le t plug

T e anticoagulant Coumadin (war arin sodium) acts

by inhibiting the synthesis o prothrombin and other vita-
min Kdependent clotting actors. By doing so, Coumadin
decreases the ability o blood to clot and is e ective in pre-
venting repeat thromboses a ter a heart attack or the orma-
tion o clots a ter surgical replacement o heart valves.
H eparin can also be used to prevent excessive blood clot-
ting. H eparin inhibits the conversion o prothrombin to
thrombin, thus preventing ormation o a thrombus.
T e most widely used anticoagulant is low-dose (81-mg)
aspirin. T is readily available drug inhibits the ormation o
tiny platelet plugs and the subsequent ormation o emboli,
which may cause blockage o small blood vessels in the brain
and lead to a stroke.
A laboratory test called the prothrombin time (P ) is
o ten used to regulate dosage o anticoagulant drugs. In this
test, thromboplastin (a blood clotting actor)
and calcium are added simultaneously to a tube
o the patients plasma and a tube containing a
normal control solution, and the time required
or clot ormation in both tubes is determined.
A patient prothrombin time in excess o the standard control
value (11 to 12.5 seconds) indicates the level o anticoagulant
e ect caused by the administered drug.
Un ortunately, P test results may vary among di erent
clinical laboratories. Variability is o ten caused by di ering
techniques or di erences in the sensitivity o reagents used.
o minimize the e ects o these and other variables and
standardize the results o anticoagulation testing, a system
called the INR (abbreviation or International Normalized
Ratio) has been developed. P is reported in seconds. T e
INR is a mathematical calculation and is reported as a num-
ber. An INR o 0.8 to 1.2 is considered normal. In regulating
anticoagulant therapy, keeping the INR between 1.5 and 3
will help ensure the prevention o unwanted
blood coagulation in at risk individuals. By
monitoring changes in the INR, a physician can
adjust the dose o anticoagulant drug needed to
maintain an appropriate level o anticoagulant
e ect.

FIGURE 13-18 Pulmonary embolism. An
embolus (clot ragment) that ormed in the leg
but broke away and now lodged in a branch o
the pulmonary artery within the lung. Arrow-
head shows the embolus blocking the artery,
M L
thus drastically reducing gas exchange be-
tween air and blood in the a ected lung.
He m o p h ilia
Hemophilia is an X-linked inherited disorder
(see Chapter 25, pp. 683-684) that a ects more
S
than 300,000 people around the world. ypi-
cally, it is transmitted rom a symptom- ree car-
I rier mother to an a ected son. H emophilia is a
 CHAPTER 13 Blood 367
RBCs e nme s he d in fibrin

3
Forma tion of fibrin a nd
tra pping of RBCs a nd
pla te le ts to form a clot.

3
Blo o d clo t

Fibrin me s h (blood clot)

Fibrin
B

reatment o hemophilia involves initiation o li estyle

changes that help prevent injury, prompt response to bleeding
episodes, avoiding drugs such as aspirin that alter the clotting 13
mechanism, and administration o actor VIII.
H istorically, only small amounts o actor VIII could be
bleeding disorder that results rom a ailure to produce one obtained rom large quantities o plasma obtained rom many
or more plasma proteins responsible or blood clottinga donors. Given the shortage o donated blood, this method
process illustrated in Figure 13-17. could not meet demand as physicians prescribed more actor
T e most common orm o the disease, called hemophilia A, VIII to prevent as well as treat bleeding episodes.
is caused by absence o normal actor VIIIone o the many Further, even with new and more e ective blood banking
clotting actors needed to orm prothrombin activator. T is seri- sa ety precautions, puri cation methods and diagnostic tests,
ous coagulation disorder has plagued the royal amilies o Eu- pooling and ractionating donated blood and plasma still in-
rope or hundreds o years and, as a result, its signs and symp- volve some risk o disease transmissionespecially H IV and
toms and the genetics o its transmission are well known. Simply viral hepatitis. Currently, recombinant methods eliminate
stated, people with hemophilia are
relatively unable to orm blood clots.
Because minor blood vessel inju-
ries are common in ordinary li e, he- S C IEN C E APPLICATIONS
mophilia can be a li e-threatening
condition. Mild orms may not be HEMATOLOGY
apparent until the individual is sub- A rican-Am e rican phys ician Charle s Richard Drew was a pio-
jected to surgery or trauma, whereas ne e r in he m ato lo gy, the s tudy o blood. During World War
more severe cases may result in re- II, he deve lope d the ide a o blood banks and re s e arche d the
quent and even spontaneous episodes be s t way to s tore blood or trans us ions to wounde d s ol-
o extensive bleeding. die rs . In New York, he s e t up the f rs t blood bank eve r, in
T e most common signs o the 1941. This blood bank s e rve d as the m ode l or a ne twork o
disease include easy bruising, deep blood banks ope ne d by the Am e rican Re d Cros s .
Many he m atologis ts continue in Drew s oots te ps , re f n-
muscle hemorrhage, nosebleeds, blood
ing and pe r e cting the practice o blood s cie nce . Many pro-
in the urine, and in severe cases, even e s s ions be ne f t rom this re s e arch. Phle bo to m is ts colle ct
bleeding into the brain. Perhaps the blood or te s ting or s torage , clinical laboratory te chnicians
Charles Richard Drew
most characteristic sign is repeated (19041950) analyze blood s am ple s , and m any di e re nt he alth pro e s -
episodes o bleeding into the joints s ionals us e blood analys is and blood trans us ions to he lp
especially the elbows, knees, and an- the ir patie nts . O cours e , m ilitary m e dics s till re ly on blood banking te chnology to pro-
kles. T e result is chronic pain and vide im m e diate aid to wounde d com bat and te rroris m victim s .
progressive joint de ormity.
 368 CHAPTER 13 Blood

these risks and are used to produce enough recombinant anti-
hemophilic actor VIII (rAHF) to meet the needs o the worlds
hemophiliac population.
Th ro m b o c y t o p e n ia
A more common type o clotting disorder results rom a de-
crease in the platelet counta condition called thrombo-
cytopenia. T is condition is characterized by bleeding rom
many small blood vessels throughout the body, most visibly as
purpurapurple splotches in the skin and mucous mem-
branes. I the number o thrombocytes alls to 20,000/mm3 or
less (normal range is 150,000 to 400,000/mm3), catastrophic
bleeding may occur.
A number o di erent mechanisms can result in thrombo-
cytopenia. For example, platelet numbers below 50,000/mm 3
may result rom mechanical destruction as blood passes over
arti cial heart valves.
T e usual cause, however, is bone marrow destruction by
drugs, chemicals, radiation, or cancer. Reduced platelet counts
are also common in immune system diseases such as lupus
and H IV/AIDS, in which a reduction in platelets occurs early
in the course o in ection.
Some drugs, such as aspirin, may cause thrombocytopenia
13 as a side e ect. In such cases, stopping the use o the drug
usually solves the problem.
Active treatment options include administration o corti-
costeroid-type drugs, which increase platelet production,
trans usion o platelets, and in severe cases, removal o the
spleen, which is a major site o platelet destruction.
Vit a m in K D e f c ie n c y
Vitamin K is needed by the body to produce several impor-
tant clotting actors. T us, a de ciency o this vitamin may
lead to impairment o the clotting mechanism.
Most vitamin K is produced by bacteria living in the intes-
tines, where it is absorbed into the bloodstream. As long as an
adults gastrointestinal (GI) tract is healthy, there is usually
enough vitamin K available or normal clotting. H owever,
in ants sometimes have clotting problems because their intes-
tinal bacteria have not yet established themselves and started
producing vitamin K.
QUICK CHECK
1. Ho w d o e s a p la te le t d i e r ro m th e o th e r o rm e d
e le m e n ts ?
2. Wh a t is th e ro le o p ro th ro m b in , th ro m b in , f b rin o g e n , a n d
f b rin in th e b lo o d clo ttin g m e ch a n is m ?
3. Wh a t is th e d i e re n ce b e tw e e n a th ro m b u s a n d a n
e m b o lu s ?
4. Id e n ti y tw o typ e s o clo ttin g d is o rd e rs .

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 349)

eosinophil granular leukocyte intrinsic actor

(ee-oh-SIN-oh-f l) (GRAN-yoo-lar LOO-koh-syte) (in-TRIN-sik)
[eos- dawn (red), -in- substance, -phil love] [gran- grain, -ul- little, -ar relating to, [intr- inside or within, -insic beside]
erythrocyte leuko- white, -cyte cell] leukocyte
(eh-RITH-roh-syte) hematology (LOO-koh-syte)
[erythro- red, -cyte cell] (hee-mah-TOL-oh-jee) [leuko- white, -cyte cell]
erythropoietin (EPO) [hema- blood, -to- combining syllable, lymphatic system
(eh-RITH-roh-POY-eh-tin [ee pee oh]) -log- words (study o ), -y activity] (lim-FAT-ik SIS-tem)
[erythro- red, -poiet- make, -in substance] hematopoiesis [lymph- water, -atic relating to]
actor VIII (hee-mat-oh-poy-EE-sis) lymphocyte
(FAK-ter ayt) [hemo- blood, -poiesis making] (LIM- oh-syte)
[VIII Roman numeral eight] hemoglobin (Hb) [lymph- water (lymphatic system), -cyte cell]
f brin (hee-moh-GLOH-bin [aych bee]) lymphoid tissue
(FYE-brin) [hemo- blood, -glob- ball, -in substance] (LIM- oyd TISH-yoo)
[f br- f ber, -in substance] hemostasis [lymph- water (lymphatic system), -oid like,
f brinogen (hee-moh-STAY-sis) tissu abric]
( ye-BRIN-oh-jen) [hemo- blood, -stasis standing] macrophage
[f br- f ber, -in- substance, -gen produce] heparin (MAK-roh- ayj)
ormed element (HEP-ah-rin) [macro- large, -phag- eat]
( ormd EL-eh-ment) [hepar- liver, -in substance] mast cell
globulin histamine (mast sel)
(GLOB-yoo-lin) (HIS-tah-meen) [mast attening, cell storeroom]
[glob- ball, -ul- little, -in substance] [hist- tissue, -amine ammonia compound] monocyte
immune system (MON-oh-syte)
(ih-MYOON SIS-tem) [mono- single, -cyte cell]
[immun- ree]
 CHAPTER 13 Blood 369

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 368)

myeloid tissue plasma protein Rh system

(MY-eh-loyd TISH-yoo) (PLAZ-mah PROH-teen) (R H SIS-tem)
[myel- marrow, -oid o or like, tissu abric] [plasma something molded or created (blood [Rh short or rhesus monkey]
neutrophil plasma), prote- primary, -in substance] serum
(NOO-troh-f l) platelet (SEER-um)
[neutr- neither, -phil love] (PLAYT-let) [serum watery body uid]
oxyhemoglobin (HbO2) [plate- at, -let small] thrombin
(ahk-see-hee-moh-GLOH-bin platelet plug (THROM-bin)
[aych bee oh too]) (PLAYT-let plug) [thromb- clot, -in substance]
[oxy- sharp (oxygen), -hemo- blood, -glob- ball, [plate- at, -let small] thrombocyte
-in substance] prothrombin (THROM-boh-syte)
phagocyte (proh-THROM-bin) [thromb- clot, -cyte cell]
(FAG-oh-syte) [pro- be ore, -thromb- clot, -in substance] vasoconstriction
[phago- eat, -cyte cell] prothrombin activator (vay-soh-kon-STRIK-shun)
plasma (proh-THROM-bin AK-tih-vay-tor) [vas- vessel, -constrict- draw tight, -tion state]
(PLAZ-mah) [pro- be ore, -thromb- clot, -in substance, white blood cell (WBC)
[plasma something molded or created] act- per orm, -iv- relating to, -at- process, (whyte blud sel [DUB-el-yoo bee see])
plasma cell -or condition] [cell storeroom]
(PLAZ-mah sel) red blood cell (RBC)
[plasma something molded or created (blood (red blud sel [ar bee see])
plasma), cell storeroom] [cell storeroom]
13

LANGUAGE OF M ED IC IN E

acidosis
(as-ih-DOH-sis)
[acid- sour, -osis condition]
acute lymphocytic leukemia (ALL)
(ah-KYOOT LIM- oh-sit-ik loo-KEE-mee-ah
[ay el el])
[acu- sharp, lymph- water (lymphatic system),
-cyt- cell, -ic relating to, leuk- white,
-emia blood condition]
acute myeloid leukemia (AML)
(ah-KYOOT MY-eh-loyd loo-KEE-mee-ah
[ay em el])
[acu- sharp, myel- marrow, -oid o or like,
leuk- white, -emia blood condition]
anemia
(ah-NEE-mee-ah)
[an- without, -emia blood condition]
anticoagulant
(an-tee-koh-AG-yoo-lant)
[anti- against, -coagul- curdle, -ant agent]
aplastic anemia
(a-PLAS-tik ah-NEE-mee-ah)
[a- without, -plast- orm, -ic relating to,
an- without, -emia blood condition]
aspiration biopsy cytology (ABC) complete blood cell count (CBC)
(as-pih-RAY-shun BYE-op-see (kom-PLEET blud sel kount [see bee see])
sye-TOL-oh-jee [ay bee see]) [cell storeroom]
[a- act o , -spir- breathe, -ation process, di erential WBC count
bio- li e, -ops- view, -y act o , cyt- cell, (di -er-EN-shal DUB-el-yoo bee see kownt)
-o- combining orm, -log- words (study o ), [di erent- di erence, -al relating to, WBC white
-y activity] blood cell]
blood doping embolism
(blud DOH-ping) (EM-boh-liz-em)
[dop- thick liquid (opium)] [embol- plug, -ism condition]
bone marrow transplant embolus
(bohn MAYR-oh TRANS-plant) (EM-boh-lus)
[trans- across, -plant sprout] [embolus plug]
chronic lymphocytic leukemia (CLL) erythroblastosis etalis
(KRON-ik LIM- oh-sit-ik loo-KEE-mee-ah (eh-rith-roh-blas-TOH-sis eh-TAL-is)
[see el el]) [erythro- red, -blast- bud or sprout,
[chron- time, -ic relating to, lymph- water -osis condition]
(lymphatic system), -cyte cell, -ic relating to, olate def ciency anemia
leuk- white, -emia blood condition] (FOH-layt deh-FISH-en-see
chronic myeloid leukemia (CML) ah-NEE-mee-ah)
(KRON-ik MY-eh-loyd loo-KEE-mee-ah [ ol- lea , -ate relating to, de- down,
[see em el]) -f c- per orm, -ency state, an- without,
[chron- time, -ic relating to, myel- marrow, -emia blood condition]
-oid like, leuk- white, -emia blood condition] hematocrit (Hct)
(hee-MAT-oh-krit [aych see tee])
[hemato- blood, -crit separate]
 370 CHAPTER 13 Blood

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 369)

hemochromatosis lymphoid neoplasm Rh-positive

(hee-moh-kroh-mah-TOH-sis) (LIM- oyd NEE-oh-plaz-em) (R H POZ-ih-tiv)
[hemo- blood, -chroma- color, -osis condition] [lymph- water (lymphatic system), -oid like, [Rh short or rhesus monkey, posit- put or
hemolytic anemia neo- new, -plasm something molded or place, -ive relating to]
(hee-moh-LIT-ik ah-NEE-mee-ah) created] sickle cell anemia
[hemo- blood, -lyt- loosen, -ic relating to, medic (SIK-ul sel ah-NEE-mee-ah)
an- without, -emia blood condition] (MED-ik) [sickle crescent-shaped tool, cell storeroom,
hemolytic disease o the newborn (HDN) [med- heal, -ic- relating to] an- without, -emia blood condition]
(hee-moh-LIT-ik dih-ZEEZ ov thuh multiple myeloma sickle cell trait
NOO-born) (MUL-tih-pul my-LOH-mah) (SIK-ul sel trayt)
[hemo- blood, -lyt- loosen, -ic relating to, [multi- many, -pl- old, myel- marrow, [sickle crescent, cell storeroom]
dis- opposite o , -ease com ort] -oma tumor] thalassemia
hemophilia myeloid neoplasm (thal-ah-SEE-mee-ah)
(hee-moh-FIL-ee-ah) (MY-eh-loyd NEE-oh-plaz-em) [thalas- sea, -emia blood condition]
[hemo- blood, -phil- love, -ia condition] [myel- marrow, -oid like, neo- new, thrombocytopenia
hemorrhagic anemia -plasm something molded or created] (throm-boh-sye-toh-PEE-nee-ah)
(HEM-oh-raj-ick ah-NEE-mee-ah) pernicious anemia [thrombo- clot, -cyto- cell, -penia lack]
[hemo- blood, -rrh(e)a- ow, -ag(e)- process or (per-NISH-us ah-NEE-mee-ah) thrombosis
state, -ic relating to, an- without, -emia blood [pernici- destruction, -ous relating to, (throm-BOH-sis)
condition] an- without, -emia blood condition] [thrombo- clot, -osis condition]
in ectious mononucleosis phlebotomist thrombus
13 (in-FEK-shuss mah-noh-noo-klee-OH-sis) ( eh-BOT-uh-mist) (THROM-bus)
[in ect- stain, -ous relating to, mono- single, [phleb- vein, -tom- cut, -ist agent] [thrombus clot]
-nucle- nut, -osis condition] polycythemia tissue plasminogen activator (TPA or tPA)
INR (international normalized ratio) (pahl-ee-sye-THEE-mee-ah) (TISH-yoo plaz-MIN-oh-jen AK-tih-vay-tor)
(aye en ar [in-ter-NASH-en-ul [poly- many, -cyt- cell, -emia blood condition] [tissu abric, plasm- something molded or
NOR-mah-lyzed RAY-shee-oh]) prothrombin time (PT) created (plasma), -in- substance,
iron def ciency anemia (proh-THROM-bin tyme) -gen produce, act- per orm, -ive relating to,
(AYE-ern deh-FISH-en-see [pro- be ore, -thromb- clot, -in substance] -or agent]
ah-NEE-mee-ah) purpura universal donor blood
[iron element 26, de- down, -f c- per orm, (PUR-pah-rah) (yoo-neh-ver-sal DOH-nor blud)
-ency state, an- without, -emia blood [purpura purple] [uni- one, -vers- turn (into), -al relating to,
condition] don- give, -or agent]
Rh-negative
leukemia (R H NEG-ah-tiv) universal recipient blood
(loo-KEE-mee-ah) [Rh short or rhesus monkey, negat- deny, (yoo-neh-ver-sal REE-sip-ee-ahnt blud)
[leuk- white, -emia blood condition] -ive relating to] [uni- one, -vers- turn (into), -al relating to,
leukocytosis RhoGAM recip- take, -ent agent]
(loo-koh-SYE-toh-sis) (ROH-gam)
[leuko- white, -cyt- cell, -osis condition] [brand name derived rom Rho 17th letter o
leukopenia Greek alphabet (re ers to Rh antigen), GAM
(loo-koh-PEE-nee-ah) rom gamma-globulin (Rh antibody)]
[leuko- white, -penia lack]
 CHAPTER 13 Blood 371

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary 2. Number
or us e w ith your device , acce s s the Au d io Ch a p te r a. RBCs4.2 to 6.2 million/mm 3 o blood
S u m m a rie s online at evolve .e ls evie r.com . b. W BCs5000 to 10,000/mm3 o blood
c. Platelets150,000 to 400,000/mm 3 o blood
Scan this s um m ary a te r re ading the chapte r to D. H ematopoiesis ormation o new blood cells
he lp you re in orce the key conce pts . Late r, us e 1. Myeloid tissue (red bone marrow) orms all blood
the s um m ary as a quick review be ore your clas s cells except some lymphocytes; ound within bones
or be ore a te s t. 2. Lymphoid tissue orms additional white blood cells
in the lymph nodes, thymus, and spleen
3. RBCs live about 4 months; W BCs live or a ew days
Blo o d Co m po s itio n (granular) to over 6 months (agranular)
A. Blood tissue
1. Blood tissue components
a. Liquid raction o whole blood (extracellular part)
Me chanis m s o Blo o d Dis e as e
called plasma (Figure 13-1) A. Most blood diseases result rom ailure o myeloid and
b. Cellular components suspended in the plasma lymphoid tissues
make up the ormed elements B. Causes include toxic chemicals, radiation, inherited
2. Normal volumes o blood de ects, nutritional de ciencies and cancers, including
a. Plasma2.6 L leukemia
b. Formed elements2.4 L C. Aspiration biopsy cytology (ABC) permits examination
c. W hole blood4 to 6 L average or 7% to 9% o o blood- orming tissues to assist in diagnosis o blood 13
total body weight diseases
3. Blood pH D. Bone marrow, cord blood, and hematopoietic stem cell
a. Blood is alkalinepH 7.35 to pH 7.45 transplants may be used to replace diseased or destroyed
b. Blood pH decreased toward neutral creates a con- blood- orming tissues
dition called acidosis
B. Blood plasma
1. Liquid raction o whole blood minus ormed ele-
Re d Blo o d Ce lls
ments (Figure 13-1) A. RBC structure and unction
2. Compositionwater containing many dissolved sub- 1. RBC o ers excellent example o how structural adap-
stances including: tation a ects biological unction
a. Nutrients, salts 2. ough and f exible plasma membrane de orms easily
b. About 1.5% o total O 2 transported in blood allowing RBCs to pass through small-diameter
c. About 10% o total CO 2 capillaries
d. Most abundant solutes dissolved in plasma are 3. Biconcave disk shape (thin center and thicker edges)
plasma proteins results in large cellular sur ace area (Figure 13-2)
(1) Albumins 4. Absence o nucleus and cytoplasmic organelles
(2) Globulins a. Limits RBC li e span to about 120 days
(3) Fibrinogen b. Provides more cellular space or hemoglobin (H b)
(4) Prothrombin 5. ransport o respiratory gases (O 2 and CO 2)
3. Plasma minus clotting actors is called serum B. RBC count
a. Serum is liquid remaining a ter whole blood clots 1. Complete blood cell count (CBC)battery o labora-
b. Serum contains antibodies tory tests used to measure the amounts or levels o
C. Formed elements many blood constituents
1. ypes (Figure 13-1 and Table 13-1) 2. H ematocrit (H ct)
a. Red blood cell; also called RBC or erythrocyte a. Also called packed cell volume (PCV)
b. W hite blood cell; also called W BC or leukocyte b. H ct expressed as the percentage o whole blood
(1) Granular leukocytesneutrophils, eosinophils, that is RBCs (Figure 13-3)
and basophils C. H emoglobin (H b)
(2) Agranular leukocyteslymphocytes and 1. Q uaternary protein made up o our polypeptide
monocytes chains, each with an oxygen-attracting heme group at
c. Platelet; also called thrombocyte center (Figure 13-4)
 372 CHAPTER 13 Blood
2. Iron (Fe), olate (a B vitamin), and vitamin B12 are
among the critical nutrients needed to manu acture
Hb
3. ransport o respiratory gases (O 2 and CO 2)
a. Combined with hemoglobin
(1) O xyhemoglobin (H b O 2)
(2) Carbaminohemoglobin (H b CO 2)
b. CO 2 converted to bicarbonate by the RBCs
4. Important role in homeostasis o acid-base balance
D. RBC abnormalities (Figure 13-5)
1. Named according to size
a. Normocytesnormal size (about 8 to 9 m in
diameter)
b. Microcyticsmall size
c. Macrocyticlarge size
2. Named according to hemoglobin content o cell
a. Normochromicnormal H b content
b. H ypochromiclow H b content
c. H yperchromichigh H b content
E. Blood ypes (Table 13-2)
1. ABO system (Figure 13-6)
a. Antigensubstance that can activate immune
system
b. Antibodysubstance made by body in response to
13 stimulation by an antigen
c. ABO blood types
(1) ype A bloodtype A sel -antigens in RBCs;
antiB type antibodies in plasma
(2) ype B bloodtype B sel -antigens in RBCs;
antiA type antibodies in plasma
(3) ype AB bloodtype A and type B sel -
antigens in RBCs; no anti-A or anti-B anti-
bodies in plasma
(4) ype O bloodno type A or type B sel -
antigens in RBCs; both anti-A and anti-B
antibodies in plasma
2. Rh system
a. Rh-positive bloodRh actor antigen present in
RBCs
b. Rh-negative bloodno Rh actor present in RBCs;
no anti-Rh antibodies present naturally in plasma;
anti-Rh antibodies, however, appear in the plasma
o Rh-negative persons i Rh-positive RBCs have
been introduced into their bodies; an RH -negative
person can generate anti-Rh antibodies ollowing
exposure to the Rh antigen
c. Erythroblastosis etalismay occur when
Rh-negative mother carries a second Rh-positive
etus; caused by mothers Rh antibodies reacting
with the etuss Rh-positive cells (Figure 13-7)
3. Combined ABO-Rh system
a. Both systems commonly used together
b. ype O : universal donor blood
c. ype AB : universal recipient blood
Re d Blo o d Ce ll Dis o rde rs
A. Most o ten related to either overproduction o RBCs
called polycythemia; or to low oxygen-carrying capacity o
bloodcalled anemia
B. Polycythemia
1. Cause is generally cancerous trans ormation o red
bone marrow
2. D ramatic increase in RBC numberso ten in excess
o 10 million/mm3 o blood; hematocrit may reach
60%
3. Signs and symptoms include:
a. Increased blood viscosity or thickness
b. Slow blood f ow and coagulation problems
c. Frequent hemorrhages
d. Distention o blood vessels and hypertension
4. reatment may include:
a. Blood removal
b. Irradiation and chemotherapy to suppress RBC
production
C. Anemia (Table 13-3)
1. Caused by low numbers or abnormal RBCs or by low
levels or de ective types o hemoglobin
a. Normal H b levels 12 to 14 g/100 mL o blood
b. Low H b level (below 9 g/100 mL o blood) classi-
ed as anemia
2. Majority o clinical signs o anemia related to low
tissue oxygen levels
a. Fatigue; skin pallor
b. Weakness; aintness; headache
c. Compensation results in increased heart and respi-
ratory rates
3. H emorrhagic anemia
a. Acuteblood loss is immediate ( or example,
surgery or trauma)
b. Chronicblood loss occurs over time ( or example,
ulcers or cancer)
4. Aplastic anemia
a. Characterized by low RBC numbers and destruc-
tion o bone marrow
b. O ten caused by toxic chemicals, irradiation, or
certain drugs
5. De ciency anemiascaused by inadequate supply o
some substance needed or RBC or hemoglobin
production
a. Pernicious anemia
(1) Caused by vitamin B12 de ciency
(2) Genetic-related autoimmune disease
(3) Decreased RBC, W BC, and platelet numbers
(4) RBCs are macrocytic
(5) Classic symptoms o anemia coupled with
central nervous system (CNS) impairment
(6) reatment is repeated vitamin B12 injections
b. Folate de ciency anemia
(1) Caused by olate (vitamin B9) de ciency
(2) Decreased RBC count
(3) Common in alcoholism and malnutrition

c. Iron de ciency anemia
(1) Caused by de ciency o or inability to absorb
iron needed or H b synthesis (dietary iron de -
ciency is common worldwide)
(2) RBCs are microcytic and hypochromic
(Figure 13-8)
(3) H ematocrit is decreased
(4) reatment is oral administration o iron
compounds
6. H emolytic anemias
a. Caused by decreased RBC li e span or increased
RBC rate o destruction
b. Symptomssuch as jaundice, swelling o spleen,
gallstone ormation, and tissue iron depositsare
related to retention o RBC breakdown products
c. Sickle cell anemia (Figure 13-9)
(1) Genetic disease resulting in ormation o
abnormal hemoglobin (H bS); primarily ound
in A rican-American people
(2) RBCs become ragile and assume sickled shape
when blood oxygen levels decrease
(3) Sickle cell traitresult o one de ective gene;
usually mild or no symptoms at all
(4) Sickle cell diseaseresult o two de ective
genes; more severe; causes blood stasis, clotting,
and crises that may be atal
(5) A ects 1 in every 600 A rican-American
newborns
d. T alassemia
(1) Group o inherited hemolytic anemias occur-
ring primarily in people o Mediterranean
descent
(2) RBCs microcytic and short lived
(3) Present as mild thalassemia trait and severe
thalassemia major
(4) H b levels o ten all below 7 g/100 mL o blood
in thalassemia major
(5) Classic symptoms o anemia coupled with skel-
etal de ormities and swelling o spleen and liver
e. H emolytic disease o the newborn (H DN)
(1) Caused by blood ABO or Rh actor incompati-
bility during pregnancy between developing
o spring and mother
(2) Maternal antibodies against etal RBCs o di -
erent blood type can cross placenta, enter the
etal circulation, and destroy some o the etuss
red cellsas in erythroblastosis etalis
(Figure 13-7)
(3) Symptoms in developing etus related to
decline in RBC numbers and H b levels; jaun-
dice, intravascular coagulation, and heart and
lung damage are common
(4) reatment may include in utero blood trans u-
sions and premature delivery o the o spring
(5) Prevention o Rh actor incompatibility now
possible by administration o RhoGAM to Rh-
negative mothers
CHAPTER 13 Blood 373
White Blo o d Ce lls
A. Introduction to W BCs
1. Categorized by presence o stained nuclei and gran-
ules in translucent cytoplasm (Figure 13-10)
a. Granulocytespossess granules that stain
b. Agranulocytesabsence o stained granules
2. W BCs are all involved in immunity
B. W BC count
1. Complete W BC countnormal range is 5000 to
10,000/mm3 o blood
2. Leukopeniaabnormally low W BC count (below
5000/mm3 o blood)
a. Occurs in requently
b. May occur with mal unction o blood- orming
tissues or diseases a ecting immune system, such as
AIDS
3. Leukocytosisabnormally high W BC count (over
10,000/mm3 o blood)
a. Frequent nding in bacterial in ections
b. Classic sign in blood cancers (leukemia)
4. Di erential WBC countcomponent test in CBC;
measures proportions o each type o W BC in blood
sample (Figures 13-1 and 13-10)
C. W BC types 13
1. Granular leukocytes (granulocytes)
a. Neutrophils
(1) Most numerous type o phagocyte
(2) Numbers increase in bacterial in ections
b. Eosinophils
(1) Weak phagocyte
(2) Active against parasites and parasitic worms
(3) Involved in allergic reactions
c. Basophils
(1) Related to mast cells in tissue spaces
(2) Both mast cells and basophils secrete histamine
(related to inf ammation)
(3) Basophils also secrete heparin (an
anticoagulant)
2. Agranular leukocytes (agranulocytes)
a. Monocytes
(1) Largest leukocyte
(2) Aggressive phagocytecapable o engul ng
larger bacteria and cancer cells (Figure 13-11)
(3) Develop into much larger cells called macro-
phages a ter leaving blood to enter tissue spaces
b. Lymphocytes
(1) B lymphocytes involved in immunity against
disease by secretion o antibodies
(2) Mature B lymphocytes called plasma cells
(3) lymphocytes involved in direct attack on
bacteria or cancer cells (not antibody
production)
 374 CHAPTER 13 Blood
White Blo o d Ce ll Dis o rde rs
A. wo major types o W BC cancers or neoplasms
1. Lymphoid neoplasmsresult rom B and lympho-
cyte precursor cells or their descendant cell types
2. Myeloid neoplasmsresult rom malignant trans or-
mation o precursor cells o granulocytic W BCs,
monocytes, RBCs, and platelets
B. Multiple myeloma (Figure 13-12)
1. Cancer o B lymphocytes called plasma cells
2. Most deadly blood cancer in people older than age 65
3. Causes bone marrow dys unction and production o
de ective antibodies
4. Characterized by:
a. Recurrent in ections and anemia
b. Destruction and racture o bones
5. reatment includes chemotherapy, drug and antibody
therapy, and marrow and stem cell transplantation
C. LeukemiasW BC-related blood cancers
1. Characterized by marked leukocytosis
2. Identi ed as:
a. Acute or chronicbased on timing o pathogenesis
(1) Acuterapid development o symptoms
(2) Chronicslow development o symptoms
13 b. Lymphocytic or myeloidbased on origin tissue o
involved cells
(1) Lymphocytica ects lymphocytes
(2) Myeloida ects granular leukocytes as they
develop in the red bone marrow
3. Chronic lymphocytic leukemia (CLL) (Figure 13-13)
a. Average age at onset is 65; rare be ore age 30
b. More common in men than in women
c. O ten diagnosed unexpectedly in routine physical
exams with discovery o marked B lymphocytic
leukocytosis
d. Generally mild symptoms include anemia, atigue,
and enlargedo ten painlesslymph nodes
e. Most patients live many years ollowing diagnosis
. reatment o severe cases involves chemotherapy
and irradiation
4. Acute lymphocytic leukemia (ALL) (Figure 13-14)
a. Primarily a disease o children between 3 and
7 years o age; 80% o children who develop leuke-
mia have this orm o the disease
b. H ighly curable in children but less so in adults
c. Onset is suddenmarked by ever, leukocytosis,
bone pain, and increases in in ections
d. Lymph node, spleen, and liver enlargement is
common
e. reatment includes chemotherapy, irradiation, and
bone marrow or stem cell transplantation
5. Chronic myeloid leukemia (CML) (Figure 13-15)
a. Accounts or about 20% o all cases o leukemia
b. O ccurs most o ten in adults between 25 and 60
years o age
c. Caused by cancerous trans ormation o granulo-
cytic precursor cells in the bone marrow
d. O nset and progression o disease is slow with
symptoms o atigue, weight loss, and weakness
e. Diagnosis o ten made by discovery o marked
granulocytic leukocytosis and extreme spleen
enlargement
. reatment by new designer drug Gleevec or bone
marrow transplantation is curative in more than
70% o cases
6. Acute myeloid leukemia (AML)
a. Accounts or 80% o all cases o acute leukemia in
adults and 20% o acute leukemia in children
b. Characterized by sudden onset and rapid
progression
c. Symptoms include leukocytosis, atigue, bone and
joint pain, spongy bleeding gums, anemia, and
recurrent in ections
d. Prognosis is poor with only about 50% o children
and 30% o adults achieving long-term survival
e. Bone marrow and stem cell transplantation has
increased cure rates in selected patients
D. In ectious mononucleosis (Figure 13-16)
1. Noncancerous W BC disorder
2. H ighest incidence between 15 and 25 years o age
3. Caused by virus present in saliva o in ected
individuals
4. Leukocytosis o atypical lymphocytes with abundant
cytoplasm and large nuclei
5. Symptoms include ever, severe atigue, sore throat,
rash, and enlargement o lymph nodes and spleen
6. Generally sel -limited and resolves without complica-
tions in about 4 to 6 weeks
Plate le ts and Blo o d Clo tting
A. Plateletsalso called thrombocytes
1. iny cell ragments lled with clot-triggering
chemicals
2. Play essential role in blood clotting
B. Blood clotting mechanism (Figure 13-17)
1. Vasoconstriction o blood vessels helps close gaps in
blood vessel wall and reduces local blood f ow
2. Blood vessel damage releases clotting actors that react
with plasma actors to orm prothrombin activator
3. At the same time, platelets adhere to the break and
orm a platelet plug and release additional clotting
actors promoting ormation o prothrombin activator
4. Prothrombin activator and calcium convert prothrom-
bin to thrombin
5. T rombin reacts with brinogen to orm brin
6. Fibrin threads orm a tangle to trap RBCs (and other
ormed elements) to produce a blood clot
C. Altering the blood clotting mechanism
1. Application o gauze (rough sur ace) to wound causes
platelet aggregation and release o clotting actors
2. Administration o vitamin K will increase synthesis o
prothrombin

Clo tting Dis o rde rs
A. Abnormal blood clots
1. ypes o abnormal clots
a. T rombusstationary blood clot
b. Emboluscirculating blood clot (Figure 13-18)
2. Anticoagulant therapy
a. Drug called tissue plasminogen activator [ PA or
tPA] used to dissolve clots that have already ormed
b. Drug war arin sodium will delay clotting by inhib-
iting prothrombin synthesis
c. H eparin delays clotting by inhibiting conversion o
prothrombin to thrombin
d. Laboratory tests used to monitor e ectiveness o
anticoagulant therapy include:
(1) Prothrombin timereported in seconds (7 to
10 seconds is normal)
(2) INR (International Normalized Ratio)a cal-
culated value reported as a number (0.8 to
1.2 is normal)
B. H emophiliaX-linked inherited disorder that results
rom inability to produce actor VIII (a plasma protein)
responsible or blood clotting
1. Most serious bleeding disease worldwide; hemo-
philia A most common orm
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Blood cons is ts o a liquid portion, the plas m a, and orm e d e le -
m e nts : re d blood ce lls , w hite blood ce lls , and plate le ts . The
unction o the blood is to carry s ubs tance s rom one part o
the body to anothe r. Many trans porte d m ate rials are dis s olve d
in the plas m a, s o the com pos ition o the plas m a varie s bas e d
on w hat is going on in the body. Be caus e o its unction, the
blood plays an im portant role in a num be r o othe r s ys te m s
s uch as the re s piratory, dige s tive , urinary, and im m une s ys -
te m s . The m ate rial in this chapte r s how s up again in late r
chapte rs .
1. Flash cards and online tutorials will help you learn the
names and unctions o the various blood cells. Check out
www.getbodysmart.com or tutorials and animations that
illustrate a white blood cell di erential test and blood
typing.
2. T e process o blood clot ormation is important, and it is
necessary that you know and understand the correct
sequence o events. Develop a concept map that illustrates
the sequence o the events that lead to a blood clot.
CHAPTER 13 Blood 375
2. Characterized by easy bruising, deep muscle hemor-
rhage, blood in urine, and repeated episodes o bleed-
ing into joints causing pain and de ormity
3. reatment includes administration o actor VIII,
injury prevention, and avoiding drugs such as aspirin
that alter the clotting mechanism
C. T rombocytopeniacaused by reduced platelet counts
1. Characterized by bleeding rom small blood vessels,
most visibly as purpura (purplish spots) in the skin
and mucous membranes
2. Platelet count below 20,000/mm 3 may cause cata-
strophic bleeding (normal platelet count 150,000 to
400,000/mm3)
3. Most common cause is bone marrow destruction by
drugs; chemicals; radiation; and diseases such as
cancer, lupus, and H IV/AIDS
4. reatment may involve trans usion o platelets,
corticosteroid-type drugs, or removal o the spleen
D. Vitamin K de ciencycan result in abnormally reduced
clotting
13
3. In order to understand the terminology, review the Lan-
guage o Science and Language o Medicine terms.
4. W hen studying the blood disorders, make a chart that
identi es the type o disorder: red blood cell, white blood
cell, or clotting disorder. List the name and the speci c
cause o each disorder.
5. As you study the ABO blood typing system, be sure you
give extra attention to learning what antigens are on the
red blood cells and what antibodies are in the plasma. T e
antigens give a blood type its name, that is, type A blood
has A antigens. Antibodies are the opposite o the blood
type. ype A blood has anti-B antibodies. ype O has no
antigens and both antibodies; type AB has both antigens
and no antibodies.
6. In your study group, review the f ash cards you made and
online resources or studying the unction o the blood
cells. Discuss the process o blood clot ormation. Go over
the blood disorder chart. Review the antigens and anti-
bodies o the various blood types. Go over the questions
and the outline summary at the end o the chapter and
discuss possible test questions.
 376 CHAPTER 13 Blood
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Name several substances ound in blood plasma.
2. Explain the unction o albumins, globulins, and
brinogen.
3. W hat is the di erence between serum and plasma?
4. W hat two types o connective tissue orm blood cells?
W here are they ound and what do each o them orm?
5. Describe the structure o a red blood cell. W hat advan-
tage does this unique shape give the red blood cell that
helps it per orm its unction?
6. Explain how type A blood di ers rom type B blood.
7. Explain the cause o erythroblastosis etalis.
8. Both aplastic anemia and pernicious anemia are charac-
terized by a low red blood cell count. H ow does the
cause o each disease condition di er?
9. W hat is the bu y coat?
10. Explain the unction o neutrophils and monocytes.
13 11. Explain the unction o lymphocytes.
12. Explain the unction o eosinophils and basophils.
13. Distinguish between leukopenia and leukocytosis.
14. H ow is hemophilia transmitted? W hat blood clotting
actors can be a ected?
15. Explain the process o blood clot ormation.
16. Di erentiate between a thrombus and an embolus.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
17. W hen a patient is being prepped or surgery, a physician
will o ten prescribe vitamin K. W hat is the signi cance
o administering vitamin K be ore surgery?
18. Explain how heparin inhibits blood clot ormation.
19. You are a medical examiner, and a body is brought to
you to determine the cause o death. You nd a very
large agglutination (not a clot) in a major vein. W hat
judgment would you make regarding the cause o death?
20. W hy is the rst Rh-positive baby born to an Rh-
negative mother usually una ected?
21. Some athletes, seeking a competitive edge, may resort to
blood doping. H ow would you explain blood doping?
W hat in ormation would you use to discourage athletes
rom participating in the practice o blood doping?
22. H ow do red blood cells con rm that structure ts
unction?
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e liquid part o the blood is called ________.
2. T ree important plasma proteins are ________,
________, and ________.
3. Blood plasma without the clotting actors is called
________.
4. T e three ormed elements o the blood are ________,
________, and ________.
5. T e two types o connective tissue that make blood cells
are ________ and ________.
6. T e red pigment in red blood cells that carries oxygen is
called ________.
7. An ________ is a oreign substance that can cause the
body to produce an antibody.
8. A person with type AB blood has ________ antigens on
the blood cell and ________ antibodies in the plasma.
9. A person with type B blood has ________ antigens on
the blood cell and ________ antibodies in the plasma.
10. ype ________ blood is considered the universal donor.
11. ype ________ blood is considered the universal
recipient.
12. A condition called ________ can develop i an Rh-
negative mother produces antibodies against the blood
o an Rh-positive etus.
13. T e term ________ is used to describe a number o
disease conditions caused by the inability o red blood
cells to carry a su cient amount o oxygen.
14. I the body produces an excess o red blood cells, the
condition is called ________.
15. W hich white blood cells are the most numerous o the
phagocytes? ________
16. W hich white blood cells produce antibodies to ght
microbes? ________
17. Prothrombin activator and the mineral ________ in the
blood convert prothrombin into thrombin in the orma-
tion o a blood clot.
18. T rombin converts the inactive plasma protein
________ into a brous gel called ________.
19. Vitamin ________ stimulates the liver to increase syn-
thesis o prothrombin.
20. A ________ is a pathological rather than curative blood
clot that stays in the place where it was ormed.
21. I a part o a blood clot is dislodged and circulates
through the bloodstream, it is called a/an ________.
22. T e ________ provides in ormation about the volume o
red blood cells in a blood sample. It is an estimate o the
proportion o red blood cells to whole blood.
23. T e ________ are the largest o the leukocytes and are
very aggressive phagocytes.
24. A ________ provides the proportions o each type o
white blood cell as percentages o the total white blood
cell count. It is a valuable diagnostic tool.
 CHAPTER 13 Blood 377

Match each blood disorder in Column A with its corresponding description or cause in Column B.

Column A
25. ________ pernicious anemia
26. ________ sickle cell anemia
27. ________ thalassemia
28. ________ hemophilia
29. ________ thrombocytopenia
30. ________ leukocytosis
31. ________ leukopenia
32. ________ aplastic anemia
Column B
a. a type o inherited anemia that produces abnormal hemoglobin and red blood cell
de ormities
b. an abnormally low white blood cell count
c. an inherited disorder in which a small amount o hemoglobin is produced; can be
major or minor
d. an inherited inability to orm some blood clotting actors
e. an abnormally low number o platelets
. a low number o red blood cells because o a lack o vitamin B12
g. a low number o red blood cells related to destruction o bone marrow
h. an abnormally high white blood cell count

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Angelas physician suspects that Angela has just su ered a
myocardial in arction, or heart attack. She tells Angela that
she is going to take a blood sample so that the hospital
lab can per orm a test to con rm her diagnosis. W hat
in ormation can Angelas blood yield to help the
physician?
2. Yvonne has just been told that she has a condition called
pernicious anemia. She looked up the de nition o this
disease in a dictionary and learned that it is caused by a
decreased availability o vitamin B12 needed or manu ac-
turing RBCs. Yvonne promptly went to the local phar-
macy to buy some vitamin B12 tablets to help her
overcome this condition. Is this a wise course o action?
3. Your brother has just been diagnosed as having anemia,
but your mother cannot seem to remember the speci c
type. She shows you a copy o your young brothers CBC
results, but no diagnosis is stated. Based on the results
given below, what would you guess is your brothers con-
dition? (H IN : see Table 13-3.) Are you likely to develop
this condition?
Folate content: normal
H ematocrit: low 13
H emoglobin content: low
Iron content: slightly high
RBC size (mean corpuscular volume): high
Vitamin B12 content: normal
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Heart
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Location o the Heart, 379

Functional Anatomy o the Heart, 380
Heart Chambers, 380
Pericardium, 381
Heart Action, 383
Heart Valves, 383
Heart Sounds, 384
Blood Flow Through the Heart, 384
Blood Supply to Heart Muscle, 385
Cardiac Cycle, 387
Electrical Activity o the Heart, 388
Conduction System, 388
Electrocardiography, 388
Cardiac Dysrhythmia, 389
Cardiac Output, 392
Def nition o Cardiac Output, 392
Heart Rate, 393
Stroke Volume, 393
Heart Failure, 394

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Discuss the location, size, and position o the heart in
the thoracic cavity.
2. Identi y and discuss the heart chambers, pericar-
dium, heart valves, and major valve disorders.
3. Discuss the normal heart sounds and identi y
common abnormal heart sounds.
4. Trace blood through the heart, compare the unctions
o the heart chambers on the right and le t sides, and
explain how a myocardial in arction might occur.
5. Explain the cardiac cycle.
6. List the anatomical components o the heart conduc-
tion system and discuss the eatures o the normal
electrocardiogram.
7. Describe the major types o cardiac dysrhythmia.
8. Explain how heart rate and stroke volume a ect
cardiac output.
9. List and describe the possible causes o heart ailure.
 R 14
Th e system that supplies our bodys transportation needs is the cardiovascular LANGUAGE OF
system. We need such a system to make sure that each cell is surrounded by f uid S C IEN C E
that is constantly replenished with oxygen, water, and nutrients as they are used
up by a cell. In addition, we need the waste products in extracellular f uid to be
Be o re re ading the
continually removed as they are released rom cells.
chapte r, s ay e ach o
the s e te rm s o ut lo ud. This w ill
A circulating stream o blood can pick up substances rom various parts o he lp yo u to avo id s tum bling ove r
the body and deliver them to othersthus allowing our body to move the m as yo u re ad.
substances around in a way that helps us maintain a relatively constant
internal environment. Clearly, circulation o the blood is critical to main-
aorta
taining the homeostatic balance o your body. (ay-OR-tah)
[aort- li ted, -a thing]
We begin the study o the cardiovascular system in this chapter with the aortic semilunar valve
heartthe pump that keeps blood moving through a closed circuit o blood (ay-OR-tik sem-ih-LOO-nar valv)
vessels. Details related to heart structure will be ollowed by a discussion o [aort- li ted, -ic relating to, semi- hal ,
how the heart unctions. Chapter 15 then continues our story with a study o -luna moon, -ar relating to]
the vessels through which blood f ows as a result o the pumping action o the apex
heart. (AY-peks)
pl., apices
(AY-pih-seez)
Lo c a t io n o t h e He a r t [apex tip]
No one needs to be told where the heart is or atrioventricular bundle (AV bundle)
what it does. Everyone knows that the (ay-tree-oh-ven-TRIK-yoo-lar
heart is in the chest, that it beats night BUN-del [ay vee BUN-del])
and day to keep the blood f owing, and [atrio- entrance courtyard,
-ventr- belly, -icul- little,
that i it stops, li e stops.
-ar relating to]
Most o us probably think o the
atrioventricular node (AV node)
heart as being located on the le t side
(ay-tree-oh-ven-TRIK-yoo-lar
o the body. As you can see in
nohd [ay vee nohd])
Figure 14-1, the heart is located be- [atrio- entrance courtyard,
tween the lungs in the lower por- -ventr- belly, -icul- little,
tion o the mediastinum. Draw an -ar relating to, nod- knot]
imaginary line through the middle atrioventricular valve (AV valve)
o the trachea in Figure 14-1 and (ay-tree-oh-ven-TRIK-yoo-lar
continue the line down through valv [ay vee valv])
the thoracic cavity to divide it [atrio- entrance courtyard,
into right and le t halves. Note -ventr- belly, -icul- little,
that about two-thirds o the mass -ar relating to]
o the heart is to the le t o this atrium
line and one-third is to the right. (AY-tree-um)
T e heart is o ten described pl., atria
as a triangular organ, shaped (AY-tree-ah)
[atrium entrance courtyard]
and sized roughly like a closed
st. In Figure 14-1 you can see that auricle
(AW-rih-kul)
[auri- ear, -icle little]

Continued on p. 395

379
 380 CHAPTER 14 Heart

Le ft common ca rotid a rte ry

Le ft s ubclavia n a rte ry
Bra chioce pha lic trunk
Arch of a orta
S upe rior ve na cava Le ft pulmona ry a rte ry

P ulmona ry trunk
Right pulmona ry a rte ry
Auricle of le ft a trium
As ce nding a orta
Le ft pulmona ry ve ins
Right pulmona ry (bra nche d)
ve ins (bra nche d)
Gre a t ca rdia c ve in
Auricle of right a trium
Circumflex a rte ry
Right corona ry a rte ry
a nd ca rdia c ve in
Bra nche s of le ft
corona ry a rte ry
S a nd ca rdia c ve in
R L

I Le ft ve ntricle

Right ve ntricle
Apex
Infe rior ve na cava

De s ce nding a orta

Tra che a

Arch of a orta

Lung

Dia phra gm
14 S

R L
FIGURE 14-1 External view o heart. Anterior view
I
(with location in thorax).

the apex, or blunt point, o the lower edge o the heart lies on
the diaphragm, pointing toward the le t.
Physicians and nurses o ten listen to the heart sounds by
placing a stethoscope on the chest wall directly over the apex
o the heart. Sounds o the so-called apical heart beat are
easily heard in this area (that is, in the space between the th
and sixth ribs on a line even with the midpoint o the le t
clavicle).
T e heart is positioned in the thoracic cavity between the
sternum in ront and the bodies o the thoracic vertebrae
behind. Because o this placement, it can be compressed or
squeezed by application o pressure to the lower portion o
the body o the sternum using the heel o the hand. Rhyth-
mic compression o the heart in this way can maintain
blood f ow in cases o cardiac arrest and, i combined
with e ective arti cial respiration, the resulting procedure,
called cardiopulmonary resuscitation (CPR), can be
li esaving.
T e exact procedures or CPR change requently as new
research data become available, so it is important or individu-
als certi ed in CPR to recerti y on a regular basis.
Locate the heart and surrounding structures in the Clear
View o the Human Body ( ollows p. 8).
Fu n c t io n a l A n a t o m y o t h e He a r t
He a r t C h a m b e r s
I you cut open a heart, you can see many o its main structural
eatures (Figure 14-2). T is organ is hollow, not solid. A partition
divides it into right and le t sides. T e heart contains our cavi-
ties, or hollow chambers. T e two upper chambers are called
 CHAPTER 14 Heart 381

Pa rie ta l pe rica rdium FIGURE 14-2 Internal view o heart. Anterior view
Pe rica rdia l s pa ce
Fa tty conne ctive o rontal section. The inset shows a cross section o the
tis s ue Vis ce ra l pe rica rdium (e pica rdium) heart wall, including the pericardium.
Myoca rdium
Corona ry
ve s s e ls
Endoca rdium

OUTS IDE INS IDE

OF OF
HEART HEART Aorta

S upe rior P ulmona ry

ve na cava trunk
P ulmona ry
Right pulmona ry a rte rie s
ve ins
Le ft pulmona ry
P ulmona ry ve ins
s e miluna r va lve

Right a trium
Le ft a trium
Right a triove ntricula r
(tricus pid) va lve Aortic s e miluna r
va lve

Le ft a triove ntricula r
(bicus pid) va lve

atria (singular, atrium), and the two lower Chorda e

chambers are called ventricles.
T e atria are smaller than the ventri- Right ve ntricle
cles, and their walls are thinner and less
muscular. Both atria orm an earlike out-
Inte rve ntricula r
pouching, called an auricle, as you can s e ptum
see in Figure 14-1.
Atria are o ten called receiving chambers
because blood enters the heart through veins that open into
these upper cavities. Eventually, blood is pumped rom the
heart into arteries that exit rom the ventricles. T e ventricles
are there ore sometimes re erred to as the discharging chambers
o the heart.
Each heart chamber is named according to its location.
T us there are right and le t atrial chambers above and right
and le t ventricular chambers below.
T e wall o each heart chamber is composed o cardiac
muscle tissue usually re erred to as the myocardium. T e
septum between the atrial chambers is called the interatrial
septum. T e interventricular septum separates the ventricles.
Each chamber o the heart is lined by a thin layer o very
smooth tissue called the endocardium (see Figure 14-2). In-
f ammation o this lining is re erred to as endocarditis. I
inf amed, the endocardial lining can become rough and abra-
sive to RBCs passing over its sur ace. Blood f owing over a
rough sur ace is subject to clotting, and a thrombus, or clot,
may orm (see Chapter 13).
Un ortunately, rough spots caused by endocarditis or inju-
ries to blood vessel walls o ten cause the release o platelet
actors. T e result is o ten the ormation o a atal blood clot.
To learn more about the interior anatomy o
the heart, go to AnimationDirect online at
evolve.elsevier.com.
te ndine a e
Le ft ve ntricle
Pa pilla ry mus cle
S
R L
I
P e r ic a r d iu m
C o ve r in g s o t h e He a r t
T e heart s coveringthe pericardiumconsists o two 14
layers o brous tissue with a small space in between them.
T e inner layer o the pericardium is called the visceral
pericardium, or epicardium. It covers the heart the way an
apple skin covers an apple. T e outer layer o pericardium is
called the parietal pericardium. It ts around the heart like
a loose- tting sack, allowing enough room or the heart to
beat.
It is easy to remember the di erence between the endocar-
dium, which lines the heart chambers, and the epicardium,
which covers the sur ace o the heart (see Figure 14-2), i you
understand the meaning o the pre xes endo- and epi-. Endo-
comes rom the Greek word meaning inside or within, and
epi- comes rom the Greek word meaning upon or on.
T e two pericardial layers slide over each other without
riction when the heart beats because these are serous mem-
branes with moist, slippery, sur aces. A thin lm o pericardial
f uid provides the lubricating moistness between the heart and
its enveloping pericardial sac.
P e r ic a r d it is
I the pericardium becomes inf amed, a condition called
pericarditis results. Pericarditis may be caused by a variety o
 382 CHAPTER 14 Heart

actors: trauma, viral or bacterial in ection, tumors, and other
actors.
T e pericardial edema that characterizes pericarditis o ten
causes the visceral and parietal pericardia to rub together
causing severe chest pain. Pericardial f uid, pus, or blood (in the
case o an injury) may accumulate in the space between the two
pericardial layers and impair the pumping action o the heart.
Called pericardial ef usion, this condition may develop into a
serious compression o the heart called cardiac tamponade.
QUICK CHECK
1. Wh a t a re th e u n ctio n s o th e a tria a n d ve n tricle s o th e
h e a rt?
2. Wh a t co ve rin g s d o e s th e h e a rt h a ve ? Wh a t is th e h e a rts
lin in g ca lle d ?
3. Wh e n th e h e a rt b e a ts , h o w d o th e tw o p e rica rd ia l la ye rs
s lid e a ga in s t e a ch o th e r w ith o u t rictio n ?

ATRIAL CONTRACTION VENTRICULAR CONTRACTION

S e miluna r S e miluna r
va lve s clos e d va lve s ope n
Atriove ntricula r Atriove ntricula r
va lve ope n va lve clos e d
Aorta
S

R L

I S upe rior
Le ft
ve na cava Le ft atrium
atrium

Rig ht Rig ht
atrium atrium
Rig ht Le ft
ve ntricle ve ntricle
Le ft
ve ntricle
Atriove ntricula r
va lve ope n Rig ht
ve ntricle Atriove ntricula r
Infe rior va lve clos e d
ve na cava

14
Right AV Le ft AV Right AV Le ft AV
(tricus pid) (mitra l) va lve ope n (tricus pid) (mitra l) va lve clos e d
va lve ope n va lve clos e d

R L

Aortic (S L) va lve
(clos e d) (ope n)

(clos e d) P ulmona ry (S L) va lve (ope n)

A B

FIGURE 14-3 Heart action. A, During atrial systole (contraction), cardiac muscle in the atrial wall con-
tracts, orcing blood through the atrioventricular (AV) valves and into the ventricles. Bottom illustration shows
superior view o all our valves, with semilunar (SL) valves closed and AV valves open. B, During ventricular
systole that ollows, the AVvalves close, and blood is orced out o the ventricles through the semilunar valves
and into the arteries. Bottom illustration shows superior view o SLvalves open and AVvalves closed.

He a r t Ac t io n
T e heart serves as a muscular
pumping device or distributing
blood to all parts o the body.
Contraction o the heart is
called systole, and relaxation is
called diastole.
W hen the heart beats (that
is, when it contracts), the atria
contract rst (atrial systole),
orcing blood that has not yet
leaked into the ventricles toward
the ventricles. Once lled, the
two ventricles contract (ventric-
ular systole) and orce blood out o the heart (Figure 14-3).
For the heart to be e cient in its pumping action, more
than just the rhythmical contraction o its muscular bers is
required. T e direction o blood f ow must be directed and
controlled. T is is accomplished by our sets o valves located
at the entrance and near the exit o the ventricles.
He a r t Va lve s
Va lve S t r u c t u r e a n d Fu n c t io n
T e two valves that separate the atrial chambers above rom
the ventricles below are called AV valves, or atrioventricular
valves. T e le t AV valve is also known as the bicuspid valve,
or mitral valve. It is located between the le t atrium and ven-
tricle. T e right AV valve is also known as the tricuspid valve.
It is located between the right atrium and ventricle.
T e AV valves prevent backf ow o blood into the atria
when the ventricles contract. Locate the AV valves in
Figures 14-2 and 14-3. Note that a number o stringlike struc-
tures called chordae tendineae attach edges o the leaf ets or
f aps o the AV valves to ngerlike projections o cardiac
muscle in the wall o the ventricles.
T e SL valves, or semilunar valves, are located between
each ventricular chamber and its large artery that carries
blood away rom the heart when contraction occurs (see
Figure 14-3). T e ventricles, like the atria, contract together.
T ere ore, the two semilunar valves open and close at the
same time.
T e pulmonary semilunar valve is located at the begin-
ning o the pulmonary artery and allows blood going to the
lungs to f ow out o the right ventricle during systole but
prevents it rom f owing back into the ventricle during dias-
tole. T e aortic semilunar valve is located at the beginning o
the aorta and allows blood to f ow out o the le t ventricle up
into the aorta but prevents backf ow into this ventricle.
Va lve D is o r d e r s
Disorders o the cardiac valves can have several e ects. For ex-
ample, a congenital de ect in valve structure can result in mild
to severe pumping ine ciency. Incompetent valves leak, al-
lowing some blood to f ow back into the chamber rom which
it came. Stenosed valves are valves that are narrower than
normal, slowing blood f ow rom a heart chamber (Figure 14-4).
CHAPTER 14 Heart 383
FIGURE 14-4 Mitral valve steno-
sis. Stenosed valves are valves that
are narrower than normal when open,
slowing blood f ow rom a heart
chamber. Compare this valve (arrow)
with the normal open valve shown in
Figure 14-3, A.
Rheumatic heart disease is cardiac damage resulting rom
a delayed inf ammatory response to streptococcal in ection
that occurs most o ten in children. A ew weeks a ter an
untreated or improperly treated streptococcal in ection, the
cardiac valves and other tissues in the body may become
inf ameda condition called rheumatic ever. I severe, the
inf ammation can result in stenosis or other de ormities o the
valves, chordae tendineae, or myocardium.
Mitral valve prolapse (MVP), a condition a ecting the
le t AV valve (mitral valve) has a genetic basis in some cases
but can result rom rheumatic ever or other actors. A pro-
lapsed mitral valve is one whose f aps extend back into the
le t atrium, causing incompetence (leaking) o the valve
(Figure 14-5). T is condition was once thought to be common,
but recent studies show that many patients previously diag-
nosed with MVP have normal heart unction.
Damaged or de ective cardiac valves o ten can be replaced
surgically. Animal valves and arti cial valves made rom
synthetic materials are commonly used in valve replacement
procedures.
14
S
R L
I
Le ft Le ft
a trium a trium
Le ft Le ft
ve ntricle ve ntricle
Norma l mitra l va lve P rola ps e d mitra l va lve
FIGURE 14-5 Mitral valve prolapse (MVP). The normal mitral valve
(upper le t) prevents backf ow o blood rom the le t ventricle into the le t
atrium during ventricular systole (contraction). The prolapsed mitral valve
(right) permits leakage because the valve f aps billow backward, parting
slightly.
 384 CHAPTER 14 Heart
C LIN ICA L APPLICATION
ECHOCARDIOGRAPHY
Although the s te thos cope is s till the bas ic tool o the
cardio lo g is t, or he art s pe cialis t, m ore s ophis ticate d m e th-
ods or de te cting abnorm alitie s in he art valve unction are
available . One w ide ly us e d te chnique is e cho cardio g raphy.
Ultras ound (extre m e ly high-pitche d s ound) dire cte d toward
the he art is re e cte d back (e choe d) by the tis s ue s (s e e the
box Me dical Im aging o the Body on p. 132 and the Cardiol-
ogy box on p. 392).
Like an airports radar, a de te ctor picks up the e choe d
ultras ound and produce s an im age s how ing di e re nt re -
gions o blood and he art tis s ue s . As the valve s and othe r
s tructure s m ove during a s e rie s o he artbe ats , the im age
change s . A cardiologis t can exam ine a continuous vide o/
audio re cording calle d an e cho cardio g ram (picture d) and
de te rm ine the nature o a valve proble m or othe r he art
dis orde r.
To see a diagram that explains the concept
o echocardiography, and additional
echocardiogram examples, check out the
article Echocardiography at Connect It! at
evolve.elsevier.com.
14
Echocardiogram. This image shows a mitral valve prolapse (MVP)
where the leaf ets (f aps) o the mitral valve (white) bulge noticeably.
Compare this image to Figure 14-5 on p. 383. RV, Right ventricle;
AO, aorta; LA, le t atrium; LV, le t ventricle.
He a r t S o u n d s
I a stethoscope is placed on the anterior chest wall, two dis-
tinct sounds can be heard. T ey are rhythmical and repetitive
sounds that are o ten described as lub dup. Disorders o the
cardiac valves are o ten diagnosed by detecting changes in
these normal valve sounds o the heart.
T e rst, or lub, sound is caused by the vibration and
abrupt closure o the AV valves as the ventricles contract.
Closure o the AV valves prevents blood rom rushing back up
into the atria during contraction o the ventricles. T is rst
sound is o longer duration and lower pitch than the second.
T e pause between this rst sound and the dup, or second
sound, is shorter than that a ter the second sound and the lub
dup o the next systole.
T e second heart sound is caused by the closing o both the
semilunar valves when the ventricles undergo diastole (relax)
(see Figure 14-3).
Abnormal heart sounds called heart murmurs are o ten
caused by disorders o the valves. For example, incompetent
valves may cause a swishing sound as a lub or dup ends.
Stenosed valves, on the other hand, o ten cause swishing
sounds just be ore a lub or dup.
Later in the chapter, when you get to Figure 14-10 (p. 388),
you will get the chance to compare the timing o the heart
sounds to other events o the cardiac pumping cycle. T is will
urther clari y the clinical importance o heart sounds as indi-
cators o heart unction.
Blo o d Flo w Th ro u g h t h e He a r t
W hen the heart beats, rst the atria contract simultaneously.
T is is atrial systole. A ter the ventricles ll with blood, they
contract together during ventricular systole. Although the atria
contract as a unit ollowed by the ventricles below, the right
and le t sides o the heart act as separate pumps. As we study
the blood f ow through the heart, the separate unctions o the
two pumps will become clearer.
Note in Figure 14-6 that blood enters the right atrium
through two large veins called the superior vena cava and
in erior vena cava. T e right heart pump receives oxygen-
poor blood rom the veins. A ter entering the right atrium, it
f ows through the right AV, or tricuspid, valve and enters the
right ventricle. W hen the ventricles contract, blood in the
right ventricle is pumped through the pulmonary semilunar
valve into the pulmonary artery and eventually to the lungs,
where oxygen is added and carbon dioxide is lost.
As you can see in Figure 14-6, oxygen-rich blood returns to
the le t atrium o the heart through our pulmonary veins. It
then passes through the le t AV, or bicuspid, valve into the le t
ventricle. W hen the le t ventricle contracts, blood is orced
through the aortic semilunar valve into the aorta and is dis-
tributed to the body as a whole.
As you can tell rom Figure 14-6, the two sides o the heart
actually pump blood through two separate circulations and
unction as two separate pumps:
Pulmonary circulationf ow o blood rom the
right ventricle to the lungs and back to the le t
atrium (shaded with blue in Figure 14-6)
Systemic circulationf ow o blood rom the le t
ventricle throughout the body and back to the right
atrium (shaded with yellow in Figure 14-6)
T e vessels o the pulmonary and systemic circulations are
discussed in Chapter 15.
O ne o the classic challenges o ten given to beginning
students is to trace the path that a blood cell would take as it
f ows rom the right atrium, all the way through both major
circulatory routes, and back to the right atrium. Learning that

FIGURE 14-6 Blood ow through
the cardiovascular system. In the S ys te mic
pulmonary circulatory route (blue), ca pilla rie s
blood is pumped rom the right side o
the heart to the gas-exchange tissues S upe rior
o the lungs. In the systemic circula- ve na cava
tion (yellow), blood is pumped rom
the le t side o the heart to all other
tissues o the body. P ulmona ry
a rte ry
Lung
CO 2
P ulmona ry
ca pilla rie s
O2
Pulmo nary
c irc ulatio n
S CO 2
P ulmona ry
R L s e miluna r
va lve
I lowe r body
Infe rior
ve na cava
S ys te mic c irc ulatio n
pathway will help in many o your uture learning and clinical
experiences.
To better understand this concept, use the Active
Concept Map Blood Flow Through the Heart at
evolve.elsevier.com.
Need help tracing the ow o blood through the
major circulatory routes? Check out the article
How to Trace the Flow o Blood at Connect It! at
evolve.elsevier.com.
Blo o d S u p p ly t o He a r t M u s c le
o sustain li e, the heart must pump blood throughout the
body on a regular and ongoing basis. As a result, the heart
muscle or myocardium requires a constant supply o blood
containing nutrients and oxygen to unction e ectively. T e
delivery o oxygen and nutrient-rich arterial blood to cardiac
muscle tissue and the return o oxygen-poor blood rom this
active tissue to the venous system is called the coronary
circulation (Figure 14-7, A).
Blood f ows into the heart muscle by way o two small
vesselsthe right and le t coronary arteries. T e coronary
CHAPTER 14 Heart 385
Circula tion
to tis s ue s
of he a d a nd
uppe r body
CO 2 O2
Aorta
Lung
CO 2
P ulmona ry
ve in
O2
O2
Circula tion
to tis s ue s of
arteries are the aortas rst branches, as you can see in
Figure 14-7, A.
Figure 14-7, B, shows that the openings into these small ves-
sels lie behind the f aps o the aortic semilunar valves. D uring 14
ventricular systole, the myocardium is contracting and putting
pressure on the coronary arteries, so little blood can enter
them. H owever, during ventricular diastole, blood that backs
up behind the aortic SL valve can f ow easily into the coro-
nary arteries.
In both coronary thrombosis and coronary embolism, a
blood clot occludes or plugs up some part o a coronary artery.
Blood cannot pass through the occluded vessel and so cannot
reach the heart muscle cells it normally supplies. Deprived o
oxygen, these cells soon become damaged. In medical terms,
myocardial in arction (MI), or tissue death, occurs.
An M I, also re erred to as a heart attack, is a common
cause o death during middle and late adulthood. Recovery
rom a myocardial in arction is possible i the amount o
heart tissue damaged was small enough so that the remain-
ing undamaged heart muscle can still pump blood e ectively
enough to supply the needs o the rest o the heart and the
body.
Coronary arteries also may become blocked as a result o
atherosclerosis, a type o hardening o the arteries in which
lipids and other substances build up on the inside wall o
 386 CHAPTER 14 Heart

C LIN ICA L APPLICATION

ANGIOGRAPHY
A s pe cial type o radiography calle d ang io g raphy is o te n us e d
to vis ualize arte rie s . A radiopaque dye a s ubs tance that can-
not be pe ne trate d by x-rays is inje cte d into an arte ry to be tte r
vis ualize ve s s e ls that would othe rw is e be invis ible in a radio-
graph. This dye is o te n calle d contras t m e dium .
Som e tim e s the dye is re le as e d through a long, thin tube
calle d a cathe te ra proce dure calle d cathe te rizatio n. The S
cathe te r can be pus he d through arte rie s until its tip is in jus t R L
the right location to re le as e the dye . As the dye be gins to cir-
culate , an ang io g ram (radiograph) w ill s how the outline o the I
arte rie s as cle arly as i they we re m ade o bone or othe r de ns e Coronary arteriogram. This angiogram o the coronary arteries shows
m ate rial (s e e f gure ). a narrowing (arrow) o the channel in the anterior ventricular (le t ante-
An angiogram o an arte ry is o te n calle d an arte riogram . An rior descending or LAD) artery o the heart. Narrowing o this artery is
angiogram o ve ins can be calle d a ve nogram or phle bogram . sometimes called the widow maker because when it becomes in-
f amed and blocked by a blood clot, a massive heart attack and sudden
death may resulto ten occurring in men in their 50s and 60s.

blood vessels. Mechanisms o atherosclerosis are discussed
urther in Chapter 15.
Coronary atherosclerosis has increased dramatically over the
last ew decades to become a leading cause o death in western
countries. Many pathophysiologists believe this increase results
rom a change in li estyle. T ey cite several important risk ac-
tors associated with coronary atherosclerosis: physical inactivity,
cigarette smoking, high- at and high-cholesterol diets, obesity,
hypertension (high blood pressure), and diabetes.
T e term angina pectoris is used to describe the severe
chest pain that occurs when the myocardium is deprived o
adequate oxygen. It is o ten a warning that the coronary arter-
ies are no longer able to supply enough blood and oxygen to
the heart muscle.
Coronary bypass surgery is a common treatment or those
who su er rom severely restricted coronary artery blood f ow.
In this procedure, veins or other vessels are harvested or re-
moved rom other areas o the body and used to bypass partial
blockages in coronary arteries (Figure 14-8).
A therapy called coronary angioplasty, a less invasive pro-
cedure, is o ten attempted rst to treat blockages to coronary
blood f ow. Angioplasty, in which a device is inserted into a
blocked artery to orce open a channel or blood f ow, is de-
scribed in greater detail in Chapter 15, pp. 406-407.

14 S upe rior
ve na cava
Aorta VENTRICULAR CONTRACTION VENTRICULAR RELAXATION
P ulmona ry (a ortic va lve ope n) (a ortic va lve clos e d)
Aortic
s e miluna r trunk Blood flow Ba ckflow of blood clos e s va lve
va lve Le ft corona ry a nd fills corona ry a rte rie s
a rte ry (LCA) Aortic va lve Aortic va lve
Right
a trium Le ft a trium
Circum ex
Right
a rte ry
corona ry
a rte ry Le ft ma rgina l
(RCA) a rte ry
Ante rior
Pos te rior inte rve ntricula r
inte rve ntricula r a rte ry
a rte ry
Le ft ve ntricle
Right ma rgina l S Right corona ry Le ft corona ry To myoca rdium
a rte ry a rte ry a rte ry
R L
Right ve ntricle
A I B
FIGURE 14-7 Coronary arteries. A, Diagram showing the major coronary arteries (anterior view). Clini-
cians o ten re er to the interventricular arteries as descending arteries. Thus a cardiologist would re er to the
le t anterior descending (LAD) artery and an anatomist would re er to the same vessel as the anterior interven-
tricular branch or artery. B, The unusual placement o the coronary artery opening behind the leaf ets o the
aortic valve allows the coronary arteries to ll during ventricular relaxation.
 CHAPTER 14 Heart 387

Le ft
s ubclavia n
a rte ry
Aorta
Aorta
Le ft inte rna l
ma mma ry Ve in gra fts
a rte ry (gra ft) from the le g Le ft
corona ry
a rte ry
Right
Le ft
corona ry
corona ry
a rte ry
a rte ry

Obs truction
Obs truction

R L

I
S ing le bypas s Triple bypas s

FIGURE 14-8 Coronary bypass. In coronary bypass surgery, blood vessels are harvested rom other parts
o the body and used to construct detours around blocked coronary arteries. Arti cial vessels also can be used.

A ter blood has passed through the capillary beds in the

myocardium, it f ows into cardiac veins, which empty into
C a r d ia c Cyc le
the coronary sinus and nally into the right atrium. Figure 14-9 T e beating o the heart is a regular and rhythmical process
shows how venous blood rom the coronary circulation enters what an engineer would call a pumping cycle. Each complete
the right atrium through this secret passage rather than heartbeat is called a cardiac cycle and includes the contrac-
through the usual pathway through the superior or in erior tion (systole) and relaxation (diastole) o atria and ventricles.
vena cava. Each cycle takes about 0.8 second to complete i the heart
is beating at an average resting rate o about 72 beats per
minute.
Figure 14-10 summarizes some o the important events o
Aorta the cardiac pumping cycle. Although it looks overly compli- 14
cated at rst, a ew minutes exploring this set o graphs can
S upe rior help make sense o all the processes you are learning about the
ve na cava
rhythm o the hearts pumping cycle. For example, note that
P ulmona ry trunk
most o the atrial blood moves into the ventricles be ore the
Le ft a trium atria have a chance to contract.
Another oddity is that there is a brie period at the be-
Gre a t ca rdia c ve in
Right
ginning o ventricular contraction where there is no change
a trium Corona ry s inus
in volume. T is occurs because it takes a moment or the
ventricular pressure to overcome the orce needed to open
Middle ca rdia c
ve in
the semilunar valves. You also can see there is another pe-
riod o constant volume as the ventricles begin to relax
Ante rior
S ma ll ca rdia c inte rve ntricula r be ore the mitral valves open and blood gushes rapidly in
ve in bra nch rom the atria.
Le ft ve ntricle
Right ve ntricle
S QUICK CHECK
R L 1. Wh a t a re s ys to le a n d d ia s to le o th e h e a rt?
2. Wh a t a re th e tw o m a jo r circu la tio n s o th e b o d y?
I 3. Wh a t ca u s e s e a ch o th e tw o m a jo r h e a rt s o u n d s ?
4. Why is th e re a b rie p e rio d a t th e b e g in n in g o ve n tricu la r
FIGURE 14-9 Coronary veins. Diagram showing the major veins o the co n tra ctio n w h e re th e re is n o ch a n g e in vo lu m e ?
coronary circulation (anterior view). Vessels near the anterior sur ace are more 5. Wh a t is a n g in a p e cto ris ?
darkly colored than vessels o the posterior sur ace seen through the heart.
 388 CHAPTER 14 Heart

Atria l s ys tole Ve ntricula r s ys tole Dia s tole Although the rate o the cardiac muscles rhythm can be
sped up or slowed down by autonomic nerve signals, the heart
m
has its own built-in conduction system or generating action
u
S D
i
r
potentials spontaneously and coordinating contractions dur-
t
A
ing the cardiac cycle (Figure 14-11).
e
l
T e most important thing to realize about this conduction
c
i
D S D
r
t
n
system is that all o the cardiac muscle bers in each region o
e
V
the heart are electrically linked together. T e intercalated disks
e
e
that were rst introduced in Chapter 4 (see Figure 4-17, p. 83)
e
g
g
n
r
l
n
n
o
a
c
i
l
a
a
are actually connections that electrically join muscle bers
t
y
u
n
c
c
h
h
c
c
o
e
a
e
c
c
i
i
l
j
r
i
t
into a single unit that can conduct an impulse through the
g
o
t
e
d
c
e
e
r
n
n
t
r
a
m
m
e
ys
d
d
i
e
l
j
a
p
entire wall o a heart chamber without stopping. T us both
u
v
e
e
e
u
u
C
s
m
c
l
l
c
c
d
d
o
o
i
l
u
u
g
g
r
i
i
v
v
u
atrial walls will contract at about the same time because all
a
t
p
d
p
d
n
n
i
n
p
r
i
i
o
o
a
e
a
e
l
l
t
e
l
l
N
N
A
R
R
R
R
i
i
v
their bers are electrically linked. Likewise, both ventricular
f
f
5 walls will contract at about the same time.
Four structures embedded in the wall o the heart special-
w
4
o
ize in generating strong action potentials and conducting
l
f
d
3
)
them rapidly to certain regions o the heart wall. T us they
n
o
i
o
m
Aortic
l
2 make sure that the atria contract and then the ventricles con-
b
/
Aortic va lve
L
va lve
c
(
clos e s tract in an e cient manner. T e main structures that make up
i
1 ope ns
t
r
o
this conduction system o the heart are as ollows:
A
0
1. Sinoatrial node, also called the SA node or the
125 pacemaker
Mitra l
e
2. Atrioventricular node, or AV node
m
va lve
u
3. AV bundle, or bundle o His
l
clos e s
o
100
v
4. Subendocardial branches, also called Purkinje bers
)
L
r
a
m
l
u
(
Impulse conduction normally starts as a spontaneous ac-
c
75
i
r
t
tion potential in the hearts pacemaker, namely, the SA node.
n
e
V
Mitra l va lve From there, it spreads, as you can see in Figure 14-11, in all di-
50 ope ns rections through the atria. Although each myocardial ber
1 2 can generate its own action potentials, because they are elec-
s
t
d
r
n
trically linked together, they normally match the activity o
a
u
e
H
o
the bers that make up the conduction system. W hen the
s
R myocardial bers do not ollow the impulses o the conduc-
m
14
a
tion system, however, a cardiac rhythm disorder may result.
r
T
g
P P
o
W hen impulses reach the AV node, it is triggered to relay
i
d
r
its own impulses by way o the AV bundle and subendocardial
a
Q
c
S Ve ntricula r
o
branches to the ventricular myocardium, causing the ventri-
r
t
s ys tole
c
cles to contract. Normally, there ore, a ventricular beat ollows
e
l
E
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 each atrial beat.
Time (s e c )
To learn more about the electrical conduction o
FIGURE 14-10 Composite chart o heart unction. This chart is a
composite o several diagrams o heart unction during rest (72 beats/min).
the heart, go to AnimationDirect online at evolve.
Along the top, S represents systole and D represents diastole o each heart elsevier.com.
chamber. Below that, details o the cardiac pumping cycle, aortic blood f ow,
ventricular volume, valve actions, heart sounds, and ECG are all adjusted to
the same time scale. Although it appears daunting at rst glance, this stack Ele c t ro c a r d io g r a p h y
o graphs will be a valuable re erence tool as you proceed through the rest
o this chapter and try to put it all together.
T e hearts conduction system generates tiny electrical cur-
rents that spread through surrounding tissues and eventually
to the sur ace o the body. T is act is o great clinical signi -
Ele c t r ic a l Ac t iv it y o t h e He a r t cance because these electrical signals can be picked up rom
the body sur ace and trans ormed into visible tracings by an
C o n d u c t io n S y s t e m instrument called an electrocardiograph.
Cardiac muscle bers can contract rhythmically on their own. T e electrocardiogram is the graphic record o the hearts
H owever, they must be coordinated by electrical signals (im- electrical activity obtained using an electrocardiograph ap-
pulses) i the heart is to pump e ectively. paratus. T is graphic chart is also called an ECGor EKG
 CHAPTER 14 Heart 389

Atriove ntric ular Inte ratrial bundle

(AV) no de S ino atrial (S A) no de and fibe rs
(pa ce ma ke r)

Inte rno dal

bundle
Right a trium and fibe rs Le ft a trium
(RA) (LA)

Inte ratrial bundle

Atriove ntric ular
(AV) no de
S ino atrial S ube ndo c ardial be rs
(S A) no de (P urkinje fibe rs ) Atriove ntric ular (AV) bundle
(pa ce ma ke r) LA
Inte rno dal Rig ht and le ft S ube ndo c ardial S ube ndo c ardial
bundle s RA branc he s o f AV bundle branc he s branc he s
Rig ht and le ft
(bundle o f His )
AV bundle
LV (P urkinje fibe rs ) branc he s (P urkinje fibe rs )
S e ptum
AV bundle RV La te ra l ve ntricula r
(of His )
wa ll S e ptum S e ptum
S La te ra l La te ra l
wa ll wa ll
R L
Rig ht ve ntricle (RV) Le ft ve ntricle (LV)
I

A B
FIGURE 14-11 Conduction system o the heart. Specialized cardiac muscle cells (red) in the wall o the
heart rapidly conduct an electrical impulse throughout the myocardium. The signal is initiated by the sinoatrial
(SA) node (pacemaker) and spreads to the rest o the atrial myocardium and to the atrioventricular (AV) node.
The AV node then initiates a signal that is conducted through the ventricular myocardium by way o the AV
bundle (o His) and Purkinje bers. Labels or parts o the hearts conduction system are highlighted in bold ont.

when spoken aloud. Skilled interpretation o these ECG

records may sometimes make the di erence between li e and
death. A normal ECG tracing is shown in Figure 14-12.
A normal ECG tracing has three very characteristic def ec-
tions, or waves, called the P wave, the QRS complex, and the
wave. T ese def ections represent the electrical activity that
regulates the contraction or relaxation o the atria or ventricles.
T e term depolarization describes the electrical activity that
triggers contraction o the heart muscle. Repolarization begins
just be ore the relaxation phase o cardiac muscle activity.
In the normal ECG shown in Figure 14-12, the small P wave
occurs with depolarization o the atria. T e QRS complex oc-
curs as a result o depolarization o the ventricles, and the
wave results rom electrical activity generated by repolariza-
tion o the ventricles. You may wonder why no visible record
o atrial repolarization is noted in a normal ECG. T e reason
is simply that the def ection is very small and is hidden by the
large QRS complex that occurs at the same time.
Now is a good time to go back and review Figure 14-10 and
explore the relationship between the ECG and other events o
the cardiac cycle. By looking at changes in blood f ow and vol-
ume, or example, you will discover that ECG def ections occur
be ore myocardial contractionsnot during these contractions.
T is occurs because depolarizations trigger contractions and a
trigger always comes be ore the event that is triggered.
Damage to cardiac muscle tissue that is caused by a myo-
cardial in arction or disease a ecting the hearts conduction
system results in distinctive changes in the ECG. T ere ore
ECG tracings are extremely valuable in the diagnosis and
treatment o heart disease.
Check out the illustrated article Electrocardiogra-
phy at Connect It! at evolve.elsevier.com.
To learn more about the electrocardiogram, go to
AnimationDirect online at evolve.elsevier.com.
QUICK CHECK
1. Lis t th e s tru ctu re s th a t m a ke u p th e co n d u ctio n s ys te m o 14
th e h e a rt.
2. Wh e re d o e s th e im p u ls e co n d u ctio n in th e h e a rt b e g in ?
3. Wh a t in o rm a tio n is in a n e le ctro ca rd io g ra m ?
4. Na m e th e th re e ch a ra cte ris tic d e e ctio n s o r wa ve s o
a n ECG.
C a r d ia c D y s r h y t h m ia
Various conditions such as endocarditis or myocardial in arc-
tion can damage the hearts conduction system and thereby
disturb the rhythmic beating o the heart. T e term dysrhythmia
re ers to an abnormality o heart rhythm. T e term arrhythmia
is still sometimes used to re er to rhythm abnormalities.
He a r t Blo c k
O ne kind o dysrhythmia is called a heart block. In AV node
block, impulses are blocked rom getting through to the ven-
tricular myocardium, resulting in the ventricles contracting at
a much slower rate than normal. O n an ECG , there may be
a large distance between the P wave and the R peak o the
QRS complex. Complete heart block occurs when the P waves
do not match up with the QRS complexes at allas in an
 390 CHAPTER 14 Heart
1 2
The he a rt wa ll is
comple te ly re la xe d,
with no cha nge in
e le ctrica l a ctivity,
s o the ECG
re ma ins cons ta nt.
De pola riza tion
Re pola riza tion
S P
R L
FIGURE 14-12 Events represented by the electrocardiogram (ECG). It is nearly impossible to illustrate
the invisible, dynamic events o heart conduction in a ew cartoon panels or snapshots, but the sketches here
give you an idea o what is happening in the heart as an ECG is recorded.
ECG that shows two or more P waves or every QRS com-
plex (Figure 14-13, A).
A physician may treat heart block by implanting in the
heart an arti cial pacemaker, a battery-operated device im-
planted under the skin and connected by thin wires to the
myocardium (Figure 14-14). T is device stimulates the myocar-
dium with timed electrical impulses that cause ventricular
contractions at a rate ast enough to maintain an adequate
circulation o blood.
To learn more about artif cial pacemaker insertion,
go to AnimationDirect online at evolve.elsevier.com.
Br a d yc a r d ia
14 Bradycardia is a slow heart rhythmless than 60 beats per
minute (Figure 14-13, B). Slight bradycardia is normal during
sleep and in conditioned athletes while they are awake (but at
rest). Abnormal bradycardia can result rom improper auto-
nomic nervous control o the heart or rom a damaged SA node.
I the problem is severe, arti cial pacemakers can be used
to increase the heart rate by taking the place o the SA node.
For example, demand pacemakers take over SA node unction
only when the heart rate alls below a level programmed into
the pacemaker by the physician.
Ta c h yc a r d ia
achycardia is a rapid heart rhythmmore than 100 beats
per minute (Figure 14-13, C).
achycardia is normal during and a ter exercise and during
the stress response. Abnormal tachycardia can result rom
improper autonomic control o the heart, blood loss or shock,
the action o drugs and toxins, ever, and other actors.
S in u s D y s r h y t h m ia
Sinus dysrhythmia is a variation in heart rate during the
breathing cycle (Figure 14-13, D). ypically, the rate increases
3
P wave occurs Atria l wa lls a re
a s the AV node comple te ly
a nd a tria l wa lls de pola rize d, a nd
de pola rize. thus no cha nge is
re corde d in the
ECG.
P
during inspiration and decreases during expiration. T e causes
o sinus dysrhythmia are not clear. T is phenomenon is com-
mon in young people and does not require treatment.
P r e m a t u r e C o n t r a c t io n s
Premature contractions, or extrasystoles, are contractions that
occur be ore the next expected contraction in a series o car-
diac cycles. For example, premature atrial contractions (PACs)
may occur shortly a ter the ventricles contractan early P
wave on the ECG. Premature ventricular contractions (PVCs)
occur when the electrical signal begins in the ventricle rather
than in the SA node (Figure 14-13, E).
Premature contractions o ten occur with lack o sleep,
anxiety, cold medications, too much ca eine or nicotine, alco-
holism, or heart damage. PVCs can occur in otherwise healthy
newborns, young children, and adult athletes ollowing in-
tense activity.
Fib r illa t io n
Frequent premature contractions can lead to brillation, a
condition in which cardiac muscle bers contract out o step
with each other. T is event can be seen in an ECG as the
absence o regular P waves or abnormal QRS and waves. In
brillation, the a ected heart chambers do not e ectively
pump blood.
Atrial brillation (AF or A- b) occurs commonly in mi-
tral stenosis, rheumatic heart disease, and in arction o the
atrial myocardium. Figure 14-13, F, shows an example o atrial
brillation in an ECG strip.
Ventricular brillation (VF or V- b) is an immediately
li e-threatening condition in which the lack o ventricular
pumping suddenly stops the f ow o blood to vital tissues. Un-
less ventricular brillation is corrected immediately by de -
brillation or some other method, death may occur within
minutes. Figure 14-13, G, shows an example o ventricular -
brillation in an ECG strip.
 CHAPTER 14 Heart 391

4 5
The QRS complex
occurs a s the a tria
re pola rize a nd the
ve ntricula r wa lls
de pola rize .
6 7
The a tria l wa lls a re now The T wave Once the ve ntricle s a re
comple te ly re pola rize d, a ppe a rs on the comple te ly re pola rize d,
the ve ntricula r wa lls a re ECG a s the we a re ba ck a t the
now comple te ly ve ntricula r wa lls ba s e line of the
de pola rize d, a nd thus re pola rize . ECGe s s e ntia lly ba ck
no cha nge is s e e n whe re we be ga n.
in the ECG.

R QRS complex QRS complex

P wave T wave P wave T wave

P P

Q Q
S S

A Comple te he a rt block

B Bra dyca rdia C Ta chyca rdia

14

D S inus dys rhythmia E P re ma ture ve ntricula r contra ctions (P VCs )

F Atria l fibrilla tion G Ve ntricula r fibrilla tion

FIGURE 14-13 Dysrhythmia. Examples o di erent types o dysrhythmia are shown as they would appear
in an electrocardiogram (ECG strip recording).
 392 CHAPTER 14 Heart

pressure (and blood f ow) enough to make de brillation

success ul. I initial de brillation is unsuccess ul, then drugs
that help reduce dysrhythmia also may be injected into the
bloodstream.
Automatic external de brillators (AED s) are becoming
increasingly available in public places. AEDs are small, light-
weight devices that detect a persons heart rhythm using small
electrode pads placed on the torso. I ventricular brillation is
detected, then a nonmedical rescuer will be talked through
some simple steps to de brillate the patient.
Internal de brillators called implantable cardioverter-
de brillators (ICD s) can be implanted much like a pace-
maker in patients prone to cardiac brillation or tachycardia.
ICDs automatically monitor or brillation, then produce a
de brillating shock without any external intervention.
Atrial ablation is the intentional destruction o heart
muscle in a speci c location to treat atrial brillation by elimi-
nating the pathway o abnormal electrical signals. Atrial
S utter (AFL)a rapid and irregular atrial rhythm o ten trig-
gered by abnormal electrical signals rom the nearby pulmo-
R L
nary veinsalso can be treated with ablation o tissue where
I the atrial wall meets these veins.

FIGURE 14-14 Artif cial pacemaker. This x-ray photograph shows the Check out the illustrated article Artif cial Cardiac
stimulus generator in the subcutaneous tissue o the chest wall. Thin, f ex- Pacemakers at Connect It! at evolve.elsevier.com.
ible wires extend through veins to the heart, where timed electrical im-
pulses stimulate the myocardium.

Fibrillation may be treated immediately by de brillation
application o an electric shock to orce cardiac muscle -
bers to once again contract in rhythm. In atrial brillation,
a drug such as digoxin (digitalis) may be used to prevent
ventricular involvement. In ventricular brillation, epineph-
rine may be injected into the bloodstream to increase blood
C a r d ia c O u t p u t
D e f n it io n o C a r d ia c O u t p u t
Cardiac output (CO) is the volume o blood pumped by one
ventricle per minute. It averages about 5 L in a normal, resting
adult. Figure 14-15 shows the distribution o the hearts output
to some o the major organs o the body.

14
S C IEN C E APPLICATIONS
CARDIOLOGY
Cardio lo gy, the s tudy and tre at-
m e nt o the he art, owe s m uch
to Dutch phys iologis t Wille m
Einthove n and his inve ntion o
the m ode rn e le ctrocardiograph in
1903. Einthove ns f rs t m ajor con-
tribution w as the inve ntion o a
m achine that could re cord e le ctro-
cardiogram s (ECGs or EKGs ) w ith
ar gre ate r s e ns itivity than the
Willem Einthoven crude m achine s o the nine te e nth
(18601927) ce ntury. The n, w ith the he lp o
Britis h phys ician Lew is Thom as ,
Einthove n de m ons trate d and nam e d the P, Q, R, S, and
T wave s and prove d that the s e wave s pre cis e ly re cord the
e le ctrical activity o the he art (s e e Figure 14-12).
In 1905, Einthove n eve n inve nte d a way that ECG data could
be s e nt rom a patie nt ove r the te le phone line to his laboratory
w he re they could be re corde d and analyze da te chnique now
calle d te le m e try. His de taile d s tudie s o ECG re cordings
change d the practice o he art m e dicine oreve r. In act, his in-
ve ntion was late r applie d to the s tudy o ne rve im puls e s and
le d to bre akthrough dis cove rie s in the ne uros cie nce s .
Cardio lo g is ts today s till us e m ode rn ve rs ions o Einthove ns
m achine to diagnos e he art dis orde rs . O cours e , biom e dical
e ngine e rs continue to deve lop re f ne m e nts to e le ctrocardio-
graph e quipm e nt and to inve nt new m achine s to m onitor he art
unction. The photo s how s a diag no s tic m e dical s o no g raphe r
pe r orm ing an e chocardiogram (s e e box on p. 384).
Biom e dical e ngine e rs and de s igne rs have worke d w ith
cardiologis ts to deve lop artif cial he art valve s , artif cial pace -
m ake rs , and eve n artif cial he arts ! With all o this m e dical
e quipm e nt be ing us e d in cardiology, and in m e dicine in ge n-
e ral, the re are als o m any te chnicians working to ke e p it all in
good re pair.
 CHAPTER 14 Heart 393

FIGURE 14-15 Cardiac output. This diagram shows 5000 mL/min 5000 mL/min
that a typical resting cardiac output (CO) o 5000 mL/min Lungs
(or 5 L/min) is distributed among the various systems and
organs o the body. GI, Gastrointestinal. 15 mm Hg Pulmo nary 5 mm Hg

Right Le ft
T e cardiac output is determined mainly by he a rt he a rt
the heart rate (H R) and stroke volume (SV). Ve nous re turn Ca rdia c output
Heart rate re ers to the number o heart beats
(cardiac cycles) per minute. T e term stroke vol- 700 S ys te mic 700
mL/min mL/min

5
ume re ers to the volume o blood ejected rom

n
0
Bra in

i
m
0
the ventricle during each beat. T e relationship

0
/
L
m
m
is illustrated by this simple equation: 225 225

L
0
/
mL/min mL/min

m
Corona ry

0
0
i
n
circula tion

5
beat volume volume
HR SV CO 1000 1000
min beat min mL/min mL/min
Kidney
T e heart rate is determined mostly by the 1250 1250
natural rhythm o the heart created by the 4 mm Hg mL/min mL/min 104 mm Hg
GI s ys te m
hearts own conduction system (see Figure 14-11
on p. 389). Abnormally decreased CO can result 1450 1450
in atigue or, with a signi cant drop in CO, even mL/min S ke le ta l mL/min
death. mus cle
375 375
mL/min mL/min
He a r t Ra t e S kin

As you learned in Chapter 10, the autonomic nervous system

(ANS) may alter the hearts rhythm to increase or decrease
H R. Figure 10-27 on p. 275 shows that the sympathetic division
o the ANS increases H R. Neurons o the sympathetic cardiac
nerve release the neurotransmitter norepinephrine (NE), which
causes the SA node to increase its usual pace and thereby in-
crease H R.
T e same gure also shows that the parasympathetic divi-
sion o the ANS slows down H R. T is happens when neurons
o the vagus nerve (cranial nerve X) release acetylcholine (ACh)
to decrease the pace o the SA node.
T e balance between the antagonistic inf uence o sympa-
thetic and parasympathetic signals to the heart is tilted by a
variety o actors. W hen blood CO 2 levels rise during exercise, 14
or example, there is a ref exive rise in H R. T is is an attempt
by the body to restore homeostasis o blood gases.
A sudden drop in blood pressure can trigger a ref exive
increase in H R as the body attempts to restore normal blood
f ow out o the heart. Stressthe recognition o a threat to
homeostatic balancealso can cause a sudden increase in H R
so that skeletal muscles will be ready to resist or avoid the
stressor.
Various dysrhythmias may a ect H R by disrupting the
normal rhythm o the heart.

S t ro k e Vo lu m e
T e volume o blood ejected by the ventricles is determined
by the volume o blood returned to the heart by the veins, or
venous return (see Figure 14-15). Generally, the higher the
venous return, the higher the SV.
Venous return can change when the volume o the blood
changes, as in dehydration or blood loss due to hemorrhage.
Various hormones, many o which will be discussed in later
chapters, can inf uence total blood volume and thus also a ect
 394 CHAPTER 14 Heart

C LIN ICA L APPLICATION

HEART MEDICATIONS
Num e rous drugs are us e d in the tre atm e nt o he art dis e as e
both in the critical care unit and in hom e he alth care . He re
are a ew exam ple s o the bas ic pharm acological tools o
cardiac care .
Antico ag ulants and antiplate le t age nts The s e drugs
preve nt clot orm ation in patie nts w ith valve dam age or w ho
have expe rie nce d a myocardial in arction. War arin (Coum a-
din), he parin, dalte parin, and danaparoid are exam ple s o
com m only us e d anticoagulants age nts that dis rupt or
block the blood clotting m e chanis m . Antiplate le t age nts
preve nt plate le ts rom s ticking toge the r to produce a blood
clot. Exam ple s o antiplate le t drugs are ace tyls alicylic acid
(as pirin), clopidogre l (Plavix), and ticlopidine (Ticlid).
Tis s ue plas m ino ge n activato r (TPA or tPA)Us ually a
s ynthe tic ve rs ion o a naturally occurring s ubs tance rom
the walls o blood ve s s e ls , TPA activate s a s ubs tance in the
blood calle d plas m inoge n, w hich dis s olve s clots that m ay
be blocking coronary arte rie s . Anothe r pre paration calle d
s tre ptokinas e , an e nzym e produce d by Stre ptococcus bac-
te ria, has s im ilar e e cts .
Be ta-adre ne rg ic blo cke rs O te n re e rre d to as be ta
blocke rs , the s e drugs block nore pine phrine re ce ptors in S
cardiac m us cle and thus re duce the rate and s tre ngth o FIGURE 14-16 Cor pulmonale. When pulmo-
nary blood backs up into the right side o the heart R L
the he artbe at. Such drugs can he lp corre ct ce rtain dys -
during right heart ailure, it may stretch the right I
rhythm ias , as we ll as re duce the am ount o oxyge n re - ventricle. Note in this photograph how large the right
quire d by the myocardium . Propranolol (Inde ral) and re late d ventricle is in comparison with the le t ventricle.
drugs are be ta-adre ne rgic blocke rs .
Calcium -channe l blo cke rs The s e drugs block the
ow o calcium ions (Ca ) into cardiac m us cle ce lls , w hich
contribute to de polarization. Blocking Ca in ow thus re - He a r t Fa ilu r e
duce s he art contractions . Calcium -channe l blocke rs m ay be Heart ailure is the inability the heart t pump en ugh
us e d in tre ating ce rtain dys rhythm ias and coronary he art
bl d t sustain li e. Put an ther way, heart ailure is a signi -
dis e as e . Som e exam ple s include diltiaze m , ve rapam il, and
ant dr p in ardia utput.
14 ni e dipine .
Dig italis This drug s low s and incre as e s the s tre ngth
H eart ailure an be the result many di erent heart dis-
o cardiac contractions . It plays an im portant part in the eases. Valve dis rders an redu e the pumping e ien y
tre atm e nt o conge s tive he art ailure and ce rtain dys rhyth- the heart en ugh t ause heart ailure. Cardiomyopathy, r
m ias . Digoxin is one o s eve ral com m only us e d digitalis disease the my ardial tissue, may redu e pumping e e -
pre parations . tiveness. A spe i event, su h as my ardial in ar ti n, an
Nitro g lyce rinThis drug dilate s (w ide ns ) coronary result in my ardial damage that auses heart ailure. D ys-
blood ve s s e ls , thus incre as ing the ow o oxyge nate d rhythmias, su h as mplete heart bl k r ventri ular bril-
blood to the myocardium . Nitroglyce rin is o te n us e d to lati n, als an impair the pumping e e tiveness the heart
preve nt or re lieve angina pe ctoris . and thus ause heart ailure. Stress als an trigger temp rary
ardi my pathy, ten alled stress cardiomyopathy r br ken
heart syndr me.
Failure the right side the heart, r right heart ailure,
SV. M vement skeletal mus les, in luding breathing, inf u- a unts r ab ut ne- urth all ases heart ailure.
en es pressure n veinswhi h in reases ven us bl d f w Right heart ailure ten results r m the pr gressi n dis-
and thus in reases the rate ven us return. ease that begins in the le t side the heart. Failure the le t
T e strength my ardial ntra ti n als helps deter- side the heart results in redu ed pumping bl d return-
mine SV. I n imbalan es an a e t mus le ber un ti n ing r m the lungs. Bl d ba ks up int the pulm nary ir u-
and thus impair ntra ti nthus als de reasing SV. Valve lati n, then int the right heart ausing an in rease in pres-
dis rders, r nary artery bl kage, r my ardial in ar ti n sure that the right side the heart simply ann t ver me.
an all de rease str ke v lume and thus may de rease ardia Right heart ailure als an be aused by lung dis rders
utput. that bstru t n rmal pulm nary bl d f w and thus verl ad
 CHAPTER 14 Heart 395

the right side the hearta nditi n alled cor pulmonale

(Figure 14-16).
Congestive heart ailure (CH F), r simply le t heart ail-
ure, is the inability the le t ventri le t pump bl d e e -
tively. M st ten, su h ailure results r m my ardial in ar -
ti n aused by r nary artery disease. It is alled congestive
heart ailure be ause it de reases pumping pressure in the
systemi ir ulati n, whi h in turn auses the b dy t retain
f uids. P rti ns the systemi ir ulati n thus be me n-
gested with extra f uid.
As stated ab ve, le t heart ailure als auses ngesti n
bl d in the pulm nary ir ulati n, termed pulmonary edema
p ssibly leading t right heart ailure.
Patients in danger death be ause heart ailure may be
andidates r heart transplants r heart implants. H eart trans-
plants are surgi al pr edures in whi h healthy hearts r m re-
ently de eased d n rs repla e the hearts patients with heart S

disease (Figure 14-17). Un rtunately, a ntinuing pr blem with
this pr edure is the tenden y the b dys immune system t
reje t the new heart as a reign tissue. M re details ab ut the
reje ti n transplanted tissues are und in Chapter 16.
H eart implants are arti ial hearts that are made bi -
l gi ally inert syntheti materials. A ter de ades alse starts
and umbers me implants with external pumps, the era the
arti ial heart seems t have nally arrived. Alth ugh still
n t widely used, a number small internal pumps have been
su ess ully implanted in patients t take ver the pumping
duties the heart.
FIGURE 14-17 Heart transplant. Human heart
R L
prepared or transplantation into a patient.
I
QUICK CHECK
1. Wh a t d o e s th e te rm d ys rhyth m ia m e a n ?
2. Wh a t is th e d i e re n ce b e tw e e n ta chyca rd ia a n d
b ra d yca rd ia ?
3. Ho w is f b rilla tio n co rre cte d ?
4. Wh a t is a tria l a b la tio n ? In w h a t in s ta n ce is it u s e d ?
5. Wh a t is ca rd ia c o u tp u t a n d h o w is it d e te rm in e d ?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 379)

bicuspid valve coronary artery heart rate (HR)

(bye-KUS-pid valv) (KOHR-oh-nayr-ee AR-ter-ee) (hart rayt [aych ar])
[bi- double, -cusp- point, -id characterized by] [corona- crown, -ary relating to, arteri- vessel] in erior vena cava
14
bundle o His coronary circulation (in-FEER-ee-or VEE-nah KAY-vah)
(BUN-del o his) (KOHR-oh-nayr-ee ser-kyoo-LAY-shun) pl., venae cavae
[Wilhelm His, J r. Swiss cardiologist] [corona- crown, -ary relating to, circulat- go (VEE-nee KAY-vee)
cardiac cycle around, -tion process] [in er- lower, -or quality, vena vein,
(KAR-dee-ak SYE-kul) coronary sinus cava hollow]
[cardi- heart, -ac relating to, cycl- circle] (KOR-oh-nayr-ee SYE-nus) mitral valve
cardiac output (CO) [corona- crown, -ary relating to, sinus hollow] (MY-tral valv)
(KAR-dee-ak OUT-put [see oh]) depolarization [mitr- bishops hat, -al relating to]
[cardi- heart, -ac relating to] (dee-poh-lar-ih-ZAY-shun) myocardium
cardiac vein [de- opposite, -pol- pole, -ar- relating to, (my-oh-KAR-dee-um)
(KAR-dee-ak vayn) -ization process] [myo- muscle, -cardi- heart, -um thing]
[cardi- heart, -ac relating to, cycle circle, diastole P wave
vena blood vessel] (dye-AS-toh-lee) (pee wave)
cardiovascular system [dia- through, -stole contraction] [named or letter o Roman alphabet]
(kar-dee-oh-VAS-kyoo-lar SIS-tem) endocardium pacemaker
[cardi- heart, -vas- vessel, -ular relating to] (en-doh-KAR-dee-um) (PAYS-may-ker)
chordae tendineae [endo- within, -cardi- heart, -um thing] parietal pericardium
(KOR-dee ten-DIN-ee) epicardium (pah-RYE-ih-tal payr-ih-KAR-dee-um)
[chorda string or cord, tendinea pulled tight] (ep-ih-KAR-dee-um) [pariet- wall, -al relating to, peri- around,
[epi- on or upon, -cardi- heart, -um thing] -cardi- heart, -um thing]

Continued on p. 396
 396 CHAPTER 14 Heart

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 395)

pericardium QRS complex systemic circulation

(payr-ih-KAR-dee-um) (kyoo ar es KOM-pleks) (sis-TEM-ik ser-kyoo-LAY-shun)
[peri- around, -cardi- heart, -um thing] [named or letters o Roman alphabet] [system- body systems, -ic relating to,
pulmonary artery semilunar valve (SL valve) circulat- go around, -tion process]
(PUL-moh-nayr-ee AR-ter-ee) (sem-ih-LOO-nar valv [es el valv]) systole
[pulmon- lung, -ary relating to, arteri- vessel] [semi- hal , -luna moon, -ar relating to] (SIS-toh-lee)
pulmonary circulation sinoatrial node (SA node) [systole contraction]
(PUL-moh-nayr-ee ser-kyoo-LAY-shun) (sye-noh-AY-tree-al nohd [es ay nohd]) T wave
[pulmon- lung, -ary relating to, circulat- go [sin- hollow (sinus), -atri- entrance courtyard, (tee wave)
around, -tion process] -al relating to, nod- knot] [named or letter o Roman alphabet]
pulmonary semilunar valve stroke volume (SV) tricuspid valve
(PUL-moh-nayr-ee sem-ee-LOO-nar valv) (strohk VOL-yoom [es vee]) (try-KUS-pid valv)
[pulmon- lung, -ary relating to, semi- hal , [stroke a striking] [tri- three, -cusp- point, -id characterized by]
-luna moon, -ar relating to] subendocardial branch venous return
pulmonary vein (sub-en-doh-KAR-dee-al) (VEE-nus reh-TURN)
(PUL-moh-nayr-ee vayn) [sub- under, -endo- within, -cardi- heart, [ven- vein, -ous relating to]
[pulmon- lung, -ary relating to, vena blood -al relating to] ventricle
vessel] superior vena cava (VEN-trih-kul)
Purkinje f ber (soo-PEER-ee-or VEE-nah KAY-vah) [ventr- belly, -icle little]
(pur-KIN-jee FYE-ber) pl., venae cavae visceral pericardium
[J ohannes E. Purkinje Czech physiologist, (VEE-nee KAY-vee) (VIS-er-al payr-ih-KAR-dee-um)
f ber thread] [super- over or above, -or quality, vena vein, [viscer- internal organ, -al relating to,
cava hollow] peri- around, -cardi- heart, -um thing]

LANGUAGE OF M ED IC IN E

ablation atrial f brillation (AF or A-f b) cardiologist

(ab-LAY-shun) (AY-tree-al f b-ril-LAY-shun (kar-dee-AH-loh-jist)
14 [ablat- take away, -tion process] [ay e or AY-f b]) [cardi- heart, -o- combining vowel, -log- words
angina pectoris [atri- entrance courtyard, -al relating to, (study o ), -ist agent]
(an-J YE-nah PEK-tor-is) f br- thread or f ber, -illa- little, cardiology
[angina strangling, pect-breast, -ation process] (kar-dee-AHL-uh-jee)
-oris relating to] atrial utter (AFL) [cardio- heart, -log- words (study o ), -y activity]
angiogram (AY-tree-al FLUT-er [ay e el]) cardiomyopathy
(AN-jee-oh-gram) [atri- entrance courtyard, -al relating to] (kar-dee-oh-my-OP-ah-thee)
[angi- vessel, -gram drawing] automatic external def brillator (AED) [cardi- heart, -myo- muscle, -path- disease,
angiography (aw-toh-MAT-ik eks-TERN-al -y state]
(an-jee-AH-gra -ee) dee-FIB-rih-lay-tor [ay ee dee]) cardiopulmonary resuscitation (CPR)
[angi- vessel, -graph- draw, -y process] [auto- sel , -mat- act, -ic relating to, (kar-dee-oh-PUL-moh-nayr-ree
extern- outside, -al relating to, de- o , ree-sus-ih-TAY-shun [see pee ar])
apical heart beat
-f br- thread, -illa- little, -at- process, [cardio- heart, -pulmon- lung, -ary relating to,
(AY-pik-al hart beet)
-or agent] resuscitat- revive, -tion process]
[apic- tip, -al relating to]
artif cial pacemaker bradycardia catheterization
(ar-tih-FISH-al PAYS-may-ker) (bray-dee-KAR-dee-ah) (kath-eh-ter-ih-ZAY-shun)
[brady- slow, -cardi- heart, -ia condition] [cathe- send down, -er agent, -tion process]
atherosclerosis
(ath-er-oh-skleh-ROH-sis) cardiac tamponade congestive heart ailure (CHF)
[ather- porridge, -sclero- harden, (KAR-dee-ak tam-poh-NOD) (kon-J ES-tiv hart FAYL-yoor [see aych e ])
[cardi- heart, -ac relating to, tampon- plug, [congest- crowd, -ive relating to]
-osis condition]
-ade condition] cor pulmonale
(kohr pul-mah-NAL-ee)
[cor- heart, pulmon- lung, -ale relating to]
 CHAPTER 14 Heart 397

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 396)

coronary angioplasty endocarditis pericardial e usion

(KOHR-oh-nayr-ee AN-jee-oh-plas-tee) (en-doh-kar-DYE-tis) (payr-ih-KAR-dee-al e -FYOO-zhen)
[corona- crown, -ary relating to, angio- vessel, [endo- within, -cardi- heart, -itis in ammation] [peri- around, -cardi- heart, -al relating to,
-plasty surgical repair] f brillation e(x)- outside, - us- pour, -sion process]
coronary bypass surgery (f b-rih-LAY-shun) pericarditis
(KOHR-oh-nayr-ee BYE-pass SER-jer-ee) [f br- f ber, -illa- little, -ation process] (payr-ih-kar-DYE-tis)
[corona- crown, -ary relating to] heart block [peri- around, -cardi- heart, -itis in ammation]
diagnostic medical sonographer (hart blok) premature contraction
(dye-ag-NOS-tik MED-ih-kul heart disease (pree-mah-TUR kon-TRAK-shun)
son-AH-gra -er) (hart dih-ZEEZ) [pre- be ore, -mature ripen, con- together,
[dia- through, -gnos- knowledge, -ic relating to, [dis- opposite o , -ease com ort] -tract- draw, -tion process]
medic- heal, -al relating to, sono- sound, rheumatic heart disease
heart ailure
-graph- draw, -er agent] (roo-MAT-ik hart dih-ZEEZ)
(hart FAYL-yoor)
dysrhythmia heart murmur [rheuma- ow, -ic relating to, dis- opposite o ,
(dis-RITH-mee-ah) (hart MUR-mur) -ease com ort]
[dys- disordered, -rhythm- rhythm, -ia condition] sinus dysrhythmia
[murmur mutter]
echocardiogram incompetent valve (SYE-nus dis-RITH-mee-ah)
(ek-oh-KAR-dee-oh-gram) (in-KOM-peh-tent valv) [sinus hollow, dys- disordered, -rhythm- rhythm,
[echo- re ect sound, -cardi- heart, -ia condition]
[in- not, -compet- coincide or f t, -ent state]
-gram drawing] stenosed valve
implantable cardioverter-def brillator (ICD)
echocardiography (im-PLAN-tah-bel KAR-dee-oh-vert-er (steh-NOSD valv)
(ek-oh-kar-dee-OG-rah- ee) dee-FIB-rih-lay-tor [aye see dee]) [stenos- narrow]
[echo- re ect sound, -cardi- heart, tachycardia
[im- in, -planta- set or place, -able capable,
-graph- draw, -y activity] (tak-ih-KAR-dee-ah)
cardio- heart, -vert- turn, -er agent, de- o ,
electrocardiogram (ECG or EKG) -f br- thread, -illa- little, -at- process, [tachy- rapid, -cardi- heart, -ia condition]
(eh-lek-troh-KAR-dee-oh-gram -or agent] thrombus
[ee see jee or ee kay jee]) mitral valve prolapse (MVP) (THROM-bus)
[electro- electricity, -cardio- heart, [thrombus clot]
(MY-tral valv PROH-laps [em vee pee])
-gram drawing] [mitr- bishops hat, -al relating to, pro- orward, ventricular f brillation (VF or V-f b)
electrocardiograph -laps- all] (ven-TRIK-yoo-lar f b-ril-LAY-shun
(eh-lek-troh-KAR-dee-oh-gra ) myocardial in arction (MI) [vee e or VEE-f b])
[electro- electricity, -cardio- heart, [ventr- belly, -icul- little, -ar relating to,
(my-oh-KAR-dee-al in-FARK-shun
-graph draw]
embolism
[em aye])
[myo- muscle, -cardi- heart, -al relating to,
f br- thread or f ber, -illa- little,
-ation process] 14
(EM-boh-liz-em) in- in, - arc- stu , -tion process]
[embol- plug, -ism condition]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Lo catio n o the He art
A. riangular rgan l ated in mediastinum with tw -thirds
the mass t the le t the b dy midline and ne-third
t the right; the apex is n the diaphragm; shape and
size a l sed st (Figure 14-1)
B. Cardi pulm nary resus itati n (CPR)heart lies
between the sternum in r nt and the b dies the th -
ra i vertebrae behind; rhythmi mpressi n the
heart between the sternum and vertebrae an maintain
bl d f w during ardia arrest; when mbined with an
arti ial respirati n pr edure, CPR an be li esaving
 398 CHAPTER 14 Heart
Functio nal Anato my o the He art
A. H eart hambers (Figure 14-2)
1. w upper hambers are alled atria (re eiving
hambers)right and le t atria
2. w l wer hambers are alled ventricles (dis harging
hambers)right and le t ventri les
3. Wall ea h heart hamber is mp sed ardia
mus le tissue alled myocardium
4. End ardiumsm th lining heart hambers
a. Inf ammati n end ardium is alled endocarditis
b. Inf amed end ardium an be me r ugh and
abrasive and thereby ause a thr mbus
B. T e peri ardium and peri arditis
1. Peri ardiuma tw -layered br us sa with a lubri-
ated spa e between the tw layers
a. Inner layer is alled vis eral peri ardium, r
epi ardium
b. O uter layer is alled parietal peri ardium
2. Peri arditisinf ammati n the peri ardium
3. Cardia tamp nade mpressi n the heart aused
by f uid building up between the vis eral peri ardium
and parietal peri ardium
C. H eart a ti n
1. C ntra ti n the heart is alled systole
2. Relaxati n the heart is alled diastole
D. H eart valves and valve dis rders (Figure 14-3)
1. Valves keep bl d f wing thr ugh the heart; prevent
ba kf w
2. Atri ventri ular (AV) valves
a. ri uspid valveat the pening the right atrium
int the ventri le
b. Bi uspid (mitral) valveat the pening the le t
atrium int the ventri le
. Ch rdae tendineaestringlike stru tures that
14 an h r the edges AV valve leaf ets t ngerlike
pr je ti ns mus le in the heart wall
3. Semilunar (SL) valves
a. Pulm nary semilunar valveat the beginning
the pulm nary artery
b. A rti semilunar valveat the beginning the
a rta
4. Valve dis rders
a. In mpetent valves leak, all wing s me bl d t
f w ba kward int the hamber r m whi h it
ame
b. Sten sed valves are narr wer than n rmal, redu ing
bl d f w (Figure 14-4)
. Rheumati heart disease ardia damage resulting
r m a delayed inf ammat ry resp nse t strept -
al in e ti n
d. Mitral valve pr lapse (MVP)in mpeten e
mitral valve aused by its edges extending ba k int
the le t atrium when the le t ventri le ntra ts
(Figure 14-5)
He art S o unds
A. w distin t heart s unds in every heartbeat, r y le
lub-dup (Figure 14-10)
B. First s und (lub) is aused by the vibrati n and l sure
AV valves during ntra ti n the ventri les
C. Se nd s und (dup) is aused by the l sure the semi-
lunar valves during relaxati n the ventri les
D. H eart murmursabn rmal heart s unds ten aused by
abn rmal valves
Blo o d Flow Thro ug h the He art
A. H eart a ts as tw separate pumpsthe right atrium and
ventri le per rming di erent un ti ns r m the le t
atrium and ventri le (Figure 14-6)
B. Sequen e bl d f w
1. Systemi ven us bl d enters the right atrium
thr ugh the superi r and in eri r venae avaepasses
r m the right atrium thr ugh the tri uspid valve t
the right ventri le
2. Fr m the right ventri le thr ugh the pulm nary semi-
lunar valve t the pulm nary artery t the lungs
3. Bl d r m the lungs thr ugh pulm nary veins t the
le t atrium, passing thr ugh the bi uspid (mitral) valve
t le t ventri le
4. Bl d in the le t ventri le is pumped thr ugh the
a rti semilunar valve int the a rta and is distributed
t the b dy as a wh le
Blo o d S upply to He art Mus cle
A. Bl d, whi h supplies xygen and nutrients t the my -
ardium the heart, f ws thr ugh the right and le t
r nary arteries (Figure 14-7)
1. Bl kage bl d f w thr ugh the r nary arteries
an ause my ardial in ar ti n (heart atta k)
2. Ather s ler sis
a. ype hardening arteries in whi h lipids
build up n the inside wall bl d vessels; an
partially r t tally bl k r nary bl d f w
b. Bl ked areas may be pened with angi plasty r
heart bypass surgery (Figure 14-8)
3. Angina pe t ris hest pain aused by inadequate
xygen t the heart
B. Systemi ven us bl d r m the my ardium is returned
t the right atrium thr ugh a ba k d r by way the
ardia sinus (n t by way either vena ava) (Figure 14-9)
Cardiac Cycle
A. H eartbeat is regular and rhythmi alea h mplete beat
alled a cardiac cycleaverage is ab ut 72 beats per minute
B. Ea h y le, ab ut 0.8 se nd l ng, subdivided int
syst le ( ntra ti n phase) and diast le (relaxati n phase)
C. Events the ardia y le an be rrelated with heart
s unds, hanges in bl d f w and v lume, and ele tri al
a tivity the heart (Figure 14-10)

Ele ctrical Activity o the He art
A. C ndu ti n system the heart (Figure 14-11)
1. Inter alated disks ele tri ally nne t all the ardia
mus le bers in a regi n t gether s that they re eive
impulses (a ti n p tentials), and thus ntra t, at
ab ut the same time
2. Spe ialized ndu ti n system stru tures generate and
transmit the ele tri al impulses that result in ntra -
ti n the heart
a. SA (sin atrial) n de, the pa emakerl ated in
the wall the right atrium near the pening the
superi r vena ava
b. AV (atri ventri ular) n del ated in the right
atrium al ng the l wer part the interatrial
septum
. AV bundle (bundle H is)l ated in the septum
the ventri le
d. Subend ardial bran hes (Purkinje bers)l ated
in the walls the ventri les
B. Ele tr ardi graphy (Figure 14-12)
1. T e tiny ele tri al impulses traveling thr ugh the
hearts ndu ti n system an be pi ked up n the
sur a e the b dy and trans rmed int visible tra -
ings by a ma hine alled an electrocardiograph
2. T e visible tra ing these ele tri al signals is alled
an electrocardiogram, r ECG r EKG
3. T e n rmal ECG has three def e ti ns, r waves
a. P waveass iated with dep larizati n the atria
b. QRS mplexass iated with dep larizati n
the ventri les
. waveass iated with rep larizati n the
ventri les
C. Cardia dysrhythmiaabn rmality heart rhythm
(Figure 14-13)
1. H eart bl k ndu ti n impulses is bl ked
a. C mplete heart bl kimpaired AV n de ndu -
ti n, pr du ing mplete diss iati n P waves
r m QRS mplexes
b. Can be treated by implanting an arti ial pa e-
maker (Figure 14-14)
2. Brady ardiasl w heart rate (less than 60 beats/min)
3. a hy ardiarapid heart rate (m re than 100 beats/
min)
4. Sinus dysrhythmiavariati n in heart rate during
breathing y le
5. Premature ntra ti n (extrasyst le) ntra ti n that
urs s ner than expe ted in a n rmal rhythm
6. Fibrillati n nditi n in whi h ardia mus le bers
are ut step, pr du ing n e e tive pumping
a ti n
a. Atrial brillati n (AF r A- b) brillati n in the
atrial my ardium
b. Ventri ular brillati n (VF r V- b) brillati n
in the ventri ular my ardium
CHAPTER 14 Heart 399
. De brillati n (ele tri al sh k) r ablati n
(destru ti n my ardial tissue) are pti ns r
treating brillati n
Cardiac Output
A. Cardia utput (CO)
1. Am unt bl d that ne ventri le an pump ea h
minuteaverage is ab ut 5 L per minute at rest
(Figure 14-15)
2. Cardia utput is determined by heart rate (H R) and
str ke v lume (SV)CO H R SV
a. H eart rate is the number beats ( ardia y les)
per minute
b. Str ke v lume is the v lume bl d eje ted r m
ne ventri le with ea h beat ( y le)
. Any a t r that a e ts H R r SV may thus als
a e t CO
B. Fa t rs that a e t heart rate
1. H R determined mainly by hearts pa emaker
2. Aut n mi nerv us system (ANS) an inf uen e
pa emaker
a. Sympatheti ardia nerve releases n repinephrine
(NE) t in rease H R
b. Parasympatheti vagus nerve ( ranial nerve X)
releases a etyl h line (ACh) t de rease H R
. Exer ise, hange in bl d pressure, stress, and dys-
rhythmias an ause hanges in H R
C. Fa t rs that a e t str ke v lume
1. Ven us returnv lume bl d returned t the heart
by veins (Figure 14-15)
a. A high ven us return results in a high SV
b. A e ted by t tal bl d v lume, whi h in turn an
be a e ted by dehydrati n, hem rrhage, vari us
h rm nes, a tivity skeletal mus les
2. Strength my ardial ntra ti n 14
a. Impaired ntra ti ns redu e SV
b. Can be inf uen ed by i n imbalan es, valve dis r-
ders, r nary artery bl kage, r MI
He art Failure
A. H eart ailureinability t pump en ugh returned bl d
t sustain li e an be aused by many di erent heart
diseases
1. Right heart ailure ailure the right side the
heart t pump bl d, usually be ause the le t side
the heart is n t pumping e e tively (Figure 14-16)
2. Le t heart ailure ( ngestive heart ailure, CH F)
inability the le t ventri le t pump e e tively,
resulting in ngesti n the systemi and pulm nary
ir ulati ns
B. Diseased hearts an be repla ed by d nated living hearts
(transplants) r by arti ial hearts (implants), alth ugh
b th pr edures have yet t be per e ted (Figure 14-17)
 400 CHAPTER 14 Heart
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the cardiovas cular s ys te m in Chapte r 5.
Chapte r 14 de als w ith the he art, the pump that move s the
blood through the blood ve s s e ls .
1. Make f ash ards and he k ut nline res ur es t help
y u learn the stru tures the heart. Review the Lan-
guage S ien e and Language Medi ine terms.
2. T e l ati n the semilunar valves sh uld be easy t
remember be ause their names tell y u where they are. It
is harder t remember where the tri uspid and mitral
valves are be ause their names d n t give any lues t
their l ati ns. An easier way t remember them is t use
their ther names, the right and le t atri ventri ular
valves. T ese names tell y u exa tly where they are,
between the atria and ventri les n the right r le t side.
3. Bl d m ves thr ugh the heart in ne dire ti n: r m the
right heart, t the lungs, t the le t heart, and ut the
a rta. Ele tri al ndu ti n thr ugh the heart wall may
make m re sense i y u remember that atria ntra t
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
14 o your new le arning.
1. Des ribe the heart and its p siti n in the b dy.
2. List the ur hambers the heart.
3. W hat is the myocardium? W hat is the endocardium?
4. Des ribe the tw layers the peri ardium. W hat is the
un ti n peri ardial f uid?
5. De ne r explain pericarditis and pericardial ef usion.
6. W hat is systole? W hat is diastole?
7. List the ur heart valves; identi y where they are l ated.
8. Explain what is meant by a mitral valve pr lapse.
9. Explain what urs in a my ardial in ar ti n.
10. ra e the f w bl d r m the superi r vena ava t
the a rta.
11. De ne angina pectoris.
12. ra e the path and name the stru tures inv lved in the
ndu ti n system the heart.
13. W hat is heart block? W hat is bradycardia? W hat is
tachycardia?
14. W hat is brillation? W hi h is m re danger us, atrial
brillati n r ventri ular brillati n?
15. Identi y the a t rs that a e t heart rate and stroke volume.
16. Di erentiate between stroke volume and cardiac output.
r m the t p d wn, but ventri les must ntra t r m the
b tt m up s the ele tri al impulse r ntra ti n must
be arried t the b tt m the ventri les be re they start
ntra ting. my-ap.us/QmBo 4 ers a tut rial n the
ele tri al ndu ti n pathways the heart. T e letters r
the ECG waves d n t stand r anything; they are arbi-
trary, but they d indi ate a sequen e events (that is,
the P tra ing mes be re the QRS mplex). Che k ut
my-ap.us/L2JjzP r a tut rial n ECG. Find additi nal
nline tips at my-ap.us/LDwVq7.
4. Make a hart the dis rders the heart. O rganizing
them based n their s ur e w uld be use ul: the peri ar-
dium, the heart mus le, the heart valves, the ndu ti n
system, r general heart ailure.
5. Bring ph t pies heart illustrati ns ( r example,
Figures 14-1, 14-2, and 14-11) t y ur study gr up. Bla ken
ut the labels and use them as t ls r learning the
stru tures the heart.
6. In y ur study gr up, dis uss the f w bl d thr ugh the
heart, the ndu ti n system, the parts the ECG, and
the hart the dis rders the heart. G ver the ques-
ti ns and the utline summary at the end the hapter
and dis uss p ssible test questi ns.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
17. Explain h w the tra ings n an ECG relate t the ele -
tri al a tivity the heart.
18. Explain h w right heart ailure is usually aused by le t
heart ailure.
19. It has been determined that Danny has a heart rate
72 beats per minute. H is str ke v lume is 70 mL. Cal-
ulate his ardia utput.
20. H w d es an angi graphy di er r m a n rmal radi -
graphi (x-ray) pr edure?
21. Explain h w bl d that has pr vided xygen and nutri-
ents t the heart mus le returns t the right atrium.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________ are the thi ker hambers the heart, s me-
times alled the dis harging hambers.
 CHAPTER 14 Heart 401

2. ________ are the thinner hambers the heart, s me-
times alled the re eiving hambers.
3. Cardia mus le tissue als may be alled ________.
4. T e ventri les the heart are separated int right and
le t sides by a wall alled the ________.
5. T e thin layer tissue lining the interi r ea h the
heart hambers is alled the ________.
6. I the peri ardium be mes inf amed, a nditi n alled
________ results.
7. W hen the heart is ntra ting, it is said t be in ________.
8. A number stringlike stru tures alled ________
________ atta h the AV valves t the walls the
ventri les.
9. T e heart valve l ated between the right atrium and
right ventri le is alled the ________ valve.
10. T e ________ is the pa emaker the heart and begins
the ntra ti n the atria.
11. T e ________ are extensi ns the atri ventri ular
bers and ause the ntra ti n the ventri les.
12. T e ECG tra ing that urs when the ventri les are
dep larizing is alled the ________.
13. T e term ________ re ers t the v lume bl d
eje ted r m the ventri le during ea h beat.
14. T e am unt bl d that 1 ventri le an pump in
1 minute is alled the ________ ________.
15. Bl d returns r m the lungs t the le t ventri le
thr ugh ________ pulm nary veins. H IN : H w many?
16. T e delivery xygen and nutrient-ri h arterial bl d
t ardia mus le tissue and the return xygen-p r
bl d r m this a tive tissue t the ven us system is
alled ________.
17. T e rst bran hes the a rta are the ________.
18. T e buildup lipids and ther substan es n the inside
wall bl d vessels is kn wn as ________.
19. C ntra ti ns that ur be re the next expe ted ntra -
ti n in a series ardia y les is kn wn as ________.
20. An ________ dete ts a pers ns heart rhythm and
enables n nmedi al res uers t de brillate a patient.
21. An alternative t an AED, whi h is implanted in the
patient and delivers a de brillating sh k with ut exter-
nal interventi n, is a(n) ________.
22. Pla e the ll wing stru tures in their pr per rder in rela-
ti n t bl d f w thr ugh the heart. Put a 1 in r nt
the rst stru ture the bl d w uld pass thr ugh and a 10
in r nt the last stru ture the bl d w uld pass thr ugh.
________ a. le t atrium
________ b. tri uspid valve (right atri ventri ular valve)
________ . right ventri le
________ d. pulm nary veins
________ e. a rti semilunar valve
________ . mitral valve (le t atri ventri ular valve)
________ g. le t ventri le
________ h. pulm nary artery
________ i. right atrium
________ j. pulm nary semilunar valve

Match each heart disorder in Column A with its corresponding description or cause in Column B.

Column A Column B
23. ________ peri arditis a. damage t the heart ells due t a la k bl d f w
24. ________ mitral valve pr lapse b. sl w heart rhythm
25. ________ my ardial in ar ti n . a nditi n in whi h the ardia mus les ntra t ut step with ea h ther
26. ________ angina pe t ris d. rapid heart rhythm 14
27. ________ heart bl k e. als alled le t heart ailure
28. ________ brady ardia . inf ammati n the peri ardium
29. ________ ta hy ardia g. a nditi n in whi h ntra ti n impulses are prevented r m getting thr ugh
30. ________ brillati n t the ventri les
31. ________ ngestive heart ailure h. severe hest pain that urs when the heart mus le is deprived xygen
i. a nditi n that all ws bl d t leak ba k int the le t atrium when the le t
ventri le ntra ts

abn rmality and its p ssible e e ts n heart un ti n.

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Y u are visiting a riend in the h spital. Beside her bed is a
vide m nit r that displays y ur riends ECG. She asks y u
what the large spikes represent an y u tell her? Suddenly
the ECG line be mes mpletely dis rganized, with n
dis ernible P, QRS, r waves. W hat may have happened?
W hat uld be d ne r her? Or is treatment ne essary?
2. Y ur lassmate Vivian t ld y u during lun htime that she
has been diagn sed with MVP. Des ribe this stru tural
Drawing n the in rmati n in y ur text, nsider what
might have aused her nditi n and s me medi al
pti ns r Vivian.
3. Un le J hn is ab ut t underg r nary bypass surgery.
H is surge n explained Un le J hns nditi n and the
surgi al pr edure t rre t it, but y ur un le was t
upset t pay l se attenti n. N w that he is almer, he
realizes that he has very little idea what triple bypass
surgery is all ab ut. Des ribe t y ur un le the pr bable
nditi n his heart and explain the planned surgery.
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Circulation o Blood
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Blood Vessels, 403 Fluctuations in Arterial Blood

Types, 403 Pressure, 417
Structure, 404 Central Venous Blood Pressure, 418
Functions, 405 Pulse, 419
Disorders o Blood Vessels, 406 Hypertension, 419
Disorders o Arteries, 406 Def nition, 419
Disorders o Veins, 408 Risk Factors, 420
Routes o Circulation, 408 Circulatory Shock, 421
Systemic and Pulmonary Circulation, Cardiogenic Shock, 421
408 Hypovolemic Shock, 421
Hepatic Portal Circulation, 409 Neurogenic Shock, 421
Fetal Circulation, 412 Anaphylactic Shock, 421
Hemodynamics, 414 Septic Shock, 421
Def ning Blood Pressure, 414
Factors That In uence Blood
Pressure, 414

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. Describe the structure and unction o
each major type o blood vessel: artery,
vein, and capillary.
2. List the major disorders o blood vessels
and explain how they develop.
3. Trace the path o blood through the sys-
temic, pulmonary, hepatic portal, and
etal circulations.
4. Def ne hemodynamics, and identi y and
discuss the actors involved in the gen-
eration o blood pressure and how they
relate to each other.
5. Def ne pulse and locate the major pulse
points on the body.
6. Def ne hypertension and its associated
risk actors and complications.
7. Explain what is meant by the term circu-
latory shock and describe the major
types.
 15
In the previ us hapter we dis ussed the basi stru ture and un ti n the LANGUAGE OF
ir ulat ry systems pump: the heart. In this hapter, we ntinue ur explana- S C IEN C E
ti n h w bl d ir ulates thr ugh the internal envir nment the b dy.
Be o re re ading the
First, the stru ture bl d vessels is dis ussed in s me detail.
chapte r, s ay e ach o
Next, we expl re the un ti ns the vessels in trans- the s e te rm s o ut lo ud. This w ill
p rting vital substan es and ex hanging them with he lp yo u to avo id s tum bling ove r
the b dys tissues and the external envir nment. the m as yo u re ad.
T en, we dis uss h w the vessels t t gether int
r utes r the ndu ti n bl d. T e last part
arteriole
this hapter deals with the driving r e (ar-TEER-ee-ohl)
bl d ir ulati nbl d pressure. [arteri- vessel, -ole little]
artery
At every pp rtunity we als dis uss maj r (AR-ter-ee)
ir ulat ry dis rders t help lari y what [arter- vessel, -y thing]
happens when n rmal un ti n ails. blood pressure
(blud PRESH-ur)
blood pressure gradient
Blo o d Ve s s e ls (blud PRESH-ur GRAY-dee-ent)
[gradi- step, -ent state]
Ty p e s
capillary
Arterial bl d is pumped r m the heart (KAP-ih-layr-ee)
thr ugh a series large distributi n [capill- hair o head, -ary relating to]
vesselsthe arteries. T e largest cardiac output (CO)
(KAR-dee-ak OUT-put [see oh])
[cardi- heart, -ac relating to]
central venous pressure
(SEN-tral VEE-nus PRESH-ur)
[centr- center, -al relating to,
ven- vein, -ous relating to]
diastolic blood pressure
(dye-ah-STOL-ik blud PRESH-ur)
[dia- apart, -stol- position,
-ic relating to]
ductus arteriosus
(DUK-tus ar-teer-ee-OH-sus)
[ductus duct, arteri- vessel,
-osus relating to]
ductus venosus
(DUK-tus veh-NOH-sus)
[ductus duct, ven- vessel (vein),
-osus relating to]
endothelium
(en-doh-THEE-lee-um)
[endo- within, -theli- nipple,
-um thing]

Continued on p. 421

403
 404 CHAPTER 15 Circulation o Blood

artery in the b dy is the a rta. Arteries subdivide int vessels
that be me pr gressively smaller and nally be me tiny
arterioles that ntr l the f w int mi r s pi ex hange
vessels alled capillaries.
In the s - alled capillary beds, the ex hange nutrients
and respirat ry gases urs between the bl d and tissue
f uid ar und the ells.
Bl d exits, r is drained, r m the apillary beds and then
enters the small venules, whi h j in with ther venules and
in rease in size, be ming veins. T e largest veins, ten
alled sinuses, are the superi r vena ava and the in eri r vena
ava.
As n ted in Chapter 14, arteries arry bl d away r m the
heart and t ward apillaries. Veins arry bl d t ward the
heart and away r m apillaries, and apillaries arry bl d
r m the tiny arteri les int tiny venules. T e a rta arries
bl d ut the le t ventri le the heart, and the venae avae
return bl d t the right atrium a ter the bl d has ir ulated
thr ugh the b dy.
S t ru c t u re
Arteries, veins, and apillaries di er in stru ture. T ree ats
r layers are und in b th arteries and veins (Figure 15-1).
O u t e r La ye r
T e uterm st layer is alled the tunica externa ( r tunica
adventitia). T e w rd tunica means at and externa means
utside.
T is uter layer is made nne tive tissue bers that
rein r e the wall the vessel s that it will n t burst under
pressure. T e nne tive bers als nne t t the extra ellu-
lar matrix surr unding tissues t help h ld the vessel in
pla e.
M id d le La ye r
Figure 15-1 sh ws that sm th mus le tissue is und in the
middle layer, r tunica media, arteries and veins. T e term
tunica media means middle at.
T is mus le layer is mu h thi ker in arteries than it is in
veins. W hy is this imp rtant? Be ause the thi ker mus le
layer in the artery wall is able t resist great pressures gener-
ated by ventri ular syst le. In arteries, the tuni a media plays
a riti al r le in maintaining bl d pressure and ntr lling
bl d distributi n.
T e tuni a media ten simply alled the mediais
m stly sm th mus le, s it is ntr lled by the aut n mi
nerv us system. T e tuni a media als s metimes in ludes a
thin layer elasti br us tissue.
Sm th mus le ells al ng the wall arteri les are s me-
times alled precapillary sphincters. T ey en ir le the arteri-
le walls and by ntra ting r relaxing, they regulate h w
mu h bl d will f w int a apillary bed, as y u an see in
Figure 15-2.
In n e r La ye r
An inner layer end thelial ells alled the tunica intima
(innerm st at) lines arteries and veins.

FIGURE 15-1 Artery and vein. Schematic drawings o an artery and a vein show comparative thicknesses
o the three layers: the outer layer or tunica externa, the muscle layer or tunica media, and the tunica intima
made o endothelium. Note that the muscle and outer layers are much thinner in veins than in arteries and that
veins have valves.

ARTERY VEIN

Tunic a intima

V
e

Tunic a me dia
ye r

Thi
ie s
15
e ins

Tunic a exte rna

ie s
Thi y
e ins
 CHAPTER 15 Circulation o Blood 405

From he a rt stru tural eature apillaries is their extreme thinness nly

Arte rio le
ne layer f at, end thelial ells mp ses the apillary
membrane. Instead three layers r ats, the apillary wall
Endothe lium
is mp sed nly nethe tuni a intima. Substan es su h
S mooth as glu se, xygen, arb n di xide, h rm nes, and wastes an
mus cle fibe r
P re ca pilla ry qui kly pass thr ugh it n their way t r r m ells.
s phincte rs (re la xe d)

Capillary
be d
Capillary
Thoroughfa re cha nne l
Endothe lium
Ve nule
To he a rt
FIGURE 15-2 Capillaries. Capillaries are microscopic, thin-walled ves-
sels that orm networks joining arterioles to venules. Smooth muscle bers
(precapillary sphincters) around the arterioles can regulate how much blood
f ows into a capillary bed. Occasionally, these bers wrap around the en-
trances to capillaries to more precisely control local blood f ow.
T e tuni a intima is a tually a single layer squam us
epithelial ells alled endothelium that lines the inner sur a e
the entire ardi vas ular system. T is single layer ells
pr vides a very sm th lining that prevents the a idental
rmati n bl d l ts. T e tuni a intima als s metimes
in ludes a thin layer elasti br us tissue.
As y u an see in Figure 15-1, many veins have a unique
stru tural eature n t present in arteries. A veins tuni a intima
is equipped with p kets that a t as ne-way valves. T ese
valves prevent the ba k-f w bl dthus keeping bl d
f wing in ne dire ti n, ba k t ward the heart.
T ese ven us valves als all w veins t a t as supplemental
pumps that help maintain venous return bl d t the
heart. Figure 15-3 sh ws h w asi nal a tivity skeletal
mus les surr unding the veins the b dy reates pressure
n bl d that drives these ven us pumps. T is explains
why stret hing, walking, and ther a tivities help impr ve
bl d ir ulati n and prevent the rmati n thr mbi
(abn rmal l ts) in the veins.
W hen a surge n uts int the b dy, nly arteries, arte-
ri les, veins, and venules an be seen. Capillaries ann t be
seen be ause they are mi r s pi . T e m st imp rtant
Fu n c t io n s
gether, arteries, apillaries, and veins all ndu t bl d
ar und the b dys ir ulat ry r utes. H wever, ea h has its
wn unique r les t play.
A r t e r ie s a n d A r t e r io le s
Arteries and arteri les distribute bl d r m the heart t ap-
illaries in all parts the b dy.
In additi n, by nstri ting r dilating, arteri les help
maintain arterial bl d pressure at a n rmal level. As we dis-
uss later in this hapter, arterial pressure is a maj r r e in
keeping bl d f wing.
C a p illa ry Exc h a n g e
Capillaries un ti n as ex hange vesselsthus arrying ut a
entral un ti n the ardi vas ular system. F r example,
glu se and xygen m ve ut the bl d in apillaries int
interstitial f uid and then n int ells. Carb n di xide and
ther substan es m ve in the pp site dire ti n (that is, int
the apillary bl d r m the ells). Fluid is als ex hanged
between apillary bl d and interstitial f uid (see Chapter 21).
Figure 15-4 illustrates the n ept that tw pp sing r es
inf uen e apillary ex hange. T ese r es in lude sm sis and
ltrati n. Re all r m Chapter 3 that osmosis is passive m ve-
ment water when s me s lutes ann t r ss the membrane
and ltration is passive m vement f uid resulting r m a
hydr stati pressure gradient (see p. 51).
Figure 15-4 sh ws that the apillary ex hange r es vary,
depending n l ati n. At the arterial end a apillary, the
utwardly dire ted r es are d minant and tend t m ve
MUS CLES RELAXED MUS CLES CONTRACTED
Low
pre s s ure
High
pre s s ure 15

Low
pre s s ure
FIGURE 15-3 Venous valve unction. Normal skeletal muscle con-
tractions push on the walls o veins, which have one-way valves that
Va lve
allow the veins to act as pumps that push blood back toward the heart. High clos e s
This is similar to the action o the myocardium and heart valves acting pre s s ure
together as a pumpexcept that this venous pump mechanism is not
continuous and rhythmic. A B
 406 CHAPTER 15 Circulation o Blood

10% volume to lympha tics stay ree bstru ti n; therwise they ann t deliver their
a nd eve ntua lly re turne d to bl d t the apillary beds (and thus the tissues they serve).
ve nous blood
A r t e r io s c le ro s is
Outwardly 90% volume re turns
A mm n type vas ular disease that ludes (bl ks)
dire c te d fo rc e : to ca pilla ry arteries and weakens arterial walls is alled arteriosclerosis,
Filtra tion
(hydros ta tic
r hardening o the arteries. Arteri s ler sis is hara terized by
Inwardly dire c te d
pre s s ure ) fo rc e : thi kening arterial walls that pr gresses t hardening as
Inwardly Os mos is al ium dep sits rm. T e thi kening and al i ati n re-
dire c te d du e the f w bl d t the tissues.
fo rc e : Outwardly I the bl d f w sl ws d wn t mu h, ischemia results.
Os mos is dire c te d fo rc e :
Filtra tion Is hemia, r de reased bl d supply t a tissue, inv lves the
(hydros ta tic gradual death ells and may lead t mplete tissue death
Blood ow Ca pilla ry pre s s ure ) a nditi n alled necrosis. I a large se ti n tissue be-
mes ne r ti , it may begin t de ay. Ne r sis that has pr -
Arte rial e nd Ve no us e nd gressed this ar is alled gangrene.
FIGURE 15-4 Capillary exchange. Osmosis (osmotic pressure) and Be ause the p tential tissue damage inv lved, arteri -
ltration (hydrostatic pressure) are major orces that drive capillary ex- s ler sis may be n t nly pain ulit may be li e-threatening
change, tending to move f uids out o the capillary at the arterial end and as well. F r example, is hemia heart mus le an lead t
into the capillary at the venous end. Excess tissue f uid can be collected by myocardial in arction (M I) (see Chapter 14).
lymphatic vessels to be returned to the venous blood. T ere are several types arteri s ler sis, but perhaps the
m st well-kn wn is atherosclerosis, des ribed in Chapter 14 as
f uids r m bl d t tissue. At the ven us end a apillary, the bl kage arteries by lipids and ther matter (Figure 15-5).
the inwardly dire ted r es are greater and thus tend t m ve Eventually, the atty dep sits in the arterial walls be me -
f uids r m tissue t bl d. Ex ess tissue f uids n t m ved int br us and perhaps al i edresulting in s ler sis (hardening).
the bl d are lle ted by the lymphati system t be eventu- H igh bl d levels trigly erides and h lester l, whi h may be
ally returned t ven us bl d (see Chapter 16). aused by a high- at, high- h lester l diet, sm king, and a ge-
Fa t rs that a e t sm ti pressure (su h as plasma albumin neti predisp siti n, are ass iated with ather s ler sis. (See
levels) r the hydr stati pressure (su h as bl d pressure) that Chapter 2 r a dis ussi n trigly erides and h lester l.)
drives ltrati n an disrupt apillary ex hangeperhaps result- In general, arteri s ler sis devel ps with advan ed age, dia-
ing in dehydrati n r verhydrati n tissue (see Chapter 21). betes, high- at and high- h lester l diets, hypertensi n (high
bl d pressure), and sm king. Arteri s ler sis an be treated by
Ve in s a n d Ve n u le s drugs alled vasodilators that trigger the sm th mus les the
Venules and veins lle t bl d r m apillaries and return it arterial walls t relax, thus ausing the arteries t dilate (widen).
t the heart. S me ases ather s ler sis are treated by me hani ally
T e larger veins als serve as bl d reserv irs be ause they pening the a e ted area an artery, a type pr edure alled
arry bl d under l wer pressure (than arteries) and an ex- angioplasty. In ne su h pr edure, a def ated ball n atta hed
pand t h ld a larger v lume bl d r nstri t t h ld a t a l ng tube alled a catheter is inserted int a partially
mu h smaller am unt. As n ted previ usly, external pressure bl ked artery and then inf ated (Figure 15-6). As the ball n
an turn veins, whi h have ne-way valves, int pumps that inf ates, the plaque ( atty dep sits and tissue) is pushed ut-
help return bl d t the heart. ward, and the artery widens t all w near-n rmal bl d f w.
In a similar pr edure, metal springs r mesh tubes alled
QUICK CHECK stents are inserted in a e ted arteries t h ld them pen.
1. Wh a t a re th e m a in typ e s o b lo o d ve s s e ls in th e b o d y? O ther types angi plasty use lasers, drills, r spinning l ps
Ho w a re th e y d i e re n t ro m e a ch o th e r? wire t lear the way r n rmal bl d f w. Severely a -
2. Why is th e tu n ica m e d ia m u ch th icke r in a rte rie s th a n in e ted arteries als an be surgi ally bypassed r repla ed, as
15 ve in s ?
3. Wh a t is th e ro le o p re ca p illa ry s p h in cte rs ?
dis ussed in Chapter 14.
4. Wh a t is th e u n ctio n o ca p illa rie s ?
To learn more about altherosclerosis and
angioplasty, go to AnimationDirect online at
D is o r d e r s o Blo o d Ve s s e ls evolve.elsevier.com.
D is o r d e r s o A r t e r ie s
As y u may have gathered r m the previ us dis ussi n, arter- A n e u ry s m
ies ntain bl d that is maintained at a relatively high pres- Damage t arterial walls aused by arteri s ler sis r ther
sure. T is means the arterial walls must be able t withstand a a t rs may lead t the rmati n an aneurysm. An aneu-
great deal r e, r they will burst. T e arteries must als rysm is a se ti n an artery that has be me abn rmally
 CHAPTER 15 Circulation o Blood 407

FIGURE 15-5 Atherosclerosis. Atherosclerotic plaque develops rom the deposition

o ats and other substances in the wall o the artery. The inset is a photograph showing a
cross section o an artery partially blocked by plaque.

Endothe lium
widened be ause a weakening the arterial wall. An-
eurysms s metimes rm a sa like extensi n the arte-
rial wall.
One reas n aneurysms are danger us is be ause they,
like ather s ler ti plaques, pr m te the rmati n
thr mbi (abn rmal l ts). A thr mbus may P la que Lume n
ause an emb lism (bl kage) in the heart r
s me ther vital tissue. An ther reas n an-
eurysms are danger us is their tenden y t
burst, ausing severe hem rrhaging that
Athe ros cle rotic
may result in death. pla que
A brain aneurysm may lead t a stroke,
r cerebrovascular accident (CVA). A
str ke results r m is hemia brain tissue
aused by an emb lism r ruptured aneurysm.
Depending n the am unt tissue a e ted and
the pla e in the brain the CVA urs, e e ts a str ke
may range r m hardly n ti eable t rippling t atal.

Check out the article Aneurysm at Connect It! at

evolve.elsevier.com.

15

A B C
FIGURE 15-6 Balloon angioplasty. A, A catheter is inserted into the vessel until it reaches the a ected
region. B, A probe with a metal tip is pushed out the end o the catheter into the blocked region o the vessel.
C, The balloon is inf ated, pushing the walls o the vessel outward. Sometimes metal coils or tubes (stents) are
inserted to keep the vessel open.
 408 CHAPTER 15 Circulation o Blood
D is o r d e r s o Ve in s
Va r ic o s e Ve in s
Varicose veins are veins in whi h bl d tends t p l rather
than ntinue n t ward the heart. Vari sities, als alled
varices (singular, varix), m st mm nly ur in super cial
veins near the sur a e the b dy (Figure 15-7).
T e large super ial veins the leg ten be me vari se
in pe ple wh stand r l ng peri ds (see Figure 15-7). T e
r e gravity sl ws the return ven us bl d t the heart
in su h ases, ausing bl d-eng rged veins t dilate. As the
veins dilate, the distan e between the f aps ven us valves
widens, eventually making them in mpetent (leaky). In m-
peten e valves auses even m re p ling in a e ted veins
an abn rmal p sitive- eedba k phen men n.
Hemorrhoids, r piles, are vari se veins in the re tum r
anus. Ex essive straining during de e ati n an reate pres-
sures that ause hem rrh ids. T e unusual pressures arry-
ing a hild during pregnan y predisp se expe tant m thers t
hem rrh ids and ther vari sities.
Vari se veins an be treated by supp rting the dilated
veins r m the utside. F r example, supp rt st kings an
redu e bl d p ling in the great saphen us vein. Surgi al
rem val vari se veins an be per rmed in severe ases.
Advan ed ases hem rrh ids are ten treated this way.
Sympt ms milder ases an be relieved by rem ving the
pressure that aused the nditi n and ther meth ds.
P h le b it is
A number a t rs an ause phlebitis, r vein inf amma-
ti n. Irritati n by an intraven us atheter, r example, is a
mm n ause vein inf ammati n.
T rombophlebitis is a ute phlebitis aused by l t (thr m-
bus) rmati n. Veins are m re likely sites thr mbus
Norma l ve in
Norma l ve nous va lve
15 Va ricos e ve in
P
P A
D
Incompe te nt (le a ky)
ve nous va lve
A B
FIGURE 15-7 Varicose veins. A, Veins near the sur ace o the body
especially in the legsmay bulge and cause venous valves to leak. B, Photo-
graph showing varicose veins on the sur ace o the leg.
rmati n than arteries be ause ven us bl d m ves m re
sl wly and is under less pressure. T r mb phlebitis is hara -
terized by pain and dis l rati n the surr unding tissue.
I a pie e a l t breaks ree, it may ause an emb lism
when it bl ks a bl d vessel. Pulmonary embolism, r ex-
ample, uld result when an emb lus l dges in the ir ulati n
the lung (see Figure 13-18 n p. 366). Pulm nary emb lism
an lead t death qui kly i t mu h bl d f w is bl ked.
QUICK CHECK
1. Wh a t is th e m e d ica l te rm o r h a rd e n in g o th e a rte rie s ?
De s crib e th is co n d itio n .
2. Wh a t is a n a n e u rys m ?
3. Wh a t ca u s e s va rico s e ve in s ?
Ro u t e s o C ir c u la t io n
T e term blood circulation is sel -explanat ry, meaning that
bl d f ws thr ugh vessels that mprise a mplete ir uit
r ir ular pattern. A route o circulation is a parti ular set
ir ular pathwayssu h as r m the heart t the lungs and
ba k r r m the heart t a parti ular rgan and ba k.
S y s t e m ic a n d P u lm o n a ry C ir c u la t io n
Bl d f w r m the le t ventri le the heart thr ugh bl d
vessels t all parts the b dy and ba k t the right atrium
the heart was des ribed in Chapter 14 as the systemic
circulation.
Starting ur st ry at the le t ventri le, bl d is pushed int
the a rta. Fr m there, it f ws int arteries that arry it int
the tissues and rgans the b dy. As sh wn by the n ept
map in Figure 15-8, bl d m ves r m arteries t arteri les t
apillaries systemi tissues. T ere, the vital tw -way ex-
hange substan es urs between bl d and ells.
Next, bl d f ws ut ea h rgans apillary beds by way
its venules and then its veins t drain eventually int the
in eri r r superi r vena ava. T ese tw great veins return
ven us bl d t the right atrium the heart.
At that p int, the bl d is sh rt ming ull ir le ba k
t its starting p int in the le t ventri le. rea h the le t ven-
tri le and start n its way again, it must rst f w thr ugh
an ther ir uit, re erred t in Chapter 14 as the pulmonary
circulation.
F ll wing al ng in Figure 15-8, bserve that ven us bl d
m ves r m the right atrium t the right ventri le and then t
the pulm nary artery t pulm nary arteri les and apillaries.
T ere, the ex hange gases between the bl d and air takes
pla e, nverting the deep rims n l r typi al de xygen-
ated bl d t the bright s arlet l r xygenated bl d.
T is xygenated bl d then f ws thr ugh lung venules int
ur pulm nary veins and returns t the le t atrium the
heart. Fr m the le t atrium, it enters the le t ventri le, r m
whi h it will n e again be pumped thr ugh ut the b dy in
the systemi ir ulati n.
Study Figure 15-9 and Table 15-1 t learn the names the
main systemi and pulm nary arteries the b dy. Likewise,
 CHAPTER 15 Circulation o Blood 409

HEART HEART

Right a trium Le ft a trium

Right AV va lve Le ft AV va lve

Right ve ntricle Le ft ve ntricle

P ulmona ry Aortic
S L va lve S L va lve

LUNGS
Ve na P ulmona ry P ulmona ry
Arte rie s Aorta
cava a rte ry ve ins

Arte riole s

Ve ins of Arte rie s of

e a ch orga n Ca pilla rie s e a ch orga n

Ve nule s

Ve nule s of Arte riole s of

e a ch orga n Ve ins e a ch orga n

Ca pilla rie s of e a ch orga n

FIGURE 15-8 Diagram o blood ow in the cardiovascular system. Blood leaves the heart through
arteries, then travels through arterioles, capillaries, venules, and veins be ore returning to the opposite side o
the heart. AV, Atrioventricular; SL, semilunar.

study Figure 15-10 and Table 15-2 r the names the main
systemi and pulm nary veins. Expl re the Clear View o the
Human Body ( ll ws p. 8) t see the l ati ns s me the
maj r bl d vessels relative t ther rgans.
To learn more about pulmonary circulation and
systemic circulation, go to AnimationDirect online
at evolve.elsevier.com.
To better understand these concepts, use the
Active Concept Map Blood Flow Through the
Heart at evolve.elsevier.com.
He p a t ic P o r t a l C ir c u la t io n
T e term hepatic portal circulation re ers t the r ute
bl d f w t and thr ugh the liver. T e term portal means
d rway and re ers t a systemi ir ulat ry r ute that is a
d rway t a se nd set systemi tissues.
Veins r m the spleen, st ma h, pan reas, gallbladder, and
intestines d n t p ur their bl d dire tly int the in eri r
vena ava as d the veins r m ther abd minal rgans. In-
stead, bl d f w r m these rgans is det ured t the liver by
means the hepati p rtal vein (Figure 15-11). T e bl d then
passes thr ugh the apillary beds and ven us spa es the
liver be re it reenters the m re dire t ven us return pathway
t the heart. Bl d leaves the liver by way the hepati veins,
whi h drain int the in eri r vena ava.
As n ted in Figure 15-8, m st the bl d f ws r m arter-
ies t arteri les t apillaries t venules t veins and ba k t the
heart. Bl d f w that is diverted t the hepati p rtal ir ula-
ti n, h wever, d es n t ll w this dire t r ute. T e diverted
ven us bl d, instead returning dire tly t the heart, is sent
instead thr ugh a se nd apillary bed in the liver. T e hepati
p rtal vein sh wn in Figure 15-11 is l ated between tw apil-
lary beds ne l ated in the digestive rgans and the ther in
the liver.
On e bl d exits r m the liver apillary beds, it returns t 15
the systemi bl d pathway, returning t the right atrium
the heart.
T e det ur ven us bl d thr ugh a se nd apillary
bed in the liver be re its return t the heart serves s me
valuable purp ses. F r example, when nutrients r m a meal
are being abs rbed, the bl d in the p rtal vein ntains a
higher-than-n rmal n entrati n glu se. Re all r m
Chapter 12 (see Figure 12-4 n p. 324) that su h high glu se
levels trigger the se reti n insulin r m pan reati islets.
Inf uen ed by insulin, liver ells rem ve the ex ess glu se
 410 CHAPTER 15 Circulation o Blood

The Major Systemic

TABLE 15-1
Occipita l Arteries
Fa cia l ARTERY TIS S UES S UPPLIED
Inte rna l ca rotid
He ad and Ne ck
Exte rna l ca rotid
Occipital Pos te rior he ad and ne ck
Right common ca rotid Le ft common ca rotid
Facial Mouth, pharynx, and ace
Le ft s ubclavia n
Right s ubclavia n Inte rnal carotid Ante rior brain and
Arch of a orta
Bra chioce pha lic m e ninge s
P ulmona ry
Exte rnal carotid Supe rf cial ne ck, ace ,
Right corona ry Le ft corona ry eye s , and larynx
Axilla ry Thora cic a orta Com m on carotid He ad and ne ck

S ple nic Ve rte bral Brain and m e ninge s

Bra chia l
Tho rax
Re na l
S upe rior me s e nte ric Le t s ubclavian Le t uppe r extre m ity
Ce lia c
Brachioce phalic He ad and arm
Abdomina l a orta Infe rior
me s e nte ric Arch o aorta Branche s to he ad, ne ck,
Common ilia c and uppe r extre m itie s
Ra dia l
Inte rna l ilia c Coronary He art m us cle
Ulna r
Exte rna l ilia c Abdo m e n
Ce liac Stom ach, s ple e n, and live r
Sple nic Sple e n
Re nal Kidneys
Supe rior Sm all inte s tine ; uppe r hal
m e s e nte ric o the large inte s tine
In e rior m e s e nte ric Lowe r hal o the large
De e p fe mora l inte s tine
Fe mora l Uppe r Extre m ity
Axillary Axilla (arm pit)
Brachial Arm
Poplite a l
Radial Late ral s ide o the hand
Ulnar Me dial s ide o the hand
Low e r Extre m ity
Inte rnal iliac Pe lvic s tructure s : vis ce ra,
ge nitalia, and re ctum
Ante rior tibia l
Exte rnal iliac Lowe r trunk and lowe r
extre m itie s
De e p e m oral De e p thigh m us cle s

S Fe m oral Thigh
Poplite al Kne e and le g
R L
Ante rior tibial and Le g
I pos te rior tibial
15
FIGURE 15-9 Principal arteries o the body.

and st re it as gly gen. T ere re, bl d leaving the liver T e hepati p rtal system is an ex ellent example
usually has a l wer bl d glu se n entrati n than bl d h w stru ture ts un ti n in helping the b dy maintain
entering the liver. h me stasis.
Liver ells als rem ve and det xi y vari us p is n us
substan es that may be present in the bl d. T e hepati p r-
To learn more about hepatic portal circulation, go
tal ir ulati n brings any new t xins abs rbed r m d di-
to AnimationDirect online at evolve.elsevier.com.
re tly t the liver where they an be det xi ed.
 CHAPTER 15 Circulation o Blood 411

The Major Systemic Occipita l

TABLE 15-2
Veins Right bra chioce pha lic Fa cia l
VEIN TIS S UES DRAINED
Right s ubclavia n Exte rna l jugula r
He ad and Ne ck
Supe rior s agittal s inus Brain S upe rior Inte rna l jugula r
Facial and ante rior Ante rior and s upe rf cial ve na cava
Le ft bra chioce pha lic
acial ace
Right
Exte rnal jugular Supe rf cial tis s ue s o the pulmona ry Le ft s ubclavia n
he ad and ne ck Axilla ry
S ma ll ca rdia c
Inte rnal jugular Sinus e s o the brain Ce pha lic
Tho rax Infe rior Gre a t ca rdia c
ve na cava
Brachioce phalic He ad, ne ck, and uppe r
Ba s ilic
extre m itie s He pa tic
Bra chia l ve ins
Subclavian Uppe r extre m itie s
He pa tic porta l
Supe rior ve na cava He ad, ne ck, and uppe r Long thora cic
extre m itie s S upe rior
S ple nic
me s e nte ric
Right and le t coronary He art
Re na l
In e rior ve na cava Lowe r body Me dia n
cubita l Infe rior
Abdo m e n me s e nte ric
Common
He patic Live r ilia c Ra dia l ve in
Long thoracic Abdom inal and thoracic Ulna r
m us cle s ve in
He patic portal Inte s tine s and ne arby
inte rnal organs Exte rna l
ilia c Digita l
Sple nic Sple e n ve ins
Supe rior m e s e nte ric Sm all inte s tine and m os t Common ilia c
o the colon Fe mora l
Inte rna l ilia c
In e rior m e s e nte ric De s ce nding colon and Gre a t
re ctum s a phe nous Fe mora l
Uppe r Extre m ity
Poplite a l
Ce phalic Late ral arm
Axillary Axilla and arm
Bas ilic Me dial arm Fibula r
(pe rone a l)
Me dian cubital Ce phalic ve in (to bas ilic
ve in) Ante rior tibia l
Radial Late ral ore arm
Pos te rior tibia l
Ulnar Me dial ore arm
S
Low e r Extre m ity
R L
Inte rnal iliac Pe lvic s tructure s : vis ce ra,
ge nitals , re ctum I
Exte rnal iliac Lowe r lim b
Fe m oral Thigh 15
Gre at s aphe nous Lowe r extre m ity FIGURE 15-10 Principal veins o the body.
Sm all s aphe nous Foot
Poplite al Le g
Fibular (pe rone al) Foot
Ante rior tibial De e p ante rior le g and
dors al oot
Pos te rior tibial De e p pos te rior le g and
plantar as pe ct
 412 CHAPTER 15 Circulation o Blood

Infe rior ve na cava

He pa tic ve ins

S toma ch

Live r Ga s tric ve in

S ple e n
He pa tic porta l ve in

Pa ncre a tic ve ins

Duode num
S ple nic ve in

Ga s troe piploic ve in
Pa ncre a s

De s ce nding colon

S upe rior me s e nte ric ve in

Infe rior me s e nte ric ve in

S ma ll inte s tine
As ce nding colon

S
Appe ndix
R L

FIGURE 15-11 Hepatic portal circulation. In this very unusual circulation, a vein is located between two
capillary beds. The hepatic portal circulation collects blood rom capillaries in visceral structures located in the
abdomen and delivers it to the liver through the hepatic portal vein. The blood leaves the liver through hepatic
veins, which deliver it to the in erior vena cava. (Organs are not drawn to scale here.)

Fe t a l C ir c u la t io n bl d, and the umbili al arteries arry xygen-p r bl d.

Cir ulati n in the b dy be re birth di ers r m ir ulati n Remember that arteries are vessels that arry bl d away r m
a ter birth be ause the etus must se ure xygen and nutrients the heart, whereas veins arry bl d t ward the heart, regard-
15 r m maternal bl d instead r m its wn lungs and diges- less the xygen ntent these vessels may have.
tive rgans.
F r the ex hange nutrients and xygen t ur between Umbilical hernia, which occurs when intestines
etal and maternal bl d, bl d vessels must arry the etal protrude through the umbilical opening in the
bl d t the placenta, where the ex hange urs, and then abdomen, are common in newborn in ants. Review
return it t the etal b dy. T ree vessels (sh wn in Figure 15-12 Hernias at Connect It! at evolve.elsevier.com.
as part the umbilical cord) a mplish this purp se. T ey
are the tw small umbilical arteries and a single, mu h larger An ther stru ture unique t etal ir ulati n is alled the
umbilical vein. ductus venosus. As y u an see in Figure 15-12, it is a tually a
T e m vement bl d in the umbili al vessels may seem ntinuati n the umbili al vein. It serves as a shunt, all w-
unusual at rst in that the umbili al vein arries xygenated ing m st the bl d returning r m the pla enta t bypass
 CHAPTER 15 Circulation o Blood 413

5
1 Duc tus arte rio s us
Be fore birth, s ubs ta nce s
P ulmona ry trunk
a re e xcha nge d with the
ma te rna l circula tion Aortic
through the pla ce nta . As ce nding a orta a rch

2 S upe rior ve na cava

Blood the n flows Le ft
into the fe ta l 4 lung
a bdome n through
the umbilica l ve in. Fo rame n ovale

3
Blood e nte rs the live r a nd conne cts
to the infe rior ve na ca va by wa y of
the ductus ve nos us .

Live r
Abdomina l a orta
Infe rior ve na cava
3 Duc tus ve no s us
He pa tic porta l ve in
Mate rna l
1 s ide
Plac e nta
Kidney
Fe ta l 2
s ide
4 Umbilic al
ve in
Blood ma y bypa s s the
pulmona ry loop by moving
from the R a trium through
the fora me n ova le to the
L a trium. Fe ta l Common ilia c a rte ry
umbilicus
5 Umbilic al
Blood ma y a ls o bypa s s arte rie s Inte rna l
the pulmona ry loop a t ilia c
the pulmona ry trunk 6
a rte rie s S
through the ductus
a rte rios us into the a orta . R L

Umbilic al I
6 c o rd
Blood is re turne d to
the pla ce nta through FIGURE 15-12 Fetal circulation.
umbilica l a rte rie s ,
which bra nch from
the inte rna l ilia c
a rte rie s .

Several ngenital dis rders result r m the ailure the

ardi vas ular system t shi t r m the etal r ute bl d
the immature liver the devel ping etus and empty dire tly f w at the time birth. T e du tus arteri sus may ail t
int the in eri r vena ava. l se, r example, and all w de xygenated bl d t bypass
w ther stru tures in the devel ping etus all w m st the lungs. 15
the bl d t bypass the devel ping lungs, whi h remain l- Similarly, the ramen vale may ail t l se and remain
lapsed until birth. T e oramen ovale shunts bl d r m the as a s - alled hole in the heart that all ws bl d t bypass the
right atrium dire tly int the le t atrium, and the ductus pulm nary ir ulati n. De e ts in the septum between atria
arteriosus nne ts the pulm nary artery t the a rta. r between ventri les an als pr du e h le-in-the-heart
At birth, the in ants umbili al bl d vessels and shunts nditi ns. Many pe ple with small h les d n t even kn w
must be rendered n n un ti nal. W hen the newb rn in ant they have them, living relatively n rmal, healthy lives. In
takes its rst deep breaths, the ardi vas ular system is sub- m derate t severe ases, h wever, a light-skinned baby may
je ted t in reased pressure. T e result is l sure the ra- appear bluish be ause the la k xygen in the systemi
men vale and rapid llapse the umbili al bl d vessels, arterial bl d. T is nditi n bluish tissue l rati n is
the du tus ven sus, and du tus arteri sus. alled cyanosis.
 414 CHAPTER 15 Circulation o Blood

the entire systemi ir ulati n is the di eren e between the

To learn more about patent (open) ductus arteri-
ous or oramen ovale, check out the article
Congenital Heart De ects at Connect It! at
evolve.elsevier.com.
QUICK CHECK
1. Ho w d o s ys te m ic a n d p u lm o n a ry circu la tio n s d i e r?
2. Wh a t is th e h e p a tic p o rta l circu la tio n ?
3. Ho w is e ta l circu la tio n d i e re n t ro m a d u lt circu la tio n ?
4. Wh a t is cya n o s is ?
To learn more about etal circulation, go to
AnimationDirect online at evolve.elsevier.com.
He m o d y n a m ic s
T e term hemodynamics re ers t the set pr esses that
inf uen e the f w bl d. As we shall see, the main r e
that drives the ntinu us f w bl d thr ugh its ir ula-
t ry r utes is blood pressure.
D e f n in g Blo o d P r e s s u r e
A g d way t explain bl d pressure might be t rst answer
a ew questi ns ab ut it. W hat is bl d pressure? Just what
the w rds indi ateblood pressure is the pressure r push
bl d as it f ws thr ugh the ardi vas ular system.
W here d es bl d pressure exist? It exists in all bl d ves-
sels, but it is highest in the arteries and l west in the veins. In
a t, i we list bl d vessels in rder a rding t the am unt
bl d pressure in them and draw a graph, as in Figure 15-13,
the graph l ks like a hill, with a rti bl d pressure at the
t p and vena aval pressure at the b tt m. T is bl d pressure
hill is sp ken as the blood pressure gradient.
M re pre isely, the bl d pressure gradient is the di eren e
between tw bl d pressures. T e bl d pressure gradient r
average r mean bl d pressure in the a rta and the bl d
pressure at the terminati n the venae avae where they j in
the right atrium the heart. T e mean bl d pressure in the
a rta, given in Figure 15-13, is 100 mm mer ury (mm H g),
and the pressure at the terminati n the venae avae is 0.
T ere re, with these typi al n rmal gures, the systemi
bl d pressure gradient is 100 mm H g (100 minus 0).
W hy is it imp rtant t understand h w bl d pressure
un ti ns? T e bl d pressure gradient is vitally inv lved in
keeping the bl d f wing. W hen a bl d pressure gradient is
present, bl d ir ulates; nversely, when a bl d pressure
gradient is n t present, bl d d es n t ir ulate.
F r example, supp se that the bl d pressure in the arteries
were t de rease t a p int at whi h it be ame equal t the
average pressure in arteri les. T e result w uld be n bl d
pressure gradient between arteries and arteri les, and there-
re n r e w uld be available t m ve bl d ut arteries
int arteri les. Cir ulati n w uld st p, in ther w rds, and
very s n li e itsel w uld ease. T at is why when arterial
bl d pressure is bserved t be alling rapidly, whether dur-
ing surgery r in s me ther ir umstan e, emergen y mea-
sures must be started qui kly t try t reverse this atal trend.
W hat we have just said may start y u w ndering ab ut
why high bl d pressure (meaning, urse, high arterial
bl d pressure) and l w bl d pressure are bad r ir ulati n.
H igh bl d pressure, r hypertension (H N), is bad r
several reas ns. F r ne thing, i bl d pressure be mes t
high, it may ause the rupture ne r m re bl d vessels
( r example, in the brain, as happens in a str ke). Chr ni
H N an als in rease the l ad n the heart, ausing abn r-
mal thi kening the my ardiumand perhaps eventually
lead t heart ailure.
But l w bl d pressure an be danger us t . I arterial
pressure alls l w en ugh, then bl d will n t f w thr ugh, r
per use, the vital rgans the b dy. Cir ulati n bl d and
thus li e will ease. Massive hem rrhage, whi h dramati ally
redu es bl d pressure, kills in this way.

Fa c t o r s Th a t In u e n c e
C LIN ICA L APPLICATION Blo o d P r e s s u r e
RAYNAUD PHENOMENON W hat auses bl d pressure, and what
A dis orde r characterize d by sudde n de cre as es in circulation in the digits (f nge rs or makes bl d pressure hange r m time
toe s), o te n in re s ponse to s tres s or te mpe rature change , is calle d Raynaud t time? Fa t rs su h as bl d v lume,
phe no m e non. The decrease d blood ow o te n cause s pale discoloration o the a - the strength ea h heart ntra ti n,
15 ected digits (s ee f gure ), ollowe d by num bne s s and cyanos is (blue discoloration) heart rate, the thi kness bl d, and
as oxyge n leve ls drop. As blood ow re turns to the digits, they m ay be com e dark resistan e t bl d f w are all part the
and re dde ro te n s we lling and answers t these questi ns. We explain
throbbing w ith pain. Symptoms urther in the paragraphs that ll w.
range rom mild to seve re .
The re is no know n caus e Blo o d Vo lu m e
o Raynaud phe nom e non, but
s om e cas e s have be e n as s oci- T e dire t ause bl d pressure is the
ate d w ith in am m atory condi- volume bl d in the vessels. T e larger
tions s uch as s cle rode rm a, the v lume bl d in the arteries, r
rhe um atoid arthritis , and lupus example, the m re pressure the bl d
e rythe m atos us . exerts n the walls the arteries, r the
higher the arterial bl d pressure.
 CHAPTER 15 Circulation o Blood 415

Driving force
100 mm Hg
S ys tolic pre s s ure 100 mm Hg
Flow ra te =
120 100 mm Hg/L/min

100 mm Hg
Flow ra te = 1 L/min
100 Re s is ta nce = 100 mm Hg/L/min

0 mm Hg
85 mm
80
)
g
H
Dia s tolic
m
pre s s ure
m
(
60
e
r
u
s
s
e
r
P
40
Aorta La rge S ma ll Arte riole s 35 mm Ve nule s S ma ll La rge Ve na e
a rte rie s a rte rie s ve ins ve ins cava e

20 15 mm
6 mm
Ca pilla rie s 2 mm
1 mm
0

FIGURE 15-13 Pressure gradient that drives blood ow. Blood f ows down a blood pressure hill
rom arteries, where blood pressure is highest, into arterioles, where it is somewhat lower, into capillaries,
where it is lower still, and so on. All numbers on the graph indicate blood pressure measured in millimeters
o mercury.

C nversely, the less bl d in the arteries, the l wer the
bl d pressure tends t be.
H em rrhage dem nstrates this relati nship between bl d
v lume and bl d pressure. H em rrhage is a pr n un ed l ss
bl d, and this de rease in the v lume bl d auses
bl d pressure t dr p. In a t, the maj r sign hem rrhage
is a rapidly alling bl d pressure.
An ther example is the a t that diureticsdrugs that
pr m te water l ss by in reasing urine utputare ten used
t treat hypertensi n (high bl d pressure). As water is l st
r m the b dy, bl d v lume de reases, and thus bl d pres-
sure de reases t a l wer level.
T e v lume bl d in the arteries is determined by h w
mu h bl d the heart pumps int the arteries and h w mu h
bl d the arteri les drain ut them. T e diameter the
arteri les plays an imp rtant r le in determining h w mu h
bl d drains ut arteries int arteri les.
Figure 15-14 summarizes s me the maj r a t rs that a -
e t arterial bl d v lume, whi h inf uen es arterial bl d
pressure, whi h is in turn the main a t r driving ntinued
bl d f w in the b dy.
S t r e n g t h o He a r t C o n t r a c t io n s
In the previ us hapter, we dis ussed that the strength and the
rate the heartbeat a e t cardiac output (CO) and there re
bl d pressure.
Ea h time the le t ventri le ntra ts, it squeezes a ertain
v lume bl d (the stroke volume [SV]) int the a rta and
n int ther arteries. T e str nger that ea h ntra ti n is,
the m re bl d it pumps int the a rta and arteriesthat is,
the SV is higher. C nversely, the weaker that ea h ntra ti n
is, the less bl d it pumpsand the l wer the str ke v lume.
Supp se that ne ntra ti n the le t ventri le pumps
70 mL bl d int the a rta, and supp se that the heart
beats 70 times a minute; 70 mL/beat 70 beats/min equals
4900 mL/min. Alm st 5 L bl d w uld enter the a rta and
arteries every minute (the CO).
N w supp se that the heartbeat were t be me weaker
and that ea h ntra ti n the le t ventri le pumps nly
50 mL instead 70 mL bl d int the a rta. I the heart
still ntra ts just 70 times a minute, it will bvi usly pump
mu h less bl d int the a rta nly 3500 mL/min instead
the m re n rmal 4900 mL/min. T is de rease in the hearts
CO de reases the v lume bl d in the arteries, and the
de reased arterial bl d v lume de reases arterial bl d
pressure.
In summary, the strength the heartbeat a e ts bl d 15
pressure in this way: a str nger heartbeat in reases bl d pres-
sure, and a weaker beat de reases it.
He a r t Ra t e
T e heart rate (H R) als may a e t arterial bl d pressure.
Y u might reas n that when the heart beats aster, m re bl d
enters the a rta, and there re the arterial bl d v lume and
bl d pressure w uld in rease.
T is is true nly i the str ke v lume d es n t de rease
sharply when the heart rate in reases. O ten, h wever, when
the heart beats aster, ea h ntra ti n the le t ventri le
 416 CHAPTER 15 Circulation o Blood

S troke volume He a rt ra te Blood vis cos ity Dia me te r of a rte riole s

Ca rdia c output pe r minute Pe riphe ra l re s is ta nce

Volume of blood e nte ring Volume of blood le aving a rte rie s

a rte rie s pe r minute pe r minute, the a rte riole runoff

Arte ria l blood volume

Arte rial blo o d pre s s ure

FIGURE 15-14 Factors a ecting blood pressure. Arterial blood pressure is directly proportional to arte-
rial blood volume. Cardiac output (CO) and peripheral resistance (PR) are directly proportional to arterial blood
volume, but or opposite reasons: CO a ects blood entering the arteries, and PR a ects blood leaving the arter-
ies. I CO increases, the amount o blood entering the arteries increases and tends to increase the volume o
blood in the arteries. I PR increases, it decreases the amount o blood leaving the arteries, which tends to in-
crease the amount o blood le t in them. Thus an increase in either CO or PR results in an increase in arterial
blood volume, which increases arterial blood pressure.

takes pla e s rapidly that it has little time t ll with bl d
and there re squeezes ut mu h less bl d than usual int
the a rta.
F r example, supp se that the heart rate speeded up r m
70 t 100 times per minute and that at the same time its
str ke v lume de reased r m 70 mL t 40 mL. Instead
a CO 70 70, r 4900 mL/min, the ardia utput
w uld have hanged t 100 40 r 4000 mL/min. Arterial
bl d v lume de reases under these nditi ns, and there-
re bl d pressure als de reases, even th ugh the heart
rate has in reased.
W hat generalizati n, then, an we make? We an say nly
that an in rease in the rate the heartbeat in reases bl d
pressure, and a de rease in the rate de reases bl d pressure.
But whether a hange in the heart rate a tually pr du es a
similar hange in bl d pressure depends n whether the
str ke v lume als hanges and in whi h dire ti n.
Blo o d Vis c o s it y
An ther a t r that needs t be menti ned in nne ti n with
bl d pressure is the viscosity bl d, r in plainer language,
its thi kness. T e thi ker the bl d, the m re resistan e t
15 f w there isand the m re bl d pressure will build up.
I bl d be mes less vis us than n rmal, bl d pressure
de reases.
F r example, i a pers n su ers a hem rrhage, f uid m ves
int the bl d r m the interstitial f uid. T is dilutes the bl d
and de reases its vis sity, and bl d pressure then alls be-
ause the de reased vis sity. A ter hem rrhage, trans u-
si n wh le bl d r plasma is pre erred t in usi n saline
s luti n. T e reas n is that saline s luti n is n t a vis us
liquid and s ann t keep bl d pressure at a n rmal level.
In a nditi n alled polycythemia, dis ussed brief y in
Chapter 13 (see Figure 13-3 n p. 353), the number red
bl d ells (RBCs) in reases bey nd n rmal and thus in-
reases bl d vis sity. T is in turn in reases bl d pressure.
An elevated RBC unt als an ur when xygen levels in
the air de rease and the b dy attempts t in rease its ability
t attra t xygen t the bl das happens when w rking at
high altitude.
Re s is t a n c e t o Blo o d Flo w
A a t r that has a huge impa t n l al bl d pressure gradi-
ents, and thus n bl d f w, is any a t r that hanges the re-
sistan e t bl d f w. T e term peripheral resistance (PR)
des ribes any r e that a ts against the f w bl d in a bl d
vessel. Vis sity bl d, r example, a e ts PR by inf uen ing
the ease with whi h bl d f ws thr ugh bl d vessels.
An ther a t r that a e ts PR is the tensi n in sm th
mus les the bl d vessel wall (Figure 15-15). W hen these
mus les are relaxed, resistan e is l w and there re bl d pres-
sure is l wthus bl d may f w easily d wn its pressure
gradient and int the vessel. W hen vessel wall mus les are
ntra ted, h wever, resistan e in reases and there re s d es
the bl d pressurethus the pressure gradient is redu ed and
bl d will n t f w s easily int the vessel.
N ti e als in Figure 15-15 that relatively min r hanges in
vessel diameter ause dramati hanges in bl d f w. T is
a t means that with very slight adjustments mus le tensi n
in bl d vessels, a wide range di erent rates bl d f w
an be a hieved.
Su h adjustment mus le tensi n in vessel walls t n-
tr l bl d pressure, and there re bl d f w, is ten alled
the vasomotor mechanism.
 CHAPTER 15 Circulation o Blood 417

De c re as e d re s is tanc e FIGURE 15-15 Vasomotor mechanism. Changes in smooth muscle tension in the wall o
an arteriole inf uence the resistance o the vessel to blood f ow. Relaxation o muscle results in
decreased resistance; contraction o muscle results in increased resistance.

Inc re as e d re s is tanc e

S mooth
mus cle
Dia me te r = 2 ce ll Dia me te r = 1
Flow = 256 mL/min Flow =
16 mL/min

Dia me te r = 1/2
Flow = 1 mL/min

S mo o th mus cle re laxatio n No rmal re s ting to ne S mo o th mus cle c o ntrac tio n

n rmal, but the in reased bl d pressure serves a g d pur-

Flu c t u a t io n s in A r t e r ia l
Blo o d P r e s s u r e
N nes bl d pressure stays the same all the time. It f u tu-
ates, even in a per e tly healthy individual. F r example, it
g es up when a pers n exer ises strenu usly. N t nly is this
p se. It in reases ir ulati n t bring m re bl d t mus les
ea h minute and thus supplies them with m re xygen and
nutrients r m re energy.
A n rmal, resting arterial bl d pressure is bel w 120/80,
r 120 mm H g syst li pressure (maximum pressure) and

HEA LTH AND WELL-BEIN G

CHANGES IN BLOOD FLOW DURING EXERCIS E
Not only doe s the ove rall rate o blood ow incre as e during
exe rcis e , but als o the re lative blood ow through the di e re nt
organs o the body change s . During exe rcis e , blood is route d
away rom the kidneys and dige s tive organs and toward the
s ke le tal m us cle s , cardiac m us cle , and s kin. Re routing o blood
is accom plis he d by contracting pre capillary s phincte rs in s om e
tis s ue s (thus re ducing blood ow ) w hile re laxing pre capillary
s phincte rs in othe r tis s ue s (thus incre as ing blood ow ). How
can hom e os tas is be be tte r m aintaine d as a re s ult o the s e
change s ? One re as on is that glucos e and oxyge n leve ls drop
rapidly in m us cle s as they us e up the s e s ubs tance s to produce
e ne rgy or exe rcis ing. Incre as e d blood ow re s tore s norm al
leve ls o glucos e and oxyge n m ore rapidly. Blood that has be e n
warm e d up in active m us cle s ow s to the s kin or cooling. This
he lps ke e p the body te m pe rature rom ge tting too high. Can
you think o othe r ways this change in blood ow he lps m ain-
tain hom e os tas is ?

13
12 At re s t
11 During exe rcis e
10
)
9
n
i
m
8
15
/
L
(
7
w
6
o
l
f
5
d
o
o
4
l
B
3
2
1
0
Bra in Ca rdia c S ke le ta l S kin Abdomina l Kidneys Othe r
mus cle mus cle orga ns
 418 CHAPTER 15 Circulation o Blood

80 mm H g diast li pressure (minimum pressure). Remem-
ber, h wever, that what is n rmal varies s mewhat am ng
individuals and als varies with age.
C e n t r a l Ve n o u s Blo o d P r e s s u r e
T e ven us bl d pressure, as y u an see in Figure 15-13, is
very l w in the large veins and alls alm st t 0 by the time
bl d leaves the venae avae and enters the right atrium. T e
ven us bl d pressure within the right atrium is alled the
central venous pressure. T e entral ven us pressure repre-
sents the l w end the pressure gradient needed t drive
bl d f w all the way ba k t the heart.
T e entral ven us pressure level is imp rtant be ause it
inf uen es the pressure that exists in the large peripheral veins.
I the heart beats str ngly, the entral ven us pressure is l w
as bl d enters and leaves the heart hambers e iently.
I the heart is weakened, h wever, entral ven us pressure
in reases, and the f w bl d int the right atrium is
sl wed. As a result, a pers n su ering heart ailure, wh is
sitting at rest in a hair, ten has distended external jugular
veins as bl d ba ks up in the ven us netw rk.
At least ve me hanisms help t keep ven us bl d m v-
ing ba k thr ugh the ardi vas ular system and ba k t the
right atrium. T ey in lude the ll wing:
1. C ntinued beating the heart, whi h pumps bl d
thr ugh the entire ardi vas ular system
2. Adequate bl d pressure in the arteries, t push
bl d t and thr ugh the veins
3. Ven us valves that ensure ntinued bl d f w in
ne dire ti nt ward the heart
4. C ntra ti n skeletal mus les, whi h squeeze veins,
pr du ing a kind pumping a ti n
5. Changing pressures in the hest avity during
breathing that pr du e a kind pumping a ti n in
the veins in the th rax
QUICK CHECK
1. Ho w d o e s th e b lo o d p re s s u re g ra d ie n t e xp la in w h a t
m a ke s b lo o d o w ?
2. Na m e o u r a cto rs th a t in u e n ce b lo o d p re s s u re .
3. Do e s a p e rs o ns b lo o d p re s s u re s ta y th e s a m e a ll th e
tim e ? Exp la in w hy th is is s o .

C LIN ICA L APPLICATION

BLOOD PRES S URE READINGS
A device calle d a s phyg m o m ano m e te r is o te n us e d to m e a- nom e te rs have be e n re place d in m any clinical s e ttings by
s ure blood pre s s ure s in both clinical and hom e he alth-care nonm e rcury device s that s im ilarly m e as ure the m axim um and
s ituations . The traditional s phygm om anom e te r is an inve rte d m inim um arte rial blood pre s s ure s in m m Hg units . In hom e
tube o m e rcury (Hg) w ith a balloonlike air cu attache d via an he alth-care s e ttings , patie nts can o te n le arn to m onitor the ir
air hos e . ow n blood pre s s ure .
The air cu is place d around a lim b, us ually the s ub-
je cts arm as s how n in the f gure . A s te thos cope s e ns or
is place d ove r a m ajor arte ry (the brachial arte ry in the
f gure ) to lis te n or the arte rial puls e . A hand-ope rate d
S o und
pum p f lls the air cu , incre as ing the air pre s s ure and firs t
pus hing the colum n o m e rcury highe r. he ard
While lis te ning through the s te thos cope , the ope ra-
No
tor ope ns the air cu s outle t valve and s low ly re duce s S o und
s o und
the air pre s s ure around the lim b. Loud, tapping Korot- las t
he ard
ko s ounds s udde nly be gin w he n the cu pre s s ure
m e as ure d by the m e rcury colum n e quals the s ys tolic
pre s s ure o te n be low 120 m m . As the air pre s s ure 120 mm Hg
s urrounding the arm continue s to de cre as e pas t the P re s s ure
m inim um arte rial pre s s ure , the Korotko s ounds dis ap- cuff
15 pe ar. The pre s s ure m e as ure m e nt at w hich the s ounds
dis appe ar is e qual to the dias tolic pre s s ure o te n 70 to Korotkoff
80 m m . s ounds
The s ubje cts blood pre s s ure is the n expre s s e d as
s ys to lic blo o d pre s s ure (the m axim um arte rial pre s -
s ure during e ach cardiac cycle ) ove r the dias to lic blo o d 80 mm Hg
pre s s ure (the m inim um arte rial pre s s ure ), s uch as
120/80 (re ad one -twe nty ove r e ighty ).
No
The f nal re ading can the n be com pare d to the ex- s o und
pe cte d value (Figure 15-17 on p. 420), patie nts age , and Elbow
various othe r individual actors . Me rcury s phygm om a-
 CHAPTER 15 Circulation o Blood 419

P u ls e
W hat y u eel when y u take a pulse is an artery expanding
and then re iling alternately. T e m ving wave expansi n/ S upe rficia l
re il results r m the hanging arterial bl d pressures that te mpora l a rte ry
ur during the ardia y le. W hen the le t ventri le eje ts
bl d during ntra ti n, expansi n the arterial wall re-
sults. W hen the a rti semilunar valve l ses, and eje ti n Fa cia l a rte ry
eases r a m ment, the elasti arterial wall re ils.
eel a pulse, y u must pla e y ur ngertips ver an ar- Ca rotid a rte ry
tery that lies near the sur a e the b dy and ver a b ne r
ther rm base. T e pulse is a valuable lini al sign. It an
pr vide in rmati n, r example, ab ut the rate, strength, and
rhythmi ity the heartbeat. It als an pr vide in rmati n
ab ut bl d pressure.
Pulse is easily determined with little r n danger r dis-
m rt. T e maj r pulse p ints are named a ter the arteries
ver whi h they are elt. L ate ea h pulse p int n Figure 15-16
and n y ur wn b dy.
T ree pulse p ints are l ated n ea h side the head and
ne k: Bra chia l a rte ry

edge the stern leid mast id mus le

a p int bel w the rner the m uth

Ra dia l a rte ry
A pulse is als dete ted at three p ints in the upper limb:

inner r medial margin the bi eps bra hii mus le

T e s - alled radial pulse is the m st requently m nit red Fe mora l a rte ry

and easily a essible in the b dy.
T e pulse als an be elt at ur l ati ns in the l wer
extremity:
Poplite a l
(pos te rior
to kne e )

-
lus (inner bump the ankle)

just bel w the bend the ankle j int

Hy p e r t e n s io n
D e f n it io n
S
15
R L
Pos te rior tibia l
M re visits t a physi ians e are related t hypertension I
(H N), r high bl d pressure, than any ther a t r. M re Dors a lis pe dis
than 60 milli n ases H N have been diagn sed in the
United States. T is nditi n urs when the r e bl d
exerted by the arterial bl d vessel ex eeds a bl d pressure
140/90 mm H g.
FIGURE 15-16 Pulse points. Each pulse point is named a ter the artery
Ninety per ent H N ases are lassi ed as primary es- with which it is associated. External pressure applied to a pulse point can
sential, r idi pathi , with n single kn wn ausative eti l gy. be used by rst responders to slow bleeding rom an injury distal to the
An ther lassi ati n, se ndary H N, is aused by kidney pulse point or pressure point.
 420 CHAPTER 15 Circulation o Blood

Blo o d Pre s s ure (BP) Clas s ific atio n s heme emphasize the belie that there is n pre ise distin ti n
between n rmal and abn rmal valuesthus even th se in the
Clas s ific atio n S ys to lic BP Dias to lic BP high-n rmal range r the prehypertensi n range may be treated
as having H N.
No rmal le s s tha n a nd le s s tha n
120 80
Ris k Fa c t o r s
Pre hype rte ns io n 120-139 or 80-89
Many risk a t rs have been identi ed in the devel pment
H N. Geneti a t rs play a large r le. T ere is an in reased
Hig h blo o d pre s s ure
sus eptibility r predisp siti n with a amily hist ry H N.
Men experien e higher rates H N at an earlier age than
S tag e 1 140-159 or 90-99 w men, and H N in A ri an-Ameri ans ar ex eeds that
hype rte ns io n Cau asians in the United States.
gre a te r tha n or gre a te r tha n or T ere is als a dire t relati nship between age and high
S tag e 2 e qua l to or e qua l to
hype rte ns io n 160 100 bl d pressure. T is is be ause as age advan es, the bl d ves-
sels be me less mpliant and there is a higher in iden e
ather s ler ti plaque buildup. T e h rm ne und in ral
FIGURE 15-17 Classif cation o hypertension. A ter age 50, the sys-
tolic pressure becomes more signi cant than diastolic pressure in assessing
ntra eptives an als ause H N. Risk a t rs in lude high
high blood pressure and associated risk o cardiovascular and renal disease. stress levels, besity, al ium de ien ies, high levels al -
h l and a eine intake, sm king, and la k exer ise.
Untreated H N has many p tential mpli ati ns in lud-
disease r h rm nal pr blems r indu ed by ral ntra ep- ing is hemi heart disease and heart ailure, kidney ailure,
tives, pregnan y, r ther auses. and str ke. As many as 400,000 pe ple per year experien e a
An ther way lassi ying hypertensi n is illustrated in the str ke. Be ause H N mani ests minimal r n vert signs, it
a mpanying hart (Figure 15-17). T is system uses syst li and is kn wn as the silent killer. H eada hes, dizziness, and aint-
diast li bl d pressure values t lassi y hypertensi n int ing have been rep rted but are n t always sympt mati
stages a rding t severity. T e guidelines that a mpany this H N. Regular s reenings at the w rksite and s reening

S C IEN C E APPLICATIONS
CIRCULATION OF THE BLOOD
The Englis h phys ician William Harvey was the f rs t to prove that
blood circulate s . Until Harveys tim e , s cie ntis ts be lieve d that
the blood o the arte rie s was s e parate rom the blood o the
ve ins e ach having di e re nt unctions in the body. Howeve r,
Harveys obs e rvations o the body, including his dis cove ry that
ve ins pos s e s s one -way valve s , le d him to dis cove r that blood
m ove s in a com ple te circle .
Although he did not dire ctly obse rve the capillarie s (even
though m icroscope s became available in his day), Harvey prove d
that they must exis t by me ans o a se rie s o cleve r expe rime nts.
William Harvey Harvey not only com ple te ly changed the way we think o the
(15781657) body, he also prove d his point w ith logical experim e nts .
William Harveys work provide s the conce ptual bas is or a
15 varie ty o m ode rn ide as and m e thods . For exam ple , toxico lo g is ts (s cie ntis ts w ho s tudy
the e e cts o pois ons ) know that the rapid s pre ad o pois ons in the body is explaine d by
Harveys m ode l o circulation.
Phle bo to m is ts , te chnicians w ho draw blood or m e dical te s ts , know w hich ve s s e ls w ill
work be s t or draw ing blood (picture d). Nurs e s and IV te chnicians that s pe cialize in intra-
ve nous the rapy m us t know how the blood circulate s in orde r to e e ctive ly add the rape utic
uids to the ir patie nts bloods tre am .
Radiologis ts and radiological te chnologis ts m us t know w hich way blood ow s in di e re nt ve s s e ls s o that contras t dye s can be
adde d to the bloods tre am to he lp vis ualize s tructure s o the body in an x-ray f lm .
Many di e re nt he alth pro e s s ionals re ly on the ir am iliarity w ith the bodys blood ow circuit w he n they m e as ure blood pre s s ure ,
inje ct intrave nous drugs , pe r orm s urge rie s , take puls e s , atte m pt to s top ble e ding a te r traum a to the body, and in m any othe r m e di-
cal proce dure s .
 CHAPTER 15 Circulation o Blood 421

N e u ro g e n ic S h o c k
b ths in malls and in h spitals ten help identi y asymp-
t mati H N. Neurogenic shock results r m widespread dilati n bl d
vessels aused by an imbalan e in aut n mi stimulati n
sm th mus les in vessel walls. T e term neurogenic literally
C ir c u la t o ry S h o c k means pr du ed by nerves.
T e term circulatory shock re ers t the ailure the ir u- Y u may re all r m Chapter 10 that aut n mi e e t rs
lat ry system t adequately deliver xygen t the tissues, su h as sm th mus le tissues are ntr lled by a balan e
resulting in the impairment ell un ti n thr ugh ut the stimulati n r m the sympatheti and parasympatheti divi-
b dy. si ns the aut n mi nerv us system. N rmally, sympa-
T e b dy has a number me hanisms that mpensate theti stimulati n maintains the mus le t ne that keeps bl d
r the hanges that ur during sh k. H wever, these vessels at their usual diameter. I sympatheti stimulati n is
me hanisms may ail t mpensate r hanges that ur in disrupted by an injury t the spinal rd r medulla, depres-
severe ases. I le t untreated, ir ulat ry sh k may lead t sive drugs, em ti nal stress, r s me ther a t r, bl d vessels
death. dilate signi antly. W idespread vas dilati n redu es bl d
Cir ulat ry ailure has a variety auses, all whi h in pressure, thus redu ing bl d f w.
s me way redu e the f w bl d thr ugh the bl d vessels
the b dy. Be ause the variety auses, ir ulat ry sh k
A n a p h y la c t ic S h o c k
is ten lassi ed as des ribed in the ll wing se ti ns.
Anaphylactic shock results r m an a ute allergi rea ti n
alled anaphylaxis. Anaphylaxis auses the same kind bl d
C a r d io g e n ic S h o c k vessel dilati n hara teristi neur geni sh k.
Cardiogenic shock results r m any type heart ailure, su h
as that a ter severe my ardial in ar ti n (heart atta k), heart
S e p t ic S h o c k
in e ti ns, and ther heart nditi ns. T e term cardiogenic
literally means pr du ed by the heart. Septic shock results r m mpli ati ns septicemia, a
Be ause the heart an n l nger pump bl d e e tively nditi n in whi h in e ti us agents release t xins int the
during heart ailure, bl d f w t the tissues the b dy de- bl d. T e t xins inv lved in septi emia ten dilate bl d
reases r st ps. vessels, thereby ausing sh k.
T e situati n is usually made w rse by the damaging e -
e ts the t xins n tissues mbined with the in reased ell
Hy p o vo le m ic S h o c k a tivity aused by the a mpanying ever.
Hypovolemic shock results r m the l ss bl d v lume in One type septi sh k is toxic shock syndrome ( SS),
the bl d vessels. T e term hypovolemia means nditi n whi h usually results r m staphyl al in e ti ns that be-
l w bl d v lume. gin in the vagina menstruating w men and spread t the
Redu ed bl d v lume results in l w bl d pressure and bl d (see Appendix A at evolve.elsevier.com).
redu ed f w bl d t tissues. H em rrhage is a mm n
ause bl d v lume l ss leading t hyp v lemi sh k. QUICK CHECK
H yp v lemia als an be aused by l ss interstitial f uid, 1. Wh e re a re th e p la ce s o n yo u r b o d y th a t yo u ca n like ly e e l
ausing bl d plasma t drain ut the vessels and int the yo u r p u ls e ?
tissue spa es. L ss interstitial f uid is mm n in hr ni 2. As o n e g e ts o ld e r, w hy is th e in cid e n ce o hyp e rte n s io n
g re a te r?
diarrhea r v miting, dehydrati n, intestinal bl kage, severe
3. De s crib e o u r d i e re n t ca u s e s o circu la to ry a ilu re .
r extensive burns, and s me ther nditi ns.

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 403) 15

oramen ovale hepatic portal circulation peripheral resistance (PR)
( oh-RAY-men oh-VAL-ee) (heh-PAT-ik POR-tall ser-kyoo-LAY-shun) (peh-RIF-er-al rih-ZIS-tens [pee ar])
[ oramen opening, ovale egg shaped] [hepa- liver, -ic relating to, port- doorway, [peri- around, -pher- boundary, -al relating to,
heart rate (HR) -al relating to, circulat- go around, re- against, -sist- take a stand, -ance state]
(hart rayt [aych ar]) -tion process] placenta
hemodynamics per use (plah-SEN-tah)
(hee-moh-dye-NAM-iks) (per-FYOOZ) [placenta at cake]
[hemo- blood, -dynam- moving orce, [per- through, - us- pour]
Continued on p. 422
-ic relating to]
 422 CHAPTER 15 Circulation o Blood

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 421)

precapillary sphincter systolic blood pressure umbilical cord

(pree-CAP-pih-layr-ee SFINGK-ter) (sis-TOL-ik blud PRESH-ur) (um-BIL-ih-kul)
[pre- be ore, -capill- hair o head, -ary relating [sy(n)- together, -stol- position, -ic relating to] [umbilic- navel, -al relating to]
to, sphincter tight band] tunica externa umbilical vein
pulmonary circulation (TOO-nih-kah ex-TER-nah) (um-BIL-ih-kul)
(PUL-moh-nayr-ee ser-kyoo-LAY-shun) [tunica tunic or coat, extern- outside] [umbilic- navel, -al relating to, vein blood
[pulmon- lung, -ary relating to, circulat- go tunica intima vessel]
around, -tion process] (TOO-nih-kah IN-tih-mah) vasomotor mechanism
pulse [tunica tunic or coat, intima innermost] (vay-soh-MOH-tor MEK-ah-niz-em)
(puls) tunica media [vas- vessel, -motor move]
stroke volume (SV) (TOO-nih-kah MEE-dee-ah) vein
(strowk VOL-yoom [es vee]) [tunica tunic or coat, media middle] (vayn)
[stroke a striking] umbilical artery [vein blood vessel]
systemic circulation (um-BIL-ih-kul AR-ter-ee) venule
(sis-TEM-ik ser-kyoo-LAY-shun) [umbilic- navel, -al relating to, arteri- vessel, (VEN-yool)
[system- organized whole (body system), -y thing] [ven- vessel (vein), -ule little]
-ic relating to, circulat- go around,
-tion process]

LANGUAGE OF M ED IC IN E

anaphylactic shock diuretic neurogenic shock

(an-ah-f h-LAK-tik shok) (dye-yoo-RET-ik) (noo-roh-J EN-ik shok)
[ana- without, -phylact- protection, -ic relating [dia- through, -ure- urine, -ic relating to] [neuro- nerve, -gen- produce, -ic relating to,
to, shock jolt] gangrene shock jolt]
aneurysm (GANG-green) phlebitis
(AN-yoo-riz-em) [gangren- gnawing sore] ( eh-BYE-tis)
[aneurysm widening] hemorrhoid [phleb- vein, -itis in ammation]
angioplasty (HEM-eh-royd) phlebotomist
(AN-jee-oh-plas-tee) [hema- blood, -rrh- ow, -oid o or like] ( eh-BOT-uh-mist)
[angio- vessel, -plasty surgical repair] hypertension (HTN) [phlebo- vein, -tom- cut, -ist agent]
arteriosclerosis (hye-per-TEN-shun [aych tee en]) plaque
(ar-tee-ree-oh-skleh-ROH-sis) [hyper- excessive, -tens- stretch or pull tight, (plak)
[arteri- vessel (artery), -sclero- harden, -sion state] [plaque patch]
-osis condition] hypovolemic shock polycythemia
cardiogenic shock (hye-poh-voh-LEE-mik shok) (pahl-ee-sye-THEE-mee-ah)
(kar-dee-oh-J EN-ik shok) [hypo- under or below, -volem- volume, [poly- many, -cyt- cell, -emia blood condition]
[cardi- heart, -gen- produce, -ic relating to, -ic relating to, shock jolt] pulmonary embolism
shock jolt] IV (intravenous) technician (PUL-moh-nayr-ee EM-boh-liz-em)
15 cerebrovascular accident (CVA) (aye-vee [in-trah-VEE-nus] tek-NISH-en) [pulmon- lung, -ary relating to, embol- plug,
(SAYR-eh-broh-VAS-kyoo-lar) [intra- within, -ven- vein, -ous relating to, -ism condition]
[cerebr- brain, -vas- vessel, -cul- little, techn- art or skill, -ic relating to, Raynaud phenomenon
-ar relating to] -ian practitioner] (ray-NO f h-NOM-eh-nohn)
circulatory shock ischemia [Maurice Raynaud French physician,
(SER-kyoo-lah-tor-ee shok) (is-KEE-mee-ah) phenomenon appearance]
[circulat- go around, -ory relating to, shock jolt] [ische- hold back, -emia blood condition] septic shock
cyanosis necrosis (SEP-tik shok)
(sye-ah-NOH-sis) (neh-KROH-sis) [septi- putrid, -ic relating to, shock jolt]
[cyan- blue, -osis condition] [necr- death, -osis condition]
 CHAPTER 15 Circulation o Blood 423

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 422)

septicemia thrombophlebitis varicose vein

(sep-tih-SEE-mee-ah) (throm-boh- eh-BYE-tis) (VAYR-ih-kohs vayn)
[septic- putrid, -(h)em- blood, -ia condition] [thrombo- clot, -phleb- vein, -itis in ammation] [varic- swollen vein, -ose characterized by,
stent toxicologist vein blood vessel]
(stent) (tok-sih-KOL-uh-jist) vasodilator
[Charles Stent English dentist] [toxic- poison, -log- words (study o ), -ist agent] (vay-so-DYE-lay-tor)
sphygmomanometer varice [vaso- vessel or duct, -dilat- widen, -or agent]
(sf g-moh-mah-NOM-eh-ter) (VAYR-ih-seez)
[sphygmo- pulse, -mano- thin, -meter measure] sing., varix
(VAYR-iks)
[varic- swollen vein]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Blo o d Ve s s e ls
A. ypes
1. Arteries and arteri les arry bl d away r m the
heart and t ward apillaries
2. Capillaries arry bl d r m the arteri les t the
venules
3. Veins and venules arry bl d t ward the heart and
away r m apillaries
B. Stru ture (Figure 15-1)
1. Arteries
a. uni a intimainner layer end thelial ells
b. uni a mediasm th mus le, thi k in arteries;
s me elasti tissue; imp rtant in bl d pressure
regulati n
. uni a externa uter layer br us nne tive
elasti tissue, may have s me elasti tissue
2. Capillariesmi r s pi vessels (Figure 15-2)
a. O nly ne layer thi kthe tuni a intima
b. Pre apillary sphin ters in arteri les determine h w
mu h bl d will f w int ea h bed apillaries
3. Veins (Figure 15-1)
a. uni a intimainner layer; ven us valves prevent
retr grade m vement bl d (Figure 15-3)
b. uni a mediasm th mus le; thin in veins
. uni a externaheavy layer br us nne tive
tissue in many veins
C. Fun ti ns
1. Arteries and arteri lesdistribute nutrients, gases,
et ., arried in the bl d by way high pressure;
assist in maintaining the arterial bl d pressure and
thus maintain bl d f w
2. Capillariesserve as ex hange vessels r nutrients,
wastes, gases, h rm nes, and f uids (a entral ardi -
vas ular un ti n)
a. Osm sis and ltrati n are maj r r es that drive
apillary ex hange (Figure 15-4)
b. O utwardly dire ted r es are greater at arterial
end apillary, m ving f uid r m bl d t tissue
. Inwardly dire ted r es are greater at ven us end
apillary, m ving f uid r m tissue t bl d
d. Ex ess tissue f uid n t returned t bl d is l-
le ted by lymphati system (see Chapter 16)
3. Veins and venules lle t bl d r return t the
heart; l w-pressure f w bl d ( mpared t arter-
ies); serve as bl d reserv irs
Dis o rde rs o Blo o d Ve s s e ls 15
A. Dis rders arteriesarteries must withstand high pres-
sure and remain ree bl kage
1. Arteri s ler sishardening arteries aused by al-
i ati n atty dep sits n arterial walls (Figure 15-5)
a. T i kening and al i ati n arterial walls redu e
f w bl d, p ssibly ausing is hemia
b. Is hemia may pr gress t ne r sis (tissue death)
and then gangrene
 424 CHAPTER 15 Circulation o Blood
. H igh bl d levels trigly erides and h lester l,
sm king, hypertensi n, advan ed age, and geneti
predisp siti n are ass iated a t rs
d. May be rre ted by vas dilat rs (vessel-relaxing
drugs) r angi plasty (me hani al widening
vessels, see Figure 15-6) r surgi al repla ement
2. Aneurysmabn rmal widening arterial wall
a. Pr m tes rmati n thr mbi that may bstru t
bl d f w t vital tissues
b. Arterial walls may burst, resulting in li e-threatening
hem rrhaging
. Cerebr vas ular a ident (CVA), r str ke
is hemia brain tissue aused by emb lism r
hem rrhage
B. Dis rders veinsl w-pressure vessels
1. Vari se veins (vari es)enlarged veins in whi h
bl d p ls (Figure 15-7)
a. H em rrh idsvari se veins in the re tum
b. reatments in lude supp rting a e ted veins r
surgi al rem val veins
2. Phlebitisvein inf ammati n; thr mb phlebitis is
a mpanied by l t (thr mbus) rmati n; may result
in atal pulm nary emb lism
Ro ute s o Circulatio n
A. Systemi and pulm nary ir ulati n (Figure 15-8)
1. Bl d ir ulati nre ers t the f w bl d thr ugh
all the vessels, whi h are arranged in a mplete
ir uit r ir ular pattern; spe i pathway t / r m an
rgan alled a route o circulation
2. Systemi ir ulati n
a. Carries bl d thr ugh ut the b dy
b. Path g es r m le t ventri le thr ugh a rta, smaller
arteries, arteri les, apillaries, venules, venae avae,
t right atrium
3. Pulm nary ir ulati n
a. Carries bl d t and r m the lungs
b. Arteries deliver de xygenated bl d t the lungs
r gas ex hange
. Path g es r m right ventri le thr ugh pulm nary
arteries, lungs, pulm nary veins, t le t atrium
4. Names main arteriessee Figure 15-9 and Table 15-1
5. Names main veinssee Figure 15-10 and Table 15-2
B. Spe ial ir ulat ry r utes
1. H epati p rtal ir ulati n (Figure 15-11)
15 a. Unique bl d r ute thr ugh the liver
b. Vein (hepati p rtal vein) exists between tw apil-
lary beds
. Assists with h me stasis bl d glu se levels
2. Fetal ir ulati n (Figure 15-12)
a. Re ers t ir ulati n be re birth
b. M di ati ns required r etus t e iently
se ure xygen and nutrients r m the maternal
bl d
. Unique stru tures in lude the pla enta, umbili al
arteries and vein, du tus ven sus, du tus arteri sus,
and ramen vale
d. Failure etal ir ulati n t shi t t usual p st-
birth ir ulati n may result in yan sis aused by
la k xygen
He m o dynam ics
A. De ning bl d pressurepush, r r e, bl d in the
bl d vessels
1. H ighest in arteries, l west in veins (Figure 15-13)
2. Bl d pressure gradient auses bl d t ir ulate
liquids an f w nly r m areas high pressure t
areas l w pressure
3. Abn rmally l w bl d pressure results in redu ed
bl d f w t tissues
4. H ypertensi n (H N)high bl d pressure
a. Can ause vessels t rupture
b. Can in rease w rkl ad heart, ausing abn rmally
thi kening my ardium
B. Fa t rs that inf uen e bl d pressure (Figure 15-14)
1. Bl d v lume
a. T e larger the v lume, the m re pressure is exerted
n vessel walls
b. Diureti sdrugs that pr m te water l ss and thus
l ss t tal bl d v lume
2. Strength heart ntra ti nsa e ts str ke v lume
(SV), whi h in turn a e ts ardia utput (CO);
str nger heartbeat in reases pressure; weaker beat
de reases it
3. H eart rate (H R)in reased rate in reases pressure;
de reased rate de reases pressure
4. Bl d vis sity (thi kness)
a. Less-than-n rmal vis sity de reases pressure,
m re-than-n rmal vis sity in reases pressure
b. P ly ythemiaabn rmally high hemat rit, whi h
in reases bl d vis sity and thus in reases bl d
pressure
5. Resistan e t bl d f w (peripheral resistan e
[PR])a e ted by many a t rs, in luding the
vas m t r me hanism (vessel mus le ntra ti n/
relaxati n) (Figure 15-15)
C. Flu tuati ns in arterial bl d pressure
1. Bl d pressure varies within n rmal range
2. N rmal systemi arterial bl d pressure is bel w
120/80 at rest
D. Central ven us pressure
1. Ven us bl d pressure within right atrium, the l w
end the pressure gradient that drives bl d f w
2. Ven us return bl d t the heart depends n at
least ve me hanisms:
a. A str ngly beating heart
b. An adequate arterial bl d pressure
. Valves in the veins
d. Pumping a ti n skeletal mus les as they ntra t
e. Changing pressures in the hest avity aused by
breathing

Puls e
A. De niti nalternate expansi n and re il the bl d
vessel wall
B. Maj r pulse p ints named a ter arteries ver whi h they
are elt (Figure 15-16)
Hype rte ns io n (HTN )
A. O urs when bl d pressure ex eeds 140/90 mm H g
(Figure 15-17)
B. Ninety per ent H N ases are primary essential (idi -
pathi ); se ndary H N an be aused by kidney disease
r ther auses
C. Many risk a t rs r H N, in luding geneti s, age,
stress, besity, and m re
D. Untreated H N may ntribute t heart disease, kidney
ailure, and str ke
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
The arte rie s and ve ins are com pos e d o thre e di e re nt tis s ue
laye rs . The re is a di e re nce in thickne s s in the s e laye rs be -
caus e arte rie s carry blood unde r highe r pre s s ure . Arte rie s and
ve ins carry blood in oppos ite dire ctions : arte rie s away rom
the he art and ve ins toward the he art. Capillarie s are the m os t
im portant blood ve s s e ls in the s ys te m . The exchange o s ub-
s tance s (e .g., O 2 , CO 2 , glucos e ) be twe e n the blood and the
tis s ue s , the unction o the cardiovas cular s ys te m , occurs in
the capillarie s . Be caus e o this , the walls o the capillarie s
m us t be ve ry thin.
1. I y u are asked t learn the names and l ati ns spe-
i bl d vessels, make f ash ards, use nline res ur es,
and use the gures in this hapter as learning t ls.
2. T e hepati p rtal system makes m re sense i y u see it
as a h me stati me hanism. T e liver helps keep the
bl d leaving the digestive system r m having t high a
n entrati n vari us nutrients, su h as glu se. It als
has a pr te tive un ti n: det xi ying the bl d.
CHAPTER 15 Circulation o Blood 425
Circulato ry S ho ck
A. Cir ulat ry sh k ailure the ir ulat ry system t
deliver xygen t the tissues adequately, resulting in ell
impairment
B. W hen the ause is kn wn, sh k an be lassi ed as
ll ws:
1. Cardi geni sh k aused by heart ailure
2. H yp v lemi sh k aused by a dr p in bl d
v lume that auses bl d pressure (and bl d f w) t
dr p
3. Neur geni sh k aused by nerve nditi n that
relaxes (dilates) bl d vessels and thus redu es bl d
f w
4. Anaphyla ti sh k aused by a severe allergi rea -
ti n hara terized by bl d vessel dilati n
5. Septi sh kresults r m mpli ati ns septi e-
mia (t xins in bl d resulting r m in e ti n)
3. Fetal ir ulati n will make sense t y u i y u nsider
the envir nment in whi h the etus is living. T e bl d
sent t the etus is already xygenated and ull digested
nutrients, s it d es n t have t g t the lungs r liver.
Figure 15-12 pr vides a visual that will help y u remember
the ir ulati n r ute.
4. A liquid always m ves r m a higher pressure t a l wer
pressure, s pressure w uld be highest leaving the heart
and l west in the vena ava. Make a hart with the dis r-
ders the vessels. It helps t rganize them by whether
they are arterial dis rders r ven us dis rders.
5. Review the des ripti ns ir ulat ry sh k und in the
hapter.
6. In y ur study gr up, review the stru ture the bl d
vessels and try t relate it t its un ti n. Dis uss hepati
p rtal ir ulati n and etal ir ulati n in terms their
advantages r e ien ies. G ver the a t rs inf uen ing
bl d pressure and the l ati n pla es where a pulse
an be taken.
7. Re er t the Language S ien e and Language Medi-
ine terms and review the questi ns and the utline
summary at the end the hapter and dis uss p ssible
test questi ns. 15
 426 CHAPTER 15 Circulation o Blood
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. List and des ribe the main types bl d vessels in the
b dy.
2. Name the three tissue layers that make up arteries and
veins.
3. W hat is arteri s ler sis?
4. De ne is hemia and gangrene.
5. Des ribe the ways in whi h arteri s ler sis an be
treated.
6. De ne phlebitis.
7. Des ribe b th systemi and pulm nary ir ulati n.
8. Explain what w uld ur i the ramen vale ailed t
l se at the time birth.
9. Name and brief y explain the ur a t rs that inf uen e
bl d pressure.
10. Identi y where y u uld nd a sinus in the bl d
vessels.
11. List ve me hanisms that keep ven us bl d m ving
t ward the right atrium.
12. W hat is ir ulat ry sh k? List the ve types ir ula-
t ry sh k.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
13. Explain h w the rmati n vari se veins is an
example a p sitive eedba k me hanism.
14. Explain hepati p rtal ir ulati n. H w is it di erent
r m n rmal ir ulati n, and what advantages are gained
r m this type ir ulati n?
15. W hen nutrients r m a meal are being abs rbed, the
bl d in the p rtal vein ntains a higher than n rmal
n entrati n glu se. W hy d es the bl d, a ter it
leaves the liver, usually have a s mewhat n rmal bl d
15 glu se n entrati n?
16. Explain the di eren es between n rmal p stnatal ir u-
lati n and etal ir ulati n. Based n the envir nment
the etus, explain h w these di eren es make etal ir u-
lati n m re e ient.
17. Explain the relati nship between the entral ven us
pressure and the pressure gradient.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e ________ are bl d vessels that arry bl d ba k t
the heart.
2. T e ________ are mi r s pi bl d vessels where sub-
stan es are ex hanged between the bl d and the tissues.
3. T e innerm st tissue layer in an artery is alled the
________.
4. A (an) ________ is a se ti n an artery that has
be me abn rmally widened be ause a weakening
the arterial wall.
5. Systemi ir ulati n inv lves m ving bl d thr ugh ut
the b dy; ________ ir ulati n inv lves m ving bl d
t the lungs and ba k.
6. Medi ati ns that trigger sm th mus les the arterial
walls t relax and widen are alled ________.
7. T e tw stru tures in the etus that all w m st the
bl d t bypass the lungs are the ________ and the
________.
8. T e strength the heart ntra ti n and bl d v lume
are tw a t rs that inf uen e bl d pressure. w ther
a t rs are ________ and ________.
9. w pp sing r es inf uen e apillary ex hange. T ey
are ________ and ________.
10. Vari se veins the re tum are ________.
11. T e term ________ re ers t a systemi ir ulat ry r ute
that is a d rway t a se nd set systemi tissues.
12. O ther than the systemi and pulm nary ir ulati n,
name an example a ir ulati n that n rms the
statement stru ture ts un ti n.
 CHAPTER 15 Circulation o Blood 427

Match each disorder in Column A with its corresponding description or cause in Column B.

Column A
13. ________ arteri s ler sis
14. ________ ne r sis
15. ________ aneurysm
16. ________ vari se veins
17. ________ hem dynami s
18. ________ ardi geni sh k
19. ________ hyp v lemi sh k
20. ________ septi sh k
21. ________ anaphyla ti sh k
22. ________ neur geni sh k
23. ________ arterial pressure
Column B
a. ell death aused by is hemia
b. dilated, bl d-eng rged veins, usually und in the legs
. ir ulat ry sh k aused by heart ailure
d. ir ulat ry sh k that is a mpli ati n septi emia
e. ir ulat ry sh k aused by an a ute allergi rea ti n
. als alled hardening the arteries
g. ir ulat ry sh k aused by aut n mi stimulati n the sm th mus les in the
bl d vessels
h. ir ulat ry sh k due t l ss bl d v lume
i. set pr esses that inf uen e the f w bl d
j. a se ti n an artery that has widened due t a weakening the arterial wall
k. maj r r e in keeping bl d f wing

Cas e S tudie s might Le s physi ian re mmend t rre t this

To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Kevin has just learned that he has hyper h lester lemia
(high bl d h lester l). O n the advi e his physi ian,
he is starting a regular exer ise pr gram. H w might this
a e t Kevins h lester l pr blem? (H IN : See Appen-
dix A at evolve.elsevier.com.) W hat vas ular dis rder
might Kevin devel p i he is n t able t rre t his
hyper h lester lemia?
2. Le is a middle-aged man wh has re ently been experi-
en ing pain in his legs, espe ially when he walks r even
m derate distan es. H is physi ian tells him that he has
ather s ler sis in a maj r artery in the a e ted leg. W hy
d es this ause pain when Le walks? W hat treatments
pr blem? Explain h w ea h will impr ve Le s nditi n.
3. I ball n angi plasty is used t rre t mitral valve ste-
n sis (see Chapter 14), what r ute must the atheter
travel i it enters at the em ral artery?
4. Jane is pregnant. H er last app intment with her bstetri-
ian was stress ul. T e d t r n ted that her babys devel-
pment was bel w average and it did n t seem very a tive
in the w mb. H e advised Jane that they were g ing t
have t in rease the nutrients and xygen in the umbili al
vein t ensure that her baby was re eiving an adequate
supply. Jane is n used. She th ught that arteries n t
veins arried nutrients and xygen. C uld her d t r have
been mistaken?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.

15
Lymphatic System and Immunity
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Lymphatic System, 429 Immune System Cells, 440

Organization o the Lymphatic Phagocytes, 440
System, 429 Lymphocytes, 441
Lymph, 430 Hypersensitivity o the Immune System,
Lymphatic Vessels, 431 444
Lymphedema, 432 Allergy, 445
Lymphoid Organs, 432 Autoimmunity, 445
Immune System, 436 Alloimmunity, 446
Function o the Immune System, 436 Immune System Def ciency, 447
Innate Immunity, 436 Congenital Immune Def ciency, 447
Adaptive Immunity, 437 Acquired Immune Def ciency, 448
Immune System Molecules, 438
Cytokines, 438
Antibodies, 439
Complement Proteins, 440

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. Describe general unctions o the lym-
phatic system and list the main lym-
phatic structures.
2. Compare innate and adaptive, inherited
and acquired, and active and passive
immunity.
3. Discuss the major types o immune
system molecules and indicate how
antibodies and complement proteins
unction.
4. Do the ollowing related to immune
system cells:
cells o the immune systems, as well
as types o each.
-
ment and unctions o B and T cells.
5. Describe the mechanisms o allergy,
autoimmunity, and alloimmunity.
6. List the major types o immune def cien-
cies and explain their causes.
 16
A ll us live in a h stile and danger us envir nment. Ea h day LANGUAGE OF
we are a ed with p tentially harm ul t xins, disease- ausing ba - S C IEN C E
teria, viruses, and even ells r m ur wn b dies that have been
trans rmed int an er us invaders. F rtunately, we are
Be o re re ading the
pr te ted r m this staggering variety bi l gi al enemies
chapte r, s ay e ach o
by a remarkable set de ense me hanisms. We re er t this the s e te rm s o ut lo ud. This w ill
pr te tive sa ety net as the immune system. he lp yo u to avo id s tum bling ove r
the m as yo u re ad.
T is system in ludes a set xed stru tural mp nents,
the lymphati rgans, al ng with a m bile gr up de en-
adaptive immunity
sive ells and m le ules that pr te t us r m in e ti n and (ah-DAP-tiv ih-MYOO-nih-tee)
disease. T is hapter begins with an verview the lym- [adapt- f t to, -ive relating to,
phati system, dis ussing a netw rk vessels that helps immun- ree, -ity state]
maintain f uid balan e and lymph id tissues that help de- a erent lymphatic vessel
end the internal envir nment. (AF- er-ent lim-FAT-ik VES-el)
[a[d]- toward, - er- carry, -ent relating
We then dis uss the basi prin iples immunity and the to, lymph- water, -atic relating to]
ways that highly spe ialized ells and m le ules pr vide us agglutinate
with e e tive and very spe i resistan e t disease. (ah-GLOO-tin-ayt)
[agglutin- glue, -ate process]
antibody
Ly m p h a t ic S y s t e m
[anti- against]
O r g a n iz a t io n o t h e Ly m p h a t ic S y s t e m antibody-mediated immunity
Maintaining the nstan y the f uid ar und ea h b dy ell is p s-
sible nly i numer us h me stati me hanisms un ti n t gether ih-MYOO-nih-tee)
e e tively in a ntr lled and integrated resp nse t hanging ndi- [anti- against, -medi- middle,
-ate process, immun- ree,
ti ns. We kn w r m Chapter 13 that the ardi vas ular system plays
-ity state]
a key r le in bringing needed substan es t ells and then rem ving the
antigen
waste pr du ts that a umulate as a result metab lism. T is ex-
hange substan es between bl d and tissue f uid urs in
[anti- against, -gen produce]
apillary beds. Many additi nal substan es that ann t enter
antigen-presenting cell (APC)
r return thr ugh the apillary walls, in luding ex ess
f uid and pr tein m le ules, are returned t the [ay pee see])
bl d as lymph. [anti- against, -gen produce,
present- place be ore, -ing action,
cell storeroom]
B cell
(bee sel)
[B bursa-equivalent tissue,
cell storeroom]
B lymphocyte
(bee LIM- oh-syte)
[B bursa-equivalent tissue,
lympho- water (lymphatic system),
-cyte cell]

Continued on p. 449

429
 430 CHAPTER 16 Lymphatic System and Immunity

Lymph is the ex ess f uid le t behind by apillary ex hange
that drains r m tissue spa es and is transp rted by way
16 lymphatic vessels t eventually reenter the bl dstream. T us
the lymphati system is an imp rtant partner the cardiovas-
cular systemb th vital mp nents the circulatory system.
In additi n t lymph and the lymphati vessels, the lym-
phati system in ludes lymph n des and lymph id rgans su h
Tons ils
Ce rvica l
S ubma ndibula r
lymph node s
node s
as the thymus and spleen (Figure 16-1). Su h lymphati stru tures
help t lter the b dys f uids, rem ving harm ul parti les be re
they an ause signi ant damage t ther parts the b dy.
To learn more about the lymphatic system, go to
AnimationDirect online at evolve.elsevier.com.
Ly m p h
Lymph rms in this way: bl d plasma lters ut the ap-
illaries int the mi r s pi spa es between tissue ells be-
ause the hydr stati pressure generated by the pumping

Right
lympha tic
duct Axilla ry Le ft inte rna l
Right inte rna l jugula r ve in
lymph jugula r ve in
node s Tho rac ic
duc t
Thymus
Right
Pa ra s te rna l s ubclavia n
lymph node s ve in

Thora cic Rig ht

duct lymphatic duc t Le ft
s ubclavia n
S ple e n Right ve in
bra chioce pha lic ve in
Le ft bra chioce pha lic
Cis te rna ve in
S upe rior ve na cava
chyli B

Inguina l
Re d bone lymph node s
ma rrow

Poplite a l
lymph node s

Lymph
ve s s e ls

R L

I
Dra ine d by thora cic duct
A C Dra ine d by right lympha tic duct

FIGURE 16-1 Lymphatic system. A, Principal organs o the lymphatic system. B, Inset showing the major
lymphatic ducts draining lymphatic f uid into veins, just be ore systemic blood is returned to the heart. C, Lymph
drainage. The right lymphatic duct drains lymph rom the upper right quarter o the body into the right subcla-
vian vein at its junction with the internal jugular vein. The thoracic duct drains lymph rom the rest o the body
into the le t subclavian vein at its junction with the internal jugular vein.
 CHAPTER 16 Lymphatic System and Immunity 431

a ti n the heart (see Figure 15-4 n p. 406). T ere, the liquid
is alled interstitial uid (IF), r tissue f uid. Mu h the
interstitial f uid g es ba k int the bl d by the same r ute it
ame ut (that is, thr ugh the apillary membrane). T e re-
mainder the interstitial f uid enters the lymphati system
be re it returns t the bl d.
T e f uid, alled lymph at this p int, enters a netw rk
tiny blind-ended tubes distributed in the tissue spa es. T ese
tiny vessels, alled lymphatic capillaries, permit ex ess tissue
f uid al ng with s me ther substan es su h as diss lved pr -
tein m le ules t leave the tissue spa es. Figure 16-2 sh ws h w
lymph rms as part the pr ess that maintains f uid h -
me stasis in the tissues the b dy.
Ly m p h a t ic Ve s s e ls
Lymphati and bl d apillaries are similar in many ways.
B th types vessels are mi r s pi and b th are rmed
r m sheets nsisting a thin layer simple squam us epi-
thelium alled endothelium. T e f attened end thelial ells that
rm bl d apillaries, h wever, t tightly t gether s that
large m le ules ann t easily enter r exit r m the vessel. T e
t between end thelial ells rming the lymphati apillar- 16
ies is n t as tight. As a result, they are m re p r us and all w
larger m le ules, in luding pr teins and ther substan es, as
well as the f uid itsel , t enter the vessel and eventually return
t the general ir ulati n.
T e m vement lymph in the lymphati vessels is ne
way. Unlike bl d, lymph d es n t f w ver and ver again
thr ugh vessels that rm a ir ular r ute. T e lymphati ves-
sels ten have a beaded appearan e resulting r m the pres-
en e valves that assist in maintaining a ne-way f w
lymph. T ese valves, similar t th se in veins, s metimes ause
lymph t ba k up behind them and ause swellings that l k
like beads.
Lymph f wing thr ugh the lymphati apillaries next
m ves int su essively larger and larger vessels s metimes
alled lymphatic venules and lymphatic veins. T ese lymphati
vessels eventually empty int ne tw terminal vessels
alled the right lymphatic duct and the thoracic duct, whi h

P ulmona ry ca pilla ry ne twork

Tis s ue ce ll
Lympha tic ca pilla rie s
Anchoring fibe rs
Lympha tic fluid

Inte rs titia l fluid (IF)

Lymph node
Lymph flo w

Lympha tic ca pilla ry Blood ca pilla ry

Lympha tic ve s s e ls

Blo o d flow
S
L

R
I

Effe re nt Lympha tic ca pilla rie s

lympha tic
ve s s e l
S ys te mic ca pilla ry
ne twork
Inte rs titia l fluid (IF)
Va lve

S inus
Nodule
(lymphoid tis s ue )
FIGURE 16-2 Role o lymphatic system in uid homeostasis.
Affe re nt lympha tic ve s s e l Fluid ltered rom blood plasma that is not reabsorbed by blood vessels
Lymph flow drains into lymphatic vessels. Lymphatic drainage prevents accumula-
tion o too much tissue f uid. Lymph nodes and other lymphoid struc-
tures lter the lymphatic f uid be ore it is returned to the bloodstream.
 432 CHAPTER 16 Lymphatic System and Immunity

return their lymph int the bl d in large veins the ne k FIGURE 16-4 Lymphangitis.
regi n. This condition is characterized by
16 Lymph r m ab ut three- urths the b dy eventually inf amed lymphatic vessels that
appear as red streaks (highlighted
drains int the th ra i du t, whi h is the largest lymphati by arrows) radiating rom the
vessel in the b dy. Lymph r m the right upper extremity and source o in ection.
r m the right side the head, ne k, and upper t rs f ws
int the right lymphati du t (see Figure 16-1).
N te in Figure 16-1 that the th ra i du t in the abd men
has an enlarged p u hlike stru ture alled the cisterna chyli
that serves as a temp rary h lding area r lymph m ving
t ward its p int entry int the veins.
Lymphati apillaries in the wall the small intestine are
given the spe ial name lacteals. T ey transp rt ats b-
tained r m digested d t the bl dstream and are dis-
ussed urther in Chapter 18.

Lym p h e d e m a
Lymphedema is an abn rmal nditi n in whi h tissues ex- P
hibit swelling (edema) be ause the a umulati n lymph. P A
Lymph may a umulate in tissue when the lymphati vessels
are partially bl ked (Figure 16-3). T is may result r m a n- D

genital abn rmality r a spe i injury r bl kage lym-

phati drainage.
Lymphedema als may result r m lymphangitis, that is,
lymphati vessel inf ammati n. Lymphangitis is hara terized
by thin, red streaks extending r m an in e ted regi n. T e
in e ti us agent that auses lymphangitis may eventually
spread t the bl dstream, ausing septi emia (bl d p is n-
ing) and p ssibly death r m septi sh k (Figure 16-4).
Rarely, lymphedema may be aused by small parasiti
w rms that in est the lymphati vessels. W hen su h in esta-
ti n bl ks the f w lymph, edema the tissues drained by
the a e ted vessels urs. In severe ases, as y u an see in
Figure 16-5, the tissues swell s mu h that the limbs l k as i
they bel ng t an elephant! F r this reas n, the nditi n is
ten alled elephantiasisliterally nditi n being like
an elephant.
Ly m p h o id O r g a n s
Lymph n des, the thymus, t nsils, and spleen are nsidered
lymphoid organs be ause they ntain lymphoid tissue. Lym-
ph id tissue is a mass devel ping lymph ytes and related
ells supp rted in a ne mesh reti ular bersmaking it a
type reti ular tissue (review Figure 4-11 n p. 79).
Lymph id rgans are imp rtant stru tural mp nents
the immune system be ause they pr vide immune de ense
and devel pment immune ells.
P
R L

P D

FIGURE 16-3 Lymphedema. Notice the signi cant swelling in the sub- FIGURE 16-5 Elephantiasis. Lymphedema caused by prolonged in es-
jects right leg and oot. tation by Filaria worms produces elephant-like limbs.
 CHAPTER 16 Lymphatic System and Immunity 433

Bi l gi al ltrati n ba teria and ther abn rmal ells by

To see an image o lymphoid tissue that includes
phag yt sis helps prevent l al in e ti ns r m spreading.
the reticular f bers and developing lymphocytes in
a lymph node, review Sites o Hematopoiesis at
Figure 16-2 sh ws that lymph enters the n de thr ugh ne 16
r m re af erent lymphatic vessels. T e term af erent is r m
Connect It! at evolve.elsevier.com.
the Latin term r arry t ward. T ese vessels deliver lymph
t the n de.
Ly m p h N o d e s On e lymph enters the n de, it per lates sl wly thr ugh
Location spa es alled sinuses that surr und nodules und in the uter
As lymph travels r m its rigin in the tissue spa es t ward ( rtex) and inner (medullary) areas the n de (see
the th ra i r right lymphati du ts and then int the ven us Figure 16-2). At the re ea h n dule is a germinal center
bl d, it is ltered by way tri kling thr ugh lymph nodes, where new immune ells are pr du ed.
whi h are l ated in lusters al ng the pathway lymphati Lymph exits r m the n de thr ugh ne r m re ef erent
vessels. S me these n des may be as small as a pinhead, and lymphatic vessels. Ef erent is r m the Latin term r arry
thers may be as large as a lima bean. away r m.
W ith the ex epti n a relatively ew single n des, m st In passing thr ugh the n de, lymph is ltered s that ba -
the larger lymph n des ur in gr ups r lusters in er- teria, an er ells, virus-in e ted ells, and damaged tissue
tain areas. Figure 16-1 sh ws the l ati ns the lusters ells are rem ved and prevented r m entering the bl d and
greatest lini al imp rtan e. ir ulating all ver the b dy (see Figure 16-6). Lymph n des
Figure 16-2 sh ws the stru ture a typi al lymph n de. a mplish this by a tw -step pr ess. First, debris is trapped
T is stru tural pattern a h ll w apsule with n dules by the web reti ular bers that suspend the lymph n dules.
lymph id tissue suspended by reti ular bers is repeated in all Next, immune ells destr y and break apart the debris by
the lymph id rgans. phag yt sis and ther bi l gi al pr esses.
Clusters lymph n des all w a very e e tive bi l gi al
To learn more about lymphatic vessels and ltrati n lymph f wing r m spe i b dy areas. Figure 16-7
lymph nodes, go to AnimationDirect online at sh ws an x-ray image alled a lymphangiogram. A spe ial
evolve.elsevier.com. dye was inje ted int the s t tissues that drain the part the
lymphati netw rk that appears in the image. Y u an see that
the dyed lymph appears in the vessels and n des the ingui-
Biological Filtration nal and pelvi regi ns.
In Figure 16-6 a small n de l ated next t an in e ted Kn wledge lymph n de l ati n and un ti n is im-
hair lli le is sh wn ltering ba teria p rtant in lini al medi ine. F r example, a s h l nurse
r m lymph. Lymph n des per rm m nit ring the pr gress a hild with an in e ted nger will
bi l gi al ltrati n, a pr ess in wat h the elb w and axillary regi ns r swelling and tender-
whi h ells (phag yti ells in ness the lymph n desa nditi n alled lymphadenitis.
this ase) alter the ntents
the ltered f uid.

Pe lvic
lymph
De a d a nd dying node s
ce lls (pus )

Ba cte ria
Affe re nt lymph
ve s s e l Inguina l
lymph
Lymph node node s Lymph
ve s s e ls
Effe re nt lymph
ve s s e l

R L

FIGURE 16-6 Lymph node unction. Section o skin in which an in ec- FIGURE 16-7 Lymphangiogram. A special dye that is opaque to x-rays
tion surrounds a hair ollicle. The yellow areas around the hair represent dead is injected into the tissue f uids that drain into the inguinal and pelvic lym-
and dying cells (pus). The black dots around the yellow areas represent bac- phatic pathways. Thus the outlines o the lymphatic vessels and lymph
teria. Bacteria entering the node via the a erent lymphatics are ltered out. nodes can be visualized.
 434 CHAPTER 16 Lymphatic System and Immunity

FIGURE 16-8 Lymphatic drainage o breast. Note the extensive network o

lymph nodes that receive lymph rom the breast. It is not necessary to learn all these
16 structuresthey are shown to emphasize the many pathways by which f uids, in ec-
tions, and cancer cells can travel to other parts o the body. S upra clavicula r node s

Mida xilla ry node s S ubclavicula r node s

Inte rpe ctora l (Rotte r) node s

Pe ctora lis ma jor mus cle

La te ra l a xillary (bra chia l) node s

Pa ra s te rna l node s

Pe ctora lis minor mus cle

S ubs ca pula r node s

Ante rior a xilla ry (pe ctora l) node s
Axilla ry ta il

Pa ra ma mma ry node s Cros s -ma mma ry pa thways

S to oppos ite bre a s t

R L
Pa thways to s ubdia phra gma tic
I node s a nd live r

T ese n des lter lymph returning r m the hand and may

For more about metastasis by way o the lym-
be me in e ted by the ba teria they trap. As menti ned in
phatic system, see the article Metastasis at
the b x Lymphedema A ter Breast Surgery, a surge n uses
Connect It! at evolve.elsevier.com.
kn wledge lymph n de un ti n when rem ving lymph
n des under the arms (axillary n des) and in ther nearby
areas during an perati n r breast an er (Figure 16-8). T ese QUICK CHECK
n des may ntain an er ells ltered ut the lymph
1. Ho w d o e s th e lym p h a tic s ys te m re tu rn u id to th e b lo o d ?
drained r m the breast. 2. Wh a t is th e ro le o lym p h n o d e s in th e b o d y?
Can er the breast is ne the m st mm n types 3. De s crib e th e d i e re n ce b e tw e e n a n a e re n t lym p h a tic
an er in w men. Un rtunately, an er ells r m a single ve s s e l a n d a n e e re n t lym p h a tic ve s s e l.
tum r us gr wth in the breast ten spread t ther areas
the b dy thr ugh the lymphati system during the pr ess
metastasis (see Figure 6-11 n p. 130). Th y m u s
As y u an see in Figure 16-1, the
thymus is a small lymph id rgan
l ated in the mediastinum, ex-
C LIN ICA L APPLICATION tending upward t ward the midline
LYMPHEDEMA AFTER BREAST S URGERY the ne k. It is mp sed lym-
ph ytes in a meshlike ramew rk
Surgical proce dure s calle d m as te cto m ie s , in w hich s om e or all o the bre as t tis s ue s are reti ular bers. T e thymus, als
re m ove d, are s om e tim e s done to tre at bre as t cance r. Be caus e cance r ce lls can s pre ad
alled the thymus gland, is largest
s o e as ily through the exte ns ive ne twork o lym phatic ve s s e ls as s ociate d w ith the bre as t
(s e e Figure 16-8), the lym phatic ve s s e ls and the ir node s are s om e tim e s als o re m ove d.
at puberty and even then weighs
Occas ionally, s uch proce dure s inte r e re w ith the norm al ow o lym ph rom the arm . nly ab ut 35 r 40 ga little m re
Whe n this happe ns , tis s ue uid m ay accum ulate in the arm re s ulting in lym phe de m a. than an un e.
In hom e he alth-care s ituations , the a e cte d arm m ay be exe rcis e d and m as s age d to Alth ugh small in size, the
re duce s we lling and e ncourage the grow th o new lym phatic ve s s e ls . Som e wom e n thymus plays a entral and riti al
we ar an e las tic s le eve that has a s im ilar e e ct. r le in the b dys vital immunity
me hanism. First, it is a s ur e

lymph ytes be re birth and is then espe ially imp rtant
in the maturati n r devel pment a type lymph yte
that then leaves the thymus and ir ulates t the spleen,
t nsils, lymph n des, and ther lymph id tissues.
T ese lymphocytes, r cells, are riti al t the un -
ti ning the immune system and are dis ussed in m re de-
tail later. A gr up h rm nes se reted by the thymus, alled
thymosins, inf uen es the devel pment ells.
T e thymus appears t mplete mu h its w rk early
in hildh d, rea hing its maximum size at puberty. T e
thymus tissue is then gradually repla ed by at and nne -
tive tissue, a pr ess alled involution. By age 60, the lym-
ph id tissue is ab ut hal its maximum size and is virtually
g ne by age 80 r s .
To n s ils
Masses lymph id tissue alled tonsils are l ated in a pr -
te tive ring under the mu us membranes in the m uth and
thr at (Figure 16-9). T ey help pr te t us against ba teria that
may invade tissues in the area ar und the penings between
the nasal and ral avities.
T e palatine tonsils are l ated n ea h side the thr at.
T e pharyngeal tonsils, kn wn as adenoids when they be-
me sw llen, lie near the p steri r pening the nasal av-
ity. A third type t nsil, the lingual tonsils, is und near
the base the t ngue.
T e t nsils serve as the rst line de ense r m the exte-
ri r and as su h are subje t t hr ni in e ti n, r tonsillitis.
T ey may have t be rem ved surgi ally i antibi ti therapy
is n t su ess ul at treating the hr ni in e ti n r i swelling
impairs breathing r swall wing.
The protective lymphoid ring ormed by the tonsils
is one o many mechanisms that help protect the
delicate tissues o the bodys airways. To preview
these strategies, check out the article Protective
Strategies o the Respiratory Tract at Connect It!
at evolve.elsevier.com.
Pa la te (cut away)
P ha rynge a l tons il
Pa la tine tons il
Lingua l tons il (be hind
root of tongue )
R L
I FIGURE 16-9 Location o tonsils. Small segments o the roo and f oor o the mouth have
been removed to show the protective ring o tonsils (lymphoid tissue) around the internal open-
ing o the nose and throat.
CHAPTER 16 Lymphatic System and Immunity 435
S p le e n
T e spleen is the largest lymph id rgan in the b dy. As y u
an see in Figure 16-1 and Figure 1-6 (p. 10), it is l ated high in 16
the upper le t quadrant the abd men lateral t the st ma h.
Alth ugh the spleen is pr te ted by the l wer ribs, it an be
injured by abd minal trauma.
T e spleen has a very large netw rk reserv ir veins and
may ntain m re than 500 mL (ab ut 1 pint) bl d.
T e spleen serves as a reserv ir r bl d that an be re-
turned t the ardi vas ular system when needed. I the
spleen is damaged and bleeding, a surgi al rem val alled a
splenectomy may be required t st p the l ss bl d and
ensure survival.
A ter entering the spleen, bl d f ws thr ugh white, pulp-
like a umulati ns lymph id tissue. As bl d f ws thr ugh
this white pulp, the spleen rem ves ba teria and ther debris
by me hani al and bi l gi al ltrati n. T e spleen als de-
str ys w rn ut red bl d ells (RBCs), whi h ten all apart
when passing thr ugh the spleens meshw rk, and salvages the
ir n und in hem gl bin r uture use.
T e white pulp the spleen als serves as a reserv ir r
m n ytes, whi h an qui kly leave the spleen t help repair
damaged tissue anywhere in the b dy during an emergen y.
Splenomegaly, r abn rmal spleen enlargement, is b-
served in a variety dis rders. F r example, in e ti us ndi-
ti ns su h as s arlet ever, syphilis, and typh id ever are
hara terized by splen megaly. Spleen enlargement s me-
times a mpanies hypertensi n. Splen megaly als a m-
panies s me rms hem lyti anemia in whi h red bl d
ells appear t be br ken apart at an abn rmally ast rate.
Surgi al rem val the spleen ten ures su h ases.
Alth ugh the spleen pr vides use ul un ti ns in main-
taining the healthy stability the b dy, we an survive with-
ut it i surgi al rem val is required t preserve ur verall
health.
Ly m p h o m a
As y u may re all r m Chapter 6, lymphoma is a term that
re ers t lymphati tum rs. Lymph mas are m st ten
malignant but in rare ases an be benign. T e tw prin ipal
ateg ries lymph ma are H odgkin disease and non-
H odgkin lymphoma.
All types lymph ma hara teristi ally ause painless
enlargements the lymph n des in the ne k and ther re-
gi ns. T is rst sign is ll wed by anemia, weight l ss, weak-
ness, ever, and spread t ther lymph id tissues. In later
stages, the lymph ma spreads t many ther areas the b dy.
 436 CHAPTER 16 Lymphatic System and Immunity

W hen dis vered early, lymph ma an be su ess ully t resp nd but have additi nal, mplex strategies t help
treated with intensive radiati n and hem therapy. Lym- eliminate the threat.
16 ph ma urs m re ten in men than in w men. T ere are many types n nspe i immune de enses in
the b dy, as y u an see by s anning Table 16-2. T e skin and
QUICK CHECK mu us membranes, r example, are n nspe i me hani al
barriers that prevent r sl w entry int the b dy ba teria
1. Why is th e thym u s im p o rta n t o r im m u n ity?
2. Wh a t a re to n s ils ? Wh a t is th e ir u n ctio n ?
and many ther substan es su h as t xins and harm ul hemi-
3. Wh a t is th e ro le o th e s p le e n ? als. ears and mu us als ntribute t n nspe i immunity.
4. Id e n ti y th e tw o p rin cip a l ca te g o rie s o lym p h o m a . ears wash harm ul substan es r m the eyes, and mu us traps
reign material that may enter thr ugh the vari us tra ts
the b dy. Phag yt sis ba teria by W BCs is als a n nspe-
Im m u n e S y s t e m i rm immunity.
Fu n c t io n o t h e Im m u n e S y s t e m To better understand the concept o innate immu-
T e b dys de ense me hanisms pr te t us r m disease- nity, use the Active Concept Map Nonspecif c
ausing mi r rganisms that invade ur b dies, r m reign Immunity at evolve.elsevier.com.
tissue ells that may have been transplanted int ur b dies,
and r m ur wn ells when they have turned malignant r
an er us. T e b dys verall de ense system is alled the im- In a m m a t o ry Re s p o n s e
mune system. T e immune system makes us immunethat is, T e in ammatory response is a set innate resp nses that
able t either resist these threats t ur health r ree urselves ten urs in the b dy. In the example sh wn in Figure 16-10,
r m them. ba teria ause tissue damage that, in turn, triggers the release
In the lymphati system, we have seen many rgans that hemi al mediat rs r m any a variety immune ells.
help pr vide de ense: lymph n des, t nsils, thymus, and Su h signal m le ules sent by ells are ten alled cytokines.
spleen. T e immune system is n t simply a small gr up S me the yt kines attra t W BCs t the area in the pr ess
rgans w rking t gether. Instead, it is an intera tive netw rk chemotaxis. gether, these a t rs pr du e the hara ter-
many rgans and billi ns reely m ving ells and trilli ns isti signs inf ammati n: heat, redness, pain, and swelling.
ree-f ating m le ules in many di erent areas the b dy. T ese signs inf ammati n are aused by in reased bl d
Be re m ving n, it is wise t remind urselves that leuko- f w (resulting in heat and redness) and vas ular permeability
cytes, r white blood cells (WBCs), d mu h the w rk the (resulting in tissue swelling and the pain that it auses) in the
immune system. ake a m ment t g ba k and review W BC a e ted regi n. Su h hanges help phag yti W BCs and
ell types in Figure 13-1 n p. 350. bene ial pr teins rea h the general area and enter the a -
e ted tissue.
Besides l al inf ammati n, systemi inf ammati n may
In n a t e Im m u n it y ur when the inf ammati n mediat rs yt kines and
O ve r v ie w ther hemi al signalstrigger resp nses that ur n a
Innate immunity is maintained by me hanisms that atta k b dy-wide basis. A systemi (b dy-wide) inf ammat ry re-
any irritant r abn rmal substan e that threatens the internal sp nse may be mani ested by a evera state abn rmally
envir nment. T is type immunity is alled innate be ause high b dy temperature. T e elevated temperature al w
we are b rn with these de enses,
whi h d n t require pri r exp sure
t a harm ul substan e r threaten- TABLE 16-1 Innate and Adaptive Immunity
ing rganism. Innate immunity is INNATE IMMUNITY ADAPTIVE IMMUNITY
als s metimes alled nonspeci c
Synonym s Nons pe cif c im m unity, native im m unity, Spe cif c im m unity, acquire d
immunity be ause it n ers gen-
ge ne tic im m unity im m unity
eral pr te ti n rather than pr te -
Spe cif city Not s pe cif cre cognize s varie ty o Spe cif cre cognize s only s pe cif c
ti n r m spe i kinds threat-
nons e l or abnorm al ce lls and particle s antige ns on ce rtain ce lls or
ening ells r hemi als. particle s
As y u an see in Table 16-1, the
Spe e d o Rapidim m e diate up to s eve ral hours Slowe rs eve ral hours to s eve ral
innate, n nspe i immune re-
re action days
sp nses are m re rapid than adap-
Me m ory None s am e re s pons e to re pe ate d expo- Ye s e nhance d re s pons e to re pe ate d
tive, spe i immune resp nsess
s ure s to s am e antige n expos ure s to s am e antige n
they are ten the rst resp nders
when threats ur in the b dy. Che m icals Com ple m e nt prote ins , inte r e rons , othe rs Antibodie s , various s ignaling
che m icals
Many the innate immune me ha-
nisms als trigger the spe i im- Ce lls Phagocyte s (ne utrophils , m acrophage s , Lym phocyte s (B ce lls and T ce lls )
de ndritic ce lls )
mune me hanisms, whi h are sl wer
 CHAPTER 16 Lymphatic System and Immunity 437

t m derate ever may a ilitate s me immune rea ti ns in ludes pr te tive me hanisms that n er very spe i pr -
and may als inhibit the repr du ti n s me ba teria. te ti n against spe i types threatening mi r rganisms
H wever, s me immun l gists still debate the r le ever r ther t xi materials. Adaptive immunity in ludes a l ng- 16
in pr te ting the b dy. term pr te tive un ti n alled immune memory, whi h all ws
A lass enzymes in bl d plasma alled complement an the immune system t e e tively st p a se nd atta k by the
trigger a as ade hemi al rea ti ns that literally pun h h les same spe i path gen.
in abn rmal ells and regulate ther immune me hanisms. In adaptive immunity, when the b dy is rst atta ked by
C mplement an be triggered in damaged r in e ted tissues by parti ular ba teria r viruses, disease sympt ms may ur
b th innate, n nspe i me hanisms and by adaptive, spe i as the b dy ghts t destr y the threatening rganism.
immune me hanismsas we dis uss later in this hapter. H wever, i the b dy is exp sed a se nd
time t the same threatening rganism,
n seri us sympt ms ur be ause
Ad a p t ive Im m u n it y Feedback
O ve r v ie w loop
Adaptive immunity is able t adapt t newly en untered
enemies. It is als alled speci c immunity be ause it He a lthy tis s ue

TABLE 16-2 Mechanisms o Innate De ense

Ba cte ria e nte r tis s ue (for exa mple )
MECHANIS M DES CRIPTION
Me chanical and Phys ical im pe dim e nts to the e ntry o
che m ical barrie rs ore ign ce lls or s ubs tance s
Skin and m ucous Form s a continuous wall that s e parate s Tis s ue da ma ge occurs
m e m brane s the inte rnal e nvironm e nt rom the
exte rnal e nvironm e nt, preve nting the
e ntry o pathoge ns
Se cre tions Se cre tions s uch as s e bum , m ucus , acids , Infla mma tion me dia tors a re re le a s e d
and e nzym e s che m ically inhibit the
activity o pathoge ns
In am m ation The in am matory response isolate s the
pathogens and stim ulates the speedy
arrival o large numbers o imm une cells
Incre a s e d
Incre a s e d
Feve r Feve r m ay e nhance im m une re actions Che mota xis va s cula r
blood ow
and inhibit pathoge ns pe rme a bility
Phagocytos is Inge s tion and de s truction o pathoge ns by
phagocytic ce lls
Ne utrophils Granular le ukocyte s that are us ually the
Incre a s e d numbe rs of
f rs t phagocytic ce ll to arrive at the
le ukocyte s a nd me dia tors
s ce ne o an in am m atory re s pons e a t s ite of tis s ue da ma ge
Macrophage s Monocyte s that have e nlarge d to be com e
giant phagocytic ce lls capable o con-
s um ing m any pathoge ns ; o te n calle d
by m ore s pe cif c nam e s w he n ound in
s pe cif c tis s ue s o the body Ba cte ria a re conta ine d,
de s troye d, a nd pha gocytize d
Natural kille r (NK) Type o lym phocyte s that kills any ce ll
ce lls lacking a norm al s e l -antige n
Com ple m e nt Group o plas m a prote ins (inactive
e nzym e s ) that produce a cas cade o
che m ical re actions that ultim ate ly
No ba cte ria re ma in Ba cte ria re ma in
caus e s lys is (rupture ) o a ore ign ce ll;
the com ple m e nt cas cade can be trig-
ge re d by adaptive or innate im m une
m e chanis m s
Tis s ue re pa ir Additiona l me dia tors
Inte r e ron (IF) Prote in produce d by ce lls a te r they
a ctiva te d
be com e in e cte d by a virus ; inhibits the
s pre ad or urthe r deve lopm e nt o a viral
FIGURE 16-10 In ammatory response. In this example, bacterial in ec-
in e ction (s e e box on p. 446) tion triggers a set o responses that tend to inhibit or destroy the bacteria.
 438 CHAPTER 16 Lymphatic System and Immunity

the rganism is destr yed qui klythe pers n is

said t be immune t that parti ular rganism. Su h
16 immunity is said t be spe i be ause pr te ti n
against ne type disease- ausing ba teria r virus
d es n t pr te t the b dy against thers.
As Table 16-1 sh ws, adaptive immune resp nses are
sl w mpared t innate immune resp nses. H wever,
adaptive immune resp nses have immune mem ry
the ability t pr du e a str nger, aster resp nse t
repeated exp sure t the same antigen. Table 16-1 sum-
marizes ther imp rtant eatures b th types im-
munity, s me whi h are dis ussed later in this
hapter.
To better understand the concept o adap-
tive immunity, use the Active Concept Map
Specif c Immunity at evolve.elsevier.com.
HEA LTH AND WELL-BEIN G
EFFECTS OF EXERCIS E ON IMMUNITY
Exe rcis e phys iologis ts have ound that
m ode rate exe rcis e incre as e s the num be r
o w hite blood ce lls (WBCs ), s pe cif cally
granular le ukocyte s and lym phocyte s . Not
only is the num be r o circulating im m une
ce lls highe r a te r exe rcis e , but the activity
o activate d T ce lls is als o incre as e d. On
the othe r hand, re s e arch als o s how s that
s tre nuous exe rcis e m ay actually inhibit im -
m une unction. Neve rthe le s s , m ode rate
exe rcis e s uch as walking, w he n e ngage d
in im m e diate ly a te r a traum a s uch as s ur-
ge ry, is o te n e ncourage d be caus e o its
im m unity-s tre ngthe ning e e cts .

Ty p e s o Ad a p t ive Im m u n it y
Spe i immunity may be lassi ed as either natural
r arti ial depending n h w the b dy is exp sed
t the harm ul agent (Table 16-3). Natural exp sure is
n t deliberate and urs in the urse everyday living. We Table 16-3 lists the vari us rms spe i immunity and
are naturally exp sed t many disease- ausing agents n a gives examples ea h.
regular basis. Arti ial exp sure is alled immunization and
is the deliberate exp sure the b dy t a p tentially harm ul QUICK CHECK
agent. 1. Wh a t is th e d i e re n ce b e tw e e n a d a p tive im m u n ity a n d
Natural and arti ial immunity may be a tive r passive. in n a te im m u n ity?
2. Ou tlin e th e ch a n g e s th a t o ccu r in th e b o d ys in a m m a to ry
re s p o n s e .
immune system resp nds t an agent that pr du es 3. De s crib e th e d i e re n ce b e tw e e n a ctive im m u n ity a n d
an immune resp nse, regardless whether that p a s s ive im m u n ity.
agent was naturally r arti ially en untered.

that has devel ped in an ther individual r animal is Im m u n e S y s t e m M o le c u le s

trans erred t an individual wh was n t previ usly
T e immune system un ti ns be ause adequate am unts
immune. F r example, antib dies in a m thers milk
de ensive pr tein m le ules and pr te tive ells. T e pr -
n er passive immunity t her nursing in ant.
tein m le ules riti al t immune system un ti ning in lude
-
cytokines, antibodies, and complement pr teins.
munity. Alth ugh passive immunity is temp rary, it
pr vides immediate pr te ti n.
Cy t o k in e s
As menti ned earlier in this hapter, yt -
TABLE 16-3 Types o Adaptive Immunity kines are hemi als released r m ells t a t
TYPE EXAMPLE as dire t agents innate, n nspe i immu-
Natural im m unity Expos ure to the caus ative age nt is not de libe rate nity. T ey an als trigger r regulate many
innate and adaptive immune resp nses. O ten
Active im m unity A child deve lops m e as le s and acquire s an im m unity to a s ub-
s e que nt in e ction
yt kines are riti al t the ell-t - ell m-
muni ati n that is needed t rdinate the
Pas s ive im m unity A e tus re ce ive s prote ction rom the m othe r through the pla-
mbined innate and adaptive a ti ns that are
ce nta, or an in ant re ce ive s prote ction via its m othe rs m ilk
unleashed during any immune resp nse.
Artif cial im m unity Expos ure to the caus ative age nt is de libe rate
Many the yt kines are pr teins alled
Active im m unity Inte ntional expos ure to the caus ative age nt, s uch as a vacci- interleukins (ILs). T is name is apt r a
nation agains t polio, activate s the im m une s ys te m and substan e used by W BCs t mmuni ate
thus con e rs im m unity
between ells, be ause inter- means be-
Pas s ive im m unity Inje ction o prote ctive m ate rial (antibodie s ) that was deve l- tween, -leuk- re ers t leuk ytes, and -in
ope d by anothe r individuals im m une s ys te m means substan e. ILs are ten inv lved in

signaling in b th innate and adaptive immune me hanisms.
F r example, ILs are inv lved in pr du ing a ever and in
a tivating the ells adaptive, spe i immunity.
A n t ib o d ie s
D e f n it io n
Antibodies are pr tein mp unds that are n rmally present
in the b dy. A de ning hara teristi an antib dy m le ule
is the uniquely shaped n ave regi ns alled combining sites
n its sur a e. An ther de ning hara teristi is the ability
an antib dy m le ule t mbine with a spe i m le ule
alled an antigen.
All antigens are m le ules that have small regi ns n their
sur a es that are uniquely shaped t t int the mbining
sites a spe i antib dy m le ule as pre isely as a key ts
int a spe i l k. Antigens are ten pr tein m le ules im-
bedded in the sur a e membranes threatening r diseased
ells su h as mi r rganisms r an er ells.
Antibodies are also called immunoglobulins (Igs)
and are grouped into classes named or letters o
the alphabet, such as IgA, IgD, IgE, IgG, and IgM.
For more discussion about immunoglobulin
classes, see the article Immunoglobulins at
Connect It! at evolve.elsevier.com.
Antibody
Inac tivate s
antig e n
Binds
antig e ns
to g e the r
(clumping )
Fac ilitate s
phag o c yto s is
FIGURE 16-11 Antibody unction. Antibodies produce humoral immunity by binding to speci c antigens to
orm antigen-antibody complexes. These complexes produce a variety o changes that inactivate or kill threat-
ening cells. WBCs, White blood cells.
CHAPTER 16 Lymphatic System and Immunity 439
Fu n c t io n s
In general, antib dies pr du e humoral immunity, r
antibody-mediated immunity, by a e ting the antigens in a 16
way that prevents them r m harming the b dy (Figure 16-11).
d this, an antib dy must rst bind t its spe i antigen.
T is rms an antigen-antibody complex. T e antigen-
antib dy mplex then a ts in ne r m re ways t make
the antigen, r the ell n whi h it is present, harmless.
F r example, i the antigen is a t xin, a substan e p is n-
us t b dy ells, the t xin is neutralized r made n np is n-
us by be ming part an antigen-antib dy mplex. O r i
antigens are m le ules in the sur a e membranes threaten-
ing ells, when antib dies mbine with them, the resulting
antigen-antib dy mplexes may agglutinate the enemy ells
(that is, make them sti k t gether in lumps). T en ma r -
phages r the ther phag ytes an rapidly destr y them by
ingesting and digesting large numbers them at ne time.
An ther imp rtant un ti n antib dies is pr m ti n
and enhan ement phag yt sis. Certain antib dy ra ti ns
help pr m te the atta hment phag yti ells t the bje t
they will engul . As a result, the nta t between the phag -
yti ell and its target is enhan ed, and the bje t is m re
easily ingested. T is pr ess ntributes t the e ien y
immune system phag yti ells, whi h is des ribed n p. 440.
Pr bably the m st imp rtant way in whi h antib dies a t
is a pr ess alled the complement cascade. O ten, when
antigens that are m le ules n an antigeni r reign ells
Antige n
Ac tivate s
c o mple me nt
c as c ade
Comple me nt
ca s ca de
Infla mma tion
Attra ction of WBCs
Ce ll de s truction
Immune
s ys te m ce lls
Initiate s
re le as e o f
inflammato ry
c he mic als
Infla mma tion
 440 CHAPTER 16 Lymphatic System and Immunity
sur a e mbine with antib dy m le ules, they hange the
shape the antib dy m le ule slightly, just en ugh t exp se
16 tw previ usly hidden regi ns. T ese are alled complement-
binding sites. T eir exp sure initiates a series events that
eventually kill the ell. T e next se ti n des ribes these events.
Biologists can produce large quantities o pure
and very specif c antibodies called monoclonal
antibodies. For details on how this medical
advance works, see the article Monoclonal Anti-
bodies at Connect It! at evolve.elsevier.com.
To learn more about antibodies and antigens, go to
AnimationDirect online at evolve.elsevier.com.
C o m p le m e n t P ro t e in s
Complement is the name used t des ribe a gr up pr tein
enzymes n rmally present in an ina tive state in bl d. T ese
pr teins may be a tivated by several triggers, in luding exp -
sure mplement-binding sites n antib dies when they
atta h t antigens. T e result is rmati n highly spe ialized
pr tein m le ules that target reign ells r destru ti n.
Re all that this pr ess is a rapid- re as ade r sequen e
events lle tively alled the complement cascade. T e end
result this pr ess is that d ughnut-shaped pr tein rings
( mplete with a h le in the middle) are rmed and literally
b re h les in the reign ell!
At rst, the tiny h les all w s dium t rapidly di use int
the ell. Next, water ll ws s dium thr ugh the pr ess
sm sis. T e ell literally bursts as the internal sm ti pres-
sure in reases (Figure 16-12).
C mplement pr teins als serve ther r les in the immune
system, su h as attra ting immune ells t a site in e ti n,
a tivating immune ells, marking reign ells r
destru ti n, and in reasing permeability bl d
vessels. C mplement pr teins als play a vital Comple me nt
r le in pr du ing the inf ammat ry resp nse.
QUICK CHECK
1. Wh a t a re a n tib o d ie s ? Ho w d o th e y w o rk?
2. Wh a t a re co m p le m e n t p ro te in s ? Ho w d o
th e y w o rk?
3. Co m p le m e n t p ro te in s s e rve w h a t ro le s in
th e im m u n e s ys te m .
4. Wh a t a re cyto kin e s ?
A ce ll
Im m u n e S y s t e m C e lls
T e primary ells the immune system in lude
the ll wing:
1. Phag ytes 2. Lymph ytes
a. Neutr phils a. Natural killer
b. M n ytes (NK) ells
. Ma r phages b. lymph ytes
d. Dendriti ells . B lymph ytes
(DCs)
P h a g o cyt e s
Phag yti W BCs are an imp rtant part the immune
system. In Chapter 13, phag ytes were des ribed as b ne
marr wderived ells that arry n phag yt sis, r ingesti n
and digesti n, reign ells r parti les (Figure 16-13).
Antib dy m le ules that bind t and at ertain reign
parti les help ma r phages un ti n e e tively. T ey serve as
f ags that alert the ma r phage t the presen e reign
material, in e ti us ba teria, r ellular debris. T ey als help
bind the phag yte t the reign material s that it an be
engul ed m re e e tively.
w imp rtant phag ytes are neutr phils and m n ytes
(see Figure 13-10, p. 361). T ese bl d phag ytes migrate ut
the bl d and int the tissues in resp nse t an in e ti n.
Neutr phils are the m st abundant immune ell in the
b dy. Be ause neutr phils are needed nly temp rarily as
phag ytes, they are sh rt-lived in the tissues. T e pus und
at s me in e ti n sites is m stly dead neutr phils.
On e in the tissues, m n ytes devel p int phag yti
ells alled macrophages. M st ma r phages then wander
thr ugh ut the tissues t engul ba teria wherever they nd
them.
An ther type phag yti ell is alled the dendritic cell
(D C). T ese highly bran hed (dendrite bran h) ells are
pr du ed in b ne marr w and are released int the bl d-
stream (Figure 16-14). S me remain in the bl d but many
migrate t tissues in nta t with the external envir nment
the skin, respirat ry lining, digestive lining, and s n. Resi-
dent DCs in these barrier regi ns help pr te t us r m threat-
ening parti les and ells.
Antib dy m le ules that bind t and at ertain reign
parti les help ma r phages un ti n e e tively. T ey serve as
f ags that alert the ma r phage t the presen e reign
material, in e ti us ba teria, r ellular debris. T ey als help
FIGURE 16-12 Complement cascade. A, Comple-
ment molecules activated by antibodies orm doughnut-
shaped complexes in a bacteriums plasma membrane.
B, Holes in the complement complex allow sodium (Na )
and then water (H2O) to di use into the bacterium. C, A ter
enough water has entered, the swollen bacterium bursts.
H 2O
Na+
Na+
Na+
Ba cte ria l
B Na+
Na+
H 2O
C
 CHAPTER 16 Lymphatic System and Immunity 441

Ba cte ria
1
Ma cropha ge
16
Lys os ome

Cycle
Nucle us
re pe a ts

5 Re le a s e
of e nd
products 2
(exocytos is ) Atta chme nt by
nons pe cific
re ce ptors

Cytos ke le ton exte nds

pla s ma me mbra ne

Re le a s e of
4 e nzyme from
lys os ome 3
P ha gocytos is
Dige s tive be gins
ve s icle (e ndocytos is )

FIGURE 16-13 Phagocytosis. Drawing shows sequence o steps in phagocytosis o bacteria. The plasma
membrane extends toward the bacterial cells, then envelops them. Once trapped, they are engul ed by the cell
and destroyed by lysosomal enzymes.

bind the phag yte t the reign material s that it an be

Ly m p h o c y t e s
engul ed m re e e tively (see Figure 16-13).
Ma r phages and D Cs per rm an ther imp rtant im- T e m st numer us ells the immune system a ter neutr -
mune un ti n besides destru ti n threatening ells and phils are the lymph ytes (Figure 16-15).
parti les. T ey als a t as antigen-presenting cells (APCs). Lymph ytes are resp nsible r antib dy pr du ti n and
Ma r phages and D Cs ingest a ell r parti le, rem ve its ther immune me hanisms. Lymph ytes ir ulate in the
antigens, and display s me b dys f uids. H uge numbers
them n their ell sur a es. them wander vigilantly thr ugh-
T e displayed antigens an then ut m st its tissues. Several
be presented t ther immune milli n str ng, lymph ytes n-
ells t trigger additi nal, adap- tinually patr l the b dy, sear hing
tive immune resp nses. ut any enemy ells that may have
entered r threatening virus-
in e ted ells and an er ells.
Devel ping and reserve lym-
ph ytes densely p pulate the
b dys widely s attered lymph
n des and its ther lymph id
FIGURE 16-14 Dendritic cell (DC). tissues, espe ially the thymus
Scanning electron micrograph showing gland in the hest and the spleen
the detail o projections o the plasma
membrane. DCs are phagocytic antigen- and liver in the abd men.
presenting cells (APCs) that are ound in We dis uss three maj r types
many areas o the body. lymph ytes here. One is the
 442 CHAPTER 16 Lymphatic System and Immunity

Lymphocyte Re d blood P la te le t ell, then the killing a ti n is turned . T us, nly abn r-
ce ll mal ells that la k n rmal sel -antigens are killed.
16 NK ells use several di erent killing meth ds, m st
whi h hemi ally trigger ap pt sis (pr grammed ell death)
in the target ell.

FIGURE 16-15 Lymphocytes. Color-enhanced scanning electron micro-
graph showing lymphocytes in yellow, red blood cells in red, and platelets
in green.
s - alled natural killer ells inv lved in innate immunity. T e
ther tw , s metimes designated as B lymphocytes and
lymphocytes r simply B cells and cellsare agents
adaptive immunity. Ea h type lymph yte has the same
appearan e, but ea h has a di erent set r les t play in
immunity.
N a t u r a l Kille r C e lls
T e natural killer (NK) cell is a type lymph yte that kills
many types tum r ells and ells in e ted by di erent kinds
viruses. Be ause they have br ad a ti n, and d n t require
pri r exp sure t an antigen, NK ells quali y as agents in-
nate, n nspe i immunity.
NK ells re gnize abn rmal ells by using tw di erent
re gniti n re ept rs. One re ept r a ts as a kill-a tivating
re ept r and binds t any several mm n sur a e m le-
ules und n ells. T us, it uld p tentially kill any ell in
the b dy. H wever, the ther re ept r is the kill-inhibiting
re ept r. I it binds t a sel antigen n a n rmal, healthy
B C e lls
Development o B Cells
All lymph ytes that ir ulate in the tissues arise r m stem
cells in the b ne marr w and g thr ugh tw stages devel-
pment. T e rst stage B- ell devel pment, trans rmati n
stem ells int immature B ells, urs in the liver and
b ne marr w be re birth but nly in the b ne marr w in
adults. Be ause this pr ess was rst dis vered in a bird r-
gan alled the bursa, these ells were named B ells.
Immature B ells are small lymph ytes that have ea h
synthesized and inserted int their yt plasmi membranes
numer us m le ules ne spe i kind antib dy
(Figure 16-16).
A ter they mature, B ells eventually leave the tissue where
they were rmed. Ea h mature, but still ina tive, B ell arries
a di erent type antib dy. T e vari us B ells then enter the
bl d and are transp rted t their new pla e residen e,
hief y the lymph n des.
T e se nd stage B- ell devel pment hanges a mature,
ina tive B ell int an a tivated B ell. N t all B ells underg
this hange. T ey d s nly i an ina tive B ell mes int
nta t with ertain n nsel r abn rmal m le ulesantigens
wh se shape ts the shape the B ells sur a e antib dy m l-
e ules. I this happens, the antib dies l k nt the antigens and
by s d ing hange the ina tive B ell int an a tivated B ell.
B- ell a tivati n als requires a hemi al signal ( yt kine) r m
an ther immune ella type ell.
T en the a tivated B ell, by dividing rapidly and repeat-
edly, devel ps int gr ups r l nes many identi al ells
all having the same type antib dy. A clone is a amily
many identi al ells, all des ended r m ne ell.
Ea h l ne B ells is made up tw kinds ells,
plasma cells (als alled ef ector cells) and memory cells, as
y u an see in Figure 16-16. Plasma ells se rete huge am unts
antib dy int the bl drep rtedly 2000 antib dy m le-
ules per se nd by ea h plasma ell r every se nd the

S te m Immature B c e lls
c e lls S ma ll lymphocyte s with
a ntibody mole cule s in
Ma ture B ce lls migra te to lymph node s, live r,
Deve lop s hortly cytopla smic me mbra ne s
a nd s ple e n; binding of a ntige n to a ntibody on
be fore a nd a fte r
s urfa ce s of ina ctive B ce lls a nd che mica l
birth into
s igna l from T ce lls cha nge s the m into

FIGURE 16-16 B-cell development. B-cell development takes place in two stages. First stage: Shortly
be ore and a ter birth, stem cells develop into immature B cells, which then mature into inactive B cells that
migrate to lymphoid organs. Second stage (occurs only when inactive B cell contacts its speci c antigen): inac-
tive B cell develops into activated B cell, which divides rapidly and repeatedly to orm a clone o plasma cells
and a clone o memory cells. Plasma cells secrete antibodies capable o combining with speci c antigen that
began the process. Stem cells maintain a constant population o newly di erentiating inactive B cells.
 CHAPTER 16 Lymphatic System and Immunity 443

ew days that it lives. Antib dies ir ulating in the bl d T e se nd stage - ell devel pment takes pla e when
nstitute an en rm us, m bile, ever- n-duty army. and i a ell mes int nta t with its spe i antigen. I
Mem ry ells an se rete antib dies but d n t immedi- this happens, the antigen binds t the pr tein n the ells 16
ately d s . T ey remain in reserve in the lymph n des until sur a e, thereby hanging the ell int an a tivated ell
they are nta ted by the same antigen that led t their r- (Figure 16-17).
mati n. T en, the mem ry ells very qui kly divide t pr du e As with B ells, ells must als re eive a hemi al signal
l nes plasma ellsand m re mem ry ells. T e plasma ( yt kine) r m an ther ell t be me a tivated. Likewise,
ells se rete large am unts antib dy. Mem ry ells, in e - a tivated ells als pr du e a l ne identi al ells, all able
e t, seem t remember their an est r a tivated-B ells en- t rea t with the same antigen.
unter with its appr priate antigen. T ey stand ready, at a And as with B ells, ells rm a gr up ef ector cells
m ments n ti e, t pr du e m re plasma ells t release an- al ng with memory cells. T e e e t r ells immediately en-
tib dies that will mbine with this antigen. gage in immune resp nses, whereas the mem ry ells d
n t. Later, i m re e e t r ells are needed, the mem ry
Function o B Cells ells divide rapidly t pr du e additi nal l nes that in-
B ells un ti n indire tly t pr du e hum ral immunity. lude m re e e t r ells.
Re all that humoral immunity is resistan e t disease rgan-
isms pr du ed by the a ti ns antib dies binding t spe i Functions o T Cells
antigens while ir ulating in b dy f uids. A tivated B ells A tivated ells pr du e ell-mediated immunity. As the
devel p int plasma ells. Plasma ells se rete antib dies int name suggests, cell-mediated immunity is resistan e t disease
the bl dthus serving as the antib dy a t ries the rganisms resulting r m the a ti ns ells hief y a tivated
b dy. T ese antib dies, like ther pr teins manu a tured r ells. One gr up a tivated ells kills in e ted ells and
extra ellular use, are rmed in the end plasmi reti ulum tum r ells dire tly. W hen b und t antigens n the abn rmal
the ell. ells sur a e, these cytotoxic cells release a substan e that a ts
as a spe i and lethal p is n against the abn rmal ell.
T C e lls A tivated ells alled helper cells pr du e their deadly
Development o T Cells e e ts indire tly by means hemi al signals that they re-
ells are lymph ytes that have underg ne their rst stage lease int the area ar und enemy ells. Am ng these is a
devel pment in the thymus gland. Stem ells r m the b ne substan e that attra ts ma r phages int the neighb rh d
marr w seed the thymus, and sh rtly be re and a ter birth, the enemy ells. T e assembled ma r phages then destr y the
they devel p int ells. T e newly rmed ells stream ut ells by phag yt sing (ingesting and digesting) them
the thymus int the bl d and migrate hief y t the lymph (Figure 16-18). H elper ells als release the yt kines needed
n des, where they take up residen e. t help trigger the a tivati n B ells.
Embedded in ea h ells yt plasmi membrane are pr - A third gr up ells alled regulatory cells helps shut
tein m le ules shaped t t nly ne spe i kind antigen d wn an immune rea ti n a ter the antigens have been de-
m le ule. str yed and als helps prevent inappr priate immune rea ti ns.

Me mo ry c e lls
S tore d in lymph node s ;
s ubs e que nt expos ure to
a ntige n trigge rs me mory
ce lls to ra pidly divide
a nd form

Ac tivate d B c e lls
Divide ra pidly a nd
re pe a te dly to form
clone s of

Plas ma c e lls

Antibo die s

S e cre te
into
blood
 444 CHAPTER 16 Lymphatic System and Immunity

FIGURE 16-17 T-cell development. The rst stage takes place in the thymus gland shortly be ore and a ter
birth. Stem cells maintain a constant population o newly di erentiating cells as they are needed. The second
16 stage occurs only when a T cell contacts antigen, which combines with certain proteins on the T cells sur ace.

S te m T c e lls Migra te to lymph node s, live r, Ac tivate d T c e lls

c e lls a nd s ple e n; binding of a ntige ns
Deve lop in thymus
gla nd s hortly be fore to prote ins on s urfa ce s of T ce lls
a nd a fte r birth into a nd che mica l s igna ls from othe r
T ce lls cha nge s the m into

QUICK CHECK Hy p e r s e n s it iv it y o t h e Im m u n e
1.
2.
Wh a t
Wh a t
a re p h a g o cyte s ? Ho w d o th e y w o rk?
a re n a tu ra l kille r (NK) ce lls ?
Sys t e m
3. Wh a t is th e ro le o B ce lls in im m u n ity? Hypersensitivity is an inappr priate r ex essive resp nse
4. Wh a t is th e ro le o T ce lls in im m u n ity? the immune system. T ere are three types: allergy, aut im-
5. Wh a t a re m e m o ry ce lls ? De s crib e th e ir u n ctio n .
munity, and all immunity.

Activa te d T ce lls

Cytotoxic He lpe r Re gula tory

T ce lls T ce lls T ce lls

Re le a s e Re le a s e Re le a s e

Compounds Compounds Compounds

tha t a ct tha t a ct tha t a ct
dire ctly indire ctly indire ctly

Ce ll po is o n B c e ll Attrac ting Mac ro phag e Inflammation Re g ulato ry fac to rs

Kills infe cte d ac tivato rs fac to rs ac tivating me diato rs Alte r functions
or tumor ce ll He lp a ctiva te He lp draw fac to rs of othe r
bound to B ce lls ma cropha ge s S pe e d up immune ce lls
a ctiva te d T ce ll towa rd pha gocytos is
thre a te ning P romote
P roduce ce lls

P romote S uppre s s e s
Infla mma tory
Antibodie s immune
re s pons e
re s pons e s
P ha gocytos is

Re duce s

FIGURE 16-18 T-cell unction. Activated T cells produce cell-

Antige n-be a ring mediated immunity by releasing various compounds in the vicinity o
pa thoge ns in ected or tumor cells. Some compounds act directly, and some act
indirectly, on these cells.

Me mo ry c e lls
S ubs e que nt expos ure to a ntige n
trigge rs me mory ce lls to
ra pidly divide a nd form
Kill infe cte d ce lls
Effe c to r c e lls a nd tumor ce lls ;
trigge r B a nd
T-ce ll a ctiva tion;
re gula te va rious
immune functions
A lle r g y
T e term allergy is used t des ribe hypersensitivity the
immune system t relatively harmless envir nmental antigens.
Antigens that trigger an allergi resp nse are ten alled
allergens. One in six Ameri ans has a geneti predisp siti n
t exhibiting an allergy s me kind.
Immediate allergi resp nses inv lve antigen-antib dy rea -
ti ns. Be re su h a rea ti n urs, a sus eptible pers n must
be exp sed t an allergen repeatedlytriggering the pr du -
ti n antib dies. A ter a pers n is thus sensitized, exp sure t
an allergen auses antigen-antib dy rea ti ns that trigger the
release histamine, kinins, and ther inf ammat ry substan es.
T ese resp nses usually ause typi al allergy sympt ms su h as
runny n se, njun tivitis, and urticaria (hives).
In s me ases allergy, h wever, exp sure t allergens
may ause nstri ti n the airways, relaxati n bl d
RES EA RC H, IS S U ES , AND TREN D S
MUCOSAL IMMUNITY
The m ucos al im m une s ys te m is a com plex s ys te m o de e ns e
dis tinct rom the s ys te m ic (inte rnal) im m une s ys te m that we
have be e n dis cus s ing in m os t o this chapte r. It is an innate
(nons pe cif c) and adaptive (s pe cif c) s ys te m that is ound
w ithin the m ucous barrie rs o the body: dige s tive tract, urinary/
re productive tracts , re s piratory tract, exocrine ducts , conjunc-
tiva (eye cove ring), m iddle e ar, and s o on. The im m une ce lls
that m ake up the m ucos al im m une s ys te m are locate d m ainly
in or ne ar m ucos a-as s ociate d lym phoid tis s ue (MALT).
The m ain unctions o the m ucos al im m une s ys te m involve
preve nting pathoge ns rom colonizing the m ucous s ur ace s o
the body, preve nting the accide ntal abs orption o antige ns
rom outs ide the body, and preve nting inappropriate or inte ns e
re s pons e s o the s ys te m ic im m une s ys te m to the s e exte rnal
antige ns .
Unde rstanding the m ucosal im mune syste m and its coop-
eration w ith the syste mic (internal) imm une syste m promis e s to
CHAPTER 16 Lymphatic System and Immunity 445
vessels, and irregular heart rhythms that an pr gress t a
li e-threatening nditi n alled anaphylactic shock (see
Chapter 15). D rugs alled antihistamines are s metimes used 16
t relieve the sympt ms this type allergy. Epinephrine
(Epi), s metimes administered with a penlike inje t r arried
by sus eptible individuals, an als redu e severe allergi
rea ti ns.
Delayed allergi resp nses, n the ther hand, inv lve ell-
mediated immunity. In contact dermatitis, r example,
ells trigger events that lead t l al skin inf ammati n a
ew h urs r days a ter initial exp sure t an antigen. Exp -
sure t p is n ivy, s aps, and ertain smeti s may ause
nta t dermatitis in this manner (Figure 16-19). H ypersensi-
tive individuals may use hypoallergenic pr du ts (pr du ts
with ut mm n allergens) t av id su h allergi rea ti ns.
Au t o im m u n it y
Autoimmunity is an inappr priate and ex essive resp nse t
sel -antigens. Dis rders that result r m aut immune resp nses
are alled autoimmune diseases. Examples aut immune dis-
eases are given in able 9 Appendix A at evolve.elsevier.com.
Sel -antigens are m le ules that are native t a pers ns
b dy and that are used by the immune system t identi y
mp nents sel . Sel -antigens an als be segments a
pers ns geneti material (DNA r RNA) r ertain pr teins
r ther hemi als made in the b dy. In aut immunity, the
immune system inappr priately atta ks these antigens.
A mm n aut immune disease is systemic lupus
erythematosus (SLE), r simply lupus. Lupus is a hr ni
inf ammat ry disease that a e ts many tissues in the b dy:
j ints, bl d vessels, kidneys, nerv us system, and skin. T e
name lupus erythematosus re ers t the red rash that s metimes
devel ps n the a e th se a i ted with SLE (Figure 16-20).
reveal new strate gie s o imm u-
nization. For exam ple, re s earch-
e rs have ound that imm unizing
through the bloodstream acti-
vate s only the inte rnal (sys-
te m ic) B cells and T ce lls. Thus a
pathoge n would have to actually
e nte r the inte rnal environme nt
be ore this type o adaptive im munity could prote ct us. Im mu-
nization o the mucos al lymphocyte s, however, can activate
both mucosal and syste m ic lym phocyte sproviding a more
thorough type o prote ction.
Anothe r advantage o m ucos al im m unization is that it is
e as ie r to adm inis te r to patie nts than im m unizations inje cte d
unde r the s kin or into the bloods tre am . For exam ple , im m uni-
zation can be de live re d by nas al s prays or drops ins te ad o
s hots .
 446 CHAPTER 16 Lymphatic System and Immunity

16

R L

FIGURE 16-20 Lupus erythematosus. A red butterf y rash on the

ace is sometimes seen in cases o systemic lupus erythematosus (SLE).

FIGURE 16-19 Contact dermatitis. Dermatitis, or skin inf ammation,
can result rom contact with allergenssubstances that trigger allergic
responses in hypersensitive individuals.
T e systemi part the name mes r m the a t that
the disease a e ts many systems thr ugh ut the b dy. T e
systemi nature SLE results r m the pr du ti n anti-
b dies against many di erent sel -antigens.
A llo im m u n it y
Alloimmunity is ex essive rea ti n the immune system t
antigens r m a di erent individual the same spe ies. It is
imp rtant in relati n t pregnan y and tissue transplants. Al-
l immunity is als s metimes alled isoimmunity.
D uring pregnan y, antigens r m the etus may enter the
m thers bl d supply and sensitize her immune system. An-
tib dies that are rmed as a result this sensitizati n may
enter the etal ir ulati n and ause an inappr priate immune
rea ti n. One example, erythr blast sis etalis, was dis ussed
in Chapter 13.
O ther path l gi al nditi ns als may be aused by dam-
age t devel ping etal tissues resulting r m atta k by the
m thers immune system. Examples in lude ngenital heart
de e ts, Graves disease, and myasthenia gravis.
issue r rgan transplants are medi al pr edures in
whi h tissue r m a d n r is surgi ally gra ted int the b dy. F r
example, skin gra ts are ten d ne t repair damage aused by
burns. D nated wh le bl d tissue is ten trans used int a
re ipient a ter massive hem rrhaging. A kidney is s metimes
rem ved r m a living d n r and gra ted int a pers n su ering

C LIN ICA L APPLICATION

INTERFERON
Inte r e ro ns (IFs ) are s m all prote ins produce d m os t o te n by e npox, m e as le s , and he patitis . IF als o s how s prom is e as an
body ce lls in re s pons e to viral in e ctions . IFs play a s ignif cant anticance r age nt. It has be e n s how n to be e e ctive in tre ating
role in producing innate (nons pe cif c) im m unity to m any vi- bre as t, s kin, and othe r orm s o cance r.
rus e s . Groups o IFs de s ignate d as alphas , be tas , gam m as ,
and om e gas all have unique biological activ-
ity and are be ing us e d m ore and m ore o te n
in clinical m e dicine .
One IF is produce d by T ce lls w ithin
hours a te r they have be e n in e cte d by a vi-
rus . This IF, w he n re le as e d rom the T ce lls ,
prote cts othe r ce lls by inte r e ring w ith the
ability o the virus to re produce as it m ove s
rom ce ll to ce ll. In the pas t, thous ands o
pints o blood had to be proce s s e d to har-
ve s t tiny quantitie s o le ukocyte (T ce ll) IF
or s tudy.
Curre ntly, di e re nt s ynthe tic type s o S
both hum an and non-naturally occurring IFs
are be ing m anu acture d in bacte ria as a M L
re s ult o ge ne -s plicing te chnique s and are
A B I
available in quantitie s s u f cie nt or clinical
us e . Synthe tic IF de cre as e s the s eve rity o Inter eron treatment. A, Cancerous skin tumors o Kaposi sarcoma (KS). B, A ter treatment
m any virus -re late d dis e as e s including chick- with alpha inter eron, the KS tumors have been reduced.
 CHAPTER 16 Lymphatic System and Immunity 447

C LIN ICA L APPLICATION 16

)
S e cond va ccina tion

d
o
IMMUNIZATION Initia l (boos te r)

o
l
b
va ccina tion
S e conda ry

n
Active imm unity can be e stablishe d artif cially by using a te ch-

i
r
re s pons e

s
e
nique calle d vaccination. The original vaccine was a live cow pox

e
t
i
i
t
d
y
virus that was injecte d into he althy pe ople to cause a mild cow-

o
d
b
o
i
pox in e ction. The te rm vaccine literally m e ans cow sub-

t
b
n
i
a
t
stance . Be cause the cow pox virus is sim ilar to the de adly

n
f
A
P rima ry

o
smallpox virus, vaccinate d individuals deve lope d antibodie s that

t
re s pons e

n
imparte d im munity agains t both cow pox and smallpox viruse s.

u
o
m
Mode rn vaccine s work on a similar principle ; substance s

that trigger the ormation o antibodie s against s pecif c patho-
gens are introduce d orally or by inje ction. Som e o the s e vac-
cine s are kille d pathogens ; some are live, atte nuate d (we ak-
e ne d) pathoge ns . Such pathoge ns s till have the ir spe cif c
antigens intact, so they can trigge r orm ation o the prope r anti-
bodie s, but they are no longe r virule nt (able to cause dis e ase ).
Although it is rare , the se vaccine s s om e time s backf re and actu-
ally cause an in e ction. Many o the newe r vaccine s get around
this pote ntial problem by us ing only the part o the pathoge n
that contains antige ns . Be cause the dise ase -causing portion is
miss ing, such vaccine s cannot caus e in e ction. Rigorous studie s
have show n that vaccine s are ge ne rally sa e and e e ctive .
The curre nt re com m e nde d s che dule s or childre n and
adults are available at my-ap.us /VaccSche d
The am ount o antibodie s in a pe rs ons blood produce d in
re s pons e to vaccination or an actual in e ction is calle d the an-
tibody tite r. As you can s e e in the graph, the initial inje ction o
vaccine trigge rs a ris e in the antibody tite r that gradually dim in-
is he s . O te n, a boos te r s hot, or s e cond inje ction, is give n to
a
(
Time
ke e p the antibody tite r high or to rais e it to a leve l that is m ore
like ly to preve nt in e ction.
The s e condary re s pons e is m ore inte ns e than the prim ary
re s pons e be caus e m e m ory B ce lls are s tanding re ady to pro-
duce a large num be r o antibodie s at a m om e nts notice . A
late r accide ntal expos ure to the pathoge n w ill trigge r an eve n
m ore inte ns e re s pons e thus preve nting in e ction.
Toxoids are s im ilar to vaccine s but us e an alte re d orm o a
bacte rial toxin (pois onous che m ical) to s tim ulate production o
antibodie s . Inje ction o toxoids im parts prote ction agains t tox-
ins , w he re as adm inis tration o vaccine s im parts prote ction
agains t pathoge nic organis m s and virus e s .
To learn more about vaccination, go to
AnimationDirect online at evolve.elsevier.com.

r m kidney ailure. Un rtunately, the immune system s me-

times rea ts against reign antigens present in the gra ted tis-
sue, ausing what is ten alled a rejection syndrome.
T e antigens m st mm nly inv lved in transplant reje -
ti n are alled human lymphocyte antigens (H LAs).
Reje ti n gra ted tissues an ur in tw ways. One is
alled host-versus-gra t rejection be ause the re ipients immune
system re gnizes reign H LAs and atta ks them, destr ying
the d nated tissue. T e ther is gra t-versus-host rejection be-
ause the d nated tissue ( r example, b ne marr w) atta ks
the re ipients H LAs, destr ying tissue thr ugh ut the re ipi-
ents b dy. Gra t-versus-h st reje ti n may lead t death.
T ere are tw ways t prevent reje ti n syndr me. One
strategy is alled tissue typing, in whi h H LAs and ther an-
tigens a p tential d n r and re ipient are identi ed. I they
mat h, tissue reje ti n is unlikely t ur. An ther strategy is
the use immunosuppressive drugs in the re ipient. Im-
mun suppressive drugs su h as cyclosporine and prednisone
suppress the immune systems ability t atta k the reign
antigens in the d nated tissue.
QUICK CHECK
1. Wh a t is a n a lle rg e n ? Ho w d o e s it a e ct th e im m u n e
s ys te m ?
2. Why is lu p u s ca lle d a n a u to im m u n e d is o rd e r ?
3. Why a re im m u n o s u p p re s s ive d ru g s g ive n to o rga n tra n s -
p la n t re cip ie n ts ?
Im m u n e S y s t e m D e f c ie n c y
Immune de ciency, r immunode ciency, is the ailure im-
mune system me hanisms in de ending against path gens.
Immune system ailure usually results r m disrupti n
lymph yte (B r ell) un ti n.
T e hie hara teristi immune de ien y is the devel-
pment unusual r re urring severe in e ti ns r an er.
Alth ugh immune de ien y by itsel d es n t ause death,
the resulting in e ti ns r an er an.
T ere are tw br ad ateg ries immune de ien ies,
based n the me hanism lymph yte dys un ti n: congeni-
tal and acquired.
C o n g e n it a l Im m u n e D e f c ie n c y
C ngenital immune de ien y, whi h is rare, results r m
impr per lymph yte devel pment be re birth. Depending
n the stage devel pment stem ells (B r ells) during
whi h the de e t urs, di erent diseases an result.
F r example, impr per B- ell devel pment an ause in-
su ien y r absen e antib dies in the bl d. I stem ells
are disrupted, a nditi n alled severe combined immune
de ciency (SCID ) results. In m st rms SCID, hum ral
immunity and ell-mediated immunity are de e tive.
emp rary immunity an be imparted t hildren with
SCID by inje ting them with a preparati n antib dies
 448 CHAPTER 16 Lymphatic System and Immunity

(gamma gl bulin). B ne marr w transplants, whi h repla e
the de e tive stem ells with healthy d n r ells, have pr ved
16 e e tive in treating s me ases SCID. Advan es in using
gene therapy als have been made in treating SCID patients
(see dis ussi n gene therapy n pp. 692693 in Chapter 25).
Ac q u ir e d Im m u n e D e f c ie n c y
A quired immune de ien y devel ps a ter birth and is n t
related t geneti de e ts. A number a t rs an ntribute
t a quired immune de ien y: nutriti nal de ien ies, im-
mun suppressive drugs r ther medi al treatments, trauma,
stress, and viral in e ti n.
One the best kn wn examples a quired immune de-
ien y is acquired immunode ciency syndrome (AID S).
T is syndr me ( lle ti n sympt ms) is aused by the
human immunode ciency virus, r H IV.
H IV, a retr virus, ntains RNA that underg es reverse
trans ripti n inside a e ted ells t rm its wn DNA. T e
viral DNA ten be mes part the ells DNA. W hen the
viral DNA is a tivated, it dire ts the synthesis its wn RNA
and pr tein at, thus stealing raw materials r m the ell.
W hen this urs in ertain ells, the ell is destr yed and
immunity is impaired. As the ell dies, it releases new ret-
r viruses that an spread the H IV in e ti n.
Alth ugh H IV an invade several types ells, it has its
m st bvi us e e ts in a ertain type ell alled a CD4
ell. W hen - ell un ti n is impaired, in e ti us rgan-
isms and an er ells an gr w and spread mu h m re easily.
Unusual nditi ns, su h as pneumocystosis (a pr t z an in e -
ti n) and Kaposi sarcoma, r KS (a type skin an er aused
by a herpes virus), als may appear. Be ause their immune
systems are de ient, AIDS patients may eventually die r m
ne these in e ti ns r an ers.
A ter in e ti n with H IV, an untreated pers n may n t
sh w signs AIDS r m nths r years. T is is be ause the
immune system an h ld the in e ti n at bay r a l ng time
be re nally su umbing t it.
H IV in e ti n has rea hed epidemi pr p rti ns in many
untries, thus quali ying as a pandemic. T ere are several
strategies r preventing the devel pment AIDS. Many
agen ies are trying t sl w the spread AIDS by edu ating
pe ple ab ut h w t av id nta t with the H IV retr virus.
H IV is spread by means dire t nta t b dy f uids, s
preventing su h nta t redu es H IV transmissi n. Sexual
relati ns, ntaminated bl d trans usi ns, and intraven us
use ntaminated needles are mm n m des H IV
transmissi n. H IV an als be a perinatal in ection, that is,
an in e ti n passing r m m ther t in ant during birth.
Many resear hers are w rking n H IV va ines. Like
many viruses, su h as th se that ause the mm n ld, H IV
hanges rapidly en ugh t make devel pment a va ine
di ult at best.
An ther way t inhibit the pr gress an H IV in e ti n is
by means hemi als su h as azid thymidine (AZ ) and
rit navir (N rvir) that bl k H IVs ability t repr du e
within in e ted ells. A ktail several antiviral drugs
w rking t gether greatly redu es the number virus parti les
in a patients bl dthus redu ing the e e ts H IV in e -
ti n. M re than a hundred su h mp unds in vari us m-
binati ns are being evaluated r use in halting the pr gress
H IV in e ti ns.
QUICK CHECK
1. Wh a t is th e d i e re n ce b e tw e e n co n g e n ita l a n d a cq u ire d
im m u n e d e f cie n cy?
2. Wh a t ca u s e s AIDS ?
3. Ho w ca n th e p ro g re s s o HIV in e ctio n b e in h ib ite d ?

S C IEN C E APPLICATIONS
VACCINES
Englis h s urge on Edward Je nne r
change d the world oreve r in 1789
w he n he inoculate d his young s on
and two othe rs agains t the te rrible
viral dis e as e , s m allpox. Us ing m a-
te rial rom the blis te rs o a patie nt
w ith the m ilde r dis e as e s w ine pox,
he was able to trigge r im m unity to
s m allpoxthe worlds f rs t vaccina-
tion. Late r, in 1796, he ound that
Edward Jenner vaccination w ith m ate rial rom cow-
(17491823) pox blis te rs worke d eve n be tte r in
prote cting pe ople rom s m allpox.
A dis e as e that had orm e rly kille d m illions upon m illions o
pe ople worldw ide eve ntually dis appe are d rom the hum an
population in the twe ntie th ce ntury be caus e o Je nne rs pio-
ne e ring e orts .
In this ce ntury, inte re s t in s m allpox vaccinations has re s ur-
ace d be caus e o the thre at o s m allpox as a we apon. Im m u-
nologis ts are at work im proving on this im portant vaccine to
prote ct pe ople agains t s uch we apons . They als o continue to
work on vaccine s or othe r in e ctious dis e as e s s uch as HIV
in e ction, new s trains o in ue nza, Ebola, Zika, and eve n dis or-
de rs s uch as he art dis e as e and cance r.
Many he alth pro e s s ionals us e vaccine s in the ir practice , o
cours e , to boos t the im m une s ys te m s o the ir clie nts . Re -
ce ntly, m is conce ptions about the s a e ty o vaccine s thre ate n
public he alth by re ducing the num be r o childre n prote cte d by
vaccine s that s ave d a w hole ge ne ration rom the devas tating
e e cts o m e as le s , polio, s m allpox, diphthe ria, and m ore .
Many phys icians als o tre at dis orde rs o the im m une s ys -
te m its e l . For exam ple , im m une de f cie ncie s s uch as AIDS,
alle rgie s s uch as hay eve r, and autoim m une dis orde rs s uch
as lupus and rhe um atoid arthritis , are tre ate d eve ry day by
phys icians and othe r he alth pro e s s ionals .
 CHAPTER 16 Lymphatic System and Immunity 449

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 429)

16
cell-mediated immunity in ammatory response nonspecif c immunity
(sel-MEE-dee-ayt-ed ih-MYOO-nih-tee) (non-speh-SIF-ik ih-MYOO-nih-tee)
[cell storeroom, -medi- middle, -ate process, [in am- set af re, -ory relating to] [non- not, -spec- orm or kind, -if c relating to,
immun- ree, -ity state] innate immunity immun- ree, -ity state]
chemotaxis palatine tonsil
(kee-moh-TAK-sis) [innat- inborn, immun- ree, -ity state]
[chemo- chemical, -taxis movement or reaction] inter eron (IF) [palat- palate, -ine relating to, tons- goiter,
cisterna chyli (in-ter-FEER-on [aye e ]) -il little]
(sis-TER-nah KYE-lee or KYE-lye) [inter- between, - er- strike, -on substance] pharyngeal tonsil
[cisterna vessel, chyli o juice] interleukin (IL)
clone (in-ter-LOO-kin [aye el]) [pharyng- throat, -al relating to, tons- goiter,
(klohn) [inter- between, -leuk- white (blood cell), -il little]
[clon- plant cutting] -in substance] plasma cell (e ector B cell)
combining site interstitial uid (IF)
(in-ter-STISH-al FLOO-id [aye e ]) [plasma something molded (blood plasma),
complement [inter- between, -stit- stand, -al relating to] cell storeroom (e ect- accomplish, -or agent,
(KOM-pleh-ment) B bursa- equivalent tissue)]
lacteal
[comple- complete, -ment result o action] (LAK-tee-al) right lymphatic duct
complement-binding site [lact- milk, -al relating to] (ryte lim-FAT-ik dukt)
[lymph- water, -atic relating to, duct lead]
lingual tonsil
[comple- complete, -ment result o action] specif c immunity
complement cascade [lingua- tongue, -al relating to, tons- goiter, (speh-SIF-ik ih-MYOO-nih-tee)
(KOM-pleh-ment kas-KAYD) -il little] [spec- orm or kind, -if c relating to,
immun- ree, -ity state]
[comple- complete, -ment result o action, lymph
cascade water all] (lim ) T cell
cytokine [lymph water] (T sel)
(SYE-toh-kyne) [T thymus gland, cell]
lymphatic capillary
[cyto- cell, -kine movement] (lim-FAT-ik KAP-ih-layr-ee) T lymphocyte
dendritic cell (DC) [lymph- water, -atic relating to, capill- hair, (tee LIM- oh-syte)
-ary relating to] [T thymus gland, lymph- water (lymphatic
system), -cyte cell]
[dendrit- tree branch, -ic relating to, lymphatic vessel
cell storeroom] (lim-FAT-ik) thoracic duct
e ector cell [lymph- water, -atic relating to] (thoh-RAS-ik)
(e -FEK-tor sel) [thorac- chest (thorax), -ic relating to,
lymph node
(lim nohd) duct lead]
[e ect- accomplish, -or agent, cell storeroom]
e erent lymphatic vessel [lymph water, nod- knot] thymosin
(EF- er-ent lim-FAT-ik VES-el) lymphoid tissue (THY-moh-sin)
(LIM- oyd) [thymos- thyme ower (thymus gland),
[e- away, - er- carry, -ent relating to,
-in substance]
lymph- water, -atic relating to] [lymph- water (lymphatic system), -oid like,
humoral immunity tissu abric] thymus
(HYOO-mor-al ih-MYOO-nih-tee) macrophage (THY-mus)
[humor- liquid, -al relating to, immun- ree, (MAK-roh- ayj) pl., thymuses or thymi
-ity state] [macro- large, -phag- eat]
(THY-mus-ez or THY-mye)
[thymus thyme ower]
immune system memory cell
(MEM-oh-ree sel)
[immun- ree (immunity)] [cell storeroom]
immunoglobulin (Ig) natural killer cell (NK cell)
(ih-myoo-noh-GLOB-yoo-lin [aye jee])
[immuno- ree (immunity), -glob- ball, -ul- small, [cell storeroom]
-in substance]
 450 CHAPTER 16 Lymphatic System and Immunity

LANGUAGE OF M ED IC IN E
16
acquired immunodef ciency syndrome (AIDS) human immunodef ciency virus (HIV) monoclonal antibody
(ah-KWYERD IM-yoo-noh-deh-FISH-en-see (ih-myoo-no-deh-FISH-en-see
[aych aye vee]) [mono- single, -clon- plant cutting, -al relating
[immuno- ree, -def ci- ail, -y state, [immuno- ree (immunity), -de- down, to, anti- against]
syn- together, -drome running or (race) -f c- per orm, -ency state, virus poison] non-Hodgkin lymphoma
course] human lymphocyte antigen (HLA) (non-HOJ -kin lim-FOH-mah)
adenoid [non- not, Thomas Hodgkin English physician,
(AD-eh-noyd) [aych el ay]) lymph- water (lymphatic system),
[adeno- gland, -oid like] [lymph- water (lymphatic system), -cyte cell, -oma tumor]
allergen anti- against, -gen produce] perinatal in ection
(AL-er-jen) hypersensitivity
[all- other, -erg- work, -gen produce] [peri- around, -nat- birth or origin, -al relating
allergy [hyper- excessive, sensitiv- able to eel, to, in ect- stain, -ion condition]
(AL-er-jee) -ity state] severe combined immune def ciency (SCID)
[all- other, -erg- work, -y state] immune def ciency
alloimmunity deh-FISH-en-see [skid])
(al-oh-ih-MYOO-nih-tee) [immun- ree (immunity), -def ci- ail, -y state] [immun- ree (immunity), -def ci- ail, -y state]
[allo- another or di erent, -immun- ree, immunization splenectomy
-ity state]
anaphylactic shock [immun- ree (immunity), -tion process] [splen- spleen, -ec- out, -tom- cut, -y action]
(an-ah-f h-LAK-tik) immunosuppressive drug splenomegaly
[ana- without, -phylact- protection, (ih-myoo-noh-soo-PRES-iv drug) (spleh-noh-MEG-ah-lee)
-ic relating to] [immuno- ree (immunity), -suppress- press [splen- spleen, -mega large, -ly relating to]
autoimmunity down, -ive relating to, drug medicine] systemic lupus erythematosus (SLE)
(aw-toh-ih-MYOO-nih-tee) isoimmunity (sis-TEM-ik LOO-pus er-ih-them-ah-
[auto- sel , -immun- ree, -ity state] (aye-soh-ih-MYOO-nih-tee) TOH-sus [es el ee])
contact dermatitis [iso- equal, -immun- ree, -ity state] [system- organized whole, -ic relating to,
lymphadenitis lupus wol , erythema- redness,
[derma- skin, -itis in ammation] (lim-FAD-in-aye-tis) -osus condition]
elephantiasis [lymph- water, -aden- gland, -itis in ammation] tonsillitis
(el-eh- an-TYE-ah-sis) lymphangiogram (tahn-sih-LYE-tis)
[elephant- elephant, -iasis condition] [tonsil- tonsil, -itis in ammation]
ever [lymph- water, -angi- vessel, -gram drawing] transplant
(FEE-ver) lymphangitis
[ ev- heat] (lim- an-J YE-tis) [trans- across, -plant set or place]
Hodgkin disease [lymph- water, -angi- vessel, -itis in ammation] vaccine
lymphedema (VAK-seen)
[Thomas Hodgkin English physician, (lim- ah-DEE-mah) [vaccin- cow (cowpox)]
dis- opposite o , -ease com ort] [lymph- water, -edema swelling]
mastectomy
(mas-TEK-toh-mee)
[mast- breast, -ectomy surgical removal]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Lym phatic Sys te m
A. O rganizati n the lymphati systemlymphati f uid
(lymph), lymphati vessels, and many lymph rgans
make up this system (Figure 16-1)
B. Lymphex ess f uid le t behind by apillary ex hange
that drains r m tissue spa es and is transp rted by lym-
phatic vessels ba k t the bl dstream
C. Lymphati vesselspermit nly ne-way m vement
lymph
1. Lymphati apillariestiny blind-ended tubes dis-
tributed in tissue spa es (Figure 16-2)
a. Mi r s pi in size
b. Sheets nsisting ne ell layer simple squa-
m us epithelium
. P r t between adja ent ells results in p r us
walls
d. Called lacteals in the intestinal wall ( at transp rta-
ti n int bl dstream)
2. Right lymphati du t
a. D rains lymph r m the right upper extremity and
right side head, ne k, and upper t rs
3. T ra i du t
a. Largest lymphati vessel
b. H as an enlarged p u h al ng its urse, alled cis-
terna chyli
. D rains lymph r m ab ut three- urths the b dy
D. Lymphedemaswelling (edema) tissues aused by
bl kage lymphati vessels (Figure 16-3)
1. Lymphangitisinf ammati n lymphati vessels;
may pr gress t septi emia (bl d in e ti n)
(Figure 16-4)
2. Elephantiasissevere lymphedema limbs resulting
r m parasite in estati n lymphati vessels
(Figure 16-5)
CHAPTER 16 Lymphatic System and Immunity 451
16
E. Lymph id rganshave masses devel ping W BCs
(lymph id tissue) and un ti ns that in lude de ense and
W BC rmati n
1. Lymph n des
a. Filter lymph (Figure 16-6)
b. L ated in lusters al ng the pathway lymphati
vessels (Figures 16-7 and 16-8)
. Lymph id tissuemass lymph ytes and related
ells inside a lymph id rgan; pr vides immune
un ti n and devel pment immune ells
d. Fl w lymph: t n de via several a erent lym-
phati vessels and drained r m n de by a single
e erent lymphati vessel
e. Lymphadenitisswelling and tenderness lymph
n des
. Can er ells an easily m ve thr ugh lymphati
vessels t ther parts the b dy in a pr ess alled
metastasis
2. T ymus
a. Lymph id tissue rgan l ated in mediastinum
b. tal weight ab ut 35 t 40 ga little m re
than an un e
. Plays a vital and entral r le in immunity
d. Pr du es lymph ytes, r ells
e. Se retes h rm ne alled thymosins, whi h inf uen e
ell devel pment
. Lymph id tissue is eventually repla ed by at
(during hildh d) in the pr ess alled involution
3. nsils (Figure 16-9)
a. C mp sed three masses lymph id tissue
ar und the penings the m uth and thr at
(1) Palatine t nsils (the t nsils)
(2) Pharyngeal t nsils (als kn wn as adenoids)
(3) Lingual t nsils
b. Subje t t hr ni in e ti n
. Enlargement pharyngeal t nsils may impair
breathing
4. Spleen
a. Stru ture
(1) Largest lymph id rgan in b dy
(2) L ated in upper le t quadrant abd men
(3) O ten injured by trauma t abd men
(4) Surgi al rem val alled splenectomy
b. Fun ti ns
(1) Phag yt sis ba teria and ld RBCs
(2) Reserv ir m n ytes, whi h are released r
emergen y tissue repairs elsewhere in the b dy
(3) A ts as a bl d reserv ir
. Splen megalyenlargement the spleen
 452 CHAPTER 16 Lymphatic System and Immunity
5. Lymph mamalignant tum r lymph n des
a. w prin ipal types: H dgkin disease and n n-
16 H dgkin lymph ma
b. All types ause painless enlargement lymph
n des
. Can spread t many ther areas the b dy
Im m une Sys te m
A. Pr te ts b dy r m path l gi al ba teria, reign tissue
ells, and an er us ells
B. Made up de ensive ells and m le ules
C. w main strategiesinnate (n nspe i ) de enses and
adaptive (spe i ) de enses (Table 16-1)
D. Innate immunity
1. Called innate be ause we are b rn with it (n pri r
exp sure needed)
2. Als alled nonspeci c immunity be ause it in ludes
me hanisms that a t generally against any type
damage r threatening agent
3. Many types innate immunity ur in the b dy
(Table 16-2)
a. N nspe i immunity is the rapid rst resp nse
and ten triggers sl wer spe i resp nses
b. Inv lves a variety signaling hemi als alled
yt kines
4. Skinme hani al barrier t ba teria and ther
harm ul agents
5. ears and mu uswash eyes and trap and kill
ba teria
6. Inf ammati n
a. Inf ammat ry resp nseattra ts immune ells t
site injury, in reases l al bl d f w, in reases
vas ular permeability; pr m tes m vement
W BCs t site injury r in e ti n (Figure 16-10)
b. Feversystemi e e t in reased b dy tempera-
ture; may in rease immune e ien y r inhibit
in e ti us agents
7. C mplement lass enzymes in bl d plasma that
an trigger a variety immune resp nses; als
inv lved in adaptive (spe i ) me hanisms
E. Adaptive immunity (Table 16-1)
1. Adaptive be ause its ability t re gnize, resp nd
t , and remember harm ul substan es r ba teria
2. Als alled speci c immunity be ause it resp nds t
parti ular antigens t whi h is has been exp sed
3. ypes adaptive immunity (Table 16-3)
a. Natural immunityexp sure t ausative agent is
n t deliberate
(1) A tivea tive disease pr du es immunity
(2) Passiveimmunity passes r m m ther t etus
thr ugh pla enta r r m m ther t hild
thr ugh m thers milk
b. Arti ial immunityexp sure t ausative agent is
deliberate
(1) A tiveva inati n results in a tivati n
immune system and l ng-term pr te ti n
(2) Passivepr te tive material devel ped in
an ther individuals immune system and given
t previ usly n nimmune individual, giving
sh rt-term pr te ti n
Im m une Sys te m Mo le cule s
A. Cyt kines
1. Cyt kines are pr tein m le ules that mmuni ate
am ng ells, rdinating immune resp nses
2. Interleukins (ILs) are an example yt kines
B. Antib dies (Figure 16-11)
1. Pr tein m le ules with spe i mbining sites
2. C mbining sites atta h antib dies t spe i antigens
( reign pr teins), rming an antigen-antib dy
mplexthis pr vides humoral immunity (antibody-
mediated immunity)
3. Antigen-antib dy mplexes may:
a. Neutralize t xins
b. Clump r agglutinate enemy ells
. Pr m te phag yt sis
C. C mplement pr teins
1. Gr up pr teins n rmally present in bl d in ina -
tive state
2. C mplement as ade
a. Imp rtant me hanism a ti n r antib dies
(1) C mplement-binding sites n antib dy are
exp sed a ter atta hing t antigen
(2) C mplement triggers a series ( as ade) rea -
ti ns that pr du e tiny pr tein rings that reate
h les in the sur a e a reign ell
b. Ultimately auses ell lysis by permitting entry
water thr ugh a de e t reated in the plasma mem-
brane the reign ell (Figure 16-12)
3. Als helps per rm ther un ti nsexamples:
attra ting immune ells t a site in e ti n, a tivat-
ing immune ells, marking reign ells r destru -
ti n, in reasing permeability bl d vessels, the
inf ammat ry resp nse
 CHAPTER 16 Lymphatic System and Immunity 453

Im m une Sys te m Ce lls ( ) Plasma ells se rete antib dies int bl d;

mem ry ells are st red in lymph n des
A. Phag ytes (d) I subsequent exp sure t the spe i 16
1. ypes antigen that a tivated the B ell urs,
a. Neutr philssh rt-lived phag yti ells; m st mem ry ells be me plasma ells and
abundant type immune ell se rete antib dies in large quantity
b. M n ytesdevel p int phag yti ma r phages b. Fun ti n B ellsindire tly, B ells pr du e
and migrate t tissues hum ral immunity
. Dendriti ells (DCs) ten und at r near (1) A tivated B ells devel p int plasma ells
external sur a es (Figure 16-14) (2) Plasma ells se rete antib dies int the bl d
2. Ingest and destr y reign ells r ther harm ul sub- (3) Cir ulating antib dies pr du e hum ral immu-
stan es via phag yt sis (Figure 16-13) nity (Figure 16-16)
3. Ma r phages and DCs a t as antigen-presenting ells 4. ells ( lymph ytes)agents adaptive
(APCs) by displaying ingested antigens n their uter immunity
sur a e t trigger spe i immune ells a. Devel pment ellsstem ells r m b ne
B. Lymph ytes marr w migrate t thymus gland (Figure 16-17)
1. Se nd m st numer us immune system ells, a ter (1) First stagestem ells devel p int ells
neutr phils; in lude NK ells, B ells, and ells (a) ells mature in the thymus during ew
(Figure 16-15) m nths be re and a ter birth
2. Natural killer (NK) ellsagents innate immunity (b) Mature ells migrate hief y t lymph
a. Can atta h t any ell, but nly kill ells la king n des
n rmal sel -antigens (2) Se nd stage ells devel p int a tivated
b. Usually kill by triggering ap pt sis (pr grammed ells
ell death) (a) O urs when, and i , antigen binds t
3. B ells (B lymph ytes)agents adaptive ells sur a e pr teins and a yt kine
immunity ( hemi al signal) is re eived r m an ther
a. Devel pment B ellsprimitive stem ells ell
migrate r m b ne marr w and g thr ugh tw (b) As with B ells, l nes made up e e t r
stages devel pment (Figure 16-16) ells and mem ry ells are rmed
(1) First stagestem ells devel p int immature b. Fun ti ns ellspr du e ell-mediated
B ells immunity (Figure 16-18)
(a) akes pla e in the liver and b ne marr w (1) Cyt t xi ellskill in e ted r tum r ells
be re birth and in the b ne marr w nly by releasing a substan e that p is ns in e ted
in adults r tum r ells
(b) B ells are small lymph ytes with anti- (2) H elper ellsrelease yt kines that attra t
b dy m le ules (whi h they have synthe- and a tivate ma r phages t kill ells by
sized) in their plasma membranes phag yt sis; pr du e yt kines that help a ti-
( ) A ter they mature, ina tive B ells migrate vate B ells
hief y t lymph n des (3) Regulat ry ellsrelease yt kines t sup-
(2) Se nd stageina tive B ell devel ps int press immune resp nses
a tivated B ell
(a) Initiated by ina tive B ells nta t with
antigens, whi h bind t its sur a e antib d-
ies, plus yt kines (signal hemi als) r m
ells
(b) A tivated B ell, by dividing repeatedly,
rms tw l nes ellsplasma (e e -
t r) ells and mem ry ells
 454 CHAPTER 16 Lymphatic System and Immunity
Hype rs e ns itivity o the Im m une
16 Sys te m
A. H ypersensitivityinappr priate r ex essive immune
resp nse (Figure 16-19)
B. Allergyhypersensitivity t harmless envir nmental
antigens (allergens)
1. Immediate allergi resp nses usually inv lve hum ral
immunity
2. Delayed allergi resp nses usually inv lve ell-
mediated immunity
C. Aut immunityinappr priate, ex essive resp nse t
sel -antigens
1. Causes aut immune diseases
2. Systemi lupus erythemat sus (SLE) hr ni
inf ammat ry disease aused by numer us antib dies
atta king a variety tissues (Figure 16-20)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the lym phatic s ys te m in Chapte r 5.
The lym phatic s ys te m is partly a s ewe r s ys te m o the body.
Plas m a is pus he d out o the capillarie s and was he s ove r the
tis s ue ce lls . The inte rs titial uid (IF) carrie s bacte ria and othe r
ce llular de bris , along w ith prote ins and lipids , into blind-e nde d
capillarie s in the lym phatic s ys te m . The uid is the n calle d
lym ph. It is carrie d to the lym ph node , w he re it is f lte re d,
cle ane d, and the n carrie d by ducts back to the blood. Ke e p
this proce s s in m ind w he n you s tudy the s tructure s o the
lym phatic s ys te m .
1. T ere are several spe i rgans in the lymphati system.
Flash ards and nline res ur es that in lude their names,
l ati ns, and un ti ns will help y u learn them.
2. A mplex n ept t understand is the inf ammat ry
resp nse. Use Figure 16-10 r devel p y ur wn n ept
map t help y u understand the steps in the inf amma-
t ry resp nse.
3. Adaptive immunity an be lassi ed as natural r arti ial
depending n h w the b dy was exp sed t the spe i
antigen, and a tive r passive depending n h w inv lved
the b dys immune system was in devel ping the resp nse.
D. All immunity (is immunity)ex essive rea ti n t anti-
gens r m an ther human
1. May ur between m ther and etus during
pregnan y
2. May ur in tissue transplants ( ausing reje ti n
syndr me)
Im m une Sys te m De f cie ncy
A. C ngenital immune de ien y, r immun de ien y
(rare)
1. Results r m impr per lymph yte devel pment
be re birth
2. Severe mbined immune de ien y (SCID) aused
by disrupti n stem ell devel pment
B. A quired immune de ien y
1. Devel ps a ter birth
2. A quired immun de ien y syndr me (AIDS)
aused by H IV in e ti n ells
4. T e natural, a tive immune resp nse is divided int
hum ral immunity and ell-mediated immunity. H um ral
immunity is mediated by the B lymph ytes, r B ells.
T ey stay in the lymph n de and se rete antib dies int
the bl d (humor means b dy f uid). T ey als rm
mem ry ells, whi h give li el ng immunity. lymph -
ytes, r ells, pr vide ell-mediated immunity. T ey
leave the lymph n de and a tively engage the antigen.
5. T e best way t learn the dis rders the immune system
is t make a hart rganized by the me hanism r ause
the dis rder: allergi rea ti n, aut immunity, all im-
munity, and immune de ien ies.
6. In y ur study gr up, use f ash ards r nline res ur es t
quiz ea h ther n the terms and stru tures the lym-
phati and immune systems. Dis uss the pr ess h w
lymph is rmed, ltered, and returned t the bl d.
Dis uss innate immunity, espe ially the inf ammati n
resp nse. Dis uss the di erent types adaptive immu-
nity. Dis uss the steps in hum ral and ell-mediated
immunity.
7. Re er t the Language S ien e and Language Medi-
ine terms and review the dis rder hart, hapter utline
summary, and the questi ns at the end the hapter and
dis uss p ssible test questi ns.
 CHAPTER 16 Lymphatic System and Immunity 455

Re vie w Que s tio ns Critical Thinking

Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
A te r f nis hing the Review Que s tions , w rite out 16
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.

1. De ne lymph and explain its un ti n. 22. Di erentiate between lymphati apillaries and bl d
2. Name the tw maj r lymphati du ts and the areas apillaries. Explain h w the di erent stru tures relate t
the b dy ea h them drains. their un ti n.
3. Des ribe the stru ture a lymph n de. 23. Explain the r le the lymph n de in the spread
4. W hat is lymphedema? W hat is the ause an er.
elephantiasis? 24. Explain the di eren e in me hanisms in the devel p-
5. Explain the de ense un ti n the lymph n de. ment the allergi rea ti n runny n se and hives,
6. W here is the thymus gland? W hat are the un ti ns and the allergi rea ti n t p is n ivy.
the thymus gland?
7. Name the three pairs t nsils and give the l ati n
ea h.
8. Name the l ati n and un ti n the spleen.
9. Explain the types innate immunity.
10. Name and di erentiate the ur types adaptive
immunity.
11. W hat are antib dies? W hat are antigens?
12. Explain the r le mplement in the immune system.
13. Explain the r le the ma r phage in the immune
system.
14. Explain the devel pment and un ti ning B ells.
15. Explain the devel pment and un ti ning ells.
16. W hat is an allergy?
17. W hat is aut immunity? Name an example an aut -
immune disease.
18. W hat is all immunity? Name an example an all im-
munity dis rder.
19. W hat are H LAs? H w are they related t tissue typing?
20. W hat is SCID? W hat is its ause?
21. List three auses a quired immun de ien y
syndr me.
 456 CHAPTER 16 Lymphatic System and Immunity

18. An attempt t identi y and mat h H LAs between the

Chapte r Te s t rgan d n r and the re ipient is alled ________.
16 A te r s tudying the chapte r, te s t your m as te ry by 19. A ngenital immune de ien y in whi h b th hum ral
re s ponding to the s e ite m s . Try to ans we r the m and ellular immunity are de e tive is alled ________.
w ithout looking up the ans we rs . 20. T e ause AIDS is ________.
21. Adaptive immunity is als kn wn as ________.
1. ________ is the f uid that leaves the bl d apillaries 22. T e ________ the spleen serves as a reserv ir r
and is n t dire tly returned t the bl d. m n ytes that an qui kly leave the spleen t help
2. Lymph r m ab ut three- urths the b dy drains int repair damaged tissue anywhere in the b dy during an
the ________. emergen y.
3. Lymph r m the right upper extremity and the right 23. ________ are released r m ells t a t as dire t agents
side the head drains int the ________. innate, n nspe i immunity.
4. An abn rmal nditi n in whi h tissue swells be ause 24. ________ is s metimes administered with a penlike
a umulati n lymph is alled ________. inje t r t redu e allergi rea ti ns.
5. T e enlarged, p u hlike stru ture in the abd men that 25. ________ ells re gnize abn rmal ells by using tw
serves as a st rage area r lymph is alled the ________. di erent re gniti n re ept rs; a kill activating re ept r
6. T e un ti n the ________ is t lter and lean the and a kill inhibiting re ept r.
lymph. 26. T e immunity that devel ps against p li a ter re eiving
7. T e many lymphati vessels that enter the lymph n de a p li va inati n is an example :
are alled ________ vessels; the single vessel leaving the a. a tive natural immunity
lymph n de is alled the ________ vessel. b. passive natural immunity
8. T e ________ are white bl d ells that mature in the . a tive arti ial immunity
thymus. T e thymus als pr du es a h rm ne alled d. passive arti ial immunity
________. 27. T e immunity that is given t the etus r newb rn by
9. T e three pairs t nsils are the ________, ________, the immune system the m ther is an example :
and ________. a. a tive natural immunity
10. T e largest lymph id rgan is the ________. b. passive natural immunity
11. T e signs ________ are heat, redness, pain, and . a tive arti ial immunity
swelling. d. passive arti ial immunity
12. ________ kills target ells by drilling h les in their 28. T e immunity that mes r m the inje ti n antib d-
plasma membrane, whi h disrupts the s dium and water ies made by an ther individuals immune system is an
balan e. example :
13. Ma r phages were ________ riginally that migrated a. a tive natural immunity
int the tissues. b. passive natural immunity
14. A hypersensitivity the immune system t a harmless . a tive arti ial immunity
envir nmental antigen is alled a (an) ________. d. passive arti ial immunity
15. An extreme allergi rea ti n ausing li e-threatening 29. T e immunity that devel ps a ter a pers n has had a
sympt ms is alled ________. disease is an example :
16. An inappr priate and ex essive resp nse t sel -antigen a. a tive natural immunity
is alled ________. b. passive natural immunity
17. Erythr blast sis is an example what ex essive . a tive arti ial immunity
immune rea ti n? ________ d. passive arti ial immunity

For each o the ollowing phrases, write a B in ront o it i it
describes the development or unctioning o a B cell or write a
T in ront o it i it describes the development or unctioning o
a T cell.
30. ________ pr du es antib dies
31. ________ s me devel p int plasma ells
32. ________ the main ell inv lved in ell-mediated
immunity
33. ________ the main ell inv lved in hum ral immunity
34. ________ devel ps in the thymus gland
35. ________ m ves t the site the antigen and releases
ell p is n
36. ________ divides rapidly int l nes n e it is a tivated
37. ________ releases a substan e that attra ts ma r phages
38. ________ s me di erentiate int mem ry ells
39. ________ mediates the nta t dermatitis allergi
resp nse
CHAPTER 16 Lymphatic System and Immunity 457
Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to 16
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. A ter having an in e ti n in the gr in, a y ung b y m-
plains pain ul swelling in his leg. On examinati n, y u
see that the entire leg is sw llen, but the pp site leg is
ne. T e attending physi ian explains that this is a m-
pli ati n the re ent gr in in e ti n, whi h inv lved the
lymph n des in that area. Can y u explain h w this may
have aused the b ys leg t swell? W hy isnt the ther leg
a e ted?
2. Keith was sledding in the sn w with his riends when he
a identally hit a tree. A ter examining Keith, the emer-
gen y r m physi ian n luded that he had ruptured his
spleen in the a ident. H w might a ruptured spleen be
treated? W hat might happen i Keiths amily r physi-
ian delays this treatment? D es Keith need his spleen t
survive?
3. Many years ag there was a am us ase a b y b rn
with severe mbined immune de ien y (SCID). H is
physi ians pla ed him in a path gen- ree hamber that
resembled a giant glass bubble. W hat purp se was served
by d ing this? W hat treatments are available t day that
might have helped this b y?
4. Merrily re ently had a maste t my. W hen she was dis-
harged, her d t r en uraged her t take a daily walk
30 minutes and t swing her arms in an upward m ti n.
W hy did he add these rders t his dis harge
instru ti ns?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Respiratory System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.
Structural Plan, 460
Overview, 460
Respiratory Tract, 460
Respiratory Mucosa, 461
Upper Respiratory Tract, 462
Nose, 462
Pharynx, 462
Larynx, 464
Disorders o the Upper Respiratory
Tract, 464
Lower Respiratory Tract, 466
Trachea, 466
Bronchial Tree, 466
Alveoli, 467
Respiratory Distress, 468
O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.
A ter you have completed this chapter, you
should be able to:
1. List the major organs o the respiratory
system and describe the unction o
each organ in relation to the major unc-
tions o the respiratory system.
2. Discuss the structures included in the
upper respiratory tract, as well as iden-
ti y and describe the major disorders o
the upper respiratory tract.
3. Discuss the structures included in the
lower respiratory tract, as well as iden-
ti y and describe the major disorders o
the lower respiratory tract.
Lungs, 469
Pleurae, 469
Disorders o the Lower Respiratory
Tract, 470
Respiration, 473
Pulmonary Ventilation, 473
Mechanics o Breathing, 473
Pulmonary Volumes, 474
Regulation o Ventilation, 475
Breathing Patterns, 477
Gas Exchange and Transport, 478
Pulmonary Gas Exchange, 478
Systemic Gas Exchange, 480
Blood Transportation o Gases, 480
4. Discuss respiration and pulmonary ven-
tilation, including the mechanics o
breathing and pulmonary volumes.
5. Describe the regulation o ventilation,
and identi y breathing patterns.
6. Compare, contrast, and explain the
mechanism responsible or the
exchange o gases that occurs during
external and internal respiration.
7. Describe the transport o gases by
blood.
 17
No ne needs t be t ld h w imp rtant the respiratory system is. T e res- LANGUAGE OF
pirat ry system serves the b dy mu h as a li eline t an air pump serves a S C IEN C E
deep-sea diver. T ink h w pani ked y u w uld eel i suddenly y ur li eline
be ame bl kedi y u uld n t breathe r a ew se nds!
Be o re re ading the
chapte r, s ay e ach o
O all the substan es that ells, and there re the b dy as a wh le, must have the s e te rm s o ut lo ud. This w ill
t survive, xygen is by ar the m st ru ial. A pers n an live a ew weeks he lp yo u to avo id s tum bling ove r
with ut d, a ew days with ut water, but nly a ew the m as yo u re ad.
minutes with ut xygen. C nstant rem val ar-
b n di xide r m the b dy is just as imp rtant
alveolar duct
r survival as a nstant supply xygen. (al-VEE-oh-lar dukt)
[alve- hollow, -ol- little,
-ar relating to]
alveolar sac
(al-VEE-oh-lar sak)
[alve- hollow, -ol- little,
-ar relating to]
alveoli
(al-VEE-oh-lye)
sing., alveolus
(al-VEE-oh-lus)
[alve- hollow, -olus little]
aortic body
T e respirat ry system ensures that xygen (ay-OR-tik BOD-ee)
is supplied t and arb n di xide (a waste [aort- li ted, -ic relating to]
pr du t) is rem ved r m the b dys ells. auditory tube
T e pr ess respirati n there re is a vital (AW-dih-toh-ree toob)
[audit- listen, -or- agent,
homeostatic mechanism. By nstantly supply-
-y relating to]
ing adequate xygen and by rem ving arb n di x-
bicarbonate ion
ide as it rms, the respirat ry system helps maintain a
(bye-KAR-boh-net)
nstant internal envir nment that enables ur b dy
[bi- two, -carbon- coal (carbon),
ells t un ti n e e tively. -ate oxygen compound]
bronchi
a mplish its un ti ns, the respirat ry system als e e - (BRONG-kye)
tively lters, warms, and humidi es the air we breathe. Respirat ry sing., bronchus
rgans su h as v al rds, sinuses, and spe ialized epithelium, (BRONG-kus)
als help pr du e spee h and make p ssible the sense smell, r [bronchus windpipe]
ol action. Even the primary un ti n gas ex hange has a se ndary bronchiole
e e tthe rem val ex ess a id r m the b dy. T is pH -balan ing un ti n (BRONG-kee-ohl)
the respirat ry system is dis ussed urther in Chapter 22. [bronch- windpipe, -ol- little]
carbaminohemoglobin (HbCO2)
Further dis ussi n that relates t dis rders the upper and l wer respirat ry (kar-bah-MEE-noh-hee-moh-
tra ts emphasizes h w disrupti ns in respirat ry system h me stasis lead t GLOH-bin [aych be see oh too])
b th anat mi al and physi l gi al mani estati ns disease. [carb- coal (carbon),
-amino- ammonia compound
(amino acid), -hemo- blood,
-glob- ball, -in substance]

Continued on p. 482

459
 460 CHAPTER 17 Respiratory System

S t r u c t u r a l P la n want t review the dis ussi n di usi n n pp. 5152 be re

O ve r v ie w
Respirat ry rgans in lude the nose, pharynx (throat), larynx
(voice box), trachea (windpipe), bronchi (branches), and lungs.
T e basi stru tural s heme this rgan system is that a AnimationDirect online at evolve.elsevier.com.
tube with many bran hes ending in milli ns extremely tiny,
very thin-walled sa s alled alveoli. Figure 17-1 sh ws the ex-
tensive bran hing the respirat ry tree in b th lungs. T ink
this air distributi n system as an upside-d wn tree.
T e tra hea r windpipe then be mes the trunk and the
br n hial tubes the bran hes. T is idea is devel ped urther
when the types br n hi and the alve li are studied in m re
17 detail later in the hapter.
A netw rk apillaries ts like a hairnet ar und ea h mi-
r s pi alve lus. In identally, this is a g d pla e r us t
think again ab ut a prin iple already menti ned several times,
namely, that stru ture and un ti n are intimately related. T e
un ti n alve liin a t, the un ti n the entire respira-
t ry systemis t distribute air l se en ugh t
bl d r a gas ex hange t take pla e between
air and bl d. T e passive transp rt pr ess
dif usion, whi h was des ribed in Chapter 3,
is the m de r the ex hange gases that
urs in the respirat ry system. Y u may
y u study the me hanism gas ex hange that urs in the
lungs and b dy tissues.
To learn more about respiratory system, go to
Re s p ir a t o ry Tr a c t
T e respirat ry tra tthe pathway air f wis ten di-
vided int upper and l wer tra ts, r divisi ns, t assist in the
des ripti n sympt ms ass iated with mm n respirat ry
pr blems su h as a ld. T e rgans the upper respirat ry
tra t are l ated utside the th rax r hest avity, whereas
th se in the l wer tra t, r divisi n, are l ated alm st entirely
within it.
T e upper respiratory tract is mp sed the n se, phar-
ynx, and larynx. T e lower respiratory tract, r divisi n,
nsists the tra hea, all segments the br n hial tree, and
the lungs.
T e designati n upper respiratory in ection
(URI) is ten used by medi al pr essi nals
t des ribe what many us all a head
ld. ypi ally, the sympt ms an upper
respirat ry in e ti n inv lve the sinuses,

Na s a l cavity
Na s opha rynx
Oropha rynx P ha rynx
Uppe r re s pira tory tra ct La ryngopha rynx

La rynx

Tra che a

Le ft a nd right
prima ry bronchi

Lowe r re s pira tory tra ct

Alve ola r
duct Alve oli

Bronchiole s
Bronchiole s Ca pilla ry S

R L
FIGURE 17-1 Structural plan o the respiratory system. The respira-
tory tract includes the nasal cavity, pharynx, larynx, trachea, bronchi, and I
lungs. The inset shows the alveolar sacs where the interchange o oxygen Alve ola r s a c
and carbon dioxide takes place through the walls o the grapelike, hollow
alveoli. Capillaries surround the alveoli.
 CHAPTER 17 Respiratory System 461

nasal avity, pharynx, and/ r larynx, whereas the sympt ms 3-5 n p. 49 t see the stru ture these tiny ell pr je ti ns
what is ten re erred t as a hest ld are similar t pneu- and h w they an m ve f uids al ng the sur a es a layer
m nia and inv lve the rgans the l wer respirat ry tra t. ells. Figure 17-2 als sh ws the presen e goblet cells, whi h
Find the maj r stru tures the respirat ry tra t in the an pr du e and release huge am unts mucus. Mu us var-
Clear View o the Human Body ( ll ws p. 8), n ting their l a- ies in mp siti n r m very watery t very thi k and sti ky,
ti ns relative t ther nearby b dy stru tures. depending n the spe i l ati n the mu sa.
Alth ugh m st the respirat ry passages are lined with
To learn more about respiratory mucosa, go to iliated pseud strati ed epithelium, there are a ew areas lined
AnimationDirect online at evolve.elsevier.com. with ther tissues. F r example, pr te tive strati ed squamous
epithelium is und just inside the n strils, vering the v al
lds the larynx, and lining the pharynx. L k ba k at
Re s p ir a t o ry M u c o s a Figure 4-4 n p. 74 t see the many layers this thi ker type
S t ru c t u re epithelium.
Be re beginning the study individual rgans in the respi- Simple squamous epitheliuman extremely thin tissue 17
rat ry system, it is imp rtant t review the hist l gy, r mi- lines the alve li the lungs where gas ex hange urs. L k
r s pi anat my, the respiratory mucosathe mem- ba k at Figure 4-3 n p. 74 t see the thinness this type
brane that lines m st the air distributi n tubes in the epithelium.
system.
Respirat ry mu sa is typi ally ciliated pseudostrati ed epi- Fu n c t io n
thelium, as y u an see in Figure 17-2. As its name implies, this Re all that in additi n t serving as air distributi n passage-
type tissue is vered with cilia. L k ba k at Figures 3-4 and ways r gas ex hange sur a es, the stru tures the respirat ry
tra t and lungs leanse, warm, and humidi y inspired air. Air
entering the n se is generally ntaminated with ne r m re
Motile cilia mm n irritants; examples in lude s me types hemi al
Goble t ce lls air p llutants, dust, p llen, ba terial rganisms, and even in-
Mucus
m
se ts. A remarkably e e tive air puri ati n me hanism re-
u
i
l
m ves alm st every rm ntaminant be re inspired air
e
h
t
i
rea hes the alve li, r terminal air sa s, in the lungs.
p
e
A layer pr te tive mu us, alled a mucous blanket, vers
d
e
i
f
nearly the entire iliated pseud strati ed epithelial lining
i
t
a
r
the air distributi n tubes in the respirat ry tree (see Figure 17-2).
t
s
o
d
M re than 125 mL respirat ry mu us is pr du ed daily. It
u
e
serves as the m st imp rtant air puri ati n me hanism. Air
s
P
is puri ed when ntaminants su h as dust, p llen, and sm ke
parti les sti k t the mu us and be me trapped.
N rmally, the leansing layer mu us ntaining inhaled
S ubmucos a Ba s e me nt ntaminants m ves upward t the pharynx r m the l wer
A me mbra ne
p rti ns the br n hial tree n the milli ns hairlike ilia
Motile cilia Goble t ce ll
that beat r m ve nly in ne dire ti n. T is me hanism is
ten alled the ciliary escalator.
Cigarette sm ke and ther irritants are dete ted by the
ilia, whi h beat rapidly in resp nsean attempt t lear ut
the ntaminants m re e iently. Pr l nged exp sure t
igarette sm ke b th in reases pr du ti n mu us and even-
tually paralyzes ilia, thus ausing a umulati ns ntami-
nated mu us t build up and remain in the respirat ry pas-
sageways r l nger peri ds time. T e result is a typi al
sm kers ugh, whi h is the b dys e rt t lear these large
quantities ntaminated mu us.

QUICK CHECK
1. Wh a t a re th e p rim a ry u n ctio n s o th e re s p ira to ry s ys te m ?
B 2. De s crib e th e ch a ra cte ris tics o th e a lve o li th a t e n a b le th e m
to p e r o rm th e ir u n ctio n o ga s e xch a n g e .
FIGURE 17-2 Respiratory mucosa. A, Light micrograph ( 200) and 3. Wh a t d is tin g u is h e s th e u p p e r re s p ira to ry tra ct ro m th e
B, scanning electron micrograph ( 2000) o the ciliated pseudostrati ed lo w e r re s p ira to ry tra ct?
epithelium typical o the respiratory lining. Note the numerous motile (mov- 4. Wh a t is th e ro le o th e re s p ira to ry m u co s a ?
ing) cilia and the mucus-producing goblet cells.
 462 CHAPTER 17 Respiratory System
U p p e r Re s p ir a t o ry Tr a c t
No s e
Air enters the respirat ry tra t thr ugh the external nares, r
n strils. It then f ws int the right and le t nasal cavities,
whi h are lined by respirat ry mu sa. A partiti n alled the
nasal septum separates these tw avities.
T e sur a e the nasal avities is m ist r m mu us and
warm r m bl d f wing just under the epithelium. Nerve
endings resp nsible r the sense smell ( l a t ry re ept rs)
are als l ated in the nasal mu sa.
Nasal polyps are painless, n n an er us tissue gr wths
that may pr je t r m the nasal mu sa. T ey are requently
17 ass iated with hr ni hay ever. O ver time, nasal p lyps may
gr w in size, partially bstru t the nasal passage, and impair
breathing. In severe ases, surgi al rem val may be required.
F ur paranasal sinuses rontal, maxillary, sphenoidal, and
ethmoidaldrain int the nasal avities (Figure 17-3). T e para-
nasal sinuses are lined with a mu us membrane that assists in
the pr du ti n mu us r the respirat ry tra t. In additi n,
these h ll w spa es help t lighten the skull b nes and serve
as res nant hambers that enhan e the pr du ti n s und.
Be ause the mu sa that lines the sinuses is ntinu us
with the mu sa that lines the n se, sinus in e ti ns, alled
sinusitis, ten devel p r m lds in whi h the nasal mu sa
is inf amed. Sympt ms sinusitis ten in lude pressure;
pain; heada he; and external tenderness, swelling, and redness.
In hr ni ases, in e ti n may spread t adja ent b ne r int
the ranial avity inf aming meninges r brain tissue. reat-
ment in ludes de ngestants, analgesi s, antibi ti sand in
rare ases, surgery t impr ve drainage.
w du ts r m the lacrimal sacs als drain int the nasal
avity, as Figure 17-3 sh ws. T e la rimal sa s lle t tears r m
the rner ea h eyelid and drain them int the nasal avity.
T is arrangement explains why y ur n se may drip a ter pr -
du ing ex ess tears, as in rying, allergies, r eye irritati n.
N te in Figure 17-3 that three shelf ike stru tures alled
conchae pr trude int the nasal avity n ea h side. T e nasal
S phe noid
s inus Fronta l s inus
Ethmoid a ir ce lls
S upe rior concha e
Middle concha e
Infe rior concha e
Ma xilla ry s inus
S S
P A
A I
FIGURE 17-3 Paranasal sinuses. A, Lateral view o the position o the sinuses in adults. B, The anterior
view shows the anatomical relationship o the paranasal sinuses to each other and to the nasal cavity.
n hae are s metimes alled nasal turbinates. T e mu sa-
vered n hae greatly in rease the sur a e ver whi h air
must f w as it passes thr ugh the nasal avity. As air m ves
ver the n hae and thr ugh the nasal avities, it is warmed
and humidi ed. T is helps explain why breathing thr ugh the
n se is m re e e tive in humidi ying inspired air than is
breathing thr ugh the m uth.
I an individual wh is ill requires supplemental xygen, it
is rst bubbled thr ugh water t redu e the am unt m is-
ture that w uld therwise have t be rem ved r m the lining
the respirat ry tree t humidi y it. Administrati n dry
xygen pulls water r m the mu sa and results in respirat ry
dis m rt and irritati n.
P h a ry n x
T e pharynx is the stru ture that many us all the thr at.
It is ab ut 12.5 m (5 in hes) l ng and an be divided int
three p rti ns (Figure 17-4). T e upperm st part the tube
just behind the nasal avities is alled the nasopharynx. T e
p rti n behind the m uth is alled the oropharynx. T e third
r l west segment is alled the laryngopharynx.
T e pharynx as a wh le serves a similar purp se r the
respirat ry and digestive tra ts that a hallway serves r a
h use. Air and d pass thr ugh the pharynx n their way t
the lungs and the st ma h, respe tively. Air enters the phar-
ynx r m the tw nasal avities r the ral avity and leaves it
by way the larynx. F d enters it r m the m uth and leaves
it by way the es phagus.
T e right and le t auditory tubes, r eustachian tubes,
pen int the nas pharynx; they nne t the middle ears with
the nas pharynx (see Figure 17-4). T is nne ti n permits
equalizati n air pressure between the middle ear and the
exteri r ear. T e lining the audit ry tubes is ntinu us
with the lining the nas pharynx and middle ear. T us just
as sinus in e ti ns an devel p r m lds in whi h the nasal
mu sa is inf amed, middle ear in e ti ns an devel p r m
inf ammati n the nas pharynx.
S phe noid s inus
La crima l s a c
Ora l cavity
R L
B I
 CHAPTER 17 Respiratory System 463

Cribriform pla te Cra nia l cavity

of e thmoid bone
Fronta l s inus S phe noid s inus

Na s a l bone
S upe rior na s a l
P ha rynge a l tons il
concha of e thmoid
(a de noids )
Middle na s a l
concha of e thmoid Pos te rior na ris
17
Ope ning of a uditory
Infe rior concha (e us ta chia n) tube
Na s opha rynx
Ante rior na ris
S oft pa la te
Ha rd pa la te
Uvula

Pa la tine tons il
Lingua l tons il
Oropha rynx
Hyoid bone
Epiglottis
Thyroid ca rtila ge (pa rt of la rynx)
(pa rt of la rynx)
La rynx La ryngopha rynx
Voca l cords
(pa rt of la rynx)
Tra che a Es opha gus

FIGURE 17-4 Head and neck. Sagittal section. The nasal septum has been removed, exposing the A P
right lateral wall o the nasal cavity so that the nasal conchae can be seen. Note also the divisions o the
I
pharynx and the position o the tonsils.

Masses lymph id tissue alled tonsils are embedded in

the mu us membrane the pharynx. Re all the l ati n
the t nsils r m the previ us hapter (see p. 435). T e lingual
tonsils and palatine tonsils are l ated in the r pharynx and
the pharyngeal tonsils, als alled the adenoids when sw l- Pa la te
len, are l ated in the nas pharynx.
As y u read in Chapter 16, these t nsils rm a ring Uvula
lymph id tissue in the thr at that pr vides immune pr te -
ti n at a riti al b undary with the external envir nment.
Alth ugh the t nsils usually pr te t us, they an als be-
me in e ted and inf amed themselvesa nditi n alled S wolle n
pa la tine
tonsillitis (Figure 17-5). tons ils
Swelling the pharyngeal t nsils aused by in e ti ns
may make it di ult r imp ssible r air t travel r m the
n se int the thr at. In these ases the individual is r ed t
S
breathe thr ugh the m uth.
In a tonsillectomy b th t nsils are generally rem ved by a R L
surge n. On e a very mm n surgi al pr edure, t nsille - I
t my, with its p tentially seri us mpli ati nsin luding
severe hem rrhageis n w per rmed nly a ter ther p- FIGURE 17-5 Tonsillitis. Enlarged palatine tonsils can be seen nearly
ti ns have been exhausted. Physi ians n w re gnize the meeting at the midline o the pharynx.
 464 CHAPTER 17 Respiratory System

value lymph id tissue in the b dys de ense me hanism and
delay rem val the t nsilseven in ases inf ammati n
(t nsillitis).
Alth ugh surgi al rem val may eventually be ne essary in
ases repeated in e ti ns, swelling, r when n nsurgi al
treatments su h as intensive antibi ti therapy pr ve ine e -
tive, the number t nsille t mies per rmed ea h year n-
tinues t de rease.
To protect the delicate gas-exchange tissues deep
inside the lungs, the respiratory tract has many
complex mechanisms that guard against injury
and disease. Check out the article Protective
17 Strategies o the Respiratory Tract at Connect It!
at evolve.elsevier.com.
La ry n x
T e larynx, r v i e b x, is l ated just bel w the pharynx. It is
mp sed nine pie es artilage. Y u kn w the largest
these (the thyroid cartilage) as the Adams apple (Figure 17-6).
w sh rt br us bands, the vocal cords, stret h a r ss the
interi r the larynx. Mus les that atta h t the larynx arti-
lages an pull n these rds in su h a way that they be me
tense r relaxed. W hen they are tense, the v i e is high
pit hed; when they are relaxed, it is l w pit hed. T e spa e
between the v al rds that hanges shape as we speak is the
glottis.
An ther pie e artilage,
alled the epiglottis, partially
vers the pening the lar-
ynx (see Figure 17-6). T e epi-
gl ttis a ts like a trapd r, To ng ue
l sing the larynx during swall wing and preventing d
and liquids r m entering the tra hea.
T e risk laryngeal cancer in reases signi antly with
sm king and al h l abuse. It urs m st ten in men ver
age 50 and is ten diagn sed be ause persistent h arseness
and di ulty in swall wing. A number therapeuti treat-
ments in luding surgery, radiati n, and hem therapy an be
urative but ab ut ne-third th se a e ted will die the
disease. I treatment inv lves surgi al rem val the larynx,
the individual must learn es phageal spee h r use an ele -
tr ni arti cial larynx t speak.
D is o r d e r s o t h e U p p e r
Re s p ir a t o ry Tr a c t
U p p e r Re s p ir a t o ry In e c t io n
Any in e ti n l alized in the mu sa the upper respirat ry
tra t (n se, pharynx, and larynx) an be alled an upper respi-
ratory in ection (URI). Alth ugh the general designati n URI
is ten used, su h in e ti ns are s metimes named r the
spe i stru ture inv lved.
Rhinitis, r m the Greek rhinos, n se,is inf ammati n and
swelling the nasal mu sa. A red, it hy, runny n se and
partially bstru ted breathing are universally re gnized as
sympt ms in ectious rhinitis. M st ases in e ti us rhinitis
are aused by viruses resp nsible r the mm n ld (rhin -
viruses) r the f u (inf uenza viruses). Alth ugh p tentially
Ba s e
of tongue
Epiglottis

Voca l
cords
Tra che a
Hyoid bone
Glottis
Epiglottis
Voca l cord Inte ra ryte noid
notch
B
Thyroid
La rynx ca rtila ge A
(Ada ms
a pple ) L R

P
Cricoid
ca rtila ge

Lume n of
tra che a

Ca rtila ge s
S of tra che a
A P Thyroid gla nd
I A C
FIGURE 17-6 Larynx. A, Sagittal section o the larynx. B, Superior view o the larynx. C, Photograph o the
larynx taken with an endoscope (optical device) inserted through the mouth and pharynx to the epiglottis.

C LIN ICA L APPLICATION
KEEPING THE TRACHEA OPEN
O te n a tube is place d through the mouth, pharynx, and larynx
into the trache a w he n patients ne ed bre athing supportes pe-
cially w he n the airway m ay collapse or be obs tructe d. This pro-
ce dure is calle d endo trache al intubatio n. The purpose o the
tube is to ens ure an open airway (se e part A o the f gure ).
To e ns ure that the tube e nte rs the trache a rathe r than the
ne arby e s ophagus (w hich le ads to the s tom ach), anatom ical
landm arks s uch as the vocal olds are us e d. Likew is e , the
dis tinct e e l o the V-s hape d pos te rior groove calle d the
ENDOTRACHEAL INTUBATION TRACHEOS TOMY
Tube for
A B in a ting cuff
seri us in sus eptible individuals, m st ases in e ti us rhi-
nitis res lve with ( r with ut!) supp rtive treatment a ter ab ut
7 t 10 days misery.
T e term allergic rhinitis, r hay ever, is used t des ribe
hypersensitivity-type rea ti ns t many types nasal irritants
and airb rne allergens in luding animal dander and plant p l-
lens. Sympt ms similar t in e ti us rhinitis may be me
hr ni and result in rmati n nasal p lyps and se ndary
in e ti ns.
Pharyngitis, r sore throat, is inf ammati n r in e ti n
the pharynx (thr at). Pain, redness, and di ulty in swall wing
are hara teristi pharyngitis. Pharyngitis may be aused by
any several path gens, in luding the strept al ba teria
that ause strep thr at (see Appendix A at evolve.elsevier.com).
Laryngitis is inf ammati n the mu us lining the
larynx. T e inf ammati n is a mpanied by edema the
laryngeal stru tures. I swelling the v al rds urs,
h arseness r l ss v i e results. T e nditi n may be
aused by ba teria, viruses, exp sure t allergens, veruse
the v i e, sm king, r ther a t rs. Even a m derate am unt
laryngeal swelling r edema, espe ially in a y ung hild, an
bstru t air f w and result in asphyxiati n.
Epiglottitis is a li e-threatening nditi n aused by Hae-
mophilus in uenzae type B (Hib) in e ti n. H ib ten stru k
hildren between 3 and 7 years age a generati n ag . H w-
ever, intr du ti n H ib va ines at the end the twentieth
entury pr du ed a 99% dr p in the in iden e this in e -
ti n, making this type epigl ttitis rare in ur day.
CHAPTER 17 Respiratory System 465
inte raryte no id no tch (Figure 17-6, B) can he lp guide the
prope r ins e rtion o the tube .
Anothe r proce dure done re que ntly in todays m ode rn hos -
pitals is a trache o s to my. This proce dure involve s the cutting o
an ope ning into the trache a (part B o the f gure ). A s urge on
m ay pe r orm this proce dure s o that a s uction device can be
ins e rte d to re m ove s e cre tions rom the bronchial tre e or s o
that an inte rm itte nt pos itive -pre s s ure bre athing (IPPB) m a-
chine can be us e d to im prove ve ntilation o the lungs .
17
Tra che a
Tra che os tomy Tra che os tomy
tube in pla ce tube
Cuff
T e term croup is used t des ribe a n nli e-threatening
type laryngitis generally seen in hildren y unger than age
3. It is aused by the parainf uenza viruses. Sympt ms in lude
a harsh barklike ugh and lab red inspirati n. A e ted hil-
dren ten devel p sympt ms a ter g ing t sleep and awaken
rightened and ughing but with ut a ever.
URIs are rather mm n, urring several times a year in
m st individuals, be ause the upper respirat ry tra t is easily
a essible t mm n airb rne path gens. Be ause the upper
respirat ry mu sa is ntinu us with the mu us lining
the sinuses, the eusta hian tube and middle ear, and l wer
respirat ry tra t, URIs have an un rtunate tenden y t
spread. It is n t unusual there re t see a mm n ld pr g-
ress t be me sinusitis r otitis media (middle ear in e ti n).
A n a t o m ic a l D is o r d e r s
D eviated septum is a nditi n in whi h the nasal septum
strays r m the midline the nasal avity.
N b dys nasal septum is exactly n the midsagittal plane,
but m st are airly l se. S me pe ple, h wever, are b rn with
a ngenital de e t the septum that results in s me degree
bl kage t ne r b th sides the nasal avity. O thers
a quire a deviated septum a ter birth as a result damage
r m an injury r in e ti n. In either ase, surgi al rre ti n
the anat mi al abn rmality ten results in n rmal breath-
ing thr ugh the n se.
Injury t the n se urs relatively ten be ause the n se
pr je ts s me distan e r m the r nt the head. Usually,
 466 CHAPTER 17 Respiratory System

mm n bumps and ther injuries ause little i any seri us Despite the stru tural sa eguard artilage rings, bl kage
damage. O asi nally, epistaxis, r n sebleed, urs. T e the tra hea s metimes urs. A tum r r an in e ti n may
m st mm n ause n sebleed is a str ng bump r bl w, enlarge the lymph n des the ne k s mu h that they
but it an result r m severe inf ammati n r rubbing (as in squeeze the tra hea shut, r a pers n may aspirate (breathe in)
rhinitis), hypertensi n, r even brain injury. Be ause the ri h a pie e d r s mething else that bl ks the windpipe.
bl d supply l se t the inside sur a e the nasal avity, even Be ause air has n ther way t get t the lungs, mplete
min r n sebleeds an pr du e a great deal bl d ausing tra heal bstru ti n auses death in a matter minutes.
them t appear t be a m re seri us injury than they are. Su ati n r m all auses, in luding h king n d
and ther substan es aught in the tra hea, kills m re than
4000 pe ple ea h yearmaking it the th maj r ause
Lo w e r Re s p ir a t o ry Tr a c t a idental deaths in the United States. M any experts re m-
mend the ve-and- ve meth d (des ribed in the b x n
Tr a c h e a p. 467 t ree the tra hea ingested d r ther reign
17 T e trachea r windpipe is a tube ab ut 11 m (4.5 in) l ng bje ts that w uld therwise bl k the airway and ause
and 2.5 m (1 in) wide. It extends r m the larynx in the ne k death in h king ases.
t the br n hi in the hest avity (see Figures 17-1 and 17-7).
T e tra hea per rms a simple but vital un ti n: it pr - QUICK CHECK
vides part the pen passageway thr ugh whi h air an rea h 1. Na m e th e o u r p a ra n a s a l s in u s e s .
the lungs r m the utside. 2. Lis t th e th re e d ivis io n s o th e p h a ryn x.
T e tra hea is lined by typi al respirat ry mu sa. Mu us 3. Wh a t is th e co m m o n n a m e o r in e ctio u s rh in itis ?
4. Wh a t d is o rd e r o th e u p p e r re s p ira to ry tra ct is co n s id e re d
glands p ssessing many g blet ells help pr du e the blanket li e th re a te n in g ?
mu us that ntinually m ves upward t ward the pharynx. 5. Wh a t ke e p s th e tra ch e a ro m co lla p s in g ?
By pushing with y ur ngers against y ur thr at ab ut an
in h ab ve the sternum, y u an eel the shape the tra hea
r windpipe. Nature has taken pre auti ns t keep this li eline
Bro n c h ia l Tr e e
pen. Its ramew rk is made an alm st n n llapsible
material15 t 20 C-shaped rings artilage pla ed ne Re all that ne way t pi ture the th usands air passages
ab ve the ther with nly a little s t tissue between them. that make up the lungs is t think an upside-d wn tree. T e
Figure 17-7, B, sh ws h w the in mplete artilage rings tra hea is the main trunk this tree; the right br n hus
permit easy swall wing by all wing the es phagus ( d tube) (the tube leading int the right lung) and the le t br n hus
t stret h within the narr w spa e in the ne k between the (the tube leading int the le t lung) are the tra heas rst
tra hea and the vertebrae. bran hes r primary bronchi.

Lume n of Po s te rio r view

tra che a
Tra che a Adve ntitia

P rima ry Mucous coa t

bronchi
S e conda ry Bre a thing S wa llowing
bronchi Mucous
gla nd

Tra che a

Hya line ca rtila ge (tra che a l ring)

S mooth mus cle (tra che a lis )
Annula r tra che a l liga me nt Es opha gus

S Ce rvica l
ve rte bra
L R B A

I L R

P
A

FIGURE 17-7 Trachea. A, Structure o trachea shown in a posterior view. Inset at top shows rom where
the transverse section was cut. B, Incomplete cartilage rings and elasticity o posterior tracheal wall allow the
esophagus to expand during swallowing.
 CHAPTER 17 Respiratory System 467

C LIN ICA L APPLICATION

FIVE-AND-FIVE RES CUE FOR CHOKING
Choking o te n occurs w he n s om e thing be com e s lodge d in the include s a pe rs ons nam e ), that is , He im lich m ane uve r, is drop-
larynx and cannot be dis lodge d by norm al coughing. Many ping rom com m on us e and the te chnique is now o te n calle d
expe rts re com m e nd that a pe rs on w ho is choking s hould re - s im ply abdo m inal thrus ts .
ce ive the f ve -and-f ve re s cue m e thod. Five blow s to the back The abdom inal thrus t m ane uve r, i the pe rs on is s tanding,
(be twe e n the s capulae ) w ith the he e l o the hand (Figure A) cons is ts o the re s cue r gras ping the pe rs on w ith both arm s
m ay be ollowe d by f ve abdom inal thrus t m ane uve rs (Fig- around the pe rs ons wais t jus t be low the rib cage and above
ure B). I ne e de d, this s e que nce m ay be re pe ate d until the the nave l (Figure B). The re s cue r m ake s a f s t w ith one hand,
obje ct is dis lodge d. gras ps it w ith the othe r, and the n de live rs an upward thrus t
Mos t accide ntal airway obs tructions re s ult rom pie ce s o agains t the diaphragm jus t be low the xiphoid proce s s o the
ood as pirate d during a m e althe condition is s om e tim e s re -
e rre d to as ca coronary. Othe r obje cts s uch as chew ing
s te rnum . Air trappe d in the lungs is pre s s urize d, hope ully orc-
ing the obje ct that is choking the pe rs on out o the airway.
17
gum or balloons are re que ntly the caus e o obs tructions in
childre n. Individuals traine d in e m e rge ncy proce dure s m us t be
able to te ll the di e re nce be twe e n airway obs truction and
othe r conditions that produce s im ilar s ym ptom s , s uch as he art
attacks . The key que s tion they m us t as k the pe rs on w ho
appe ars to be choking is , Can you talk? A pe rs on w ith
an obs tructe d airway w ill not be able to s pe ak, eve n w hile
cons cious .
In the f ve -and-f ve re s cue , the f ve back blow s he lp dis -
lodge ore ign m ate rial rom the larynx. The abdom inal thrus t
m ane uve r us e s air alre ady pre s e nt in the lungs to expe l the
obje ct obs tructing the airway.
The abdom inal thrus t m ane uve r was orm e rly nam e d a te r
the phys ician w ho he lpe d popularize it or ge ne ral us e in the
1970s , He nry He im lich. More re ce ntly, the e ponym (te rm that A B

T e right primary br n hus is m re verti al and in line ea h alve lar sa is made up numer us alveoli, ea h
with the terminal tra hea than is the le t. As a result, aspirated whi h resembles a single, h ll w grape. N ti e in the se ti ned
bje ts that enter the tra hea tend t enter and l dge in the part Figure 17-8 that s me the alve li are inter nne ted
right primary br n hus r lung m re ten than the le t. with ea h ther. T is anat mi al eature all ws m re e ien y
In ea h lung, the primary br n hi bran h int smaller in ventilating all the alve li equallysupp rting the n ept
secondary bronchi. Cartilage rings in the wall ea h se nd- that structure ts unction.
ary br n hus, like th se the tra hea
and primary br n hi, keep the air pas- Bronchiole
sages pen. T e se ndary br n hi di-
A lve o li
P ulmona ry a rte riole
vide int smaller and smaller tubes, ulti- P ulmona ry ve nule Alve li are very e e tive in pr m ting the rapid
mately bran hing int tiny tubes wh se and e e tive ex hange xygen and arb n
walls ntain nly sm th mus len di xide between bl d ir ulating thr ugh the
artilage rings. T ese very small passage- lung apillaries and alve lar air.
ways are alled bronchioles. Te rmina l bronchiole On e again, stru ture and un ti n are
T e br n hi les subdivide int l sely related. w aspe ts the stru -
mi r s pi tubes alled alveolar Alve ola r s a c ture alve li assist in di usi n and
ducts, whi h resemble the main stem make them able t per rm this
a bun h grapes (Figure 17-8). un ti n admirably.
Ea h alve lar du t ends in several First, the wall ea h alve lus is
Alve oli
alveolar sacs, ea h whi h resem- made up m stly a single layer
bles a luster grapes, and the wall simple squam us epithelial ells alled
Alve ola r duct
type I cells. T e walls the apillaries
that surr und and lie in nta t with
FIGURE 17-8 Bronchioles and alveoli. Bronchioles subdi- them are als made thin, f at end the-
vide to orm tiny tubes called alveolar ducts, which end in clusters lial ells. T is means that, between the
o alveoli called alveolar sacs. bl d in the apillaries and the air in ea h
 468 CHAPTER 17 Respiratory System

alve lus, there is a barrier less than 1 mi r n thi k. T is ex-
tremely thin barrier is alled the respiratory membrane
(Figure 17-9).
Se nd, there are milli ns alve li. T is means that t -
gether they reate an en rm us sur a e r gas ex hange. T e
t tal sur a e area all alve li t gether is appr ximately 84
square meters (915 square eet)ab ut the size a small
h mes f r plan. T is huge sur a e area all ws large am unts
xygen and arb n di xide t be rapidly ex hanged.
T e sur a e the respirat ry membrane inside ea h alve -
lus is vered by a substan e alled sur actant. Sur a tant
helps redu e sur ace tension r sti kiness the watery mu us
lining the alve likeeping the alve li r m llapsing as air
17 m ves in and ut during respirati n. N te the di eren e in
appearan e between the sur a tant-pr du ing ells alled
type II cellsand the f attened type I cells sh wn in Figure 17-9.
D n t n use the respiratory membrane that separates air
in the alve li r m bl d in the surr unding pulm nary apil-
laries with the respiratory mucosa (see Figure 17-2) that lines the
tubes the respirat ry tree.
To learn more about respiratory membrane, go to
AnimationDirect online at evolve.elsevier.com.
Re s p ir a t o ry D is t r e s s
Respirat ry distress results r m the b dys relative inability t
inf ate the alve li the lungs n rmally. Respiratory distress
syndrome (RD S) is a nditi n m st ten aused by absen e
r impairment the sur a tant in the f uid that lines the
alve li.
In a n t Re s p ir a t o ry D is t r e s s
In ant respiratory distress syndrome (IRD S) is a very seri-
us, li e-threatening nditi n that ten a e ts premature
in ants less than 37 weeks gestati n r th se wh weigh
less than 2.2 kg (5 lb) at birth. IRDS is the leading ause
death am ng premature in ants in the United States, laiming
m re than 5000 premature babies ea h year. T e disease, har-
a terized by a la k sur a tant in the alve lar air sa s, a e ts
50,000 babies annually.
Sur a tant redu es the sur a e tensi n the water f uid n
the ree sur a e the alve lar walls and permits easy m ve-
ment air int and ut the lungs. T e ability the b dy
t manu a ture this imp rtant substan e is n t ully devel-
ped until sh rtly be re birthn rmally ab ut 40 weeks
a ter n epti n.
In newb rn in ants wh are unable t manu a ture sur a -
tant, many air sa s llapse during expirati n be ause the

S urfa cta nt-producing Fluid conta ining Ba s e me nt Re d

(type II) ce ll s urfa cta nt la yer me mbra ne s blood ce ll

Ma cropha ge

Alve olus Fluid Ca pilla ry

conta ining e ndothe lium
s urfa cta nt

Alve ola r RBC

e pithe lium
O2 O2
Type II O2
Ca pilla rie s ce ll Type I
ce ll Ca pilla ry Inte rs titia l s pa ce CO 2 CO 2
Alve ola r CO 2
e pithe lium
Ba s e me nt Ba s e me nt
me mbra ne me mbra ne
FIGURE 17-9 Alveolus. Each alveolus is continually ventilated with resh air. The inset
shows a magni ed view o the respiratory membrane composed o the alveolar wall (sur actant,
epithelial cells, and basement membrane), interstitial f uid, and the wall o a pulmonary capillary Alve olus Ca pilla ry
(basement membrane and endothelial cells). The gases, CO2 (carbon dioxide) and O2 (oxygen),
di use across the respiratory membrane. RBC, Red blood cell. Re s pira tory me mbra ne
 CHAPTER 17 Respiratory System 469

in reased sur a e tensi n. T e e rt required t reinf ate these
llapsed alve li is mu h greater than that needed t reinf ate
n rmal alve li with adequate sur a tant. T e baby s n devel-
ps lab red breathing, and sympt ms respirat ry distress
appear sh rtly a ter birth.
Current treatment IRDS usually inv lves delivering air
under pressure and applying prepared sur a tant dire tly int
the babys airways by means a tube.
Ad u lt Re s p ir a t o ry D is t r e s s
Adult respiratory distress syndrome (ARD S) is aused by
impairment r rem val sur a tant in the alve li. F r ex-
ample, a idental inhalati n reign substan es su h as
water, v mit, sm ke, r hemi al umes an ause ARDS.
Edema the alve lar tissue an impair sur a tant and redu e
the alve lis ability t stret h, ausing respirat ry distress.
ARDS an be treated with supplemental xygen supplied
by nasal pr ngs r, in s me ases, end tra heal intubati n and
a me hani al ventilat r. T e underlying ause the nditi n
is then assessed and treated.
Lu n g s
T e lungs are airly large rgans. T ey devel p t ll m st
the th ra i avity, leaving a small entral spa ethe
mediastinum r the heart, large bl d vessels, thymus,
and es phagus. N te in Figure 17-10 that deep
gr ves alled ssures subdivide ea h lung
int l bes. T e right lung has three
l bes and the le t lung has tw .
Figure 17-10 sh ws the relati nship the lungs t the rib
age at the end a n rmal expirati n. T e narr w, superi r
p rti n ea h lung, up under the llarb ne, is the apex. T e
br ad, in eri r p rti n resting n the diaphragm is the base.
Ea h lung is made up all the elements the br n hial
tree, alve li, and pulm nary bl d vesselsal ng with n-
ne tive tissues, lymphati vessels, and nerves. Ea h lung,
there re, is a mbinati n several kinds stru tures that
rm a unit r respirati n.
P le u r a e
A pleura is a ser us membrane that vers the uter sur a e
ea h lung and lines the inner sur a e the rib age. T e 17
pleura resembles ther ser us membranes in relati n t its
stru ture and un ti n. Like the perit neum r peri ardium,
the pleura is an extensive, thin, m ist, slippery membrane. It
lines a large, l sed avity the b dy and vers the rgans
l ated within it.
T e parietal pleura lines the walls the th ra i avity. T e
visceral pleura vers the lungs, and the intrapleural spa e lies
between the tw pleural membranes (Figure 17-11).
N rmally the intrapleural spa e ntains just en ugh pleu-
ral f uid t make b th p rti ns the pleura m ist and slip-
pery and able t glide easily against ea h ther as the lungs
expand and def ate with ea h breath.
Tra che a

Firs t rib S te rnum

(ma nubrium)

Right s upe rior lobe Le ft s upe rior lobe

Right prima ry bronchus Le ft prima ry bronchus

Horizonta l fis s ure

Body of s te rnum
Right middle lobe

Oblique fis s ure Oblique fis s ure

S eve nth rib

Right infe rior lobe Le ft infe rior lobe

S te rnum S
FIGURE 17-10 Lungs. The tra- (xiphoid proce s s )
chea is an airway that branches to R L
orm a treelike ormation o bronchi I
and bronchioles. Note that the right
lung has three lobes and the le t lung
has two lobes. The rib cage is shown
semitransparent so that lung struc-
tures are easily visible.
 470 CHAPTER 17 Respiratory System

Ve rte bra

Right lung
Le ft lung

P rima ry bronchus Pa rie ta l ple ura

P ulmona ry a rte ry Vis ce ra l ple ura

P ulmona ry ve in Intra ple ura l s pa ce

17 Vis ce ra l ple ura P ulmona ry trunk

Pa rie ta l ple ura
He a rt
Intra ple ura l s pa ce
P
S te rnum
R L

FIGURE 17-11 Lungs and pleura. The inset shows where the body was cut to show this transverse section
o the thorax. A serous membrane lines the thoracic wall (parietal pleura) and then olds inward near the bron-
chi to cover the lung (visceral pleura). The intrapleural space contains a small amount o serous pleural f uid.

Pleurisy is an inf ammati n the parietal pleura, hara - T e pleural spa e may als ll with ther substan es, whi h
terized by di ulty in breathing and stabbing pain. T e dis- in reases the pressure n the lung's uter sur a e ausing the
m rt and restri ti n n rmal breathing ass iated with lung t llapse. C llapse ( r in mplete expansi n) the lung
pleurisy are aused by the nstant rubbing ba k and rth r any reas n is alled atelectasis. W hile llapsed, the lung
the vis eral and parietal pleurae during breathing. Pleurisy an ann t be easily ventilated, making the a e ted lung virtually
be aused by tum rs, in e ti ns (su h as pneum nia and tu- useless in breathing.
ber ul sis), and ther a t rs. F r example, a pun ture w und t the hest wall r a
rupture the vis eral pleura may ause pneumothorax
Norma l lung
(Figure 17-12). Pneum th rax (literally air in the th rax) is the
Che s t wa ll
presen e air in the pleural spa e n ne side the hest. An
P le ura l
s pa ce
injury r disease als may ause hemothorax, the presen e
Outs ide a ir rus he s
in due to dis ruption bl d in the pleural spa e. B th nditi ns are p tentially li e
of che s t wa ll a nd threatening unless medi al treatment is re eived.
pa rie ta l ple ura

QUICK CHECK
1. Wh a t lu n g s tru ctu re s s e rve to d is trib u te a ir, a n d w h ich
Lung a ir rus he s out s tru ctu re s s e rve a s ga s e xch a n g e rs ?
due to dis ruption of
2. De s crib e th e u n ctio n o s u r a cta n t.
vis ce ra l ple ura
3. Wh a t is th e re s p ira to ry m e m b ra n e ?
4. Wh a t ca u s e s p le u ris y?
5. Ho w d o e s a p n e u m o th o ra x d i e r ro m a h e m o th o ra x?
S

R L

I D is o r d e r s o t h e Lo w e r
Dia phra gm Me dia s tinum Re s p ir a t o ry Tr a c t
FIGURE 17-12 Pneumothorax. Air may accumulate in the pleural Lo w e r Re s p ir a t o ry In e c t io n
space i the visceral pleura ruptures and air rom the lung rushes out or A ute bronchitis is a mm n nditi n hara terized by
when atmospheric air rushes in through a wound in the chest wall and pa-
rietal pleura. In either case, the lung collapses and normal respiration is a ute inf ammati n the br n hi, m st mm nly aused by
impaired. I blood accumulates in the pleural space, the condition is called in e ti n. Be ause the tra hea is ten als inv lved, the n-
hemothorax. diti n may be alled tracheobronchitis. T is nditi n is ten

pre eded by a URI that seems t m ve d wn int the tra hea
and br n hi a ter several days.
A ute br n hitis ten starts with a n npr du tive ugh
that pr gresses t a deep ugh that pr du es sputum n-
taining mu us and pus.
Pneumonia is an a ute inf ammati n the lungs in whi h
the alve li and br n hi be me plugged with thi k f uid
(exudate).
T e vast maj rity pneum nia ases results r m in e -
ti n by Streptococcus pneumoniae ba teria, but it an be aused
by several ther ba teria, viruses, and ungi (see Appendix A
at evolve.elsevier.com).
Pneum nia is hara terized by a high ever, severe hills,
heada he, ugh, and hest pain. T e a t that ea h day m re
than 10,000 liters p tentially ntaminated air enters the
respirat ry system helps explain why pneum nia is su h a
mm n illnessespe ially in individuals with l wered resis-
tan e r impaired immune systems.
ypes pneum nia in lude lobar pneumonia, whi h typi-
ally a e ts an entire l be the lung, and bronchopneumonia
in whi h pat hes in e ti n are s attered al ng p rti ns
the br n hial tree (Figure 17-13). T e term aspiration pneumo-
nia des ribes lung in e ti ns aused by inhalati n v mit r
ther in e tive material. It is mm n in a ute al h l int xi-
ati n and as a result anesthesia.
uberculosis ( B) is a hr ni ba illus in e ti n aused by
M ycobacterium tuberculosis (see Appendix A at evolve.elsevier
.com). B is a highly ntagi us disease transmitted thr ugh
inhalati n r swall wing dr plets ntaminated with the
B ba illus. It usually a e ts the lungs and surr unding tis-
sues but an invade any ther tissue r rgan as well.
S upe rior lobe
Oblique fis s ure
Infe rior lobe
S su
R L
I ible bstru ti n
FIGURE 17-13 Lobar pneumonia. Exudate lls many o the alveoli and
ducts o a single lobe o the le t lung. Note the di erence in texture and
color o the a ected in erior lobe. See Figure 17-10.
CHAPTER 17 Respiratory System 471
Early stages B are hara terized by atigue, hest pain,
pleurisy, weight l ss, and ever. As the disease pr gresses, lung
hem rrhage and dyspnea may devel p.
T e name tuberculosis literally means nditi n having
tuber les, whi h des ribes the pr te tive apsules the b dy
rms ar und l nies B ba illi. Su ess ul treatment re-
quires a mbinati n drugs and ther therapies r an ex-
tended peri dusually l nger than a year. B a e ts up t a
third the w rlds p pulati n and is a maj r ause death
in many p r, densely p pulated regi ns the w rld. It has
re ently reemerged as a seri us health pr blem in s me maj r
U.S. ities.
Any lung in e ti n is usually treated primarily with antibi-
ti therapy dire ted at the spe i type path gen sus- 17
pe ted as the ause. Supp rtive therapy t maintain bl d
xygen n entrati n and minimize patient dis m rt is
used al ngside antibi ti therapy.
Re s t r ic t ive P u lm o n a ry D is o r d e r s
Restrictive pulm nary dis rders inv lve restri ti n (redu ed
stret h) the alve li, as the name implies. Be ause inspira-
ti n requires that the lungs have the ability t stret ha
pr perty alled compliancerestri tive dis rders redu e a
pers ns ability t inhale n rmally. H w su h hanges in
pulm nary v lumes are measured is des ribed in a later
se ti n.
S me restri tive dis rders arise in nne tive tissue the
lung itsel . F r example, inf ammati n r brosis (s arring)
lung tissue aused by exp sure t asbest s, al, r sili n dust
an redu e mplian e and thus restri t alve li. Restri ti n
breathing als an be aused by the pain that a mpanies
pleurisy r me hani al injuries, su h as rib ra tures.
An ther type restri tive dis rder is cystic brosis (CF),
whi h was des ribed in Chapter 3 (see p. 55). Re all that CF
is hara terized by thi kened f uids in the lungs, whi h re-
stri ts mplian e.
O b s t r u c t ive P u lm o n a ry D is o r d e r s
A number di erent nditi ns may ause bstru ti n
the airways. F r example, exp sure t igarette sm ke and
ther mm n air p llutants an trigger a ref exive nstri -
ti n br n hial airways. O bstru tive dis rders may bstru t
inspiration and expiration, whereas restri tive dis rders mainly
restri t inspiration. In bstru tive dis rders, the t tal lung
apa ity may be n rmal, r even high, but the time it takes t
inhale r exhale maximally is signi antly in reased.
S me maj r bstru tive dis rders are summarized here
and in Figure 17-14.
A ute bstru ti n the airways, as when a pie e d
bl ks air f w, requires immediate a ti n t av id death r m
ati n (see the b x n p. 467).
Chronic obstructive pulmonary disease (COPD ) is a
br ad term used t des ribe nditi ns pr gressive irrevers-
expirat ry air f w. Pe ple with COPD
have hr ni di ulties with breathing, mainly emptying
their lungs, and have visibly hyperinf ated hests. T se with
COPD ten have a pr du tive ugh and int leran e
 472 CHAPTER 17 Respiratory System

NORMAL CHRONIC BRONCHITIS

S ubmucos a l Enla rge d
gla nd s ubmucos a l gla nd
Air tube s na rrow a s Infla mma tion
a re s ult of swolle n of e pithe lium
S mooth mus cle tis s ue s a nd exce s s ive
mucus production.
Bronchiole

Mucus
Re s pira tory a ccumula tion
Epithe lium
bronchiole
17 Alve oli Hype rinfla tion
of a lve oli

A B

AS THMA EMPHYS EMA

Ede ma of re s pira tory

S mooth
mucos a a nd exce s s ive
mus cle Enla rge me nt
mucus production
cons triction a nd de s truction
obs truct a irways.
of a lve ola r wa lls

Mucus

Wa lls of a lve oli a re torn

Mucus a nd ca nnot be re pa ire d.
plug Alve oli fus e into la rge
Hype rinfla tion a ir s pa ce s.
of a lve oli
C D
FIGURE 17-14 Major obstructive pulmonary disorders.

a tivity. T e maj r dis rders bserved in pe ple with COPD
are hr ni br n hitis and emphysema.
In N rth Ameri a, t ba use is the primary ause
COPD, but air p lluti n, asthma, and respirat ry in e ti ns
als play a r le. COPD is a leading ause death, and the
death rate r m COPD is increasing! Until a ew years ag ,
m re men had COPD than w men. H wever, the in rease
sm king am ng w men is th ught t a unt r the a t that
the urren e rate r emale COPD is gr wing rapidly.
A ute respirat ry ailure an ur when any the dis r-
ders that pr du e COPD be me intense. H eart ailure re-
sulting r m the vas ular resistan e that devel ps with COPD
is an ther p ssible ut me. Alth ugh there is n ure r
hr ni bstru tive respirat ry nditi ns, limiting sympt ms
an impr ve quality li e. Br n h dilat rs and rti ste-
r ids have been used t relieve s me the airway bstru ti n
inv lved in COPD.
Chronic bronchitis is a hr ni inf ammati n the br n-
hi and br n hi les. It is hara terized by edema and ex es-
sive mu us pr du ti n, whi h bl k air passages. Pe ple with
hr ni br n hitis have di ulty with exhaling and ten
ugh deeply as they try t disl dge the a umulating mu us.
T e maj r ause hr ni br n hitis is igarette sm king r
exp sure t igarette sm ke. Exp sure t ther air p llutants
als may ause hr ni br n hitis.
Emphysema may result r m the pr gressi n hr ni
br n hitis r ther nditi ns as air be mes trapped within
alve li and auses them t enlarge. As the alve li enlarge, their
walls rupture and then use int large irregular spa es. T e
rupture alve li redu es the t tal sur a e area the lung,
making breathing di ult. Emphysema patients ten devel p
hypoxia, r xygen de ien y, in the internal envir nment.
Severe lung damage caused by emphysema is
sometimes treated surgically. For micrographs
showing emphysema damage and a description o
surgical options, see the article Lung Volume Reduc-
tion Surgery at Connect It! at evolve.elsevier.com.
Asthma is an bstru tive dis rder hara terized by re ur-
ring spasms the sm th mus le in the walls the br n hi-
les. T e mus le ntra ti ns narr w the airways, making
 CHAPTER 17 Respiratory System 473

breathing di ult. Inf ammati n (edema and ex essive mu us relatively nstant setp int n entrati n these bl d gases
pr du ti n) usually a mpanies the spasms, urther bstru t- is required r survival, there are mplex regulat ry me ha-
ing the airways. Asthma an be triggered by stress, heavy ex- nisms that ntr l them.
er ise, in e ti n, r inhaling allergens r ther irritants. Figure 17-15 summarizes the maj r n epts respirat ry
physi l gy, and we use it as the basis dis ussi n in the re-
Lu n g C a n c e r maining se ti ns this hapter. Re er t this gure a ter
Lung an er is a malignan y pulm nary tissue that n t reading ea h se ti n t help y u put y ur new learning int a
nly destr ys the vital gas-ex hange tissues the lungs but, use ul big pi ture and deepen y ur understanding.
like ther an ers, als may invade ther parts the b dy
(metastasis).
Surgery is the m st e e tive treatment r lung an er P u lm o n a ry Ve n t ila t io n
kn wn, but nly hal the pers ns diagn sed as having lung
M e c h a n ic s o Br e a t h in g
an er are g d andidates r surgery be ause extensive
spread the disease (metastasis) at the time diagn sis. In Pulm nary ventilati n, r breathing, has tw phases. 17
a lobectomy, nly the a e ted l be a lung is rem ved. Inspiration, r inhalation, m ves air int the lungs, and
Pneumonectomy is the surgi al rem val an entire lung. expiration, r exhalation, m ves air ut the lungs.
T e lungs are en l sed within the th ra i avity. T us
Review the article Metastasis at Connect It! at hanges in the shape and size the th ra i avity result in
evolve.elsevier.com. hanges in the air pressure within that avity and in the lungs.
T is di eren e in air pressure is the driving r e m ve-
QUICK CHECK
ment air int and ut the lungs. Air m ves r m an area
where pressure is high t an area where pressure is l wer.
1. Wh a t is th e d i e re n ce b e tw e e n b ro n ch o p n e u m o n ia a n d
Anything that f wswhether it is bl d, lymph, r air
lo b a r p n e u m o n ia ?
2. Do re s trictive p u lm o n a ry d is o rd e rs re s trict m a in ly in s p ira - ll ws this primary prin iple: a f uid always f ws d wn a
tio n o r e xp ira tio n ? pressure gradient.
3. Give tw o e xa m p le s o ch ro n ic o b s tru ctive p u lm o n a ry F r ventilati n t ur, the tissues the th rax and lungs
d is e a s e (COPD). must remain b th compliant (able t stret h) and elastic (able
4. Why is s u rg e ry a n e e ctive tre a tm e n t o r o n ly h a l o th e
t re il a ter stret h). Respirat ry mus les are resp nsible r
p e rs o n s d ia g n o s e d w ith lu n g ca n ce r?
the hanges in the shape the th ra i avity that hange the
internal air pressures inv lved in breathing.
Re s p ir a t io n In s p ir a t io n
Respiration means ex hange gases ( xygen and arb n Inspirati n urs when the hest avity enlarges. As the th -
di xide) between a living rganism and its envir nment. I the rax enlarges, the lungs expand al ng with it, and air rushes
rganism nsists nly ne ell, gases an m ve dire tly int them and d wn int the alve li. T is happens be ause
between it and the envir nment. I , h wever, the rganism a very imp rtant law physi s: the v lume and pressure a
nsists billi ns ells, as d ur b dies, m st its ells gas are inversely pr p rti nal. T at means that when the v l-
are t ar rem ved r m the air s ur e r a dire t ex hange ume a gas g es up, as it d es when we expand the th rax,
gases t ur. ver me this bsta le, a pair rgans then the pressure g es d wn. T us, air pressure in the lungs
the lungspr vides a pla e where air and a ir ulating f uid de reases during inspirati n. W hen air pressure in the lungs is
(bl d) an me l se en ugh t ea h ther r xygen t less than atm spheri air pressure, air rushes d wn its pressure
m ve ut the air int the bl d while arb n di xide m ves gradient int the lungs.
ut the bl d int the air. Mus les that in rease the v lume the th rax are lassi-
Breathing, r pulmonary ventilation, is the pr ess that ed as inspiratory muscles. T ese in lude the diaphragm and
m ves air int and ut the lungs. It makes p ssible the the external intercostal muscles.
ex hange gases between air in the lungs and in the bl d. T e diaphragm is the d me-shaped mus le separating the
gether, these pr esses are ten alled external respiration. abd minal avity r m the th ra i avity. T e diaphragm
In additi n, ex hange gases urs between the bl d f attens ut when it ntra ts during inspirati n. Instead
and the ells the systemi tissues the b dy, whi h then use pr truding up int the hest avity, as it d es at rest, it m ves
the xygen in the bi hemi al pathways that trans er energy d wn t ward the abd minal avity as it ntra ts. T us the
r m nutrient m le ules t aden sine triph sphate (A P). ntra ti n r f attening the diaphragm makes the hest
gether, these pr esses are alled internal respiration. avity l nger r m t p t b tt m. T e diaphragm is the m st
T e term cellular respiration re ers t the use xygen by imp rtant mus le inspirati n. Nerve impulses passing
ells in the pr ess metab lism, whi h is dis ussed urther thr ugh b th phrenic nerves stimulate the diaphragm t
in Chapter 19. ntra t.
All these respirat ry pr esses require transp rt gases T e external inter stal mus les are l ated between the
( xygen and arb n di xide) by the bl d. And be ause a ribs. W hen they ntra t, they pull the ribs upward and
 474 CHAPTER 17 Respiratory System

Re gula tion of bre a thing

Alve oli
P ulmona ry
ve ntila tion
Exte rna l
re s pira tion Re s pira tory
control ce nte rs

P ulmona ry
ga s O2
CO 2
excha nge

17
Motor output
P ulmona ry to re s pira tory
circula tion mus cle s

Tra ns port O 2 s e ns or
S ys te mic circula tion CO 2 s e ns or
pH s e ns or

S
L
O2
R
I S ys te mic
tis s ue ga s CO 2
excha nge
Inte rna l
re s pira tion Ce llula r Ce ll
re s pira tion

FIGURE 17-15 Overview o respiration. This chapter is organized around the principle that respiratory
unction includes external respiration (ventilation and pulmonary gas exchange), transport o gases by blood,
and internal respiration (systemic tissue gas exchange and cellular respiration). Cellular respiration is discussed
separately (see Chapter 19). Regulatory mechanisms centered in the brainstem use eedback rom blood gas
sensors to regulate ventilation.

utward. T is enlarges the th rax by in reasing the size the
avity r m anteri r t p steri r and r m side t side.
C ntra ti n the inspirat ry mus les in reases the v lume
the th ra i avity and redu es lung air pressure bel w atm -
spheri air pressure, drawing air int the lungs (Figure 17-16).
Ex p ir a t io n
Q uiet, resting expirati n is rdinarily a passive pr ess that
begins when the inspirat ry mus les relax and return t
their resting length. T e th ra i avity then returns t its
smaller size. T e elasti nature th ra i and lung tissue
als auses these rgans t re il and de rease in size.
Be ause v lume and pressure are inversely pr p rti nal
( ne g es up as the ther g es d wn), as lung v lume de-
reases, the lung air pressure in reases. As the lung air pres-
sure rises ab ve atm spheri air pressure, air f ws d wn its
pressure gradient and utward thr ugh the respirat ry
passageways.
W hen we speak, sing, r d heavy w rk, we may need m re
r e ul expirati n t in rease the rate and depth ventilati n.
D uring m re r e ul expirati n, the expiratory muscles (in-
ternal inter stals and several abd minal mus les) ntra t.
W hen ntra ted, the internal inter stal mus les pull the
rib age inward and de rease the r nt-t -ba k size
the th rax. C ntra ti n the abd minal mus les pushes the
abd minal rgans against the underside the diaphragm,
pushing it arther upward int the th ra i avity. As the
th ra i avity de reases in size, the air pressure within it
in reases ab ve atm spheri air pressure and air f ws ut
the lungs (see Figure 17-16).
To learn more about pulmonary ventilation, go to
AnimationDirect online at evolve.elsevier.com.
P u lm o n a ry Vo lu m e s
A spe ial devi e alled a spirometer is used t measure the
am unt air ex hanged in breathing. Figure 17-17 illustrates
the vari us pulm nary v lumes that an be measured as a
subje t breathes int a spir meter.

INS PIRATION
Lungs
expa nd
Dia phra gm
contra cts
FIGURE 17-16 Mechanics o breathing. During inspiration, the diaphragm contracts, increasing the vol-
ume o the thoracic cavity. This increase in volume results in a decrease in pressure, which causes air to rush
into the lungs. During expiration, the diaphragm returns to an upward position, reducing the volume in the tho-
racic cavity. Air pressure increases then, orcing air out o the lungs. The insets show the classic model in which
a jar represents the rib cage, a rubber sheet represents the diaphragm, and a balloon represents the lungs.
We take appr ximately 500 mL (ab ut a pint) air int ur
lungs with ea h n rmal inspirati n and expel it with ea h n r-
mal expirati n. Be ause this am unt mes and g es regularly
like the tides the sea, it is re erred t as the tidal volume ( V).
T e largest am unt air that we an breathe ut in ne
expirati nby inhaling as deeply as p ssible, then exhaling
ullyis kn wn as the vital capacity (VC). In n rmal y ung
men, this is ab ut 4800 mL. N rmal ranges r VC vary with
age, gender, b dy size, tness, and ther variables.
idal v lume and vital apa ity are requently measured in
patients with lung r heart disease, nditi ns that ten lead t
abn rmal v lumes air being m ved in and ut the lungs.
O bserve the area in Figure 17-17 that represents the
expiratory reserve volume (ERV). T is is the am unt air
that an be r ibly exhaled a ter expiring the tidal v lume.
C mpare this with the area in Figure 17-17 that represents the
inspiratory reserve volume (IRV). T e IRV is the am unt
air that an be r ibly inspired ver and ab ve a n rmal in-
spirati n. As the tidal v lume in reases, the ERV and IRV
de rease.
Residual volume (RV) is simply the air that remains in
the lungs a ter the m st r e ul expirati n.
N te in Figure 17-17 that vital apa ity is the t tal tidal
v lume, inspirat ry reserve v lume, and expirat ry reserve
v lume r expressed in an ther way: VC V IRV
ERV. In pulm nary termin l gy, a capacity is a mbinati n
tw r m re pulm nary v lumes.
Clini ally use ul pulm nary v lumes and are des ribed in
Table 17-1.
QUICK CHECK
1. Wh a t is in te rn a l re s p ira tio n ?
2. Ho w d o e s th e d ia p h ra g m o p e ra te d u rin g in s p ira tio n ?
Du rin g e xp ira tio n ?
3. Wh a t n e rve s s tim u la te th e d ia p h ra g m to co n tra ct?
4. Wh a t is th e vita l ca p a city? Ho w is it m e a s u re d ?
CHAPTER 17 Respiratory System 475
EXPIRATION
Air
Lung
Dia phra gm Lungs
re coil
Dia phra gm
re la xe s
17
Re g u la t io n o Ve n t ila t io n
Ho m e o s t a s is o Blo o d G a s e s
Alth ugh we may take nly 12 t 18 breaths a minute at rest,
we take nsiderably m re than this when we are exer ising.
N t nly d we take m re breaths, but ur tidal v lume als
in reases with physi al a tivity.
T e reas n ur respirat ry rate hanges is be ause ur
b dy attempts t maintain a high setp int level xygen
and a l w setp int level arb n di xide in ur bl d.
W hen ur ells use up xygen qui kly during exer ise, they
draw m re xygen r m the bl dredu ing bl d xygen
n entrati n bel w its set p int. Likewise, ells release
waste arb n di xide int the bl d m re rapidly during
exer isethus raising the bl d arb n di xide n entra-
ti n ab ve its set p int.
Vari us regulat ry me hanisms resp nd t these hanges
thr ugh negative eedba k l ps that reverse bl d gas n-
entrati ns ba k t ward their setp int valuesby hanging
ur respirat ry rate and depth breathing.
Br a in s t e m C o n t ro l o Re s p ir a t io n
Changes in respirati n depend n pr per un ti ning the
mus les respirati n. T ese mus les are stimulated by ner-
v us impulses that riginate in respiratory control centers
l ated in the brainstem.
T e brainstem enters are inf uen ed by input r m a num-
ber sens ry re ept rs l ated in di erent areas the b dy.
T ese re ept rs an sense the need r hanging the rate r
depth respirati ns t maintain h me stasis. Certain re ep-
t rs sense arb n di xide r xygen levels, whereas thers
sense bl d a id levels r the am unt stret h in lung
tissues.
A gr up ntr l enters in the medullathe medul-
lary rhythmicity areaseem t pr du e the basi rhythm
breathing. A n rmal resting breathing rate is ab ut 12 t 18
 476 CHAPTER 17 Respiratory System

breaths a minute. T e tw m st imp rtant ntr l enters in

Gre ate r ac tivity the medulla r regulating breathing rhythm are alled the
Re s ting s tate (force ful ins pira tion ventral respiratory group (VRG) and the dorsal respiratory
(norma l bre a thing) plus force ful expira tion) group (DRG). T e VRG pr vides the basi rhythm genera-

)
t r r breathing. D RG adjusts the breathing rhythm when

l
Re s pira tory

)
a
L
c
m
i
re s e rve bl d pH r arb n di xide levels hangeas they w uld

t
e
0
r
volume

o
during exer ise.

0
e
2
Ins pirato ry diminis he s

h
6
Several ntr l enters in the p nsthe pontine respiratory

t
-
re s e rve vo lume (IRV)

0
,
L
0
group (PRG)seem t pr vide input t the DRG and thus

m
(3000-3300 mL)

7
5
0
(
help t m dulate the basi rhythm as needed under a variety

0
)
C
0
5
L
hanging nditi ns in the b dy.

-
T
0
(
0
T e depth and rate respirati n an be inf uen ed by

y
5
t
4
i
(
many inputs t the respirat ry ntr l enters r m ther

c
Tidal volume (TV) (500 mL) (Volume of

17

)
a
C
exhaled air after normal ins pira tion)

p
V
areas the brain r r m sens ry re ept rs l ated utside

a
(
c
Expirato ry

y
Expiratory
the entral nerv us system (Figure 17-18).

g
t
re s e rve vo lume (ERV)

n
i
reserve volume

c
u
(1000-1200 mL)

a
diminishes

l
p
l
C e r e b r a l C o r t e x C o n t ro l o Re s p ir a t io n
a
a
t
c
o
T
l
Re s idual vo lume (RV)
a
(1200 mL) t
i
V
T e erebral rtex an inf uen e respirati n by sending nerve
signals that a e t the un ti n the respirat ry enters the
Time brainstem. In ther w rds, an individual may v luntarily ver-
ride the aut mati brainstem rhythm breathing and speed
A up r sl w d wn the breathing rate r greatly hange the
pattern respirati n during a tivities. T is ability permits us
Re s idua l volume t hange respirat ry patterns and even t h ld ur breath r
sh rt peri ds t a mm date a tivities su h as speaking, eat-
Expira tory ing, r swimming under water.
re s e rve volume Tota l lung
ca pa city T is v luntary ntr l respirati n has limits. As indi-
Tida l volume Vita l ated in a later se ti n, ther a t rs su h as bl d arb n
ca pa city di xide levels are mu h m re p wer ul in ntr lling respira-
Ins pira tory
B re s e rve volume ti n than ns i us ntr l. Regardless erebral intent t
the ntrary, we resume breathing when ur b dies sense the
FIGURE 17-17 Pulmonary ventilation volumes. The chart in A shows need r m re xygen r i arb n di xide levels in rease t
a tracing like that produced with a spirometer. The diagram in B shows the
pulmonary volumes as relative proportions o an inf ated balloon (see ertain levels.
Figure 17-16). During normal, quiet breathing, about 500 mLo air is moved
into and out o the respiratory tract, an amount called the tidal volume. Dur- Re s p ir a t o ry Re e xe s
ing orce ul breathing (like that during and a ter heavy exercise), an extra Chemoref exes
3300 mL can be inspired (the inspiratory reserve volume), and an extra Chemoreceptors l ated in the carotid and aortic bodies are
1000 mL or so can be expired (the expiratory reserve volume). The largest
volume o air that can be moved in and out during ventilation is called the sens ry re ept rs that are sensitive t in reases in bl d ar-
vital capacity. Air that remains in the respiratory tract a ter a orce ul expira- b n di xide level and de reases in bl d xygen levelb th
tion is called the residual volume. See Table 17-1. whi h ur as ells d m re w rk.

TABLE 17-1 Pulmonary Volumes and Capacities

TYPICAL TYPICAL
VOLUME DES CRIPTION VALUE CAPACITY FORMULA VALUE
Tidal volum e Volum e m ove d into or out o the 500 m L (0.5 L) Vital capacity (VC) TV IRV ERV 4500-5000 m L
(TV) re s piratory tract during a norm al (4.5-5.0 L)
re s piratory cycle
Ins piratory Maxim um volum e that can be 3000-3300 m L Ins piratory capac- TV IRV 3500-3800 m L
re s e rve m ove d into the re s piratory tract (3.0-3.3 L) ity (IC) (3.5-3.8 L)
volum e (IRV) a te r a norm al ins piration
Expiratory Maxim um volum e that can be 1000-1200 m L Functional re s idual ERV RV 2200-2400 m L
re s e rve m ove d out o the re s piratory (1.0-1.2 L) capacity (FRC) (2.2-2.4 L)
volum e (ERV) tract a te r a norm al expiration
Re s idual Volum e re m aining in the re s pira- 1200 m L (1.2 L) Total lung capacity TV IRV ERV 5700-6200 m L
volum e (RV) tory tract a te r m axim um (TLC) RV (5.7-6.2 L)
expiration
 CHAPTER 17 Respiratory System 477

Corte x Ca rotid che more ce ptors

(volunta ry control) a nd ba rore ce ptors

Aortic che more ce ptors

a nd ba rore ce ptors

Limbic s ys te m
(e motiona l re s pons e s )

P RG

Apne us tic ce nte r 17

P ons
Ce ntra l che more ce ptors S tre tch re ce ptors
in lungs a nd
thora x

Me dulla ry DRG
rhythmicity
S a re a Re s pira tory
VRG
mus cle s
A P
Me dulla
I

FIGURE 17-18 Regulation o respiration. Respiratory control centers in the brainstem control the basic
rate and depth o breathing. The brainstem also receives input rom other parts o the body; in ormation rom
chemoreceptors and stretch receptors can alter the basic breathing pattern, as can emotional and sensory input.
Despite these controls, the cerebral cortex can override the automatic control o breathing to some extent to
accomplish activities such as singing or blowing up a balloon. Green arrows show the f ow o regulatory in or-
mation as it f ows into the respiratory control centers. The purple arrow shows the f ow o regulatory in orma-
tion rom the control centers to the respiratory muscles that provide the power needed or breathing. DRG,
Dorsal respiratory group; PRG, pontine respiratory group; VRG, ventral respiratory group.

Su h hem re ept rs als sense and resp nd t in reasing
bl d a id levels. Be ause arb n di xide rms an a id in
the bl d plasma, bl d pH g es d wn when w rkand thus
bl d CO 2 levelsg up.
T e ar tid b dy re ept rs are und at the p int where
the mm n ar tid arteries divide, and the a rti b dies are
small lusters hem sensitive ells that lie adja ent t the
a rti ar h near the heart (see Figure 17-18).
W hen stimulated by in reasing levels bl d arb n di-
xide, de reasing xygen levels, r in reasing bl d a idity
(l wer plasma pH ), these re ept rs send nerve impulses t the
respirat ry regulat ry enters. T is signal is interpreted as a
hange away r m the set p ints r these physi l gi al vari-
ables, s the ntr l enters (integrat rs) m di y respirat ry
rates t bring them ba k t ward their set p ints.
T e bl d CO 2 level is the m st p wer ul stimulus driving
respirati n. T at is, the respirat ry ntr l enters seem t
resp nd very qui kly t even min r shi ts in plasma CO 2.
Pulmonary Stretch Ref exes
Stret h re ept rs in the lungs are l ated thr ugh ut the pul-
m nary airways and in the alve li (see Figure 17-18). Nerve
impulses generated by these re ept rs inf uen e the n rmal
pattern breathing and pr te t the respirat ry system r m
ex ess stret hing aused by harm ul verinf ati n.
W hen the tidal v lume air has been inspired, the lungs
are expanded en ugh t stimulate stret h re ept rs that then
send inhibit ry impulses t the inspirat ry enter. Relax-
ati n inspirat ry mus les urs, and expirati n ll ws.
A ter expirati n, the lungs are su iently def ated t inhibit
the stret h re ept rs, and inspirati n is then all wed t start
again.
Br e a t h in g P a t t e r n s
A number lini al terms are used t des ribe breathing pat-
terns. Eupnea, r example, re ers t a n rmal respirat ry rate.
D uring eupnea, the need r xygen and arb n di xide ex-
hange is being met, and the individual is usually n t aware
their breathing pattern.
T e terms hyperventilation and hypoventilation de-
s ribe very rapid and deep r sl w and shall w respirati ns,
respe tively. H yperventilati n s metimes results r m a
ns i us v luntary e rt pre eding exerti n. O r it an re-
sult r m psy h l gi al a t rsas in s - alled hysteri al
hyperventilati n.
 478 CHAPTER 17 Respiratory System

TABLE 17-2 Examples o Breathing Patterns and Spirograms QUICK CHECK

1. Wh e re a re th e re s p ira to ry co n tro l
NAME OF PATTERN DES CRIPTION
ce n te rs lo ca te d ?
Eupne a Norm al bre athing 2. Wh a t is a ch e m o re ce p to r? Ho w d o e s it
in u e n ce b re a th in g ?
3. Wh a t is th e m o s t p o w e r u l s tim u lu s
Hype rve ntilation Rapid, de e p re s pirations th a t in u e n ce s re s p ira tio n ?
4. Wh a t is hyp e rve n tila tio n ?
Hyp ove n tila tio n ?

Hypove ntilation Slow, s hallow re s pirations

G a s Exc h a n g e a n d
Apne a Ce s s ation o re s pirations
Tr a n s p o r t
17 P u lm o n a ry G a s Exc h a n g e
Cheyne -Stoke s Alte rnating apne a and
re s piration hype rve ntilation Bl d pumped r m the right ventri le
the heart enters the pulm nary artery and
eventually enters the lungs. It then f ws
thr ugh the th usands tiny pulm nary
apillaries that are in l se pr ximity t
the air- lled alve li (see Figure 17-9).
External respiration, r the ex hange
gases between the bl d and alve lar air,
C LIN ICA L APPLICATION urs by di usi n. Di usi n is a passive
S UDDEN INFANT DEATH SYNDROME pr ess resulting in m vement d wn a n-
entrati n gradient (see Table 3-2 n p. 51).
S udde n in ant de ath s yndro m e (S IDS ) is the third-ranking caus e o in ant de ath
T at is, substan es m ve r m an area
and accounts or about 1 in 9 o the ne arly 30,000 in ant de aths re porte d e ach
high n entrati n t an area l wer n-
ye ar in the Unite d State s . Som e tim e s calle d crib de ath, SIDS occurs m os t re -
que ntly in babie s w ith no obvious m e dical proble m s w ho are younge r than
entrati n the di using substan e.
3 m onths o age . The exact caus e o de ath can s e ldom be de te rm ine d eve n a te r T e am unts r n entrati ns
exte ns ive te s ting and autops y. s me bl d substan es are measured in
SIDS occurs at a highe r rate in A rican-Am e rican and Native -Am e rican babie s terms weight. Rep rting h w many
than in w hite , His panic, or As ian in ants , although the re as ons re m ain a mys te ry. milligrams a parti ular substan e are
Re gardle s s o in ant e thnicity, re ce nt data s ugge s t that ce rtain pre cautions , s uch present in 100 mL bl d (mg/dL) is
as having babie s s le e p only on the ir backs and ke e ping cribs re e o pillow s or ne example. H wever, the n entrati n
plus h toys that m ight partially cove r the nos e or m outh, m ay re duce the incide nce a parti ular gas in air r within the
o SIDS. Als o im portant is the e lim ination o s m oking during pre gnancy and pro- bl d is expressed as the pressure exerted
te cting in ants rom expos ure to s e cond-hand cigare tte s m oke a te r birth.
by that gas and is rep rted in millimeters
Although the exact caus e o SIDS re m ains unknow n, abnorm alitie s in the
mer ury (mm H g). Re all r m Chap-
re gulatory ce nte rs o the brains te m that control bre athing m ay play a role in this
tragic proble m .
ter 15 that bl d pressure levels are als
rep rted in mm H g.
Several di erent gases are present in
b th air and bl d. T e t tal pressure all
gases present in an air r bl d sample is,
D yspnea re ers t lab red r di ult breathing and is ten urse, the sum the pressures exerted by ea h the gases
ass iated with hyp ventilati n. D yspnea that is relieved by present. Be ause the pressure the s - alled respiratory
m ving int an upright r sitting p siti n is alled orthopnea. gases xygen (O 2) and arb n di xide (CO 2)in air r
I breathing st ps mpletely r a brie peri d, regardless bl d nstitutes nly a part the t tal pressure present,
ause, it is alled apnea. their n entrati n is rep rted as a partial pressure (P). T e
A series y les alternating apnea and hyperventilati n symb l used t designate partial pressure is the apital letter
is alled Cheyne-Stokes respiration (CSR). CSR urs in P pre eding the hemi al symb l r the gas. F r respirat ry
riti al diseases su h as ngestive heart ailure, brain injuries, gases the symb ls PO2 and PCO2 are used.
r brain tum rs. CSR als may ur in the ase a drug Instead re erring dire tly t n entrati n, respirat ry
verd se. physi l gists state that bl d gas parti les di use r m an
Failure t resume breathing a ter a peri d apnea is alled area high partial pressure t an area l wer partial pressure.
respiratory arrest. Understanding the r le partial pressures bl d gases in
Examples breathing patterns are summarized in n rmal gas ex hange is imp rtant in the diagn sis and treat-
Table 17-2. ment many disease nditi ns.
 CHAPTER 17 Respiratory System 479

O 2 is ntinually rem ved r m the bl d and used by the
b dy ells. By the time bl d f ws int the pulm nary apil-
laries, it has a Po 2 ab ut 40 mm H g. Be ause alve lar air
is ri h in xygen (Po 2 100 mm H g), di usi n auses m ve-
ment xygen r m the area high partial pressure (alve -
lar air) t the area l wer partial pressure ( apillary bl d).
Put an ther way, xygen di uses d wn its partial pressure
gradient.
Di usi n arb n di xide als urs between bl d in
pulm nary apillaries and alve lar air. Bl d f wing thr ugh
the pulm nary apillaries is high in CO 2, having a Pco 2
46 mm H g. T e Pco 2 alve lar air is ab ut 40 mm H g. T ere-
re, di usi n arb n di xide results in its m vement r m an
area high partial pressure in the pulm nary apillaries t an
area l wer partial pressure in alve lar air. T en r m the al-
ve li, arb n di xide leaves the b dy in expired air (Figure 17-19).

PULMONARY GAS EXCHANGE

Ins pire d Expire d

Carbo n dioxide (CO2 ) a ir a ir Oxyg e n (O2 )
17
Alve olus P O 2 100 mm Hg
P CO 2 40 mm Hg
Alve ola r a ir Alve olus
CO 2 O2

P CO 2 46 mm Hg
Alve olus P O 2 40 mm Hg
H2 O
P la s ma CO 2 P la s ma
H2 CO 3 O2
O2
H+ HCO 3 CO 2 Hb
CO 2 O2
RBC Hb RBC

P ulmona ry a rte ry P ulmona ry ve in

Ca rbon dioxide (CO 2 ) dis s ocia te s from O 2 diffus e s out of a lve ola r a ir into blood
bica rbona te ions (HCO 3 ) a nd he moglobin a nd binds with he moglobin (Hb) in re d
a nd diffus e s out of blood into a lve ola r a ir. blood ce lls (RBCs ) to form oxyhe moglobin.

S YS TEMIC GAS EXCHANGE

S ys te mic ve ins S ys te mic a rte rie s

Carbo n dioxide (CO2 ) Oxyg e n (O2 )
H+ HCO 3 He a rt
H2 CO 3 RBC Hb
Hb
H2 O CO 2 O2 RBC
CO 2
P la s ma
P O 2 100 mm Hg
P CO 2 40 mm Hg CO 2 O2
P la s ma
CO 2 O 2
CO 2 O2
Tis s ue ce ll Tis s ue ce ll
P CO 2 46 mm Hg Ce lls
P O 2 40 mm Hg

CO 2 diffus e s into blood a nd s ome of it binds to Hb in Oxyhe moglobin dis s ocia te s, re le a s ing O 2 ,
RBCs to form ca rba minohe moglobin. Mos t CO 2 combine s which diffus e s from RBCs a nd a cros s the
with wa te r to form ca rbonic a cid (H2 CO 3 ), which ca pilla ry wa ll to tis s ue ce lls.
dis s ocia te s to form H+ a nd HCO 3 (bica rbona te ) ions.

FIGURE 17-19 Exchange and transport o gases. The top panel o the diagram shows pulmonary gas
exchange and the bottom panel shows systemic gas exchange. In each, the le t inset shows the transport and
movement o carbon dioxide (CO2) and the right inset shows the transport and movement o oxygen (O2).
 480 CHAPTER 17 Respiratory System
S y s t e m ic G a s Exc h a n g e
T e ex hange gases that urs between bl d in systemi
apillaries and the b dy ells is alled internal respiration.
As y u w uld expe t, the dire ti n m vement xygen
and arb n di xide during internal respirati n is just the p-
p site that n ted in the ex hange that urs during exter-
nal respirati n when gases are ex hanged between the bl d
in the pulm nary apillaries and the air in alve li.
D uring the pr ess internal respirati n xygen m le ules
m ve rapidly ut the bl d thr ugh the systemi apillary
membrane int the interstitial f uid and n int the ells that
make up the tissues. At the same time, arb n di xide m le-
ules leave the ells, di use thr ugh the interstitial f uid and
17 then enter the systemi apillaries, eventually being transp rted
t the lungs r eliminati n r m the b dy. T e xygen is used
by the ells in their metab li a tivities. ra e these m vements
bl d gases r y ursel in Figure 17-19, bottom panel.
D i usi n results in the m vement xygen r m an
area high partial pressure in the systemi apillaries
(Po 2 100 mm H g) t an area l wer partial pressure
(Po 2 40 mm H g) in the ells where it is needed. D i usi n
is als resp nsible r the m vement CO 2 r m an area
HEA LTH AND WELL-BEIN G
MAXIMUM OXYGEN CONS UMPTION
Exe rcis e phys iologis ts us e m axim um oxyge n cons um ption
(VO 2 m ax) as a pre dictor o a pe rs ons capacity to do ae robic
exe rcis e . An individuals VO 2 m ax re pre s e nts the am ount o oxy-
ge n take n up by the lungs , trans porte d to the tis s ue s , and
us e d to do work. VO 2 m ax is de te rm ine d large ly by he re ditary
actors , but ae robic (e ndurance ) training can incre as e it by as
m uch as 35% . Many e ndurance athle te s are now us ing VO 2 m ax
m e as ure m e nts to he lp the m de te rm ine and the n m aintain
the ir pe ak condition.
Oxygen Supplements
Oxyge n the rapy is the adm inis tration o oxy-
ge n to individuals s u e ring rom hypoxia
an ins u f cie nt oxyge n s upply to the tis -
s ue s . Clinically, hypoxia is diagnos e d
w he n the oxyge n s aturation o arte rial
blood plas m a drops be low 80% . Indi-
viduals w ith ce rtain re s piratory prob-
le m s , s uch as e m phys e m a, m ay re -
quire s upple m e ntal oxyge n in orde r
to m aintain a norm al li e s tyle .
Oxyge n (O 2 ) in the orm o com -
pre s s e d gas is com m only s tore d in and
dis pe ns e d rom s m all, gre e n, m e tal cyl-
inde rs or tanks (s e e the f gure ). Be -
caus e the oxyge n dis pe ns e d rom s uch
tanks is o te n cold and dry, it m ay ne e d
to be warm e d and m ois te ne d, ge ne rally
high partial pressure in the ells (Pco 2 46 mm H g) t an
area l wer partial pressure (Pco 2 43 mm H g) in the sys-
temi apillaries.
Simply stated, during internal respirati n xygenated
bl d enters systemi apillaries and is hanged int de xy-
genated bl d as it f ws thr ugh them. In the pr ess
l sing xygen, the waste pr du t arb n di xide is pi ked up
and transp rted t the lungs r rem val r m the b dy.
Blo o d Tr a n s p o r t a t io n o G a s e s
Bl d transp rts the respirat ry gases, xygen and arb n
di xide, in a diss lved state, either as a single substan e r
mbined with ther hemi als.
Immediately up n entering the bl d, b th xygen and
arb n di xide diss lve in the plasma, but be ause f uids an
h ld nly small am unts gas in s luti n, m st the xygen
and arb n di xide rapidly rm a hemi al uni n with hem -
gl bin r water. On e gas m le ules are b und t an ther
m le ule, their plasma n entrati n (partial pressure) de-
reases and m re gas an di use int the plasma. In this way,
mparatively large v lumes the gases an be transp rted.
by bubbling the re le as e d gas through wate r, to preve nt dam -
age to the re s piratory tract. Supple m e ntal oxyge n is de live re d
through a m as k or tube s that le ad into the nas al pas s age (na-
s al prongs ).
Supple m e ntal (and ge ne rally ve ry expe ns ive ) oxyge n is
now be ing dis pe ns e d or re cre ational purpos e s at tre ndy oxy-
ge n bars . De live ry is at low ow leve ls and, although cons id-
e re d s a e or he althy individuals , has m ore ps ychological than
m e as urable phys iological e e cts .
Bre athing s upple m e ntal oxyge n or s hort pe riods a te r
s tre nuous exe rcis e is anothe r nonm e dical application o oxy-
ge n the rapy. Although it m ay s horte n re cove ry tim e s or s om e
athle te s , it s e ldom provide s m ore than trans itory be ne f ts .
Som e e ndurance athle te s , s uch as cyclis ts and long-dis tance
runne rs w ho pe r orm at high altitude s , have us e d oxyge n
te nts or bags to provide lowe r O 2 leve ls ove r longe r
pe riods o s le e p or re s t to im prove
pe r orm ance or re duce the ne e d
or high altitude training be ore
com pe tition.
Mos t s port-s anctioning groups
have now que s tione d the e thics o
this longe r-te rm us e o s upple m e n-
tal oxyge n or have banne d the prac-
tice outright as a orm o doping
(s e e box p. 354).
 CHAPTER 17 Respiratory System 481

Tr a n s p o r t o O x yg e n
Only very limited am unts xygen an be diss lved in the
bl d. O the t tal am unt xygen that bl d an trans-
p rt, ab ut 20.4 mL in 100 mL bl d, nly ab ut 1.5% r
0.3 mL is a tually diss lved. Many times that am unt, ab ut
21.1 mL, mbines with the hem gl bin (H b) in 100 mL
bl d t rm oxyhemoglobin (H bO 2) s that it an be ar-
ried t the tissues and used by the b dy ells.
mbine with hem gl bin, xygen must rst di use
int the red bl d ells t rm xyhem gl bin. H em gl bin
m le ules are large pr teins that ntain ur ir n- ntaining
heme mp nents, ea h whi h is apable mbining
with an xygen m le ule.
In many ways ea h hem gl bin m le ule a ts as the ulti-
mate xygen sp nge. O xygen ass iates with hem gl bin
rapidlys rapidly, in a t, that ab ut 97% the bl ds
hem gl bin has united with xygen, and be me xygenated
bl d, by the time it leaves the pulm nary apillaries t re-
turn t the heart.
O xygenated bl d is und in the pulm nary veins and
systemi arteries. N rmally, xygenated bl d is 97% satu-
rated. S - alled de xygenated bl d, und in the systemi
veins and pulm nary arteries, is ab ut 75% saturated with
xygen. T e di eren e in xygen saturati n results r m the
release xygen r m xyhem gl bin t supply the b dy
ells. T ere re, the hemi al mbinati n xygen and he-
m gl bin is said t be reversible with xyhem gl bin r-
mati n r xygen release dependent n the partial pressure
xygen driving the rea ti n.
Summing up, we an say that xygen travels in tw rms:
(1) as simply diss lved O 2 in the plasma and (2) as a mbina-
ti n O 2 and hem gl bin ( xyhem gl bin). O these tw
rms transp rt, xyhem gl bin is the arrier the vast
maj rity the t tal xygen transp rted by the bl d.
Un ortunately, other gases can also bind to hemo-
globin, perhaps rendering the Hb incapable o
transporting oxygen. For a common example o
this, see the article Carbon Monoxide Poisoning at
Connect It! at evolve.elsevier.com.
Tr a n s p o r t o C a r b o n D io x id e
Carb n di xide is a by-pr du t ellular metab lism and
plays an imp rtant and ne essary r le in regulating the pH
b dy f uids. H wever, i it a umulates in the b dy bey nd
n rmal limits (40 t 50 mm H g in ven us bl d), it an
qui kly be me t xi . Eliminati n ex ess CO 2 r m the
b dy urs when it enters the alve li and is expelled during
expirati n. F r this t ur, CO 2 must be transp rted in the
bl d t the lungs in ne three rms, as des ribed in the
ll wing se ti ns.
Carbon Dioxide
Ab ut 10% the t tal am unt arb n di xide in bl d is
arried in the dissolved orm. It is this diss lved CO 2 that pr -
du es the Pco 2 bl d plasma. H wever, all CO 2 in the bl d
must pass thr ugh the diss lved state be re m ving int r
ut any the states des ribed in the ll wing se ti ns.
Carbaminohemoglobin
Ab ut 20% the t tal CO 2 transp rted in the bl d is in the
rm carbaminohemoglobin (H bCO 2). H bCO 2 is rmed
by the binding arb n di xide t hem gl bin.
T e rmati n this mp und is a elerated by an in-
rease in Pco 2as the extra diss lved CO 2 binds t hem -
gl bin. Likewise, rmati n H bCO 2 is sl wed r even 17
reversedby a de rease in Pco 2.
Bicarbonate
Ab ut 70% the t tal CO 2 transp rted in the bl d is ar-
ried in the rm bicarbonate ions (HCO 3 ).
W hen CO 2 diss lves in water (as in bl d plasma), s me
the CO 2 m le ules ass iate with water (H 2O) t rm
carbonic acid (H 2CO3). O n e rmed, s me the H 2CO 3
m le ules diss iate t rm hydr gen (H ) and bi arb nate
(H CO 3 ) i ns. T e speed this pr ess is quite sl w when it
urs in the plasma, but the rate rea ti n in reases dra-
mati ally within RBCs be ause the presen e an enzyme
alled carbonic anhydrase (CA). T e rea ti n is summarized
by the ll wing hemi al equati n:
CO 2 H 2O u v H 2CO 3 u v H H CO 3
Carbon Water Carbonic H yd rogen Bicarbonate
d ioxid e acid ion ion
N te that the arr ws g in b th dire ti ns. T is indi ates
that the rea ti n is reversibleit an g in either dire ti n. I
bi arb nate is being rmed, CO 2 m le ules entering int
plasma are ntinually rem ved r m the bl d and travel t
the lungs as bi arb nate. And, when the pr ess is reversed in
the lungs, CO 2 an be released r m bi arb nate t enter the
alve lar air and then be exhaled.
QUICK CHECK
1. Wh e n re e rrin g to re s p ira to ry ga s e s , e xp la in th e u s e o
p a rtia l p re s s u re (P).
2. Exp la in th e p ro ce s s o in te rn a l re s p ira tio n .
3. In w h a t o rm d o e s oxyg e n tra ve l in th e b lo o d ? Wh a t o rm
d o e s ca rb o n d ioxid e tra ve l in th e b lo o d ?
To better understand these concepts, use the
Active Concept Map Transport o Oxygen and
Carbon Dioxide in the Blood at evolve.elsevier.com.
 482 CHAPTER 17 Respiratory System

S C IEN C E APPLICATIONS
RES PIRATORY MEDICINE
The Danis h phys ician Chris tian
Bohr le t a le gacy o achieve m e nt
in s cie nce in m ore ways than one .
His s on Nie ls Bohr (cre ator o the
Bohr m ode l o the atom s e e n in
Figure 2-2 on p. 26) and his grand-
s on Aage Bohr both won Nobe l
Prize s in s cie nce , as did his s tude nt
Augus t Krogh. Chris tian Bohrs
17 contributions to unde rs tanding re s -
Christian Bohr (18551911) piration, howeve r, have als o le t a
las ting m ark on re s piratory phys iol-
ogy and m e dicine re s ulting in thre e Nobe l Prize nom inations
o his ow n.
Bohrs m os t am ous dis cove ry was the act that a de cre as e
in plas m a pH or an incre as e in P CO 2 w ill de cre as e he m oglobins
binding a f nity w ith oxyge n. Calle d the Bohr e e ct, this phe -
nom e non explains how he m oglobin s o e as ily give s up its oxy-
ge n in ve ry active tis s ue s like m us cle s during exe rcis e w he re
an incre as e in CO 2 and the accom panying acidity re e cts the
am ount o ce llular work and thus an incre as e d us e o oxyge n.
The contributions o Bohr and m any othe rs to todays un-
de rs tanding o the re lations hip o re s piration, blood gas e s , and
pH continue to play a ce ntral role in he alth care . Today, count-
le s s phys icians , nurs e s , re s pirato ry the rapis ts , e m e rge ncy
m e dical te chnicians (EMTs ), and param e dics , continue to
be ne f t rom an unde rs tanding o the s e undam e ntal principle s
o phys iology.

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 459)

carbonic anhydrase (CA) di usion heme

(kar-BON-ik an-HYE-drayz [see ay]) (dih-FYOO-zhen) (heem)
[carbo- coal, -ic relating to, a- without, [di us- spread out, -sion process] [hem- blood]
-hydr- water, -ase enzyme] epiglottis homeostatic mechanism
carotid body (ep-ih-GLOT-is) (hoh-mee-oh-STAT-ik MEK-ah-niz-em)
(kah-ROT-id BOD-ee] [epi- upon, -glottis mouth o windpipe] [homeo- same or equal, -static relating to
[caro- heavy sleep, -id relating to] eustachian tube standing still]
cellular respiration (yoo-STAY-shun toob) inspiration (inhalation)
(SEL-yoo-lar res-pih-RAY-shun) [Bartolomeo Eustachio, Italian anatomist, (in-spih-RAY-shun [in-huh-LAY-shun])
[cell storeroom, -ular relating to, re- again, -an relating to] [in- in, -spir- breathe, -ation process]
-spir- breathe, -ation process] expiration (exhalation) inspiratory muscle
chemoreceptor (eks-pih-RAY-shun [eks-huh-LAY-shun]) (in-SPY-rah-tor-ee MUS-el)
(kee-moh-ree-SEP-tor) [ex- out, -pir- breathe, -ation process (ex- out, [in- in, -spir- breathe, -tory relating to,
[chemo- chemical, -recept- receive, -or agent] -hal- breathe, -ation process)] mus- mouse, -cle little]
chemore ex expiratory muscle inspiratory reserve volume (IRV)
(kee-moh-REE- eks) (eks-PYE-rah-tor-ee MUS-el) (in-SPY-rah-tor-ee ree-SERV VOL-yoom
[chemo- chemical, -re- back or again, [ex- out o , -[s]pir- breathe, -tory relating to, [aye ar vee])
- ex bend] musc- mouse, -cle little] [in- in, -spir- breathe, -tory relating to]
ciliary escalator expiratory reserve volume (ERV) interarytenoid notch
(SIL-ee-ayr-ee ES-kuh-lay-ter) (eks-PYE-rah-tor-ee ree-ZERV VOL-yoom (IN-ter-ar-ih-tee-noyd notch)
[cili- eyelash, -ary relating to, escalat- scale, [ee ar vee]) [inter- among, -aryten- ladle, -oid like]
-or agent] [ex- out o , -[s]pir- breathe, -tory relating to] internal respiration
compliance external nares (in-TER-nal res-pih-RAY-shun)
(kom-PLY-ans) (eks-TER-nal NAY-reez) [intern- inside, -al relating to, re- again,
[compli- f ll up, -ance act o ] sing., naris -spir- breathe, -ation process]
conchae (NAY-ris) lacrimal sac
(KONG-kee or KONG-kay) [extern- outside, -al relating to, naris nostril] (LAK-rih-mal sak)
sing., concha external respiration [lacrima- tear, -al relating to]
(KONG-kah) (eks-TER-nal res-pih-RAY-shun) laryngopharynx
[concha sea shell] [extern- outside, -al relating to, re- again, (lah-ring-goh-FAYR-inks)
diaphragm -spir- breathe, -ation process o ] [laryng- voice box (larynx), -pharynx throat]
(DYE-ah- ram) glottis larynx
[dia- across, -phrag- enclose, -(u)m thing] (GLOT-is) (LAYR-inks)
[glottis mouth o windpipe] [larynx voice box]
 CHAPTER 17 Respiratory System 483

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 482)

lingual tonsil partial pressure (P) respiratory mucosa

(LING-gwal TAHN-sil) (PAR-shal PRESH-ur [pee]) (RES-pih-rah-tor-ee myoo-KOH-sah)
[ling- tongue, -al relating to, tons- goiter, pharyngeal tonsil [re- again, -spir- breathe, -tory relating to,
-il little] ( ah-RIN-jee-al TAHN-sil) mucus slime]
lower respiratory tract [pharyng- throat, -al relating to, tons- goiter, respiratory system
(LOW-er RES-pih-rah-tor-ee trakt) -il little] (RES-pih-rah-tor-ee SIS-tem)
[re- again, -spir- breathe, -tory relating to, pharynx [re- again, -spir- breathe, -tory relating to]
tract trail] (FAYR-inks) secondary bronchi
lung [pharynx throat] (SEK-on-dayr-ee BRONG-kye)
mucus
(MYOO-kus)
phrenic nerve
(FREN-ik)
sing., bronchus
(BRONG-kus) 17
[mucus slime] [phren- mind, -ic relating to] [second- second, -ary relating to,
bronchus windpipe]
nasal cavity pleura
(NAY-zal KAV-ih-tee) (PLOO-rah) sur actant
[nas- nose, -al relating to, cav- hollow, pl., pleurae (sur-FAK-tant)
-ity state] (PLOO-ree) [combination o sur (ace) act(ive) a(ge)nt]
nasal septum [pleura side o body (rib)] tidal volume (TV)
(NAY-zal SEP-tum) primary bronchi (TYE-dal VOL-yoom [tee vee])
[nas- nose, -al relating to, septum wall] (PRYE-mayr-ee BRONG-kye) [tid- time, -al relating to]
nasopharynx sing., bronchus tonsils
(nay-zoh-FAYR-inks) (BRONG-kus) (TAHN-silz)
[naso- nose, -pharynx throat] [prim- f rst, -ary relating to, bronchus windpipe] [tons- goiter, -il little]
nose pulmonary ventilation trachea
ol action (PUL-moh-nayr-ee ven-tih-LAY-shun) (TRAY-kee-ah)
(ohl-FAK-shun) [pulmon- lung, -ary relating to, vent- an or [trachea rough duct]
create wind, -tion process] turbinate
[ol act- smell, -tion condition]
oropharynx residual volume (RV) (TUR-bih-nayt)
(or-oh-FAYR-inks) (reh-ZID-yoo-al VOL-yoom [ar vee]) [turbin- top (spinning toy), -ate o or like]
[residu- remainder, -al relating to] upper respiratory tract
[oro- mouth, -pharynx throat]
oxyhemoglobin (HbO2) respiration (UP-er RES-pih-rah-tor-ee trakt)
(ahk-see-hee-moh-GLOH-bin [aych bee (res-pih-RAY-shun) [re- again, -spir- breathe, -tory relating to,
oh too]) [re- again, -spir- breathe, -ation process] tract trail]
[oxy- sharp, -hemo- blood, -glob- ball, respiratory control center vital capacity (VC)
-in substance] (RES-pih-rah-tor-ee kon-TROL SEN-ter) (VYE-tal kah-PAS-ih-tee [vee see])
[re- again, -spir- breathe, -tory relating to] [vita- li e, -al relating to, capac- hold, -ity state]
palatine tonsil
(PAL-ah-tine TAHN-sil) respiratory membrane vocal cords
[palat- palate, -ine relating to, tons- goiter, (RES-pih-rah-tor-ee MEM-brayn) (VOH-kull kordz)
-il little] [re- again, -spir- breathe, -tory relating to, [voca- voice, -al relating to, cord- string]
membran- thin skin]
paranasal sinus
(payr-ah-NAY-zal SYE-nus)
[para- beside, -nas- nose, -al relating to,
sinus hollow]

LANGUAGE OF M ED IC IN E

abdominal thrust adult respiratory distress syndrome (ARDS) apnea

(ab-DOM-ih-nal thrust) (ah-DULT RES-pih-rah-tor-ee dis-TRESS (AP-nee-ah)
[abdomin- belly, -al relating to] SIN-drohm [ardz or ay ar dee es]) [a- not, -pne- breathe, -a condition]
adenoid [re- again, -spir- breathe, -tory relating to, asthma
(AD-eh-noyd) syn- together, -drome running or (race) (AZ-mah)
[adeno- gland, -oid like] course] [asthma panting]
 484 CHAPTER 17 Respiratory System

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 483)

atelectasis eupnea pneumonia

(at-eh-LEK-tay-sis) (YOOP-nee-ah) (noo-MOH-nee-ah)
[atele- incomplete, -ectasis extension] [eu- easily, -pne- breathe, -a condition] [pneumon- lung, -ia condition]
bronchitis hemothorax pneumothorax
(brong-KYE-tis) (hee-moh-THOH-raks) (noo-moh-THOH-raks)
[bronch- windpipe, -itis in ammation] [hemo- blood, -thorax chest] [pneumo- air or wind, -thorax chest]
chemoreceptor hyperventilation respiratory arrest
(kee-moh-ree-SEP-tor) (hye-per-ven-tih-LAY-shun) (RES-pih-rah-tor-ee ah-REST)
[chemo- chemical, -recept- receive, -or agent] [hyper- excessive, -vent- an or create wind, [re- again, -spir- breathe, -tory relating to]

17 Cheyne-Stokes respiration (CSR)

(chain stokes res-pih-RAY-shun
-tion process]
hypoventilation
respiratory distress syndrome (RDS)
(RES-pih-rah-tor-ee dih-STRESS
[see es ar]) (hye-poh-ven-tih-LAY-shun) SIN-drohm [ar dee es])
[J ohn Cheyne Scots physician, William [hypo- under or below, -vent- an or create [re- again, -spir- breathe, -tory relating to,
Stokes Irish physician, re- again, wind, -tion process] syn- together, -drome running or (race)
-spir- breathe, -ation process o ] hypoxia course]
chronic bronchitis (hye-POK-see-ah) rhinitis
(KRON-ik brong-KYE-tis) [hypo- under or below, -ox- oxygen, -ia (rye-NYE-tis)
[chron- time, -ic relating to, bronch- windpipe, condition] [rhin- nose, -itis in ammation]
-itis in ammation] in ant respiratory distress syndrome (IRDS) respiratory therapist
chronic obstructive pulmonary disease (IN- ant RES-pih-rah-toh-ree dih-STRESS (RES-pih-rah-tor-ee THAYR-ah-pist)
(COPD) SIN-drohm [irdz or aye ar dee es]) [re- again, -spir- breathe, -tory relating to,
(KRON-ik ob-STRUK-tiv PUL-moh-nayr-ee [re- again, -spir- breathe, -tory relating to, therap- treatment, -ist agent]
dih-ZEEZ [see oh pee dee]) syn- together, -drome course] sinusitis
[chron- time, -ic relating to, obstruct- block, laryngeal cancer (sye-nyoo-SYE-tis)
-ive relating to, pulmon- lung, -ary relating (lah-RIN-jee-al or lar-in-J EE-al KAN-ser) [sinus- hollow, -itis in ammation]
to, dis- opposite o , -ease com ort] [laryng- voice box (larynx), -al relating to, spirometer
croup cancer crab or malignant tumor] (spye-ROM-eh-ter)
(kroop) laryngitis [spir- breathe, -meter measure]
[croup croak] (lar-in-J YE-tis) sputum
deviated septum [laryng- voice box (larynx), -itis in ammation] (SPYOO-tum)
(DEE-vee-ay-ted SEP-tum) lobectomy [sputum spit]
[devia- turn aside, -ate process, (loh-BEK-toh-mee) sudden in ant death syndrome (SIDS)
septum partition] [lob- lobe, -ec- out, -tom- cut, -y action] (SUD-den IN- ant deth SIN-drohm [sidz])
dyspnea nasal polyp [syn- together, -drome running or (race) course]
(DISP-nee-ah) (NAY-zal PAH-lip) tonsillectomy
[dys- pain ul, -pne- breathe, -a condition] [nas- nose, -al relating to, polyp cuttlef sh] (tahn-sih-LEK-toh-mee)
emergency medical technician (EMT) orthopnea [tonsil- tonsil, -ec- out, -tom- cut, -y action]
(eh-MER-jen-see MED-ih-kal tek-NISH-en (or-THOP-nee-ah) tonsillitis
[ee em tee]) [ortho- straight or upright, -pne- breathe, (tahn-sih-LYE-tis)
[medic- heal, -al relating to, techn- art or skill, -a condition] [tonsil- tonsil, -itis in ammation]
-ic relating to, -ian practitioner] paramedic tracheostomy
emphysema (payr-ah-MED-ik) (tray-kee-OS-toh-mee)
(em-f h-SEE-mah) [para- beside, -med- heal, -ic- relating to] [trache- rough duct (trachea), -os- mouth or
[em- in, -physema blowing or pu f ng up] pharyngitis opening, -tom- cut, -y action]
endotracheal intubation ( ayr-in-J YE-tis) tuberculosis (TB)
(en-doh-TRAY-kee-al in-too-BAY-shun) [pharyng- throat (pharynx), -itis in ammation] (too-ber-kyoo-LOH-sis [tee bee])
[endo- within, -trache- rough duct, -al relating pleurisy [tuber- swelling, -cul- little, -osis condition]
to, in- within, -tub- tube, -ation process] (PLOOR-ih-see) upper respiratory in ection (URI)
epiglottitis [pleur- side o body (rib), -itis in ammation] (UP-er RES-pih-rah-tor-ee in-FEK-shun
(ep-ih-glot-AYE-tis) pneumonectomy [yoo ar aye])
[epi- upon, -glotti- mouth o windpipe, (noo-moh-NEK-toh-mee) [re- again, -spir- breathe, -tory relating to,
-itis in ammation ] [pneumon- lung, -ec- out, -tom- cut, -y action] in ec- stain, -tion process]
epistaxis
(ep-ih-STAK-sis)
[epi- upon, -staxis drip]
 CHAPTER 17 Respiratory System 485

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary d. Fr ntal, maxillary, sphen id, and ethm id sinuses
or us e w ith your device , acce s s the Au d io Ch a p te r drain int n se (Figure 17-3)
S u m m a rie s online at evolve .e ls evie r.com . 2. Fun ti ns
a. Warms and m istens inhaled air
Scan this s um m ary a te r re ading the chapte r to b. C ntains sense rgans smell ( l a t ry re ept rs)
he lp you re in orce the key conce pts . Late r, us e B. Pharynx
the s um m ary as a quick review be ore your clas s 1. Stru ture (Figure 17-4)
or be ore a te s t. a. Pharynx (thr at) ab ut 12.5 m (5 in hes) l ng
b. Divided int nas pharynx, r pharynx, and 17
laryng pharynx
S tructural Plan . w nasal avities, m uth, es phagus, larynx, and
A. O verview audit ry tubes all have penings int pharynx
1. Basi plan respirat ry system w uld be similar t d. nsils rm ring lymph id tissue ar und
an inverted tree i it were h ll w; leaves the tree thr at
w uld be mparable t alve li, with the mi r s pi (1) Pharyngeal t nsils and penings audit ry
sa s en l sed by netw rks apillaries (Figure 17-1) tubes pen int nas pharynx
2. Di usi n is the m de r gas ex hange that urs in (2) Lingual and palatine t nsils und in
the respirat ry me hanism r pharynx
B. Divided int upper and l wer t better des ribe l a- (3) nsillitisinf ammati n t nsils; t nsille -
ti ns in the air pathway the respirat ry system t my is surgi al rem val t nsils (Figure 17-5)
1. Upper respirat ry tra tn se, pharynx, and larynx e. Mu us membrane lines pharynx
2. L wer respirat ry tra ttra hea, br n hial tree, and 2. Fun ti ns
lungs a. Passageway r d and liquids
C. Respirat ry mu sa b. Air distributi n; passageway r air
1. Stru ture . nsilspr vide immune pr te ti n
a. Mu us membrane that lines the air distributi n C. Larynx
tubes in the respirat ry tree (Figure 17-2) 1. Stru ture (Figure 17-6)
b. Ciliated pseud strati ed epitheliumlines m st a. L ated just bel w pharynx; als re erred t as the
tra t; pr du es mu us v i eb x
. Strati ed squam us epitheliumlines n strils, b. Nine pie es artilage rm ramew rk
v al lds, pharynx; pr te tive un ti n (1) T yr id artilage (Adams apple) is largest
d. Simple squam us epitheliumlines alve li; a ili- (2) Epigl ttis partially vers pening int larynx
tates gas ex hange . Mu us lining
2. Fun ti n d. V al rds stret h a r ss interi r larynx; spa e
a. M re than 125 mL mu us pr du ed ea h day between rds is the gl ttis
rms a mu us blanket ver mu h the respira- 2. Fun ti ns
t ry mu sa a. Air distributi n; passageway r air t m ve t and
b. Mu us serves as an air puri ati n me hanism by r m lungs
trapping inspired irritants su h as dust and p llen b. V i e pr du ti n
. Ciliary es alat r ilia n mu sal ells beat in 3. Laryngeal an er
nly ne dire ti n, m ving mu us upward t a. In iden e in reases with age and al h l abuse
pharynx r rem val b. O urs m st ten in men ver age 50
. I larynx rem ved, es phageal spee h r ele tri
arti ial larynx needed r spee h
Uppe r Re s pirato ry Tract D. Dis rders the upper respirat ry tra t
A. N se 1. Upper respirat ry in e ti n (URI)
1. Stru ture a. Rhinitisnasal inf ammati n, as in a ld, inf u-
a. Nasal septum separates interi r n se int tw enza, r allergy
avities (1) In e ti us rhinitis mm n ld
b. Mu us membrane lines n se (2) Allergi rhinitishay ever
. Nasal p lypsn n an er us gr wths that pr je t b. Pharyngitis (s re thr at)inf ammati n r in e -
r m nasal mu sa (ass iated with hr ni hay ti n the pharynx
ever)
 486 CHAPTER 17 Respiratory System
. Laryngitisinf ammati n the larynx resulting
r m in e ti n r irritati n
(1) Epigl ttitisli e-threatening
(2) Cr upn nli e-threatening
2. Anat mi al dis rders
a. Deviated septumseptum that is abn rmally ar
r m the midsagittal plane ( ngenital r a quired)
b. Epistaxis (bl dy n se) an result r m me hani al
injuries t the n se, hypertensi n, r ther a t rs
Low e r Re s pirato ry Tract
A. ra hea
17 1. Stru ture (Figure 17-7)
a. ube (windpipe) ab ut 11 m (4.5 in hes) l ng
that extends r m larynx int the th ra i avity
b. Mu us lining
. C-shaped rings artilage h ld tra hea pen, but
all w r swall wing
2. Fun ti npassageway r air t m ve t and r m
lungs
3. O bstru ti n
a. Bl kage tra hea ludes the airway, and i
mplete, auses death in minutes
b. ra heal bstru ti n auses m re than 4000 deaths
annually in the United States
. Five-and- ve maneuver is a li esaving te hnique
used t ree the tra hea bstru ti ns; als see
abdominal thrusts in b x n p. 467
d. ra he st mysurgi al pr edure in whi h a tube
is inserted int an in isi n in the tra hea s that a
pers n with a bl ked airway an breathe
B. Br n hial tree
1. Stru ture
a. ra hea bran hes int right and le t br n hi
(1) Right primary br n hus m re verti al than le t
(2) Aspirated bje ts m st ten l dge in right
primary br n hus r right lung
b. Ea h br n hus bran hes int smaller and smaller
tubes (se ndary br n hi), eventually leading t
br n hi les
. Br n hi les end in lusters mi r s pi alve lar
sa s, the walls whi h are made up alve li
(Figure 17-8)
2. Fun ti nair distributi n; passageway r air t m ve
t and r m alve li
C. Alve li (Figure 17-9)
1. Respirat ry membranethin wall that separates pul-
m nary bl d r m alve lar air, all wing di usi n
gases; f at type I ells rm single, thin layer
2. Fun ti nex hange gases between air and bl d
3. Sur a tantsubstan e released by type II ells int
alve li t redu e sur a e tensi n and thus prevent l-
lapse alve li
D. Respirat ry distressrelative inability t inf ate the
alve li
1. In ant respirat ry distress syndr me (IRDS)leading
ause death in premature in ants, resulting r m
la k sur a tant pr du ti n in alve li
2. Adult respirat ry distress syndr me (ARDS)
impairment sur a tant by inhalati n reign sub-
stan es r ther nditi ns
E. Lungs
1. Stru ture (Figure 17-10)
a. Sizelarge en ugh t ll the th ra i avity,
ex ept r middle spa e (mediastinum) upied by
heart, large bl d vessels, thymus, and es phagus
b. Apexnarr w upper part ea h lung, under
llarb ne
. Basebr ad l wer part ea h lung; rests n
diaphragm
2. Fun ti nbreathing (pulm nary ventilati n)
F. Plurae
1. T in membrane that lines th ra i avity (parietal
pleura) and vers uter sur a e lungs (vis eral
pleura)
2. M ist, sm th, slippery ser us membrane redu es
ri ti n between the lungs and hest wall during
breathing (Figure 17-11)
3. Pleurisyinf ammati n the pleura
4. Atele tasis llapse r in mplete expansi n the
lung (alve li) (Figure 17-12); an be aused by:
a. Pneum th raxpresen e air in the pleural spa e
b. H em th raxpresen e bl d in the pleural
spa e
G. Dis rders the l wer respirat ry tra t
1. L wer respirat ry in e ti n
a. A ute br n hitis, r tra he br n hitisinf amma-
ti n the br n hi r br n hi and tra hea aused
by in e ti n (usually resulting r m the spread a
URI)
b. Pneum nia (Figure 17-13)a ute inf ammati n
(in e ti n) in whi h lung airways be me bl ked
with thi k exudates
(1) L bar pneum niaa e ts entire l be lung
(2) Br n h pneum niain e ti n s attered al ng
br n hial tree
. uber ul sis ( B) hr ni , highly ntagi us
lung in e ti n hara terized by tuber les in the
lung; an pr gress t inv lve tissues utside
the lungs and pleura
2. Restri tive pulm nary dis rders redu e mplian e
(the ability lung tissues t stret h), parti ularly
during inspirati n
a. Fa t rs inside the lungs, su h as br sis (s arring)
r inf ammati n, may restri t breathing
b. Fa t rs utside the lungs, su h as pain r m injury
r pleurisy, may restri t breathing
. T e thi kened f uid in the lungs urring in ysti
br sis als restri ts lung mplian e

3. O bstru tive pulm nary dis rders
a. O bstru t airways, thus bstru ting inspirati n and
expirati n
b. A ute bstru ti n an be immediately
li e-threatening
. Chr ni bstru tive pulm nary disease (COPD)
an devel p r m pre-existing bstru tive ndi-
ti ns (Figure 17-14)
d. Chr ni br n hitis hr ni inf ammati n the
br n hial tree
e. Emphysemaredu ed sur a e area lungs aused
by rupture r ther damage t alve li
. Asthmare urring spasms the airways a m-
panied by edema and mu us pr du ti n
4. Lung an ermalignant tum r the lungs, a-
si nally treatable with surgery, hem therapy, and
radiati n
Re s piratio n
A. Respirati n inv lves several pr esses and me hanisms
1. External respirati npulm nary ventilati n (breath-
ing) and pulm nary gas ex hange
2. ransp rt gases by bl d and regulati n setp int
levels bl d gases
3. Internal respirati nsystemi gas ex hange and ellu-
lar respirati n
B. Figure 17-15 summarizes all these pr esses and thus
serves as a big pi ture view respirati n
Pulm o nary Ve ntilatio n
A. Me hani s breathing (Figure 17-16)
1. Basi prin iples
a. Pulm nary ventilati n in ludes tw phases alled
inspiration (m vement air int lungs) and expi-
ration (m vement air ut lungs)
b. Changes in size and shape th rax ause hanges
in air pressure within that avity and in the lungs
be ause as v lume hanges, pressure hanges in the
pp site dire ti n
. Pressure di eren es (gradients) ause air t m ve
int r ut lungs; air m ves r m high air pres-
sure t ward l w air pressure
d. T rax and lungs must remain:
(1) C mpliantable t stret h
(2) Elasti able t re il a ter stret h
2. Inspirati n (inhalati n)
a. A tive pr essair m ves int lungs
b. Inspirat ry mus les in lude diaphragm and exter-
nal inter stals
(1) Diaphragm f attens when stimulated by
phreni nerves during inspirati nin reases
t p-t -b tt m length th rax
(2) External inter stal mus les ntra t and
elevate the ribsin reases the size the
th rax r m r nt t ba k and r m side t side
CHAPTER 17 Respiratory System 487
. In rease in size the th ra i avity redu es pres-
sure within it; air then enters the lungs by m ving
d wn its pressure gradient
3. Expirati n (exhalati n)
a. Q uiet expirati n is rdinarily a passive pr ess
b. D uring expirati n, th rax returns t its resting size
and shape
. Elasti re il lung tissues aids in expirati n
d. Expirat ry mus les used in r e ul expirati n are
internal inter stals and abd minal mus les
(1) Internal inter stals ntra ti n depresses the
rib age and de reases the size the th rax
r m r nt t ba k
(2) C ntra ti n abd minal mus les elevates the 17
diaphragm, thus de reasing size the th ra i
avity r m t p t b tt m
e. Redu ti n in the size the th ra i avity
de reases its v lume and thus in reases its pressure,
s air m ves d wn the pressure gradient and leaves
the lungs
B. Pulm nary v lumes (Figure 17-17 and Table 17-1)
1. V lumes air ex hanged (int and ut b dy) in
breathing an be measured with a spir meter
2. idal v lume ( V)am unt n rmally breathed in r
ut with ea h breath
3. Vital apa ity (VC)largest am unt air that ne
an breathe ut in ne expirati n
4. Expirat ry reserve v lume (ERV)am unt air that
an be r ibly exhaled a ter expiring the tidal v lume
5. Inspirat ry reserve v lume (IRV)am unt air that
an be r ibly inhaled a ter a n rmal inspirati n
6. Residual v lume (RV)air that remains in the lungs
a ter the m st r e ul expirati n
C. Regulati n ventilati n
1. Regulati n respirati n permits the b dy t adjust t
varying demands r xygen supply and arb n
di xide rem val by maintaining setp int n entra-
ti ns bl d gases
2. Brainstem ntr l respirati n (Figure 17-18)
a. M st imp rtant entral regulat ry enters in brain-
stem are alled respiratory control centers
b. Medullary entersunder resting nditi ns, the
medullary rhythmi ity area pr du es a n rmal rate
and depth respirati ns (12 t 18 per minute)
. P ntine entersas nditi ns in the b dy vary,
these enters in the p ns an alter the a tivity
the medullary rhythmi ity area, thus adjusting
breathing rhythm
d. Brainstem enters are inf uen ed by in rmati n
r m ther parts the brain and r m sens ry
re ept rs l ated in ther b dy regi ns
3. Cerebral rtexv luntary (but limited) ntr l
respirat ry a tivity
4. Respirat ry ref exes
a. Chem ref exes hem re ept rs resp nd t hanges
in arb n di xide, xygen, and bl d a id levels
re ept rs l ated in ar tid and a rti b dies
 488 CHAPTER 17 Respiratory System
b. Pulm nary stret h ref exesresp nd t the stret h
re ept rs in lungs, thus pr te ting respirat ry
rgans r m verinf ati n
D. Breathing patterns (Table 17-2)
1. Eupnean rmal breathing
2. H yperventilati nrapid and deep respirati ns
3. H yp ventilati nsl w and shall w respirati ns
4. D yspnealab red r di ult respirati ns
5. O rth pneadyspnea relieved by m ving int an
upright r sitting p siti n
6. Apneast pped respirati n
7. Cheyne-St kes respirati n (CSR) y les alternat-
ing apnea and hyperventilati n ass iated with riti al
17 nditi ns
8. Respirat ry arrest ailure t resume breathing a ter a
peri d apnea
Gas Exchange and Trans po rt
A. Pulm nary gas ex hangeex hange gases in lungs
(Figure 17-19)
1. Carbamin hem gl bin breaks d wn int arb n
di xide and hem gl bin
2. Carb n di xide m ves ut lung apillary bl d int
alve lar air and ut b dy in expired air
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the re s piratory s ys te m in Chapte r 5.
The s tructure s o the re s piratory s ys te m can be de s cribe d as
tube s and bags . All the s tructure s exce pt the alve oli are tube s .
The ir job is to ge t air to and rom the alve oli, w he re oxyge n
and carbon dioxide are exchange d in the blood.
1. Flash ards and nline res ur es an be used t learn the
names, l ati ns, and un ti ns the stru tures the
respirat ry system.
2. Lungs are passive rgans. Remember that in rder r air
t be m ved in and ut the lung, the pressure the
hest avity must be raised r l wered. l wer the pres-
sure, the v lume must in rease (B yles law); this is d ne
by ntra ting the diaphragm, whi h auses air t enter
the lung. W hen the diaphragm relaxes, the v lume the
hest avity de reases, the pressure g es up, and the air is
pushed ut the lung.
3. W hen xygen gets t the lung, it rms a weak b nd with
hem gl bin in the bl d. W hen the bl d gets t the
3. O xygen m ves r m alve li int lung apillaries
4. H em gl bin mbines with xygen, pr du ing
xyhem gl bin
B. Systemi gas ex hangeex hange gases in tissues
(Figure 17-19)
1. O xyhem gl bin breaks d wn int xygen and
hem gl bin
2. O xygen m ves ut tissue apillary bl d int tissue
ells
3. Carb n di xide m ves r m tissue ells int tissue
apillary bl d
4. H em gl bin mbines with arb n di xide, rming
arbamin hem gl bin
C. Bl d transp rtati n gases
1. ransp rt xygen
a. Only small am unts xygen (O 2) an be dis-
s lved in bl d
b. M st xygen mbines with hem gl bin t rm
xyhem gl bin (H bO 2) t be arried in bl d
2. ransp rt arb n di xide
a. Diss lved arb n di xide (CO 2)10%
b. Carbamin hem gl bin (H bCO 2)20%
. Bi arb nate i ns (H CO 3 )70%
tissue, it gives up the xygen and takes n arb n di xide.
T e bl d arries arb n di xide as bi arb nate i n r by
mbining it with hem gl bin. W hen the bl d gets t
the lung, the arb n di xide diss iates and is exhaled.
Figure 17-19 sh ws CO 2 leaving the bl d.
4. Review the Language S ien e and Language Medi-
ine terms. Che k ut my-ap.us/M 0GBpB r respirat ry
system tut rials.
5. T e dis rders the respirat ry system an be learned by
making a hart the vari us dis rders. O rganize the
hart by me hanism r ause: upper respirat ry in e ti ns,
l wer respirat ry in e ti ns, restri tive dis rders, and
bstru tive dis rders.
6. In y ur study gr up, g ver the f ash ards the stru -
tures the respirat ry system and pulm nary v lumes.
Dis uss the pr esses inspirati n, expirati n, and regu-
lati n respirati n. Dis uss external and internal respira-
ti n. G ver the respirat ry dis rders hart, hapter
utline summary, and the questi ns at the end the
hapter, and dis uss p ssible test questi ns.
 CHAPTER 17 Respiratory System 489

Re vie w Que s tio ns Critical Thinking

Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.

1. Di erentiate between the respirat ry membrane and the 28. Explain the e e t sm king has n the b dys ability t
respirat ry mu sa. m ve material trapped in the respirat ry mu sa.
2. Des ribe the iliary es alat r. 29. A ter strenu us exer ise, inexperien ed athletes will
3. List the un ti ns the paranasal sinuses. quite ten attempt t re ver and resume n rmal
4. W hat is the un ti n the audit ry tube? breathing by bending ver r sitting d wn. Using the
5. W hat is the un ti n the epigl ttis? me hani s ventilati n, h w w uld y u m di y the 17
6. Des ribe, in de reasing rder size, the air tubes the re very pra ti es these athletes?
lung. 30. Cal ulate y ur vital apa ity and t tal lung apa ity i
7. W hat nstitutes an upper respirat ry in e ti n? y ur pulm nary ventilati n v lumes were as ll ws:
8. Des ribe rhinitis, pharyngitis, and laryngitis. tidal v lume500 mL; inspirat ry reserve v lume
9. W hat is IRDS? W hat substan e is missing r m the 3200 mL; expirat ry reserve v lume1100 mL; and
lung that auses IRDS? residual v lume1150 mL.
10. Des ribe the pleura. W hat is the un ti n pleural
f uid?
11. W hat is atele tasis?
12. H w is tuber ul sis transmitted r m pers n t pers n?
W hat is the path gen that auses tuber ul sis?
13. W hat urs t restri t breathing in asthma?
14. W hat is br n hitis?
15. W hat pr ess in emphysema auses the redu ti n in
lung sur a e area?
16. Distinguish between l bar pneum nia, br n h pneum -
nia, and aspirati n pneum nia.
17. De ne pulm nary mplian e.
18. Name and explain the v lumes that make up vital
apa ity.
19. Di erentiate between external, internal, and ellular
respirati n.
20. Explain the me hani al pr ess inspirati n.
21. Explain the me hani al pr ess expirati n.
22. Explain the un ti n hem re ept rs in regulating
breathing.
23. Explain the un ti n stret h re ept rs in regulating
breathing.
24. Identi y the tw m st imp rtant ntr l enters in the
medulla r regulating breathing rhythm.
25. Explain h w the Po 2 and the Pco 2 impa ts h w gas is
ex hanged between the lung and the bl d, and the
bl d and the tissues.
26. W hat is a spir meter?
27. Des ribe Cheyne-St kes respirati n.
 490 CHAPTER 17 Respiratory System

Chapte r Te s t 15. T e right lung is made up ________ l bes, and the

A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e rgans the respirat ry system are designed t
per rm tw basi un ti ns: ________ and ________.
2. T e upper respirat ry tra t nsists the ________, the
________, and the ________.
3. T e membrane that separates the air in the alve li r m
the bl d in the surr unding apillaries is alled the
________.
17 4. T e membrane that lines m st the air distributi n
tubes the respirat ry system is alled the ________.
5. Nerve endings resp nsible r the sense ________ are
l ated in the nasal mu sa.
6. T e r ntal, maxillary, sphen idal, and ethm idal avities
make up the ________.
7. T e ________ sa s drain tears int the nasal avity.
8. T e ________ pr trude int the nasal avities and un -
ti n t warm and humidi y the air.
9. T e ________ is the stru ture that an als be alled the
throat.
10. T e ________ is als alled the voice box.
11. T e ________ is the large air tube in the ne k.
12. T e ur pr gressively smaller air tubes that nne t the
tra hea and the alve li are the ________, ________,
________, and ________.
13. Ex rine mu us glands p ssessing many ________
ells help pr du e mu us.
14. ________ is a substan e made by the lung t redu e the
sur a e tensi n water in the alve li.
le t lung is made up ________ l bes.
16. A llapse the lung r any reas n is alled ________.
17. Air in the pleural spa e is alled a ________.
18. A series y les alternating apnea and hyperventila-
ti n is alled ________ respirati n.
19. T e ex hange gases between the bl d and the tissues
is alled ________.
20. T e ________ is the m st imp rtant mus le in
respirati n.
21. T e ex hange gases by di usi n is a mplished by
way di usi n d wn their ________ ________
gradient.
22. O xygen is arried in the bl d as ________.
23. Carb n di xide is arried in the bl d as the ________
i n r mbines with hem gl bin as ________.
24. T e basi respirat ry rhythm enters are l ated in the
________ the brain.
25. ________ are the sens ry re ept rs that help keep the
lung r m verexpanding.
26. ________ are the sens ry re ept rs that help m di y
respirat ry rates by dete ting the am unt arb n
di xide, xygen, r a id levels in the bl d.
27. T e am unt air that is m ved in and ut the lung
during n rmal, quiet breathing is alled ________
v lume.
28. T e three v lumes that make up vital apa ity are
________, ________, and ________.
29. T e v lume in luded in t tal lung apa ity, but n t vital
apa ity, is ________ v lume.

Match each disorder in Column A with its description or cause in Column B.

Column A
30. ________ rhinitis
31. ________ pharyngitis
32. ________ laryngitis
33. ________ deviated septum
34. ________ epistaxis
35. ________ IRDS
36. ________ pneum nia
37. ________ tuber ul sis
38. ________ emphysema
39. ________ asthma
Column B
a. n sebleed
b. a nditi n in whi h the nasal septum strays r m the midline the nasal avity
. a hr ni ba illus in e ti n that usually a e ts the lung and is aused by a
my ba terium
d. an inf ammati n the mu us lining the larynx
e. a nditi n in whi h ruptured alve li redu e the sur a e area the lung, making
breathing di ult
. an inf ammati n the nasal mu sa
g. an bstru tive dis rder hara terized by re urring spasms the sm th mus les
the br n hi
h. an a ute inf ammati n the lungs
i. an inf ammati n r in e ti n the pharynx
j. a disease hara terized by a la k sur a tant in the alve li; usually urs in
premature in ants

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Curtis was having un al ngside a neighb rh d swim-
ming p l when he was a identally pushed int the p l.
Alth ugh he is a g d swimmer, the suddenness the
all aught him guard and he inhaled s me water
be re he was able t gain ntr l the situati n.
Lu kily, a nearby swimmer assisted Curtis t the edge
the p l, but Curtis ntinued t have great di ulty in
breathing. Can y u name the syndr me that Curtis must
be exhibiting? Explain what has happened t Curtiss
lungs t ause his breathing di ulty.
2. Walter has aspergill sis in his lungs. T is disease has
aused a partial bl kage b th his br n hi. D es
Walter have a restri tive r bstru tive nditi n? W hat
signs w uld y u l k r t n rm y ur diagn sis i
Walter uses a spir meter t test his breathing? W hat type
path geni rganism aused Walters pr blem? (H IN :
See Appendix A at evolve.elsevier.com.)
CHAPTER 17 Respiratory System 491
3. W hile y u are hatting with y ur riend at an expensive
restaurant, she suddenly st ps in midswall w and l ks
pani ked. W hen y u ask what is wr ng, she indi ates that
she ant speak and runs t ward the restr m. W hat
sh uld y u d ? Assume that y ur rst aid d es n t
w rkwhat pr edure might emergen y medi al pers n-
nel use t help y ur riend?
4. m was an enduran e runner. H e was an average m-
petit r but was h pe ul that i he stu k with it, he might
impr ve en ugh t earn a s h larship at a university.
A ter a year n the team, he was dis uraged be ause his
per rman e did n t impr ve en ugh t even be nsid-
ered r any type distan e athleti s. A ter talking t his
a h, he was tempted t see an exer ise physi l gist t 17
determine his maximum xygen nsumpti n (VO 2 max).
W hat type in rmati n w uld this test pr vide t help
m with uture de isi ns regarding running r his high
s h l team?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Digestive System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.

Overview o Digestion, 494 Pancreas, 511

Wall o the Digestive Tract, 495 Structure and Function, 511
Mouth, 496 Disorders o the Pancreas, 511
Structure o the Oral Cavity, 496 Large Intestine, 512
Teeth and Salivary Glands, 497 Structure, 512
Disorders, 499 Function, 513
Pharynx, 501 Disorders o the Large Intestine, 514
Structure, 501 Appendix, 515
Function, 502 Structure and Function, 515
Esophagus, 502 Appendicitis, 516
Structure and Function, 502 Peritoneum, 516
Re ux, 503 Location, 516
Stomach, 504 Extensions, 516
Structure, 504 Peritonitis, 517
Function, 505 Ascites, 517
Disorders, 505 Digestion, 517
Small Intestine, 506 Overview o Digestions, 517
Structure, 506 Enzymes and Chemical Digestion, 517
Function, 508 Carbohydrate Digestion, 518
Disorders, 508 Protein Digestion, 518
Liver and Gallbladder, 509 Lipid Digestion, 519
Structure, 509 End Products o Digestion, 519
Function, 509 Absorption, 519
Disorders, 509 Mechanisms o Absorption, 519
Sur ace Area and Absorption, 520

O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.

A ter you have completed this chapter, you
should be able to:
1. List the main and accessory organs o
the digestive system and discuss
primary mechanisms o the digestive
system.
2. List and describe the our layers o the
digestive tract wall, and discuss the value
o each layer to the digestive organs.
3. Discuss the structures o the mouth: the
oral cavity, teeth, and salivary glands,
as well as the disorders o the mouth.
4. Discuss the structure and unction o
the pharynx, esophagus, and stomach,
as well as the disorders o the stomach.
5. Discuss the structure, unction, and dis-
orders o the small intestine.
6. Discuss the structure, unction, and
disorders o the liver, gallbladder, and
pancreas.
7. Discuss the structure, unction, and
disorders o the large intestine, appen-
dix, and peritoneum.
8. Def ne and contrast mechanical and
chemical digestion.
9. Discuss the basics o carbohydrate,
protein, and lipid digestion and give the
end-products o each process.
10. Describe the process o absorption
and how structural adaptations o the
digestive tube a ect the rate and e f -
ciency o nutrient absorption.
 18
A ll us enj y a g d meal! F d pre eren es di er widely LANGUAGE OF
am ng ultures and individuals, but there is n d ubt that the S C IEN C E
sight, smell, taste, texture, and espe ially the nutrient ntent
the ds we eat ntribute in many ways t ur
Be o re re ading the
quality li e. Alth ugh we d n t live t eat, we
chapte r, s ay e ach o
ertainly must eat t live. the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
T e ingesti n d is the rst step in an the m as yo u re ad.
imp rtant and mplex bi l gi al pr ess that
begins when we nsume a meal. Nutrients un-
absorption
derg three rms pr essing in the b dy: (ab-SORP-shun)
digestion, absorption, and metabolism. Di- [absorp- swallow, -tion process]
gesti n and abs rpti n are per rmed by the alimentary canal
rgans the digestive system. Metab lism, n (al-eh-MEN-tar-ee kah-NAL)
the ther hand, is per rmed by all b dy ells. T is [aliment- nourishment,
hapter des ribes digestive rgans, ass iated dis- -ary relating to]
ease states, and the pr esses digesti n and amylase
abs rpti n. T e metab lism nutrients (AM-eh-lays)
a ter they have been abs rbed is dis- [amyl- starch, -ase enzyme]
ussed in Chapter 19. anal canal
(AY-nal kah-NAL)
[an- ring (anus), -al relating to]
anus
(AY-nus)
[anus ring]
ascending colon
(ah-SEND-ing KOH-lon)
[a[d]- toward, -scend- climb,
colon large intestine]
bicuspid
(bye-KUS-pid)
[bi- double, -cusp- point,
-id characterized by]
bile
(byle)
[bil- liver secretion]
body
(BOD-ee)
[body main part]
bolus
(BOW-lus)
[bolus lump]
canine
(KAY-nyne)
[can- dog, -ine relating to]

Continued on p. 520

493
 494 CHAPTER 18 Digestive System

S
Common
R L Cys tic he pa tic
Pa rotid gla nd duct duct S ple e n
I
S ubma ndibula r Tongue
s a liva ry gla nd
S ublingua l Live r
P ha rynx s a liva ry gla nd
La rynx S to m a c h

Tra che a
Es opha gus
Ga llbla dde r Pa ncre a s
Dia phra gm Duode num

Tra ns ve rs e Live r
colon
S toma ch
He pa tic S ple e n TABLE 18-1 Organs o the Digestive System
flexure S ple nic MAIN ORGAN ACCES S ORY ORGAN
of colon flexure
of colon Mouth Te e th and tongue
As ce nding
Salivary glands
colon De s ce nding
Parotid
Ile um colon
Ce cum Subm andibular
S igmoid Sublingual
Ve rmiform colon
a ppe ndix Pharynx (throat) Tons ils
Ana l
18 Re ctum ca na l Es ophagus
Stom ach
Sm all inte s tine Live r
Duode num Gallbladde r
FIGURE 18-1 Digestive system. Je junum Pancre as
Ile um

Many the maj r stru tures the digestive tra t are sh wn in Large inte s tine Ve rm i orm appe ndix
the layers the Clear View o the Human Body ( ll ws p. 8), Ce cum
Colon
whi h sh ws their relati nships t ther b dy stru tures.
As ce nding colon
Trans ve rs e colon
O ve r v ie w o D ig e s t io n De s ce nding colon
Sigm oid colon
As y u an see in Figure 18-1, the main rgans the digestive Re ctum
system rm a ntinu us mus ular tube varying widths Anal canal
and pen at b th ends. T is l ng, winding tube is alled the
alimentary canal. T e term gastrointestinal (GI) tract te h-
ni ally re ers nly t the p rti n the alimentary anal that a mplish the un ti n making nutrients available
in ludes the st ma h and intestines, but it is ten used t t ea h ell the b dy, the digestive system uses vari us
designate the entire digestive tract. me hanisms (Table 18-2).
In the adult, this h ll w digestive tube is ab ut 9 meters First, mplex ds must be taken int the GI tra t in a
(29 eet) l ng. T ink the tube as a passageway that extends pr ess alled ingestion.
thr ugh the b dy like a hallway thr ugh a building. T us the T en, the ingested d material must be br ken d wn
d we eat and even the nutrient materials released by the int simpler nutrients in the pr ess that gives this system its
digestive pr ess are n t truly part the b dy until they name: digestion. T e breakd wn, r digesti n, d mate-
have been abs rbed thr ugh the wall the GI tra t and enter rial is b th mechanical and chemical in nature.
ur b dys internal envir nment. T e teeth are used t physi ally break d wn large hunks
Table 18-1 lists the rgans the digestive system. T e main d be re it is swall wed. T e hurning material in the
organs digesti n are th se that make up the alimentary a- st ma h then ntinues the me hani al digestive pr ess.
nal. T e accessory organs digesti n are n t segments the physi ally break d wn large hunks d matter int
tube, but are either within r surr unding the tube. F r ex- smaller bits and t m ve it al ng the tra t, m vement r
ample, the teeth and t ngue are inside the m uth and the vari- motility the GI wall is required.
us digestive glands surr und the tra t and pass their se re- In hemi al digesti n, large nutrient m le ules are redu ed
ti ns thr ugh du ts int the lumen the alimentary anal. t smaller m le ules. T is pr ess requires secretion
 CHAPTER 18 Digestive System 495

TABLE 18-2 Primary Mechanisms o the Digestive System

MECHANIS M DES CRIPTION
Inge s tion Proce s s o taking ood into the m outh, s tarting it on its journey through the dige s tive tract
Dige s tion A group o proce s s e s that bre ak com plex nutrie nts into s im ple r one s , thus acilitating the ir abs orption; m e chanical
dige s tion phys ically bre aks large chunks into s m all bits ; che m ical dige s tion bre aks m ole cule s apart
Motility Move m e nt by the m us cular com pone nts o the dige s tive tube , including proce s s e s o m e chanical dige s tion; exam ple s
include pe ris tals is and s e gm e ntation
Se cre tion Re le as e o dige s tive juice s (containing e nzym e s , acids , bas e s , m ucus , bile , or othe r products that acilitate dige s tion);
s om e dige s tive organs als o s e cre te e ndocrine horm one s that re gulate dige s tion or m e tabolis m o nutrie nts
Abs orption Move m e nt o dige s te d nutrie nts through the gas trointe s tinal (GI) m ucos a and into the inte rnal e nvironm e nt
Elim ination Excre tion o the re s idue s o the dige s tive proce s s ( e ce s ) rom the re ctum , through the anus ; de e cation
Re gulation Coordination o dige s tive activity (m otility, s e cre tion, othe r dige s tive proce s s e s )

digestive enzymes and ther pr du ts int the lumen the

Wa ll o t h e D ig e s t ive Tr a c t
GI tra t. A ter the digestive pr esses have altered the physi- T e digestive tra t has been des ribed as a mus ular tube that
al and hemi al mp siti n ingested d, the resulting extends r m the m uth t the anus. T e wall this digestive
nutrients are ready r the pr ess absorption, r m ve- tube is ashi ned ur layers tissue (Figure 18-2). T e in-
ment thr ugh the GI mu sa int the internal envir nment. side, r h ll w spa e within the tube, is alled the lumen. T e
Part the digestive system, the large intestine, als serves ur layers, named r m the inside at t the utside the
as an rgan elimination, ridding the b dy waste mate- tube, are as ll ws:
rial, r eces, resulting r m the digestive pr ess. 18
1. Mu sa r mu us membrane
2. Submu sa
To get an overview o the digestive system, go to
3. Mus ularis
AnimationDirect online at evolve.elsevier.com.
4. Ser sa

Me s e nte ry Ne rve
S e ro s a
Blood
ve s s e ls Conne ctive tis s ue laye r

Pe ritone um

S ubmuc o s a

Gla nd in s ubmucos a

Duct from gla nd

Muc o s a

Lymph nodule
Mus c ularis

Circula r mus cle laye r

FIGURE 18-2 Wall o digestive tract. Segment
Longitudina l mus cle o the small intestine represents the general structure
laye r o the gastrointestinal (GI) wall. The our layers include
the mucosa, submucosa, muscularis, and serosa.
 496 CHAPTER 18 Digestive System

Alth ugh the same ur tissue ats Contra ction Bolus 1

rm every rgan the alimentary tra t, A ring of contra ction occurs
their stru ture varies r m rgan t whe re the GI wa ll is s tre tche d,
rgan. T e mucosa the es phagus, a nd the bolus is pus he d forwa rd.
r example, is mp sed t ugh and A
abrasi n-resistant strati ed epithelium.
T e mu sa the remainder the tra t 2
The moving bolus trigge rs a ring
is a deli ate layer simple lumnar of contra ction in the ne xt re gion
epithelium stru tured r abs rpti n and tha t pus he s the bolus e ve n
se reti n. T e mu us pr du ed by either B fa rthe r a long.
type epithelium ats the lining the
alimentary anal.
T e submucosa, as the name im- 3
The ring of contra ction move s
plies, is a nne tive tissue layer that like a wa ve a long the GI tra ct to
lies just bel w the mu sa. It ntains pus h the bolus forwa rd.
C
many bl d vessels, lymphati vessels,
and nerves. FIGURE 18-3 Peristalsis. Peristalsis is a progressive type o movement in which material is pro-
w r three layers mus le tissue pelled rom point to point along the gastrointestinal (GI) tract. Here, a ball or bolus o material is pro-
make up the muscularis (see Figure 18-2). pelled by ringlike waves o smooth muscle contractions that produce peristalsis.
T ese mus le layers have an imp rtant
r le t play in pr du ing motility r m vement the GI tra t
To learn more about intestinal motility, go to
during the digestive pr ess.
AnimationDirect online at evolve.elsevier.com.
Peristalsis is a rhythmi , wavelike ntra ti n the gut
wall aused by repeating waves ringlike ntra ti n al ng
18 the ir ular mus le layer in the mus ularis. T is type se- Mo u t h
quen ed ntra ti n squeezes and pushes ingested d mate-
rial rward thr ugh the digestive tubes internal pathway
S t r u c t u r e o t h e O r a l C a v it y
similar t h w y u might squeeze t thpaste ut its tube T e mouth, r oral cavity, is a h ll w hamber with a r , a
(Figure 18-3). f r, and walls. F d enters, r is ingested, int the digestive
In additi n t peristalti ntra ti ns that ause material tra t thr ugh the m uth, and the pr ess digesti n begins
t m ve rward, alternating ntra ti n bers the mus- immediately. Like the remainder the digestive tra t, the
ularis within a single regi n, r segment, the G I tra t als m uth is lined with mu us membrane.
pr du es a ba k-and- rth r swishing type intestinal T er the m uth is rmed by the hard palate and
m tility alled segmentation (Figure 18-4). As peristalti so t palate (Figure 18-5). T e hard palate is a b ny stru ture in
m vement pushes material d wn the G I tra t, segmentati n the anteri r r r nt p rti n the m uth, rmed by parts
ntra ti ns assist in mixing nutrients with digestive jui es the palatine and maxillary b nes. T e s t palate is l ated
and helps ntinue the me-
hani al breakd wn larger 1
Contra ction Bolus Ringlike re gions of contra ction
parti les.
occur a t inte rva ls a long the GI
Peristalsis and segmentati n tra ct.
an ur in an alternating se-
quen e. W hen this happens, A
material is hurned and mixed 2
as it sl wly pr gresses al ng the P re vious ly contra cte d re gions
re la x a nd a dja ce nt re gions now
GI tra t in l se nta t with contra ct, e ffe ctive ly chopping
the intestinal mu sa, whi h a- the conte nts of e a ch s e gme nt
ilitates abs rpti n nutrients. into s ma lle r chunks .
B
T e serosa is the uterm st
vering r at the digestive
3
tube. In the abd minal avity, The loca tion of the contra cte d
this ser sa vering is alled the re gions continue s to a lte rna te
visceral peritoneum. T e l ps ba ck a nd forth, chopping a nd
the digestive tra t are an h red C mixing the conte nts of the GI
lume n.
t the p steri r wall the ab-
d minal avity by a large d uble
ld perit neal tissue alled FIGURE 18-4 Segmentation. Segmentation is a back-and- orth action that breaks apart chunks o ood and
the mesentery. mixes in digestive juices. GI, Gastrointestinal.
 CHAPTER 18 Digestive System 497

P hiltrum
Ce ntra l incis or
Uppe r lip
La te ra l incis or
Ha rd pa la te
Ca nine (cus pid)
S oft pa la te
P re mola rs
Uvula
Mola rs
Pa la tine
tons il
Fre nulum
Root of
tongue Wis dom tooth
(third mola r)
Body of
tongue S ix-ye a r mola r
(firs t mola r)
Tip of S
tongue S ublingua l ducts
R L S ublingua l gla nd
Lowe r lip (unde r the mucous
I me mbra ne )
S ubma ndibula r duct
A B Gum (gingiva )

FIGURE 18-5 Mouth. A, Mouth cavity showing hard and so t palates, tongue sur ace, and uvula. B, Under-
sur ace o tongue showing renulum, sublingual gland, and opening o sublingual duct. GI, Gastrointestinal.

ab ve the p steri r r rear p rti n the m uth. It is s t T e incisors are ten alled the r nt teeth. In is rs have
be ause it nsists hief y mus le. a sharp utting edge (Figure 18-6) used t bite r ut d 18
H anging d wn r m the enter the s t palate is an el n- int manageable p rti ns t begin the pr ess mastication,
gated pr ess alled the uvula. T e uvula and the s t palate r hewing d.
prevent any d and liquid r m entering the nasal avities T e canine teeth, s metimes alled cuspids, are usually
ab ve the m uth and als assist in spee h and swall wing. m re el ngated and p inted in appearan e and un ti n t
T e f r the m uth nsists the t ngue and its pier e r tear the d that is being eaten int smaller shreds.
mus les. T e t ngue is made skeletal mus le vered with T is t th type is parti ularly large in meat-eating mammals
mu us membrane. It is an h red t b nes in the skull and t su h as d gs r ats.
the hy id b ne in the ne k. T e teeth re erred t as premolars are als alled bicuspids
A thin membrane alled the renulum atta hes the t ngue and are l ated just p steri r t the anine teeth. T ey have
t the f r the m uth. O asi nally the renulum is t tw p ints alled usps that an saw thr ugh t ugh, br us
sh rt t all w ree m vements the t ngue and must be ut despe ially when m ved rward and ba kward against
r surgi ally repaired t all w n rmal spee h and swall wing. the prem lars in the pp sing jaw.
N te in Figure 18-5, A, that the t ngue an be divided int Behind the prem lars are the molars, r tricuspids. T e
a blunt rear p rti n alled the root, a p inted tip, and a entral m lars have mparatively larger sur a e areas with three
body. grinding r rushing usps n the sur a e.
T e many small bumps n the sur a e the t ngue are T e hewing made p ssible by the teeth begins the me-
alled papillae. Re all r m Chapter 11 that taste buds, whi h hani al breakd wn d r digesti n. A ter d has been
ntain sens ry re ept rs, are l ated n the sides these hewed, it is rmed int a small r unded mass alled a bolus
papillae and hemi ally analyze d that may be swall wed. s that it an be swall wed.
Figure 11-18 n p. 308 sh ws the detailed stru ture these By the time a baby is 2 years ld, he r she pr bably has a
papillae. ull set 20 baby teeth the primary r deciduous teeth. By
the time a y ung adult is s mewhere between 17 and 24 years
ld, a ull set 32 permanent teeth is generally present.
Te e t h T e average age r utting the rst t th (erupti n
Ty p e s o Te e t h t th thr ugh the gum) is ab ut 6 m nths, and the average
T e shape and pla ement the teeth assist them in their age r l sing the rst baby t th and starting t ut the per-
un ti ns and are lassi ed as ne ur types: manent teeth is ab ut 6 years. Figure 18-6 gives the names
the teeth and sh ws whi h nes are la king in the de idu us,
1. In is r r baby, set teeth.
2. Canine I an individual d es n t rm wisd m teeth (third m lars),
3. Prem lar then the number adult teeth w uld be nly 28. T is is n-
4. M lar sidered a n rmal variati n and urs m st ten in Asians
 498 CHAPTER 18 Digestive System

De c iduo us (primary) te e th Adult te e th

Eruptio n Ce ntra l incis or
(mo nths )
La te ra l incis or
Ce ntra l incis or 6-8 Ca nine
La te ra l incis or 7-12 Firs t pre mola r
Ca nine A S e cond
16-20
Firs t pre mola r
R L
mola r 12-16 Firs t mola r
S e cond P Uppe r jaw
Uppe r jaw S e cond
mola r 20-30 mola r
Third mola r
(wis dom
tooth)

Eruptio n
18-22 (ye ars )
Lowe r jaw
P 17-24
16-24
14-18 R L
10-14
7-9 A Lowe r jaw
A 6-8 5-8

10-14
FIGURE 18-6 Types o teeth. In the deciduous (primary) set, also called 9-13
baby teeth, there are no premolars and only two pairs o molars in each 9-14
jaw. Generally, the lower teeth erupt be ore the corresponding upper teeth.
18 B
7-10
7-8

(30%), less requently in Cau asians and Native Ameri ans

(ab ut 12%), and nly rarely in A ri an-Ameri ans (1% t 2%).

QUICK CHECK S a liva ry G la n d s

1. De f n e th e a lim e n ta ry ca n a l a n d n a m e th e o u r la ye rs o T ree pairs salivary glandsthe par tids, submandibulars,
th e a lim e n ta ry ca n a l. and sublingualsse rete m st (ab ut 1 L) the watery saliva
2. Wh a t th re e kin d s o p ro ce s s in g d o n u trie n ts u n d e rg o in pr du ed ea h day in the adult.
th e b o d y?
3. De s crib e th e in te rio r o th e m o u th in clu d in g th e h a rd a n d
s o t p a la te , u vu la , re n u lu m , to n g u e a n d p a p illa e .
4. Lis t th e o u r m a jo r typ e s o te e th . Cus p

Ena me l
Ty p ic a l To o t h De ntin
Crown
A typi al t th an be divided int three main parts: r wn, P ulp cavity
ne k, and r t (Figure 18-7). with ne rve s
T e crown is the p rti n that is exp sed and visible in the a nd ve s s e ls
m uth. It is largely made a b nelike material alled dentin Ne ck Gingiva
(gum)
that is vered by enamel. Enamel is the hardest material
made by the b dy and is ideally suited t withstand the grind- Root ca na l
ing that urs during the hewing hard and brittle ds. Pe riodonta l
T e r t and ne k ea h t th are vered by cementum. liga me nt
T e enter the t th ntains a pulp avity nsisting Root
Pe riodonta l
nne tive tissue, bl d and lymphati vessels, and sens ry me mbra ne
nerves. Ce me ntum
T e neck a t th is the narr w p rti n surr unded by
Bone
the pinkish gingiva r gum. T e ne k j ins the r wn the
t th t the r t.
T e root the t th ts int a s ket the upper r
FIGURE 18-7 Typical tooth. A molar is sectioned here to show its bony
l wer jaw b nethe maxilla r mandible (see Figure 8-10 n socket and details o its three main parts: crown, neck, and root. Enamel
p. 184). A br us periodontal membrane lines ea h t th (over the crown) and cementum (over the neck and root) surround the dentin
s ket and an h rs the t th t the b ne. layer. The pulp contains nerves and blood vessels.

C LIN ICA L APPLICATION
MALOCCLUS ION
Malo cclus io n o the te e th occurs w he n m is s ing te e th cre ate
w ide s pace s in the de ntition, w he n te e th ove rlap, or w he n
m alpos ition o one or m ore te e th preve nts corre ct alignm e nt
o the m axillary and m andibular de ntal arche s (Figure s A and
B). Malocclus ion that re s ults in protrus ion o the uppe r ante rior
te e th caus ing the m to hang ove r the lowe r ante rior te e th is
calle d ove rbite (Figure A), w he re as the pos itioning o the lowe r
te e th outs ide the uppe r te e th is calle d unde rbite (Figure B).
A B
T e salivary glands (Figure 18-8) are typi al the a ess ry
glands ass iated with the digestive system be ause they are
l ated utside the digestive tube itsel and must nvey their
se reti ns by way du ts int the tra t. Be ause they have
se ret ry du ts, they are nsidered exocrine glands.
T e parotid glands, largest the salivary glands, lie just
in eri r and anteri r t ea h ear at the angle the jaw. T e
par tid gland se retes a s luti n ntaining sodium bicarbonate
(NaHCO3), a base that helps neutralize ba terial a ids. T e
Pa rotid duct
Pa rotid gla nd
S ubma ndibula r gla nd
S ubma ndibula r duct
S
S ublingua l gla nd
A P
I
FIGURE 18-8 Salivary glands. The salivary glands and their associated
ducts.
CHAPTER 18 Digestive System 499
De ntal m alocclus ion m ay caus e s ignif cant proble m s and
chronic pain in the unctioning o the te m porom andibular joint,
contribute to the ge ne ration o he adache s , or com plicate rou-
tine m as tication o ood. Fortunate ly, eve n s eve re m alocclu-
s ion proble m s can be corre cte d by the us e o brace s and othe r
de ntal appliance s . Ortho do ntics is that branch o de ntis try
that de als w ith the preve ntion and corre ction o pos itioning ir-
re gularitie s o the te e th and m alocclus ion.
penings the par tid du ts an be und by l king in a 18
mirr r at the insides the heeks and next t the se nd
m lar t th n either side the upper jaw.
T e du ts the submandibular glands pen int the
m uth n either side the lingual renulum (Figure 18-5, B).
T e du ts the sublingual glands pen int the f r the
m uth.
Saliva als ntains mu us and a digestive enzyme alled
salivary amylase, whi h begins the pr ess breaking d wn
mplex arb hydrates. Water and mu us m isten and lubri-
ate the hewed d, all wing it t pass with less ri ti n
thr ugh the es phagus and n int the st ma h.
D is o r d e r s o t h e M o u t h
In e ti ns, an er, ngenital de e ts, and ther dis rders
the m uth and teeth an result in a variety seri us mpli-
ati ns. Su h nditi ns may ause pain r even damage t
the m uth and teeth that makes hewing and swall wing
di ultperhaps ausing a pers n t redu e the intake
d, thereby resulting in malnutriti n. M uth in e ti ns r
an er may spread t nearby tissues: the nasal avity (then n
t the sinuses, middle ear, and brain) r thr at (and n t the
es phagus, larynx, and th ra i rgans).
Ca n c e r
Can er the m uth may result r m exp sure t ar in gens
und in t ba sm ke r in s - alled sm keless t ba
( hewing t ba ), espe ially in mbinati n with heavy al -
h l nsumpti n. Sm kers may devel p white pat hes, r
leukoplakia, whi h may devel p int malignant tum rs.
Leuk plakia ten devel ps in the ld between heek
and gum in users sm keless t ba (Figure 18-9, A). T e
 500 CHAPTER 18 Digestive System

C LIN ICA L APPLICATION

MUMPS
Mum ps is an acute viral dis e as e characte rize d by s we lling o the parotid s ali-
vary glands , as you can s e e in the photo. Mos t o us think o m um ps as a
childhood dis e as e be caus e it m os t o te n a e cts childre n be twe e n the age s o
5 and 15 ye ars o age . Howeve r, it can occur in adults o te n producing a m ore
s eve re in e ction.
The m um ps in e ction can a e ct othe r tis s ue s in addition to the parotid
gland, including the joints , pancre as , myocardium , and kidneys . In about 25%
o in e cte d m e n, m um ps caus e s in am m ation o the te s te s , or orchitis . Orchi-
tis re s ulting rom m um ps ve ry rare ly caus e s e nough dam age to re nde r a m an
s te rile .
Mum ps is uncom m on in deve lope d countrie s be caus e o the MMR S
(m um ps -m e as le s -rube lla) vaccine give n to m os t childre n. Howeve r, the re are R L
occas ional outbre aks e s pe cially in crowde d e nvironm e nts . The re has be e n a
99% de cre as e in m um ps cas e s due to MMR vaccination. I

nditi n, alled snuf dippers pouch, may lead t t th dentin, and ementum teeth that results in the rmati n
and gum diseases and ral an er. a permanent de e t alled a cavity (Figure 18-9, C).
Lip an er may result r m the ar in geni e e ts sun- Many pe ple living in the United States, Canada, and
light, whi h an be av ided by the use lip balms ntaining Eur pe are a e ted by the disease. De ay urs n t th
18 suns reen. T e m st mm n rm m uth an er is squa- sur a es where d debris, a id-se reting ba teria, and plaque
m us ell ar in ma (Figure 18-9, B). a umulate. Sugar is the main ingredient in d that all ws
ba teria t pr du e the a id that damages the pr te tive t th
D e n t a l C o n d it io n s enamel.
th de ay, r dental caries, is ne the m st mm n I the disease g es untreated, t th de ay results in in e -
diseases in the devel ped w rld. It is a disease the enamel, ti n, l ss teeth, and inf ammati n the s t tissues in the

A S nuff dippe r's pouch B S qua mous ce ll ca rcinoma C De nta l ca rie s

R L

I
D De nta l impla nts E Ora l thrus h

FIGURE 18-9 Mouth disorders. A, Snu dippers pouch. This individual has developed leukoplakia in the
area between cheek and gum used or placement o chewing tobacco. B, Squamous cell carcinoma o lip. Exces-
sive long-term exposure to ultraviolet light (UV) such as in sunlight increases the risk o skin cancer.
C, Dental caries. These permanent de ects, or cavities, are lled with decayed dental tissues. D, Dental implant.
A permanent dental prosthesis will be a xed to the anchor a ter bone grows and healing has occurred. E, Oral
thrush (Candida albicans). Inf amed mucous membrane is covered with patches o creamy-white exudates.
 CHAPTER 18 Digestive System 501

FIGURE 18-10 Congenital de ects o

the mouth. A, Bilateral cle t lip in an in-
ant. B, Cle t palate.

m uth. Ba teria als may

invade the paranasal sinuses
r extend t the sur a e
the a e and ne k r enter
S
the bl dstream, ausing
seri us mpli ati ns. R L
Dental aries are treated I
by rem val the de ayed
p rti n the t th l- A B
l wed by repair and lling
the de e t using a variety materials in luding p r elain C o n g e n it a l D e e c t s
and metal all ys. Cle t lip and cle t palate (Figure 18-10) represent the m st
I l st be ause disease r trauma, teeth an be repla ed mm n rms ngenital de e t a e ting the m uth. T ey
with dental appliances, whi h in lude rem vable dentures and may ur al ne r t gether and are aused by a ailure
permanently xed r implanted teeth. S alled dental im- stru tures in the upper lip r palate t use r l se pr perly
plants are an h rs s rewed int h les that have been drilled during embry ni devel pment. T e nditi n may be inher-
int a jawb ne t supp rt an arti ial t th r denture. Ab ut ited r be a sp ntane us abn rmality.
6 m nths a ter inserti n, new b ne will have used with and Cle t lip, whi h may ur n ne r b th sides, is gener-
stabilized the an h r, permitting the atta hment the arti - ally repaired s n a ter birth. Surgi al repair le t palate is 18
ial t th r dental applian e (Figure 18-9, D). usually d ne later in the rst year li e. M dern re nstru -
Gingivitis is the general term r inf ammati n r in e - tive surgery te hniques help minimize p ssible l ng-term
ti n the gums. M st ases gingivitis result r m p r mpli ati ns that uld in lude s arring, spee h impairment,
dental hygieneinadequate brushing and n f ssing. Gingi- dental pr blems, and p tential em ti nal maladjustment.
vitis als may be a mpli ati n ther nditi ns su h as
diabetes mellitus, vitamin de ien y, r pregnan y.
Periodontitis is the inf ammati n the peri d ntal QUICK CHECK
membrane, r periodontal ligament, whi h an h rs the t th 1. Wh a t a re th e th re e m a in p a rts o a typ ica l to o th ?
t the b ne the jaw. Peri d ntitis is ten a mpli ati n 2. Wh a t a re th e th re e p a irs o s a liva ry g la n d s ?
advan ed r untreated gingivitis and may spread t the sur- 3. Wh a t is s n u d ip p e rs p o u ch ?
4. Dis tin g u is h b e tw e e n d e n ta l ca rie s , g in g ivitis , a n d
r unding b ny tissue. Destru ti n peri d ntal membrane p e rio d o n titis .
and b ne results in l sening and eventually mplete l ss 5. Na m e th e tw o m o s t co m m o n o rm s o co n g e n ita l d e e ct
teeth. Peri d ntitis is the leading ause t th l ss am ng a e ctin g th e m o u th .
adults.

In e c t io n
T rush, r oral candidiasis, is a m uth in e ti n aused by a P h a ry n x
type yeast kn wn as Candida (see Figure 6-7 n p. 123).
S t ru c t u re
Candidiasis auses ream- l red heesy pat hes exudate
t appear n an inf amed t ngue and ral mu sa (Figure 18-9, T e pharynx is a tubelike stru ture made mus le and lined
E). T e in e ti n usually extends int the oropharynxthe with mu us membrane. N te its l ati n in Figure 18-11. Be-
regi n the thr at nearest the m uth. ause its l ati n behind the nasal avities and m uth, it
T rush is s metimes bserved in therwise healthy hildren un ti ns as part b th the respirat ry and digestive systems.
but is m st ten seen in adults wh are immun suppressed, Air must pass thr ugh the pharynx n its way t the lungs,
su h as AIDS patients, r in individuals wh have been n and a mass hewed d must pass thr ugh it n its way t
antibi ti therapy. T e bene ial ba teria that are n rmal in- the st ma h.
habitants the mi r bi me the m uth usually prevent the Re all that the pharynx as a wh le is subdivided int three
yeast p pulati n r m expanding int an in e ti n. anat mi al mp nents: nasopharynx, oropharynx, and
laryngopharynx. Als re all that the pr te tive lymph id
ring rmed by the three maj r pairs tonsils in the pharynx
Review the article The Human Microbiome at
guards against in e ti ns the respirat ry and digestive
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tra ts.
 502 CHAPTER 18 Digestive System

Cra nia l cavity

P ha rynge a l tons il
(a de noids )
Ha rd pa la te
Nas o pharynx
S oft pa la te

Uvula
Pa la tine tons il
Oro pharynx
Lingua l tons il

Epiglottis
Hyoid bone
Laryng o pharynx

Voca l cords

18 Tra che a

Es opha gus

FIGURE 18-11 Pharynx. This midsagittal section o the S

head and neck shows the pharynx and related structures. The
green dotted lines mark the approximate boundaries o the re- A P
gions o the pharynx. Notice that the esophagus runs in eriorly I
rom the pharynx, behind the trachea.

Review Protective Strategies o the Respiratory To learn more about the pharynx and swallowing,
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Fu n c t io n
O the three anat mi al divisi ns, the r pharynx is a tively
and m st dire tly inv lved in the digestive pr ess be ause
its imp rtant r le in a spe ialized and rdinated type GI
tra t m tility inv lved in swall wing. T e swall wing a ab ut 25 m (10 in hes) l ng that extends r m the pharynx
mass hewed d is alled deglutition.
First, masti ati n inv lves v luntary m vements that result
in rmati n a ball r bolus d in the m uth that is
then m ved inv luntarily thr ugh the r pharynx and int
the es phagus and, nally, int the st ma h.
Swall wing is a mplex pr ess requiring the rdina-
ti n pharyngeal mus les and ther mus les and stru tures
in the head and ne k. Regulation v luntary swall wing
m vements is dependent n nerv us impulses riginating in
the m t r rtex the erebrum. Inv luntary m vements are
regulated by impulses riginating in the swall wing r deglu-
titi n enter l ated in the medulla and p ns the brain-
stem (see Figure 10-13 n p. 261).
Es o p h a g u s
S t r u c t u r e a n d Fu n c t io n
T e esophagus is a llapsible, mus ular, mu us-lined tube
t the st ma h. It is the rst segment the digestive tube
pr per, and the ur layers that rm the wall the GI tra t
an be easily identi ed when it is se ti ned. Its mus ular walls
make it a dynami passageway able t push d t ward the
st ma h.
Ea h end the es phagus is guarded by a mus ular
sphincter. Sphin ters are valvelike rings mus le tissue that
ten surr und tubular stru tures r b dy penings. In the GI
tra t they n rmally a t t keep ingested material m ving in
ne dire ti n d wn the tube. T e upper esophageal sphincter
(UES) helps prevent air r m entering the tube during respi-
rati n, and the lower esophageal sphincter (LES) n rmally
prevents ba kf w a idi st ma h ntents.

Es opha gus
Dia phra gm
Lowe r
e s opha ge a l
s phincte r
Fluid in
s toma ch
R L
FIGURE 18-12 Re ux. In gastroesophageal ref ux disease (GERD), ref ux
(backf ow) o gastric acid up into the esophagus causes irritation o the lin-
ing o the esophagus.
Re u x
T e terms heartburn and acid indigestion are ten used t
des ribe a number unpleasant sympt ms experien ed by
m re than 60 milli n Ameri ans ea h m nth. Ba kward f w
st ma h a id up int the es phagus auses these sympt ms
(Figure 18-12), whi h typi ally in lude burning and pressure
behind the breastb ne. T e term gastroesophageal re ux
disease (GERD ) is used t better des ribe this very mm n
and s metimes seri us medi al nditi n.
In its simplest rm, GERD sympt ms are mild and ur
nly in requently (twi e a week r less). In these ases, av id-
ing pr blem ds r beverages, st pping sm king, r l sing
weight i needed may s lve the pr blem. Additi nal treatment
with ver-the- unter anta ids r n n-pres ripti n-strength
a id-bl king medi ati ns als may be help ul.
M re severe and requent epis des GERD an trigger
asthma atta ks, ause severe hest pain, result in bleeding, r
pr m te a narr wing (stri ture) r hr ni irritati n the
es phagus (Figure 18-13). In these ases, m re p wer ul inhibit rs
st ma h a id pr du ti n may be pres ribed. Other drugs that
strengthen the LES and thus redu e ba kf w st ma h a id
are als used in m derate t severe ases GERD.
Several minimally invasive surgi al pr edures r treating
seri us ases GERD are als available. In su h pr edures,
whi h are d ne n an utpatient basis, a f exible tube alled an
endoscope is used t insert and then rem ve the ne essary
medi al devi es required r treatment. I GERD is le t un-
treated, seri us path l gi al (pre an er us) hanges in the
es phageal lining may devel pa nditi n alled Barrett
esophagus.
A sign Barrett es phagus is evident when the es phagus
is viewed with an end s pe. T e l r the es phageal
CHAPTER 18 Digestive System 503
R L
S A
FIGURE 18-13 Esophageal in ammation. Chronic inf ammation o
I the esophagus is characteristic o GERD (gastroesophageal ref ux disease).
Arrows show reddened, inf amed areas about midway along esophagus.
This damage is caused by the requent splashing back o acids rom the
stomach.
mu sa hanges r m a pink t a reddish salm n l r, indi- 18
ating ellular hanges that are aused by ntinual exp sure
the es phagus t st ma h a id. A sample the lining
the es phagus is rem ved and viewed under the mi r s pe
t make the diagn sis Barrett es phagus.
O ther than heartburn, sympt ms Barretts may in lude
tr uble swall wing, v miting bl d, and weight l ss that re-
sults be ause eating is pain ul. reatment may in lude medi-
ati ns that redu e st ma h a id pr du ti n and li estyle
hanges aimed at preventing the ref ux a id int the
es phagus. T ese hanges in lude:
-
ing sleep
a eine, ni tine, and al h l
n the st ma h
Hia t a l He r n ia
GERD is a mm n sympt m hiatal hernia. A hernia re-
sults r m an rgan being pushed thr ugh a wall that n rmally
a ts as a barrier. In hiatal hernia, the st ma h pushes thr ugh
the gap, r hiatus, in the diaphragm that all ws the es phagus
t pass thr ugh it (Figure 18-14). O ten the l wer es phagus
be mes enlarged, all wing a idi st ma h ntents t bypass
the LES and f w upward int the es phagus.
Check out the illustrated article Hernias at
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 504 CHAPTER 18 Digestive System

S t ru c t u re
T e three divisi ns the st ma h sh wn in Figure 18-15 are
S
the undus, body, and pylorus. T e undus is the enlarged
R L p rti n t the le t and ab ve the pening the es phagus
I
int the st ma h. T e b dy is the large entral regi n the
Es opha gus
st ma h, and the pyl rus is the l wer narr w se ti n, whi h
He rnia te d
portion of j ins with the rst part the small intestine. T e upper right
s toma ch b rder the st ma h is kn wn as the lesser curvature, and the
LES l wer le t b rder is alled the greater curvature.
T e st ma h l ks small when it is empty, n t mu h bigger
than a large sausage, but it expands nsiderably a ter a large
meal. H ave y u ever elt s un m rtably ull a ter eating that
y u uld n t take a deep breath? I s , it pr bably meant that
Dia phra gm y ur st ma h was s ull material that it upied m re
spa e than usual and was pushed up against the diaphragm.
T is made it hard r the diaphragm t ntra t and m ve
d wnward as mu h as ne essary r y u t take a deep breath.
In ntrast t ther regi ns the digestive tra t, there are
three layers sm th mus le in the st ma h wall (see
Figure 18-15). T e mus le bers that run lengthwise, ar und,
and bliquely make the st ma h ne the str ngest internal
rganswell able t break up hunks ingested d int
tiny parti les and t mix them th r ughly with gastri jui e t
S toma ch rm a semis lid mixture alled chyme. St ma h mus le n-
18 tra ti ns als result in peristalsis, whi h pr pels hyme d wn
FIGURE 18-14 Hiatal hernia. Note herniated portion o stomach pushed the digestive tra t.
through diaphragm. LES, Lower esophageal sphincter.
Mu us membrane lines the st ma h, rming the gastric
mucosa. It ntains th usands mi r s pi gastric glands
that se rete gastric juice int the st ma h. Cells in the st ma h
als se rete a hemi al alled intrinsic actor that pr te ts vita-
S t o m a ch min B12 and saves it r its later abs rpti n in the distal small
T e stomach (Figure 18-15) lies in the upper part the ab- intestine. S me individuals may require vitamin B12 inje ti ns
d minal avity just under the diaphragm. It serves as a large a ter s me st ma h surgeries.
p u h that ingested material enters a ter it has been hewed, W hen the st ma h is empty, its lining lies in lds alled
swall wed, and passed thr ugh the es phagus. rugae.

Es opha gus Fundus FIGURE 18-15 Stomach. A portion o the anterior wall
has been cut away to reveal the three muscle layers o the
stomach wall. Notice that the mucosa lining the stomach
Ga s troe s opha ge a l ope ning
orms olds called rugae.
Lowe r e s opha ge a l
s phincte r (LES )
Body of s toma ch

S e ros a
P yloric
s phincte r P ylorus Longitudina l mus cle laye r
Duode na l
re
tu

bulb
a

Circula r mus cle laye r

rv

u Mus cula ris

Le s s e r c
Oblique mus cle laye r

S ubmucos a

Mucos a
S
e
t ur
r va R L
c u
a te r
G re I
Duode num Ruga e
 CHAPTER 18 Digestive System 505

Fu n c t io n
whi h are brief y des ribed in this se ti n. Many these
A ter material has entered the st ma h by passing thr ugh dis rders are hara terized by ne r m re these signs and
the mus ular LES at the distal end the es phagus, the di- sympt ms:
gestive pr ess ntinues.
1. Gastritisst ma h inf ammati n
C ntra ti n the st ma hs mus ular walls mixes the
2. Anorexia hr ni l ss appetite
swall wed material th r ughly with the gastri jui e and
3. Nauseaunpleasant eeling that ten leads t
breaks it d wn int hyme, whi h eventually be mes m re
v miting
and m re lique ed. T is lique a ti n pr ess is a ntinuati n
4. Emesisv miting
the me hani al digesti n that begins in the m uth.
M stly water, gastri jui e als ntains hydrochloric acid
(HCl) that un lds pr teins by breaking hydr gen b nds. P y lo r ic C o n d it io n s
T en, enzymes als present in the gastri jui e break apart T e pyl ri sphin ter is lini al imp rtan e be ause
s me the peptide b nds within pr tein m le ulesall part pylorospasm is a airly mm n nditi n in in ants. T e
hemi al digesti n. pyl ri mus le bers d n t relax n rmally in in ants with this
Partial digesti n pr teins urs a ter hyme is held in nditi n. As a result, hyme is n t able t leave the st ma h,
the st ma h r s me time by the pyloric sphincter mus le. and the in ant v mits nutrients instead digesting and ab-
T e sm th mus le bers the sphin ter stay ntra ted s rbing them. T e nditi n is relieved by the administrati n
m st the time and thereby l se the pening the a drug that relaxes sm th mus les.
pyl rus int the small intestine. A ter hyme has been mixed An ther abn rmality the pyl ri sphin ter is alled
in the st ma h and pr tein digesti n gets under way, it begins pyloric stenosisan bstru tive narr wing its pening.
its passage thr ugh the pyl ri sphin ter int the rst part T is nditi n an be rre ted surgi ally in in an y.
the small intestine.
G a s t r ic U lc e r
An ulcer is a raterlike w und r s re in a membrane aused
QUICK CHECK by tissue destru ti n. Current statisti s sh w that ab ut 1 in 18
1. Wh a t a re th e th re e a n a to m ica l co m p o n e n ts o th e 10 individuals in the United States will su er r m either a
p h a ryn x? gastri (st ma h) r du denal ul er in his r her li etime
2. Wh a t is a h ia ta l h e rn ia ? (Figure 18-16, A).
3. Wh a t is GERD?
Ul ers ause disintegrati n, l ss, and death tissue as they
4. Na m e th e th re e d ivis io n s o th e s to m a ch .
er de the layers the wall the st ma h r du denum.
T ese raterlike lesi ns ause gnawing r burning pain and
may ultimately result in hem rrhage, per rati n, widespread
To learn more about the stomach, go to inf ammati n, s arring, and ther very seri us medi al m-
AnimationDirect online at evolve.elsevier.com. pli ati ns. Usually per rati n d es n t ur, but small, re-
peated hem rrhages ver l ng peri ds an ause anemia.
Ex essive a id se reti n was th ught r many years t be
D is o r d e r s o t h e S t o m a c h
the primary ause ul ers. It is n w kn wn that m st gastri
S ig n s a n d S y m p t o m s and du denal ul ers result r m in e ti n with the Helico-
Gastroenterology is the study (ology) the st ma h (gastro) bacter pylori (H. pylori) ba terium (Figure 18-16, B). T is is es-
and intestines (entero) and their diseases. T e st ma h is the pe ially s i the in e ted individual has a geneti predisp si-
p tential site numer us diseases and nditi ns, s me ti n t ul er devel pment. T e ba terium burr ws thr ugh the
pr te tive mu us lining the GI tra t and
when it makes nta t with the epithe-
FIGURE 18-16 Disorders o the stomach. A, Gastric ulcer. lium, it triggers immune rea ti ns that
Epithe lium
B, Helicobacter pylori may in ect the stomach mucosa and trig- in lude the inf ammat ry resp nse.
ger immune responses that reduce the acid-protective mucus
that lines the stomach. T ese resp nses impair the gastri lin-
H. pylori
ings ability t pr du e a id-pr te tive
Ruga e mu us. H. pylori in e ti n is diagn sed
by bi psy, breath, r bl d antib dy tests.
Mucus
L ng-term use ertain pain medi-
ati ns su h as aspirin and ibupr en,
alled nonsteroidal antiin ammatory
Ulce r drugs (NSAIDs) als an ause ul ers
be ause they t de rease the se reti n
mu us. NSAID-indu ed ul ers an
be treated by st pping NSAID use and
taking a id-redu ing drugs until the ul-
B er heals.
 506 CHAPTER 18 Digestive System

C LIN ICA L APPLICATION

UPPER GASTROINTESTINAL X-RAY STUDY
The uppe r GI (UGI) s tudy cons is ts o a s e rie s o x-rays o the lowe r
e s ophagus , s tom ach, and duode num , produce d w ith the aid o a con-
tras t m e dium , us ually barium s ul ate . The te s t is us e d to de te ct ulce r-
ations , tum ors , in am m ations , or anatom ical m alpos itions s uch as hia-
tal he rnia (protrus ion o the s tom ach through the diaphragm ).
Obs truction o the uppe r GI tract is als o e as ily de te cte d w ith the UGI
s e rie s .
Firs t the patie nt drinks a avore d liquid containing barium s ul ate .
The n x-rays are take n pe riodically as the contras t m e dium trave ls
through the s ys te m the lowe r e s ophagus , gas tric wall, pyloric chan-
ne l, and duode num ; e ach s tructure is evaluate d or de e cts .
Be nign pe ptic ulce r is a com m on pathological condition that m ay
a e ct the s e GI are as . Tum ors , cys ts , or e nlarge d organs ne ar the s tom -
ach can als o be ide ntif e d w he n the re is an anatom ical dis tortion o the
outline o the uppe r GI tract.
Com pare the x-ray im age s how n he re w ith the s tom ach s tructure s
de picte d in Figure 18-15. Ide nti y as m any o the s e s tructure s as you
can in the x-ray. Can you locate the gre ate r and le s s e r curvature s ?
Fundus , body, and pyloric are as ? Location o the pyloric s phincte r?
Note that although a m ajority o the barium contras t m ate rial has
poole d in the s tom ach, s om e has pas s e d through the pyloric s phincte r, S

18 the re by outlining the duode num . R L

T e dis very that m st ul ers are aused by a ba terial S m a ll In t e s t in e

rganism led t devel pment a number newer treatment
pr grams. T ese treatments were designed t eradi ate the
ba teria by use antibi ti s while simultane usly bl king r
redu ing st ma h a id se reti n.
Currently, the standard antibi ti -based treatment used
m st ten t b th heal ul ers and prevent re urren es is
alled triple therapy. It requires that three medi ati ns be
taken n urrently r ab ut 2 weeks. M re than ne y le
may be required. riple therapy mbines a st ma h-lining
pr te t r su h as bismuth subsali ylate (Pept -Bism l) and/
r an a id redu er with tw di erent antibi ti s.
S t o m a ch Ca n c e r
Stomach cancer has been linked t ex essive al h l nsump-
ti n, use hewing t ba , eating sm ked r heavily pre-
served d, and t H. pylori in e ti n.
Un rtunately, there is n pra ti al way t s reen the gen-
eral p pulati n r st ma h an er in its earliest stages. M st
st ma h an ers, usually aden ar in mas, have already me-
tastasized be re they are und be ause patients treat them-
selves r the early warning signs heartburn, bel hing, and
nausea. Later warning signs st ma h an er in lude hr ni
indigesti n, v miting, an rexia, st ma h pain, and bl d in
the e es.
Surgi al rem val the malignant tum rs has been the
m st su ess ul meth d treating st ma h an er.
S t ru c t u re
T e small intestine is r ughly 7 meters (20 eet) l ng. H w-
ever, it is n ti eably smaller in diameter than the large intes-
tine, s in this respe t its name is appr priate (Figure 18-17).
Di erent names identi y three di erent se ti ns the small
intestine: duodenum, jejunum, and ileum.
a mm date su h a l ng tube within the relatively
sh rt abd minal avity, it must be iled int many l ps. In
this way, a small b dy avity an ntain a very l ng tube with
a large sur a e area.
M st the hemi al digesti n urs in the rst regi n
the small intestine, the du denum. T e du denum is C-shaped
and urves ar und the head the pan reas (Figure 18-18).
A idi hyme enters the bulb the du denum r m the
st ma h. T is area is the site requent ul erati n (du denal
ul ers).
T e middle third the du denum ntains the penings
du ts that empty pan reati jui e and bile r m the liver int the
small intestine. As y u an see in Figure 18-18, the tw penings
are l ated at tw bumps alled the minor duodenal papilla and
major duodenal papilla. O asi nally a gallst ne bl ks du ts
that drain thr ugh the maj r du denal papilla, ausing symp-
t ms su h as severe pain, jaundi e, and digestive pr blems.
Sm th mus le in the wall the small intestine n-
tra ts t pr du e peristalsis, the wavelike ntra ti n that
 CHAPTER 18 Digestive System 507

Longitudina l mus cle

Circula r mus cle Mus cula ris
S e ros a

Me s e nte ry S ubmucos a

Mucos a

P lica (fold)

Mag nific atio n o f je junal

muc o s al wall

Lymph nodule
S e g me nt
o f je junum Epithe lium

S ingle villus
18

Microvilli

Muc o s al villi

Epithe lium
Microvilli

Epithe lia l ce ll Mucos a

La cte a l (lymph ca pilla ry)

Arte ry a nd ve in
Two c e lls o f the villus e pithe lium
s ho wing brus h bo rde r (mic rovilli)
A

FIGURE 18-17 Small intestine. A, Note the our

tissue coats or layers and the presence o villi and micro-
villi, which increases the area available or absorption.
B, X-ray study showing small intestine lled with con-
trast medium to outline it clearly. C, Laparoscopic view o
abdominopelvic cavity, with loops o small intestine
B C visible.
 508 CHAPTER 18 Digestive System

Corpus (body)
of ga llbla dde r

X
Right a nd le ft
X he pa tic ducts
Ne ck of
ga llbla dde r
Common he pa tic duct

Common bile duct

Cys tic duct

Pa ncre a s
Live r
X

Minor duode na l pa pilla Pa ncre a tic

duct
X
Ma jor duode na l pa pilla
S

Duode num R L
S upe rior me s e nte ric
I
a rte ry a nd ve in
18 S phincte r mus cle s

FIGURE 18-18 Gallbladder and bile ducts. X marks the locations where gallstone blockages commonly
occur. Obstruction o the hepatic or common bile duct by stone or spasm blocks the exit o bile rom the liver,
where it is ormed, and prevents bile rom being ejected into the duodenum (choledocholithiasis).

m ves hyme thr ugh the G I tra t and eventually t the M illi ns and milli ns villi jut inward r m the mu us
large intestine. lining. T is large abs rptive sur a e area all ws r aster
abs rpti n nutrients r m the intestine int the bl d and
lymphyet an ther ase structure ts unction.
Fu n c t io n In additi n t the milli ns villi that in rease sur a e area
T e main un ti ns the small intestine are digestion and in the small intestine, ea h villus is itsel vered by epithelial
absorption. Nearly all the hemi al digesti n and abs rpti n ells, whi h ea h have a brushlike b rder mp sed
the digestive system urs in the small intestine. microvilli. T e mi r villi urther in rease the sur a e area
T e mu us lining the small intestine, as with that ea h villus r abs rpti n nutrients.
the st ma h, ntains th usands mi r s pi glands. T ese Sm th mus le in the wall the small intestine ntra ts
intestinal glands se rete the intestinal jui e that is ri h in a t pr du e peristalsis, the wavelike ntra ti n that m ves
variety enzymes as well as water and i ns. T e pan reas hyme thr ugh the intestinal tra t and t the large intestine
se retes bi arb nate int the lumen (h ll w interi r) the (see Figure 18-3 n p. 496). Segmentati n a tivity helps mix the
du denum t neutralize the st ma h a id and als adds en- digestive jui es with hyme and als makes abs rpti n m re
zymes t digest ats, pr teins, and arb hydrates that are ab- e ient (see Figure 18-4 n p. 496).
s rbed by the intestine.
Several stru tural eatures the lining the small in-
testine make it espe ially well-suited t abs rpti n nutri-
D is o r d e r s o t h e S m a ll In t e s t in e
ents and water. T e m st bvi us eature is multiple ir ular Many dis rders the small intestine inv lve inf ammati n, a
lds alled plicae (see Figure 18-17). T ese lds are them- nditi n termed enteritis. I the st ma h is als inf amed,
selves vered with th usands tiny ngers alled villi. the nditi n is termed gastroenteritis.
Under the mi r s pe, the villi an be seen pr je ting int Ba terial t xins r ther irritants in the hyme, in luding
the lumen the intestine. Inside ea h villus lies a ri h net- st ma h a id, an ause enteritis. Irritati n r inf ammati n in
w rk bl d apillaries that abs rb the pr du ts arb - the du denum an pr du e a eeling nausea that leads t
hydrate and pr tein digesti n (sugars and amin a ids). T e emesis (v miting). Be ause the du denum may be emptied
villi als ntain lymphati apillaries alled lacteals that al ng with the st ma h during v miting, it is mm n t
abs rb ats. bserve yell wish r br wnish bile in the v mit.

X-ray studies the small intestine, as well as dire t view-
ing either the inside lumen r exteri r sur a e using an
end s pe, are use ul t ls in b th diagn sis and treatment
intestinal disease.
Malabsorption syndrome is a general term re erring t a
gr up sympt ms resulting r m the ailure the small
intestine t abs rb nutrients pr perly. T ese sympt ms in-
lude an rexia, weight l ss, abd minal bl ating, ramps, ane-
mia, and atigue. A number underlying nditi ns an
ause malabs rpti n syndr me, in luding mu sal hanges
due t surgery, bl d f w hanges, r disease.
An ther dis rder alled maldigestion inv lves a de it
digestive enzymes r bile salts. T is redu es digesti n
and thereby redu es the am unt nutrients available r
abs rpti n.
Live r a n d G a llb la d d e r
S t ru c t u re
T e liver is s large that it lls the entire upper right p rti n
the abd minal avity and even extends partway int the le t
side (see Figure 18-1 and review Figure 1-6 n p. 10).
Be ause its ells se rete a substan e alled bile int du ts,
the liver is lassi ed as an ex rine gland. In a t, the liver is
the largest gland in the b dy. Bile ntains a mixture sub-
stan es, s me whi h have dire t digestive un ti ns de-
s ribed in the next se ti n.
T e liver als serves an ex ret ry r le, as it rem ves yell w-
ish bile pigments rmed by the breakd wn hem gl bin
r m ld RBCs and puts them int the bile r eliminati n
r m the b dy. T e liver has a wide variety ther metab li
un ti ns that are dis ussed later in Chapter 19.
HEA LTH AND WELL-BEIN G
EXERCIS E AND FLUID UPTAKE
Replacement o uids lost during exercise, primarily through
sweating, is essential or maintaining homeostasis. Nearly
everyone increases his or her intake o uids during and a ter
exercise. The main limitation to e f cient uid replacement is
how quickly uid can be absorbed, rather than how much a
person drinks. Very little water is absorbed until it reaches the
intestines, where it is absorbed almost immediately. Thus the
rate o gastric emptying into the intestine is critical.
Large volum e s o uid le ave the s tom ach and e nte r the
inte s tine s m ore rapidly than s m all volum e s . Howeve r, large
volum e s m ay cre ate an uncom ortable e e ling during exe r-
cis e . Cool uids (8 C to 13 C) e m pty m ore quickly than
warm uids . Fluids w ith a high s olute conce ntration e m pty
s low ly and m ay caus e naus e a or s tom ach cram ps . Thus
large am ounts o cool, dilute , or is otonic uids are be s t or
re placing uids quickly during exe rcis e .
The duration o exe rcis e doe s not a e ct gas tric e m pty-
ing, but the inte ns ity can. Stre nuous exe rcis e practically
s huts dow n gas tric e m ptying. Thus the harde r you work,
the harde r it is to re place los t uids .
CHAPTER 18 Digestive System 509
L k again at Figure 18-18. First, identi y the hepatic ducts.
T ey drain bile ut the liver, a a t suggested by the name
hepati , whi h mes r m the Greek w rd r liver (hepar).
Next, n ti e the du t that drains bile int the small intestine
(du denum), the common bile duct.
T e liver ntinu usly se retes bile. I there is n hyme
in the du denum, then ir ular sphin ter mus les within
the du denal papillae remain l sedand the bile ba ks up
the mm n bile du t int the cystic duct that leads t the
gallbladder. T e lded lining the gallbladder all ws it t
expand and thus a t as an verf w reserv ir r bile. T e
gallbladder als n entrates st red bile by reabs rbing
water r m bile ba k int the bl d.
To learn more about bile ducts, go to
AnimationDirect at evolve.elsevier.com.
Fu n c t io n
Chemi ally, bile ntains signi ant quantities h lester l
and substan es (bile salts) that a t as detergents t me hani-
ally break up, r emulsi y, ats. Be ause ats rm large gl b-
ules, they must be br ken d wn, r emulsi ed, int smaller
parti les t in rease the sur a e area t aid digesti n.
In additi n t emulsi ati n ats, bile that is eliminated 18
r m the b dy in the e es serves as a me hanism r ex reting
h lester l r m the b dy. B th emulsi ati n ats and
eliminati n h lester l r m the b dy are primary un -
ti ns bile.
W hen hyme ntaining lipid r at enters the du denum,
it initiates a me hanism that ntra ts the gallbladder and
r es bile int the small intestine. Fats in hyme trigger the
se reti n the h rm ne cholecystokinin (CCK) r m the
intestinal mu sa the du denum. T is h rm ne then trav-
els thr ugh the bl dstream and pr m tes ntra ti n the
gallbladderand nsequently bile f ws int the du denum.
Se reti n CCK is a g d example a h rm ne a ting t
regulate GI m tility.
QUICK CHECK
1. Wh a t b a cte riu m is a s s o cia te d w ith u lce rs ?
2. Id e n ti y th e d i e re n t s e ctio n s o th e s m a ll in te s tin e in th e
o rd e r in w h ich chym e p a s s e s th ro u g h th e m .
3. Wh a t is ga s tro e n te ritis ?
4. Wh a t is th e ga llb la d d e r? Wh e re is b ile o rm e d , a n d w h a t is
its u n ctio n ?
D is o r d e r s o t h e Live r a n d G a llb la d d e r
G a lls t o n e s a n d J a u n d ic e
Gallstones are s lid lumps material (m stly h lester l)
that rm in the gallbladder in 1 in 10 Ameri ans. S me gall-
st nes never ause pr blems and are alled silent gallstones,
whereas thers pr du e pain ul sympt ms r ther medi al
mpli ati ns and are alled symptomatic gallstones.
Cholelithiasis literally means nditi n having bile
(gall) st nes and ten urs in the presen e gallbladder
inf ammati n, r cholecystitis.
 510 CHAPTER 18 Digestive System
Gallst nes ten rm when the h lester l n entrati n
in bile be mes ex essive, ausing rystallizati n r pre ipita-
ti n t ur (Figure 18-19). St ne rmati n is mu h m re
likely t ur i the gallbladder d es n t empty regularly and
hemi ally imbalan ed r h lester l-laden bile remains in
the gallbladder r l ng peri ds time.
W hen a gallst ne bl ks the mm n bile du ta ndi-
ti n alled choledocholithiasisbile is n t able t drain int
the du denum (see Figure 18-18). In su h a ase, e es then
appear gray-white be ause the pigments r m bile that n r-
mally give e es its hara teristi l r are absent. O ten, pain
a mpanies this nditi n. T e pain is alled biliary colic.
Furtherm re, be ause bile ann t be released int the di-
gestive tra t, ex essive am unts bile pigments are instead
abs rbed int the bl d. A yell wish skin dis l rati n alled
jaundice results. O bstru ti n the mm n hepati du t
als leads t jaundi e be ause when bile ann t drain ut
18
A abd minal surgi al pr edures less mm n (Figure 18-19, B).
A
R L
P
B t ing needles ntaminated with even tra e am unts
FIGURE 18-19 Gallstones. A, Inf amed gallbladder lled with yellow
cholesterol gallstones. B, View o the gallbladder be ore removal using a
laparoscope (viewing tube) inserted into the abdomen during surgery.
the liver, it is abs rbed int the bl d. Bile is n t abs rbed
r m the gallbladder s n jaundi e urs i nly the ysti
du t is bl ked.
T e relati nship dieting and weight l ss t gallst ne
rmati n is under intense s rutiny. Physi ians have kn wn
r years that in severely bese individuals (b dy mass index
[BMI] ver 40) the liver pr du es higher levels h lester l
and the risk devel ping gallst nes is in reased. H wever,
nly re ently have s ientists established with ertainty that
signi ant and rapid weight l ss greatly in reases the risk
sympt mati gallst ne rmati n that may require surgerya
pr edure alled cholecystectomy.
Check out the article Gallstones and Weight Loss
at Connect It! at evolve.elsevier.com.
Bariatrics ( r m G reek baros, weight) is a spe ialized
eld medi ine that deals with treatment besity. S -
alled bariatric surgical procedures used r pr du ing weight
l ss, su h as the Lap Band Adjustable Gastric Banding System,
the m re traditi nal restri tive gastri banding pr edure
(verti al-banded gastr plasty), r m re extensive bypass p-
erati ns (RGB, r Roux-en-Y gastric bypass), all redu e the
size the st ma h and alm st always result in rapid p st-
surgi al weight l ss, but m re than ne-third these pa-
tients devel p gallst nes.
Un rtunately, individuals wh h se n nsurgi al ap-
pr a hes t a hieve signi ant and rapid weight l ss, su h as
veryl w- al rie, ultral w- at r arb hydrate diets, als
experien e higher rates gallst ne rmati n. In these ases,
st ne rmati n is related t imbalan es in bile hemistry and
delayed emptying r in mplete gallbladder ntra ti ns.
I surgery is required r rem val sympt mati gall-
st nes, lapar s pi te hniques have made the need r pen
Gallst nes an s metimes be treated (diss lved) ver time r
prevented r m devel ping in individuals experien ing rapid
weight l ss by ral administrati n a naturally urring bile
nstituent alled ursodeoxycholic acid (A tigall).
He p a t it is
Hepatitis is a general term re erring t inf ammati n the
liver. H epatitis is hara terized by jaundi e, liver enlargement,
an rexia, abd minal dis m rt, gray-white e es, and dark
urine.
A number di erent nditi ns an pr du e hepatitis.
Al h l, drugs, r ther t xins may ause hepatitis. It may
ur as a mpli ati n ba terial r viral in e ti n r para-
site in estati n. Hepatitis A, r example, results r m in e ti n
by a virus that may be und in ntaminated d.
An ther viral hepatitis, hepatitis B, is m re severe. It was
hist ri ally alled serum hepatitis be ause it is ten transmit-
ted by ntaminated bl d serum. Impr perly sterilized tat-
hepatitis Bin e ted bl d (0.004 mL), will ause disease.
T ere are va ines t prevent in e ti n with b th hepatitis A
and hepatitis B viruses.
 CHAPTER 18 Digestive System 511

S
Azygos ve in
R L Es opha ge a l va rice s
I

FIGURE 18-20 Liver damage. A, Alcoholic cirrhosis where liver sur ace
is hard and covered with nodules that look like pebbles. B, Varicose veins S upe rior
me s e nte ric ve in He pa tic porta l ve in
(varices) o the esophagus caused by reduction o blood f ow through liver
with cirrhosis. B

Hepatitis C is a rm liver inf ammati n aused by Pa n c re a s

in e ti n with the hepatitis C virus (H CV). It is m st -
ten ass iated with trans usi n ntaminated bl d r
intraven us drug abuse. T e disease may be me hr ni
and result in irrh sis (see later se ti n) r liver an er
many m nths r even years a ter exp sure. O ral drugs are
n w available that have a ure rate nearly 100% when
taken r 3 m nths. Va ines r hepatitis C are als being
devel ped.
C ir r h o s is
H epatitis, hr ni al h l abuse, malnutriti n, r in e ti n
may lead t a degenerative liver nditi n kn wn as cirrhosis.
T e liver has a remarkable ability t regenerate its damaged
tissue, but this pr ess has its limits. F r example, when the
t xi e e ts al h l a umulate aster than the liver an
regenerate itsel , damaged tissue is repla ed with a n dular,
pebble-like br us r atty tissue instead n rmal tissue
(Figure 18-20, A).
N matter what the ause liver irrh sis, the sympt ms
are the same: nausea, an rexia, gray-white st ls, weakness,
and pain. I the ause irrh sis is rem ved and high-pr tein
ds are eaten, the liver may be able t repair itsel given
en ugh time. I the damage is extensive, a liver transplant may
be the nly h pe saving s me ne with irrh sis the liver.
A ute r hr ni liver dis rders su h as hepatitis r ir-
rh sis an bl k the f w bl d thr ugh the liver, thus
ausing it t ba k up int the hepatic portal circulation
(Figure 15-11 n p. 412. As a result, the bl d pressure in the
hepati ir ulati n in reases abn rmallya nditi n alled
portal hypertension.
relieve the pressure p rtal hypertensi n, the b dy
rms additi nal new veins that nne t t the exiting systemi
veins (Figure 18-20, B). T is ten auses the veins lining the
es phagus, st ma h, and ther rgans t widen and be me
vari se. I these vari sities rupture a ter er si n by st ma h
a id, v miting bl d urs. T is an lead t massive bleed-
ing that may result in death.
S t r u c t u r e a n d Fu n c t io n
T e pan reas lies behind the st ma h in the n avity pr -
du ed by the C shape the du denum (see Figure 18-18).
It is an ex rine gland that se retes pancreatic juice int 18
du ts and als an end rine gland that se retes h rm nes
int the bl d. L ate the pan reas and nearby stru tures in
Figure 18-21, whi h sh ws a transverse se ti n a human
adaver.
Pan reati jui e se reted int the du denum ntains en-
zymes that digest all three maj r kinds energy-yielding
nutrients arb hydrates, pr teins, and lipids. It als ntains
s dium bi arb nate, an alkaline substan e that neutralizes the
hydr hl ri a id in the a idi hyme that enters the intes-
tines r m the st ma h.
Pan reati jui e enters the du denum the small intestine
at the same pla e that bile enters be ause b th the mm n
bile and pan reati du ts pen int the du denum at the ma-
j r du denal papilla (see Figure 18-18).
Between the ells that se rete pan reati jui e int du ts lie
lusters ells that have n nta t with any du ts. T ese are
the pancreatic islets (islets o Langerhans), whi h se rete
the h rm nes the pan reasmainly insulin and glucagon
des ribed in Chapter 12.
To learn more about pancreatic ducts, go to
AnimationDirect at evolve.elsevier.com.
D is o r d e r s o t h e P a n c r e a s
Dis rders the pan reas in lude diabetes mellitus (D M), in
th se ases DM inv lving the inability the islet ells t
make insulin.
An ther pan reati dis rder is pancreatitis, whi h is
inf ammati n the pan reas. Acute pancreatitis may result
r m bl kage the mm n bile du t. T e bl kage auses
 512 CHAPTER 18 Digestive System

Infe rior ve na cava Abdomina l a orta S toma ch Pa ncre a s

Live r Inte s tine

Ve rte bra l
bone Pe ritone a l
s pa ce

Le ft
Right
kidney
kidney

R L
18 P

FIGURE 18-21 Abdominal organs. The photograph o a transverse section o a cadaver shows the relative
position o some o the major digestive organs o the abdomen. Such a view is typical in imaging methods such
as computed tomography (CT) scanning and magnetic resonance imaging (MRI).

pan reati enzymes t ba k up int the pan reas and digest
it. T is is a very seri us and p tentially atal nditi n.
An ther nditi n that bl ks the f w pan reati en-
zymes is cystic brosis (CF), whi h is an inherited dis rder
that disrupts ell membrane transp rt and auses ex rine
glands t pr du e ex essively thi k se reti ns. T i k pan reati
se reti ns may build up and bl k pan reati du ts, disrupting
the f w pan reati enzymes and damaging the pan reas.
An ther seri us pan reati dis rder is pancreatic cancer. Usu-
ally a rm adenocarcinoma, advan ed pan reati an er laims
the lives nearly all its patients within 5 years a ter diagn sis.
La r g e In t e s t in e
S t ru c t u re
T e large intestine is nly ab ut 1.5 meters (5 eet) in length.
It has a mu h larger diameter than the small intestine and
rms the l wer r terminal p rti n the digestive tra t.
Chyme ntaining undigested and unabs rbed material
r m ingested d enters the large intestine a ter passing
thr ugh a sphin ter alled the ileocecal valve (Figure 18-22).
Chyme, whi h has the nsisten y s up, sl wly hanges t
the m re s lid nsisten y e al matter as water and salts
are reabs rbed during its passage thr ugh the small intestine.
It is this pastelike material that passes thr ugh the valve int
the large intestine.
T e subdivisi ns the large intestine are listed bel w in
the rder in whi h hyme r e es passes thr ugh them.
1. Ce um
2. As ending l n
3. ransverse l n
4. Des ending l n
5. Sigm id l n
6. Re tum
7. Anal anal
N te in Figure 18-22 that the ile e al valve pens int a
p u hlike area alled the cecum. T e pening itsel is ab ut
5 r 6 m (2 in hes) ab ve the beginning the large intes-
tine. Material in the e um f ws upward t a regi n the
large intestine alled the colon. e hni ally the l n d es n t
in lude the entire large intestine, but ten the terms colon
and large intestine are used inter hangeably. T e l n is di-
vided int three segments: ascending, transverse, and descend-
ing l n.
Material m ves int the l n n the right side the
b dyint the ascending colon. T e hepatic exure r
right colic exure is the bend between the as ending l n
and the transverse colon, whi h extends a r ss the r nt
the abd men r m right t le t. T e splenic exure r le t
colic exure marks the p int where the descending colon
turns d wnward n the le t side the abd men. T e sigmoid
colon is the S-shaped segment that terminates in the rectum.
 CHAPTER 18 Digestive System 513

He pa tic porta l ve in Aorta Tra ns ve rs e

Infe rior ve na cava S ple nic colon S ple nic (le ft colic)
ve in flexure
S upe rior me s e nte ric a rte ry
He pa tic
(right colic) Ta e nia e coli
flexure

Infe rior me s e nte ric

a rte ry a nd ve in

Fa tty a ppe nda ge

As ce nding colon

De s ce nding colon

Me s e nte ry
Ile oce ca l va lve S igmoid a rte ry
Ile um
a nd ve in

Ce cum Ha us tra

Ve rmiform a ppe ndix

Re ctum
S igmoid colon
18
S
S upe rior re cta l
Exte rna l a na l a rte ry a nd ve in R L
s phincte r mus cle
I
A Anus

No rmal Dive rtic ulo s is Appe ndic itis

B C D
FIGURE 18-22 Large intestine. A, Artists drawing o the large intestine. B, X-ray o large intestine and ter-
minal ileum lled with barium contrast material (barium enema). C, X-ray o a barium enema showing diverticulosis
(arrowheads). D, Acute appendicitis. Appendix is gangrenous and showing signs o ischemia and putre action.

T e terminal p rti n the re tum is alled the anal canal, nutrients may be released r m ellul se and ther bers and
whi h ends at the external pening, r anus. abs rbed.
In additi n t their digestive r le, ba teria in the large in-
testine have ther imp rtant un ti ns. T ey are resp nsible
Fu n c t io n r the synthesis vitamin K needed r n rmal bl d l t-
D uring its m vement thr ugh the large intestine, material ting and r the pr du ti n s me the B- mplex vita-
that remains a ter digesti n in the small intestine is a ted n mins. A ter they are rmed, these vitamins are abs rbed r m
by bene ial ba terial mmunities alled the intestinal the large intestine and enter the bl d. T e intestinal mi r -
microbiome r ora. As a result ba terial a ti n, additi nal bi me als plays a r le in supp rting immune un ti ns that
 514 CHAPTER 18 Digestive System

pr te t us r m many intestinal diseases,

s me whi h may be li e-threatening. C LIN ICA L APPLICATION
S me ba teria als pr du e gases that
es ape r m the l n thr ugh the anus INFANT DIARRHEA
a phen men n alled f atulen e r atus. Seve re diarrhe a caus e d by a rotavirus , an inte s tinal in e ction, kills m ore than
500,000 in ants and young childre n worldw ide e ach ye ar. De ath can re s ult rom
Review The Human s eve re de hydration caus e d by 20 or m ore e pis ode s o diarrhe a in a s ingle day.
Microbiome at Connect It! Curre ntly, m ore than 3 m illion U.S. childre n s u e r s ym ptom s o rotavirus inte s tinal
at evolve.elsevier.com. in e ction annually and 55,000 re quire hos pitalization.
Good m e dical care has lim ite d the num be r o U.S. in ant de aths caus e d by the
Alth ugh s me additi nal abs rpti n dis e as e e ach ye ar to jus t a ew. In deve lope d countrie s , re lative ly new and prom is -
ing vaccine s provide good prote ction agains t the virus . Un ortunate ly, in deve lop-
water, salts, and vitamins urs in the large
ing countrie s , rotavirus -induce d diarrhe a re m ains one o the le ading caus e s o
intestine, this segment the digestive tube
in ant m ortality.
is n t as well suited r abs rpti n as is the Until rotavirus vaccine s can be m ore w ide ly dis tribute d and adm inis te re d, one
small intestine. N villi are present in the o the be s t tre atm e nt options available in m any are as o the world involve s oral
mu sa the large intestine. As a result, adm inis tration o libe ral dos e s o a s im ple , e as ily pre pare d s olution containing
mu h less sur a e area is available r ab- s ugar and s alt. The s alt-s ugar s olution us e d in this o ral re hydratio n the rapy (ORT)
s rpti n. Salts, espe ially s dium, are ab- re place s nutrie nts and e le ctrolyte s los t in diarrhe al uid. Be caus e the re place m e nt
s rbed by a tive transp rt, and water is uid can be pre pare d rom re adily available and inexpe ns ive ingre die nts , it is par-
m ved int the bl d by sm sis. ticularly valuable in the tre atm e nt o in ant diarrhe a in deve loping countrie s .
T e e ien y and speed abs rpti n
substan es thr ugh the wall the large
intestine are l wer than in the small intes-
tine. N rmal passage material al ng the lumen the large T e high water ntent l se st ls an be aused by
18 intestine takes ab ut 3 t 5 days. high m tility, whi h de reases the time the intestines have t
w sphin ter mus les stay ntra ted t keep the anus reabs rb water r m the e es. Watery st ls als may result
l sed ex ept during de ecationthe eliminati n e es. r m the a ti n t xins that auses ells in the intestinal lin-
Sm th r inv luntary mus le mp ses the internal anal ing t m ve water int the GI tra t rather than ut the
sphincter, but v luntary skeletal mus le rms the external anal tra t. Be ause the water l ss inv lved, untreated diarrhea
sphincter. T is anat mi al a t s metimes be mes highly may qui kly lead t dehydrati nand p ssibly nvulsi ns r
imp rtant r m a pra ti al standp int. F r example, ten death (see b x n in ant diarrhea, ab ve).
a ter a pers n has had a str ke, the v luntary anal sphin ter at Constipation results r m de reased intestinal m tility. I
rst be mes paralyzed. T is means, urse, that the indi- passage e es thr ugh the large intestine is pr l nged be-
vidual has n ntr l at that time ver b wel m vements. y nd 5 days, the e es l se v lume and be me m re s lid
be ause ex essive water reabs rpti n. T is redu ti n in
v lume de reases stimulati n the b wel-emptying ref ex,
D is o r d e r s o t h e La r g e In t e s t in e resulting in retenti n e esa p sitive- eedba k a e t that
M st the mm n dis rders the large intestine relate t makes the nditi n even w rse.
in ammation r abnormal motility, r rate m vement the A ute nstipati n ten results r m intestinal bl kage,
intestinal ntents. Abn rmally rapid m tility thr ugh the l w- ber diets, tum rs, r diverticulitis. reatment a ute
large intestine may result in diarrhea, and abn rmally sl w nstipati n usually inv lves treatment the underlying ause.
m tility may result in constipation. T ese and ther nditi ns
are brief y des ribed in this se ti n. In a m m a t o ry C o n d it io n s
D iverticulitis is an inf ammati n abn rmal sa like p u hes
M o t ilit y D is o r d e r s the intestinal wall alled diverticula (Figure 18-22, C). Diver-
D iarrhea usually urs when the intestinal ntents m ve s ti ula ten devel p in adults lder than 50 years age wh
qui kly that the resulting e es are m re f uid than n rmal. eat a l w- ber diet. As previ usly menti ned, diverti ulitis
Diarrhea is hara terized by requent passing watery e es. an be a ause nstipati n.
In inf ammat ry nditi ns su h as dysentery, the watery Colitis re ers t any inf ammat ry nditi n the large
e es als may ntain mu us, bl d, r pus. Diarrhea is ten intestine. I present r pr l nged peri ds time, inf amma-
a mpanied by abd minal rampsa sympt m aused by t ry b wel disease be mes a signi ant risk a t r r
ex essive ntra ti ns the intestinal mus les. l re tal an er. Sympt ms litis in lude diarrhea and
T e in reased intestinal m tility that auses diarrhea ten abd minal ramps r nstipati n. S me rms litis als
results r m the presen e ba terial t xins, parasites, r ther may pr du e bleeding and intestinal ul ers.
irritants. T e intestines ref exively speed up, a me hanism C litis may be a result em ti nal stress, as in irritable
that qui kly disp ses the irritant. bowel syndrome. It als may result r m an aut immune
 CHAPTER 18 Digestive System 515

disease, as in ulcerative colitis. An ther type aut immune absen e an er ells in regi nal lymph n des r distant
litis is Crohn disease, whi h ten als a e ts the small b dy l ati ns (metastases).
intestine. Early warning signs this mm n type an er in-
I m re nservative treatments ail, litis may be r- lude hanges in b wel habits ( nstipati n r diarrhea),
re ted by surgi al rem val the a e ted p rti ns the de reased st l diameter, re tal bleeding that may be bvi us
l n. (gr ss r visible) r hidden ( ult r mi r s pi ), abd mi-
nal pain, unexplained anemia, weight l ss, and atigue. Large
To learn more about a common medical imaging b wel bstru ti n is the m st mm n mpli ati n l n
procedure used to assess the structure o the an er.
colon, check out the article Barium Enema Study reatment requiring surgi al rem val a tum r in the
at Connect It! at evolve.elsevier.com. distal re tum als may require the reati n a colostomy
(see b x bel w). In additi n t surgery, b th re tal and l n
an er are ten treated by use hem therapy. Radiati n
C o lo r e c t a l C a n c e r therapy is seld m used in treatment l n an er but has
Colorectal cancer is a malignan y, usually adenocarcinoma, an imp rtant r le in treatment re tal malignan y.
the lumnar epithelium that lines the lumen the l n
and/ r re tum. M st l re tal an ers riginate r m n n-
malignant colonic polyps that gradually underg malignant A p p e n d ix
trans rmati n. C l re tal an er urs m st ten a ter age
S t r u c t u r e a n d Fu n c t io n
50 and in reases in in iden e dramati ally a ter age 75. T e
disease is slightly m re mm n in men than in w men and T e vermi orm appendix ( r m vermis w rm and orm
nstitutes the se nd leading ause death r m an er in shape) is, as the name implies, a w rmlike, tubular stru ture.
the United States and the urth m st mm n type an er N te in Figure 18-22 that the appendix is dire tly atta hed t
diagn sed a ter pr state, breast, and lung malignan y. the ba k the e um. T e appendix ntains a blind, tubelike
Diagn sis l re tal an er is made during a digital interi r lumen that mmuni ates with the lumen the large 18
re tal examinati n r as a result dire t visualizati n the intestine 3 m (1 in h) bel w the pening the ile e al
re tum and l wer l n during sigmoidoscopy, r the en- valve int the e um.
tire l n during a colonoscopy. O ther diagn sti t ls in- T e appendix serves as a s rt in ubat r r breeding
lude the use barium enemas, ultras und, vari us x-ray gr und r the n npath geni intestinal ba teria n rmally
based te hniques, and magneti res nan e imaging. residing in the l n. Maintaining a n rmal intestinal mi r -
Certain dietary habits, espe ially a high saturated at in- bi me helps prevent path geni ba teria r m be ming es-
take, and geneti predisp siti n are kn wn risk a t rs. T e tablished. W hen the n rmal mi r bi me the gut is dis-
pr gn sis r re very r m l re tal an er is based n a rupted, r example by in e ti n r antibi ti s, bene ial
number a t rs, in luding the degree penetrati n (i any) ba teria hidden away in the appendix an easily migrate int
the tum r thr ugh the b wel wall, and the presen e r the l n t rest re the n rmal e l gi al balan e.

C LIN ICA L APPLICATION

COLOSTOMY
Co lo s to my is a s urgical proce dure in w hich an artif cial anus is cre ate d on
the abdom inal wall by cutting the colon and bringing the cut e nd or e nds
out to the s ur ace to orm an ope ning calle d a s to m a (s e e f gure ). This
m ay be done during a s urge ry to re m ove a tum or or a s e ction o the co-
lon. A te r he aling o the colon, the colos tomy m ay be s urgically reve rs e d
(re m ove d). S toma
He alth-care worke rs he lp colos tomy patie nts le arn to acce pt the
change in body im age , w hich m ay caus e e m otional dis com ort. The pa-
tie nt or care give r is als o traine d in the re gular changing o the dis pos able
Exte rna l
bag, including how to cle an the s tom a and how to preve nt irritation, colle ction ba g
chapping, or in e ction. Irrigation o the colon w ith is otonic s olutions is
s om e tim e s ne ce s s ary. De odorants m ay be adde d to the re s h bag to
preve nt unple as ant odors . Patie nts are als o taught to m anage the ir die t
to include low-re s idue ood and to avoid oods that produce gas or
caus e diarrhe a. Fluid intake a te r colos tomy is als o care ully m anage d.
 516 CHAPTER 18 Digestive System Pe ritone um Re trope ritone a l s pa ce
Intra pe ritone a l s pa ce Lume n of hollow orga ns

S
Review The Human Microbiome at Connect It! at
A P
evolve.elsevier.com.
I Live r

A p p e n d ic it is Le s s e r
ome ntum
Inf ammati n the appendix, r appendicitis, is a mm n Vis ce ra l S toma ch
and p tentially very seri us medi al pr blem (Figure 18-22, D). pe ritone um
T e pening between the lumen the appendix and the Pe ritone a l s pa ce Pa ncre a s
(re trope ritone a l)
e um is quite large in hildren and y ung adultsa a t Pa rie ta l
great lini al signi an e be ause undigested hunks r e al pe ritone um Duode num
material trapped in the appendix may irritate and inf ame its (re trope ritone a l)
Gre a te r
mu us lining, ausing appendi itis. T e pening between the ome ntum Tra ns ve rs e
appendix and the e um is ten mpletely bliterated in colon
S ma ll inte s tine
elderly pers ns, whi h explains the l w in iden e appendi- Me s e nte ry
itis in this p pulati n. Urina ry bla dde r
(re trope ritone a l) Re ctum
A site n the sur a e the anteri r abd minal wall is - (re trope ritone a l)
ten used t help in the diagn sis appendi itis and t esti-
mate the l ati n the appendix internally. It is alled the Anus
M cBurney point and is l ated in the right l wer quadrant A
the abd men ab ut a third the way al ng a line r m the
right anteri r superi r ilia spine t the umbili us. Extreme S
sensitivity and pain are mm n when the abd men per- R L
s ns with a ute appendi itis is palpated ver this p int.
Gre a te r
18 I in e ti us material be mes trapped in an inf amed ap-
pendix, the appendix may rupture and release the material
I
ome ntum
Tra ns ve rs e Tra ns ve rs e
int the abd minal avity. In e ti n the perit neum and colon me s ocolon
ther abd minal rgans an be li e threatening. Appendi itis J e junum
is the m st mm n the a ute abd minal nditi ns that Pa ncre a s
require surgery. It a e ts 7% t 12% the p pulati n, gener-
ally be re age 30. Me s e nte ry De s ce nding
colon

QUICK CHECK
1. Wh a t is ch o le lith ia s is ?
2. Wh a t is h e p a titis C? Wh a t a re co m m o n ca u s e s o h e p a ti-
tis C?
3. Na m e th e s e ve n s u b d ivis io n s o th e la rg e in te s tin e .
4. Wh a t is th e m o s t co m m o n a cu te a b d o m in a l co n d itio n
re q u irin g s u rg e ry?
P e r it o n e u m
Lo c a t io n
T e peritoneum is a large, m ist, slippery sheet serous
membrane that lines the abd minal avity and vers the r-
gans l ated in it, in luding m st the digestive rgans. T e
parietal layer the perit neum lines the abd minal avity.
T e vis eral layer the perit neum rms the uter, r ver-
ing, layer ea h abd minal rgan.
T e small spa e between the parietal and vis eral layers is
alled the peritoneal space. It ntains just en ugh perit neal
f uid t keep b th layers the perit neum m ist and able t
slide reely against ea h ther during breathing, digestive m ve-
ments, and twisting r bending the t rs (Figure 18-23, A).
O rgans utside the parietal perit neum, su h as the kid-
neys, are said t be retroperitoneal.
Ile um
S igmoid
colon
B
FIGURE 18-23 Peritoneum. A, The parietal layer o the peritoneum
lines the abdominopelvic cavity and then extends as a series o mesenteries
to orm the visceral layer that covers abdominal organs. B, The transverse
colon and greater omentum are raised and the small intestine is pulled to
the side to show the mesentery.
Ex t e n s io n s
T e tw m st pr minent extensi ns the perit neum are the
mesentery and the greater mentum.
T e mesentery (Figure 18-23, B), an extensi n between the
parietal and vis eral layers the perit neum, is shaped like a
giant, pleated an. Its smaller edge atta hes t the lumbar re-
gi n the p steri r abd minal wall, and its l ng, l se uter
edge en l ses m st the small intestine, an h ring it t the
p steri r abd minal wall.
T e greater omentum is a p u hlike extensi n the vis-
eral perit neum r m the l wer edge the st ma h, part
the du denum, and the transverse l n. Shaped like a large
 CHAPTER 18 Digestive System 517

apr n, it hangs d wn ver the intestines, and be ause sp tty Pe ritone um Re trope ritone a l s pa ce
dep sits at give it a la y appearan e, it has been ni knamed Intra pe ritone a l s pa ce Lume n of hollow orga ns
the lace apron. It may envel p a badly inf amed appendix, wall-
ing the appendix r m the rest the abd minal rgans.

P e r it o n it is
Peritonitis is the inf ammati n the perit neum resulting S ubphre nic
r m a ba terial in e ti n r an ther irritating nditi n. re ce s s
Perit nitis m st mm nly results r m an in e ti n that Vis ce ra l Live r
pe ritone um
urs a ter the rupture the appendix r ther abd min -
Pa rie ta l
pelvi rgan. It is hara terized by abd minal distenti n, pain, pe ritone um
S toma ch
nausea, v miting, ta hy ardia (rapid heart rate), ever, dehy- Pe ritone a l
drati n, and ther signs and sympt ms. Cir ulat ry sh k s pa ce Pa ncre a s
pr gressing t heart ailure may result. (re trope ritone a l)
Gre a te r
Duode num
ome ntum
(re trope ritone a l)
A s c it e s Tra ns ve rs e colon
S ma ll
Ascites is the abn rmal a umulati n f uid in the perit - inte s tine Me s e nte ry
neal spa e (Figure 18-24).
Urina ry bla dde r Re ctum
Fluid enters the perit neal spa e r m the bl d be ause (re trope ritone a l)
(re trope ritone a l)
l al hypertensi n (high bl d pressure) r an sm ti imbal-
an e in the plasma (l w plasma pr tein levels). T is nditi n Anus S
may be a mpanied by abd minal swelling and de reased
urinary utput. It mm nly urs as a mpli ati n ir-
A P
18
rh sis, ngestive heart ailure, kidney disease, perit nitis, A I

an er, r malnutriti n.

D ig e s t io n
O ve r v ie w o D ig e s t io n s
D igestion, a mplex pr ess that urs in the alimentary
anal, nsists physi al and hemi al hanges that prepare
nutrients r abs rpti n.
M echanical digestion breaks ingested d int tiny parti-
les, mixes them with digestive jui es, m ves them al ng the A
alimentary anal, and nally eliminates the digestive wastes S I
r m the b dy. Chewing (masti ati n), swall wing (degluti-
ti n), peristalsis, and de e ati n are nsidered pr esses B P

me hani al digesti n (see Figure 18-3 and Figure 18-4).

Chemical digestion breaks d wn large, n nabs rbable nutri-
ent m le ules int smaller, abs rbable m le ulesm le ules
that are able t pass easily thr ugh the intestinal mu sa int
bl d and lymph. Chemi al digesti n nsists numer us
hemi al rea ti ns atalyzed by enzymes in saliva, gastri
jui e, pan reati jui e, and intestinal jui e.
En z y m e s a n d C h e m ic a l D ig e s t io n
Enzymes are un ti nal pr tein m le ules that a t as catalysts.
T at is, they speed up spe i hemi al rea ti ns with ut
themselves being hanged r nsumed during the rea ti n
pr ess.
D uring hemi al digesti n, ertain enzymes very sele -
tively speed up the breakd wn spe i nutrient m le ules
FIGURE 18-24 Ascites. Ascites results rom an accumulation o f uid in
the peritoneal space. A, The arrows indicate water ltering out o the peri-
toneal blood vessels, resulting rom hypertension, or di using out o the
vessels because o an osmotic imbalance in the blood. B, Abdominal bloat-
ing in ascites.
and n thers. Enzymes resp nsible r speeding up the
breakd wn ats, r example, have n e e t n arb hy-
drates r pr teins.
T e breakd wn pr ess a ilitated by digestive enzymes is
alled hydrolysisan imp rtant type hemi al rea ti n
rst dis ussed in Chapter 2. Re all that during hydr lysis,
enzymes speed up rea ti ns that add water (hydro) t hemi-
ally break up r split (lysis) larger m le ules int smaller
m le ules (see Figure 2-6 n p. 29).
 518 CHAPTER 18 Digestive System

T e names many enzymes end with the su x -ase m-
bined with the w rd that des ribes the type substan e in-
v lved in the hemi al rea ti n. Lipase, r example, is a at-
digesting enzyme that a ts n lipids ( ats) and protease
enzymes serve t break d wn pr tein nutrients int smaller
m le ules. All the digestive enzymes an be lassi ed as hy-
drolases be ause they atalyze hydr lysis rea ti ns.
To better understand this concept, use the Active
Concept Map Digestion o Carbohydrates, Pro-
teins, and Fats at evolve.elsevier.com.
C a r b o h yd r a t e D ig e s t io n
Very little digesti n arb hydrates (star hes and sugars)
urs be re they rea h the small intestine. Salivary
amylase usually has little time t d its w rk be ause s
many us swall w ur d s ast. G astri jui e ntains
n arb hydrate-digesting enzymes.
A ter the arb hydrates rea h the small intestine, pan re-
ati and intestinal enzymes digest the star hes and sugars. A
pan reati enzyme (pan reati amylase) starts the pr ess by
breaking star hes d wn int d uble sugars, r disaccharides
(see Figure 2-8 n p. 32).
18 T ree intestinal enzymesmaltase, sucrase, and lactase
digest disa harides by hanging them int monosaccharides
(simple sugars). M altase digests maltose (malt sugar), sucrase
digests sucrose ( rdinary ane r table sugar), and lactase di-
gests lactose (milk sugar).
M any adults and s me hildren pr du e a l w am unt
la tase and there re have di ulty digesting la t se
espe ially when nsumed in large am unts, as in eating
dairy pr du ts. T is nditi n is alled lactose intolerance
and may pr du e digestive sympt ms su h as gas, bl ating,
ramps, r diarrhea. La t se int leran e an be managed by
av iding ds high in la t se and/ r taking a la tase sup-
plement when eating dairy pr du ts.
T e end pr du ts arb hydrate digesti n are m n sa -
harides, whi h the m st abundant is glu se.
P ro t e in D ig e s t io n
Pr tein digesti n starts in the st ma h. Hydrochloric acid
(HCl) in gastri jui e helps un ld the large, mplex pr tein
shapes (see Figure 2-12 n p. 34). T is un lding all ws diges-
tive enzymes t rea h the peptide bonds that h ld the amino
acids t gether.
Pepsinogen, a pr tein in gastri jui e, is nverted int
a tive pepsin enzyme by the H Cl. Pepsin then begins break-
ing peptide b nds t rm sh rter and sh rter hains
amin a ids.
In the intestine, ther enzymestrypsin in pan reati
jui e and peptidases in intestinal jui e nish the j b
pr tein digesti n.

TABLE 18-3 Chemical Digestion

DIGESTIVE JUICES S UBSTANCE DIGESTED
AND ENZYMES (OR HYDROLYZED) RES ULTING PRODUCT*
S aliva
Salivary amylas e Starch (polys accharide ) Maltos e (a double s ugar, or
dis accharide )
S a liva
Gas tric Juice
Prote as e (pe ps in) plus Prote ins Partially dige s te d prote ins
hydrochloric acid
Pancre atic Juice
Prote as e s (e .g., tryps in) Prote ins (intact or partially Pe ptide s and am ino acids
dige s te d)
Ga s tric
Lipas e s Fats e m uls if e d by bile Fatty acids , m o no g lyce ride s ,
juice
and g lyce ro l
Pa ncre a tic
Pancre atic amylas e Starch Maltos e
juice
Inte s tinal Enzym e s
Pe ptidas e s Pe ptide s Am ino acids
Sucras e Sucros e (cane s ugar) Gluco s e and ructo s e (s im ple
s ugars , or m onos accharide s )
Lactas e Lactos e (m ilk s ugar) Gluco s e and galacto s e (s im ple
Inte s tina l s ugars )
Maltas e e nzyme s Maltos e (m alt s ugar) Gluco s e

*Subs tance s in bold ace type are e nd products o dige s tion (that is , com ple te ly dige s te d nutrie nts re ady or abs orption).

Se cre te d in inactive orm (tryps inoge n); activate d by e nte rokinas e , an e nzym e in the inte s tinal brus h borde r.

Brus h-borde r e nzym e s .

Glucos e is als o calle d dextros e ; ructos e is als o calle d levulos e .
 CHAPTER 18 Digestive System 519

W hen the pr tease enzymes have nally split up the large
pr tein m le ules int individual amin a ids, pr tein diges-
ti n is mpleted. H en e the end pr du t pr tein digesti n
is amin a ids.
Lip id D ig e s t io n
Just as with arb hydrates, very little at and il digesti n -
urs be re they rea h the small intestine. M st lipids are
undigested until a ter being emulsi ed int tiny dr plets by
bile in the du denum.
A ter the lipids are trapped inside tiny dr plets, pan reati
lipase splits them int their mp nents. rigly erides and
ther large lipid m le ules are thus br ken d wn int atty
acids and glycerol (see Figure 2-9 n p. 32), the end pr du ts
at digesti n.
En d P ro d u c t s o D ig e s t io n
Table 18-3 and Figure 18-25 summarize s me key a ts ab ut
hemi al digesti n.
W hen arb hydrate digesti n has been mpleted, star hes
(p lysa harides) and d uble sugars (disa harides) have been
hanged mainly t glu se, a simple sugar (m n sa haride).
T e end pr du ts pr tein digesti n, n the ther hand, are
amin a ids. Fatty a id and gly er l are the end pr du ts
at digesti n.
A b s o r p t io n
M e c h a n is m s o A b s o r p t io n
A ter d is digested, the resulting nutrients are abs rbed
and m ve thr ugh the mu us membrane lining the small
intestine int the bl d and lymph (see Figure 18-25). In ther
w rds, nutrient absorption is the pr ess by whi h m le ules
amin a ids, glu se, atty a ids, and gly er l g r m the
lumen the intestines int the ir ulating f uids the b dy.
Abs rpti n nutrients is just as essential as digesti n
ds. T e reas n is airly bvi us. As l ng as d stays in the
intestines, it ann t n urish the milli ns ells that mp se
all ther parts the b dy. T eir lives depend n the abs rpti n

FIGURE 18-25 Digestion and absorption. Concept map summarizing how the digestive system breaks down
major nutrients and moves them into the internal environment, where they can be used or metabolic unction.
18
Polys a ccha ride s Fa ts

Dig e s tio n Emuls ific atio n

Dis a ccha ride s P rote ins Fa t drople ts

Dig e s tio n Dig e s tio n Dig e s tio n

Fa tty a cids,
Mine ra l ions Wa te r Monos a ccha ride s Amino a cids glyce rol

Ac tive Ac tive Ac tive

trans po rt Os mo s is trans po rt trans po rt Diffus io n

Ac tive Os mo s is Diffus io n Diffus io n S e c re tio n

trans po rt

To live r

Blood ca pilla ry La cte a l

(lymph ca pilla ry)
To thora cic duct
 520 CHAPTER 18 Digestive System
S C IEN C E APPLICATIONS
digested d and its transp rtati n t them by the ir ulat- GASTROENTEROLOGY
ing bl d. The word g as tro e nte ro lo gy
Many imp rtant minerals, su h as s dium, are a tively te lls you by its parts that it is
transp rted thr ugh the intestinal mu sa. Water ll ws by the s tudy (-ology) o the s tom -
sm sis. O ther nutrients, su h as m n sa harides and amin ach (gas tro-) and the inte s tine s
a ids, are als a tively transp rted thr ugh the intestinal mu- (-e nte ro-).
sa and then di use int the bl d apillaries in the intes- One o the pioneering gastro-
tinal villi. enterologists was the American
Fatty a ids and gly er l di use int the abs rptive ells physician William Beaumont. In
1822, the young Qubcois trap-
the GI tra t and then are reassembled int trigly erides. T e
per Alexis St. Martin was shot
trigly erides are then repa kaged int ph sph lipid- ated
William Beaumont with a musket near the Army
spheres and se reted int the la teals within intestinal villi. (17851853) hospital in Michigan where Beau-
A ter eventually entering and traveling thr ugh the bl d- mont was working. Beaumont
stream, the trigly erides are br ken d wn again in adip se and treated his woundalthough expecting St. Martin to die rom
mus le tissue. the injury. However, St. Martin recovered and lived a long li e
T e water-s luble vitamins (vitamin C and the B vita- even though the wound did not heal properly. For his entire
mins) are diss lved in water and abs rbed primarily r m the li e therea ter, an open hole remained in his abdomen that led
small intestine. T e at-s luble vitamins (vitamins A, D, E, directly into the stomach. Being grate ul or his spared li e and
and K) are abs rbed al ng with the end pr du ts at diges- in need o income, St. Martin reluctantly allowed Beaumont
ti n in the small intestine and then pass int the la teals. to study gastric secretion through the opening.
Ove r m any ye ars , Be aum ont m ade care ul obs e rva-
Ba terial a ti n in the l n als pr du es s me vitamin K
tions about how the s tom ach w orks . Many o his conclu-
that is abs rbed thr ugh the lining the large intestine. s ions are s till valid and s e rve as the oundation or m ode rn
gas troe nte rology.

18 S u r a c e A r e a a n d A b s o r p t io n Be caus e o the com plexity and im portance o dige s tive

Stru tural adaptati ns the digestive tube, in luding lds in
the lining mu sa, villi, and mi r villi, in rease the abs rptive
sur a e and the e ien y and speed abs rpti n and trans er
materials r m the intestinal lumen t b dy f uids.
Bi l gists s metimes apply the prin iples the eld
study alled ractal geometry t human anat my. S ientists
w rking in this eld study sur a es alled ra tal sur a es
with a seemingly in nite area, su h as the lining the small
intestine. Fra tal sur a es have bumps that have bumps that
have bumps, and s n.
T e ra tal-like nature the intestinal lining is repre-
sented in Figure 18-17. T e pli ae ( lds) have villi, the villi have
mi r villi, and even the mi r villi have bumps that ann t be
seen in the gure. T us the abs rptive sur a e area the small
intestine is alm st limitless, making the abs rptive apability
the human GI tra t truly remarkable.
proce s s e s , m any phys icians and nurs e s s pe cialize in gas -
troe nte rology today. Howeve r, othe r he alth-care provide rs
s uch as patie nt care te chnicians and nurs ing as s is tants
s till ne e d a bas ic know le dge o dige s tive s tructure and
unction in orde r to care or patie nts e e ctive ly. Eve n work-
e rs in the f e lds o die te tics , nutrition, and ood s e rvice
be ne f t rom know le dge o the principle s o dige s tion.
QUICK CHECK
1. Na m e th e tw o m o s t p ro m in e n t e xte n s io n s o th e
p e rito n e u m .
2. Wh a t is th e d i e re n ce b e tw e e n m e ch a n ica l d ig e s tio n a n d
ch e m ica l d ig e s tio n ?
3. De s crib e th e ro le o e n zym e s in ch e m ica l d ig e s tio n .
4. Wh a t a re th e e n d p ro d u cts o ca rb o hyd ra te d ig e s tio n ? Fa t
d ig e s tio n ? Pro te in d ig e s tio n ?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 493)

catalyst cholecystokinin (CCK) common bile duct

(KAT-ah-list) (koh-lee-sis-toh-KYE-nin [see see kay]) (KOM-on byle dukt)
[cata- lower, -lys- loosen, -st agent] [chole- bile, -cyst- bag, -kin- movement, [duct path]
cecum -in substance] crown
(SEE-kum) chyme (krown)
[cec- blind or hidden, -um thing] (kyme) cuspid
cementum [chym- juice] (KUS-pid)
(see-MEN-tum) colic exure [cusp- point, -id characterized by]
[cement- mortar, -um thing or substance] (KOHL-ik FLEK-shur) cystic duct
[col- colon, -ic relating to, ex- bend, (SIS-tik dukt)
-ure action] [cyst- sac, -ic relating to, duct path]
 CHAPTER 18 Digestive System 521

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 520)

deciduous teeth undus lactase

(deh-SID-yoo-us teeth) (FUN-dus) (LAK-tayz)
[decid- all o , -ous relating to] [ undus bottom] [lact- milk, -ase enzyme]
de ecation gallbladder lacteal
(de -eh-KAY-shun) (GAWL-blad-er) (LAK-tee-al)
[de- remove, - eca- waste ( eces), [gall- bile] [lact- milk, -al relating to]
-tion process] gastric gland lactose
deglutition (GAS-trik gland) (LAK-tohs)
(deg-loo-TISH-un) [gastr- stomach, -ic relating to, gland acorn] [lact- milk, -ose carbohydrate (sugar)]
[deglut- swallow, -tion process] gastrointestinal tract (GI tract) large intestine
dentin (gas-troh-in-TES-tih-nul trakt [jee aye (larj in-TES-tin)
(DEN-tin) trakt]) laryngopharynx
[dent- tooth, -in substance] [gastr- stomach, -intestin- intestine, -al relating (lah-ring-go-FAYR-inks)
descending colon to, tract trail] [laryng- voice box (larynx), -pharynx throat]
(dih-SEND-ing KOH-lon) gingiva lipase
[de- down, -scend- climb, colon large intestine] (J IN-jih-vah) (LYE-payz or LIP-ayz)
digestion [gingiva gum] [lip- at, -ase enzyme]
(dye-J ES-chun) greater omentum liver
[digest- break apart, -tion process] (GRAYT-er oh-MEN-tum) (LIV-er)
digestive system [omentum membrane covering intestines] lower esophageal sphincter (LES)
(dye-J ES-tiv SIS-tem) hard palate (LOH-er eh-so -eh-J EE-al SFINGK-ter
[digest- break apart, -tive relating to] (hard PAL-et) [el ee es]) 18
duodenum hepatic duct [eso- carry, -phag- ood, -al relating to,
(doo-oh-DEE-num) (heh-PAT-ik dukt) sphinc- bind tight, -er agent]
[duodeni- 12 f ngers, shortened rom [hepa- liver, -ic relating to, duct path] lumen
intestinum duodenum digitorum intestine o hepatic exure (LOO-men)
12 f nger-widths] (heh-PAT-ik FLEK-sher) [lumen light or window]
elimination [hepa- liver, -ic relating to, ex- that may be major duodenal papilla
(eh-lim-uh-NAY-shun) bent, -ure action] (MAY-jer doo-oh-DEE-nul
[e- out, -limen- threshold, -ation process] hydrochloric acid (HCl) [or doo-AH-de-nul] pah-PIL-ah)
emulsi y (hye-droh-KLOR-ik AS-id [aych see el]) [major larger, duoden- 12 f ngers, shortened
(eh-MUL-seh- ye) [hydro- water, -chlor- green (chlorine), rom intestinum duodenum digitorum
[e- out, -muls- milk, -i- combining vowel, -ic relating to, acid sour] intestine o 12 f nger-widths, -al relating to,
- y process] hydrolysis papilla nipple]
enamel (hye-DROHL-ih-sis) maltase
(ih-NA-mel) [hydro- water, -lysis loosening] (MAWL -tayz)
[en- in, -amel melt] ileocecal valve [malt- grain, -ase enzyme]
enzyme (il-ee-oh-SEE-kal valv) maltose
(EN-zyme) [ileum groin or ank, cec- blind or hidden, (MAWL-tohs)
[en- in, -zyme erment] -al relating to] [malt- grain, -ose carbohydrate (sugar)]
esophagus ileum mastication
(ee-SOF-ah-gus) (IL-ee-um) (mas-tih-KAY-shun)
[eso- carry, -phagus ood] [ileum groin or ank] [mastica- chew, -ation process]
eces incisor mesentery
(FEE-seez) (in-SYE-zer) (MEZ-en-tayr-ee)
[ eces waste] [in- into, -cis- cut, -or agent] [mes- middle, -enter- intestine, -y thing]
ractal geometry ingestion metabolism
(FRAK-tal jee-OM-eh-tree) (in-J ES-chun) (meh-TAB-oh-liz-im)
[ ract- break, -al relating to, geo- land, [in- within, -gest- carry, -tion process] [meta- over, -bol- throw, -ism action]
-metr- measure, -y activity] intestinal gland microbiome
renulum (in-TES-tih-nal gland) (my-kroh-BYE-ohm)
(FREN-yoo-lum) [intestin- intestine, -al relating to, gland acorn] [micro- small, -bio- li e, -ome entire collection]
[ ren- bridle, -ul- little, -um thing] jejunum
(jeh-J OO-num)
[jejun- empty, -um thing] Continued on p. 522
 522 CHAPTER 18 Digestive System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 521)

microvilli periodontal membrane retroperitoneal

(my-kroh-VIL-ee) (payr-ee-oh-DON-tull MEM-brayn) (reh-troh-pair-ih-toh-NEE-al)
sing., microvillus [peri- around, -dont- tooth, -al relating to, [retro- backward, peri- around,
(my-kroh-VIL-us) membrane thin skin] -tone- stretched, -al relating to]
[micro- small, -villi shaggy hairs] pepsin root
minor duodenal papilla (PEP-sin) rugae
(MYE-ner doo-oh-DEE-nul [peps- digestion, -in substance] (ROO-gee)
[or doo-AH-de-nul] pah-PIL-ah) pepsinogen sing., ruga
[minor smaller, duoden- 12 f ngers, shortened (pep-SIN-oh-jen) [ruga wrinkle]
rom intestinum duodenum digitorum [peps- digestion, -in substance, -o- combining secretion
intestine o 12 f nger-widths, -al relating to, orm, -gen produce] (seh-KREE-shun)
papilla nipple] peptidase [secret- separate, -tion process]
molar (PEP-tyd-ayz) segmentation
(MOHL-ar) [pept- digestion, -ide chemical, -ase enzyme] (seg-men-TAY-shun)
[mol- millstone, -ar relating to] peristalsis [segment- cut section, -ation process]
motility (payr-ih-STAL-sis) serosa
(moh-TIL-ih-tee) [peri- around, -stalsis contraction] (see-ROH-sah)
[mot- move, -il- relating to, -ity state] peritoneal space [ser- watery uid, -os- relating to, -a thing]
mouth (payr-ih-toh-NEE-al) serous
mucosa [peri- around, -tone- stretched, -al relating to] (SEE-rus)
(myoo-KOH-sah) peritoneum [ser- watery uid, -ous relating to]
18 pl., mucosae (payr-ih-toh-NEE-um) sigmoid colon
(myoo-KOH-see) [peri- around, -tone- stretched, -um thing] (SIG-moyd KOH-lon)
[muc- slime, -os- relating to, -a thing] permanent teeth [sigm- sigma ( or ) 18th letter o Greek
muscularis (PER-mah-nent teeth) alphabet (Roman S), -oid like, colon large
(mus-kyoo-LAYR-is) pharynx intestine]
[mus- mouse, -cul- little, -ar- relating to, (FAYR-inks) small intestine
-is thing] (smahl in-TEST-in)
[pharynx throat]
nasopharynx plica so t palate
(nay-zoh-FAYR-inks) (PLYE-kah) (PAL-et)
[naso- nose, -pharynx throat] pl., plicae [palat- roo o mouth]
neck (PLYE-kee) sphincter
(nek) [plica old] (SFINGK-ter)
oral cavity premolar [sphinc- bind tight, -er agent]
(OR-al KAV-ih-tee) (pree-MOHL-ar) splenic exure
[or- mouth, -al relating to, cav- hollow, [pre- be ore, -mola- millstone, -ar relating to] (SPLEN-ik FLEK-shur)
-ity state] protease [splen- spleen, -ic relating to, ex- bend,
oropharynx (PROH-tee-ayz) -ure action]
(or-oh-FAYR-inks) [prote- protein, -ase enzyme] stomach
[oro- mouth, -pharynx throat] (STUM-uk)
pyloric sphincter
pancreatic islet (islet o Langerhans) (pye-LOR-ik SFINGK-ter) [stomach mouth]
(pan-kree-AT-ik aye-let) (AYE-let o [pyl- gate, -or- to guard, -ic relating to, sublingual gland
LAHN-ger-hans) sphinc- bind tight, -er agent] (sub-LING-gwall gland)
[pan- all, -creat- esh, -ic relating to, isl- island, pylorus [sub- under, -lingua- tongue, -al relating to,
-et little] [Paul Langerhans German (pye-LOR-us) gland acorn]
pathologist] [pyl- gate, -orus guard] submandibular gland
papilla rectum (sub-man-DIB-yoo-lar gland)
(pah-PIL-ah) (REK-tum) [sub- under, -mandibul- chew (mandible or
pl., papillae [rect- straight, -um thing] jawbone), -ar relating to, gland acorn]
(pah-PIL-ee)
regulation submucosa
[papilla nipple]
(reg-yoo-LAY-shun) (sub-myoo-KOH-sah)
parotid gland [regula- rule, -tion process] [sub- under, -muc- slime, -os- relating to,
(per-AH-tid gland) -a thing]
[par- beside, -ot- ear, -id relating to,
gland acorn]
 CHAPTER 18 Digestive System 523

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 522)

sucrase trypsin vermi orm appendix

(SOO-krayz) (TRIP-sin) (VERM-ih- orm ah-PEN-diks)
[sucr- sugar, -ase enzyme] [tryps- pound, -in substance] [vermi- worm, - orm shape, append- hang upon,
sucrose upper esophageal sphincter (UES) -ix thing]
(SOO-krohs) (UP-er eh-so -eh-J EE-al SFINGK-ter villus
[sucr- sugar, -ose carbohydrate (sugar)] [yoo ee es]) (VIL-us)
transverse colon [eso- carry, -phag- ood (eat), -al relating to, pl., villi
(tranz-VERS KOH-len) sphinc- bind tight, -er agent] (VIL-aye)
[trans- across, -vers- turn, colon large intestine] uvula [villus shaggy hair]
tricuspid (YOO-vyoo-lah)
(try-KUS-pid) [uva- grape (or bunch o grapes), -ula little]
[tri- three, -cusp- point, -id characterized by]

LANGUAGE OF M ED IC IN E

anorexia cirrhosis dental caries

(an-oh-REK-see-ah) (sih-ROH-sis) (DENT-al KAYR-ees)
[an- without, -orex- appetite, -ia condition] [cirrhos- yellow-orange, -osis condition] [dent- tooth, -al relating to, caries decay] 18
appendicitis cle t lip diabetes mellitus (DM)
(ah-pen-dih-SYE-tis) (kle t lip) (dye-ah-BEE-teez MELL-ih-tus) [dee em]
[appendic- hang upon, -itis in ammation] [cle t split] [diabetes pass-through or siphon,
ascites cle t palate mellitus honey-sweet]
(ah-SYE-tees) (kle t PAL-et) diarrhea
[ascit- bag, -es condition] [cle t split, palate roo o mouth] (dye-ah-REE-ah)
bariatrics colitis [dia- through, -rrhea ow]
(bayr-ee-AT-riks) (koh-LYE-tis) diverticulitis
[bari- weight, -iatr- physician, -ic relating to] [col- colon, -itis in ammation] (dye-ver-tik-yoo-LYE-tis)
Barrett esophagus colonoscopy [diverticul- bypath, -itis in ammation]
(BAHR-ett ee-SOF-ah-gus) (koh-lon-AH-skah-pee) dysentery
[Norman R. Barrett English surgeon, eso- carry, [colon large intestine, -scop- see, -y activity] (DIS-en-tayr-ee)
-phag- ood (eat)] colorectal cancer [dys- ill, -enter- intestines, -y activity]
biliary colic (koh-loh-REK-tal KAN-ser) emesis
(BIL-yah-ree KOL-ik) [colo- colon, -rect- straight, -al relating to, (EM-eh-sis)
[bil- bile, -ary relating to, col- colon, cancer crab or malignant tumor] [emesis vomit]
-ic relating to] colostomy endoscope
cholecystectomy (kah-LAH-stoh-mee) (EN-doh-skohp)
(kohl-eh-sis-TEK-toh-mee) [colo- large intestine, -stom- mouth (opening), [endo- within, -scop- see]
[chole- bile, -cyst- bag, -ec- out, -tom- cut, -y activity] enteritis
-y action] constipation (en-ter-AYE-tis)
cholecystitis (kon-stih-PAY-shun) [enter- intestine, -itis in ammation]
(koh-leh-sis-TYE-tis) [constipa- crowd together, -ation process] gallstone
[chole- bile, -cyst- bag, -itis in ammation] Crohn disease (GAWL-stohn)
choledocholithiasis (krohn dih-ZEEZ) [gall- bile]
(koh-LED-uh-koh-lih-THY-ah-sis) [Burrill B. Crohn American physician, gastritis
[chole- bile, -doch- containing, -lith- stone, dis- opposite o , -ease com ort] (gas-TRY-tis)
-iasis condition] cystic f brosis (CF) [gastr- stomach, -itis in ammation]
cholelithiasis (SIS-tik ye-BROH-sis (see e )) gastroenteritis
(koh-leh-lih-THY-ah-sis or [cyst- sac, -ic relating to, f br- f ber, (gas-troh-en-ter-AYE-tis)
koh-leh-lih-THEE-ah-sis) -osis condition] [gastr- stomach, -enter- intestine,
[chole- bile, -lith- stone, -iasis condition] -itis in ammation]

Continued on p. 524
 524 CHAPTER 18 Digestive System

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 523)

gastroenterology malabsorption syndrome peritonitis

(gas-troh-en-ter-AHL-oh-jee) (mal-ab-SORP-shun SIN-drohm) (payr-ih-toh-NYE-tis)
[gastr- stomach, -entero- intestine, [mal- bad, -ab- rom, -sorp- suck, -tion process, [peri- around, -ton- stretch (peritoneum),
-o- combining vowel, -log- words (study o ), syn- together, -drome running or (race) -itis in ammation]
-y activity] course] portal hypertension
gastroesophageal re ux disease (GERD) maldigestion (PORT-al hye-per-TEN-shun)
(gas-troh-eh-so -eh-J EE-al REE- uks (mal-dye-J ES-chun) [port- doorway, -al relating to,
dih-ZEEZ [gerd]) (mal- bad, -digest- break apart, -tion process] hyper- excessive, -tens- stretch or pull
[gastro- stomach, -eso- carry, -phag- ood (eat), malocclusion tight, -sion state]
-al relating to, re- again or back, - ux ow, (mal-oh-CLEW-zhun) pyloric stenosis
dis- opposite o , -ease com ort] [mal- bad, -oc- against, -clu- shut or close, (pye-LOR-ik steh-NOH-sis)
gingivitis -sion state] [pyl- gate, -or- guard, -ic relating to,
(jin-jih-VYE-tis) nausea stenos- narrow, -osis condition]
[gingiv- gum, -itis in ammation] (NAW-zee-ah) pylorospasm
heartburn [naus- ship, -ea condition] (pye-LOHR-oh-spaz-um)
(hart-burn) nursing assistant [pyl- gate, -or- guard, -spasm twitch or
Helicobacter pylori (NURS-ing ah-SIS-tent) involuntary contraction]
(HEEL-ih-koh-BAK-ter pye-LOH-ree) [nurs- nourish or nurture, assist- help, sigmoidoscopy
[Helic- helix, -bacter rod (bacterium), pyl- gate, -ant agent] (SIG-moyd-os-koh-pee)
-or- guard, -i o the] oral candidiasis [sigm- sigma ( or ) 18th letter o Greek
hepatitis (OR-al kan-dih-DYE-eh-sis) alphabet (Roman S), -oid- like, -scop- see,
18 (hep-ah-TYE-tis)
[hepat- liver, -itis in ammation]
[or- mouth, -al relating to, candid- white,
-iasis condition]
-y activity]
snu dippers pouch
hepatitis C virus (HCV) oral rehydration therapy (ORT) (snu DIP-erz powch)
(hep-ah-TYE-tis see VYE-rus (OR-al ree-hye-DRAY-shun THAYR-ah-pee) [snu powered tobacco]
[aych see vee]) [or- mouth, -al relating to, re- back again, stoma
[hepat- liver, -itis in ammation, C letter o -hydra- water, -ation process, (STOH-mah)
Roman alphabet, virus poison] therapy treatment] pl., stomata
hiatal hernia orthodontics (STOH-mah-tuh or stoh-MAH-tuh)
(hye-AY-tal HER-nee-ah) (or-thoh-DON-tiks) [stoma mouth]
[hiat- gap, -al relating to, hernia rupture] [ortho- straight or upright, -odont- tooth, thrush
jaundice -ic relating to] (thruhsh)
(J AWN-dis) pancreatitis [thrush throat]
[jaun- yellow, -ice state] (pan-kree-ah-TYE-tis) triple therapy
lactose intolerance [pan- all, -creat- esh, -itis in ammation] (TRIP-pul THAYR-ah-pee)
(LAK-tohs in-TOL-er-ans) patient care technician [tri- three, -pl- plus or added, therapy treatment]
[lact- milk, -ose carbohydrate (sugar), in- not, (PAY-shent kayr tek-NISH-en) ulcer
-toler- bear, -ance state] [techn- art or skill, -ic relating to, (UL-ser)
leukoplakia -ian practitioner] [ulcer sore]
(loo-koh-PLAY-kee-ah) periodontitis upper GI (UGI)
[leuko- white, -plak- at area (tongue), (payr-ee-oh-don-TYE-tis) (upper jee aye [yoo jee aye])
-ia condition] [peri- around, -odont- tooth, -itis in ammation] [GI gastrointestinal]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Ove rvie w o Dige s tio n
A. Alimentary anal, digestive tra t, r gastr intestinal (GI)
tra t (Figure 18-1)
1. Extends r m m uth t anus9 meters (29 eet) in
length
2. Inv lved in digesti n and abs rpti n nutrients
3. Main rgans are part the tra t and a ess ry rgans
are inside r surr unding the tra t (Table 18-1)
B. Primary me hanisms the digestive system
1. T e digestive system uses many me hanisms
(Table 18-2)
2. Ingesti n mplex ds taken int the GI tra t
3. Digesti ngr up pr esses that break mplex
nutrients int simpler nes
a. Me hani al digesti nbreakup large hunks
d int smaller bits
b. Chemi al digesti nbreaks large m le ules int
smaller nes
4. M tilitya number GI m vements resulting r m
mus ular ntra ti n
5. Se reti nrelease digestive jui es and h rm nes
that a ilitate digesti n
6. Abs rpti nm vement digested nutrients int the
internal envir nment the b dy
7. Eliminati nm vement residues digesti n ut
alimentary anal
8. Regulati nneural, h rm nal, and ther me hanisms
that regulate digestive a tivity
Wall o the Dige s tive Tract
A. Digestive tra t des ribed as mus ular tube that extends
r m m uth t anus; the inner h ll w spa e is alled the
lumen
B. Wall the digestive tube is rmed by ur layers
(Figure 18-2)
1. Mu satype varies depending n GI l ati n
(t ugh and strati ed r deli ate and simple epithe-
lium); mu us pr du ti n
2. Submu sa nne tive tissue layer
CHAPTER 18 Digestive System 525
3. Mus ularis ir ular, l ngitudinal, and blique (in
st ma h) layers sm th mus le imp rtant in GI
m tility
a. Peristalsiswavelike m vement pushes d
d wn the tra t (Figure 18-3)
b. Segmentati nba k-and- rth mixing m ve-
ment (Figure 18-4)
4. Ser saser us membrane that vers the utside
abd minal rgans; it atta hes the digestive tra t t the
wall the abd min pelvi avity by rming lds
alled mesenteries
Mo uth
A. Stru ture ral avity
1. R rmed by hard palate (parts maxillary and
palatine b nes) and s t palate, an ar h-shaped mus le
separating m uth r m pharynx; uvula, a d wnward
pr je ti n s t palate helps in spee h and swall w-
ing (deglutiti n) 18
2. Fl r rmed by t ngue and its mus les, lingual
renulum ( ld mu sa that helps an h r t ngue)
(Figure 18-5)
B. eeth
1. ypes teethin is rs, anines ( uspids), prem lars
(bi uspids), and m lars (tri uspids)
a. wenty teeth in de idu us r baby set; average age
r utting rst t th ab ut 6 m nths; set mplete
at ab ut 30 m nths age
b. T irty-tw teeth in permanent set; 6 years ab ut
average age r starting t ut rst permanent
t th; set mplete usually between ages 17 and
24 years (Figure 18-6)
2. ypi al t th (Figure 18-7)
a. T ree main parts r wn, ne k, and r t
b. Enamel, whi h vers the r wn, is hardest tissue
in b dy
C. Salivary glands (Figure 18-8)
1. Saliva
a. Ex rine gland se reti n f ws thr ugh salivary
du ts int the m uth
b. Watery mixture ntains enzymes (salivary amylase),
s dium bi arb nate (NaH CO 3), and mu us
(1) Begins digesti n arb hydrates
(2) Lubri ates d during masti ati n
(3) Neutralizes ba terial a ids in m uth
2. Par tid glands
a. Largest salivary glands
b. Pr du es saliva ntaining NaH CO 3
3. Submandibular glandsdu ts pen n either side
lingual renulum
4. Sublingual glandsmultiple du ts pen int f r
m uth
 526 CHAPTER 18 Digestive System
D. Dis rders the M uth
1. In e ti ns, an er, ngenital de e ts, and ther dis r-
ders an ause seri us mpli ati ns in luding malnu-
triti n; in e ti ns and an er an spread t ther
stru tures
2. Can er
a. Leuk plakiapre an er us nditi n m uth
tissue
(1) Snu dippers p u h aused by use
hewing t ba (Figure 18-9, A)
(2) Squam us ell ar in mam st mm n
rm m uth an er (Figure 18-9, B)
3. Dental nditi ns
a. Dental aries (Figure 18-9, C)
(1) th disease resulting in permanent de e t
alled a avity
(2) In e ti n may spread t ther adja ent tissues
r t bl d
(3) L st r diseased teeth may be repla ed by den-
tures r implants (Figure 18-9, D)
b. Gingivitisgum inf ammati n r in e ti n
(1) M st ases result r m p r ral hygiene
(2) Can be a mpli ati n diabetes, vitamin
de ien y, r pregnan y
18 . Peri d ntitisinf ammati n peri d ntal
membrane
(1) O ten a mpli ati n advan ed r untreated
gingivitis
(2) Leading ause t th l ss am ng adults
4. In e ti n
a. T rush, r ral andidiasis
(1) Caused by yeast rganisms the Candida
gr up
(2) Pat hes heesy-l king exudate rm ver
an inf amed t ngue and ral mu sa, whi h
it hes and bleeds easily (Figure 18-9, E)
(3) C mm n in immun suppressed individuals
(with AIDS) r a ter antibi ti therapy
5. C ngenital de e ts
a. Cle t lip and le t palatem st mm n ngeni-
tal de e ts the m uth (Figure 18-10)
(1) May ur al ne r t gether
(2) Caused by ailure m uth stru tures t use
during embry ni devel pment
Pharynx
A. Stru ture
1. T ree divisi ns: nas pharynx, r pharynx, laryng -
pharynx (Figure 18-11)
2. nsils rm lymph id ring that prevents digestive
tra t in e ti n
B. Fun ti ndeglutiti n (swall wing)
1. O r pharynx pharyngeal segment m st inv lved in
deglutiti n
2. Deglutiti n m vements regulated by m t r rtex
erebrum (v luntary) and deglutiti n enter
brainstem (inv luntary)
Es o phag us
A. Mus ular, mu us-lined tube ab ut 25 m (10 in hes)
l ng
B. C nne ts pharynx t st ma h
C. D ynami passageway r dmus ular walls help push
b lus t ward st ma h
D. Sphin ters at ea h end es phagus help keep ingested
material m ving in ne dire ti n d wn the tube
1. Upper es phageal sphin ter (UES)
2. L wer es phageal sphin ter (LES)
E. Ref ux
1. Gastr es phageal ref ux disease (GERD)
a. Ba kf w a idi st ma h ntents int es pha-
gus auses sympt ms heartburn and indigesti n
b. M ild sympt ms treated by n nsurgi al measures
in lude dietary hanges, weight l ss, a id bl king
r bu ering medi ati ns, and drugs that
strengthen LES
. Severe and requent epis des GERD an trigger
asthma atta ks, ause severe hest pain, bleeding, r
narr wing and hr ni irritati n es phagus
(Figure 18-12)
d. Untreated GERD may result in a pre an er us
nditi n alled Barrett es phagus (Figure 18-13)
2. H iatal hernia
a. St ma h pushes thr ugh hiatus in the diaphragm
(Figure 18-14)
b. Chara terized by ref ux (GERD); all ws st ma h
a id t bypass LES
S to m ach
A. Stru ture
1. Divisi ns undus (r unded base), b dy (main part),
pyl rus (apex)
2. Sizeexpands a ter large meal; ab ut size large
sausage when empty (Figure 18-15)
3. Mus ularismany sm th mus le bers in three
layers; ntra ti ns pr du e hurning m vements
(peristalsis)
4. Mu sa
a. Many mi r s pi gastri glands se rete gastri
jui e ntaining enzymes, hydr hl ri a id, and
intrinsi a t r int st ma h
b. Mu us membrane lies in lds (rugae) when
st ma h is empty
5. Pyl ri sphin ter mus le l ses pening between
pyl rus (l wer part st ma h) and du denum
B. Fun ti n
1. F d enters st ma h thr ugh LES and digestive
pr ess ntinues
2. Partial digesti n pr teins urs a ter hyme is held
in the st ma h r s me time
C. Dis rders the st ma h
1. Signs and sympt ms
a. Gastr enter l gystudy st ma h and intestines
and their diseases
 CHAPTER 18 Digestive System 527

b. St ma h is site numer us p ssible diseases and b. Segmentati n mixes digestive jui es with hyme
nditi ns and helps with abs rpti n
. Gastri diseases ten exhibit these signs r symp- C. Dis rders the small intestine
t ms: gastritis (inf ammati n), an rexia (appetite 1. Enteritisintestinal inf ammati n
l ss), nausea (upset st ma h), and emesis (v miting) 2. Gastr enteritisinf ammati n st ma h and
2. Pyl r spasmabn rmal spasms the pyl ri intestines
sphin ter 3. Malabs rpti n syndr megr up sympt ms result-
a. C mm n nditi n in in ants ing r m ailure t abs rb nutrients pr perly (e.g.,
b. Pyl ri sten sis is similar abn rmality bstru tive an rexia, weight l ss, abd minal bl ating, ramps,
narr wing the pyl ri pening anemia, and atigue)
3. Ul er pen w und aused by a id in gastri jui e
(Figure 18-16)
a. O ten urs in du denum r st ma h
Live r and Gallbladde r
b. Ass iated with in e ti n by the ba terium Helico- A. Stru ture (Figure 18-18)
bacter pylori and use NSAIDs 1. Liver
. Current treatment inv lves triple therapy a. Largest ex rine gland
4. St ma h an er b. Fills upper right se ti n abd minal avity and
a. In reased risk with nsumpti n al h l, pre- extends ver int le t side (Figure 18-1)
served d, use hewing t ba , and in e ti n . Se retes bile, a mixture hemi als in water
by H. pylori d. Ex ret ry r ute r yell wish bile pigments r m
b. N pra ti al way t s reen r early stages bl d ( r m breakd wn ld RBCs)
e. Many ther metab li un ti ns (dis ussed in
Chapter 19)
S m all Inte s tine 2. Gallbladder
A. Stru ture a. L ati nundersur a e the liver, sa with 18
1. Sizeab ut 7 meters (20 eet) l ng but nly 2 m r lded interi r
s in diameter (Figure 18-17) b. Fun ti n n entrates and st res bile pr du ed in
2. Divisi ns the liver
a. D u denum 3. D u ts (Figure 18-18)
b. Jejunum a. H epati drains bile r m liver
. Ileum b. Cysti du t by whi h bile enters and leaves
3. Many iled l ps a mm date a l ng tube within gallbladder
the sh rt abd minal avity . C mm n bile rmed by uni n hepati and
4. D u denum is site mu h hemi al digesti n ysti du ts; drains bile r m hepati r ysti du ts
a. D u ts r m pan reas and liver enter tra t here int du denum
b. Maj r and min r du denal papillae are bumps B. Fun ti n
where the se reti ns enter 1. Bile ntains bile salts that emulsi y the ats in hyme
B. Fun ti n 2. Bile ntains h lester l that an be eliminated r m
1. Main un ti nsdigesti n and abs rpti n; small the b dy
intestine d es m st these un ti ns r the digestive 3. CCK ( h le yst kinin) is a h rm ne triggered by at
system in hyme; CCK auses the gallbladder t ntra t and
2. Intestinal se reti ns and digesti ns push st red bile int du ts leading t du denum
a. Intestinal glandsmany mi r s pi glands se rete C. Dis rders the liver and gallbladder
intestinal jui e (water, enzymes, i ns) 1. Gallst neshard lumps made h lester l, rystal-
b. Pan reati and liver se reti ns lized bile pigments, and al ium salts
. M st hemi al digesti n urs in du denum a. Ch lelithiasis nditi n having gallst nes
3. Abs rpti n (Figure 18-19)
a. H uge abs rptive sur a e area b. Ch le ystitisinf ammati n the gallbladder;
(1) Cir ular lds (pli ae) may a mpany h lelithiasis
(2) Intestinal villi and mi r villimi r s pi . St nes an bstru t bile analsa nditi n alled
nger-shaped pr je ti ns h led h lithiasis ausing jaundi e
(3) Bl d apillaries abs rb arb hydrate and 2. H epatitisliver inf ammati n
pr tein pr du ts (sugars; amin a ids) a. Chara terized by liver enlargement, jaundi e,
(4) La teals (lymph apillaries) abs rb ats an rexia, dis m rt, gray-white e es, and dark urine
4. M tilitysm th mus le bers ntra t t pr du e b. Caused by a variety a t rs: t xins; ba teria;
m vements viruses; hepatitis A, B, and C; and parasites
a. Peristalsis pushes hyme al ng, t ward large
intestine
 528 CHAPTER 18 Digestive System
3. Cirrh sisdegenerati n liver tissue inv lving
repla ement n rmal (but damaged) tissue with
br us and atty tissue (Figure 18-20, A)
4. P rtal hypertensi nhigh bl d pressure in the
hepati p rtal veins aused by bstru ti n bl d
f w in a diseased liver; may ause vari sities sur-
r unding systemi veins (Figure 18-20, B)
Pancre as
A. Ex rine and end rine gland that lies behind st ma h
(Figure 18-18 and Figure 18-21)
B. Ex rine pan reati ells se rete pan reati jui e
1. M st imp rtant digestive jui e, ntaining enzymes t
digest arb hydrates, pr teins, lipids; ntains s dium
bi arb nate that neutralizes st ma h a id in hyme
2. Se reted int pan reati du ts; main du t empties int
du denum
C. Pan reati islets (islets Langerhans)end rine ells
n t nne ted with pan reati du ts; se rete h rm nes
glu ag n and insulin int the bl d
D. Pan reati dis rders
1. Diabetes mellitus (DM)s me ases DM result
r m ailure pan reati islets t se rete su ient
18 insulin
2. Pan reatitisinf ammati n pan reas
a. A ute pan reatitis results r m bl ked du ts that
r e pan reati jui e t ba kf w
b. Pan reati enzymes digest the gland
3. Cysti br sisthi k se reti ns bl k f w pan re-
ati jui e
4. Pan reati an ervery seri us; atal in the maj rity
ases
Large Inte s tine
A. Stru ture (Figure 18-22)
1. Ce umblind-end p u h at beginning large intes-
tine; hyme enters e um thr ugh ile e al valve
2. C l nas ending, transverse, des ending, and
sigm id segments
3. Re tumempties e es thr ugh anal anal and exter-
nal pening alled anus
B. Fun ti n
1. Mi r bi me (f ra)mi r rganisms that help digest
nutrients, pr du e vitamins, and supp rt immune pr -
te ti n; pr du e gases (f atulen e r f atus)
2. Abs rpti n water, salts, vitamins
3. In reased m tility may pr du e diarrhea and
de reased m tility may result in nstipati n
4. De e ati neliminati n e es; regulated by v lun-
tary and inv luntary anal sphin ters
C. Dis rders the large intestine ten relate t abn rmal
m tility (rate m vement ntents)
1. M tility dis rders
a. Diarrhearesults r m abn rmally in reased intes-
tinal m tility; may result in dehydrati n r
nvulsi ns
b. C nstipati nresults r m de reased intestinal
m tility
2. Inf ammat ry nditi ns
a. Diverti ulitis (inf ammati n abn rmal p u hes
alled diverticula)may ause nstipati n
(Figure 18-22, C)
b. C litisgeneral name r any inf ammat ry ndi-
ti n the large intestine
3. C l re tal an era mm n malignan y the
l n and re tum ass iated with l ni p lyps; risk
a t rs in lude advan ed age, l w- ber and high- at
diets, and geneti predisp siti n
Appe ndix
A. Blind, w rm-shaped tube e um (Figure 18-22)
B. Fun ti ns as an in ubat r r ba teria the intestinal
mi r bi me
C. Appendi itisinf ammati n r in e ti n appendix
1. I appendix ruptures, in e ti us material may spread t
ther rgans (Figure 18-22, D)
2. M st mm n a ute abd minal nditi n requiring
surgery
3. A e ts 7% t 12% p pulati n y unger than
30 years
Pe rito ne um
A. L ati n and des ripti nlarge sheet ser us mem-
brane (Figure 18-23)
1. Parietal layer perit neum lines abd minal avity
2. Vis eral layer perit neum vers abd minal rgans
3. Perit neal spa elies between parietal and vis eral
layers; pr du es lubri ating perit neal (ser us) f uid
4. Retr perit nealdes ribes stru tures utside the
parietal perit neum, su h as kidneys
B. Extensi ns perit neumlargest are the mesentery
and greater mentum (Figure 18-23, B)
1. Mesenteryextensi n parietal perit neum, whi h
atta hes m st small intestine t p steri r abd mi-
nal wall
2. Greater mentum (la e apr n)hangs d wn r m
l wer edge st ma h and transverse l n in r nt
intestines
C. Perit nitisinf ammati n perit neum resulting r m
in e ti n r ther irritant; ten a mpli ati n rup-
tured appendix
D. As itesabn rmal a umulati n f uid in perit neal
spa e; ten auses bl ating abd men (Figure 18-24)
Dige s tio n
A. De niti npr ess that trans rms nutrients int a
rm that an be abs rbed and used by ells (Table 18-2)
1. Me hani al digesti n hewing, swall wing, and
peristalsis break ingested material int tiny parti les,
mix them well with digestive jui es, and m ve them
al ng the digestive tra t

2. Chemi al digesti nbreaks up large nutrient m le-
ules int smaller m le ules that an be easily
abs rbed; br ught ab ut by digestive enzymes
B. Enzymes and hemi al digesti n (Table 18-3 and
Figure 18-25)
1. Enzymespr tein m le ules that a t as atalysts,
speeding up hemi al rea ti ns
2. Chemi al digesti nspe i enzymes speed up
breakd wn spe i m le ules and n thers
3. H ydr lysisenzymati rea ti ns that add water t
break large m le ules int smaller m le ules
C. Carb hydrate digesti nmainly in small intestine
1. Pan reati amylasebreaks star hes d wn int
disa harides
2. Intestinal jui e enzymes
a. Maltasedigests malt se
b. Su rasedigests su r se
. La tasedigests la t se; de ien y is alled lactose
intolerance
D. Pr tein digesti nstarts in st ma h; mpleted in small
intestine
1. H ydr hl ri a id in gastri jui es un lds large pr -
teins and nverts pepsin gen t a tive pepsin
2. Gastri jui e enzyme pepsin partially digests pr teins
3. Pan reati enzyme trypsin digests pr teins int
smaller peptides
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the dige s tive s ys te m in Chapte r 5. The
s tructure s o the dige s tive s ys te m can be divide d into two
parts : the tube calle d the gas trointe s tinal tract and the acce s -
s ory organs (organs that are not part o the tube ). In m os t
cas e s , the acce s s ory organs produce s ubs tance s that are re -
le as e d into the tube . The tube is com pos e d o our laye rs o
tis s ue . The actual proce s s o dige s tion occurs ins ide this tube .
1. Make f ash ards and he k nline res ur es t help y u
learn the name, l ati n, and un ti n the rgans
the gastr intestinal tra t and the a ess ry rgans.
2. Devel p a n ept map t utline the r ute nutrients take
thr ugh the digestive system. In lude the enzymes
present in ea h rgan where appli able. Y u als may
wish t in lude what nutrients are digested and/ r
abs rbed in ea h rgan.
3. Make a hart the dis rders the digestive system.
Gr up them by the rgan that is a e ted and the me ha-
nism r ause the dis rder.
CHAPTER 18 Digestive System 529
4. Intestinal peptidases break apart peptides int indi-
vidual amin a ids
E. Fat digesti n
1. Bile ntains n enzymes but emulsi es ats (breaks
at dr plets int very small dr plets)
2. Pan reati lipase breaks d wn emulsi ed ats t atty
a ids and gly er l in small intestine
Abs o rptio n
A. Me hanisms abs rpti n
1. De niti npr ess by whi h digested nutrients m ve
r m intestine int bl d r lymph
2. Me hanisms in lude di usi n, sm sis, and a tive
transp rt (Figure 18-25)
3. Nutrients and m st water, minerals, and vitamins are
abs rbed r m small intestine; s me water and
vitamin K als abs rbed r m large intestine
B. Sur a e area and abs rpti n
1. Stru tural adaptati ns in rease abs rptive sur a e area
2. Fra tal ge metrystudy irregular ragmented
ge metri shapes su h as th se in lining intestine
that have alm st unlimited sur a e area
18
4. T e pr ess digesti n is explained in terms what
type nutrient is being digested: arb hydrates, ats, r
pr teins. T e hemi al pr ess digesti n uses s me su -
xes that an make the pr esses easier t learn. T e su x
-ose indi ates that the substan e is a arb hydrate. T e
su x -ase indi ates the substan e is an enzyme. In many
ases, the rst part the enzymes name tells y u what
substan e is being digested. Maltose is digested by the
enzyme maltase. I y u kn w this general rule, remember-
ing what digests what be mes a l t easier. T e pr tein
enzymes pepsin and trypsin are ex epti ns t this rule.
5. F r a better understanding the terms, re er t the Lan-
guage S ien e and the Language Medi ine se ti ns.
6. In y ur study gr up, review y ur f ash ards the stru -
tures the digestive system and y ur hart the dis r-
ders the digestive system. Use Table 18-3 t quiz ea h
ther n the enzymes, the substan es they digest, and the
end pr du ts they pr du e. Review the hapter utline
summary and the questi ns at the ba k the hapter,
and dis uss p ssible test questi ns.
 530 CHAPTER 18 Digestive System
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Name and des ribe the ur layers the wall the gas-
tr intestinal tra t.
2. Name the un ti n the uvula and s t palate.
3. Identi y the un ti n the di erent types teeth.
4. Des ribe the three main parts the t th.
5. W hat is leuk plakia? W hat uld devel p r m it?
6. Distinguish between gingivitis and peri d ntitis.
7. Name the three pairs salivary glands and des ribe
where the du t r m ea h enters the m uth.
8. Identi y where arb hydrate digesti n begins.
9. De ne deglutiti n.
10. W hat is the un ti n the upper and l wer es phageal
sphin ter mus les?
11. De ne peristalsis.
12. Name the three parts the triple therapy used t treat
ul ers?
18 13. Explain h w bile r m the liver and gallbladder rea hes
the small intestine. W hat is the un ti n
h le yst kinin?
14. W hat is the relati nship between b dy weight and the
rmati n gallst nes?
15. De ne hepatitis. W hat are the signs and sympt ms
hepatitis?
16. W hat is ntained in pan reati jui e?
17. W hat d the ba teria in the large intestine ntribute t
the b dy?
18. List the seven subdivisi ns the large intestine.
19. Des ribe the mesentery and the greater mentum.
20. De ne the terms peritonitis and ascites.
21. Di erentiate between me hani al digesti n and hemi-
al digesti n.
22. Brief y des ribe the pr ess arb hydrate digesti n.
23. Brief y des ribe the pr ess at digesti n.
24. Brief y des ribe the pr ess pr tein digesti n.
25. Explain the pr ess abs rpti n. W hat un ti n d the
la teals have in abs rpti n?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
26. W hat w uld happen i the small intestine had n pli ae,
villi, r mi r villi?
27. Bile d es n t ause a hemi al hange; what is the e e t
bile n at, and why d es this make at digesti n m re
e ient?
28. S me pe ple are la t se int lerant. T is means they are
less able t ully digest la t se sugar. W hat enzyme is
pr bably n t un ti ning pr perly and what type
nutrients sh uld these pe ple try t av id?
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. Nutrients underg three kinds pr essing in the b dy.
All ells per rm metab lism, but ________ and
________ are per rmed by the digestive system.
2. A thin membrane alled the ________ atta hes the
t ngue t the f r the m uth.
3. T e ________ and ________ prevent d and liquids
r m entering the nasal avity ab ve the m uth when
d is swall wed.
4. T e three main parts the t th are ________,
________, and ________.
5. T e three salivary glands are the ________, ________,
and ________.
6. T e ________ layer the wall the gastr intestinal
tra t ntains bl d vessels and nerves.
7. T e ________ is the innerm st layer the wall the
gastr intestinal tra t.
8. T e tube nne ting the m uth and st ma h is the
________.
9. T e three divisi ns the st ma h are the ________,
________, and ________.
10. Gastri jui e is mp sed ________ and ________.
11. A ter the st ma h mixes the swall wed b lus th r ughly
with the gastri jui e, the nutrients leave the st ma h in
a semis lid mixture alled ________.
12. A nditi n during in an y when the pyl ri bers d
n t relax n rmally is alled ________.
13. T e three divisi ns the small intestines are the
________, ________, and ________.
14. T e tiny ngerlike pr je ti ns vering the pli ae the
small intestines are alled ________.
15. T e lymphati vessels in the villi are alled the ________.
16. T e mm n bile du t is rmed by the uni n the
________ r m the liver and the ________ r m the
gallbladder.
17. T e pan reas se retes ________ ________ whi h neu-
tralizes the hydr hl ri a id in the gastri jui e that
enters the small intestines.
18. T e part the large intestine between the as ending
and des ending l n is the ________.
19. T e tw m st pr minent extensi ns the perit neum
are the ________ and the ________.
20. T e pr ess by whi h digested nutrients are m ved r m
the digestive system t the ir ulating f uids is alled
________.
 CHAPTER 18 Digestive System 531

Match each term in Column A with its corresponding statement in Column B.

Column A Column B
21. ________ emulsi ati n a. enzyme that is made in the pan reas and digests at
22. ________ amylase b. enzyme that is made in the small intestine and digests pr tein
23. ________ pepsin . gland that pr du es bile
24. ________ h le yst kinin d. the nal end pr du t pr tein digesti n
25. ________ peptidase e. e e t bile has n at dr plets
26. ________ ysti . the rm that d takes in the m uth s that it an be swall wed easily
27. ________ b lus g. the nal end pr du t arb hydrate digesti n
28. ________ simple sugars h. ne the nal end pr du ts at digesti n
29. ________ amin a id i. enzyme that is made in b th the salivary glands and the pan reas and digests star h
30. ________ liver j. enzyme that is made in the st ma h and digests pr tein
31. ________ lipase k. h rm ne that stimulates the ntra ti n the gallbladder
32. ________ gly er l l. du t that nne ts the gallbladder t the mm n bile du t

Match each disorder in Column A with its cause or description in Column B.

Column A
33. ________ gingivitis
34. ________ peri d ntitis
35. ________ gastr enteritis
36. ________ ul er
37. ________ h le ystitis
38. ________ hepatitis
39. ________ diverti ulitis
40. ________ litis
41. ________ perit nitis
42. ________ as ites
Column B
a. inf ammati n the st ma h and intestines
b. a liver inf ammati n; B type is m re seri us than A type
. inf ammati n abn rmal utp u hings in the large intestine
d. inf ammati n the peri d ntal membrane
e. abn rmal a umulati n f uid in the perit neal spa e
. a general term r the inf ammati n the large intestine 18
g. a general term r gum inf ammati n r in e ti n
h. inf ammati n the perit neum
i. inf ammati n the gallbladder
j. pen w unds aused by gastri a id, ten ass iated with Helicobacter pylori

when he lies d wn in bed. H is physi ian believes Fred

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Be ause Alyse has ailed t regularly brush r f ss her
teeth, she has been in rmed that she may eventually l se
s me her teeth. Give the sequen e events in whi h a
ailure t brush and f ss the teeth w uld lead t l ss
teeth.
2. Y u have been diagn sed as having a gastri ul er. Y ur
physi ian pres ribed the drug am tidine (Pep id). T is
drug has an a ti n similar t imetidine, but it is mu h
m re p tent. H w will am tidine help y ur ul er? Y ur
br ther als has an ul er, but his physi ian has pres ribed
su ral ate (Cara ate), a medi ati n that has an antipepsin
a ti n and tends t adhere t membrane injuries. Explain
h w su ral ate might help y ur br thers ul er.
3. Fred has been experien ing re urring epis des heart-
burn, espe ially when he bends ver t la e his sh es r
may have a hiatal hernia. n rm this diagn sis, she
has s heduled Fred r a barium swall w. In this test, a
barium- ntaining f uid that bl ks x-rays is swall wed s
that the st ma h appears as a bright mass in a radi graph.
I Fred has a hiatal hernia, what sh uld the radi l gist see
n the radi graph? Can y u explain what aused the
sympt ms that br ught Fred in t see his physi ian?
4. Jim wants t begin an exer ise pr gram. H e is 25 and has
n t been a tive in the past be ause he be mes dehy-
drated s rapidly and be mes ill. H is d t r has ered
s me suggesti ns that might help. Cir le what y u w uld
suggest and then er a reas n r his requent
dehydrati n.
a. Drink (large r small) v lumes water
b. Drink ( l r warm) liquids
. Drink f uids with (high r l w) s lute n entrati n
d. (Mild r intense) exer ise is best
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Nutrition and Metabolism
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Metabolic Function o the Liver, 534

Macronutrients, 534
Dietary Sources o Nutrients, 534
Carbohydrate Metabolism, 535
Fat Metabolism, 537
Protein Metabolism, 538
Micronutrients, 538
Vitamins, 538
Minerals, 540
Regulating Food Intake, 541
Metabolic Rates, 541
Metabolic and Eating Disorders, 542
Metabolic Imbalances, 542
Eating Disorders, 543
Body Temperature, 544
Thermoregulation, 544
Abnormal Body Temperature, 545

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Describe the role o the liver in metabolism.
2. Describe the metabolic roles o carbohydrates, ats,
proteins, vitamins, and minerals.
3. Describe mechanisms that regulate ood intake, and
def ne basal metabolic rate, as well as list some
actors that a ect it.
4. List and describe three disorders associated with
eating or metabolism.
5. Discuss the physiological mechanisms that regulate
body temperature.
 19
N u t r it io n and metab lism are w rds that are ten used t getherbut LANGUAGE OF
what d they mean? Nutrition is a term that re ers t the ds that we eat S C IEN C E
and the nutrients they ntain. Pr per nutriti n requires a balan e the three
basi types energy-yielding nutrientscarbohydrates, ats, and proteins plus
Be o re re ading the
essential vitamins and minerals. Malnutriti n is a de ien y r imbalan e in
chapte r, s ay e ach o
the nsumpti n nutrients. the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
pr m te g d health, the United States, Canada, and ther g vernments the m as yo u re ad.
and rganizati ns pr vide individualized nline d guides that help a pers n
determine the pr per am unts and balan e nutrients (Figure 19-1).
acetyl CoA
(ah-SEET-il koh ay)
A g d phrase t remember in nne ti n with the w rd metabolism is use [acetyl vinegar, CoA coenxyme A]
nutrients be ause basi ally this is what metab lism isthe use the b dy aerobic
makes nutrients a ter they have been digested, abs rbed, and ir ulated t (ayr-OH-bik)
ells. It uses them in tw ways: as an energy s ur e and as building [aer- air, -bi- li e, -ic relating to]
bl ks r making mplex hemi al mp unds. agricultural scientist
(ag-rih-KUL-cher-al SYE-en-tist)
Be re they an be used in these tw ways, nutrients [agr- f eld, -cultur- tilling, -al relating
have t be assimilated. Assimilation urs when to, scien- knowledge, -ist agent]
nutrient m le ules enter ells and underg many amino acid
hemi al hanges there. All the hemi al rea - (ah-MEE-no AS-id)
ti ns that release energy r m nutrient m le- [amino NH2, acid sour]
ules make up the pr ess catabolism, a anabolism
vital pr ess be ause it is the nly way that (ah-NAB-oh-liz-em)
the b dy has supplying itsel with energy [ana- up, -bol- throw (build),
r d ing any w rk. Catab lism breaks nu- -ism action]
trient m le ules d wn int smaller m le- anaerobic
ules and releases energy in the pr ess. (an-ayr-OH-bik)
T e many hemi al rea ti ns that build [an- without, -aer- air, -bi- li e,
-ic relating to]
these smaller nutrient m le ules int
m re mplex hemi al mp unds antioxidant
(an-tee-OK-seh-dent)
nstitute the pr ess anabolism.
[anti- against, -oxi- sharp (oxygen),
-ant agent]
Catab lism and anab lism t gether
appetite center
make up the pr ess metab lism.
(AP-ah-tyte SEN-ter)
Metab lism is the ng ing rem d- [a(d)- toward, -pet- seek out,
eling and maintenan ebreaking -ite relating to]
and buildingthat hara terizes assimilation
all li e. (ah-sim-ih-LAY-shun)
[assimila- make alike, -tion process]
T is hapter expl res many basal metabolic rate (BMR)
the basi ideas ab ut why ertain (BAY-sal met-ah-BAHL-ik rayt
nutrients are ne essary r sur- [bee em ar])
vival, h w they are used by the [bas- basis, -al relating to,
b dy, and what an g wr ng in meta- over, -bol- throw,
metab li and eating dis rders. -ic relating to]

Continued on p. 546

533
 534 CHAPTER 19 Nutrition and Metabolism

M e t a b o lic Fu n c t io n o t h e Live r
As we dis ussed in Chapter 18, the liver plays an imp rtant
r le in me hani al digesti n lipids be ause it se retes bile.
Re all that bile breaks large at gl bules int smaller dr plets
at that are m re easily digested by the enzyme lipase.
In additi n, the liver per rms many ther un ti ns ne es-
sary r healthy survival. T e liver plays a maj r r le in the
metab lism all three main types nutrients.
F r example, the liver helps maintain a n rmal bl d glu-
se n entrati n r a ew h urs a ter a meal by st ring
glu se when it is verly abundant then releasing the glu se
int the bl d as needed. Many mplex hemi al rea ti ns,
regulated by many di erent h rm nes, assist in these st rage
and release pr esses.
Liver ells als arry ut the rst steps pr tein and at
metab lism. Liver ells als synthesize several kinds pr - FIGURE 19-1 Food guide. Canada, the United States, and many other
teins. T ese pr teins, when released int bl d, are alled the countries provide online, individualized ood guides that help people deter-
mine proper amounts and a healthy balance o nutrients. The website
blood proteins, r plasma proteins. Pr thr mbin and brin - ChooseMyPlate.gov is hosted by the U.S. Department o Agriculture (USDA).
gen, plasma pr teins rmed by liver ells, play essential parts
in bl d l tting (see p. 365). An ther plasma pr tein made
by liver ells, albumin, helps maintain n rmal bl d v lume. QUICK CHECK
T e liver an als det xi y the b dy t xi substan es
1. Wh a t a re th e th re e b a s ic n u trie n t typ e s ?
su h as ba terial pr du ts and ertain drugs. On e det xi ed, 2. Wh a t is m e ta b o lis m ?
these hemi als are ten easier t ex rete r m the b dy. T e 3. De s crib e a t le a s t th re e u n ctio n s o th e live r.
liver an als st re several substan es, n tably ir n and vita-
mins A and D.
T e liver is assisted by an interesting and unique stru tural M a c ro n u t r ie n t s
pattern the bl d vessels that supply it. Re all r m Chap-
D ie t a ry S o u r c e s o N u t r ie n t s
ter 15 that the hepati p rtal vein delivers bl d dire tly r m
the gastr intestinal tra t t the liver (see Figure 15-11). T is Put simply, the mp nents ds that are digested and ab-
arrangement all ws bl d that has just abs rbed nutrients and s rbed by the b dy are alled nutrients. T e big threenutrients
ther substan es t be pr essed by the liver be re being in ur diets are arb hydrates ( arbs), lipids ( ats and ils),
distributed thr ugh ut the b dy. T us ex ess nutrients and and pr teins. Be ause they rm the bulk ur diet, these
vitamins an be st red and t xins an be rem ved e iently three nutrients are s metimes alled macronutrients. Vitamins
r m bl d arriving r m the GI tra tbe re the bl d and minerals, by ntrast, are alled micronutrients be ause
19 rea hes ther areas the b dy. they are needed in nly very small quantities in ur diet.

TABLE 19-1 Major Macronutrients

NUTRIENT DIETARY S OURCES FUNCTIONS
Carbo hydrate
Monos accharide (glucos e , Fruit, honey, corn s yrup Us e d as a s ource o e ne rgy; us e d to build othe r carbohydrate s
galactos e , ructos e )
Dis accharide (s ucros e , lactos e , Sugar, ruit, dairy, m alte d Source o m onos accharide s ( or e ne rgy)
m altos e ) grain products
Polys accharide (s tarch, die tary Grains , ve ge table s , nuts , Source o m onos accharide s ( or e ne rgy); die tary f be r prom ote s e f cie nt
f be r) ruits dige s tive unction
Fat (Lipid)
Triglyce ride (abs orbe d as atty Me at, ve ge table oils Provide e ne rgy
acids , glyce rol) Structural padding
Chole s te rol Me at, e ggs , dairy Trans ports lipids ; s tabilize s ce ll m e m brane s ; is bas is o s te roid horm one s
Pro te in
Many type s (abs orbe d as indi- Me at, e ggs , dairy, ve ge ta- Form s tructure s o the body (f be rs s uch as ke ratin and collage n)
vidual am ino acids ) ble s , nuts Facilitate che m ical re actions (e nzym e s )
Se nd s ignals and re gulate unctions (ne urotrans m itte rs , nons te roid horm one s )
Produce m ove m e nt (myof lam e nts )
May be us e d or e ne rgy
 CHAPTER 19 Nutrition and Metabolism 535

Table 19-1 summarizes the three ma r nutrients, their prin- S TORAGE

(in live r and mus c le c e lls )
ipal s ur es in ur d, and their main un ti ns in ur
b dy. T e ll wing se ti ns expl re s me these un ti ns Glycoge n
m re deeply.
Glucos e Glucos e Glucos e Glucos e Glucos e
C6 C6 C6 C6 C6
C a r b o h yd r a t e M e t a b o lis m
Glycoge ne s is Glycoge nolys is
Carb hydrates are the pre erred energy nutrient the b dy. (a na bolis m) (ca ta bolis m)
T e larger arb hydrate m le ules are mp sed smaller ANAEROBIC
building bl ks, primarily glucose (see Chapter 2). H uman (in c yto plas m)
ells atab lize (break d wn) glu se rather than ther sub- Glucos e
stan es as l ng as en ugh glu se enters them t supply their C6
energy needs.
ADP
G lu c o s e C a t a b o lis m
Glu se atab lism inv lves three series hemi al rea ti ns 2 ATP
alled metab li pathways, that ur in a pre ise sequen e:
1. Gly lysis
2. Citri a id y le ( r Krebs y le) P yruvic a cid P yruvic a cid
C3 C3
3. Ele tr n transp rt system (E S)
Glycolysis, the rst step glu se atab lism, urs in AEROBIC
(in mito c ho ndrio n)
the yt plasm ea h ell the b dy. As Figure 19-2 sh ws,
gly lysis breaks d wn glu se (a six- arb n m le ule) int Ca rbon Ca rbon
tw pyruvic acids (three arb n m le ules). Gly lysis re- dioxide dioxide
C C
leases a small am unt energyen ugh t generate tw Ace tyl CoA Ace tyl CoA
aden sine triph sphate (A P) m le ulesbut requires n C2 C2 Ca rbon
xygen t d s . We thus say that it is an anaerobic pr ess. dioxide
Ca rbon
dioxide C
Ea h pyruvi a id m le ule may then m ve int a mito-
C Citric Citric
chondrion ne the ells tiny battery hargers that trans- a cid a cid
ers mu h m re the nutrient energy t A P (see Figure 3-2 cycle cycle Ca rbon
n p. 45). A ter pyruvi a id is br ken d wn int the 2- arb n e- e- dioxide
Ca rbon C
a etyl m le ule, a coenzyme A (CoA) then es rts it int the dioxide
O2
C Ele ctron Tra ns port S ys te m
citric acid cycle r Krebs cycle as a m le ule alled acetyl
CoA. T e itri a id y le releases high-energy ele tr ns as it
breaks d wn the a etyl C A (tw arb ns) int tw arb n
ADP 36 ATP
19
di xides (ea h having nly ne arb n) using enzymes l ated
inside the mit h ndri n. FIGURE 19-2 Metabolism o glucose. Glucose can be stored as sub-
T e hemi al rea ti ns gly lysis and the itri a id y- units o glycogen in liver and muscle cells until needed to make adenosine
triphosphate (ATP). A ter glycogen is split apart, each individual glucose
le release energy st red in the glu se m le ule. M re than
molecule undergoes glycolysis in the cytoplasm. Glycolysis splits one mol-
hal the released energy is in the rm high-energy ele - ecule o glucose (six carbon atoms) into two molecules o pyruvic acid (three
tr ns. T e electron transport system, embedded in the inner carbon atoms each) and produces enough energy to generate two ATPs.
lds the mit h ndri n, trans ers the energy r m these Each pyruvic acid is converted to the two-carbon acetyl molecule, which is
ele tr ns t m le ules A P. escorted by coenzyme A (CoA) into the citric acid cycle in the mitochondrion
as acetyl CoA. The citric acid cycle breaks apart each pyruvic acid molecule
Up t 36 m le ules A P an be generated in the mit -
into three carbon dioxide molecules (one carbon atom each) and many high-
h ndri n r every riginal glu se m le ule that enters this energy electrons. The electron transport system (also in the mitochondrion)
metab li pathway. T e rest the energy riginally st red in uses energy rom these electrons to generate up to 36 ATPs in the presence
the glu se m le ule is released as heat, whi h ntributes t o oxygen (O2). ADP, Adenosine diphosphate.
a pers ns b dy temperature.
T e metab li pathway inside the mit h ndri n is, in
ntrast t gly lysis, an xygen-using r aerobic pr ess. A ATP
ell ann t perate the itri a id y le r ele tr n transp rt A P serves as the dire t s ur e energy r d ing ellular w rk
systemwhere m st the energy glu se is released in all kinds living rganisms r m ne- ell plants t trilli n-
with ut xygen. ell animals, in luding humans. Am ng bi l gi al mp unds,
there re, A P ranks as ne the m st imp rtant.
To better understand these concepts, use the
T e energy trans erred t A P m le ules di ers in tw
Active Concept Map Metabolism o Glucose to
ways r m the energy st red in nutrient m le ules: (1) the
Generate ATP at evolve.elsevier.com.
energy in A P m le ules is n t st red but is released alm st
 536 CHAPTER 19 Nutrition and Metabolism

P hos pha te FIGURE 19-3 Adenosine triphosphate (ATP). A, The structure o ATP. A single adenos-
Ade nos ine groups ine group (A) has three attached phosphate groups (P). The high-energy bonds between the
phosphate groups can release chemical energy to do cellular work. B, ATP energy cycle. ATP
ATP A P P P stores energy in its last high-energy phosphate bond. When that bond is later broken, energy
is released to do cellular work. The adenosine diphosphate (ADP) and phosphate groups that
High-e ne rgy bonds result can be resynthesized into ATP, capturing additional energy rom nutrient catabolism.
A

ATP
A P P P

Ene rgy High-e ne rgy bonds Ene rgy

ADP
From A P P P To
nutrie nt ce llula r
B ca ta bolis m proce s s e s

instantane usly, and (2) it an be used dire tly t d ellular
w rk.
Release the energy st red in nutrient m le ules urs
mu h m re sl wly be ause atab lism nutrients must ur
rst. Energy released r m nutrient m le ules ann t be used
dire tly r d ing ellular w rk. It must rst be trans erred t
A P m le ules and then be suddenly released r m them.
HEA LTH AND WELL-BEIN G
CARBOHYDRATE LOADING
A num be r o athle te s and othe rs w ho m us t occas ionally
s us tain e ndurance exe rcis e or a s ignif cant pe riod practice
carbo hydrate lo ading , or g lyco ge n lo ading . As w ith live r
ce lls , s om e s ke le tal m us cle f be rs can take up and s tore
19 glucos e in the orm o glycoge n. By ce as ing inte ns e exe r-
cis e and s w itching to a die t high in carbohydrate s 2 or
3 days be ore an e ndurance eve nt, an athle te can caus e the
s ke le tal m us cle s to s tore alm os t tw ice as m uch glycoge n
as us ual. This allow s the m us cle s to s us tain ae robic exe r-
cis e or up to 50% longe r than us ual. The conce pt o carbo-
hydrate loading has be e n us e d to prom ote the us e o e n-
e rgy bar s port s nacks and s om e s ports or e ne rgy drinks .
As Figure 19-3 sh ws, A P is made up an aden sine
gr up and three ph sphate gr ups. T e apa ity A P t
release large am unts energy is und in the high-energy
b nds that h ld the ph sphate gr ups (P) t gether, repre-
sented as urvy lines. W hen a ph sphate gr up breaks
the m le ule, an adenosine diphosphate (ADP) m le ule and
ree ph sphate gr up result. Energy that had been h lding the
ph sphate b nd t gether is reed t d ellular w rkmus le
ber ntra ti ns, r example.
As y u an see in Figure 19-3, the ADP and ph sphate are
reunited by the energy pr du ed by arb hydrate atab lism,
making A P a reusable energy-st rage m le ule. Only
en ugh A P r immediate ellular requirements is made at
any ne time. New A P is nstantly being made t meet
hanging ellular demands. Glu se that is n t needed im-
mediately r A P pr du ti n is built up (by anab li pr -
esses) int larger m le ules that are st red r later use.
A n a b o lis m
Glu se anab lism is alled glycogenesis. Carried n hief y
by liver and mus le ells, gly genesis nsists a series
rea ti ns that j in glu se m le ules t gether, like many
beads in a ne kla e, t rm glycogen, a mp und s me-
times alled animal starch.
Later, when the glu se st red as gly gen is needed t
make A P, a pr ess alled glycogenolysis breaks d wn gly-
gen in the liver r mus le ells t release individual glu se
m le ules. Gly gen lysis is an example atab lism.

Re g u la t io n o C a r b o h yd r a t e M e t a b o lis m
S mething w rth n ting is that the am unt glu se and
ther nutrients in the bl d n rmally d es n t hange very
mu h, n t even when we g with ut d r many h urs,
when we exer ise and use a l t nutrients r energy, r when
we sleep and use ew nutrients r energy. T e am unt
glu se in ur bl d, r example, usually stays at ab ut 80 t
110 mg in 100 mL bl d when we are asting between
meals.
Several h rm nes help regulate arb hydrate metab lism t
keep bl d glu se at a n rmal level. Insulin is ne the m st
 300 150 CHAPTER 19 Nutrition and Metabolism 537
Ins ulin
Glucos e

)
L
I
n
d
200 100
/
s
g
u
m
l
i
HEA LTH AND WELL-BEIN G

n
(
e
(

s
U
o
100 50 LOW-CARB DIETS

/
c
m
u
l
L
G
)
Low-carbohydrate die ts have be com e incre as ingly popular
am ong thos e atte m pting we ight los s . Whe n carbohydrate
0 0
catabolis m e quals e ne rgy ne e ds , ats are not take n out o
0 1 2 3 4 5 6
s torage and catabolize d. Low-carbohydrate die ts are bas e d
Time (hr)
on the rationale that w he n the body is not s upplie d w ith
FIGURE 19-4 Role o insulin. Insulin operates in a negative eedback exce s s am ounts o carbohydrate s to m e e t its e ne rgy
loop that prevents blood glucose concentration rom increasing too ar ne e ds , it w ill not conve rt the s urplus carbohydrate s to at
above the normal range. A ter a meal, intestinal absorption rises and he- and s tore it. Ins te ad, the body re lie s on at m e tabolis m to
patic portal blood glucose concentration increasesas shown by the blue s upply e ne rgy ne e ds be twe e n m e als . This eve ntually re -
line in the graph. Insulin secretion by the pancreatic islets increases in re- duce s ove rall triglyce ride s tore s in the body, and as a re s ult,
sponse (orange line). Insulin promotes uptake o glucose (out o the blood) the pe rs on los e s the ir exce s s we ight. In addition, s om e
by liver cells. As blood glucose decreases to its setpoint level, eedback to
re s e arch s tudie s on the s e die ts have de m ons trate d an im -
the pancreatic islets reduces insulin secretionthus maintaining normal
blood glucose concentration. One expects to see a sharp rise in blood insulin prove d plas m a lipid prof le .
levels shortly a ter a meal high in carbohydrates. Howeve r, the re is s till m uch controve rs y re garding the
m any type s o low-carbohydrate die ts and w hich are m os t
s a e and e e ctive or thos e s truggling w ith obe s ity, diabe -
imp rtant these. Alth ugh the exa t details its me hanism te s , and othe r dis orde rs . Ultim ate ly, the m os t s ucce s s ul
a ti n are still being w rked ut, insulin is kn wn t a eler- we ight-re ducing die t m ay be the one that e ach pe rs on can
ate glu se transp rt thr ugh ell membranes. As insulin se re- s tick to or the longe s t duration and produce s the be s t long-
ti n in reases, m re glu se leaves the bl d and enters the te rm he alth e e cts .
ellsparti ularly the liver ells (see Figure 12-4 n p. 324 and
Figure 19-4).
little insulin se reti n r resistan e t insulin e e ts, anteri r pituitary gland, cortisone se reted by the adrenal
su h as urs in pe ple with vari us rms diabetes mellitus rtex, epinephrine se reted by the adrenal medulla, and
(DM ), pr du es the pp site e e ts. Less glu se leaves the glucagon se reted by the pan reati islets are ur the
bl d and enters ells. M re glu se there re remains in the m st imp rtant h rm nes that in rease bl d glu se.
bl d, and less glu se is metab lized by ells. In ther w rds, M re in rmati n ab ut these h rm nes an be und in
high bl d glu se (hypergly emia) and a l w rate glu se Chapter 12.
metab lism hara terize insulin de ien y r resistan e.
Insulin is the nly h rm ne that signi antly l wers the To learn more about the citric acid cycle, go to
bl d glu se level. Several ther h rm nes, n the ther AnimationDirect online at evolve.elsevier.com.
hand, an in rease it. Growth hormone se reted by the
Fa t M e t a b o lis m
19
Lipids, like arb hydrates, are primar-
ily energy nutrients. As ells begin t
RES EA RC H, IS S U ES , AND TREN D S run l w n adequate am unts glu-
MEAS URING ENERGY se t atab lize a ew h urs a ter a
Phys iologis ts s tudying m e tabolis m m us t be able to expre s s a quantity o e ne rgy in meal, they immediately shi t t the
m athe m atical te rm s . The unit o e ne rgy m e as ure m e nt m os t o te n us e d is the calorie atab lism trigly erides at r
(cal). A calo rie is the am ount o e ne rgy ne e de d to rais e the te m pe rature o 1 g o energy.
wate r 1 C. Be caus e phys iologis ts o te n de al w ith ve ry large am ounts o e ne rgy, the Fats are rst br ken d wn int atty
large r unit, kilo calo rie (kcal) or Calo rie (notice the uppe rcas e C), is us e d. The re are a ids and gly er l in adip se tissue and
1000 cal in 1 kcal or Calorie . Nutritionis ts in the Unite d State s pre e r to us e Calorie released int the bl d stream. In ells,
w he n they expre s s the am ount o e ne rgy s tore d in a nutrie nt. atty a ids are br ken d wn t rm
Mos t phys iologis ts in the Unite d State s and m os t nutritionis ts outs ide the Unite d a etyl C A, whi h then pr eeds
State s pre e r to us e the m e tric unit jo ule (J) or kilojoule (kJ ) ins te ad o calorie -bas e d
thr ugh the itri a id y le (see
units . A s im ple way to conve rt kilocalorie s to kilojoule s is kcal 4.2 kJ.
Figure 19-2). Gly er l is nverted t a
mp und that an enter the gly lysis
To learn more about measuring energy, including examples o the
pathway in a pr ess is kn wn as
energy content o macronutrients and the energy cost o common
gluconeogenesis.
activities, review the article Measuring Energy at Connect It! at
Glu ne genesis, dis ussed in Chap-
evolve.elsevier.com.
ter 12, is a pr ess that is per rmed
mainly by liver ells. By nverting the
 538 CHAPTER 19 Nutrition and Metabolism

mp nents at int m le ules that enter the pathway r

TABLE 19-2 Amino Acids
glu se atab lism, this pr ess all ws energy t be trans erred
r m a nutrient t A Pwhi h an be used dire tly r w rk ES S ENTIAL NONES S ENTIAL
in the ells the b dy. (INDIS PENS ABLE) (DIS PENS ABLE)
Fat atab lism happens n rmally when a pers n g es His tidine * Alanine
with ut arb hydrates r a ew h urs. It happens abn rmally Is ole ucine Arginine
in individuals with untreated DM. Be ause an insulin de - Le ucine As paragine
Lys ine As partic acid
ien y, t little glu se enters the ells a diabeti pers n t
Me thionine Cys te ine
supply all energy needs. T e result is that the ells atab lize
Phe nylalanine Glutam ic acid
ats t make up the di eren e (Figure 19-5). Thre onine Glutam ine
In all pers ns, ats n t needed r atab lism are instead Tryptophan Glycine
anab lized (built up) t rm trigly erides and then are st red Valine Proline
in adip se tissue, whi h ntributes t weight gain. Se rine
Tyros ine

P ro t e in M e t a b o lis m *Es s e ntial in in ants and, pe rhaps , adult m ale s .

Can be s ynthe s ize d rom phe nylalanine ; the re ore , is none s s e ntial as long
In a healthy pers n, pr teins are atab lized t release energy as phe nylalanine is in the die t.
nly t a very small extent. W hen at reserves are l w, as they
are in the starvati n that a mpanies ertain eating dis rders are th se that must be in the diet. Nonessential amino acids an
su h as an rexia nerv sa, the b dy an start t use m re its be missing r m the diet be ause they an be made by the b dy
pr tein m le ules as an energy s ur e. Ex ess pr teins in the (Table 19-2).
diet an als be used r energy.
Spe i ally, the amino acids that make up pr teins are
ea h br ken apart. T e nitr gen gr up amine is rem ved by QUICK CHECK
the liver and nverted t the waste pr du t urea. T e rest 1. Na m e th re e m a cro n u trie n ts a n d tw o m icro n u trie n ts .
the m le ule is nverted by glu ne genesis t a rm that 2. Id e n ti y th e s e rie s o ch e m ica l re a ctio n s th a t m a ke u p th e
an enter the itri a id y leand thus release energy t p ro ce s s o g lu co s e m e ta b o lis m .
3. Ho w is e n e rg y tra n s e rre d ro m g lu co s e to ATP?
harge up A P (see Figure 19-5). 4. Ho w a re p ro te in s u s e d o n ce th e y a re a b s o rb e d in to th e
A ter a shi t t relian e n pr tein atab lism as a maj r b o d y?
energy s ur e urs, death may qui kly ll w be ause vital 5. Wh a t a re e s s e n tia l a m in o a cid s ?
pr teins in the mus les and nerves are atab lized.
A m re mm n situati n in n rmal b dies is pr -
tein anab lism, the pr ess by whi h the b dy M ic ro n u t r ie n t s
builds amin a ids int mplex pr tein m- Ca rbohydra te s Vit a m in s
p unds ( r example, enzymes and pr teins that
19 rm the stru ture the ell). Pr teins are assem- O ve r v ie w o Vit a m in s
bled r m a p l at least 20 di erent kinds One glan e at the label any pa kaged d pr d-
amin a ids. I any ne type amin a id is de ient, u t reveals the imp rtan e we pla e n vitamins
vital pr teins ann t be synthesizeda Glucos e and minerals. We kn w that arb hydrates,
seri us health threat. ats, and pr teins are used by ur b dies
One way y ur b dy maintains t build imp rtant m le ules and t
a nstant supply amin a ids pr vide energy. S why d we need vi-
is by making them r m ther Fa tty a cids Amino tamins and minerals?
Fa ts Glyce rol a cids P rote ins
mp unds already present First, lets dis uss the imp rtan e
in the b dy. Only ab ut hal vitamins. Vitamins are rgani m le-
the required 20 types ules needed in small quantities r n rmal
amin a ids an be made Ene rgy
Citric metab lism thr ugh ut the b dy.
by the b dy, h wever. T e a cid M st vitamin m le ules atta h t enzymes r
remaining types amin cycle coenzymes (m le ules that assist enzymes) and help
a ids must be supplied in them w rk pr perly. Many enzymes are t tally use-
the diet. Essential amino acids less with ut the appr priate vitamins t a tivate them.
S me vitamins play ther imp rtant r les in the
b dy. F r example, a rm vitamin A plays an imp r-
tant r le in dete ting light in the sens ry ells the retina.
FIGURE 19-5 Catabolism o nutrients. Fats, carbohydrates,
and proteins can be converted to products that enter the citric Vitamin D an be nverted t a h rm ne that helps
CO 2 regulate al ium h me stasis in the b dy, and vitamin E
acid cycle to yield energy that is trans erred to adenosine tri-
phosphate (ATP). a ts as an antioxidant that prevents highly rea tive xygen
 CHAPTER 19 Nutrition and Metabolism 539

m le ules alled ree radicals r m

damaging DNA and m le ules in C LIN ICA L APPLICATION
ell membranes.
M st vitamins ann t be made CHOLESTEROL
by the b dy, s we must eat them Cho le s te ro l is a type o lipid that has m any us e s in the body (s e e Chapte r 2). The body
in ur d. T e b dy an st re at- de rive s s te roid horm one s rom chole s te rol (s e e Chapte r 12) and us e s chole s te rol to s ta-
s luble vitaminsA, D, E, and bilize the phos pholipid bilaye r that orm s the plas m a m e m brane and m e m branous organ-
Kin the liver r later use. Be- e lle s o all ce lls (s e e Chapte r 3).
ause the b dy ann t st re water- So w hy doe s s uch a us e ul s ubs tance have s uch a bad re putation? The re as on lie s in
s luble vitamins su h as B vitamins the act that an exce s s o chole s te rol in the blood, a condition calle d hype rcho le s te ro le m ia,
and vitamin C, they must be n- incre as e s the ris k o deve loping athe ros cle ros is (s e e arrow in f gure ). You m ay re call rom
Chapte r 14 that athe ros cle ros is deve lops into a type o arte rios cle ros is , or hard-
tinually supplied in the diet. Vita-
e ning o the arte rie s , that can le ad to he art dis e as e , s troke , and othe r
min de ien ies an lead t severe
proble m s .
metab li pr blems. Table 19-3 lists Hype rchole s te role m ia occurs m os t o te n in pe ople w ith a ge ne tic
s me the m re well-kn wn vita- pre dis pos ition but is ce rtainly als o a e cte d by othe r actors s uch
mins, their s ur es, un ti ns, and as die t and exe rcis e . Pe ople w ith hype rchole s te role m ia are
sympt ms de ien y. e ncourage d to s w itch to die ts low in chole s te rol and s atu-
rate d ats and to participate in ae robic exe rcis e , both o
Vit a m in Im b a la n c e s w hich te nd to lowe r blood chole s te rol leve ls . Drugs
Vitamin de ien y, r avitamin- s uch as s tatins are o te n us e d to control blood
osis, an lead t severe metab li chole s te rol w he n exe rcis ing and die t are not
pr blems. F r example, avitamino- s u f cie nt.
Chapte r 2 dis cus s e s di e re nt type s o cho- Athe ros cle rotic
sis C (vitamin C de ien y) an
le s te rol and the ir role s in he alth and dis e as e . pla que
lead t scurvy (Figure 19-6). S urvy
results r m the inability the
b dy t manu a ture and maintain
llagen bers. As y u may have
gathered r m y ur studies thus ar, llagen bers are riti al vitamin A are nsumed daily ver a peri d 3 m nths r
in many the nne tive tissues that h ld the b dy t gether. m re. T is nditi n rst mani ests itsel with dry skin, hair
In s urvy, the b dy alls apart in the same way that a negle ted l ss, an rexia (appetite l ss), and v miting, but may pr gress
h use eventually alls apart. t severe heada hes and mental disturban es, liver enlarge-
M re details ab ut s urvy and ther types avitamin sis ment, and asi nally irrh sis. A ute hypervitamin sis A,
are given in Appendix A at evolve.elsevier.com. hara terized by v miting, abd minal pain, and heada he, an
S me rms hypervitaminosis r vitamin ex ess ur i a massive verd se is ingested.
an be just as seri us as a de ien y vitamins. F r example, Ex esses the at-s luble vitamins (A, D, E, and K) are
hr ni hypervitaminosis A an ur i very large am unts generally m re seri us than ex esses the water-s luble 19

S C IEN C E APPLICATIONS
FOOD S CIENCE
At the daw n o the twe ntie th ce n-
tury, one f gure loom e d large in the
world o o o d s cie nce Ge orge
Was hington Carve r. Born a s lave
on a Mis s ouri plantation during the
Civil War, Carve r ove rcam e gre at
obs tacle s to be com e one o the
m os t adm ire d Am e rican s cie ntis ts
o his e ra. Although tale nte d in
m us ic and art, it was his knack or
George Washington Carver agriculture that le d him to a long
(18641943) and s ucce s s ul care e r as a pro e s -
s or, re s e arche r, and inve ntor in the
agriculture de partm e nt o Alabam as Tus ke ge e Ins titute .
At Tus ke ge e , his work re s ulte d in the cre ation o 325 prod-
ucts m ade rom pe anuts , ne arly 200 products rom yam s
(s we e t potatoe s ), and hundre ds m ore rom othe r plants native
to the s outhe rn Unite d State s . Deve lopm e nt o the s e new
products he lpe d poor arm e rs s urvive by allow ing the m to
m ake m oney rom a varie ty o crops that thrive d on the ir land.
Today, bre akthroughs continue to be m ade in the world o
agriculture and ood s cie nce . Farm e rs and ranche rs work
clos e ly w ith ag ricultural s cie ntis ts and te chnicians to im -
prove ood crops and to im prove m e thods o rais ing live s tock.
As did Carve r, they s trive to work in ways that be ne f t the land
and pe ople . O cours e , nutritionis ts , die titians , che s , and ood
pre pare rs all play a role in ge tting the s e crops to our table in a
he althy and appe tizing way.
Food s cie ntis ts and othe r indus trial s cie ntis ts work to de -
ve lop te chnologie s and m e thods or pre paring, pre s e rving,
s toring, and packaging oods .
 540 CHAPTER 19 Nutrition and Metabolism

TABLE 19-3 Major Vitamins

VITAMIN
Vitam in A
B-com plex vitam ins
B1 (thiam ine )
B2 (ribo avin)
B3 (niacin)
B5 (pantothe nic acid)
B6 (pyridoxine )
B9 ( olic acid)
B12 (cyanocobalam in)
Biotin (vitam in H)
Vitam in C (as corbic acid)
Vitam in D (calci e rol)
Vitam in E (tocophe rol)
Vitam in K (group)
DIETARY S OURCE
Gre e n and ye llow ve ge table s ,
dairy products , and live r
Grains , m e at, and le gum e s
Gre e n ve ge table s , organ m e at,
e ggs , and dairy products
Me at and grains
Organ m e at, e ggs , and live r
Ve ge table s , m e at, and grains
Ve ge table s
Me at and dairy products
Ve ge table s , m e at, and e ggs
Fruits and gre e n ve ge table s
Dairy products and f s h live r oil
Gre e n ve ge table s and s e e ds
Mos tly rom inte s tinal bacte ria
Als o s pinach, othe r ve ge table s ,
and m e at/dairy products
FUNCTIONS
Maintains e pithe lial tis s ue and pro-
duce s vis ual pigm e nts
He lps e nzym e s in the citric acid cycle
Aids e nzym e s in the citric acid cycle
He lps e nzym e s in the citric acid cycle
Aids e nzym e s that conne ct at and car-
bohydrate m e tabolis m
He lps e nzym e s that catabolize am ino
acids
Aids e nzym e s in am ino acid catabolis m
and blood
Involve d in blood production and othe r
proce s s e s
He lps e nzym e s in am ino acid catabo-
lis m and at and glycoge n s ynthe s is
He lps in m anu acture o collage n f be rs
Aids in calcium abs orption
Prote cts ce ll m e m brane s rom oxidation
dam age
Ne e de d to produce s om e clotting
actors
CONS EQUENCES OF
DEFICIENCY
Night blindne s s and aking s kin
Ne rve proble m s (be ribe ri), he art
m us cle we akne s s , and e de m a
In am m ation o s kin and eye s
Pe llagra (s caly de rm atitis and
m e ntal dis turbance s ) and
ne rvous dis orde rs
Los s o coordination; de cre as e d
pe ris tals is (rare )
Convuls ions , irritability, and ane m ia
Dige s tive dis orde rs and ane m ia;
ne ural de e cts in e m bryo or
e tus
Pe rnicious ane m ia
Me ntal and m us cle proble m s (rare )
Scurvy and de ge ne ration o s kin,
bone , and blood ve s s e ls
Ricke ts and s ke le tal de orm ity
Mus cle and re productive dis orde rs
(rare )
Clotting dis orde rs (m os t o te n in
in ants )

19
vitamins (B mplex and C) be ause at-s luble vitamins are
st red, whereas ex ess water-s luble vitamins an be ex reted.

FIGURE 19-6 Scurvy. In scurvy, lack o vitamin C impairs the normal
maintenance o collagen-containing connective tissues, causing bleeding
and ulceration o the skin, gums, and other tissues, as these lesions on the
skin show.
M in e r a ls
Minerals are just as essential r health as vitamins. Minerals
are in rgani elements r salts und naturally in the earth
and in many ds. As with vitamins, mineral i ns an bind
t enzymes and help them w rk e e tively.
Minerals als un ti n in a variety ther vital hemi al
rea ti ns. F r example, s dium, al ium, and ther minerals
are required r nerve ndu ti n and r ntra ti n in
mus le bers. W ith ut these minerals, the brain, heart, and
respirat ry mus les w uld ease t un ti n.
In rmati n ab ut s me the m re imp rtant minerals is
summarized in Table 19-4.
Like vitamins, minerals are bene ial nly when taken in
the pr per am unts. Many the minerals listed in Table 19-4
are required nly in tra e am unts. Any intake su h miner-
als bey nd the re mmended tra e am unt may be me
t xi perhaps even li e threatening.
 CHAPTER 19 Nutrition and Metabolism 541

TABLE 19-4 Major Minerals

MINERAL DIETARY S OURCE FUNCTIONS SYMPTOMS OF DEFICIENCY
Calcium (Ca) Dairy products , le gum e s , and He lps blood clotting, bone orm ation, and Bone de ge ne ration and ne rve and
ve ge table s ne rve and m us cle unction m us cle m al unction
Chlorine (Cl) Salty oods Aids in s tom ach acid production and acid- Acid-bas e im balance
bas e balance
Cobalt (Co) Me at He lps vitam in B12 in blood ce ll production Pe rnicious ane m ia
Coppe r (Cu) Se a ood, organ m e ats , and Involve d in extracting e ne rgy rom the citric Fatigue and ane m ia
le gum e s acid cycle and in blood production
Iodine (I) Se a ood and iodize d s alt Aids in thyroid horm one s ynthe s is Goite r (thyroid e nlarge m e nt) and
de cre as e o m e tabolic rate
Iron (Fe ) Me at, e ggs , ve ge table s , and Involve d in extracting e ne rgy rom the citric Fatigue and ane m ia
le gum e s acid cycle and in blood production
Magne s ium (Mg) Ve ge table s and grains He lps m any e nzym e s Ne rve dis orde rs , blood ve s s e l dilation,
and he art rhythm proble m s
Mangane s e (Mn) Ve ge table s , le gum e s , and grains He lps m any e nzym e s Mus cle and ne rve dis orde rs
Phos phorus (P) Dairy products and m e at Aids in bone orm ation and is us e d to Bone de ge ne ration and m e tabolic
m ake ATP, DNA, RNA, and phos pholipids proble m s
Potas s ium (K) Se a ood, m ilk, ruit, and m e at He lps m us cle and ne rve unction Mus cle we akne s s , he art proble m s ,
and ne rve proble m s
Sodium (Na) Salty oods Aids in m us cle and ne rve unction and uid We akne s s and dige s tive ups e t
balance
Zinc (Zn) Many oods He lps m any e nzym e s Me tabolic proble m s

Foods that go beyond simply providing the nutri- M e t a b o lic Ra t e s

ents needed or health and wellness because they
have specif c characteristics that prevent disease
are o ten called unctional oods. To learn more
about this concept, review the article Functional
Foods at Connect It! at evolve.elsevier.com.
Re g u la t in g Fo o d In t a k e
Me hanisms r regulating d intake are still n t learly
underst d. T at the hypothalamus in the dien ephal n the
brain plays a part in these me hanisms, h wever, seems er-
tain. T ere appears t be b th an appetite center that pr -
m tes the eeling hunger and a satiety center that pr -
m tes the eeling that we are satis ed r ull in the
hyp thalamus. T e balan e a tivity between these tw
enters appears t be the entral me hanism that regulates
d intake.
T ere are many a t rs that inf uen e these hyp thalami
enters and there re inf uen e the regulati n d intake.
Am ng the many a t rs identi ed in a e ting appetite are
h rm nes, neur transmitters, em ti ns, envir nmental ues,
d sensati ns, habits, and m re. S me examples a t rs
that a e t the appetite-regulating enters the hyp thala-
mus are listed in Table 19-5. It is n t imp rtant t mem rize
all these a t rs, but reading thr ugh them will help y u un-
derstand the mplexity ur b dys regulati n d MR the individual eating the diet, r n weight l ss will
intake.
T e basal metabolic rate (BMR) is the rate at whi h nutri-
ents are atab lized under basal nditi ns (that is, when
the individual is resting but awake, is n t digesting d,
and is n t adjusting t a ld external temperature). O r,
stated di erently, the BM R is the energy (measured in
al ries) that must be pr du ed per h ur by atab li rea - 19
ti ns just t keep the b dy alive, awake, and m rtably
warm.
pr vide energy r mus ular w rk, as well as digesti n
and abs rpti n nutrients, an additi nal am unt energy
must be pr du ed by atab lism nutrients. T e am unt
additi nal energy r m nutrients needed depends mainly n
h w mu h w rk the individual d es. T e m re a tive he r she
is, the m re nutrients the b dy must atab lize and the higher
the t tal metab li rate will be. T e total metabolic rate
( MR) is the t tal am unt energy used by the b dy per
day (Figure 19-7).
W hen the number al ries in y ur d intake equals
y ur MR, y ur weight remains nstant (ex ept r p ssible
sh rt-term variati ns resulting r m water retenti n r water
l ss). W hen y ur d intake pr vides m re al ries than y ur
MR, y u gain weight; when y ur d intake pr vides ewer
al ries than y ur MR, y u l se weight. Nature d es n t
rget t unt al ries. A redu ing diet must make use this
kn wledge. T e diet must in lude ewer al ries than the
be a hieved.
 542 CHAPTER 19 Nutrition and Metabolism

TABLE 19-5 Factors That In uence Appetite*

FACTORS THAT STIMULATE APPETITE FACTORS THAT INHIBIT APPETITE S OURCE
Endoge nous opioid pe ptide s (EOP) Alpha-m e lanocyte s tim ulating horm one ( -MSH) Hypothalam us
Gam m a-am inobutyric acid (GABA) Cocaine - and am phe tam ine -re gulate d trans cript (CART)
Ne urope ptide Y (NPY) Corticotropin-re le as ing horm one (CRH)
Nore pine phrine (NE)
Orexins
Em otions Em otions Ne rvous s ys te m (outs ide
Environm e ntal s tim uli Environm e ntal s tim uli hypothalam us )
Food s e ns ations (e .g., tas te , s m e ll, texture ) Food s e ns ations (e .g., tas te , s m e ll)
Inte rnal s tim uli (e .g., blood te m pe rature , glucos e ) Inte rnal s tim uli (e .g., blood te m pe rature , glucos e )
Li e s tyle choice s and habits Li e s tyle choice s and habits
Cortis ol Adre nal cortex
Ghre lin (GHRL) Chole cys tokinin (CCK) Gas trointe s tinal (GI) tract
Glucagon-like pe ptide -1 (GLP-1)
Le ptin Adipos e tis s ue
Inte rle ukin 18 (IL-18)
Glucos e Live r
Ins ulin Pancre as
Pancre atic polype ptide (PP)

*Factors that a e ct appe tite -re gulating ce nte rs in the hypothalam us .

Rapid, signif cant weight loss carries a risk o

health risks. One such risk is outlined in the article
Gallstones and Weight Loss at Connect It! at
evolve.elsevier.com.
To learn more about the actors that in uence
metabolic rate, go to AnimationDirect online at
evolve.elsevier.com.
19 QUICK CHECK
1. Wh a t is th e ove ra ll jo b o vita m in s in th e b o d y?
2. Wh a t is a n o th e r n a m e o r th e ra te a t w h ich n u trie n ts a re
ca ta b o lize d u n d e r re s tin g co n d itio n s ?
3. Ho w d o e s th e n u m b e r o ca lo rie s co n s u m e d re la te to a
p e rs o ns b o d y w e ig h t?
4. Wh a t is th e d i e re n ce b e tw e e n th e a p p e tite ce n te r a n d th e
s a tie ty ce n te r? Wh e re a re th e s e ce n te rs lo ca te d ?
M e t a b o lic a n d Ea t in g D is o r d e r s
M e t a b o lic Im b a la n c e s
Dis rders hara terized by a disrupti n r imbalan e n r-
mal metab lism an be aused by several di erent a t rs.
F r example, inborn errors o metabolism are a gr up ge-
neti nditi ns inv lving a de ien y r absen e a parti u-
lar enzyme. Spe i enzymes are required by ells t arry ut
ea h step every metab li rea ti n. Alth ugh an abn rmal
geneti de may a e t the pr du ti n nly a single en-
zyme, the resulting abn rmal metab lism may have wide-
spread e e ts. Spe i diseases resulting r m inb rn err rs
metab lism, su h as phenylketonuria (PKU), are dis ussed in
Chapter 25.
A number metab li dis rders are mpli ati ns ther
nditi ns. F r example, y u may re all r m Chapter 12
that b th hyperthyr idism and hyp thyr idism have pr und
e e ts n the BMR. Diabetes mellitus a e ts metab lism

S ize Sex Body compos ition Age Amount of Mis ce lla ne ous
(s urfa ce a re a ) (le a n/fa t ra tio) thyroid hormone (fe ve r, drugs , e motions )

Bas al me tabo lic Exe rcis e a nd a ll Food inta ke Environme nta l

rate kinds of mus cula r (the rmic te mpe ra ture
a ctivity e ffe ct of food)

To tal me tabo lic

rate

FIGURE 19-7 Factors that determine the basal and total metabolic rates.
 CHAPTER 19 Nutrition and Metabolism 543

thr ugh ut the b dy when an insulin de ien y limits the hr ni li e-threatening diseases, in luding diabetes melli-
am unt glu se available r use by the ells. tus, many rms an er, and heart disease.

P ro t e in -C a lo r ie M a ln u t r it io n
Ea t in g D is o r d e r s Protein-calorie malnutrition (PCM) is an abn rmal ndi-
S me metab li dis rders result r m disrupti ns n rmal ti n resulting r m a de ien y al ries in general and
me hanisms in the b dy that maintain h me stasis. F r ex- pr tein in parti ular. PCM is likely t result r m redu ed
ample, the b dy has several me hanisms that maintain a rela- intake d but may als be aused by in reased nutrient
tively nstant level glu se in the bl dglu se that is l ss r in reased use nutrients by the b dy. Table 19-6 sum-
required by ells r li e-sustaining atab lism. As menti ned marizes a ew the wide variety nditi ns that may lead
earlier in this hapter, during starvation r in ertain eating t PCM.
disorders, these me hanisms may be me unbalan ed as they Mild ases PCM ur requently during illness. As
attempt t maintain bl d glu se h me stasis. many as ne in ve patients admitted t the h spital is signi -
A ew the m re well-kn wn eating and nutriti n dis r- antly maln urished. M re severe ases PCM are likely t
ders are brief y des ribed in the ll wing se ti ns. ur in parts the w rld where d, espe ially pr tein-ri h
d, is relatively unavailable.
A n o r e x ia N e r vo s a T ere are tw rms advan ed PCM: marasmus and
A behavi ral dis rder hara terized by hr ni re usal t eat, kwashiorkor (Figure 19-8).
anorexia nervosa ten results r m an abn rmal ear be m- Marasmus results r m an verall la k al ries and pr -
ing bese. T is nditi n is m st mm nly seen in teenage girls teins, su h as when su ient quantities d are n t avail-
and y ung adult w men and is ten linked t em ti nal stress. able. Marasmus is hara terized by pr gressive wasting
reatment plans are usually dire ted at s lving the result- mus le and sub utane us tissue a mpanied by f uid and
ing nutriti nal de it, while at the same time dealing with the ele tr lyte imbalan es.
underlying behavi ral pr blem.

Bu lim ia
Bulimia is a behavi ral dis rder
hara terized by insatiable rav-
ing r d alternating with peri-
ds sel -deprivati n. T e sel -
deprivati n that ll ws a d
binge is ten a mpanied by
depressi n.
Pe ple with a rm this dis-
rder alled bulimarexia pur-
p sely indu e the v miting ref ex
t purge themselves d they
just ate. Ex essive v miting in this
way an have a variety nse-
quen es, in luding damage t the
es phagus, pharynx, m uth, and
teeth by st ma h a id.
O b e s it y
O besity is n t an eating dis rder
itsel but may be a result hr ni
vereating behavi r. Like an rexia
nerv sa and bulimia, eating dis r-
ders hara terized by hr ni
vereating usually have an under-
lying em ti nal ause.
O besity is de ned as an abn r-
mal in rease in the pr p rti n
at in the b dy. M st the ex ess
at is st red in the sub utane us
tissue and ar und the vis era.
O besity is a risk a t r r a variety
TABLE 19-6 Some Causes o Protein-Calorie Malnutrition
CONDITION IMPACT ON NUTRIENTS
Co nditio ns That Re duce Nutrie nt Intake
Anorexia Abs e nce o appe tite ; re duce d m otivation to e at
Cachexia Syndrom e as s ociate d w ith cance r involve s appe tite los s , s eve re
we ight los s , and we akne s s
Dys phagia Di f culty in s wallow ing; inhibition o norm al e ating
Gas trointe s tinal obs truction Inability o ood to be dige s te d or abs orbe d
Naus e a Ups e t s tom ach; dis com ort, w hich inhibits appe tite
Pain Dis com ort, w hich dis courage s e ating 19
Pove rty Inability to acquire prope r nutrie nts
Social is olation Abs e nce o s ocial cue s or m otivation or e ating
Subs tance abus e Re duction or re place m e nt o the m otivation to e at
Tooth proble m s Di f culty in chew ing, w hich dis courage s or preve nts e ating
Co nditio ns That Incre as e Lo s s o Nutrie nts
Diarrhe a Incre as e d inte s tinal m otility, w hich re duce s abs orption o nutrie nts
Glycos uria Los s o glucos e in the urine
He m orrhage Los s o blood and the nutrie nts it contains
Malabs orption Failure to prope rly abs orb nutrie nts , w hich caus e s nutrie nts to
pas s through the body unabs orbe d
Co nditio ns That Incre as e the Us e o Nutrie nts by the Bo dy
Burns Los s o nutrie nts rom dam age d tis s ue s
Feve r Incre as e d te m pe rature and m e tabolic rate , w hich incre as e rate o
nutrie nt catabolis m
In e ction Incre as e d im m une activity and tis s ue re pair, w hich incre as e the
rate o nutrie nt us e
Traum a and s urge ry Incre as e d im m une activity, tis s ue re pair, and hom e os tatic-com -
pe ns ating m e chanis m s , w hich incre as e the rate o nutrie nt us e
Tum ors Incre as e d tis s ue grow th, w hich incre as e s the rate o nutrie nt us e
 544 CHAPTER 19 Nutrition and Metabolism

FIGURE 19-8 Protein-calorie malnu-

trition (PCM). A, Marasmus results rom
starvation. B, Kwashiorkor results rom a
diet su cient in calories but de cient in
protein. Note the abdominal bloating typi-
cal in kwashiorkor.

Kwashi rk r results r m a diet

that has su ient al ries, but is
de ient in pr teinas when a
hild is weaned r m milk t l w-
pr tein ds. Kwashi rk r als
auses wasting tissues, but un-
like marasmus, it is a mpanied
by pr n un ed as ites (abd minal
bl ating) and f aking dermatitis.
T e as ites results r m a de -
ien y plasma pr teins, whi h A B
hanges the sm ti balan e the
bl d and thus pr m tes sm sis water r m the bl d me hanisms that keep b dy temperature in its n rmal range
int the perit neal spa e (see Figure 18-24). (36.2 C t 37.6 C, r 97 F t 100 F).
Nutriti n dis rders, in luding many spe i de ien y T e skin is ten inv lved in negative- eedba k l ps that
diseases, are summarized in Appendix A at evolve.elsevier.com. maintain b dy temperature. W hen the b dy is verheated,
bl d f w t the skin in reases (see the b x Exercise and the
QUICK CHECK
Skin n p. 156). Warm bl d r m the b dys re an then be
1. Ho w d o a n o re xia n e rvo s a a n d b u lim ia d i e r? Ho w a re led by the skin, whi h a ts as a radiat r. At the skin, heat
th e s e co n d itio n s a like ?
an be l st r m bl d by the ll wing me hanisms, whi h
2. Ob e s ity is a ris k a cto r o r w h ich li e -th re a te n in g d is e a s e s ?
3. Na m e a t le a s t e ig h t ca u s e s o p ro te in -ca lo rie m a ln u tritio n . are als illustrated in Figure 19-9:
1. Radiationf w heat waves r m the bl d and
skin
Bo d y Te m p e r a t u r e 2. Conductiontrans er heat energy t the skin
Th e r m o r e g u la t io n and then t ler external envir nment
3. Convectiontrans er heat energy t ler air
C nsidering that m re than 60% the energy released
19 r m nutrient m le ules during atab lism is nverted t
that is ntinually f wing away r m the skin
4. Evaporationabs rpti n heat r m bl d and
heat rather than being trans erred t A P, it is n w nder
skin by water (sweat) vap rizati n
that maintaining a nstant b dy temperature an be a
hallenge. M aintaining h me stasis b dy temperature, r W hen ne essary, heat an be nserved by redu ing bl d
thermoregulation, is the un ti n the hyp thalamus. f w in the skin, as illustrated in Chapter 7 (see the b x n
T e hyp thalamus perates a variety negative- eedba k p. 156). H eat an als be nserved by redu ing any the

RADIATION CONDUCTION CONVECTION EVAPORATION

A Flow of he a t wave s away B Tra ns fe r of he a t e ne rgy C Tra ns fe r of he a t e ne rgy D Abs orption of he a t from
from the blood a nd s kin to the s kin a nd the n to to coole r a ir tha t is blood a nd s kin by wa te r
coole r exte rna l continua lly flowing away (swe a t) va poriza tion
e nvironme nt from the s kin

FIGURE 19-9 Mechanisms o heat loss. Heat can be lost rom the blood and skin by means o radiation,
conduction, convection, and evaporation. Heat can be conserved by altering blood f ow in the skin or wearing
warm clothing to block the mechanisms shown here.
 CHAPTER 19 Nutrition and Metabolism 545

ur me hanisms des ribed. F r example, warm l thing an Fe ve r

t tally r partially bl k any these me hanisms. FeverA ever r ebrile state is an unusually high b dy
A number ther me hanisms an be alled n t temperature ass iated with a systemi inf ammati n re-
help maintain the h me stasis b dy temperature. H eat- sp nse. In the ase in e ti ns, hemi als alled pyrogens
generating mus le a tivity su h as shivering (sh rt-term) (literally, re-makers) ause the therm stati ntr l enters
and se reti n metab lism-regulating h rm nes (l ng- the hyp thalamus t pr du e a ever. Be ause the b dys
term) are tw the b dys pr esses that an be altered t therm stat is reset t a higher setting, a pers n eels a need
adjust the b dys temperature (Figure 19-10, A). C nversely, t warm up t this new temperature and ten experien es
an elevated b dy temperature an be redu ed by in reasing hills as the ebrile state begins.
bl d f w and sweating in the skin (Figure 19-10, B). T e T e high b dy temperature ass iated with in e ti us ever
n ept using eedba k ntr l l ps in h me stati is th ught t enhan e the b dys immune resp nses, helping
me hanisms was rst intr du ed in Chapter 1. t eliminate the path gen. Strategies aimed at redu ing the
temperature a ebrile pers n are m st ten n rmally un-
tera ted by the b dys heat-generating me hanisms and thus
A b n o r m a l Bo d y Te m p e r a t u r e have the e e t urther weakening the in e ted pers n.
Maintenan e b dy temperature within a narr w range is Under rdinary ir umstan es, it is best t let the ever break
ne essary r the n rmal un ti ning the b dy. As n its wn a ter the path gen is destr yed.
Figure 19-11 sh ws, straying t ar ut the n rmal range
b dy temperatures an have very seri us physi l gi al nse- M a lig n a n t Hy p e r t h e r m ia
quen es. T e ll wing se ti ns identi y a ew these imp r- Malignant hyperthermia (MH) is an inherited nditi n
tant nditi ns related t b dy temperature. hara terized by an abn rmally in reased b dy temperature

Exe rcis e
Dis turbanc e Feedback
loop
Co ld Bo dy
wind te mpe rature
de c re as e s

Incre a s e s

Te mpe ra ture
De te cte d by Te mpe ra ture 37 C De te cte d by
incre a s e s
Co ntro lle d de cre a s e s 19
c o nditio n
Ra dia tion Blood
Mus cle s Cold Conduction te mpe ra ture Te mpe ra ture
(s hive r) re ce ptors Conve ction Variable re ce ptors
Effe c to r S e ns o r Ra dia tion
S e ns o r
Effe c to rs
S we a t Blood
gla nds ve s s e ls S kin
Fe e ds (s e cre te ) (dila te )
S igna ls
ba ck to

S e tpoint Actua l S e ns ory

S kin
te mpe ra ture Te mpe ra ture ne rve
be rs

Corre ction
s igna ls via 37C 38C
ne rve be rs
S e tpoint body Brain Actua l body Fe e ds informa tion
te mpe ra ture Inte g rato r te mpe ra ture via ne rve be rs
A B Hypotha la mus Inte g rato r ba ck to

FIGURE 19-10 Feedback control o thermoregulation. A, When body temperature drops below its set-
point value, integrators in the hypothalamus o the brain trigger shivering o skeletal muscle e ectors, which
produces heat that raises body temperature back toward its set point. B, When body temperature rises above
its setpoint value, the bodys response is to increase sweating and blood f ow to the skin, which acilitates loss
o heat by several mechanismsand brings the body temperature down toward its set point.
 546 CHAPTER 19 Nutrition and Metabolism

happens when envir nmental temperatures are high. Alth ugh

a n rmal b dy temperature is maintained, the l ss water and
ele tr lytes an ause weakness, vertig , nausea, and p ssible
122 50 l ss ns i usness. H eat exhausti n may als be a mpa-
104 40
nied by skeletal mus le ramps that are ten alled heat
n cramps. H eat exhausti n is treated with rest (in a l envir n-
113 45 ment) a mpanied by f uid repla ement.

He a t s t ro k e
104 40 Als alled sunstroke, heatstroke is a severe, s metimes
atal nditi n resulting r m the inability t maintain a
n rmal b dy temperature in an extremely warm envir n-
95 35 ment. Su h therm regulat ry ailure may result r m a -
t rs su h as ld age, disease, drugs that impair therm regu-
lati n, r simply be aused by verwhelming elevated
envir nmental temperatures.
86 30
H eatstr ke is hara terized by b dy temperatures 41 C
(105 F) r higher; ta hy ardia; heada he; and h t, dry skin.
77 25
C n usi n, nvulsi ns, r l ss ns i usness may ur.
95 35 Unless the b dy is led and b dy f uids are repla ed im-
mediately, death may result.
F Hy p o t h e r m ia
Hypothermia is the inability t maintain a n rmal b dy tem-
perature in extremely ld envir nments. H yp thermia is
hara terized by b dy temperatures l wer than 35 C (95 F);
shall w and sl w respirati ns; and a aint, sl w pulse. H yp -
thermia is usually treated by sl wly warming the a e ted
pers ns b dy.

FIGURE 19-11 Body temperature range. This diagram, modeled a ter
a thermometer, shows some o the physiological consequences o abnormal
body temperature. The normal range o body temperature under a variety o
conditions is shown in the inset.
19 (hyperthermia) and mus le rigidity when exp sed t ertain
anestheti s. T e drug dantrolene (Dantrium), whi h inhibits
heat-pr du ing mus le ntra ti ns, has been used t prevent
r relieve e e ts this nditi n.
He a t Ex h a u s t io n
Heat exhaustion urs when the b dy l ses a large am unt
f uid resulting r m heat-l ss me hanisms. T is usually
Fro s t b it e
Frostbite is l al damage t tissues aused by extremely l w
temperatures. Damage t tissues results r m rmati n i e
rystals a mpanied by a redu ti n in l al bl d f w.
Necrosis (tissue death) and even gangrene (de ay dead tis-
sue) an result r m r stbite.
QUICK CHECK
1. De s crib e th e o u r m a in wa ys th a t h e a t le a ve s th e b o d y.
2. Why w o u ld a e ve r b e a n o rm a l re s p o n s e to in ju ry o r
in e ctio n ?
3. Wh a t ca n h a p p e n to th e b o d y w ith e xce s s ive e xp o s u re to
h e a t?

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 533)

calorie cholesterol conduction

(KAL-or-ee) (koh-LES-ter-ol) (kon-DUK-shun)
[calor- heat, -ie ull o ] [chole- bile, -stero- solid, -ol alcohol] [con- with, duct- lead, -tion process]
carbohydrate loading citric acid cycle convection
(kar-boh-HYE-drayt LOHD-ing) (SIT-rik AS-id SYE-kul) (kon-VEK-shun)
[carbo- carbon, -hydr- hydrogen, -ate oxygen] [citr- lemon, -ic relating to, acid sour, [con- together, -vect- carry, -tion process]
catabolism cycle circle]
(kah-TAB-oh-liz-em)
[cata- against, -bol- throw, -ism condition]
 CHAPTER 19 Nutrition and Metabolism 547

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 546)

electron transport system (ETS) glycolysis plasma protein

(eh-LEK-tron TRANZ-port SIS-tem (glye-KAHL-ih-sis) (PLAZ-mah PROH-teen)
[ee tee es]) [glyco- sweet (glucose), -o- combining vowel, [plasma substance, prote- primary,
[electr- electricity, -on subatomic particle, -lysis loosening] -in substance]
trans- across, -port carry] insulin pyrogen
evaporation (IN-suh-lin) (PYE-roh-jen)
(ee-vap-oh-RAY-shun) [insul- island, -in substance] [pyro- heat, -gen produce]
[e- out rom, -vapor steam, -ation process] joule (J or j) pyruvic acid
ood science (jool) (pye-ROO-vik AS-id)
( ood SYE-ens) [J ames Prescott J oule English physicist] [pyr- heat, -uv- grape, -ic relating to]
[scienc- knowledge] kilocalorie (kcal; also calorie) radiation
ree radical (KIL-oh-kal-oh-ree) (ray-dee-AY-shun)
( ree RAD-ih-kal) [kilo- one thousand, -calor- heat, -ie ull o ] [radiat- send out rays, -ion process]
[radic- root, -al relating to] Krebs cycle satiety center
gluconeogenesis (krebz SYE-kul) (sah-TYE-eh-tee SEN-ter)
(gloo-koh-nee-oh-J EN-eh-sis) [Sir Hans Adol Krebs British biochemist, [sati- enough or ull, -ety state]
[gluco- sweet (glucose), -neo- new, cycl- circle] thermoregulation
-gen- produce, -esis process] macronutrient (ther-moh-reg-yoo-LAY-shun)
glycogen (MAK-roh-NOO-tree-ent) [therm- heat, -o- combining vowel,
(GLYE-koh-jen) [macro- large, -nutri- nourish, -ent agent] -regula- rule, -ation process]
[glyco- sweet, -gen produce] metabolism total metabolic rate (TMR)
glycogen loading (meh-TAB-oh-liz-em) (TOH-tal met-ah-BOL-ik rayt [tee em ar])
(GLYE-koh-jen LOHD-ing) [meta- over, -bol- throw, -ism action] [meta- over, -bol- throw, -ic relating to]
[glyco- sweet (glucose), -gen produce] micronutrient urea
glycogenesis (MY-kroh-NOO-tree-ent) (yoo-REE-ah)
(glye-koh-J EN-eh-sis) [micro- small, -nutri- nourish, -ent agent] [urea urine]
[glyco- sweet (glucose), -gen- produce, nutrition vitamin
-esis process] (noo-TRIH-shun) (VYE-tah-min)
glycogenolysis [nutri- nourish, -tion process] [vita- li e, -amin ammonia compound]
(glye-koh-jeh-NOL-ih-sis)
[glyco- sweet (glucose), -gen- produce,
-o- combining vowel, -lysis loosening]

19

LANGUAGE OF M ED IC IN E

anorexia nervosa ever hypervitaminosis

(an-oh-REK-see-ah ner-VOH-sah) (FEE-ver) (hye-per-vye-tah-mih-NOH-sis)
[an- without, -orex- appetite, -ia condition, rostbite [hyper- excessive, -vita- li e, -amin- ammonia
nerv- nerve, -osa relating to] (FROST-byte) compound, -osis condition]
avitaminosis heat exhaustion hypothermia
(ay-vye-tah-mih-NOH-sis) (heet eg-ZAWS-chun) (hye-poh-THER-mee-ah)
[a- without, -vita- li e, -amin- ammonia heatstroke [hypo- under or below, -therm- heat,
compound, -osis condition] (HEET-strohk) -ia abnormal condition]
bulimarexia [stroke strike] kwashiorkor
(boo-lee-mah-REK-see-ah) hypercholesterolemia (kwah-shee-OR-kor)
[bu- ox, -lim- hunger, -orex- appetite, [kwashiorkor one who is displaced ( rom the
(hye-per-koh-les-ter-ohl-EE-mee-ah)
-ia condition] breast)]
[hyper- excessive, -chole- bile, -stero- solid,
bulimia -ol- alcohol, -emia blood condition] malignant hyperthermia (MH)
(boo-LEE-mee-ah) (mah-LIG-nant hye-per-THERM-ee-ah
[bu- ox, -lim- hunger, -ia condition] [em aych])
[malign- bad, -ant state, hyper- excessive,
-therm- heat, -ia abnormal condition]

Continued on p. 548
 548 CHAPTER 19 Nutrition and Metabolism

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 547)

marasmus phenylketonuria (PKU) scurvy

(mah-RAZ-mus) ( en-il-kee-toh-NOO-ree-ah) (SKER-vee)
[marasmus a wasting] [phen- shining (phenol), -yl- chemical, [scur- sour milk, -vy a swelling]
obesity -keton- acetone, -ur- urine, -ia condition] statin
(oh-BEES-ih-tee) protein-calorie malnutrition (PCM) (STAT-in)
[ob- over, -es- eat, -ity state] (PROH-teen-KAL-or-ee mal-noo-TRISH-un [stat- stand, -in substance]
[pee see em])
[prote- primary, -in substance, calor- heat,
-ie ull o , mal- bad, -nutri- nourish,
-tion process]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
Macro nutrie nts
or us e w ith your device , acce s s the Au d io Ch a p te r A. Dietary s ur es nutrients
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
B. Carb hydrate metab lism
De f nitio ns
A. Nutriti nenergy-yielding nutrients, vitamins, and min-
erals that are ingested and assimilated int the b dy
19 (Figure 19-1)
B. Metab lismpr ess using nutrient m le ules as
energy s ur es and as building bl ks r ur wn
m le ules
C. Catab lismpr ess that breaks nutrient m le ules
d wn, releasing their st red energy; xygen used in
atab lism
D. Anab lismpr ess that builds nutrient m le ules int
mplex hemi al mp unds
Me tabo lic Functio n o the Live r
A. Se retes bile t help me hani ally digest lipids by emul-
si ying them
B. Pr esses bl d immediately a ter it leaves the gastr in-
testinal tra t
1. H elps maintain n rmal bl d glu se n entrati n
2. Site pr tein, arb hydrate, and at metab lism
3. Rem ves t xins r m the bl d
C. Synthesizes several kinds plasma pr teins, in luding
albumins, brin gen, l tting a t rs, et .
D. St res use ul substan es, in luding gly gen, lipids,
ertain vitamins
1. Nutrients d mp nents digested and abs rbed
by the b dy
2. Ma r nutrientsnutrients needed in large daily
quantities ( arb hydrates, ats, pr teins) (Table 19-1)
3. Mi r nutrientsnutrients needed in tiny daily quanti-
ties (vitamins and minerals) (Table 19-3 and Table 19-4)
1. Carb hydrates are the pre erred energy nutrient the
b dy
2. T ree series hemi al rea ti ns that ur in a
pre ise sequen e make up the pr ess glu se
metab lism (Figure 19-2)
a. Gly lysis urs in yt plasm the ell
(1) Anaer bi pr ess (uses n xygen)
(2) Changes glu se t pyruvi a id, whi h is then
nverted int a etyl C A
(3) Yields small am unt energy (trans erred t
A P)
b. Citri a id y le (Krebs y le) urs in the
mit h ndria
(1) Aer bi pr ess (requires xygen)
(2) Changes a etyl C A t arb n di xide
(3) M st energy leaving the itri a id y le is in
the rm high-energy ele tr ns
. Ele tr n transp rt system (E S) urs in the
mit h ndria
(1) rans ers energy r m high-energy ele tr ns
( r m itri a id y le) t A P m le ules
(2) A P serves as dire t s ur e energy r ells
(Figure 19-3)
3. Aden sine triph sphate (A P)energy trans erred t
A P di ers r m energy in nutrient m le ules
a. N t st red; released alm st instantly
b. Can be used dire tly t d ellular w rk

4. Anab lism and st rage glu se
a. Glu se that is n t needed immediately r making
A P is st red as gly gen (a l ng hain glu se
subunits) in liver and mus le ells
b. Gly genesisanab li pr ess j ining glu se
m le ules t gether in a hain t rm gly gen
(st ring glu se r later use)
. Gly gen lysis atab li pr ess breaking
apart gly gen hains, releasing individual glu se
m le ules r use in making A P
5. Bl d glu se level n entrati n glu se in
bl d
a. N rmally maintained between ab ut 80 and
110 mg per 100 mL bl d during asting
b. Insulin a elerates the m vement glu se ut
the bl d int ells, there re de reasing bl d
glu se and in reasing glu se atab lism
(Figure 19-4)
C. Fat metab lism
1. Fats (trigly erides) are primarily an energy nutrient
2. Fatty a ids and gly er l nverted t rms glu se
by glu ne genesis t be atab lized and energy
trans erred t A P (Figure 19-5)
3. Ex ess atty a ids are anab lized t rm trigly erides
that are st red in adip se tissue
D. Pr tein metab lism
1. Pr teins are atab lized r energy nly a ter arb hy-
drate and at st res are depleted; ex ess dietary pr -
teins an als be atab lized r energy
2. Glu ne genesis breaks apart amin a ids t nvert
them t a rm that enters the itri a id y le t
pr du e A P; the nitr gen us waste pr du t alled
urea is rmed in this pr ess (Figure 19-5)
3. Essential amino acids are th se that must be in the diet
be ause the b dy ann t make them (Table 19-2)
Micro nutrie nts
A. Vitamins
1. O rgani m le ules that are needed in small am unts
r n rmal metab lism (Table 19-3)
a. May bind t enzymes and enzymes t help them
w rk e e tively
b. Vitamin A has r le in visi n
. Vitamin D nverts t a h rm ne that regulates
al ium h me stasis
d. Vitamin E is an anti xidant that pr te ts against
ree radi als
2. Vitamin imbalan es
a. Avitamin sisde ien y a vitamin
(1) Can lead t severe metab li pr blems
(2) Avitamin sis C an lead t s urvy (Figure 19-6)
b. H ypervitamin sisex ess a vitamin
(1) Can be just as seri us as avitamin sis
(2) May be hr ni r a ute
CHAPTER 19 Nutrition and Metabolism 549
B. Mineralsin rgani m le ules und naturally in the
earth
1. Required by the b dy r n rmal un ti n, in luding
nerve ndu ti n (Table 19-4)
2. May atta h t enzymes t a ilitate their w rk
Re g ulating Fo o d Intake
A. Regulat ry enters in the hyp thalamus play a primary
r le in ntr lling d intake
1. Appetite enterpr du es eelings hunger
2. Satiety enterpr du es eelings satis a ti n
B. F d intake regulati n results r m balan e between
hyp thalami ntr l enters
C. Many diverse a t rs inf uen e the hyp thalami ntr l
enters (Table 19-5)
Me tabo lic Rate s
A. Basal metab li rate (BMR)rate metab lism when a
pers n is lying d wn but awake, n t digesting d, and
when the envir nment is m rtably warm
B. tal metab li rate ( MR)the t tal am unts
energy, expressed in al ries, used by the b dy per day
(Figure 19-7)
Me tabo lic and Eating Dis o rde rs
A. Disrupti n r imbalan e n rmal metab lism an be
aused by several di erent a t rs
1. Inb rn err rs metab lismgeneti nditi ns
inv lving de ient r abn rmal metab li enzymes
2. S me metab li dis rders are mpli ati ns ther
nditi ns
a. H rm nal imbalan es and eating dis rders
B. Eating dis rders 19
1. An rexia nerv sa hara terized by hr ni re usal
t eat
2. Bulimiaan alternating pattern raving d
ll wed by a peri d sel -denial; in bulimarexia, the
sel -denial triggers sel -indu ed v miting
3. O besityabn rmally high pr p rti n b dy at;
may be a sympt m an eating dis rder; risk a t r
r many hr ni diseases
4. Pr tein- al rie malnutriti n (PCM)results r m a
de ien y al ries in general and pr teins in parti -
ular; examples are marasmus and kwashi rk r
(Figure 19-8 and Table 19-6)
Bo dy Te m pe rature
A. T erm regulati n
1. H yp thalamusregulates the h me stasis b dy
temperature (therm regulati n) thr ugh a variety
pr esses
2. Bl d f w t the skin in reases when b dy is
verheated
 550 CHAPTER 19 Nutrition and Metabolism
3. H eat is l st thr ugh the skin by several me hanisms
(Figure 19-9)
a. Radiati nf w heat waves r m the bl d and
skin
b. C ndu ti ntrans er heat energy t the skin
and then t ler external envir nment
. C nve ti ntrans er heat energy t ler air
that is ntinually f wing away r m the skin
d. Evap rati nabs rpti n heat r m bl d and
skin by water (sweat) vap rizati n
4. T e b dy an generate heat t maintain h me stasis
ver the sh rt term (shivering) r the l ng term
( hanges in metab li rates)
5. H eating and ling b dy is ntr lled by eedba k
l ps that maintain a stable b dy temperature
(Figure 19-10)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
This chapte r be gins by explaining the unctions o the live r and
the im portance o the portal s ys te m , both o w hich we re dis -
cus s e d in e arlie r chapte rs .
1. T e pr ess metab lism re ers t the b dys use
nutrients. Fats and arb hydrates are used primarily r
energy.
19 2. Gly lysis urs in the yt plasm the ell; it requires
n xygen but pr du es very little energy. T e end pr d-
u ts gly lysis enter the itri a id ( r Krebs) y le,
whi h urs in the mit h ndria. T is pr ess requires
xygen and pr du es mu h m re energy. S me the end
pr du ts the itri a id y le are high-energy m le ules
that are used t nvert ADP int A P; this is d ne in
the ele tr n transp rt system. Energy st red between the
ph sphates the A P m le ules an be used r the
needs the ell. Fat and pr tein m le ules an be m di-
ed s they an enter the itri a id y le.
3. T e term nonessential amino acids is s mewhat misleading;
it d es n t mean y ur b dy d es n t need themit
means that they an be made r m ther amin a ids.
B. Abn rmal b dy temperature an have seri us physi l gi-
al nsequen es (Figure 19-11)
1. Fever ( ebrile state)unusually high b dy tempera-
ture ass iated with systemi inf ammati n resp nse
2. Malignant hyperthermia (MH )inherited nditi n
that auses in reased b dy temperature (hyperthermia)
and mus le rigidity when exp sed t ertain anestheti s
3. H eat exhausti nresults r m l ss f uid as the
b dy tries t l itsel ; may be a mpanied by heat
ramps
4. H eatstr ke (sunstr ke) verheating b dy resulting
r m ailure therm regulat ry me hanisms in a
warm envir nment
5. H yp thermiaredu ed b dy temperature resulting
r m ailure therm regulat ry me hanisms in a
ld envir nment
6. Fr stbitel al tissue damage aused by extreme
ld; may result in ne r sis r gangrene
4. Vitamins and minerals assist in enzyme un ti n. Y u an
learn the names and un ti ns the vitamins and miner-
als r m the tables in the text r by making f ash ards
and he king nline res ur es. better understand the
terms in this hapter, re er t the Language S ien e
and the Language Medi ine se ti ns.
5. Metab li rates des ribe h w qui kly y ur b dy is using
nutrients. T e basal metab li rate (BMR) is the am unt
nutrients y u burn just t stay alive and awake. Y ur
t tal metab li rate ( MR) depends n h w a tive y u
are. Che k ut this website that all ws y u t al ulate
y ur BMR: bmi-calculator.net/bmr-calculator/.
6. Make a hart t help y u learn the metab li dis rders.
O rganize the hart based n the me hanism r ause
ea h dis rder: de ien y r ex ess vitamins, nutriti n
dis rders, and dis rders temperature regulati n.
7. In y ur study gr up, review the f ash ards r the vita-
mins and minerals r Tables 19-2 and 19-3. Dis uss the
pr esses arb hydrate, pr tein, and at metab lism.
Dis uss what nstitutes basal and t tal metab li rates
and the ways heat an be l st r m the b dy. Review the
metab li dis rders hart, hapter utline summary and
the questi ns at the end the hapter, and dis uss p ssi-
ble test questi ns.
 CHAPTER 19 Nutrition and Metabolism 551

Re vie w Que s tio ns Critical Thinking

Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.

1. De ne anab lism and atab lism. 24. Di erentiate between abs rpti n and assimilati n.
2. Explain the un ti n the liver. 25. Explain the advantage the b dy gains by having the
3. C mpare ma r nutrients and mi r nutrients bl d g thr ugh the hepati p rtal system.
4. Brief y explain the pr ess gly lysis. 26. Diagram the A P-ADP y le. In lude where the energy
5. Brief y explain the itri a id y le. is added and where the energy is released.
6. W hat is the un ti n the ele tr n transp rt system? 27. A man went n a 10-day va ati n. H is t tal metab li
7. Explain the ways in whi h energy st red in A P is di - rate was 2600 al ries a day. H is t tal al rie intake was
erent r m energy st red in nutrient m le ules. 3300 al ries a day. H e began the trip weighing
8. List the primary h rm nes that tend t in rease the 178 p unds. W hat did he weigh when he g t ba k r m
am unt sugar in the bl d. va ati n? (3500 ex ess al ries 1 p und)
9. Identi y when at atab lism usually urs. 28. Supp se y ur diet nsisted nly pr tein. Is it p ssible
10. Identi y when pr tein atab lism usually urs. r a pers n t keep r m gaining weight by eating nly
11. Explain what is meant by a n nessential amin a id. pr tein? Explain.
12. Explain the use statin drugs. 29. Explain the pr ess glu ne genesis and its un ti n
13. Name three water-s luble and three at-s luble vitamins. in at metab lism.
14. De ne avitamin sis. Name a dis rder aused by avita-
min sis. W hat vitamin de ien y auses this dis rder?
15. Name the signs and sympt ms vitamin A
hypervitamin sis.
16. Name three minerals needed by the b dy.
17. Brief y explain the un ti n vitamins and minerals in
the b dy.
18. L ate the satiety enter.
19. Di erentiate between basal and t tal metab li rate.
20. Distinguish between marasmus and kwashi rk r.
21. Name and explain ur ways heat an be l st thr ugh
the skin.
22. Explain the ause and sympt ms malignant 19
hyperthermia.
23. Distinguish between heat exhausti n and heatstr ke in
terms a pers ns b dy temperature.
 552 CHAPTER 19 Nutrition and Metabolism

8. ________ is the number al ries that must be used

Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e pr ess ________ urs when nutrient m le-
ules enter the ell and underg hemi al hange.
2. ________ is the term used t des ribe all the hemi al
pr esses that release energy r m nutrients.
3. T e plasma pr teins ________ and ________ are made
in the liver and are imp rtant in bl d l t rmati n.
4. T e vitamins ________ and ________ an be st red in
the liver.
5. T e h rm ne ________ is kn wn t a elerate glu se
transp rt thr ugh ell membranes.
6. An ex ess am unt h lester l in the bl d results in a
nditi n alled ________.
7. T e B vitamins are ________ s luble, whereas vitamins
K and E are ________ s luble.
just t keep the b dy alive, awake, and m rtably
warm.
9. In rder t l se weight, y ur t tal al ri intake must be
less than y ur ________.
10. One way heat an be l st by the skin is ________, whi h
is the trans er heat t the air that is ntinually
f wing away r m the skin.
11. One way heat an be l st by the skin is ________, whi h
is the abs rpti n heat by water (sweat) vap rizati n.
12. ________ is the pr ess used by the b dy as the se nd
h i e energy metab lism.
13. In the healthy b dy, ________ is used alm st ex lusively
r anab lism rather than atab lism.
14. ________ are amin a ids needed by the b dy, but they
an be made r m ther amin a ids i they are n t sup-
plied dire tly by the diet.

Match each term in Column A with its corresponding description in Column B.

Column A Column B
15. ________ gly lysis a. part the ell in whi h gly lysis urs
16. ________ glu ne genesis b. the part arb hydrate metab lism that d es n t require xygen
17. ________ ele tr n transp rt . pr ess that nverts high-energy m le ules r m the itri a id y le int A P
system d. pr ess that nverts gly er l int a mp und that an enter the gly lysis
18. ________ mit h ndria pathway
19. ________ yt plasm e. the b dys dire t s ur e energy
20. ________ A P . m le ule that results when aden sine triph sphate l ses a ph sphate gr up
21. ________ gly genesis g. the part the ell in whi h the itri a id y le takes pla e
22. ________ ADP h. glu se anab lism

19
 CHAPTER 19 Nutrition and Metabolism 553

Match each disorder in Column A with its corresponding description or cause in Column B.

Column A
23. ________ avitamin sis
24. ________ hypervitamin sis
25. ________ an rexia nerv sa
26. ________ bulimia
27. ________ marasmus
28. ________ kwashi rk r
29. ________ malignant
hyperthermia
30. ________ heat exhausti n
31. ________ heatstr ke
32. ________ hyp thermia
33. ________ r stbite
Column B
a. behavi ral dis rder hara terized by a hr ni re usal t eat
b. in reased b dy temperature aused by exp sure t anestheti s
. type malnutriti n that results r m an verall la k al ries
d. an verheating pr blem in whi h the b dy is dehydrated but the b dy temperature
is n rmal
e. l al tissue damage aused by i e rystals rming in the ells
. nditi n that results in the devel pment s urvy
g. behavi ral dis rder hara terized by insatiable raving r d alternating with
sel -deprivati n; may in lude d binges
h. a b dy temperature l wer than 95 F
i. verheating pr blem in whi h the b dy temperature an be as high as 105 F;
p tentially li e-threatening
j. type malnutriti n that results r m a la k pr tein with su ient t tal al ries
k. a vitamin ex ess, usually inv lving at-s luble vitamins

Cas e S tudie s replies that he su ered r m s urvy as a mer hant marine

To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. A riend y urs is helping y u h p rew d n a h t
day. She mplains mus le ramps and nausea but has
a n rmal b dy temperature. W hat has happened t her?
H w w uld y u help y ur riend?
2. W hile l king thr ugh an ld amily album, y u ant
help but n ti e that y ur great-great-great-grand athers
smile reveals that he has n teeth. W hen asked why this
an est r l st his teeth at an early age, y ur grandm ther
and l st all his teeth as a result. Is this p ssible? Can y u
explain h w s urvy an ause the l ss teeth?
3. Andrea is planning t ad pt a t tally vegetarian dieta
diet that in ludes n meats r animal pr du ts. H er
riends have v i ed s me n ern that her new diet may
n t ntain ertain essential amin a ids. W hat is an
essential amin a id? W hy must her diet ntain these
nutrients?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.

19
Urinary System
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.
Kidneys, 556
Location o the Kidneys, 556
Gross Structure o the Kidney, 556
Microscopic Structure o the Kidney,
557
Overview o Kidney Function, 559
Formation o Urine, 560
Filtration, 560
Reabsorption, 561
Secretion, 562
Summary o Urine Formation, 562
Control o Urine Volume, 563
Antidiuretic Hormone, 563
Aldosterone, 563
Atrial Natriuretic Hormone, 563
Abnormalities o Urine Volume, 563
O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.
A ter you have completed this chapter, you
should be able to:
1. Do the ollowing related to the kidneys:
o the kidneys and explain how they
act as vital organs in maintaining ho-
meostasis.
describe the role each component
plays in the balancing o blood and
ormation o urine.
2. Explain the importance o f ltration,
tubular reabsorption, and tubular secre-
tion in renal physiology.
Elimination o Urine, 564
Ureters, 564
Urinary Bladder, 565
Urethra, 565
Micturition, 565
Abnormalities o Urine Output, 566
Urinalysis, 567
Renal and Urinary Disorders, 567
Obstructive Disorders, 567
Urinary Tract In ections, 569
Glomerular Disorders, 570
Kidney Failure, 571
3. Discuss the mechanisms that control
urine volume.
4. Describe the structure and unction o
the ureters, urinary bladder, and
urethra.
5. Describe the process o micturition and
the control problems that requently
occur with this process.
6. Explain the purpose and importance o
urinalysis.
7. List the major renal and urinary disor-
ders and explain the mechanism o
each disorder.
 TER 20
As y u might guess r m its name, the urinary LANGUAGE OF
system per rms the un ti ns pr du ing and S C IEN C E
ex reting urine r m the b dy. W hat y u might n t
guess s easily is h w essential these un ti ns are r
Be o re re ading the
the maintenan e h me stasis and healthy sur-
chapte r, s ay e ach o
vival. T e nstan y b dy f uid v lumes and the the s e te rm s o ut lo ud. This w ill
levels many imp rtant hemi als depend n he lp yo u to avo id s tum bling ove r
n rmal urinary system un ti n. W ith ut a ully the m as yo u re ad.
un ti nal urinary system, the n rmal mp si-
ti n bl d ann t be maintained r l ng, and
aldosterone
seri us nsequen es s n ll w. (AL-doh-steh-rohn or
al-DAH-stayr-ohn)
T e urinary system is mp sed tw kidneys, [aldo- aldehyde, -stero- solid or
tw ureters, ne bladder, and ne urethra steroid derivative, -one chemical]
(Figure 20-1). Find the maj r stru tures the antidiuretic hormone (ADH)
urinary system in the Clear View o the Human (an-tee-dye-yoo-RET-ik
Body ( ll ws p. 8). HOR-mohn [ay dee aych])
[anti- against, -dia- through,
We begin ur dis ussi n with the -uret- urination, -ic relating to,
kidneys. T e kidneys lear r hormon- excite]
lean the bl d the many waste atrial natriuretic hormone (ANH)
pr du ts ntinually pr du ed as a (AY-tree-al nay-tree-yoo-RET-ik
result metab lism nutrients in HOR-mohn [ay en aych])
[atria- entrance courtyard (atrium
b dy ells. As nutrients are burned r energy,
o heart), -al relating to,
the waste pr du ts pr du ed must be rem ved
natri- natrium (sodium),
r m the bl d, r they qui kly a umulate -uret- urination, -ic relating to,
t t xi levelsa nditi n alled uremia r hormon- excite]
uremic poisoning. Bowman capsule
(BOH-men KAP-sul)
T e kidneys als play a vital r le in maintaining [William Bowman English anatomist,
ele tr lyte, water, and a id-base balan es in the caps- box, -ule little]
b dy. In this hapter, we dis uss the stru ture calyx
and un ti n ea h rgan the urinary sys- (KAY-liks)
tem. We als dis uss disease nditi ns pr - pl., calyces
du ed by abn rmal un ti ning the urinary (KAY-lih-seez)
system. In the ll wing hapters, we ntinue [calyx seed pod or cup]
the st ry by expl ring f uid and ele tr lyte collecting duct (CD)
balan e in Chapter 21 and a id-base balan e (koh-LEK-ting dukt [see dee])
in Chapter 22. [duct a leading]
cortical nephron
For an introduction to the urinary (KOHR-tih-kal NEF-ron)
system, go to AnimationDirect [cortic- bark (cortex), -al relating to,
nephro- kidney, -on unit]
online at evolve.elsevier.com.
countercurrent mechanism
(KON-ter-ker-rent MEK-a-niz-em)
[counter- against, -current ow]

Continued on p. 574

555
 556 CHAPTER 20 Urinary System

Kid n e y s A heavy ushi n atthe renal at padn rmally en-

ases ea h kidney and helps h ld it in pla e.
Lo c a t io n o t h e Kid n e y s
N te the relatively large diameter the renal arteries in
l ate the kidneys n y ur wn b dy, stand ere t and put y ur Figure 20-1, A. N rmally, a little m re than 20% the t tal
hands n y ur hips with y ur thumbs meeting ver y ur ba k- bl d pumped by the heart ea h minute enters the kidneys.
b ne. W hen y u are in this p siti n, y ur kidneys lie ab ve y ur T e rate bl d f w thr ugh this rgan is am ng the high-
thumbs n either side y ur spinal lumn, but their pla ement est in the b dy. T is is understandable be ause ne the
is higher than y u might think. N te in Figure 20-1 that the right main un ti ns the kidney is t rem ve waste pr du ts
kidney, whi h t u hes the liver, is l wer than the le t. r m the bl d. Maintenan e a high rate bl d f w and
B th kidneys are pr te ted a bit by the l wer, p steri r n rmal bl d pressure in the kidneys is essential r the r-
part the rib age. T ey are l ated under the mus les the mati n urine.
ba k and behind ( utside) the parietal perit neumthe mem-
brane that lines the abd minal avity (see Figure 20-1, C). Be-
G ro s s S t r u c t u r e o t h e Kid n e y
ause this retroperitoneal l ati n, a surge n an perate
n a kidney r m behind with ut utting thr ugh the parietal Ex t e r n a l A n a t o m y
perit neum. On e the perit neum has been ut r pened, the T e kidneys resemble lima beans in shape, that is, r ughly val
p tential r spread in e ti n thr ugh ut the entire ab- with a medial indentati n (see Figure 20-1, A). T e medial in-
d minal avity in reases. dentati n, alled the hilum, is where vessels, nerves, and the

S pinous
Adre na l S
S ple e n proce s s of
gla nd
Lowe r e dge firs t lumba r L R
Live r Re na l a rte ry of ple ura ve rte bra
Le ft kidne y I
Re na l ve in
Twe lfth rib
Le ft kidne y Ele ve nth rib
Right
kidne y Twe lfth rib
Abdomina l
Right kidne y
a orta
Ure te r
Infe rior
ve na ca va S pinous proce s s
Urina ry of fourth lumba r
bla dde r ve rte bra
Common
S
ilia c a rte ry B
a nd ve in
R L

I Ure thra Kidney

A
Re na l pe lvis
Infe rior
ve na ca va

P e ritone um Re na l fa t pa d

P e ritone a l
20 Re na l
ve in
ca vity Re na l a rte ry
Ure te r
A
Le ft kidne y
R L
Urina ry bla dde r
P
S
S pinous
Abdomina l Mus cle proce s s D R L
a orta
C of ve rte bra
I
FIGURE 20-1 Urinary system. A, Anterior view o urinary organs. B, Sur ace markings o the kidneys,
eleventh and twel th ribs, spinous processes o L1 to L4, and lower edge o pleura viewed rom behind. C, Hori-
zontal (transverse) section o the abdomen showing the retroperitoneal position o the kidneys. D, X-ray lm o
the urinary organs.
 CHAPTER 20 Urinary System 557

Inte rlobula r
Ca ps ule (fibrous )
a rte rie s

Re na l
column Corte x Re na l
Re na l pa pilla of
s inus pyra mid
Minor ca lyce s

Ma jor ca lyce s
Hilum Fa t Hilum Re na l
pe lvis
Re na l
pe lvis
Re na l
pa pilla of
pyra mid Ure te r Re na l
Me dulla ry column
Me dulla pyra mid
S Me dulla ry
pyra mid
Ure te r M L

I
A B
FIGURE 20-2 Kidney. Internal structure. A, Artists rendering o a coronal section o the kidney. B, Photo-
graph o coronal section o a preserved human kidney.

ureter nne t with the kidney. An average-sized kidney mea-
sures appr ximately 11 7 3 m (4.3 2.7 1.2 in).
T ere is a t ugh br us capsule that rms the exteri r wall
the kidney.
In t e r n a l A n a t o m y
I y u were t sli e thr ugh a kidney r m side t side and
pen it like the pages a b k ( alled a coronal section), y u
w uld see the stru tures sh wn in Figure 20-2. Identi y ea h
the ll wing parts:
1. Renal cortexthe uter part the kidney (the
w rd cortex mes r m the Latin w rd r bark, s
the rtex an rgan is its uter layer).
2. Renal medullathe inner p rti n the kidney.
3. Renal pyramidsthe triangular divisi ns the
medulla the kidney. Extensi ns rti al tissue
that dip d wn int the medulla between the renal
pyramids are alled renal columns.
4. Renal papilla (pl. papillae)narr w, innerm st end
a pyramid.
5. Renal pelvis(als alled the kidney pelvis) an ex-
pansi n the upper end a ureter (the tube that
drains urine int the bladder).
6. Calyx (pl. calyces)a divisi n the renal pelvis (the
papilla a pyramid pens int ea h alyx).
M ic ro s c o p ic S t r u c t u r e o t h e Kid n e y
M re than a milli n mi r s pi units alled nephrons make
up ea h kidneys interi r (Figure 20-3). T e shape a nephr n
is unique, unmistakable, and admirably suited t its un ti n
pr du ing urine. It l ks a little like a tiny unnel with a
very l ng stem, but it is an unusual stem in that it is highly
nv lutedthat is, it has many bends in it.
T e nephr n is mp sed tw prin ipal mp nents: the
renal corpuscle and the renal tubule. T e renal rpus le an be
subdivided still urther int tw parts and the renal tubule int
ur regi ns r segments. Identi y ea h part the renal r-
pus le and renal tubule des ribed in Figure 20-4 and Figure 20-5.
A. Renal corpuscle
1. Glomerular capsulethe up-shaped t p a
nephr n. T e h ll w, sa like gl merular apsule
surr unds the gl merulus. Als alled Bowman
capsule.
2. Glomerulusa netw rk bl d apillaries
tu ked int the gl merular apsule. N te in
Figure 20-4, B that the small artery (af erent arteriole)
that delivers bl d t the gl merulus is larger in
diameter than the ef erent arteriole that drains
bl d r m the gl merulus and that it is relatively
sh rt. T is partly explains the high bl d pressure
that exists in the gl merular apillaries. T is high 20
pressure is required t lter wastes r m the bl d.
B. Renal tubule
1. Proximal convoluted tubule (PC )the rst
segment a renal tubule. T e PC is alled
proximal be ause it lies nearest the tubules rigin
r m the gl merular apsule, and it is alled con-
voluted be ause it has several bends.
2. Nephron loop (Henle loop)the extensi n
the pr ximal tubule int the renal medulla. O b-
serve that the nephr n l p nsists a straight
 558 CHAPTER 20 Urinary System

Glome rulus cove re d by Cortica l Juxta me dulla ry

glome rula r ca ps ule ne phron ne phron
Me dulla
Re na l ca ps ule
Pa pilla
Re na l Dis ta l convolute d tubule (DCT)
pe lvis
Ca lyx P roxima l convolute d tubule (P CT)
Ure te r
Arte riole
Glome rulus
S Re na l corpus cle
Glome rula r
L M ca ps ule
As ce nding limb of ne phron loop
I

De s ce nding limb of ne phron loop

FIGURE 20-3 Location o nephrons. Magni ed
wedge cut rom a kidney shows an example o a corti-
cal nephron and a juxtamedullary nephron. The blood
vessels surrounding each nephron are not shown so that
the nephrons are seen clearly (compare to Figure 20-5).

Colle cting duct (CD)

Ne phron loop
descending limb, a hairpin turn, and a
straight ascending limb.
3. D istal convoluted tubule (D C )the
part the tubule distal t the as ending
limb the nephr n l p. T e DC ex- Urine r m the lle ting du ts exits r m the pyramid
tends r m the as ending limb t the lle t- thr ugh the papilla and enters the alyx and renal pelvis be-
ing du t. re f wing int the ureter.
4. Collecting duct (CD )a straight (that is, n t L k again at Figure 20-3. N ti e the di ering l ati ns
nv luted) part a renal tubule. Distal tubules the tw nephr ns in the illustrati n. One is l ated high in
several nephr ns j in t rm a single lle t- the rtex and is typi al ab ut 85% all nephr ns. Neph-
ing du t. r ns in this gr up are l ated alm st entirely in the renal

Affe re nt a rte riole

Affe re nt
a rte riole
Glome rula r
ca ps ule

Dis ta l tubule Glome rula r-

ca ps ula r
me mbra ne

20 Glome rulus

Effe re nt
a rte riole Glome rula r
ca pilla rie s
Juxta glome rula r (J G) ce lls
Effe re nt a rte riole
A P roxima l tubule B
FIGURE 20-4 Renal corpuscle. A, Schematic showing relationship o glomerulus to glomerular capsule
(Bowman capsule)together called the renal corpuscleand adjacent structures. B, Scanning electron micro-
graph showing several glomeruli and their associated blood vessels. The di erence in diameters o a erent and
e erent arterioles is clearly visible.

rtex and are alled cortical nephrons. T e remainder, alled
juxtamedullary nephrons, have their renal rpus les near
the jun ti n (juxta) betweevn the rtex and medullary layers.
T ese nephr ns have nephr n l ps that dip ar int the me-
dulla. Juxtamedullary nephr ns have an imp rtant r le in
n entrating urine.
O ve r v ie w o Kid n e y Fu n c t io n
T e kidneys are vital rgans. T e un ti n they per rm, that
rming urine, is essential r h me stasis and mainte-
nan e li e. Early in the pr ess urine rmati n, f uid,
ele tr lytes, and wastes r m metab lism are ltered r m the
bl d and enter the nephr n. Additi nal wastes may be se-
reted int the tubules the nephr n while substan es use ul
t the b dy are reabs rbed int the bl d.
N rmally the kidneys balan e the am unt many sub-
stan es entering and leaving the bl d ver time s that
n rmal n entrati ns an be maintained. In sh rt, the kid-
neys adjust their utput t equal the intake the b dy. By
Glome rula r ca ps ule
Re na l corpus cle
Glome rulus
Effe re nt a rte riole
Juxta glome rula r (J G) a ppa ra tus
Affe re nt a rte riole
Dis ta l convolute d tubule (DCT)
Arte ry a nd ve in
Pe ritubula r ca pilla rie s
As ce nding limb of ne phron loop
De s ce nding limb of ne phron loop
CHAPTER 20 Urinary System 559
eliminating wastes and adjusting f uid and ele tr lyte bal-
an e, the kidneys play an essential part in maintaining h -
me stasis the wh le b dy.
H me stasis ann t be maintainedn r an li e itsel i
the kidneys ail and the nditi n is n t s n rre ted. Ni-
tr gen us waste pr du ts a umulate as a result pr tein
breakd wn and qui kly rea h t xi levels i n t ex reted. I
kidney un ti n is greatly redu ed be ause aging, injury, r
disease, li e an be maintained by using an arti ial kidney t
leanse the bl d wastes.
Ex reti n t xins and nitr gen- ntaining waste
pr du ts su h as urea and amm nia represents nly ne the
imp rtant resp nsibilities the kidney. T e kidneys als play
a key r le in regulating the levels many hemi al substan es
in the bl d su h as hl ride, s dium, p tassium, and bi ar-
b nate. T e kidneys als regulate the pr per balan e between
b dy water ntent and salt by sele tively retaining r ex ret-
ing b th substan es as requirements demand.
In additi n, the ells the juxtaglomerular ( JG) apparatus
(see Figure 20-4, A, and Figure 20-5) als un ti n in bl d v lume
P roxima l convolute d
tubule (P CT)
Pe ritubula r ca pilla rie s
FIGURE 20-5 Nephron structure. Cross sec-
tions rom the our segments o the renal tubule
are shown. The di erences in appearance in tu-
bular cells seen in a cross section ref ect the di -
ering unctions o each nephron segment. A gap
in the nephron loop represents additional length
that cannot be shown in the allotted space.
20
Colle cting duct (CD)
 560 CHAPTER 20 Urinary System Glome rulus P e ritubula r ca pilla rie s
Dis ta l
tubule
and bl d pressure regulati n. W hen bl d pressure is l w, Na (DCT)
whi h ten urs when bl d plasma v lume is l w, these JG
ells se rete an enzyme that triggers a system (dis ussed later in H 2O
this hapter) t help rest re n rmal bl d v lume and pressure.
Yet an ther imp rtant un ti n the kidney is se reti n
lome rula r P roxima l
the h rm ne erythropoietin (EPO). As a resp nse t hy- ca ps ule tubule (P CT)
poxia, a de ien y xygen in the b dy, erythr p ietin is
K H 2O
released int the bl dstream. EPO travels in the bl dstream Glucos e
t the red b ne marr w, where it stimulates the pr du ti n NH 3
additi nal erythr ytes (red bl d ells). T e additi nal eryth- NH 3
r ytes in rease the ability the bl d t abs rb and trans-
p rt xygen t xygen-starved tissues. H
EPO is s metimes used as a drug ( ne brand is Pr rit) t
treat anemia aused by riti al illness su h as an er. EPO is
s metimes abused by athletes attempting t impr ve their Ne phron loop Colle cting
athleti per rman e by b sting hemat ritthus in reasing duct (CD)
the xygen- arrying apa ity their bl d. (See Blood Dop-
ing on p. 354.) FIGURE 20-6 Formation o urine. Dia-
Filtra tion
As y u pr bably guessed, kidney disease an ause anemia gram shows examples o the steps in urine
Re a bs orption
by redu ing the b dys ability t pr du e EPO when needed. ormation in successive parts o a nephron:
S e cre tion
W ith all these vital un ti ns, it is easy t understand why ltration, reabsorption, and secretion.
the kidneys are ten nsidered t be am ng the m st im-
p rtant h me stati rgans in the b dy.
Filt r a t io n
To learn more about the kidney, go to Urine rmati n begins with the pr ess ltration, whi h
AnimationDirect at evolve.elsevier.com. g es n ntinually in the renal rpus les (gl merular ap-
sules plus their en ased gl meruli). Bl d f wing thr ugh the
QUICK CHECK gl meruli exerts pressure, and this gl merular bl d pressure is
1. Na m e s ix g ro s s s tru ctu re s o th e kid n e y. high en ugh t push water and diss lved substan es thr ugh
2. Wh a t a re th e p rim a ry s tru ctu re s o a n e p h ro n ? the glomerular-capsular membrane int the gl merular ap-
3. Wh a t is th e re la tio n s h ip o th e g lo m e ru la r ca p s u le w h e n sule. I the gl merular bl d pressure were t dr p bel w a
d is cu s s in g th e s e g m e n ts o th e re n a l tu b u le a n d th e d ire c- ertain level, ltrati n and urine rmati n w uld ease. H em-
tio n a l te rm s p roxim a l a n d d is ta l ? rrhage, r example, may ause a pre ipit us dr p in bl d
4. Wh a t is th e u n ctio n o th e h o rm o n e e ryth ro p o ie tin ?
pressure ll wed by kidney ailure.

Fo r m a t io n o U r in e
T e kidneys tw milli n r m re nephr ns
balan e the mp siti n the bl d plasma, C LIN ICA L APPLICATION
thus helping maintain a h me stati n-
stan y r the internal envir nment the THE AGING KIDNEY
wh le b dy. In per rming this riti al un - As w ith othe r body organs , the kidneys unde rgo both age -re late d s tructural
ti n, the kidneys nephr ns must f ush ut change s and de cre as ing unctional capacity. Adults olde r than 35 ye ars o age
ex ess r waste m le ules by ex reting urine. gradually los e unctional ne phron units , and kidney we ight actually de cre as e s .
T e nephr ns rm urine by way a m- By approxim ate ly 80 to 85 ye ars o age , m os t individuals w ill have expe rie nce d
binati n three pr esses: a 30% re duction in total kidney m as s .
20 1. Filtrati n
In s pite o a num e rical re duction in actual kidney ne phron units and a de -
cre as e in the m e tabolic activity o re m aining tubular ce lls , m os t o the s e indi-
2. Reabs rpti n viduals continue to exhibit norm al kidney unction. This is pos s ible be caus e
3. Se reti n olde r pe rs ons ge ne rally have a lowe r ove rall le an body m as s and the re ore a
re duce d production o was te products that m us t be excre te d rom the body.
Figure 20-6 summarizes these three pr esses.
Howeve r, the m argin o s a e ty is als o re duce d, and any s tre s s on the re m ain-
ing unctional ne phrons , s uch as a s ys te m ic in e ction or a re duction in kidney
To better understand this blood ow, can produce alm os t im m e diate s ym ptom s o kidney ailure .
concept, use the Active Concept Marginal kidney unction in old age m ay m ake it di f cult to excre te drugs
that are e as ily cle are d rom the blood o younge r pe rs ons , and dos age s o m any
Map Formation o Urine at
m e dications have to be adjus te d accordingly or olde r patie nts .
evolve.elsevier.com.
 CHAPTER 20 Urinary System 561

Gl merular ltrati n n rmally urs at the rate
125 mL per minute. T is is equivalent t ab ut 180 L (nearly
50 gall ns) glomerular ltrate being pr du ed by the kid-
neys every day.
O bvi usly n ne ever ex retes anywhere near 180 L
urine per day. W hy? Be ause m st the f uid that leaves the
bl d by gl merular ltrati n, the rst pr ess in urine rma-
ti n, returns t the bl d by the se nd pr essreabsorption.
Re a b s o r p t io n
Reabsorption is the m vement substan es ut the renal
tubules int the bl d apillaries l ated ar und the tubules
(peritubular apillaries). Water, glu se, and ther nutrients,
as well as s dium and ther i ns, are substan es that are reab-
s rbed. Reabs rpti n begins in the pr ximal nv luted tu-
bules and ntinues in the nephr n l p, distal nv luted
tubules, and lle ting du ts.
Large am unts waterappr ximately 120 L per day
are reabs rbed by sm sis r m the pr ximal tubules. In ther
w rds, r ughly tw -thirds the 180 L water that leaves
the bl d ea h day by gl merular ltrati n returns t the
bl d by pr ximal tubule reabs rpti n. T e pr ximal tubules
als reabs rb ab ut tw -thirds m st i ns, as well as nearly
all the small rgani m le ules.
Smaller am unts water and i ns are later reabs rbed in
the nephr n l ps, distal tubules, and lle ting du ts.
C mm n table salt (NaCl) nsumed in the diet r in-
tr du ed by intraven us (IV) in usi n n rmal saline
(0.9% NaCl) r ther NaCl-
ntaining f uids, pr vides
the b dy with s dium i ns
(Na ) and hl ride i ns
(Cl ). F r the m st part, s dium i ns are a tively trans-
p rted ba k int bl d r m the tubular f uid in all segments
the kidney tubule ex ept the lle ting du ts.
S dium reabs rpti n in the nephr n l p is a spe ial ase.
T e nephr n l p and its surr unding peritubular apillaries
dip ar int the medulla and then return ba k up in what is
alled countercurrent f w (see Figure 20-5 n p. 559). T is un-
ter urrent f wf w in pp site dire ti ns ltrate ba k
up the nephr n l p permits transp rt large am unts s -
dium and hl ride int the interstitial f uid the medulla. T is
makes the medulla very salty r hyperosmotic. H yper s-
m ti s luti ns are s named be ause they generally pr m te
sm sis water (int them), as d hypert ni s luti ns.
In additi n, the unter urrent f w bl d in the peritu-
bular apillaries surr unding the nephr n l p ails t rem ve
all the ex ess s dium and hl ride r m the renal medulla.
gether, these countercurrent mechanisms maintain
hyper sm ti nditi ns in the medulla. By maintaining a
hyper sm ti medulla, the kidney is able t n entrate urine
by reabs rbing m re water by sm sis than therwise p ssi-
ble. H w the kidney thus regulates urine v lume is vered
subsequently.
T e am unt s dium reabs rbed depends largely n the
b dys intake. In general the greater the am unt s dium
intake, the less the am unt reabs rbed and the greater the
am unt ex reted in the urine. Als , the less s dium intake, the
greater the reabs rpti n r m kidney tubules and the less ex-
reted in the urine.
Rather than being a tively reabs rbed r m renal tubules
as are s dium i ns (Na ), hl ride i ns (Cl ) passively m ve
int bl d be ause they arry a negative ele tri al harge. T e
p sitively harged s dium i ns that have been reabs rbed and
m ved int the bl d attra t the negatively harged hl ride
i ns r m the tubule f uid int the peritubular apillaries.
Figure 20-7 explains the details h w s dium, hl ride, and
water are reabs rbed a r ss the tubule wall and int the peri-
tubular bl d. ake a ew minutes t review ea h step in the
diagram.

Lume n of Wa ll of Inte rs titia l P e ritubula r

tubule tubule s pa ce ca pilla ry
FIGURE 20-7 Reabsorption o ions and
water. 1 Sodium ions (Na ) are pumped rom
the tubule cell to interstitial f uid (IF), thereby
increasing the interstitial Na concentration to
Na Na
a level that drives di usion o Na into blood.
1 Na Na
As Na is pumped out o the cell, more Na 20
passively di uses in rom the ltrate to maintain
ATP an equilibrium o concentration. Enough Na
2 Cl Cl ADP moves out o the tubule and into blood that an
electrical gradient is established (blood is posi-
Cl Cl tive relative to the ltrate). 2 Electrical attrac-
3 H 2O H 2O tion between oppositely charged particles
drives di usion o negative ions in the ltrate,
such as chloride (Cl ), into blood. 3 When the
H 2O H 2O ion concentration in blood increases, osmosis o
water rom the tubule occurs. Thus active trans-
Filtrate Epithe lial c e ll IF Blo o d port o sodium creates a situation that promotes
passive transport o negative ions and water.
 562 CHAPTER 20 Urinary System Lume n of Wa ll of Inte rs titia l P e ritubula r
tubule tubule s pa ce ca pilla ry

All the ltered glu se is n rmally reabs rbed r m the

G Glucos e
pr ximal tubules int peritubular apillary bl d. N ne this
valuable nutrient is wasted by being l st in the urine. Figure 20-8 G Na+ Na+
Na+
sh ws h w s dium-glu se arriers in the tubule wall all w
glu se m le ules t passively tag al ng as s dium is a tively Na+ Na+
reabs rbed ba k int the bl d. G ATP
G
T e transport maximum ( max)the largest am unt Na+
G G
any substan e that an be reabs rbed at ne timeis deter-
G
mined mainly by the number available transp rters that Epithe lial
substan e. T e transp rt maximum any substan e helps G c e ll Blo o d
determine the renal thresholdthe am unt substan e in Filtrate c apillary
IF
the bl d ab ve whi h the kidney ex retes the ex ess sub-
stan e in the urine.
FIGURE 20-8 Reabsorption o glucose. The presence o sodium
Un rtunately, s metimes n t all the glu se in the tubule glucose transporters provides a way or the active transport o sodium to
ltrate is re vered by the bl d. F r example, in diabetes mel- also passively transport glucose across tubule cells and eventually back into
litus (DM ), i bl d glu se n entrati n in reases ab ve the the blood. The availability o these transporters may limit how much glucose
renal thresh ld, tubular ltrate then ntains m re glu se can be reabsorbed at one time.
than kidney tubule ells an reabs rb. T ere are n t en ugh
s dium-glu se transp rters t handle the ex ess glu se im- Many substan es that are se reted r m peritubular bl d
mediately. S me the glu se there re remains behind in enter the ltrate primarily in the pr ximal tubule and, t a
the urine. Glu se in the urineglycosuriais a well-kn wn lesser extent, the distal nv luted tubule and lle ting du ts.
sign DM. T e maj r ex epti n t this rule thumb is p tassium
Retaining glu se in the urine als pr m tes ther lassi i n, whi h is se reted primarily int the lle ting du ts in an
sympt ms DM. F r example, high glu se n entrati n in ex hange with s dium. Urine v lume p tassium i ns (K )
the tubular ltrate means that less water will leave the tubules varies greatly with diet. S me diuretic drugs, whi h stimulate
by sm sis. T us urine is dilute and has a higher than n rmal the pr du ti n urine (see the b x n p. 591), are said t be
v lumeresulting in the ex essive urinati n (polyuria) typi al p tassium wasting be ause they in rease secretion p tas-
untreated DM. T is in reased l ss water r m the b dy, sium int tubular f uid and thus its ex reti n in the urine.
in turn, triggers thirst alled polydipsiaals a lassi indi- In the distal nv luted tubules and lle ting du ts, s -
at r DM. N w is a g d time t review the DM n ept dium se reti n is dependent n h rm nes that are als im-
map sh wn in Figure 12-18 n p. 337. p rtant in regulating urine v lume, as dis ussed bel w. Am-
m nia is se reted passively by di usi n.
Kidney tubule se reti n plays a ru ial r le in maintaining
S e c r e t io n the b dys f uid, ele tr lyte, and a id-base balan e dis ussed in
Secretion is the pr ess by whi h substan es m ve int urine Chapters 21 and 22.
in the distal and lle ting du ts r m bl d in the apillaries
ar und these tubules. In this respe t, se reti n is reabs rpti n
in reverse. W hereas reabs rpti n m ves substan es ut the
S u m m a ry o U r in e Fo r m a t io n
urine int the bl d, se reti n m ves substan es ut the In summary, the ll wing pr esses urring in su essive
bl d int the urine. p rti ns the nephr n a mplish the un ti n urine
ubular se reti n serves an imp rtant un ti n by help- rmati n (Table 20-1):
ing t rem ve r lear the bl d ex ess p tassium and
hydr gen i ns, ertain drugs in luding peni illin and phen - 1. Filtration water and diss lved substan es ut
barbital, and numer us wastes su h as urea, uri a id, and the bl d in the gl meruli int the gl merular
reatinine. apsule.

20
TABLE 20-1 Functions o Parts o Nephron in Urine Formation
PROCES S IN
PART OF NEPHRON URINE FORMATION S UBSTANCES MOVED
Glom e rulus and glom e rular Filtration Wate r and s olute s ( or exam ple , s odium and othe r ions , glucos e and othe r nutri-
caps ule e nts f lte ring out o glom e ruli into glom e rular caps ule s )
Proxim al tubule Re abs orption Wate r and s olute s (glucos e , am ino acids , Na )
Se cre tion Nitroge nous was te s , s om e drugs
Ne phron loop Re abs orption Sodium and chloride ions
Dis tal and colle cting tubule s Re abs orption Wate r, s odium , and chloride ions
Se cre tion Am m onia, potas s ium ions , hydroge n ions , and s om e drugs

2. Reabsorption water and diss lved substan es
ut kidney tubules ba k int bl d. T is prevents
substan es needed by the b dy r m being l st in
urine. Usually, up t 99% water, s dium, and hl -
ride ltered ut gl merular bl d is retrieved r m
tubulesal ng with 100% glu se and ther
small rgani m le ules.
3. Secretion hydr gen i ns, p tassium i ns, and
ertain drugs r m bl d int kidney tubules.
To learn more about urine ormation, go to
AnimationDirect at evolve.elsevier.com.
QUICK CHECK
1. Wh a t a re th e th re e b a s ic p ro ce s s e s th a t o ccu r in th e
n e p h ro n ?
2. Wh e re d o e s f ltra tio n o ccu r in th e n e p h ro n ?
3. Wh e re d o e s re a b s o rp tio n o ccu r in th e n e p h ro n ?
C o n t ro l o U r in e Vo lu m e
T e b dy has ways t ntr l the am unt and mp siti n
the urine that it ex retes. It d es this mainly by ntr lling the
am unt water and diss lved substan es that are reabs rbed
by the kidney tubules.
A n t id iu r e t ic Ho r m o n e
An example regulating water reabs rpti n in kidney tubules
inv lves a h rm ne alled antidiuretic hormone (AD H) se-
reted r m the p steri r pituitary gland. ADH de reases the
am unt urine by making lle ting du ts (CDs) permeable
t water.
I n ADH is present, the CDs are pra ti ally imperme-
able t water, s little r n water is reabs rbed r m them.
W hen ADH appears in the bl d, CDs be me permeable t
water and water is reabs rbed r m them. As a result, less
water is l st r m the b dy as urine, and thus m re water is
retained by the b dythink it in whi hever way y u nd
it easier t remember. At any rate, r this reas n ADH an
a urately be des ribed as the water-retaining h rm ne r
the urine-de reasing h rm ne.
Re all that the unter urrent me hanisms the nephr n
l p and its apillaries maintain a hyper sm ti (salty) me-
dulla. W hen ltrate m ves d wn the lle ting du ts, the a -
ti n ADH all ws sm sis water t equilibrate with the
hyper sm ti interstitial f uid the medullathus rem ving
m re water r m the ltrate than w uld therwise be p ssible.
Maintaining a salty r hyper sm ti medulla all ws ADH t
have a pr n un ed e e t in n entrating urine, thereby n-
serving the b dys valuable water.
A ld o s t e ro n e
T e h rm ne aldosterone, se reted by the adrenal rtex,
plays an imp rtant part in ntr lling the kidney tubules re-
abs rpti n s dium. Primarily, it stimulates the tubules t
CHAPTER 20 Urinary System 563
reabs rb s dium at a aster rate. Se ndarily, ald ster ne als
in reases tubular water reabs rpti n be ause water always
ll ws s dium by sm sis whenever p ssible. T e term salt-
and water-retaining hormone there re is an apt des riptive
ni kname r ald ster ne. Like ADH , ald ster ne redu es
urine v lume.
T e kidney itsel is resp nsible r triggering ald ster ne
se reti n, a a t that illustrates the imp rtan e the kidney
in regulating verall f uid v lume and bl d pressure in the
b dy. W hen bl d v lume and pressure dr p bel w n rmal,
this is sensed by ells in the JG apparatus. JG ells then release
an enzyme alled renin that initiates the renin-angiotensin-
aldosterone system (RAAS). T e RAAS eventually pr du es
nstri ti n bl d vessels and by d ing s , raises bl d
pressure. T e RAAS als triggers adrenal gland se reti n
ald ster ne, whi h pr m tes water retenti n and thus in-
reases t tal bl d v lumethus als ntributing t a rise in
bl d pressure. Figure 20-9 illustrates the main events the
RAAS and h w it a ts t rest re n rmal plasma v lume and
bl d pressure. Ald ster ne me hanisms are als dis ussed in
the next hapter.
A t r ia l N a t r iu r e t ic Ho r m o n e
An ther h rm ne, atrial natriuretic hormone (ANH) se-
reted r m the hearts atrial wall, has the pp site e e t
ald ster ne. ANH is the primary atrial natriuretic peptide
(ANP) h rm ne in humans. ANH stimulates kidney tubules
t se rete m re s dium and thus l se m re water. ANH is
a salt- and water-losing hormone. T us ANH in reases urine
v lume while redu ing bl d v lume.
T e b dy se retes ADH , ald ster ne, and ANH in di er-
ent am unts, depending n the h me stati balan e b dy
f uids at any parti ular m ment.
A b n o r m a lit ie s o U r in e Vo lu m e
S metimes the kidneys d n t ex rete n rmal am unts
urine as a result kidney disease, end rine imbalan es, ar-
di vas ular disease, stress, r a variety ther nditi ns.
H ere are s me terms ass iated with abn rmal am unts
urine:
1. Anuriaabsen e urine
2. O ligurias anty am unt urine
3. Polyuriaunusually large am unt urine
Be ause a hange in urine v lume r utput is a signi ant 20
indi at r many types f uid alterati ns and diseases, mea-
surement b th f uid intake and f uid utput (urine v lume)
ver a spe i ed peri d time, ten abbreviated as I & O, is
a mm n pra ti e in lini al medi ine. T e n rmal adult
urine utput is ab ut 1500 t 1600 mL per day.
QUICK CHECK
1. Wh a t is th e u n ctio n o ANH?
2. Ho w d o ADH a n d a ld o s te ro n e a e ct u rin e o u tp u t?
3. Ho w d o a n u ria a n d p o lyu ria d i e r?
 564 CHAPTER 20 Urinary System

Norma l Norma l Elim in a t io n o U r in e

blood pla s ma
pre s s ure volume On e urine is rmed by the kidneys, it must be eliminated r m
the b dy. O ur dis ussi n n w returns t a us n anat my as
we dis uss the plumbing needed t drain the urine away.
S ome fa ctor S ome fa ctor

Ure t e rs
Urine drains ut the lle ting tubules ea h kidney int
Low Low
blood pla s ma the renal pelvis and d wn the ureter int the urinary bladder
pre s s ure volume (see Figure 20-1). T e renal pelvis is the basinlike upper end
the ureter l ated inside the kidney. Ureters are narr w tubes
1 less than 6 millimeters (mm) ( in h) wide and 25 t 30 en-
timeters ( m) (10 t 12 in hes) l ng.
Juxta glome rula r Mu us membranes eaturing easily stret hable transi-
a ppa ra tus
re le a s e s re nin
tional epithelium line b th ureters and ea h renal pelvis. N te
Re s tore s Re s tore s
in Figure 20-10 that the ureter has a thi k, mus ular wall. C n-
tra ti n the mus ular at pr du es peristalti -type m ve-
2
ments that assist in m ving urine d wn the ureters int the
bladder. T e lining membrane the ureters is ri hly supplied
Re nin conve rts a ngiote ns inoge n
in pla s ma to a ngiote ns in I with sens ry nerve endings.
Epis des renal colicpain aused by the passage a
kidney st nehave been des ribed in medi al writings sin e
antiquity. Kidney st nes ause intense pain i they have sharp
Angiote ns in-conve rting e nzyme edges r are large en ugh t distend the walls r ut the lining
(ACE) conve rts a ngiote ns in I to the ureters r urethra as they pass r m the kidneys t the
a ngiote ns in II
exteri r the b dy. S me the pain is aused by tearing r
3 stret hing the urinary liningal ng with the a mpany-
4 ing inf ammati n. H wever, mu h the pain is ass iated
with ramping mus les that attempt t push a kidney st ne
Angiote ns in II Angiote ns in II rward. T e term li is used be ause its similarity t
promote s promote s a dre na l
va s ocons triction gla nd s e cre tion
of a rte riole s of a ldos te rone
Lume n Tra ns itiona l e pithe lium
5

Aldos te rone
promote s wa te r
re a bs orption by
kidney

FIGURE 20-9 Renin-angiotensin-aldosterone system (RAAS).

1 Low plasma volume reduces blood pressure below normal, which is
detected by juxtaglomerular (JG) cells in the juxtaglomerular apparatus o
the kidney.
2 This triggers JG cells to release the enzyme renin, which converts an-
giotensinogen into angiotensin I.
3 The angiotensin converting enzyme (ACE) ( ound in various tissues)
20 then converts angiotensin I to angiotensin II.
4 Angiotensin II stimulates constriction o arteriolar smooth muscles,
increasing blood pressure back toward normal.
5 Angiotensin II also triggers adrenal gland secretion o aldosterone,
which promotes water retention by the kidney and thus restoration o
normal blood volume and pressure.
Adipos e Conne ctive tis s ue S mooth
tis s ue (la mina propria ) mus cle

FIGURE 20-10 Ureter cross section. Note the many olds o the mucous
lining (transitional epithelium) that permit stretching as urine passes through
the tube. A thick muscular layer o smooth muscle helps pump urine toward
the bladder. On its outer sur ace the ureter is covered by a tough brous connec-
tive tissue coat.
 CHAPTER 20 Urinary System 565

pain ul ramps s metimes experien ed in the mus le layers Ure te r Cut e dge of
the l n. Urina ry pe ritone um
mucos a
Medical imaging techniques can clearly outline (tra ns itiona l
e pithe lium) S mooth
the segments o the urinary tract to show possible mus cle
abnormalities. To see examples, check out the
article Visualizing the Urinary Tract at Connect It! Trigone
at evolve.elsevier.com. Ope ning
of ure te r Ope ning
of ure te r
U r in a ry Bla d d e r Ruga e

T e empty urinary bladder lies in the pelvis just behind the

Inte rna l
pubi symphysis. W hen ull urine, it pr je ts upward int
P ros ta te urina ry
the l wer p rti n the abd minal avity. In w men it sits in s phincte r
gla nd
r nt the uterus, whereas in men, it rests n the pr state.
Exte rna l P ros ta tic ure thra
Elasti bers and inv luntary mus le bers in the wall
urina ry
the urinary bladder make it well suited r expanding t h ld s phincte r Bulboure thra l
variable am unts urine and then ntra ting t empty it- gla nd S
sel . Mu us membrane ntaining transiti nal epithelium
R L
lines the urinary bladder (Figure 20-11). T e lining is l sely
atta hed t the deeper mus ular layer s that the bladder is A I
very wrinkled and lies in lds alled rugae when it is empty.
W hen the bladder is lled, its inner sur a e may stret h until
it is sm th. Kidne y
N te in Figure 20-11, A, that ne triangular area n the ba k
r p steri r sur a e the bladder is ree rugae. T is area, S
Ure te r
S
alled the trigone, is always sm th. T ere, the lining mem- P A A P
brane is tightly xed t the deeper mus le at. T e trig ne Bla dde r
I I
extends between the penings the tw ureters ab ve and P ubic
the p int exit the urethra bel w. s ymphys is
Re ctum Ure thra Re ctum
Ure t h ra P e nis
Urina ry
leave the b dy, urine passes r m the bladder, d wn the me a tus
urethra, and ut its external pening, the urinary meatus. B Ute rus Va gina P ros ta te gla nd
In ther w rds, the urethra is the l west and last part the FIGURE 20-11 Urinary bladder. A, Frontal view o a ully distended
urinary tra t. male bladder dissected to show the interior. Note the relationship o the
T e same sheet mu us membrane that lines ea h renal prostate gland, which surrounds the urethra as it exits the bladder. This re-
pelvis, the ureters, and the bladder extends d wn int the lationship is discussed in Chapter 23. B, Sagittal section o the emale uri-
urethra, t . It is w rth n ting the ntinuity the urinary nary system (le t) and the male urinary system (right) showing relationship
o the bladder to other anatomical structures.
mu us lining be ause it a unts r the a t that an in e -
ti n the urethra may spread upward thr ugh the urinary
tra t t ause cystitis (bladder in e ti n).
T e urethra is a narr w tube; it is nly ab ut 4 m urethral sphincter is l ated at the bladder exit, and the external
(1 in hes) l ng in a w man, but it is ab ut 20 m (8 in hes) urethral sphincter ir les the urethra just bel w the ne k the
l ng in a man. In a man, the urethra has tw un ti ns: (1) it bladder (see Figure 20-11). W hen ntra ted, b th sphin ters
is the terminal p rti n the urinary tra t, and (2) it is the seal the bladder and all w urine t a umulate with ut 20
passageway r m vement the repr du tive f uid (semen) leaking t the exteri r. T e internal urethral sphin ter is inv l-
r m the b dy. In a w man, the urethra is a part nly the untary, and the external urethral sphin ter is mp sed
urinary tra t. striated mus le and is under v luntary ntr l.
T e mus ular wall the bladder permits this rgan t
a mm date a nsiderable v lume urine with very little
M ic t u r it io n in rease in pressure until a v lume 300 t 400 mL is
T e terms micturition, urination, and voiding all re er t the rea hed. As the v lume urine in reases, the need t v id
passage urine r m the b dy r the emptying the bladder. may be n ti ed at v lumes 150 mL, but mi turiti n in
w sphincters (rings mus le tissue) a t as valves that adults d es n t n rmally ur mu h bel w v lumes
guard the pathway leading r m the bladder. T e internal 350 mL.
 566 CHAPTER 20 Urinary System
As the bladder wall stret hes, nerve impulses are transmit-
ted t the se nd, third, and urth sa ral segments the
spinal rd, and an emptying re ex is initiated. T e ref ex
auses ntra ti n the mus le the bladder wall and re-
laxati n the internal sphin ter. Urine then enters the ure-
thra. I the external sphin ter, whi h is under v luntary n-
tr l, is relaxed, mi turiti n urs. V luntary ntra ti n
the external sphin ter an suppress the emptying ref ex until
the bladder is lled t apa ity, when l ss ntr l urs.
C ntra ti n this p wer ul sphin ter an als abruptly ter-
minate urinati n v luntarily.
H igher enters in the brain als un ti n in mi turiti n by
integrating bladder ntra ti n and internal and external
sphin ter relaxati n, with the perative ntra ti n pel-
vi and abd minal mus les.
A b n o r m a lit ie s o U r in e O u t p u t
Urinary retention is a nditi n in whi h n urine is v ided.
T e kidneys pr du e urine, but the bladder, r ne reas n r
an ther, ann t empty itsel . In urinary suppression the p-
p site is true. T e kidneys d n t pr du e any urine, but the
bladder retains the ability t empty itsel .
C LIN ICA L APPLICATION
URINARY CATHETERIZATION
Urinary cathe te rizatio n is the pas s age or ins e rtion o a hollow
tube or cathe te r through the ure thra into the bladde r or the
w ithdrawal o urine (s e e f gure ). It is a m e dical proce dure com -
m only pe r orm e d on patie nts w ho unde rgo prolonge d s urgical
or diagnos tic proce dure s or w ho expe rie nce proble m s w ith
urinary re te ntion.
Corre ct cathe te rization proce dure s re quire as e ptic te ch-
nique s to preve nt the introduction o in e ctious bacte ria into
20
S S
P A
I I
A Fe male
Mi turiti n is a mplex b dy un ti n. It requires ntr l
and integrati n b th v luntary and inv luntary nerv us
system mp nents a ting n a variety anat mi stru tures.
Un rtunately, h me stati ntr l pr blems ur quite re-
quently in this mplex system. In additi n t the 15% t 20%
hildren wh experien e s me degree enuresis, v iding
dys un ti n a e ts nearly 15 milli n adult Ameri ans. Pe ple
ver 60 are espe ially at risk, with elderly w men a e ted al-
m st twi e as ten as men.
Urinary incontinence r enuresis re ers t inv luntary
v iding r l ss urine in an lder hild r adult. Urge incon-
tinence is ass iated with sm th mus le vera tivity in the
bladder wall. T e term stress incontinence is ten used t de-
s ribe the type urine l ss ass iated with laughing, ugh-
ing, r heavy li ting. It is a mm n pr blem in w men with
weakened pelvi f r mus les ll wing pregnan y. S - alled
over ow incontinence is hara terized by intermittent dribbling
urine. It results r m urinary retenti n and an verdistended
bladdera mm n pr blem in men with an enlarged pr s-
tate gland (see Chapter 23).
Re ex incontinence urs in the absen e any sens ry
warning r awareness. It is mm n in nerv us system dis r-
ders su h as str ke, parkins nism, r spinal rd injury. I
the urinary s ys te m . Clinical s tudie s have prove d that im prope r
cathe te rization te chnique s caus e bladde r in e ctions a condi-
tion calle d cys titis and point out the ne e d or exte ns ive train-
ing o he alth pro e s s ionals w ho pe r orm cathe te rizations . To
m inim ize the ris k o in e ction, s om e acilitie s now us e ultra-
s ound im aging o the bladde r to de te rm ine w he the r urine is
be ing involuntarily re taine d in the bladde rre placing the or-
m e r practice o cathe te rizing a patie nt at tim e d inte rvals .
A P
B Male

t tally ut r m spinal innervati n, the bladder mus ulature
a quires s me aut mati a ti n, and peri di but unpredi t-
able v iding ursa nditi n alled neurogenic bladder.
Bed wetting at night (nocturnal enuresis) ten urs in a
hild wh is bey nd the age when v luntary bladder ntr l
is expe ted. In iden e is higher in b ys than in girls and is
ten due t maturati nal delay the mplex urinary re-
f exes needed r v luntary ntr l mi turiti n.
QUICK CHECK
1. Th ro u g h w h a t tu b e d o e s u rin e le a ve th e kid n e y?
2. Wh a t s tru ctu ra l ch a ra cte ris tics o th e b la d d e r a llo w it to
e xp a n d to h o ld u rin e ?
3. Th ro u g h w h a t s tru ctu re d o e s u rin e p a s s ro m th e b la d d e r
to th e o u ts id e o th e b o d y?
4. Wh a t is ove r o w in co n tin e n ce ?
U r in a ly s is
T e physi al, hemi al, and mi r s pi examinati n urine
is termed urinalysis. Like bl d, urine is a f uid wh se study
an reveal mu h ab ut the n rmal and abn rmal un ti ning
the b dy. Changes in the n rmal hara teristi s urine r
the appearan e abn rmal urine hara teristi s may be a
sign disease. Table 20-2 lists b th the n rmal and abn rmal
hara teristi s urine.
In lini al and lab rat ry situati ns, a standard urinalysis is
ten re erred t as a r utine and mi r s pi urinalysis, r
simply an R and M. T e r utine p rti n is a series
physi al and hemi al tests, whereas the mi r s pi part
re ers t the study urine sediment with a mi r s pe. T is
series lab rat ry tests pr vides the variety in rmati n
ten ne essary r a physi ian t make a diagn sis.
Crushing injuries o skeletal muscle release intra-
cellular contents into the bloodstream, which
puts a heavy burden on the kidneys. Review the
article Rhabdomyolysis and how it can be
detected through urinalysis at Connect It! at
evolve.elsevier.com.
HEA LTH AND WELL-BEIN G
PROTEINURIA AFTER EXERCIS E
Pro te inuria is the pre s e nce o plas m a prote ins in the urine . Prote inuria is
probably the m os t im portant indicator o re nal dis e as e (ne phro pathy)
be caus e only dam age d ne phrons cons is te ntly allow plas m a prote in m ol-
e cule s to le ave the blood. Howeve r, inte ns e exe rcis e caus e s te m porary
prote inuria in m any individuals . Som e exe rcis e phys iologis ts be lieve d that
inte ns e athle tic activitie s caus e kidney dam age , but s ubs e que nt re s e arch
has rule d out that explanation. One curre nt hypothe s is is that horm onal
change s during s tre nuous exe rcis e incre as e the pe rm e ability o the ne ph-
rons f ltration m e m brane , allow ing s om e plas m a prote ins to e nte r the
f ltrate . Som e pos texe rcis e prote inuria is us ually cons ide re d norm al.
CHAPTER 20 Urinary System 567
Re n a l a n d U r in a ry D is o r d e r s
Y u may have experien ed the dis m rt and pain ul, burn-
ing urinati n, alled dysuria, ass iated with a bladder in e -
ti n r kn w s me ne wh has. Bladder in e ti n is the m st
mm n urinary dis rder, but it usually is n t seri us i
pr mptly treated. A number renal and urinary dis rders are
very seri us, h wever. Any dis rder that signi antly redu es
the e e tiveness the kidneys is immediately li e threaten-
ing. In this se ti n, we dis uss s me li e-threatening kidney
diseases, as well as a ew the less seri us but m re mm n
dis rders.
O b s t r u c t ive D is o r d e r s
O bstru tive urinary dis rders are abn rmalities that inter ere
with n rmal urine f w anywhere in the urinary tra t. T e
severity bstru tive dis rders depends n the l ati n
the inter eren e and the degree t whi h the f w urine is
impaired. O bstru ti n urine f w usually results in ba king
up the urine, perhaps all the way t the kidney itsel .
T e term hydronephrosis is used t des ribe path l gi al
swelling r enlargement the renal pelvis and aly es aused
by bl kage urine utf w. T e nditi n may be the result
ngenital pr blems r be aused by bl kage aused by st nes,
tum rs, r inf ammati n. Regardless ause, i le t untreated,
mu h the internal stru ture the kidney is l st as the rtex
thins and medullary tissue is destr yed (Figure 20-12).
S me the m re imp rtant bstru tive nditi ns are
summarized in the ll wing paragraphs.
Re n a l C a lc u li
Renal calculi, r kidney stones, are rystallized mineral hunks
that devel p in the renal pelvis r aly es (Figure 20-13). Cal uli
devel p when al ium and ther minerals, su h as uri a id,
rystallize n the renal papillae, then break int the urine.
Staghorn calculi are large, bran hed st nes that rm in, and
take the shape , the pelvis and bran hed aly es.
I the st nes are small en ugh, they will simply f w
thr ugh the ureters and eventually be v ided with the urine.
Larger st nes may bstru t the ureters, ausing an intense
pain alled renal colic as rhythmi mus le ntra -
ti ns the ureter attempt t disl dge the st nes.
H ydr nephr sis may ur i the st ne d es n t
m ve r m its bstru ting p siti n.
Tu m o r s 20
um rs the urinary system typi ally bstru t
urine f w, p ssibly ausing hydr nephr sis in ne
r b th kidneys. M st kidney tum rs are malig-
nant ne plasms alled renal cell carcinomas. T ey
usually ur nly in ne kidney. Renal ell ar i-
n ma metastasizes m st ten t the lungs and
b ne tissue. Bladder cancer urs ab ut as re-
quently as renal an er (ea h a unts r ab ut
tw in every hundred an er ases) and is ten
und in ass iati n with bladder st nes.
 568 CHAPTER 20 Urinary System

TABLE 20-2 Characteristics o Urine

NORMAL CHARACTERISTICS
Co lo r and Clarity
Norm al urine : Should be cle ar; color varie s w ith s pe cif c gravity
(Occas ionally, norm al urine m ay be cloudy be caus e o high
die tary leve ls o at or phos phate .)
Dilute urine : Light ye llow to ye llow
Conce ntrate d urine : Dark ye llow to dark am be r
ABNORMAL CHARACTERISTICS
Abnorm ally colore d urine m ay re s ult rom : (1) pathological conditions ,
(2) ce rtain oods , and (3) num e rous drugs :
1. Pathological conditions (exam ple s ):
Kidney cance r (he m orrhage )re d (RBCs )
Bile duct obs truction (galls tone s )orange /ye llow (bilirubin)
Ps e udom onas in e ctiongre e n (bacte rial toxins )

r
e
b
Rhabdomyolys is brow n

m
w

a
llo

rk
2. Foods (exam ple s ):
r
e
ye
w

a
b

D
llo

m
rk

Be e ts re d
w

A
ye

a
llo

D
t

Rhubarbbrow n
h

Y
ig
L

Carrots dark ye llow

Vitam in s upple m e nts bright ye llow
3. Drugs (exam ple s ):
Pyridium (urinary tract analge s ic)orange
Dilantin (anticonvuls ant)pink/re d brow n
Dyre nium (diure tic)pale blue
Cloudy urine m ay re s ult rom (exam ple s ):
1. Bacte riaactive in e ction o urinary s ys te m organs
2. Blood ce lls
RBCs he m orrhage rom kidney cance r
WBCs pus rom urinary tract in e ction (UTI)
3. Cas ts various type s o tube like clum ps (blood ce ll, e pithe lial,
hyaline , waxy, e tc.) that orm in dis e as e d re nal tube s
4. Prote inuria(prote inus ually album in) in urine
5. Crys tals us ually uric acid or phos phate /calcium oxalate in con-
ce ntrate d urine
Co m po unds
Mine ral ions ( or exam ple , Na , Cl , K ) Ke tone s ge ne rally ace tone
Nitroge nous was te s : Am m onia, cre atinine , ure a, uric acid Prote inge ne rally album in
Urine pigm e nt: Urochrom e (product o bilirubin m e tabolis m ) Glucos e
Crys tals ge ne rally uric acid and phos phate or calcium oxalate
Pigm e nts abnorm al leve ls o bilirubin m e tabolite s
Odo r
Slight arom atic Strong, s we e t, ruity (ace tone ) odoruncontrolle d diabe te s m e llitus
Som e oods produce a characte ris tic odor (as paragus ) Foul odorurinary tract in e ctions (UTIs )
Am m onialike odor on s tanding m ay re s ult rom de com pos ition in Mus ty odorphe nylke tonuria
s tore d urine Maple s yrup odorconge nital de e ct in prote in m e tabolis m
pH
4.6-8.0 (ave rage 6.0) High pH during alkalos is kidneys com pe ns ate by excre ting exce s s
Toward Low Norm al: Som e oods (m e at and cranbe rrie s ) and drugs bas e
(chlorothiazide diure tics ) Low pH during acidos is kidneys com pe ns ate by excre ting exce s s H
Toward High Norm al: Som e oods (citrus ruits , dairy products ) and
drugs (bicarbonate antacids )

20 S pe cif c Gravity
Adult: 1.005-1.030 (us ually, 1.010-1.025) Above norm al lim its glycos uria, prote inuria, de hydration, high s olute
Elde rly: Value s de cre as e w ith age load (m ay re s ult in pre cipitation o s olute s and kidney s tone
New born: 1.001-1.020 orm ation)
Be low norm al lim its chronic re nal dis e as e s (inability to conce ntrate
urine ), ove rhydration

Renal and bladder an er have ew sympt ms early in their thr ugh the urethra and int the bladder permits dire t inspe -
devel pment, ther than tra es bl d in the urine, r ti n, bi psy, and surgi al rem val r treatment bladder and
hematuria. As the an er devel ps, pelvi pain and sympt ms ther urinary tra t lesi ns (Figure 20-14, A). T e h ll w tube al-
urinary bstru ti n may ur. Inserti n a cystoscope l ws passage light, a viewing lens, and vari us atheters and

S
L M
I r m ba terial in e ti n, ten gonorrhea (see Appendix A at
FIGURE 20-12 Hydronephrosis. Note the dramatic enlargement o the
renal pelvis and calyces caused by blockage and backing up o urine.
perative devi es. Figure 20-14, B sh ws the appearan e a
malignant tum r n the bladder wall be re its rem val during
a surgi al yst s pi pr edure.
Renal tumors may require a biopsy to determine
i they are cancerous. To learn more about how
a needle biopsy can be used or this purpose,
see the article Kidney Biopsy at Connect It! at
evolve.elsevier.com.
U r in a ry Tr a c t In e c t io n s
M st urinary tract in ections (U Is) are aused by ba teria,
m st ten gram-negative types. U Is an inv lve the ure-
thra, bladder, ureter, and kidneys. C mm n types urinary
tra t in e ti ns are summarized in the ll wing paragraphs.
C LIN ICA L APPLICATION
REMOVAL OF KIDNEY STONES US ING ULTRAS OUND
Statis tics s ugge s t that approxim ate ly 1 in eve ry 1000 adults in
the Unite d State s s u e rs rom kidney s tone s , or re nal calculi,
at s om e point in his or he r li e . Although s ym ptom s o excruci-
ating pain are com m on, m any kidney s tone s are s m all e nough
to pas s s pontane ous ly out o the urinary s ys te m . I this is pos -
s ible , no the rapy is re quire d othe r than tre atm e nt or pain and
antibiotics i the calculi are as s ociate d w ith in e ction. Large r
s tone s , howeve r, m ay obs truct the ow o urine and the re ore
are m uch m ore s e rious and di f cult to tre at.
Form e rly, only traditional s urgical proce dure s we re e e c-
tive in re m oving re lative ly large s tone s that orm e d in the caly-
ce s and re nal pe lvis o the kidney. In addition to the ris ks that
CHAPTER 20 Urinary System 569
M L
FIGURE 20-13 Renal calculi. Coronal ( rontal) section o kidney, par-
tially cut and opened like a book, showing a large stone (arrow) in the renal
pelvis.
U r e t h r it is
Urethritis is inf ammati n the urethra that mm nly results
evolve.elsevier.com). N ng n al urethritis is usually aused
by chlamydial in e ti n (see Appendix A). Males (parti ularly
in ants) su er r m urethritis m re ten than d emales.
Cy s t it is
Cystitis is a term that re ers t an inf ammati n the blad-
der. Cystitis m st mm nly urs as a result in e ti n but
als an a mpany al uli, tum rs, r ther nditi ns. Ba -
teria usually enter the bladder thr ugh the urethra. Cystitis
urs m re ten in w men than in men be ause the emale
urethra is sh rter and l ser t the anus (a s ur e ba teria)
than in the male. Bladder in e ti ns are hara terized by pel-
vi pain, an urge t urinate requently, pain ul urinati n (dys-
uria), and bl d in the urine (hematuria).
I ystitis aused by ba terial in e ti n be mes severe and
hr ni , the bladder epithelium may be me ul erated and
vered with exudate. Extensi n the in e ti n may then in-
f ame the ureters, renal pelvis, and kidney tissues. One mm n
rm n nba terial ystitis is urethral syndrome. Urethral
always accom pany m ajor m e dical proce dure s , s urgical re - 20
m oval o s tone s rom the kidneys re que ntly re quire s rathe r
exte ns ive hos pital and hom e re cove ry pe riods , las ting 6 we e ks
or m ore .
A te chnique that us e s ultras ound to pulve rize the s tone s s o
that they can be us he d out o the urinary tract w ithout s ur-
ge ry is now us e d in hos pitals acros s the Unite d State s . The
s pe cially de s igne d ultras ound ge ne rator re quire d or the pro-
ce dure is calle d a litho tripto r. Us ing a lithotriptor, phys icians
bre ak up the s tone s w ith ultras ound wave s in a proce s s
calle d litho trips yw ithout m aking an incis ion. Re cove ry tim e
is m inim al, and both patie nt ris k and cos ts are re duce d.
 570 CHAPTER 20 Urinary System

Pa pilla ry tumor Cys tos cope

in bla dde r wa ll in ure thra

A B
FIGURE 20-14 Imaging o bladder cancer. A, Cystoscope in male bladder. B, Cystoscopic view o a
cancerous growth (a transitional cell carcinoma) on the bladder wall.

syndr me, whi h urs m st mm nly in y ung w men, has
unkn wn auses but ten devel ps int a ba terial in e ti n.
T e term overactive bladder re ers t the need r re-
quent urinati n. T e am unts v ided are generally small, and
eelings extreme urgen y and pain (dysuria) are mm n.
T e nditi n is alled interstitial cystitis and is treated with
drugs t de rease nerv us stimulati n and with physi al dis-
tenti n the bladder with f uid t in rease apa ity. T e
nditi n is an ther type n nba terial ystitis be ause
sympt ms ur with ut eviden e ba terial in e ti n. S me
lini ians believe it is aut immune in rigin be ause it is ten
ass iated with lupus (see Chapter 16).
P ye lo n e p h r it is
Nephritis is a general term re erring t kidney disease, espe-
ially inf ammat ry nditi ns. Pyelonephritis is literally
pelvis nephritis and re ers t inf ammati n the renal
pelvis and nne tive tissues the kidney. As with ystitis,
pyel nephritis is usually aused by ba terial in e ti n but als
an result r m viral in e ti n, my sis, al uli, tum rs, preg-
nan y, and ther nditi ns.
Acute pyelonephritis devel ps rapidly and is hara terized by
ever, hills, pain in the sides (f ank), nausea, and an urge t
urinate requently. It ten results r m the spread in e ti n
r m the l wer urinary tra t r thr ugh the bl d r m ther
rgans. Chronic pyelonephritis may be an aut immune disease
but is ten pre eded by a ba terial in e ti n r urinary
20 bl kage.
Review the nature o the in ammatory response
in the article In ammation at Connect It! at
evolve.elsevier.com.
G lo m e r u la r D is o r d e r s
Glomerulonephritis is a gr up dis rders that result r m
damage t the gl merular- apsular membrane. T is damage
an be aused by immune me hanisms, heredity, r ba terial
in e ti ns. W ith ut su ess ul treatment, gl merular dis r-
ders an pr gress t kidney ailure.
N e p h ro t ic S y n d ro m e
Nephrotic syndrome is a lle ti n signs and sympt ms
that a mpany vari us gl merular dis rders. T is syndr me
is hara terized by the ll wing:
1. Proteinuriapresen e pr teins (espe ially albu-
min) in the urine. Pr tein, n rmally absent r m urine,
lters thr ugh damaged gl merular- apsular mem-
branes and is n t reabs rbed by the kidney tubules.
2. Hypoalbuminemial w albumin n entrati n in
the bl d, resulting r m the l ss albumin r m
the bl d thr ugh h les in the damaged gl meruli.
Albumin is the m st abundant plasma pr tein. Be-
ause it n rmally ann t leave the bl d vessels, it
usually remains as a permanents lute in the plasma.
T is keeps plasma water n entrati n l w and thus
prevents sm sis large am unts water ut
the bl d and int tissue spa es. (Review the dis us-
si n sm sis in Chapter 3 t help y u understand
this pr ess.) In hyp albuminemia, this sm ti
un ti n is l st, and f uid leaks ut bl d vessels
thr ugh ut the b dy and int tissue spa es, ausing
widespread edema.
3. Edemageneral tissue swelling aused by a umu-
lati n f uids in the tissue spa es. Edema ass iated
with nephr ti syndr me is aused by l ss plasma
pr tein (albumin) and the resulting sm sis f uid
r m the bl d.
N te that hematuria (bl d in the urine) is n t a eature
nephr ti syndr me.
Ac u t e G lo m e r u lo n e p h r it is
A ute gl merul nephritis is the m st mm n rm kid-
ney disease. It is aused by a delayed immune resp nse t
strept al in e ti nthe same me hanism that auses
 CHAPTER 20 Urinary System 571

S C IEN C E APPLICATIONS
FIGHTING INFECTION
Un ortunate ly, the s tructure o the re s is t com m on antibiotics . UTIs and othe r type s o in e ctions
urinary tract puts it at ris k or in e c- now re quire m ore powe r ul antibiotics and othe r s pe cial te ch-
tion by bacte ria and othe r m icroor- nique s to s top the m . Unle s s curre nt e orts to reve rs e this
ganis m s . Be caus e it is ope n to the tre nd be com e e e ctive , s om e s cie ntis ts e ar that the e ra o
exte rnal e nvironm e nt, bacte ria can s im ple antibiotic the rapy m ay be ne aring an e nd.
e nte r e as ily. In wom e n, the s hort Many pro e s s ions are involve d in the f ght agains t in e ction.
le ngth o the ure thra and its loca- Me dical s upply te chnicians e ns ure that device s s uch as ure -
tion clos e to the anus m ay urthe r thral cathe te rs are s te rile ( re e o m icroorganis m s ) be ore they
incre as e the ris k o bacte ria ge tting are package d and s e nt to hos pitals and clinics (picture d).
to the urinary bladde r. Anothe r ris k Phys icians , nurs e s , and othe rs w ho de al dire ctly w ith pa-
Alexander Fleming actor is poor te chnique by he alth- tie nts ne e d to le arn prope r s te rile te chnique to e ns ure that
(18811955) care worke rs w he n they ins e rt in e ctions are not introduce d by m e dical proce dure s . To he lp in
cathe te rs (tube s ) into the ure thras this e ort, m os t organizations de s ignate an in e ctio n co ntro l
o patie nts w ho ne e d he lp voiding the ir bladde rs o urine . m anage ra he alth pro e s s ional w ith the re s pons ibility o pre -
A bre akthrough in the tre atm e nt o urinary tract in e ctio ns ve nting no s o co m ial in e ctio ns (in e ctions that be gin in the
(UTIs ) cam e in 1928 in the laboratory o Scots re s e arche r hos pital). Com m unity he alth expe rts including e pide m io lo g is ts
Alexande r Fle m ing. Som e m old s pore s accide ntally contam i- and he alth s e rvice o f ce rs rom the U.S. gove rnm e nts Ce nte rs
nate d one o the dis he s in w hich Fle m ing was grow ing bacte - or Dis e as e Control and Preve ntion (CDC) als o he lp preve nt the
ria. He m arve le d at the act that no bacte ria could grow ne ar s pre ad o in e ction in local com m unitie s and worldw ide . O
the colony o m old. He is olate d a s ubs tance rom the m old cours e , pharm acology re s e arche rs , m icro bio lo g is ts , and oth-
that was re s pons ible or this antibacte rial e e ct and nam e d it e rs continue in the que s t to f nd newe r and be tte r tre atm e nts
pe nicillin. or UTIs and othe r in e ctions that thre ate n hum an he alth.
Earlie r Fle m ing had dis cove re d anothe r natural antibiotic
(lys ozym e ) that e e ctive ly attacke d bacte ria that did not o te n
caus e dis e as e , s o this conce pt was not totally new to him .
Howeve r, through urthe r expe rim e nts , Fle m ing s howe d that
pe nicillin was e e ctive agains t a varie ty o bacte ria that do
caus e s e rious in e ctions in hum ans , w hich m ade it an invalu-
able the rape utic tool.
Pe nicillin was toute d as the f rst miracle drug and rapidly
be came the tool o choice in f ghting bacte ria. In 1943 another
bre akthrough came w he n laboratory worke r Mary Hunt brought
a m oldy cantaloupe to work and res e arche rs ound that the new
type o m old produce d e nough pe nicillin to m ake com me rcial
production o the antibiotic possible .
Although orm s o pe nicillin and othe r antibiotics de rive d
rom natural s ource s are s till the we apon o choice in battling
m any in e ctions , m any bacte ria are evolving into s trains that

valve damage in rheumati heart disease (see Chapter 14). F r devel p. Immune me hanisms are believed t be the maj r
this reas n, it is s metimes alled postin ectious glomerulone- auses hr ni gl merul nephritis.
phritis. O urring 1 t 6 weeks a ter a strept al in e ti n,
this dis rder is hara terized by hematuria, liguria, pr tein-
uria, and edema.
Kid n e y Fa ilu r e 20
Antibi ti therapy and bed rest are the usual treatments r Kidney ailure, r renal ailure, is simply the ailure the
a ute gl merul nephritis. Re very is ten mplete but may kidney t pr perly pr ess bl d and rm urine. Renal ailure
pr gress t a hr ni rm gl merul nephritis. an be lassi ed as either acute r chronic.

C h ro n ic G lo m e r u lo n e p h r it is Ac u t e Re n a l Fa ilu r e
Chronic glomerulonephritis is the general name r a variety A ute renal ailure is an abrupt redu ti n in kidney un ti n
n nin e ti us gl merular dis rders hara terized by pr gres- hara terized by liguria and a sharp rise in nitr gen us m-
sive kidney damage leading t renal ailure. Early stages p unds in the bl d. T e nitr gen- ntaining substan es re-
hr ni gl merul nephritis are asympt mati . As this dis r- sult r m the breakd wn amin a ids used r energy in
der pr gresses, hematuria, pr teinuria, liguria, and edema ellular respirati n.
 572 CHAPTER 20 Urinary System
T e n entrati n nitr gen us wastes in the bl d is
ten assessed by the blood urea nitrogen (BUN) test. A high
BUN result may indi ate ailure the kidneys t rem ve urea
r m the bl d.
A ute renal ailure an be aused by a variety a t rs that
alter bl d pressure r therwise a e t gl merular ltrati n.
F r example, hem rrhage, severe burns, a ute gl merul ne-
phritis r pyel nephritis, r bstru ti n the l wer urinary
tra t may pr gress t kidney ailure. I the underlying ause
a ute renal ailure is su ess ully treated, re very is usually
rapid and mplete.
C LIN ICA L APPLICATION
ARTIFICIAL KIDNEY
The artif cial kidney is a m e chanical device that us e s the prin-
ciple o dialys is to re m ove or s e parate was te products rom the
blood. In the eve nt o kidney ailure , the proce s s , appropriate ly
calle d he m o dialys is (he m o blood and lys is s e parate ), is
im ple m e nte d as a li e -s aving inte rve ntion or the patie nt.
During a he m odialys is tre atm e nt, a s e m ipe rm e able m e m -
brane is us e d to s e parate large (nondi us ible ) particle s s uch as
blood ce lls rom s m all (di us ible ) one s s uch as ure a and othe r
was te s . Figure A s how s blood rom the radial arte ry pas s ing
through a porous (s e m ipe rm e able ) ce llophane tube that is
hous e d in a tanklike containe r. The tube is s urrounde d by a
bath or dialyzing s olution containing varying conce ntrations o
e le ctrolyte s and othe r che m icals . The pore s in the m e m brane
are s m all and allow only ve ry s m all m ole cule s , s uch as ure a, to
e s cape into the s urrounding uid. Large r m ole cule s and blood
ce lls cannot e s cape and are re turne d through the tube to re e n-
te r the patie nt via a w ris t ve in.
By cons tantly re placing the bath s olution in the dialys is tank
w ith re s hly m ixe d s olution, was te m ate rials in the blood can
be re duce d to low leve ls . As a re s ult, was te s s uch as ure a in
the blood rapidly pas s into the s urrounding was h s olution.
For a patie nt w ith com ple te kidney ailure , two or thre e
he m odialys is tre atm e nts a we e k are re quire d. The s e dialys is
tre atm e nts are now be ing m onitore d and controlle d by s ophis -
ticate d com pute r com pone nts and s o tware that have be e n
inte grate d into the m os t curre nt he m odialys is e quipm e nt.
From artery
20 Blood pump
To Bubble
ve in tra p
Dia lys is
me mbra ne
Compre s s e d Fre s h dia lys is Cons ta nt Us e d dia lys is
A CO 2 a nd a ir uid te mpe ra ture ba th
C h ro n ic Re n a l Fa ilu r e
Chr ni renal ailure is a sl w, pr gressive nditi n resulting
r m the gradual l ss nephr ns. T ere are d zens dis-
eases that may result in the gradual l ss nephr n un ti n,
in luding diabetes, in e ti ns, gl merul nephritis, tum rs,
systemi aut immune dis rders, and bstru tive dis rders.
Polycystic kidney disease (PKD ) is ne the m st m-
m n geneti dis rders in humans. In PKD, large f uid- lled
p kets ( ysts) devel p in the epithelium the kidney tu-
bules. In this nditi n, primary cilia (n nm ving ilia) n the
epithelial ells that rm kidney tubules ail t d their n rmal
New and dram atic advance s in both tre atm e nt te chnique s and
e quipm e nt are expe cte d in the uture . Although m os t he m odi-
alys is tre atm e nts are adm inis te re d in hos pital or clinical s e t-
tings , e quipm e nt de s igne d or us e in the hom e is available and
is appropriate or m any individuals . Patie nts and the ir am ilie s
us ing this e quipm e nt are initially ins tructe d in its us e and the n
m onitore d and s upporte d on an ongoing bas is by hom e he alth-
care pro e s s ionals .
Anothe r te chnique us e d in the tre atm e nt o re nal ailure is
calle d co ntinuo us am bulato ry pe rito ne al dialys is (CAPD).
In this proce dure , 1 to 3 L o s te rile dialys is uid is introduce d
dire ctly into the pe ritone al cavity through an ope ning in the
abdom inal wall (Figure B). Pe ritone al m e m brane s in the ab-
dom inal cavity trans e r was te products rom the blood into the
dialys is uid, w hich is the n draine d back into a plas tic containe r
a te r about 2 hours . This te chnique is le s s expe ns ive than he -
m odialys is and doe s not re quire the us e o com plex e quip-
m e nt. CAPD is the m ore re que ntly us e d hom e -bas e d dialys is
tre atm e nt or patie nts w ith chronic re nal ailure . CAPD is not
practical or all patie nts , howeve r, and s ucce s s ul long-te rm
tre atm e nt is gre atly e nhance d by s upport rom pro e s s ionals
traine d in hom e he alth-care s e rvice s .
To learn more about dialysis, go to
AnimationDirect online at evolve.elsevier.com.
Dia lys is uid
Diffus ion
of wa s te
products
s uch a s
ure a
Abdomina l
ca vity
uid B
 CHAPTER 20 Urinary System 573

3
2

e
g
e

ta
g
ta

S
1

S
e
g
ta
S
)
L
d
/
g
200

m
(
)
N
U
150

B
(
n
e
g
o
100

r
t
i
n
a
e
r
50

u
d
Norma l BUN le ve l

A B S
FIGURE 20-15 Polycystic kidney disease. A, Ex- M L
ternal view shows characteristic cysts. B, Lateral view I
o a kidney partially cut along a rontal plane and then
opened like a book to view the cysts inside the kidney.
j b regulating ell gr wth. T e epithelial ells then ver-
p pulate and bstru t the kidney tubules. T e bstru ti ns
result in p kets ba ked-up urine alled cysts. Eventually,
PKD leads t kidney ailure.
One the m st mm n rms PKD is alled adult
polycystic kidney disease. It is hereditary and appears in 1 in 500
t 1000 pers ns. Sympt ms the disease, whi h in lude
f ank pain and hematuria, generally appear a ter age 40 and
pr gress sl wly. Eventually, the kidneys a hieve en rm us size
as they ll with gr wing numbers ysts (Figure 20-15). De-
stru ti n tissue results in pr gressive renal ailure.
As kidney un ti n is l st, the gl merular ltrati n rate
(GFR) de reases, ausing the bl d urea nitr gen (BUN) and
reatinine levels t limb. Chr ni renal ailure an be des ribed
as pr gressing thr ugh the three stages sh wn in Figure 20-16
and des ribed here:
1. Stage 1D uring the rst stage, s me nephr ns are
l st but the remaining healthy nephr ns mpensate
by enlarging and taking ver the un ti n the l st
nephr ns. T is stage is ten asympt mati and may
last r years, depending n the underlying ause.
2. Stage 2T e se nd stage is ten alled renal insu -
ciency. D uring this stage, the kidney an n l nger
adapt t the l ss nephr ns. T e remaining healthy
nephr ns ann t handle the urea l ad, and BUN
o
o
l
B
0
100 75 50 25 0
Glo me rular ltratio n rate (GFR)
(Pe rc e ntag e o f no rmal)
FIGURE 20-16 The three stages o chronic renal ailure. Stage 1: As
nephrons are lost (indicated by decreasing GFR), the remaining healthy neph-
rons compensatekeeping BUN values within the normal range. Stage 2: As
more than 75% o kidney unction is lost, BUN levels begin to climb. Stage 3:
Uremia (elevated BUN) results rom massive loss o kidney unction.
levels limb dramati ally. Be ause the kidneys ability
t n entrate urine is impaired, p lyuria and dehy-
drati n may ur.
3. Stage 3T e nal stage hr ni renal ailure is
alled uremia r uremic syndrome. Uremia literally
means high bl d urea and is hara terized by a
very high BUN value aused by l ss kidney un -
ti n. D uring this stage, l w GFR auses l w urine
pr du ti n and liguria. Be ause f uids are retained
by the b dy rather than being eliminated by the
kidneys, edema and hypertensi n ten ur. T e
uremi syndr me in ludes a l ng list ther symp-
t ms aused dire tly r indire tly by the l ss kid-
ney un ti n. Unless an arti ial kidney is used r a
new kidney is transplanted, the pr gressive l ss
kidney un ti n eventually auses death.
QUICK CHECK
1. Ho w d o re n a l ca lcu li d e ve lo p ?
2. De f n e n e p h ro tic s yn d ro m e a n d lis t its ch a ra cte ris tics .
3. Wh a t is a cu te re n a l a ilu re ? Ho w is it a s s e s s e d ?
20
 574 CHAPTER 20 Urinary System

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 555)

distal convoluted tubule (DCT) micturition renin

(DIS-tall KON-voh-LOO-ted TOO-byool (mik-too-RISH-un) (REE-nin)
[dee see tee]) [mictur- urinate, -tion process] [ren- kidney, -in substance]
[dist- distance, -al relating to, con- together, nephron renin-angiotensin-aldosterone system
-volut- roll, tub- tube, -ule little] (NEF-ron) (RAAS)
emptying re ex [nephro- kidney, -on unit] (REE-ninan-jee-oh-TEN-sin
(EMP-tee-ing REE- eks) nephron loop al-DAH-stayr-ohn SYS-tem [ar ay ay es])
[re- again, - ex bend] (NEF-ron loop) [ren- kidney, -in substance, angio- vessel,
erythropoietin (EPO) [nephro- kidney, -on unit] -tens- pressure or stretch, -in substance,
(eh-RITH-roh-POY-eh-tin [ee pee oh]) aldo- aldehyde, -stero- solid or steroid
proximal convoluted tubule (PCT)
[erythro- red, -poiet- make, -in substance] (PROK-sih-mal KON-voh-LOO-ted derivative, -one chemical]
f ltration TOO-byool [pee see tee]) retroperitoneal
(f l-TRAY-shun) [proxima- near, -al relating to, con- together, (reh-troh-payr-ih-toh-NEE-al)
[f ltr- strain, -ation process] -volut- roll, tub- tube, -ule little] [retro- backward, -peri- around,
-tone- stretched, -al relating to]
glomerular-capsular membrane reabsorption
(gloh-MER-yoo-lar KAP-sul-er (ree-ab-SORP-shun) rugae
MEM-brayne) [re- back again, -ab- rom, -sorp- suck, (ROO-gee)
[glomer- ball, -ul- little, -ar relating to, -tion process] sing., ruga
caps- box, -ul- little, -ar relating to, [ruga wrinkle]
renal column
membrane thin skin] (REE-nall KOWL-um) secretion
glomerular capsule [ren- kidney, -al relating to] (seh-KREE-shun)
(gloh-MER-yoo-lar KAP-sul) [secret- separate, -tion process]
renal corpuscle
[glomer- ball, -ul- little, -ar relating to, (REE-nal KOR-pus-ul) sphincter
caps- box, -ule little] [ren- kidney, -al relating to, corpus- body, (SFINGK-ter)
glomerular f ltrate -cle little] [sphinc- bind tight, -er agent]
(gloh-MER-yoo-lar f l-TRAYT) renal cortex transport maximum (Tmax)
[glomer- ball, -ul- little, -ar relating to, (REE-nal KOR-teks) (TRANZ-port MAKS-im-um)
f ltr- strain, -ate result] [ren- kidney, -al relating to, cortex bark] [trans- across, -port carry, maximum greatest]
glomerulus renal medulla trigone
(gloh-MAYR-yoo-lus) (REE-nal meh-DUL-ah) (TRY-gohn)
pl., glomeruli [ren- kidney, -al relating to, medulla middle] [tri- three, -gon- corner]
(gloh-MAYR-yoo-lye) renal papilla ureter
[glomer- ball, -ul- little, -us thing] (REE-nal pah-PIL-uh) (yoo-REE-ter or YOOR-eh-ter)
Henle loop pl., papillae [ure- urine, -ter agent or channel]
(HEN-lee loop) (pah-PIL-ee) urethra
[Friedrich Gustave Henle German anatomist] [ren- kidney, -al relating to, papilla nipple] (yoo-REE-thrah)
hilum renal pelvis [ure- urine, -thr- agent or channel]
(HYE-lum) (REE-nal PEL-vis) urinary meatus
pl., hila pl., pelves (YOOR-ih-nayr-ee mee-AY-tus)
(HYE-lah) (PEL-veez) [urin- urine, -ary relating to, meatus passage]
[hilum least bit] [ren- kidney, -al relating to, pelvis basin] urinary system
hyperosmotic renal pyramid (YOOR-ih-nayr-ee SYS-tem)
(hye-per-os-MOT-ik) (REE-nal PIR-ah-mid) [urin- urine, -ary relating to]
[hyper- excessive or above, -osmo- push, [ren- kidney, -al relating to] urination
20 -ic relating to] renal threshold (yoor-ih-NAY-shun)
juxtaglomerular (J G) apparatus (REE-nal THRESH-old) [urin- urine, -ation process]
(juks-tah-gloh-MER-yoo-lar [jay jee] [ren- kidney, -al relating to] voiding
ap-ah-RAT-us) renal tubule (VOYD-ing)
[juxta- near or adjoining, -glomer- ball, (REE-nal TOOB-yool) [void- empty, -ing action]
-ul- little, -ar relating to, apparatus tool] [ren- kidney, -al relating to, tub- pipe,
juxtamedullary nephron -ule small]
(jux-tah-MED-oo-lar-ee NEF-ron)
[juxta- near or adjoining, -medulla- middle,
-ary relating to, nephro- kidney, -on unit]
 CHAPTER 20 Urinary System 575

LANGUAGE OF M ED IC IN E

anuria hydronephrosis penicillin

(ah-NOO-ree-ah) (hye-droh-neh-FROH-sis) (pen-ih-SIL-in)
[a- not, -ur- urine, -ia condition] [hydro- water, -nephr- kidney, -osis condition] [penicill- brush (Penicillum mold),
blood urea nitrogen (BUN) test hypoalbuminemia -in substance]
(blud yoo-REE-ah NYE-troh-jen [bun] test) (hye-poh-al-byoo-min-EE-mee-ah) polycystic kidney disease (PKD)
[urea urine, nitro- soda, -gen produce] [hypo- under or below, -alb- white, -emia blood (pahl-ee-SIS-tik KID-nee dih-ZEEZ
catheterization condition] [pee kay dee])
(kath-eh-ter-ih-ZAY-shun) I &O [poly- many, -cyst- bag, -ic relating to,
[cathe- send down, -er agent, -tion process o ] (aye and oh) dis- opposite o , -ease com ort]
continuous ambulatory peritoneal dialysis [I input, & and, O output] polydipsia
(CAPD) in ection control (pahl-ee-DIP-see-ah)
(kon-TIN-yoo-us AM-byoo-lah-tor-ee (in-FEK-shun KON-trol) [poly- many, -dips- thirst, -ia condition]
payr-ih-toh-NEE-al dye-AL-ih-sis [in ect- stain, -ion state] polyuria
[see ay pee dee]) interstitial cystitis (pahl-ee-YOO-ree-ah)
[ambulat- walk, -ory relating to, (in-ter-STISH-al sis-TYE-tis) [poly- many, -ur- urine, -ia condition]
peritone- peritoneum, -al relating to, [inter- between, -stit- stand, -al relating to, proteinuria
dia- through, -lysis loosening] cyst- bag, -itis in ammation] (proh-teen-YOO-ree-ah)
cystitis lithotripsy [prote- f rst rank, -in- substance, -ur- urine,
(sis-TYE-tis) (LITH-oh-trip-see) -ia condition]
[cyst- bag, -itis in ammation] [litho- stone, -trips- pound, -y action] pyelonephritis
cystoscope lithotriptor (pye-eh-loh-neh-FRY-tis)
(SIS-toh-skohp) (LITH-oh-trip-tor) [pyel- renal pelvis, -nephr- kidney,
[cyst- bag, -scop- see] [litho- stone, -trip- pound, -or agent] -itis in ammation]
diuretic drug microbiologist renal calculi
(dye-yoo-RET-ik drug) (my-kroh-bye-OL-uh-jist) (REE-nal KAL-kyoo-lye)
[dia- through, -ure- urine, -ic relating to] [micro- small, -bio- li e, -log- words (study o ), sing., calculus
dysuria -ist agent] (KAL-kyoo-lus)
(dis-YOO-ree-ah) [ren- kidney, -al relating to, calc- limestone,
needle biopsy
[dys- disordered, -ur- urine, -ia condition] -ul- little, -i things]
(NEE-dil BYE-op-see)
edema [bio- li e, -ops- view, -y action] renal colic
(eh-DEE-mah) nephritis (REE-nal KOL-ik)
[edema a swelling] [ren- kidney, -al relating to, col- colon,
(neh-FRY-tis)
-ic relating to]
enuresis [nephr- kidney, -itis in ammation]
(en-yoo-REE-sis) nephropathy renal ailure
[en- in, -uresis urinate] (neh-FROP-ah-thee) (REE-nal FAIL-yoor)
[ren- kidney, -al relating to]
epidemiologist [nephro- kidney, -path disease, -y state]
(ep-ih-dee-mee-OL-uh-jist) nephrotic syndrome uremia
[epi- upon, -dem- people, -log- words (study o ), (neh-FROT-ik SIN-drohm) (yoo-REE-mee-ah)
-ist agent] [ur- urine, -emia blood condition]
[nephr- kidney, -ic relating to, syn- together,
glomerulonephritis -drome running or (race) course] uremic poisoning
(gloh-mer-yoo-loh-neh-FRY-tis) neurogenic bladder (yoo-REE-mik POY-zun-ing)
[glomer- ball, -ul- little, -nephr- kidney, [ur- urine, -em- blood condition, -ic relating to]
(noor-oh-J EN-ik BLAD-der)
-itis in ammation] [neuro- nerves, -gen- produce, -ic relating to, urethritis
glycosuria bladder pimple] (yoo-reh-THRY-tis)
(glye-koh-SOO-ree-ah) nosocomial in ection [ure- urine, -thr- agent or channel (urethra), 20
[glyco- sweet (glucose), -ur- urine, -itis in ammation]
(no-zoh-KOHM-ee-al in-FEK-shun)
-ia condition] [noso- disease, -com- care, -al relating to, urinalysis
hematuria in- into, - ec- put, -tion process] (yoor-in-AL-is-is)
(hem-ah-TOO-ree-ah) [ur- urine, -in- chemical, -(an)a- apart,
oliguria
[hema- blood, -ur- urine, -ia condition] -lysis loosen or break]
(ohl-ih-GOO-ree-ah)
hemodialysis [olig- ew or little, -ur- urine, -ia condition] urinary incontinence
(hee-moh-dye-AL-ih-sis) overactive bladder (YOOR-ih-nayr-ee in-KON-tih-nens)
[hemo- blood, -dia- through or between, [urin- urine, -ary relating to, in- without,
(OH-ver-ak-tiv BLAD-der)
-lysis loosening] contin- contain, -ence ability]

Continued on p. 576
 576 CHAPTER 20 Urinary System

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 575)

urinary retention urinary suppression urinary tract in ection (UTI)

(YOOR-in-ayr-ee ree-TEN-shun) (YOOR-in-ayr-ee sup-PRESH-un) (YOOR-ih-nayr-ee trakt in-FEK-shun [yoo
[urin- urine, -ary relating to, re- back, [urin- urine, -ary relating to, sup- (sub-) down, tee aye])
-ten- hold, -tion condition] -press- press, -ion condition] [urin- urine, -ary relating to, tract trail,
in ect- stain, -tion condition]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary 2. Renal rpus le (Figure 20-4)
or us e w ith your device , acce s s the Au d io Ch a p te r a. Gl merular apsule up-shaped t p nephr n;
S u m m a rie s online at evolve .e ls evie r.com . als alled Bowman capsule
b. Gl merulusnetw rk bl d apillaries sur-
Scan this s um m ary a te r re ading the chapte r to r unded by gl merular apsule
he lp you re in orce the key conce pts . Late r, us e 3. Renal tubule (Figure 20-5)
the s um m ary as a quick review be ore your clas s a. Pr ximal nv luted tubule (PC ) rst segment
or be ore a te s t. b. Nephr n l p (H enle l p)extensi n pr ximal
tubule; nsists des ending limb, l p, and
as ending limb
Kidneys . Distal nv luted tubule (D C )extensi n
A. L ati nunder ba k mus les, behind parietal perit - as ending limb nephr n l p
neum, just ab ve waistline; right kidney usually a little d. C lle ting du t (CD)straight extensi n distal
l wer than le t (Figure 20-1) tubule
B. Gr ss stru ture (Figure 20-2) 4. L ati n nephr ns
1. External anat my a. C rti al nephr ns85% t tal; m st nephr n
a. Kidney resembles a lima bean that is 11 m is l ated in renal rtex
7 m 3 m b. Juxtamedullary nephr nshave imp rtant r le in
b. H ilummedial indentati n where vessels, nerves, n entrating urine; renal rpus les are l ated
ureter nne t near b undary between rtex and medulla
. Capsule br us uter wall D. Kidney un ti n
2. Internal anat my 1. Ex rete t xins and nitr gen us wastes
a. C rtex uter layer kidney tissue 2. Regulate levels many hemi als in bl d
b. Medullainner p rti n kidney 3. Maintain water balan e
. Pyramidstriangular divisi ns tissue within the 4. H elp regulate bl d pressure and v lume
renal medulla 5. Regulate red bl d ell pr du ti n by se reting eryth-
d. Papillanarr w, innerm st end a renal pyramid r p ietin (EPO)
e. Pelvisexpansi n upper end ureter; lies
inside kidney
20 . Caly esdivisi ns renal pelvis; ea h papilla
Fo rm atio n o Urine
a es a alyx A. Milli ns nephr ns balan e bl d and f ush the ex ess/
C. Mi r s pi stru ture the kidney wastes as urine in a pr ess that in ludes three un ti ns:
1. Interi r kidney mp sed m re than 1 milli n ltrati n, reabs rpti n, and se reti n (Figure 20-6 and
mi r s pi nephr n units (Figure 20-3) Table 20-1)
a. Unique shape nephr n well suited t un ti n
b. Prin ipal mp nents are renal rpus le and renal
tubule
 CHAPTER 20 Urinary System 577

B. Filtrati n
1. G es n ntinually in renal rpus les
Elim inatio n o Urine
2. Gl merular bl d pressure auses water and diss lved A. Ureters (Figure 20-10)
substan es t lter ut gl meruli int the gl meru- 1. Stru ture
lar apsulea r ss the gl merular- apsular membrane a. L ng, narr w mus ular tubes
3. N rmal gl merular ltrati n rate 125 mL per minute b. Lined with mu us membrane
C. Reabs rpti n . Expanded upper end rms renal pelvis l ated
1. M vement substan es ut renal tubules int inside kidney
bl d in peritubular apillaries 2. Fun ti ndrain urine r m renal pelvis t urinary
2. Water, nutrients, and i ns are reabs rbed (Figure 20-7) bladder
3. Water is reabs rbed by sm sis r m pr ximal tubules B. Bladder
4. C unter urrent me hanisms in the nephr n l p and 1. Stru ture (Figure 20-11)
surr unding peritubular apillaries n entrate s dium a. Elasti mus ular rgan, apable great expansi n
and hl ride t make the renal medulla hyper sm ti , b. Lined with mu us membrane arranged in rugae,
whi h helps n entrate urine (see Control o Urine as is st ma h mu sa
Volume subsequently). 2. Fun ti ns
5. ransp rt maximum ( max)largest am unt sub- a. St rage urine be re v iding
stan e that an be reabs rbed at ne time b. V iding
a. Determined by the number available transp rt- 3. Cystitisbladder in e ti n
ers the substan e C. Urethra
b. Determines the renal thresh ldab ve this level, 1. Stru ture (Figure 20-11)
the kidney rem ves the substan e r m bl d and a. Narr w tube r m urinary bladder t exteri r
ex retes in urine b. Lined with mu us membrane
6. All glu se is reabs rbed al ng with s dium, as l ng . O pening urethra t the exteri r alled urinary
as glu se levels remain within a n rmal range and meatus
there are en ugh s dium-glu se transp rters t 2. Fun ti ns
a mm date all the glu se (Figure 20-8) a. Passage urine r m bladder t exteri r the
D. Se reti n b dy
1. M vement substan es int urine in the distal b. Passage male repr du tive f uid (semen) r m
tubule and lle ting du ts r m bl d in peritubular the b dy
apillaries D. Mi turiti n
2. H ydr gen i ns, p tassium i ns, and ertain drugs are 1. Passage urine r m b dy (als alled urination r
se reted by a tive transp rt voiding)
3. Amm nia is se reted by di usi n 2. Regulat ry sphin ters
a. Internal urethral sphin ter (inv luntary)
b. External urethral sphin ter (v luntary)
Co ntro l o Urine Vo lum e 3. Bladder wall expansi n permits st rage urine with
A. Antidiureti h rm ne (ADH )se reted by p steri r little in rease in pressure
pituitary; pr m tes water reabs rpti n by lle ting 4. Emptying ref ex
du ts; redu es urine v lume a. Initiated by stret h ref ex in bladder wall
B. H yper sm ti (salty) nditi ns in the renal medulla b. Bladder wall ntra ts
help ADH n entrate urine and thus nserve the . Internal sphin ter (inv luntary) relaxes
b dys water d. External sphin ter (v luntary) relaxes and urinati n
C. Ald ster nese reted by adrenal gland, triggered by the urs
renin-angi tensin-ald ster ne system (RAAS); pr m tes e. Enuresisinv luntary urinati n in y ung hild
s dium and water reabs rpti n in nephr n; redu es urine 5. Urinary retenti nurine pr du ed but n t v ided
v lume (Figure 20-9) 6. Urinary suppressi nn urine pr du ed but bladder 20
D. Atrial natriureti h rm ne (ANH ) ne the peptide is n rmal
h rm nes (ANPs) se reted by atrial ells in heart; pr - 7. Urinary in ntinen e (enuresis)urine is v ided
m tes l ss s dium and water int kidney tubules; inv luntarily
in reases urine v lume a. Urge in ntinen eass iated with sm th mus le
E. Abn rmalities urine v lume vera tivity in the bladder wall
1. Anuriaabsen e urine b. Stress in ntinen eass iated with weakened
2. O ligurias anty am unt urine pelvi f r mus les
3. P lyuriaunusually large am unt urine . O verf w in ntinen eass iated with urinary
retenti n and verdistended bladder
 578 CHAPTER 20 Urinary System
d. Ref ex in ntinen e urs in absen e any
sens ry warning r awareness mm n ll wing
a str ke r spinal rd injury
e. N turnal enuresisnighttime bed wetting
. Neur geni bladderperi di but unpredi table
v iding; related t paralysis r abn rmal un ti n
the bladder
Urinalys is
A. Examinati n the physi al, hemi al, and mi r s pi
hara teristi s urine (Table 20-2)
B. May help determine the presen e and nature a path -
l gi al nditi n
Re nal and Urinary Dis o rde rs
A. O bstru tive dis rders inter ere with n rmal urine f w,
p ssibly ausing urine t ba k up and ause hydr ne-
phr sis r ther kidney damage
1. H ydr nephr sisenlargement renal pelvis and
aly es aused by bl kage urine f w (Figure 20-12)
2. Renal al uli (kidney st nes) rystallized mineral
hunks in renal pelvis r aly es; may bl k ureters,
ausing intense pain alled renal colic (Figure 20-13)
3. um rsrenal ell ar in ma (kidney an er) and
bladder an er (Figure 20-14); ten hara terized by
hematuria (bl d in the urine)
B. Urinary tra t in e ti ns (U Is) are ten aused by
gram-negative ba teria
1. Urethritisinf ammati n the urethra
2. Cystitisinf ammati n r in e ti n the urinary
bladder
3. Pyel nephritisinf ammati n the renal pelvis and
nne tive tissues the kidney; may be a ute (in e -
ti us) r hr ni (aut immune)
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
20 Review the s ynops is o the urinary s ys te m in Chapte r 5. The
unction o the urinary s ys te m is to m aintain the hom e os tas is
o the blood plas m a.
1. T e names, l ati ns, and un ti ns the rgans the
urinary system, the internal stru ture the kidney, and
the mi r s pi stru tures the nephr n all an be
learned using f ash ards and nline res ur es. F r a
better understanding the terms in this hapter, re er t
the Language S ien e and Language Medi ine
se ti ns.
C. G l merular dis rders result r m damage t the
gl merular- apsular membrane the renal rpus les
1. Nephr ti syndr me a mpanies many gl merular
dis rders
a. Pr teinuriapr tein in the urine
b. H yp albuminemial w plasma pr tein (albumin)
level; aused by l ss pr teins t urine
. Edematissue swelling aused by l ss water
r m plasma as a result hyp albuminemia
2. A ute gl merul nephritis is aused by delayed
immune resp nse t a strept al in e ti n
3. Chr ni gl merul nephritis is a sl w inf ammat ry
nditi n aused by immune me hanisms and ten
leads t renal ailure
D. Kidney ailure, r renal ailure, urs when the kidney
ails t un ti n
1. A ute renal ailureabrupt redu ti n in kidney un -
ti n that is usually reversible
2. Chr ni renal ailuresl w, pr gressive l ss neph-
r ns aused by a variety underlying diseases
a. P ly ysti kidney disease (PKD)numer us f uid-
lled ysts destr y kidney tissue as they gr w;
hereditary (Figure 20-15)
b. Pr gressi n kidney ailure (Figure 20-16)
(1) Stage 1early in this dis rder, healthy neph-
r ns ten mpensate r the l ss damaged
nephr ns
(2) Stage 2 ten alled renal insu ciency; l ss
kidney un ti n ultimately results in uremia
(high BUN levels) and its li e-threatening
nsequen es
(3) Stage 3 alled uremia r uremic syndrome;
mplete kidney ailure results in death unless
a new kidney is transplanted r an arti ial
kidney substitute is used
2. T e rmati n urine inv lves three pr esses: ltrati n,
reabs rpti n, and se reti n. Filtrati n was dis ussed in
Chapter 3. Reabs rpti n is the pr ess taking material
ut the urine and returning it t the bl d. Se reti n is
the pr ess taking material ut the bl d and
putting it int the urine.
3. Urine v lume is ntr lled by three h rm nes, ea h pr -
du ed by a di erent rgan. Remember that the b dy
ann t dire tly m ve water; it must rst m ve s lute by
di usi n r a tive transp rt and then pull the water a ter
it by sm sis. Make f ash ards r ea h the three h r-
m nes; in lude the name the h rm ne, where it is
made, its me hanism a ti n, and its verall e e t n
urine v lume.
 CHAPTER 20 Urinary System 579

4. Make a hart the dis rders the urinary system.
O rganize it based n the me hanism r ause ea h dis-
rder: bstru tive dis rders, urinary tra t in e ti ns, gl -
merular dis rders, and kidney ailure.
5. T e anal gy a mbined waste-water treatment and
garbage disp sal a ility linked t an in redibly e ient
re y ling enter may help y u t understand the big
pi ture urinary system un ti n.
6. In y ur study gr up, review the material in this hapter
using the f ash ards and nline res ur es. Use y ur ell
ph ne and make ph t pies the gures the rgans
the urinary system, the internal stru ture the kidney,
and the mi r s pi stru ture the nephr n. Dis uss
h w the kidney rms urine and the h rm nes inv lved
in regulating urine v lume. Make sure y u kn w whether
ea h the h rm nes will in rease r de rease urine
v lume. G ver the pr ess mi turiti n, the hart
dis rders the urinary system, hapter utline summary
and the questi ns at the end the hapter; dis uss p ssi-
ble test questi ns.

Re vie w Que s tio ns Critical Thinking

Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.

1. Des ribe the l ati n the kidneys. 24. Explain h w salt and water balan e is maintained by
2. Name and des ribe the internal stru tures the ald ster ne and ADH .
kidneys. 25. W hy is pr per bl d pressure ne essary r pr per
3. Name the prin ipal mp nents the renal rpus le kidney un ti n?
and the renal tubule. 26. I a pers n were d ing strenu us w rk n a h t day and
4. De ne ltrati n, reabs rpti n, and se reti n as they perspiring heavily, w uld there be a great deal ADH
apply t kidney un ti n. in the bl d r very little? Explain y ur answer.
5. Brief y explain the rmati n urine.
6. Name several substan es eliminated r regulated by the
kidney.
7. Explain the un ti n the juxtagl merular apparatus.
8. Identi y the three h rm nes that regulate urine v lume.
9. Des ribe the stru ture the ureters.
10. Des ribe renal li .
11. Des ribe the stru ture the bladder. W hat is the
trig ne?
12. Des ribe the stru ture the urethra.
13. Brief y explain the pr ess mi turiti n.
14. Di erentiate between retenti n and suppressi n
urine.
15. De ne in ntinen e. W hat an ause in ntinen e?
16. Brief y explain what in rmati n a hemi al urinalysis
pr vides r medi al aregivers.
17. Explain what asts are and why they are s metimes
und in a urine sample. 20
18. De ne hydr nephr sis.
19. W hat is an ther term r renal al uli? W hat are they
usually made ?
20. Name the m st mm n urinary dis rder.
21. Brief y explain the ll wing dis rders: urethritis, ystitis,
and pyel nephritis.
22. De ne pr teinuria and hyp albuminemia.
23. Brief y des ribe the three stages hr ni renal ailure.
 580 CHAPTER 20 Urinary System

Chapte r Te s t 11. T e nephr ns rm urine by way a mbinati n

A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e kidneys re eive ab ut ________% the t tal
am unt bl d pumped by the heart ea h minute.
2. T e renal rpus le is made up tw stru tures, the
________ and the ________.
3. T e tw parts the renal tubules that extend int the
medulla the kidney are the ________ and the
________.
4. T e tw parts the renal tubules that are in the rtex
the kidney are the ________ and the ________.
5. A physi al, hemi al, and mi r s pi examinati n
the urine is alled a ________.
6. ________ are rystallized mineral hunks that devel p
in the renal pelvis r aly es.
7. T e inv luntary mus le, ________, is at the exit the
bladder.
8. ________ is a nditi n in whi h the bladder is able t
empty itsel but n urine is being pr du ed by the
kidneys.
9. ________ is a nditi n in whi h a pers n v ids urine
inv luntarily.
10. ________ is a nditi n in whi h the bladder is ull and
the kidney is pr du ing urine but the bladder is unable
t empty itsel .
three bl d-balan ing pr esses: ________, ________,
and ________.
12. ________ me hanisms maintain hyper sm ti ndi-
ti ns in the medulla.
13. S me ________ drugs, whi h stimulate the pr du ti n
urine, are said t be p tassium wasting be ause they
in rease se reti n p tassium.
14. T e h rm ne ________ is released r m the p steri r
pituitary gland and redu es the am unt water l st in
the urine.
15. ________ is a h rm ne that is se reted by the adrenal
rtex and plays a r le in the reabs rpti n s dium.
16. Juxtagl merular ells release an enzyme that initiates the
________ system.
17. T e ushi n that n rmally en ases ea h kidney is the
________.
18. T e medial indentati n n the kidney where vessels,
nerves, and the ureter nne t with the kidney is the
________.
19. Appr ximately 85% all nephr ns are l ated alm st
entirely in the renal rtex and are alled rti al neph-
r ns. T e remainder the nephr ns are alled
________.
20. ________ s luti ns pr m te sm sis water int them,
just as d hypert ni s luti ns. An example is the un-
ter urrent me hanisms that maintain the ________ n-
diti ns in the medulla.

Match each term in Column A with its corresponding description in Column B.

Column A Column B
21. ________ rtex a. inner layer the kidney
22. ________ medulla b. expansi n the ureter in the kidney
23. ________ pyramid . up-shaped part the nephr n that at hes ltrate
24. ________ pelvis d. tube leading r m the bladder t utside the b dy
25. ________ urethra e. netw rk apillaries nestled within the gl merular apsule
26. ________ bladder . sa like stru ture used t h ld urine until it is v ided
27. ________ ureter g. uter part the kidney
28. ________ trig ne h. an area the bladder that has penings r the tw ureters and the urethra
29. ________ gl merular apsule i. the part the renal tubules that is l ated between the pr ximal and distal
30. ________ gl merulus nv luted tubules
31. ________ nephr n l p j. tube nne ting the kidney and bladder
k. triangular divisi n in the medulla the kidney
20
 CHAPTER 20 Urinary System 581

Match each disorder in Column A with its corresponding description or cause in Column B.

Column A
32. ________ hydr nephr sis
33. ________ renal al uli
34. ________ urethritis
35. ________ ystitis
36. ________ pyel nephritis
37. ________ hyp albuminemia
38. ________ pr teinuria
Column B
a. an inf ammati n the urethra that mm nly results r m a ba terial in e ti n
b. an ther term r a kidney st ne
. pr tein, espe ially albumin, in the urine
d. nditi n aused by urine ba king up int the kidney, ausing swelling the renal
pelvis and aly es
e. an inf ammati n the bladder
. l w albumin in the bl d due t l ss albumin thr ugh damaged gl meruli
g. inf ammati n the renal pelvis and nne tive tissue the kidney

Cas e S tudie s 3. H arriet is re eiving continuous ambulatory peritoneal dialy-

To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Sue has anorexia nervosa (see Chapter 19). H er b dy at
ntent has de reased t a level that is ar bel w n rmal.
H w might the hanging stru ture the b dy a e t the
p siti n Sues kidneys? H w an a hange in the p si-
ti n ne r b th kidneys lead t kidney ailure?
2. Drugs alled thiazide diuretics are s metimes pres ribed t
ntr l hypertensi n (high bl d pressure). T ese drugs
a t n kidney tubules in a way that inhibits reabs rpti n
water. H w d es inhibiti n water reabs rpti n by
the kidney redu e high bl d pressure? W hat e e ts
w uld su h drugs have n the v lume urine utput?
sis (CAPD). As y u may re all r m the b xed essay
earlier in this hapter, f uid is intr du ed int the perit -
neal avity and later withdrawn. D y u think that this
dialysis f uid is hypert ni , is t ni , r hyp t ni t
n rmal bl d plasma? Give reas ns r y ur answer.
4. Je has learned r m his ur l gist that his kidney disease
has pr gressed t renal ailure and that he must in lude
dialysis in his treatment plan. Be ause y u w rk n the
dialysis unit the h spital, Je has asked y u t explain
h w the hem dialysis ma hine w rks. H e als asks i the
unit is p rtable s that he an use it at h me, i ne essary.
W hat will y u tell Je ?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.

20
Fluid and Electrolyte Balance
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Body Fluid Volumes, 584

Body Fluid Compartments, 584
Extracellular Fluid, 585
Intracellular Fluid, 585
Mechanisms That Maintain Fluid Balance, 585
Overview o Fluid Balance, 585
Regulation o Fluid Output, 586
Regulation o Fluid Intake, 587
Exchange o Fluids by Blood, 588
Fluid Imbalances, 588
Dehydration, 588
Overhydration, 589
Importance o Electrolytes in Body Fluids, 589
Electrolytes and Nonelectrolytes, 589
Ions, 589
Electrolyte Functions, 589
Electrolyte Imbalances, 591
Homeostasis o Electrolytes, 591
Sodium Imbalance, 592
Potassium Imbalance, 592
Calcium Imbalance, 592

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Describe how body uid volumes relate to age,
gender, and body weight.
2. List, describe, and compare the body uid compart-
ments and their subdivisions.
3. Explain the mechanisms used by the body to maintain
uid balance, discussing the avenues by which water
enters and leaves the body and the orces that move
uids into and out o the blood.
4. Describe examples o common uid imbalances.
5. Discuss the nature and importance o electrolytes in
body uids.
6. Describe examples o common electrolyte
imbalances.
HAPTER 21
Ha ve y u ever w n-
dered why y u s metimes
ex rete great v lumes
urine and at ther
times ex rete alm st
n ne at all? W hy s me-
times y u eel s thirsty
that y u an hardly get en ugh
t drink and ther times y u want
n liquids at all? T ese nditi ns and
many m re relate t ne the b dys m st
imp rtant un ti nsthat maintaining
its uid and electrolyte balance.
T e phrase uid balance implies h -
me stasis, r relative nstan y
b dy f uid levelsa nditi n re-
quired r healthy survival. It
means that b th the t tal v l-
ume and distributi n water
in the b dy remain n rmal
and relatively nstant.
B dy input r intake
water must be balan ed by
utput. I water in ex-
ess requirements en-
ters the b dy, it must be
eliminated, and, i ex ess
l sses ur, pr mpt re-
pla ement is riti al. Be-
ause f uid balan e re ers t
n rmal h me stasis, f uid im-
balan e means that the t tal v l-
ume water in the b dy r the am unts
in ne r m re its f uid mpartments have
in reased r de reased bey nd n rmal limits.
Electrolytes are substan es su h as salts that diss lve r break
apart in water s luti n t rm ele tri ally harged at ms ( r
gr ups at ms) alled ions. Electrolyte balance re ers t
h me stasis r relative nstan y n rmal ele tr lyte levels
in the b dy f uids.
T e vari us types b dy f uids serve di ering un ti ns in
di erent areas the b dy. d s , ea h type b dy f uid
must maintain di ering levels and types ele tr lytes
LANGUAGE OF
S C IEN C E
Be o re re ading the
chapte r, s ay e ach o
the s e te rm s o ut lo ud. This w ill
he lp yo u to avo id s tum bling ove r
the m as yo u re ad.
anion
(AN-aye-on)
[ana- up, -ion to go (ion)]
cation
(KAT-aye-on)
[cat- down, -ion to go (ion)]
dissociate
(dih-SOH-see-ayt)
[dis- apart, -socia- unite, -ate action]
electrolyte
(eh-LEK-troh-lyte)
[electro- electricity, -lyt- loosening]
electrolyte balance
(eh-LEK-troh-lyte BAL-ans)
[electro- electricity, -lyt- loosening]
extracellular uid (ECF)
(eks-trah-SEL-yoo-lar FLOO-id
[ee see e ])
[extra- outside, -cell- storeroom,
-ular relating to]
uid balance
(FLOO-id BAL-ans)
uid compartment
(FLOO-id kom-PART-ment)
interstitial uid (IF)
(in-ter-STISH-al FLOO-id [aye e ])
[inter- between, -stit- stand,
-al relating to]
intracellular uid (ICF)
(in-trah-SEL-yoo-lar FLOO-id
[aye see e ])
[intra- occurring within,
-cell- storeroom, -ular relating to]
ion
(AYE-on)
[ion to go]
Continued on p. 594
583
 584 CHAPTER 21 Fluid and Electrolyte Balance

FIGURE 21-1 Relative volumes o three body uids. Values repre- T e reas n f uid v lume values in re eren e tables
sent typical f uid distribution in a young adult male. are based n n n bese individuals is that adip se, r
21 at tissue, ntains the least am unt water any
b dy tissue. T e m re at present in the b dy, the
within a very narr w range n rmal. F r example, less the t tal water ntent per kil gram b dy
bl d, lymph, intra ellular f uid, interstitial f uid, weight. T ere re, regardless age, bese indi-
erebr spinal f uid, and j int and eye f uids all viduals, with their high b dy at ntent, have
depend n mplex h me stati me hanisms t less b dy water per kil gram weight than
adjust and maintain n rmal levels appr priate slender pe ple.
ele tr lytes required r that Alth ugh a n n bese male b dy typi ally
parti ular type b dy f uid t nsists ab ut 60% water, an bese male
un ti n as it sh uld. r
P la s ma 3L may nsist nly 50% water r even
less. T e emale b dy ntains slightly
)
a
F
l
u
C
l
l
H ealth and s metimes even less water per kil gram weight be-
E
e
(
c
a
survival itsel depend n main- ause n average it ntains slightly
d
r
i
xt
u
Inte rs titia l
l
f
taining the pr per v lume and m re at than the male b dy.
E
fluid (IF) 12 L
distributi n b dy water and N te in Figure 21-2 that age, as well as
the appr priate levels and types gender, inf uen es the am unt water in the b dy.
ele tr lytes within it. In this Remember that b dy f uids are n t all in a single,
hapter y u will nd a dis us- Intra ce llula r ntinu us spa e in the b dybut ten un ti n
si n b dy f uids and ele tr - fluid (ICF) 25 L as i they are.
lytes, their n rmal values, the me h- In ants have m re water as mpared with b dy
anisms that perate t keep them n rmal, and s me weight than adults either sex. In a newb rn,
the m re mm n types f uid and ele tr lyte water may a unt r up t 80% t tal b dy
imbalan es. weight. T e per entage water is even higher in
premature in ants. T e need r a high water
ntent in the early stages li e is the reas n
Bo d y Flu id Vo lu m e s f uid imbalan es in in ants aused by diarrhea, r
O the hundreds mp unds present in y ur b dy, the m st example, an be s seri us.
abundant is water. Medi al re eren e tables ten re er t av- T e per entage b dy water de reases rapidly during the
erage f uid v lumes based n healthy n n bese y ung adults. rst 10 years li e and by ad les en e, adult values are
In su h tables, males weighing 70 kg (154 p unds) will have rea hed and gender di eren es, whi h a unt r ab ut a
n average ab ut 60% their b dy weight, nearly 40 L, as 10% variati n in b dy f uid v lumes between the sexes, have
water (Figure 21-1). Y ung emales average ab ut 50% water. devel ped.
In elderly individuals, the am unt water per kil gram
100 b dy weight de reases. One reas n is that ld age is ten a -
mpanied by a de rease in mus le mass (65% water) and an
in rease in at (20% water). Certain drugs r t xins may have
m re p tent e e ts in the elderly be ause they be me m re
t
h
g
n entrated in the smaller v lume water present in the
i
e
w
b dies s me elderly pe ple. O urse, su h drugs r t xins
y
d
may have a redu ed e e t when diluted in the larger relative
o
b
am unt water in a y ung pers ns b dy. In b th ases, the
l
a
50
t
key a t r is the per entage b dy weight represented by
o
t
f
water.
o
e
g
a
t
n
Bo d y Flu id C o m p a r t m e n t s
e
c
r
e
P
F r the sake dis ussi n, the f uids the b dy are th ught
as being ntained in the reti al mpartments. Ea h
0 these uid compartments is a tually a gr up separated
Newborn Adult Adult spa es in the b dy that in many ways un ti n as i they are
infa nt ma le fe ma le all in ne mpartment. Using this n ept, t tal b dy f uid
(75%) (60%) (50%)
an be subdivided int tw maj r f uid mpartments alled
FIGURE 21-2 Water in the body. Proportion o body weight typically the extracellular and the intracellular f uid mpartments. Y u
made up o water in in ants, adult males, and adult emales. an see the maj r f uid mpartments illustrated in Figure 21-3.
 CHAPTER 21 Fluid and Electrolyte Balance 585

34% Extra ce llula r uid compa rtme nt

21
Inte rs titia l uid

P la s ma

Tra ns ce llula r
uid
Lymph

66% Intra ce llula r uid compa rtme nt

FIGURE 21-3 Distribution o total body water. The f uids o the body are separated by membranes into
unctional compartments o the body. The intracellular f uid (ICF) compartment includes all the f uids inside
all the cells o the body. The extracellular f uid (ECF) compartment includes the interstitial f uid (IF) between cells
o most tissues and the plasma o the blood tissue. ECF also includes lymph and transcellular f uids.

Ex t r a c e llu la r Flu id In t r a c e llu la r Flu id

Extracellular uid (ECF) nsists mainly the liquid part T e term intracellular uid (ICF) re ers t the largest v l-
wh le bl d alled the plasma, und in the bl d vessels, ume b dy f uid by ar. It is l ated inside all the ells the
and the interstitial uid (IF) that surr unds the ells. b dy. Water has many un ti ns inside the ell but mainly
In additi n, a smaller v lume lymph and transcellular serves as a s lvent in whi h imp rtant hemi al rea ti ns
uids are part the extra ellular f uid mpartment. rans- the ell an ur.
ellular f uids in lude erebr spinal f uid (CSF), f uids the
eyeball, and the syn vial j int f uids. QUICK CHECK
Table 21-1 lists typi al per entage b dy weight values r 1. Wh a t a re e le ctro lyte s a n d w h a t is e le ctro lyte b a la n ce ?
the extra ellular f uid mpartments. Figure 21-3 sh ws the 2. Wh a t a re th e tw o m a in u id co m p a rtm e n ts o th e b o d y?
3. Wh a t is m e a n t b y th e te rm u id b a la n ce ?
distributi n f uids in the extra ellular f uid mpartment as
4. Wh a t is th e la rg e s t vo lu m e o b o d y u id ?
a per entage t tal b dy water.

TABLE 21-1 Volumes o Body Fluid Compartments*

M e c h a n is m s Th a t M a in t a in
ADULT ADULT Flu id Ba la n c e
BODY FLUID INFANT MALE FEMALE O ve r v ie w o Flu id Ba la n c e
Extrace llular Fluid
Under n rmal nditi ns, h me stasis the t tal v lume
Plas m a 4 4 4
water in the b dy is maintained r rest red primarily by
Inte rs titial uid, lym ph, and 26 16 11 devi es that adjust utput (by adjusting urine v lume) t
trans ce llular uids
intake and se ndarily by me hanisms that adjust f uid
Intrace llular Fluid 45 40 35 intake. T ere is n questi n ab ut whi h the tw me h-
TOTAL 75 60 50 anisms is m re imp rtant; the b dys hie me hanism, by
*Pe rce ntage o body we ight. Com pare to volum e in lite rs in Figure 21-1 and ar, r maintaining f uid balan e is that adjusting its
pe rce ntage o total body wate r in Figure 21-2. f uid utput s that it equals its f uid intake.
 586 CHAPTER 21 Fluid and Electrolyte Balance

O bvi usly, as l ng as utput and intake are

TABLE 21-2 Typical Daily Water Input and Output*
equal, the t tal am unt water in the b dy
21 d es n t hange. Figure 21-4 sh ws the three INTAKE OUTPUT
main s ur es f uid intake: Wate r in oods 700 m L Lungs (wate r in expire d air) 350 m L
Inge s te d liquids 1500 m L Skin
1. Liquids we drink
2. Water in the ds we eat Wate r orm e d by catabolis m 200 m L By di us ion 350 m L
3. Water rmed by atab lism nutri- By s we at 100 m L
ents ( ellular respirati n) Kidneys (as urine ) 1400 m L

We als see in Figure 21-4 the main avenues Inte s tine s (in e ce s ) 200 m L
water utput by the b dy: TYPICAL DAILY TOTALS 2400 m L 2400 m L

1. Water vap r l st when we exhale *Am ounts vary w ide ly am ong individuals and w ithin the s am e individual, de pe nding on m any
actors .
2. Sweat that evap rates r m the skin
3. Urine utput by the kidney
4. Water l st in the e es Re g u la t io n o Flu id O u t p u t
Table 21-2 gives the n rmal v lumes ea h avenue water Ro u t e s o Flu id O u t p u t
input and utput. H wever, these an vary a great deal and Table 21-2 als indi ates that f uid utput r m the b dy urs
still be nsidered n rmal. thr ugh ur rgans: the kidneys, lungs, skin, and intestines.
A number a t rs a t as me hanisms r balan ing plasma, T e f uid utput that f u tuates the m st is that ex reted
IF, and ICF v lumes. T e three main a t rs are as ll ws: r m the kidneys. T e b dy maintains f uid balan e mainly by
hanging the v lume urine ex reted t mat h hanges in
1. Regulating f uid utput the v lume f uid intake. Every ne kn ws this r m experi-
2. Regulating f uid input en e. T e m re liquid ne drinks, the m re urine ne ex retes.
3. Ex hanging f uids between mpartments and r m C nversely, the less the f uid intake, the less the urine v lume.
pla e t pla e within the b dy H w hanges in urine v lume me ab ut was dis ussed

INPUTS OUTPUTS

1
Wa te r in foods 1
Lungs (wa te r va por)

2 H 2O
Inge s te d liquids

S toma ch H 2O

Blood ve s s e l

H 2O

Inte s tine s
2
S kin (s we a t)

H 2O

3
Kidne y (urine )

3
Tis s ue ca ta bolis m

4
FIGURE 21-4 Fluid balance. Pri- La rge inte s tine (fe ce s )
mary mechanisms o f uid intake and
f uid output by the body.
 CHAPTER 21 Fluid and Electrolyte Balance 587

n pp. 563-564. T is w uld be a g d time t review th se

To learn more about the aldosterone regulation
paragraphs.
It is imp rtant t remember r m y ur study the urinary
mechanism, go to AnimationDirect online at
evolve.elsevier.com.
21
system that the rate water and salt res rpti n by the renal
tubules is the m st imp rtant a t r in determining urine
v lume. Urine v lume is regulated hief y by h rm nes that Re g u la t io n o Flu id In t a k e
a e t kidney tubule un ti n.
Physi l gists disagree ab ut the details the me hanism r
A D H M e c h a n is m ntr lling and regulating f uid intake t mpensate r a -
t rs that w uld lead t dehydrati n.
Antidiuretic hormone (ADH) release r m the p steri r pitu-
In general the me hanism r regulating f uid intake ap-
itary in reases as the ECF v lume the b dy de reases be-
pears t perate in the ll wing ways. W hen dehydrati n
l w n rmal. In Chapter 12, we learned that ADH pr m tes
starts t devel pthat is, when f uid l ss r m the b dy ex-
water reabs rpti n r m the kidney tubule ba k int the
eeds f uid intake hanges ur in the ECF. T e ECF v l-
bl d. T is redu es urine v lume by retaining m re water in
ume de reases and the s lute n entrati n ( sm ti pres-
the b dy. T us, ADH redu es water utput r m the b dy.
sure) the ECF in reases.
A ld o s t e ro n e M e c h a n is m Sens ry re ept rs in the brain and elsewhere in the b dy
dete t the hange in the v lume and n entrati n extra-
Aldosterone r m the adrenal rtex w rks with ADH t re-
ellular f uids aused by dehydrati n. T ey relay this in rma-
du e water utput even urther. Ald ster ne in reases Na
ti n t the thirst enters the hyp thalamus. Signals r m
reabs rpti n by the kidney tubules. Be ause water ll ws
the hyp thalamus ause water nservati n thr ugh ut the
s dium, water reabs rpti n int the bl d als in reases.
b dy, in luding a de rease in salivary se reti n. De reased
T us, the b dy retains water that w uld therwise be l st in
salivati n pr du es a dry-m uth eeling that enhan es a
the urine. T us we see that ADH and ald ster ne are water-
eeling thirst. T e dry m uth auses a pers n t eel
nserving h rm nes.
thirsty and t drink water. D rinking water in reases f uid
Figure 21-5 tra es the ald ster ne me hanism in m re de-
intake and thereby mpensates r previ us f uid l sses. T is
tail. Begin in the upper right the diagram and ll w, in
tends t rest re f uid balan e (Figure 21-6).
sequen e, ea h step t see h w the ald ster ne me hanism
I an individual takes n thing by m uth r days, an his
helps maintain a nstant v lume ECF in the b dy.
f uid utput de rease t zer ? T e answern be mes
A N H M e c h a n is m bvi us a ter reviewing the in rmati n in Table 21-2. Despite
Atrial natriuretic hormone (ANH) r m the
atrial wall the heart, n the ther hand,
in reases urine v lume. ANH is released Norma l ECF
when bl d v lume is higher than n rmal, volume (blood a nd
(ba ck towa rd) inte rs titia l fluid)
whi h stret hes the atrium. ANH pr m tes
S ome fa ctor
s dium l ss r m the bl d int kidney tu- (e .g., nothing by
bules. Be ause water ll ws s dium, water mouth for 24 hours )
is als l st r m the bl dthus in reasing
l ss water in the urine. T ere re, ANH Feedback
is a water-l ss h rm ne r diuretic loop De cre a s e s ECF
volume , including
h rm ne. de cre a s e d blood
Incre a s e s
Please review h rm nal ntr l ECF volume volume , which
urine v lume in Chapter 20
(pp. 563-564).
De cre a s e s De cre a s e s a rte ria l
urine blood pre s s ure
volume

Trigge rs kidne y to
Incre a s e s Incre a s e s initia te the re nin-
FIGURE 21-5 Aldosterone mechanism. kidne y tubule tota l Na a ngiote ns ion-
Aldosterone restores normal extracellular re a bs orption conte nt a ldos te rone s ys te m
f uid (ECF) volume when such levels decrease of wa te r of body
below normal. Excess aldosterone, however,
leads to excess ECF volumethat is, excess
blood volume (hypervolemia) and excess in- Incre a s e s kidne y Adre na l corte x
terstitial f uid volume (edema)and also tubule re a bs orption incre a s e s its
leads to an excess o the total Na content of Na s e cre tion of
a ldos te rone
o the body.
 588 CHAPTER 21 Fluid and Electrolyte Balance

pushed ltered ut bl d int the IF. T e e e t an

Feedback in rease in apillary bl d pressure, then, is t trans er f uid
21 loop r m bl d t IF. In turn, this uid shi t, as it is alled, hanges
bl d and IF v lumes. It de reases bl d v lume by in reas-
Norma l tota l ing IF v lume. I , n the ther hand, apillary bl d pressure
volume of body wa te r
de reases, less f uid lters ut bl d int IF.
Water ntinually m ves in b th dire ti ns thr ugh the
membran us walls apillaries (see Figure 21-4). T e am unt
Te nds to that m ves ut apillary bl d int IF depends largely n
re s tore
apillary bl d pressure, a water-pushing r e. T e am unt
S ome fa ctor that m ves in the pp site dire ti n (that is, int bl d r m
(e .g., e xce s s ive
s we a ting) IF) depends largely n the n entrati n pr teins in bl d
plasma. Review Figure 15-4 n p. 406 t re resh y ur kn wl-
edge these r es.
Plasma pr teins ntribute t sm ti pressure and thereby
a t as a water-pulling r water-h lding r e. T ey h ld water
Incre a s e s De cre a s e s tota l
volume of in the bl d and pull it int the bl d r m IF. I , r example,
uid inta ke
body wa te r the n entrati n pr teins in bl d de reases appre iably
as in pr tein de ien yless water m ves int bl d r m IF
by sm sis (see Figure 3-8 n p. 52). As a result, bl d v lume
de reases and IF v lume in reases ausing edema.
O the three main b dy f uids, IF v lume varies the m st.
Ca us e s dry De cre a s e s Plasma v lume usually f u tuates nly slightly and brief y. I a
mouth, thirs t s e cre tion
of s a liva pr n un ed hange in its v lume urs, adequate ir ulati n
ann t be maintained.

To learn more about uid shi t, go to

FIGURE 21-6 Thirst mechanism. A basic mechanism or adjusting in-
take to compensate or excess output o body f uid is diagrammed here.
every e rt h me stati me hanisms t mpensate r
zer intake, s me utput (l ss) f uid urs as l ng as li e
ntinues. Water is ntinually l st r m the b dy thr ugh
expired air and di usi n thr ugh skin.
Alth ugh the b dy adjusts f uid intake, a t rs that adjust
f uid utput, su h as ele tr lytes and bl d pr teins, are ar
m re imp rtant.
QUICK CHECK
1. Wh ich d o e s th e b o d y p rim a rily a d ju s t, u id in ta ke o r u id
o u tp u t?
2. Wh a t a re th e ch ie wa ys th a t u id le a ve s th e b o d y?
3. Ho w d o e s th e b o d y m a in ta in u id b a la n ce ?
4. Na m e th e h o rm o n e s th a t re g u la te u rin e vo lu m e .
5. De s crib e th e m e ch a n is m th a t re g u la te s u id in ta ke .
Exc h a n g e o Flu id s b y Blo o d
Besides regulating input and utput f uids, the b dy helps
maintain a nstan y internal f uid balan e by ex hanging
f uids between f uid mpartments. T e bl d plasma is the
m bile medium that an m ve f uids ar und the b dy qui kly
t even ut any l al f uid imbalan es.
Capillary bl d pressure is a water-pushing r e.
It pushes f uid ut the bl d in apillaries int the IF.
T ere re, i apillary bl d pressure in reases, m re f uid is
AnimationDirect online at evolve.elsevier.com.
Flu id Im b a la n c e s
Fluid imbalan es are mm n ailments. T ey take several
rms and stem r m a variety auses, but they all share a
mm n hara teristi that abn rmally l w r abn r-
mally high v lumes ne r m re b dy f uids.
D e h yd r a t io n
Signi ant l ss water r m the b dy, r dehydration, is
the f uid imbalan e seen m st ten. Figure 21-7 sh ws h w
h t weather r exer ise an ause dramati in reases in water
utputmainly by sweating. Dehydrati n is a p tentially
danger us nditi n that an s n lead t death i a pers n
is unable t rest re the b dys f uid v lume.
In severe dehydrati n, IF v lume de reases rst, but eventu-
ally, i treatment has n t been given, ICF and plasma v lumes
als de rease bel w n rmal levels. Either t small a f uid in-
take r t large a f uid utput auses dehydrati n. Pr l nged
diarrhea r v miting may result in dehydrati n due t the l ss
b dy f uids. T is is parti ularly true in in ants where the t tal
f uid v lume is mu h smaller than it is in adults.
A lini al sign dehydrati n is a de rease in the skins
turgorthe expe ted resilien y skin due t the utward
pressure interstitial f uid (Figure 21-8). H wever, this sign is
less reliable in the extremities the elderly be ause a natu-
ral l ss skin turg r due t aging. In aged patients, the skin
ver the rehead r sternum an be he ked.
 CHAPTER 21 Fluid and Electrolyte Balance 589

7000
C rre ti n the neur l gi al impairment al ng with water
restri ti n an reverse the sympt ms.
6000
Re s pira tion
S kin
Water int xi ati n an happen in n rmal individuals i 21
Fe ce s water intake is s rapid that the urinary me hanisms water
Urine l ss ann t keep up. Alth ugh this is unusual, it an happen
)
5000
L
m
as witnessed by milli ns a ew years ag when a radi stati n
(
t
held a water drinking ra e n the air and a ntestant died
u
4000
p
t
r m the e e ts severe water int xi ati n.
u
o
3000
r
e
t
a
W
2000 QUICK CHECK
1. Ho w d o e s a n in cre a s e in ca p illa ry b lo o d p re s s u re ca u s e
1000 u id to m o ve in to th e IF?
2. Ho w d o p la s m a p ro te in s a e ct u id b a la n ce ?
0 3. Wh a t co n d itio n s m ig h t p ro d u ce d e hyd ra tio n ?
Norma l Hot P rolonge d 4. Wh a t is wa te r in toxica tio n ?
te mpe ra ture we a the r exe rcis e

FIGURE 21-7 Water output by the body under varying conditions.

Note that water loss rom sweating ( rom the skin) increases total water
loss by the body when the weather is hot and during prolonged exercise.
O ve r h yd r a t io n
T e nditi n having m re water in the b dy than needed
r healthy survival is alled overhydration. Alth ugh verhy-
drati n d es ur, it is less mm n than dehydrati nand
is usually untera ted by a rapid l ss water in the urine.
One grave danger giving intraven us f uids t rapidly
r in t large an am unt is verhydrati n, whi h an put
t heavy a burden n the heart by in reasing the v lume
bl d t be pumped.
Water intoxication may result r m rapidly drinking large
v lumes water r giving hyp t ni s luti ns t pers ns un-
able t dilute and ex rete urine n rmally. T is may ur in
patients with kidney insu ien y r abn rmal thirst me ha-
nisms resulting r m neur l gi al dis rders. Water ntent is
elevated, and plasma s dium levels are diluted. Devel pment
subtle mental hanges su h as n usi n and lethargy ur.
I int xi ati n is severe, stup r, seizures, and ma may result.
FIGURE 21-8 Testing or dehydration. A decrease o skin resiliency or
turgor is a sign o dehydration. Skin that does not return quickly to its normal
shape a ter being pinched (or tented) indicates interstitial water loss. This
sign is less reliable in the extremities o the elderly, who naturally experi-
ence loss o turgor due to aging.
Im p o r t a n c e o Ele c t ro ly t e s
in Bo d y Flu id s
Ele c t ro ly t e s a n d N o n e le c t ro ly t e s
T e b nds that h ld t gether the m le ules ertain rgani
substan es su h as glu se are su h that they d n t permit
the mp und t break up, r dissociate, in water s luti n.
Su h mp unds are alled nonelectrolytes. Crystals su h as
rdinary table salt, r s dium hl ride (NaCl), that have ionic
bonds that permit them t break up, r diss iate, in water
s luti n int separate parti les (Na and Cl ) are electrolytes.
Io n s
T e diss iated parti les an ele tr lyte are alled ions and
arry either a p sitive r negative ele tri al harge. As a gr up,
all p sitively harged i ns, su h as Na , are alled cations. All
negatively harged i ns, su h as Cl , are alled anions. Ea h
the b dy f uid mpartments ntains di ering levels
many imp rtant i nsb th p sitively harged ati ns and
negatively harged ani ns. S metimes the diss iated i ns are
themselves alled electrolytes.
Imp rtant ati ns in lude s dium (Na ), al ium (Ca ),
p tassium (K ), and magnesium (Mg ). Imp rtant ani ns
in lude hl ride (Cl ), bi arb nate (H CO 3 ), ph sphates
(H 2PO 4 and H PO 4 ), and many pr teins. Pr teins an be
ani ni when they ntain negatively harged amin a ids
amin a id side gr ups that have gained ele tr ns t give
them an ele tri al harge.
Figure 21-9 sh ws that alth ugh ECF ntains a number
imp rtant i ns, by ar the m st abundant are s dium (p si-
tive) and hl ride (negative). H wever, in the ICF, we nd
m stly p tassium (p sitive) and ani ni pr teins (negative).

Ele c t ro ly t e Fu n c t io n s
A variety ele tr lytes have imp rtant nutrient r regulat ry
r les in the b dy. Many i ns are maj r r imp rtant tra e
elements in the b dy (see Appendix C at evolve.elsevier.com).
 590 CHAPTER 21 Fluid and Electrolyte Balance

h w ECF ele tr lyte n entrati n a e ts f uid v l-

150 P la s ma umes, remember this ne sh rt senten e: Where so-
150 142 145
21 Inte rs titia l
Intra ce llula r
dium goes, water soon ollows.
117 I , r example, the n entrati n s dium in
100 104 interstitial f uid spa es rises ab ve n rmal, the v l-
ume IF s n rea hes abn rmal levels t a
L
/
nditi n alled edema, whi h results in tissue
q
E
m
swelling (see b x bel w). Edema may ur in any
54
50 rgan r tissue the b dy. H wever, the lungs,
brain, and dependent b dy areas su h as the legs and
24 27
12 12 14 l wer ba k are a e ted m st ten. One the m st
4.3 4.4 5.04 .8 ~0 4
0
mm n areas r swelling t ur is in the sub u-
0
Na+ K+ Ca++ HCO3 Cl P rote in tane us tissues the ankle and t.
Alth ugh wide variati ns are p ssible, the aver-
Catio ns Anio ns age daily diet ntains ab ut 100 milliequivalents
FIGURE 21-9 Electrolytes ound in uid compartments o the body. Note that s dium. T e milliequivalent (mEq) is a unit mea-
sodium (Na ) is the dominant positive ion and chloride (Cl ) is the dominant negative ion surement related t i n rea tivity.
in the extracellular f uid compartments (plasma and interstitial f uid). However, in the in- In a healthy individual, s dium ex reti n r m
tracellular f uid compartment, potassium (K ) and anionic proteins dominate. mEq/L, mil- the b dy by the kidney is ab ut the same as intake.
liequivalent per liter. T e kidney a ts as the hie regulat r s dium
levels in b dy f uids. It is imp rtant t kn w that
Ir n, r example, is required r hem gl bin pr du ti n, and many ele tr lytes su h as s dium n t nly pass int and ut
i dine must be available r synthesis thyr id h rm nes. the b dy but als m ve ba k and rth between a number
Ele tr lytes als are required r many ellular a tivities su h b dy f uids during ea h 24-h ur peri d.
as nerve ndu ti n and mus le ntra ti n. Figure 21-10 sh ws the large v lumes s dium- ntaining
In additi n, ele tr lytes inf uen e the m vement water internal se reti ns pr du ed ea h day. D uring a 24-h ur pe-
am ng the three f uid mpartments the b dy. remember ri d, m re than 8 liters f uid ntaining 1000 t 1300 mEq

C LIN ICA L APPLICATION

EDEMA
Ede m a m ay be de f ne d as the pre s e nce o abnorm ally large 3. A de cre as e in the co nce ntratio n o plas m a pro te ins .
am ounts o uid in the inte rs titial tis s ue s pace s o the body. This de cre as e can be caus e d by le akage into the inte r-
The te rm pitting e de m a is us e d to de s cribe de pre s s ions in s titial s pace s o prote ins norm ally re taine d in the blood.
s wolle n s ubcutane ous tis s ue that do not rapidly re f ll a te r an This m ay occur as a re s ult o incre as e d capillary pe rm e -
exam ine r has exe rte d f nge r pre s s ure (s e e photo). This type o ability caus e d by in e ction, burns , or s hock.
e de m a is o te n a s ym ptom in thos e w ith conge s tive he art
ailure .
The condition is a clas s ic exam ple o uid im balance and
m ay be caus e d by dis turbance s in any actor that gove rns the
inte rchange be twe e n blood plas m a and IF com partm e nts . Ex-
am ple s include the ollow ing:
1. Re te ntio n o e le ctro lyte s (e s pe cially Na ) in the
e xtrace llular uid. This can re s ult rom incre as e d aldo-
s te rone s e cre tion or can occur during s e rious kidney
dis e as e .
2. An incre as e in capillary blo o d pre s s ure . Norm ally,
uid is draw n rom the tis s ue s pace s into the ve nous
e nd o a tis s ue capillary be caus e o the low ve nous
pre s s ure and the re lative ly high wate r-pulling orce o
the plas m a prote ins . This balance is ups e t by anything
that incre as e s the capillary hydros tatic pre s s ure . The
ge ne ralize d ve nous conge s tion o he art ailure is the
m os t com m on caus e o w ide s pre ad e de m a. In patie nts
w ith this condition, blood cannot ow re e ly through the
capillary be ds , and the re ore the pre s s ure w ill incre as e Pitting edema. Note the ngertip-shaped depressions (arrows) that do
until ve nous re turn o blood im prove s . not rapidly re ll a ter an examiner has exerted pressure.
 Inte rnal s e c re tio ns
S a liva
1500 mL
Ga s tric
s e cre tions
2500 mL
P a ncre a tic
s e cre tions
500 mL
Bile
500 mL
Inte s tina l
s e cre tions
3000 mL
FIGURE 21-10 Sodium-containing internal secretions. The total
volume o these secretions may reach 8000 mLor more in 24 hours.
s dium are p ured int the digestive system as part sa-
liva, gastri se reti ns, bile, pan reati jui e, and IF se reti ns.
T is s dium, al ng with m st that ntained in the diet, is
alm st mpletely reabs rbed in the intestines. Very little
s dium is l st in the e es. Pre ise regulati n and ntr l
s dium levels are required r survival.
QUICK CHECK
1. Wh a t is th e d i e re n ce b e tw e e n a n e le ctro lyte a n d a
n o n e le ctro lyte ?
2. Wh a t a re s o m e o th e m a jo r ro le s o io n s in th e b o d y?
3. Id e n ti y th e u n ctio n s o e le ctro lyte s in th e b o d y.
Ele c t ro ly t e Im b a la n c e s
Ho m e o s t a s is o Ele c t ro ly t e s
Ele tr lyte balan e, like f uid balan e, is related t intake and
utput spe i ele tr lytes. Als imp rtant is the abs rp-
ti n ele tr lytes that are ingested, their nal distributi n in
the b dy f uids, and their availability r use by the b dy ells.
ECF n rmally ntains di ering levels s me ele tr -
lytes than d es ICF. In rder t maintain di erent n entra-
ti ns ele tr lytes in the di erent b dy f uids, di ering h -
me stati me hanisms that inf uen e intake, abs rpti n,
distributi n, and ex reti n these ele tr lytes are needed.
Any disrupti n in a h me stati me hanism that ntr ls
the level r n rmal hemi al a tivity a parti ular ele tr -
lyte in any the di erent b dy f uids pr du es an electrolyte
imbalance. Su h imbalan es are widespread and ten very
seri us and s metimes atal mani estati ns disease.
CHAPTER 21 Fluid and Electrolyte Balance 591
C LIN ICA L APPLICATION 21
DIURETICS
The word diure tic is rom the Gre e k word dioure tikos
m e aning caus ing urine . By de f nition a diure tic drug is a
s ubs tance that prom ote s or s tim ulate s the production o
urine . Re call that an incre as e in urine volum e re pre s e nts a
los s o wate r rom the body.
As a group, diure tics are am ong the m os t com m only
us e d drugs in m e dicine . They are us e d be caus e o the ir role
in in ue ncing wate r and e le ctrolyte balance , e s pe cially s o-
dium , in the body. For exam ple , diure tics can be us e d to
re m ove uid rom the body to re duce blood pre s s ure in
patie nts w ith hype rte ns ion (HTN).
Diure tics have the ir e e ct on tubular unction in the
ne phron, and the di e ring type s o diure tics are o te n clas -
s if e d according to the ir m ajor s ite o action. Exam ple s
would include (1) proxim al tubule diure tics s uch as ace tazol-
am ide (Diam ox), (2) ne phron loop diure tics s uch as e th-
acrynic acid (Ede crin) or uros e m ide (Las ix), and (3) dis tal
tubule diure tics s uch as chlorothiazide (Diuril).
Ca e ine produce s its m ildly diure tic e e cts by inhibiting
wate r re abs orption in the proxim al tubule s o the kidney.
Clas s if cation o diure tic drugs als o can be m ade accord-
ing to the e e ct the drug has on the leve l or conce ntration
o s odium (Na ), chloride (Cl ), potas s ium (K ), and bicar-
bonate (HCO 3 ) ions in the tubular uid.
Alcohol is als o a diure tic. It re duce s s e cre tion o ADH,
w hich is a wate r-cons e rving horm one . Thus wate r that
would have othe rw is e be e n cons e rve d by the body is los t
unde r the in ue nce o alcohol.
Diure tics are s om e tim e s abus e d by athle te s to quickly
re duce the ir we ight jus t be ore an eve nt or we igh-in. Los s
o wate r rom the body doe s in act re duce a pe rs ons
we ight, but it als o re duce s his or he r athle tic ability by cre -
ating the condition o de hydration. Diure tics (exce pt or le -
gitim ate the rape utic us e ) are include d on the Prohibite d
Lis t by the World Anti-Doping Age ncy.
Nurs ing im plications or care give rs m onitoring patie nts
re ce iving diure tics both in hos pitals and in hom e he alth-
care e nvironm e nts include (1) ke e ping a care ul re cord o
body we ight and uid intake and output and (2) as s e s s ing
the patie nt or s igns and s ym ptom s o e le ctrolyte and wa-
te r im balance . For exam ple , diure tic-induce d de hydration
re s ulting in a los s o only 6% o initial body we ight w ill
caus e tingling in the extre m itie s , s tum bling gait, he adache ,
eve r, and an incre as e in both puls e and re s piratory rate s .
Appendix C at evolve.elsevier.com lists the n rmal values
many imp rtant ele tr lytes and identi es disease states that
may result in variati ns ab ve r bel w n rmal levels. Ele tr -
lyte imbalan es inv lving s dium, p tassium, and al ium are
mm n in lini al medi ine and are des ribed in the ll w-
ing se ti ns.
Check out the article Fluid and Electrolyte Therapy
at Connect It! at evolve.elsevier.com.
 592 CHAPTER 21 Fluid and Electrolyte Balance

TABLE 21-3 Electrolyte Imbalances

21 BLOOD
ELECTROLYTE IMBALANCE CONCENTRATION POS S IBLE OUTCOMES
Sodium (Na ) Hype rnatre m ia 145 m Eq/L He adache ; con us ion; s e izure s
Hyponatre m ia 136 m Eq/L In s eve re cas e s : com a and de ath
Potas s ium (K ) Hype rkale m ia 5.1 m Eq/L We ake ning and paralys is o s ke le tal m us cle
Hypokale m ia 3.5 m Eq/L Cardiac dys rhythm ia or arre s t gas trointe s tinal (GI) m otility proble m s
Calcium (Ca ) Hype rcalce m ia 5.25 m Eq/L Fatigue , m us cle we akne s s , dim inis he d re exe s ; im paire d cardiac
conduction
Hypocalce m ia 4.2 m Eq/L Mus cle cram ping and tw itching o m us cle s , hype ractive re exe s ;
cardiac dys rhythm ia

dietary p tassium; abuse laxatives and ertain diureti s in

S o d iu m Im b a la n c e
T e term natrium is the Latin w rd r s dium. T e pre xes
hyper- and hypo- re er t ab ve and bel w, respe tively.
Kn wing this makes the terms hypernatremia and hyponatremia
easier t understand and remember. Hypernatremia is used
t des ribe a bl d s dium level m re than 145 mEq/L.
Hyponatremia urs when bl d s dium level is bel w
136 mEq/L (see Appendix C at evolve.elsevier.com and Table 21-3).
H ypernatremia may result r m veruse salt tablets,
dehydrati n, r pr l nged diarrhea. Regardless ause, the
nditi n is hara terized by a relative de it water t salt
in the ECF. H yp natremia urs when there is relatively t
mu h water in the ECF mpartment r the am unt s -
dium present. T is an ur i ex essive antidiureti h rm ne
is pr du ed r a ter massive in usi n IV f uids, su h as 5%
dextr se in water, that d n t ntain s dium.
H yp natremia als may be aused by ex essive salt l ss
resulting r m burns r ertain diureti s.
B th these nditi ns a e t entral nerv us system
(CNS) un ti ning and are hara terized by heada he; n u-
si n; seizures; and, in the m st severe ases, ma and death.
P o t a s s iu m Im b a la n c e
T e n rmal range r p tassium in bl d is 3.5 t 5.1 mEq/L
(see Appendix C at evolve.elsevier.com). Alth ugh m st the
t tal b dy p tassium is inside the ells, f u tuati ns r imbal-
an e in the relatively small am unts present in the ECF will
ause seri us illness.
Hyperkalemia is the lini al term used t des ribe bl d
p tassium levels m re than 5.1 mEq/L. (Kalium is the
Latin w rd r p tassium.) Elevati n p tassium may be
extreme weight l ss pr grams; r by l ss p tassium be ause
diarrhea, v miting, r gastri su ti n. As with hyperkale-
mia, l w p tassium levels ause skeletal mus le weakness and
ardia pr blems. Figure 21-11 sh ws the e e ts l w p tas-
sium (2.2 mEq/L) in redu ing ventri ular mus le un ti n
and thus ausing a pr l nged S segment in the ele tr ar-
di gram (ECG).
In additi n, sm th mus le in the gastr intestinal tra t
d es n t ntra t pr perly, ausing abd minal distenti n and
diminished rate passage intestinal ntents.
C a lc iu m Im b a la n c e
Cal ium is the m st abundant mineral in the b dy. It serves
as a basi stru tural building bl k in b ne and teeth. In ad-
diti n, it is essential r the maintenan e a n rmal heart-
beat, r un ti ning nerves and mus les, and r the r le it
plays in metab lism, bl d agulati n, and in many ther
enzymati rea ti ns. Failure h me stati me hanisms that
regulate levels this imp rtant ele tr lyte an result in ata-
str phi illness.
T e n rmal range r serum al ium is 8.4 t
10.5 mg/dL r 4.2 t 5.25 mEq/L (see Appendix C at
evolve.elsevier.com and Table 21-3).
Hypercalcemia urs when bl d al ium levels rise
ab ve n rmal limits. T e nditi n may be aused by ex essive
input r by in reased abs rpti n that may ur ll wing an
verd se vitamin D. Elevated levels als an result r m
V2
P rolonge d

related t in reased intake, a shi t r m the intra ellular f uid

int the bl d aused by tissue trauma r burns, r in ases
renal ailure, by an inability the kidneys t ex rete ex ess
p tassium.
Many the lini al mani estati ns hyperkalemia are
related t mus le mal un ti n (see Table 21-3). As p tassium
levels in rease, skeletal mus les weaken and paralysis devel-
ps. Severe hyperkalemia results in ardia arrest.
Hypokalemia re ers t a l w bl d p tassium level (bel w
3.5 mEq/L). It may be aused by asting; ad diets l w in
T U
P
QRS
FIGURE 21-11 Hypokalemia e ects on heart unction. Low potassium
levels (hypokalemia) can cause changes in heart unction, including a prolonged
ST segment caused by the presence o an extra wave called the U wave. Com-
pare to the normal ECG (electrocardiogram) in Figure 14-10 on p. 388.
 CHAPTER 21 Fluid and Electrolyte Balance 593

shi ts al ium r m b ne int the ECF aused by Paget
disease (see p. 202), ther b ne tum rs, r hyperparathyr id-
ism bl d levels that will als in rease i the kidney ann t
n rmally ex rete ex ess al ium in the urinea side e e t
ertain diureti s.
Regardless ause, hyper al emia de reases neur mus u-
lar ability t be stimulatedresulting in atigue, mus le weak-
ness, diminished ref exes, and delayed atri ventri ular n-
du ti n in the heart.
Hypocalcemia may result r m dietary al ium de ien y,
de reased abs rpti n r availability, and as a result in-
reased al ium ex reti n. Diseases su h as pan reatitis, hyp -
parathyr idism, ri kets, and ste mala ia and hr ni renal
insu ien y all l wer bl d al ium levels.
Clini al signs hyp al emia inv lve increased neur mus-
ular ex itability, ramping and twit hing mus les, hyper-
a tive ref exes, and abn rmal ardia rhythms hara terized by 21
impairment my ardial ntra tility. F r example, light
taps n the heek t stimulate the a ial nerve (CN VII) may
pr du e the Chvostek signan abn rmal spasm a ial
mus lesin hyp al emi patients.
QUICK CHECK
1. Wh a t a re th e ca u s e s o hyp e rn a tre m ia ? Hyp o n a tre m ia ?
2. Hyp o ka le m ia m a y ca u s e w h a t co n d itio n s ?
3. Why is ca lciu m a s ig n if ca n t m in e ra l in o u r b o d y?

S C IEN C E APPLICATIONS
THE CONSTANCY OF THE BODY
In 1834, a young Claude Be rnard Today, ne arly eve ry he alth-care pro e s s ional us e s conce pts
le t w hat he thought o at the tim e bas e d on Be rnards original ide a to he lp ke e p patie nts alive and
as his boring job as an appre n- he althy. Thos e w ho us e the s e ide as m os t dire ctly are the
tice apothe cary (druggis t) in Lyon, nurs e s , he alth te chnicians , IV te chnicians (picture d), and oth-
France , to m ake his ortune as a e rs w ho care or patie nts on an hour by hour bas is . It is the s e
playw right in Paris . His plays we re pro e s s ionals w ho m us t cons tantly as s e s s the uid balance o
not appre ciate d in Paris , but he patie nts and pos s ibly adm inis te r the rapie s to bring the ir uids
took a m e dical cours e w hile the re back into balance . Maintaining a he althy uid and e le ctrolyte
and ound that m any o the doc- balance is one o the key e le m e nts o s ucce s s ul patie nt care
tors appre ciate d his re s e arch s kills . in the m ode rn hos pital and clinic.
Claude Bernard Be rnard we nt on to be com e one o
(18131877) the m os t im portant f gure s in the
s tudy o hum an phys iology.
Be rnard m ade groundbre aking dis cove rie s in the unctions
o the pancre as and the live r, dis cove re d the exis te nce o
m us cle s that control blood ve s s e l dilation, and w rote a m an-
ual on expe rim e ntal m e dicine that s e t the s tandard in re -
s e arch practice or a ce ntury. Howeve r, one o the m os t un-
dam e ntal contributions he m ade to hum an phys iology is the
ide a that the body is m ade up o ce lls living in an inte rnal uid
e nvironm e nt.
Be rnard s tate d that the inte rnal uid e nvironm e nt o the
body is m aintaine d in a re lative ly cons tant s tate and thats
w hat e ns ure s the s urvival o the ce lls and the re ore als o e n-
s ure s the s urvival o the w hole body. Re call rom Chapte r 1
that we now call this conce pt hom e os tas is (s e e p. 14). It was
Be rnard w ho s howe d that the actions o horm one s and othe r
control m e chanis m s m aintain cons tant conditions in the bodys
inte rnal uid e nvironm e nt. And it was Be rnard w ho s howe d
that ne arly eve ry unction o the body s om e how re late s to the
s ucce s s o ke e ping body uids cons tant.
 594 CHAPTER 21 Fluid and Electrolyte Balance

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 583)

21
nonelectrolyte plasma transcellular uid
(non-ee-LEK-troh-lyte) (PLAZ-mah) (tranz-SEL-yoo-lar)
[non- not, -electro- electricity, -lyt- loosening] [plasma substance] [trans- across, -cell- storeroom,
-ular relating to]

LANGUAGE OF M ED IC IN E

Chvostek sign hypernatremia IV (intravenous) technician

(ke-VOSH-tek syne) (hy-per-nah-TREE-mee-ah) (aye-vee [in-trah-VEE-nus] tek-NISH-en)
[Franz Chvostek Austrian surgeon] [hyper- excessive, -natri- natrium (sodium), [intra- within, -ven- vein, -ous relating to,
dehydration -emia blood condition] techn- art or skill, -ic relating to,
(dee-hye-DRAY-shun) hypocalcemia -ian practitioner]
[de- remove, -hydro water, -ation process] (hye-poh-kal-SEE-mee-ah) overhydration
diuretic [hypo- under or below, -calc- lime (calcium), (oh-ver-hye-DRAY-shun)
(dye-yoo-RET-ik) -emia blood condition] [over- above, -hydr- water, -ation process]
[dia- through, -ure- urine, -ic relating to] hypokalemia pitting edema
edema (hye-poh-kal-EE-mee-ah) (pit-ing eh-DEE-mah)
(eh-DEE-mah) [hypo- under or below, -kal- kalium (potassium), [edema swelling]
[edema swelling] -emia blood condition] turgor
hypercalcemia hyponatremia (TUR-ger)
(hye-per-kal-SEE-mee-ah) (hye-poh-nah-TREE-mee-ah) [turg- swell, -or condition]
[hyper- excessive, -calc- lime (calcium), [hypo- under or below, -natri- natrium (sodium), water intoxication
-emia blood condition] -emia blood condition] (WAH-ter in-TOK-sih-kay-shen)
hyperkalemia [in- in, -toxic- poison, -ation process]
(hy-per-kal-EE-mee-ah)
[hyper- excessive, -kal- kalium (potassium),
-emia blood condition]
 CHAPTER 21 Fluid and Electrolyte Balance 595

OUTLINE S UMMARY 21

To dow nload a digital ve rs ion o the chapte r s um m ary C. Intra ellular f uid (ICF)largest f uid mpartment
or us e w ith your device , acce s s the Au d io Ch a p te r 1. L ated inside ells
S u m m a rie s online at evolve .e ls evie r.com . 2. Serves as s lvent t a ilitate intra ellular hemi al
rea ti ns
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e Me chanis m s That Maintain
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Fluid Balance
A. S ur es f uid intake (Figure 21-4 and Table 21-2)
1. Liquids we drink
Bo dy Fluid Vo lum e s 2. Water in d we eat
A. Water is the m st abundant b dy mp und 3. Metab li water ( r m ellular respirati n)
1. Re eren es t average b dy water v lume in re er- B. S ur es f uid utput (Figure 21-4 and Table 21-2)
en e tables are based n a healthy, n n bese, 70-kg 1. Water vap r (during respirati n)
male 2. Sweating ( r m skin)
2. V lume averages 40 L in a 70-kg male (Figure 21-1) 3. Urine ( r m kidney)
a. Plasma (3 L) 4. Water l st in the e es
b. Interstitial f uid (12 L) C. T ree main a t rs a e t plasma, IF, and ICF v lumes
. Intra ellular f uid (25 L) 1. Regulating f uid utput
3. Water is 80% b dy weight in newb rn in ants; 60% 2. Regulating f uid input
in adult males; 50% in adult emales (Figure 21-2) 3. Ex hanging f uid am ng mpartments and ar und
4. Variati n in t tal b dy water is related t : b dy
a. tal b dy weight individual D. Regulati n f uid utput
b. Fat ntent b dythe m re at in the b dy the 1. O rgans resp nsible r f uid utputlungs, skin,
less the t tal water ntent per kil gram b dy kidneys, and large intestine
weight (adip se tissue is l w in water ntent) 2. Fluid utput, mainly urine v lume, adjusts t f uid
. Gender emale b dy has ab ut 10% less than intake
male b dy (Figure 21-2) 3. Antidiureti h rm ne (ADH )
d. Agein a newb rn in ant, water may a unt r a. ADH released r m p steri r pituitary gland when
80% t tal b dy weight. In the elderly, water per ECF v lume is l w
kil gram weight de reases (mus le tissuehigh b. ADH pr m tes water reabs rpti n r m kidney
in waterrepla ed by at whi h is l wer in water) tubules int bl d
. Water is thus retained by b dy and less f uid is l st
in urine
Bo dy Fluid Co m partm e nts 4. Ald ster ne (Figure 21-5)
A. T e f uids the b dy are ntained within di erent a. Ald ster ne released r m adrenal rtex.
mpartments the b dy (Figure 21-3 and Table 21-1) b. Ald ster ne in reases kidney tubule reabs rpti n
B. Extra ellular f uid (ECF) alled internal envir nment s dium in kidney tubules
b dy; surr unds ells and transp rts substan es t and . Water ll ws s dium r m tubules int bl d
r m them d. Water is retained by ECF (and t tal b dy f uid) by
1. Plasmaliquid part wh le bl d de reasing urine v lume
2. Interstitial f uid (IF)surr unds the ells
3. rans ellularlymph; j int f uids; erebr spinal f uid;
eye hum rs
 596 CHAPTER 21 Fluid and Electrolyte Balance
5. Atrial natriureti h rm ne (ANH )
a. ANH is released r m hearts atrial wall in resp nse
21 t high bl d v lume
b. ANH pr m tes s dium l ss r m bl d int
kidney tubules
. Water ll ws s dium r m bl d, thus in reasing
l ss water in urine
E. Regulati n f uid intake (Figure 21-6)
1. Sens ry re ept rs dete t hange in v lume and ECF
n entrati n and send signals t the hyp thalamus
2. Signals r m hyp thalamus ause eeling thirst,
whi h triggers drinking f uids t rest re balan e
F. Ex hange f uids by bl d
1. C nstan y internal f uid balan e als maintained by
ex hanging f uids between f uid mpartments
2. In reased apillary bl d pressure trans ers f uid r m
bl d t IFa f uid shi t
3. Bl d plasma pr tein n entrati n ntributes t
sm ti pressure, thus attra ting water and h lding it
in the plasma
Fluid Im balance s
A. Dehydrati nt tal v lume b dy f uids smaller than
n rmal
1. IF v lume shrinks rst, and then i treatment is n t
given, ICF v lume and plasma v lume de rease
2. Dehydrati n urs when f uid utput ex eeds intake
r an extended peri d (Figure 21-7 and Figure 21-8)
B. O verhydrati nt tal v lume b dy f uids larger than
n rmal
1. Fluid intake ex eeds utput
2. Ex ess v lume burdens pumping a ti n heart
C. Water int xi ati np ssibly li e-threatening neur l gi-
al impairment aused by severe verhydrati n and
a mpanying ele tr lyte imbalan e
Im po rtance o Ele ctro lyte s
in Bo dy Fluids
A. Ele tr lytes and n nele tr lytes
1. N nele tr lytes rgani substan es that d n t break
up r diss iate when pla ed in water s luti n (e.g.,
glu se)
2. Ele tr lytes mp unds that break up r diss iate
in water s luti n int separate parti les alled i ns
(e.g., rdinary table salt r s dium hl ride)
B. I nsthe diss iated parti les an ele tr lyte that
arry an ele tri al harge
1. Cati ns are p sitively harged i ns (e.g., p tassium
[K ] and s dium [Na ])
2. Ani ns are negatively harged i ns (e.g., hl ride
[Cl ], bi arb nate [H CO 3 ], ani ni pr teins)
C. Ele tr lyte mp siti n b dy f uids (Figure 21-9)
1. ECF d minated by s dium (p sitive) and hl ride
(negative)
2. ICF d minated by p tassium (p sitive) and ani ni
pr teins (negative)
D. Edemaswelling aused by high IF v lume
E. S dium- ntaining internal se reti ns (Figure 21-10)
Ele ctro lyte Im balance s (Table 21-3)
A. Related t intake and utput ele tr lytes and als
abs rpti n and distributi n ele tr lytes in b dy f uids
and availability r use by b dy ells
B. S dium imbalan e
1. H ypernatremiabl d s dium m re than 145 mEq/L
2. Chara terized by relative de it water t salt in ECF
3. Causes in lude veruse salt tablets; dehydrati n;
and pr l nged diarrhea
4. H yp natremiabl d s dium less than 136 mEq/L
a. Results when there is relatively t mu h water in
the ECF r the am unt s dium present
b. Causes in lude ex essive se reti n antidiureti
h rm ne; massive in usi n s dium- ree IV s lu-
ti n; burns; and pr l nged use ertain diureti s
. Sympt ms b th hyper- and hyp natremia are
related t CNS mal un ti n and in lude heada he,
n usi n, seizures, and ma
C. P tassium imbalan e
1. H yperkalemiabl d p tassium m re than
5.1 mEq/L
a. Causes in lude in reased intake; shi t p tassium
r m ICF t bl d aused by tissue trauma and
burns; renal ailure

b. Clini al signs hyperkalemia are related t mus le
mal un ti n and in lude skeletal mus le weakness,
paralysis, and ardia arrest
2. H yp kalemiabl d p tassium less than 3.5 mEq/L
a. Causes in lude asting; diets l w in p tassium;
abuse laxatives and ertain diureti s; diarrhea;
v miting; gastri su ti n
b. Clini al signs in lude skeletal mus le and ardia
pr blems; sm th mus le weakness ausing
abd minal distenti n; and sl w rate passage
GI ntents (Figure 21-11)
D. Cal ium imbalan e
1. H yper al emiabl d al ium levels m re than
10.5 mg/dL (5.25 mEq.L)
a. Caused by ex essive input; in reased abs rpti n;
shi ts al ium r m b ne t ECF; Paget disease
and ther b ne tum rs; hyperparathyr idism
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Chapte r 21 expands on s om e o the m ate rial rom Chapte r 20.
A quick review o Chapte r 20 w ill be tte r pre pare you or this
chapte r.
1. Make f ash ards and he k nline res ur es t help y u
learn the terms in this hapter.
2. F r a better understanding the terms in this hapter,
review the Language S ien e and Language Medi-
ine se ti ns.
3. Ele tr lytes are harged parti les r i ns. One the
un ti ns i ns is t ntr l water m vement. T e b dy
ann t dire tly ntr l water m vement s it must m ve
ele tr lytes and water will then ll w.
CHAPTER 21 Fluid and Electrolyte Balance 597
b. Clini al signs related t de reased neur mus ular
a tivity atigue; mus le weakness; diminished
ref exes; ardia pr blems 21
2. H yp al emiabl d al ium levels less than
8.4 mg/dL (4.2 mEq/L)
a. Caused by dietary de ien y, de reased abs rpti n
r availability, in reased ex reti n, pan reatitis,
hyp parathyr idism, ri kets and ste mala ia, and
renal insu ien y
b. Clini al signs related t in reased neur mus ular
irritability ramping, mus le twit hing; hypera -
tive ref exes; and abn rmal ardia rhythms
4. T e apillary pressure and bl d pr tein me hanism regu-
lates the m vement water between the bl d and
interstitial f uid. Bl d pressure determines the am unt
plasma that is pushed ut int the interstitial f uid, and
plasma pr teins determine the am unt water that gets
pulled ba k int the bl d.
5. In y ur study gr up, review the f ash ards with the terms.
Dis uss h w ele tr lytes un ti n in regulating water
m vement. G ver the ald ster ne me hanism (see
Figure 21-5). Dis uss the plasma pr tein and apillary
bl d pressure me hanism r regulating the balan e
between bl d plasma and interstitial f uid. Review the
questi ns and hapter utline summary at the end the
hapter and dis uss p ssible test questi ns.
 598 CHAPTER 21 Fluid and Electrolyte Balance
Re vie w Que s tio ns
21 Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Name and give the l ati n the three main f uid m-
partments the b dy. W hi h these make up ECF?
2. Explain transcellular uids and list the transcellular uids
in the b dy.
3. List the a t rs that inf uen e the per entage water in
the b dy. Explain the e e t ea h a t r.
4. List the three s ur es water r the b dy.
5. Identi y the main a t rs that a t as me hanisms r bal-
an ing plasma, IF, and ICF v lumes.
6. List the ur rgans r m whi h f uid utput urs.
7. Explain h w ald ster ne inf uen es water m vement
between the kidney tubules and the bl d.
8. Explain why the b dy is unable t redu e its f uid utput
t zer n matter h w dehydrated it is.
9. Explain the r le apillary bl d pressure in water
m vement between the plasma and interstitial f uid.
10. Explain the r le plasma pr teins in water m vement
between the plasma and interstitial f uid.
11. De ne dehydrati n and name a p ssible ause.
12. De ne verhydrati n and name a p ssible ause.
13. Di erentiate between an ele tr lyte and a
n nele tr lyte.
14. Name three imp rtant ani ns.
15. Name three imp rtant ati ns.
16. W hat are the lini al mani estati ns hyperkalemia?
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
17. Regarding f uid and ele tr lyte balan e, what w uld be
the nsequen es a large l ss skin (e.g., third-
degree burns r s raping injuries)?
18. I a pers n rapidly drank a liter distilled water, h w
w uld their ICF be a e ted?
19. Al h l and a eine are b th diureti s. Explain h w
they a e t diuresis in the b dy.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e extra ellular f uid mpartment is mp sed
________ and ________.
2. T e largest v lume water in the human b dy is n-
tained in whi h f uid mpartment? ________
3. T e b dys hie me hanism r maintaining f uid
balan e is t adjust its ________.
4. T e b dy has three s ur es f uid intake; the liquids we
drink, the ds we eat, and ________.
5. T e ur rgans r m whi h f uid utput urs are the
________, ________, ________, and ________.
6. Urine v lume is regulated by three h rm nes: ADH
released r m the pituitary gland, ________ released
r m the adrenal rtex, and ________ released r m the
heart.
7. W hen ele tr lytes diss iate in water, they rm harged
parti les alled ________.
8. T e m st abundant negatively harged parti le in the
bl d is ________.
9. T e m st abundant p sitively harged parti le in the
bl d is ________.
10. Depressi ns in sw llen sub utane us tissue that d n t
re ll a ter an examiner has exerted nger pressure is
re erred t as ________.

Indicate whether each o the next f ve questions is true or alse:
11. ________ In general, an bese pers n has m re water
per p und b dy weight than a slim pers n.
12. ________ In general, a man has less water per p und
b dy weight than a w man.
13. ________ In general, an in ant has less water per p und
b dy weight than an adult.
14. ________ ANH is a diureti h rm ne.
15. ________ T e average diet ntains 100 mEq s dium.
16. W hen the bl d level ald ster ne in reases:
a. s dium is m ved r m the bl d t the kidney
tubules
b. s dium is m ved r m the kidney tubules t the
bl d
. m re urine is rmed
d. ANH is released
17. Ald ster ne auses:
a. an in rease in ICF
b. a de rease in ICF
. an in rease in ECF
d. a de rease in ECF
18. In reased apillary pressure:
a. m ves f uid r m the intra ellular mpartment t the
extra ellular mpartment
b. m ves f uid r m the plasma t the interstitial f uid
. m ves f uid r m the interstitial f uid t the plasma
d. has n e e t n f uid m vement
19. Bl d plasma pr teins a t t :
a. m ve interstitial f uid int the plasma
b. m ve plasma int the interstitial f uid
. m ve extra ellular f uid int the intra ellular spa e
d. m ve interstitial f uid int the extra ellular spa e
20. Signs hyp al emia may be mani ested as a result :
a. pan reatitis
b. hyp parathyr idism
. ste mala ia
d. all the ab ve
CHAPTER 21 Fluid and Electrolyte Balance 599
Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to 21
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Like m st pe ple in the United States, m ingests 20 t
30 times m re s dium ea h day than he needs r sur-
vival. H w d es ms b dy mpensate r this imbal-
an e t rest re h me stasis?
2. J has n t eaten anything all day but has nsumed an
ex essive am unt distilled water. W ill this a e t her
urine utput? W hat unusual hara teristi s are likely t
appear in a urinalysis J s urine?
3. J is verhydrated (see Case Study number 2). T is
hapter states that overhydration an pla e a danger usly
heavy burden n the heart. Explain h w verhydrati n
an tax the heart.
4. Liam and his riend l ve t sail in the gul . T ey stay ut
r l ng peri ds at a time and are ten n the b at r
days. T ey try t nserve d and water when n trips
but d n t want t be lish and put their health at risk.
Can y u er a suggesti n that might help Liam and his
riend m nit r their hydrati n while n extended trips?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Acid-Base Balance
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

pH o Body Fluids, 601

Using the pH Scale, 601
The pH Unit, 602
Mechanisms That Control pH o Body Fluids, 602
Overview o pH Control Mechanisms, 602
Integration o pH Control, 603
Bu ers, 603
Respiratory Mechanism o pH Control, 606
Urinary Mechanism o pH Control, 606
pH Imbalances, 607
Acidosis and Alkalosis, 607
Metabolic and Respiratory Disturbances, 607
Compensation or pH Imbalances, 609

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Discuss the concept o pH, including:

base and explain the di erence

between strong and weak acids.
2. Do the ollowing related to mechanisms that control
pH o body uids:

uids.

mechanisms o pH control.
3. Compare and contrast acidosis and alkalosis.
4. Discuss the two types o respiratory disturbances.
 22
Ac id -b a s e balan e is ne the m st imp r- LANGUAGE OF
tant the b dys h me stati me hanisms. Main- S C IEN C E
taining acid-base balance means keeping the
n entrati n hydr gen i ns in b dy f u-
Be o re re ading the
ids relatively nstant. E e tive un ti n-
chapte r, s ay e ach o
ing many imp rtant b dy pr teins, the s e te rm s o ut lo ud. This w ill
su h as ellular enzymes and hem gl - he lp yo u to avo id s tum bling ove r
bin, l sely depends n maintaining the m as yo u re ad.
pre ise regulati n hydr gen i n n-
entrati n. T is is vital imp rtan e. I
acidic
the hydr gen i n n entrati n veers (ah-SID-ik)
away r m n rmal even slightly, seri us [acid- sour, -ic relating to]
illness r even death may ur. H ealthy acid-base balance
survival depends n the ability the b dy t
maintain, r qui kly rest re, the a id-base bal- [acid sour, bas- oundation,
an e its f uids i imbalan es ur. bal- twice, -lanc- dish (two
scales)]
A id-base regulati n requires a series rdinated alkaline
h me stati me hanisms that inv lve the bl d and
ther b dy f uids, the lungs, and the kidneys. Ultimately [alkal- ashes, -ine relating to]
all these me hanisms are based n hemi al pr esses. bu er
Re all that many imp rtant hemi al prin iples related t the (BUF-er)
li e pr ess were vered in Chapter 2. Y u may wish t re er ba k [bu e- cushion, -er agent]
t th se prin iples bi hemistry as y u study h w the b dy s bu er pair
pre isely regulates its a id-base balan e. (BUF-er payr)
[bu e- cushion, -er agent]
carbonic anhydrase (CA)
p H o Bo d y Flu id s (kar-BON-ik an-HYE-drays
As rst utlined in Chapter 2, water and all water s luti ns ntain [see ay])
[carbo- coal, -ic relating to,
hydrogen ions (H ) and hydroxide ions (OH ). pH is an a r nym r
an- without, -hydr- water,
p wer H . T e term pH ll wed by a number indi ates a s luti ns
-ase enzyme]
hydr gen i n n entrati n mpared with hydr xide n entrati n.
compensation
(kom-pen-SAY-shun)
U s in g t h e p H S c a le [compens- balance, -tion process]
homeostasis
At pH 7.0 a s luti n ntains an equal n entrati n hydr gen and (hoh-mee-oh-STAY-sis)
hydr xide i ns. T ere re pH 7.0 als indi ates that a f uid is neutral in [homeo- same or equal,
rea ti n (that is, neither a idi n r alkaline) (Figure 22-1). T e pH pure -stasis standing still]
water, r example, is 7.0. hydrogen ion (H )
(HYE-droh-jen AYE-on)
[hydro- water, -gen produce,
ion to go]
hydroxide ion (OH )
(hye-DROK-side aye-on)
[hydr- water (hydrogen), -ox- sharp
(oxygen), -ide chemical, ion to go]

Continued on p. 611

601
 602 CHAPTER 22 Acid-Base Balance

bl d, n the ther hand, is a bit l wer at 7.37but n rmally

n t bel w 7.35. In lini al pra ti e, the terms arterial and
ven us always re er t the systemi ir ulati nn t the
pulm nary ir ulati nunless stated therwise.
By applying the in rmati n given in the previ us para-
graph, y u an dedu e the answers t the ll wing questi ns.
Is arterial bl d slightly a idi r slightly alkaline? Is ven us
bl d slightly a idi r slightly alkaline?
Arterial and ven us bl d are b th slightly alkaline be-
ause b th have a pH slightly higher than 7.0. Ven us bl d,
h wever, is less alkaline than arterial bl d be ause ven us
bl ds pH ab ut 7.37 is slightly l wer than arterial bl ds
pH ab ut 7.4.
22
To better understand this concept, use the Active
Concept Map Concept o pH at evolve.elsevier.com.

Th e p H U n it
L king at the le t side Figure 22-1, we see that the pH unit
is based n exp nents 10 r m ne unit t the next. T at
means that n the pH s ale m ving r m ne unit t the next
multiplies the relative H n entrati n by 10 times. T us the
di eren e between pH 7 and pH 6 is a ten old in rease in H .
M ving r m pH 7 t pH 5 is a hundred old in rease in H
n entrati n.
T is ten ld di eren e between pH units is imp rtant t
remember when we l k at the n rmal pH range bl d
plasmaa key f uid mpartment the b dy. W hat may
seem like a small hange in a idity at rst glan e is really
10 times bigger than it l ks!
A related mathemati al quirk the pH unit is that the
di eren e between any tw pH values bel w 7.4 is larger than
it w uld be ab ve 7.4.
FIGURE 22-1 The pH range. The overall pH range is expressed numeri-
cally on what is called a logarithmic scale o 1 to 14. This means that a M e c h a n is m s Th a t C o n t ro l
change o 1 pH unit represents a ten old di erence in actual concentration
o hydrogen ions. Note that as the concentration o H ions increases, the p H o Bo d y Flu id s
solution becomes increasingly acidic and the pH value decreases. As OH
concentration increases, the pH value also increases, and the solution be- O ve r v ie w o p H C o n t ro l M e c h a n is m s
comes more and more basic, or alkaline. A pH o 7 is neutral; a pH o 2 is
very acidic, and a pH o 13 is very basic. T e b dy has three me hanisms r regulating the pH its
f uids. T ey are
1. Bu er me hanism in bl d
2. Respirat ry me hanism
A pH higher than 7.0 indi ates an alkaline s luti n
3. Urinary me hanism
(that is, ne with a l wer n entrati n hydr gen than
hydr xide i ns). T e m re alkaline a s luti n, the higher gether, the listed pr esses nstitute the mplex pH h -
is its pH value. Alkaline s luti ns are als alled basic me stati me hanismthe ma hinery that n rmally keeps
s luti ns. bl d slightly alkaline with a pH that stays remarkably n-
A pH l wer than 7.0 indi ates an acidic s luti n (that is, stant. Its usual limits are very narr w, ab ut 7.35 t 7.45.
ne with a higher hydr gen i n n entrati n than hydr xide T e slightly l wer pH ven us bl d mpared with ar-
i n n entrati n). T e higher the hydr gen i n n entra- terial bl d results primarily r m arb n di xide (CO 2) en-
ti n, the l wer the pH and the m re a idi a s luti n is. tering ven us bl d as a waste pr du t ellular metab lism.
W ith a pH as l w as 1.6, gastri jui e is the m st a idi As arb n di xide enters the bl d, s me it mbines with
substan e in the b dy. Saliva ten has a pH 7.7, n the water (H 2O) and is nverted int arb ni a id by carbonic
alkaline side. N rmally, the pH arterial bl d is ab ut anhydrase (CA), an enzyme und in red bl d ells. T e l-
7.4with a n rmal upper limit 7.45. T e pH ven us l wing hemi al equati n represents this rea ti n. I y u need
 CHAPTER 22 Acid-Base Balance 603

S C IEN C E APPLICATIONS
THE BODY IN BALANCE
Ke e ping the pH o the body s table
is but one as pe ct o m aintaining
he alth. The Am e rican phys iologis t
Walte r Cannon gave us a nam e or
the principle o balance , or con-
s tancy, o the inte rnal uid e nviron-
m e nt o the bodyho m e o s tas is .
In 1932, his popular book The Wis -
dom o the Body f nally gave a
w ith uid and e le ctrolyte balance , know le dge o the m e cha-
nis m s o acid-bas e balance is critical in dire ct patie nt care .
The re ore , m any phys icians , nurs e s , re s piratory the rapis ts
(picture d), IV te chnicians , f rs t re s ponde rs ( or exam ple , e m e r-
ge ncy m e dical te chnicians and param e dics ), and othe rs ne e d
a bas ic know le dge o how the body m aintains a cons tancy o
pH in the blood.

Walter Brad ord Cannon

nam e to the conce pt f rs t ex-
plaine d by Claude Be rnard s eve n
22
(18711945) de cade s e arlie r (s e e p. 593). How-
eve r, Cannon did m ore than nam e
the conce pt. In his book, Cannon explaine d the incre dibly
com plex s e t o m e chanis m s that allow s our bodie s to adjus t
to tre m e ndous inte rnal and exte rnal uctuations that would
othe rw is e kill us .
Much o Cannons thought cam e rom his groundbre aking
dis cove rie s in how the body cope s w ith s tre s s . In exam ining
the f ght-or- ight re s pons e , the e e cts o e m otional s tim uli, the
m e chanis m s o cardiovas cular s hock, and in deve loping the
cas e s tudy approach to le arning about hum an he alth and
dis e as e , Walte r Cannon deve lope d a cle ar unde rs tanding o the
inte ractive nature o the organs o the body. It was Cannon w ho
le d s cie ntis ts to look at the ir work in this new ram ework that
explains the big picture o hum an body unction.
Cannons explanation o hom e os tas is revolutionize d the
way we look at the bodyand how we look at patie nt care . As

t review hemi al rmulas and equati ns, please re er t harm ul swings in pH when added a ids r bases enter b dy
Chapter 2. f uids. I this immediate-a ting hemi al ntr l me hanism
is unable t stabilize the pH , the lungs and kidneys an b th
arb ni
anhydrase pr vide a physiological pH control mechanism t halt and reverse
CO 2 H 2O 8888888n H 2CO 3 harm ul pH shi ts. T e lungs resp nd in 1 t 2 minutes when
the brainstem adjusts the respirat ry rate (see Figure 17-18) and
T e lungs rem ve the equivalent m re than 30 L thus the adjustment CO 2 is a mplished.
arb ni a id ea h day r m the ven us bl d by eliminati n I the respirat ry me hanism is unable t st p the pH
CO 2. T is alm st unbelievable quantity a id is s well shi t, p wer ul but sl wer-a ting renal me hanisms will be
bu ered that a liter ven us bl d ntains nly ab ut initiated within 24 h urs. Details ea h me hanism are dis-
1/100,000,000 grams m re H than d es 1 liter arterial ussed in the paragraphs that ll w.
bl d. W hat in redible nstan y! T e pH h me stati
me hanism d es indeed ntr l e e tivelyast nishingly s .
Bu ers
To better understand this concept, use the Active Buf ers are hemi al substan es that prevent a sharp hange
Concept Map Transport o Oxygen and Carbon in the pH a f uid when an a id r base is added t it. Str ng
Dioxide in the Blood at evolve.elsevier.com. a ids and bases, i added t bl d, w uld diss iate alm st
mpletely and release large quantities H r O H i ns.
T e result w uld be drasti hanges in bl d pH . Survival
In t e g r a t io n o p H C o n t ro l itsel depends n pr te ting the b dy r m su h drasti pH
Integrati n the three h me stati me hanisms that a t t hanges.
maintain the pH b dy f uids is illustrated in Figure 22-2. M re a ids than bases are usually added t b dy f uids.
T ink the ir ulating bl d and RBCs as pr viding a T is is be ause atab lism, a pr ess that g es n ntinually
chemical pH control mechanism, whi h is based n bu ers (dis- in every ell the b dy, pr du es a ids that enter bl d as it
ussed later), and whi h a ts immediately t help prevent f ws thr ugh tissue apillaries. Alm st immediately, ne
 604 CHAPTER 22 Acid-Base Balance

CIRCULATION is rdinary baking s da (s dium bi arb nate, r NaH CO 3)

and arb ni a id (H 2CO 3).
H 2O + CO 2 H 2CO 3 H + + HCO 3 Let us nsider, as a spe i example bu er a ti n,
Carbo nic
anhydras e h w the NaH CO 3H 2CO 3 system w rks with a str ng a id
r base.
I a str ng base, su h as s dium hydr xide (NaOH ), were
LUNGS KIDNEY added t this bu er system, the rea ti n sh wn in Figure 22-3
pH pH w uld take pla e. T e H H 2CO 3 3), the weak

Re s pira tory
a id the bu er pair, mbines with the OH the str ng
ce nte rs in base NaOH t rm H 2O. N te what this a mplishes. It
bra ins te m de reases the number OH i ns added t the s luti n, and
this in turn prevents the drasti rise in pH that w uld ur
with ut bu ering.
22 Re s pira tion ra te
a nd de pth Figure 22-4 sh ws h w a bu er system w rks with a str ng
a id. Alth ugh use ul in dem nstrating the prin iples bu -
er a ti n, H Cl r similar str ng a ids are never intr du ed
CO 2 give n off Ra te of H+ s e cre tion dire tly int b dy f uids under n rmal ir umstan es. Instead,
the NaH CO 3 bu er system is m st ten alled n t bu er
FIGURE 22-2 Integration o pH control mechanisms. Elevated CO2 a number weaker a ids pr du ed during atab lism. La ti
levels result in increased ormation o carbonic acid in red blood cells. The a id is a g d example. As a weak a id, it d es n t diss iate
resulting increase in hydrogen ions, coupled with elevated CO2 levels, as mpletely as H Cl. In mplete diss iati n la ti a id
causes an increase in respiratory rate and secretion o hydrogen ions by the results in ewer hydr gen i ns being added t the bl d and a
kidneys, thus helping to regulate the pH o body f uids. less drasti l wering bl d pH than w uld ur i H Cl
were added in an equal am unt.
the salts present in bl da bu er, that isrea ts with these W ith ut bu ering, h wever, la ti a id buildup results in
relatively str ng a ids t hange them int weaker a ids. T e signi ant H a umulati n ver time. T e resulting de rease
weaker a ids de rease bl d pH nly slightly, whereas the pH an pr du e seri us a id sis. O rdinary baking s da
str nger a ids rmed by atab lism w uld have de reased it (s dium bi arb nate, r NaH CO 3) is ne the main bu ers
greatly i they were n t bu ered. the n rmally urring xed a ids in bl d. La ti a id is
Bu ers nsist tw kinds substan es and are there re ne the m st abundant the xed a ids (a ids that d
ten alled buf er pairs. O ne the main bl d bu er pairs n t break d wn t rm a gas).

Buffe r pa ir

S odium Ca rbonic S odium Wa te r

hydroxide a cid Na + a nd H+ bica rbona te
Na OH H HCO 3 switch pla ce s Na HCO 3 H OH

Dis s ocia te s a lmos t comple te ly Dis s ocia te s ve ry little

(ma ny OH a dde d to s olution) (few OH a dde d to s olution)

H 2O H + H 2O H 2O
Na+ OH OH Na+

Na+ Na+ OH Na+ H 2O H 2O OH H 2O

OH OH Na+ OH H 2O H 2O H 2O

FIGURE 22-3 Bu ering action o carbonic acid. Bu ering o base NaOH by H2CO3. As a result o bu er
action, the strong base (NaOH) is replaced by NaHCO3 and H2O. As a strong base, NaOH dissociates almost
completely and releases large quantities o OH . Dissociation o H2O is minimal. Bu ering decreases the
number o OH ions in the system.
 CHAPTER 22 Acid-Base Balance 605

Buffe r pa ir

Hydrochloric S odium Ca rbonic S odium

a cid bica rbona te H+ a nd Na + a cid chloride

H Cl Na HCO 3 switch pla ce s H HCO 3 Na Cl

Dis s ocia te s Dis s ocia te s

a lmos t comple te ly ve ry little
+
(few H a dde d to s olution)
(ma ny H+ a dde d to s olution)

H+ Cl Cl Cl
H 2CO 3 22
H+
H 2CO 3
H 2CO 3
H+ H+ Cl Cl
H 2CO 3
Cl H+ H+ H+ HCO 3 H 2CO 3

FIGURE 22-4 Bu ering action o sodium bicarbonate. The acid HCl is bu ered by NaHCO3. As a result
Note that HCl, 3).
being a strong acid, dissociates almost completely and releases more H than H2CO3. Bu ering decreases
the number o H ions in the system.

Figure 22-5 sh ws the mp unds rmed by bu ering the newly rmed H 2CO 3. N rmal arterial bl d
la ti a id (a xed a id), pr du ed by n rmal atab lism. T e with a pH 7.45 ntains 20 times m re NaH CO 3
ll wing hanges in bl d result r m bu ering xed a ids than H 2CO 3. I this rati de reases, bl d pH de-
in tissue apillaries: reases bel w 7.45.
3. T e H n entrati n bl d in reases slightly.
1. T e am unt H 2CO 3 in bl d in reases slightly H 2CO 3 adds hydr gen i ns t bl d, but it adds
be ause an a id (su h as la ti a id) is nverted t ewer them than la ti a id w uld have be ause it
H 2CO 3. is a weaker a id than la ti a id. In ther w rds,
2. T e am unt bi arb nate in bl d the bu ering me hanisms d n t t tally prevent
(mainly NaH CO 3) de reases be ause Buffe r pa ir bl d hydr gen i n n entrati n r m in reas-
bi arb nate i ns be me part ing. It simply minimizes the in rease.

La ctic S odium Ca rbonic S odium

a cid bica rbona te H+ a nd Na + a cid la cta te
switch pla ce s
H Na HCO 3 H HCO 3 Na la cta te

Dis s ocia te s to s ome exte nt Dis s ocia te s ve ry little

la cta te H+ H H+ HCO 3 H 2CO 3

la cta te H+ H H 2CO 3 H 2CO 3

la cta te H+ H 2CO 3 H 2CO 3

FIGURE 22-5 Lactic acid bu ered by sodium bicarbonate.

acids are bu ered by NaHCO3 3, or H2CO3, a weaker acid than lactic acid)
replaces lactic acid. As a result, ewer H ions are added to blood than would be added i lactic acid were not
bu ered.
 606 CHAPTER 22 Acid-Base Balance

4. Bl d pH de reases slightly be ause the small remains in the bl d leaving the lung apillaries, s less it
in rease in bl d H n entrati n. is available r mbining with water t rm H 2CO 3.
H en e a ter expirati n the bl d ntains less H 2CO 3, has
H 2CO 3 is the m st abundant a id in b dy f uids be ause it ewer hydr gen i ns, and has a higher pH (ab ut 7.4) than
is rmed by the bu ering xed a ids and als be ause CO 2 d es the de xygenated bl d entering the pulm nary ir u-
rms it by mbining with H 2O. Large am unts CO 2, an lati n (pH 7.37).
end pr du t atab lism, ntinually p ur int tissue apil- Let us nsider n w h w a hange in respirati ns an alter
lary bl d r m ells. Mu h the H 2CO 3 rmed in bl d bl d pH . Supp se y u were t pin h y ur n se shut and h ld
di uses int red bl d ells where it is bu ered by the p tas- y ur breath r a ull minute r a little l nger. O bvi usly, n
sium salt hem gl bin. CO 2 w uld leave y ur b dy by way expired air during that
S me the H 2CO 3 breaks d wn t rm the gas CO 2 and time, and the bl ds CO 2 ntent w uld nsequently in-
water (H 2O). T is takes pla e in the bl d as it m ves thr ugh rease. T is w uld in rease the am unt H 2CO 3 and the
the lung apillaries. T e next part ur dis ussi n explains hydr gen i n n entrati n bl d, whi h in turn w uld
22 h w this a e ts bl d pH . de rease bl d pH .
T e b dy has ther bu er pair systems that als ntribute H wever, this situati n w uld n t last r l ng. T e respi-
t the stability bl d pH . F r example, there is a phosphate rat ry ntr l enters in y ur brainstem dete t the dr pping
buf er system and protein buf er system. T e pr tein system in- pH and rising CO 2 in y ur bl d and resp nd str ngly by
ludes b th plasma pr teins and hem gl bin. r ing y u t inhale (see Chapter 17, pp. 475-478). T is sur-
vival me hanism explains why a pers n ann t h ld his r her
QUICK CHECK breath inde nitely. It als explains why during exer ise, a dr p
1. Wh a t th re e m e ch a n is m s d o e s th e b o d y h a ve o r re g u la t- in pH aused by in reased mus le pr du ti n CO 2 triggers
in g p H o b o d y u id s ? an in rease in breathing rate. O urse, the pp site is true as
2. Wh a t is p rim a rily re s p o n s ib le o r th e s lig h tly lo w e r p H in wellwhen bl d pH in reases t r ab ve n rmal, then the
ve n o u s b lo o d ?
3. Wh a t a re b u e rs ?
rate breathing sl ws.

U r in a ry M e c h a n is m o p H C o n t ro l
Re s p ir a t o ry M e c h a n is m o p H C o n t ro l M st pe ple kn w that the kidneys are vital rgans and that
Respirati ns play a vital part in ntr lling pH . W ith every li e s n ebbs away i they st p un ti ning. One reas n is that
expirati n, CO 2 and H 2O leave the b dy in the expired air. the kidneys are the b dys m st e e tive regulat rs bl d
T e CO 2 has di used ut the pulm nary bl d as it pH . T ey an eliminate mu h larger am unts a id than an
m ves thr ugh the lung apillaries. Less CO 2 there re the lungs and, i it be mes ne essary, they als an ex rete
ex ess base. T e lungs ann t.
In sh rt, the kidneys are the
b dys last and best de ense
HEA LTH AND WELL-BEIN G against wide variati ns in bl d
BICARBONATE LOADING pH . I they ail, h me stasis
pH a id-base balan e ails.
The buildup o lactic acid in the blood, released as
Be ause m re a ids than
a waste product rom working muscles, has been
blamed or the soreness and atigue that some- bases usually enter bl d, m re
times accompany strenuous exercise. Some ath- a ids than bases are usually ex-
letes have adopted a technique called bicarbonate reted by the kidneys. In ther
loading, ingesting large amounts o sodium bicar- w rds, m st the time the
bonate (NaHCO 3) to counteract the e ects o lactic kidneys a idi y urine; that is,
acid buildup. they ex rete en ugh a id t give
This practice is m os t popular or s ports involv- urine an a id pH , requently as
ing brie powe r ul m us cle contractions that re ly l w as 4.8. (H w d es this m-
on ae robic re s piration that produce s lactic acid pare with n rmal bl d pH ?)
quickly. The ir the ory is that atigue is avoide d be -
T e tubules the kidneys
caus e the NaHCO 3 , a bas e , bu e rs the lactic acid.
rid the bl d ex ess a id
However, bicarbonate loading does not work or
everyone. When it does, it is only under limited and at the same time nserve
conditions. Un ortunately, the diarrhea that o ten the base present in it by se ret-
results can trigger uid and electrolyte imbalances. ing H i ns int the urine
Long-term NaHCO 3 abuse can lead to disruption o while retaining H CO 3 in the
acid-base balance and its disastrous e ects. bl d. M u h the ex ess H
is mbined with the amine
 CHAPTER 22 Acid-Base Balance 607

C LIN ICA L APPLICATION

DIABETIC KETOACIDOS IS
An im portant part o hom e care or diabe tics involve s m onitor-
ing the leve l o glucos e in the blood and, e s pe cially or patie nts
taking ins ulin, care ully watching or the appe arance o ke to ne
bo die s in the urine .
Accum ulation o the s e acidic s ubs tance s in the blood re -
s ults rom the exce s s ive m e tabolis m o ats , m os t o te n in
thos e pe ople w ith uncontrolle d type 1 diabe te s . Som e type 2
diabe tics m ay als o deve lop ke toacidos is unde r s eve re condi-
tions . The s e individuals have trouble m e tabolizing carbohy-
drate s and ins te ad burn at as a prim ary e ne rgy s ource . Ke tone
bodie s are one way that the body trans ports the atty acids
22
rom s tore d at to othe r ce lls o the body.
The accum ulation o ke tone bodie s re s ults in a condition
calle d diabe tic ke to acido s is that caus e s the blood to be com e
dange rous ly acidic. As blood leve ls o ke tone s incre as e , they
s pill ove r into the urine and can be de te cte d by us e o ap- Ketonuria. Using a chemical test strip to check or the presence o
propriate re age nt s trips . Ke tone s als o m ay give a ruity odor ketone bodies in the urine o a diabetic patient.
to the bre ath and urine . As the body com pe ns ate s or the aci-
dos is , rapid bre athing m ay occur.

gr up (NH 2) an amin a id (glutami a id) t rm am-
m nia (NH 3) and amm nium i ns (NH 4 ) be re it is se-
reted int urine.
QUICK CHECK
1. Ho w ca n b re a th in g a e ct th e p H o b lo o d ?
2. By w h a t m e ch a n is m ca n th e kid n e y ch a n g e th e p H o th e
b lo o d ?
3. Wh a t is th e th e o ry b e h in d b ica rb o n a te lo a d in g , a n d
w h a t is th e lo n g te rm e e ct o th is p ra ctice ?
Fr m a lini al standp int, disturban es in a id-base bal-
an e an be nsidered dependent n the relative quantities
(rati ) H 2CO 3 and NaH CO 3 in the bl d. C mp nents
this imp rtant bu er pair must be maintained at the
pr per rati (20 times m re NaH CO 3 than H 2CO 3) i a id-
base balan e is t remain n rmal. It is rtunate that the
b dy an regulate b th hemi als in the NaH CO 3H 2CO 3
bu er system. Bl d levels NaH CO 3 an be regulated by
the kidneys and H 2CO 3 levels by the respirat ry system
(lungs).

p H Im b a la n c e s
Ac id o s is a n d A lk a lo s is
T e hemistry li e an perate nly within the range pH
6.8-8.0. T e range ptimal human un ti n is mu h nar-
r wer than thatpH 7.35 t 7.45. Acidosis and alkalosis are
the tw kinds pH r a id-base imbalan e that an threaten
ur health and survival.
Alth ugh any pH value ab ve 7.0 is nsidered hemi ally
basi , in lini al medi ine the term acidosis is used t des ribe
the nditi n that pr du es an arterial bl d pH less than
7.35 and alkalosis is used t des ribe the nditi n that pr -
du es an arterial bl d pH greater than 7.45.
In a id sis the bl d pH alls as H i n n entrati n
in reases r bases are l st. O nly rarely d es it all as l w as 7.0
(neutrality), and alm st never d es it be me even slightly
a idi , be ause death usually urs be re the pH dr ps this
mu h. In alkal sis, whi h devel ps less ten than a id sis, the
bl d pH is higher than n rmal be ause a l ss a ids r
an a umulati n bases.
M e t a b o lic a n d Re s p ir a t o ry
D is t u r b a n c e s
w types disturban es, metab li and respirat ry, an alter
the pr per rati these mp nents. Metab li disturban es
a e t the bi arb nate (NaH CO 3) element the bu er pair,
and respirat ry disturban es a e t the H 2CO 3 element, as
ll ws:
1. Metab li disturban es
a. Metabolic acidosis (bi arb nate de it). Patients
in metab li a id sis with a bi arb nate de it
ten su er r m renal disease, un ntr lled dia-
betes, pr l nged diarrhea, r have ingested t xi
hemi als su h as anti reeze (ethylene gly l) r
w d al h l (methan l).
b. Metabolic alkalosis (bi arb nate ex ess). T e bi-
arb nate ex ess in metab li alkal sis an result
r m diureti therapy, l ss a id- ntaining
gastri f uid aused by v miting r su ti n, r
r m ertain diseases su h as Cushing syndr me.
 608 CHAPTER 22 Acid-Base Balance

C LIN ICA L APPLICATION

VOMITING
Vom iting, s om e tim e s re e rre d to as e m e s is , is the orcible A vom iting ce nte r in the brains te m re gulate s the m any
e m ptying or expuls ion o gas tric and occas ionally inte s tinal coordinate d, but prim arily involuntary, s te ps involve d (s e e il-
conte nts through the m outh. It can occur as a re s ult o m any lus tration). The pe rnicious vom iting o pre gnancy and the s e -
s tim uli, including oul odors or tas te s , irritation o the s tom ach ve re and re pe titive (cyclic) vom iting that s om e tim e s occurs in
or inte s tinal m ucos a caus e d by ood pois oning, ce rtain bacte - childhood, e s pe cially w ith pyloric obs truction in in ants , can be
rial or viral in e ctions , and alcohol intoxication. li e thre ate ning be caus e o the uid, e le ctrolyte , and acid-bas e
im balance s that m ay re s ult.
One o the m os t re que nt and s e rious com plications o re -
pe titive vom iting that continue s ove r tim e is m e tabo lic
22 1 Me ta bolic ba la nce be fore
ons e t of a lka los is
alkalo s is . The bicarbonate exce s s o m e tabolic alkalos is re -
s ults indire ctly be caus e o the m as s ive los s o chloride . The
los t chloride , w hich is a com pone nt o hydrochloric acid (HCl)
in gas tric s e cre tions , is re place d by bicarbonate in the extrace l-
H 2CO 3 HCO 3 lular uid. The re s ult is m e tabolic alkalos is (s e e illus tration).
The body com pe ns ate s or the im balance by s uppre s s ing
re s pirations to incre as e blood CO 2 leve ls and, ultim ate ly, leve ls
o H2 CO 3 in the extrace llular uid. The kidneys als o as s is t in the
com pe ns ation proce s s by cons e rving H and e lim inating ad-
ditional HCO 3 in an alkaline urine .
2 Me ta bolic a lka los is The rapy to actually re s tore the bu e r pair (NaHCO 3 to
H2 CO 3 ) ratio to norm al include s intrave nous adm inis tration o
chloride -containing s olutions s uch as no rm al s aline (0.9%
H2 C HCO 3 incre a s e s
O3 NaCl). The chloride ions o the s olution re place the bicarbonate
HC be ca us e of los s
O3 ions and thus he lp re lieve the bicarbonate exce s s that is re -
of chloride ions
or exce s s inge s tion s pons ible or the im balance .
of s odium
bica rbona te
Review the article Fluid and Electrolyte Therapy
at Connect It! at evolve.elsevier.com.
3 Bodys compe ns a tion Alka line
urine
H + + HCO 3
CO 2 + H 2O
CO 2 H2 C O H+
3 +
HC O
3 HCO 3 Hype rs a liva tion
CO 2 occurs
S oft pa la te ris e s
Bre a thing s uppre s s e d Kidneys cons e rve La rynx a nd
to hold CO 2 H+ ions a nd hyoid bone a re Epiglottis clos e s
e limina te HCO 3 drawn forwa rd
in a lka line urine
4 The ra py re quire d to re s tore
me ta bolic ba la nce
Dia phra gm
contra cts s ha rply
Chloride -
HCO 3 Cl conta ining
H 2CO 3 Fundus
s olution
Lowe r be come s fla ccid
e s opha ge a l S toma ch mus cle s a nd
HCO s phincte r a bdomina l mus cle s
3ions re pla ce d re la xe s contra ct s harply
A by Cl ions B

2. Respirat ry disturban es the bl d. Causes in lude depressi n the respi-

a. Respiratory acidosis (H 2CO 3 ex ess). T e in- rat ry enter by drugs r anesthesia r by pulm -
rease in H 2CO 3 hara teristi respirat ry a i- nary diseases su h as emphysema and pneum nia.
d sis is aused m st requently by sl w breathing Seri us respirat ry a id sis als ll ws re very
(hyp ventilati n), whi h results in ex ess CO 2 in r m ardia arrest.
 CHAPTER 22 Acid-Base Balance 609

C LIN ICA L APPLICATION

CARDIAC ARREST AND RES PIRATORY ACIDOS IS
A cascade o rapid-f re catastrophic homeostatic ailures 1
ollows cardiac arrestthe sudden cessation o blood Me ta bolic ba la nce
pumping by the heart. One such ailure involves almost be fore ca rdia c a rre s t
immediate development o respiratory acidosis (carbonic
acid excess) caused by retention o CO 2 in the body H 2CO 3 HCO 3
when respiration ceases and blood ow through the lung
capillaries stops. Even i emergency CPR (cardiopulmo-
nary resuscitation) measures can restore breathing and
start the heart beating again, respiratory acidosis must 2
Re s pira tory a cidos is
be success ully treated and normal blood pH levels re-
stored quickly in order to sustain li e.
whe n pulmona ry
blood flow s tops
22
As in othe r type s o pH im balance s , abs olute
change s in the am ount or ratio o the bicarbonate -
carbonic acid bu e r pair com pone nts is the f rs t line o CO 2
de e ns e to preve nt m as s ive change s in blood pH. The n, O3
CO 2 CO 3 HC
the body initiate s both re s piratory and re nal com pe ns a- H2
tory m e chanis m s to he lp de al w ith the carbonic acid CO 2
exce s s in s eve re re s piratory acidos is .
The m os t im portant re s piratory com pe ns atory
m e chanis m incre as e d bre athing rate doe s blow Bre a thing is s uppre s s e d,
o s om e additional CO 2 but cannot s ignif cantly lowe r holding CO 2 in body
the ve ry e levate d carbonic acid buildup that ollow s
cardiac arre s t and re m ains a te r the blood bu e rs have 3
Bodys compe ns a tion
be e n ove rw he lm e d.
H 2CO 3
Finally, re nal com pe ns atory m e chanis m s that s tabi-
CO 2 HCO 3
lize blood pH and he lp control m any orm s o re s pira-
tory acidos is are initiate d a te r cardiac arre s t. They in- HC O 3 HCO 3
H 2C O 3
clude (1) de cre as ing the e lim ination o bicarbonate ions CO 2 + H 2O +
(HCO 3 ) and (2) incre as ing the e lim ination o hydroge n H+ Acidic
ions (H ) in acidic urine . Although he lp ul in controlling urine
chronic orm s o re s piratory acidos is that deve lop Kidneys cons e rve
s low ly ove r tim e , the s e s low-acting hom e os tatic com - HCO 3 ions a nd
pe ns atory m e chanis m s are unable to ade quate ly ad- e limina te H+ ions
Blood flow a nd bre a thing in a cidic urine
dre s s the s e rious , acute -ons e t acidos is that ollow s re s tore d a nd blows
cardiac arre s t. Me dical inte rve ntion is re quire d. off CO 2
In the pas t, im m e diate intrave nous (IV) in us ion o
bicarbonate - or lactate -containing s olutions (lactate is 4
The ra py re quire d to
conve rte d to bicarbonate ions in the live r) was cons id- re s tore me ta bolic
e re d the e m e rge ncy tre atm e nt o choice in tre ating ba la nce
La cta te -
re s piratory acidos is a te r cardiac arre s tand the s e s o- H 2CO 3 HCO 3
Ve ntila tion Re duce s La cta te conta ining
lutions are s till us e d or that purpos e . Howeve r, clinical the ra py s olution
CO 2
s tudie s have s how n that aggre s s ive tre atm e nt e m ploy-
ing controlle d ve ntilation to dram atically incre as e CO 2
e lim ination rom the body m ay, in m any cas e s , be m ore La cta te s olution us e d
e e ctive in re s toring pH balance . in the ra py is conve rte d
to bica rbona te ions
in the live r

b. Respiratory alkalosis (H 2CO 3 de it). H yper-
ventilati n leads t a H 2CO 3 de it aused by
ex essive l ss CO 2 in expired air. T e result is
respirat ry alkal sis. Anxiety (hyperventilati n
syndr me), verventilati n patients n ventila-
t rs, r hepati ma an all redu e H 2CO 3 and
CO 2 t danger usly l w levels.
C o m p e n s a t io n o r p H Im b a la n c e s
W hen a id sis r alkal sis urs in the b dy, ur vari us
pH -balan ing me hanismsbu ers and the respirat ry and
urinary me hanismstry t rest re balan e as s n as p ssi-
ble. We ten use the term compensation r this set pr -
esses be ause the b dy is using means that mpensate r
the abn rmal shi t in pH .
 610 CHAPTER 22 Acid-Base Balance

C mpensati n is a lini ally imp rtant n ept. Be ause

Crushing injuries o skeletal muscle can cause
mpensati n me hanisms in the b dy an qui kly untera t
metabolic acidosis. Review the article Rhabdo-
an abn rmal shi t in bl d pH , a pers n may have a seri us,
myolysis at Connect It! at evolve.elsevier.com.
ng ing medi al nditi n and yet temp rarily have what ap-
pears t be a n rmal bl d pH .
F r example, a pers n uld have a metab li disease su h
as diabetes that auses a id sis, but is hyperventilating t m- QUICK CHECK
pensate r the dr p in pH . Su h a patient uld have a n rmal 1. Wh a t is a cid o s is ? Wh a t is a lka lo s is ?
arterial bl d pH . T e underlying nditi n, h wever, has n t 2. Wh a t a cto rs m a y ca u s e a m e ta b o lic d is tu rb a n ce in p H?
been res lved. T is ase w uld be labeled compensated metabolic 3. Wh a t s itu a tio n s m a y ca u s e a re s p ira to ry d is tu rb a n ce
acidosis. I the respirat ry system had n t yet mpensated r in p H?
4. Ho w d o e s vo m itin g s o m e tim e s cre a te a n a cid -b a s e
the dr p in pH resulting r m the metab li nditi n, then
im b a la n ce ?
we w uld label it a ase uncompensated metabolic acidosis.
22

C LIN ICA L APPLICATION

ARTERIAL BLOOD GAS ANALYS IS
Clinically, as s e s s m e nt o prim ary acid-bas e im balance s o te n
involve s an analys is o the arte rial blo o d gas e s (ABGs ). This
is a laboratory te s t o blood take n rom a s ys te m ic arte ry (m os t
blood s am ple s are take n rom a s ys te m ic ve in). As the nam e
s ugge s ts , this te s t s how s the key characte ris tics o blood re -
late d to re s piratory unction:
1. Oxyge n partial pre s s ure or PO 2
2. Oxyge n s aturation o he m oglobin or % S O 2
3. pH
4. Conce ntration o bicarbonate ions or HCO 3
5. Carbon dioxide partial pre s s ure or P CO 2
Som e tim e s the s e value s are labe le d w ith an a to e m pha-
s ize that the s e are arte rial value s , as in Pa O 2 or Pa CO 2 . Note
that although not all the s e value s are actually gas e s , they are
a e cte d by blood gas e s . ABG te s t re s ults not only reve al a
patie nts re s piratory s tatus , the pH, P CO 2 , and HCO 3 com po-
ne nts can als o give key in orm ation about s tatus o acid-bas e
hom e os tas is (s e e accom panying table ).
pH is the f rs t re s ult to look at w he n as s e s s ing pH s tatus .
I the re s ult is be low 7.35, the re is acidos is , and i it is above
7.45, the re is alkalos is .
To de te rm ine the prim ary s tatus , one next looks at the P CO 2
re s ult. I the pH is low and P CO 2 is above 45 m m Hg, the pri-
m ary s tatus is re s piratory acidos is , and i pH is high and P CO 2
is be low 35 m m Hg, the s tatus is re s piratory alkalos is .
Next, look at the HCO 3 re s ult. I pH is low and HCO 3 is
be low 22 m Eq/L, the prim ary s tatus is m e tabolic acidos is . I
the pH is high and the HCO 3 is above 26 m Eq/L, the prim ary
s tatus is m e tabolic alkalos is .
One m ay the n try to de te rm ine w he the r com pe ns ation is
occurring in the body. This can be done by looking at the pH-
balancing m e chanis m not dire ctly involve d in de te rm ining
the prim ary s tatus to s e e i it has change d in a w ay that
counte rbalance s or com pe ns ate s orthe prim ary prob-
le m . For e xam ple , i the arte rial pH is low (acidotic) and the
P CO 2 (acid) is high, as in re s piratory acidos is , the body m ay
com pe ns ate by incre as ing the HCO 3 (bas e ). Like w is e , i the
arte rial pH is high (alkalotic) and the HCO 3 (bas e ) is high, as
in m e tabolic alkalos is , the body m ay com pe ns ate by incre as -
ing the P CO 2 (acid).

Arterial Blood Gas Analysis or Acid-Base Status

ACIDOSIS ALKALOSIS
ABG NORMAL
COMPONENT VALUES RES PIRATORY METABOLIC RES PIRATORY METABOLIC
pH 7.35-7.45 7.35 7.35 7.45 7.45
P CO 2 35-45 m m Hg 45 Uncom pe ns ate d: 35 Uncom pe ns ate d:
35-45 35-45
Com pe ns ate d: Com pe ns ate d:
35 45
HCO 3 22-26 m Eq/L Uncom pe ns ate d: 22 Uncom pe ns ate d: 26
22-26 22-26
Com pe ns ate d: Com pe ns ate d:
26 22
, De cre as e ; , incre as e ; ABG, arte rial blood gas ; P CO 2 , carbon dioxide pre s s ure ; [HCO 3 ], bicarbonate conce ntration
 CHAPTER 22 Acid-Base Balance 611

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 601)

ketone body normal saline pH

(KEE-tohn BOD-ee) (NOR-mall SAY-leen) (pee aych)
[keto- acetone, -one chemical] [sal- salt, -ine relating to] [abbreviation or potenz power,
neutral hydrogen hydrogen]
(NOO-trel)
[neutr- neither, -al relating to]

LANGUAGE OF M ED IC IN E
22

acidosis diabetic ketoacidosis metabolic alkalosis

(as-ih-DOH-sis) (dye-ah-BET-ik kee-toh-as-ih-DOH-sis)
[acid- sour, -osis condition] [diabet- siphon (diabetes mellitus), -ic relating [meta- over, -bol- throw, -ic relating to,
alkalosis to, keto- acetone, -acid- sour, -osis condition] alkal- ashes, -osis condition]
emesis respiratory acidosis
[alkal- ashes, -osis condition] (EM-eh-sis) (RES-pih-rah-tor-ee as-ih-DOH-sis)
arterial blood gas (ABG) [emesis vomiting] [re- again, -spir- breathe, -tory relating to,
(ar-TEER-ee-al blud gas) metabolic acidosis acid- sour, -osis condition]
[arteri- airpipe (artery), -al relating to] respiratory alkalosis
bicarbonate loading [meta- over, -bol- throw, -ic relating to,
acid- sour, -osis condition] [re- again, -spir- breathe, -tory relating to,
[bi- two, -carbon- coal (carbon), -ate oxygen] alkal- ashes, -osis condition]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary B. N rmal range bl d pH is appr ximately 7.35 t 7.45
or us e w ith your device , acce s s the Au d io Ch a p te r 1. Arterial bl d pH ab ut 7.45
S u m m a rie s online at evolve .e ls evie r.com . 2. Ven us bl d pH ab ut 7.35
C. pH s ale based n multiples 10
Scan this s um m ary a te r re ading the chapte r to 1. H n entrati n hanges by 10 times r ea h pH
he lp you re in orce the key conce pts . Late r, us e unit
the s um m ary as a quick review be ore your clas s 2. Large pH f u tuati ns may appear small
or be ore a te s t.
Me chanis m s that Co ntro l
pH o Bo dy Fluids pH o Bo dy Fluids
A. pH a number that indi ates the relative hydr gen i n A. pH h me stati me hanismthree rdinated h me -
(H ) n entrati n ( mpared with OH ) a f uid stati me hanisms a t t maintain the n rmal pH
(Figure 22-1) b dy f uids and prevent pH swings when ex ess a ids r
1. pH 7.0 indi ates neutrality (neutral s luti n) bases are present (Figure 22-2)
2. pH higher than 7.0 indi ates alkalinity (alkaline r 1. Chemi al pH ntr l me hanismbased n bu ers
basi s luti n; base) in bl d/RBCs/and b dy f uidsa t immediately
3. pH less than 7.0 indi ates a idity (a id s luti n)
 612 CHAPTER 22 Acid-Base Balance
2. Physi l gi al pH ntr l me hanisms
a. Changes in pH regulated by hanges in respirat ry
rate that result in hanges in bl d CO 2a t
within minutes
b. Changes in pH regulated by altered renal a tivity
a t within h urs
B. Bu ers
1. De niti n hemi al substan es that prevent a sharp
hange in the pH a f uid when an a id r base is
added t it (Figure 22-3 and Figure 22-4)
2. Bu ers usually in lude tw di erent hemi als
alled a bu er pair
3. Fixed a ids are bu ered mainly by s dium bi arb n-
22 ate (NaH CO 3)
4. Changes in bl d pr du ed by bu ering xed
a ids in the tissue apillaries (Figure 22-5)
a. Am unt arb ni a id (H 2CO 3) in bl d
in reases slightly
b. Am unt NaH CO 3 in bl d de reases; rati
am unt NaH CO 3 t the am unt H 2CO 3
d es n t n rmally hange; n rmal rati is 20:1
. H n entrati n bl d in reases slightly
d. Bl d pH de reases slightly bel w arterial level
5. B dy has ther bu er pair systems
a. Ph sphates
b. Pr teins (plasma pr teins and hem gl bin)
C. Respirat ry me hanism pH ntr l
1. Respirati ns rem ve s me CO 2 r m bl d as bl d
f ws thr ugh lung apillaries
2. Am unt H 2CO 3 in bl d is de reased and thereby
its H n entrati n is de reased; this in turn
in reases bl d pH
3. Respirat ry ntr l enters in brainstem rea t t
dr pping pH and pr m te in reased respirati ns;
when pH in reases, then breathing sl ws
D. Urinary me hanism pH ntr l
1. Kidneys are the b dys m st e e tive regulat r
bl d pH
2. Usually urine is a idi ed by way the distal tubules
se reting hydr gen i ns int the urine r m bl d in
ex hange r H CO 3 being retained in the bl d;
mu h the ex ess H is se reted as amm nia (NH 3)
and amm nium i ns (NH 4 )
pH Im balance s
A. A id sis and alkal sis are the tw kinds pH , r a id-
base, imbalan es
1. Disturban es in a id-base balan e depend n relative
quantities NaH CO 3 and H 2CO 3 in the bl d
2. B dy an regulate b th the mp nents the
NaH CO 3H 2CO 3 bu er system
a. Bl d levels NaH CO 3 are regulated by kidneys
b. H 2CO 3 levels are regulated by lungs
B. Metab li and respirat ry disturban esb th an alter
the n rmal 20:1 rati NaH CO 3 t H 2CO 3 in bl d
1. Metab li disturban es a e t the NaH CO 3 levels in
bl d
a. Metab li a id sisbi arb nate (NaH CO 3) de it
b. Metab li alkal sisbi arb nate (NaH CO 3)
ex ess; mpli ati n severe v miting (see b x,
p. 608)
2. Respirat ry disturban es a e t the H 2CO 3 levels in
bl d
a. Respirat ry a id sis (H 2CO 3 ex ess)
b. Respirat ry alkal sis (H 2CO 3 de it)
C. C mpensati n r pH imbalan es
1. C mpensated a id sis r alkal sis urs when the
b dys pH -balan ing me hanisms temp rarily un-
tera t an abn rmal shi t in pH
2. Un mpensated a id sis r alkal sis urs when
the b dys me hanisms have n t yet n rmalized
the pH

ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Le arning the conce pts pre s e nte d in this chapte r w ill be e as ie r
i you review a little bas ic che m is try.
1. T e pH s ale, a ids, and bases are vered at the begin-
ning the hapter. I y u need m re an explanati n
than that presented here, review Chapter 2 r he k
nline res ur es.
2. Bu er systems an be th ught as hydr gen r hydr x-
ide i n sp nges. T ey rem ve th se i ns s they will have
less an e e t n the pH a s luti n, in this ase, the
bl d. In the NaH CO 3H 2CO 3 bu er system, the
s dium bi arb nate an abs rb hydr gen i ns by having
the hydr gen repla e the s dium. T e arb ni a id an
give up ne its hydr gen at ms that then an rea t
with a hydr xide i n t rm water. In b th ases the pH
the s luti n will hange very little.
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Explain the relati nship between pH and the relative
n entrati n hydr gen and hydr xide i ns in a
s luti n.
2. List the three primary me hanisms the b dy has r reg-
ulating the pH its f uids.
3. Write ut the hemi al rea ti n rmula that nverts
arb n di xide and water t arb ni a id. W hat
enzyme atalyzes this rea ti n?
4. De ne bu er.
CHAPTER 22 Acid-Base Balance 613
3. Bl d arries arb n di xide as arb ni a id. W hen the
lungs exhale arb n di xide, there is less arb ni a id in
the bl d and s the pH the bl d rises. T e kidneys
use a similar bu er system t se rete hydr gen i ns.
4. T e bu er system in the bl d usually w rks well, but it
an be verwhelmed. A id sis is a nditi n in whi h the
bl d be mes t a idi , and alkal sis is a nditi n in
whi h the bl d be mes t basi . Devel p a n ept
map the respirat ry and urinary me hanisms ntr l
inv lved in maintaining n rmal pH b dy f uids. 22
5. I y u have di ulty with the hemistry in this hapter,
dis uss it in y ur study gr up. S me ne in the gr up may
have a str nger hemistry ba kgr und. Review the Lan-
guage S ien e and Language Medi ine se ti ns.
Dis uss the pH system. Care ully g ver the diagrams
the bl d and kidney bu er systems. Review the types
a id sis and alkal sis and what auses ea h them. G
ver the questi ns and the hapter utline summary at
the end the hapter and dis uss p ssible test questi ns.
5. Explain buf er pairs.
6. Explain h w a bu er pair w uld rea t i m re hydr gen
i ns were added t the bl d.
7. Explain h w a bu er pair w uld rea t i m re hydr xide
i ns were added t the bl d.
8. List the ur hanges that ur in the bl d as the
result bu ering xed a ids.
9. Explain the respirat ry me hanism pH ntr l.
10. Des ribe h w hanges in the respirati n rate an a e t
bl d pH .
11. Explain h w the hemi al rea ti n that urs in the
distal tubule the kidney using NaH 2PO 4 rem ves
hydr gen i ns r m the bl d.
12. De ne acidosis and alkalosis.
13. Explain metab li disturban es the bu er pair.
14. Explain respirat ry disturban es the bu er pair.
 614 CHAPTER 22 Acid-Base Balance

Critical Thinking Chapte r Te s t

A te r f nis hing the Review Que s tions , w rite out A te r s tudying the chapte r, te s t your m as te ry by
the ans we rs to the s e m ore in-de pth que s tions to re s ponding to the s e ite m s . Try to ans we r the m
he lp you apply your new know le dge . Go back to w ithout looking up the ans we rs .
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult. 1. T e enzyme that nverts arb n di xide and water int
arb ni a id is ________.
15. H w w uld y u explain pH in terms the i ns 2. ________ are hemi als that prevent sharp hanges in
inv lved? W hat w uld be the hydr gen i n n entra- pH when an a id r base is added t a s luti n.
ti n a s luti n with a pH 4? W ith a pH 6? 3. I a str ng a id su h as H Cl were added t the bu er
16. Explain h w ex essive v miting auses metab li pair NaH CO 3 and H 2CO 3, the NaH CO 3 w uld be me
alkal sis and explain why n rmal saline an be used t ________.
22 rre t it. 4. I a str ng base su h as NaOH were added t the bu er
17. W hat is the pr per rati NaH CO 3 and H 2CO 3 in a pair in questi n 3, the H 2CO 3 w uld be me ________.
bu er pair? Explain h w the b dy an use this rati t 5. T e part the nephr n that is imp rtant in regulati n
rre t un mpensated metab li a id sis. bl d pH is the ________.
18. T e h rm ne ald ster ne a e ts kidney tubule un ti n. 6. W hen Na2H PO 4 is used by the kidney t rem ve
O ne the e e ts is t in rease H se reti n by the hydr gen i ns r m the bl d, the end pr du t that
kidney tubules. W hat e e t d es this a ti n have n the leaves the b dy in the urine is ________.
pH the internal envir nment (bl d plasma)? W hat 7. W hen amm nia is used by the kidney t rem ve hydr -
might ur i there is hyperse reti n ald ster ne? gen i ns r m the bl d, the end pr du t that leaves the
H w w uld this hange i there is hyp se reti n b dy in the urine is ________.
ald ster ne? 8. T e kidney is m re e e tive in pH regulati n than the
lung be ause it an rem ve ex ess ________, whi h the
lung ann t.
9. T e nditi n in whi h the bl d pH is higher than
n rmal is alled ________.
10. T e nditi n in whi h the bl d pH is l wer than
n rmal is alled ________.
11. In rder r the bu er pair t un ti n rre tly, the
n entrati n NaH CO 3 must be ________ times
greater than the n entrati n H 2CO 3.
12. Metab li disturban es usually have an e e t n the
________ part the bu er pair.
13. Respirat ry disturban es usually have an e e t n the
________ part the bu er pair.
14. Severe v miting is a metab li disturban e that an
ause metab li ________.
 CHAPTER 22 Acid-Base Balance 615

15. An a id s luti n has:

a. a pH greater than 7.0
Cas e S tudie s
b. a pH less than 7.0 To s olve a cas e s tudy, you m ay have to re e r to
. m re hydr xide i ns than hydr gen i ns the glos s ary or index, othe r chapte rs in this text-
d. b th b and book, and othe r re s ource s .
16. An alkaline s luti n has:
a. a pH greater than 7.0 1. C mpensated respirat ry a id sis is mm nly und in
b. a pH less than 7.0 pers ns with hr ni br n hitis, an bstru tive respirat ry
. m re hydr gen i ns than hydr xide i ns dis rder dis ussed in Chapter 17. State what abn rmal
d. b th b and bl d values a pers n sh uld expe t in su h a ase, and
17. W hi h the ll wing statements is true? what a t rs pr du ed them.
a. A s luti n with a pH 5 has m re hydr gen i ns 2. Larry is a diabeti wh is su ering r m metab li a id -
than a s luti n with a pH 2. sis. H is breathing seems abn rmally rapid. Is there a n-
b. A s luti n with a pH 9 is a base. ne ti n between Larrys a id sis and his rapid breathing? 22
. T e pH value in reases as the number hydr gen I s , explain the nne ti n.
i ns in reases. 3. Elizabeth was advised by her d t r at her annual physi-
d. B th a and are true. al that her urine spe imen indi ated the presen e
18. Arterial bl d has a pH 7.45, and ven us bl d has a ket ne b dies thr ugh ut the spe imen. She asked what
pH 7.35; there re: ket ne b dies were and was t ld that they are a idi
a. arterial bl d is slightly m re a id than ven us bl d pr du ts at metab lism. H e wanted t ndu t s me
b. arterial bl d is slightly m re alkaline than ven us additi nal bl d w rk t investigate the p ssibility dia-
bl d betes. Elizabeth is n used. Isnt diabetes a dis rder
. ven us bl d is slightly m re alkaline than arterial inv lving arb hydrate metab lism? W hy is the d t r
bl d n erned ab ut at metab lism and n t n erned ab ut
d. b th a and sugars? Can y u help Elizabeth understand ket ne
F r questi ns 19 thr ugh 24, ll in the blank with either in- b dies, diabeti ket a id sis, and why the d t r will be
creases r decreases, as appr priate. ndu ting additi nal bl d w rk?

19. W hen a xed a id is bu ered in the bl d, the am unt Answers to Active Learning Questions can be ound online
NaH CO 3 in the bl d ________. at evolve.elsevier.com.
20. W hen a xed a id is bu ered in the bl d, the am unt
hydr gen i ns in the bl d ________.
21. W hen a xed a id is bu ered in the bl d, the am unt
H 2CO 3 in the bl d ________.
22. W hen a xed a id is bu ered in the bl d, the pH
the bl d ________.
23. Anything that auses an ex essive in rease in the respi-
rati n rate auses the pH the bl d t ________.
24. Anything that auses an appre iable de rease in the res-
pirati n rate auses the pH the bl d t ________.
25. IV n rmal saline is given t patients with severe emesis.
T is is d ne t repla e the ________ i ns and t rest re
h me stasis.
Reproductive Systems
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.
Sexual Reproduction, 617
Producing O spring, 617
Male and Female Systems, 618
Male Reproductive System, 618
Structural Plan, 618
Testes, 619
Reproductive Ducts, 622
Accessory Glands, 623
External Genitals, 623
Disorders o the Male Reproductive
System, 624
In ertility and Sterility, 624
Disorders o the Testes, 625
Disorders o the Prostate, 625
Disorders o the Penis and Scrotum,
625
Female Reproductive System, 627
Structural Plan, 627
Ovaries, 627
O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.
A ter you have completed this chapter, you
should be able to:
1. Discuss the process o sexual repro-
duction, and describe the common
structural and unctional characteristics
between the male and emale systems.
2. Describe the structure and unction o
the male reproductive system, including
the gross and microscopic structure
o the gonads, the developmental steps
in spermatogenesis, and the primary
unctions o the sex hormones.
3. List the major disorders o the male
reproductive system and brie y
describe each.
Reproductive Ducts, 630
Accessory Glands, 631
External Genitals, 632
Menstrual Cycle, 633
Disorders o the Female Reproductive
System, 635
Hormonal and Menstrual Disorders,
635
In ection and In ammation, 636
Tumors and Related Conditions, 637
In ertility, 638
Summary o Male and Female
Reproductive Systems, 639
Sexually Transmitted Diseases, 639
4. Describe the structure and unction o
the emale reproductive system, includ-
ing the gross and microscopic structure
o the gonads and the unctions o the
sex hormones. Also identi y and discuss
the phases o the endometrial or men-
strual cycle and correlate each phase
with its occurrence in a typical 28-day
cycle.
5. List the major disorders o the emale
reproductive system and brie y
describe each.
6. Def ne the term sexually transmitted
disease and describe the major types.
 R 23
Th e imp rtan e repr du tive system un ti n is n tably di erent r m LANGUAGE OF
that any ther rgan system the b dy. O rdinarily, systems un ti n t S C IEN C E
maintain the relative stability and survival the individual rganism. T e
repr du tive system, n the ther hand, ensures survival n t the indi-
Be o re re ading the
vidual but the genes that hara terize the human spe ies. In b th sexes,
chapte r, s ay e ach o
rgans the repr du tive system are adapted r the spe i sequen e the s e te rm s o ut lo ud. This w ill
un ti ns that are n erned primarily with trans erring genes t a he lp yo u to avo id s tum bling ove r
new generati n spring. the m as yo u re ad.

T is hapter expl res the n rmal and path l gi al anat my and

accessory organ
physi l gy the repr du tive systems in b th sexes and ends (ak-SES-oh-ree OR-gun)
with a dis ussi n sexually transmitted diseases. A ter study [access- extra, -ory relating to,
the repr du tive system in b th sexes, in Chapter 24 y u organ instrument]
will learn m re ab ut the t pi human devel pmenta acrosome
pr ess extending r m ertilizati n t death. Chapter 25 (AK-roh-sohm)
wraps up the st ry the human b dy by examining [acro- top or tip, -some body]
the basi prin iples geneti s. andropause
(AN-droh-pawz)
[andro- male, -paus- cease]
S e x u a l Re p ro d u c t io n antrum
(AN-trum)
P ro d u c in g O s p r in g [antrum cave]
Sexual reproduction requires tw parent areola
rganisms, a male and emale, ea h (ah-REE-oh-lah)
whi h ntributes hal the nu lear [are- area or space, -ola little]
hr m s mes needed t rm the rst Bartholin gland
ell an spring rganism. Asexual (BAR-tul-in or bar-TOH-lin gland)
reproduction, n the ther hand, requires [Caspar Bartholin Danish physician,
nly ne parent wh pr du es an - gland acorn]
spring geneti ally identi al t itsel . body
An advantage sexual repr - (BOD-ee)
[body main part]
du ti n is that a new mixture
genes in ea h spring breast
(brest)
in reases the variety ge-
neti hara teristi s in the bulbourethral gland
(BUL-boh-yoo-REE-thral gland)
p pulati n. T is variety
[bulb- swollen root, -ure- urine,
hara teristi s makes
-thr- agent or channel (urethra),
it m re likely that in the -al relating to, gland acorn]
ase envir nmental
cervix
hanges su h as disease, (SER-viks)
natural disaster, r shi t- pl., cervices or cervixes
ing limati nditi ns, (SER-vis-eez or SER-viks-ez)
there will be at least s me [cervix neck]
individuals likely t survive clitoris
and arry n the repr du - (KLIT-oh-ris)
tive line. [clitoris small key or latch]

Continued on p. 641

617
 618 CHAPTER 23 Reproductive Systems

T e repr du tive system ea h parent pr du es the sex r
repr du tive ells alled gametes needed t rm the - als
spring. T ese gametes, alled an ovum ( r m the emale par-
ent) and a sperm ( r m the male parent), use during the
pr ess ertilizati n. T e new spring ell that results is
alled the zygote. A ter many mpli ated and amazing de-
vel pmental stages, the zyg te ultimately devel ps int the
new individual.
Ea h repr du tive system als pr du es h rm nes that
regulate devel pment the se ndary sex hara teristi s that
pr m te su ess ul repr du ti n. F r example, h rm nes reate
stru tural and behavi ral di eren es in the sexes that permit
adults t re gnize and rm sexual attra ti ns with the pp -
site sex. Repr du tive h rm nes and ther regulat ry me ha-
nisms give us the urge t have sex, whi h is ten rein r ed
with the pleasant sensati ns that sexual a tivity an pr du e.
T is sex drive is essential t su ess in pr du ing spring.
Sexual maturity and the ability t repr du e are a hieved
by the end puberty. T e male repr du tive system nsists
rgans wh se un ti ns are t pr du e, trans er, and ulti-
mately intr du e mature sperm int the emale repr du tive
tra t, where the nu lear hr m s mes r m ea h parent an
unite t rm a new spring.
23 M a le a n d Fe m a le S y s t e m s
r devel pment the se ndary sexual hara teristi s but
r n rmal repr du tive un ti ns in b th sexes.
QUICK CHECK
1. What a re ga m e te s ?
2. When do sexual m aturity and the ability to reproduce occur?
3. What is the ultim ate unctio n o the re productive s ys te m s?
To learn more about the reproductive systems, go
to AnimationDirect online at evolve.elsevier.com.
M a le Re p ro d u c t ive S y s t e m
S t r u c t u r a l P la n
Re p ro d u c t ive Tr a c t
Y u may re all r m Chapter 20 (see p. 565) that in males the
urethra has a dual un ti n. It serves as a passageway r both
urine and semen r m the b dy. T e term urogenital tract is
s metimes used in pla e reproductive tract t des ribe this
dual urinary and repr du tive un ti n.
S many rgans make up the male repr du tive system
that we need t l k rst at the stru tural plan the system
as a wh le. Repr du tive rgans an be lassi ed as essential
r accessory.

Alth ugh the rgans and spe i un ti ns the male and Es s e n t ia l O r g a n s

emale repr du tive systems are dis ussed separately, it is im- T e essential organs repr du ti n in men and w men are
p rtant t understand that a mm n general stru ture and alled the gonads. T e g nads men nsist a pair
un ti n an be identi ed between the systems in b th sexes main sex glands alled the testes. We intr du ed the term sex
and that b th sexes ntribute in uniquely imp rtant ways t gland in Chapter 12 (End rine System) t emphasize their
verall repr du tive su ess. r le in pr du ing sex hormones. T e testes pr du e the male
In b th men and w men, the rgans the repr du tive sex h rm ne testosterone. H wever, g nads have additi nal
system are adapted r the spe i sequen e un ti ns that primary un ti ns. T e testes, r example, als pr du e the
permit devel pment sperm r va ll wed by su ess ul male sex ellsthe sperm r spermatozoa.
ertilizati n and then the n rmal devel pment and birth a
baby. In additi n, pr du ti n h rm nes that permit devel- Ac c e s s o ry O r g a n s
pment se ndary sex hara teristi s, su h as breast devel- T e accessory organs repr du ti n in men nsist the
pment in w men and beard gr wth in men, urs as a result ll wing stru tures:
n rmal repr du tive system a tivity.
1. A series passageways r du ts that arry the sperm
As y u study the spe i s ea h system, keep in mind
r m the testes t the exteri r
that the male rgans un ti n t pr du e, st re, and ulti-
2. Additi nal sex glands that pr vide se reti ns that
mately intr du e mature sperm int the emale repr du -
pr te t and nurture sperm
tive tra t and that the emale system is stru tured t pr -
3. T e external repr du tive rgans alled the external
du e va, re eive the sperm, and permit ertilizati n. In
genitals
additi n, the emale repr -
du tive system permits the Table 23-1 lists the names
ertilized vum t devel p TABLE 23-1 Male Reproductive Organs the essential and a ess ry
and mature until birth. ES S ENTIAL ORGANS ACCES S ORY ORGANS rgans repr du ti n in
T e mplex and y li Gonads : te s te s (right te s tis Ducts : e pididym is (two), vas de - men, and Figure 23-1 sh ws
ntr l repr du tive un - and le t te s tis ) e re ns (two), e jaculatory duct the l ati n m st them.
ti ns in b th men and (two), and ure thra T e table and the illustrati n
w men are parti ularly ru- Supportive s ex glands : s e m inal are in luded very early in the
ial t verall repr du tive ve s icle s (two), bulboure thral hapter t pr vide a prelimi-
su ess in humans. T e pr - (Cow pe r) glands (two), and nary but imp rtant verview.
du ti n sex h rm nes pros tate gland Re er ba k t this table and
ultimately ntr lled by the Exte rnal ge nitals : s crotum and illustrati n requently as y u
brainis required n t nly pe nis
learn ab ut ea h rgan in the
 CHAPTER 23 Reproductive Systems 619

Ure te r

S e mina l ve s icle

Urina ry bla dde r

Eja cula tory duct

P ros ta te gla nd Va s (ductus )

de fe re ns

Re ctum

Bulboure thra l Ure thra

(Cowpe r) gla nd

Anus Pe nis
Epididymis
Fore s kin
Te s tis
(pre puce )
S crotum S
FIGURE 23-1 Male reproductive sys-
P A
tem. Sagittal section o pelvis showing lo-
cations o male reproductive organs.
Exte rna l
urina ry
I
23
me a tus

pages that ll w. Als nd the maj r stru tures the male Te s t is Fu n c t io n s

repr du tive system in the Clear View o the Human Body
( ll ws p. 8).
Te s t e s
S t r u c t u r e a n d Lo c a t io n
T e paired testes are the g nads in males. T ey are l ated in
the p u hlike scrotum, whi h is suspended utside the
b dy avity behind the penis as y u an see in Figure 23-1. T is
exp sed l ati n pr vides an envir nment ab ut 1 C t 3 C
ler than n rmal re b dy temperature, an imp rtant re-
quirement r the n rmal pr du ti n and survival sperm.
Ea h testis is a small, val gland ab ut 3.8 m (1.5 in hes)
l ng and 2.5 m (1 in h) wide. T e testis is shaped like an egg
that has been f attened slightly r m side t side. N te in
Figure 23-2 that ea h testis is surr unded by a t ugh, whitish
membrane alled the tunica albuginea. T is membrane v-
ers the testis and then enters the gland t rm the many septa
that divide it int se ti ns r l bules.
As y u an see in Figure 23-2, ea h l bule nsists a nar-
r w but l ng and iled semini erous tubule. T ese iled
stru tures rm the bulk the testi ular tissue mass. Small
end rine ells lying near the septa that separate the l bules
an be seen in Figure 23-3. T ese are the interstitial cells the
testes that se rete the male sex h rm ne testosterone.
Ea h semini er us tubule is a l ng du t with a entral lu-
men r passageway (see Figure 23-3). Sperm devel p in the
walls the tubule and are then released int the lumen and
begin their j urney t the exteri r the b dy.
Spermatogenesis
Sperm pr du ti n is als alled spermatogenesis. Fr m pu-
berty n, the semini er us tubules ntinu usly rm sperma-
t z a, r sperm. Alth ugh the number sperm pr du ed
ea h day diminish with in reasing age, m st men ntinue t
pr du e signi ant numbers thr ugh ut li e.
T e testes prepare r sperm pr du ti n be re puberty by
in reasing the numbers sperm pre urs r (stem) ells alled
spermatogonia. T ese ells are l ated near the uter edge
ea h semini er us tubule (Figure 23-4, A). Be re puberty, sper-
mat g nia in rease in number by the pr ess mit ti ell
divisi n, whi h was des ribed in Chapter 3. Re all that mit -
sis results in the divisi n a parent ell int tw daughter
ells, ea h identi al t the parent and ea h ntaining a m-
plete py the geneti material represented in the n rmal
number 46 hr m s mes.
T e hyp thalamus is a small but un ti nally imp rtant
stru ture l ated near the base the brain. One its many
un ti ns, in b th males and emales, is t se rete gonadotropin-
releasing hormone (GnRH), whi h then stimulates the ante-
ri r pituitary t se rete the g nad tr pins ollicle-stimulating
hormone (FSH) and luteinizing hormone (LH). A gonadotro-
pin is a h rm ne that has a stimulating e e t n the gonadsthe
testes and varies.
Y u may want t review these r les the hyp thalamus
and pituitary gland in Chapter 10 (p. 261) and Chapter 12
(p. 326). Als , peek ahead t Figure 23-16, where y u will see
the hyp thalamus and pituitary depi ted at the t p the
diagram.
 620 CHAPTER 23 Reproductive Systems

Va s (ductus )
de fe re ns Epididymis Te s tis Ne rve s a nd blood ve s s e ls Epididymis
in the s pe rma tic cord

S e minife rous
tubule s
Te s tis

Va s (ductus )
de fe re ns

L M

I
Tunica
S e ptum Lobule a lbugine a
A B
FIGURE 23-2 Tubules o the testis and epididymis. The ducts and tubules are exaggerated in size. In the
photograph, the testis is the egg-shaped mass in the center; note that the comma-shaped epididymis, seen on
23 the le t, is continuous with the vas (ductus) de erens.

W hen a b y enters puberty, ir ulating levels FSH ause spermat g nium and the ther rms an ther type ell
a spermat g nium t underg a unique series ell divisi ns alled a primary spermatocyte. T ese primary spermat ytes
t pr du e sperm ells. W hen the spermat g nium underg es then underg an ther type ell divisi n hara terized by
ell divisi n and mit sis under the inf uen e FSH , it pr - meiosis, whi h ultimately results in sperm rmati n.
du es tw daughter ells. One these ells remains as a N te in Figure 23-4, B, that in mei sis tw ell divisi ns
ur (n t ne as in mit sis) and that ur daughter ells (n t
tw as in mit sis) are rmed. T e daughter ells are alled
Tunica Inte rs titia l S e minife rous S pe rma toge nic spermatids. Unlike the tw daughter ells that result r m
a lbugine a ce lls tubule ce lls
mit sis, the ur spermatids ea h have nly hal the geneti
material in its nu leus and hal the nu lear hr m s mes
(23) ther b dy ells. T ese spermatids then devel p int
spermat z a.
L k again at the diagram mei sis in Figure 23-4, B. It
sh ws that ea h primary spermat yte ultimately pr du es
ur sperm ells. N te that, in the p rti n a semini er us
tubule sh wn in Figure 23-4, spermat g nia are und at the
uter sur a e the tubule, primary and se ndary spermat -
ytes lie deeper in the tubule wall, and mature but imm tile
sperm are seen ab ut t enter the lumen the tube and begin
their j urney thr ugh the repr du tive du ts t the exteri r
the b dy.

To learn more about spermatogenesis, go to

AnimationDirect online at evolve.elsevier.com.

FIGURE 23-3 Testis tissue. Several semini erous tubules surrounded
by septa containing interstitial cells are shown.
Sperm
Sperm are am ng the smallest and m st unusual ells in the
b dy (Figure 23-5, A). T e term sperm mes r m Latin sper-
matozoan meaning seed animal. T is is be ause, s mewhat
like a seed, ea h sperm ell is part the repr du tive pr ess.
 CHAPTER 23 Reproductive Systems 621

And ea h sperm ell has a tail and m ves independently
s mewhat like a mi r s pi animal.
All the hara teristi s that a baby will inherit r m its
ather at ertilizati n are ntained in the nu lear hr m -
s mes und in ea h sperm head. H wever, this geneti in r-
mati n r m the ather will unite with hr m s mes n-
tained in the m thers vum nly i su ess ul ertilizati n
urs.
T e r e ul eje ti n f uid ntaining sperm, r
ejaculation, int the emale vagina during sexual inter-
urse is nly ne step in the l ng j urney that these sex
ells must make be re they an meet and ertilize an vum.
a mplish their task, these tiny pa kages geneti in-
rmati n are equipped with tails r m tility and enzymes
t penetrate the uter membrane the vum when nta t
urs with it.
T e stru ture a mature sperm is diagrammed in
Figure 23-5, B. N te the sperm head ntaining the nu leus
with its geneti material r m the ather. T e sperm head is
vered by the acrosomea aplike stru ture ntaining
enzymes that enable the sperm t break d wn the vering
the vum and permit entry i nta t urs.
In additi n t the head with its vering a r s me, ea h
sperm has a midpiece and an el ngated tail. Mit h ndria in
the midpie e release aden sine triph sphate (A P) t
pr vide energy r the tail m vements required t pr pel the
sperm and all w them t swim r relatively l ng distan es
thr ugh the emale repr du tive du ts. T e tail is a tually a
agellum, previ usly des ribed in Chapter 3see Figure 3-4
and Figure 3-5 (p. 49).
Production o Testosterone
In additi n t spermat genesis, the ther un ti n the
testes is t se rete the male h rm ne testosterone. T is un -
ti n is arried n by the interstitial cells the testes, n t by
their semini er us tubules. T e g nad tr pin LH stimulates
interstitial ells t devel p and pr du e test ster ne.
est ster ne serves the ll wing general un ti ns:
1. est ster ne mas ulinizes. T e vari us hara teristi s
that we think as maledevel p be ause test ster-
nes inf uen e. F r instan e, when a y ung b ys v i e
hanges, it is test ster ne that brings this ab ut.
B
S pe rma togonia
(ge rm ce lls )
46
23
Mitotic divis ion
46

Da ughte r ce ll
46

P rima ry
s pe rma tocyte
S pe rma tocyte
46
S pe rma tids Me ios is I

S e conda ry
Ba s e me nt s pe rma tocyte s
23 23
me mbra ne

S pe rma togonia Me ios is II

S pe rma tids 23 23 23 23

Ma ture
s pe rm ce ll
S pe rma tids 23 23 23 23
be coming
A S us te nta cula r s pe rm ce lls
ce ll

Lume n of
s e minife rous
tubule
23
FIGURE 23-4 Spermatogenesis. A, Cross section o semini erous tu- 23 23
bule shows layers o cells undergoing the process o spermatogenesis. 23
B, Diagram o spermatogenesis, including the role o meiosis in producing S pe rm ce lls
daughter sperm cells with hal the number o nuclear chromosomes ound in
typical body cells.
 622 CHAPTER 23 Reproductive Systems
A B
FIGURE 23-5 Human sperm. A, Micrograph shows the heads and long, slender tails o many spermatozoa.
B, Illustration shows the components o a mature sperm cell and an enlargement o a sperm head and midpiece.
23
2. est ster ne pr m tes and maintains the devel p-
ment the male a ess ry rgans (pr state gland,
seminal vesi les, and s n).
3. est ster ne has a stimulating e e t n pr tein
anab lismit is an anabolic steroid h rm ne. est s-
ter ne thus is resp nsible r the greater average
mus ular devel pment and strength the male.
A g d way t remember test ster nes un ti ns is t think
it as the mas ulinizing h rm ne and the anab li h r-
m ne.G ba k and review the b x Enhancing M uscle Strength
in Chapter 9 (p. 227), whi h dis usses the abuse anab li
ster ids by s me athletes.
QUICK CHECK
1. Lis t th e a cce s s o ry o rga n s o re p ro d u ctio n in m e n .
2. In w h a t s p e cif c s tru ctu re s o th e g o n a d a re th e s p e rm
p ro d u ce d ?
3. Wh a t is a g o n a d o tro p in ?
4. S u m m a rize th e g e n e ra l u n ctio n s o te s to s te ro n e .
Re p ro d u c t ive D u c t s
O ve r v ie w
T e du ts thr ugh whi h sperm must pass a ter exiting r m
the testes until they rea h the exteri r the b dy are imp r-
tant mp nents the a ess ry repr du tive stru tures. T e
ther tw mp nents in luded in the listing a ess ry
rgans repr du ti n in the malethe supp rtive sex glands
and external genitalsare dis ussed separately here.
Acros ome
Nucle us
He a d
Mitochondria
Midpie ce
Ta il
Ta il
Sperm are rmed within the walls the semini er us
tubules the testes. W hen they exit r m these tubules
within the testis, they enter and then pass, in sequen e,
thr ugh the epididymis, vas de erens (du tus de erens), eja u-
lat ry du t, and the urethra n their j urney ut the b dy.
Ep id id y m is
Ea h epididymis nsists a single and very tightly iled
tube ab ut 6 m (20 eet) in length. It is a mma-shaped
stru ture (see Figure 23-2) that lies al ng the t p and behind
the testes inside the s r tum. Sperm mature and devel p
their ability t m ve, r swim, as they pass thr ugh the
epididymis.
Cells lining the epididymis se rete nutrients r devel ping
sperm and als rem ve substantial am unts ex ess testi u-
lar f uid as the devel ping sex ells enter and eventually pass
thr ugh the lumen this highly iled tube.
Epididymitis is a pain ul inf ammati n the epididymis.
(Re all that the su x -itis signi es inf ammati n .) Epi-
didymitis ten urs in ass iati n with sexually transmit-
ted diseases, r S Ds (see Table 23-4). T e nset pain is
upled with redness and swelling the verlying s r tum,
ever, and the appearan e white bl d ells (W BCs) in the
urine.
Va s D e e r e n s
T e vas de erens, r ductus de erens, is the tube that permits
sperm t exit r m the epididymis and pass r m the s r tal
sa upward int the pelvi avity (see Figure 23-1). Ea h vas
de erens is a thi k, sm th, very mus ular, and m vable tube
that an easily be elt r palpated thr ugh the thin skin
the s r tal wall. It passes thr ugh the inguinal anal int the
 CHAPTER 23 Reproductive Systems 623

se reti ns t the gelatin us f uid part

C LIN ICA L APPLICATION the semen, in lude the tw seminal
vesi les, ne pr state gland, and tw
VAS ECTOMY bulb urethral (C wper) glands. In ad-
Seve ring or clam ping o the vas de e re ns that is , a vas e cto my, us ually done diti n t the pr du ti n sperm, the
through an incis ion in the s crotum m ake s a m an s te rile . Why? Be caus e it inte rrupts semini er us tubules the testes n-
the route to the exte rior rom the e pididym is . To le ave the body, s pe rm m us t journey tribute s mewhat less than 5% the
in s ucce s s ion through the e pididym is , vas de e re ns , e jaculatory duct, and ure thra. seminal f uid v lume.
Usually 3 t 5 mL (ab ut 1 tea-
Vasectomy is one o many types o reproductive planning called sp n) semen is eja ulated at ne
contraception. For more strategies, and how they help illustrate how time, and ea h milliliter n rmally n-
reproduction unctions, see the article Contraception at Connect It! tains ab ut 20 milli n t 100 milli n
at evolve.elsevier.com. sperm. T ese numbers vary nsider-
ably in healthy men, even r m day t
day. Semen is slightly alkaline and
pr te ts sperm r m the a idi envi-
pelvi avity as part the spermatic cord, a nne tive tissue r nment the emale repr du tive tra t.
sheath that als en l ses bl d vessels and nerves.
S e m in a l Ve s ic le s
Eja c u la t o ry D u c t a n d U r e t h r a T e paired seminal vesicles (see Figure 23-1) are p u hlike
On e in the pelvi avity, the vas de erens extends ver the t p glands that ntribute ab ut 60% the seminal f uid v lume.
and d wn the p steri r sur a e the bladder, where it j ins T eir se reti ns are yell wish, thi k, and ri h in the sugar
the du t r m the seminal vesi le t rm the ejaculatory duct ru t se. T is ra ti n the seminal f uid helps pr vide a
(Figure 23-6). s ur e energy r the highly m tile sperm.
N te in Figure 23-1 and Figure 23-6 that the eja ulat ry du t 23
passes thr ugh the substan e the pr state gland and per- P ro s t a t e G la n d
mits sperm t empty int the urethra, whi h eventually T e prostate gland lies just bel w the bladder and is shaped
passes thr ugh the penis and pens t the exteri r at the like a d ughnut. T e urethra passes thr ugh the enter the
external urinary meatus. pr state be re traversing the penis t end at the external
urinary ri e.
T e pr state se retes a thin, milk- l red f uid that nsti-
Ac c e s s o ry G la n d s tutes ab ut 30% the t tal seminal f uid v lume. T is p r-
T e term semen, r seminal uid, is used t des ribe the ti n the eja ulate helps t a tivate the sperm and maintain
mixture sex ells r sperm pr du ed by the testes and their m tility.
the se reti ns the a ess ry r supp rtive sex glands. T e
a ess ry glands, whi h ntribute m re than 95% the Bu lb o u r e t h r a l G la n d s
Ea h the tw bulbourethral glands (als alled Cowper
glands) resembles a pea in size and shape. T ey are l ated
just bel w the pr state gland and empty their se reti ns int
Ba s e of the penile p rti n the urethra. Be ause this f uid is ten
bla dde r released just be re the rest the semen is eja ulated, it is
Va s (ductus ) alled "pre-eja ulate."
S de fe re ns
T e mu uslike se reti ns the bulb urethral glands serve
L R Ure te r several un ti ns. T ey neutralize any residue sperm
I
damaging a idi urine in the urethra. T ey als lubri ate the
S e mina l urethra t pr te t sperm r m ri ti n damage and add t the
ve s icle
external lubri ati n the penis needed r inter urse.
Le ft
T e bulb urethral glands ntribute less than 5% the
e ja cula tory seminal f uid v lume eja ulated r m the urethra.
duct

Pos te rior Ex t e r n a l G e n it a ls
s urfa ce of
pros ta te T e penis and s r tum nstitute the external repr du tive
rganss metimes alled the genitals r genitalia.
FIGURE 23-6 Male accessory glands. Dissection photo showing blad- T e penis (Figure 23-7) is the rgan that, when made sti
der, prostate, vas de erens, le t ejaculatory duct, and seminal vesicles rom and ere t by the lling its sp ngy, r ere tile, tissue mp -
behind. nents with bl d during sexual ar usal, an enter and dep sit
 624 CHAPTER 23 Reproductive Systems

C LIN ICA L APPLICATION

Bla dde r
MALE CIRCUMCIS ION
In re ce nt de cade s , the re has be e n dis agre e m e nt am ong
P ros ta te Ope nings of m e dical pro e s s ionals re garding w he the r routine circum ci-
e ja cula tory ducts
s ion is jus tif e d in all m ale in ants . Ce rtainly, circum cis ion
m ay be re quire d i the ore s kin f ts s o tightly ove r the glans
Bulboure thra l that it cannot be re tracte d, a condition calle d phim o s is .
gla nd Als o, i the ore s kin cannot be re place d to its us ual pos i-
Bulb
tion a te r it has be e n re tracte d be hind the glans , a condition
Crus pe nis
calle d paraphim o s is , circum cis ion m ay be re quire d.
Ope ning A te r a ew ye ars o w ithholding the re com m e ndation,
of bulboure thra l m os t he alth expe rts are again re com m e nding routine cir-
gla nds cum cis ion to re duce the s pre ad o hum an im m unode f -
cie ncy virus (HIV) and othe r s exually trans m itte d in e ctions
Corpus (STIs ) bas e d on exte ns ive re s e arch f ndings . Howeve r, the re
ca ve rnos um are ris ks to circum cis ion, including los s o its norm al prote c-
Ure thra tive and s e ns ory role , and m any que s tion the e thics o a
s urge ry in w hich the patie nt cannot give in orm e d cons e nt.
Corpus
De e p a rte ry s pongios um
At the distal end the sha t the penis is the enlarged
Gla ns pe nis glans penis, r m re simply glans. T e glans is dense with
sens ry re ept rs that help stimulate the male sexual resp nse.
23 Fore s kin T e external urinary meatus is the pening the urethra at
(pre puce ) the tip the glans.
T e skin the distal end the penis is lded d ubly t
A Exte rna l urina ry rm a l se- tting retra table, llar ar und the glans alled
me a tus S the oreskin, r prepuce. Besides pr te ting the glans r m
abrasi n, the reskin is als dense with sens ry re ept rs.
R L
Surgi al rem val the reskin is alled circumcision (see
I Clini al Appli ati n b x ab ve).
Corpus Dors a l blood
T e scrotum is a skin- vered p u h suspended r m the
ca ve rnos um ve s s e ls of pe nis gr in. Internally, it is divided int tw sa s by a septum; ea h
sa ntains a testis, epididymis, the l wer part the vas
de erens, and the beginning the spermati rds.

Corpus
s pongios um
Ure thra D
R L
B V
FIGURE 23-7 Penis. A, In this sagittal section o the penis viewed rom
above, the urethra is exposed throughout its length and can be seen exiting
rom the bladder and passing through the prostate gland be ore entering the
penis to end at the external urinary meatus. B, Photograph o a cross section
o the sha t o the penis showing the three columns o erectile or cavernous
tissue. Note the urethra within the substance o the corpus spongiosum.
sperm in the vagina during inter urse. T e penis has three
separate lumns ere tile tissue in its sha t: ne corpus
spongiosum, whi h surr unds the urethra, and tw corpora
cavernosa, whi h lie d rsally. T e sp ngy nature ere tile
tissue is apparent in Figure 23-7.
D is o r d e r s o t h e M a le
Re p ro d u c t ive S y s t e m
In e r t ilit y a n d S t e r ilit y
Several dis rders the male repr du tive system ause
in ertility. In ertility is an abn rmally l w ability t repr -
du e. I there is a mplete inability t repr du e, the ndi-
ti n is alled sterility.
In ertility r sterility inv lves an abn rmally redu ed a-
pa ity t deliver healthy sperm t the emale repr du tive
tra t. Redu ed repr du tive apa ity may result r m a t rs
su h as a de rease in the testespr du ti n sperm, stru tural
abn rmalities in the sperm, r bstru ti n the repr du tive
du ts.
Males in general d n t have a well-de ned andropause,
r essati n ertility, in late adulth d that l sely parallels
emale men pause. H wever, sensitivity the testis t LH
may begin t de line a ter age 50, ausing test ster ne levels
t dr p. I it is a signi ant dr p, it may be alled l w . L w

test ster ne pr du ti n an ause sperm pr du ti n t als
de line s mewhat. Even s , many men remain ertile thr ugh-
ut li e.
D is o r d e r s o t h e Te s t e s
Re d u c e d S p e r m P ro d u c t io n
Disrupti n the sperm-pr du ing un ti n the semini er-
us tubules an result in de reased sperm pr du ti n, a ndi-
ti n alled oligospermia. I the sperm count is t l w, in ertil-
ity may result. A large number sperm is needed t ensure
that many sperm will rea h the vum and diss lve its ating,
all wing a single sperm t unite with the vum.
O lig spermia an result r m a t rs su h as in e ti n, e-
ver, radiati n, malnutriti n, and high temperature in the testes.
In s me ases, lig spermia is temp raryas in s me a ute
in e ti ns. O lig spermia is a leading ause in ertility. O
urse, t tal absen e sperm pr du ti n results in sterility.
C ry p t o r c h id is m
Early in etal li e the testes are l ated in the abd min pelvi
avity near the kidneys but n rmally des end int the s r tum
ab ut 2 m nths be re birth. O asi nally a baby is b rn with
undes ended testes, a nditi n alled cryptorchidism, whi h
is readily dete ted by palpati n the s r tum at delivery. T e
w rd cryptorchidism is r m the Greek w rds kryptikos (hid-
den) and orchis (testis).
Failure the testes t des end may be aused by h rm nal
imbalan es in the devel ping etus r by a physi al de ien y
r bstru ti n. Regardless ause, in the rypt r hid in ant,
the testes remain hidden in the abd min pelvi avity.
Be ause the higher temperature inside the b dy avity in-
hibits spermat genesis, measures must be taken t bring the
testes d wn int the s r tum t prevent permanent sterility.
Early treatment rypt r hidism by inje ti n test ster-
ne, whi h stimulates the testes t des end, may result in
n rmal testi ular and sexual devel pment. T e nditi n may
als be rre ted surgi ally.
Te s t ic u la r C a n c e r
M st testicular tumors are an er us and arise r m sperm-
pr du ing ells the semini er us tubules. Externally, they
m st ten appear as a n ntender mass xed n the testis.
Malignan ies the testes are m st mm n am ng men
15 t 30 years ld. In additi n t age gr up, this type an er
is ass iated with geneti predisp siti n, trauma r in e ti n
the testis, and rypt r hidism.
reatment testi ular an er is m st e e tive when the
diagn sis is made early in the devel pment the tum r.
Many physi ians en urage male patients t per rm m nthly
sel -examinati n their testes, espe ially i they are in a
high-risk gr up. T e sel -examinati n inv lves palpating ea h
testispre erably a ter a warm sh wer when the s r tum is
relaxed and the testes are des ended and a essible. Ea h
testis sh uld be palpated thr ugh the s r tal wall between the
thumb and the index and middle ngers. T ey sh uld eel
rm, sm th, and rubbery but n t hard. T e examinati n may
CHAPTER 23 Reproductive Systems 625
result in s me tenderness but sh uld n t be pain ul. Any lump
r hange in texture sh uld be rep rted t a physi ian r
urther assessment.
D is o r d e r s o t h e P ro s t a t e
Be n ig n P ro s t a t ic Hy p e r t ro p h y
A n n an er us nditi n alled benign prostatic hypertrophy
(BPH) is a mm n pr blem in lder men. T e nditi n is
hara terized by an enlargement r hypertr phy the pr state
gland. BPH is s mm n in late adulth dm re than 90%
men ver 80that it is nsidered a usual part aging.
T e a t that the urethra passes thr ugh the enter the
pr state a ter exiting r m the bladder is a matter nsider-
able lini al signi an e in this nditi n. As the pr state en-
larges, it squeezes the urethra, p ssibly l sing it s mpletely
that urinati n be mes very di ult r even imp ssible.
In severe ases nly, surgi al rem val a part the gland
r the entire gland, a pr edure alled prostatectomy, may
be me ne essary.
P ro s t a t e C a n c e r
Prostate cancer is the se nd leading ause an er deaths
in men. M st are aden ar in mas the glandular tissue.
Early diagn sis is riti al r survival (see the Clini al Ap- 23
pli ati n b x n page 626).
On e an er is n rmed, treatment depends n the stage
an er and the age and health the patient. Wat h ul wait-
ing is mm nly re mmended r s me early stage pr state
an ers, but m re advan ed ases may require pr state t my
ten in mbinati n with ther therapies. Opti ns in lude
systemi hem therapy, ry therapy ( reezing) pr stati
tissue, mi r wave therapy, h rm nal therapy, and vari us types
external beam x-ray radiati n treatments.
One treatment pr t l inv lves pla ing small radi a tive
seeds dire tly int the pr state tum r, where they give
very l alized an er- elldestr ying radiati n r ab ut a
year. T e treatment is alled brachytherapy r m the Greek
term brachymeaning sh rt distan e. T e radiati n is lim-
ited t a sh rt distan e be ause the radi a tive seeds are
pla ed in r near the tum r itsel , thus redu ing any radiati n
exp sure t surr unding healthy tissue.
D is o r d e r s o t h e P e n is a n d S c ro t u m
P e n is D is o r d e r s
In ection, Cancer, and Structural Disorders
T e penis is subje t t cancerous tumors and is a e ted by numer-
us sexually transmitted diseases, r S D s (see Table 23-4).
Devel pment herpes vesi les; genital warts; and vari us le-
si ns the reskin, glans, and penile sha t are mm n.
Structural abnormalities su h as phimosis and paraphimosis,
dis ussed in the b x n the pp site page, an bstru t the
f w urine r result in urinary tra t in e ti ns.
T e term hypospadias des ribes a ngenital nditi n
that is hara terized by the pening the urethral meatus n
the underside the glans r penile sha t. Surgi al rre ti n
 626 CHAPTER 23 Reproductive Systems

C LIN ICA L APPLICATION

DETECTING PROSTATE CANCER
Many o the 32,000 m e n w ho die e ach ye ar rom pros tate cance rthe S e mina l ve s icle
m os t com m on nons kin orm o cance r in Am e rican m e n and a le ading P ros ta te gla nd
caus e o cance r de aths in m e n ove r 50could be s ave d i the cance rs
we re de te cte d e arly e nough to allow e e ctive tre atm e nt. Seve ral s cre e n-
ing te s ts are now available or e arly de te ction o pros tate cance r.
For exam ple , phys icians can s om e tim e s de te ct pros tate cance r e arly
by palpating the pros tate through the wall o the re ctum us ing a glove d,
lubricate d f nge r. This is calle d a digital re ctal exam .
The pros tate -s pe cif c antige n (PSA) te s t is a blood te s t that as s e s s e s
the leve l o a blood prote in that m ay incre as e in pros tate cance r. Although
controve rs ial w he n us e d alone or cance r s cre e ning be caus e o pote ntially
m is le ading re s ults , it re m ains a valuable te s t or m onitoring pros tate
P
he alth.
Be caus e o the prevale nce o pros tate cance r, adult m e n are e ncour- I S
age d to have re gular pros tate exam inations and to re port any urinary or
A
s exual di f culty to the ir phys icians .

23
is per rmed i the de e t is likely t ause ur l gi al r repr - A drug alled Muse (alpr stadil) is available as a tiny s t
du tive pr blems. pellet that is inserted int the urethra using a small appli at r.
T e term epispadias re ers t a mu h less mm n n- A similar drug available in s luti n, Caverje t, is inje ted di-
genital de e t that inv lves the pening the urethral meatus re tly int the penis.
n the d rsal r t p sur a e the glans r penile sha t. As a result multiple pti ns, even m derate t severe
ere tile dys un ti n urring in sexually a tive men an be
Erectile Dys unction treated with nsiderable su ess.
Failure t a hieve r maintain an ere ti n the penis ade-
quate en ugh t permit sexual inter urse is alled erectile S c ro t u m D is o r d e r s
dys unction (ED ) r impotence. ED a e ts men all ages but Swelling the s r tum an be aused by a variety ndi-
is experien ed m st ten a ter age 65. Imp ten e d es n t ti ns. One the m st mm n auses s r tal swelling is
a e t sperm pr du ti n but in ertility ten results be ause an a umulati n f uid alled a hydrocele. H ydr eles may
n rmal inter urse may n t be p ssible. be ngenital, resulting r m stru tural abn rmalities present
In the past, psy h l gi al pr blems su h as anxiety, depres- at birth.
si n, and stress were ten ited as the m st imp rtant auses In adults, hydr ele ten urs when f uid pr du ed by
imp ten e in sexually a tive men. T ere is n d ubt that the ser us membrane lining the s r tum is n t abs rbed
su h nditi ns ntribute t ED. H wever, urrent resear h pr perly. T e ause adult hydr ele is n t always kn wn,
suggests that purely psy h l gi al pr blems pr bably a unt but in s me ases, it an be linked t trauma r in e ti n.
r ar ewer ases imp ten e than previ usly th ught. Swelling the s r tum may als ur when the intestines
We n w kn w that ED is requently aused by medi al push thr ugh the weak area the abd minal wall that sepa-
pr blems related t abn rmal vas ular r neural ntr l rates the abd min pelvi avity r m the s r tum. T is ndi-
penile bl d f w. Arteri s ler sis, diabetes, al h l abuse, ti n is a rm inguinal hernia. I the intestines pr trude
numer us medi ati ns, radiati n therapy, tum rs, spinal rd t ar int the s r tum, the digestive tra t may be me b-
trauma, and surgery, espe ially i pelvi rgans su h as the stru ted, resulting in death.
pr state are inv lved, may all ntribute t ED. In adults, inguinal hernia ten urs while li ting heavy
reatment pti ns r ED in lude use drugs that in- bje ts, be ause the high internal pressure generated by the
rease bl d f w t the sp ngy avern us tissue the penis ntra ti n abd minal mus les. Inguinal herniati n als
ausing it t sti en and be me ere t. O ral medi ati ns su h may be ngenital (Figure 23-8).
as Viagra (sildena l), Levitra (vardena l), Cialis (tadala l), Small inguinal hernias may be treated with external sup-
and Uprima (ap m rphine) are generally pre erred by men p rts that prevent rgans r m pr truding int the s r tum;
wh d n t have medi al nditi ns that pre lude their use. m re seri us hernias must be repaired surgi ally.
 CHAPTER 23 Reproductive Systems 627

Pe ritone um

Norma l

S Inte s tine S
protruding
R L into s crotum A P

Ing uinal he rnia I No rmal Co ng e nital ing uinal I

he rnia

FIGURE 23-8 Inguinal hernia. Congenital inguinal hernia in in ant male.

read ab ut ea h stru ture in the pages that ll w. Als nd

Although less common, inguinal hernias also
the maj r stru tures the emale repr du tive system in the
occur in emales. Review the article Hernias at
Clear View o the Human Body ( ll ws p. 8).
Connect It! at evolve.elsevier.com.

QUICK CHECK O va r ie s 23
1. Wh a t d u ct le a d s ro m th e e p id id ym is ? S t r u c t u r e a n d Lo c a t io n
2. Wh ich o rga n s p ro d u ce th e u id in s e m e n ? T e paired varies are the g nads emales. T ey have a
3. Wh a t is th e u n ctio n o th e e re ctile tis s u e ? pu kered, uneven sur a e; ea h weighs ab ut 3 g. T e varies
4. Id e n ti y th e tre a tm e n ts o r b e n ig n p ro s ta tic hyp e rtro p hy.
resemble large alm nds in size and shape. T ey are atta hed
t ligaments in the pelvi avity n ea h side the uterus.
Embedded in a nne tive tissue matrix just bel w the
Fe m a le Re p ro d u c t ive S y s t e m uter layer ea h vary in a newb rn baby girl are ab ut hal
a milli n ovarian ollicles. Ea h lli le ntains an oocyte,
S t r u c t u r a l P la n an immature stage the emale sex ell.
T e stru tural plan the repr du tive system in b th sexes is By the time a girl rea hes puberty, h wever, urther devel-
similar in that rgans are hara terized as essential r accessory. pment has resulted in the rmati n a redu ed number
(ab ut 400,000) what are then alled primary ollicles.
Es s e n t ia l O r g a n s Ea h primary lli le has a layer granulosa cells ar und the
T e essential rgans repr du ti n in w men, the gonads, yte.
are the paired ovaries. T e emale sex ells, r ova, are pr - T e pr gressi n devel pment r m primary lli le t
du ed in the varies. T e varies als pr du e the h rm nes vulati n is sh wn in Figure 23-10. As the thi kness the
estr gen and pr gester ne. granul sa ell layer ar und the yte in reases, a h ll w
hamber alled an antrum appears, and a secondary ollicle is
Ac c e s s o ry O r g a n s rmed.
T e a ess ry rgans repr du ti n in w men nsist the D uring the repr du tive li etime m st w men, nly
ll wing stru tures: ab ut 350 t 500 these primary lli les ully devel p int
1. A series du ts r m di ed du t stru tures that
extend r m near the varies t the exteri r TABLE 23-2 Female Reproductive Organs
2. Additi nal sex glands, in luding the mammary glands,
ES S ENTIAL ORGANS ACCES S ORY ORGANS
whi h have an imp rtant repr du tive un ti n nly
Gonads : ovarie s (right ovary Ducts : ute rine tube s (two),
in w men
and le t ovary) ute rus , vagina
3. T e external repr du tive rgans r external genitals Acce s s ory s ex glands : ve s tibular
Table 23-2 lists the names
the essential and a ess ry emale glands (two pairs ), bre as ts
rgans repr du ti n, and Figure 23-9 sh ws the l ati n (two)
Exte rnal ge nitals : vulva
m st them. Re er ba k t this table and illustrati n as y u
 628 CHAPTER 23 Reproductive Systems

Ova ry
Ute rine (fa llopia n) tube
Body of ute rus

Ure te r Fundus of ute rus

Ce rvix
Urina ry bla dde r

Re ctum
S ymphys is pubis

Anus Ure thra

Clitoris
Va gina
La bium minus

La bium ma jus
S

FIGURE 23-9 Female reproductive sys- P A

23 tem. Sagittal section o pelvis showing loca-
I
tions o emale reproductive organs.

mature ollicles. It is the mature lli le that releases an vum A ter vulati n, the ruptured lli le is trans rmed int a
r p tential ertilizati na pr ess alled ovulation. F lli- h rm ne-se reting glandular stru ture alled the corpus
les that d n t mature degenerate and are reabs rbed int luteum, whi h is des ribed later. Corpus luteum is a Latin
the varian tissue. phrase meaning yell w b dyan appr priate name t de-
T e sa ntaining a mature vum is the mature ovarian s ribe the yell w appearan e this glandular stru ture.
ollicle ten alled a graa an ollicle, in h n r the
D ut h anat mist Regnier de Graa wh dis vered it s me O va ry Fu n c t io n s
300 years ag . Oogenesis
T e pr du ti n emale gametes, r sex ells, is alled
oogenesis.
Ovula tion Corpus Blood T e unusual rm ell divisi n that results in
lute um ve s s e ls sperm rmati n, mei sis, is als resp nsible r devel-
pment va. D uring the devel pmental phases expe-
rien ed by the emale sex ell r m its earliest stage t
De ge ne ra ting just a ter ertilizati n, tw mei ti ell divisi ns ur.
corpus lute um
Oocyte As a result mei sis in the emale sex ell, the
number hr m s mes is redu ed equally in ea h
Ma ture
follicle daughter ell t hal the number (23) und in ther
(gra a fia n b dy ells (46).
follicle ) H wever, the am unt yt plasm is divided un-
equally am ng the daughter ells, as y u an see in
Figure 23-11. T e result is rmati n ne large
vum and small daughter ells alled polar bodies
Antrum that degenerate. T e vum, with its large supply
Gra nulos a S e conda ry Gra nulos a P rima ry
yt plasm, is ne the b dys largest ells and is
ce lls follicle ce lls follicle s A uniquely stru tured t pr vide nutrients r rapid devel-
pment the embry until implantati n in the uterus
FIGURE 23-10 Ovary. Cross section o ovary shows successive L M
stages o ovarian ollicle and ovum development. Begin with the rst urs.
stage (primary ollicle) and ollow around clockwise to the nal state P At ertilizati n, the nal phase mei ti ell divisi n
(degenerating corpus luteum). in the vum mpletes, and the last p lar b dy is released.
 CHAPTER 23 Reproductive Systems 629

FIGURE 23-11 Oogenesis. Production o

BEFORE BIRTH
a mature ovum and subsequent ertilization
are shown as a series o cell divisions. Notice
that meiosis pauses in meiosis I be ore birth, Oogonium OOCYTE 46
then resumes in some primary oocytes begin-
ning at puberty. Meiosis II does not complete
until ertilization occurs. Mitos is

P rima ry 46
oocyte
T e sex ells r m b th parents unite
ully and the n rmal hr m s me Me ios is be gins
number (46) is a hieved in the zyg te (growth)
that is rmed. Me ios is s tops a t propha s e I

Production o Estrogen CHILDHOOD

and Progesterone
T e se nd maj r un ti n the P rima ry
46 (ina ctive )
oocyte
vary, in additi n t genesis, is
se reti n the sex h rm nes, estro-
gen and progesterone. H rm ne pr - REPRODUCTIVE YEARS
du ti n in the vary begins at pu-
(growth)
berty with the y li devel pment
and maturati n the vum. T e
granul sa ells ar und the yte in P rima ry
the gr wing and mature lli le se-
oocyte
46
23
rete estr gen. T e rpus luteum,
whi h devel ps a ter vulati n,
hief y se retes pr gester ne but als
s me estr gen. Me ios is re s ume s
Estrogen is the sex h rm ne that
auses the devel pment and mainte- P rima ry
nan e the emale secondary sex oocyte
characteristics and stimulates gr wth
the epithelial ells lining the
uterus. S me the a ti ns estr - Me ios is
gen in lude the ll wing: S e conda ry s tops a t Firs t pola r
23 body
oocyte me ta pha s e II
1. Devel pment and matura-
ti n emale repr du tive Fe rtiliza tion
Me ios is re s ume s
rgans, in luding the exter-
nal genitals
2. Appearan e pubi hair 23
and breast devel pment
3. Devel pment emale
b dy nt urs by dep si- Me ios is comple te d
ti n at bel w the skin
sur a e and in the breasts
and hip regi n Zygote
23
23 23 23
4. Initiati n the rst men- 23
strual y le S e cond Pola r
pola r body bodie s
Progesterone is pr du ed by the
rpus luteum, whi h is a glandular
stru ture that devel ps r m a lli le that has just released uterus and a ts with estr gen t initiate the menstrual y le
an vum. I stimulated by the appr priate anteri r pituitary in girls entering puberty.
h rm ne, the rpus luteum pr du es pr gester ne r T e surgi al term oophorectomy is used t des ribe re-
ab ut 11 days a ter vulati n. Pr gester ne stimulates pr - m val the varies. I b th varies are rem ved, sterility re-
li erati n and vas ularizati n the epithelial lining the sults and men pause ll ws.
 630 CHAPTER 23 Reproductive Systems

unique repr du tive un ti ns in mind as

C LIN ICA L APPLICATION we n w learn h w structure ts unction in
the emale repr du tive tra t.
HORMONE REPLACEMENT THERAPY
Horm one re place m e nt the rapy (HRT) us ing e s troge n alone or in com bination w ith U t e r in e Tu b e s
proge s tin (s ynthe tic proge s te rone ) is s om e tim e s us e d to re duce m ode rate to T e tw uterine tubes, als alled
s eve re s ym ptom s o m e nopaus e s uch as hot as he s . The s e s ym ptom s re s ult allopian tubes r oviducts, serve as
rom the drop in e s troge n that characte rize s m e nopaus e . Although HRT m ay have du ts r the varies, even th ugh they
s om e be ne f ts in re ducing or preve nting chronic dis orde rs s uch as os te oporos is , are n t atta hed t them. T e uter end
de m e ntia, or he art dis e as e , the re are pote ntially s e rious he alth ris ks as we ll.
ea h tube terminates in an expanded,
The re ore HRT is us e d only or the m ore s e rious m e nopaus e cas e s and not to
unnel-shaped stru ture that has ringe-
preve nt chronic dis e as e . To ke e p the ris ks low, HRT re quire s care ul analys is o an
individuals s ituation and de te rm ination o the lowe s t pos s ible e e ctive dos e in
like pr je ti ns alled mbriae al ng its
the s horte s t pos s ible tre atm e nt pe riod. Alte rnative drug the rapie s m ay be jus t as edge. T is part the tube urves ver
e e ctive as HRT in s om e cas e s . the t p ea h vary (Figure 23-12) and
pens int the pelvi avity. T e inner
end ea h uterine tube atta hes t the
uterus, and the avity inside the tube
QUICK CHECK pens int the avity in the uterus. Ea h tube is ab ut
10 m (4 in hes) in length.
1. Id e n ti y th e e s s e n tia l o rga n s o re p ro d u ctio n in w o m e n .
2. Wh e re a re th e e m a le g la n d s lo ca te d ? A ter vulati n, the dis harged vum rst enters the pelvi
3. Wh a t is o o g e n e s is ? avity and then enters the uterine tube assisted by the wave-
4. Wh ich e m a le s e x h o rm o n e ca u s e s th e d e ve lo p m e n t a n d like m vement the mbriae and the beating the ilia n
m a in te n a n ce o th e e m a le s e co n d a ry s e x ch a ra cte ris tics ? their sur a e. On e in the tube, the vum begins its j urney t
the uterus. S me va never nd their way int the vidu t and
23 remain in the pelvi avity where they are reabs rbed. In
Chapter 24 the details ertilizati n, whi h n rmally urs
Re p ro d u c t ive D u c t s
in the uter ne-third the uterine tube, are dis ussed.
O ve r v ie w T e mu sal lining the uterine tubes is dire tly ntinu-
T e repr du tive du ts in the male and emale repr du tive us with the lining the pelvi avity n ne end and with
tra t are similar in s me undamental ways. First, b th sets the lining the uterus and vagina n the ther. T is is
du ts lead r m ea h the paired g nads, then j in int a great lini al signi an e be ause in e ti ns the vagina r
single passage that leads ut the b dy. Se nd, b th male uterus su h as g n rrhea may pass int the abd min pelvi
and emale du ts arry gametes away r m the g nads. avity, where they may be me li e threatening.
H wever, be ause humans are pla ental mammals, the e-
male repr du tive du ts als have entral r les in re eiving Ut e ru s
sperm r m the male, ertilizati n, and prenatal devel pment T e uterus is a small rgan nly ab ut the size a
un ti ns n t needed in the male repr du tive tra t. Keep these pearbut it is extremely str ng. It is alm st all mus le, r

Ute rine (fa llopia n) tube Fundus

Body of ute rus

Ova ry

Fimbria e Endome trium

Wa ll of ute rus Pe rime trium

Myome trium Ute rine a rte ry a nd ve in

Ce rvix
Ce rvica l ca na l
S
FIGURE 23-12 Uterus. Sectioned view shows muscle L R
layers o the uterus and its relationship to the ovaries and Va gina (cut)
vagina. I
 CHAPTER 23 Reproductive Systems 631

myometrium, with nly a small avity inside. D uring preg-
nan y the uterus gr ws many times larger s that it be mes
big en ugh t h ld a ull-term etus and a nsiderable
am unt f uid.
T e uterus is mp sed several maj r regi ns. T e up-
per p rti n the uterus is the body. Just ab ve the level
where the uterine tubes atta h t the b dy the uterus, it
r unds ut t rm a bulging pr minen e alled the undus
(see Figure 23-12). T e l wer, narr w ne k se ti n is alled the
cervix.
Ex ept during pregnan y, the uterus lies in the pelvi avity
just behind the urinary bladder. By the end pregnan y, it
has be me large en ugh t extend up t the t p the ab-
d min pelvi avity. It then pushes the liver against the un-
derside the diaphragma a t that explains a mment
su h as I ant seem t take a deep breath sin e Ive g tten s
big, made by many w men late in their pregnan ies.
Hysterectomy is surgi al rem val the uterus. It may be
ex ised and rem ved thr ugh a typi al in isi n in the abd -
men (abdominal hysterectomy), thr ugh the vagina (vaginal
hysterectomy), r lapar s pi ally (laparoscopic hysterectomy). In
total hysterectomy b th the b dy and ervix are rem ved; in
subtotal hysterectomy nly the b dy the uterus is rem ved,
sparing the ervix.
T e uterus un ti ns in three pr essesmenstruati n,
pregnan y, and lab r. T e rpus luteum st ps se reting pr -
gester ne and de reases its se reti n estr gens ab ut
11 days a ter vulati n. Ab ut 3 days later, when the pr ges-
ter ne and estr gen n entrati ns in the bl d are at their
l west, menstruati n starts. Small pie es the mu us mem-
brane lining the uterus, r the endometrium pull l se,
leaving t rn bl d vessels underneath. Bl d and bits en-
d metrium tri kle ut the uterus int the vagina and ut
the b dy.
Immediately a ter menstruati n, the end metrium starts
t repair itsel . It again gr ws thi k and be mes lavishly sup-
plied with bl d in preparati n r pregnan y.
I ertilizati n d es n t take pla e, the uterus n e m re
sheds the lining made ready r a pregnan y that did n t -
ur. Be ause these hanges in the uterine lining ntinue t
repeat themselves, they are sp ken as the menstrual cycle
(see pp. 633-635).
I ertilizati n urs, pregnan y begins, and the end me-
trium remains inta t. T e events pregnan y are dis ussed in
Chapter 24.
Menstruati n rst urs during puberty, ten ar und the
age 12 t 13 years but s metimes even earlier. N rmally it
repeats itsel ab ut every 28 days r 13 times a year r s me
30 t 40 years be re it eases at the time menopause,
when a w man is s mewhere ar und the age 50 years.
Va g in a
T e vagina is a distensible tube ab ut 10 m (4 in hes) l ng
made mainly sm th mus le and lined with mu us mem-
brane. It lies in the pelvi avity between the urinary bladder
and the re tum, as y u an see in Figure 23-9. As the part
the emale repr du tive tra t that pens t the exteri r, the
vagina is the rgan that re eives the penis during inter urse
and thr ugh whi h sperm enter during their j urney t meet
an vum.
T e vagina is als the rgan r m whi h a baby emerges t
meet its new w rld, and s it is als alled the birth canal.
Ac c e s s o ry G la n d s 23
Ve s t ib u la r G la n d s
w pairs ex rine glands lie imbedded in tissue t the le t
and right the vaginal utlet and release mu us f uid int
the vestibule the vulva (des ribed later in Figure 23-14).
One pair these small glands are alled the greater
vestibular glands, and the ther pair are alled the lesser
vestibular glands. T e greater vestibular glands are als alled
Bartholin glands, and the lesser vestibular glands may be
alled Skene glands r emale prostate.
Mu us r m these glands may ntribute t lubri ati n
during sexual inter urse.
T e vestibular glands have lini al imp rtan e be ause they
may be me in e ted. F r example, Neisseria gonorrhoeaethe
ba teria that ause g n rrheaare ten hard t eliminate
n e they in e t a vestibular gland (see Table 23-4).

Br e a s t s
T e breasts lie ver the pe t ral mus les
C LIN ICA L APPLICATION and are atta hed t them by brous suspen-
ECTOPIC PREGNANCY sory ligaments ( C per). Breast size is
determined m re by the am unt at
The te rm e cto pic pre g nancy is us e d to de s cribe a pre gnancy re s ulting rom the ar und the glandular (milk-se reting) tis-
im plantation o a e rtilize d ovum in any location othe r than the ute rus . Occas ion- sue than by the am unt glandular tissue
ally, be caus e the oute r e nds o the ute rine tube s ope n into the pe lvic cavity and itsel . H en e the size the breast has little
are not actually conne cte d to the ovarie s , an ovum doe s not e nte r an oviduct but
t d with its ability t se rete adequate
be com e s e rtilize d and re m ains in the pe lvic cavity.
Although rare , i im plantation occurs on the s ur ace o an abdom inal organ or
am unts milk a ter the birth a baby.
on one o the m e s e nte rie s , deve lopm e nt m ay continue to te rm . In s uch cas e s , Ea h breast nsists 15 t 20 divi-
de live ry by ce s are an s e ction is re quire d. Mos t e ctopic pre gnancie s involve im plan- si ns r l bes that are arranged radially
tation in the ute rine tube and are the re ore calle d tubal pre gnancie s . I a tubal (Figure 23-13). Ea h l be nsists several
pre gnancy is not te rm inate d, catas trophic rupture o the ute rine tube and de ath o l bules, and ea h l bule nsists milk-
both e tus and m othe r is like ly to occur. se reting glandular ells. T e milk-se ret-
ing ells are arranged in grapelike lusters
 632 CHAPTER 23 Reproductive Systems

Clavicle
Contra ctile Pe ctora lis minor mus cle
ce lls Inte rcos ta l mus cle

Fa s cia of pe ctora l mus cle s

Ductule
Pe ctora lis ma jor mus cle
Milk
Alve olus
Ductule
Duct
Milk-s e cre ting
e pithe lia l ce lls La ctife rous
duct
La ctife rous
s inus
FIGURE 23-13 Female breast. Sagittal section shows the gland xed to the overly- Nipple
ing skin and the pectoral muscles by the suspensory ligaments (o Cooper). Each lobule pore s
o secretory tissue is drained by a lacti erous duct that opens through the nipple. The
inset (le t) shows one o the milk-producing alveoli o the mammary gland. Lobe s
Adipos e
tis s ue S
small h ll w hambers alled alveoli (see Figure 23-13, inset).
S us pe ns ory P A
Small ntra tile ells surr und the alve li and push milk int liga me nts
du ts when stimulated by oxytocin (O ) released r m the (of Coope r) I
p steri r pituitary glandan event alled milk let-d wn.
Small lacti erous ducts drain the alve li and nverge t - Can er us ells r m breast tum rs ten spread t ther
ward the nipple like the sp kes a wheel. Only ne la ti er- areas the b dy thr ugh the lymphati system. T is lym-
23 us du t leads r m ea h l be t an pening in the nipple. phati drainage is dis ussed in Chapter 16 (see als Figure 16-8).
Ea h la ti er us du t widens int a lacti erous sinus just be re
rea hing the nipple. Ea h sinus a ts like the bulb at the end Females and males both have breastsand
an eyedr pper, pumping milk ut the nipple as an in ant either can get breast cancer. For more in orma-
rhythmi ally squeezes its jaws as it nurses. tion on male and emale breast health, check out
T e l red sur a e area ar und the nipple is the areola. It the articles Male Breast Health and Breast Sel -
ntains many tiny bumps alled areolar glands. Are lar Examination at Connect It! at evolve.elsevier.com.
glands are large seba e us glands that se rete skin ils that
nditi n the skin while nursing an in ant. T e are la als has
To learn more about breast structure, go to
a netw rk sm th mus les that ntra t t ause the nipple
AnimationDirect online at evolve.elsevier.com.
t be me ere twhi h ten helps an in ant lat h n t the
breast at the m st e ient l ati n.
QUICK CHECK
1. Wh a t is a n o th e r n a m e o r th e u te rin e tu b e s ?
2. Wh a t th re e m a jo r u n ctio n s d o e s th e u te ru s p e r o rm ?
3. Wh a t s u b s ta n ce is co n d u cte d th ro u g h la cti e ro u s d u cts ?
C LIN ICA L APPLICATION 4. De s crib e th e u n ctio n o th e a re o la r g la n d s .
FIBROCYSTIC DIS EAS E
The te rm s f bro cys tic dis e as e and m am m ary dys plas ia Ex t e r n a l G e n it a ls
are jus t two o the m any nam e s or a group o conditions
characte rize d by be nign lum ps in one or both bre as ts . It is T e external genitalia w men nsist several stru tures
com m on in adult wom e n be ore m e nopaus e , occurring in lle tively alled the vulva. T ese in lude:
hal o all wom e n at s om e tim e , and is cons ide re d the m os t
re que nt bre as t le s ion. 1. M ns pubis
The lum ps that characte rize f brocys tic dis e as e are o te n 2. Clit ris
pain ul, e s pe cially during the s e cre tory phas e o the re pro- 3. External urinary meatus
ductive cycle . Tre atm e nt is us ually aim e d at re lieving pain or 4. Labia min ra
te nde rne s s that m ay occur. Although it is com m only calle d 5. H ymen
a dis e as e , m os t expe rts agre e that f brocys tic dis e as e is 6. Openings vestibular gland du ts
s im ply a colle ction o norm al variations in bre as t tis s ue . 7. O ri e ( pening) vagina
Eve n though the lum ps as s ociate d w ith f brocys tic dis e as e 8. Labia maj ra
are be nign, any s us picious lum p or othe r change in bre as t
tis s ue s hould be re garde d as pos s ibly cance rous until de - T e mons pubis is a skin- vered pad at ver the sym-
te rm ine d othe rw is e by a phys ician. physis pubis. Pubi hair appears n this m und at at pu-
berty and persists thr ugh ut li e.
 CHAPTER 23 Reproductive Systems 633

Mons pubis

Fore s kin (pre puce ) La bium ma jus

Clitoris (gla ns )

La bium minus
Exte rna l urina ry me a tus Ope ning of le s s e r ve s tibula r
(S ke ne ) gla nd
Ve s tibule
Ve s tibula r Orifice of va gina
(clitora l) bulb Hyme n
Gre a te r ve s tibula r
(Ba rtholin) gla nd

A
Pe rine um
R L
Anus
P

FIGURE 23-14 Vulva. External emale genitals and related structures, shown rom an in erior view.

Extending d wnward r m the elevated m ns pubis are the maj rity w men, these hanges ur with alm st pre ise
labia majora, literally large lips. T ese el ngated lds, regularity thr ugh ut their repr du tive years. T e rst indi- 23
whi h are mp sed mainly at and glands, are vered ati n hanges mes with the rst menstrual peri d. T e
with pigmented skin and pubi hair n the uter sur a e and rst menses r menstrual f w is re erred t as the menarche.
are sm th and ree r m hair n the inner sur a e. T e labia A typi al menstrual y le vers a peri d ab ut 28 days.
minoraliterally small lipsare nestled medially between H wever, the length the y le varies am ng w men. S me
the labia maj ra and are vered with thin skin. T ese tw w men, r example, may have a regular y le that vers
small lips j in anteri rly at the midline. ab ut 24 days. T e length the y le als varies within ne
T e spa e between the labia min ra is the vestibule w man. S me w men, r example, may have irregular y les
(Figure 23-14). Several genital stru tures are l ated in the ves- that range r m 21 t 28 days, whereas thers may be 2 t
tibule. T e glans r head the clitoris, whi h is mp sed 3 m nths l ng.
ere tile tissue similar t that und in the penis, is l ated just
behind the anteri r jun ti n the labia min ra. T e deeper DAYS 15
ere tile tissue the lit ris bran hes int tw bulbs, ne Me ns e s (me ns trual) pe rio d
whi h an be seen under a labium majus in the ut-away n S ma ll pa tche s of de a d ce lls
right side the spe imen in Figure 23-14. of ute rine lining s lough off,
le aving torn blood ve s s e ls ;
Situated between the glans lit ris and the vaginal pening me ns trua l ble e ding come s
is the external urinary meatus. from the s e torn ve s s e ls
T e vaginal ri e is b rdered by a thin ld mu us
DAYS 1528
membrane alled the hymen. O asi nally, the hymen par-
S e c re to ry phas e
tially bl ks the vaginal pening. T e du ts the vestibular Ute rine lining pre pa re s for
glands pen n either side the vaginal ri e, medial t the pre gna ncy (tha t is, impla nta tion
labia min ra. of fe rtilize d ovum) by growing DAYS 613
thicke r, s e cre ting, a nd Pro life rative phas e
T e term perineum is used t des ribe the area between deve loping gre a te r blood s upply; Epithe lia l ce lls
the vaginal pening and anus. T is area is s metimes ut in a on la s t day, blood s upply re produce, re pa iring
surgi al pr edure alled an episiotomy t prevent tearing de cre a s e s gre a tly, ca us ing s ome ute rine lining
lining ce lls to die
tissue during hildbirth.
DAY 14
Ovulatio n
M e n s t r u a l Cyc le Ovum is re le a s e d from ova ry
O ve r v ie w a nd move s into ute rine
(fa llopia n) tube for pos s ible
T e menstrual y le nsists many hanges in the uterus, fe rtiliza tion
varies, and breasts and in the hyp thalamus and anteri r
pituitary glands se reti n h rm nes (Figure 23-15). In the FIGURE 23-15 28-day menstrual cycle.
 634 CHAPTER 23 Reproductive Systems Hypotha la mus

GnRH

P ituita ry gla nd

LH
Gona dotropin
cycle
FS H
LH conce ntra tion
FS H conce ntra tion
Follicula r pha s e Lute a l pha s e

Ova ria n cycle

Deve loping Corpus Lute a l Corpus

follicle s Ovula tion lute um re gre s s ion a lbica ns

Es troge n conce ntra tion

Ova ria n
hormone cycle P roge s te rone conce ntra tion
23
Me ns trua l Me ns e s
Ute rine Ute rine gla nd
(e ndome tria l)
blood ve s s e ls
cycle

Me ns e s P rolife ra tive S e cre tory pha s e Me ns e s

pha s e

2 4 6 8 10 12 16 18 20 22 24 26 28 days

Ovula tion

FIGURE 23-16 Female reproductive cycle. Diagram illustrates the interrelationship o pituitary, ovarian, and
uterine unctions throughout a typical 28-day cycle. Asharp increase in luteinizing hormone (LH) levels causes ovula-
tion, whereas menstruation (sloughing o o the endometrial lining) is initiated by lower levels o progesterone.
Phases T e secretory phase the menstrual y le begins at vu-
Ea h y le nsists three phases. T e three peri ds time lati n and lasts until the next menses begins. It is during this
in ea h y le are alled the menses, the proli erative phase, and phase the menstrual y le that the uterine lining rea hes its
the secretory phase. Re er ten t Figure 23-16 as y u read ab ut greatest thi kness and the vary se retes its highest levels
the events urring during ea h phase the y le in the pr gester ne.
hyp thalamus and pituitary gland, the vary, and in the
uterus. Be sure that y u d n t verl k the event that urs O v u la t io n
ar und day 14 a 28-day y le. As a general rule, during the 30 r 40 years that a w man has
T e menses is a peri d 4 r 5 days hara terized by peri ds, nly ne vum matures ea h y le. H wever, there
menstrual bleeding. T e rst day menstrual f w is nsid- are ex epti ns t this rule. S me y les, m re than ne ma-
ered day 1 the menstrual y le. tures, and s me y les n vum matures.
T e proli erative phase begins a ter the menstrual f w O vulati n urs 14 days be re the next menses begins. In
ends and lasts until vulati n. D uring this peri d the lli les a 28-day y le, this means that vulati n urs ar und day 14
mature, the uterine lining thi kens (pr li erates), and estr gen the y le, as sh wn in Figure 23-16. (Re all that the rst day
se reti n in reases t its highest level. the menses is nsidered the rst day the y le.) In a

30-day y le, h wever, vulati n w uld n t ur n the 14th
y le day, but instead n the 16th. And in a 25-day y le,
vulati n w uld ur n the 11th y le day.
T e time vulati n has great pra ti al imp rtan e
be ause the p ssibility ertilizati nthe usi n a
sperm and egg an ur nly during a sh rt peri d
time during ea h menstrual y le. Alth ugh a ew super
sperm may remain viable r up t 5 days, m st sperm retain
their ertilizing p wer r nly 24 t 72 h urs a ter being
dep sited in the emale repr du tive tra t ll wing eja u-
lati n. And, the yte remains viable and apable being
ertilized r nly ab ut 12 t 24 h urs a ter vulati n. A
w mans ertile peri d there re lasts nly a ew days ea h
y le r m between 3 t 5 days be re, and n later than
24 h urs a ter, vulati n.
To learn more about ovulation, go to
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C o n t ro l o t h e M e n s t r u a l Cyc le
T e anteri r pituitary gland plays a riti al r le in regulat-
ing the y li hanges that hara terize the un ti ns
the emale repr du tive system (see Chapter 12). As
n ted earlier, se reti n G nRH r m the hyp thalamus
stimulates the anteri r pituitary gland t se rete the g -
nad tr pins FSH and LH . Fr m day 1 t ab ut day 7 the
menstrual y le, G nRH sele tively stimulates the anteri r
pituitary gland t se rete in reasing am unts FSH . A
high bl d n entrati n FSH stimulates several imma-
ture varian lli les t start gr wing and se reting estr gen
(see Figure 23-16).
W rking t gether, in reasing levels estr gen and GnRH
in bl d stimulate the anteri r pituitary gland t release in-
reasing am unts LH . LH auses maturing a lli le and
its vum, vulati n (rupturing mature lli le with eje ti n
vum), and luteinizati n ( rmati n a yell w b dy, the
rpus luteum, r m the ruptured lli le).
W hi h h rm neFSH r LH w uld y u all the vu-
lating h rm ne? D y u think vulati n uld ur i the
bl d n entrati n FSH remained l w thr ugh ut the
menstrual y le? I y u answered LH t the rst questi n and
n t the se nd, y u answered b th questi ns rre tly. O vu-
lati n ann t ur i the bl d level FSH stays l w be-
ause a high n entrati n this h rm ne is essential t
stimulati n varian lli le gr wth and maturati n. W ith a
l w level FSH , n lli les start t gr w, and there re n ne
be me ripe en ugh t vulate. O vulati n is aused by the
mbined a ti ns FSH and LH . Birth ntr l pills that
ntain estr gen substan es suppress FSH se reti n. T is in-
dire tly prevents vulati n.
O vulati n urs, as we have said, be ause the mbined
a ti ns the tw anteri r pituitary h rm nes, FSH and LH .
T e next questi n is: what auses menstruati n? A brie an-
swer is this: a sudden, sharp de rease in estr gen and pr ges-
ter ne se reti n t ward the end the se ret ry phase auses
the uterine lining t break d wn and an ther menstrual pe-
ri d t begin.
CHAPTER 23 Reproductive Systems 635
D is o r d e r s o t h e Fe m a le
Re p ro d u c t ive S y s t e m
Ho r m o n a l a n d M e n s t r u a l
D is o r d e r s
Dys m e n o rrh e a
Menstrual cramps, r dysmenorrhea, are terms used t de-
s ribe the ramping, pain ul peri ds that a e t 75% t 80%
w men at s me time during their repr du tive years. F r
signi ant numbers th se a e ted, severe l wer abd minal
ramping and ba k pain a mpanied by heada he, nausea,
and v miting will disrupt their s h l, w rk, athleti , r ther
a tivities.
Primary dysmenorrhea is the m st mm n type urring
in ad les ents and y ung w men. Sympt ms, whi h an last
r m h urs t days and vary in severity r m y le t y le,
are aused by verpr du ti n pr staglandins in the inner
lining the uterus. Pr staglandins ause spasms that de-
rease bl d f w and xygen delivery t uterine mus le re-
sulting in pain. F rtunately, primary dysmen rrhea is n t
ass iated with pelvi disease, su h as an in e ti n r tum r,
and generally an be treated e e tively with ver-the- unter
anti-inf ammat ry drugs su h as ibupr en and napr xen,
whi h de rease pr staglandin pr du ti n. In severe ases a 23
physi ian may pres ribe m re p wer ul anti-inf ammat ry
drugs r ertain h rm nes, in luding ral ntra eptives, t
alter menstrual y le a tivity.
Secondary dysmenorrhea re ers t menstrual-related pain
aused by s me type pelvi path l gy. T e pr blem is gen-
erally a gyne l gi al pr blem a e ting ne r m re repr -
du tive rgan. reatment se ndary dysmen rrhea inv lves
treating the underlying dis rder.
Am e n o rrh e a
Amenorrhea is the absen e n rmal menstruati n.
Primary amenorrhea is the ailure menstrual y les t
begin and may be aused by a variety a t rs, su h as h r-
m ne imbalan es, geneti dis rders, brain lesi ns, r stru -
tural de rmities the repr du tive rgans.
Secondary amenorrhea urs when a w man wh has pre-
vi usly menstruated sl ws t three r ewer y les per year.
Se ndary amen rrhea may ur with weight l ss, preg-
nan y, la tati n, men pause, r disease the repr du tive
rgans.
reatment amen rrhea inv lves treating the underlying
dis rder r nditi n.
D y s u n c t io n a l U t e r in e Ble e d in g
D ys unctional uterine bleeding (D UB) is irregular r ex es-
sive uterine bleeding that m st ten results r m either a
h rm nal imbalan e r s me type stru tural pr blem that
auses a disrupti n bl d supply. DUB is a signi ant
medi al pr blem a e ting nearly 2 milli n w men in the
United States ea h year. Ex essive uterine bleeding ver time
an result in li e-threatening anemia be ause the hr ni
l ss bl d.
 636 CHAPTER 23 Reproductive Systems
C LIN ICA L APPLICATION
AMENORRHEA IN FEMALE ATHLETES
Failure to have a m e ns trual pe riod is calle d am e no rrhe a.
Am e norrhe a occurs in s om e e m ale athle te s , probably
re s ulting rom a body at com pos ition that is too low to
s us tain norm al re productive unction. Although it ke e ps
the he m atocrit (re d blood ce ll leve l) highe r than during
m e ns truation, it is not cons ide re d a de s irable condition.
Be s ide s in e rtility, am e norrhe a m ay caus e othe r prob-
le m s . For exam ple , the low blood leve ls o e s troge n
as s ociate d w ith long-te rm am e norrhe a m ay caus e os -
te oporos is (los s o bone m as s ).
diagn se the ause DUB, a physi ian may empl y
x-ray r ultras und studies t l k at the nt urs the uter-
ine avity, l k dire tly inside the uterus using a teles pe-like
instrument inserted thr ugh the vagina and ervix r examine
tissue btained by bi psy t ex lude an er.
I h rm nal imbalan e is the ause, it is the ex essive
23 gr wth and breakd wn deli ate end metrial tissue that
results in heavy bleeding. Stru tural pr blems, su h as gr wth
a uterine malignan y, p lyps, r br ids (dis ussed n
pp. 637638), als may ause DUB by ausing injury t the
bl d vessels the uterine wall r lining.
reatment D UB generally begins with administrati n
n nster idal anti-inf ammat ry drugs and h rm nal ma-
nipulati n using l w-d se birth ntr l pills. I nservative
treatment ails t st p the end metrial lining r m hem r-
rhaging, hystere t my remains ne the m st e e tive
urative pti ns. Currently, ab ut 20% hystere t mies
per rmed ea h year are r treatment abn rmal uterine
bleeding.
Less invasive pr edures, in luding endometrial ablation
te hniques, are n w being used m re requently t destr y the
end metrial lining and halt the bleeding. In thermal ablation,
a ball n is inserted int the uterus and lled with f uid. A
heat pr be is then inserted int the ball n and the f uid is
heated t a temperature that will destr y the end metrium. In
radio requency ablation, a g ld-plated mesh abri is used t ll
the uterine avity and is then harged with radi requen y
energy that destr ys the damaged and bleeding end metrial
ells. B th pr edures arry less risk and have sh rter re very
peri ds than d es a hystere t my.
P r e m e n s t r u a l S y n d ro m e
Premenstrual syndrome (PMS) is a nditi n that inv lves a
lle ti n sympt ms that regularly ur in s me w men
during the se ret ry phase their repr du tive y les. Symp-
t ms in lude irritability, atigue, nerv usness, depressi n, and
ther pr blems that are ten distressing en ugh t a e t
pers nal relati nships. Be ause the ause PMS is still un-
lear, urrent treatments us n relieving the sympt ms.
In e c t io n a n d In a m m a t io n
In e c t io n s
In e ti ns the emale repr du tive tra t are ten lassi ed
as exogenous r endogenous. Ex gen us in e ti ns result r m
path geni rganisms transmitted r m an ther pers n, su h
as sexually transmitted diseases (S D s).
Endogenous in ections result r m path gens that n r-
mally inhabit the intestines, vulva, r vagina. Y u may re all
r m Chapter 6 that many areas the b dy are n rmally
inhabited by path geni mi r bes but that they ause in e -
ti n nly when there is a hange in nditi ns, r they are
m ved t a new area.
P e lv ic In a m m a t o ry D is e a s e
Pelvic in ammatory disease (PID ) urs as either an a ute
r hr ni inf ammat ry nditi n that an be aused by sev-
eral di erent path gens, whi h usually spread upward r m
the vagina. PID is a maj r ause in ertility and sterility and
a e ts m re than 800,000 w men ea h year in the United
States. It is a mm n mpli ati n ll wing in e ti n by
g n al (Neisseria gonorrhoeae) and hlamydial mi r r-
ganisms (see Table 23-4).
In PID any inf ammati n inv lving the uterus, uterine
tubes, varies, and ther pelvi rgans ten results in devel-
pment s ar tissue and adhesi ns. As a result, seri us m-
pli ati ns, in luding in ertility resulting r m tubal bstru -
ti n r ther damage t the repr du tive tra t, may ur.
Uterine tube inf ammati n is termed salpingitis and inf am-
mati n the varies is alled oophoritis.
Lapar s pi examinati n is ten used t make a de nitive
diagn sis r t determine the severity the in e ti n and the
repr du tive rgans inv lved. Alth ugh s me hlamydial in-
e ti ns may n t ause sympt ms, m st ases PID are a -
mpanied by ever, pelvi tenderness, and pain. Un rtunately,
be ause s arring and adhesi ns, pain may ntinue even
a ter antibi ti therapy has eliminated the a tive in e ti n.
I le t untreated, PID in e ti ns may spread t ther tis-
sues, in luding the bl d, resulting in septi sh k and death.

Va g in it is
Vaginitis is inf ammati n r in e ti n the vaginal lining.
Vaginitis m st ten results r m S Ds r r m a yeast
in e ti n. Yeast in e ti ns are usually pp rtunisti in e ti ns
the ungus Candida albicans, pr du ing vaginal candidiasis
(see Appendix A at evolve.elsevier.com). Candidiasis in e ti ns
are hara terized by a whitish dis hargea sympt m kn wn
as leukorrhea.
Tu m o r s a n d Re la t e d C o n d it io n s
Be n ig n U t e r in e Tu m o r s
T e terms broid, myoma, and bromyoma are all w rds
used t des ribe benign (n n an er us) tum rs uterine -
br us r sm th mus le tissue.
Individual br ids may ur but multiple gr wths are n t
unusual. Fibr ids are mm n in w men during their repr -
du tive years and devel p m st ten in the my metrium
the uterine b dy and rarely in the ervix. T e a t that they are
seld m seen be re puberty, in rease in size during pregnan y,
and tend t shrink in p stmen pausal w men suggests that
age and estr gen levels may play a r le in their devel pment.
Fibr ids range in size r m small asympt mati n dules t
massive tum rs that may be pain ul and exert pressure n
ther pelvi rgans. Gr wth during pregnan y may result in
pla ental hem rrhage r malpresentati n the etus, m-
pli ating lab r and delivery.
In additi n t pain, sympt ms benign uterine tum rs
will vary depending n the size and l ati n the tum r. F r
example, i a large br id mpresses the bladder and re tum,
sympt ms urinary requen y and nstipati n may result.
Even small tum rs devel ping beneath the end metrium an
ause severe hem rrhage (D UB).
um r size, l ati n, and severity sympt ms determine
treatment pti ns. A relatively new te hnique, similar t a
heart atheterizati n, alled uterine artery embolization inv lves
snaking a small atheter thr ugh an artery in the gr in int the
arterial vessel supplying bl d t a br id. iny inert pellets are
then inje ted int the artery, bl king the f w bl d. T e
pr edure results in dramati shrinkage the treated br id
and a redu ti n in sympt ms, in luding hem rrhage.
Surgi al rem val individual br ids r, in m re severe
ases, hystere t my may be indi ated.
O va r ia n Cy s t s
O varian cysts are very mm n f uid- lled ysts that devel p
either r m lli les that ail t rupture mpletely ( ol-
licular cysts) r r m rp ra lutea that ail t de- de
generate (luteal cysts).
M st w men devel p a number these hese
ysts during their repr du tive years and nd
their presen e d es n t represent a diagn -
sis p ly ysti vary syndr me. Alth ughh
varian ysts are ten multiple, they rarely
ely
be me danger us. H wever, n asii n
they may be me quite large and pain ul and
be diagn sed by palpati n r ultras n graphy.
raphy.
CHAPTER 23 Reproductive Systems 637
Luteal ysts are less mm n than lli ular ysts but tend
t ause m re sympt ms, su h as pelvi pain and menstrual
irregularities. Rarely, rupture a large luteal yst will result in
internal bleeding that requires surgi al interventi n. T e vast
maj rity all varian ysts will disappear within a ew
m nths their appearan e, m st within 60 days.
Polycystic ovary syndrome (PCOS) is a nditi n that
a e ts 10% repr du tive-age w men but als an a e t
girls as y ung as 11 years ld. It is hara terized by enlarged
varies that usually are studded with f uid- lled ysts ab ut
0.5 t 1.5 m in diameter (Figure 23-17). T e ysts are und
n b th varies and devel p r m mature lli les that ail t
rupture mpletely. C rp ra lutea are generally absent.
W men with PCOS requently have numer us end rine
abn rmalities, in luding high levels test ster ne, in re-
quent menstrual y les, and persistent an vulati n. PCOS is
the m st mm n ause emale in ertility.
En d o m e t r io s is
Endometriosis is the presen e un ti ning end metrial
tissue utside the uterus. T e displa ed end metrial tissue an
ur in many di erent pla es thr ugh ut the b dy but is
m st ten und in r n pelvi and abd minal rgans. T e
tissue rea ts t varian h rm nes in the same way as the n r-
mal end metriumexhibiting a y le gr wth and sl ugh- 23
ing .
Sympt ms end metri sis may in lude unusual bleed-
ing, dysmen rrhea, and pain during inter urse. I sympt ms
are mild, pain medi ati ns are s metimes e e tive. O ral n-
tra eptives, whi h alter the h rm ne levels that pr du e en-
d metrial hanges during the menstrual y le, are e e tive in
redu ing the a tivity end metri sis.
Ca n c e r
Malignancies repr du tive and related rgans, espe ially the
breasts, a unt r the maj rity an er ases am ng w men.
Breast Cancer
Ab ut 1 in 8 w men eventually get breast an er, ten a rm
aden ar in ma. reatment breast an er is ten su -
ess ul i the an er us tum r is dete ted early. Be ause su h
tum rs are ten painless, m st physi ians re mmend regu-
lar, requent sel -examinati n breast tissue, as well as an-
nual mamm grams r w men (see Chapter 6). reatments
ten inv lve surgery, hem therapy, and radiati n therapy.
Breast surgeries an be very nservative, as in a simple
lump rem val r lumpectomy. I metastasis t sur-
r unding tissue is suspe ted, a m di ed
radical mastectomy may be per rmed.
this pr edure the entire breast, with
In th
nearby lymph n des, is rem ved.
near
FIGURE 23-17 Polycystic ovary syn-
drome (PCOS). The ovary is studded with
f uid- lled cysts developed rom ollicles that
have ailed to rupture.
 638 CHAPTER 23 Reproductive Systems Brus h Ce rvix

Just as lumpe t my results in less trauma than m di ed

radi al maste t my, s alled limited- eld radiation an pr -
vide e e tive treatment r learly de ned early-stage an ers
that have n t spread. It d es s with sh rter treatment y les
and ewer side e e ts than wh le-breast radiati n.
In the past, a ter w men had mpleted their initial treat-
ment r breast an er they had ew pti ns available t lessen
the p ssibility re urren e. F r a number years the drug
tamoxi en has been used extensively t prevent the re urren e
breast an er ueled by estr gen. It d es s by bl king the S pe culum
estr gen re ept r sites n the an er ell membrane. Un rtu- A
nately, tam xi en e e tiveness is limited t ab ut 5 years.
I S
Newer drugs lassi ed as aromatase inhibitors a tually
bl k estr gen pr du ti n, instead bl king estr gen re- A P
ept rs. T is type drug may repla e tam xi en r be pre-
s ribed r use a ter 5 years tam xi en therapy. O ther ra-
ti nal drugs and ther treatments are being devel ped t alter
r bl k ru ial metab li pathways in treating breast and
ther rms an er.

Ovarian Cancer
Ovarian cancer is an ther malignan y that a e ts 1 in
70 w men in Ameri a. Usually a type aden ar in ma,
varian an er is di ult t dete t early and is ten n t easily
23 apparent until it has gr wn int a large mass. Regular pelvi
B
examinati ns that in lude palpati n the varies may result
in earlier dete ti n.
Risk a t rs r varian an er in lude age ( ver 40), in er-
tility, hildlessness r ew hildren, a hist ry mis arriages,
and end metri sis.
O varian an er is ten treated by surgi al rem val the
varies mbined with radiati n therapy and hem therapy.

Uterine Cancer
Can er the uterus an a e t the b dy the uterus r the
ervix.
Can ers the uterine b dy m st ten inv lve the end -
metrium (endometrial cancer) and m stly a e t w men be-
y nd hildbearing years; a mm n sympt m is p stmen -
pausal uterine bleeding. Risk a t rs r this type an er
in lude besity, pr l nged estr gen therapy, and in ertility.
Cervical cancer urs m st ten in w men between the
ages 30 and 50.
Cervi al an er is ten diagn sed early, thr ugh s reening
tests su h as the Papanicolaou test, r Pap smear (Figure 23-18).
In this test, ells swabbed r m the ervix are smeared n a
glass slide, stained, and examined mi r s pi ally t deter-
mine whether any abn rmalities exist. Current re mmenda-
ti ns suggest tw Pap smears 1 year apart beginning at age 21.
I these tw Pap smears are negative (that is, revealing n
abn rmalities), subsequent Pap smears sh uld ur every 1 t
3 years therea ter.
Be ause early r requent inter urse is a risk a t r r
ervi al an er, sexually a tive y ung w men sh uld have their
rst Pap smear mu h earlierand have ll w-ups d ne m re
ten.
Be ause s reening tests and ther early dete ti n meth ds
have been s su ess ul, the death rates r uterine an ers
C
FIGURE 23-18 Papanicolaou (Pap) smear. A, Obtaining a Pap smear.
B, Appearance o normal cervical epithelial cells in Pap smear. C, Appearance
o cervical cancer cells in Pap smear. Note the reduction in cytoplasm and in-
creased prominence o the nuclei compared with normal epithelial cells.
have dr pped dramati ally ver the last ew de ades. Be ause
human papillomavirus (HPV) in e ti ns dramati ally in rease
the risk devel ping ervi al an er, widespread use H PV
va ines in b th men and w men have already begun t re-
du e the spread H PVthus redu ing death rates r m this
type an er.
In e r t ilit y
Like in the male repr du tive system, vari us dis rders an
disrupt n rmal un ti n the emale repr du tive tra t s that
su ess ul repr du ti n is unlikely (in ertility) r imp ssible
(sterility). In e ti ns, tum rs, h rm nal imbalan es, and ther
a t rs an ntribute t in ertility r sterility in w men.
 CHAPTER 23 Reproductive Systems 639

S C IEN C E APPLICATIONS
REPRODUCTIVE S CIENCES
The s tudy o hum an re production,
and e s pe cially s exual unction, has
m any cultural im plications . So it is
no wonde r that Am e rican re s e arch-
e rs William Mas te rs and Virginia
Johns on e ncounte re d a gre at de al
o controve rs y during the ir de cade s
o pione e ring work in the f e ld o
hum an s ex and re production. They
we re the f rs t to s tudy hum an s ex-
William Masters ual phys iology in the laboratory.
(19152001) Dr. William Mas te rs was a
gyne co lo g is t (phys ician s pe cializ-
ing in wom e ns he alth) and Virginia Johns on was traine d in
ps ychology. In 1966, the ir book Hum an Sexual Re s pons e
cle arly explaine d the phys iology o s ex or the f rs t tim e . Be -
s ide s m aking dis cove rie s in the phys iology o hum an s ex and
re production, they als o deve lope d the rapie s or tre ating s ex-
re late d conditions , and they traine d
the rapis ts rom around the world.
In addition to the broad f e lds o
biology, m e dicine , ps ychology, and
the be havioral s cie nce s , the pio-
ne e ring work o Mas te rs and John-
s on pave d the way or advance s in
s uch dive rs e and s pe cialize d are as
o know le dge as com parative ne u-
ros cie nce and s ocial dynam ics .
Today, the re are m any opportu- Virginia Johnson
nitie s to apply know le dge o re pro- (1925-2013)
ductive s cie nce in a varie ty o pro-
e s s ions . Re productive he alth nurs e s , gyne cologis ts , and
uro lo g is ts o te n provide prim ary re productive care to adult
m e n and w om e n. Re productive m e dicine clinical s ta he lp
couple s im prove e rtility. Ps ychologis ts and couns e lors he lp
patie nts s truggling w ith various s e xual conce rns .

F r example, inf ammati n r in e ti n the uterine S u m m a ry o M a le a n d Fe m a le 23

tubes an result in s arring that bl ks sperm r m rea hing
the vum r prevents the vum r m traveling t the uterus.
In e ti ns, an er, r h rm nal imbalan es may inhibit the
emale repr du tive y le, preventing the pr du ti n and re-
lease a healthy vum ea h y le. Su h nditi ns als may
inter ere with the devel pment the uterine lining that is
essential r su ess ul pregnan y.
Be ause sexual repr du ti n requires n rmal un ti n
b th male and emale systems, in ertility a uple may re-
sult r m the in ertility either partner. A uple is nsid-
ered in ertile i a pregnan y d es n t ur a ter a year
reas nably requent sexual inter urse (with ut ntra ep-
ti n). W hen uples seek help r in ertility pr blems, ne
the rst steps in diagn sis is t determine whether there is a
pr blem in the male partner r the emale partner r b th.
For in ormation on strategies available to couples
to prevent pregnancy, see the article Contracep-
tion at Connect It! at evolve.elsevier.com.
Re p ro d u c t ive S y s t e m s
T e repr du tive systems in b th sexes rev lve ar und the
pr du ti n repr du tive ells, r gametes (sperm and va),
as well as me hanisms t ensure uni n these tw ells; the
usi n these ells enables trans er parental geneti in r-
mati n t the next generati n.
Table 23-3 mpares several anal g us mp nents the
repr du tive systems in b th sexes. Y u an see that men and
w men have similar stru tures t a mplish mplementary
un ti ns. In additi n, the emale repr du tive system permits
devel pment and birth the springthe rst subje t
ur next hapter.
S e x u a lly Tr a n s m it t e d D is e a s e s
Sexually transmitted diseases (S D s), rmerly alled vene-
real diseases (VDs), are in e ti ns aused by mmuni able
path gens su h as viruses, ba teria, ungi, r pr t z ans (see
Appendix A at evolve.elsevier.com).

TABLE 23-3 Analogous* Features o the Reproductive Systems

FEATURE FEMALE MALE
Es s e ntial organs Ovarie s Te s te s
Sex ce lls Ova (e ggs ) Spe rm
Horm one s Es troge n and proge s te rone Te s tos te rone
Horm one -producing ce lls Granulos a ce lls and corpus lute um Inte rs titial ce lls
Duct s ys te m s Ute rine ( allopian) tube s , ute rus , and vagina Epididym is , vas de e re ns , and ure thra
Exte rnal ge nitals Clitoris and vulva Pe nis and s crotum

* Re s e m bling or s im ilar in s om e re s pe cts .

 640 CHAPTER 23 Reproductive Systems

T e term sexually transmitted in ection (S I) is s me-
times used in pla e the term S D but d es n t have exa tly
the same meaning. An S I is an in e ti n that may r may
n t ause sympt ms. An S D urs when an S I pr gresses
t a tually pr du e sympt ms that make a pers n eel si k
making S I a br ader term than S D.
T e a t r that links all these in e ti ns r diseases and
gives this ateg ry its name is the a t that they are transmitted
by sexual nta t. T e term sexual contact re ers t sexual inter-
urse in additi n t any nta t between the genitals ne
pers n and the b dy an ther pers n.
Diseases lassi ed as S Ds an be transmitted sexually, but
that is n t the nly way t transmit them. F r example, human
immunode ciency virus (HIV) in e ti n is a viral nditi n that
an be spread thr ugh sexual nta t but is als spread by
trans usi n in e ted bl d and use ntaminated medi al

TABLE 23-4 Examples o Sexually Transmitted Diseases (STDs)

DIS EAS E PATHOGEN DES CRIPTION
Acquire d im m unode f - Virus : Hum an im m unode f - HIV is trans m itte d by dire ct contact o body uids , o te n during s exual contact.
cie ncy s yndrom e cie ncy virus (HIV) A te r a pe riod that s om e tim e s las ts m any ye ars , HIV in e ction produce s the con-
(AIDS) dition know n as AIDS. AIDS is characte rize d by dam age to lym phocyte s (T ce lls ),
re s ulting in im m une s ys te m im pairm e nt. De ath re s ults rom s e condary in e c-
tions or tum ors .
Candidias is Fungus : Candida albicans This ye as t in e ction is characte rize d by a w hite dis charge (le ukorrhe a), pe e ling o
s kin, and ble e ding. Although it can occur as an ordinary opportunis tic in e ction, it
m ay be trans m itte d s exually as we ll.
Chancroid Bacte rium : Hae m ophilus A highly contagious STI, chancroid is characte rize d by papule s on the s kin o the
ducreyi ge nitals that eve ntually ulce rate . About 90% o cas e s are re porte d by m e n.
Chlamydia Bacte rium : Chlamydia The m os t com m on STD, m os t in e cte d pe ople have no s ym ptom s ; s ym ptom s
trachom atis include burning pain and dis charge ; e as ily tre ate d w ith antibiotics ; i not tre ate d,
23 m ay progre s s to PID.
Ge nital he rpe s Virus : He rpe s s im plex virus HSV caus e s blis te rs on the s kin o the ge nitals . The blis te rs m ay dis appe ar te m po-
(HSV) rarily but m ay re appe ar occas ionally, e s pe cially as a re s ult o s tre s s .
Ge nital warts Virus : Hum an papillom avirus Ge nital warts are nipple like ne oplas m s o s kin cove ring the ge nitals . An e e ctive
(HPV-6, HPV-7) vaccination is available . HPV is know n to caus e ce rvical cance r.
Giardias is Protozoan: Giardia lam blia This inte s tinal in e ction m ay be s pre ad by s exual contact. Sym ptom s range rom
m ild diarrhe a to m alabs orption s yndrom e , w ith about hal o all cas e s be ing
as ym ptom atic.
Gonorrhe a Bacte rium : Ne is s e ria Gonorrhe a prim arily involve s the ge nital and urinary tracts but can a e ct the throat,
gonorrhoe ae conjunctiva, or lowe r inte s tine s . It m ay progre s s to PID.
He patitis Virus : He patitis B virus (HBV) This acute -ons e t live r in am m ation m ay deve lop into a s eve re chronic dis e as e ,
pe rhaps e nding in de ath.
Lym phogranulom a Bacte rium : Chlamydia This chronic STD is characte rize d by ge nital ulce rs , s wolle n lym ph node s , he ad-
ve ne re um (LGV) trachom atis ache , eve r, and m us cle pain. C. trachom atis in e ction m ay caus e a varie ty o
othe r s yndrom e s , including conjunctivitis , uroge nital in e ctions , and s ys te m ic
in e ctions . C. trachom atis in e ctions cons titute the m os t com m on STI in the
Unite d State s (nongonorrhe al ure thritis ) and o te n progre s s to PID.
Pubic (crab) lice Anim al: Phthirius pubis Characte rize d by itching and the pre s e nce o vis ible nits (lice e ggs on pubic hairs )
or craw ling lice , this in e s tation is tre ate d by m e dication, m anual re m oval o nits ,
and tre atm e nt o clothing, towe ls , be dding.
Scabie s Anim al: Sarcopte s s cabie i Scabie s is caus e d by in e s tation by the itch m ite , w hich burrow s into the s kin to lay
e ggs . About 2 to 4 m onths a te r initial contact, a hype rs e ns itivity re action
occurs , caus ing a ras h along e ach burrow that itche s inte ns e ly. Se condary bacte -
rial in e ction is pos s ible .
Syphilis Bacte rium : Tre pone m a Although trans m itte d s exually, s yphilis can a e ct any s ys te m . Prim ary s yphilis is
pallidum characte rize d by chancre s ore s on expos e d are as o the s kin. I the prim ary
in e ction goe s untre ate d, s e condary s yphilis m ay appe ar 2 m onths a te r chan-
cre s dis appe ar. The s e condary s tage occurs w he n the s piroche te has s pre ad
throughout the body, pre s e nting a varie ty o s ym ptom s , and it is s till highly
contagious eve n through kis s ing. Te rtiary s yphilis m ay appe ar ye ars late r, pos s i-
bly re s ulting in de ath.
Trichom onias is Protozoan: Trichom onas This urological in e ction is as ym ptom atic in m os t wom e n and ne arly all m e n. Vagini-
vaginalis tis m ay occur, characte rize d by itching or burning, and a oul-s m e lling dis charge .

AIDS, Acquire d im m unode f cie ncy s yndrom e ; HIV, hum an im m unode f cie ncy virus ; PID, pe lvic in am m atory dis e as e ; STI, s exually trans m itte d in e ction.
 CHAPTER 23 Reproductive Systems 641

instruments su h as intraven us needles and syringes. Candi- QUICK CHECK

diasis, r yeast in e ti n, is a mm n pp rtunisti in e ti n,
but it als an be transmitted thr ugh sexual nta t. T e Z ika
virus is widely transmitted by m squit ve t rs, but an als be
transmitted thr ugh sexual nta t.
Sexually transmitted diseases are the m st mm n all
mmuni able diseases. Table 23-4 summarizes a ew the
prin ipal S Ds.
1. Wh ich e m a le s tru ctu re is m a d e o e re ctile tis s u e ?
2. Wh a t is a n o th e r te rm o r m e n s e s ?
3. Wh ich h o rm o n e re a ch e s a h ig h p e a k ju s t b e o re
ovu la tio n ?
4. Wo m e n w ith p o lycys tic ova ry s yn d ro m e re q u e n tly s u e r
ro m w h a t co n d itio n s ?

For more in ormation on STDs, including photo-

graphs o their typical signs, see the article
Sexually Transmitted Diseases at Connect It! at
evolve.elsevier.com.

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 617)

corpora cavernosa external urinary meatus gonadotropin-releasing hormone (GnRH)

(KOHR-pohr-ah kav-er-NO-sah) (eks-TER-nal YOOR-ih-nayr-ee mee-AY-tus) (goh-nah-doh-TROH-pin ree-LEES-ing
sing., corpus cavernosum pl., meatus or meatuses HOR-mohn [jee en ar aych])
(KOHR-pus kav-er-NO-sum) (mee-AY-tus or mee-AY-tus-ez) [gon- o spring, -ad- relating to, -trop- nourish,
[corpus body, cavern- large hollow, [extern- outside, -al relating to, urin- urine, -in substance, hormon- excite]
-os- relating to, -um thing]
corpus luteum
-ary relating to, meatus channel or passage]
allopian tube
graaf an ollicle
(GRAH- ee-en FOL-lih-kul)
23
(KOHR-pus LOO-tee-um) ( al-LOH-pee-an toob) [Reijnier de Graa Dutch physician, -an relating
pl., corpora lutea [Gabriele Fallopio Italian anatomist] to, oll- bag, -icle little]
(KOHR-pohr-ah LOO-tee-ah) f mbria granulosa cell
[corpus body, lute- yellow, -um thing] (FIM-bree-ah) (gran-yoo-LOH-sah sel)
corpus spongiosum pl., f mbriae [gran- grain, -ul- little, -osa relating to,
[corpus body, spong- sponge, -os- relating (FIM-bree-yee) cell storeroom]
to, -um thing] [f mbria ringe] greater vestibular gland
(KOHR-pus spun-jee-OH-sum) ollicle-stimulating hormone (FSH) (GRAYT-er ves-TIB-yoo-lar gland)
Cowper gland (FOL-lih-kul-STIM-yoo-lay-ting HOR-mohn [vestibul- entrance hall, -ar relating to,
(KOW-per gland) [e es aych]) gland acorn]
[William Cowper English anatomist, [ oll- bag, -icle little, stimul- excite, -at- process, hymen
gland acorn] -ing action, hormon- excite] (HYE-men)
ductus de erens oreskin [hymen membrane]
(DUK-tus DEF-er-enz) (FORE-skin) interstitial cell
[ductus duct, de- away rom, - er- bear or carry] [ ore- ront, -skin a hide] (in-ter-STISH-al sel)
ejaculation undus [inter- between, -stit- stand, -al relating to,
(ee-jak-yoo-LAY-shun) (FUN-dus) cell storeroom]
[e- out or away, -jacula- throw, -ation process] [ undus bottom] labia majora
ejaculatory duct gamete (LAY-bee-ah mah-J OH-rah)
(ee-J AK-yoo-lah-toh-ree dukt) (GAM-eet) sing., labium majus
[e- out or away, -jacula- throw, -ory relating to, [gamet- sexual union or marriage partner] (LAY-bee-um MAY-jus)
duct a leading or path] [labia lips, majora large]
genital
endometrium (J EN-ih-tal) labia minora
(en-doh-MEE-tree-um) pl., genitalia (LAY-bee-ah mih-NO-rah)
[endo- within, -metr- womb, -um thing] (jen-ih-TAYL-yah) sing., labium minus
epididymis [gen- produce, -al relating to] (LAY-bee-um MYE-nus)
(ep-ih-DID-ih-mis) glans [labia lips, minora small]
[epi- upon, -didymis pair] (glans) lacti erous duct
essential organ [glans acorn] (lak-TIF-er-us dukt)
(eh-SEN-shul OR-gun) gonad [lact- milk, - er- bear or carry, -ous having to do
[organ instrument] (GOH-nad) with, duct a leading or path]
estrogen [gon- o spring, -ad relating to]
(ES-troh-jen)
[estro- renzy, -gen produce] Continued on p. 642
 642 CHAPTER 23 Reproductive Systems

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 641)

lesser vestibular gland perineum sperm

(LES-er ves-TIB-yoo-lar gland) (payr-ih-NEE-um) (sperm)
[vestibul- entrance hall, -ar relating to, [peri- around or near, -ine- excrete or evacuate, pl., sperm
gland acorn] -um thing] [sperm seed]
luteinizing hormone (LH) polar body spermatid
(loo-tee-in-AYE-zing HOR-mohn [el aych]) (POH-lar BOD-ee) (SPER-mah-tid)
[lute- yellow, -izing process, hormon- excite] [pol- pole, -ar relating to] [sperm- seed, -id relating or belonging to]
meiosis prepuce spermatogenesis
(my-OH-sis) (PREE-pus) (sper-mah-toh-J EN-eh-sis)
[mei- smaller, -osis process] [pre- be ore, -puc- penis] [sperm- seed, -gen- produce, -esis process]
menarche primary ollicle spermatogonia
(meh-NAR-kee) (PRYE-mayr-ee FOL-ih-kul) (sper-mah-toh-GOH-nee-ah)
[men- month, -arche beginning] [prim- f rst, -ary state, olli- bag, -cle small] [sperm- seed, -gonia o spring]
menopause primary spermatocyte spermatozoon
(MEN-oh-pawz) (PRYE-mayr-ee SPER-mah-toh-syte) (sper-mah-tah-ZOH-on)
[men- month, -paus- cease] [prim- f rst, -ary state, sperm- seed, -cyte cell] pl., spermatozoa
menses progesterone (sper-mah-tah-ZOH-ah)
(MEN-seez) (proh-J ES-ter-ohn) [sperm- seed, -zoon animal]
[menses months] [pro- provide or, -gester- bearing (pregnancy), testis
menstrual cycle -stero- solid or steroid derivative, (TES-tis)
(MEN-stroo-al SYE-kul) -one chemical] pl., testes
23 [mens- month, -al relating to, cycle circle] proli erative phase (TES-teez)
(PROH-li -er-eh-tiv ayz) [testis witness (male gonad)]
mons pubis
(monz PYOO-bis) [proli- o spring, - er- bear or carry, -at- process, testosterone
[mons mountain, pubis groin] -ive relating to] (tes-TOS-teh-rohn)
prostate gland [testo- witness (testis), -stero- solid or steroid
myometrium
(my-oh-MEE-tree-um) (PROS-tayt gland) derivative, -one chemical]
[myo- muscle, -metr- womb, -um thing] [pro- be ore, -stat- set or place, gland acorn] tunica albuginea
oocyte puberty (TOO-nih-kah al-byoo-J IN-ee-ah)
(OH-oh-syte) (PYOO-ber-tee) [tunica tunic or coat, albuginea white]
[oo- egg, -cyte cell] [pubert- age o maturity, -y state] urethra
oogenesis scrotum (yoo-REE-thrah)
(oh-oh-J EN-eh-sis) (SKROH-tum) [ure- urine, -thr- agent or channel]
[oo- egg, -gen- produce, -esis process] [scrotum bag] uterine tube
ovarian ollicle secretory phase (YOO-ter-in toob)
(oh-VAYR-ee-an FOL-ih-kul) (SEEK-reh-toh-ree ayz) [uter- womb, -ine relating to]
[ov- egg, -arian relating to, oll- bag, -icle little] [secret- separate, -ory relating to] uterus
ovary semen (YOO-ter-us)
(OH-var-ee) (SEE-men) [uterus womb]
[ov- egg, -ar- relating to, -y location o process] [semen seed] vagina
oviduct seminal uid (vah-J YE-nah)
(OH-vih-dukt) (SEM-ih-nal FLOO-id) [vagina sheath]
[ovi- egg, - duct a leading or path] [semin- seed, -al relating to] vas de erens
ovulation seminal vesicle (vas DEF-er-enz)
(ov-yoo-LAY-shun) (SEM-ih-nal VES-ih-kul) [vas duct or vessel, de- away rom, - er- bear or
[semin- seed, -al relating to, vesic- blister, carry]
[ov- egg, -ation process]
ovum -cle little] vestibule
(OH-vum) semini erous tubule (VES-tih-byool)
pl., ova (seh-mih-NIF-er-us TOOB-yool) [vestibul- entrance hall]
(OH-vah) [semin- seed, - er- bear or carry, -ous relating vulva
[ovum egg] to, tub- tube, -ul- little] (VUL-vah)
Skene gland [vulva wrapper]
penis
(PEE-nis) (skeen gland) zygote
pl., penes or penises [Alexander J ohnston Chalmers Skene American (ZYE-goht)
[penis male sex organ] gynecologist, gland acorn] [zygot- union or yoke]
 CHAPTER 23 Reproductive Systems 643

LANGUAGE OF M ED IC IN E

amenorrhea epispadias oligospermia

(ah-men-oh-REE-ah) (ep-is-PAY-dee-us) (ol-ih-goh-SPER-mee-ah)
[a- without, -men- month, -rrhea ow] [epi- on or above, -spad- rip or split, [oligo- ew or little, -sperm- seed, -ia condition]
benign prostatic hypertrophy (BPH) -ias condition] oophorectomy
(be-NYNE proh-STAT-ik hye-PER-troh- ee erectile dys unction (ED) (oh-o -eh-REK-toh-mee)
[bee pee aych]) (eh-REK-tyle dis-FUNK-shun [ee dee]) [oophoro- ovary, -ec- out, -tom- cut, -y action]
[benign kind, pro- be ore, -stat- set or place, [erect- set up, -ile relating to, dys- bad or oophoritis
-ic relating to, hyper- excessive or above, pain ul, - unc- per orm, -tion process] (oh-o -eh-RYE-tis)
-troph- nourishment, -y state] allopian tube [oophoro- ovary, -itis in ammation]
brachytherapy ( al-LOH-pee-an toob) ovarian cyst
(BRAKE-ee-THAYR-ah-pee) [Gabriele Fallopio Italian anatomist] (oh-VAYR-ee-an SIST)
[brachy- short, -therapy curing] f broid [ov- egg, -arian relating to, cyst bag]
candidiasis (FYE-broyd) oviduct
(kan-dih-DYE-eh-sis) [f br- f ber, -oid o or like] (OH-vih-dukt)
[candid- white, -asis condition] f brocystic disease [ovi- egg, -duct a leading or path]
circumcision ( ye-broh-SIS-tik dih-ZEEZ) Papanicolaou (pap) test
(ser-kum-SIH-zhun) [f br- thread or f ber, cyst- sac, -ic relating to, (pah-peh-nik-oh-LAH-oo test)
[circum- around, -cision cutting] dis- opposite o , -ease com ort] [George N. Papanicolaou Greek physician]
contraception f bromyoma paraphimosis
(kon-trah-SEP-shun) ( ye-broh-my-OH-mah) (para-f h-MOH-sis)
[contra- against, -cept- receive (conceive), [f bro- f ber, -my- muscle, -oma tumor] [para- beside, -phim- muzzle, -osis condition]
-tion process] gynecologist pelvic in ammatory disease (PID) 23
cryptorchidism (gye-neh-KOL-oh-jist) (PEL-vik in-FLAM-ah-tor-ee dih-ZEEZ
(krip-TOR-kih-diz-em) [gyneco- woman or emale gender, -log- words [pee aye dee])
[crypt- hidden, -orchid- testis, -ism condition] (study o ), -ist agent] [pelv- basin, -ic relating to, in am- set af re,
dys unctional uterine bleeding (DUB) hydrocele -ory relating to, dis- opposite o ,
(dis-FUNK-shun-al YOO-ter-in BLEED-ing (HYE-droh-seel) -ease com ort]
[dee yoo bee]) [hydro- water, -cele tumor] phimosis
[dys- di f cult, - unction- per ormance, hypospadias (f h-MOH-sis)
-al relating to, uter- womb, -ine relating to] (hye-poh-SPAY-dee-us) [phim- muzzle, -osis condition]
dysmenorrhea [hypo- under or below, -spad- rip or split, polycystic ovary syndrome (PCOS)
(dis-men-oh-REE-ah) -ias condition] (pahl-ee-SIS-tik OH-var-ee SIN-drohm
[dys- pain ul, -men- month, -rhea ow] hysterectomy [pee see oh es])
ectopic pregnancy (his-teh-REK-toh-mee) [poly- many, -cyst- bag, -ic relating to, ov- egg,
(ek-TOP-ik PREG-nan-see) [hyster- uterus, -ec- out, -tom- cut, -y action] -ar- relating to, -y location o process,
[ec- out o , -top- place, -ic relating to] in ertility syn- together, -drome running or (race)
endogenous in ection (in- er-TIL-ih-tee) course]
(en-DOJ -en-us in-FEK-shun) [in- not, - ertil- ruit ul, -ity state] premenstrual syndrome (PMS)
[endo- within, -gen- produce, -ous relating to, inguinal hernia (pree-MEN-stroo-al SIN-drohm
in- into, - ec- put, -tion process] (ING-gwih-nal HER-nee-ah) [pee em es])
endometrial ablation [inguin- groin, -al relating to, hernia rupture] [pre- be ore, -mens- month, -al relating to,
(en-doh-MEE-tree-al ab-LAY-shun) syn- together, -drome running or (race)
leukorrhea
[endo- within, -metr- womb, -al relating to, course]
(loo-koh-REE-ah)
ab- away rom, -lat- carry, -tion process] [leuko- white, -rrhea ow] prostate cancer
endometriosis mammary dysplasia (PROS-tayt KAN-ser)
(en-doh-mee-tree-OH-sis) [pro- be ore, -stat- set or place, cancer crab or
(MAM-mah-ree dis-PLAY-zhah)
[endo- within, -metr- womb, -osis condition] malignant tumor]
[mamma- breast, -ry relating to,
epididymitis dys- disordered, -plas(m)- substance or orm, prostatectomy
(ep-ih-did-ih-MY-tis) -ia condition] (pros-tah-TEK-toh-mee)
[epi- upon, -didymi- pair, -itis in ammation] [pro- be ore, -stat- set or place (prostate gland),
menstrual cramp
-ec- out, -tom- cut, -y action]
episiotomy (MEN-stroo-al kramp)
(eh-piz-ee-OT-oh-mee) [mens- month, -al relating to, cramp bent] radical mastectomy
[episio- pubic region, -tom- cut, -y action] myoma (RAD-ih-kal mas-TEK-toh-mee)
[radic- root, -al relating to, mast- breast,
(my-OH-mah)
-ec- out, -tom- cut, -y action]
[my- muscle, -oma tumor]
Continued on p. 644
 644 CHAPTER 23 Reproductive Systems

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 643)

salpingitis sterility vaginitis

(sal-pin-J YE-tis) (steh-RIL-ih-tee) (vaj-ih-NYE-tis)
[salping- tube, -itis in ammation] [steril- barren, -ity state] [vagin- sheath (vagina), -itis in ammation]
sexually transmitted disease (STD) urologist vasectomy
(SEKS-yoo-al-ee trans-MIH-ted dih-ZEEZ (yoo-ROL-uh-jist) (va-SEK-toh-mee)
[es tee dee]) [uro- urine, -log- words (study o ), -ist agent] [vas- vessel (vas de erens), -ec- out, -tom- cut,
[dis- opposite o , -ease com ort] -y action]
sexually transmitted in ection (STI)
(SEKS-yoo-al-ee trans-MIH-ted
in-FEK-shun [es tee aye])
[in- into, - ec- put, -tion process]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
23 or us e w ith your device , acce s s the Au d io Ch a p te r
Male Re pro ductive Sys te m
S u m m a rie s online at evolve .e ls evie r.com . A. Stru tural plan the repr du tive tra t (als alled uro-
genital tract)
Scan this s um m ary a te r re ading the chapte r to 1. O rgans lassi ed as essential r accessory (Figure 23-1
he lp you re in orce the key conce pts . Late r, us e and Table 23-1)
the s um m ary as a quick review be ore your clas s 2. Essential rgans repr du ti n are the g nads (testes
or be ore a te s t. in men), whi h pr du e sex ells (spermat z a)
3. A ess ry rgans repr du ti n
a. D u tspassageways that arry sperm r m testes
S e xual Re pro ductio n t exteri r
A. Pr du ing spring b. Sex glandspr du e pr te tive and nutrient s lu-
1. Sexual repr du ti n inv lves tw parents (unlike ne- ti n r sperm
parent asexual repr du ti n); in reases variati n . External genitals
geneti traits am ng spring same parents B. estesthe g nads men
2. Gametessex ells that use at ertilizati n t rm a 1. Stru ture and l ati n (Figure 23-1 and Figure 23-2)
ne- elled zyg te, the rst ell the spring a. estes in s r tumtemperature is l wer than
a. Spermgamete r m the male parent inside b dy
b. O vumgamete r m the emale parent b. C vered by tuni a albuginea, whi h divides testis
3. Repr du tive h rm nes regulate sexual hara teristi s int l bules ntaining semini er us tubules
that pr m te su ess ul repr du ti n . Interstitial ells pr du e test ster ne (Figure 23-3)
4. Ability t repr du e begins at puberty 2. estis un ti ns
B. Male and emale systems a. Spermat genesis is pr ess sperm pr du ti n
1. C mm n general stru ture and un ti n an be iden- (Figure 23-4)
ti ed between the systems in b th sexes (1) FSH r m pituitary stimulates spermat genesis
2. Systems adapted r devel pment sperm r va l- (2) Sperm pre urs r ells alled spermatogonia
l wed by su ess ul ertilizati n, devel pment, and (3) Mei sis pr du es primary spermat yte, whi h
birth spring rms ur spermatids with 23 hr m s mes
3. Sex h rm nes in b th sexes are imp rtant in devel p- (4) Spermat z amale repr du tive ell
ment se ndary sexual hara teristi s and n rmal (Figure 23-5)
repr du tive system a tivity (a) Eja ulati n r e ul eje ti n ( r m the
penis) f uid ntaining sperm
(b) H ead ntains geneti material

( ) A r s me ntains enzymes t assist
sperm in penetrati n vum
(d) Mit h ndria pr vide energy r
m vement
b. Pr du ti n test ster ne by interstitial ells
(1) LH r m pituitary stimulates interstitial ells t
devel p and pr du e test ster ne
(2) est ster ne un ti n
(a) est ster ne mas ulinizes and pr m tes
devel pment male a ess ry rgans
(b) Stimulates pr tein anab lism (anab li
ster id) and devel pment mus le
strength
C. Repr du tive du tsdu ts thr ugh whi h sperm pass
a ter exiting testes until they exit r m the b dy
1. Epididymissingle, iled tube ab ut 6 m in length;
lies al ng the t p and behind ea h testis in the
s r tum
a. Sperm mature and devel p the apa ity r m tility
as they pass thr ugh the epididymis
b. Epididymitispain ul inf ammati n
2. Vas de erensals alled ductus de erens
a. Re eives sperm r m the epididymis and transp rts
them r m s r tal sa thr ugh the pelvi avity
b. Passes thr ugh inguinal anal and then j ins du t
seminal vesi le t rm the eja ulat ry du t
(Figure 23-6)
D. A ess ry glandspr du e mp nents semen
1. Semenals alled seminal uid
a. Mixture sperm and se reti ns a ess ry sex
glands
b. Average 3 t 5 mL per eja ulati n, with ea h
milliliter ntaining ab ut 20 milli n t 100 milli n
sperm (highly variable, even day t day)
2. Seminal vesi les
a. P u hlike glands that pr du e ab ut 60%
seminal f uid v lume
b. Se reti n is yell wish, thi k, and ri h in ru t se t
pr vide energy needed by sperm r m tility
3. Pr state gland
a. Shaped like a d ughnut and l ated bel w bladder
b. Urethra passes thr ugh the gland
. T in, milk- l red se reti n that represents 30%
seminal f uid v lume
d. A tivates sperm and is needed r ng ing sperm
m tility
4. Bulb urethral glandsals alled Cowper glands
a. Resemble peas in size and shape
b. Se rete mu uslike f uid (less than 5% seminal
f uid v lume) that lubri ates terminal p rti n
urethra
CHAPTER 23 Reproductive Systems 645
E. External genitalsals alled genitalia
1. Penis and s r tum (Figure 23-7)
2. Penis has three lumns ere tile tissue
a. w d rsal lumns alled corpora cavernosa
b. O ne ventral lumn surr unding urethra alled
corpus spongiosum
3. Glans penisdistal end penis
a. C vered by reskin (prepu e)
b. Surgi al rem val reskin alled circumcision
4. S r tumskin- vered p u h suspended r m gr in
a. Divided int tw sa s by a septum
b. Ea h sa ntains a testis, epididymis, part vas
de erens, and beginning spermati rds
Dis o rde rs o the Male
Re pro ductive Sys te m
A. In ertility and sterility may result r m repr du tive
dis rders
1. In ertilityredu ed repr du tive ability
2. Sterilityt tal inability t repr du e
3. N distin t andr pause ( essati n ertility) in late
adulth d, as in emale men pause
a. est ster ne pr du ti n may de line (l w ) in
late adulth d 23
b. L w may redu e ertility in s me men; many
men remain ertile r their li etimes
B. Dis rders the testes
1. O lig spermial w sperm pr du ti n
2. Crypt r hidismundes ended testes
3. esti ular an erm st mm n in males ages 15
t 30
C. Dis rders the pr state
1. Benign pr stati hypertr phy (BPH )enlargement
pr state mm n in lder men
2. Pr state an ermalignan y pr state tissue
a. Pr state t mysurgi al rem val part r all
the pr state
b. Bra hytherapysmall radi a tive seeds pla ed in
pr state
D. Dis rders the penis and s r tum
1. Penis dis rders
a. Phim sistight reskin ann t be retra ted ver
glans (B x, p. 624)
b. Paraphim sis reskin ann t be repla ed t usual
p siti n a ter it has been retra ted behind the glans
(B x, p. 624)
. H yp spadiasurethra pens n underside glans
r sha t
d. Epispadiasurethra pens n t p glans r sha t
e. Ere tile dys un ti n (ED) ailure t a hieve r
maintain ere ti n the penis
 646 CHAPTER 23 Reproductive Systems
2. S r tum dis rders
a. H ydr elea umulati n watery f uid in the
s r tum
b. Inguinal herniapr trusi n abd min pelvi
rgans, p ssibly int the s r tum (Figure 23-8)
Fe m ale Re pro ductive Sys te m
A. Stru tural plan rgans lassi ed as essential r a es-
s ry (Figure 23-9 and Table 23-2)
1. Essential rgans are g nads ( varies), whi h pr du e
sex ells ( va)
2. A ess ry rgans repr du ti n
a. D u ts r m di ed du tsin luding vidu ts,
uterus, and vagina
b. Sex glandsin luding th se in the breasts
. External genitals
B. O varies
1. Stru ture and l ati n
a. Paired glands weighing ab ut 3 g ea h
b. Resemble large alm nds
. Atta hed t ligaments in pelvi avity n ea h side
uterus
d. Mi r s pi stru ture (Figure 23-10)
23 (1) O varian lli les ntain yte, whi h is
immature sex ell (ab ut hal a milli n at birth)
(2) Primary lli lesab ut 400,000 at puberty
are vered with granul sa ells
(3) Ab ut 350 t 500 mature lli les vulate
during the repr du tive li etime m st
w mens metimes alled graa an ollicles
(4) Se ndary lli les have h ll w hamber alled
antrum
(5) C rpus luteum rms a ter vulati n
2. O vary un ti ns
a. O genesis (Figure 23-11)
(1) Inv lves mei ti ell divisi n (mei sis) that
pr du es daughter ells with equal hr m -
s me numbers (23) but unequal yt plasm
(2) O vum is large; p lar b dies are small and
degenerate
b. Pr du ti n estr gen and pr gester ne
(1) Granul sa ells surr unding the yte in the
mature and gr wing lli les pr du e estr gen
(2) C rpus luteum pr du es pr gester ne
(3) Estr gen auses devel pment and maintenan e
se ndary sex hara teristi s
(4) Pr gester ne stimulates se ret ry a tivity
uterine epithelium and assists estr gen in initi-
ating menses
3. Surgi al rem val alled oophorectomy
C. Repr du tive du ts
1. B th male and emale repr du tive du ts arry
gametes r m ea h ( tw ) g nads, j in int a single
passage, and exit the b dy
2. Only the emale du ts als un ti n in re eiving
sperm, ertilizati n, and prenatal devel pment
3. Uterine tubesals alled allopian tubes r oviducts
a. Extend ab ut 10 m r m uterus int pelvi avity
b. Expanded distal end surr unded by mbriae
. Mu sal lining tube is dire tly ntinu us with
lining pelvi avity
d. Surgi al rem val alled hysterectomy
4. Uterus mp sed b dy, undus, and ervix
(Figure 23-12)
a. Lies in pelvi avity just behind urinary bladder
b. My metrium is mus le layer
. End metrium l st in menstruati n
d. Men pauseend repetitive menstrual y les
(ab ut 45 t 50 years age)
e. Surgi al rem val alled hysterectomy
(1) Rem val may be abd minal, vaginal, r
lapar s pi
(2) tal hystere t myrem val b th b dy and
ervix uterus
(3) Subt tal hystere t myrem val b dy
uterus nly ( ervix remains)
5. Vagina
a. Distensible tube ab ut 10 m l ng
b. L ated between urinary bladder and re tum in the
pelvis
. Re eives penis during sexual inter urse and is
birth anal r n rmal delivery baby at end
pregnan y
D. A ess ry glands
1. Greater and lesser vestibular glands
a. Se rete mu us f uid that may lubri ate during
sexual inter urse
b. D u ts pen int vestibule (between labia min ra)
. Clini ally imp rtant when they be me in e ted
(e.g., Neisseria gonorrhoeae ba teria that ause
g n rrhea)
2. Breasts (Figure 23-13)
a. L ated ver pe t ral mus les th rax
b. Size determined by at quantity m re than am unt
glandular (milk-se reting) tissue
. La ti er us du ts drain at nipple, whi h is sur-
r unded by pigmented are la
d. Lymphati drainage leads t spread an er ells
t ther b dy areas
E. External genitals (Figure 23-14)
1. Vulva in ludes m ns pubis, lit ris, external urinary
meatus, penings vestibular glands, ri e
vagina, labia min ra and maj ra, and hymen

2. Perineum
a. Area between vaginal pening and anus
b. Surgi al ut during birth alled episiotomy
F. Menstrual y leinv lves many hanges in the uterus,
varies, vagina, and breasts (Figure 23-15 and Figure 23-16)
1. Lengthab ut 28 days, varies r m y le t y le
am ng individuals and in the same individual
2. Phases
a. Mensesab ut the rst 4 r 5 days the y le,
varies s mewhat
(1) Chara terized by sl ughing bits end me-
trium (uterine lining) with bleeding
(2) First day f w is day 1 menstrual y le
b. Pr li erative phasedays between the end
menses and vulati n; varies in length
(1) T e sh rter the y le, the sh rter the pr li era-
tive phase; the l nger the y le, the l nger the
pr li erative phase
(2) Chara terized by pr li erati n (repair)
end metrium
. Se ret ry phasedays between vulati n and
beginning next menses
(1) Chara terized by urther thi kening
end metrium
(2) Se reti n by its glands in preparati n r
implantati n ertilized vum
3. O vulati ntypi ally ne vum released per y le,
14 days be re next menses; timing vulati n is
use ul in timing sexual inter urse t maximize
ertility
4. C ntr l mbined a ti ns the anteri r pituitary
h rm nes FSH and LH ause vulati n; sudden
sharp de rease in estr gens and pr gester ne bring n
menstruati n i pregnan y d es n t ur
Dis o rde rs o the Fe m ale
Re pro ductive Sys te m
A. H rm nal and menstrual dis rders
1. D ysmen rrhea (menstrual ramps)pain ul
menstruati n
2. Amen rrheaabsen e n rmal menstruati n
3. D ys un ti nal uterine bleeding (DUB)irregular r
ex essive bleeding resulting r m a h rm nal imbal-
an e r path l gy
4. Premenstrual syndr me (PMS) lle ti n symp-
t ms that ur in s me w men be re menstruati n
B. In e ti n and inf ammati n
1. Ex gen us in e ti ns are ten sexually transmitted;
end gen us in e ti ns are aused by rganisms already
in r n the b dy
2. Pelvi inf ammat ry disease (PID)a ute inf amma-
t ry nditi n the uterus, uterine tubes, r varies
aused by in e ti n
CHAPTER 23 Reproductive Systems 647
3. Vaginitisin e ti n vaginal lining, it m st ten
results r m S Ds r yeast in e ti ns
C. um rs and related nditi ns
1. Benign tum rs the uterusmy ma, br ids,
br my ma
2. O varian ystsf uid- lled enlargements; usually
benign
a. F lli ular ystsm st mm n
b. Luteal ystsm st sympt mati
. M st res lve in 60 days
3. P ly ysti vary syndr me (PCOS)enlarged varies
with many f uid- lled ysts
a. A e ts 10% repr du tive-age w men
b. M st mm n ause emale in ertility
(Figure 23-17)
4. End metri sispresen e un ti ning end metrial
tissue utside the uterus
5. Breast an er is the m st mm n type an er in
w men
6. Cervi al an er is ten dete ted by a Papani la u
test (Pap smear) (Figure 23-18)
D. In ertility an result r m a t rs su h as in e ti n and
inf ammati n, tum rs, and h rm nal imbalan es
S um m ary o Male and Fe m ale 23
Re pro ductive Sys te m s
A. In men and w men the rgans the repr du tive
system are adapted r the spe i sequen e un ti ns
that permit devel pment sperm r va ll wed by the
su ess ul ertilizati n and then the n rmal devel pment
and birth spring
B. T e male rgans pr du e, st re, and ultimately intr du e
mature sperm int the emale repr du tive tra t
C. T e emale system pr du es va, re eives the sperm, and
permits ertilizati n ll wed by etal devel pment and
birth, with la tati n a terward
D. Men and w men have anal g us repr du tive stru tures
(Table 23-3)
E. Pr du ti n sex h rm nes is required r devel pment
se ndary sex hara teristi s and r n rmal repr du -
tive un ti ns in b th sexes
S e xually Trans m itte d Dis e as e s
A. Sexually transmitted in e ti ns (S Is) an pr gress int
S Ds
B. S Is/S Ds are transmitted sexually but an als be
transmitted in ther ways
C. S Ds are the m st mm n all mmuni able
diseases
D. S Ds are aused by a variety rganisms (Table 23-4)
 648 CHAPTER 23 Reproductive Systems
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Review the s ynops is o the m ale and e m ale re productive
s ys te m s in Chapte r 5.
1. Mu h Chapter 23 deals with the names, l ati ns, and
un ti ns the stru tures the male and emale repr -
du tive systems. Make f ash ards and he k nline
res ur es t help y u learn this material. Review the Lan-
guage S ien e and Language Medi ine se ti ns.
2. An e e tive way t understand the male repr du tive
du ts is t tra e sperm in sequen e r m p int rma-
ti n thr ugh the repr du tive du ts t eja ulati n.
3. T e r le the male in repr du ti n is t pr du e as
many sperm as p ssible, s ur un ti nal sperm are pr -
du ed r m mei sis. T e emales r le is the pr du ti n
ne egg ntaining 23 hr m s mes; 69 the riginal
92 hr m s mes need t be thr wn away. T is is the
23 un ti n the p lar b dies.
4. T e resp nsibility the emale repr du tive system is t
pr du e an egg and prepare the b dy r a p ssible preg-
nan y. T e repr du tive y le assists in d ing this.
5. T e repr du tive y le is regulated by ur h rm nes: tw
r m the pituitary gland and tw r m the vary. F lli le-
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Des ribe the stru ture and l ati n the testes.
2. Des ribe the un ti n g nad tr pin-releasing
h rm ne.
3. Des ribe the stru ture sperm.
4. List the un ti ns test ster ne.
5. List and brief y des ribe the repr du tive du ts the
male repr du tive system.
6. List and brief y des ribe the glands the male repr -
du tive system. W hat d es ea h gland ntribute t the
seminal f uid?
7. Distinguish between in ertility, sterility, and imp ten e.
stimulating h rm ne d es exa tly what its name implies.
Luteinizing h rm ne helps stimulate vulati n that auses
the egg lli le t be me the rpus luteum. Estr gen
begins the initial preparati n the uterus. Pr gester ne
prepares the uterus t re eive a ertilized egg. T ink
pr gester ne as pr (in av r ) gester ne (gestati n);
this may help y u remember what it d es. C nstru t a
diagram that dem nstrates h rm nal integrati n in the
menstrual y le.
6. T e dis rders the repr du tive system an be put n a
hart t help y u learn them. O rganize the dis rders
the male repr du tive system based n the spe i stru -
ture the male system that is a e ted. Dis rders the
emale system an be rganized based n the spe i
stru ture the emale repr du tive system r n men-
struati n dis rders.
7. In y ur study gr up, g ver the f ash ards the stru -
tures and ph t py gures t help y u learn the l a-
ti ns. Dis uss the pr ess mei sis and the di eren es
between spermat genesis and genesis. Dis uss the
repr du tive y le with emphasis n the un ti n the
h rm nes. G ver the hart the dis rders, the hapter
utline summary, and the questi ns at the end the
hapter, and dis uss p ssible test questi ns.
8. Des ribe ir um isi n and list the advantages and disad-
vantages ir um isi n.
9. W hat is lig spermia? W hat is rypt r hidism?
10. B th a hydr ele and an inguinal hernia will pr du e
swelling in the s r tum. Explain the di eren e between
these tw nditi ns.
11. Des ribe the stru ture and l ati n the varies.
12. Explain the devel pment an varian lli le r m the
primary lli le t the rpus luteum.
13. List the un ti ns estr gen.
14. List the un ti ns pr gester ne.
15. Des ribe the stru ture the uterine tubes.
16. Des ribe the stru ture the uterus.
17. Des ribe the stru ture the vagina.
18. Des ribe the stru ture the breast.
19. Explain what urs during the pr li erative phase
the repr du tive y le.

20. Explain what urs during the se ret ry phase the
repr du tive y le.
21. Name the ur h rm nes inv lved in the regulati n
the repr du tive y le. W here is ea h made, and what is
the un ti n ea h?
22. W hat is dysmen rrhea? W hat is amen rrhea?
23. Distinguish between salpingitis and ph ritis.
24. Des ribe end metri sis and identi y s me medi al treat-
ment strategies r this mm n dis rder.
25. Distinguish between ar matase inhibit rs and
tam xi en.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
26. Di erentiate between spermat genesis and genesis.
H w d these di eren es relate t the r le the male
and emale in repr du ti n?
27. H w is the pr state gland related t the urethra? W hat
pr blems an result r m this relati nship?
28. W hy are the testes l ated utside the b dy avity in the
s r tum?
29. Female athletes may experien e an undesirable nditi n
alled amenorrhea. W hat eviden e an y u nd t
supp rt this statement?
30. Des ribe the hara teristi s benign pr stati hyper-
tr phy (BPH ) and an er the pr state.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e essential rgans the male repr du tive system are
the ________.
2. T e p u hlike sa where the male g nads are l ated is
alled the ________.
3. T e membrane that vers the testis and als divides the
interi r int l bes is alled the ________.
4. T e ________ is a l ng du t in the testis where sperm
devel p.
5. T e ________ are the ells in the testes that se rete
test ster ne.
6. T e primary spermat yte devel ps r m a ell alled
the ________.
7. T e primary spermat yte rms sperm ells by under-
g ing a type ell divisi n alled ________.
CHAPTER 23 Reproductive Systems 649
8. T e sperm ell ntains an ________, whi h ntains an
enzyme that an digest the vering the vum.
9. T e ________ is a repr du tive du t that nsists a
tightly iled tube that lies al ng the t p and behind
the testis.
10. T e ________ is a repr du tive du t that permits the
sperm t m ve ut the s r tum upward int the
pelvi avity.
11. T e ________ is a gland that se retes a thin, milk-
l red f uid that makes up ab ut 30% the seminal
f uid.
12. T e ________ are a pair glands that pr du e a thi k,
yell wish, ru t se-ri h f uid that makes up ab ut 60%
the seminal f uid.
13. T e penis is mp sed three lumns ere tile
tissue: ne is alled the rpus sp ngi sum, and the
ther tw are alled the ________.
14. ________ is the term used r a baby wh is b rn with
an undes ended testi le.
15. T e essential rgans the emale repr du tive system
are the ________.
16. An ther name r a mature varian lli le is a
________ lli le.
17. T e pr ess that pr du es the emale gamete is alled
________. 23
18. Mei sis in the emale pr du es ne large vum and
three small daughter ells alled ________, whi h
degenerate.
19. Mei sis is n t ully mplete in an vum until ________
urs.
20. T e ________ are repr du tive tubes nne ting the
vary and the uterus.
21. T e mus le layer the uterus is alled the ________.
22. T e uterus is mp sed several regi ns: the narr w
l wer part bel w the b dy is alled the ________.
23. T e innerm st layer the uterus, whi h is shed during
menstruati n, is alled the ________.
24. T e ________ is the part the emale repr du tive
system that pens t the exteri r.
25. T e ________ glands are glands that se rete a mu us-
like f uid int the vestibule.
26. T e milk-se reting glandular ells the breast are
arranged in grapelike stru tures alled ________. T ese
drain int ________ du ts that nverge t ward the
nipple.
27. T e ________ is mp sed ere tile tissue, similar t
that und in the penis.
28. T e rst menses is kn wn as the ________.
29. T e term ________ is used t des ribe a pregnan y
resulting r m the implantati n a ertilized vum in
any l ati n ther than the uterus.
 650 CHAPTER 23 Reproductive Systems

Match each disorder in Column A with its description or cause in Column B.

Column A
30. ________ rypt r hidism
31. ________ benign pr stati
hypertr phy
32. ________ hydr ele
33. ________ inguinal hernia
34. ________ dysmen rrhea
35. ________ amen rrhea
36. ________ salpingitis
37. ________ Pap smear
38. ________ my ma
39. ________ end metri sis
40. ________ syphilis
41. ________ genital herpes
Column B
a. a swelling the s r tum aused by the verpr du ti n ser us f uid
b. the la k n rmal menstruati n
. used t s reen r ervi al an er
d. the presen e un ti nal end metrial tissue utside the uterus
e. the inf ammati n the uterine tubes
. a sexually transmitted disease aused by a ba terium
g. nditi n that urs when a testis ails t des end int the s r tum
h. pain ul menstruati n syndr me
i. swelling the s r tum aused by intestine pushing thr ugh a weak part the
abd minal wall
j. a sexually transmitted disease aused by a virus
k. a n n an er us nditi n hara terized by enlargement the pr state
l. benign br id tum r the uterus

Match each term in Column A with its corresponding description in Column B.

Column A
42. ________ FSH
43. ________ menstruati n
44. ________ rpus luteum
45. ________ estr gen
23 46. ________ se ret ry phase
47. ________ pr gester ne
48. ________ LH
49. ________ pr li erative phase
50. ________ vulati n
Column B
a. term r the egg lli le a ter vulati n
b. varian h rm ne that rea hes the highest n entrati n in the pr li erative phase
. aused by a rapid dr p in the bl d levels estr gen and pr gester ne
d. phase the repr du tive y le that begins a ter vulati n
e. varian h rm ne that rea hes its highest n entrati n during the se ret ry phase
. term used t des ribe the egg being released r m the vary
g. phase the repr du tive y le during whi h the uterine wall begins t thi ken
h. pituitary h rm ne that stimulates the rmati n an egg lli le
i. pituitary h rm ne that an be alled the vulating h rm ne

Cas e S tudie s
To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. As stated in the b x n p. 626, ne pr edure that has
been mm nly used t s reen r pr state an er is pal-
pati n the pr state thr ugh the wall the re tum.
Explain why digital ( nger) palpati n the pr state is
the nly way t examine this gland r m the utside
with ut spe ial equipment. W hat ther pr state dis r-
ders might be dete ted this way?
CHAPTER 23 Reproductive Systems 651
2. Liz and Z eke have me t their physi ian with a
pr blem: a ter 2 years trying, they have n t been able
t n eive. A rding t the te hni al de niti n, is this
uple in ertile? On examinati n, Liz has been und t
have pelvi inf ammat ry disease (PID). C uld this n-
diti n have aused in ertility?
3. H eather, age 22, brief y he ks her breasts every ew
m nths and has never dete ted anything abn rmal.
H wever, a r utine examinati n by her physi ian has
revealed s me small, tender lumps in b th breasts. D es
she have breast an er? Can y u think any reas n that
H eather did n t dete t this nditi n hersel ?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
23
Growth, Development, and Aging
O U T L IN E
Scan this outline be ore you begin to read the chapter,
as a preview o how the concepts are organized.
Prenatal Period, 654
Fertilization to Implantation, 654
Amniotic Cavity and Placenta, 654
Periods o Development, 656
Formation o the Primary Germ
Layers, 657
Histogenesis and Organogenesis, 658
Birth, 658
Parturition, 658
Stages o Labor, 661
Multiple Births, 661
Disorders o Pregnancy, 662
Implantation Disorders, 662
Preeclampsia, 662
O B J E C T IV E S
Be ore reading the chapter, review these goals or
your learning.
A ter you have completed this chapter, you
should be able to:
1. Discuss the concept o development as
a biological process characterized by
continuous modif cation and change.
2. Discuss the major developmental
changes characteristic o the prenatal
stage o li e rom ertilization to birth.
3. Identi y the three primary germ layers
and several derivatives in the adult body
that develop rom each layer.
4. Discuss the three stages o labor that
characterize a normal vaginal birth, and
the occurrence o multiple births.
Gestational Diabetes, 662
Fetal Death, 662
Birth De ects, 663
Postpartum Disorders, 663
Postnatal Period, 664
Growth, Development, and Aging, 664
In ancy, 665
Childhood, 666
Adolescence, 666
Adulthood, 666
Older Adulthood, 667
Aging, 667
Mechanisms o Aging, 667
E ects o Aging, 668
5. Distinguish the di erences between
monozygotic and dizygotic twins and
identi y treatments that increase the
likelihood o multiple births.
6. Identi y and describe the major disor-
ders associated with pregnancy.
7. List and discuss the major developmen-
tal changes characteristic o the f ve
postnatal periods o li e.
8. Discuss the e ects o aging on the
major body organ systems.
HAPTER 24
Ma ny y ur ndest and m st vivid mem ries are LANGUAGE OF
pr bably ass iated with y ur birthdays. T e day S C IEN C E
birth is an imp rtant milest ne li e. M st pe ple
ntinue t remember their birthday in s me spe-
Be o re re ading the
ial way ea h year; birthdays serve as pleasant and
chapte r, s ay e ach o
nvenient re eren e p ints t mark peri ds the s e te rm s o ut lo ud. This w ill
transiti n r hange in ur lives. T e a tual day he lp yo u to avo id s tum bling ove r
birth marks the end ne phase li e alled the m as yo u re ad.
the prenatal period and the beginning a
se nd alled the postnatal period. T e prena-
adolescence
tal peri d begins at n epti n and ends at (ad-oh-LES-ens)
birth; the p stnatal peri d begins at birth and [adolesc- grow up, -ence state]
ntinues until death. adulthood
(ah-DULT-hood)
Alth ugh imp rtant peri ds in ur lives su h amniotic cavity
as hildh d and ad les en e are ten (am-nee-OT-ik KAV-ih-tee)
remembered as a series individual [amnio- etal membrane, -ic relating
and is lated events, they are in real- to, cav- hollow, -ity state]
ity part an ng ing and n- apoptosis
tinu us pr ess. In reviewing (ap-oh-TOH-sis or ap-op-TOH-sis)
the many hanges that ur [apo- away, -ptosis alling]
during the y le li e r m blastocyst
n epti n t death, it is (BLAS-toh-sist)
ten nvenient t is - [blasto- bud, -cyst pouch]
late ertain peri ds su h childhood
as in an y r adulth d (CHILD-hood)
r study. It is imp rtant chorion
t remember, h wever, (KOH-ree-on)
that li e is n t a series [chorion skin]
st p-and-start events r chorionic villi
individual and is lated (koh-ree-ON-ik VIL-aye)
peri ds time. Instead, [chorion- skin, -ic relating to]
ectoderm
(EK-toh-derm)
[ecto- outside, -derm skin]
embryo
(EM-bree-oh)
[em- in, -bryo f ll to bursting]
embryology
(em-bree-OL-oh-gee)
[em- in, -bryo- f ll to bursting,
-log- words (study o ), -y activity]
embryonic phase
(em-bree-ON-ik ayz)
[em- in, bryo f ll to bursting,
-ic relating to]

Continued on p. 671

653
 654 CHAPTER 24 Growth, Development, and Aging

it is a bi l gi al pr ess that is hara terized by ntinu us
m di ati n and hange.
T is hapter dis usses s me the events and hanges that
ur in the devel pment a human r m n epti n t
death. Study devel pment during the prenatal peri d is
ll wed by a dis ussi n the birth pr ess and a review
hanges that ur during in an y and adulth d. Finally
s me imp rtant hanges that ur in the individual rgan
systems the b dy as a result aging are dis ussed.
P r e n a t a l P e r io d
T e prenatal stage o development begins at the time n ep-
ti n r ertilization (that is, at the m ment the emale vum
and the male sperm ells unite) (Figure 24-1). T e peri d
prenatal devel pment ntinues until the birth the hild
ab ut 39 weeks later. T e s ien e the devel pment the
spring be re birth is alled embryology. It is a st ry
bi l gi al marvels, des ribing the means by whi h a new hu-
man li e is started and the steps by whi h a single mi r s pi
ell is trans rmed int a mplex human being.
FIGURE 24-1 Fertilization. Fertilization is a speci c biological event. It
occurs when the male and emale sex cells use. A ter union between a
sperm cell and the ovum has occurred, the cycle o li e begins. The scanning
electron micrograph shows spermatozoa attaching themselves to the sur-
ace o an ovum. Only one will penetrate and ertilize the ovum.
Cytopla s m Ovum Nucle us S pe rm ce ll
Fe r t iliz a t io n t o Im p la n t a t io n
A ter vulati n the dis harged vum rst enters the pelvi
avity and then nds its way int the uterine ( all pian) tubes.
Sperm ells swim up the uterine tube t ward the vum. L k
at the relati nship the vary, the tw uterine tubes, and the
uterus in Figure 24-2. Re all r m Chapter 23 that ea h uterine
tube extends utward r m the uterus r ab ut 10 m. It then
ends in the pelvi avity near the vary, as y u an see in
Figure 24-2, in an pening surr unded by ringelike pr esses,
the mbriae.
Sperm ells that are dep sited in the vagina must enter and
swim thr ugh the uterus and thr ugh the uterine tube t
meet the vum. Fertilizati n m st ten urs in the uter
ne-third the vidu t as sh wn in Figure 24-2.
T e ertilized vum, r zygote, is geneti ally mpleteit
is a new single- elled spring. ime and n urishment are all
that is needed r expressi n hara teristi s su h as sex,
b dy build, and skin l r that were determined at the time
ertilizati n. As y u an see in the gure, the zyg te immedi-
ately begins mit ti divisi n, and in ab ut 3 days a s lid mass
ells alled a morula is rmed (see Figure 24-2). T e ells
the m rula ntinue t divide, and by the time the devel ping
embry rea hes the uterus, it is a h ll w ball ells alled a
blastocyst.
D uring the 10 days r m the time ertilizati n t the
time when the blast yst mpletes implantation in the uter-
ine lining, ew nutrients r m the m ther are available. T e
rapid ell divisi n taking pla e up t the blast yst stage -
urs with n signi ant in rease in t tal mass mpared with
the zyg te (Figure 24-3). One the spe ializati ns the
vum is its in redible st re nutrients that help supp rt this
embry ni devel pment until implantati n has urred.

A m n io t ic C a v it y a n d P la c e n t a
24 N te in Figure 24-4 that the blast yst nsists an uter layer
ells and an inner ell mass. As the blast yst devel ps, it
rms a stru ture with tw avities, the yolk sac and amniotic
cavity.
T e y lk sa is m st imp rtant in animals, su h as birds,
that depend heavily n y lk as the s le s ur e nutrients r
the devel ping embry . In these animals the y lk sa digests
the y lk and pr vides the resulting nutrients t the embry .
Be ause uterine f uids pr vide nutrients t the devel ping hu-
man embry until the pla enta devel ps, the un ti n the
y lk sa is n t a nutritive ne. Instead, it has ther un ti ns,
in luding pr du ti n bl d ells and stem ells that later
rm gametes in the g nads.

The yolk sac is an important site o hematopoiesis

in early development. To see a diagram showing
the shi t in locations o blood-cell ormation over
the li e span, review the article Sites o Hemato-
poiesis at Connect It! at evolve.elsevier.com.

T e amni ti avity be mes a f uid- lled, sh k-abs rbing

sa , s metimes alled the bag o waters, in whi h the embry
 CHAPTER 24 Growth, Development, and Aging 655

S pe rma tozoa
Divide d zygote

Fe rtilizatio n

Ute rine (fa llopia n) tube

Firs t
mitos is Morula

Dis cha rge d Ute rus

ovum

Bla s tocys t

Corpus lute um
Fimbria e
Ovulatio n

Implantatio n
Deve loping
follicle s

Ova ry
S
FIGURE 24-2 Fertilization and implantation. At ovulation,
R L
an ovum is released rom the ovary and begins its journey through
the uterine tube. While in the tube, the ovum is ertilized by a I
sperm to orm the single-celled zygote. A ter a ew days o rapid
mitotic division, a ball o cells called a morula is ormed. A ter the
morula develops into a hollow ball called a blastocyst, implanta-
tion occurs.

f ats during devel pment. T e chorion, sh wn in Figure 24-4
and Figure 24-5, devel ps int an imp rtant etal membrane
in the placenta. T e chorionic villi sh wn in Figure 24-5
nne t the bl d vessels the h ri n t the rest the
pla enta. T e pla enta (see Figure 24-5) an h rs the devel p-
ing etus t the uterus and pr vides a bridge r the ex-
hange nutrients and waste pr du ts between m ther and
spring.
T e pla enta is a unique stru ture that has a temp rary but
very imp rtant series un ti ns during pregnan y. It is
mp sed tissues r m m ther and hild and un ti ns n t
nly as a stru tural an h r and nutritive bridge but als as an
ex ret ry, respirat ry, and end rine rgan (see Figure 24-5).
Pla ental tissue n rmally separates the maternal bl d,
whi h lls the la unae the pla enta, r m the etal bl d s
that n intermixing urs. T e very thin layer pla ental 24
tissue that separates maternal and etal bl d als serves as an
e e tive barrier that an pr te t the devel ping spring
r m many harm ul substan es that may enter the m thers
bl dstream.
Un rtunately, t xi substan es, su h as al h l and s me
in e ti us rganisms, may n netheless penetrate this pr te tive

A B C D
FIGURE 24-3 Early stages o development. A, Fertilized ovum or zygote. B to D, Early cell divisions
produce more and more cells. The solid mass o cells shown in D orms the morulaan early stage in embry-
onic development.
 656 CHAPTER 24 Growth, Development, and Aging

pla ental barrier and injure the FIGURE 24-4 Implantation and development.
devel ping spring. T e cyto- Trophobla s t The hollow blastocyst implants itsel in the uterine
megalovirus (CMV), the Z ika Impla nte d bla s tocys t
lining about 10 days a ter ovulation. Until the pla-
centa is unctional, nutrients are obtained by di usion
virus (Z V), r the ba terium Inne r ce ll ma s s rom uterine f uids. Notice the developing chorion and
that auses syphilis, r exam- how the blastocyst eventually orms a yolk sac and
ple, an easily pass thr ugh the amniotic cavity.
pla enta and ause tragi devel p-
mental de e ts in the etus.

To learn more about ertilization and implantation, Ute rine lining

go to AnimationDirect online at evolve.elsevier.com. Yolk s a c
Ute rine gla nds a nd ve s s e ls

P e r io d s o D e ve lo p m e n t Amniotic cavity
T e length pregnan y (ab ut 39 weeks) alled the
gestation periodis divided int three 3-m nth segments
alled trimesters. A number terms are used t des ribe
devel pment during these peri ds kn wn as the rst, se nd,
and third trimesters pregnan y.
D uring the rst trimester, r 3 m nths, pregnan y, many
terms are used. Z ygote des ribes the vum just a ter ertiliza-
ti n by a sperm ell. A ter ab ut 3 days nstant ell divi-
si n, the s lid mass ells, identi ed earlier as the morula, Deve loping chorion
enters the uterus. C ntinued devel pment trans rms the Yolk s a c
m rula int the h ll w blastocyst, whi h then implants int Amniotic cavity
the uterine wall. Embryonic dis k
T e embryonic phase devel pment extends r m the
third week a ter ertilizati n until the end week 8
gestation. D uring this peri d in the rst trimester, the term
embryo is used t des ribe the devel ping spring. By day
35 gestati n (Figure 24-6, A), the heart is beating and, al-
th ugh the embry is nly 8 mm (ab ut 38 in h) l ng, the eyes Figure 24-6, C, sh ws the stage devel pment the etus
and s - alled limb buds, whi h ultimately rm the arms at the end the rst trimester gestati n. B dy size is ab ut
and legs, are learly visible. 7 t 8 m (3.2 in hes) l ng. T e a ial eatures the etus are
T e peri d devel pment extending r m week 9 t week apparent, the limbs are mplete, and gender an be identi-
24 39 is termed the etal phase. D uring this peri d, the term ed. By m nth 4 (Figure 24-6, D) all rgan systems are m-
embryo is repla ed by etus. plete and in pla e.

Ma te rna l ve nule Umbilica l a rte rie s

Umbilica l ve in
Ma te rna l a rte riole
Umbilica l cord

Endome trium

P la ce nta
Ma te rna l blood
Fe ta l ve nule
Fe ta l a rte riole Chorionic villi
A B

FIGURE 24-5 Placenta. The close placement o the etal blood supply and the maternal blood in the pla-
centa permits di usion o nutrients and other substances. It also orms a thin barrier to prevent di usion o
most harm ul substances. No mixing o etal and maternal blood occurs. A, Diagram showing a cross section
o the placental structure. B, Photograph o a normal, ull-term placenta ( etal side) showing the branching o
the placental blood vessels.
 CHAPTER 24 Growth, Development, and Aging 657

Branc hial arc he s

RES EA RC H, IS S U ES , AND
TREN D S
Eye
IN VITRO FERTILIZATION
He a rt
The Latin te rm in vitro m e ans , lite rally, w ithin a glas s . In
the cas e o in vitro e rtilization, it re e rs to the glas s labora-
tory dis h w he re an ovum and s pe rm are m ixe d and w he re
e rtilization occurs . Arm
In the clas s ic te chnique , the ovum is obtaine d rom the bud
Le g Limb
m othe r by f rs t ins e rting a f be r-optic view ing ins trum e nt buds
bud
calle d a laparo s co pe through a ve ry s m all incis ion in the A
wom ans abdom e n. A te r it is in the pe lvic cavity, the device
allow s the phys ician to view the ovary and the n puncture
and s uck up an ovum rom a m ature ollicle . Ove r the
ye ars , re f ne m e nts to this te chnique have be e n m ade and
le s s invas ive proce dure s , s uch as the ins e rtion o a ne e dle
through the vaginal wall, are curre ntly be ing us e d. A te r the
ovum is harve s te d, it is m ixe d w ith s pe rm s o that e rtiliza-
tion occurs .
A te r about 2 days grow th in a te m pe rature -controlle d
e nvironm e nt, the deve loping zygote , w hich by the n has
re ache d the 8- or 16-ce ll s tage , is re turne d by the phys ician
to the m othe rs ute rus . I im plantation is s ucce s s ul, grow th B
w ill continue and the s ubs e que nt pre gnancy w ill progre s s .
In the m os t s ucce s s ul e rtility clinics in the Unite d State s ,
a norm al te rm birth w ill occur in about 30% o in vitro e r-
tilization atte m pts .
With the adve nt o ge nom ics (s e e Chapte r 25), we are
now able to che ck e m bryos or ge ne tic dis orde rs be ore
im planting the m . Howeve r, the controve rs ial practice o
s e le cting e m bryos or ge nde r has caus e d e thicis ts to de -
bate w he the r the s cre e ning o e m bryos is appropriate
m e dical practice .

To f nd out more about related assisted

reproductive technologies (ARTs), check out
the article In Vitro Fertilization at Connect It!
C 24
at evolve.elsevier.com.

Fo r m a t io n o t h e P r im a ry G e r m La ye r s
At the very beginning the embry ni stage, all the ells are
stem cells. Stem ells are unspe ialized ells that repr du e t
rm spe i lines spe ialized ells. At this stage, they have
their highest stemness r p ten ythat is, they are apable
pr du ing many di erent kinds ells in the b dy.
Adult stem ells remain a ter early devel pment, but an nly D
pr du e a ew spe ialized kinds ells in a parti ular tissue. We
have already en untered these adult stem ells when we dis- FIGURE 24-6 Embryos and etuses. A, At 35 days. B, At 49 days. C, At
the end o the rst trimester. D, At 4 months.
ussed hematopoiesis rmati n red bl d ells (RBCs),
white bl d ells (WBCs), and plateletsin b ne marr w.
Other stem ells are und in the skin, many glands, mus les, su h as the skin, nerv us tissue, mus les, r digestive rgans.
nerve tissue, b ne, and the gastr intestinal (GI) tra t. Adult stem Table 24-1 lists a number stru tures derived r m ea h the
ells repla e the spe ialized ells in a tissue and thus ensure sta- three primary germ layers:
ble, un ti nal p pulati ns the ell types needed r survival.
Early in the rst trimester pregnan y, three layers 1. Endoderminside layer
stem ells devel p that embry l gists all the primary germ 2. Mesodermmiddle layer
layers (Table 24-1). Ea h layer gives rise t de nite stru tures 3. Ectoderm utside layer
 658 CHAPTER 24 Growth, Development, and Aging

TABLE 24-1 Primary Germ Layer Derivatives QUICK CHECK

1. Wh a t is th e p o s tn a ta l p e rio d ? Th e p re n a ta l p e rio d ?
Lung buds 2. Wh a t is a zyg o te ? Ho w is it d i e re n t ro m a m o ru la o r
b la s to cys t?
3. Na m e a n d d e s crib e th e th re e p rim a ry g e rm la ye rs .
Live r a nd P ha rynx
pa ncre a s 4. Wh a t a re s te m ce lls ?
He a rt 5. Wh a t is m e a n t b y th e te rm o rga n o g e n e s is ?
Bra in
Eye
Bir t h
Amnion P a r t u r it io n
Gut T e pr ess births metimes alled parturitionis the
p int transiti n between the prenatal and p stnatal peri ds
li e.
As pregnan y draws t a l se, the uterus be mes irrita-
ble and, ultimately, mus ular ntra ti ns begin and ause the
ECTODERM MES ODERM ENDODERM ervix t dilate r pen, thus permitting the etus t m ve
Epide rmis of s kin De rmis of s kin Lining of r m the uterus thr ugh the vagina, r birth anal, t the
Tooth e na me l Circula tory s ys te m ga s trointe s tina l tra ct exteri r. W hen ntra ti ns ur, the amni ti sa r bag
Le ns a nd corne a Ma ny gla nds Lining of lungs water ruptures, and lab r begins.
of eye Adre na l cortex Lining of he pa tic a nd T e pr ess n rmally begins with the etus taking a
Oute r e a r pa ncre a tic ducts head-d wn p siti n against the ervix (Figure 24-8, 1). A
Kidneys
Na s a l cavity Kidney ducts a nd breech birth is ne in whi h the etus ails t turn head
Gona ds bla dde r
Fa cia l bone s Mus cle d wnward and nsequently the eet are b rn rst. T is
Ante rior pituita ry gla nd
S ke le ta l mus cle s Bone s (a de nohypophys is ) nditi n usually requires the spring t be b rn by
in he a d (exce pt fa cia l) cesarean section. O ten alled simply a C-section, it is a
Thymus gla nd
Bra in a nd s pina l cord surgi al pr edure in whi h the newb rn is delivered
Thyroid gla nd
S e ns ory ne urons thr ugh an in isi n in the abd men and uterine wall. T e
Pa ra thyroid gla nd
Adre na l me dulla pr edure may be d ne when abn rmal nditi ns the
Tons ils
m ther r etus ( r b th) make n rmal vaginal delivery
hazard us r imp ssible.
His t o g e n e s is a n d O r g a n o g e n e s is
T e pr ess h w the primary germ layers devel p int To learn more about cesarean section, go to
many di erent kinds tissues is alled histogenesis. T e way AnimationDirect online at evolve.elsevier.com.
in whi h th se tissues arrange themselves int rgans is alled
24 organogenesis.
T e as inating st ry hist genesis and rgan genesis in
human devel pment is l ng and mpli atedits telling be- RES EA RC H, IS S U ES ,
l ngs t the s ien e embryology. But r the beginning
student anat my and physi l gy, it seems su ient t ap-
AND TREN D S
pre iate that human devel pment begins when tw sex ells HOW LONG DOES PREGNANCY
unite t rm a single- elled zyg te. It is als ne essary t LAST?
understand that the springs b dy ev lves by a series This s e e m s like a s illy que s tion to m os t o us ; the ans we r
pr esses nsisting ell di erentiati n, multipli ati n, is 9 m onths , is nt it? Actually, the le ngth o ge s tation (the
gr wth, and rearrangement, all whi h take pla e in a de - am ount o tim e one is pre gnant) is de f ne d in di e re nt ways
nite, rderly sequen e (Figure 24-7). in di e re nt s ituations and can vary rom one pre gnancy to
Devel pment stru ture and un ti n g hand in hand, anothe r.
and r m 4 m nths gestati n, when every rgan system is The ave rage ges tation in hum ans is 266 days , starting at
mplete and in pla e, until term (ab ut 280 days), etal de- the day o conce ption. But phys icians inste ad usually count
vel pment is mainly a matter gr wth. Figure 24-8, step 1, rom the beginning o the womans last me nstrual pe riod, or
an ave rage o 280 days. But thes e are only ave rages . What
sh ws the n rmal intrauterine pla ement a etus just be re
is normal in one case can be di e re nt rom what is norm al in
birth in a ull-term pregnan y. anothe r case . In practice , any pregnancy o le ss than 37
we e ks (259 days ) is said to be pre mature , and any lasting
To learn more about how the various body more than 42 we e ks (294 days) is said to be pos tm ature.
tissues and organs develop, review the article So as w ith m any s tatis tics re garding hum an unction,
w hat is norm al can be s poke n o only in ge ne ralitie s and
Embryonic Development o Tissues at Connect It!
ave rage s .
at evolve.elsevier.com.
 CHAPTER 24 Growth, Development, and Aging 659

1s t 2nd 3rd
trime s te r trime s te r trime s te r

P re -e mbryonic Embryonic Fe ta l pe riod

pe riod pe riod (we e k 9full-te rm)
1 2 3 4 5 6 7 8 9 16 20-36 38

1-ce lle d
zygote

Ce ntra l ne rvous s ys te m
Morula
He a rt

Uppe r limbs

Lowe r limbs
Bla s tocys t
Ea rs

Eye s

Te e th
Implantation
Ma jor birth de fe cts Pa la te
S ponta ne ous Minor birth de fe cts
a bortion Exte rna l ge nita lia

FIGURE 24-7 Critical periods o neonatal development. The red areas show when teratogens are most
likely to cause major birth de ects, and the yellow areas show when minor de ects are more likely to arise.
Numbers re er to weeks o gestation.

24
RES EA RC H, IS S U ES , AND TREN D S
FREEZING UMBILICAL CORD BLOOD
The conce pt o de ve lopm e nt o blood ce lls rom re d bone Whe n the um bilical cord is cut a te r birth, the blood that
m arrow, a proce s s calle d he m ato po ie s is , w as introduce d in re m ains in the cord is s im ply draine d into a s te rile bag (s e e
Chapte r 13. Ultim ate ly, the pre s e nce o s te m ce lls is re - photo), roze n, and the n s tore d in liquid nitroge n in one o
quire d or bone m arrow to produce blood ce lls . The act that about a doze n cord-blood ce nte rs in the Unite d State s .
um bilical cord blood is rich in the s e s te m ce lls has gre at clini-
cal s ignif cance .
In the pas t, i the s te m ce lls in the bone m arrow o a child
we re de s troye d as a re s ult o le uke m ia or by che m othe rapy,
de ath would re s ult unle s s a bone m arrow trans plant was pos -
s ible . In us ion o s tore d um bilical cord blood obtaine d rom the
child at the tim e o birth is an attractive alte rnative . The blood
is rich in s te m ce lls and can be obtaine d w ithout ris k. This
proce dure is m uch m ore cos t-e e ctive than a bone m arrow
trans plant.
Re m oving and re e zing um bilical cord blood at the tim e o
birth m ay be com e a type o biological ins urance agains t s om e
type s o le uke m ia that m ay a e ct a child late r in li e . Cord
blood is re adily available at birth and is a be tte r s ource o s te m
ce lls than is bone m arrow.
 660 CHAPTER 24 Growth, Development, and Aging

P la ce nta P ubic s ymphys is

Urina ry bla dde r

Ure thra

Va gina
1
The re la tion Ce rvix
of the fe tus
to the mothe r. Re ctum

P la ce nta

2
Amniotic s a c Umbilica l cord
rupture s. Ce rvix
of ute rus dila te s.
Va gina
Amniotic s a c
Ce rvix

3
Dila tion of the
ce rvix is comple te.
Rupture in
a mniotic s a c
Rupture d a mniotic s a c
wide ns.

4 P la ce nta
24 The fe tus is
expe lle d from
the ute rus a nd
through the birth
ca na l.

5
The pla ce nta is Ute rus
expe lle d. Umbilica l cord
P la ce nta
(ma te rna l s ide ) A

S I
P la ce nta
(fe ta l s ide ) P

FIGURE 24-8 Parturition.


S t a g e s o La b o r
Labor is the pr ess that results in the birth an in ant. It
has three stages (Figure 24-8, steps 2 to 5):
Stage oneperi d r m nset uterine ntra -
ti ns until dilati n the ervix is mplete.
Stage twoperi d r m the time maximal Divide d inne r
ervi al dilati n until the spring exits thr ugh
the vagina.
Stage threepr ess expulsi n the pla enta
thr ugh the vagina.
T e time required r n rmal vaginal birth varies
widely and may be inf uen ed by many variables, in luding
whether the w man has previ usly had a hild. In m st
ases, stage ne lab r lasts r m 6 t 24 h urs, and stage
tw lasts r m a ew minutes t an h ur. Delivery the
pla enta (stage three) n rmally urs within 15 minutes
a ter the birth the in ant.
Figure 1-12 n p. 16 illustrates the r le xyt in (O )
in pr m ting a rapid delivery. A syntheti versi n O is
s metimes given therapeuti ally i lab r be mes danger usly
sl w.
assess the general nditi n a newb rn, a system that
evaluates ve health riteria is ten used. T e riteria are heart
rate (H R), respirati n, mus le t ne, skin l r, and resp nse t
stimuli. Ea h aspe t is s red as 0, 1, r 2depending n the
nditi n the in ant. T e resulting t tal s re is alled the
Apgar score. T e Apgar s re in a mpletely healthy new-
b rn is 10.
To learn more about the three stages o birth, go to
AnimationDirect online at evolve.elsevier.com.
M u lt ip le Bir t h s
T e term multiple births re ers t the birth tw r m re in-
ants r m the same pregnan y. T e birth twins is m re
mm n than the birth triplets, quadruplets, r quintuplets.
Multiple-birth spring are ten b rn prematurely, s
they are at a greater than n rmal risk mpli ati ns in in-
an y. H wever, premature in ants that have m dern medi al
are available have a mu h l wer risk mpli ati ns than
with ut su h are.
winning, r d uble births, an result r m at least tw di -
erent natural pr esses, des ribed in the ll wing paragraphs.
Identical twins result r m the splitting embry ni tis-
sue r m the same zyg te early in devel pment. F r this rea-
s n identi al twins are als alled monozygotic twins. As
Figure 24-9, A, sh ws, identi al twins usually share the same
pla enta but have separate umbili al rds.
Be ause they devel p r m the same ertilized egg, iden-
ti al twins have the same geneti de. D espite this, identi-
al twins are n t abs lutely identi al in terms stru ture
and un ti n. D i erent envir nmental a t rs and pers nal
experien es lead t individuality even in geneti ally identi al
twins.
CHAPTER 24 Growth, Development, and Aging 661
Ide ntica l Fra te rna l
twins twins
Fe rtiliza tion
Inne r
ce ll ma s s Bla s tocys t
ce ll ma s s
Trophobla s t s ta ge Trophobla s t
P la ce nta
Amnion
Amnion
Fe ta l
s ta ge P la ce nta s
Amniotic Amniotic
cavitie s cavitie s
A B
FIGURE 24-9 Multiple births. A, Identical (monozygotic) twins develop
when embryonic tissue rom a single zygote splits to orm two individuals.
Notice that the placenta and the part o the amnion separating the amniotic
cavities are shared by the twins. B, Fraternal (dizygotic) twins develop when
two ova are ertilized at about the same time, producing two separate zy-
gotes. Notice that each raternal twin has its own placenta and amnion.
Fraternal twins result r m the ertilizati n tw di er-
ent va by tw di erent spermat z aand are thus als
alled dizygotic twins (Figure 24-9, B). Dizyg ti twinning
requires the pr du ti n m re than ne mature vum dur-
ing a single menstrual y le, a trait that is ten inherited.
Multiple vulati ns als may ur in resp nse t ertain
ertility drugs, espe ially the g nad tr pin preparati ns.
Fraternal twins are n m re l sely related geneti ally than
any ther br ther-sister relati nship. Be ause tw separate 24
ertilizati ns must ur, it is even p ssible r raternal twins
t have di erent bi l gi al athers. riplets, quadruplets, and
ther multiple births may be identi al, raternal, r any
mbinati n.
M re and m re ten, multiple births result r m medi al
treatments. F r example, ertility-enhan ing drugs s metimes
in rease the number eggs released at vulati n and thus
in rease the likelih d multiple births. In vitro ertilizati n
and ther repr du tive medi al pr edures ten inv lve im-
plantati n multiple embry sin reasing the dds su -
ess ul repr du ti n while als in reasing the dds multiple
births (see the Resear h, Issues, and rends b x n p. 657).
QUICK CHECK
1. Ho w d o e s a b re e ch b irth d i e r ro m a n o rm a l b irth ?
2. Na m e a n d d e s crib e th e th re e s ta g e s o la b o r?
3. Ho w d o m u ltip le b irth s o ccu r?
4. Id e n ti y th e p rim a ry d i e re n ce b e tw e e n id e n tica l a n d ra -
te rn a l tw in s .
5. Wh a t is a n Ap ga r s co re ?
 662 CHAPTER 24 Growth, Development, and Aging

D is o r d e r s o P r e g n a n c y severe hem rrhaging that ten results, s metimes hidden in

Im p la n t a t io n D is o r d e r s
A pregnan y has the best han e a su ess ul ut me, the
birth a healthy baby, i the blast yst is implanted pr perly
in the uterine wall. H wever, pr per implantati n d es n t
always ur. Many spring are l st be re implantati n -
urs, ten r unkn wn reas ns.
As menti ned in the previ us hapter, implantati n ut-
side the uterus results in an e t pi pregnan y. I the blast -
yst implants in a regi n end metri sis (abn rmally l -
ated end metrial tissue) r n rmal perit neal membrane, the
pregnan y may be su ess ul i there is r m r the devel p-
ing etus t gr w. E t pi pregnan ies that d su eed must
be delivered by C-se ti n rather than by n rmal vaginal birth.
I an e t pi pregnan y urs in a uterine tube, whi h ann t
stret h t a mm date the devel ping spring, the tube
may rupture and ause li e-threatening hem rrhaging. S -
alled tubal pregnancies are the m st mm n type e t pi
pregnan y.
O asi nally, the blast yst implants in the uterine wall
near the ervix. T is in itsel may present n pr blem, but i
the pla enta gr ws t l sely t the ervi al pening a ndi-
ti n alled placenta previa results. T e n rmal dilati n and
s tening the ervix that urs in the third trimester ten
auses painless bleeding as the pla enta near the ervix sepa-
rates r m the uterine wall. T e massive bl d l ss that may
result an be li e threatening r b th m ther and spring
(Figure 24-10, A).
Separati n the pla enta r m the uterine wall an
even when implantati n urs in the upper part the uterus.
W hen this urs in a pregnan y 20 weeks r m re, the
nditi n is alled abruptio placentae. C mplete separati n
the pla enta auses the immediate death the etus. T e
24
P la ce nta He morrha ge P la ce nta
the uterus, may ause ir ulat ry sh k and death the
m ther within minutes. A esarean se ti n and perhaps als a
hystere t my must be per rmed immediately t prevent
bl d l ss and death (Figure 24-10, B).
P r e e c la m p s ia
Preeclampsia, als alled toxemia o pregnancy, is a seri us
dis rder that urs in ab ut 1 in every 20 pregnan ies. T is
dis rder is hara terized by the nset a ute hypertensi n
a ter the twenty- urth week, a mpanied by pr teinuria and
edema.
T e auses pree lampsia are largely unkn wn, despite
intense resear h e rts. Pree lampsia an result in mpli a-
ti ns su h as abrupti pla entae, str ke, hem rrhage, etal
malnutriti n, and l w birth weight.
Pree lampsia an pr gress t eclampsia, a li e-threatening
rm t xemia that auses severe nvulsi ns, ma, kidney
ailure, and perhaps death the etus and m ther.
G e s t a t io n a l D ia b e t e s
T e term gestational diabetes mellitus (GD M) is applied in
ases hypergly emia (high bl d glu se) that rst ur
during pregnan y. S me ases diagn sed as GDM a tually
may be previ usly undiagn sed ases type 1 DM r type 2
DM . N w is a g d time t review DM in Chapter 12 n
pp. 335-337.
ur T e nditi ns pregnan y pr m te insulin resistan e in
ells. I insulin resistan e is already an issue, then the insulin
resistan e is even m re a pr blem. GDM results r m the
ailure the pan reati islets t pr du e additi nal insulin t
mpensate r this in reased insulin resistan e.
As Figure 12-18 n p. 337 sh ws, the insulin resistan e that
urs in DM pr du es a wide variety hanges in b dy
un ti n. T ere re, impr perly managed GDM an have
health e e ts in either r b th the m ther and etus during
pregnan y.
F r example, high bl d glu se in the etus an lead t
weight gain, whi h results in delivery a large in anta risk
a t r r mpli ati ns during lab r and delivery. GDM an
als in rease the risk needing t deliver by C-se ti n, rather
than a vaginal delivery. GDM may in rease the risk hyper-
tensi n that may pr gress t pree lampsia.

Fe t a l D e a t h
Ce rvix S A miscarriage is the l ss an embry r etus be re the
twentieth week ( r a etus weighing less than 500 g r 1.1 lb).
P A
A B e hni ally kn wn as a spontaneous abortion, the m st
I mm n ause su h a l ss is a stru tural r un ti nal de-
e t in the devel ping spring. Abn rmalities the m ther,
FIGURE 24-10 Implantation disorders. A, Placenta previa is the con-
dition where the placenta grows too closely to the cervical opening. B, Ab- su h as hypertensi n, uterine abn rmalities, and h rm nal
ruptio placentae is the condition where there is complete separation o the imbalan es, an als ause sp ntane us ab rti ns. A ter
placenta, causing the death o the etus. 20 weeks, delivery a li eless in ant is termed a stillbirth.

Bir t h D e e c t s
Devel pmental pr blems present at birth are ten alled
birth de ects. Su h abn rmalities may be stru tural r un -
ti nal, perhaps even inv lving behavi r and pers nality.
Birth de e ts may be aused by geneti a t rs su h as ab-
n rmal genes r inheritan e an abn rmal number hr -
m s mes. Birth de e ts als may be aused by exp sure t
envir nmental a t rs alled teratogensespe ially during
rgan genesis. erat gens in lude:
r al h l
Zika virus, r yt megal virus
S me terat gens are als mutagens be ause they d their
damage by hanging the geneti de in ells the devel p-
ing embry . Nutriti nal de ien ies during pregnan y als
an lead t birth de e ts.
As Figure 24-7 sh ws, the peri d during the rst trimester
when the tissues are beginning t di erentiate and the rgans
are just starting t devel p is the time that terat gens are m st
likely t ause damage. In a t, terat gens an ause sp ntane-
us ab rti n (mis arriage) i signi ant damage urs during
the pre-embry ni stage.
RES EA RC H, IS S U ES , AND TREN D S
ANTENATAL DIAGNOS IS AND TRE
TREATMENT
Advance s in ante natal m e dicine or be ore -birth th the rapy
now pe rm it exte ns ive diagnos is and tre atm e nt o dis e as e in
the e tus m uch like any othe r patie nt. This new dim e nns ion in
m e dicine be gan w ith te chnique s by w hich Rh e tus e s could
co be
give n trans us ions be ore birth.
Ultra s ound
tra ns duce r
A A
S I
A B
P P
CHAPTER 24 Growth, Development, and Aging 663
Umbilical hernia, which occurs when intestines pro-
trude through the umbilical opening in the abdomen,
is common in newborn in ants. Review the article
Hernias at Connect It! at evolve.elsevier.com.
P o s t p a r t u m D is o r d e r s
Puerperal ever, r childbed ever, is a syndr me p stpar-
tum m thers hara terized by ba terial in e ti n that pr -
gresses t septi emia (bl d in e ti n) and p ssibly death.
Until the 1930s, puerperal ever was the leading ause
maternal death laiming the lives m re than 20% p st-
partum w men. M dern antisepti te hniques prevent m st
p stpartum in e ti ns n w. Puerperal in e ti ns that d ur
are usually treated su ess ully by an immediate and intensive
pr gram antibi ti therapy.
A ter a hild is b rn, it needs the n urishment m thers
milk t survive. H wever, a number dis rders la tati n
(milk pr du ti n) may ur t prevent a m ther r m nurs-
ing her in ant. F r example, anemia, malnutriti n, em ti nal
stress, and stru tural abn rmalities the breast an all inter-
ere with n rmal la tati n.
Mastitis, r breast inf ammati n, ten aused by in e -
ti n, an result in la tati n pr blems r pr du ti n milk
Curre nt proce dure s us ing im age s provide d by ultras ound
e quipm e nt (s e e f gure s ) allow phys icians to pre pare or and
pe r orm , be ore birth, corre ctive s urgical proce dure s s uch as
bladde r re pair. The s e proce dure s als o allow phys icians to m oni- 24
tor the progre s s o othe r type s o tre atm e nt on a deve loping
e tus . Figure A s how s place m e nt o the ultras ound trans duce r
on the abdom inal wall. The re s ulting im age is calle d an
ultras o no g ram . Figure s B and C s how two-dim e ns ional and
thre e -dim e ns ional type s o ultras onogram o a 20-we e k and
21-we e k e tus (re s pe ctive ly).
I S
C
 664 CHAPTER 24 Growth, Development, and Aging

RES EA RC H, IS S U ES , AND TREN D S

FETAL ALCOHOL SYNDROME
S
Cons um ption o alcohol by the m othe r during pre gnancy can have tragic e e cts on a de -
ve loping e tus . Educational e orts to in orm pre gnant wom e n about the dange rs o alco- R L
hol are now re ce iving national atte ntion. Eve n ve ry lim ite d cons um ption o alcohol during
I
pre gnancy pos e s s ignif cant hazards to the deve loping e tus be caus e alcohol can e as ily
cros s the place ntal barrie r and e nte r the e tal bloods tre am .
Whe n alcohol e nte rs the e tal blood, the pote ntial re s ult, calle d e tal alco ho l s yndro m e (FAS ), can
caus e tragic co nge nital abnorm alitie s s uch as s m all he ad, or m icro ce phaly (s e e f gure ), low birth
we ight, deve lopm e ntal dis abilitie s s uch as m e ntal re tardation, and eve n e tal de ath.

ntaminated with path geni rganisms. In many ultures, P o s t n a t a l P e r io d

the availability ther nursing m thers r breast-milk sub-
stitutes all ws pr per n urishment the in ant when la ta-
ti n pr blems devel p. M st breast-milk substitutes are r-
mulati ns milk r m an ther mammal, su h as a w.
In ants wh la k the enzyme lactase may n t be able t
digest the la t se present in human r animal milk, resulting
in a nditi n alled lactose intolerance. In ants with la t se
int leran e are s metimes given a la t se- ree milk substitute
made r m s y beans r ther plant pr du ts.
QUICK CHECK
1. Wh a t d is o rd e rs ca n re s u lt ro m im p ro p e r im p la n ta tio n in
th e u te rin e wa ll?
2. Wh a t co m p lica tio n s m a y o ccu r a s a re s u lt o
p re e cla m p s ia ?
3. Wh a t is a te ra to g e n ? Give s o m e e xa m p le s o te ra to g e n s .
4. Wh a t is g e s ta tio n a l d ia b e te s ?
G ro w t h , D e ve lo p m e n t , a n d Ag in g
T e postnatal period begins at birth and lasts until death.
Alth ugh it is ten divided int maj r peri ds r study, we
need t understand and appre iate that gr wth, devel pment,
and aging are ntinu us pr esses that ur thr ugh ut the
li e y le.
Gradual hanges in the physi al appearan e the b dy as
a wh le and in the relative pr p rti ns the head, trunk, and
limbs are quite n ti eable between birth and ad les en e.
N te in Figure 24-11 the bvi us hanges in the size b nes
and in the pr p rti nate sizes between di erent b nes and
b dy areas. T e head, r example, be mes pr p rti nately
smaller. W hereas the in ant head is appr ximately ne- urth
the t tal height the b dy, the adult head is nly ab ut
ne-eighth the t tal height. T e a ial b nes als sh w sev-
eral hanges between in an y and adulth d. In an in ant the

24

Newborn 2-ye a r-old 5-ye a r-old 13-ye a r-old Adult

FIGURE 24-11 Developmental changes in body proportions. Note the dramatic di erences in head
size. As the individual grows, there is a gradual change in the relative proportions o the head, trunk, and limbs.
The head becomes proportionately smaller, and the legs become proportionately longer and the trunk shorter.
 CHAPTER 24 Growth, Development, and Aging 665

TABLE 24-2 U.S. Population Projections by Age Group*

PERCENT
2020 2030 2040 2050 2060 CHANGE
Total population 334,503 359,402 380,219 398,328 416,795 25%
In ants and To ddle rs
0-4 ye ars 20,568 21,178 21,471 22,147 22,778 11%
Childre n
5-13 ye ars 36,824 38,322 39,087 39,887 41,193 12%
Ado le s ce nts
14-17 ye ars 16,737 16,773 17,627 17,854 18,338 10%
Adults
18-44 ye ars 120,073 126,589 128,669 132,370 136,310 14%
45-64 ye ars 83,861 82,434 91,021 98,074 100,013 19%
Olde r Adults
65 ye ars 56,441 74,107 82,344 87,996 98,164 74%
85 ye ars 6,727 9,132 14,634 18,972 19,724 193%
100 ye ars 89 138 193 387 604 579%
* Num be rs in thous ands ; li e s tage s are be s t f t to available s tatis tical age groups . (Source : U.S. Ce ns us Bure au.)

a e is ne-eighth the skull FIGURE 24-12 Neonate. The um-

sur a e, but in an adult the a e is bilical cord has been cut, separating
hal the skull sur a e. the neonate rom the placental blood
supply, which requires the in ant to
An ther hange in pr p rti n breathe to get the oxygen once sup-
inv lves the trunk and l wer ex- plied by the mother.
tremities. T e legs be me pr -
p rti nately l nger and the trunk
pr p rti nately sh rter. In addi- in dramati ally redu ed in ant
P
ti n, the th ra i and abd minal m rtality.
nt urs hange, r ughly speak- I S Many the hanges that
ing, r m r und t ellipti al. A
ur in the ardi vas ular and
Su h hanges are g d exam- respirat ry systems at birth are
ples the ever- hanging and n- ne essary r survival. W hereas 24
g ing nature gr wth, devel pment, and aging. It is un rtu- the etus t tally depends n the m ther r li e supp rt, the
nate that many the hanges that ur in the later years newb rn in ant must be me t tally sel -supp rting in terms
li e d n t result in in reased un ti n. T ese degenerative bl d ir ulati n and respirati n immediately a ter birth. A
hanges are ertainly imp rtant, h wever, and are dis ussed babys rst breath is deep and r e ul. T e stimulus t breathe
later in this hapter. T e ll wing are the m st mm n p st- results primarily r m the in reasing am unts arb n di x-
natal peri ds: (1) in ancy, (2) childhood, (3) adolescence, (4) adult- ide (CO 2) that a umulate in the bl d a ter the umbili al
hood, and (5) older adulthood. rd is ut ll wing delivery.
Table 24-2 illustrates pr je ted hanges in U.S. p pulati n Many devel pmental hanges ur between the end the
numbers in sele ted age-gr ups by de ade thr ugh the year ne natal peri d and 18 m nths age. Birth weight d ubles
2060. N ti e that the lder adulth d gr up is expe ted t during the rst 4 m nths and then triples by 1 year. T e baby
have the largest per entage gain. als in reases in length by 50% by the 12th m nth. T e baby
at that a umulated under the skin during the rst year be-
gins t de rease, and the plump in ant be mes leaner.
In a n c y Early in in an y the baby has nly ne spinal urvature
T e peri d in ancy begins abruptly at birth and lasts ab ut (Figure 24-13, A). T e lumbar urvature appears between 12 and
18 m nths. T e rst 4 weeks in an y are ten re erred t 18 m nths, and the n e-helpless in ant be mes a t ddler
as the neonatal period (Figure 24-12). D ramati hanges ur wh an stand (Figure 24-13, B).
at a rapid rate during this sh rt but riti al peri d. One the m st striking hanges t ur during in an y is
Neonatology is the medi al and nursing spe ialty n- the rapid devel pment the nerv us and mus ular systems.
erned with the diagn sis and treatment dis rders the T is permits the in ant t ll w a m ving bje t with the eyes
newb rn r neonate. Advan es in this area have resulted (2 m nths); li t the head and raise the hest (3 m nths); sit
 666 CHAPTER 24 Growth, Development, and Aging

FIGURE 24-13 Spinal curvatures. A, Normal rounded cur-

vature o the vertebral column in an in ant. B, Normal vertebral
curvature in a toddler. The dark shadow emphasizes the distinct
lumbar curvature that develops with the ability to walk. Com-
pare to adult curvatures in Figure 8-14, A, on p. 186.

the testi les, whi h begins between 10

and 13 years age.
B th sexes sh w a spurt in height dur-
ing ad les en e. In girls the spurt in
height begins between the ages 10 and
12 and is nearly mplete by age 14 r 15.
In b ys the peri d rapid gr wth begins
between 12 and 13 and is generally m-
plete by age 16. See Figure 24-14.
S
S
A P Ad u lt h o o d
A P
I Many devel pmental hanges that begin
I
early in hildh d are n t mpleted until
A B the early r middle years adulthood.
Examples in lude the maturati n b ne,
when well supp rted (4 m nths); rawl (10 m nths); stand resulting in the ull l sure the gr wth plates, and hanges
al ne (12 m nths); and run, alth ugh a bit sti y (18 m nths). in the size and pla ement ther b dy mp nents su h as
the sinuses. Many b dy traits d n t be me apparent r years
C h ild h o o d
24
Childhood extends r m the end in an y t sexual matu- 23
rity r puberty12 t 14 years in girls and 14 t 16 years in 22
b ys. O verall, gr wth during early hildh d ntinues at a 21
rather rapid pa e, but m nth-t -m nth gains be me less 20 Girls
nsistent. 19 Boys
By the age 6 years, the hild appears m re like a pread - 18
les ent than an in ant r t ddler. T e hild be mes less 17
24 hubby, the p tbelly be mes f atter, and the a e l ses its 16
babyish l k. T e nerv us and mus ular systems ntinue t 15
)
devel p rapidly during the middle years hildh d; by
r
14
y
/
10 years age the hild has devel ped numer us m t r and
m
13
c
(
rdinati n skills. 12
n
i
T e deciduous teeth, whi h begin t appear at ab ut
a
11
g
t
6 m nths age, are l st during hildh d, beginning at ab ut
h
10
g
i
6 years age. T e permanent teeth, with the p ssible ex epti n
e
9
H
the third m lars, r wisd m teeth, all erupt by age 14. 8
7
6
Ad o le s c e n c e
5
T e average age range adolescence varies, but generally the 4
teenage years (13 t 19) are alled the ad les ent years. T is 3
peri d is marked by rapid and intense physi al gr wth, whi h 2
ultimately results in sexual maturity. 1
Many the devel pmental hanges that ur during this
peri d are ntr lled by the se reti n sex h rm nes and are 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
lassi ed as secondary sex characteristics. Breast devel p- Ag e (yr)
ment is ten the rst sign appr a hing puberty in girls,
FIGURE 24-14 Growth in height. The gure shows typical patterns o
beginning ab ut age 10. M st girls begin t menstruate at 12 gain in height to adulthood or girls and boys. Notice the rapid gain in height
t 13 years age, whi h is ab ut 3 years earlier than a entury during the rst ew years, a period o slower growth, and then another burst
ag . In b ys the rst sign puberty is ten enlargement o growth during adolescence nally ending at the beginning o adulthood.
 CHAPTER 24 Growth, Development, and Aging 667

85% 65%
Ag in g
M e c h a n is m s o Ag in g
Older adulth d is hara terized by the pr esses senescence,
Ca rdia c
Bra in we ight
output a t re s t r degenerative aging. Un rtunately, the me hanisms and
auses aging are n t well underst d. A ew the m re likely
hyp theses are utlined here.
55%
Citric 80% S me ger nt l gists believe that an imp rtant aging
a cid me hanism is the limit n ell repr du ti n. Lab rat ry
cycle
experiments have sh wn that many types human ells
Ba s a l Re s pira tory
ann t repr du e m re than 50 times, thus limiting the
me ta bolic ca pa city of maximum li e span. Cells die ntinually, in a pr ess alled
ra te lungs apoptosis, n matter what a pers ns age, but in lder adult-
h d many dead ells are n t repla ed, ausing degenerati n
50% 65% tissues.
Perhaps the ells are n t repla ed be ause the surr unding
ells have rea hed their limit repr du ti n. Perhaps di er-
Live r Kidney ma s s
en es in ea h individuals aging pr ess result r m di eren es
blood ow in the repr du tive apa ity ells.
T e ellular death me hanism seems t perate in indi-
85% viduals with progeria, a rare, geneti nditi n in whi h a
63% pers n appears t age rapidly.
Conduction A variety a t rs that a e t the rates ell death and
Live r ve locity of ell repr du ti n have been ited as auses aging. S me
we ight ne rve be r
ger nt l gists believe that nutriti n, injury, disease, and ther
FIGURE 24-15 Changes in older adulthood. Insets show proportion o envir nmental a t rs a e t the aging pr ess. A ew have
remaining unction in the organs o a person in late adulthood compared even pr p sed that aging results r m ellular hanges aused
with that o a 20-year-old. These are average numbers, so many individuals by sl w-a ting aging viruses und in all living ells. O ther
experience ar di erent situations.
ger nt l gists have pr p sed that aging is aused by aging
genesgenes in whi h aging is prepr grammed.
Yet an ther pr p sed ause aging is aut immunity. Y u
a ter birth. N rmal balding patterns, r example, are deter- may re all r m Chapter 16 that aut immunity urs when
mined at the time ertilizati n by heredity but d n t appear the immune system atta ks a pers ns wn tissues.
until maturity.
As a general rule, adulth d is hara -
terized by maintenan e existing b dy 24
tissues. W ith the passage years, the n-
g ing e rt maintenan e and repair
RES EA RC H, IS S U ES , AND TREN D S
b dy tissues be mes m re and m re di - PROGERIA
ult. As a result, degenerati n begins. It is Proge ria, als o calle d Hutchins on-Gil ord proge ria
the pr ess aging, and it ulminates in s yndrom e , is a rare , atal condition in w hich chil-
death. dre n appe ar to age rapidly.
In proge ria, the re productive capacity o ce lls
s e e m s to be dim inis he d due to a toxic prote in
O ld e r Ad u lt h o o d calle d proge rin, w hich is als o ound in norm al ce lls
M st b dy systems are in peak nditi n at m uch lowe r leve ls and incre as e s as we age .
and un ti n at a high level e ien y Thus the tis s ue s o childre n w ith proge ria ail to
during the early years adulth d. As a m aintain or re pair the m s e lve s norm ally, and m any
o the de ge ne rative conditions m ore com m only
pers n gr ws lder, a gradual but ertain
s e e n in e lde rly individuals appe ar.
de line takes pla e in the un ti ning Som e o the s e conditions can be s e e n in this
every maj r rgan system in the b dy. T e photograph o a boy w ith proge ria: are as o tight-
study aging is alled gerontology. e ne d s kin w ith s tipple d coloration; hair los s ; los s
Many the bi l gi al hanges ass iated o s ubcutane ous at; and s ti , partially exe d
with advan ing age are sh wn in Figure 24-15. joints . Childre n w ith proge ria die o cardiovas cular
T e illustrati n highlights the pr p rti n dis e as e at an ave rage age o 14 ye ars .
remaining un ti n in a number rgans
in older adulthood when mpared with a
20-year- ld pers n.
 668 CHAPTER 24 Growth, Development, and Aging

Da ma ge d
Mitochondrion mitochondria
in he a lthy young ce ll AGING in old ce ll

Nutrie nts Mole cula r Nutrie nts

a nd O 2 complex a nd O 2

Ae robic
re s pira tion

ATP
ATP
Fre e ra dica ls
ATP
ATP
ATP Fre e -ra dica l
ATP production da ma ge incre a s e s
ATP ATP de cre a s e s ATP
ATP ATP
ATP
Abunda nt ATP
ATP
ATP ATP

FIGURE 24-16 Free-radical theory o aging. Free-radical production by cells, one o many possible
mechanisms o the aging processes, may increase as a person gets older, increasing the amount o cellular
damage. Free radicals are highly reactive orms o oxygen that are normal by-products o cellular respiration in
the mitochondria (shown) and other cell processes. As one ages, the number o ree radicals increases as cel-
lular e ciency decreases. Thus more cellular damage occurs, especially damage to cellular membranes, caus-
ing degeneration o the cell.

One p pular the ry aging states that xygen ree radicals S k in

play a maj r r le in ellular aging (Figure 24-16). Free radi als are T e skin (integumentary system) be mes dry, thin, and in-
highly rea tive rms xygen that n rmally result r m el- elasti with advan ing age. It sags n the b dy be ause
24 lular a tivities, but may damage the ell. As a pers ns ells in reased wrinkling and skin lds. Pigmentati n hanges and
pr du e m re and m re ree radi als during the later years, the thinning r l ss hair are als mm n nditi ns as-
m re damage urs t ellular stru tures and un ti ns. s iated with the aging pr ess.
Alth ugh the auses and basi me hanisms aging are yet
t be underst d, at least many the signs aging are bvi- S k e le t a l S y s t e m
us. T e remainder this hapter deals with a number the In lder adulth d, b nes underg hanges in texture, degree
m re mm n degenerative hanges that requently hara - al i ati n, and shape. Instead lean- ut margins, lder
terize pr esses aging. b nes devel p indistin t and shaggy-appearing margins with
spursa pr ess alled lipping. T is type degenerative
QUICK CHECK hange restri ts m vement be ause the piling up b ne
tissue ar und the j ints.
1. Do th e p ro p o rtio n s o th e h u m a n b o d y ch a n g e d u rin g
p o s tn a ta l d e ve lo p m e n t? W ith advan ing age, hanges in al i ati n may result in
2. Wh a t is th e n e o n a ta l p e rio d o d e ve lo p m e n t? redu ti n b ne size and in b nes that are p r us and sub-
3. Wh a t b io lo g ica l ch a n g e s h a p p e n d u rin g p u b e rty? je t t ra ture. T e l wer ervi al and th ra i vertebrae are
4. Wh a t is s e n e s ce n ce ? the sites requent ra tures. T e result is urvature the
5. Wh a t a re re e ra d ica ls , a n d w h a t ro le d o th e y h a ve in th e spine and the sh rtened stature s typi al late adulth d.
a g in g p ro ce s s ?
Degenerative j int diseases su h as osteoarthritis are als
mm n in elderly adults.
H wever, many the aging e e ts seen in the skelet n
E e c t s o Ag in g an be lessened by physi al a tivityespe ially i exer ise
Alth ugh advan ed age brings with it the higher risk many starts earlier in li e. L ss b ne mass and redu ed m bility
dis rders, it als brings s me bi l gi al advantages. We ex- an be av ided r redu ed by an ng ing pr gram physi al
pl re just a ew the hanges ass iated with aging here. a tivity upled with g d nutriti n.

RES EA RC H, IS S U ES , AND TREN D S
EXTENDING THE HUMAN LIFE S PAN
In the pas t ew de cade s , the incre as e d availability o be tte r
ood, s a e r s urroundings , and advance d m e dical care has ex-
te nde d quality living or m any around the world. But eve n
s im ple change s in li e s tyle , re gardle s s o m ode rn m e dical
wonde rs , can ke e p the e e cts o aging rom cre e ping up too
s oon. Pe rhaps the thre e m os t im portant low te ch m e thods
or im proving the quality o li e as you age are he alth ul die t,
exe rcis e , and s tre s s m anage m e nt.
A he alth ul die t is not available to s om e individuals , but it is
available to m os t o us . We are le arning m ore eve ry day about
w hat kind o die t is be s t, eve n to the point o be ing able to
m anage s pe cif c dis e as e s through die t.
Exe rcis e pe r orm e d on a re gular bas is , eve n i light or m od-
e rate , cannot only ke e p our s ke le tal and m us cular s ys te m s
C e n t r a l N e r vo u s S y s t e m
Advan ing age brings with it the risk dementiathe l ss
mem ry and ther un ti ns ns i us thinkingand
ther degenerative nditi ns that a e t the entral nerv us
system. F r m st us, h wever, ur mem ries remain m stly
inta t and have helped us devel p a mature ability t reas n
and make de isi ns. Alth ugh s me elderly individuals su er
r m depressi n, espe ially when they be me ill r separated
r m amily, the average elderly pers n is happier than during
early and middle adulth d.
S p e c ia l S e n s e s
T e sense rgans, as a gr up, all sh w a gradual de line in
per rman e and apa ity as a pers n ages.
M st pe ple are arsighted by age 65 be ause eye lenses
be me hardened and l se elasti ity; the lenses ann t be
urved t a mm date r near visi n. T is hardening the
lens is alled presbyopia, whi h means ld eye. Many indi-
viduals rst n ti e the hange at ab ut 40 r 45 years age,
when it be mes di ult t d l se-up w rk r read with ut
h lding printed material at arms length. T is explains the
in reased need, with advan ing age, r bi als, r glasses that
in rp rate tw lenses, t assist the eye in a mm dating r
near and distant visi n.
L ss transparen y the lens r its vering apsule is
an ther mm n age-related eye hange. I the lens a tually
be mes l udy and signi antly impairs visi n, it is alled a
cataract and must be rem ved surgi ally.
T e in iden e glaucoma, the m st seri us age-related
eye dis rder, in reases with age. Glau ma auses an in rease
in the pressure within the eyeball and, unless treated, ten
results in blindness. T e risk retinal degenerati n r de-
ta hment als in reases with age.
In many elderly pe ple a very signi ant l ss hair ells
in the spiral rgan the inner ear auses a seri us de line in
the ability t hear ertain requen ies. In additi n, the ear-
drum and atta hed ssi les be me m re xed and less able
CHAPTER 24 Growth, Development, and Aging 669
m ore f t but als o can de cre as e agings e e cts on the ne rvous
s ys te m , e ndocrine s ys te m , dige s tive s ys te m , and im m une
s ys te m the lis t s e e m s e ndle s s .
And las t, eve n ancie nt and s im ple te chnique s o s tre s s
m anage m e nt s uch as m e ditation and tai chi have be e n s how n
to he lp re duce the e e cts o aging and the dis e as e s that o te n
accom pany aging s uch as he art dis e as e and s troke s .
In s hort, we can us ually s tay young longe r i we e at right,
exe rcis e , and re lax.
What roles do genes play in how long we live?
Check out the article Genes and Longevity at
Connect It! at evolve.elsevier.com.
t transmit me hani al s und waves. S me degree hearing
impairment is universally present in the lder adult.
T e senses smell and taste are als de reased. T e result-
ing l ss appetite may be aused partly by the repla ement
taste buds with nne tive tissue ells. Only ab ut 40%
the taste buds present at age 30 remain in an individual at
age 75.
C a r d io va s c u la r S y s t e m
Degenerative heart and bl d vessel disease are am ng the
m st mm n and seri us e e ts aging. Fatty dep sits
build up in bl d vessel walls and narr w the passageway r
the m vement bl d, mu h as the build-up s ale in a
water pipe de reases f w and pressure. T e resulting ndi-
ti n, alled atherosclerosis, ten leads t eventual bl kage 24
the r nary arteries and a heart atta k (my ardial in-
ar ti n [MI]).
I atty a umulati ns r ther substan es in bl d vessels
al i y, a tual hardening the arteries, r arteriosclerosis
urs. Rupture a hardened vessel in the brain (str ke r
erebr vas ular a ident [CVA]) is a requent ause seri us
disability r death in the lder adult.
Hypertension (H N), r high bl d pressure, is als
m re mm n. H ardening arteries redu es their elasti ity,
whi h an ntribute t abn rmally high arterial pressure.
Re s p ir a t o ry S y s t e m
In lder adulth d the stal artilages that nne t the ribs
t the sternum be me hardened r al i ed. T is makes it
di ult r the rib age t expand and ntra t as it n rmally
d es during inspirati n and expirati n. In time the ribs gradu-
ally be me xed t the sternum, and hest m vements be-
me di ult. W hen this urs the rib age remains in a
m re expanded p siti n, respirat ry e ien y de reases, and
a nditi n alled barrel hest results.
W ith advan ing years, a generalized atr phy r wasting
mus le tissue takes pla e as the ntra tile mus le ells are
 670 CHAPTER 24 Growth, Development, and Aging
S C IEN C E APPLICATIONS
EMBRYOLOGY
Rita Levi-Montalcini had jus t f n-
is he d a m e dical de gre e in he r na-
tive Italy w he n in 1938 the Fas cis t
gove rnm e nt unde r Mus s olini barre d
all non-Aryans rom working in
acade m ic and pro e s s ional care e rs .
Be ing Jew is h, Levi-Montalcini was
orce d to m ove to Be lgium to work.
But w he n Be lgium was about to be
invade d by the Nazis , s he de cide d
Rita Levi-Montalcini to re turn hom e to Italy and work in
(19092012) s e cre t.
He r hom e laboratory was ve ry
crude , but in it s he m ade s om e im portant dis cove rie s about
how the ne rvous s ys te m deve lops during e m bryonic deve lop-
m e nt. A te r World War II, s he was invite d to Was hington Uni-
ve rs ity in St. Louis to work. The re , s he dis cove re d the exis -
te nce o ne rve grow th actor (NGF), or w hich s he late r won
repla ed by nne tive tissue. T is l ss mus le ells de-
reases the strength the mus les ass iated with inspirati n
and expirati n.
U r in a ry S y s t e m
T e number nephr n units in the kidney de reases by al-
m st 50% between the ages 30 and 75. Als , be ause less
bl d f ws thr ugh the kidneys as an individual ages, there is
a redu ti n in verall un ti n and ex ret ry apa ity r the
ability t pr du e urine. In the bladder, signi ant age-related
pr blems ten ur be ause diminished mus le t ne.
Mus le atr phy (wasting) in the bladder wall results in de-
24 reased apa ity and inability t empty r v id mpletely.
Re p ro d u c t ive S y s t e m s
Alth ugh m st men and w men remain sexually a tive
thr ugh ut their later years, me hanisms the sexual re-
sp nse may hange, and ertility de lines. In men, ere ti n
may be m re di ult t a hieve and maintain. Urgen y r
sex may de lineperhaps r m redu ed test ster ne r
l w . In w men, lubri ati n the vagina may de rease.
Men an ntinue t pr du e gametes as they age, but -
asi nally they exhibit a de line in test ster ne severe en ugh
t ause in ertilitya pr ess s metimes alled andropause.
W men experien e a essati n repr du tive y ling be-
tween the ages 45 and 60menopause. Men pause re-
sults r m a de rease in estr gen bel w that needed t sustain
repr du ti n.
T e pr ess men pause is n t a disease nditi n and is
nsidered a natural peri d bi l gi al transiti n in a w mans
the 1986 Nobe l Prize . He r dis cove ry o a che m ical that re gu-
late s the grow th o new ne rve s during e arly brain deve lopm e nt
has le d to m any di e re nt paths o inve s tigation. For exam ple ,
by le arning m ore about grow th re gulators , we now know m ore
about how the ne rvous s ys te m deve lops , as we ll as othe r tis -
s ue s , organs , and s ys te m s o the body.
Today, m any pro e s s ions m ake us e o the dis cove rie s o
e m bryo lo gythe s tudy o e arly deve lopm e nt. Not only are
the s e dis cove rie s im portant or he alth pro e s s ionals s uch as
o bs te tricians , o bs te tric nurs e s , and othe rs involve d in pre na-
tal he alth care , but they are als o im portant in unde rs tanding
adult m e dicine m ore ully. In act, eve n ge ro nto lo gy (s tudy o
aging) and ge riatrics (tre atm e nt o the age d) have be ne f te d
rom e m bryological re s e arch. How ? By providing ins ights on
how tis s ue deve lopm e nt is re gulate d in the e m bryo, s cie ntis ts
can be tte r unde rs tand how to pos s ibly s tim ulate dam age d tis -
s ue in olde r adults to re pair or re ge ne rate its e l .
li e. H wever, in additi n t the essati n menstrual y les,
the de rease in bl d estr gen levels during this peri d a -
unts r a number mm n and ten tr ubling sympt ms
whi h in lude h t f ashes, sleep disturban es, and dryness and
thinning the vaginal wall in many w men.
In the past, these men pause-related sympt ms resulting
r m l w estr gen levels were alm st always treated with es-
tr gen given as h rm ne repla ement therapy (H R ) r m re
simply, h rm ne therapy (H ). In re ent years this pra ti e
has been used m re are ully be ause the in reased risk
s me rms an er, str ke, bl d l tting dis rders, and
ther seri us side e e ts in s me lder w men wh had been
using H R r l ng peri ds r had begun H R well a ter the
nset men pause. H R ntinues t be used in many
y unger w men when they rst enter men pause.
F rtunately, medi ati ns ther than estr gen are als avail-
able t e e tively treat r prevent m st men pausal sympt ms
and ther health pr blems, su h as l ss b ne mass, r ste -
p r sis (see Chapter 8), and heart disease, that in rease in re-
quen y in lder w men wh have l wer bl d estr gen levels.
As with any therapy, treatment r men pause-related symp-
t ms requires are ul, individualized risk-bene t analysis.
QUICK CHECK
1. Wh a t a re s o m e ch a n g e s th a t o ccu r in th e s ke le to n a s o n e
ages?
2. Ho w d o e s o n es e ye s ig h t ch a n g e d u rin g la te a d u lth o o d ?
3. Wh a t ch a n g e s in th e ca rd io va s cu la r s ys te m o ccu r in o ld e r
a d u lts ?
4. Ho w is kid n e y u n ctio n a e cte d d u rin g o ld a g e ?
 CHAPTER 24 Growth, Development, and Aging 671

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 653)

endoderm in ancy postnatal period

(EN-doh-derm) (IN- an-see) (POST-nay-tal PEER-ee-id)
[endo- within, -derm skin] [in- not, - anc- speak, -y state] [post- a ter, -nat- birth, -al relating to]
ertilization labor prenatal period
(FER-tih-lih-ZAY-shun) (LAY-ber) (PREE-nay-tal PEER-ee-id)
[ ertil- ruit ul, -ization process] mesoderm [pre- be ore, -nat- birth, -al relating to]
etal phase (MEZ-oh-derm) primary germ layer
(FEE-tal ayz) [meso- middle, -derm skin] (PRYE-mayr-ee jerm LAY-er)
[ et- o spring, -al relating to] morula [prim- f rst, -ary state, germ sprout]
etus (MOR-yoo-lah) secondary sex characteristic
(FEE-tus) [mor- mulberry, -ula little] (SEK-on-dayr-ee sex kayr-ak-ter-IS-tik)
[ etus o spring] neonatal period [second- second, -ary relating to]
ree radical (nee-oh-NAY-tal PEER-ee-id) senescence
( ree RAD-ih-kal) [neo- new, -nat- birth, -al relating to] (seh-NES-enz)
[radic- root, -al relating to] neonate [senesc- grow old, -ence state]
gestation (NEE-oh-nayt) stem cell
(jes-TAY-shun) [neo- new, -nat- born] [stem stem o plant, cell storeroom]
[gesta- bear, -tion process] older adulthood trimester
gestation period (OLD-er ah-DULT-hood) (TRY-mes-ter)
(jes-TAY-shun PEER-ee-id) organogenesis [tri- three, -me(n)s- month, -ster thing]
[gesta- bear, -tion process] (or-gah-noh-J EN-eh-sis) yolk sac
hematopoiesis [organ- instrument (organ), -gen- produce, (yohk sak)
(hee-mat-oh-poy-EE-sis) -esis process] [yolk yellow part]
[hemo- blood, -poiesis making] parturition zygote
histogenesis (pahr-too-RIH-shun) (ZYE-goht)
(his-toh-J EN-eh-sis) [parturi- give birth, -tion process] [zygot- union or yoke]
[histo- tissue, -gen- produce, -esis process] placenta
implantation (plah-SEN-tah)
(im-plan-TAY-shun) [placenta at cake]
[im- in, -plant- set or place, -ation process]

24
LANGUAGE OF M ED IC IN E

abruptio placentae assisted reproductive technology (ART) cesarean section

(ab-RUP-shee-oh plah-SEN-tay) (ah-SIS-ted ree-proh-DUK-tiv (seh-SAYR-ee-an SEK-shun)
[ab- away rom, -ruptio rupture, placentae o at tek-NOL-oh-jee [ay ar tee]) [J ulius Caesar Roman emperor, -ean relating to,
cake (placenta)] [re- again, -pro- orward, -duct- bring or carry, sect- cut, -ion condition]
antenatal medicine -ive relating to, techn- art or skill, congenital
(an-tee-NAY-tal MED-ih-sin) -log- words (study o ), -y activity] (kon-J EN-ih-tall)
[ante- be ore, -nat- birth, -al relating to] atherosclerosis [con- with, -genit- born, -al relating to]
Apgar score (ath-er-oh-skleh-ROH-sis) dementia
(AP-gar skor) [ather- porridge, -sclero- harden, (de-MEN-shah)
[Virginia Apgar American physician] -osis condition] [de- o , -mens- mind, -ia condition o ]
arteriosclerosis birth de ect dizygotic twins
(ar-tee-ree-oh-skleh-ROH-sis) (berth DEE- ekt) (dye-zye-GOT-ik twinz)
[arteri- vessel (artery), -sclero- harden, cataract [di- two, zygot- union or yoke, -ic relating to,
-osis condition] (KAT-ah-rakt) twin two old]
[cataract broken water] eclampsia
(ee-KLAMP-see-ah)
[ec- out, -lamp- shine, -sia condition]

Continued on p. 672
 672 CHAPTER 24 Growth, Development, and Aging

LANGUAGE OF M ED IC IN E (co n tin u e d ro m p . 671)

etal alcohol syndrome (FAS) lactose intolerance osteoarthritis

(FEE-tal AL-koh-hol SIN-drohm [e ay es]) (LAK-tohs in-TOL-er-ans) (os-tee-oh-ar-THRY-tis)
[ et- o spring, -al relating to, syn- together, [lact- milk, -ose carbohydrate (sugar), in- not, [osteo- bone, -arthr- joint, -itis in ammation]
-drome running or (race) course] -toler- bear, -ance state] placenta previa
raternal twins laparoscope (plah-SEN-tah PREE-vee-ah)
( rah-TERN-al twinz) (LAP-ah-roh-skope) [placenta at cake, previa gone be ore]
[ rater- brother, -al relating to, twin two old] [laparo- abdomen, -scop- see] preeclampsia
geriatrics mastitis (pree-ee-KLAMP-see-ah)
(jayr-ee-A-triks) (mas-TYE-tis) [pre- be ore, -ec- out, -lamp- shine,
[ger- old, -iatr- treatment, -ic relating to] [mast- breast, -itis in ammation] -sia condition]
gerontology menopause presbyopia
(jayr-on-TOL-uh-jee) (MEN-oh-pawz) (pres-bee-OH-pee-ah)
[ger- old, -onto- age, -log- words (study o ), [men- month, -paus- cease] [presby- aging, -op- vision, -ia condition]
-y activity] microcephaly progeria
gestational diabetes mellitus (GDM) (my-kroh-SEF-ah-lee) (proh-J EER-ee-ah)
(jes-TAY-shun-al dye-ah-BEE-teez [micro- small, -ceph- head, -al relating to, [pro- early, -ger- old age, -ia condition]
MELL-ih-tus) -y state] puerperal ever
[gesta- bear, -tion- process, -al relating to, monozygotic twins (pyoo-ER-per-al FEE-ver)
diabetes pass-through or siphon, (mahn-oh-zye-GOT-ik twinz) [puerp- childbirth, -al relating to]
mellitus honey-sweet] [mono- one, zygot- union or yoke, -ic relating to, spontaneous abortion
glaucoma twin two old] (spon-TAY-nee-us ah-BOR-shun)
(glaw-KOH-mah) neonatology [sponte- willingly, -ous relating to, ab- away
[glauco- gray or silver, -oma tumor (growth)] (nee-oh-nay-TOL-oh-jee) rom or amiss, -or- be born, -tion process]
hypertension (HTN) [neo- new, -nat- born, -log- words (study o ), stillbirth
(hye-per-TEN-shun [aych tee en]) -y activity] (STIL-berth)
[hyper- excessive, -tens- stretch or pull tight, obstetric nurse teratogen
-sion state] (ob-STET-rik nurs) (TER-ah-toh-jen)
identical twins [ob- in ront, -stet- stand, -tric(s) emale agent, [terato- monster, -gen produce]
(aye-DEN-tih-kal twinz) nurs- nourish or nurture] ultrasonogram
[identic- sameness, -al relating to, twin two old] obstetrician (ul-trah-SON-uh-gram)
(ob-steh-TRISH-an) [ultra- beyond, -sono- sound, -gram drawing]
[ob- in ront, -stet- stand, -tric(s) emale agent,

24 -ian practitioner]

OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
Pre natal Pe rio d
S u m m a rie s online at evolve .e ls evie r.com . A. Prenatal peri d begins at n epti n and ntinues until
birth (ab ut 39 weeks) (Figure 24-1)
Scan this s um m ary a te r re ading the chapte r to B. S ien e etal gr wth and devel pment is alled
he lp you re in orce the key conce pts . Late r, us e embryology
the s um m ary as a quick review be ore your clas s C. Fertilizati n t implantati n requires ab ut 10 days
or be ore a te s t. 1. Fertilizati n n rmally urs in uter third vidu t
(uterine r all pian tube) (Figure 24-2)
2. Fertilized vum alled a zygote; zyg te is geneti ally
mpleteall that is needed r expressi n heredi-
tary traits is time and n urishment

3. A ter 3 days ell divisi n, the zyg te has devel ped
int a s lid ell mass alled a morula (Figure 24-3)
4. C ntinued ell divisi ns the m rula pr du e a
h ll w ball ells alled a blastocyst
5. Blast yst implants in the uterine wall ab ut 10 days
a ter ertilizati n
6. Blast yst rms the amni ti avity and h ri n
the pla enta (Figure 24-4)
7. Pla enta pr vides r ex hange nutrients between
the m ther and etus (Figure 24-5)
D. Peri ds devel pment
1. Length pregnan y r gestati n peri d is ab ut
39 weeks
2. Embry ni phase extends r m the third week a ter
ertilizati n t the end week 8 gestati n
3. Fetal phase extends r m week 8 t week 39
gestati n
4. All rgan systems are rmed and un ti ning by
m nth 4 gestati n (Figure 24-6)
E. Stem ellsunspe ialized ells that repr du e t rm
spe i lines spe ialized ells
F. T ree primary germ layersappear in the devel ping
embry a ter implantati n the blast yst (Table 24-1):
1. End derminside layer
2. Mes dermmiddle layer
3. E t derm utside layer
G. H ist genesis and rgan genesis (Figure 24-7)
1. F rmati n new rgans ( rgan genesis) and tissues
(hist genesis) urs r m spe i devel pment the
primary germ layers
2. Ea h primary germ layer gives rise t de nite stru -
tures su h as the skin and mus les
3. Gr wth pr esses in lude ell di erentiati n, multi-
pli ati n, gr wth, and rearrangement
4. Fr m 4 m nths gestati n until delivery, the devel-
pment the spring is mainly a matter gr wth
Birth
A. Pr ess birth alled parturition (Figure 24-8)
1. At the end week 39 gestati n, the uterus
be mes irritable
2. Fetus takes head-d wn p siti n against the ervix
3. Mus ular ntra ti ns begin, and lab r is initiated
4. Amni ti sa (bag waters) ruptures
5. Cervix dilates
6. Fetus m ves thr ugh vagina t exteri r
B. Stages lab r
1. Stage neperi d r m nset uterine ntra ti ns
until dilati n the ervix is mplete
2. Stage tw peri d r m the time maximal ervi al
dilati n until the spring exits thr ugh the vagina
3. Stage threepr ess expulsi n the pla enta
thr ugh the vagina
4. Clini ians s metimes re er t the re very peri d
immediately ll wing delivery the pla enta as the
urth stage lab r
CHAPTER 24 Growth, Development, and Aging 673
5. Apgar s re assesses general nditi n a newb rn
in ant
6. Cesarean se ti n (C-se ti n)surgi al delivery,
usually thr ugh an in isi n in the abd men and
uterine wall
C. Multiple birthstw r m re in ants r m the same
pregnan y (Figure 24-9)
1. Identi al siblings result r m the splitting tissue
r m the same zyg te, making them geneti ally
identi al
2. Fraternal siblings devel p r m di erent va that are
ertilized separately
Dis o rde rs o Pre g nancy
A. Implantati n dis rders (Figure 24-10)
1. E t pi pregnan yimplantati n utside the uterus
(e.g., tubal pregnan y)
2. Pla enta previagr wth the pla enta at r near
ervi al pening, ten resulting in separati n the
pla enta r m the uterine wall
3. Abrupti pla entaeseparati n a n rmally pla ed
pla enta r m the uterine wall
B. Pree lampsia (t xemia pregnan y)
1. Syndr me pregnan y that in ludes hypertensi n,
pr teinuria, and edema
2. May pr gress t e lampsia, a severe t xemia that may
result in death
C. Gestati nal diabetes mellitus (GDM)
1. Insulin resistan e in reases during pregnan y, and i
the pan reati islets ail t mpensate by in reasing
se reti n insulin, then GDM may result
2. May ause health issues in m ther and/ r etus,
in luding hypertensi n/pree lampsia, abn rmal etal
weight gain (lab r/delivery risk), and in reased risk r
C-se ti n delivery 24
D. Fetal death
1. Sp ntane us ab rti n (mis arriage)l ss be re week
20 ( r 500 g)
2. Stillbirthl ss a ter 20 weeks
E. Birth de e ts
1. May be inherited (congenital abnormalities) r a quired
2. A quired de e ts are aused by terat gens (agents that
disrupt n rmal devel pment)
F. P stpartum dis rders
1. Puerperal ever is aused by ba terial in e ti n that
may pr gress t septi emia and death; urs in
m thers a ter delivery (p stpartum)
2. La tati n and thus in ant nutriti n an be disrupted
by anemia, malnutriti n, and ther a t rs
a. Mastitisinf ammati n r in e ti n the breast
b. Milk an be supplied by an ther nursing m ther r
by breast-milk substitutes
. La t se int leran e results r m an in ants inabil-
ity t digest la t se present in human r animal
milk
 674 CHAPTER 24 Growth, Development, and Aging
Po s tnatal Pe rio d
A. P stnatal peri d begins at birth and lasts until death
B. Divisi ns p stnatal peri d int is lated time rames
an be misleading; li e is a ntinu us pr ess; gr wth
and devel pment are ntinu us (Table 24-2)
C. O bvi us hanges in the physi al appearan e the
b dyin wh le and in pr p rti n ur between birth
and maturity (Figure 24-11)
D. Divisi ns p stnatal peri d
1. In an y
2. Childh d
3. Ad les en e and adulth d
4. O lder adulth d
E. In an y
1. First 4 weeks alled neonatal period (Figure 24-12)
2. Ne nat l gymedi al and nursing spe ialty n-
erned with the diagn sis and treatment dis rders
the newb rn
3. Many ardi vas ular hanges ur at the time
birth; etus is t tally dependent n m ther, whereas
the newb rn must immediately be me t tally sel -
supp rting (respirati n and ir ulati n)
4. Respirat ry hanges at birth in lude a deep and r e-
ul rst breath
5. Devel pmental hanges between the ne natal peri d
and 18 m nths in lude:
a. D ubling birth weight by 4 m nths and tripling
by 1 year
b. Fi ty per ent in rease in b dy length by 12 m nths
. Devel pment n rmal spinal urvature by
15 m nths (Figure 24-13)
d. Ability t raise head by 3 m nths
e. Ability t rawl by 10 m nths
. Ability t stand al ne by 12 m nths
24 g. Ability t run by 18 m nths
F. Childh d
1. Extends r m end in an y t puberty13 years in
girls and 15 in b ys
2. O verall rate gr wth remains rapid but de elerates
3. C ntinuing devel pment m t r and rdinati n
skills
4. L ss de idu us r baby teeth and erupti n per-
manent teeth
G. Ad les en e
1. Average age range ad les en e is r m 13 t
19 years
2. Peri d rapid gr wth resulting in sexual maturity
(ad les en e)
3. Appearan e se ndary sex hara teristi s regulated
by se reti n sex h rm nes
4. Gr wth spurt typi al ad les en e; begins in girls at
ab ut 10 and in b ys at ab ut 12 (Figure 24-14)
H . Adulth d
1. Gr wth plates ully l se in adult; ther stru tures
su h as the sinuses a quire adult pla ement
2. Adulth d hara terized by maintenan e existing
b dy tissues
3. Degenerati n b dy tissue begins in adulth d
I. O lder adulth d
1. Degenerative hanges hara terize lder adulth d, r
aging (Figure 24-15)
2. Ger nt l gythe study aging
3. Every rgan system the b dy underg es degenera-
tive hanges, eventually ulminating in death
Ag ing
A. Senes en ethe pr ess degenerative aging
B. Me hanisms agingn t well underst d
1. Cellular me hanismlimited ell repr du ti n and
ap pt sis ( ell death) als limits the li espan tissues
and the wh le rganism; pr geria is a nditi n
rapid ell death that mimi s senes en e
2. Free-radi al the rythe number xygen ree radi-
als in reases as ne ages, thus in reasing the rate
ellular damage
3. O ther a t rs may play a r le: nutriti n, injury, disease,
envir nmental and geneti a t rs, viruses, and
aut immunity
C. E e ts aging
1. Integumentary system (skin)
a. W ith age, skin sags and be mes thin, dry, and
wrinkled ( r inelasti )
b. Pigmentati n pr blems are mm n
. Frequent thinning r l ss hair urs
2. Skeletal system
a. Aging auses hanges in the texture, al i ati n,
and shape b nes
b. B ne spurs devel p ar und j ints
. B nes be me p r us and ra ture easily
d. Degenerative j int diseases su h as ste arthritis
are mm n
e. Physi al a tivity an redu e l ss b ne mass and
m bility
3. Central nerv us system
a. In reased risk dementia
b. Mature reas ning ability
4. Spe ial senses
a. All sense rgans sh w a gradual de line in per r-
man e with age
b. Eye lenses be me hard and ann t a mm date
r near visi n; result is arsightedness in many
pe ple by age 45 (presby pia)
. L ss transparen y lens r rnea is mm n
( atara t)

d. Glau ma (in rease in pressure in eyeball) is ten
the ause blindness in lder adulth d
e. L ss hair ells in inner ear pr du es requen y
dea ness in many lder pe ple
. De reased transmissi n s und waves aused by
l ss elasti ity eardrum and xing the b ny
ear ssi les is mm n in lder adulth d
g. S me degree hearing impairment is universally
present in the aged
h. Ability t smell and taste may be redu ed; nly
ab ut 40% the taste buds present at age 30
remain at age 75
5. Cardi vas ular system
a. Degenerative heart and bl d vessel disease is
am ng the m st mm n and seri us e e ts
aging
b. Fat dep sits in bl d vessels (ather s ler sis)
de rease bl d f w t the heart and may ause
mplete bl kage the r nary arteries
. H ardening arteries (arteri s ler sis) may result
in rupture bl d vessels, espe ially in the brain
(str ke)
d. H ypertensi n r high bl d pressure is mm n in
lder adulth d
6. Respirat ry system
a. Cal i ati n stal artilages auses rib age t
remain in expanded p siti n, resulting in barrel
hest
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
Be ore s tudying this chapte r, quickly review the re productive
s ys te m s in Chapte r 23. Als o review the s ynops is o all the
organ s ys te m s ound in Chapte r 5.
1. Make f ash ards and he k nline res ur es t help y u
learn the early devel pmental stages. It w uld be help ul
t in lude the rder in whi h ea h devel pmental stage
urs. Remember t als in lude the un ti ns the
amni n, h ri n, and pla enta.
2. T e term germ in primary germ layer re ers t germinate.
All the stru tures the b dy me r m ne the
primary germ layers. Ea h is named based n its l ati n
in the devel ping embry . Endoderm means inner skin,
mesoderm means middle skin, and ectoderm means uter
skin. Devel p a hart r f ash ards t help y u learn t
mat h up the primary germ layers and the stru tures that
devel p r m ea h layer.
CHAPTER 24 Growth, Development, and Aging 675
b. Wasting respirat ry mus les de reases respira-
t ry e ien y
. Respirat ry membrane thi kens; m vement
xygen r m alve li t bl d is sl wed
7. Urinary system
a. Nephr n units de rease in number by 50% between
ages 30 and 75
b. Bl d f w t kidney, and there re ability t rm
urine, de reases
. Bladder pr blems su h as inability t v id m-
pletely are aused by mus le wasting in the bladder
wall
8. Repr du tive system
a. Changes in the sexual resp nse
(1) Menere ti n is m re di ult t a hieve and
maintain; urgen y r sex may de line due t
de lining test ster ne
(2) W menlubri ati n during inter urse may
de rease
b. Changes in ertility
(1) Menmay ntinue t be ertile thr ugh ut
later adult years
(2) W menexperien e men pause ( essati n
repr du tive y ling) between the ages 45
and 60
3. Review the Language S ien e and Language Medi-
ine se ti ns r a better understanding the 24
termin l gy.
4. T e stages lab r, the imp rtant events in the p stnatal
peri ds, and the e e ts ld age n vari us rgan
systems als an be put n f ash ards t a ilitate
learning.
5. Make a hart the dis rders pregnan y; rganize it by
me hanism r ause: implantati n dis rders, pree lamp-
sia, birth de e ts, and p stpartum dis rders.
6. In y ur study gr up, g ver the f ash ards the stages
devel pment, making sure y u kn w the pr per
sequen e. G ver y ur hart and f ash ards r the
primary germ layers and what rgans me r m ea h
layer. Review the f ash ards r the stages lab r, the
p stnatal peri ds, and the e e ts aging, and review the
hart the dis rders. Review the questi ns at the end
the hapter and the hapter utline summary and dis uss
p ssible test questi ns.
 676 CHAPTER 24 Growth, Development, and Aging
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Explain what urs between the time vulati n and
the implantati n the ertilized egg int the uterus.
2. Explain the un ti n the h ri n and pla enta.
3. Explain the un ti n the y lk sa and amni ti avity.
4. Name the three primary germ layers, and name three
stru tures that devel p r m ea h layer.
5. De ne hist genesis and rgan genesis.
6. Des ribe and give the appr ximate length ea h the
three stages lab r.
7. Des ribe a bree h birth.
8. W hat is the di eren e between identi al and raternal
twins?
9. W hat is an e t pi pregnan y? W here is it m st likely
t ur?
10. W hat is pla enta previa? W hat is abrupti pla entae?
11. W hat is pree lampsia?
12. W hat is a terat gen?
13. W hat is the stimulus r a babys rst breath?
14. Name three devel pmental hanges that ur during
in an y.
15. Brief y explain what bi l gi al devel pments ur
during hildh d.
16. Brief y explain what bi l gi al devel pments ur
during ad les en e.
17. Brief y explain what bi l gi al devel pments ur
during adulth d.
18. W hat is pr geria?
24 19. Explain the e e ts aging n the skeletal system.
20. Explain the e e ts aging n the respirat ry system.
21. Explain the e e ts aging n the ardi vas ular
system.
22. Explain the e e ts aging n visi n.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
23. Explain the pr edure a physi ian might use i a n rmal
vaginal delivery w uld be danger us r the m ther r
spring.
24. W hy w uld y ur physi ian be relu tant t treat y ur
men pause-related sympt ms with h rm ne repla e-
ment therapy (H R )?
25. Based up n what y u kn w, explain h w a s und exer-
ise pr gram an redu e s me the mm n e e ts
aging.
Chapte r Te s t
A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. T e s ien e the devel pment the spring be re
birth is alled ________.
2. ________ m st ten urs in the uter ne-third
the vidu t.
3. T e ertilized vum is alled a ________.
4. A ter ab ut 3 days mit sis, the ertilized vum rms
a s lid mass ells alled the ________.
5. Mit sis ntinues, and by the time the devel ping egg
rea hes the uterus, it has be me a s lid ball ells
alled the ________.
6. At the very beginning the embry ni stage, all the
ells are ________.
7. T e ________ an h rs the devel ping etus t the
uterus and pr vides a bridge r the ex hange sub-
stan es between the m ther and spring.
8. T e ________ peri d lasts ab ut 39 weeks and is
divided int trimesters.
9. T e three primary germ layers are the ________, the
________, and the ________.
10. ________ ells are unspe ialized ells that are apable
pr du ing many di erent kinds ells.
11. T e pr ess by whi h the primary germ layers devel p
int tissues is alled ________.
12. T e pr ess by whi h tissues devel p int rgans is
alled ________.
13. T e pr ess birth is alled ________.
 CHAPTER 24 Growth, Development, and Aging 677

14. wins resulting r m tw di erent va being ertilized
by tw di erent sperm are alled ________ twins.
15. wins resulting r m the splitting embry ni tissue
r m the same zyg te are alled ________ twins.
16. Envir nmental agents that an disrupt n rmal hist gen-
esis and rgan genesis are alled ________.
17. A ter 20 weeks, delivery a li eless in ant is termed a
________.
18. T e rst 4 weeks in an y is re erred t as the
________ peri d.
19. ________ is a syndr me p stpartum m thers hara -
terized by ba terial in e ti n that pr gresses t septi e-
mia and p ssibly death.
20. ________ is a degenerative j int disease that is mm n
t lder adults.
21. ________ means ld eye and auses lder adults t be
arsighted.
22. I the lens the eye be mes l udy and impairs visi n,
the nditi n is alled a ________.
23. ________ is an ther name r hardening the
arteries.
24. ________ are highly rea tive rms xygen that n r-
mally result r m ellular a tivities, but may damage the
ell.

Match each term in Column A with its corresponding description in Column B.

Column A
25. ________ in an y
26. ________ hildh d
27. ________ ad les en e
28. ________ adulth d
29. ________ lder adulth
Column B
a. peri d during whi h the de idu us teeth are l st
b. peri d during whi h l sure the b ne gr wth plates urs
. peri d that begins at birth
d. senes en e
d e. peri d during whi h the se ndary sex hara teristi s usually begin t devel p

Match each disorder in Column A with its corresponding description or cause in Column B.

Column A
30. ________ e t pi pregnan y
31. ________ abrupti pla entae
32. ________ pla enta previa
33. ________ pree lampsia
34. ________ puerperal ever
35. ________ mastitis
36. ________ pr geria
Column B
a. a nditi n in whi h the blast yst implants t l se t the ervi al pening
the uterus
b. inf ammati n the breast
. a p stpartum dis rder hara terized by a ba terial in e ti n that pr gresses t
septi emia
d. an inherited nditi n in whi h the pers n seems t age very rapidly
e. separati n the pla enta r m the uterine wall in a pregnan y 20 weeks r
l nger
. a dis rder hara terized by a ute hypertensi n a ter 24 weeks pregnan y 24
g. the implantati n the blast yst utside the uterus

Cas e S tudie s ass iated with the m derate drinking d ne by Abes

To s olve a cas e s tudy, you m ay have to re e r to
the glos s ary or index, othe r chapte rs in this text-
book, and othe r re s ource s .
1. Mary is pregnant with her rst hild and is t uring the
maternity f r a l al h spital in preparati n r the
up ming birth. She keeps asking ab ut their pre auti ns
regarding asepti te hnique in the h me-style birthing
r ms. She is n erned be ause her wn grandm ther
died an in e ti n a ter delivering Marys m ther. W hy
sh uld Mary be n erned? W hat might happen i the
h spital d es n t en r e asepti te hnique in the birth-
ing r m?
2. w -year- ld Abe has always been small r his age and
is n w diagn sed as having devel pmental disabilities.
Abes grandm ther believes that these disabilities are
m ther during her pregnan y. Is Abes grandm ther
simply trying t justi y her meddling r uld his
m thers drinking have aused his pr blems?
3. La t se int leran e is s metimes treated by rem ving
la t se r m the diet. F r example, in ants with la t se
int leran e may be given a la t se- ree milk substitute t
av id the indigesti n, diarrhea, abd minal dis m rt, and
ther sympt ms this nditi n. O lder hildren and
adults with la t se int leran e may av id dairy pr du ts
and ther ds high in la t se. Y ur riend Aileen, wh
has la t se int leran e, takes a tablet with her av rite i e
ream ( h late udge) that helps her av id any pr b-
lems. W hat might this tablet ntain?
Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
Genetics and Genetic Diseases
O U T L IN E
Scan this outline be ore you begin to read the
chapter, as a preview o how the concepts are
organized.

Genetics and Human Disease, 679

Chromosomes and Genes, 680
Mechanisms o Gene Function, 680
Human Genome, 680
Distribution o Chromosomes to O spring, 681
Gene Expression, 682
Hereditary Traits, 682
Sex-Linked Traits, 683
Genetic Mutations, 684
Genetic Diseases, 684
Mechanisms o Genetic Disease, 684
Single-Gene Diseases, 686
Epigenetic Conditions, 688
Chromosomal Diseases, 688
Prevention and Treatment o Genetic Diseases, 689
Genetic Counseling, 689
Treating Genetic Diseases, 692

O B J E C T IV E S
Be ore reading the chapter, review these goals
or your learning.

A ter you have completed this chapter, you should be

able to:
1. Explain how genes can cause disease.
2. Distinguish between dominant and recessive genetic
traits.
3. Describe sex-linked inheritance and explain how
genetic mutations may occur.
4. Explain the mechanisms o genetic disease and list
some important inherited diseases.
5. Describe how nondisjunction can result in trisomy or
monosomy and list some disorders that result rom it.
6. List some tools used in genetic counseling and
explain how they are used to help clients.
7. Describe how genetic disorders can be treated.
 25
It seems that t day we are hearing m re and m re ab ut LANGUAGE OF
the relati nship genetics, the s ienti study S C IEN C E
inheritan e, and human disease. P pular news
magazines are running st ry a ter st ry n the
Be o re re ading the
rev luti n in treating atal inherited dis rders
chapte r, s ay e ach o
by using s mething alled gene therapy. the s e te rm s o ut lo ud. This w ill
H ealth and s ien e bl gs keep us in rmed he lp yo u to avo id s tum bling ove r
the latest dis veries genes inv lved the m as yo u re ad.
with disease, human behavi r, and even
l ngevity. elevisi n pr grams utline the
autosome
pr gress the largest rdinated bi l gi- (AW-toh-sohm)
al quest that any ne an remember: map- [auto- sel , -som- body]
ping the entire human geneti de, listing carrier
all the pr teins en ded there, and w rking (KARE-ee-er)
ut h w genes are regulated. codominance
(koh-DOM-ih-nance)
Clearly, a pers n ann t be in rmed [co- together, -domina- rule,
ab ut the me hanisms human disease -ance state]
t day with ut s me kn wledge basi crossing-over
geneti s. In this hapter, we brief y re- (KROS-ing OH-ver)
view the essential n epts geneti s dominant gene
and explain h w misin rmati n in the (DOM-ih-nant jeen)
geneti de an ause disease. [domina- rule, -ant state,
gen- produce]
epigenetics
G e n e t ic s a n d Hu m a n (ep-ih-jeh-NET-iks)
D is e a s e [epi- upon, gen- produce,
-ic relating to]
H ist ry sh ws that humans have been gamete
aware inheritan e r th usands (GAM-eet)
years; h wever, it was n t until [gamet- sexual union or marriage
the 1860s that the s ienti partner]
gene
(jeen)
[gen- produce]
genetic mutation
(jeh-NET-ik myoo-TAY-shun)
[gene- produce, -ic relating to,
muta- change, -ation process]
genetics
(jeh-NET-iks)
[gen- produce, -ic relating to]
genome
(J EE-nohm)
[gen- produce (gene), -ome entire
collection]

Continued on p. 694

679
 680 CHAPTER 25 Genetics and Genetic Diseases
study inheritan egenetics was b rn. At that time, a
m nk living in what is n w part Cze hia dis vered the
basi me hanism by whi h traits are transmitted r m parents
t spring. T at man, Greg r Mendel, dem nstrated that
independent units (whi h we n w all genes) are resp nsible
r the inheritan e bi l gi al traits.
T e s ien e geneti s devel ped r m Mendels quest t
explain h w n rmal bi l gi al hara teristi s are inherited. As
time went by, and m re geneti studies were d ne, it be ame
lear that ertain diseases have a geneti basis. In Chapter 6,
y u learned that s me diseases are inherited dire tly. F r ex-
ample, the bl d- l tting dis rder alled hemophilia is inher-
ited by hildren r m a parent wh has the geneti de r
hem philia.
O ther diseases are nly partly determined by geneti s; that
is, they inv lve geneti risk a t rs (see Chapter 6). F r ex-
ample, ertain rms skin an er are th ught t have a ge-
neti basis. A pers n wh inherits the geneti de ass iated
with skin an er will devel p the disease nly i the skin is
als heavily exp sed t the ultravi let radiati n in sunlight.
C h ro m o s o m e s a n d G e n e s
M e c h a n is m s o G e n e Fu n c t io n
Mendel pr p sed that the geneti de is transmitted t - details the human gen me, mu h w rk still lies ahead in
spring in dis rete, independent units that we n w all genes.
In Chapter 3 we stated that ea h gene is a sequen e nu le -
tide bases in the de xyrib nu lei a id (DNA) m le ule (als
see Chapter 2). Ea h gene ntains a geneti de that the ell
trans ribes t a messenger RNA (mRNA) m le ule. Ea h
mRNA m le ule m ves t a rib s me, where the de is
translated t rm a spe i pr tein m le ule.
Many the pr tein m le ules thus rmed are enzymes,
un ti nal pr teins that permit spe i bi hemi al rea ti ns
t ur (see Chapter 2). Be ause enzymes regulate the bi -
hemistry the b dy, they regulate the entire stru ture and
un ti n the b dy. T us genes determine the stru ture and
un ti n the human b dy by pr du ing a set spe i
regulat ry enzymes.
As des ribed in Chapter 3, genes are simply segments a
DNA m le ule. W hile the geneti des its genes are being
a tively trans ribed, the DNA is in a threadlike rm alled
hr matin. D uring ell divisi n, ea h repli ated strand
hr matin ils t rm a mpa t mass alled a hr m s me
(Figure 25-1). T us ea h DNA m le ule an be alled either a
25 chromatin strand r a chromosome. Genes may be a tively tran-
s ribed in the hr matin rm DNA but n t in the hr -
m s me rm. make things easy, h wever, we will simply
use the term chromosome r DNA and the term gene r ea h
distin t en ding segment within a DNA m le ule.
Hu m a n G e n o m e
T e entire lle ti n geneti material in ea h typi al ell
the human b dy is alled the genome. T e typi al human
gen me in ludes 46 individual nu lear hr m s mes and ne
mit h ndrial hr m s me.
In 2003, the H uman Genome Project (H GP)a pub-
li ly unded, w rldwide llab rati n t map all the genes
in the human gen mewas mpleted. T is landmark event
in ided exa tly with the tieth anniversary the dis v-
ery D NA. We n w kn w that the human gen me n-
tains nly ab ut 19,000 r s genes. T is is ar less than
riginally estimated and am ng the smallest gen mes any
animal!
We als kn w that less than 2% the DNA arries genes
that de r pr teins. T e rest has been alled junk DNA,
r n n ding DNA, be ause it is n t used dire tly t make
pr teins.
A small p rti n this n n ding DNA seems t be made
up br ken bits genes that are n l nger un ti nal
remnants ur ev luti nary past alled pseudogenes. A -
rding t the ng ing H GP sh t ENCODE (Encyclope-
dia o DNA Elements), h wever, ab ut 80% the n n ding
DNA is made up regi ns that regulate the timely swit hing
genes n and .
T e urrent dra t the human gen me sh ws us that
m st ding genes tend t lie in lusters, separated by l ng
stret hes n n ding DNA. H undreds newly dis vered
genes in the human gen me seem t be ba terial in rigin,
perhaps inserted there by ba teria in ur distant an est rs.
Alth ugh we n w seem t have the verall pi ture the
the eld genomics, the analysis the gen mes de. Be-
sides lling in the remaining details the r ugh dra t, we
have mu h w rk t d in dis vering all the p ssible muta-
ti ns that might exist (see the dis ussi n later in this hapter)
and all the pr teins en ded by the genes that make up the
human gen me.
T e quest t analyze the gen me has generated an ther
eld alled proteomics, the analysis the pr teins en ded
by the gen me. T e entire gr up pr teins en ded by the
human gen me is alled the human proteome. T e ultimate
g al pr te mi s is t understand the r le ea h pr tein in
the b dy. Understanding the r les every single pr tein in
the b dy will ertainly g a l ng way t ward impr ving ur
kn wledge the n rmal un ti n the b dy as well as the
me hanisms r many diseases.
In rmati n btained ab ut the human gen me an be
expressed in a variety ways. As y u an see in Figure 25-1, an
ideogram, r simple art n a hr m s me, is ten used
in gen mi s t sh w the verall physi al stru ture a hr -
m s me. T e nstri ti n in the ide gram sh ws the relative
p siti n the hr m s mes entr mere. T e sh rter seg-
ment the hr m s me is alled the p-arm and the l nger
segment is alled the q-arm.
T e bands in an ide gram a hr m s me sh w stain-
ing landmarks and help identi y the regi ns the hr m -
s me. S metimes physi al maps genes will sh w exa t
p siti ns individual genes n the p-arm and q-arm a
hr m s me.
A m re detailed representati n a gene w uld sh w the
a tual sequen e nu le tide bases, abbreviated here a, c, g,
and t r adenine, cytosine, guanine, and thymine, as y u see in
Figure 25-1.
 CHAPTER 25 Genetics and Genetic Diseases 681

Human cell
(metaphase)

Mic ro g raph o f
c hro mo s o me s
1 2 3 4 5

Karyo type
6 7 8 9 10

Chromatin 11 12 13 14 15

16 Y
17 18
X

1 m
19 20 21 22

Ce ntro me re

Chromosome Ideogram Gene sequence

FIGURE 25-1 Human genome. A cell taken rom the body is stained and photographed. A digital micro-
graph o nuclear chromosomes is then processed, sorting the 46 chromosomes into numbered pairs o decreas-
ing size to orm a chart called the karyotype. Each chromosome is a coiled mass o chromatin (DNA). In this
gure, di erentially stained bands in each chromosome appear as di erent bright colors. Such bands are use ul
as re erence points when identi ying the locations o speci c genes within a chromosome. The staining bands
are also represented on an ideogram, or simple graph, o the chromosome as re erence points to locate speci c
genes. The genes themselves are usually represented as the actual sequence o nucleotide bases, abbreviated
here as a, c, g, and t. In this gure, the sequence o one exon (segment) o a gene called GPI rom chromosome
19 is shown. Each o these representations can be thought o as a type o genetic map.

D is t r ib u t io n o C h ro m o s o m e s chromosomes may n t mat h, but the remaining 22 pairs

t o O s p r in g
Ea h ell the human b dy ntains 46 hr m s mes. T e
nly ex epti ns t this prin iple are the gametesmale
spermatozoa and emale ova. Chapter 23 intr du ed a spe ial
rm nu lear divisi n alled meiosis (Figure 25-2) that pr -
du es gametes with nly 23 hr m s mesexa tly hal the
usual number.
W hen a sperm (with its 23 hr m s mes) unites with an
vum (with its 23 hr m s mes) at n epti n, a zygote with
46 hr m s mes is rmed. T us the zyg te has the same
number hr m s mes as ea h b dy ell in the parents.
As Figure 25-1 sh ws, the 46 human hr m s mes an be
arranged in 23 pairs a rding t size. One pair alled the sex
autosomes always appear t be nearly identi al t ea h ther.
Be ause hal an springs hr m s mes are r m the 25
m ther and hal are r m the ather, a unique blend inher-
ited traits is rmed. A rding t prin iples rst dis vered
by M endel, ea h hr m s me ass rts itsel independently
during mei sis (see Figure 25-2). T is means that as sperm are
rmed, hr m s me pairs separate and the maternal and
paternal hr m s mes get mixed up and redistribute them-
selves independently the ther hr m s me pairs. T us
ea h sperm is likely t have a dif erent set 23 hr m -
s mes. Be ause va are rmed in the same manner, ea h
vum is likely t be geneti ally di erent r m the vum that
pre eded it.
 682 CHAPTER 25 Genetics and Genetic Diseases

Me io s is
(Chroma tin FIGURE 25-3 Crossing-over. Genes (or
Diploid pa re nt ce ll be ginning linked groups o genes) rom one chromo-
to conde ns e ) some are exchanged with matching genes
in the other chromosome o a pair during
meiosis.
(Chromos ome s
a ligne d a long
ce nte r of ce ll)

Meios is I

Me iosis II

Ha ploid
ga me te s

Othe r po s s ible alig nme nts

Me ios is I Me ios is I Me ios is I
Me ios is II Me ios is II Me ios is II
FIGURE 25-2 Meiosis. In meiosis, a series o two divisions results in
the production o gametes with hal the number o chromosomes o the
original parent cell. In this gure, the original cell has our chromosomes and
the gametes each have two chromosomes. During the rst division o meio-
sis, pairs o similar chromosomes line up along the cells equator or even
distribution to daughter cells. Because di erent pairs assort independently
o each other, any o our (22) di erent combinations o chromosomes may
occur. Because human cells have 23 pairs o chromosomes, more than 8 mil-
lion (223) di erent combinations are possible.
Independent ass rtment hr m s mes ensures that ea h
spring r m a single set parents is very likely t be geneti-
ally uniquea phen men n kn wn as genetic variation.
T e principle o independent assortment als applies t
individual genes r gr ups genes. D uring ne phase
mei sis, pairs mat hing hr m s mes line up al ng the
equat r the ell and ex hange genes. T is pr ess is alled
crossing-over be ause genes r m a parti ular l ati n r ss
ver t the same l ati n n the mat hing gene (Figure 25-3).
S metimes a wh le gr up stays t gether and r sses ver as a
25 single unita phen men n alled gene linkage. Cr ssing-
ver intr du es additi nal p ssibilities r geneti variati n
am ng spring a set parents.
QUICK CHECK
1. Ho w d o g e n e s p ro d u ce b io lo g ica l tra its ?
2. Wh o m ig h t b e co n s id e re d th e o u n d e r o th e s cie n tif c
s tu d y o g e n e tics ?
3. Wh a t is th e d i e re n ce b e tw e e n a n a u to s o m e a n d a s e x
ch ro m o s o m e ?
4. Lis t s o m e m e ch a n is m s th a t in cre a s e g e n e tic va ria tio n
a m o n g h u m a n o s p rin g .
G e n e Ex p r e s s io n
He r e d it a ry Tr a it s
G e n e P a ir s
Mendel dis vered that the geneti units we n w all genes
may be expressed di erently am ng individual spring. A -
ter rig r us experimentati n with pea plants, he dis vered
that ea h inherited trait is ntr lled by tw sets similar
genes, ne r m ea h parent.
We n w kn w that ea h aut s me in a pair mat hes its
partner in the type genes it ntains. In ther w rds, i ne
aut s me has a gene that inf uen es hair l r, its partner will
als have a gene that inf uen es hair l rin the same l a-
ti n n the aut s me. Alth ugh b th genes spe i y s mething
ab ut hair l r, they may n t spe i y the same hair l r.
D o m in a n c e a n d Re c e s s ive n e s s
Mendel als dis vered that s me genes and the traits they
ntr l are d minant and s me are re essive. A dominant
gene is ne wh se e e ts are seen and that is apable mask-
ing the e e ts a recessive gene r the same trait.
C nsider the example albinism, a la k melanin pig-
ment in the skin and eyes. Be ause they la k dark pigmenta-
ti n, pe ple with this nditi n have di ulty with seeing
and pr te ting themselves r m burns in dire t sunlight. T e
genes that ause albinism are re essive; the genes that ause
n rmal melanin pr du ti n are d minant.
By nventi n, d minant genes are represented by upper-
ase letters and re essive genes by l wer ase letters. One an
represent the gene r albinism as a and the gene r n rmal
skin pigmentati n as A. A pers n with the gene mbinati n
AA has tw d minant genesand s will exhibit a n rmal skin
l r. S me ne with the gene mbinati n Aa will als have
n rmal skin l r be ause the n rmal gene A is d minant ver
the re essive albinism gene a. Only a pers n with the gene
mbinati n aa will have albinism be ause there is n d mi-
nant gene t mask the e e ts the tw re essive genes.
In the example albinism, a pers n with the gene mbi-
nati n Aa is said t be a geneti carrier albinism. T is
 CHAPTER 25 Genetics and Genetic Diseases 683

Mothe r Offs pring Fa the r

(ca rrie r) (ca rrie r)

Aa AA Aa
A
Norma l
pigme nta tion
A
Ovum
Aa S pe rm

Norma l a
a pigme nta tion
(ca rrie r)
Ovum S pe rm
aa
FIGURE 25-4 Inheritance o albinism.
Albinism is a recessive trait, producing abnormalities only in those Albinis m
with two recessive genes (a). Presence o the dominant gene (A)
prevents albinism.

means that the pers n an transmit the albinism gene, a, t
spring. T us tw n rmal parents ea h having the gene
mbinati n Aa an pr du e b th n rmal hildren and hil-
dren that have albinism (Figure 25-4).
C o d o m in a n c e
W hat happens i tw di erent d minant genes ur t -
gether? Supp se there is a gene A 1 r light skin and a gene
A 2 r dark skin. In a rm d minan e alled codominance,
they will simply have equal e e ts and a pers n with the gene
mbinati n A 1A 2 will exhibit a skin l r that is s mething
between light and dark.
We stated in Chapter 13 that the genes r si kle ell ane-
mia behave this way. A pers n with tw si kle ell genes will
have sickle cell anemia, whereas a pers n with ne n rmal gene
and ne si kle ell gene will have a mu h milder nditi n
alled sickle cell trait.
S e x-Lin k e d Tr a it s
We stated earlier that, in additi n t the 22 pairs aut s mes,
there is ne pair sex hr m s mes. N ti e in Figure 25-1 that
the hr m s mes this pair d n t have mat hing stru tures.
T e larger sex hr m s me is alled the X chromosome, and the
smaller ne is alled the Y chromosome. T e X hr m s me is
s metimes alled the emale chromosome be ause it has genes
that determine emale sexual hara teristi s.
I a pers n has nly X hr m s mes, she is geneti ally a
emale. T e Y hr m s me is ten alled the male chromo-
some be ause any ne p ssessing a Y hr m s me is geneti-
ally a male. T us all n rmal emales have the sex hr m -
s me mbinati n XX and all n rmal males have the
mbinati n XY. Be ause men pr du e b th X-bearing and
Y-bearing sperm, any tw parents an pr du e male r emale
hildren (Figure 25-5).
T e large X hr m s mes ntain many genes besides
th se needed r emale sexual traits. Genes r pr du ing
ertain l tting a t rs, the ph t pigments in the retina the
eye, and many ther pr teins are als und n the X hr m -
s me. T e tiny Y hr m s me, n the ther hand, ntains
ew genes ther than th se that determine the male sexual
hara teristi s.
Males and emales need at least ne n rmal X hr m -
s me therwise, the genes r l tting a t rs and ther es-
sential pr teins w uld be missing. N nsexual traits arried n
sex hr m s mes are alled sex-linked traits. M st sex-linked

Mothe r Offs pring Fa the r

XX XY
Fe ma le XX X Ma le 25
X Fe ma le
Ovum
S pe rm

Y
X
Ovum XY S pe rm
Ma le

FIGURE 25-5 Sex determination. The presence o the Ychromosome speci es maleness. In the absence
o a Ychromosome, an individual develops into a emale.
 684 CHAPTER 25 Genetics and Genetic Diseases

Offs pring

Mothe r Fa the r
(ca rrie r) XX
Fe ma le
XX ca rrie r XY
X
X XY S pe rm

Ovum
Color-blind
ma le

Y
X XX S pe rm

Ovum Norma l fe ma le

XNorma l X chromos ome

XAbnorma l X chromos ome FIGURE 25-6 Sex-linked inheritance. Some
YNorma l Y chromos ome XY orms o color blindness involve recessive X-linked
genes. In this case, a emale carrier o the abnormal
Norma l ma le gene can produce male children who are color blind.

traits are alled X-linked traits be ause they are determined by
the genes in the large X hr m s me.
D minant X-linked traits appear in ea h pers n as ne
w uld expe t r any d minant trait. In emales, re essive
X-linked genes are masked by d minant genes in the ther
X hr m s me. Only emales with tw re essive X-linked
genes an exhibit the re essive trait.
Be ause males inherit nly ne X hr m s me ( r m the
m ther), the presen e nly ne re essive X-linked gene is
en ugh t pr du e the re essive trait. In sh rt, in males, there
are n mat hing genes in the Y hr m s me t mask re essive
genes in the X hr m s me. F r this reas n, X-linked re essive
traits appear mu h m re mm nly in males than in emales.
An example a re essive X-linked nditi n is red-green
color blindness, whi h inv lves a de ien y ph t pigments
in the retina (see Chapter 11). In this nditi n, male hildren
a parent wh arries the re essive abn rmal gene n an
X hr m s me may be l r blind (Figure 25-6). A emale an
inherit this rm l r blindness nly i her ather is l r
blind and her m ther is l r blind r is a l r blindness
25 arrier.
T e X hr m s me has been studied in great detail by
many resear hers, and general l ati ns r genes ausing at
least 59 distin t X-linked diseases have been identi ed.
mutati ns are believed t be aused by mutagensagents
that ause mutati ns. Geneti mutagens in lude hemi als,
s me rms radiati n, and even viruses. S me mutati ns
inv lve a hange in the geneti de within a single gene,
perhaps a slight rearrangement the nu le tide sequen e.
O ther mutati ns inv lve damage t a p rti n a hr m -
s me r a wh le hr m s me. F r example, a p rti n a
hr m s me may mpletely break away.
Bene ial mutati ns all w rganisms t adapt t their en-
vir nments. Be ause su h mutant genes bene t survival, they
tend t spread thr ugh ut a p pulati n ver the urse
several generati ns. H arm ul mutati ns inhibit survival, s
they are n t likely t spread thr ugh the p pulati n. M st
harm ul mutati ns kill the rganism in whi h they ur r
at least prevent su ess ul repr du ti nand s are never
passed t spring. I a harm ul mutati n is nly mildly harm-
ul, it may persist in a p pulati n ver many generati ns.
QUICK CHECK
1.
2.
Wh a t is a d o m in a n t g e n e tic tra it? A re ce s s ive tra it?
Wh a t is co d o m in a n ce ?
3. Ho w ca n a m u ta n t g e n e b e n e f t a h u m a n p o p u la tio n ?
4. Wh a t is X-lin ke d in h e rita n ce ?

G e n e t ic M u t a t io n s G e n e t ic D is e a s e s
M e c h a n is m s o G e n e t ic D is e a s e
T e term mutation simply means hange. A genetic
mutation is a hange in the geneti de. Ro le o G e n e s in D is e a s e
Mutati ns may ur sp ntane usly, with ut the inf uen e As s ien e writer Matt Ridley repeatedly and emphati ally
a t rs utside the DNA itsel . H wever, m st geneti states in his best-selling b k Genome: T e Autobiography o a
 CHAPTER 25 Genetics and Genetic Diseases 685

Species in 23 Chapters, GENES ARE NO H ERE O Ep ig e n e t ic s

CAUSE DISEASE.
Alth ugh we ten hear new disease genes being dis-
vered and the pa e is rapidly in reasingthe un ti n
these genes is n t t ause disease any m re than the un ti n
an arm is t ause b ne ra tures. I y u break an arm, a
n rmal b ne is br ken and ails t serve its usual un ti n. In
geneti dis rders, a n rmal gene r hr m s me is br ken
(mutated) and ails t serve its usual un ti n. Su h a gene is
s metimes alled a disease gene be ause when it is br ken, it
is inv lved in the me hanism a parti ular disease.
Keep this simplebut ten verl kedprin iple in
mind as y u read the ll wing paragraphs.
S in g le -G e n e M e c h a n is m s
As we just stated, geneti diseases are diseases pr du ed by an
abn rmality in the geneti de. Many geneti diseases are
aused by individual mutant genes that are passed r m ne
generati n t the next, making them single-gene diseases.
T e l ati ns s me the genes inv lved in sele ted
single-gene diseases are sh wn in Figure 25-7. In single-gene
diseases, the mutant gene may make an abn rmal pr du t that
auses disease, r it may ail t make a pr du t required r
n rmal un ti n. S me disease nditi ns result r m the
mbined e e ts inheritan e and envir nmental a t rs.
We expl re spe i examples single-gene diseases later.
Epigenetics (imprinting) is the s ien e that des ribes h w
envir nmental and behavi ral a t rs may result in spring
with geneti traits that ann t be explained by genes al ne.
F r example, the diet parents r grandparents may pr -
vide hemi al gr ups t the hr m s mes that may swit h a
ertain gene n r . T us the genes may be imprinted r
hemi ally marked, and ertain diseases may r may n t be
seen in the spring.
T ee et the envir nment n genes als explains why
identi al twins may n t always share the same disease traits.
Be ause they are n t s lely aused by geneti me hanisms, su h
nditi ns are n t geneti diseases in the usual sense the
w rdthey are instead said t inv lve a genetic predisposition.
Learn more in the illustrated article Epigenetics at
Connect It! at evolve.elsevier.com.
C h ro m o s o m a l M e c h a n is m s
S me geneti diseases d n t result r m an abn rmality in a
single gene. Instead, these diseases result r m hr m s me
breakage r r m the abn rmal presen e r absen e entire
hr m s mes.
F r example, a nditi n alled trisomy may ur in whi h
there is a triplet aut s mes rather than a pair. ris my

RES EA RC H, IS S U ES , AND TREN D S

MITOCHONDRIAL INHERITANCE
Mitochondria are tiny, bacteria-like organe lle s pre se nt in eve ry
ce ll o the body (se e Figure 3-2). Like a bacte rium, e ach mito-
Review the article In Vitro Fertilization at
chondrion has its ow n circular DNA m ole cule, some time s called Connect It! at evolve.elsevier.com.
mito cho ndrial DNA (m DNA o r mtDNA). The f gure s how s an
ide ogram o the structure o a mitochondrial chrom os ome . Alzhe ime r dis e a s e Le be r he re dita ry
Inhe ritance o m DNA occurs only through ones m othe r Pa rkins on dis e a s e optic ne uropa thy
be caus e the ew m itochondria that a s pe rm m ay contribute to
the ovum during e rtilization do not s urvive . Be caus e m DNA
contains the only ge ne tic code or s eve ral im portant e nzym e s
involve d in the m e tabolic pathway that re charge s ade nos ine
Ma te rna lly
triphos phate (ATP) in our ce lls , it has the pote ntial or carrying inhe rite d
m utations that produce dis e as e . de a fne s s
Mitochondrial inhe ritance is now know n to trans m it ge ne s
or s eve ral de ge ne rative ne rve and m us cle dis orde rs . One Mitochondria l
s uch dis e as e is Le be r he re ditary o ptic ne uro pathy. In this e nce pha lopa thy
dis e as e , young adults be gin los ing the ir eye s ight as the optic la ctic a cidos is ;
s troke -like e pis ode s
25
ne rve de ge ne rate s re s ulting in total blindne s s by age 30.
Some me dical re se archers be lieve that at least some orms
o several othe r dise ase s are associated w ith m DNA m utations.
The se dise ase s include Parkinson dis ease , Alzheim e r dise ase
(AD), diabe te s me llitus (DM) w ith de a ne ss, and mate rnally in-
herite d orm s o de a ne ss , myopathy, and cardiomyopathy.
Re s e arche rs are deve loping expe rim e ntal protocols or in
Myoclonic e pile ps y; Ne uroge nic mus cle
vitro e rtilization (IVF) in w hich m itochondrial inhe ritance o ra gge d re d mus cle fibe rs we a kne s s
dis e as e m ay be avoide d by us ing an e gg donor w ith norm al
m itochondria but us ing the e gg nucle us rom a m othe r w ith Map o mitochondrial DNA. Ideogram showing locations o some
m utate d m tDNA. mtDNA genes associated with various diseases.
 686 CHAPTER 25 Genetics and Genetic Diseases

Huntington dis e a s e FIGURE 25-7 Location o genes involved in genetic dis-

Rh dis e a s e eases. The ideogram o each chromosome is labeled with the
S pinoce re be lla r
a ta xia , type 1 location o just one or two examples o the many genes associ-
Fa milia l ated with genetic disease.
colon ca nce r Achondropla s ia
Conge nita l a dre na l
Ga uche r hype rpla s ia
dis e a s e Usually tris my any aut s me pair is atal.
S pina l mus cula r H wever, i tris my urs in aut s me pair 13, 15,
Re tinitis a trophy II a nd III 18, 21, r 22, a pers n may survive r a time but n t
pigme ntos a
Fa milia l polypos is with ut pr und devel pmental de e ts.
of the colon Monosomy, the presen e nly ne aut s me
1 2 3 4 5 6 instead a pair, als may result r m n epti n in-
v lving a gamete pr du ed by n ndisjun ti n (see
Figure 25-8). Like tris my, m n s my may pr du e
li e-threatening abn rmalities.
S ickle ce ll dis e a s e
Be ause m st tris mi and m n s mi individuals
Ma ligna nt die be re they an repr du e, these nditi ns are
me la noma
n t usually passed r m generati n t generati n.
ris my and m n s my are ngenital nditi ns
Multiple e ndocrine
ne opla s ia , type 2 that are s metimes re erred t as chromosomal genetic
diseases. Spe i examples are dis ussed later.
Cys tic fibros is

Obe s ity QUICK CHECK

Burkitt lymphoma Chronic mye loid 1. Ho w a re s in g le -g e n e d is e a s e s d i e re n t ro m ch ro -

le uke mia m o s o m a l co n d itio n s ?
7 8 9 10 11
2. What is no n d is ju nctio n? How ca n it caus e tris om y?

Polycys tic kidney

dis e a s e
S in g le -G e n e D is e a s e s
T ere are many single-gene diseases. Only a ew ex-
Re tinobla s toma Ma rfa n s yndrome amples are dis ussed here and summarized in Table 25-1.
Alzhe ime r Bre a s t ca nce r a nd
ova ria n ca nce r Cy s t ic Fib ro s is
dis e a s e
Tay-S a chs dis e a s e Cystic brosis (CF) is aused by a re essive gene in
P he nylke tonuria hr m s me 7 that des r a pr tein alled CF R
Ne urofibroma tos is
(CF transmembrane conductance regulator). CF R n r-
12 13 14 15 16 17 mally regulates the trans er s dium and hl ride
i ns a r ss ell membranes and serves as a hl ride
i n hannel.
Ade nos ine
de a mina s e W hen this gene is missing a single d n, the
de ficie ncy
Mus cula r dys trophy abn rmal versi n CF R auses impairment i n
transp rt a r ss ell membranes. Su h disrupti n
Fa milia l hype r-
chole s te role mia auses ex rine ells t se rete thi k mu us and sweat.
Adre nole uko-
dys trophy
T e thi kened mu us is espe ially tr ubles me in the
Amyloidos is
Amyotrophic la te ra l gastr intestinal and respirat ry tra ts, where it an
Pa ncre a tic ca nce r s cle ros is ause bstru ti n that leads t death.
25 Myotonic
Infe rtility A arrier nly ne abn rmal CF R gene, h w-
dys trophy
Ne urofibroma tos is, ever, may have impr ved resistan e t diarrheal dis-
type 2
eases su h as h lera.
18 19 20 21 22 XY He mophilia ,
type s A a nd B
Advan ed therapies r CF have greatly impr ved
quality and length li e, but it is still a very seri us
nditi n.
results r m a mistake in mei sis alled nondisjunction when
a pair hr m s mes ails t separate. T is pr du es a gamete P h e n y lk e t o n u r ia
with tw aut s mes that are stu k t gether instead the Phenylketonuria (PKU) is aused by a re essive gene that ails
usual ne. W hen this abn rmal gamete j ins with a n rmal t pr du e the enzyme phenylalanine hydroxylase. T is enzyme is
gamete t rm a zyg te, the zyg te has a triplet aut s mes needed t nvert the amin a id phenylalanine int an ther
(Figure 25-8). amin a id, tyr sine. T us phenylalanine abs rbed r m ingested
 CHAPTER 25 Genetics and Genetic Diseases 687

Mothe r Fa the r

Offs pring

Ovum

Tris omy
Nondis junction S pe rm

Ovum

S pe rm
Monos omy

FIGURE 25-8 E ects o nondisjunction. Nondisjunction, ailure o a chromosome pair to separate during
gamete production, may result in trisomy or monosomy in the o spring.

d a umulates, resulting in the abn rmal presen e phenyl-
ket ne in the urine (hen e the name phenylketonuria).
A high n entrati n phenylalanine in the b dy de-
str ys brain tissue, s babies b rn with this nditi n are at
risk pr gressive mental retardati n and perhaps death.
M any PKU patients are identi ed at birth by state-
mandated tests. O n e identi ed, PKU vi tims are put n
diets l w in phenylalanine, thus av iding a t xi a umula-
ti n it.
Y u may be amiliar with the printed warning r phenyl-
ket nuri s mm nly seen n pr du ts that ntain aspartame
(NutraSweet) r ther substan es made r m phenylalanine.
T e mutant PKU gene may have riginated am ng the
Celts in western Eur pe, where it ered pr te ti n against

TABLE 25-1 Examples o Single-Gene Disorders

DIS ORDER
He m ophilia (s om e orm s )
Albinis m
Sickle ce ll ane m ia and
s ickle ce ll trait
Re d-gre e n color blindne s s
(X-linke d)
Cys tic f bros is (CF)
Phe nylke tonuria (PKU)
Tay-Sachs dis e as e
Os te oge ne s is im pe r e cta
Multiple ne urof brom atos is
Duche nne m us cular dys -
trophy (DMD) (X-linke d)
Hype rchole s te role m ia
Huntington dis e as e (HD)
Seve re com bine d im m une
de f cie ncy (SCID)
DOMINANCE DES CRIPTION
Re ce s s ive Group o blood-clotting dis orde rs caus e d by a ailure to orm clotting actors VIII, IX, or XI
(X-linke d)
Re ce s s ive Lack o the dark-brow n pigm e nt m e lanin in the s kin and eye s , re s ulting in vis ion proble m s
and s us ce ptibility to s unburn and s kin cance r
Codom inant Blood dis orde r in w hich abnorm al he m oglobin is produce d, caus ing re d blood ce lls to
de orm into a s ickle s hape
Re ce s s ive Inability to dis tinguis h re d and gre e n light, re s ulting rom a de f cie ncy o photopigm e nts
in the cone ce lls o the re tina
Re ce s s ive Condition characte rize d by exce s s ive s e cre tion o thick m ucus and conce ntrate d s we at,
o te n caus ing obs truction o the gas trointe s tinal (GI) or re s piratory tracts
Re ce s s ive Exce s s o phe nylke tone in the urine , w hich is caus e d by accum ulation o phe nylalanine in
the tis s ue s and m ay caus e brain injury and de ath
Re ce s s ive Fatal condition in w hich abnorm al lipids accum ulate in the brain and caus e dam age that
le ads to de ath by age 4
Dom inant Group o conne ctive tis s ue dis orde rs characte rize d by im pe r e ct s ke le tal deve lopm e nt
that produce s brittle bone s
25
Dom inant Dis orde r characte rize d by m ultiple , s om e tim e s dis f guring, be nign tum ors o the Schwann
ce lls (ne uroglia) that s urround ne rve f be rs
Re ce s s ive Mus cle dis orde r characte rize d by progre s s ive atrophy o s ke le tal m us cle w ithout ne rve
involve m e nt; caus e d by lack o norm al dys trophin prote in that s upports m us cle f be r
s tructure
Dom inant High blood chole s te rol that m ay le ad to athe ros cle ros is and othe r cardiovas cular proble m s
Dom inant De ge ne rative brain dis orde r characte rize d by chore a (purpos e le s s m ove m e nts ), progre s s -
ing to s eve re de m e ntia and de ath by age 55
Re ce s s ive Failure o the lym phocyte s to deve lop prope rly, in turn caus ing ailure o the im m une s ys -
te m s de e ns e o the body; us ually caus e d by ade nos ine de am inas e (ADA) de f cie ncy
 688 CHAPTER 25 Genetics and Genetic Diseases

the t xi e e ts m lds gr wing n grains

st red in ld, damp limates.
RES EA RC H, IS S U ES , AND TREN D S
Check out the article GENETIC BAS IS OF CANCER
Phenylketonuria at Connect It! You le arne d in Chapte r 6 that s om e orm s o cance r are thought to be caus e d,
at evolve.elsevier.com. at le as t in part, by abnorm al ge ne s calle d o nco ge ne s .
One hypothe s is s tate s that m os t norm al ce lls contain s uch cance r-caus ing
ge ne s . Howeve r, it is unce rtain how the s e ge ne s be com e activate d and pro-
Ta y-S a c h s D is e a s e duce cance r. Pe rhaps oncoge ne s can trans orm a ce ll into a cance r ce ll only
ay-Sachs disease ( SD ) is a re essive n- w he n ce rtain e nvironm e ntal conditions occur.
diti n inv lving ailure t make a subunit Anothe r hypothe s is s tate s that norm al ce lls contain anothe r clas s o ge ne s ,
an essential lipid-pr essing enzyme, hexosa- s om e tim e s calle d tum o r s uppre s s o r ge ne s . According to this hypothe s is ,
s uch ge ne s re gulate ce ll divis ion s o that it proce e ds norm ally. Whe n a tum or
minidase. Abn rmal lipids a umulate in the
s uppre s s or ge ne is non unctional be caus e o a ge ne tic m utation or exce s s ive
brain tissue ay-Sa hs vi tims, ausing
m e thylation, it the n allow s ce lls to divide abnorm allypos s ibly producing can-
severe retardati n and death by 4 years age. ce r. I m ate rnal and pate rnal tum or s uppre s s or ge ne s are both a e cte d, the
T ere is urrently n spe i therapy r this cance r ris k would be m ore pronounce d.
nditi n. Anothe r pos s ible ge ne tic bas is or cance r re late s to the ge ne s that gove rn
SD is m st prevalent am ng ertain the ce lls ability to re pair dam age d DNA. As m e ntione d in Chapte r 7, a rare
Jewish p pulati ns. S me epidemi l gists ge ne tic dis orde r calle d xe ro de rm a pig m e nto s um is characte rize d by the in-
believe that this ethni distributi n is related ability o s kin ce lls to re pair ge ne tic dam age caus e d by ultraviole t radiation in
t the hyp thesis that heter zyg us arriers s unlight. Individuals w ith this condition alm os t always deve lop s kin cance r
the ay-Sa hs gene have a higher than w he n expos e d to dire ct s unlight. The ge ne tic abnorm ality doe s not caus e s kin
n rmal resistan e t tuber ul sis ( B)a cance r dire ctly but inhibits the ce lls cance r-preve nting m e chanis m s .
p tentially atal disease that n e killed mil-
li ns in the r wded Jewish ghett s many
large ities. Residents these B-in ested areas wh arried in the X hr m s me. M ethylati n may ur when a string
the ay-Sa hs gene apparently survived l ngerand repr - repeating gene mp nents, kn wn as CG G in the n r-
du ed m re requentlythan n n arriers. mal pr tein gene, gets t l ng. T e l nger length the
ay-Sa hs is als und in higher than average requen ies repeating CG G nu le tides results in a greater severity
in Fren h Canadians in s utheastern Q uebe and Cajun the syndr me.
Fren h amilies in s uthern L uisianapr bably due t the O vermethylati n this se ti n DNA turns the gene
genes presen e in several unders these amily gr ups, r a pr tein that n rmally prevents this geneti rm men-
rather than natural sele ti n by the threat B. tal retardati n.
FXS is m re mm n in males be ause they nly inherit
ne py the X hr m s me. Females may have a milder
Ep ig e n e t ic C o n d it io n s
rm be ause they may inherit a n rmal X hr m s me that
T e study h w envir nment and behavi r may inf uen e is able t make s me the n rmal pr tein.
the genes r b th health and disease is rapidly gr wing. S me ther epigeneti diseases may in lude type 2 diabe-
S me diseases are th ught t be the result epigeneti tes mellitus (DM) and ardi vas ular disease. Can er risk may
hanges in DNA that alter gene a tivity that auses dis rders. als have epigeneti mp nents. T e m re we understand
T e number epigeneti diseases may a tually be huge. ab ut the epigeneti basis disease, the m re likely it is that
S me an ers have been sh wn t be related t a redu ti n we will nd e e tive treatments r even ures.
in hemi al markers kn wn as methyl groups ( CH 3). O ther
an ers are ass iated with t mu h methylati n, whi h may
inhibit genes that n rmally prevent an er gr wth. reatment
C h ro m o s o m a l D is e a s e s
an ers with agents that either in rease r de rease meth- S me geneti dis rders are n t inherited but result instead
25 ylati n abn rmal ells is being resear hed. r m n ndisjun ti n during gamete rmati n. As Figure 25-8
H wever, n t all epigeneti nditi ns are ass iated with sh ws, n ndisjun ti n results in tris my r m n s my.
methylati n. Acetyl groups ( COCH 3) r ubiquitin pr tein
als may mark the DNA, while ther me hanisms inv lve the Tr is o m y 2 1
RNA m le ules that regulate the pr du ti n pr teins in T e m st well-kn wn hr m s mal dis rder is trisomy 21,
the ell. whi h pr du es a gr up sympt ms alled D own syndrome.
As sh wn in Figure 25-9, A, this nditi n is hara terized by
Review the article Epigenetics at Connect It! at a triplet hr m s me 21 rather than the usual pair.
evolve.elsevier.com. In the general p pulati n, tris my 21 urs in nly 1
every 600 r s live births. A ter age 35, h wever, a m thers
Fragile X syndrome (FXS) is a disease that is th ught t han es pr du ing a tris mi hild in rease dramati ally
be ass iated with vermethylati n a se ti n the DNA t as high as 1 in 80 births by age 40. D wn syndr me results
 CHAPTER 25 Genetics and Genetic Diseases 689

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18

19 20 21 22 X Y
A

R L

FIGURE 25-9 Down syn- A I

drome. A, Down syndrome is

usually associated with trisomy
o chromosome 21, as you can
see in this karyotype. B, A child
with Down syndrome. Notice 1 2 3 4 5
the distinctive anatomical ea-
tures: olds around the eyes,
X 6 7 8 9 10 11 12
f attened nose, round ace, and
B small hands with short ngers.
13 14 15 16 17 18 19 20
r m tris my 21 and rarely r m ther geneti abn rmalities
(whi h an be inherited).
Y 21 22
D wn syndr me is hara terized by mental retardati n B
(ranging r m mild t severe) and multiple de e ts that in-
lude distin tive a ial appearan e (Figure 25-9, B), enlarged FIGURE 25-10 Kline elter syndrome. A, This young man exhibits
many o the characteristics o Kline elter syndrome: small testes, some de-
t ngue, sh rt hands and eet with stubby digits, ngenital velopment o the breasts, sparse body hair, and long limbs. B, This syn-
heart disease, and sus eptibility t a ute leukemia. Pe ple drome results rom the presence o two or more X chromosomes with a
with D wn syndr me have a sh rter-than-average li e expe - Ychromosome (genotypes XXYor XXXY, or example).
tan y but an survive t ld age.
urner syndr me an be redu ed by h rm ne therapy using
XXY estr gens and gr wth h rm ne. Cardi vas ular de e ts may
Kline elter syndrome is an ther geneti dis rder resulting be repaired surgi ally.
r m n ndisjun ti n hr m s mes (Figure 25-10, B). T is
dis rder urs in males with a Y hr m s me and at least QUICK CHECK
tw X hr m s mes, typi ally the XXY pattern. 1. Ho w d o e s a vo id a n ce o p h e nyla la n in e in th e d ie t re d u ce
Chara teristi s Kline elter syndr me may in lude l ng th e p ro b le m s a s s o cia te d w ith p h e nylke to n u ria (PKU)?
legs, enlarged breasts, learning di ulties, small testes, steril- 2. Wh a t is tris o m y 21?
3. Wh a t is a n e xa m p le o a e m a le ch ro m o s o m a l d is e a s e th a t
25
ity, and hr ni pulm nary disease (Figure 25-10, A). is ca u s e d b y th e m o n o s o m y co n d itio n XO?

XO
urner syndrome, s metimes alled XO syndrome, urs in
emales with a single sex hr m s me, X. Like the nditi ns
P r e ve n t io n a n d Tr e a t m e n t
des ribed earlier, it results r m n ndisjun ti n during gamete o G e n e t ic D is e a s e s
rmati n (Figure 25-11, B).
G e n e t ic C o u n s e lin g
urner syndr me is hara terized by ailure the varies
and ther sex rgans t mature ( ausing sterility), ardi vas- T e term genetic counseling re ers t pr essi nal nsulta-
ular de e ts, dwar sm r sh rt stature, a webbed ne k, and ti ns with amilies regarding geneti diseases. rained geneti
p ssible learning dis rders (see Figure 25-11, A). Sympt ms unsel rs may help a amily determine the risk pr du ing
 690 CHAPTER 25 Genetics and Genetic Diseases

Ge ne ra tion

II

III

FIGURE 25-12 Pedigree. Pedigrees chart the genetic history o amily

lines. Squares represent males, and circles represent emales. Fully shaded
symbols indicate a ected individuals; partly shaded symbols indicate carri-
ers, and unshaded symbols indicate una ected noncarriers. Roman numer-
als indicate the order o generations. This pedigree reveals the presence o
an X-linked recessive trait.

symb ls represent carriers a re essive trait. A h riz ntal line

between symb ls designates a sexual relati nship that pr -
S du ed spring.
T e pedigree is use ul in determining the p ssibility
R L
pr du ing spring with ertain geneti dis rders. It als may
I tell a pers n whether he r she might have a geneti dis rder
A that appears late in li e, su h as Huntington disease (HD). In
either ase, a amily an prepare em ti nally, nan ially, and
medi ally be re a risis urs.

1 2 3 4 5 Pu n n e tt S qu a re
T e Punnett square, named a ter the English geneti ist
Reginald Punnett, is a grid used t help determine the prob-
X 6 7 8 9 10 11 12
ability inheriting geneti traits.
As Figure 25-13, A, sh ws, genes in the m thers gametes are
represented al ng ne axis the grid, and genes in the a-
13 14 15 16 17 18 19 20 thers gametes are al ng the ther axis. T e rati di erent
gene mbinati ns in the spring predi ts their pr bability
Y 21 22
urren e in the next generati n.
We an see in Figure 25-13, A, that spring pr du ed by
tw arriers PKU (a re essive dis rder) have a ne in ur
B (25%) han e inheriting this re essive nditi n. T ere is a
tw in ur (50%) han e that an individual hild pr du ed
FIGURE 25-11 Turner syndrome. A, This woman exhibits many o the will be a PKU arrier.
characteristics o Turner syndrome, including short stature, webbed neck, Figure 25-13, B, sh ws that spring between a arrier and
and sexual immaturity. B, As this karyotype shows, Turner syndrome results
rom monosomy o sex chromosomes (genotype XO). a n n arrier ann t inherit PKU. W hat is the han e an
individual spring being a PKU arrier in this ase?
hildren with geneti diseases. Parents with a high risk pr - Figure 25-13, C, sh ws the pr bability pr du ing an a e ted
du ing hildren with geneti dis rders may de ide t av id spring when a PKU patient and a PKU arrier have hil-
having hildren. Geneti unsel rs may als help evaluate dren. Figure 25-13, D, sh ws the geneti pr bability when a
whether any spring already b rn have a geneti dis rder and PKU patient and a n n arrier pr du e hildren.
er advi e n treatment r are. A gr wing list t ls is avail-
25 able t geneti unsel rs, s me whi h are des ribed bel w. Ka ryo t y p e
Dis rders that inv lve tris my (extra hr m s mes), m n -
P e d ig r e e s my (missing hr m s mes), and br ken hr m s mes an
A pedigree is a hart that illustrates geneti relati nships in a be dete ted a ter a karyotype is pr du ed.
amily ver several generati ns (Figure 25-12). Using medi al T e rst step in pr du ing a kary type is getting a sample
re rds and amily hist ries, the geneti unsel rs assemble ells r m the individual t be tested. T is an be d ne by
the hart, beginning with the lient and m ving ba kward s raping ells r m the lining the heek r r m a bl d
thr ugh as many generati ns as are kn wn. sample ntaining white bl d ells (W BCs).
Squares represent males; ir les represent emales. Fully Fetal tissue an be lle ted by amniocentesis, a pr edure
shaded symb ls represent a e ted individuals, whereas un- in whi h etal ells f ating in the amni ti f uid are lle ted
shaded symb ls represent n rmal individuals. Partially shaded with a syringe (Figure 25-14). Chorionic villus sampling is a
 CHAPTER 25 Genetics and Genetic Diseases 691

C LIN ICA L APPLICATION

DNA ANALYS IS
As a re s ult o the inte ns e e orts unde r way to m ap the e ntire The accuracy o DNA analys is us ing the s e te chnique s re lie s
hum an ge nom e , new te chnique s have be e n deve lope d to ana- on s eve ral im portant actors . For exam ple , contam ination o
lyze the ge ne tic m ake up o individuals . Autom ate d m achine s s am ple s m us t be avoide d by us ing ve ry s trict laboratory proto-
can now che m ically analyze chrom os om e s and re ad the ir cols . The num be r o di e re nt DNA s e que nce s analyze d, and
s e que nce o nucle otide s the ge ne tic code . the chrom os om al locations o thos e s e que nce s are als o im por-
One m e thod by w hich this is done is calle d e le ctro pho re s is , tant actors .
w hich m e ans e le ctric s e paration (A). In e le ctrophore s is , DNA
ragm e nts are che m ically proce s s e d, the n place d in a thick
uid or ge l. An e le ctric f e ld in the ge l caus e s the DNA rag-
m e nts to s e parate into groups according to the ir re lative s ize s .
The patte rn (B) that re s ults re pre s e nts the s e que nce o codons
in the DNA ragm e nt.
This proce ss is als o the bas is or so-calle d DNA
f nge rprinting . Like a f nge rprint pattern, e ach pers ons DNA
se quence is unique . A ter the exact se que nce s or spe cif c dis -
e ase s have bee n dis cove re d, gene tic couns e lors w ill be able to
provide more de tails about the ge netic m ake up o the ir clie nts.
This te chnique is als o use d in ore nsic scie nce to show that an
individual was at the scene o the crime and le t their DNA.

DNA fra gme nts

Ele ctric
curre nt
A ()

Ge l

(+)

pr edure in whi h ells r m h ri ni villi that surr und a
y unger embry (see Chapter 24) are lle ted thr ugh the
pening the ervix.
Newer, less invasive pr edures that use etal ells r etal
DNA re vered r m maternal bl d are in devel pment and
may s n be used widely. T e newer tests have very l w risks
r mpli ati ns mpared with amni entesis and h ri-
ni villus sampling.
C lle ted etal ells are gr wn in a spe ial ulture medium
and all wed t repr du e. Cells in metaphase (when the hr -
m s mes are m st distin t) are stained and ph t graphed
using a mi r s pe. T e hr m s mes are ut ut the
ph t and pasted n a hart in pairs a rding t size, as in
Figures 25-1 and 25-9, A. Geneti unsel rs then examine the 25
kary type, l king r hr m s me abn rmalities. W hat
hr m s me abn rmality is visible in Figure 25-9, A? Is this a
male r emale kary type?
QUICK CHECK
1. Wh a t is g e n e tic co u n s e lin g ?
2. Ho w a re p e d ig re e s u s e d b y g e n e tic co u n s e lo rs ?
3. Ho w is a Pu n n e tt s q u a re u s e d to p re d ict m a th e m a tica l
p ro b a b ilitie s o in h e ritin g s p e cif c g e n e s ?
4. Ho w is a ka ryo typ e p re p a re d ? Wh a t is its p u rp o s e ?
 692 CHAPTER 25 Genetics and Genetic Diseases

FIGURE 25-13 Punnett square. The Punnett square Mothe r

is a grid used to determine relative probabilities o pro- P P P P
ducing o spring with speci c gene combinations. Phenyl-
ketonuria (PKU) is a recessive disorder caused by the
gene p. P is the normal gene. A, Possible results o cross
Pp P PP PP p Pp Pp

between two PKU carriers. Because one in our o the

o spring represented in the grid has PKU, a genetic
counselor would predict a 25% chance that this couple p Pp Pp p Pp Pp
will produce a PKU baby at each birth. B, Cross between
a PKU carrier and a normal noncarrier. C, Cross between
a PKU patient and a PKU carrier. D, Cross between a PKU P p B D
patient and a normal noncarrier.

P KU
P p P p Pp ca rrie r

Fa the r
P PP Pp Pp pp
P p pp P KU
Pp
p p Pp pp p Pp pp PP Norma l

A C

riti al stages devel pment, severe mpli ati ns an be

Tr e a t in g G e n e t ic D is e a s e s
av ided. In Kline elter and urner syndr mes, h rm ne therapy
Tr e a t in g S y m p t o m s and surgery an alleviate s me sympt ms. H wever, there are
Until this entury, the nly h pe treating any geneti disease n e e tive treatments r a vast maj rity geneti dis rders.
was t treat the sympt ms. In s me diseases, su h as PKU, this
w rks well. I th se a e ted by PKU simply av id large G e n e Th e r a p y
am unts phenylalanine in their diets, espe ially during Medi al s ien e n w ers us s me h pe treating geneti
dis rders bey nd just alleviating sympt msa newer ap-
pr a h alled gene therapy.
A
Gene Replacement
S I
In a strategy s metimes alled gene replacement, genes that
P spe i y pr du ti n abn rmal, disease- ausing pr teins are
repla ed by n rmal r therapeuti genes. get the thera-
peuti genes t ells that need them, resear hers are using
geneti ally altered viruses as arriers. In Chapter 6, we men-
ti ned that viruses are easily apable inserting new genes
int the human gen me. I the therapeuti genes behave as
expe ted, a ure may result. T us the g al gene repla ement
therapy is t geneti ally alter existing b dy ells in the h pe
eliminating the ause a geneti disease.
Alth ugh alled gene repla ement, this therapy d es n t
a tually repla e the de e tive genesit instead inserts n rmal
genes s that n rmal pr teins an repla e abn rmal r miss-
25 ing pr teins in the b dys metab li pathways.

Gene Augmentation
In a therapy alled gene augmentation, n rmal genes are
intr du ed with the h pe that they will augment (add t ) the
pr du ti n the needed pr tein. In ne rm gene aug-
mentati n, virus-altered ells are inje ted int the bl d r
implanted under the skin a patient t pr du e adequate
FIGURE 25-14 Amniocentesis. In amniocentesis, a syringe is used to am unts the missing pr tein.
collect amniotic f uid. Ultrasound imaging is used to guide the tip o the
syringe needle to prevent damage to the placenta and etus (see box on An ther appr a h is t use ba terial DNA rings alled
p. 663). Fetal cells in the collected amniotic f uid can then be chemically plasmids that have been altered by re mbinant DNA te h-
tested or used to produce a karyotype o the developing o spring. niques t arry the therapeuti gene(s). A m re re ent
 CHAPTER 25 Genetics and Genetic Diseases 693

appr a h used the human engineered chromosome (H EC).
In the H EC appr a h, a set therapeuti genes is in rp -
rated int a separate strand DNA that is inserted int a
ells nu leus, thus a ting like an extra, r rty-seventh, hr -
m s me. Gene augmentati n attempts t add geneti ally al-
tered ells t the b dy, rather than t hange existing b dy
ells as in gene repla ement therapy.
RNA Inter erence
RNA inter erence (RNAi) als may be me a weap n against
geneti dis rders in an appr a h alled RNAi therapy. RNAi
is a meth d silencing parti ular genes, thus rendering them
unable t pr du e their en ded pr teins. W hen harnessed in
the lab rat ry, RNAi an turn ne gene at a timegreatly
in reasing the han es guring ut whi h pr tein is en-
ded by that gene and what the un ti n that pr tein is.
W hen used therapeuti ally, RNAi may be able t silen e
spe i genes inv lved in disease me hanisms.
Potential o Gene Therapy
T e use geneti therapy began in 1990 with a gr up y ung
hildren having adenosine deaminase (ADA) de ciency. In
this rare re essive dis rder, the gene r pr du ing the enzyme
ADA is missing r m b th aut s mes in pair 20. De ien y
ADA results in severe combined immune de ciency
(SCID ), making its vi tims highly sus eptible t in e ti n (see
Chapter 16).
As Figure 25-15 sh ws, white bl d ells r m ea h patient
were lle ted and in e ted with viruses arrying therapeuti
genes. A ter repr du ing 1000- ld, the geneti ally altered
white bl d ells were then inje ted int the patient. Be ause
this treatment augments ells already present with geneti ally
altered ells, it is a rm gene augmentati n therapy.
Currently hundreds gene therapy trials r diverse ge-
neti dis rders, an er, and even aging are pr p sed r ng -
ing. T usands lab rat ry experiments in anti ipati n
human trials are als under way. H urdles t ver me be re
we see widespread su ess gene therapies in lude ur la k
detailed kn wledge many the disease genes and
h w multiple-gene diseases might be e e tively treated
n t t menti n the high sts and risks inv lved. It is t
early t say r sure, but there may s n me a time when
many geneti diseases are treated r even uredwith
gene therapy.
To learn more about vector-mediated gene
therapy, go to AnimationDirect online at
evolve.elsevier.com.
QUICK CHECK
1. Ho w a re m o s t g e n e tic d is o rd e rs tre a te d to d a y?
2. Ho w d o e s g e n e re p la ce m e n t th e ra p y w o rk?
3. Wh a t is th e h u m a n e n g in e e re d ch ro m o s o m e (HEC)?

A 11 B
White blood ce lls (WBCs ) a re colle cte d
from the pa tie nt a nd a re culture d
1
The ra pe utic
ge ne is
s plice d into
a pla s mid
(DNA ring)

2 2
Virus e s ca rrying P la s mids
the the ra pe utic a re a llowe d
ge ne infe ct the to re produce
WBCs

3
P la s mids ca rrying
25
4 the the ra pe utic
3 ge ne a re de live re d
Pe riodic infus ions
Gene tically a ltered cells are to the lungs by a
of ge ne tica lly
culture d until they have mis t inha ling device
a lte re d WBCs
multiplie d up to 1000-fold
a re give n

FIGURE 25-15 Gene therapy. A, This method o gene augmentation therapy was used to treat children
stricken with a orm o severe combined immune de ciency syndrome (SCID). White blood cells taken rom the
patient were in ected with viruses carrying the therapeutic gene. The altered cells were reproduced and in-
jected into the bloodstream, thereby reducing the immunity-inhibiting e ects o SCID. B, Gene augmentation
therapy in this example uses plasmids containing the therapeutic gene or cystic brosis (CF) and delivers them
to the lung tissues by means o a common inhaler.
 694 CHAPTER 25 Genetics and Genetic Diseases

S C IEN C E APPLICATIONS
GENETICS AND GENOMICS
The Moravian-Ge rm an Gre gor Me n-
de l was born to pe as ant arm e rs
w ho taught him how plants and ani-
m als are bre d or s pe cif c traits .
Me nde ls acce ptance into a m onas -
te ry allowe d him to s tudy the s ci-
e nce that would late r he lp him
unde rs tand the m e chanis m o in-
he ritance o biological traits .
Convince d that particle s in
Gregor Mendel the ce lls o the pare nts we re re -
(18221884) s pons ible or inhe ritance o traits ,
Me nde l carrie d out the now a-
m ous expe rim e nts w ith s eve ral ge ne rations o pe a plants . In
his re port Expe rim e nts w ith Plant Hybrids , Me nde l outline d
w hat has be com e the oundation o the s cie nce o ge ne tics .
Not only did he reve al the pre s e nce o ge ne tic particle s (w hich
are now calle d ge ne s ) and the bas ic patte rns o how they are
trans m itte d to o s pring, he als o s e t in m otion two im portant
m ove m e nts in m ode rn biology.
Firs t, Me nde l was am ong the f rs t to us e m athe m atical
analys is to s upport his the ory about inhe ritance . Me nde ls
work pione e re d the s ys te m atic us e o m athe m atics , quantif e d
m e as ure m e nts , and applie d s tatis tics in biological re s e arch.
Today, m e dical re s e arche rs o te n e nlis t the he lp o s tatis ti-
cians , m athe m aticians , com pute r program m e rs , and othe rs in
de s igning expe rim e nts , analyzing data, and inte rpre ting re -
s ults . In act a w hole f e ld, s om e tim e s calle d biom athe m atics ,
has now e m e rge d to apply the principle s o m athe m atics to
biological s tudy.
Se cond, Me nde l was the f rs t to dis cove r how the biologi-
cal m e chanis m s o inhe ritance worke d in living organis m s .
This , o cours e , le d to the s cie nce o ge ne tics . Many dis ci-
pline s have s ince grow n rom the s tudy and application o ge -
ne tics . For exam ple , ge ne tic co uns e lo rs us e principle s o
ge ne tics to advis e clie nts w ho w is h to produce o s pring but
are worrie d about pos s ible ge ne tic dis orde rs . Agricultural s ci-
e ntis ts us e ge ne tic principle s in re f ning hybrid crop plants and
live s tock. Ge ne tic e ng ine e rs deve lop ways to m anipulate the
ge ne tic code to produce a varie ty o the rapie s and e nhance d
biological characte ris tics o agricultural products . Ge nom ics
s cie ntis ts analyze the ge ne tic code s o organis m s to he lp us
be tte r unde rs tand s tructure and unction, w hich m ay le ad to
be tte r tre atm e nts or ge ne tic dis orde rs .

LANGUAGE OF S C IEN C E (co n tin u e d ro m p . 679)

genomics p-arm pseudogene

(jeh-NOH-miks) (pee arm) (SOOD-oh-jeen)
[gen- produce (gene), -om- entire collection, [p petite (small)] [pseudo- alse, gen- produce]
-ic relating to] principle o independent assortment q-arm
meiosis (PRIN-suh-puhl ov in-dih-PEN-dent (kyoo arm)
(my-OH-sis) uh-SORT-ment ) [q ollows p in Roman alphabet]
[mei- smaller, -osis process] [princip- oundation, in- not, -de- upon, recessive gene
mitochondrial DNA (mDNA, mtDNA) -pend- hang, -ent state, assort- match into (ree-SES-iv jeen)
(my-toh-KON-dree-al dee en ay groups, -ment process] [recess- retreat, -ive relating to, gen- produce]
[em dee en ay, em tee dee en ay]) proteome sex chromosome
[mito- thread, -chondrion- granule, -al relating (PROH-tee-ohm) (seks KROH-moh-sohm)
to, DNA deoxyribonucleic acid] [prote- f rst rank (protein), -ome entire [chrom- color, -som- body]
nondisjunction collection] sex-linked trait
(non-dis-J UNK-shun) proteomics (seks-linked trayt)
[non- not, -dis- split in two, junc- join, (proh-tee-OH-miks)
25 -tion condition] [prote- f rst rank (protein), -om- entire
collection, -ic relating to]
 CHAPTER 25 Genetics and Genetic Diseases 695

LANGUAGE OF M ED IC IN E

adenosine deaminase (ADA) def ciency genetic counseling pedigree

(ah-DEN-oh-seen dee-AM-ih-nayse (jeh-NET-ik KOWN-sel-ing) (PED-ih-gree)
[ay dee ay] dee-FISH-en-see) [gene- produce, -ic relating to, counsel- consult, [ rom pied de grue cranes oot pattern]
[adenosine blend o adenine and ribose, -ing process] phenylketonuria (PKU)
de- remove, -amin- ammonia, -ase enzyme, genetic counselor ( en-il-kee-toh-NOO-ree-ah [pee kay yoo])
de- down, -f ci- per orm, -ency quality] (jeh-NET-ik KOWN-sel-er) [phen- shining (phenol), -yl- chemical,
albinism [gene- produce, -ic relating to, counsel- consult, -keton- acetone, -ur- urine, -ia condition]
(AL-bih-niz-em) -or agent] plasmid
[alb- white, -in- characterized by, -ism state] genetic engineer (PLAS-mid)
amniocentesis (jeh-NET-ik en-juh-NEER) [plasm- ormed substance, -id belonging to]
(am-nee-oh-sen-TEE-sis) [gene- produce, -ic relating to, engin- devise or Punnett square
[amnio- birth membrane, -cent- prick, design, -eer practitioner] (PUN-it skwayr)
-esis process] human engineered chromosome (HEC) [Reginald C. Punnett English geneticist]
chorionic villus sampling (HYOO-man en-juh-NEERD RNA inter erence (RNAi)
(koh-ree-ON-ik VIL-lus SAM-pling) KROH-meh-sohm [aych ee see]) (ar en ay in-ter-FEER-ens [ar en ay aye])
[chorion- skin, -ic relating to, villus shaggy hair] [engin- devise or design, -eer practitioner, [RNA ribonucleic acid, inter- between,
chromosomal genetic disease -ed state, chrom- color, -som- body] - ere- strike, -ence process]
(kroh-moh-SOH-mal jeh-NET-ik) Human Genome Project (HGP) RNAi therapy
[chrom- color, -soma- body, -al relating to, (HYOO-man J EE-nome PROJ -ekt (ar en ay aye THAYR-ah-pee)
gen- produce, -ic relating to, dis- opposite o , [aych jee pee]) [RNA- ribonucleic acid, -i inter erence,
-ease com ort] (gen- to produce, -om(e)- whole collection] therapy treatment]
cystic f brosis ideogram severe combined immune def ciency (SCID)
(SIS-tik ye-BROH-sis) (ID-ee-oh-gram) (seh-VEER kom-BYNED ih-MYOON
[cyst- sac, -ic relating to, f br- f ber, [ide- idea, -gram drawing] deh-FISH-en-see [skid])
-osis condition] karyotype [immun- ree (immunity), -def ci- ail, -y state]
DNA f ngerprinting (KAYR-ee-oh-type) single-gene disease
(dee en ay FING-ger-print-ing) [karyo- nucleus, -type kind] (SING-jul jeen dih-ZEEZ)
[DNA deoxyribonucleic acid] Kline elter syndrome [gen- produce or generate, dis- opposite o ,
Down syndrome (KLINE- el-ter SIN-drohm) -ease com ort]
(down SIN-drohm) [Harry F. Kline elter American physician, Tay-Sachs disease (TSD)
[J ohn L. Down English physician, syn- together, syn- together, -drome running or (race) (TAY-saks dih-ZEEZ [tee es dee])
-drome running or (race) course] course] [Warren Tay English ophthalmologist,
electrophoresis Leber hereditary optic neuropathy Bernard Sachs American neurologist,
(eh-lek-troh- oh-REE-sis) (LEE-ber heh-RED-ih-tayr-ee OP-tik dis- opposite o , -ease com ort]
[electro- electricity, -phor- carry, -esis process] noo-ROP-ah-thee) trisomy
ragile X syndrome (FXS) [Theodor von Leber German ophthalmologist, (TRY-soh-mee)
(FRAJ -il eks SIN-drohm [e ex es]) her- heir, -it(y) state, -ary relating to, [tri- three, -som- body (chromosome), -y state]
[ ragil- rail, X sex chromosome X, syn- together, opt- vision, -ic relating to, neuro- nerves, tumor suppressor gene
-drome running or (race) course] -path- disease, -y state] (TOOM-er suh-PRES-er jeen)
gene augmentation monosomy [tumor swelling, suppress- press down,
(jeen awg-men-TAY-shun) (MON-oh-soh-mee) -or agent, gen- produce or generate]
[gen- produce or generate, aug- increase, [mono- single, -som- body (chromosome), Turner syndrome
-ment- state, -ation process] -y state] (TUR-ner SIN-drohm)
gene linkage mutagen [Harry H. Turner American endocrinologist,
(jeen LINK-ej) (MYOO-tah-jen)
[muta- change, -gen produce]
syn- together, -drome running or (race) 25
[gen- produce or generate] course]
gene replacement oncogene xeroderma pigmentosum
(jeen ree-PLAYS-ment) (ON-koh-jeen) (zeer-oh-DER-mah pig-men-TOH-sum)
[gen- produce or generate] [onco- swelling or mass (cancer), -gen- produce [xero- dry, -derma skin, pigment- paint, -osum
or generate] characterized by]
gene therapy
(jeen THAYR-a-pee)
[gen- produce or generate, therapy treatment]
 696 CHAPTER 25 Genetics and Genetic Diseases
OUTLINE S UMMARY
To dow nload a digital ve rs ion o the chapte r s um m ary
or us e w ith your device , acce s s the Au d io Ch a p te r
S u m m a rie s online at evolve .e ls evie r.com .
Scan this s um m ary a te r re ading the chapte r to
he lp you re in orce the key conce pts . Late r, us e
the s um m ary as a quick review be ore your clas s
or be ore a te s t.
Ge ne tics and Hum an Dis e as e
A. Geneti sthe s ienti study bi l gi al inheritan e
B. Inherited traits an pr du e disease (see Chapter 6)
Chro m o s o m e s and Ge ne s
A. Me hanisms gene un ti n
1. Geneindependent geneti units (DNA segments)
that arry the geneti de
2. Genes di tate the pr du ti n enzymes and ther
m le ules, whi h in turn di tate the stru ture and
un ti n a ell
3. Genes are a tive in the hr matin (strand) rm and
ina tive when DNA is in the hr m s me ( mpa t)
rm (Figure 25-1)
B. T e human gen me (Figure 25-1)
1. Gen meentire set human hr m s mes (46 in
nu leus ea h ell, 1 mit h ndrial hr m s me)
a. Map the entire human gen me (nearly all nu le-
tides in sequen e) was mpleted in 2003
b. C ntains ab ut 19,000 r s genes and large
am unts n n ding DNA, in luding n n un -
ti ning pseud genes
2. Gen mi sanalysis the sequen e ntained in the
gen me
3. Pr te mi sanalysis the entire gr up pr teins
en ded by the gen me, alled the human proteome
4. Gen mi in rmati n an be expressed in vari us
ways
a. Ide gram art n a hr m s me sh wing the
entr mere as a nstri ti n and the sh rt segment
(p-arm) and l ng segment (q-arm)
25 b. Genes are ten represented as their a tual
sequen e nu le tide bases expressed by the
letters a, c, g, and t
C. Distributi n hr m s mes t spring
1. Mei ti ell divisi n pr du es gametes with 23 hr -
m s mes ea h (Figure 25-2)
2. At n epti n, tw gametes j in and pr du e a zyg te
with 46 hr m s mesthe mplete human gen me
3. wenty-tw pairs hr m s mes are alled auto-
somes; ea h member a pair resembles its partner
4. T e hr m s mes in the remaining pair (pair 23) are
alled sex chromosomes
5. Geneti variati n am ng spring is in reased by:
a. Independent ass rtment hr m s mes during
gamete rmati n (Figure 25-2)
b. Cr ssing- ver genes r linked gr ups genes
between hr m s me partners during mei sis
(Figure 25-3)
Ge ne Expre s s io n
A. H ereditary traits
1. D minant genes have e e ts that appear in the -
spring (d minant rms a gene are ten repre-
sented by upper ase letters)
a. A geneti arrier is a pers n wh arries a re essive
gene but d es n t sh w its e e ts be ause
masking e e t a d minant gene
b. C d minant genes are tw r m re genes that are
all d minant and when they appear t gether
pr du e a mbined e e t in spring
2. Re essive genes have e e ts that d n t appear in the
spring when they are masked by a d minant gene
(re essive rms a gene are represented by l wer ase
letters)
B. Sex-linked traits (Figures 24-5 and 24-6)
1. T e large X hr m s me ( emale hr m s me) n-
tains genes r emale sexual hara teristi s and many
ther traits
2. T e small Y hr m s me (male hr m s me) n-
tains nly genes r male sexual hara teristi s
3. N rmal males have XY as pair 23; n rmal emales
have XX as pair 23
4. N nsexual traits arried n sex hr m s mes are sex-
linked traits; m st are X-linked traits
C. Geneti mutati ns
1. Can result in abn rmalities in the geneti de that
ause disease
2. M st believed t be aused by mutagens
Ge ne tic Dis e as e s
A. Me hanisms geneti disease
1. Genes are n t there t ause disease; mal un ti ns
geneti de may ause disease
2. Single-gene diseases result r m individual mutant
genes ( r gr ups genes) that are passed r m gener-
ati n t generati n (Figure 25-7)
3. Epigeneti s (imprinting) inv lves envir nmental
a t rs that may result in spring with geneti traits
that ann t be explained by genes al ne; may inv lve
geneti predisp siti n r disease
4. Chr m s mal diseases result r m hr m s me
breakage r r m n ndisjun ti n ( ailure a

hr m s me pair t separate during gamete rma-
ti n) (Figure 25-8)
a. ris mya hr m s me triplet (instead the
usual pair)
b. M n s mya single hr m s me (instead a pair)
B. Examples single-gene diseases (Table 25-1)
1. Cysti br sisre essive aut s mal nditi n hara -
terized by ex essive se reti n mu us and sweat,
ten ausing bstru ti n the gastr intestinal r
respirat ry tra ts
2. Phenylket nuria (PKU)re essive aut s mal ndi-
ti n hara terized by ex ess phenylket ne in urine,
aused by a umulati n phenylalanine in tissues;
may ause brain injury and death
3. ay-Sa hs disease ( SD) is a re essive nditi n
inv lving ailure t make a subunit an essential
lipid-pr essing enzyme
C. Examples epigeneti nditi ns
1. Result r m abn rmal additi n methyl gr ups,
a etyl gr ups, r ubiquitin pr teins that mark DNA
and a e t gene un ti n
2. Examples in lude ragile X syndr me (FXS), type 2
diabetes mellitus (DM), and ardi vas ular disease
D. Examples hr m s mal diseases
1. D wn syndr meusually aused by tris my hr -
m s me 21; hara terized by mental retardati n and
multiple stru tural de e ts (Figure 25-9)
2. Kline elter syndr me aused by the presen e tw
r m re X hr m s mes in a male (usually tris my
XXY); hara terized by l ng legs, enlarged breasts, l w
intelligen e, small testes, sterility, hr ni pulm nary
disease (Figure 25-10)
3. urner syndr me aused by m n s my the
X hr m s me (XO); hara terized by immaturity
ACTIVE LEARNING
STUDY TIPS
Cons ide r us ing the s e tips to achieve s ucce s s in
m e e ting your le arning goals .
This chapte r cove rs one o the m os t publicly dis cus s e d are as
in biology. Storie s on DNA f nge rprinting, ge ne the rapy, and
ge ne tically e ngine e re d m e dications and oods are o te n in the
m e dia. An unde rs tanding o the topics dis cus s e d in this chap-
te r w ill allow you to be tte r evaluate w he the r the s torie s you
he ar and re ad are bas e d on good s cie nce .
1. T e hapter requires an understanding DNA; a review
the material in Chapter 3 may be help ul. It is imp r-
tant t understand h w DNA ntr ls the a tivity the
ell:
DNA mRNA enzyme
bi hemi al rea ti ns in the ell.
CHAPTER 25 Genetics and Genetic Diseases 697
sex rgans (resulting in sterility), sh rt stature, webbed
ne k, ardi vas ular de e ts, and learning dis rders
(Figure 25-11)
Pre ve ntio n and Tre atm e nt
o Ge ne tic Dis e as e s
A. Geneti unselingpr essi nal nsultati ns with
amilies regarding geneti diseases
1. Pedigree hart illustrating geneti relati nships ver
several generati ns (Figure 25-12)
2. Punnett squaregrid used t determine the pr babil-
ity inheriting geneti traits (Figure 25-13)
3. Kary typearrangement hr m s me ph t -
graphs used t dete t abn rmalities
a. Amni entesisinv lves lle ti n etal ells
f ating in the amni ti f uid (Figure 25-14)
b. Ch ri ni villus samplinginv lves lle ti n
embry ni ells r m utside h ri ni tissue
B. reating geneti diseases
1. M st urrent treatments r geneti diseases are based
n relieving r av iding sympt ms rather than
attempting a ure
2. Gene therapymanipulates genes t ure geneti
pr blems (Figure 25-15); m st rms gene therapy
have just begun in humans
a. Gene repla ement therapyabn rmal genes in
existing b dy ells are repla ed by therapeuti genes
b. Gene augmentati n therapy ells arrying n rmal
genes are intr du ed int the b dy t augment
pr du ti n a needed pr tein
. RNAi therapyRNA inter eren esilen es indi-
vidual genes that ause disease
2. Make f ash ards t review the Language S ien e and
the Language Medi ine se ti ns r the geneti terms.
Be sure t understand h w the geneti makeup the
parents determines the pr bability r traits in the -
spring in b th aut s mal and sex-linked traits.
3. T e use spe i terms t designate the geneti nsti-
tuti n r gene mbinati n n ne hand, and the appear- 25
an e r expressi n that gene mbinati n in the
individual n the ther, is ten n using. Repeated use
terms in the rre t ntext and in njun ti n with
written expressi n the appr priate gen type is help ul.
T us, individuals with gen types r skin pigmentati n
AA and Aa have an identi al phen type (n rmal skin pig-
mentati n), whereas a gen type aa pr du es a di erent
phen type (albinism).
4. Make a hart the geneti dis rders and rganize them
based n the me hanism r ause, single-gene r
hr m s mal.
 698 CHAPTER 25 Genetics and Genetic Diseases
5. T ere are many nline tut rials that ver pedigrees,
Punnett squares, and kary types. Y u will als nd several
websites that pr vide geneti pr blems. C mpleting these
pr blems will help y u determine relative pr babilities
pr du ing spring with spe i gene mbinati ns.
6. Be able t di erentiate between gene repla ement and
gene augmentati n therapy.
7. In y ur study gr up, review the geneti terms using f ash
ards. Dis uss the relati nship between the DNA
Re vie w Que s tio ns
Write out the ans we rs to the s e que s tions a te r
re ading the chapte r and review ing the Chapte r
Sum m ary. I you s im ply think through the ans we r
w ithout w riting it dow n, you w ill not re tain m uch
o your new le arning.
1. Explain h w the DNA de is able t regulate the bi -
hemistry the ell.
2. As they are used in this hapter, de ne chromosome and
gene.
3. W hat is the human pr te me?
4. W hat is meant by independent assortment?
5. De ne r explain the terms dominant, recessive, and
codominant in regard t geneti s.
6. W hat is a sex-linked trait?
7. De ne r explain the terms nondisjunction, trisomy, and
monosomy.
8. W hat is a pedigree hart?
9. W hat is a Punnett square?
10. W hat is a kary type? W hat are the tw meth ds used t
harvest ells r a kary type?
11. Explain the di eren e between gene augmentati n and
gene repla ement therapy.
12. Name and brief y des ribe the tw single-gene diseases
dis ussed in the hapter.
13. Name and brief y des ribe the three hr m s mal dis-
eases dis ussed in the hapter. Indi ate whether the dis-
eases are the result tris my r m n s my.
25
sequen e and the bi hemi al a tivity the ell. Q uiz
ea h ther n the pr bability vari us traits in the -
spring, based n the parental genes. G ver the dis rders
hart and the di eren e in the type in rmati n gained
by a pedigree, a Punnett square, and a kary type. G ver
the questi ns at the end the hapter and the hapter
utline summary and dis uss p ssible test questi ns.
Critical Thinking
A te r f nis hing the Review Que s tions , w rite out
the ans we rs to the s e m ore in-de pth que s tions to
he lp you apply your new know le dge . Go back to
s e ctions o the chapte r that re late to conce pts
that you f nd di f cult.
14. H w d es r ssing- ver ntribute t geneti variati n?
15. Sin e all hildren inherit 50% their genes r m their
m ther and 50% their genes r m their ather, why
d nt we all have hara teristi s hal way between th se
ur m ther and th se ur ather?
16. W hy must a b y always inherit an X-linked gene su h
as l r blindness r m his m ther?
17. W hi h type geneti mutati n has the greatest l ng-
term impa t n the p pulati n, harm ul r bene ial?
Explain y ur answer.
18. I parents are n erned that their hild might be b rn
with D wn syndr me, what w uld be the best way t
determine this: a pedigree, a Punnett square, r a kary -
type? Explain y ur answer.
19. Design a Punnett square r a m ther and ather wh
are b th arriers r SCID. Use S r the n rmal gene
and s r the re essive gene.
20. W hat is ele tr ph resis?
 CHAPTER 25 Genetics and Genetic Diseases 699

Chapte r Te s t 8. N nsexual traits arried n the sex hr m s me are

A te r s tudying the chapte r, te s t your m as te ry by
re s ponding to the s e ite m s . Try to ans we r the m
w ithout looking up the ans we rs .
1. ________ is the s ienti study inheritan e.
2. T e end pr du t pr tein synthesis is requently an
________, whi h helps regulate the bi hemistry the
b dy.
3. M st the ells the human b dy ntain ________
hr m s mes, but gametes ntain ________
hr m s mes.
4. A ________ gene is ne wh se e e ts are seen and is
apable masking a ________ gene r the same trait.
F r questi ns 5, 6, and 7, let A stand r the d minant gene
r n rmal skin pigment and let a stand r the re essive gene
r albinism.
5. A ather with Aa and a m ther with AA have a
________% pr bability r having a hild with albinism.
6. A ather with Aa and a m ther with Aa have a
________% pr bability r having a hild with albinism.
7. A ather with Aa and a m ther with albinism have a
________% pr bability r having a hild with albinism.
alled ________ traits.
9. C l r blindness is arried n the X hr m s me. I the
ather is l r blind and the m ther is n t a arrier, the
pr bability having a l r blind s n w uld be
________%.
10. A hange in the geneti de is alled a ________.
11. A mistake in mei sis when a pair hr m s mes ails
t separate is alled ________.
12. ________ is a nditi n in whi h there is a triplet
aut s mes rather than the n rmal pair.
13. ________ is a nditi n in whi h there is a single aut -
s me rather than the n rmal pair.
14. A ________ is a hart that illustrates the geneti rela-
ti nship in a amily ver several generati ns.
15. A ________ is a grid used t determine the pr bability
inheriting a geneti trait.
16. A ________ is a ph t graph hr m s mes arranged
in pairs; amni entesis an supply the ells r this.
17. Can er is th ught t be aused, at least in part, by
abn rmal genes alled ________.
18. An ________, r simple art n a hr m s me, is
ten used in gen mi s t sh w the verall physi al
stru ture a hr m s me.
19. ________ is the s ien e that des ribes h w envir nmen-
tal and behavi ral a t rs may result in spring with
geneti traits that ant be explained by genes al ne.

Match each disorder in Column A with its corresponding cause or description in Column B.

Column A
20. ________ ysti br sis
21. ________ phenylket nuria
22. ________ D wn syndr me
23. ________ Kline elter syndr me
24. ________ urner syndr me
25. ________ l r blindness
Column B
a. a dis rder aused by tris my 21
b. a dis rder aused by a re essive gene that ails t pr du e the enzyme
phenylalanine hydr xylase
. a dis rder aused by the tris my nditi n XXY
d. a nditi n aused by a re essive gene that auses an impairment in hl ride i n
transp rt a r ss the ell membrane
e. a sex-linked trait that inhibits the pr du ti n ertain ph t pigments
. a dis rder aused by the m n s my nditi n XO

Cas e S tudie s 2. A y ung in ant just b rn at Mem rial H spital has

To s olve a cas e s tudy, you m ay have to re e r to parents that b th rep rt a hist ry ay-Sa hs disease in
the glos s ary or index, othe r chapte rs in this text- their amilies. Assuming b th parents have the ay-Sa hs
book, and othe r re s ource s . gene, what is the pr bability that this in ant will devel p
this deadly disease? 25
1. Q uentins amily physi ian suspe ts that Q uentin may 3. Be ky and Elli tt have been t ld that Elli tt is a arrier
have Kline elter syndr me. Q uentins l ng limbs, small r PKU. Using p as the re essive gene and P as the
testes, and enlarged breasts seem t supp rt the diagn sis. n rmal gene, devel p a Punnett square that will predi t
W hat test might the physi ian rder t n rm the syn- the pr bability ne their hildren inheriting the
dr me? W hat test results w uld be expe ted? W hat geneti disease.
auses the geneti abn rmality that pr du es Kline elter
syndr me? Answers to Active Learning Questions can be ound online
at evolve.elsevier.com.
This pa ge inte ntiona lly le ft bla nk
APPENDIX A
Ex a m p le s o P a t h o lo g ic a l able 5 C nditi ns Caused by Pr t z a
able 6 C nditi ns Caused by Path geni Animals
C o n d it io n s able 7 C nditi ns Caused by Physi al Agents
able 1 Leading H ealth Pr blems able 8 End rine C nditi ns
able 2 Viral C nditi ns able 9 Aut immune Diseases
able 3 Ba terial C nditi ns able 10 De ien y Diseases
able 4 My ti (Fungal) C nditi ns able 11 Geneti C nditi ns

TABLE 1 Leading Health Problems

CONDITION CHAPTER REFERENCE
Dis e as e s o the he art and blood ve s s e ls Chapte rs 14 and 15
Cance r Chapte r 6
Stroke Chapte r 10
Chronic lowe r re s piratory dis e as e s Chapte r 17
Accide nts Chapte r 6
Diabe te s m e llitus Chapte r 12
Alzhe im e r dis e as e (AD) Chapte r 10
Pne um onia and in ue nza Chapte rs 6 and 17
Kidney dis e as e Chapte r 20
Se ptice m ia Chapte rs 15, 16, and 24

TABLE 2 Viral Conditions

DIS EAS E
Acquire d im m unode f cie ncy
s yndrom e (AIDS)
Acute T-ce ll lym phocytic
le uke m ia (ATLL)
Chicke npox (varice lla) and
s hingle s (he rpe s zos te r)
Com m on cold and uppe r
re s piratory in e ctions
(URIs )
Feve r blis te rs and he rpe s
Hantavirus pulm onary
s yndrom e
He patitis (in e ctious )
He patitis (s e rum )
VIRUS
Hum an im m unode f cie ncy
virus (HIV)
Hum an T-lym photropic
virus 1 (HTLV-1)
Varice lla zos te r virus (VZV)
Rhinovirus e s
He rpe s s im plex 1 and 2
Hantavirus
He patitis A virus
He patitis B virus
DES CRIPTION
HIV in e ction is trans m itte d by dire ct contact w ith body uids , pe rhaps w ithin
w hite blood ce lls (WBCs ) in blood or s e m e n. It m ay progre s s to AIDS, w hich
is characte rize d by T-lym phocyte dam age , re s ulting in im m une dys unction.
De ath is pos s ible rom s e condary in e ctions or tum ors .
This orm o cance r in adults can be caus e d by the oncovirus ( cance r virus )
HTLV-1. This dis e as e is one o m any orm s o le uke m ia and doe s not appe ar
until at le as t 30 ye ars a te r initial in e ction. HTLV-1 is trans m itte d in the s am e
m anne r as HIV.
Chicke npox m os t o te n appe ars in unvaccinate d childre n, typically involving blis -
te rs and eve r. He rpe s zos te r, com m only know n as s hingle s , occurs late r (in
adulthood) in thos e w ho had the varice lla in e ction at an e arlie r age . Shingle s
o te n involve s a ras h along a s ingle de rm atom e on one s ide o the body and
is accom panie d by s eve re pain.
This m ild, contagious in e ction is characte rize d by nas al in am m ation, we ak-
ne s s , cough, and low-grade eve r. Doze ns o di e re nt rhinovirus e s have be e n
type d.
This virus caus e s blis te rs on the hands or ace ( eve r blis te rs ) or ge nitals (ge nital
he rpe s ). The blis te rs m ay dis appe ar te m porarily but m ay re appe ar, e s pe cially
as a re s ult o s tre s s .
This s e rious viral dis e as e is characte rize d by eve r and ulike s ym ptom s that
o te n progre s s to re s piratory ailure ; it is s pre ad by rode nt excre ta.
The live r in am m ation caus e d by this virus is characte rize d by s low ons e t and
com ple te re cove ry. This virus is s pre ad by dire ct contact or contam inate d
ood or wate r.
This acute -ons e t live r in am m ation m ay deve lop into a s eve re chronic dis e as e ,
pe rhaps e nding in de ath.

e1 C pyright 2018, Elsevier In . All rights reserved.

 APPENDIX A e2

TABLE 2 Viral Conditionscontd

DIS EAS E VIRUS DES CRIPTION
He patitis (non-A; non-B) He patitis C This viral live r in am m ation is trans m itte d by contam inate d blood; initially m ild
cas e s m ay be com e chronic and ove r long pe riods progre s s to cirrhos is and
live r ailure .
In e ctious m ononucle os is Eps te in-Barr virus (EBV) This acute in e ction is characte rize d by eve r; s ore throat; incre as e d count and
abnorm al s hape o lym phocyte s ; and live r, s ple e n, or lym ph node s we lling.
In ue nza In ue nza A, B, C, e tc. This highly contagious re s piratory in e ction is characte rize d by s ore throat, eve r,
cough, m us cle pain, and we akne s s . New s trains o virus e s A, B, and C
appe ar at inte rvals us ually originating in As ia.
Me as le s Morbillivirus This acute , contagious re s piratory in e ction is characte rize d by eve r, he adache ,
and the m e as le s ras h.
Mum ps Paramyxovirus This acute in e ction is characte rize d by s wolle n parotid s alivary glands ; eve r;
and in adult m ale s , s wolle n te s te s ; m um ps is m os t com m on in childre n but
can occur at any age .
Poliomye litis Poliovirus 1, 2, and 3 This acute in e ction has s eve ral di e re nt orm s (de pe nding on exte nt o in e c-
tion): as ym ptom atic, m ild, nonparalyzing, and paralyzing. It is no longe r
com m on in the Unite d State s be caus e o s ucce s s ul vaccination program s .
Rabie s Rabie s virus This atal in e ction o the ce ntral ne rvous s ys te m is us ually trans m itte d through
the bite s o in e cte d anim als .
Rube lla (Ge rm an m e as le s ) Rube lla virus This contagious in e ction is characte rize d by uppe r re s piratory in am m ation,
s wolle n lym ph node s , joint pain, and m e as le s -like ras h. In pre gnant wom e n, it
can s pre ad to the e tus and caus e conge nital de e cts .
Viral e nce phalitis (Many di e re nt virus e s ) Viral e nce phalitis is a ge ne ral te rm or any brain in am m ation caus e d by a virus .
Brain dam age m ay occur, pe rhaps caus ing de ath. Many di e re nt orm s exis t
be caus e m any di e re nt virus e s m ay in e ct the brain (e .g., St. Louis e nce phali-
tis , Cali ornia e nce phalitis , and e quine e nce phalitis ). Mos t e nce phalitis virus e s
are trans m itte d by m os quitoe s .
Warts , ge nital warts , and Hum an papillom avirus e s Warts are nipple like ne oplas m s o the s kin. Forty-s ix HPV type s have be e n ide n-
ce rvical cance r (HPV) tif e d. HPV type s 6 and 11 caus e ge nital warts , a com m on s exually trans m it-
te d dis e as e (STD).

TABLE 3 Bacterial Conditions

DIS EAS E ORGANIS M DES CRIPTION
Acute bacte rial Staphylococcus , Hae m ophilus , This acute in am m ation o the conjunctiva cove ring the eye is characte rize d by a
conjunctivitis Prote us , and othe r organis m s dis charge o m ucous pus ; it is highly contagious (com pare w ith trachom a).
Anthrax Bacillus anthracis Us ually trans m itte d rom arm anim als , this in e ction is characte rize d by a re ddis h-
brow n s kin le s ion but can als o in e ct the re s piratory tract. It can be atal.
Botulis m Clos tridium botulinum (bacillus ) This is a pos s ibly atal ood pois oning re s ulting rom inge s tion o ood contam i-
nate d w ith toxins produce d by C. botulinum .
Bruce llos is Bruce lla s pe cie s (bacilli) Als o calle d undulant eve r, this bacte rial in e ction is trans m itte d rom arm anim als
and is characte rize d by chills , eve r, we ight los s , and we akne s s . Se rious com pli-
cations can occur i it is not tre ate d.
Chole ra Vibrio chole rae (curve d) This acute inte s tinal in e ction is characte rize d by diarrhe a, vom iting, cram ps , de hy-
dration, and e le ctrolyte im balance caus e d by bacte rial toxins . It can be atal i
untre ate d. It s pre ads through contam inate d ood or wate r.
De ntal carie s Stre ptococcus m utans (coccus ) Tooth de m ine ralization is caus e d by acids orm e d w he n nutrie nts on the tooths
and othe r organis m s s ur ace are m e tabolize d by bacte ria. It can progre s s to a bacte rial invas ion o
the tooths pulp cavity and beyond.
Diphthe ria Coryne bacte rium diphthe riae Diphthe ria is an acute , contagious dis e as e characte rize d by s ys te m ic pois oning by
(bacillus ) bacte rial toxins and deve lopm e nt o a als e m e m brane lining o the throat
that m ay obs truct bre athing. Untre ate d, it m ay be atal.
Epiglottitis Hae m ophilus in ue nzae Acute in am m ation o e piglottis is characte rize d by eve r, s ore throat, and s we ll-
ing (e m e rge ncy tre atm e nt to m aintain airway m ay be ne ce s s ary).
Continue d
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e3 APPENDIX A

TABLE 3 Bacterial Conditionscont'd

DIS EAS E ORGANIS M DES CRIPTION
Exte rnal otitis Ps e udom onas ae ruginos a, In am m ation o the exte rnal e ar canal is us ually caus e d by bacte ria but can als o
(s w im m e rs e ar) Staphylococcus aure us , re s ult rom he rpe s in e ctions , alle rgy, and othe r actors .
Stre ptococcus pyoge ne s , e tc.
Gas troe nte ritis (Many di e re nt bacte ria) Gas troe nte ritis is a ge ne ral te rm or any in am m ation o the gas trointe s tinal tract.
Many di e re nt bacte rial in e ctions can caus e this condition. (Se e
Salm one llos is .)
Gonorrhe a Ne is s e ria gonorrhoe ae (coccus ) This com m on STD in e cts prim arily the ge nital and urinary tracts but can a e ct
the throat, conjunctiva, or lowe r inte s tine s . It m ay progre s s to pe lvic in am m a-
tory dis e as e (s e e late r e ntry).
Le gionnaire s Le gione lla pne um ophila This is a type o pne um onia characte rize d by in ue nza-like s ym ptom s ollowe d by
dis e as e (bacillus ) high eve r, m us cle pain, and he adache pos s ibly progre s s ing to dry cough and
ple uris y. It is s pre ad by m ois t e nvironm e ntal s ource s (e .g., air conditioning
cooling units and s oil) rathe r than pe rs on-to-pe rs on contact.
Lym e dis e as e Borre lia burgdor e ri (s piroche te ) Although the f rs t cas e s we re know n only ne ar Lym e , Conne cticut, this tick-borne
dis e as e is now e nde m ic ove r m uch o the Unite d State s . It us ually f rs t pre -
s e nts as a bulls -eye ras h but late r m ay caus e chronic ne rve , he art, and joint
proble m s .
Lym phogranulom a Chlamydia trachom atis (s m all) This chronic STD is characte rize d by ge nital ulce rs , s wolle n lym ph node s , he ad-
ve ne re um (LGV) ache , eve r, and m us cle pain. C. trachom atis in e ction m ay caus e a varie ty o
othe r s yndrom e s , including conjunctivitis , uroge nital in e ctions , and s ys te m ic
in e ctions . C. trachom atis in e ctions cons titute the m os t com m on STD in the
Unite d State s .
Me ningitis Stre ptococcus pne um oniae , Me ningitis is any in am m ation o the m e ninge s cove ring the brain and s pinal
Ne is s e ria m e ningitidis , cord. Seve ral di e re nt bacte ria can in e ct the m e ninge s , as can s eve ral ungi;
Hae m ophilus in ue nzae , and the condition can be m ild, but i s eve re , it can caus e de ath.
othe r organis m s
Parrot eve r Chlamydia ps ittaci (s m all) Als o calle d ornithos is , this pne um onia-like in e ction is trans m itte d by parrots and
(ps ittacos is ) othe r birds . It is characte rize d by cough, eve r, los s o appe tite , and s eve re
he adache .
Pe lvic in am m atory Ne is s e ria gonorrhoe ae (coccus ), PID re e rs to any exte ns ive in am m ation o the e m ale pe lvic s tructure s . Chronic
dis e as e (PID) Mycoplas m a hom inis (s m all in am m ation as s ociate d w ith PID can caus e tis s ue dam age that le ads to
re e -living), and othe r s te rility.
organis m s
Pe rtus s is (w hooping Borde te lla pe rtus s is (bacillus ) Pe rtus s is is an acute , contagious in e ction o the re s piratory tract characte rize d by
cough) coughs that e nd w ith w hooping re s pirations .
Pne um onia Stre ptococcus pne um oniae An acute lung in e ction that com m only deve lops a te r the u or s om e othe r condi-
(coccus ) and othe r organis m s tion that preve nts cle arance o the lungs . It is characte rize d by blockage o the
pulm onary airways .
Q eve r Coxie lla burne tii (s m all) Q ( or que ry ) eve r us ually involve s re s piratory in e ction and is characte rize d by
eve r, he adache , and m us cle pain. Acute and chronic orm s m ay deve lop a te r
expos ure to in e cte d anim als or anim al products ; this is a ricke tts ial dis e as e .
Rhe um atic eve r Group A be ta-he m olytic s tre pto- This in am m atory dis e as e re s ults rom a de laye d re action to s tre p in e ction; it
cocci (cocci) m ay a e ct he art, brain, joints , or s kin.
Rocky Mountain Ricke tts ia ricke tts ii (s m all) This s om e tim e s atal, tick-borne dis e as e is characte rize d by eve r, chills , he ad-
s potte d eve r ache , m us cle pain, ras h, cons tipation, and he m orrhagic le s ions ; it m ay progre s s
(RMSF) to s hock and re nal ailure .
Salm one llos is Salm one lla s pe cie s (bacilli) This type o bacte rial gas troe nte ritis is caus e d by inge s tion o contam inate d ood.
Shige llos is (Shige lla Shige lla s pe cie s (bacilli) This com m on dis e as e is characte rize d by bloody, m ucous diarrhe a; cram ps ; eve r;
dys e nte ry and and atigue . It can caus e de hydration, e le ctrolyte im balance , and acidos is i not
bacillary tre ate d. Antibiotic-re s is tant s trains o Shige lla organis m s m ake this condition a
dys e nte ry) s e rious he alth thre ate s pe cially in are as w ith poor s anitation.
Staphylococcal Staphylococcus s pe cie s (cocci) The s e bacte rial in e ctions are characte rize d by abs ce s s e s ; one s uch in e ction is
in e ction s taphylococcal s calde d s kin s yndrom e (SSSS), a s kin dis orde r o in ants and
young childre n.

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 APPENDIX A e4

TABLE 3 Bacterial Conditionscontd

DIS EAS E ORGANIS M DES CRIPTION
Syphilis Tre pone m a pallidum This s exually trans m itte d dis e as e can a e ct any s ys te m . Prim ary s yphilis is char-
(s piroche te ) acte rize d by chancre s ore s on expos e d are as o the s kin. Untre ate d, s e condary
s yphilis m ay appe ar 2 m onths a te r chancre s dis appe ar. The s e condary s tage
occurs w he n the s piroche te has s pre ad throughout the body, pre s e nting a
varie ty o s ym ptom s , and is s till highly contagious eve n through kis s ing. Te r-
tiary s yphilis m ay occur ye ars late r, pos s ibly re s ulting in de ath.
Te tanus Clos tridium te tani (bacillus ) In this acute , s om e tim e s atal ce ntral ne rvous s ys te m in e ction, the bacte ria
us ually e nte r a wound and the n produce a toxin that caus e s he adache , eve r,
and pain ul m us cle s pas m s .
Toxic s hock s yn- Staphylococcus aure us s trains This acute , s eve re toxic in e ction is as s ociate d w ith the us e o highly abs orbe nt
drom e (TSS) (cocci) tam pons but can occur unde r a varie ty o circum s tance s . It be gins as a high
eve r, he adache , s ore throat, e tc., and m ay progre s s to re nal ailure , live r
ailure , and pos s ibly de ath.
Trachom a (chlamyd- Chlamydia trachom atis (s m all) This chronic in e ction o the conjunctiva cove ring the eye is characte rize d by
ial conjunctivitis ) pain ul in am m ation, photophobia (light s e ns itivity), and exce s s ive production
o te ars ; i untre ate d, it w ill progre s s to orm granular le s ions that eve ntually
a e ct the corne a and caus e blindne s s .
Tube rculos is Mycobacte rium tube rculos is This chronic in e ction us ually a e cts the lungs (pulm onary tube rculos is ) and is
characte rize d by atigue , dys pne a, and chronic cough and is trans m itte d by
inhalation or inge s tion o bacte ria.
Typhoid eve r Salm one lla typhi (bacillus ) Als o calle d e nte ric eve r, this condition is characte rize d by eve r, he adache , cough,
diarrhe a, and ras h; it is trans m itte d through contam inate d ood or wate r.

TABLE 4 Mycotic (Fungal) Conditions

DIS EAS E ORGANIS M
As pe rgillos is As pe rgillus s pe cie s (m old)
Blas tomycos is Blas tomyce s de rm atitidis
(m old*)
Candidias is Candida albicans and
othe r s pe cie s (ye as ts )
Coccidioidomycos is Coccidioide s im m itis
(San Joaquin eve r) (m old*)
His toplas m os is His toplas m a caps ulatum
(m old*)
Mycos is (Many type s )
Tine a Epide rm ophyton, Micros -
porum , and Trichophy-
ton s pe cie s (m olds )
DES CRIPTION
This uncom m on, opportunis tic m old in e ction by any o a num be r o di e re nt s pe cie s
has m any di e re nt orm s . It o te n a e cts the e ar but can a e ct any organ, w he re it
produce s characte ris tic ungus ball le s ions . I the in e ction be com e s w ide s pre ad,
it can be atal.
As w ith his toplas m os is , m os t cas e s o blas tomycos is are as ym ptom atic. The m os t
com m on s ym ptom atic orm s are s kin ulce rs and bone le s ions , but the in e ction m ay
s pre ad to the lungs , kidneys , or ne rvous s ys te m .
This opportunis tic ye as t in e ction is characte rize d by a w hite dis charge , pe e ling, and
ble e ding; candidias is has s eve ral orm s , de pe nding on the s eve rity and w he re it
occurs : thrus h (s kin), diape r ras h (s kin), vaginitis , e ndocarditis , e tc. It can be trans -
m itte d s exually, m aking it a s exually trans m itte d in e ction (STI).
Also calle d des e rt eve r, this condition is endem ic to dry regions o the s outhwes te rn
Unite d State s and Ce ntral and South Am e rica. It is characte rize d by cold- or in ue nza-
like s ym ptom s. A sm all num be r o case s deve lop into m ore se rious in e ction.
His toplas m os is is a ungal in e ction m os t com m on in the Midwe s te rn Unite d State s ,
w he re it is s pre ad through contam inate d s oil. In m os t cas e s , it is as ym ptom atic, but
acute pne um onia m ay deve lop in a ew cas e s .
Mycos is is a ge ne ral te rm us e d to de s cribe any dis e as e caus e d by ungi. Mycos e s is
the plural orm .
Exam ple s o opportunis tic cutane ous mycos e s include tine a pe dis (athle tes oot),
tine a cruris (jock itch), tine a corporis (body ringworm ), tine a capitis (s calp ringworm ),
and tine a unguium (nail ungus ). All are characte rize d by in am m ation accom panie d
by itching, s caling, and (occas ionally) pain ul le s ions .

* The s e m olds are norm ally m ultice llular but trans orm to a unice llular phas e w he n they in e ct hum ans .

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e5 APPENDIX A

TABLE 5 Conditions Caused by Protozoa

DIS EAS E ORGANIS M DES CRIPTION
Am e bias is and am e bic Entam oe ba his tolytica, Entam oe ba Us ually acquire d through contam inate d ood and wate r, this condition is an
dys e nte ry pole cki, and othe r organis m s am e bic in e ction o the inte s tine or live r. Mild cas e s are as ym ptom atic.
(am e ba) More s eve re orm s are characte rize d by diarrhe a, abdom inal pain, jaun-
dice , and we ight los s .
Balantidias is Balantidium coli (ciliate ) B. coli can be carrie d as ym ptom atically in the gas trointe s tinal tract. The
dis e as e is characte rize d by abdom inal pain, naus e a, and diarrhe a. It m ay
progre s s to inte s tinal ulce ration and s ubs e que nt s e condary in e ctions .
Giardias is (trave le rs Giardia lam blia ( age llate ) Inte s tinal in e ction is s pre ad through contam inate d ood or wate r or through
diarrhe a) pe rs on-to-pe rs on contact. Sym ptom s range rom m ild diarrhe a to m alab-
s orption s yndrom e , w ith about hal o all cas e s be ing as ym ptom atic.
Is os porias is Is os pora be lli (s porozoan) Trans m itte d through contam inate d ood or oral-anal s exual contact, is os poria-
s is is an inte s tinal in e ction that m ay be as ym ptom atic. Sym ptom atic m an-
i e s tations range rom m ild to s eve re , re s e m bling giardias is .
Malaria Plas m odium s pe cie s (s porozoa) This s e rious dis e as e is caus e d by blood-ce ll paras ite s that re quire two hos ts :
m os quitoe s and hum ans (or othe r anim als ). Malaria is characte rize d by
eve r, ane m ia, s wolle n s ple e n, and pos s ible re laps e m onths or ye ars late r.
Toxoplas m os is Toxoplas m a gondii (s porozoan) A com m on in e ction o blood and othe r tis s ue ce lls , this condition is o te n
as ym ptom atic. It is trans m itte d through cat e ce s and unde rcooke d m e at.
It is characte rize d by eve r, lym phatic involve m e nt, he adache , atigue ,
ne rvous dis orde rs , and he art proble m s . I trans m itte d rom m othe r to
e tus , it can caus e conge nital de e cts that o te n le ad to de ath.
Trichom onias is Trichom onas vaginalis ( age llate ) This uroge nital in e ction is as ym ptom atic in m os t e m ale patie nts and ne arly
all m ale patie nts . Vaginitis m ay occur, characte rize d by itching or burning
and a oul-s m e lling dis charge . It is us ually s pre ad through s exual contact.

TABLE 6 Conditions Caused by Pathogenic Animals

DIS EAS E ORGANIS M
As carias is (roundworm As caris lum bricoide s (ne m atode )
in e s tation)
Bite s and s tings Arachnida and Ins e cta
Ente robias is (pinworm Ente robius ve rm icularis
in e s tation) (ne m atode )
Fis h tapeworm Diphyllobothrium latum
in e s tation (platyhe lm inth)
Live r uke in e s tation Fas ciola he patica, Opis thorchis
s ine ns is , and othe r organis m s
(platyhe lm inths )
Pork and be e tapeworm Tae nia s olium (pork tapeworm )
in e s tation and Tae nia s aginata (be e
tapeworm ) (platyhe lm inths )
DES CRIPTION
This condition is trans m itte d through contam inate d ood or contact w ith con-
tam inate d s ur ace s (s uch as hands ). Eggs hatch in the s m all inte s tine , and
the larvae trave l to the lungs , w he re they caus e coughing and eve r. Inte s -
tinal and live r involve m e nt als o m ay be s e rious .
Sym ptom s o bite s and s tings us ually re s ult rom m e chanical injury and the
re le as e o toxins at the injury s ite . Som e individuals m ay be hype rs e ns i-
tive to ce rtain toxins and thus exhibit an alle rgic re action, pe rhaps eve n
anaphylaxis and de ath. Bite s and s tings als o m ay trans m it pathoge ns
w he n the culprit is a ve ctor.
This is a com m on paras ite in e s tation in w hich e ggs can be trans m itte d by
contam inate d hands (a com m on caus e o re in e ction) or on inhale d dus t
particle s . The in e s tation is localize d in the large inte s tine . The adult e m ale
lays e ggs around the outs ide o the anus , caus ing itching and pos s ibly
ins om nia.
Spre ad by e ating unde rcooke d, contam inate d f s h, this condition is us ually
as ym ptom atic but can caus e pe rnicious ane m ia i too m uch vitam in B12 is
abs orbe d rom the hos t.
Trans m itte d through wate rcre s s contam inate d by in e cte d s nails , e s pe cially
in s he e p-rais ing re gions ; this in e s tation caus e s in am m ation and s we lling
o the live r. The s ym ptom s m ay progre s s to include he patitis , bile duct
obs truction, and s e condary in e ctions .
This in e s tation is s pre ad by e ating unde rcooke d, contam inate d pork or be e .
Adult tapeworm s m ature in the gas trointe s tinal tract, us ually producing
m ild s ym ptom s o diarrhe a and we ight los s . Larvae m ay s pre ad to othe r
tis s ue , s om e tim e s caus ing s e rious in e ctions .

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 APPENDIX A e6

TABLE 6 Conditions Caused by Pathogenic Animalscontd

DIS EAS E ORGANIS M
Schis tos om ias is (s nail Schis tos om a m ans oni,
eve r) Schis tos om a japonicum , and
Schis tos om a hae m atobium
(platyhe lm inths )
Trichinos is (thre adworm Trichine lla s piralis (ne m atode )
in e s tation)
DES CRIPTION
This is a paras itic condition trans m itte d in the orm o s kin-pe ne trating para-
s ite s re le as e d by re s hwate r s nails in wate r contam inate d by hum an
e ce s . Characte ris tics o the dis e as e de pe nd on the organs involve d and
the s pe cie s o uke .
This is an in e s tation characte rize d by diarrhe a, naus e a, and eve r, pos s ibly
progre s s ing to m us cle pain and atigue . In s eve re cas e s , the he art, lungs ,
and brain m ay be com e involve d, s om e tim e s re s ulting in de ath. The para-
s ite is trans m itte d through unde rcooke d pork, be ar, and othe r m e ats .

TABLE 7 Conditions Caused by Physical Agents

CONDITION MECHANIS M
Bone racture Me chanical injury (e .g., inte ns e pre s s ure ,
blow to the body, and abnorm al turn
w hile be aring we ight)
Burn Che m ical age nts (e .g., acids and bas e s ),
inte ns e he at, ionizing radiation (e .g.,
x-rays and gam m a rays ), non-ionizing
radiation (e .g., ultraviole t), e le ctricity
Cance r Me chanical injury, ionizing radiation (e .g.,
x-rays and gam m a rays ), non-ionizing
radiation (e .g., ultraviole t), che m ical
age nts (e .g., irritants and carcinoge ns )
Chronic obs tructive pul- Che m ical pollutants (in air), airborne
m onary dis e as e (COPD) particulate s
Contus ion Me chanical injury (e .g., blow to the body
and inte ns e pre s s ure )
Crus h s yndrom e Me chanical pre s s ure (inte ns e )
Diarrhe a Che m ical age nts (inge s te d), ionizing radi-
ation (e .g., x-rays and gam m a rays )
He adache Me chanical injury (e .g., blow to the
he ad), che m ical pollutants (e .g.,
inhale d organic com pounds )
He aring im pairm e nt High-volum e (inte ns ity) s ound (e .g.,
nois e pollution)
Hype rs e ns itivity re action Che m ical s ubs tance s in e nvironm e nt,
and phys ical alle rgy light (as in photos e ns itivity), te m pe ra-
ture (as in cold or he at s e ns itivity)
Lace ration Me chanical injury (s harp-e dge d obje ct)
C pyright 2018, Elsevier In . All rights reserved.
DES CRIPTION
Com ple te or incom ple te bre ak o hard bone tis s ue in one or m ore
localize d are as is o te n characte rize d by pain, s we lling, and
lim ite d m otion; com pound racture s bre ak the s kin and m ay
thus allow in e ction.
This is an injury to tis s ue s caus e d by the actors lis te d in w hich
the exte nt o the injury is proportional to expos ure to the caus -
ative age nt and pe rce nt o body are a a e cte d; it caus e s
burning pain and re s ulting in am m ation re s pons e . Untre ate d
or s eve re burns m ay be com e in e cte d and m ay caus e s eve re
uid los s .
Malignant ne oplas m (abnorm al tis s ue grow th) is characte rize d by
invas ion o s urrounding tis s ue and m e tas tas is (s pre ad) to othe r
parts o the body; it o te n progre s s e s to de ath i not tre ate d.
This group o dis orde rs is characte rize d by progre s s ive , irreve rs ible
obs truction o air ow in the lungs . Two m ain orm s are : chronic
bronchitis , e m phys e m a. The incide nce in the U.S. population
has incre as e d w ith expos ure to air pollutants , including ciga-
re tte s m oke (prim ary and s e cond-hand).
A contus ion is a localize d tis s ue le s ion characte rize d by bre akage
o blood ve s s e ls and s urrounding tis s ue ce lls w ithout exte rnal
ble e ding; it is s om e tim e s calle d a bruis e .
This s eve re , li e -thre ate ning condition is characte rize d by m as s ive
de s truction o m us cle and bone , he m orrhage , uid los s , hypo-
vole m ic s hock, he m aturia (bloody urine ), and kidney ailure
o te n progre s s ing to com a.
Fre que nt pas s ing o loos e , wate ry e ce s (s tools ) re s ults rom
incre as e d pe ris tals is (m otility) o the colon, in this cas e re s ulting
rom irritation by phys ical age nts ; the re s ulting uid and e le ctro-
lyte im balance m ay caus e de hydration or anothe r li e -thre ate n-
ing condition.
Pain in the he ad in this cas e re s ults rom injury by the age nts
lis te d.
Chronic expos ure to loud nois e caus e s he aring los s proportional to
expos ure re s ulting rom dam age to the s piral organ (o Corti).
Inappropriate , inte ns e im m une re action to othe rw is e harm le s s
phys ical age nts is characte rize d by urticaria (hive s ), e de m a, and
othe r alle rgy s ym ptom s ; s pe cif c antige ns are us ually as s oci-
ate d w ith the re action.
This is a m e chanical injury in w hich tis s ue is cut or torn, o te n
characte rize d by ble e ding; i untre ate d, it m ay be com e in e cte d.
Continue d
e7 APPENDIX A

TABLE 7 Conditions Caused by Physical Agentscontd

CONDITION MECHANIS M
Naus e a Che m ical age nts (inge s te d), ionizing radi-
ation (e .g., x-rays and gam m a rays )
Pne um onia Inhale d s ubs tance s
Pois oning Naturally occurring toxins , s ynthe tic
toxins , drugs (e .g., abus e , ove rdos e ,
toxic inte raction), e nvironm e ntal pol-
lutants (e .g., air, wate r)
Radiation s ickne s s Ionizing radiation (e .g., x-rays and gam m a
rays )
Vis ual im pairm e nt Me chanical injury (e .g., blow to the
he ad), inte ns e light (e .g., dire ct s un-
light and las e r), ionizing radiation (e .g.,
x-rays and gam m a rays ), non-ionizing
radiation (e .g., ultraviole t)
Windburn and abras ion Abras ive s (e .g., w indblow n particle s and
burn rough s ur ace s )
DES CRIPTION
This is an unple as ant s e ns ation o the gas trointe s tinal tract that
com m only pre ce de s the urge to vom it (that is , ups e t
s tom ach ).
This abnorm al condition is characte rize d by acute in am m ation o
the lungs (in this cas e , trigge re d by irritation caus e d by inhale d
s ubs tance ) in w hich alve oli and bronchial pas s age s be com e
plugge d w ith thick uid (exudate ).
This condition re s ults rom expos ure to a pois on or toxina s ub-
s tance that im pairs he alth or de s troys li e ; e e cts m ay be local
or s ys te m ic. Som e tim e s antidote s reve rs e toxicity, but s om e -
tim e s the condition is irreve rs ible . The toxin m ay be inge s te d,
inje cte d, inhale d, or abs orbe d through s kin or m ay e nte r the
body in s om e othe r way.
De pe nding on the le ngth, inte ns ity, and location o expos ure to
radiation, this condition m ay be m ild (he adache , naus e a, vom it-
ing, anorexia, and diarrhe a) to s eve re (s te rility, e tal injury,
cance r, alope cia, and cataracts ); exce s s ive radiation expos ure
m ay caus e de ath.
A blow to the he ad m ay caus e de tachm e nt o the re tina; inte ns e
light or othe r radiation m ay dam age re tinal tis s ue . Radiation als o
m ay cloud the le ns or corne a, producing cataracts .
This injury is s im ilar to a he at or che m ical burn but is caus e d by
m e chanical abras ion o the s kin or othe r tis s ue s .

TABLE 8 Endocrine Conditions

CONDITION MECHANIS M DES CRIPTION
Acrom e galy Hype rs e cre tion o grow th horm one This is a chronic m e tabolic dis orde r characte rize d by gradual e nlarge -
(GH) during adulthood m e nt or e longation o acial bone s and extre m itie s .
Addis on dis e as e Hypos e cre tion o adre nal cortical hor- Caus e d by tube rculos is , autoim m unity, or othe r actors , this li e -
m one s (adre nal cortical ins u f cie ncy) thre ate ning condition is characte rize d by we akne s s , anorexia,
we ight los s , naus e a, irritability, de cre as e d cold tole rance , de hydra-
tion, incre as e d s kin pigm e ntation, and e m otional dis turbance ; it
m ay le ad to an acute phas e (adre nal cris is ) characte rize d by circula-
tory s hock.
Aldos te ronis m Hype rs e cre tion o aldos te rone O te n caus e d by adre nal hype rplas ia, this condition is characte rize d by
s odium re te ntion and potas s ium los s producing Conn s yndrom e :
s eve re m us cle we akne s s , hype rte ns ion (high blood pre s s ure ),
kidney dys unction, and cardiac proble m s .
Cre tinis m Hypos e cre tion o thyroid horm one This conge nital condition is characte rize d by dwarf s m , re tarde d m e ntal
during e arly deve lopm e nt deve lopm e nt, acial pu f ne s s , dry s kin, um bilical he rnia, and lack o
m us cle coordination.
Cus hing dis e as e Hype rs e cre tion o adre nocorticotropic Caus e d by s e cre tory ade nom a o the ante rior pituitary; incre as e d
horm one (ACTH) ACTH caus e s hype rs e cre tion o adre nocortical horm one s , producing
Cus hing s yndrom e .
Cus hing s yndrom e Hype rs e cre tion (or inje ction) o This m e tabolic dis orde r is characte rize d by at de pos its on uppe r back,
glucocorticoids s triate d pad o at on che s t and abdom e n, rounde d m oon ace ,
m us cular atrophy, e de m a, hypokale m ia (low blood potas s ium ), and
pos s ible abnorm al s kin pigm e ntation; it occurs in thos e w ith
Cus hing dis e as e .
Diabe te s ins ipidus Hypos e cre tion o (or ins e ns itivity to) This m e tabolic dis orde r is characte rize d by extre m e polyuria (exce s s ive
antidiure tic horm one (ADH) urination) and polydips ia (exce s s ive thirs t) caus e d by a de cre as e in
the kidneys re te ntion o wate r.

C pyright 2018, Elsevier In . All rights reserved.


TABLE 8 Endocrine Conditionscontd
CONDITION
Ge s tational diabe te s
m e llitus (GDM)
Gigantis m
Grave s dis e as e (GD)
Has him oto dis e as e
Hype rparathyroidis m
Hype rthyroidis m (adult)
Hypothyroidis m (adult)
Ins ulin s hock
Myxe de m a
Os te oporos is
Pituitary dwarf s m
Sim ple goite r
Ste rility
Type 1 diabe te s m e lli-
tus (type 1 DM)
Type 2 diabe te s m e lli-
tus (type 2 DM)
Winte r (s e as onal a e c-
tive dis orde r [SAD])
de pre s s ion
C pyright 2018, Elsevier In . All rights reserved.
MECHANIS M
Te m porary de cre as e in blood leve ls o
ins ulin during pre gnancy
Hype rs e cre tion o GH be ore age 25
Hype rs e cre tion o thyroid horm one
Autoim m une dam age to thyroid caus ing
hypos e cre tion o thyroid horm one
Hype rs e cre tion o parathyroid horm one
(PTH)
Hype rs e cre tion o thyroid horm one
Hypos e cre tion o thyroid horm one
Hype rs e cre tion (or ove rdos e inje ction)
o ins ulin, de cre as e d ood intake , and
exce s s ive exe rcis e
Extre m e hypos e cre tion o thyroid
horm one during adulthood
Hypos e cre tion o e s troge n in pos t-
m e nopaus al wom e n
Hypos e cre tion o GH be ore age 25
Lack o iodine in die t
Hypos e cre tion o s ex horm one s
Hypos e cre tion o ins ulin
Ins e ns itivity o targe t ce lls to ins ulin
Hype rs e cre tion o (or hype rs e ns itivity
to) m e latonin
APPENDIX A e8
DES CRIPTION
This carbohydrate -m e tabolis m dis orde r occurs in s om e pre gnant
wom e n; it is characte rize d by polydips ia, polyuria, ove re ating, we ight
los s , atigue , and irritability.
This condition is characte rize d by extre m e s ke le tal s ize caus e d by
exce s s prote in anabolis m during s ke le tal deve lopm e nt.
This inhe rite d, pos s ibly autoim m une dis e as e is characte rize d by
hype rthyroidis m .
Enlarge m e nt o thyroid (goite r) is s om e tim e s accom panie d by hypothy-
roidis m , typically occurring be twe e n age s 30 and 50; it is 20 tim e s
m ore com m on in e m ale s than in m ale s .
This condition is characte rize d by incre as e d re abs orption o calcium
rom bone tis s ue and kidneys and incre as e d abs orption by the gas -
trointe s tinal tract; it produce s hype rcalce m ia, re s ulting in con us ion,
anorexia, abdom inal pain, m us cle pain, and atigue , pos s ibly pro-
gre s s ing to circulatory s hock, kidney ailure , and de ath.
This condition, characte rize d by ne rvous ne s s , exophthalm os (protrud-
ing eye s ), tre m or, we ight los s , exce s s ive hunge r, atigue , he at intol-
e rance , he art arrhythm ia, and diarrhe a, is caus e d by a ge ne ral
acce le ration o body unction.
This condition, characte rize d by s luggis hne s s , we ight gain, s kin
dryne s s , cons tipation, arthritis , and ge ne ral s low ing o body unc-
tion, m ay le ad to myxe de m a, com a, or de ath i untre ate d.
Hypoglyce m ic (low blood glucos e ) s hock is characte rize d by ne rvous -
ne s s , s we ating and chills , irritability, hunge r, and pallorprogre s s ing
to convuls ion, com a, and de ath i untre ate d.
This is a s eve re orm o adult hypothyroidis m characte rize d by e de m a
o the ace and extre m itie s , o te n progre s s ing to com a and de ath.
This bone dis orde r is characte rize d by los s o m ine rals and collage n
rom bone m atrix, producing hole s or poros itie s that we ake n the
s ke le ton.
This condition is characte rize d by re duce d s ke le tal s ize caus e d by
de cre as e d prote in anabolis m during s ke le tal deve lopm e nt.
Enlarge m e nt o thyroid tis s ue re s ults rom the inability o the thyroid
to m ake thyroid horm one be caus e o a lack o iodine ; a pos itive -
e e dback s ituation deve lops in w hich low thyroid horm one leve ls
trigge r hype rs e cre tion o thyroid-s tim ulating horm one (TSH) by the
pituitary, w hich s tim ulate s thyroid grow th.
This is a los s o re productive unction.
This inhe rite d condition w ith s udde n childhood ons e t is characte rize d
by polydips ia, polyuria, ove re ating, we ight los s , atigue , and irritabil-
ity re s ulting rom the inability o ce lls to s e cure and m e tabolize
carbohydrate s .
This carbohydrate -m e tabolis m dis orde r w ith s low adult ons e t is
thought to be caus e d by a com bination o ge ne tic and e nvironm e n-
tal actors that re duce ins ulin s e ns itivity and produce polydips ia,
polyuria, ove re ating, we ight los s , atigue , and/or irritability and othe r
s ym ptom s . High carbohydrate intake ove r s eve ral ye ars , producing
obe s ity, is a m ajor ris k actor.
This abnorm al e m otional s tate is characte rize d by s adne s s and m e lan-
choly re s ulting rom exagge rate d m e latonin e e cts ; m e latonin leve ls
are inhibite d by s unlight s o they incre as e w he n day le ngth
de cre as e s during w inte r.
e9 APPENDIX A

TABLE 9 Autoimmune Diseases

DIS EAS E
Addis on dis e as e
Cardiomyopathy
Diabe te s m e llitus (type 1)
Glom e rulone phritis
Grave s dis e as e (type o
hype rthyroidis m )
He m olytic ane m ia
Multiple s cle ros is (MS)
Myas the nia gravis
Myxe de m a
Pe rnicious ane m ia
Re productive in e rtility
Rhe um atic eve r
Rhe um atoid arthritis
Sys te m ic lupus
e rythe m atos us
Ulce rative colitis
POS S IBLE S ELF ANTIGEN
Sur ace antige ns on adre nal ce lls
Cardiac m us cle
Pancre atic is le t ce lls , ins ulin, and ins ulin
re ce ptors
Blood antige ns that orm im m une com -
plexe s that are de pos ite d in kidney
Thyroid-s tim ulating horm one (TSH) re ce p-
tors on thyroid ce lls
Sur ace antige ns on re d blood ce lls (RBCs )
Antige ns in mye lin s he aths o ne rvous
tis s ue
Antige ns at ne urom us cular junction (NMJ )
Antige ns in thyroid ce lls
Antige ns on gas tric parie tal ce lls and
intrins ic actor
Antige ns on s pe rm or tis s ue s urrounding
ovum (e gg)
Cardiac ce ll m e m brane s (cros s re action
w ith group A s tre ptococcal antige n)
Collage n
Num e rous
Mucous ce lls o colon
DES CRIPTION
Hypos e cre tion o adre nal horm one s re s ults in we akne s s , re duce d
blood glucos e , naus e a, los s o appe tite , and we ight los s .
Dis e as e o cardiac m us cle (that is , the myocardium ) re s ults in a
los s o pum ping e f cie ncy (he art ailure ).
Hypos e cre tion o ins ulin by the pancre as re s ults in extre m e ly e le -
vate d blood glucos e leve ls (in turn caus ing a hos t o m e tabolic
proble m s , eve n de ath i untre ate d).
Dis e as e o the f ltration apparatus o the kidney (re nal corpus cle )
re s ults in uid and e le ctrolyte im balance and pos s ibly total
kidney ailure and de ath.
Hype rs e cre tion o thyroid horm one re s ults in incre as e in m e ta-
bolic rate .
Condition o low RBC count in the blood re s ults rom exce s s ive
de s truction o m ature RBCs (he m olys is ).
Progre s s ive de ge ne ration o mye lin s he aths re s ults in w ide s pre ad
im pairm e nt o ne rve unction (e s pe cially m us cle control).
Mus cle dis orde r is characte rize d by progre s s ive we akne s s and
chronic atigue .
Hypos e cre tion o thyroid horm one in adulthood caus e s de cre as e d
m e tabolic rate ; it is characte rize d by re duce d m e ntal and phys i-
cal vigor, we ight gain, hair los s , and e de m a.
Abnorm ally low RBC count re s ults rom the inability to abs orb
vitam in B12 , a s ubs tance critical to RBC production.
This is an inability to produce o s pring (in this cas e , re s ulting
rom de s truction o gam e te s ).
This caus e s rhe um atic he art dis e as e and in am m atory cardiac
dam age (e s pe cially to the e ndocardium or valve s ).
In am m atory joint dis e as e is characte rize d by s ynovial in am m a-
tion that s pre ads to othe r f brous tis s ue s .
Chronic in am m atory dis e as e has w ide s pre ad e e cts and is char-
acte rize d by arthritis , a re d ras h on the ace , and othe r s igns .
Chronic in am m atory dis e as e o the colon is characte rize d by
wate ry diarrhe a containing blood, m ucus , and pus .

TABLE 10 Def ciency Diseases*

CONDITION DEFICIENT S UBSTANCE DES CRIPTION
Avitam inos is K Vitam in K This occurs alm os t exclus ive ly in childre n and is characte rize d by an im paire d
blood-clotting ability.
Be ribe ri Vitam in B1 (thiam ine ) Pe riphe ral ne rve condition is characte rize d by diarrhe a, atigue , anorexia, e de m a,
he art ailure , and lim b paralys is le ading to m us cle atrophy.
Folate de f cie ncy Folic acid Blood dis orde r is characte rize d by a de cre as e in re d blood ce ll (RBC) count.
ane m ia
Iron de f cie ncy Iron (Fe ) Blood dis orde r is characte rize d by a de cre as e in s ize and pigm e ntation o RBCs
ane m ia that caus e s atigue and pallor.
Kwas hiorkor Prote in and calorie s This orm o prote in-calorie m alnutrition is characte rize d by was ting o m us cle and
s ubcutane ous tis s ue , de hydration, le thargy, e de m a and as cite s , and re tarde d
grow th; it is caus e d by de f cie ncy o prote ins in the pre s e nce o ade quate
caloric intake (s e e m aras m us ).
Maras m us Prote in and calorie s This orm o prote in-calorie m alnutrition is characte rize d by progre s s ive was ting o
m us cle and s ubcutane ous tis s ue accom panie d by uid and e le ctrolyte im bal-
ance s ; it is caus e d by de f cie ncy o both prote in and calorie s (s e e kwas hiorkor).

* De f cie ncy m ay be caus e d by die tary de f cie ncy or an inability to abs orb or che m ically proce s s the lis te d s ubs tance s .
C pyright 2018, Elsevier In . All rights reserved.
 APPENDIX A e 10

TABLE 10 Def ciency Diseasescontd

CONDITION DEFICIENT S UBSTANCE DES CRIPTION
Night blindne s s Vitam in A Re lative inability to s e e in dim light re s ults rom ailure to produce s u f cie nt
(nyctalopia) photopigm e nt in the rods o the re tina.
Os te om alacia Vitam in D, calcium (Ca), and/or Adult orm o ricke ts is characte rize d by re duce d m ine ralization o bone tis s ue
phos phorus (P) accom panie d by we akne s s , pain, anorexia, and we ight los s .
Pe llagra Vitam in B3 (niacin) or trypto- Dis e as e is characte rize d by s un-s e ns itive s caly de rm atitis , in am m ation o m ucos a,
phan (an am ino acid) diarrhe a, con us ion, and de pre s s ion.
Pe rnicious ane m ia Vitam in B12 Blood dis orde r is characte rize d by a re duce d num be r o RBCs , caus ing we akne s s ,
pallor, tingling o the extre m itie s , and anorexia.
Prote in-calorie m al- Prote in and calorie s Abnorm al condition re s ulting rom die tary de f cie ncy o calorie s in ge ne ral and
nutrition (PCM) prote in in particular; its orm s include kwas hiorkor and m aras m us .
Ricke ts Vitam in D, calcium (Ca), and/or Juve nile orm o os te om alacia is characte rize d by we akne s s and abnorm al s ke le tal
phos phorus (P) orm ation re s ulting rom re duce d m ine ralization o bone tis s ue .
Scurvy Vitam in C Re duce d m anu acture and m ainte nance o collage n and othe r unctions re s ults in
we akne s s , ane m ia, and e de m a; we akne s s o gingiva and loos e ning o te e th;
and he m orrhaging (e s pe cially in s kin and m ucous m e m brane s ).
Sim ple goite r Iodine (I) Enlarge m e nt o thyroid tis s ue re s ults rom inability o thyroid to m ake thyroid
horm one be caus e o lack o iodine ; pos itive - e e dback s ituation deve lops : low
thyroid horm one leve ls trigge r hype rs e cre tion o thyroid-s tim ulating horm one
(TSH) by pituitary, w hich s tim ulate s thyroid grow th.
Zinc de f cie ncy Zinc (Zn) Condition is characte rize d by atigue , de cre as e d ale rtne s s , re tarde d grow th,
de cre as e d s m e ll and tas te s e ns itivity, and im paire d he aling and im m unity.

TABLE 11 Genetic Conditions

CHROMOS OME
LOCATION DIS EAS E DES CRIPTION
S ing le -Ge ne Inhe ritance (Nucle ar DNA)
Do m in a n t
7, 17 Os te oge ne s is im pe r e cta Group o conne ctive tis s ue dis orde rs is characte rize d by im pe r e ct s ke le tal deve lop-
m e nt that produce s brittle bone s .
17 Multiple ne urof brom atos is Dis orde r is characte rize d by m ultiple , s om e tim e s dis f guring be nign tum ors o the
Schwann ce lls (ne uroglia) that s urround ne rve f be rs .
5 Hype rchole s te role m ia High blood chole s te rol m ay le ad to athe ros cle ros is and othe r cardiovas cular proble m s .
4 Huntington dis e as e (HD) De ge ne rative brain dis orde r is characte rize d by chore a (purpos e le s s m ove m e nts ) pro-
gre s s ing to s eve re de m e ntia and de ath by age 55.
Co d o m in a n t
11 Sickle ce ll ane m ia Blood dis orde r in w hich abnorm al he m oglobin is produce d, caus ing re d blood ce lls
Sickle ce ll trait (RBCs ) to de orm into a s ickle s hape ; s ickle ce ll ane m ia is the s eve re orm , and
s ickle ce ll trait is the m ilde r orm .
11, 16 Thalas s e m ia Group o inhe rite d he m oglobin dis orde rs is characte rize d by production o hypochro-
m ic, abnorm al RBCs .
Re ce s s ive (Au to s o m a l)
7 Cys tic f bros is (CF) Condition is characte rize d by exce s s ive s e cre tion o thick m ucus and conce ntrate d
s we at, o te n caus ing obs truction o the gas trointe s tinal or re s piratory tracts .
15 Tay-Sachs dis e as e Fatal condition in w hich abnorm al lipids accum ulate in the brain and caus e tis s ue
dam age ; le ads to de ath by age 4.
12 Phe nylke tonuria (PKU) Exce s s o phe nylke tone in the urine is caus e d by accum ulation o phe nylalanine in the
tis s ue s ; it m ay caus e brain injury and de ath i phe nylalanine (am ino acid) intake is
not m anage d prope rly.
Continue d

C pyright 2018, Elsevier In . All rights reserved.

e 11 APPENDIX A

TABLE 11 Genetic Conditionscontd

CHROMOS OME
LOCATION DIS EAS E DES CRIPTION
S ing le -Ge ne Inhe ritance (Nucle ar DNA)co ntd
Re ce s s ive (Au to s o m a l)co n td
11 Albinis m (total) Lack o the dark brow n pigm e nt m e lanin in the s kin and eye s re s ults in vis ion prob-
le m s and s us ce ptibility to s unburn and s kin cance r.
20 Seve re com bine d im m une Failure o the lym phocyte s to deve lop prope rly caus e s ailure o the im m une s ys te m s
de f cie ncy (SCID) de e ns e o the body; it is us ually caus e d by ade nos ine de am inas e (ADA) de f cie ncy.
Re ce s s ive (X-Lin ke d )
23 (X) He m ophilia Group o blood clotting dis orde rs is caus e d by a ailure to orm clotting actors VIII, IX,
or XI.
23 (X) Duche nne m us cular dys - Mus cle dis orde r is characte rize d by progre s s ive atrophy o s ke le tal m us cle w ithout
trophy (DMD) ne rve involve m e nt caus e d by m utation o dys trophin ge ne .
23 (X) Re d-gre e n color blindne s s Inability to dis tinguis h re d and gre e n light re s ults rom a de f cie ncy o photopigm e nts
in the cone ce lls o the re tina.
23 (X) Fragile X s yndrom e Me ntal re tardation re s ults rom bre akage o X chrom os om e in m ale s .
23 (X) Ocular albinis m Form o albinis m in w hich the pigm e nte d laye rs o the eye ball lack m e lanin; re s ults in
hype rs e ns itivity to light and othe r proble m s .
23 (X) Androge n ins e ns itivity Inhe rite d ins e ns itivity to androge ns (s te roid s ex horm one s as s ociate d w ith m ale ne s s )
re s ults in re duce d e e cts o the s e horm one s .
23 (X) Cle t palate (X-linke d orm ) One orm o a conge nital de orm ity in w hich the s kull ails to deve lop prope rly; it is
characte rize d by a gap in the palate (plate s e parating m outh rom nas al cavity).
23 (X) Re tinitis pigm e ntos a Condition caus e s blindne s s , characte rize d by clum ps o m e lanin in re tina o eye s .
S ing le -Ge ne Inhe ritance (Mito cho ndrial DNA)
m DNA Le be r he re ditary optic Optic ne rve de ge ne ration in young adults re s ults in total blindne s s by age 30.
ne uropathy
m DNA Parkins on dis e as e Ne rvous dis orde r is characte rize d by involuntary tre m bling and m us cle rigidity.
Chro m o s o m al Abno rm alitie s
Tris o m y
21 Dow n s yndrom e Condition is characte rize d by m e ntal re tardation and m ultiple s tructural de e cts .
23 Kline e lte r s yndrom e Condition is caus e d by the pre s e nce o two or m ore X chrom os om e s in a m ale (XXY);
it is characte rize d by long le gs , e nlarge d bre as ts , low inte llige nce , s m all te s te s , s te -
rility, and chronic pulm onary dis e as e .
Mo n o s o m y
23 Turne r s yndrom e Condition is caus e d by m onos omy o the X chrom os om e (XO); it is characte rize d by
im m aturity o s ex organs (caus ing s te rility), we bbe d ne ck, cardiovas cular de e cts ,
and le arning dis orde rs .

C pyright 2018, Elsevier In . All rights reserved.

APPENDIX B
English as well: the meaning sense hanges when we
M e d ic a l Te r m in o lo g y add the pre x non- t make the w rd nonsense.
able 1 W rd Parts C mm nly Used as Pre xes b. A su x is a w rd part that is added t the end an
able 2 W rd Parts C mm nly Used as Su xes existing w rd t alter its meaning. On e again, su xes
able 3 W rd Parts C mm nly Used as R ts are als s metimes used in English. F r example, the
meaning sense hanges when we add the su x -less t
I y u are un amiliar with it, medi al and s ienti termin l- make the w rd senseless. A mplex term an have a se-
gy an seem verwhelming. T e length and apparent m- ries su xes, a series pre xes, r b th. F r example,
plexity many medi al terms seem mpletely reign and the w rd senselessness has tw su xes: -less and -ness.
mysti ying t pe ple wh have n t had any training r pra - . A root is a w rd part that serves as the starting p int
ti e in s ienti termin l gy. Alth ugh kn wledge s me r rming a new term. In the previ us examples in
basi w rd parts and a ew rules r using them are required, English, the w rd sense was the r t t whi h was added
medi al termin l gy is n t as di ult as it seems. T is ap- a pre x r a su x. W rd parts mm nly used as r ts
pendix pr vides what y u need t get y u started n y ur way als an be used as su xes r pre xes in rming a new
t understanding medi al termin l gy. First, there are a hand- term. Als , several r ts are s metimes mbined t
ul hints t help y u learn and use medi al terms. Se nd, rm a larger r t t whi h su xes r pre xes an be
there are several tables ntaining many the m st m- added.
m nly used w rd parts and examples h w they are used. d. Combining vowels are v wels (a, e, i, o, u, y) that are
T is appendix d es n t attempt t tea h y u the entire eld used t link w rd parts ten t make pr nun iati n
medi al termin l gy, but with the in rmati n given here that new mbinati n w rd easier. F r example, t
and a little pra ti e, y u will s n be me m rtable with link the su x -tion t the r t sense, we must use the
the basi s. mbining v wel -a- t rm the new term sensation.
Using the -e r m the riginal r t w rd w uld make
the term di ult t pr n un e. A r t and a mbining
Hin t s o r Le a r n in g a n d U s in g v wel t gether, su h as sensa-, is ten alled the
combining orm the w rd part.
M e d ic a l Te r m s 3. An ther set rules r using Latin and Greek terms that
1. Many medi al terms are derived r m the Latin and Greek y u will nd use ul relate t pluralizati n. rm a plural
languages. T is is be ause many the anat mists, physi- in English, we ten simply add -s r -es t a w rd. F r
l gists, and physi ians ar und the w rld wh dis vered example, the plural r sense is senses. Be ause we have
the basi prin iples m dern li e s ien e used these lan- ad pted these medi al terms and br ught them int the
guages themselves s that they uld mmuni ate with English language, in many ases we simply use the plural-
ea h ther with ut having t learn d zens native lan- izati n rules English and add the -s r -es when multi-
guages. T us Latin and Greek have be me the universal ples are being dis ussed. O ten, h wever, y u will run
language s ienti termin l gy. N t nly many the a r ss a term that has been pluralized a rding t Latin
w rds but als s me the rules usage are derived r m r Greek rules. T is brie list will help y u distinguish be-
these lassi al languages. T e m re use ul th se rules are tween many plural and singular rms:
given later in this se ti n.
2. One set rules r using Latin and Greek is essential t S INGULAR PLURAL EXAMPLE
understanding medi al termin l gy. B th these lan- -a -ae Am pulla, am pullae
guages rely n the ability t mbine w rd parts t make -ax -ace s Thorax, thorace s
new w rds. T us alm st all medi al terms are nstru ted -e n -e na Lum e n, lum e na
by mbining smaller w rd elements t make a meaning ul -e n -ina Foram e n, oram ina
term. Be ause this mbining te hnique, many medi al
-ex -ice s Cortex, cortice s
terms appear at rst glan e t be l ng and mplex. H w-
-is -e s Ne uros is , ne uros e s
ever, i y u read a new term as a series w rd elements
rather than a single w rd, y u will nd it less imp sing. -ix -ice s Appe ndix, appe ndice s
One the easiest ways t learn medi al termin l gy is t -on -a Mitochondrion, m itochondria
devel p the ability t instantly analyze new terms t dis- -um -a Datum , data
ver the w rd parts that mp se them. W rd parts di er -ur -ora Fe m ur, e m ora
in terms exa tly h w they t t gether with ther w rd -us -I Villus , villi
parts t rm a mplete term.
-yx -yce s Calyx, calyce s
a. A pre x is a w rd part that is added t the beginning
an existing w rd t alter its meaning. We use pre xes in -m a -m ata Lym phom a, lym phom ata

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e 13 APPENDIX B

4. C rre t spelling medi al terms is essential t their
meanings. T is is espe ially true terms that are very l se
in spelling but very di erent in meaning. F r example, the
perineum is the regi n the trunk ar und the genitals and
anus, whereas the peritoneum is a membrane that lines the
abd minal avity and vers abd minal rgans. A mistake
that inv lves just ne letter an hange the meaning a
w rd, as in the ase ilium (part the b ny pelvis) and
ileum (part the small intestine).
5. C mmuni ating verbally is just as imp rtant as written
mmuni ati n, s rre t pr nun iati n is as imp rtant
as rre t spelling. Medi al terms an usually be pr -
n un ed ph neti allyby s unding ut ea h letter s und
ea h syllable. It is best t he k the pr nun iati n keys
given in ea h hapter and in the gl ssary i y u are un er-
tain h w t pr n un e any w rd presented in this text.
6. As y u kn w, pra ti e makes per e t. Pra ti e using the
medi al terms in this r an ther b k until y u be me
m rtable with medi al termin l gy. It w nt take l ng
and y ull pr bably have un d ing it.

TABLE 1 Word Parts Commonly Used as Pref xes

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
a- Without, not Apne a Ce s s ation o bre athing
ad-, a - Toward A e re nt Carrying toward
an- Without, not Anuria Abs e nce o urination
ante - Be ore Ante natal Be ore birth
anti- Agains t; re s is ting Antibody Unit that re s is ts ore ign s ubs tance s
auto- Se l Autoim m unity Se l -im m unity
bi- Two; double Bicus pid Two-pointe d
circum - Around Circum cis ion Cutting around
co-, con- With; toge the r Conge nital Born w ith
contra- Agains t Contrace ptive Agains t conce ption
de - Dow n rom , undoing De f brillation Stop f brillation
dia- Acros s ; through Diarrhe a Flow through (inte s tine s )
dipl- Two old, double Diploid Two s e ts o chrom os om e s
dys - Bad; dis orde re d; di f cult Dys plas ia Dis orde re d grow th
e ctop- Dis place d Ectopic pre gnancy Dis place d pre gnancy
e - Away rom E e re nt Carrying away rom
e m -, e n- In, into Encys t Enclos e in a cys t
e ndo- Within Endocarditis In am m ation o he art lining
e pi- Upon Epimys ium Cove ring o a m us cle
ex-, exo- Out o , out rom Exophthalm os Protruding eye s
extra- Outs ide o Extrape ritone al Outs ide the pe ritone um
e u- Good Eupne a Good (norm al) bre athing
hapl- Single Haploid Single s e t o chrom os om e s
he m -, he m at- Blood He m aturia Bloody urine
he m i- Hal He m iple gia Paralys is in hal the body
hom (e )o- Sam e ; e qual Hom e os tas is Staying the s am e
hype r- Ove r; above Hype rplas ia Exce s s ive grow th
hypo- Unde r; be low Hypode rm ic Be low the s kin
in ra- Be low, be ne ath In raorbital Be low the (eye ) orbit
inte r- Be twe e n Inte rve rte bral Be twe e n ve rte brae
intra- Within Intracranial Within the s kull
is o- Sam e , e qual Is om e tric Sam e le ngth
m acro- Large Macrophage Large e ate r (phagocyte )
m e ga- Large ; m illion(th) Me gakaryocyte Ce ll w ith large nucle us
mes- Middle Me s e nte ry Middle o inte s tine

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 APPENDIX B e 14

TABLE 1 Word Parts Commonly Used as Pref xescontd

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
m e ta- Beyond, a te r Me tatars al Beyond the tars als (ankle bone s )
m icro- Sm all; m illionth Microcytic Sm all-ce lle d
m illi- Thous andth Millilite r Thous andth o a lite r
m ono- One (s ingle ) Monos omy Single chrom os om e
ne o- New Ne oplas m New m atte r
non- Not Nondis junction Not dis joine d
oligo- Few, s canty Oliguria Scanty urination
ortho- Straight; corre ct, norm al Orthopne a Norm al bre athing
para- By the s ide o ; ne ar Parathyroid Ne ar the thyroid
pe r- Through Pe rm e able Able to go through
pe ri- Around; s urrounding Pe ricardium Cove ring o the he art
poly- Many Polycythe m ia Condition o having m any blood ce lls
pos t- A te r Pos tm orte m A te r de ath
pre - Be ore Pre m e ns trual Be ore m e ns truation
pro- Firs t; prom oting Proge s te rone Horm one that prom ote s pre gnancy
quadr- Four Quadriple gia Paralys is in our lim bs
re - Back again Re ux Back ow
re tro- Be hind Re trope ritone al Be hind the pe ritone um
s e m i- Hal Se m ilunar Hal -m oon
s ub- Unde r Subcutane ous Unde r the s kin
s upe r-, s upra- Ove r, above , exce s s ive Supe rior Above
trans - Acros s ; through Trans cutane ous Through the s kin
tri- Thre e ; triple Triple gia Paralys is o thre e lim bs

TABLE 2 Word Parts Commonly Used as Su f xes

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
-al, -ac Re lating to Inte s tinal Re lating to the inte s tine s
-algia Pain Ne uralgia Ne rve pain
-aps , -apt Fit; as te n Synaps e Fas te n toge the r
-arche Be ginning; origin Me narche Firs t m e ns truation
-as e Signif e s an e nzym e Lipas e Enzym e that acts on lipids
-blas t Sprout; m ake Os te oblas t Bone m ake r
-ce nte s is A pie rcing Am nioce nte s is Pie rcing the am niotic s ac
-cide To kill Fungicide Fungus kille r
-clas t Bre ak; de s troy Os te oclas t Bone bre ake r
-crine Re le as e ; s e cre te Endocrine Se cre te w ithin
-e ctomy A cutting out Appe nde ctomy Re m oval o the appe ndix
-e m ia Re e rs to blood condition Hype rchole s te role m ia High blood chole s te rol leve l
-e m e s is Vom iting He m ate m e s is Vom iting blood
- ux Flow Re ux Back ow
-ge n Cre ate s ; orm s Lactoge n Milk produce r
-ge ne s is Cre ation, production Ooge ne s is Egg production
-gram * Som e thing w ritte n Ele ctroe nce phalogram Re cord o brains e le ctrical activity
-graph(y)* To w rite , draw Ele ctrocardiograph Apparatus that re cords he arts e le ctrical activity
* A te rm e nding in -graph re e rs to an apparatus that re s ults in a vis ual and/or re corde d re pre s e ntation o biological phe nom e na, w he re as a te rm e nding in
-graphy is the te chnique or proce s s o us ing the apparatus . A te rm e nding in -gram is the re cord its e l . Exam ple : In e le ctrocardiography, an e le ctrocardiograph
is us e d in producing an e le ctrocardiogram . Continue d

C pyright 2018, Elsevier In . All rights reserved.

e 15 APPENDIX B

TABLE 2 Word Parts Commonly Used as Su f xescontd

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
-hydrate Containing H2 O (wate r) De hydration Los s o wate r
-ia, -s ia Condition; proce s s Arthralgia Condition o joint pain
-ias is Abnorm al condition Giardias is Giardia in e s tation
-ic, -ac Re lating to Cardiac Re lating to the he art
-in Signif e s a prote in Re nin Kidney prote in
-is m Signif e s condition o Gigantis m Condition o gigantic s ize
-itis Signif e s in am m ation o Gas tritis Stom ach in am m ation
-le m m a Rind; pe e l Ne urile m m a Cove ring o a ne rve f be r
-le ps y Se izure Epile ps y Se izure upon s e izure
-lith Stone ; rock Lithotrips y Stone -crus hing
-logy Study o Cardiology Study o the he art
-lunar Moon; m oonlike Se m ilunar Hal -m oon
-m alacia So te ning Os te om alacia Bone s o te ning
-m e galy Enlarge m e nt Sple nom e galy Sple e n e nlarge m e nt
-m e tric, -m e try Me as ure m e nt, le ngth Is om e tric Sam e le ngth
-oid Like ; in the s hape o Sigm oid S-s hape d
-om a Tum or Lipom a Fatty tum or
-opia Vis ion, vis ion condition Myopia Ne ars ighte dne s s
-os e Signif e s a carbohydrate Lactos e Milk s ugar (e s pe cially s ugar)
-os is Condition, proce s s De rm atos is Skin condition
-os copy View ing Laparos copy View ing the abdom inal cavity
-os tomy Form ation o an ope ning Trache os tomy Form ing an ope ning in the trache a
-otomy Cut Lobotomy Cut o a lobe
-philic Loving Hydrophilic Wate r-loving
-pe nia Lack Le ukope nia Lack o w hite (ce lls )
-phobic Fe aring Hydrophobic Wate r- e aring
-phragm Partition Diaphragm Partition s e parating thoracic and abdom inal cavitie s
-plas ia Grow th, orm ation Hype rplas ia Exce s s ive grow th
-plas m Subs tance , m atte r Ne oplas m New m atte r
-plas ty Shape ; m ake Rhinoplas ty Re s haping the nos e
-ple gia Paralys is Triple gia Paralys is in thre e lim bs
-pne a Bre ath, bre athing Apne a Ce s s ation o bre athing
-(r)rhage , -(r)rhagia Bre aking out, dis charge He m orrhage Blood dis charge
-(r)rhaphy Sew, s uture Me ninge orrhaphy Suturing o m e ninge s
-(r)rhe a Flow Diarrhe a Flow through (inte s tine s )
-s om e Body Chrom os om e Staine d body
-te ns in, -te ns ion Pre s s ure Hype rte ns ion High pre s s ure
-tonic Pre s s ure , te ns ion Is otonic Sam e pre s s ure
-trips y Crus hing Lithotrips y Stone -crus hing
-ule Sm all, little Tubule Sm all tube
-uria Re e rs to urine condition Prote inuria Prote in in the urine

C pyright 2018, Elsevier In . All rights reserved.

 APPENDIX B e 16

TABLE 3 Word Parts Commonly Used as Roots

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
-acro- Extre m ity Acrom e galy Enlarge m e nt o extre m itie s
-ade n- Gland Ade nom a Tum or o glandular tis s ue
-alve oli- Sm all hollow ; cavity Alve olus Sm all air s ac in the lung
-angi- Ve s s e l Angioplas ty Re s haping a ve s s e l
-arthr- Joint Arthritis Joint in am m ation
-as the n- We akne s s Myas the nia Condition o m us cle we akne s s
-bar- Pre s s ure Barore ce ptor Pre s s ure re ce ptor
-bili- Bile Bilirubin Orange -ye llow bile pigm e nt
-brachi- Arm Brachial Re lating to the arm
-brady- Slow Bradycardia Slow he art rate
-bronch- Air pas s age Bronchitis In am m ation o pulm onary pas s age s (bronchi)
-calc- Calcium ; lim e s tone Hypocalce m ia Low blood calcium leve l
-capn- Sm oke Hype rcapnia Elevate d blood CO 2 leve l
-carcin- Cance r Carcinoge n Cance r produce r
-card- He art Cardiology Study o the he art
-ce phal- He ad, brain Ence phalitis Brain in am m ation
-ce rv- Ne ck Ce rvicitis In am m ation o (ute rine ) ce rvix
-che m - Che m ical Che m othe rapy Che m ical tre atm e nt
-chol- Bile Chole cys te ctomy Re m oval o bile (gall) bladde r
-chondr- Cartilage Chondrom a Tum or o cartilage tis s ue
-chrom - Color Chrom os om e Staine d body
-corp- Body Corpus lute um Ye llow body
-cortico- Re lating to cortex Corticos te roid Ste roid s e cre te d by (adre nal) cortex
-crani- Skull Intracranial Within the s kull
-crypt- Hidde n Cryptorchidis m Unde s ce nde d te s tis
-cus p- Point Tricus pid Thre e -pointe d
-cut(an)- Skin Trans cutane ous Through the s kin
-cyan- Blue Cyanos is Condition o blue ne s s
-cys t- Bladde r Cys titis Bladde r in am m ation
-cyt- Ce ll Cytotoxin Ce ll pois on
-dactyl- Finge rs , toe s (digits ) Syndactyly Joine d digits
-de ndr- Tre e ; branche d Oligode ndrocyte Branche d ne rvous tis s ue ce ll
-de nt- Tooth De ntalgia Toothache
-de rm - Skin De rm atitis Skin in am m ation
-dias tol- Re lax; s tand apart Dias tole Re laxation phas e o he artbe at
-dips - Thirs t Polydips ia Exce s s ive thirs t
-e jacul- To throw out Ejaculation Expuls ion (o s e m e n)
-e le ctr- Ele ctrical Ele ctrocardiogram Re cord o e le ctrical activity o he art
-e nte r- Inte s tine Ente ritis Inte s tinal in am m ation
-e ryth(r)- Re d Erythrocyte Re d (blood) ce ll
-e s the - Se ns ation Ane s the s ia Condition o no s e ns ation
- e br- Feve r Fe brile Re lating to eve r
-gas tr- Stom ach Gas tritis Stom ach in am m ation
-ge s t- To be ar, carry Ge s tation Pre gnancy
-gingiv- Gum s Gingivitis Gum in am m ation
-glom e r- Wound into a ball Glom e rulus Rounde d tu t o ve s s e ls
Continue d

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e 17 APPENDIX B

TABLE 3 Word Parts Commonly Used as Rootscontd

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
-glos s - Tongue Hypoglos s al Unde r the tongue
-gluc- Glucos e , s ugar Glucos uria Glucos e in urine
-glutin- Glue Agglutination Sticking toge the r (o particle s )
-glyc- Sugar (carbohydrate ); glucos e Glycolipid Carbohydrate -lipid com bination
-he pat- Live r He patitis Live r in am m ation
-his t- Tis s ue His tology Study o tis s ue s
-hydro- Wate r Hydroce phalus Wate r on the brain
-hys te r- Ute rus Hys te re ctomy Re m oval o the ute rus
-iatr- Tre atm e nt Podiatry Foot tre atm e nt
-kal- Potas s ium Hype rkale m ia Elevate d blood potas s ium leve l
-kary- Nucle us Karyotype Array o chrom os om e s rom nucle us
-ke rat- Corne a Ke ratotomy Cutting o the corne a
-kin- To m ove ; divide Kine s the s ia Se ns ation o body m ove m e nt
-lact- Milk; m ilk production Lactos e Milk s ugar
-lapar- Abdom e n Laparos copy View ing the abdom inal cavity
-le uk- White Le ukorrhe a White ow (dis charge )
-lig- To tie , bind Ligam e nt Tis s ue that binds bone s
-lip- Lipid ( at) Lipom a Fatty tum or
-lys - Bre ak apart He m olys is Bre aking o blood ce lls
-m al- Bad Malabs orption Im prope r abs orption
-m e lan- Black Me lanin Black prote in
-m e n-, -m e ns -, (-m e ns tru-) Month (m onthly) Am e norrhe a Abs e nce o m onthly ow
-m e tr- Ute rus Endom e trium Ute rine lining
-m uta- Change Mutage n Change -m ake r
-my-, -myo- Mus cle Myopathy Mus cle dis e as e
-myc- Fungus Mycos is Fungal condition
-mye l- Marrow Mye lom a (Bone ) m arrow tum or
-myx- Mucus Myxe de m a Mucous e de m a
-nat- Birth Ne onatal Re lating to new borns (in ants )
-natr- Sodium Natriure s is Elevate d s odium in urine
-ne phr- Ne phron, kidney Ne phritis Kidney in am m ation
-ne ur- Ne rve Ne uralgia Ne rve pain
-noct-, -nyct- Night Nocturia Urination at night
-ocul- Eye Binocular Two-eye d
-odont- Tooth Pe riodontitis In am m ation (o tis s ue ) around the te e th
-onco- Cance r Oncoge ne Cance r ge ne
-ophthalm - Eye Ophthalm ology Study o the eye
-orchid- Te s tis Orchiditis Te s tis in am m ation
-os te o- Bone Os te om a Bone tum or
-oto- Ear Otos cle ros is Harde ning o e ar tis s ue
-ov-, -oo- Egg Ooge ne s is Egg production
-oxy- Oxyge n Oxyhe m oglobin Oxyge n-he m oglobin com bination
-path- Dis e as e Ne uropathy Ne rve dis e as e
-pe d- Childre n Pe diatric Re lating to tre atm e nt o childre n
-phag- Eat Phagocytos is Ce ll e ating
-pharm - Drug Pharm acology Study o drugs

C pyright 2018, Elsevier In . All rights reserved.

 APPENDIX B e 18

TABLE 3 Word Parts Commonly Used as Rootscontd

WORD PART MEANING EXAMPLE MEANING OF EXAMPLE
-phle b- Ve in Phle bitis Ve in in am m ation
-photo- Light Photopigm e nt Light-s e ns itive pigm e nt
-phys io- Nature ( unction) o Phys iology Study o biological unction
-pino- Drink Pinocytos is Ce ll drinking
-plex- Tw is te d; wove n Ne rve plexus Com plex o inte rwove n ne rve f be rs
-pne um o- Air, bre ath Pne um othorax Air in the thorax
-pne um on- Lung Pne um onia Lung condition
-pod- Foot Podocyte Ce ll w ith e e t
-poie - Make ; produce He m opoie s is Blood ce ll production
-pol- Axis , having pole s Bipolar Having two e nds
-pre s by- Old Pre s byopia Old vis ion
-proct- Re ctum Proctos cope Ins trum e nt or view ing the re ctum
-ps e ud- Fals e Ps e udopodia Fals e e e t
-ps ych- Mind Ps ychiatry Tre atm e nt o the m ind
-pye l- Pe lvis Pye logram Im age o the re nal pe lvis
-pyo- Pus Pyoge nic Pus -producing
-pyro- He at; eve r Pyroge n Feve r produce r
-re n- Kidney Re nocortical Re e rring to the cortex o the kidney
-rhino- Nos e Rhinoplas ty Re s haping the nos e
-rigor- Sti ne s s Rigor m ortis Sti ne s s o de ath
-s arco- Fle s h; m us cle Sarcole m m a Mus cle f be r m e m brane
-s cle r- Hard Scle rode rm a Hard s kin
-s e m e n-, -s e m in- Se e d; s pe rm Se m ini e rous tubule Spe rm -be aring tubule
-s e pt- Contam ination Se ptice m ia Contam ination o the blood
-s igm - Gre e k or Rom an S Sigm oid colon S-s hape d colon
-s in- Cavity; re ce s s Paranas al s inus Cavity ne ar the nas al cavity
-s on- Sound Sonography Im aging us ing s ound
-s piro-, -s pire Bre athe Spirom e te r Me as ure m e nt o bre athing
-s tat-, -s tas - A s tanding, s topping Hom e os tas is Staying the s am e
-s yn- Toge the r Syndrom e Signs appe aring toge the r
-s ys tol- Contract; s tand toge the r Sys tole Contraction phas e o the he artbe at
-tachy- Fas t Tachycardia Rapid he art rate
-the rm - He at The rm ore ce ptor He at re ce ptor
-throm b- Clot Throm bos is Condition o abnorm al blood clotting
-tom - A cut; a s lice Tom ography Im age o a s lice or s e ction
-tox- Pois on Cytotoxin Ce ll pois on
-troph- Grow ; nouris h Hype rtrophy Exce s s ive grow th
-tym pan- Drum Tym panum Eardrum
-varic- Enlarge d ve s s e l Varicos e ve in Enlarge d ve in
-vas - Ve s s e l, duct Vas ocons triction Ve s s e l narrow ing
-ve s ic- Bladde r; blis te r Ve s icle Blis te r
-vol- Volum e Hypovole m ic Characte rize d by low volum e

C pyright 2018, Elsevier In . All rights reserved.

APPENDIX C

C lin ic a l a n d La b o r a t o ry Va lu e s C o n ve r s io n Fa c t o r s
H ere is a set data n substan es in the b dy that are m- t o In t e r n a t io n a l S y s t e m
m nly measured in lini al r resear h lab rat ries t assess
the h me stati balan e, and thus the general health,
o U n it s (S I U n it s )
individuals. Depending n the ntext, y u may see di erent ways re-
p rting the same values. In the table bel w are s me nver-
able 1 Bl d, Plasma, and Serum Values si n a t rs that help y u nvert mm n values r m the
able 2 Urine C mp nents ust mary manner rep rting t the Internati nal System
able 3 C nversi n Fa t rs (SI Units) (SI) r equivalent.

TABLE 1 Blood, Plasma, and Serum Values

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Acid phos phatas e Wom e n: 0.01-0.56 s igm a units /m L in kidney dis e as e
Me n: 0.13-0.63 s igm a units /m L in pros tate cance r
a te r traum a and in eve r
Alkaline phos phatas e Adult: 13-39 IU/I in bone dis orde rs
Child: up to 104 IU/I in live r dis e as e
during pre gnancy
in hypothyroidis m
Bicarbonate 22-26 m Eq/L in m e tabolic alkalos is
in re s piratory alkalos is
in m e tabolic acidos is
in re s piratory acidos is
Blood ure a nitroge n (BUN) 5-25 m g/dL w ith incre as e d prote in intake
in kidney ailure
Blood volum e Wom e n: 65 m L/kg body we ight during he m orrhage
Me n: 69 m L/kg body we ight
Calcium 8.4-10.5 m g/dL in hype rvitam inos is D
in hype rparathyroidis m
in bone cance r and othe r bone dis e as e s
in s eve re diarrhe a
in hypoparathyroidis m
in avitam inos is D (ricke ts and os te om alacia)
Carbon dioxide conte nt 24-32 m Eq/L in s eve re vom iting
in re s piratory dis orde rs
in obs truction o inte s tine s
in acidos is
in s eve re diarrhe a
in kidney dis e as e
Chloride 96-107 m Eq/L in hype rve ntilation
in kidney dis e as e
in Cus hing s yndrom e
in diabe tic acidos is
in s eve re diarrhe a
in s eve re burns
in Addis on dis e as e
Clotting tim e 5-10 m inute s in he m ophilia
(occas ionally) in othe r clotting dis orde rs
Coppe r 100-200 m cg/dL in s om e live r dis orde rs

COPD, Chronic obs tructive pulm onary dis e as e ; IU, Inte rnational Unit; m cg, m icrogram ; m Eq, m illie quivale nt; m ol, m ole ; L, m icrolite r.
* Value s vary w ith the analys is m e thod us e d; 100 m L 1 dL.

e 19 C pyright 2018, Elsevier In . All rights reserved.

 APPENDIX C e 20

TABLE 1 Blood, Plasma, and Serum Valuescontd

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Cre atinine phos phokinas e (CPK) Wom e n: 5-35 m illiunits /m L in Duche nne m us cular dys trophy
Me n: 5-55 m illiunits /m L during myocardial in arction
in m us cle traum a
Cre atinine 0.6-1.5 m g/dL in s om e kidney dis orde rs
Glucos e 70-110 m g/dL ( as ting) in diabe te s m e llitus
in kidney dis e as e
in live r dis e as e
during pre gnancy
in hype rthyroidis m
in hypothyroidis m
in Addis on dis e as e
in hype rins ulinis m
He m atocrit (packe d ce ll volum e ) Wom e n: 38% -47% in polycythe m ia
Me n: 40% -54% in s eve re de hydration
in ane m ia
in le uke m ia
in hype rthyroidis m
in cirrhos is o live r
He m oglobin Wom e n: 12-16 g/dL in polycythe m ia
Me n: 13-18 g/dL in COPD
New born: 14-20 g/dL in conge s tive he art ailure
in ane m ia
in hype rthyroidis m
in cirrhos is o live r
He m oglobin A1c or glycos ylate d he m oglobin 5.0% -7.5% in diabe te s m e llitus
Hom ocys te ine 5-15 m ol/L in he art dis e as e
Iron 50-150 m cg/dL (can be highe r in in live r dis e as e
m e n) in ane m ia (s om e orm s )
in iron de f cie ncy ane m ia
Lactic de hydroge nas e (LDH) 60-120 units /m L during myocardial in arction
in ane m ia (s eve ral orm s )
in live r dis e as e
in acute le uke m ia and othe r cance rs
Lipids total 450-1000 m g/dL in diabe te s m e llitus
in kidney dis e as e
in hypothyroidis m
in hype rthyroidis m
in inhe rite d hype rchole s te role m ia
in chronic he patitis
in hype rthyroidis m
in athe ros cle ros is
in acute he patitis
in hypothyroidis m
High-de ns ity lipoprote in (HDL) 40 m g/dL w ith re gular exe rcis e
Low-de ns ity lipoprote in (LDL) 180 m g/dL w ith high- at die t
in diabe te s m e llitus
in COPD
Triglyce ride s 40-150 m g/dL in cardiovas cular dis e as e
in diabe te s m e llitus
in hype rthyroidis m
w ith exe rcis e
Fatty acids 190-420 m g/dL
Phos pholipids 145-200 m g/dL
Continue d

C pyright 2018, Elsevier In . All rights reserved.

e 21 APPENDIX C

TABLE 1 Blood, Plasma, and Serum Valuescontd

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Me an corpus cular volum e 82-98 L or in various orm s o ane m ia
Os m olality 285-295 m Os m /L or in uid and e le ctrolyte im balance s
P CO 2 35-43 m m Hg in s eve re vom iting
in re s piratory dis orde rs
in obs truction o inte s tine s
in acidos is
in s eve re diarrhe a
in kidney dis e as e
pH 7.35-7.45 during hype rve ntilation
in Cus hing s yndrom e
during hypove ntilation
in acidos is
in Addis on dis e as e
Phos phorus 2.5-4.5 m g/dL in hype rvitam inos is D
in kidney dis e as e
in hypoparathyroidis m
in acrom e galy
in hype rparathyroidis m
in hypovitam inos is D (ricke ts and os te om alacia)
Plas m a volum e Wom e n: 40 m L/kg body we ight or in uid and e le ctrolyte im balance s
Me n: 39 m L/kg body we ight during he m orrhage
Plate le t count 150,000-400,000/m m 3 in he art dis e as e
in cance r
in cirrhos is o live r
a te r traum a
in ane m ia (s om e orm s )
during che m othe rapy
in s om e alle rgie s
PO 2 75-100 m m Hg (bre athing s tandard in polycythe m ia
air) in ane m ia
in COPD
Potas s ium 3.8-5.1 m Eq/L in hypoaldos te ronis m
in acute kidney ailure
in vom iting or diarrhe a
in s tarvation
Prote intotal 6-8.4 g/dL (total) in s eve re de hydration
Album in 3.5-5 g/dL (total) during he m orrhage
(total) in s tarvation
Globulin 2.3-3.5 g/dL
Re d blood ce ll (RBC) count Wom e n: 4.2-5.4 m illion/m m 3 in polycythe m ia
Me n: 4.5-6.2 m illion/m m 3 in de hydration
in ane m ia (s eve ral orm s )
in Addis on dis e as e
in s ys te m ic lupus e rythe m atos us
Re ticulocyte count 25,000-75,000/m m 3 (0.5% -1.5% o in he m olytic ane m ia
RBC count) in le uke m ia and m e tas tatic carcinom a
in pe rnicious ane m ia
in iron de f cie ncy ane m ia
during radiation the rapy
Sodium 136-145 m Eq/L in de hydration
in traum a or dis e as e o the ce ntral ne rvous
s ys te m
or in kidney dis orde rs
in exce s s ive s we ating, vom iting, diarrhe a
in burns (s odium s hi t into ce lls )
Spe cif c gravity 1.058 or in uid im balance s
C pyright 2018, Elsevier In . All rights reserved.
 APPENDIX C e 22

TABLE 1 Blood, Plasma, and Serum Valuescontd

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Trans am inas e 10-40 units /m L during myocardial in arction
in live r dis e as e
Uric acid Wom e n: 2.5-7.5 m g/dL in gout
Me n: 3-9 m g/dL in toxe m ia o pre gnancy
during traum a
Vis cos ity 1.4-1.8 tim e s the vis cos ity o wate r in polycythe m ia
in de hydration
White Blo o d Ce ll Co unt
Total 4500-11,000/m m 3 (total) in acute in e ctions
(total) in traum a
(total) in s om e cance rs
(total) in ane m ia (s om e orm s )
(total) during che m othe rapy
Ne utrophils 60% -70% o total (ne utrophil) in acute in e ction
Eos inophils 2% -4% o total (e os inophil) in alle rgie s
Bas ophils 0.5% -1% o total (bas ophil) in s eve re alle rgie s
Lym phocyte s 20% -25% o total (lym phocyte ) during antibody re actions
Monocyte s 3% -8% o total (m onocyte ) in chronic in e ctions

TABLE 2 Urine Components

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Ro utine Urinalys is
Ace tone and ace toace tate 0 during as ting
in diabe tic acidos is
Album in 0-trace in hype rte ns ion
in kidney dis e as e
a te r s tre nuous exe rcis e (te m porary)
Am m onia 20-70 m Eq/L in live r dis e as e
in diabe te s m e llitus
Bile and bilirubin during obs truction o the bile ducts
Calcium 150 m g/day in hype rparathyroidis m
in hypoparathyroidis m
Color Trans pare nt ye llow, s traw-colore d, or am be r Abnorm al color or cloudine s s m ay indicate blood in urine , bile ,
bacte ria, drugs , ood pigm e nts , or high s olute conce ntration
Nitrite Ne gative in bacte riuria
Odor Characte ris tic s light odor Ace tone odor in diabe te s m e llitus (diabe tic ke tos is )
Os m olality 500-800 m Os m /L in de hydration
in he art ailure
in diabe te s ins ipidus
in aldos te ronis m
pH 4.6-8.0 in alkalos is
during urinary in e ctions
in acidos is
in de hydration
in e m phys e m a
Potas s ium 25-100 m Eq/L in de hydration
in chronic kidney ailure
in diarrhe a or vom iting
in adre nal ins u f cie ncy
m Eq, Millie quivale nt; m Os m , m illios m ol.
* Value s vary w ith the analys is m e thod us e d. Continue d
C pyright 2018, Elsevier In . All rights reserved.
e 23 APPENDIX C

TABLE 2 Urine Componentscontd

TEST NORMAL VALUES * S IGNIFICANCE OF A CHANGE
Ro utine Urinalys is co ntd
Sodium 75-200 m g/day in s tarvation
in de hydration
in acute kidney ailure
in Cus hing s yndrom e
Cre atinine cle arance 100-140 m L/m in in kidney dis e as e
Cre atinine 1-2 g/day in in e ctions
in s om e kidney dis e as e s
in ane m ia (s om e orm s )
Glucos e 0 in diabe te s m e llitus
in hype rthyroidis m
in hype rs e cre tion o adre nal cortex
Ure a cle arance 40 m L blood cle are d pe r m inute in s om e kidney dis e as e s
Ure a 25-35 g/day in s om e live r dis e as e s
in he m olytic ane m ia
during obs truction o bile ducts
in s eve re diarrhe a
Uric acid 0.6-1.0 g/day in gout
in s om e kidney dis e as e s
Micro s co pic Exam inatio n
Bacte ria 10,000/m L during urinary in e ctions
Blood ce lls (RBC) 0-trace in pye lone phritis
rom dam age by calculi
in in e ction
in cance r
Blood ce lls (WBC) 0-trace in in e ctions
Blood ce ll cas ts (RBC) 0-trace in pye lone phritis
Blood ce ll cas ts (WBC) 0-trace in in e ction
Crys tals 0-trace in urinary re te ntion
Ve ry large crys talline m as s e s are calculi
Epithe lial cas ts 0-trace in s om e kidney dis orde rs
in he avy m e tal toxicity
Granular cas ts 0-trace in s om e kidney dis orde rs
Hyaline cas ts 0-trace in s om e kidney dis orde rs
in eve r

TABLE 3 Conversion Factors (SI Units)

NORMAL RANGE NORMAL RANGE
(in units as (in S I units , m o le cular units ,
cus to m arily CONVERS ION Inte rnatio nal Units , o r
COMPONENT re po rte d) FACTOR de cim al ractio ns )
Bio che m ical Co m po ne nts o Blo o d*
Ace toace tic acid (s e rum [S]) 0.2-1.0 m g/dL 98 19.6-98.0 m ol/L
Ace tone (S) 0.3-2.0 m g/dL 172 51.6-344.0 m ol/L
Album in (S) 3.2-4.5 g/dL 10 32-45 g/L
Am m onia (plas m a [P]) 20-120 m cg/dL 0.588 11.7-70.5 m ol/L
Amylas e (S) 60-160 Som ogyi units /dL 1.85 111-296 units /L
Bas e , total (S) 145-160 m Eq/L 1 145-160 m m ol/L
L, Fe m tolite r; kPa, kilopas cal; m m ol, m illim ole ; m ol, m icrom ole ; ng, nanogram ; nm ol, nanom ole ; pm ol, picom ole ; pg, picogram .
* The Inte rnational Com m itte e or Standardization in He m atology re com m e nds that the num be rs re m ain the s am e but that the units change , s o that he m o-
globin is expre s s e d as gram s pe r de cilite r (g/dL) eve n though othe r m e as ure m e nts are expre s s e d as units pe r lite r (U/L).
C pyright 2018, Elsevier In . All rights reserved.
 APPENDIX C e 24

TABLE 3 Conversion Factors (SI Units)contd

NORMAL RANGE NORMAL RANGE
(in units as (in S I units , m o le cular units ,
cus to m arily CONVERS ION Inte rnatio nal Units , o r
COMPONENT re po rte d) FACTOR de cim al ractio ns )
Bio che m ical Co m po ne nts o Blo o dco ntd
Bicarbonate (P) 21-28 m Eq/L 1 21-28 m m ol/L
Bile acids (S) 0.3-3.0 m g/dL 10 3-30 m g/L
2.547 0.8-7.6 m ol/L
Bilirubin, dire ct (S) Up to 0.3 m g/dL 17.1 Up to 5.1 m ol/L
Bilirubin, indire ct (S) 0.1-1.0 m g/dL 17.1 1.7-17.1 m ol/L
Blood gas e s (B)
P CO 2 arte rial 35-40 m m Hg 0.133 4.66-5.32 kPa
PO 2 arte rial 95-100 m m Hg 0.133 12.64-13.30 kPa
Calcium (S) 8.5-10.5 m g/dL 0.25 2.1-2.6 m m ol/L
Chloride (S) 95-103 m Eq/L 1 95-103 m m ol/L
Cre atine (S) 0.1-0.4 m g/dL 76.3 7.6-30.5 m ol/L
Cre atinine (S) 0.6-1.2 m g/dL 88.4 53-106 m ol/L
Cre atinine cle arance (P) 107-139 m L/m in 0.0167 1.78-2.32 m L/s e c
Fatty acids (total) (S) 8-20 m g/dL 0.01 0.08-2.00 m g/L
Fibrinoge n (P) 200-400 m g/dL 0.01 2.00-4.00 g/L
Gam m a globulin (S) 0.5-1.6 g/dL 10 5-16 g/L
Globulins (total) (S) 2.3-3.5 g/dL 10 23-35 g/L
Glucos e ( as ting) (S) 70-110 m g/dL 0.055 3.85-6.05 m m ol/L
Ins ulin (radioim m unoas s ay) (P) 4.24 IU/m L 0.0417 0.17-1.00 m cg/L
0.20-0.84 m cg/L 172.2 35-145 pm ol/L
Iodine , BEI (S) 3.5-6.5 m cg/dL 0.079 0.28-0.51 m ol/L
Iodine , PBI (S) 4.0-8.0 m cg/dL 0.079 0.32-0.63 m ol/L
Iron, total (S) 60-150 m cg/dL 0.179 11-27 m ol/L
Iron-binding capacity (S) 300-360 m cg/dL 0.179 54-64 m ol/L
17-Ke tos te roids (P) 25-125 m cg/dL 0.01 0.25-1.25 m g/L
Lactic de hydroge nas e (S) 80-120 units at 30 C 0.48 38-62 units /L at 30 C
Lactate pyruvate 100-190 units /L at 37 C 1 100-190 units /L at 37 C
Lipas e (S) Che rry-Crandall 278 0-417 units /L
0-1.5 units /m L
Lipids (total) (S) 400-800 m g/dL 0.01 4.00-8.00 g/L
Chole s te rol 150-250 m g/dL 0.026 3.9-6.5 m m ol/L
Triglyce ride s 75-165 m g/dL 0.0114 0.85-1.89 m m ol/L
Phos pholipids 150-380 m g/dL 0.01 1.50-380 g/L
Fre e atty acids 9.0-15.0 m M/L 1 9.0-15.0 m m ol/L
Nonprote in nitroge n (S) 20-35 m g/dL 0.714 14.3-25.0 m m ol/L
Phos phatas e (P)
Acid (units /dL) Che rry-Crandall 2.77 0-5.5 units /L
King-Arm s trong 1.77 0-5.5 units /L
Bodans ky 5.37 0-5.5 units /L
Alkaline (units /dL) King-Arm s trong 1.77 30-120 units /L
Bodans ky 5.37 30-120 units /L
Be s s ey-Low ry-Brock 16.67 30-120 units /L
Phos phorus , inorganic (S) 3.0-4.5 m g/dL 0.323 0.97-1.45 m m ol/L
Potas s ium (P) 3.8-5.0 m Eq/L 1 3.8-5.0 m m ol/L
Continue d
C pyright 2018, Elsevier In . All rights reserved.
e 25 APPENDIX C

TABLE 3 Conversion Factors (SI Units)contd

NORMAL RANGE NORMAL RANGE
(in units as (in S I units , m o le cular units ,
cus to m arily CONVERS ION Inte rnatio nal Units , o r
COMPONENT re po rte d) FACTOR de cim al ractio ns )
Bio che m ical Co m po ne nts o Blo o dco ntd
Prote ins , total (S) 6.0-7.8 g/dL 10 60-78 g/L
Album in 3.2-4.5 g/dL 10 32-45 g/L
Globulin 2.3-3.5 g/dL 10 23-35 g/L
Sodium (P) 136-142 m Eq/L 1 136-142 m m ol/L
Te s tos te rone (S)
Male 300-1200 ng/dL 0.035 10.5-42.0 nm ol/L
Fe m ale 30-95 ng/dL 0.035 1.0-3.3 nm ol/L
Thyroid te s ts (S)
Thyroxine (T4 ) 4-11 m cg/dL 12.87 51-142 nm ol/L
T4 expre s s e d as iodine 3.2-7.2 m cg/dL 79.0 253-569 nm ol/L
T3 re s in uptake 25% -38% re lative uptake 0.01 0.25% -0.38% re lative uptake
TSH (thyroid-s tim ulating 0.5-2.0 IU/L 0.000001 0.5-20 10 6
Inte rnational Units /L
horm one ) (S)
Ure a nitroge n (S) 8-23 m g/dL 0.357 2.9-8.2 m m ol/L
Uric acid (S) 2-6 m g/dL 59.5 0.120-0.360 m m ol/L
Vitam in B12 (S) 160-195 pg/m L 0.74 118-703 pm ol/L
He m ato lo gy Value s *
Re d ce ll volum e (m ale ) 25-35 m L/kg body m as s 0.001 0.025-0.035 L/kg body m as s
Re d ce ll volum e ( e m ale ) 20-30 m L/kg body m as s 0.001 0.020-0.030 L/kg body m as s
He m atocrit 40% -50% 0.01 0.40-0.50
He m oglobin 13.5-18.0 g/dL 10 135-180 g/L
He m oglobin 13.5-18.0 g/dL 0.155 2.09-2.79 m m ol/L
RBC count 4.5-6.3 10 6 / L 1 4.6-6.3 1012 /L
WBC count 4.5-10.3 10 3 / L 1 4.5-10.3 10 9 /L
Me an corpus cular volum e 80-96 m3 1 80-96 L

C pyright 2018, Elsevier In . All rights reserved.

GLOS S ARY
A
abdomen (AB-d h-men) b dy area between the diaphragm and
pelvis
abdominal (ab-DOM-ih-nal) relating t the abd men
abdominal cavity (ab-DOM-ih-nal KAV-ih-tee) the avity n-
taining the abd minal rgans
abdominal muscles (ab-DOM-ih-nal MUS-els) mus les supp rt-
ing the anteri r aspe t the abd men
abdominal quadrants (ab-D OM-ih-nal KWOD-rants) ur t p -
graphi subdivisi ns the abd men determined by tw imagi-
nary lines dividing the b dy thr ugh the navel ne verti al, ne
h riz ntal; health pr essi nals use these designati ns t help
l ate spe i internal rgans
abdominal regions (ab-DOM-ih-nal REE-juns) nine t p graphi
subdivisi ns the abd men determined by ur imaginary lines
n gured in a ti -ta -t e pattern; anat mists use these named
regi ns t identi y the l ati n internal rgans
abdominal thrust (ab-DOM-ih-nal thrust) emergen y pr edure
in whi h sudden pressure n the abd men a pers n wh is
h king may disl dge material r m the airway; rmerly alled
Heimlich maneuver
abdominopelvic cavity (ab-DOM-ih-n h-PEL-vik KAV-ih-tee)
the single avity ntaining the abd minal and pelvi rgans
abdominopelvic quadrant (ab-D OM-ih-n h-PEL-vik KWOD-
rant) any ur regi ns rmed by dividing the abd min pelvi
avity by an imaginary r ss rmed by a verti al and h riz ntal
line
abdominopelvic region (ab-D O M-ih-n h-PEL-vik REE-jun)
sur a e area the b dy related t the abd min pelvi avity
abduct (ab-D UK ) t m ve away r m the midline the b dy ( r
regi n)
abduction (ab-DUK-shun) m ving away r m the midline the
b dy ( r regi n); pp site m ti n adduction
ablation (ab-LAY-shun) destru ti n r utting; r example, the
intenti nal destru ti n atrial mus le tissue t treat atrial bril-
lati n r atrial f utter
ABO system (ay bee h SIS-tem) human bl d lassi ati n system
based n RBC antigens (A, B, AB, and O ) and their rresp nd-
ing antib dies
abruptio placentae (ab-RUP-shee- h plah-SEN-tay) separati n
n rmally p siti ned pla enta r m the uterine wall; may result in
hem rrhage and death the etus and/ r m ther
absorption (ab-SORP-shun) passage a substan e thr ugh a
membrane, su h as skin r mu sa, int bl d
accessory organ (ak-SES- h-ree OR-gan) an rgan that assists
ther rgans in a mplishing their un ti ns
acetabulum (as-eh- AB-y -lum) s ket in the hip b ne ( x xae
r inn minate b ne) int whi h the head the emur ts
acetylcholine (ACh) (as-ee-til-KOH -leen) hemi al neur transmitter
acid (AS-id) any substan e that, when diss lved in water, ntributes
t an ex ess H i ns (that is, a l w pH )
acid-base balance (AS-id bays BAL-ans) maintaining the n en-
trati n hydr gen i ns in b dy f uids
acidic (ah-SID-ik) having the nature an a id (a pH l wer
than 7.0)
acidosis (as-ih-D OH -sis) nditi n in whi h there is an ex essive
pr p rti n a id in the bl d and thus an abn rmally l w bl d
pH ; pp site alkalosis
acne (AK-nee) a ba terial in e ti n the skin hara terized by red
pustules rmed when hair lli les be me in e ted
acne vulgaris (AK-nee vul-GAR-is) inf ammat ry skin nditi n
a e ting seba e us gland du ts; see comedones
acquired immunity (ah-KW YERD ih-MYO O -nih-tee) immunity
that is btained a ter birth thr ugh the use inje ti ns r exp -
sure t a harm ul agent
acquired immunode ciency syndrome (AID S) (ah-KW YERD
IM-y -n h-deh-FISH -en-see SIN-dr hm [aydz]) disease in
whi h the human immun de ien y virus atta ks ells, thereby
mpr mising the b dys immune system
acromegaly (ak-r h-MEG-ah-lee) nditi n aused by hyperse re-
ti n gr wth h rm ne a ter puberty, resulting in enlargement
a ial eatures (e.g., jaw, n se), ngers, and t es
acrosome (AK-r h-s hm) spe ialized stru ture vering the sperm
head ntaining enzymes that break d wn the vering the
vum t all w entry
actin (AK-tin) ntra tile pr tein und in the thin my laments
skeletal mus le
action potential (AK-shun p h- EN-shal) nerve impulse
active transport (AK-tiv RANS-p rt) m vement a substan e
int and ut a living ell requiring the use ellular energy
acute (ah-KYO O ) intense; rapid nset, sh rt in durati nas in
a ute disease
acute lymphocytic leukemia (ALL) (ah-KYOO LIM- h-sit-ik
l -KEE-mee-ah) type a ute (rapid nset and pr gressi n) bl d
an er mm n in hildren 3 t 7 years age; hara terized by
an er us trans rmati n and in reased numbers B lymph ytes
acute myeloid leukemia (AML) (ah-KYO O MY-eh-l yd l -
KEE-me-ah) type a ute (rapid nset and pr gressi n) bl d
an er m st mm n in adults; hara terized by an er us trans-
rmati n and in reased numbers myel id pre urs r ells
adaptation (ad-ap- AY-shun) nditi n many sens ry re ept rs
in whi h the magnitude a re ept r p tential de reases ver a
peri d time in resp nse t a ntinu us stimulus
adaptive immunity (ah-DAP-tiv ih-MYO O -nih-tee) a system
immunity with mem ry a spe i antigen and the ability t
resp nd t that antigen, in ntrast t the n nspe i nature
innate immunity; an ther name r speci c immunity
Addison disease (AD ) (AD-ih-s n dih-ZEEZ) disease the adre-
nal gland resulting in l w bl d glu se, weight l ss, weakness,
in rease in bl d s dium, and de rease in bl d p tassium
adduct (ad-D UK ) t m ve t ward the midline the b dy ( r
regi n)
adduction (ad-D UK-shun) m ving t ward the midline the b dy
( r regi n); pp site m ti n abduction
adductor muscle (ad-D UK-t r MUS-el) any several mus les that
addu t a j int, m ving a b dy part in r m the side (lateral) and
thus t ward the midline (median r midsagittal plane) the
b dy r the b dy regi n; r example, the pe t ralis maj r and
latissimus d rsi mus les ntra t t gether t pull the arm t ward
the trunk, thus adducting the sh ulder j int
701
702 GLOSSARY
adenine (ADD-eh-een) ne several nitr gen- ntaining bases
that make up nu le tides, whi h in turn make up nu lei a ids
su h as DNA and RNA; in the ell, it an hemi ally bind t
an ther nitr gen us base, thymine ( r t) r ura il (U r u), t
rm a m re mplex stru ture r in translating geneti des;
symb lized by the letter A r a; see also guanine, cytosine,
thymine, uracil
adenocarcinoma (ad-eh-n h-kar-sih-NO H -mah) an er glan-
dular epithelium
adeno bromas (ad-eh-n h- ye-BROH -mahs) benign ne plasms
rmed in epithelial and nne tive tissues
adenohypophysis (ad-eh-n h-hye-POF-ih-sis) anteri r pituitary
gland, whi h has the stru ture an end rine gland
adenoid (AD-eh-n yd) literally, glandlike; aden ids, r pharyngeal
tonsils, are paired lymph id stru tures in the nas pharynx; see also
tonsils
adenoma (ad-eh-NOH -mah) benign tum r glandular epithelium
adenosine deaminase (ADA) de ciency (ah-DEN- h-seen dee-
AM-ih-nayse dee-FISH -en-see) rare, inherited nditi n in
whi h pr du ti n the enzyme aden sine deaminase is de -
ient, resulting in severe mbined immune de ien y (SCID);
rst human dis rder treated by gene therapy
adenosine diphosphate (AD P) (ah-DEN- h-seen dye-FAH S- ayt)
m le ule similar t aden sine triph sphate but ntaining nly
tw ph sphate gr ups
adenosine triphosphate (A P) (ah-DEN- h-seen try-FAH S- ayt)
hemi al mp und that pr vides energy r use by b dy ells
adipose (AD-ih-p hs) at tissue; spe ialized tissue that st res lipids
adolescence (ad- h-LES-ens) peri d li e between puberty and
adulth d
adrenal cortex (ah-DREE-nal KOR-teks) uter p rti n adrenal
gland that se retes h rm nes alled corticoids
adrenal gland (ah-DREE-nal) gland that rests n the t p the
kidneys, made up the rtex and medulla
adrenal medulla (ah-DREE-nal meh-DUL-ah) inner p rti n
adrenal gland that se retes epinephrine and n repinephrine
adrenergic ber (ad-ren-ER-jik FYE-ber) any the ax ns wh se
terminals release n repinephrine and epinephrine
adrenocorticotropic hormone (AC H) (ah-dree-n h-k r-teh-
k h- RO H -pi H OR-m hn) h rm ne that stimulates the adre-
nal rtex t se rete larger am unts h rm nes
adult polycystic kidney disease (ah-D UL pah-lee-sis-ti KID-nee
dih-ZEEZ) hereditary nditi n hara terized by devel pment
multiple ysti spa es in ne r b th kidneys that ten ll
with lear f uid r bl d
adult respiratory distress syndrome (ARD S) (ah-D UL RES-
pih-rah-t r-ee dis- RES sin-dr hm) relative inability t
inf ate alve li n rmally; aused by impairment r rem val
sur a tant ll wing a idental inhalati n destru tive
substan es
adulthood (ah-DUL -h d) peri d li e a ter ad les en e
aerobic (ayr-OH -bik) requiring xygen
aerobic training (ayr-OH -bik RAYN-ing) ntinu us vig r us
exer ise requiring the b dy t in rease its nsumpti n xygen
and devel p the mus les ability t sustain a tivity ver a l ng
peri d
af erent (AF- er-ent) arrying r nveying t ward the enter (e.g.,
an a erent neur n arries nerve impulses t ward the entral ner-
v us system); pp site ef erent
af erent lymphatic vessel (AF- er-ent lim-FA -ik VES-el) any
small lymphati vessel that arries lymphati f uid t ward a
lymph n de; mpare t ef erent lymphatic vessel
af erent neuron (AF- er-ent NO O-r n) neur n that ndu ts im-
pulses t ward the entral nerv us system; generally a sens ry
neur n
age (ayj) h w ld an rganism is, usually measured r m time
birth, hat hing, r rmati n as an independent rganism
age-related macular degeneration (AMD ) (MAK-y -lar dih-jen-
uh-RAY-shun) pr gressive deteri rati n ma ula lutea retina
ausing l ss entral visual eld
agglutinate (ah-GLO O-tin-ayt) antib dies ausing antigens t
lump r sti k t gether
aging process (AYJ-ing PRAH -ses) the gradual degenerative
hanges that ur a ter y ung adulth d as a pers n ages
agranular leukocyte (ah-GRAN-y -lar LO O-k h-syte) lass
white bl d ell (leuk yte) that d es n t exhibit granules when
stained; in ludes m n ytes and lymph ytes; als alled non-
granular leukocyte r agranulocyte
agricultural scientist (ag-rih-KUL- her-al SYE-en-tist) s ientist
wh studies the gr wing r ps
AID S-related complex (ARC) (AYDS ree-LAY-ted KOM-pleks)
early mani estati n AIDS that pr du es ever, weight l ss, and
sw llen lymph n des in th se wh se immune systems are less
de ient than th se with ull-bl wn AIDS
albinism (AL-bih-niz-em) re essive, inherited nditi n hara ter-
ized by a la k the dark br wn pigment melanin in the skin and
eyes, resulting in visi n pr blems and sus eptibility t sunburn
and skin an er; ular albinism is a la k pigment in the layers
the eyeball
albumin (al-BYO O-min) ne several types pr teins n rmally
und in bl d plasma; it helps thi ken the bl d
aldosterone (al-DOS-ter- wn) h rm ne that stimulates the kidney
t retain s dium i ns and water
alimentary canal (al-eh-MEN-tar-ee kah-NAL) prin ipal tubelike
stru ture the digestive system extending r m m uth t anus
s metimes alled the gastrointestinal (GI) tract
alkaline (AL-kah-lin) base; any substan e that, when diss lved in
water, ntributes t an ex ess OH i ns (thus reating a high
pH value)
alkaline phosphatase (AL-kah-lin FOS- ah-tays) enzyme present
in bl d plasma in high n entrati n during ertain liver and
malignant b ne marr w dis rders
alkalosis (al-kah-LO H -sis) nditi n in whi h there is an
ex essive pr p rti n alkali (base) in the bl d; pp site
acidosis
allergen (AL-er-jen) harmless envir nmental antigen that stimu-
lates an allergi rea ti n (hypersensitivity rea ti n) in a sus epti-
ble, sensitized pers n
allergy (AL-er-jee) hypersensitivity the immune system t rela-
tively harmless envir nmental antigens
all or none (all r nun) prin iple that a pr ess will ur at its maxi-
mum r n t at all, n e it begins
allied health pro essions (AL-ayed helth pr h-FESH -unz) elds
health- are w rk su h as therapists, medi al assistants, te hni-
ians, and thers, wh are n t physi ians r nurses
alloimmunity (al- h-ih-MYO O -nih-tee) ex essive rea ti n the
immune system t antigens r m a di erent individual the
same spe ies; s metimes alled isoimmunity
alopecia (al- h-PEE-sha) lini al term re erring t hair l ss
alpha cell (AL- ah sel) pan reati ell that se retes glu ag n
alveolar duct (al-VEE- h-lar dukt) airway that bran hes r m the
smallest br n hi les; alve lar sa s arise r m alve lar du ts
alveolar sac (al-VEE- h-lar sak) sa s in the lungs that arise r m the
alve lar du ts and resemble a luster grapes

alveolus (al-VEE- h-lus) (pl., alve li) literally, a small avity; alve li
lungs are mi r s pi sa like dilati ns terminal br n hi les
Alzheimer disease (AD ) (AH LZ-hye-mer dih-ZEEZ) brain dis r-
der the middle and late adult years hara terized by l ss
mem ry and dementia
amenorrhea (ah-men- h-REE-ah) absen e n rmal menstruati n
amino acid (ah-MEE-n AS-id) stru tural units r m whi h pr -
teins are built
amniocentesis (AM-nee- h-sen- EE-sis) pr edure in whi h a
sample amni ti f uid is rem ved with a syringe r use in
geneti testing, perhaps t pr du e a kary type the etus; m-
pare with chorionic villus sampling
amniotic cavity (am-nee-O -ik KAV-ih-tee) avity within the
blast yst that will be me a f uid- lled sa in whi h the embry
will f at during devel pment
ameba (ah-MEE-bah) (pl., amebas r amebae) pr t z an hang-
ing shape apable ausing in e ti n
amphiarthrosis (am- ee-ar- H RO H -sis) slightly m vable j int
su h as the ne j ining the tw pubi b nes
amylase (AM-eh-lays) enzyme that digests arb hydrates; see also
salivary amylase
anabolic steroid (an-ah-BOL-ik S AYR- yd) a lipid m le ule
the ster id variety that a ts as a h rm ne t stimulate anab lism
(spe i ally pr tein synthesis) in b dy tissues su h as mus le
(e.g., test ster ne)
anabolism (ah-NAB- h-liz-em) pr ess in whi h ells make m-
plex m le ules (e.g., h rm nes) r m simpler mp unds (e.g.,
amin a ids); pp site catabolism
anaerobic (an-aXyr-OH -bik) requiring n xygen
anal canal (AY-nal kah-NAL) terminal p rti n the re tum
anaphase (AN-ah- ayz) stage mit sis; dupli ate hr m s mes
m ve t p les dividing ell
anaphylactic shock (an-ah- h-LAK-tik sh k) ir ulat ry ailure
(sh k) aused by a type severe allergi rea ti n hara terized
by bl d vessel dilati n; may be atal
anaplasia (an-ah-PLAY-zhee-ah) gr wth abn rmal (undi eren-
tiated) ells, as in a tum r r ne plasm
anatomical position (an-ah- O M-ih-kal p h-ZISH -un) the stan-
dard neutral re eren e p siti n r the b dy used t des ribe sites
r m ti ns vari us b dy parts; gives meaning t dire ti nal
terms
anatomist (ah-NA - h-mist) pr essi nal engaged in the study
the stru ture an rganism and the relati nships its parts
anatomy (ah-NA - h-mee) the study the stru ture an rgan-
ism and the relati nships its parts
androgen (AN-dr h-jen) male sex h rm ne
andropause (AN-dr h-pawz) essati n ertility in lder adult
males; n t well-de ned in humans
anemia (ah-NEE-mee-ah) de ient number red bl d ells r
de ient hem gl bin
anesthesia (an-es- H EE-zhah) l ss sensati n
aneurysm (AN-y -riz-em) abn rmal widening the arterial wall;
aneurysms pr m te the rmati n thr mbi and als tend t
burst
angina pectoris (an-JYE-nah PEK-t r-is) severe hest pain result-
ing when the my ardium is deprived su ient xygen
angiogram (AN-jee- h-gram) medi al image vessels pr du ed by
angiography
angiography (an-jee-AH -gra -ee) radi graphy in whi h radi paque
ntrast medium is inje ted int a vessel t make it m re visible
in a medi al image (angi gram); in arteries the image is alled an
GLOSSARY 703
arteriogram; in veins, a venogram r phlebogram; in lymphati ves-
sels, a lymphangiogram
angioplasty (AN-jee- h-plas-tee) medi al pr edure in whi h ves-
sels luded by arteri s ler sis are pened (i.e., the hannel r
bl d f w is widened)
Angstrom (ANG -strum) 0.1 mm (1/10,000,000,000 a meter r
ab ut 1/250,000,000 an in h); abbreviated
anion (AN-aye- n) negatively harged parti le; a negative i n
anorexia (an- h-REK-see-ah) l ss appetite (a sympt m, rather
than a distin t dis rder)
anorexia nervosa (an- h-REK-see-ah ner-VO H -sah) behavi ral
eating dis rder hara terized by hr ni re usal t eat, ten re-
lated t an abn rmal ear be ming bese
antagonist (an- AG- h-nist) any agent that has the pp site e e t
the agent t whi h it is mpared; r example, a h rm ne
antag nist pp ses the e e t the mpared h rm ne
antagonist muscle (an- AG- h-nist MUS-el) a mus le having p-
p sing a ti ns t an ther mus le; r example, mus les that f ex
the arm are antag nists t mus les that extend it
antebrachial (an-tee-BRAY-kee-al) relating t the rearm
antenatal medicine (an-tee-NAY-tal MED-ih-sin) prenatal medi ine
anterior (an- EER-ee- r) r nt r ventral; pp site posterior r
dorsal
anthrax (AN-thraks) ba terial in e ti n aused by Bacillus anthracis,
rdinarily a e ting herbiv res (sheep, attle, g ats, antel pe) and
ten killing them; rarely it urs in humans thr ugh a idental
r intenti nal exp sure t ba terial sp res thr ugh inhalati n r
skin nta t; inhalati n anthrax is li e-threatening but an be
treated su ess ully with medi ati n; utane us anthrax is less
seri us, hara terized by a reddish-br wn pat h n the skin that
ul erates and then rms a dark, nearly bla k s ab, ll wed by
mus le pain, internal hem rrhage (bleeding), heada he, ever,
nausea, and v miting
anthropology (an-thr h-PO L- h-jee) s ien e human rigins,
ulture, hara teristi s, s iety, and belie s
antibiotic (an-tih-by-O -ik) mp und usually pr du ed by living
rganisms that destr ys r inhibits mi r bes
antibody (AN-tih-b d-ee) substan e pr du ed by the b dy that
destr ys r ina tivates a spe i substan e (antigen) that has en-
tered the b dy
antibody-mediated immunity (AN-tih-b d-ee MEE-dee-ayt-ed
ih-MYO O-nih-tee) immunity that is pr du ed when antib dies
make antigens unable t harm the b dy; als re erred t as hu-
moral immunity
anticoagulant (an-tee-k h-AG-y -lant) agent that pp ses bl d
l tting
antidepressant (an-tee-deh-PRES-ant) drug that inhibits lini ally
signi ant eelings depressi n r sadness
antidiuretic hormone (AD H) (an-tee-dye-y -RE -ik H O R-
m hn) h rm ne pr du ed in the p steri r pituitary gland t
regulate the balan e water in the b dy by a elerating the re-
abs rpti n water
antigen (AN-tih-jen) substan e that, when intr du ed int the b dy,
auses rmati n antib dies against it
antigen-presenting cell (APC) (AN-tih-jen prih-ZEN -ing sel)
any a variety immune ells that present pr tein ragments
(antigens) n their sur a e and thus all w re gniti n and rea -
ti n by ther immune system ells; in lude ma r phages, den-
driti ells (D Cs), and B ells
antihistamine (an-tih-H IS-tah-meen) agent that inhibits histamine,
an inf ammati n agent
704 GLOSSARY
antioxidant (an-tee-O K-seh-dent) substan e su h as vitamin E that
an inhibit ree radi als ( xidants), whi h are highly rea tive,
ele tr n-seeking m le ules urring n rmally in ells but whi h
may damage ele tr n-dense m le ules su h as DNA r m le ules
in ell membranes
antiplatelet agent (an-tee-PLAY -let) drug therapy that inhibits
platelets
antiviral drug (an-tee-VYE-ral [ r an-tih-VYE-ral] drug) thera-
peuti agent that inhibits viral repli ati n in b dy ells
antrum (AN-trum) avity
anuria (ah-NO O-ree-ah) absen e urine
anus (AY-nus) distal end r utlet the re tum
aorta (ay-OR-tah) main and largest artery in the b dy
aortic body (ay-OR-tik BOD-ee) small luster hem sensitive
ells that resp nd t arb n di xide and xygen levels
aortic semilunar valve (ay-OR-tik sem-ih-LO O-nar valv) valve
between the a rta and le t ventri le that prevents bl d r m
f wing ba k int the ventri le
apex (AY-peks) p inted end a ni al stru ture
Apgar score (AP-gar) system assessing general health newb rn
in ant, in whi h heart rate, respirati n, mus le t ne, skin l r,
and resp nse t stimuli are s red (a per e t t tal s re is 10);
named r the Ameri an physi ian Virginia Apgar
apical (AY-pik-al) relating t the apex (tip) an rgan, ell, r ther
stru ture; in a ell, ten re ers t the sur a e a ing the lumen
the rgan
apical heart beat (AY-pik-al hart beet) heart s und dete ted ver the
hearts apex in the spa e between the th and sixth ribs n a line
even with the midp int the le t lavi le
aplastic anemia (ay-PLAS-tik ah-NEE-mee-ah) bl d dis rder
hara terized by a l w red bl d ell unt, aused by destru ti n
myel id tissue in the b ne marr w
apnea (AP-nee-ah) temp rary essati n breathing
apocrine (AP- h-krin) relating t a ateg ry ex rine gland that
pin hes at its api al tip t release its se reti n
apocrine sweat gland (AP- h-krin swet gland) any the sweat
glands l ated in the axilla and genital regi ns; these glands en-
large and begin t un ti n at puberty
apoptosis (ap- h- OH -si r ap- p- OH -sis) pr grammed ell
death by means several bi hemi al pr esses built int ea h
ell; ap pt sis lears spa e r newer ells, as in early embry ni
devel pment r in tissue repair
appendage (ah-PEN-dij) s mething that is atta hed; r example,
an atta hed b dy part su h as an arm
appendicitis (ah-pen-dih-SYE-tis) inf ammati n the vermi rm
appendix
appendicular (ah-pen-DIK-y -lar) relating t the upper and l wer
extremities the b dy
appendicular skeleton (ah-pen-DIK-y -lar SKEL-eh-t n) the
b nes the upper and l wer extremities the b dy
appendix (ah-PEN-diks) see vermi orm appendix
appetite center (AP-ah-tyte SEN-ter) luster neur ns in the
hyp thalamus wh se impulses ause an in rease in appetite
aqueous (AY-kwee-us) liquid mixture in whi h water is the s lvent;
r example, saltwater is an aque us s luti n be ause water is the
s lvent
aqueous humor (AY-kwee-us H YO O -m r) watery f uid that lls
the anteri r hamber the eye, in r nt the lens
aqueous solution (AY-kwee-us suh-LO O-shun) a mixture made up
m le ules diss lved in water
arachnoid mater (ah-RAK-n yd MAH -ter) deli ate, weblike mid-
dle membrane vering the brain, the meninges
arch any stru ture resembling an ar h r ar , as in the ar hlike ar-
rangement t supp rt stru tures; the pr ess rming an
ar h, as when f exing r extending the spine t rm an ar h
archaea (ark-EE-ah) type mi r be resembling ba teria but with
di erent hemi al makeup (espe ially in the ell wall) and di er-
ent metab li pathways; ten apable thriving in very harsh
envir nments (very h t, very a id, very salty, et .); n t kn wn t
in e t humans
areola (ah-REE- h-lah) (pl., are lae) small spa e; the pigmented
ring ar und the nipple
areolar connective tissue (ah-REE- h-lar k h-NEK-tiv ISH -
y ) a type nne tive tissue nsisting bers and a variety
ells embedded in a l se matrix s t, sti ky gel
arrector pili (ah-REK-t r PYE-lye) sm th mus les the skin that
are atta hed t hair lli les; when ntra ti n urs, the hair
stands up, resulting in g se f esh r g se bumps
arrhythmia (ah-RI H -mee-ah) see dysrhythmia
arterial blood gas (ABG) (ar- EER-ee-al blud gas) any the
bl d hara teristi s related t respirat ry gases n rmally mea-
sured in a lab analysis arterial bl d (Po 2, Pco 2, %SO 2, pH ,
[H CO 3 ])
arteriole (ar- EER-ee- hl) small bran h an artery
arteriosclerosis (ar-tee-ree- h-skleh-ROH -sis) hardening arter-
ies; materials su h as lipids (as in ather s ler sis) a umulate in
arterial walls, ten be ming hardened via al i ati n
artery (AR-ter-ee) vessel arrying bl d away r m the heart
arthritis (ar- H RY-tis) inf ammat ry j int disease, hara terized by
inf ammati n the syn vial membrane and a variety systemi
signs r sympt ms
arthroplasty (AR-thr h-plas-tee) the t tal r partial repla ement
a diseased j int with an arti ial devi e (pr sthesis)
arthropod (AR-thr h-p d) type animal apable in esting r
parasitizing humans
arthroscopy (ar- H RO S-skah-pee) pr ess viewing internal
stru tures a j int apsule using a lighted s pe inserted
thr ugh s t tissues
articular cartilage (ar- IK-y -lar KAR-tih-lij) artilage vering
the j int ends b nes
articulation (ar-tik-y -LAY-shun) pla e jun ti n between tw
r m re b nes the skelet n; als alled a joint
arti cial kidney (ar-tih-FISH -al KID-nee) me hani al devi e that
rem ves wastes r m the bl d that w uld n rmally be rem ved
by the kidney
arti cial pacemaker (ar-tih-FISH -al PAYS-may-ker) an ele tri al
devi e that is implanted int the heart t treat a heart bl k
ascending colon (ah-SEND-ing KOH -l n) p rti n the l n
extending r m the e um t the hepati f exure
ascites (ah-SYE-tees) abn rmal a umulati n f uid in intraperi-
t neal spa e
aseptic technique (ay-SEP-tik tek-NEEK) appr a h t limiting the
spread in e ti n by preventing r redu ing nta ts with n-
taminated sur a es
asexual (ay-SEKS-y -al) ne- elled plants and ba teria that d n t
pr du e spe ialized sex ells
aspiration biopsy cytology (as-pih-RAY-shun BYE- p-see sye-
OL- h-jee) pr edure that draws myel id tissue int a syringe;
all ws r examinati n tissue t n rm r reje t diagn sis
assimilation (ah-sim-ih-LAY-shun) takes pla e when nutrient m l-
e ules enter the ell and underg hemi al hanges
assisted reproductive technology (AR ) (ah-SIS-ted ree-pr h-
D UK-tiv tek-NOL- h-jee) any several medi al te hniques
used t enhan e ertility

association area (ah-s h-see-AY-shun AYR-ee-ah) regi n
erebral rtex the brain that un ti ns t put t gether r as-
s iate in rmati n r m many parts the brain t help make
sense r analyze the in rmati n
asthma (AZ-mah) bstru tive pulm nary dis rder hara terized by
re urring spasms mus les in br n hial walls a mpanied by
edema and mu us pr du ti n, making breathing di ult
astigmatic keratotomy (AK) (AY-stig-mat-i kayr-ah- O -ah-
mee) type re ra t ry eye surgery r treatment astigmatism
that inv lves pla ement transverse uts a r ss the rneal sur-
a e t alter its shape
astigmatism (ah-S IG-mah-tiz-em) irregular urvature the rnea
r lens that impairs re ra ti n a well- used image in the eye
astrocyte (AS-tr h-syte) a neur glial ell
atelectasis (at-eh-LEK-tay-sis) t tal r partial llapse the alve li
the lung
atherosclerosis (ath-er- h-skleh-RO H -sis) type hardening
the arteries in whi h lipids and ther substan es build up n the
inside wall bl d vessels
athletic trainer (ath-LE -ik RAY-ner) health are pr essi nal
wh w rks with a physi ian and spe ializes in preventi n, diag-
n sis, and therapy sp rts-related injuries
atlas (A -lis) an ther name r the rst ervi al vertebra (C1)
atom (A - m) smallest parti le a pure substan e (element) that
still has the hemi al pr perties that substan e; mp sed
pr t ns, ele tr ns, and neutr ns (subat mi parti les)
atomic mass (ah- AH -mik MAS) mbined t tal number pr -
t ns and neutr ns in an at m
atomic number (ah- AH -mik NUM-ber) t tal number pr t ns
in an at ms nu leus; at ms ea h element have a hara teristi
at mi number
atrial brillation (A- b or AF) (AY-tree-al b-ril-LAY-shun) re-
quent, ha ti premature ntra ti ns the atrium
atrial utter (AFL) (AY-tree-al FLU -er) a rapid and irregular
atrial rhythm ten triggered by abn rmal ele tri al signals r m
the nearby pulm nary veins
atrial natriuretic hormone (ANH) (AY-tree-al nay-tree-y -RE -
ik H O R-m hn) h rm ne se reted by the heart ells that regu-
lates f uid and ele tr lyte h me stasis
atrioventricular (AV) bundle (ay-tree- h-ven- RIK-y -lar BUN-
del) bundle rapidly ndu ting ardia mus le bers that ex-
tend r m the AV n de t the subend ardial bran hes (Purkinje
bers); inv lved in rdinati n heart mus le ntra ti n; als
kn wn as bundle o His
atrioventricular (AV) node (ay-tree- h-ven- RIK-y -lar n hd) a
small mass spe ial impulse-generating ardia mus le tissue
near the jun ti n the le t atrium and ventri le; part
ndu ti n system the heart
atrioventricular (AV) valve (ay-tree- h-ven- RIK-y -lar valv)
either tw valves that separate the atrial hambers r m the
ventri les
atrium (AY-tree-um) (pl., atria) hamber r avity; r example,
atrium ea h side the heart
atrophy (A -r h- ee) wasting away tissue; de rease in size
part; s metimes re erred t as disuse atrophy
audiologist (aw-dee-OL-uh-jist) health- are pr essi nal wh
treats hearing dis rders
auditory tube (AW-dih-t h-ree t b) tube extending r m inside
the middle ear t the thr at t equalize air pressure; als alled
the eustachian tube
auricle (AW-rih-kul) part the ear atta hed t the side the head;
earlike appendage ea h atrium the heart
GLOSSARY 705
the autoimmunity (aw-t h-ih-MYO O -nih-tee) pr ess in whi h a
pers ns immune system atta ks the pers ns wn b dy tissues
the underlying ause several diseases
automated lamellar keratoplasty (ALK) (AW-t h-may-ted lah-
MEL-ahr kayr-A - h-plast-ee) type re ra t ry eye surgery
that empl ys a mi r kerat me t ut a ap rneal tissue,
whi h is repla ed a ter the underlying tissue is reshaped
automatic external de brillator (AED ) (aw-t h-MA -ik eks-
ERN-al dee-FIB-rih-lay-t r) small, lightweight devi e that
dete ts a pers ns heart rhythm using small ele tr de pads pla ed
n the t rs and, i ventri ular brillati n is dete ted, a n nmedi-
al res uer will be led thr ugh s me simple steps t de brillate
the vi tim by applying brie ele tr sh k t the heart
autonomic ef ector (aw-t h-NOM-ik e -FEK-t r) tissues t whi h
aut n mi neur ns ndu t impulses
autonomic nervous system (ANS) (aw-t h-NOM-ik NER-vus
SIS-tem) divisi n the human nerv us system that regulates
inv luntary a ti ns
autonomic neuron (aw-t h-NOM-ik NO O-r n) m t r neur ns
that make up the aut n mi nerv us system
autopsy (AW-t p-see) systemati disse ti n and analysis a dead
b dy, ten r the purp se dis vering the ause death and/
r the presen e health nditi ns; als alled necropsy
autosome (AW-t h-s hm) ne the 44 (22 pairs) hr m s mes in
the human gen me ther than the tw sex hr m s mes; means
same b dy, re erring t the a t that members a pair aut -
s mes mat h ea h ther in size and ther stru tural eatures
AV bundle (AV BUN-dul) bers in the heart that relay a nerve
impulse r m the AV n de t the ventri les; als kn wn as the
bundle o His
avitaminosis (ay-vye-tah-mih-NOH -sis) general name r any n-
diti n resulting r m a vitamin de ien y
avulsion racture (ah-VUL-shun FRAK- hur) ra ture urring
when a p wer ul mus le ntra ti n pulling n a ligament us r
tendin us atta hment t a b ne r ibly pulls a ragment b ne
ree r m underlying sse us tissue
axial (AK-see-al) relating t the entral axis the b dy: head, ne k,
and t rs r trunk
axial skeleton (AK-see-al SKEL-eh-t n) the b nes the head,
ne k, and t rs
axilla (AK-sil-ah) relating t the armpit
axillary (AK-sih-layr-ee) relating t the area inside the sh ulder
j int r armpit
axon (AK-s n) nerve ell pr ess that transmits impulses away r m
the ell b dy
the
B
B cell (bee sel) a lymph yte; a tivated B ells devel p int plasma
ells, whi h se rete antib dies int the bl d
B lymphocyte (bee LIM- h-syte) immune system ell that pr -
du es antib dies against spe i antigens
bacillus (bah-SIL-us) (pl., ba illi) r d-shaped ba terium
a bacterium (bak- EER-ee-um) mi r be apable ausing disease; it is
a primitive, single- elled rganism with ut membran us rganelles
Bard endoscopic suturing system (BARD en-d h-SKOP-ik SO O-
hur-ing SIS-tem) use an end s pe t pla e sutures in the
l wer es phageal sphin ter t narr w the lumen
bariatrics (bayr-ee-A -riks) eld medi ine that deals with treat-
ment besity
Barrett esophagus (BAH R-ett ee-SOF-ah-gus) pre an er us n-
diti n es phageal lining
706 GLOSSARY
Bartholin gland (BAR-t h-lin) ex rine mu us gland l ated n
either side the vaginal utlet; als kn wn as greater vestibular
gland
bartholinitis (bar-t h-lin-AYE-tis) inf ammati n the Barth lin
glands, a ess ry rgans the emale repr du tive tra t
basal cell carcinoma (BAY-sal sel ar-sih-NO H -mah) skin an-
er, ten urring n upper a e, with l w p tential r
metastasizing
basal ganglia (BAY-sal GANG-glee-ah) see basal nuclei r cerebral
nuclei
basal metabolic rate (BMR) (BAY-sal met-ah-BAH L-ik rayt)
number al ries heat that must be pr du ed per h ur by
atab lism t keep the b dy alive, awake, and m rtably warm
basal nuclei (BAY-sal NO O -klee-aye) islands gray matter l ated
in the erebral rtex that are resp nsible r aut mati m ve-
ments and p stures; als alled basal ganglia r cerebral nuclei
base 1. A hemi al that, when diss lved in water, redu es the relative
n entrati n H i ns in the wh le s luti n (s metimes by
adding O H i ns) 2. In the ntext nu lei a ids (DNA and
RNA), base r nitrogen base re ers t ne part a nu le tide
(sugar, ph sphate, and base) that is the basi building bl k
nu lei a id m le ules; p ssible bases in lude adenine, thymine,
guanine, yt sine, and ura il
basement membrane (BAYS-ment MEM-brayn) the nne tive
tissue layer the ser us membrane that h lds and supp rts the
epithelial ells
basophil (BAY-s h- l) white bl d ell that stains readily with basi
dyes
BBB see blood-brain barrier
Bell palsy (bell PAW L-zee) temp rary r permanent paralysis
a ial eatures aused by damage t ranial nerve VII ( a ial
nerve)
benign (be-NYNE) re ers t a tum r r ne plasm that d es n t
metastasize r spread t di erent tissues
benign prostatic hypertrophy (BPH) (be-NYNE pr h-S A -ik
hye-PER-tr h- ee) benign enlargement the pr state, a ndi-
ti n mm n in lder males
benign tumor (be-NYNE O O -mer) a n n an er us and generally
harmless ne plasm
beta-adrenergic blocker (BAY-tahad-ren-ER-jik) drug that bl ks
beta-adrenergi re ept rs and there re prevents dilati n bl d
vessels and in reased ntra ti n heart mus le; als alled beta
blocker
beta cell (BAY-tah sel) pan reati islet ell that se retes insulin
bicarbonate ion (bye-KAR-b h-nayt EYE- n) negative i n m-
m n in water s luti ns, in luding b dy f uids; H CO 3 ; ten a ts
as a bu er t in rease pH (redu e a idity) a s luti n
bicarbonate loading (bye-KAR-b h-net LO H D-ing) ingesting
large am unts s dium bi arb nate t untera t the e e ts
la ti a id buildup, thereby redu ing atigue; h wever, there are
p tentially danger us side e e ts
biceps brachii (BYE-seps BRAY-kee-aye) the primary f ex r the
rearm
biceps emoris (BYE-seps FEM- h-ris) p wer ul f ex r the leg
biconcave (bye-KO N-kayv) depressed r aved in n tw sides, as
in the pin hed disk shape red bl d ells
bicuspid (bye-KUS-pid) having tw p ints; bi uspid t th (als
alled premolar) has a large f at sur a e and tw grinding usps;
see also bicuspid valve
bicuspid valve (bye-KUS-pid valv) ne the tw AV valves, it is
l ated between the le t atrium and ventri le; als alled the
mitral valve r le t atrioventricular (AV) valve
bilateral symmetry (bye-LA -er-al SIM-eh-tree) n ept the
right and le t sides the b dy being appr ximate mirr r images
ea h ther
bilayer (BYE-lay-er) d uble layer
bile (byle) substan e that redu es large at gl bules int smaller
dr plets at that are m re easily br ken d wn
bile duct (byle dukt) du t that drains bile int the small intestine and
is rmed by the uni n the mm n hepati and ysti du ts
biliary colic (BIL-yah-ree KOL-ik) pain that may ur when a
gallst ne bl ks the mm n bile du ta nditi n alled
choledocholithiasis
biochemist (bye- h-KEM-ist) s ientist wh w rks primarily in the
eld bi hemistry; see biochemistry
biochemistry (bye- h-KEM-is-tree) s ien e hemistry living
rganisms
biological ltration (bye-EH -lah-jih-kal l- RAY-shun) pr ess in
whi h ells alter the ntents the ltered f uid
biomedical engineering (bye- h-MED-ik-al en-juh-NEER-ing)
eld ma hine design applied t therapeuti strategies; als
alled bioengineering
biopsy (BYE- p-see) pr edure in whi h living tissue is rem ved
r m a patient r lab rat ry examinati n, as in determining the
presen e an er ells; see als needle biopsy
bioterrorism (bye- h- AYR- r-iz-em) unlaw ul release bi l gi-
al agents (t xins r path gens) r the purp se intimidati n
birth de ect (DEE- ekt) any abn rmality, whether aused by geneti
r envir nmental a t rs, that exists at birth; see teratogen
blackhead des ripti n sebum that a umulates, darkens, and en-
larges s me the du ts the seba e us glands; als alled a
comedo
bladder (BLAD-der) a sa , usually re erring t the urinary bladder
blastocyst (BLAS-t h-sist) p stm rula stage devel ping embry ;
h ll w ball ells
blister (BLIS-ter) f uid- lled skin lesi n; see vesicle
blood (blud) type nne tive tissue hara terized by a watery
liquid matrix (bl d plasma) and a variety m bile ells that
in lude red bl d ells, white bl d ells, and platelets
blood-brain barrier (BBB) (blud brayn BAYR-ee-er) stru tural and
un ti nal barrier rmed by astr ytes and bl d vessel walls in
the brain; it prevents s me substan es r m di using r m the
bl d int brain tissue
blood doping (blud D O H -ping) a pra ti e used t impr ve athleti
per rman e by rem ving red bl d ells weeks be re an event
and then rein using them just be re mpetiti n t in rease the
xygen- arrying apa ity the bl d
blood pressure (blud PRESH -ur) pressure bl d in the bl d
vessels, expressed as syst li pressure ver diast li pressure (e.g.,
120/80 mm H g)
blood pressure gradient (blud PRESH -ur GRAY-dee-ent) the di -
eren e between any tw bl d pressures in the b dy; r exam-
ple, the pressure di eren e between the bl d in the le t ventri le
the heart and the bl d in the a rta is a pressure gradient
blood types (blud) the di erent types bl d that are identi ed by
ertain antigens in red bl d ells (A, B, AB, O, and Rh-negative
r Rh-p sitive)
blood urea nitrogen (BUN) test (y -REE-ah NYE-tr h-jen) lin-
i al lab rat ry measurement the am unt nitr gen in urea
present in the bl d and used as a measure the e ien y the
kidneys ability t lear urea r m the b dy
body (BOD-ee) uni ed and mplex assembly stru turally and
un ti nally intera tive mp nents (as in human body); the main
r entral part a stru ture (as in cell body r body o an organ)

body composition (BOD-ee m-p h-ZISH -un) assessment that
identi es the per entage the b dy that is lean tissue and the
per entage that is at
boil (BOY-el) see uruncle
bolus (BOW-lus) a small, r unded mass masti ated d ready t
be swall wed
bond a hemi al b nd r uni n between tw r m re at ms t rm
a m le ule; see ionic bond and covalent bond
bone (b hn) highly spe ialized nne tive tissue wh se matrix is
hard and al i ed
bone marrow (b hn MAYR- h) s t material that lls avities
the b nes; red b ne marr w is vital t bl d ell rmati n; yel-
l w b ne marr w is ina tive atty tissue
bone marrow transplant (b hn MAYR- h RANS-plant) treat-
ment in whi h healthy bl d- rming marr w tissue r m a d -
n r is intraven usly intr du ed int a re ipient
bony labyrinth (BOH N-ee LAB-eh-rinth) the f uid- lled mplex
maze three spa es (the vestibule, semi ir ular anals, and -
hlea) in the temp ral b ne
Bouchard node (b -SH AR n hd) any the abn rmal enlarge-
ments seen at the pr ximal interphalangeal j ints in pe ple with
ste arthritis
bovine spongi orm encephalopathy (BSE) (BOH -vyne SPUN-
jeh- rm en-se -uh-LO P-uh-thee) als kn wn as mad cow dis-
ease; a degenerative disease the entral nerv us system aused
by pri ns that nvert n rmal pr teins the nerv us system int
abn rmal pr teins, ausing l ss nerv us system un ti n; the
abn rmal rm the pr tein als may be inherited; see also prion
Bowman capsule (BOH -men KAP-sul) the up-shaped beginning
a nephr n that surr unds the gl merulus; als alled Bowmans
capsule r glomerular capsule
brachial (BRAY-kee-al) relating t the arm
brachialis (bray-kee-AL-is) skeletal mus le the arm that f exes
the rearm at the elb w
brachytherapy (brak-ih- H AYR-uh-pee) pla ement radi a tive
seeds in l se r dire t nta t with an er us tissue
bradycardia (bray-dee-KAR-dee-ah) sl w heart rhythm (bel w
60 beats/minute)
breast (brest) anteri r aspe t the hest; in emales, als an a es-
s ry sex rgan
bronchiole (BRONG-kee- hl) small bran h a br n hus
bronchitis (br ng-KYE-tis) inf ammati n the br n hi the
lungs, hara terized by edema and ex essive mu us pr du ti n
that auses ughing and di ulty in breathing (espe ially expi-
rati n); i the tra hea is als inf amed, this nditi n may be re-
erred t as tracheobronchitis
bronchus (BRONG-kus) (pl., br n hi) the bran hes the tra hea
buccal (BUK-al) relating t the heek
buf er (BUF-er) mp und that mbines with an a id r with a base
t rm a weaker a id r base, thereby lessening the hange in
hydr gen-i n n entrati n that w uld ur with ut the bu er
buf er pair (BUF-er payr) tw kinds hemi al substan es that
t gether prevent a sharp hange in the pH a f uid; r example,
s dium bi arb nate (NaH CO 3) and arb ni a id (H 2CO 3)
buf y coat thin layer white bl d ells (W BCs) and platelets l -
ated between red bl d ells (RBCs) and plasma in a entri-
uged sample bl d
bulboid corpuscle (BUL-b yd KOH R-pus-ul) mu us membrane
re ept r that dete ts sensati ns t u h and vibrati n; als
kn wn as Krause end bulb
bulbourethral gland (BUL-b h-y -REE-thral) small glands l -
ated just bel w the pr state gland wh se mu uslike se reti ns
GLOSSARY 707
lubri ate the terminal p rti n the urethra and ntribute less
than 5% the seminal f uid v lume; als kn wn as Cowper
gland
bulimarexia (b -lee-mah-REK-see-ah) nditi n in whi h pe ple
purp sely indu e the v miting ref ex t purge themselves d
they just ate; an eating dis rder
bulimia (b -LEE-mee-ah) behavi ral eating dis rder hara ter-
ized by an alternating pattern vereating ll wed by sel -
denial (and perhaps purging GI ntents)
bundle o His (BUN-dul his) see AV bundle
burn (bern) an injury t tissues resulting r m nta t with heat,
hemi als, ele tri ity, ri ti n, r radiant and ele tr magneti
energy; lassi ed int three ateg ries, depending n the number
tissue layers inv lved
bursa (BER-sah) (pl., bursae) small, ushi nlike sa s und between
m ving b dy parts, whi h make m vement easier
bursitis (ber-SYE-tis) inf ammati n a bursa
C
cachexia (kah-KEES-ee-ah) syndr me ass iated with an er and
ther hr ni diseases that inv lves l ss appetite, weight l ss,
and general weakness
calcaneus (kal-KAY-nee-us) heel b ne; largest tarsal in the t
calcitonin (C ) (kal-sih- OH -nin) a h rm ne se reted by the
thyr id gland that de reases al ium in the bl d
calcium-channel blocker (KAL-see-um CH AN-al) drug that in-
hibits the pening al ium hannels in ell membranes; r
example, used t redu e heart mus le ntra ti ns
calculi (KAL-ky -lye) hard, rystalline st nes that rm in the lu-
men h ll w rgans su h as the gallbladder r liver (biliary
al uli) r renal passages (renal al uli)
callus (KAL-us) b ny tissue that rms a s rt llar ar und the
br ken ends ra tured b ne during the healing pr ess
calorie (c) (KAL- r-ee) heat unit; the am unt heat needed t
raise the temperature 1 g water 1 C
Calorie (C) (KAL- r-ee) heat unit; kil al rie; the am unt heat
needed t raise the temperature 1 kil gram water 1 C
calyx (KAY-liks) up-shaped divisi n the renal pelvis
canaliculi (kan-ah-LIK-y -lye) an extremely narr w tubular pas-
sage r hannel in mpa t b ne
cancellous bone (KAN-seh-lus) b ne tissue ntaining tiny, bran h-
ing trabe ulae; als kn wn as spongy bone r trabecular bone
cancer (KAN-ser) tum r (ne plasm) apable metastasizing
(spreading) t ther parts the b dy
candidiasis (kan-dih-D YE-eh-sis) in e ti n aused by Candida
yeast
canine (KAY-nyne) relating t a d g, as in the canine tooth with the
l ngest r wn and the l ngest r t, whi h is l ated lateral t
the se nd in is r that serves t pier e r tear d being eaten;
the anine t th is als alled a cuspid t th
capillary (KAP-ih-layr-ee r kap-IL-ah-ree) tiny vessels that n-
ne t arteri les and venules
capillary blood pressure (KAP-ih-layr-ee blud PRESH -ur) the
bl d pressure und in the apillary vessels
capsule (KAP-sul) h ll wed ut spa e und in diarthr ti j ints,
h lds the b nes j ints t gether while still all wing m vement;
made br us nne tive tissue lined with a sm th, slippery
syn vial membrane
carbaminohemoglobin (H bCO 2) (kar-bah-MEE-n h-hee-m h-
G LOH -bin) mp und rmed by the uni n arb n di xide
with hem gl bin
708 GLOSSARY
carbohydrate (kar-b h-H YE-drayt) rgani mp unds ntaining
arb n, hydr gen, and xygen in ertain spe i pr p rti ns (C,
H , O in a 1:2:1 rati ); r example, sugars, star hes, and
ellul se
carbohydrate loading (kar-b h-H YE-drayt LO H D-ing) a meth d
used by athletes t in rease the st res mus le gly gen, all w-
ing m re sustained aer bi exer ise; als alled glycogen loading
carbon (KAR-bun) ne the hemi al elements und in great
quantity in the human b dy and always und in rgani m-
p unds; symb lized by C, as in CO 2 ( arb n di xide)
carbon dioxide (KAR-bun dye-AH K-syde) m le ule made up
ne arb n at m and tw xygen at ms; symb lized by the r-
mula CO 2; pr du ed by pr esses ellular respirati n as a waste
pr du t that must be ex reted r m the b dy thr ugh the respira-
t ry system
carbonic anhydrase (CA) (kar-BO N-ik an-H YE-drays) the en-
zyme that nverts arb n di xide int arb ni a id
carbuncle (KAR-bung-kul) a mass nne ted b ils, pus- lled
lesi ns ass iated with hair lli le in e ti ns; see uruncle
carcinogen (kar-SIN- h-jen) substan e that pr m tes the devel p-
ment an er
carcinoma (kar-sih-NOH -mah) malignant tum r that arises r m
epithelial tissue
cardiac (KAR-dee-ak) relating t the heart
cardiac arrest (KAR-dee-ak ar-RES ) abn rmal nditi n in
whi h the heart suddenly st ps pumping bl d, as a ter ventri u-
lar brillati n
cardiac cycle (KAR-dee-ak SYE-kul) ea h mplete heartbeat, in-
luding ntra ti n and relaxati n the atria and ventri les
cardiac muscle (KAR-dee-ak MUS-el) the inv luntary type
mus le tissue that makes up the heart wall
cardiac muscle tissue (KAR-dee-ak MUS-el ISH -y ) see cardiac
muscle
cardiac output (CO) (KAR-dee-ak O U -put) v lume bl d
pumped by ne ventri le per minute
cardiac sphincter (KAR-dee-ak SFINGK-ter) a ring mus le be-
tween the st ma h and es phagus that prevents d r m reen-
tering the es phagus when the st ma h ntra ts
cardiac tamponade (KAR-dee-ak tam-p h-NO D) mpressi n
the heart aused by f uid buildup in the peri ardial spa e, as in
peri arditis r me hani al damage t the peri ardium
cardiac vein (KAR-dee-ak vayn) any vein that arries bl d r m
the my ardial apillary beds t the r nary sinus and int the
right ventri le
cardiogenic shock (kar-dee- h-JEN-ik sh k) ir ulat ry ailure
(sh k) aused by heart ailure; literally heart- aused sh k
cardiologist (kar-dee-AH -l h-jist) physi ian r resear her wh
spe ializes in the stru ture and un ti n the heart and ass i-
ated stru tures
cardiology (kar-dee-OL- h-jee) study and treatment the heart
and heart disease
cardiomyopathy (kar-dee- h-my-OP-ah-thee) general term r
disease the my ardium (heart mus le)
cardiopulmonary resuscitation (CPR) (kar-dee- h-PUL-m h-
nayr-ree ree-sus-ih- AY-shun) mbined external ardia (heart)
massage and arti ial respirati n
cardiovascular (kar-dee- h-VAS-ky -lar) relating t the heart and
bl d vessels
cardiovascular system (kar-dee- h-VAS-ky -lar SIS-tem) the sys-
tem that transp rts ells thr ugh ut the b dy by way bl d
vessels; s metimes als alled circulatory system
caries (KAYR-ees) de ay teeth r b ne; see cavity
carotid body (kah-RO -id BOD-ee) hem re ept r l ated in the
ar tid artery that dete ts hanges in xygen, arb n di xide, and
bl d a id levels
carpal (KAR-pul) relating t the wrist
carpal tunnel syndrome (KAR-pul UN-el SIN-dr hm) mus le
weakness, pain, and tingling in the radial side (thumb side) the
wrist, hand, and ngersperhaps radiating t the rearm and
sh ulder; aused by mpressi n the median nerve within the
arpal tunnel (a passage al ng the ventral n avity the wrist)
carrier (KAYR-ee-er) in geneti s, a pers n wh p ssesses the gene
r a re essive trait, but wh d es n t a tually exhibit the trait
cartilage (KAR-tih-lij) a spe ialized, br us nne tive tissue that
has the nsisten y a rm plasti r gristlelike gel
catabolism (kah- AB- h-liz-em) breakd wn nutrient m-
p unds r yt plasm int simpler mp unds; pp site
anabolism, the ther phase metab lism
catalyst (KA -ah-list) hemi al that speeds up rea ti ns with ut
being hanged itsel
cataract (KA -ah-rakt) pa ity the lens the eye
catecholamine (kat-eh-KOH L-ah-meen) ateg ry signaling
m le ule that in ludes n repinephrine and epinephrine
catheterization (kath-eh-ter-ih-Z AY-shun) passage a f exible
tube ( atheter) int the bladder thr ugh the urethra r the with-
drawal urine (urinary atheterizati n)
cation (KA -aye- n) p sitively harged parti le; a p sitive i n
cavity (KAV-ih-tee) h ll w pla e r spa e in a t th resulting r m
de ay; als re erred t as dental caries
cecum (SEE-kum) blind p u h; the p u h at the pr ximal end
the large intestine
cell (sel) the basi bi l gi al and stru tural unit the b dy nsist-
ing a nu leus surr unded by yt plasm and en l sed by a
membrane
cell body (sel BOD-ee) the main part a neur n r m whi h the
dendrites and ax ns extend
cell-mediated immunity (sel MEE-dee-ayt-ed ih-MYO O -nih-tee)
resistan e t disease rganisms resulting r m the a ti ns ells;
hief y ells
cellular respiration (SEL-y -lar res-pih-RAY-shun) enzymes in
the mit h ndrial wall and matrix using xygen t break d wn
glu se and ther nutrients t release energy needed r ellular
w rk
cementum (see-MEN-tum) b nelike dental tissue vering the
ne k and r t areas teeth
centimeter (SEN-tih-mee-ter) 1100 a meter; appr ximately 2.5 m
equal 1 in h
central canal (SEN-tral kah-NAL) l ngitudinal anal ntaining
vas ular elements and nerv us tissue l ated in the enter an
ste n, r H aversian system; entral anal any stru ture
central nervous system (CNS) (SEN-tral NER-vus SIS-tem) the
brain and spinal rd
central venous pressure (SEN-tral VEE-nus PRESH -ur) ven us
bl d pressure within the right atrium that inf uen es the pres-
sure in the large peripheral veins
centriole (SEN-tree- hl) ne a pair tiny ylinders in the en-
tr s me a ell; believed t be inv lved with the spindle bers
rmed during mit sis
centromere (SEN-tr h-meer) a beadlike stru ture that atta hes ne
hr matid t an ther during the early stages mit sis
centrosome (SEN-tr h-s hm) area the yt plasm near the nu-
leus that rdinates the building and breaking up mi r tu-
bules in the ell
cephalic (seh-FAL-ik) relating t the head

cerebellum (sayr-eh-BEL-um) the se nd largest part the human
brain that plays an essential r le in the pr du ti n n rmal
m vements
cerebral cortex (seh-REE-bral KO R-teks) a thin layer gray mat-
ter made up neur n dendrites and ell b dies that mp se the
sur a e the erebrum
cerebral nuclei (seh-REE-bral NO O-klee-aye) islands gray matter
l ated in the erebral rtex that are resp nsible r aut n mi
m vements and p stures; als alled basal nuclei r basal ganglia
cerebral palsy (CP) (seh-REE-bral PAWL-zee) abn rmal nditi n
hara terized by permanent, n npr gressive paralysis (usually spas-
ti paralysis) ne r m re extremities aused by damage t m t r
ntr l areas the brain be re, during, r sh rtly a ter birth
cerebrospinal uid (CSF) (seh-ree-br h-SPY-nal FLO O-id) f uid
that lls the subara hn id spa e in the brain and spinal rd and
in the erebral ventri les
cerebrovascular accident (CVA) (seh-ree-br h-VAS-ky -lar a i-
dent) a hem rrhage r essati n bl d f w thr ugh erebral
bl d vessels resulting in destru ti n neur ns; mm nly
alled a stroke
cerebrum (SAYR-eh-brum) the largest and upperm st part the
human brain that ntr ls ns i usness, mem ry, sensati ns,
em ti ns, and v luntary m vements
cerumen (seh-RO O-men) ear wax
ceruminous gland (seh-RO O-mih-nus) gland that pr du es a waxy
substan e alled cerumen (ear wax)
cervical (SER-vih-kal) relating t the ne k
cervicitis (ser-vih-SYE-tis) inf ammati n the ervix the uterus
cervix (SER-viks) ne k; any ne klike stru ture
cesarean section (seh-SAYR-ee-an SEK-shun) surgi al rem val
a etus, ten thr ugh an in isi n the skin and uterine wall; als
alled C-section
chemical level (KEM-ih-kal LEV-el) the level the b dys rgani-
zati n that in ludes at ms and m le ules; the hemi al sub-
stan es that make up the b dys stru ture
chemoreceptor (kee-m h-ree-SEP-t r) any re ept r that resp nds
t hemi al hanges; r example, re ept rs that dete t the
hemi als taste and smell
chemore ex (kee-m h-REE-f eks) any rea ti n triggered by a
hemi al hange, as when the heart rate hanges in resp nse t
shi t in xygen n entrati n in the bl d
chemotaxis (kee-m h- AK-sis) pr ess in whi h white bl d ells
m ve t ward the s ur e inf ammati n mediat rs
chemotherapy (kee-m h- H AYR-ah-pee) te hnique using
hemi als t treat disease (e.g., in e ti ns, an er)
chest see thorax
Cheyne-Stokes respiration (CSR) ( hain-st kes res-pih-RAY-
shun) pattern breathing ass iated with riti al nditi ns
su h as brain injury r drug verd se and hara terized by y les
apnea and hyperventilati n
childhood age peri d r m in an y t puberty
chiropractic (kye-r h-PRAK-tik) system therapy based n the
prin iple that alignment the skelet n pr m tes healing
chiropractor (KYE-r h-prak-ter) physi ian spe ializing in hir -
pra ti therapy, whi h is based n the prin iple that alignment
the skelet n pr m tes healing
Chlamydia (klah-MID-ee-ah) small ba terium that in e ts human
ells as an bligate parasite
cholangiography (k hl-an-jee-O G-rah- ee) spe ialized x-ray pr -
edure used t visualize the gallbladder and the maj r bile and
pan reati du ts
GLOSSARY 709
cholecystectomy (k hl-eh-sis- EK-t h-mee) surgi al rem val
the gallbladder
cholecystitis (k h-leh-sis- YE-tis) inf ammati n the gallbladder
cholecystokinin (CCK) (k h-lee-sis-t h-KYE-nin) h rm ne se-
reted r m the intestinal mu sa the du denum that stimu-
lates the ntra ti n the gallbladder, resulting in bile f wing
int the du denum
choledocholithiasis (k h-LED-uh-k h-lih- H Y-ah-sis) nditi n
a gallst ne bl king the mm n bile du t; a type
cholelithiasis
cholelithiasis (k h-leh-lih- H EE-ah-sis) nditi n having gall-
st nes ( mp sed h lester l r bile salts), hard mineral de-
p sits that may rm and lle t in the gallbladder
cholera (KAH L-er-ah) p tentially atal, in e ti us ba terial disease
hara terized by severe diarrhea, v miting, ramps, dehydrati n;
see also Appendix A, able 3
cholesterol (k h-LES-ter- l) ster id lipid und in many b dy tis-
sues and in animal at
cholinergic ber (k h-lin-NER-jik FYE-ber) ax n wh se terminals
release a etyl h line
chondrocyte (KON-dr h-syte) artilage ell
chondroma (k n-DROH -mah) benign tum r artilage
chondrosarcoma (k n-dr h-sar-KOH -mah) an er artilage
tissue
chordae tendineae (KOR-dee ten-DIN-ee) stringlike stru tures
that atta h the AV valves t the wall the heart
chorion (KO H -ree- n) stru ture that devel ps int an imp rtant
etal membrane in the pla enta
chorionic gonadotropin (hCG) (k h-ree-O N-ik g h-nah-d h-
ROH -pin) any several h rm nes that are se reted as the
uterus devel ps during pregnan y
chorionic villi (k h-ree-ON-ik VIL-aye) stru tures that nne t
the bl d vessels the h ri n t the pla enta
chorionic villus sampling (CVS) (k h-ree-ON-ik VIL-lus SAM-
pling) pr edure in whi h a tube is inserted thr ugh the (uterine)
ervi al pening and a sample the h ri ni tissue surr unding
a devel ping embry is rem ved r geneti testing; mpare with
amniocentesis
choroid (KO H -r yd) middle layer the eyeball that ntains a dark
pigment t prevent the s attering in ming light rays
choroid plexus (KO H -r yd PLEK-sus) a netw rk brain apillar-
ies that are inv lved with the pr du ti n erebr spinal f uid
chromatid (KRO H -mah-tid) ne a pair identi al strands
within a repli ated hr m s me
chromatin granule (KROH -mah-tin GRAN-y -ul) deep-staining,
grainy-appearing substan e in the nu leus ells; ndenses int
distin t hr m s mes during ell divisi n
chromosomal genetic disease (kr h-m h-SOH -mal jeh-NE -ik)
disease that results r m hr m s mal breakage r r m abn r-
mal presen e r absen e entire hr m s mes
chromosome (KROH -meh-s hm) DNA m le ule that has iled
t rm a mpa t mass during mit sis r mei sis; ea h hr m -
s me is mp sed regi ns alled genes, ea h whi h transmits
hereditary in rmati n
chronic (KRON-ik) l ng-lasting, as in hr ni disease
chronic bronchitis (KRO N-ik br ng-KYE-tis) hr ni inf amma-
ti n the br n hi and br n hi les. It is hara terized by
edema and ex essive mu us pr du ti n, whi h ten bl k air
passages
chronic lymphocytic leukemia (CLL) (KRON-ik LIM- h-sit-ik
l -KEE-mee-ah) type hr ni (sl w nset and pr gressi n)
710 GLOSSARY
bl d an er m st mm n in lder adults; hara terized by an-
er us trans rmati n and in reased numbers B lymph ytes
chronic myeloid leukemia (CML) (KRON-ik MY-l yd l -KEE-
mee-ah) type hr ni (sl w nset and pr gressi n) bl d
an er hara terized by an er us trans rmati n and in reased
numbers granul yti white bl d ells (W BCs)
chronic obstructive pulmonary disease (COPD ) (KRON-ik b-
S RUK-tiv PUL-m h-nayr-ee dih-ZEEZ) general term re er-
ring t a gr up dis rders hara terized by pr gressive, irrevers-
ible bstru ti n air f w in the lungs; see bronchitis, emphysema
chronic traumatic encephalopathy (C E) (KRO N-ik traw-MA -
ik en-se -al-O P-path-ee) brain dis rder resulting r m repeated
trauma t the brain that inv lves a umulati n abn rmal
pr teins and is hara terized by mem ry l ss and parkins nism
Chvostek sign (ke-VOSH -tek syne) abn rmal spasms a ial
mus les in hyp al emi patients in resp nse t light taps t
stimulate the a ial nerve (CN VII); named r Austrian surge n
Franz Chv stek
chyme (kyme) partially digested d mixture leaving the st ma h
cilia (SIL-ee-ah) (sing., ilium) tiny, hairlike pr je ti ns ells that
dete t hanges utside the ell; s me ilia an m ve, pr pelling
mu us al ng a sur a e
ciliary escalator (SIL-ee-ayr-ee ES-kuh-lay-ter) pr ess ilia
m ving mu us and entrapped parti les upward and ut the
respirat ry tra t
ciliary muscle (SIL-ee-ayr-ee MUS-el) sm th mus le in the iliary
b dy the eye that suspends the lens and un ti ns in a m-
m dati n us r near visi n
ciliate (SIL-ee-at) type pr t z an having ilia
cilium (SIL-ee-um) see cilia
circulatory shock (SER-ky -lah-t r-ee) ailure the ir ulat ry
( ardi vas ular) system t deliver adequate xygen t the tissues
the b dy
circulatory system (SER-ky -lah-t r-ee SIS-tem) see cardio-
vascular system
circumcision (ser-kum-SIH -zhun) surgi al rem val the reskin
r prepu e n the penis r lit ris
circumduct (ser-kum-D UK ) t m ve a part s its distal end m ves
in a ir le
circumduction (ser-kum-D UK-shun) m ving a part s its distal
end m ves in a ir le
circumvallate (ser-kum-VAL-ayt) re erring t anything en ir led
with a ridge r m at
circumvallate papilla (ser-kum-VAL-ayt pah-PIL-ah) any the
huge d melike bumps with entral p sts n the p steri r sur a e
the t ngue mu sa that rm a transverse r w; ea h ne n-
tains th usands taste buds
cirrhosis (sih-RO H -sis) degenerati n liver tissue hara terized by
the repla ement damaged liver tissue with br us r atty n-
ne tive tissue
cisterna chyli (sis- ER-nah KYE-lee) an enlarged p u h n the
th ra i du t that serves as a st rage area r lymph m ving t -
ward its p int entry int the ven us system
citric acid cycle (SI -rik AS-id SYE-kul) the se nd series
hemi al rea ti ns in the pr ess glu se metab lism; it is an
aer bi pr ess; als re erred t as the Krebs cycle
clavicle (KLAV-ih-kul) llar b ne, nne ts the upper extremity t
the axial skelet n
cleavage urrow (KLEE-vij F UR- h) appears at the end ana-
phase and begins t divide the ell int tw daughter ells
cle t lip (kle t) ngenital de e t resulting in ne r m re le ts in
the upper lip
cle t palate (kle t PAL-et) ngenital de e t resulting in a ssure
the palate in the r the m uth
clinical laboratory technician (KLIN-ih-kal LAB-rah-t r-ee tek-
NISH -en) health- are w rker wh lle ts samples and s ienti -
ally analyzes tissues, b dy f uids, and ther materials r medi al
purp ses; als alled medi al lab rat ry te hn l gist r te hni ian
clitoris (KLI - h-ris) ere tile tissue l ated within the vestibule
the vagina
clone (kl hn) any a amily many identi al ells des ended r m
a single parent ell
closed racture (FRAK- hur) simple ra ture; a b ne ra ture in
whi h the skin is n t pier ed by b ne ragments
coccus (KOK-us) (pl., i) spheri al ba terial ell
cochlea (KO H K-lee-ah) snail shell r stru ture similar shape;
relates t a stru ture within the inner ear
cochlear duct (KOH K-lee-ar dukt) membran us tube within the
b ny hlea the inner ear
cochlear implant (KO H K-lee-ar IM-plant) arti ial hearing devi e
that uses ele tr ni ir uits t per rm the un ti ns the -
hlea the inner ear
cochlear nerve (KOH K-lee-ar nerv) part vestibul hlear nerve
( ranial nerve VIII) atta hed t the hlea; sens ry nerve re-
sp nsible r hearing
codominance (k h-D O M-ih-nan e) in geneti s, a rm d mi-
nan e in whi h tw d minant versi ns a trait are b th ex-
pressed in the same individual
codon (KOH -d n) in RNA, a triplet three base pairs that des
r a parti ular amin a id
coenzyme (k h-EN-zyme) m le ule that assists an enzyme during
metab lism, ten by arrying a m le ule ( r m le ule ragment)
r m ne hemi al pathway t an ther
colic exure (le t or right) (KO H L-ik FLEK-shur) bend the
l n; the le t colic exure is als alled the spleni f exure and the
right colic exure is als alled the hepatic exure
colitis (k h-LYE-tis) any inf ammat ry nditi n the l n and/
r re tum
collagen (KAH L-ah-jen) prin ipal rgani nstituent nne -
tive tissue
collecting duct (CD ) (k h-LEK-ting dukt) a straight part a renal
tubule rmed by distal tubules several nephr ns j ining t gether
colloid (KO L- yd) diss lved parti les with diameters 1 t
100 millimi r ns (1 millimi r n equals ab ut 1/25,000,000 in h)
colon (KOH -l n) see intestine
colonoscopy (k h-l n-AH -skah-pee) medi al pr edure in whi h
the lining the l n is he ked r l re tal an er r ther
abn rmalities by inserting a f exible s pe thr ugh the anus and
int the l n
color blindness (KUL- r BLIND-nes) X-linked inherited ndi-
ti n in whi h ne r m re ph t pigments in the nes the
retina are abn rmal r missing
colorectal cancer (k hl- h-REK-tal KAN-ser) mm n rm
an er, usually aden ar in ma, ass iated with advan ed age,
l w- ber/high- at diet, and geneti predisp siti n
colostomy (kah-LAH -st h-mee) surgi al pr edure in whi h an
arti ial anus is reated n the abd minal wall by utting the
l n and bringing the ut ends ut t the sur a e t rm an
pening alled a stoma
columnar (k h-LUM-nar) ell shape in whi h ells are higher than
they are wide
combining site (k m-BINE-ing syte) antigen-binding site; any the
antigen re ept r regi ns n an antib dy m le ule; shape ea h
mbining site is mplementary t shape a spe i antigen

comedones (k m-eh-DOH NZ) (sing., med ) inf amed lesi ns
ass iated with early stages a ne rmed when seba e us gland
du ts be me bl ked
comminuted racture (k m-ih-NO O -ted FRAK- hur) b ne ra -
ture hara terized by many b ne ragments
common bile duct (KOM- n byle dukt) du t r m the liver that
empties int the du denum; made up the merging the he-
pati du t with the ysti du t
communicable (k h-MYO O-nih-kah-bil) able t spread r m ne
individual t an ther
compact bone (k m-PAK ) see dense bone
compensated metabolic acidosis (KOM-pen-say-ted met-ah-
BO L-ik as-ih-D OH -sis) the b dys su ess ul adjustment its
b dy hemistry r the purp se returning the bl d pH value
t near n rmal levels a ter metab li a id sis has devel ped
compensation (k m-pen-SAY-shun) pr ess by whi h the b dy at-
tempts t untera t a shi t away r m h me stati balan e, thus
mpensating r the hange
complement (KOM-pleh-ment) any several ina tive pr tein en-
zymes n rmally present in bl d that when a tivated kill reign
ells by diss lving them
complement-binding sites (KOM-pleh-ment BIND-ing) l ati ns
n an antib dy m le ule that be me available a ter exp sure t
an antigen and that bind t mplement pr teins in the bl d
plasma t trigger a mplement as ade (immune system re-
sp nse) that harms the antigen- ntaining ell
complement cascade (KO M-pleh-ment kas-KAYD) rapid- re se-
ries hemi al rea ti ns inv lving pr teins alled complements
(n rmally present in bl d plasma) triggered by ertain antib dy-
antigen rea ti ns (and ther stimuli) and resulting in the rma-
ti n tiny pr tein rings that reate h les in a reign ell and
thus ause its destru ti n
complementary base pairing (k m-pleh-MEN-tah-ree bays
PAYR-ing) b nding purines and pyrimidines in DNA; adenine
always binds with thymine, and yt sine always binds with
guanine
complete blood cell count (CBC) (k m-PLEE blud sel k wnt)
lini al bl d test that usually in ludes standard red bl d ell,
white bl d ell, thr mb yte unts, the di erential white bl d
ell unt, hemat rit, and hem gl bin ntent
complete racture (k m-PLEE FRAK- hur) b ne ra ture har-
a terized by mplete separati n b ne ragments
compliance (k m-PLY-ans) the ease stret h a materialas in
lung mplian e, the stret hability the lung tissues
compound (KOM-p und) substan e having m re than ne kind
element
computed tomography (C ) (k m-PYO O-ted t h-MO G-rah-
ee) radi graphi imaging te hnique in whi h a patient is s anned
with x-rays and a mputer nstru ts an image that appears t
be a ut se ti n the pers ns b dy
concave (KON-kave) a r unded, s mewhat depressed sur a e
concave curvature (k n-KAYV KUR-vah- hur) inward r secondary
urvatures the adult vertebral lumn in the ervi al and lum-
bar regi ns
concentric contraction (k n-SEN -rik k n- RAK-shen) type
is t ni mus le ntra ti n in whi h a mus les length
de reases
concentric lamella (k n-SEN-trik lah-MEL-ah) ring al i ed
matrix surr unding the entral (H aversian) anal
concha (KO NG -kah) (pl., n hae) shell-shaped stru ture; r
example, b ny pr je ti ns int the nasal avity; als alled
turbinate
GLOSSARY 711
concussion (k n-KUSH -in) type traumatic brain injury ( BI)
resulting r m a j lt t the head that bends the brainstem and
auses temp rary hemi al hanges in the brain, pr du ing any
a variety un ti nal hanges
conduction (k n-D UK-shun) in regard t b dy temperature regula-
ti n, trans er heat energy t the skin and then the external
envir nment
conductive keratoplasty (CK) (k n-D UK-tiv ker-ah-t h-PLAS-
tee) therapy using radi requen y (RF) energy t heat hair-thin
pr bes that are then used t hange the shape the rnea t
rre t visi n
condyloid joint (KON-dih-l yd j ynt) ellips idal j int in whi h an
val pr ess ts int an val s ket
cone re ept r ell l ated in the retina that is stimulated by bright
light; di erent types nes are stimulated by di erent ranges
wavelengths ( l rs)
congenital (k n-JEN-ih-tall) term that re ers t a nditi n present
at birth; ngenital nditi ns may be inherited r may be a -
quired in the w mb r during delivery
congestive heart ailure (CHF) (k n-JES-tiv hart FAYL-y r) le t
heart ailure; inability the le t ventri le t pump e e tively,
resulting in ngesti n in the systemi and pulm nary
ir ulati ns
conjunctiva (k n-junk- IH -vah) mu us membrane that lines the
eyelids and vers the s lera (white p rti n)
conjunctivitis (k n-junk-tih-VYE-tis) inf ammati n the n-
jun tiva, usually aused by irritati n, in e ti n, r allergy
connective tissue (k h-NEK-tiv ISH -y ) m st abundant and
widely distributed tissue in the b dy and has numer us
un ti ns
connective tissue membrane (k h-NEK-tiv ISH -y MEM-
brane) ne the tw maj r types b dy membranes; mp sed
ex lusively vari us types nne tive tissue
constipation (k n-stih-PAY-shun) nditi n aused by de reased
m tility the large intestine, resulting in the rmati n small,
hard e es and di ulty in de e ati n
contact dermatitis (KON-takt der-mah- YE-tis) a l al skin in-
f ammati n that lasts a ew h urs r days and is initiated by the
skin being exp sed t an antigen
continuous ambulatory peritoneal dialysis (CAPD ) (k n- IN-
y -us AM-by -lah-t r-ee payr-ih-t h-NEE-al dye-AL-ih-
sis) an alternative rm treatment r renal ailure that may be
used instead the m re mplex and expensive hemodialysis
contraception (k n-trah-SEP-shun) repr du tive planning with a
g al av iding pregnan y
contractile unit (k n- RAK-til YO O-nit) the sar mere, the basi
un ti nal unit skeletal mus le
contractility (k n-trak- IL-ih-tee) ability t ntra t a mus le
contraction (k n- RAK-shun) ability mus le ells t sh rten r
ntra t
control center (k n- RO H L SEN-ter) part a h me stati eed-
ba k l p that integrates (puts t gether) set p int (prepr -
grammed) in rmati n with a tual sensed in rmati n ab ut a
physi l gi al variable and then p ssibly sends ut a signal t an
e e t r t hange the variable
contusion (k n- O O -zhun) l al injury aused by me hani al
trauma hara terized by limited hem rrhaging under the skin, as
in a mus le ntusi n r skin ntusi n aused by a bl w t the
b dy; a bruise
convection (k n-VEK-shun) trans er heat energy t air that is
f wing away r m the skin
convex (KON-veks) a r unded, s mewhat elevated sur a e
712 GLOSSARY
convex curvature (k n-VEKS KUR-vah- hur) the th ra i r sa ral
utward urving the adult vertebral lumn; an in ant has
single primary utward urvature the length its spine
cor pulmonale (k hr pul-mah-NAL-ee) ailure the right atrium
and ventri le t pump bl d e e tively, resulting r m bstru -
ti n pulm nary bl d f w
cornea (KO R-nee-ah) transparent, anteri r p rti n the s lera
corneal stem cell transplant (KOR-nee-al stem sel tranz-PLAN )
pr edure in whi h adult stem ells harvested r m adavers are
transplanted int and ar und the edges the rneas a re ipi-
ent t regr w a healthy rnea
coronal (k h-RO H -nal) literally like a r wn; a r nal plane di-
vides the b dy r an rgan int anteri r and p steri r regi ns
coronary angioplasty (KOH R- h-nayr-ee AN-jee- h-plas-tee)
medi al pr edure in whi h a devi e is inserted int a bl ked
r nary artery t r e pen a hannel r bl d f w thr ugh
the my ardium the heart
coronary artery (KOH R- h-nayr-ee AR-ter-ee) the right and le t
r nary arteries are the rst arteries t bran h the a rta; they
supply bl d t the my ardium (heart mus le)
coronary bypass surgery (KO H R- h-nayr-ee BYE-pass SER-
jer-ee) surgery t relieve severely restri ted r nary bl d f w;
veins are taken r m ther parts the b dy and then reatta hed
where needed t bypass the partial bl kage
coronary circulation (KOH R- h-nayr-ee ser-ky -LAY-shun) de-
livery xygen and rem val waste pr du t r m the my ar-
dium (heart mus le)
coronary embolism (KOH R- h-nayr-ee EM-b h-liz-em) bl king
a r nary bl d vessel by a l t
coronary heart disease (KOH R- h-nayr-ee hart dih-ZEEZ) dis-
ease (bl kage r ther de rmity) the vessels that supply the
my ardium (heart mus le); ne the leading auses death
am ng adults in the United States
coronary sinus (KOH R- h-nayr-ee SYE-nus) area that re eives
de xygenated bl d r m the r nary veins and empties it int
the right atrium
coronary thrombosis (KO H R- h-nayr-ee thr m-BO H -sis) rma-
ti n a bl d l t in a r nary bl d vessel
coronary vein (KO H R- h-nayr-ee vane) any vein that arries bl d
r m the my ardial apillary beds t the r nary sinus
coronavirus (k h-ROH N-ah-vye-rus) ateg ry RNA- ntaining
viruses that in e t humans and ther vertebrate animals, s me-
times ausing severe respirat ry in e ti ns (and s metimes intes-
tinal in e ti ns and neur l gi al syndr mes); r example, SARS
(severe acute respiratory syndrome) is aused by a type r -
navirus, SARS-associated coronavirus (SARS-C V)
corpora cavernosa (KO H R-p hr-ah kav-er-NOH -sah) (sing., r-
pus avern sum) tw lumns ere tile tissue und in the sha t
the penis
corpus callosum (KOH R-pus kah-LOH -sum) brain stru ture at
whi h the right and le t erebral hemispheres are j ined
corpus luteum (KO H R-pus LO O -tee-um) a h rm ne-se reting
glandular stru ture that is trans rmed a ter vulati n r m a
ruptured lli le; it se retes hief y pr gester ne, with s me estr -
gen se reted as well
corpus spongiosum (KOH R-pus spun-jee-OH -sum) a lumn
ere tile tissue surr unding the urethra in the penis
cortex (KOH R-teks) uter part an internal rgan; r example,
the uter part the erebrum and the kidneys
cortical nephron (KOH R-tih-kahl NEF-r n) mi r s pi unit
the kidney that makes up 85% all nephr n units in the kidney;
is l ated alm st entirely in the renal rtex
corticoid (KOH R-tih-k yd) any the h rm nes se reted by the
three ell layers the adrenal rtex
cortisol (KO H R-tih-s l) h rm ne se reted by the adrenal rtex t
stimulate the availability glu se in the bl d; in large
am unts, rtis l an depress immune un ti ns, as when it is
used as a drug treatment; see hydrocortisone
cosmetic surgery (k z-ME -ik SUR-jeh-ree) surgi al medi al spe-
ialty used n impr ving nes appearan e
cosmetician (k z-meh- ISH -un) w rker wh spe ializes in the
manu a ture, sale, r appli ati n makeup r ther pr du ts
that a e t nes appearan e
cotransport (k h- RANZ-p rt) a tive transp rt pr ess in whi h
tw substan es are m ved t gether a r ss a ell membrane; r
example, s dium and glu se may be transp rted t gether a r ss
a membrane
countercurrent mechanism (KO N-ter-ker-rent M EK-uh-niz-
em) system in whi h renal tubule ltrate f ws in pp site di-
re ti ns, maintaining a hyper sm ti medulla; a ilitates urine
n entrati n
covalent bond (k h-VAYL-ent) hemi al b nd rmed by tw at-
ms sharing ne r m re pairs ele tr ns
Cowper gland see bulbourethral gland
coxal bone (k k-SAL) the pelvi b ne r hipb ne (als kn wn as the
os coxae r the innominate bone); rmed by usi n three distin t
b nes (ilium, is hium, and pubis) during skeletal devel pment
cramps (kramps) pain ul mus le spasms (inv luntary twit hes) that
result r m irritating stimuli, as in mild inf ammati n, r r m i n
imbalan es
cranial (KRAY-nee-al) relating t ( r t ward) the head
cranial cavity (KRAY-nee-al KAV-ih-tee) spa e inside the skull that
ntains the brain
cranial nerve (CN) (KRAY-nee-al nerv) any 12 pairs nerves
that atta h t the undersur a e the brain and ndu t impulses
between the brain and stru tures in the head, ne k, and th rax
craniosacral (kray-nee- h-SAY-kral) relating t parasympatheti
nerves
cranium (KRAY-nee-um) b ny vault made up eight b nes that
en ases the brain
crenation (kreh-NAY-shun) abn rmal n t hing in an erythr yte
aused by shrinkage a ter suspensi n in a hypert ni s luti n
cretinism (KREE-tin-iz-em) dwar sm aused by hyp se reti n
the thyr id gland
crista ampullaris (KRIS-tah am-py -LAYR-is) a spe ialized re-
ept r l ated within the semi ir ular anals that dete ts head
m vements
Crohn disease (kr hn dih-ZEEZ) hr ni inf ammat ry b wel
disease
crossing-over (KROS-ing OH -ver) phen men n that urs dur-
ing mei sis when pairs h m l g us hr m s mes synapse and
ex hange genes
croup (kr p) n nli e-threatening type laryngitis generally seen
in hildren less than 3 years age; hara terized by barklike
ugh and aused by parainf uenza viruses
crown (kr wn) t pm st part an rgan r ther stru ture, su h as
a t th
cruciate ligament (KRU-shee-ayt LIG-uh-ment) either tw
r ssed ligaments inside the knee j int avity that nne t the
tibia t the emur; the anterior cruciate ligament (ACL) and the
posterior cruciate ligament (PCL)
crural (KRO OR-al) relating t the leg (s metimes the entire l wer
extremity)
crust (krust) s ab; area the skin vered by dried bl d r exudate

cryptorchidism (krip- O R-kih-diz-em) undes ended testi les
cubital (KYO O-bih-tall) relating t the elb w
cuboid (KYO O-b yd) resembling a ube
cuboidal (KYO O-b yd-al) ell shape resembling a ube
culture (KUL - hur) gr wth mi r bes in a lab rat ry medium
r the purp se is lating and identi ying path gens r m hu-
man b dy f uids
cupula (KYO O -py -lah) the small up-shaped, f aplike stru ture at
the base ea h semi ir ular anal the ear that bends during
m vement the head t a ilitate the sense dynami
equilibrium
Cushing syndrome (KO OSH -ing SIN-dr hm) nditi n aused by
the hyperse reti n glu rti ids r m the adrenal rtex
cuspid (KUS-pid) having usps r p ints; r example, the canine
tooth l ated lateral t the se nd in is r that serves t pier e r
tear d being eaten is als alled a cuspid tooth
cutaneous (ky - AYN-ee-us) relating t the skin
cutaneous membrane (ky - AYN-ee-us MEM-brane) primary
rgan the integumentary system; the skin
cuticle (KYO O -tih-kul) skin ld vering the r t the nail
cyanosis (sye-ah-NOH -sis) nditi n in whi h light-skinned indi-
viduals exhibit a bluish l rati n resulting r m relatively l w
xygen ntent in the arterial bl d; literally blue nditi n
cyclic AMP (SIK-lik A M P) (aden sine m n ph sphate) ne
several se nd messengers that delivers in rmati n inside the
ell and thus regulates the ells a tivity
cystic duct (SIS-tik dukt) j ins with the mm n hepati du t t
rm the mm n bile du t
cystic brosis (CF) (SIS-tik ye-BROH -sis) inherited disease in-
v lving abn rmal hl ride i n (Cl ) transp rt; auses se reti n
abn rmally thi k mu us and ther pr blems
cystitis (sis- YE-tis) inf ammati n r in e ti n the urinary bladder
cystoscope (SIS-t h-sk hp) h ll w instrument inserted thr ugh ure-
thra int the bladder that permits passage a light s ur e and
surgi al instruments t be used r dire t examinati n, bi psy, surgi-
al rem val, r treatment bladder r ther urinary tra t lesi ns
cytokine (SYE-t h-kyne) hemi al released r m ells t trigger r
regulate innate and adaptive immune resp nses
cytokinesis (sye-t h-kin-EE-sis) pr ess by whi h a dividing ell
splits its yt plasm and plasma membrane int tw distin t
daughter ells; yt kinesis happens al ng with mit sis ( r mei -
sis) during the ell divisi n pr ess
cytology (sye- O L- h-jee) study ells
cytologist (SYE- OL-uh-jist) s ientist wh studies ells
cytoplasm (SYE-t h-plaz-em) the gel-like substan e a ell ex lu-
sive the nu leus and ther rganelles
cytosine (SYE-t h-seen) ne several nitr gen- ntaining bases
that make up nu le tides, whi h in turn make up nu lei a ids
su h as DNA and RNA; in the ell, it an hemi ally bind t
an ther nitr gen us base, guanine (G r g), t rm a m re m-
plex stru ture r in translating geneti des; symb lized by the
letter C r c; see also guanine, adenine, thymine, uracil
cytoskeleton (sye-t h-SKEL-eh-t n) ells internal supp rting,
m ving ramew rk
cytotoxic cell (sye-t h- OK-sik) ell killing ell
D
deciduous (deh-SID-y -us) temp rary; shedding stru tures at a
ertain stage gr wth; r example, deciduous teeth, whi h are
mm nly re erred t as baby teeth, are shed t make way r the
permanent adult teeth
GLOSSARY 713
decubitus ulcer (deh-KYO O -bih-tus UL-ser) pressure s re that
ten devel ps ver a b ny pr minen e, su h as the heel, when
lying in ne p siti n r pr l nged peri ds
deep in anat my, a stru ture is deep t an ther stru ture when it is
urther inside the b dy; pp site super cial
de ecation (de -eh-KAY-shun) eliminati n e es
de brillation (deh- b-rih-LAY-shun) ele tri al stimulati n the
heart in rder t rest re n rmal heart rhythm (used when the
heart brillates, r gets ut rhythm); see ventricular brillation
and automatic external de brillator
degeneration (dih-jen-uh-RAY-shun) a bi l gi al pr ess, still
s mewhat puzzling t s ientists, in whi h tissues break
d wn as a n rmal nsequen e aging; degenerati n ne
r m re tissues resulting r m disease, whi h an ur at any
time
deglutition (deg-l - ISH -un) swall wing
dehydration (dee-hye-DRAY-shun) lini al term that re ers t an
abn rmal l ss f uid r m the b dys internal envir nment
dehydration synthesis (dee-hye-DRAY-shun SIN-the-sis) hemi-
al rea ti n in whi h large m le ules are rmed by rem ving
water r m smaller m le ules and j ining them t gether
deltoid (DEL-t yd) having a triangular shape; r example, the
delt id mus le
dementia (deh-MEN-shah) syndr me brain abn rmalities that
in ludes l ss mem ry, sh rtened attenti n span, pers nality
hanges, redu ed intelle tual apa ity, and m t r dys un ti n
dendrite (DEN-dryte) bran hing r treelike; a nerve ell pr ess
that transmits impulses t ward the b dy
dendritic cell (D C) (DEN-drih-tik) phag yti ells the immune
system
dengue (DENG-gay r DENG-gee) seri us viral in e ti n aused
by a type f avivirus
dense bone b ne that has a hard, dense uter layer; als alled com-
pact bone
dense brous connective tissue (dense FYE-brus k h-NEK-tiv
ISH -y ) nne tive tissue nsisting pr tein bers pa ked
densely in the matrix
dental caries (DEN -al KAYR-ees) see caries
dentin (DEN-tin) hie b nelike dental tissue vered by enamel in
r wn and by ementum in ne k and r t areas t th
deoxyribonucleic acid (D NA) (dee- k-see-rye-b h-n k-LAY-ik
AS-id) geneti material the ell that arries the hemi al
blueprint the b dy
depilatories (deh-PIL-ah-t h-rees) hair rem vers
depolarization (dee-p h-lar-ih-Z AY-shun) the ele tri al a tivity
that triggers a ntra ti n the heart mus le
dermal-epidermal junction (D EJ) (DER-malEP-ih-der-mal
JUNK-shun) jun ti n between the thin epidermal layer the
skin and the dermal layer; pr vides supp rt r the epidermis
dermal papilla (DER-mal pah-PIL-ah) (pl., papillae) upper regi n
the dermis that rms part the dermal-epidermal jun ti n
and rms the ridges and gr ves ngerprints
dermatitis (der-mah- YE-tis) general term re erring t any inf am-
mati n the skin
dermatome (DER-mah-t hm) skin sur a e area supplied by a single
spinal nerve
dermatosis (der-mah- O H -sis) general term meaning skin
nditi n
dermis (DER-mis) the deeper the tw maj r layers the skin,
mp sed dense br us nne tive tissue interspersed with
glands, nerve endings, and bl d vessels; s metimes alled the
true skin
714 GLOSSARY
descending colon (dih-SEND-ing KOH -l n) p rti n the l n
that lies in the verti al p siti n, n the le t side the abd men;
extends r m bel w the st ma h t the ilia rest
developmental process (dee-vel- p-MEN-tal PROS-es) hanges
and un ti ns urring during a humans early years as the b dy
be mes m re e ient and m re e e tive
deviated septum (DEE-vee-ay-ted SEP-tum) abn rmal nditi n
in whi h the nasal septum (dividing wall between the tw nasal
air passages) is l ated ar r m its n rmal p siti n, p ssibly b-
stru ting n rmal nasal breathing
diabetes insipidus (dye-ah-BEE-teez in-SIP-ih-dus) nditi n re-
sulting r m hyp se reti n ADH in whi h large v lumes
urine are rmed and, i le t untreated, may ause seri us health
pr blems
diabetes mellitus (dye-ah-BEE-teez mel-AYE-tus) a nditi n re-
sulting when the pan reati islets se rete t little insulin, result-
ing in in reased levels bl d glu se
diabetic ketoacidosis (dye-ah-BE -ik kee-t h-as-ih-D O H -sis)
l w bl d pH resulting r m an a umulati n ket ne b dies in
the bl d in diabetes mellitus
diabetic retinopathy (dye-ah-BE -ik ret-in-AH -path-ee) gr wth
r hem rrhage bl d vessels aused by diabetes mellitus
diagnostic medical sonographer (dye-ag-NOS-tik MED-ih-kul
s n-AH -gra -er) health pr essi nal wh uses s n graphy t ex-
amine internal b dy stru tures as a medi al diagn sti strategy
dialysis (dye-AL-ih-sis) separati n smaller (di usible) parti les
r m larger (n ndi usible) parti les thr ugh a semipermeable
membrane
diaphragm (DYE-ah- ram) membrane r partiti n that separates
ne thing r m an ther; the f at mus ular sheet that separates the
th rax and abd men and is a maj r mus le respirati n
diaphysis (dye-AF-ih-sis) (pl., diaphyses) sha t a l ng b ne
diarrhea (dye-ah-REE-ah) de e ati n liquid e es
diarthrosis (dye-ar- H ROH -sis) (pl., diarthr ses) reely m vable
j int
diastole (dye-AS-t h-lee) relaxati n the heart, interp sed be-
tween its ntra ti ns; pp site systole
diastolic blood pressure (dye-ah-S O L-ik blud PRESH -ur) bl d
pressure in arteries during diast le (relaxati n) the heart
diencephalon (dye-en-SEF-ah-l n) between brain; parts the
brain between the erebral hemispheres and the mesen ephal n
(midbrain)
dietitian (dye-eh- ISH -en) pers n wh w rks in nutriti n s ien e
by devel ping health ul meals and dietary health strategies; als
dietician
dif erential WBC count (di -er-EN-shal W BC k wnt) spe ial type
white bl d ell (W BC) unt in whi h pr p rti ns ea h
type W BC are rep rted as per entages the t tal unt
dif erentiate (di -er-EN-shee-ayt) t be me di erent in stru ture
and un ti n, as when s me the riginal ells early devel p-
mental stages di erentiate t be me mus le ells and ther ells
be me nerve ells, et .
dif erentiation (di -er-EN-shee-AY-shun) pr ess by whi h daugh-
ter ells be me di erent in stru ture and un ti n (by using
di erent genes r m the gen me, all ells the b dy share), as
when s me the riginal ells early devel pmental stages di -
erentiate t be me mus le ells and ther ells be me nerve
ells, and s n
dif usion (dih-FYO O -zhen) spreading; r example, s attering
diss lved parti les
digestion (dye-JES- hun) the breakd wn d materials either
me hani ally (i.e., by hewing) r hemi ally (i.e., by a ti n
digestive enzymes)
digestive system (dih-JES-tiv SIS-tem) rgans that w rk t gether
t ensure pr per digesti n and abs rpti n nutrients
digital (DIJ-ih-tal) in anat my, relating t ngers and t es
digitalis (dij-ih- AL-is) drug used t treat atrial brillati n; dig xin
is an example a digitalis preparati n
diploe (DIP-l h-EE) regi n an ell us (sp ngy) b ne within the
wall a f at b ne the ranium; als spelled diplo
directional term any term used t give dire ti n in the b dy, su h as
le t, right, anteri r, p steri r, superi r, in eri r, et .
disaccharide (dye-SAK-ah-ryde) d uble sugar, su h as su r se,
malt se, r la t se; type arb hydrate made up tw sa ha-
ride gr ups (m n sa harides)
discharging chambers (dis-CH ARJ-ing CH AYM-bers) the tw
l wer hambers the heart alled ventricles
disease (dih-ZEEZ) any signi ant abn rmality in the b dys stru -
ture r un ti n that disrupts a pers ns vital un ti n r physi al,
mental, r s ial well-being
dislocation (dis-l w-KAY-shun) abn rmal m vement b dy parts,
as in separati n b nes a j int; see subluxation
dissection (dye-SEK-shun) utting te hnique used t separate b dy
parts r study
dissociate (dih-SOH -see-ayt) t break apart a mp und in s luti n
dissociation (dih-s h-see-AY-shun) separati n i ns as they dis-
s lve in water
distal (DIS-tal) t ward the end a stru ture; pp site proximal
distal convoluted tubule (D C ) (DIS-tal KON-v h-l -ted
O O-by l) the part the tubule distal t the as ending limb
the nephr n l p in the kidney
disuse atrophy (DIS-y s A -r h- ee) nditi n in whi h pr -
l nged ina tivity results in the mus les getting smaller in size; see
also atrophy
diuretic (dye-y -RE -ik) re erring t s mething that pr m tes
the pr du ti n urine
diuretic drug (dye-y -RE -ik drug) therapeuti substan e that
pr m tes r stimulates the pr du ti n urine; diureti drugs are
am ng the m st mm nly used drugs in medi ine
diverticulitis (dye-ver-tik-y -LYE-tis) inf ammati n diverti ula
(abn rmal utp u hings) the large intestine, p ssibly ausing
nstipati n
dizygotic twins (dye-zye-GO -ik twinz) see raternal twins
D NA (dee en ay) see deoxyribonucleic acid
D NA ngerprinting (dee en ay FING-ger-print-ing) te hnique
used t analyze the geneti makeup individuals; mpares
nu le tide sequen es using ele tr ph resis
D NA replication (dee en ay rep-lih-KAY-shun) the unique ability
DNA m le ules t make pies themselves
dominant gene (D O M-ih-nant jeen) in geneti s, a dominant gene
has e e ts that appear in the spring (d minant rms a gene
are ten represented by upper ase letters); mpare with
recessive gene
dopamine (D O H -pah-meen) hemi al neur transmitter
doping (DOH -ping) the additi n bl d ( r bl d pr du ts),
ster ids, r ther per rman e-enhan ing substan es t the
bl dstream, a pra ti e per rmed by s me athletes that an have
seri us (even atal) side e e ts and is utlawed w rldwide
dorsal (D OR-sal) re erring t the ba k; pp site ventral; in hu-
mans, the p steri r is d rsal
dorsal body cavity (DOR-sal BOD-ee KAV-ih-tee) in ludes the
ranial and spinal avities
dorsal cavity see dorsal body cavity
dorsal root ganglion (DOR-sal r t GANG-lee- n) gangli n
the d rsal r t l ated near the spinal rd; where the neur n ell
b dy the dendrites the sens ry neur n is l ated

dorsi ex (d r-sih-FLEKS) t bend the t with the t es p inting
upward
dorsi exion (d r-sih-FLEK-shun) m vement in whi h the t p
the t is elevated (br ught t ward the r nt the leg) with the
t es p inting upward
double helix (H EE-lix) shape DNA m le ules; a d uble spiral
dowagers hump (D OW-ah-jerz) kyph sis (abn rmal ba kward
urvature th ra i spine) aused by vertebral mpressi n
ra tures in ste p r sis
D own syndrome (SIN-dr hm) gr up sympt ms usually aused
by tris my hr m s me 21; hara terized by mental retarda-
ti n and multiple stru tural de e ts, in luding a ial, skeletal, and
ardi vas ular abn rmalities
D uchenne muscular dystrophy (D MD ) (d -SH EN MUS-ky -
lar DIS-tr h- ee) rm mus ular dystr phy (abn rmal mus le
devel pment in whi h n rmal mus le is repla ed with at and
br us tissue) inherited n the X hr m s me and hara terized
by mild leg mus le weakness that pr gresses rapidly t in lude
the sh ulder mus les and eventually death r m ardia r respi-
rat ry mus le weakness; als alled pseudohypertrophy ( alse
mus le gr wth)
ductless gland (DUK -les) spe ialized gland that se retes h r-
m nes dire tly int the bl d; end rine gland
ductus arteriosus (D UK-tus ar-teer-ee-O H -sus) nne ts the a rta
and the pulm nary artery, all wing m st bl d t bypass the e-
tuss devel ping lungs
ductus de erens (D UK-tus DEF-er-enz) a thi k, sm th, mus ular
tube that all ws sperm t exit r m the epididymis and pass r m
the s r tal sa int the abd minal avity; als kn wn as the vas
de erens
ductus venosus (D UK-tus veh-NOH -sus) a ntinuati n the
umbili al vein that shunts bl d returning r m the pla enta past
the etuss devel ping liver dire tly int the in eri r vena ava
duodenal papillae (d - h-DEE-nal pah-PIL-ee) du ts l ated in
the middle third the du denum that empty pan reati diges-
tive jui es and bile r m the liver int the small intestine; there
are tw du ts, the maj r du denal papilla and the min r papilla
duodenum (d - h-DEE-num r d -AH -deh-num) the rst subdi-
visi n the small intestine where m st hemi al digesti n urs
dura mater (D O O-rah MAH -ter) literally str ng r hard m ther;
uterm st layer the meninges
dust cells ma r phages that ingest parti ulate matter in the small air
sa s the lungs
dwar sm (dw r-FIZ-em) nditi n abn rmally small stature,
s metimes resulting r m hyp se reti n gr wth h rm ne
dysentery (DIS-en-tayr-ee) inf ammat ry nditi n l n har-
a terized by requent diarrhea that may ntain bl d r pus
dys unctional uterine bleeding (D UB) (dis-F UNK-shun-al YO O-
ter-in BLEED-ing) irregular r ex essive bleeding r m the
uterus resulting r m a h rm nal imbalan e
dysmenorrhea (dis-men- h-REE-ah) pain ul menstruati n
dyspnea (DISP-nee-ah) di ult r lab red breathing
dysrhythmia (dis-RI H -mee-ah) any abn rmality ardia
rhythm
dysuria (dis-YO O -ree-ah) pain ul, burning urinati n
E
eardrum (EAR-drum) the tympani membrane that separates the
external ear and middle ear
eccentric contraction (ek-SEN -rik k n- RAK-shun) type
is t ni mus le ntra ti n in whi h a mus les length in reases
under a l ad
GLOSSARY 715
eccrine (EK-rin) relating t an ex rine gland with se ret ry ells
that release se reti ns by ex yt sis, with ut l sing part the
ell as in apocrine glands
eccrine sweat gland (EK-rin swet gland) small sweat glands distrib-
uted ver the t tal b dy sur a e
echocardiogram (ek- h-KAR-dee- h-gram) medi al image pr -
du ed by a type s n graphy alled echocardiography
echocardiography (ek- h-kar-dee-O G-rah- ee) heart imaging
te hnique in whi h ultras und waves e h ba k r m heart tis-
sues t rm a ntinu us re rding heart stru ture m vement
during a series ardia y les
eclampsia (eh-KLAMP-see-ah) p tentially atal nditi n ass iated
with t xemia pregnan y; hara terized by nvulsi ns and ma
ectoderm (EK-t h-derm) the innerm st the primary germ layers
that devel ps early in the rst trimester pregnan y
ectopic pregnancy (ek- O P-ik PREG-nan-see) a pregnan y in
whi h the ertilized vum implants s mepla e ther than in the
uterus
eczema (EK-zeh-mah) inf ammat ry skin nditi n ass iated with
a variety diseases and hara terized by erythema, papules,
vesi les, and rusts
edema (eh-DEE-mah) a umulati n f uid in a tissue, as in in-
f ammati n; swelling
ef ector (e -FEK-t r) any rgan that has an e e t n the b dys in-
ternal envir nment in resp nse t eedba k; r example, v lun-
tary and inv luntary mus le, the heart, and glands
ef ector B cell (e -FEK-t r bee sel) ell that di erentiates r m a B
ell; synthesizes and se retes huge am unts antib dies
ef ector cell (e -FEK-t r) any ell that has an e e t in the b dy; a
ell that a ts as an e e t r; r example, the a tivated rms B
ells and ells are alled ef ector cells
ef ector cell (e -FEK-t r tee sel) ell that di erentiates r m a
ell; auses nta t killing a target ell
ef erent (EF- er-ent) arrying r m, as in ef erent neurons that trans-
mit impulses r m the entral nerv us system t the periphery;
pp site af erent
ef erent lymphatic vessel (EE- er-ent lim VES-el) any the small
lymphati vessels that arry lymphati f uid away r m a lymph
n de; mpare t af erent lymphatic vessel
ef erent neuron (EF- er-ent NO O-r n) neur n that transmits im-
pulses away r m the entral nerv us system and t ward the pe-
riphery; generally a motor neuron; mpare t af erent neuron
ehrlichiosis (ur-lik-ee-O H -sis) ba terial in e ti n transmitted by
ti ks and similar t Lyme disease
ejaculation (ee-jak-y -LAY-shun) sudden dis harging semen
r m the b dy
ejaculatory duct (ee-JAK-y -lah-t h-ree dukt) du t rmed by the
j ining the vas de erens and the du t r m the seminal vesi le
that all ws sperm t enter the urethra
elastin (e-LAS-tin) stret hy pr tein und in elasti ber
electrocardiogram (ECG or EKG) (eh-lek-tr h-KAR-dee- h-
gram) graphi re rd the hearts a ti n p tentials
electrocardiograph (e-lek-tr h-KAR-dee- h-gra ) ma hine that
pr du es ele tr ardi grams, graphi re rds the hearts ele -
tri al a tivity (v ltage f u tuati ns)
electroencephalogram (EEG) (eh-lek-tr h-en-SEF-uh-l h-gram)
graphi representati n v ltage hanges in brain tissue used t
evaluate nerve tissue un ti n
electrolyte (eh-LEK-tr h-lyte) substan e that diss iates int i ns
in s luti n, rendering the s luti n apable ndu ting an ele -
tri urrent
electrolyte balance (eh-LEK-tr h-lyte BAL-ans) h me stasis
ele tr lytes
716 GLOSSARY
electron (eh-LEK-tr n) small, negatively harged subat mi parti-
le und in the uter regi ns an at m
electron microscope (eh-LEK-tr n MY-kr h-sk pe) a devi e that
pr du es a greatly enlarged image a tiny stru ture by using a
beam ele tr ns used by magnets (rather than a beam
light used by glass lenses, as in a light mi r s pe)
electron transport system (E S) (eh-LEK-tr n RANZ-p rt
SIS-tem) ellular pr ess within mit h ndria that trans ers en-
ergy r m high-energy ele tr ns r m gly lysis and the itri
a id y le t A P m le ules s that the energy is available t d
w rk in the ell
electrophoresis (eh-lek-tr h- h-REE-sis) lab rat ry pr edure in
whi h di erent types m le ules are separated a rding t
m le ular weight by passing a weak ele tri urrent thr ugh their
liquid medium
element (EL-eh-ment) pure substan e, mp sed nly ne type
at m
elephantiasis (el-eh- an- YE-ah-sis) extreme lymphedema (swell-
ing due t lymphati bl kage) in the limbs aused by a parasiti
w rm in estati n, s alled be ause the limbs swell t elephant
pr p rti ns
elimination (eh-lim-uh-NAY-shun) m ving s mething ut the
b dy, as in de e ati n
embolism (EM-b h-liz-em) bstru ti n a bl d vessel by reign
matter arried in the bl dstream
embolus (EM-b h-lus) a bl d l t r ther substan e (su h as a
bubble air) that is m ving in the bl d and may bl k a bl d
vessel
embryo (EM-bree- h) animal in early stages intrauterine devel-
pment; in humans, the rst 3 m nths a ter n epti n
embryology (em-bree-O L- h-gee) study the devel pment an
individual r m n epti n t birth
embryonic phase (em-bree-O N-ik ayz) the peri d extending r m
ertilizati n until the end the eighth week gestati n; during
this phase the term embryo is used
emesis (EM-eh-sis) v miting
emphysema (em- h-SEE-mah) abn rmal nditi n hara terized
by trapping air in alve li the lung that auses them t rup-
ture and use t ther alve li
emptying re ex (EMP-tee-ing REE-f eks) the ref ex that auses the
ntra ti n the bladder wall and relaxati n the internal
sphin ter t all w urine t enter the urethra, whi h is ll wed by
urinati n i the external sphin ter is v luntarily relaxed
emulsi y (eh-MUL-seh- ye) in digesti n, when bile breaks up ats
enamel (ih-NA-mel) hard, mineralized nne tive tissue, harder
than b ne, rms hard vering exp sed t th sur a es; hardest
substan e in b dy
endemic (en-DEM-ik) re ers t a disease native t a l al regi n
the w rld
endocarditis (en-d h-kar-DYE-tis) inf ammati n the lining
the heart
endocardium (en-d h-KAR-dee-um) thin layer very sm th tis-
sue lining ea h hamber the heart
endochondral ossi cation (en-d h-KON-dral s-ih- h-KAY-shun)
the pr ess in whi h m st b nes are rmed r m artilage m dels
endocrine (EN-d h-krin) se reting int the bl d r tissue f uid
rather than int a du t; pp site ex rine
endocrine gland (EN-d h-krin gland) any du tless gland that is
part the end rine system and se retes h rm nes int inter el-
lular spa es and the bl d
endocrine system (EN-d h-krin SIS-tem) the series du tless
glands that are und in the b dy
endocrinologist (en-d h-krin-OL- h-jist) s ientist r physi ian
spe ializing in endocrinology
endocrinology (en-d h-krin-OL- h-jee) study end rine glands
and their un ti ns
endoderm (EN-d h-derm) the uterm st layer the primary germ
layers that devel ps early in the rst trimester pregnan y
endogenous in ection (en-D OJ-en-us in-FEK-shun) in e ti n
aused by path gens that n rmally inhabit the intestines, vulva,
r vagina
endolymph (EN-d h-lim ) lear p tassium-ri h f uid that lls the
membran us labyrinth the inner ear
endometrial ablation (en-d h-MEE-tree-al ab-LAY-shun) thera-
peuti destru ti n end metrial tissue (the tissue that n rmally
lines the uterus)
endometriosis (en-d h-mee-tree-OH -sis) presen e un ti ning
end metrial tissue utside the uterus
endometrium (en-d h-MEE-tree-um) mu us membrane lining
the uterus
endoneurium (en-d h-NO O -ree-um) the thin wrapping br us
nne tive tissue that surr unds ea h ax n in a nerve
endoplasmic reticulum (ER) (en-d h-PLAZ-mik reh- IK-y -
lum) netw rk tubules and vesi les in yt plasm; tw types:
rough and smooth
endorphin (en-D O R- n) hemi al in the entral nerv us system
that inf uen es pain per epti n; a natural painkiller
endoscope (EN-d h-sk hp) f exible tube inserted thr ugh a small
in isi n in rder t view internal rgans and s metimes t pass
medi al devi es int the b dy r rem ve tissue r m the b dy
endosteum (en-DOS-tee-um) a br us membrane that lines the
medullary avity
endothelium (en-d h- H EE-lee-um) squam us epithelial ells
that line the inner sur a e the entire ardi vas ular system and
the vessels the lymphati system
endotracheal intubation (en-d h- RAY-kee-al in-t -BAY-
shun) medi al pr edure in whi h a tube is pla ed thr ugh the
m uth, pharynx, and larynx int the tra hea t ensure an pen
airway
endurance training (en-D UR-an e RAYN-ing) ntinu us vig r-
us exer ise requiring the b dy t in rease its nsumpti n
xygen and devel p the mus les ability t sustain a tivity ver a
pr l nged peri d time
energy level limited regi n surr unding the nu leus an at m at a
ertain distan e ntaining ele tr ns; als alled a shell
enkephalin (en-KEF-ah-lin) peptide hemi al in the entral ner-
v us system that a ts as a natural painkiller
enteritis (en-ter-AYE-tis) inf ammati n the small intestine
enuresis (en-y -REE-sis) inv luntary urinati n
environmental health (en-VYE-r n-ment-al helth) eld publi
health that uses n the health e e ts ur surr undings
(natural and arti ial)
enzyme (EN-zyme) bi hemi al atalyst all wing hemi al rea -
ti ns t take pla e in a suitable time rame
eosinophil (ee- h-SIN- h- l) white bl d ell that is readily
stained by e sin
epicardium (ep-ih-KAR-dee-um) the inner layer the peri ardium
that vers the sur a e the heart; it is als alled the visceral
pericardium
epidemic (ep-ih-DEM-ik) re ers t a disease that urs in many
individuals at the same time
epidemiologist (ep-ih-dee-mee-O L-uh-jist) s ientist engaged in
the study, preventi n, and treatment the urren e, distribu-
ti n, and transmissi n diseases in human p pulati ns

epidemiology (EP-ih-dee-mee-O L- h-jee) study the urren e,
distributi n, and transmissi n diseases in human p pulati ns
epidermis (ep-ih-DER-mis) alse skin; uterm st layer the skin
epididymis (ep-ih-D ID -ih-mis) ne tw mma-shaped,
l ng, tightly iled tubes that arry sperm r m testes t vas
de erens
epididymitis (ep-ih-did-ih-MY-tis) inf ammati n the epididymis
epigastric region (ep-ih-GAS-trik) the superi r entral regi n
the abd min pelvi avity
epigenetics (ep-ih-jeh-NE -iks) any pr ess inheritan e ther
than dire t DNA inheritan e, s metimes by adding a methyl
gr up ( r ther hemi al) t DNA, as in maternal/paternal im-
printing genes
epiglottis (ep-ih-GLO -is) lidlike artilage verhanging the en-
tran e t the larynx
epiglottitis (EP-ih-gl t-aye-tis) li e-threatening type laryngitis
generally seen in hildren 3 t 7 years age; hara terized by
laryngeal edema and high ever and aused by Haemophilus in u-
enzae virus
epilepsy (EP-ih-lep-see) a seizure dis rder hara terized by re ur-
ring seizures
epinephrine (Epi) (ep-ih-NEF-rin) adrenaline; h rm ne se reted
by the adrenal medulla
epineurium (ep-ih-NO O-ree-um) a t ugh br us sheath that v-
ers the wh le nerve
epiphyseal racture (ep-ih-FEEZ-ee-al FRAK- hur) when the
epiphyseal plate is separated r m the epiphysis r diaphysis; this
type ra ture an disrupt the n rmal gr wth the b ne
epiphyseal line (ep-ih-FEEZ-ee-al lyne) p int usi n seen in a
mature b ne that repla es the epiphyseal artilage r gr wth plate
that n e separated the epiphysis and diaphysis a gr wing b ne
epiphyseal plate (ep-ih-FEEZ-ee-al) the artilage plate that is be-
tween the epiphysis and the diaphysis and all ws gr wth t ur;
s metimes re erred t as a growth plate
epiphysis (eh-PIF-ih-sis) (pl., epiphyses) end a l ng b ne
episiotomy (eh-piz-ee-O - h-mee) a surgi al pr edure used dur-
ing birth t prevent a la erati n the m thers perineum r the
vagina
epispadias ngenital de e t in males hara terized by pening
urethral meatus n d rsal (t p) sur a e glans r penile sha t
epistaxis (ep-ih-S AK-sis) lini al term re erring t a bl dy n se
epithelial membrane (ep-ih- H EE-lee-al MEM-brane) mem-
brane mp sed epithelial tissue with an underlying layer
spe ialized nne tive tissue
epithelial tissue (ep-ih- H EE-lee-al ISH -y ) vers the b dy
and its parts; lines vari us parts the b dy; rms ntinu us
sheets that ntain n bl d vessels; lassi ed a rding t shape
and arrangement
equilibration (ee-kwi-lib-RAY-shun) the state r a t ming int
equilibrium r balan ed state
equilibrium (ee-kwi-LIB-ree-um) a balan ed state; a state in whi h
tw r m re parts a system remain in a relatively nstant
pr p rti n t ea h ther
erectile dys unction (ED ) (ee-REK-tyl dis-F UNK-shun) dis r-
der in whi h the penis ails t be me ere t during the male
sexual resp nse, usually due t a la k relaxati n in sm th
mus les in the wall bl d vessels in the penis; the drug Vi-
agra (sildena l) treats ED by pr m ting the same resp nse in
the penis as NO (nitri a id), whi h relaxes sm th mus les in
the vessel walls
ergonomics (er-g h-NO M-iks) applied study w rkers and their
w rk envir nment
GLOSSARY 717
erythema (er-ih- H EE-mah) redness r inf ammati n the skin
r mu us membranes
erythroblastosis etalis (eh-rith-r h-blas- O H -sis et- AL-is)
nditi n a etus r in ant aused by the m thers Rh anti-
b dies rea ting with the babys Rh-p sitive RBCs, hara ter-
ized by massive agglutinati n the bl d and resulting in
li e-threatening ir ulat ry pr blems
erythrocyte (eh-RI H -r h-syte) red bl d ell; literally red ell
erythropoietin (EPO) (eh-RI H -r h-POY-eh-tin) gly pr tein
se reted t in rease red bl d ell pr du ti n in resp nse t xy-
gen de ien y
esophagus (ee-SOF-ah-gus) the mus ular, mu us-lined tube that
nne ts the pharynx with the st ma h; als kn wn as the
oodpipe
essential reproductive organ (ee-SEN-shal ree-pr h-DUK-tiv
OR-gan) repr du tive rgan that must be present r repr du -
ti n t ur; als kn wn as gonad
estrogen (ES-tr h-jen) sex h rm ne se reted by the vary that
auses the devel pment and maintenan e the emale se ndary
sex hara teristi s and stimulates gr wth the epithelial ells
lining the uterus
etiology (ee-tee-OH L- h-jee) the ry, r study, the a t rs in-
v lved in ausing a disease
eupnea (YO O P-nee-ah) n rmal respirati n
eustachian tube (y -S AY-shun t b) see auditory tube
evaporation (ee-vap- h-RAY-shun) heat being l st r m the skin by
sweat being vap rized
eversion (ee-VER-zhun) m vement that turns a b dy part (su h as
the t) utward
evert (ee-VER ) t turn utward
excimer laser surgery (EK-zim-er LAY-zer SIR-jer-ee) re ra t ry
eye surgery that uses an ex imer r l laser t vap rize rneal
tissue in treating mild t m derate nearsightedness; als alled
photore ractive keratectomy (PRK)
excoriation (eks-k h-ree-AY-shun) skin lesi n in whi h epidermis
has been rem ved, as in a s rat h w und
exercise physiologist (EK-ser-syze z-ee-O L-uh-jist) s ientist wh
studies the pr ess mus ular exer ise and related phen mena
exhalation (eks-huh-LAY-shun) m ving air ut the lungs; p-
p site inhalation, r inspiration; als kn wn as expiration
exocrine (EK-s h-krin) se reting int a du t; pp site end rine
exocrine gland (EK-s h-krin) glands that se rete their pr du ts int
du ts that empty nt a sur a e r int a avity; r example,
sweat glands
exophthalmos (ek-s - H AL-mus) nditi n abn rmally pr -
truding eyeballs, urring in a rm hyperthyr idism alled
Graves disease; als alled exophthalmia
experimental control (eks-payr-ih-MEN-tel k n- ROL) any pr -
edure within a s ienti experiment that ensures that the test
situati n itsel is n t a e ting the ut me the experiment
experimentation (eks-payr-ih-men- AY-shun) per rming an ex-
periment, whi h is usually a test a tentative explanati n
nature alled a hypothesis
expiration (eks-pih-RAY-shun) m ving air ut the lungs; pp -
site inhalation, r inspiration; als kn wn as exhalation
expiratory muscle (eks-PYE-rah-t r-ee MUS-el) any the mus-
les that all w m re r e ul expirati n t in rease the rate and
depth ventilati n; the internal inter stals and the abd minal
mus les
expiratory reserve volume (ERV) (eks-PYE-rah-t r-ee ree-ZERV
VO L-y m) the am unt air that an be r ibly exhaled a ter
expiring the tidal v lume ( V)
718 GLOSSARY
extend (ek-S END) t in rease the angle between tw b nes at a
j int; pp site ex
extension (ek-S EN-shun) in reasing the angle between tw b nes
at a j int
external acoustic canal (eks- ER-nal ah-KO O -stik kah-NAL) a
urved tube (appr ximately 2.5 m l ng) extending r m the
auri le the ear int the temp ral b ne, ending at the tympani
membrane; als external auditory canal
external ear (eks- ER-nal) the uter part the ear that is made up
the auri le and the external audit ry anal
external genitalia (eks- ER-nal jen-ih- AYL-yah) external repr -
du tive rgans; als alled genitals r simply genitalia
external intercostals (eks- ER-nal in-ter-KO S-talls) inspirat ry
mus les that enlarge the th rax, ausing the lungs t expand and
air t rush in
external nares (eks- ER-nal NAY-reez) (sing., naris) n strils
external oblique (eks- ER-nal h-BLEEK) the uterm st layer
the anter lateral abd minal wall
external otitis (eks- ER-nal h- YE-tis) a mm n in e ti n
the external ear; als kn wn as swimmers ear
external respiration (eks- ER-nal res-pih-RAY-shun) the ex-
hange gases between air in the lungs and in the bl d
external urinary meatus (eks- ER-nal YO O R-ih-nayr-ee mee-
AY-tus) external pening the urinary tra t
extracellular uid (ECF) (eks-trah-SEL-y -lar FLO O-id) the
water und utside ells l ated in tw mpartments be-
tween ells (interstitial f uid) and in the bl d (plasma)
F
ace ( ays) anteri r aspe t the head r skull; any f at sur a e the
external aspe t a stru ture
acial (FAY-shal) re erring t the a e
actor VIII (FAK-ter ayt) ne the bl d l tting a t rs ( agula-
ti n a t rs)
allen arch nditi n in whi h the tend ns and ligaments the
weaken, all wing the n rmally urved ar h t f atten ut
allopian tube ( al-LO H -pee-an t b) see uterine tube
alse ribs the eighth, ninth, and tenth pairs ribs, whi h are atta hed
t the artilage the seventh ribs rather than the sternum
ascia (FASH -ee-ah) general name r the br us nne tive tissue
masses l ated thr ugh ut the b dy
ascicle (FAS-ih-kul) small bundle bers, as in a small bundle
nerve bers r mus le bers
asciculus ( ah-SIC-y -lus) little bundle
at ne the three basi nutrient types; primarily a s ur e
energy
atigue ( ah- EEG ) l ss mus le p wer; weakness; state ex-
hausti n r tiredness
at tissue ( ISH -y ) see adipose
atty acid (FA -tee AS-id) pr du t at digesti n; building bl k
at m le ules
ebrile seizure (FEB-ril SEE-zhur) abn rmal brain a tivity aused
by a ever
eces (FEE-seez) waste material dis harged r m the intestines
eedback loop (FEED-bak l p) a highly mplex and integrated
mmuni ati n ntr l netw rk, lassi ed as negative r p sitive;
negative eedba k l ps are the m st imp rtant and numer us
h me stati ntr l me hanisms
emoral (FEM- r-al) re erring t the thigh
emur (FEE-mur) the thigh b ne, whi h is the l ngest b ne in the
b dy
ertilization (FER-tih-lih-Z AY-shun) the a ti n that takes pla e at
the m ment the emales vum and the males sperm ell unite
etal alcohol syndrome (FAS) (FEE-tal AL-k h-h l SIN-dr hm) a
nditi n that may ause ngenital abn rmalities in a baby; it
results r m a w man nsuming al h l during pregnan y
etal phase (FEE-tal ayz) peri d extending r m the eighth t the
thirty-ninth week gestati n; during this phase the term etus is
used
etus (FEE-tus) unb rn y ung, espe ially in the later stages; in hu-
man beings, r m the third m nth the intrauterine peri d until
birth
ever (FEE-ver) elevated b dy temperature bey nd the n rmal set
p int; usually triggered by the immune system in resp nse t
in e ti n r injury
ber (FYE-ber) threadlike stru ture; r example, nerve ber r l-
lagen ber
brillation ( b-rih-LAY-shun) nditi n in whi h individual mus-
le bers, r small gr ups bers, ntra t asyn hr n usly ( ut
time) with ther mus le bers in an rgan, pr du ing n e e -
tive m vement
brin (FYE-brin) ins luble pr tein in l tted bl d
brinogen ( ye-BRIN- h-jen) s luble bl d pr tein that is n-
verted t ins luble brin during l tting
broid (FYE-br yd) see bromyoma
bromyoma ( ye-br h-my-O H -mah) benign tum r sm th
mus le and br us nne tive tissue mm nly urring in the
uterine wall, where it is ten alled a broid; see also myoma
bromyositis ( ye-br h-my- h-SYE-tis) inf ammati n mus le
tissue a mpanied by inf ammati n nearby tend n tissue
brosarcoma ( ye-br h-sar-KO H -mah) an er br us nne -
tive tissue
brosis ( ye-BRO H -sis) nditi n in whi h br us tissue repla es
damaged tissues
brous connective tissue (FYE-brus k h-NEK-tiv ISH -y )
str ng, n nstret hable, white llagen bers that mp se
t tend ns
bula (FIB-y -lah) the slender n nweight-bearing b ne l ated
n the lateral aspe t the leg
bularis (muscle) group ( b-YO O-lay-ris [MUS-el] gr p) gr up
lateral mus les the leg that a t t pr nate the t, r tating
it t ward the midline, and plantar f ex the t, pulling it t es-
d wnward; als alled the peroneus group
ght-or- ight response ( yte r f yte) the hanges pr du ed by in-
reased sympatheti impulses all wing the b dy t deal with any
type stress
ltration ( l- RAY-shun) m vement water and s lutes thr ugh
a membrane by a higher hydr stati pressure n ne side
mbria (FIM-bree-ah) (sing., mbriae) ringelike pr je ti n
rst-degree burn min r burn with nly minimal dis m rt and n
blistering; epidermis may peel but n dermal injury urs; see also
partial-thickness burn
ssure (FISH -ur) el ngated break r gr ve
agellate (FLAJ-eh-lat) pr t z an p ssessing f agella
agellum (f ah-JEL-um) (pl., f agella) single pr je ti n extending
r m the ell sur a e; nly example in human is the tail the
male sperm
at bone ne the ur types b ne; the r ntal b ne is an ex-
ample a f at b ne
at eet nditi n in whi h the tend ns and ligaments the t are
weak, all wing the n rmally urved ar h t f atten ut
atulence (FLA -y -lens) presen e air r ther gases in the
lumen the gastr intestinal tra t

avivirus (FLAV-ih-vye-rus) ateg ry RNA- ntaining viruses
that typi ally require an inse t ve t r t transmit them t hu-
mans; examples f avivirus in e ti ns in lude yell w ever, den-
gue, St. L uis en ephalitis, and West Nile virus (W NV)
ex (f eks) t bend; r example, t de rease the angle between tw
b nes at the j int
exion (FLEK-shun) a t bending; de reasing the angle between
tw b nes at the j int
oating ribs (FLOW-ting) the eleventh and twel th pairs ribs,
whi h are nly atta hed t the th ra i vertebrae
uid balance (FLO O -id BAL-ans) h me stasis f uids; the v l-
umes interstitial f uid, intra ellular f uid, and plasma and t tal
v lume water remain relatively nstant
uid compartment (FLO O-id k m-PAR -ment) any the areas
in the b dy where the f uid is l ated; r example, interstitial f uid
olate de ciency anemia (FOH -layt deh-FISH -en-see ah-NEE-
mee-ah) bl d dis rder hara terized by a de rease in the red
bl d ell unt, aused by a de ien y li a id in the diet (as
in maln urished individuals)
ollicle (FOL-lih-kul) a p ket r bubble; r example, the p ket
skin r m whi h a hair gr ws
ollicle-stimulating hormone (FSH) (FO L-lih-kul S IM-y -
lay-ting H OR-m hn) h rm ne present in males and emales; in
males, FSH stimulates the pr du ti n sperm; in emales, FSH
stimulates the varian lli les t mature and the lli le ells t
se rete estr gen
ontanel (FON-tah-nel) any the s t sp ts n an in ants head;
in mpletely ssi ed area in the in ant skull
ood science ( d SYE-ens) study the hara teristi s d and
e e ts st ring, handling, and preparing d zymes, s me neur transmitters, s me h rm nes; mpare t
oramen ( h-RAY-men) small pening; r example, the vertebral
ramen, whi h all ws the spinal rd t pass thr ugh the verte-
bral anal
oramen ovale ( h-RAY-men h-VAL-ee) shunts bl d r m the
right atrium dire tly int the le t atrium all wing m st bl d t
bypass the babys devel ping lungs; either a pair small val
penings r nerves in the sphen id b ne; literally oval hole
orensic science ( h-REN-zik SYE-ens) eld s ienti investi-
gati n applied t legal questi ns, su h as ause death, rime
s ene investigati n, and related matters
oreskin (FORE-skin) a l se- tting, retra table asing l ated ver
the glans the penis; als kn wn as the prepuce
ormed elements ( rmd EL-eh-mentz) ellular (RBC, W BC, and
platelet) p rti n bl d bl d tissue, in ntrast t the un-
rmed (liquid) nature bl d plasma
ormula (FO R-my -lah) sh rthand n tati n r a hemi al stru -
ture su h as an at m r m le ule, as in C r arb n and H 2O r
water
ourth-degree burn mplete destru ti n epidermis, dermis, and
sub utane us tissue with additi nal damage bel w sub utane us
tissue t mus le and b ne; see ull-thickness burn
ovea centralis (FOH -vee-ah sen- RAL-is) small depressi n in the
ma ula lutea where nes are m st densely pa ked; visi n is
sharpest where light rays us n the vea
ractal geometry (FRAK-tal jee-O M-eh-tree) the study sur a es
with a seemingly in nite area, su h as the lining the small
intestine
ragile X syndrome (FXS) (FRAJ-il eks SIN-dr hm) nditi n in
whi h mental retardati n results r m breakage X hr m -
s me in males
raternal twins ( rah- ERN-al twinz) birth tw siblings at
the same time that have devel ped r m tw separate zyg tes
GLOSSARY 719
(dizyg ti ); als alled dizygotic twins; ntrast with identical
(monozygotic) twins
reckle (FREK-uhl) small br wn r red ma ules that are a mm n
geneti variant n rmal skin pigmentati n
ree nerve ending (nerv END-ing) simple nerve re ept r in the skin
that resp nds t pain
ree radical (RAD-ih-kal) highly rea tive, ele tr n-seeking m le-
ules that ur n rmally in ells but may damage ele tr n-dense
m le ules su h as DNA r m le ules in ell membranes; ree
radi als may be inhibited by anti xidants, su h as vitamin E
renulum (FREN-y -lum) the thin membrane that atta hes the
t ngue t the f r the m uth
rontal (FRON-tal) relating t the rehead r t the anteri r aspe t
a stru ture
rontal bone rehead b ne
rontal muscle (FRUN-tall MUS-el) ne the mus les a ial
expressi n; it m ves the eyebr ws and urr ws the skin the
rehead
rontal plane (FRUN-tal playn) lengthwise plane running r m side
t side, dividing the b dy int anteri r and p steri r p rti ns
rontal sinusitis (FRON-tall sye-ny -SYE-tis) inf ammati n in
the r ntal sinus
rostbite (FRO S -byte) l al tissue damage aused by extreme ld
ull-thickness burn burn that (1) destr ys epidermis, dermis, and
sub utane us tissue (see third-degree burn); and (2) extends be-
l w skin and sub utane us tissue t rea h mus le and b ne (see
ourth-degree burn)
unctional protein (F UNK-shen-al PRO H -teen) pr tein that has
the r le regulating hemi al rea ti ns in the b dy, su h as en-
structural protein
undus (o stomach) (F UN-dus) enlarged p rti n t the le t and
ab ve the pening the es phagus int the st ma h
undus (o uterus) (F UN-duss YO O -ter-us) bulging pr minen e
ab ve level where uterine tubes atta h t the b dy the uterus
ungus (F UNG-us) (pl., ungi) rganism similar t plants but la k-
ing hl r phyll and apable pr du ing my ti ( ungal)
in e ti ns
uruncle (F UR-un-kul) b il; a pus- lled avity rmed by s me hair
lli le in e ti ns
G
G protein a pr tein m le ule usually embedded in a ells plasma
membrane that plays an imp rtant r le in getting a signal r m a
re ept r (als in the plasma membrane) t the inside the ell
galactose (gah-LAK-t hs) simple sugar (m n sa haride) und in
la t se (milk sugar)
gallbladder (GAW L-blad-er) h ll w sa nne ted t the mm n
bile du t and that st res and n entrates bile
gallstone (GAW L-st hn) s lid n reti ns r st nes, ten m-
p sed h lester l r bile salts, und in the gallbladder; see also
cholelithiasis
gamete (GAM-eet) either the tw sex ells, sperm (spermat z a)
and egg ( va), that have hal the usual number nu lear hr -
m s mes (the hapl id number)
ganglion (GANG-lee- n) (pl., ganglia) a regi n unmyelinated
nerve tissue (usually this term is used nly r regi ns in the pe-
ripheral nerv us system [PNS])
ganglion cell (GANG-lee- n sel) ph t re ept r ell the eyes
retina that d es n t help rm an image but instead helps dete t
hanges in envir nmental light t syn hr nize the b dys internal
720 GLOSSARY
l k t external daily, m nthly, and seas nal y les; mpare t
rod and cone
gangrene (GANG-green) tissue death (ne r sis) that inv lves de ay
tissue
gastric gland (G AS-trik) glands in st ma h lining that se rete en-
zymes, mu us, r hydr hl ri a id
gastritis (gas- RY-tis) inf ammati n the lining the st ma h
gastrocnemius (GAS-tr k-NEE-mee-us) super ial mus le the
al the leg, nne ted (al ng with the s leus mus le) t the
al aneus b ne the t by way the A hilles ( al aneal) ten-
d n; its a ti n is t d rsif ex the t, bending the t es upward
gastroenteritis (gas-tr h-en-ter-EYE-tis) inf ammati n the
st ma h and intestines
gastroenterology (gas-tr h-en-ter-AH L- h-jee) study and treat-
ment diseases the gastr intestinal (GI) tra t
gastroesophageal re ux disease (GERD ) (gas-tr h-eh-s -eh-
JEE-al REE-f uks dih-ZEEZ [gerd]) a set sympt ms result-
ing r m a hiatal hernia that all ws st ma h (gastri ) ntents t
f w ba k (ref ux) int the es phagus; sympt ms in lude heart-
burn r hest pain and ughing r h king during r just a ter a
meal; als kn wn as GERD
gastroesophageal sphincter (gas-tr h-eh-s -eh-JEE-al SFINK-
ter) a ring sm th mus le ar und the pening the st ma h
at the l wer end the es phagus that a ts as a valve t all w d
t enter the st ma h but prevents st ma h ntents r m m ving
ba k int the es phagus
gastrointestinal (GI) tract (gas-tr h-in- ES-tih-nul trakt) tubelike
stru ture the digestive system extending r m st ma h t
anuss metimes meant t in lude the entire alimentary canal
(m uth t anus)
gene (jeen) ne many segments a hr m s me (DNA m le-
ule); ea h gene ntains the geneti de r synthesizing a
pr tein m le ule su h as an enzyme r h rm ne
gene linkage (jeen LINK-ej) phen men n that may ur during
crossing-over mei ti divisi n in whi h a wh le gr up genes
stays t gether and r sses ver as a single unit
gene replacement therapeuti te hnique that repla es genes that
spe i y pr du ti n abn rmal pr teins with n rmal genes
gene therapy (jeen H AYR-ah-pee) manipulati n genes t ure
geneti pr blems; m st rms gene therapy have n t yet been
pr ven e e tive in humans
general senses ( JEN-er-al SEN-sez) senses dete ted by simple,
mi r s pi re ept rs widely distributed thr ugh ut the b dy
(skin, mus les, tend ns, j ints, et .) inv lving m des pain,
temperature, t u h, pressure, r b dy p siti n
genetic (jeh-NE -ik) relating t the geneti de and bi l gi al
heredity; see als genetics
genetic counseling (jeh-NE -ik KOW N-se-ling) pra ti e n-
sulting with amilies regarding geneti diseases
genetic counselor (jeh-NE -ik KOW N-se-l r) s ien e pr es-
si nal wh nsults with amilies regarding geneti diseases
genetic engineer (jeh-NE -ik en-juh-NEER) s me ne wh spe-
ializes in manipulating the geneti de
genetic mutation (jeh-NE -ik my - AY-shun) hange in the ge-
neti material within a gen me; may ur sp ntane usly r as a
result mutagens
genetics (jeh-NE -iks) s ienti study heredity and the geneti
de
genital see external genitalia
genital ducts (jen-ih-tall dukts) tubelike stru tures in the embry
that devel p int repr du tive rgans; als applies t adult repr -
du tive du ts
genitalia (jen-ih- AYL-yah) repr du tive rgans; see external
genitalia
genome ( JEE-n hm) entire set hr m s mes in a ell; the human
genome re ers t the entire set human hr m s mes
genomics (jeh-NOH -miks) eld endeav r inv lving the analysis
the geneti de ntained in the human r ther spe iesgen me
geriatrics (jayr-ee-A -riks) medi al spe ialty that uses n treat-
ment the elderly
gerontology (jayr- n- O L- h-jee) study the aging pr ess
gestation (jes- AY-shun) pregnan y
gestation period (jes- AY-shun PEER-ee- d) the time length r
peri d pregnan y, appr ximately 9 m nths in humans
gestational diabetes mellitus (GD M) (jes- AY-shun-al dye-ah-
BEE-teez MELL-ih-tus) nditi n hara terized by a temp -
rary de rease in bl d levels insulin during pregnan y
ghrelin (GRAY-lin) h rm ne se reted by epithelial ells lining the
st ma h; ghrelin b sts appetite, sl ws metab lism, and redu es
at burning; may be inv lved in the devel pment besity
gigantism (jye-G AN-tiz-em) a nditi n pr du ed by hyperse re-
ti n gr wth h rm ne during the early years li e; results in a
hild wh gr ws t giganti size
gingiva ( JIN-jih-vah) (pl., gingivae) gums ( the m uth)
gingival ( JIN-jih-val) relating t the gums ( the m uth)
gingivitis (jin-jih-VYE-tis) inf ammati n the gum (gingiva), -
ten as a result p r ral hygiene
gland se reting stru ture
glandular epithelium (GLAN-dy -lar ep-ih- H EE-lee-um) ells
that are spe ialized r se reting a tivity
glans (glanz) the sensitive distal end the sha t the penis r
lit ris
glaucoma (glaw-KOH -mah) dis rder hara terized by elevated
pressure in the eye
glia (GLEE-ah) supp rting ells nerv us tissue; see neuroglia
gliding joint (GLY-ding j ynt) type diarthr ti j int rmed by
f at sur a es that glide past ea h ther
glioma (glee-O H -mah) ne the m st mm n types brain
tum rs
globulin (GLOB-y -lin) a type plasma pr tein that in ludes
antib dies
glomerular capsule (gl h-MER-y -lar KAP-sul) see Bowman
capsule
glomerular ltrate (gl h-MER-y -lar l- RAY ) watery f uid
ltered r m the plasma renal bl d apillaries int the gl -
merular apsule the gl merulus
glomerular-capsular membrane (gl h-MER-y -lar KAP-s -
lahr) membrane made up gl merular end thelium, basement
membrane, and vis eral layer the gl merular (B wman) ap-
sule; un ti n is ltrati n
glomerulonephritis (gl h-mer-y -l h-neh-FRY-tis) inf ammat ry
disease the gl merular- apsular membranes the kidney
glomerulus (gl h-MAYR-y -lus) mpa t luster; r example,
apillaries in the kidneys
glottis (GLO -is) the spa e between the v al rds
glucagon (GLO O -kah-g n) h rm ne se reted by alpha ells the
pan reati islets
glucocorticoid (GC) (gl -k h-KO R-tih-k yd) h rm ne that in-
f uen es nutrient metab lism; se reted by the adrenal rtex
gluconeogenesis (gl -k h-nee- h-JEN-eh-sis) rmulati n
glu se r gly gen r m pr tein r at mp unds
glucose (GLO O -k hs) m n sa haride r simple sugar; the prin i-
pal bl d sugar
gluteal (GLO O -tee-al) r near the butt ks

gluteus maximus (GLO O-tee-us MAX-ih-mus) maj r extens r
the thigh and als supp rts the t rs in an ere t p siti n
glycerol (GLIS-er- hl) pr du t at digesti n
glycogen (GLYE-k h-jen) p lysa haride made up a hain
glu se (m n sa haride) m le ules; animal star h
glycogen loading (GLYE-k h-jen LOH D-ing) see carbohydrate
loading
glycogenesis (glye-k h-JEN-eh-sis) rmati n gly gen r m
glu se r r m ther m n sa harides, ru t se, r gala t se
glycogenolysis (glye-k h-jeh-NOL-ih-sis) hydr lysis gly gen
t glu se-6-ph sphate r t glu se
glycolysis (glye-KAH L-ih-sis) the rst series hemi al rea ti ns
in glu se metab lism; hanges glu se t pyruvi a id in a series
anaer bi rea ti ns
glycosuria (glye-k h-SO O -ree-ah) glu se in the urine; a sign
diabetes mellitus
goblet cell (GOB-let sel) any the spe ialized, g blet-shaped ells
und in simple lumnar epithelium that pr du e mu us
goiter (GO Y-ter) enlargement the thyr id gland
Golgi apparatus (GOL-jee ap-ah-RA-tus) small sa s sta ked n
ne an ther near the nu leus that make arb hydrate m-
p unds, mbine them with pr tein m le ules, and pa kage the
pr du t in a gl bule
Golgi tendon receptors (GOL-jee EN-d n ree-SEP-t rs) sens rs
that are resp nsible r pr pri epti n
gonad (GOH -nad) essential rgan repr du ti n that pr du es
gametes: testis in males; vary in emales
gonadotropin (g h-nah-d h- ROH -pin) any the h rm nes
(FSH and LSH ) pr du ed by the anteri r pituitary r embry ni
tissue (hCG) that stimulate gr wth and maintenan e the testes
r varies
gonadotropin-releasing hormone (GnRH) (g h-nah-d h- ROH -
pin ree-LEES-ing H O R-m hn) h rm ne released by the hyp -
thalamus that stimulates the anteri r pituitary gland t release its
g nad tr pin h rm nes
gout (g wt) abn rmal nditi n in whi h ex ess uri a id is dep s-
ited in j ints and ther tissues as s dium urate rystalsthe
rystals pr du e inf ammati n r gout arthritis
gouty arthritis (g w- EE ar- H RY-tis) metab li dis rder in
whi h ex ess bl d levels uri a id are dep sited within the
syn vial f uid j ints and ther tissues
graa an ollicle (GRAH - ee-en FOL-ih-kul) sa the vary that
ntains a mature vum
gradient (GRAY-dee-ent) a sl pe r di eren e between tw levels;
r example, bl d pressure gradient: a di eren e between the
bl d pressure in tw di erent vessels
gram the unit measure in the metri system n whi h mass is
based (appr ximately 454 grams equals 1 p und)
Gram-staining technique (gram S AYN-ing tek-NEEK) pr ess
in mi r bi l gy in whi h a spe i mixture stains is used
t distinguish between di erent ateg ries ba teria (gram-
p sitive vs. gram-negative ba teria)
granular leukocyte (GRAN-y -lar LO O-k h-syte) white bl d
ell (leuk yte) with granules visible in yt plasm when stained;
als alled granulocyte
granulosa cell (gran-y -LOH -sah sel) ell layer surr unding the
yte
Graves disease (gravz dih-ZEEZ) inherited, p ssibly immune en-
d rine dis rder hara terized by hyperthyr idism a mpanied
by ex phthalm s (pr truding eyes)
gray matter (MA -er) tissue in the entral nerv us system made up
ell b dies and unmyelinated ax ns and dendrites
GLOSSARY 721
greater omentum (GRAY -er h-MEN-tum) a p u hlike exten-
si n the vis eral perit neum
greater vestibular gland (ves- IB-y -lar gland) either the ex -
rine mu us glands l ated n either side the vaginal utlet;
als kn wn as Bartholin gland; see also lesser vestibular gland
growth hormone (GH or hGH) (H OR-m hn) h rm ne se reted
by the anteri r pituitary gland that ntr ls the rate skeletal
and vis eral gr wth
guanine (GWAH -neen) ne several nitr gen- ntaining bases
that make up nu le tides, whi h in turn make up nu lei a ids
su h as DNA and RNA; in the ell, it an hemi ally bind t
an ther nitr gen us base, yt sine (C r c), t rm a m re m-
plex stru ture r in translating geneti des; symb lized by the
letter G r g; see also cytosine, adenine, thymine, uracil
gustation (gus- AY-shun) the pr ess tasting
gustatory cell (GUS-tah-t r-ee sel) ells taste
gynecologist (gye-neh-KO L-uh-jist) physi ian spe ializing in med-
i ine the emale repr du tive system
gyrus ( JYE-rus) (pl., gyri) nv luted ridge und n the brains
sur a e
H
hair ollicle (hayr FOL-ih-kul) a small tube where hair gr wth
urs
hair papilla (hayr pah-PIL-ah) a small, ap-shaped luster ells
l ated at the base the lli le where hair gr wth begins
hamstring muscle (H AM-string MUS-el) p wer ul f ex r the
hip made up the semimembran sus, semitendin sus, and bi-
eps em ris mus les
Haversian canal (H AV-er-zhen r hah-VER-zhun kah-NAL) the
entral anal in the ste n (H aversian system) that ntains a
bl d vessel; named r English physi ian Cl pt n H avers; als
alled central canal the ste n
Haversian system (H AV-er-zhen r hah-VER-zhun SIS-tem)
stru tural unit mpa t b ne tissue made up n entri lay-
ers (lamellae) hard b ne matrix and b ne ells ( ste ytes);
named r English physi ian Cl pt n H avers; als alled osteon
health (helth) physi al, mental, and s ial well-being; the absen e
disease
heart block (hart bl k) a bl kage impulse ndu ti n r m atria
t ventri les s that the heart beats at a sl wer rate than n rmal
heart disease (hart dih-ZEEZ) any a gr up ardia dis rders
that t gether nstitute the leading ause death in the United
States
heart ailure (hart FAYL-y r) inability the heart t pump re-
turned bl d su iently
heart murmur (hart MUR-mur) abn rmal heart s und that may
indi ate valvular insu ien y (leaking) r sten sing (narr wing;
bl kage) the valve
heart rate (HR) (hart rayt) heart beats ( ardia y les) per unit
time; usually expressed as beats/min (beats per minute)
heartburn (H AR -burn) es phageal pain aused by ba kf w
st ma h a id int es phagus
heat exhaustion (heet eg-ZAWS- hun) nditi n aused by f uid
l ss resulting r m a tivity therm regulat ry me hanisms in a
warm external envir nment
heatstroke (heet str hk) li e-threatening nditi n hara terized by
high b dy temperature; ailure therm regulat ry me hanisms
t maintain h me stasis in a very warm external envir nment
Heberden node (H EB-er-den n hd) any the abn rmal enlarge-
ments seen at the distal interphalangeal j ints in ste arthritis
722 GLOSSARY
Heimlich maneuver see abdominal thrust
Helicobacter pylori (H EEL-ih-k h-BAK-ter pye-LO H -ree) spiral-
shaped ba terium kn wn t be a maj r ause gastri and du -
denal ul ers
helix (H EE-lix) (pl., heli es) a spiral, as in the helix the ear (a ld
that spirals ar und the external ear)
helper cell ( H cell) immune system ells that help B ells di er-
entiate int antib dy-se reting plasma ells; als help rdinate
ellular immunity thr ugh dire t nta t with ther immune ells
hematocrit (Hct) (hee-MA - h-krit) v lume per ent bl d ells
in wh le bl d
hematology (hee-mah- O L- h-jee) study the bl d
hematopoiesis (hee-mah-t h-p y-EE-sis) bl d ell rmati n
hematopoietic tissue (hee-mah-t h-p y-E -ik ISH -y ) spe-
ialized nne tive tissue that is resp nsible r the rmati n
bl d ells and lymphati system ells; und in red b ne marr w,
spleen, t nsils, and lymph n des
hematuria (hem-ah- O O-ree-ah) sympt m bl d in the urine,
ten the result a renal r urinary dis rder
heme (heem) ir n- ntaining hemi al gr up und in hem gl bin
hemiplegia (hem-ee-PLEE-jee-ah) paralysis (la k v luntary
mus le ntr l) ne entire side the b dy (ex ept the a e)
hemochromatosis (hee-m h-kr h-mah- O H -sis) nditi n har-
a terized by ex ess availability ir n in the bl d; als alled
iron storage disease
hemodialysis (hee-m h-dye-AL-ih-sis) use dialysis t separate
waste pr du ts r m the bl d
hemoglobin (H b) (hee-m h-GLOH -bin) ir n- ntaining pr tein
in red bl d ells
hemolytic anemia (hee-m h-LI -ik ah-NEE-mee-ah) any a and br n h nstri ti n
gr up bl d dis rders hara terized by de ient r abn rmal
hem gl bin that auses de rmati n and ragility red bl d
ells (e.g., si kle ell anemia, thalassemia)
hemolytic disease o the newborn (H D N) (hee-m h-LI -ik dih-
ZEEZ v thuh NO O -b rn) nditi n aused by bl d ABO r
Rh a t r in mpatibility during pregnan y between devel ping
spring and m ther
hemophilia (hee-m h-FIL-ee-ah) any a gr up X-linked in-
herited bl d l tting dis rders aused by a ailure t rm l t-
ting a t rs VIII, IX, r XI
hemorrhagic anemia (H EM- h-raj-i k ah-NEE-mee-ah) gr up
nditi ns hara terized by l w xygen- arrying apa ity
bl d; aused by de reased red bl d ell (RBC) li e span and/ r
in reased rate RBC destru ti n
hemorrhoid (H EM-eh-r yd) vari se vein in the re tum; hem r-
rh ids are als alled piles
hemostasis (hee-m h-S AY-sis) st ppage bl d f w
hemothorax (hee-m h- H OH -raks) abn rmal nditi n in whi h
bl d is present in the pleural spa e surr unding the lung, p s-
sibly ausing llapse the lung
Henle loop (H EN-lee l p) extensi n the pr ximal tubule the
kidney; als alled nephron loop
heparin (H EP-ah-rin) naturally urring substan e that inhibits
rmati n a bl d l t; has been used as a drug t inhibit
l tting
hepatic duct (heh-PA -ik dukt) any the liver du ts that drain bile
ut the liver
hepatic exure (heh-PA -ik FLEK-sher) the bend between the
as ending l n and the transverse l n; als alled hepatic colic
exure
hepatic portal circulation (heh-PA -ik POR-tall ser-ky -LAY-
shun) the r ute bl d f w thr ugh the liver
hepatic portal vein (heh-PA -ik PO R-tall vane) delivers bl d di-
re tly r m the gastr intestinal tra t t the liver
hepatitis (hep-ah- YE-tis) inf ammati n the liver due t viral r
ba terial in e ti n; injury; damage r m al h l, drugs, r ther
t xins; r ther a t rs
hepatitis C virus (HCV) (hep-ah- YE-tis see VYE-rus) ne
several types virus that auses liver inf ammati n and may
eventually lead t irrh sis r liver an er i n t treated
herniated (slipped) disk (H ER-nee-ayt-ed disk) rupture a -
br artilage intervertebral disk that permits the pulpy re the
disk t push against the spinal rd r spinal nerve r ts, ausing
pain
herpes zoster (H ER-peez ZOS-ter) viral in e ti n that a e ts the
skin a single dermat me; mm nly kn wn as shingles
hiatal hernia (hye-AY-tal H ER-nee-ah) a bulging ut (hernia)
the st ma h thr ugh the pening (hiatus) the diaphragm
thr ugh whi h the es phagus n rmally passes; this nditi n may
prevent the valve between the es phagus and st ma h r m l s-
ing, thus all wing st ma h ntents t f w ba k int the es pha-
gus; see also gastroesophageal re ux disease
hiccup (H IK-up) inv luntary spasm di ntra ti n the
diaphragm
hilum (H YE-lum) (pl., hila) small pening n the side an rgan
(lung, kidney, lymph n de) t all w vessels and nerves t enter/exit
hinge joint (hinj j ynt) type diarthr ti syn vial j int that all ws
m vement ar und a single axis in the manner a hinge
hip the j int nne ting the legs t the trunk
histamine hemi al released by bas phils and mast ells in allergi
and inf ammat ry rea ti ns; results in bl d vessel vas dilati n
histogenesis (his-t h-JEN-eh-sis) rmati n tissues r m pri-
mary germ layers embry
histologist (hih-S OL-uh-jist) s ientist that studies tissue stru ture
and un ti n
hives see urticaria
Hodgkin disease (H OJ-kin dih-ZEEZ) type lymph ma (malig-
nant lymph tum r) hara terized by painless swelling lymph
n des in the ne k, pr gressing t ther regi ns
homeostasis (h h-mee- h-S AY-sis) relative uni rmity the
n rmal b dys internal envir nment
homeostatic mechanism (h h-mee- h-S A -ik MEK-ah-nih-
zem) a system that maintains a nstant envir nment enabling
b dy ells t un ti n e e tively
hormone (H OR-m hn) substan e se reted by an end rine gland
human engineered chromosome (HEC) (H YO O -man en-juh-
NEERD KROH -meh-s hm) gene augmentati n pr edure that
inserts therapeuti genes int a separate strand DNA that is
inserted int nu leus ell
Human Genome Project (HGP) (H YO O -man JEE-n me PRO J-
ekt) a w rldwide llab rative e rt s ientists and thers t
map ut the entire human gen me and study the bi l gi al,
medi al, and ethi al aspe ts their dis veries; the H G P is
largely unded by U.S. g vernment s ur es su h as the D OE
(Department Energy) and the NIH (Nati nal Institutes
H ealth); a urrently a tive H GP sh t is ENCODE (T e En-
cyclopedia o DNA Elements); see genome, genomics
human immunode ciency virus (HIV) (H YO O-man ih-my -
n h-deh-FISH -en-see VYE-rus) the retr virus that auses a -
quired immun de ien y syndr me (AIDS)
human lymphocyte antigen (HLA) (H YO O-man LIM- h-syte
AN-tih-jen) type sel -antigen that the immune system uses t
distinguish nes wn tissue r m that a reign entity

humerus (H YO O -mer-us) the se nd l ngest b ne in the b dy; the
l ng b ne the arm
humoral immunity (H YO O -m r-al ih-MYO O-nih-tee) see
antibody-mediated immunity
Huntington disease (H D ) (H UN-ting-t n dih-ZEEZ ) degenera-
tive, inherited brain dis rder hara terized by h rea (purp se-
less m vements) pr gressing t severe dementia and death by
age 55
hyaline cartilage (H YE-ah-lin KAR-tih-lij) m st mm n type
artilage; appears gelatin us and gl ssy
hybridoma (hye-brid-OH -mah) used r hybrid ells that ntinue
t pr du e the same antib dy as the riginal lymph yte
hydrocele (H YE-dr h-seel) abn rmal a umulati n watery f uid,
as an ur in the s r tum
hydrocephalus (hye-dr h-SEF-ah-lus) abn rmal a umulati n
erebr spinal f uid; water n the brain
hydrochloric acid (HCl) (hye-dr h-KLO R-ik AS-id) mp und
rmed by the hydr gen i n and hl ride i n, whi h releases the
hydr gen i n in water t rm an a id; pr du ed in great quantity
by gastri glands in the st ma h
hydrocortisone (hye-dr h-KO R-tih-z hn) a h rm ne rdinarily
se reted by the adrenal rtex as rtis l, but as hydr rtis l it is
used as a drug t redu e inf ammati n r ther immune un -
ti ns; see cortisol
hydrogen (H YE-dr h-jen) ne the hemi al elements und in
great quantity in the human b dy; symb lized by H , as in H 2O
(water); may rm i ns su h as H (hydr gen i n) r O H (hy-
dr xide i n)
hydrogen bond (H YE-dr h-jen b nd) weak hemi al b nd that
urs between the partial p sitive harge n a hydr gen at m
valently b und t a nitr gen r xygen at m and the partial
negative harge an ther p lar m le ule
hydrogen ion (H YE-dr h-jen aye- n) und in water and water
s luti ns; pr du es an a idi s luti n; symb l is H
hydrolysis (hye-DROH L-ih-sis) hemi al rea ti n in whi h water
is added t a large m le ule, ausing it t break apart int smaller
m le ules
hydronephrosis (hye-dr h-neh-FROH -sis) path l gi al swelling r
enlargement renal pelvis r aly es aused by bl kage urine
utf w
hydrostatic pressure (hye-dr h-S A -ik PRESH -ur) the r e a
f uid pushing against s me sur a e
hydroxide ion (hye-DROK-side aye- n) und in water and water
s luti ns; pr du es an alkaline s luti n; symb l is O H
hydroxyurea (hye-DROK-see-y -REE-ah) an antine plasti (an-
titum r) drug
hymen (H YE-men) G reek r membrane; mu us membrane that
may partially r entirely lude the vaginal utlet
hyoid bone (H YE- yd b hn) U-shaped b ne the ne k between
the mandible and the larynx
hyperacidity (hye-per-ah-SID-ih-tee) ex essive se reti n a id; an
imp rtant a t r in the rmati n ul ers
hypercalcemia (hye-per-kal-SEE-mee-ah) a nditi n in whi h
harm ul ex esses al ium are present in the bl d
hypercholesterolemia (hye-per-k h-les-ter- hl-EE-mee-ah) n-
diti n high bl d h lester l ntent
hyperglycemia (hye-per-glye-SEE-mee-ah) higher than n rmal
bl d glu se n entrati n
hyperkalemia (hy-per-kal-EE-mee-ah) abn rmally high bl d p -
tassium level
hypernatremia (hy-per-nah- REE-mee-ah) abn rmally high bl d
s dium level
GLOSSARY 723
hyperopia (hye-per-OH -pee-ah) re ra tive dis rder the eye
aused by a sh rter than n rmal eyeball; arsightedness
hyperosmotic (hye-per- s-MO -ik) relating t s luti ns that gen-
erally pr m te sm sis water (int them)
hyperplasia (hye-per-PLAY-zee-ah) gr wth an abn rmally large
number ells at a l al site, as in a ne plasm r tum r
hypersecretion (hye-per-seh-KREE-shun) t mu h a substan e
is being se reted
hypersensitivity (hye-per-SEN-sih-tiv-ih-tee) inappr priate r ex-
essive resp nse the immune system
hypertension (H N) (hye-per- EN-shun) abn rmally high bl d
pressure
hyperthyroidism (hye-per- H YE-r yd-iz-em) verse reti n
thyr id h rm nes, whi h in reases metab li rate resulting in l ss
weight, in reased appetite, and nerv us irritability
hypertonic (hye-per- ON-ik) a s luti n ntaining a higher level
salt (NaCl) than is und in a living red bl d ell (ab ve 0.9%
NaCl)
hypertrophy (hye-PER-tr h- ee) in reased size a part aused by
an in rease in the size its ells
hyperventilation (hye-per-ven-tih-LAY-shun) very rapid, deep
respirati ns
hypervitaminosis (hye-per-vye-tah-mih-NOH -sis) general name
r any nditi n resulting r m an abn rmally high intake
vitamins
hypoalbuminemia (hye-p h-al-by -min-EE-mee-ah) nditi n
l w albumin (pr tein) in the bl d plasma; it ten results
r m renal dis rders r malnutriti n; l ss plasma pr tein usu-
ally auses edema the tissue spa es
hypocalcemia (hye-p h-kal-SEE-mee-ah) abn rmally l w bl d
al ium level
hypochondriac region (hye-p h-KO N-dree-ak REE-jun) the le t
and right upper regi ns the abd min pelvi avity, just un-
der the l wer part the rib artilage and n either side the
epigastri regi n; used when the abd min pelvi avity is visu-
alized as being subdivided int nine regi ns as in a ti -ta -t e
grid
hypodermis (hye-p h-DER-mis) the l se rdinary (are lar) tissue
just under the layers skin and super ial t the mus les; made
l se nne tive tissue and at; als alled subcutaneous tissue
r super cial ascia
hypogastric region (hye-p h-G AS -rik REE-jun) the entral
l wer regi n the abd min pelvi avity, bel w the st ma h
and umbili us (navel) and between the le t and right ilia regi ns;
used when the abd min pelvi avity is visualized as being sub-
divided int nine regi ns as in a ti -ta -t e grid
hypoglycemia (hye-p h-glye-SEE-mee-ah) l wer-than-n rmal
bl d glu se n entrati n
hypokalemia (hye-p h-kal-EE-mee-ah) abn rmally l w bl d p -
tassium level
hyponatremia (hye-p h-nah- REE-mee-ah) abn rmally l w bl d
s dium level
hyposecretion (hye-p h-seh-KREE-shun) t little se reti n a
substan e
hypospadias (hye-p h-SPAY-dee-us) ngenital de e t in males
hara terized by pening urethral meatus n underside the
glans r penile sha t
hypothalamus (hye-p h- H AL-ah-mus) p rti n the f r and
lateral wall the third ventri le the brain
hypothermia (hye-p h- H ER-mee-ah) ailure therm regulat ry
me hanisms t maintain h me stasis in a very ld external
envir nment
724 GLOSSARY
hypothesis (hye-PO H -eh-sis) (pl., hyp theses) a pr p sed expla-
nati n an bserved phen men n
hypothyroidism (hye-p h- H YE-r yd-iz-em) underse reti n
thyr id h rm nes; early in li e results in retinism; later in li e
results in myxedema
hypotonic (hye-p h- ON-ik) a s luti n ntaining a l wer level
salt (NaCl) than is und in a living red bl d ell (bel w 0.9%
NaCl)
hypoventilation (hye-p h-ven-tih-LAY-shun) sl w and shall w
respirati ns
hypovitaminosis (hye-p h-VY E-ah-min- h-sis) nditi n
having t ew vitamin m le ules in the b dy r n rmal
un ti n
hypovolemic shock (hye-p h-v h-LEE-mik) ir ulat ry ailure
(sh k) aused by a dr p in bl d v lume that auses bl d pres-
sure (and bl d f w) t dr p; literally l w v lume sh k
hypoxia (hye-PO CK-see-ah) abn rmally l w n entrati n xy-
gen in the bl d r tissue f uids
hysterectomy (his-teh-REK-t h-mee) surgi al rem val the
uterus
I
I & O measurement b th f uid intake and f uid utput (urine
v lume) ver a spe i ed peri d time; abbreviati n input
and utput
identical (monozygotic) twins birth tw siblings at the same time
that have devel ped r m a single zyg te that splits int tw
spring early during devel pment; als alled monozygotic twins;
ntrast with raternal (dizygotic) twins
ideogram (ID-ee- h-gram) a simple art n a hr m s me used
in gen mi s t sh w the verall stru ture the hr m s me,
in luding staining landmarks and the relative p siti n the
entr mere
idiopathic (id-ee- h-PA H -ik) relating t a disease undeter-
mined ause
ileocecal valve (il-ee- h-SEE-kal valv) the sphin terlike stru ture
between the end the small intestine and the beginning the
large intestine
ileum (IL-ee-um) the distal p rti n the small intestine
iliac crest (IL-ee-ak krest) the superi r edge the ilium
iliac region (IL-ee-ak REE-jun) the le t and right l wer regi ns
the abd min pelvi avity, near the ilia regi n the pelvis and
n either side the hyp gastri regi n; termin l gy used t
des ribe the abd min pelvi avity when it is visualized as being
subdivided int nine regi ns as in a ti -ta -t e grid; als alled
le t and right inguinal regions
iliopsoas (il-ee- h-SO H -as) a f ex r the thigh and an imp rtant
stabilizing mus le r p sture
ilium (IL-ee-um) ne the three separate b nes that use t rm
the s xae r hip b ne
immune de ciency (ih-MYO O N deh-FISH -en-see) general term
r mplete r relative ailure the immune system t de end
the internal envir nment the b dy
immune system (ih-MYO ON SIS-tem) the b dys de ense system
against disease
immunization (ih-my -nih-Z AY-shun) deliberate arti ial exp -
sure t disease t pr du e a quired immunity in the b dy
immunoglobulin (Ig) (ih-my -n h-GLOB-y -lin) antib dy
immunology (im-y -NO L- h-jee) study immune system un -
ti ns and me hanisms
immunosuppressive drug (ih-my -n h-s -PRES-iv drug) m-
p und that suppresses, r redu es, the apa ity the immune
system; su h drugs are s metimes used t prevent reje ti n
transplanted tissues
immunotherapy (ih-my -n h- H AYR-ah-pee) therapeuti te h-
nique that b lsters a pers ns immune system in an attempt t
ntr l a disease
impacted racture (im-PAK-ted FRAK- hur) ra ture in whi h
b ne ragments are driven int ea h ther
impetigo (im-peh- YE-g ) a highly ntagi us ba terial skin in e -
ti n that urs m st ten in hildren
implantable cardioverter-de brillator (ICD ) (im-PLAN-tah-bel
KAR-dee- h-vert-er dee-FIB-rih-lay-t r) surgi ally implanted
medi al devi e that aut mati ally m nit rs r brillati n, then
pr du es a de brillating sh k with ut any external
interventi n.
implantation (im-plan- AY-shun) urs when a ertilized vum
implants in the uterus
impotence (IM-p h-tense) ailure t a hieve ere ti n the penis
results in an inability t repr du e; als alled erectile dys unction
(ED)
inborn immunity (IN-b rn ih-MYO O -nih-tee) immunity t dis-
ease that is inherited
incisor (in-SYE-zer) any the r nt teeth, whi h are adapted r
utting
incompetent (cardiac) valve (in-KO M-peh-tent [KAR-dee-ak]
valv) ardia valve that leaks, all wing s me bl d t f w ba k
int the hamber r m whi h it ame
incomplete racture (in-k m-PLEE FRAK- hur) b ne ra ture
in whi h the b ne ragments remain partially j ined
incontinence (in-KON-tih-nens) nditi n in whi h an individual
v ids urine r e es inv luntarily
incubation (in-ky -BAY-shun) early, latent stage an in e ti n,
during whi h an in e ti n has begun but signs r sympt ms have
n t yet devel ped
incus (IN-kus) the anvil, the middle ear b ne that is shaped like an
anvil
induced abortion (in-D O O S ah-BO R-shun) purp se ul termina-
ti n a pregnan y be re the etus is able t survive utside the
w mb
in ancy (IN- an-see) the age range r m birth t ab ut 18 m nths
age
in ant respiratory distress syndrome (IRD S) (IN- ant RES-pih-
rah-t h-ree dih-S RESS SIN-dr hm) leading ause death in
premature babies, aused by a la k sur a tant in the alve lar air
sa s
in ection control (in-FEK-shun KON-tr l) any pra ti e intended
t limit the spread in e ti n in a p pulati n
in ectious (in-FEK-shus) des ribes any nditi n r substan e that
an indu e an in e ti n r is hara terized by in e ti n by a
path gen
in ectious arthritis (in-FEK-shuss ar- H RY-tis) inf ammati n
j int tissues aused by a variety path gens (e.g., Lyme
arthritis)
in ectious mononucleosis (in-FEK-shuss mah-n h-n -klee-O H -
sis) a viral (n n an er us) white bl d ell (W BC) dis rder m-
m n in y ung adults; hara terized by leuk yt sis atypi al
lymph ytes and severe atigue
in erior (in-FEER-ee- r) l wer; pp site superior
in erior vena cava (in-FEER-ee- r VEE-nah KAY-vah) ne tw
large veins arrying bl d int the right atrium

in ertility (in- er- IL-ih-tee) l wer-than-n rmal ability t repr du e
in ammation (in-f ah-MAY-shun) gr up resp nses t a tissue
irritant marked by signs redness, heat, swelling, and pain
in ammation mediator (in-f ah-MAY-shun MEE-dee-ay-t r)
hemi al (e.g., pr staglandins, histamine, kinins) released by ir-
ritated tissues that pr m tes the events the inf ammati n
resp nse
in ammatory (in-FLAM-ah-t h-ree) relating t inf ammati n, an
immune resp nse that ten pr du es heat, swelling, redness, and
pain
in ammatory exudate (in-FLAM-ah-t h-ree EK-s -dayt) f uid
that a umulates in inf amed tissues as a result in reased per-
meability bl d vessels
in ammatory response (in-FLAM-ah-t h-ree ree-SPONS) innate
(n nspe i ) immune pr ess pr du ed in resp nse t injury and
resulting in redness, pain, heat, and swelling and pr m ting
m vement white bl d ells t the a e ted area
ingestion (in-JES- hun) taking in mplex ds, usually by
m uth
inguinal (ING-gwih-nal) the gr in
inguinal hernia (ING-gwih-nal H ER-nee-ah) pr trusi n ab-
d min pelvi rgans thr ugh the inguinal anal and int the
s r tum
inhalation (in-hah-LAY-shun) breathing in; pp site exhalation,
r expiration; als alled inspiration
inherited immunity (in-H AYR-ih-ted ih-MYO O -nih-tee) see
inborn immunity
inhibiting hormone (IH) (in-H IB-ih-ting H OR-m hn) h rm ne
pr du ed by the hyp thalamus that sl ws the release anteri r
pituitary h rm nes
innate immunity (in-AY ih-MYO ON-ih-tee) see n nspe i
immunity
inorganic compound (in- r-GAN-ik KOM-p wnd) mp und
wh se m le ules d n t ntain arb n- arb n r arb n-
hydr gen b nds
INR a r nym r internati nal n rmalized rati
insertion (in-SER-shun) atta hment a mus le t the b ne that it
m ves when ntra ti n urs (as distinguished r m its
rigin)
inspiration (in-spih-RAY-shun) m ving air int the lungs;
pp site exhalation r expiration; als re erred t as
inhalation
inspiratory muscle (in-SPY-rah-t r-ee MUS-el) the mus les that
in rease the size the th rax, in luding the diaphragm and ex-
ternal inter stals, and all w air t rush int the lungs
inspiratory reserve volume (IRV) (in-SPY-rah-t r-ee ree-ZERV
VOL-y m) the am unt air that an be r ibly inspired ver
and ab ve a n rmal respirati n
insulin (IN-suh-lin) h rm ne se reted by the pan reati islets
integument (in- EG-y -ment) the skin
integumentary system (in-teg-y -M EN-tar-ee SIS-tem) the
b dy system mprising nly the skin; the skin is an rgan
and a system
interarytenoid notch (IN-ter-ar-ih-tee-n yd n t h) V-shaped
gr ve between the aryten id artilages the larynx ten used
as a guide r inserting a tube sa ely int the airway
intercalated disk (in- ER-kah-lay-ted disk) any the gap-jun ti n
nne ti ns that rm between ardia mus le bers, visible as
thin dark bands in stained mi r s pi spe imens
intercostal muscle (in-ter-KO S-tal MUS-el) the respirat ry mus-
les l ated between the ribs
GLOSSARY 725
inter eron (IF) (in-ter-FEER- n) small pr teins pr du ed by the
immune system that inhibit virus multipli ati n
interleukins (IL) (in-ter-LO O -kins) any several intra ellular
signals ( yt kines) released by white bl d ells (leuk ytes), usu-
ally inv lved in immune resp nses
internal oblique muscle (in- ER-nal h-BLEEK MUS-el) mus le
rming part the middle layer the anter lateral abd minal
walls
internal respiration (in- ER-nal res-pih-RAY-shun) the ex hange
gases that urs between the bl d and ells the b dy
international normalized ratio (INR) (in-ter-NASH -en-ul NO R-
mah-lyzed RAY-shee- h) meth d expressing the prothrombin
time (time it takes r a bl d sample t l t a ter tissue thr m-
b plastin [pr thr mbin a tivat r] is added) based n interna-
ti nal standards
interneuron (in-ter-NO O-r n) nerve that ndu ts impulses r m
a sens ry neur n t a m t r neur n
interphalangeal joint (in-ter- ah-LAN-jee-al j ynt) arti ulati n
that exists between the heads the phalanges and the bases
the m re distal phalanges
interphase (IN-ter- ayz) the phase immediately be re the visible
stages ell divisi n when the DNA ea h hr m s me repli-
ates itsel
interstitial (in-ter-S ISH -al) in between; ten used t des ribe the
spa e r substan e between ells
interstitial cell (in-ter-S ISH -al sel) end rine ells in the testes
that se rete the male sex h rm ne, test ster ne
interstitial cell-stimulating hormone (ICSH) (in-ter-S ISH -al
sel S IM-y -lay-ting H O R-m hn) the previ us name r lu-
teinizing h rm ne in males; auses testes t devel p and se rete
test ster ne
interstitial cystitis (in-ter-S ISH -al sis- YE-tis) see overactive
bladder
interstitial uid (IF) (in-ter-S ISH -al FLO O-id) f uid l ated in
the mi r s pi spa es between the ells
intestinal gland (in- ES-tih-nal) th usands glands und in the
mu us membrane the mu sa the small intestines; se rete
intestinal digestive jui es
intestine (in- ES-tin) the part the digestive tra t thr ugh whi h
d remains pass a ter leaving the st ma h; separated int tw
segments, the small and the large
intracellular uid (ICF) (in-trah-SEL-y -lar FLO O -id) f uid l -
ated within the ells; largest f uid mpartment
intramembranous ossi cation (in-trah-MEM-brah-nus s-ih- h-
KAY-shun) pr ess by whi h m st f at b nes are rmed within
nne tive tissue membranes
intramuscular injection (IM) (in-trah-MUS-ky -lar in-JEK-
shun) administrati n medi ati n int the mus le
intraocular pressure (in-trah-OK-y -lar PRESH -ur) f uid pres-
sure within the eyeball
intravenous (IV) (in-trah-VEE-nus) within, r int , a vein
intrinsic actor (in- RIN-sik FAK-ter) substan e that binds t m l-
e ules vitamin B12, pr te ting them r m the a ids and enzymes
the st ma h; se reted by parietal ells gastri glands
inversion (in-VER-zhun) m vement that turns the s le the t
inward, t ward the median
invert (in-VER ) t m ve a part inward
in vitro (in VEE-tr h) urring in a test tube, dish, r ther lab ra-
t ry apparatus
involuntary muscle (in-VOL-un-tayr-ee MUS-el) sm th mus le
that is n t under ns i us ntr l and is und in rgans su h as
726 GLOSSARY
the st ma h and small intestine; ardia mus le is als an inv l-
untary type mus le; see smooth muscle and cardiac muscle
involution (in-v h-LO O-shun) return an rgan t its n rmal
size a ter an enlargement; als a ter retr grade r degenerative
hange
ion (AYE- n) ele tri ally harged at m r gr up at ms
ionic bond (aye-ON-ik) hemi al b nd rmed by the p sitive-
negative attra ti n between tw i ns
iris (AYE-ris) ir ular, pigmented ring mus le tissue behind the
rnea; the enter the iris is per rated by the pupil
iron de ciency anemia (AYE-ern deh-FISH -en-see ah-NEE-mee-
ah) nditi n in whi h there are inadequate levels ir n in the
diet ausing less hem gl bin t be pr du ed; results in extreme
atigue
ischemia (is-KEE-mee-ah) redu ed f w bl d t tissue resulting
in impairment ell un ti n
ischium (IS-kee-um) ne three separate b nes that rms the s
xae
islet o Langerhans see pancreatic islet
isoimmunity (aye-s h-ih-MYO O-nih-tee) immune resp nse t
antigens an ther human, as in transplanted (gra ted) tissues;
als alled alloimmunity; in s me ases it is alled rejection
syndrome
isometric contraction (aye-s h-ME -rik) type mus le ntra -
ti n in whi h mus le d es n t sh rten
isotonic (aye-s h- O N-ik) relating t equal r uni rm pressures r
tensi n
isotonic contraction (aye-s h- ON-ik) type mus le ntra ti n
that maintains uni rm tensi n r pressure
isotope (AYE-s h-t hp) at m with the same at mi number as
an ther at m but with a di erent at mi weight (that is, with a
di erent number neutr ns in the nu leus the at m)
IV (intravenous) technician (aye-vee [in-trah-VEE-nus] tek-
NISH -en) health- are pr essi nal spe ializing in preparati n
and administrati n therapeuti f uids and medi ines int veins
J
jaundice ( JAW N-dis) abn rmal yell wing skin, mu us mem-
branes, and white eyes
jejunum (jeh-JO O-num) the middle third the small intestine
joint (j ynt) see articulation
joint capsule (j ynt CAP-s l) br us nne tive tissue sleeve, lined
with syn vial membrane, that h lds t gether pp sing ends
arti ulating b nes in a syn vial j int
joule ( J or j) (j l) unit measuring energy; see calorie
juvenile rheumatoid arthritis ( JRA) ( JO O -veh-naye-il RO O -
mah-t yd ar- H RY-tis) rm rheumat id arthritis a e ting
pe ple under 16 years age; it may a e t b ne devel pment
juxtaglomerular ( JG) apparatus (jux-tah-gl h-MER-y -lar ap-
ah-RA -us) mplex ells in nephr n near the gl merulus and
adja ent t distal tubule and a erent arteri le; se retes enzyme
(renin) imp rtant in regulati n bl d pressure
juxtamedullary nephron (jux-tah-MED- -lar-ee NEF-r n)
nephr n units with renal rpus les l ated near the jun ti n
between rtex and medullary layers kidney; see also nephron
K
Kaposi sarcoma (KS) (KAH -p h-see sar-KOH -mah) a malignant
ne plasm ( an er) the skin aused by the Kap si sar ma
related herpes virus (KSH V), r human herpes virus 8 (H H V8),
and hara terized by purplish sp ts n the skin; is mainly und
in ertain ethni gr ups and in th se with immune de ien ies
karyotype (KER-ee- h-type) rdered arrangement ph t graphs
hr m s mes r m a single ell used in geneti unseling t
identi y hr m s mal dis rders su h as tris my r m n s my
keloid (KEE-l yd) an unusually thi k, irregularly shaped, pr gres-
sively enlarging br us s ar n the skin
keratin (KAYR-ah-tin) pr tein substan e und in hair, nails, uter
skin ells, and h rny tissues
ketoacidosis (kee-t h-as-ih-D O H -sis) a nditi n abn rmally
l w bl d pH (a idity) aused by the presen e an abn rmally
large number ket ne b dies r ket a ids that are pr du ed
when ats are nverted t rms glu se t be used r el-
lular respirati n; ten urs in th se with diabetes mellitus,
when it is m re spe i ally alled diabetic ketoacidosis; see also
acidosis
ketone body (KEE-t hn BO D-ee) a idi pr du t lipid metab -
lism; they may a umulate abn rmally in bl d individuals
with un ntr lled type 1 diabetes
kidney (KID-nee) rgan that leanses the bl d waste pr du ts
pr du ed ntinually by metab lism
kidney dialysis (KID-nee dye-AL-ih-sis) therapy r kidney ailure
in whi h ma hines pump bl d thr ugh permeable tubes in an
external apparatus, all wing waste pr du ts t di use ut the
bl d and int a salt-water type ele tr lyte f uid that surr unds
the semipermeable dialysis tubes.
kilocalorie (Kcal) (KIL- h-kal- h-ree) 1000 al ries
kinesthesia (kin-es- H EE-zee-ah) mus le sense; that is, sense
p siti n and m vement b dy parts
Kline elter syndrome (KLINE- el-ter SIN-dr hm) geneti dis r-
der aused by the presen e tw r m re X hr m s mes in a
male (typi ally tris my XXY); hara terized by l ng legs, en-
larged breasts, l w intelligen e, small testes, sterility, hr ni
pulm nary disease
Krause end bulb (kr ws) mu us membrane re ept r that dete ts
sensati ns t u h and vibrati n; als kn wn as bulboid
corpuscle
Krebs cycle see citric acid cycle
Kupf er cell (KO O P- er sel) phag yti ell und in spa es be-
tween liver ells
kwashiorkor (kwah-shee-O R-k r) nutriti nal dis rder that results
r m a pr tein de ien y in the presen e su ient al ries
kyphosis (kye-FO H -sis) abn rmally exaggerated th ra i urvature
the vertebral lumn
L
labia majora (LAY-bee-ah mah-JO H -rah) large lips the vulva
labia minora (LAY-bee-ah mih-NOH -rah) small lips the vulva
labor (LAY-ber) the pr ess that results in the birth the baby
laboratory technician (LAB-rah-t r-ee tek-NISH -en) a trained
assistant in a medi al r s ienti lab rat ry
lacrimal gland (LAK-rih-mal) gland that pr du es tears; ne gland
l ated in the upper lateral p rti n ea h eye rbit
lacrimal sac (LAK-rih-mal sak) widened upper part nas la rimal
du t that ndu ts tears r m the la rimal glands
lactase (LAK-tayse) enzyme that breaks d wn la t se
lacteal (LAK-tee-al) a lymphati vessel l ated in ea h villus the
intestine; serves t abs rb at materials r m the hyme passing
thr ugh the small intestine
lacti erous duct (lak- IF-er-us dukt) the du t that drains the grape-
like luster milk-se reting glands in the breast

lactogenic hormone (lak-t h-JEN-ik H O R-m hn) see prolactin
lactose (LAK-t hs) disa haride sugar und in milk; als alled
milk sugar
lactose intolerance (LAK-t hs in- OL-er-ans) la k the enzyme
la tase, resulting in an inability t digest la t se (a disa haride
present in milk and dairy pr du ts)
lacuna (lah-KO O-nah) (pl., la unae) spa e r avity; r example,
la unae in b ne ntain b ne ells
lambdoidal suture (LAM-d yd-al SO O- hur) the imm vable j int
rmed by the parietal and ipital b nes
lamella (lah-MEL-ah) (pl., lamellae) thin layer, as b ne
lamellar corpuscle (lah-MEL-ar KO R-pus-ul) sens ry re ept r
with a layered en apsulati n und deep in the dermis that de-
te ts pressure n the skin sur a e; als kn wn as Pacini corpuscle
lamina propria (LAM-in-ah PRO H -pree-ah) br us nne tive
tissue underlying the epithelium in mu us membranes
lanugo (lah-NO O -g ) the extremely ne and s t hair und n a
newb rn in ant
laparoscope (LAP-ah-r h-sk pe) spe ialized pti al viewing tube
large intestine (in- ES-tin) part GI tra t that in ludes e um;
as ending, transverse, des ending and sigm id l ns; re tum;
and anal anal
laryngeal cancer (lah-RIN-jee-al r lar-in-JEE-al KAN-ser) malig-
nan y the v i eb x (larynx)
laryngitis (lar-in-JYE-tis) inf ammati n the mu us tissues the
larynx (v i e b x)
laryngopharynx (lah-ring-g h-FAYR-inks) the l west part the
pharynx
larynx (LAYR-inks) the v i e b x l ated just bel w the pharynx;
the largest pie e artilage making up the larynx is the thyr id
artilage, mm nly kn wn as the Adams apple
laser-assisted in situ keratomileusis (LASIK) (LAY-zer ah-SIS-
ted in SYE-t kayr-at- h-mil-YO O-sis) re ra t ry eye surgery
using a mi r kerat me t ut a rneal ap, whi h is repla ed
a ter an ex imer laser is used t vap rize and reshape underlying
rneal tissue
laser therapy (LAY-zer H AYR-ah-pee) use laser (intense beams
light) t destr y a tum r, abn rmal tissue, damaged tissue, r
s ars
laser thermal keratoplasty (L K) (LAY-zer H ER-mull kayr-A -
h-plast-ee) re ra t ry eye surgery empl ying ultrash rt bursts
(3 se nds) laser energy t reshape the rnea
lateral (LA -er-al) r t ward the side; pp site medial
lateral longitudinal arch (LA -er-al lawnj-ih- O OD-in-al) uter
lengthwise (anter p steri r) supp rt stru ture the t lithotriptor (LI H - h-trip-t r) a spe ialized ultras und generat r
latissimus dorsi (lah- IS-ih-mus D O R-sye) an extens r the arm
law a s ienti law is a the ry, r explanati n, a s ienti prin iple
that is based n experimentati n results and supp rted by s ien-
tists wh have an extra rdinarily high degree n den e in its
validity
Leber hereditary optic neuropathy (LEE-ber heh-RED-ih-tayr-ee
OP-tik n -RO P-ah-thee) inherited nditi n in whi h y ung
adults begin l sing their eyesight as the pti nerve degenerates
resulting in t tal blindness by age 30
lens (lenz) the re ra ting me hanism the eye that is l ated di-
re tly behind the pupil
leptin (LEP-tin) h rm ne, se reted by at-st ring ells, that regu-
lates h w hungry r ull we eel and h w at is metab lized by the
b dy
lesion (LEE-zhun) any bje tive abn rmality in a b dy stru ture
lesser vestibular gland (LES-er ves- IB-y -lar gland) either
the ex rine mu us glands l ated n the sides the urinary
GLOSSARY 727
utlet in w men; als kn wn as Skene gland; see also greater
vestibular gland
leukemia (l -KEE-mee-ah) bl d an er hara terized by an in-
rease in white bl d ells
leukocyte (LO O-k h-syte) white bl d ells
leukocytosis (l -k h-SYE-t h-sis) abn rmally high white bl d
ell numbers in the bl d
leukopenia (l -k h-PEE-nee-ah) abn rmally l w white bl d ell
numbers in the bl d
leukoplakia (l -k h-PLAY-kee-ah) white pat hes in the m uth,
mm nly seen in hr ni igarette sm kers; may lead t m uth
an er
leukorrhea (l -k h-REE-ah) whitish dis harge r m the ur geni-
tal tra t
leukotriene (l -k h- RY-een) yt kine mp und that un ti ns
as an inf ammati n mediat r
levels o organization (LEV-elz v r-gan-ih-ZAY-shun) gr up-
ings stru tural mp nents r m mi r s pi t gr ss, used as
a manner rganizing n epts bi l gi al s ale
levodopa (LEV- h-d h-pah) hemi al manu a tured by the brain
ells and then nverted int the neur transmitter d pamine; has
been used t treat dis rders inv lving d pamine de ien ies su h
as Parkins n disease; als alled L-dopa
li estyle (LYFE-style) the m de living a pers n, in luding eat-
ing habits, a tivity, and h i e envir nment, whi h may n t be
mpletely v luntary
ligament (LIG -ah-ment) b nd r band nne ting tw bje ts; in
anat my, a band white br us tissue nne ting b nes
limbic system (LIM-bik) a lle ti n vari us small regi ns the
brain that a t t gether t pr du e em ti n and em ti nal re-
sp nse; s metimes alled the em ti nal brain
linear racture (LIN-ee-ar FRAK- hur) b ne ra ture hara terized
by a ra ture line that is parallel t the b nes l ng axis
lingual tonsil (LING-gwal AH N-sil) t nsil l ated at the base
the t ngue
lipase (LYE-payse) at-digesting enzymes
lipid (LIP-id) rgani m le ule usually mp sed gly er l and
atty a id units; types in lude trigly erides, ph sph lipids, and
h lester l; a at, wax, r il
lipoma (lih-PO H -mah) benign tum r adip se ( at) tissue
lipoprotein (lip- h-PROH -teen) substan e that is part lipid and
part pr tein; pr du ed mainly in the liver
lithotripsy (lih-th h- RIP-see) use ultras und waves t break up
kidney st nes with ut making an in isi n
that is used t pulverize kidney st nes
liver (LIV-er) large, multil bed ex rine gland in the right upper
abd minal quadrant, pr du ing bile and having many metab li
un ti ns
liver glycogenolysis (LIV-er glye-k h-jeh-NOL-ih-sis) hemi al
pr ess by whi h liver gly gen is nverted t glu se
lobectomy (l h-BEK-t h-mee) surgi al rem val a single l be
an rgan, as in the rem val ne l be a lung
lock-and-key model (l k and kee MAH D-el) n ept that explains
h w m le ules rea t when they t t gether in a mplementary
way in the same manner that a key ts int a l k t ause the
l k t pen r l se; the anal gy is ten used t explain the
a ti n h rm nes, enzymes, and ther bi l gi al m le ules
longitudinal arch (l n-jih- O O -dih-nal) tw ar hes, the medial
and lateral, that extend lengthwise in the t
loop o Henle (l p H EN-lee) see Henle loop
loose brous connective tissue see areolar tissue
728 GLOSSARY
lordosis (l r-DOH -sis) abn rmally exaggerated lumbar urvature
the vertebral lumn; may als re er t n rmal n avity the
lumbar urvature
lower esophageal sphincter (LES) (LOH -er eh-s -eh-JEE-al
SFINGK-ter) ring mus ular tissue (sphin ter) l ated be-
tween terminal es phagus and st ma h
lumbar (LUM-bar) l wer ba k, between the ribs and pelvis
lumbar puncture (LUM-bar PUNK- hur) when s me erebr spi-
nal f uid is withdrawn r m the subara hn id spa e in the lumbar
regi n the spinal rd
lumbar region (LUM-bar REE-jun) the le t and right middle re-
gi ns the abd min pelvi avity, near the lumbar area the
vertebral lumn and n either side the umbili al regi n; ter-
min l gy used when the abd min pelvi avity is visualized as
being subdivided int nine regi ns as in a ti -ta -t e grid
lumen (LO O-men) (pl., lumina r lumens) the h ll w spa e within
a tube
lung rgan respirati n; the right lung has three l bes and the le t
lung has tw l bes
lunula (LO O -ny -lah) res ent-shaped white area under the pr x-
imal nail bed
luteinization (l -tee-in-ih-Z AY-shun) the pr ess devel pment
a rpus luteum (g lden b dy) in the vary a ter an vum is
released r m the lli le; stimulated by the a ti n luteinizing
h rm ne (LH ) r m the anteri r pituitary
luteinizing hormone (LH) (l -tee-in-AYE-zing H OR-m hn) an-
teri r pituitary h rm ne that stimulates the devel pment
rpus luteum (literally yell w b dy) that se retes h rm nes at
the sur a e the vary a ter a lli le has released its vum; a
tr pi h rm ne als kn wn as LH
Lyme arthritis (lyme ar- H RY-tis) in e ti us rm j int inf am-
mati n (arthritis) ass iated with Lyme disease; aused by a spi-
r hete ba terium arried by deer ti ks
lymph (lim ) spe ialized f uid rmed in the tissue spa es that re-
turns ex ess f uid and pr tein m le ules t the bl d via lym-
phati vessels
lymph node (lim ) per rms bi l gi al ltrati n lymph n its way
t the ardi vas ular system
lymph nodule (lim NO D-y l) is a mass lymph id tissue (devel-
ping white bl d ells) within a lymph n de r making up a
pat h lymph n dules (as in the t nsils)
lymphadenitis (lim-FAD-in-aye-tis) inf ammati n a lymph
n de, usually aused by a ba terial in e ti n r asi nally a
ne plasm (benign r an er us), and hara terized by swelling
and tenderness
lymphangiogram (lim-FAN-jee- h-gram) radi graph (x-ray)
part the lymphati netw rk, whi h is pr du ed by inje ting a
spe ial dye that is paque t x-rays int the s t tissues drained
by the lymphati netw rk
lymphangitis (lim- an-JYE-tis) inf ammati n lymph vessels, usu-
ally aused by in e ti n, hara terized by ne red streaks extend-
ing r m the site in e ti n; may pr gress t septi emia (bl d
in e ti n)
lymphatic capillary (lim-FA -ik CAP-ih-layr-ee) any the tiny,
blind-ended tubes r draining ex ess interstitial f uid distributed
in the tissue spa es
lymphatic duct (lim-FA -ik dukt) terminal vessel int whi h lym-
phati vessels empty lymph; the du t then empties the lymph int
the ardi vas ular system
lymphatic system (lim-FA -ik SIS-tem) a system that plays a riti-
al r le in the un ti ning the immune system, m ves f uids
and large m le ules r m the tissue spa es and at-related nutri-
ents r m the digestive system t the bl d
lymphatic tissue (lim-FA -ik ISH -y ) see lymphoid tissue
lymphatic vessel (lim-FA -ik VES-el) vessel that arries lymph t
its eventual return t the ardi vas ular system
lymphedema (lim- ah-DEE-mah) swelling (edema) tissues
aused by partial r t tal bl kage the lymph vessels that drain
the a e ted tissue
lymphocyte (LIM- h-syte) ne type white bl d ell
lymphoid neoplasm (LIM- yd NEE- h-plaz-em) abn rmal pr -
li erati n lymph id tissue r lymph id pre urs r ells ten
ass iated with an er us trans rmati n
lymphoid tissue (LIM- yd ISH -y ) tissue that is resp nsible r
manu a turing lymph ytes and m n ytes; und m stly in the
lymph n des, thymus, and spleen
lymphoma (lim-FO H -mah) an er lymph id tissue
lyse (lyze) disintegrati n a ell
lysosome (LYE-s h-s hm) membran us rganelles ntaining vari-
us enzymes that an diss lve m st ellular mp unds; thus
alled digestive bags r suicide bags ells
M
macronutrient (MAK-r h-NO O -tree-ent) nutrient needed in large
am unts; arb hydrates, ats, and pr teins
macrophage (MAK-r h- ayj) phag yti ells in the immune
a system
macula (MAK-y -lah) (pl., ma ulae r ma ulas) strip sens ry
epithelium in the utri le and sa ule; pr vides in rmati n re-
lated t head p siti n r a elerati n [macula sp t]
macula lutea (MAK-y -lah LO O -tee-ah) (pl., ma ulae luteae)
yell wish area near enter retina lled with nes permitting
a ute image rmati n and l r visi n
macular degeneration see age-related macular degeneration (AMD )
macule (MAK-y l) a f at skin lesi n distinguished r m the sur-
r unding tissue by a di eren e in l rati n
mad cow disease see bovine spongi orm encephalopathy
magnetic resonance imaging (MRI) (mag-NE -ik REZ-ah-nans
IM-ah-jing) s anning te hnique that uses a magneti eld t
indu e tissues t emit radi waves that an be used by mputer
t nstru t a se ti nal view a patients b dy
major duodenal papilla (MAY-jer d - h-DEE-nul [ r d -AH -
de-nul] pah-PIL-ah) mus ular bump in lining du denum
where mm n bile du t enters; als alled greater duodenal
papilla
a malabsorption syndrome (mal-ab-SORP-shun SIN-dr hm) gr up
sympt ms ass iated with the ailure t abs rb nutrients pr p-
erly: an rexia, as ites, ramps, anemia, atigue
maldigestion (mal-dye-JES- hun) ailure t ully digest nutrients in
the gut
malignant (mah-LIG-nant) re erring t s mething harm ul
malignant hyperthermia (MH) (mah-LIG-nant hye-per- H ERM-
ee-ah) inherited nditi n hara terized by an abn rmally
in reased b dy temperature (hyperthermia) and mus le rigidity
when a pers n is exp sed t ertain anestheti s (e.g.,
su inyl h line)
malignant tumor (mah-LIG -nant O O-mer) a tum r r ne plasm
that is apable metastasizing r spreading t new tissues (i.e.,
an er)
malleus (MAL-ee-us) hammer; the tiny middle ear b ne that is
shaped like a hammer

malnutrition (mal-n - RISH -un) insu ient r imbalan ed in-
take nutrients, ten ausing any a variety diseases
malocclusion (mal- h-CLEW-zhun) abn rmal nta t between
the teeth the upper and l wer jaw
maltase (MAW L-tayz) enzyme that breaks apart malt se and
thereby atalyzes the nal steps arb hydrate digesti n
maltose (MAW L-t hs) disa haride sugar rmed by the break-
d wn star h
mammary (MAM-mah-ree) relating t the breasts r milk-pr du ing
glands within the breasts
mammary dysplasia (MAM-mah-ree dis-PLAY-zhah) gr up
nditi ns hara terized by benign lumps in ne r b th breasts;
als alled brocystic disease
mammary gland (MAM-mah-ree) milk-pr du ing ex rine gland
the breasts; un ti nally lassi ed as external a ess ry sex rgan in
emales but is stru turally part the integumentary system
marasmus (mah-RAZ-mus) rm pr tein- al rie malnutriti n;
results r m an verall la k al ries and pr tein
massage therapy (mah-SAH J H AYR-ah-pee) pressing, rubbing,
r ther manipulati n mus le and ther s t tissue t prevent
r treat a variety health nditi ns
masseter (mah-SEE-ter) large mus le the heek, used t li t the
l wer jaw (mandible) and thus pr vide hewing m vement
mast cell immune system ell (related t the bas phil) that se retes
histamine and ther inf ammat ry hemi als
mastectomy (mas- EK-t h-mee) surgi al rem val the breast
mastication (mas-tih-KAY-shun) hewing
mastitis (mas- YE-tis) inf ammati n r in e ti n the breast
mastoiditis (mas-t yd-AYE-tis) inf ammati n the air ells within
the mast id p rti n the temp ral b ne; usually aused by
in e ti n
matrix (MAY-triks) the intra ellular substan e a tissue; r ex-
ample, the matrix b ne is al i ed, whereas that bl d is
liquid
matter any substan e that upies spa e and has mass
mature ollicle (mah-CH UR FO L-lih-kul) see graa an ollicle
maxilla (mak-SIH -lah) upper jaw b ne
maximum oxygen consumption (VO 2max) (MAX-ih-mum OKS-
ih-jen k n-SUMP-shun) the maximum am unt xygen taken
up by the lungs, transp rted t the tissues, and used t d w rk
mechanoreceptor (mek-an- h-ree-SEP-t r) re ept rs that are me-
hani al in nature; r example, equilibrium and balan e sens rs
in the ears
medial (MEE-dee-al) r t ward the middle; pp site lateral
medial longitudinal arch (MEE-dee-al l n-jih- O O-dih-nal) in-
ner lengthwise (anter p steri r) supp rt stru ture the t the abd minal avity
mediastinum (MEE-dee-as- YE-num) a subdivisi n in the mid-
p rti n the th ra i avity
medic (MED-ik) member a military medi al rps
medicine (MED-ih-sin) pra ti e applying s ienti prin iples t
the preventi n and treatment health nditi ns
medulla (meh-D UL-ah) Latin r marr w; the inner p rti n an
rgan in ntrast t the uter p rti n r rtex
medulla oblongata (meh-D UL-ah b-l ng-GAH -tah) the l west
part the brainstem; an enlarged extensi n the spinal rd;
the vital enters are l ated within this area
medullary cavity (med-O O -layr-ee KAV-ih-tee) h ll w area inside
the diaphysis the b ne that ntains yell w b ne marr w
meibomian gland (my-BOH -mee-an gland) any the small seba-
e us glands al ng the edge (tarsus) the eyelid; an be me
in e ted, resulting in a sty
GLOSSARY 729
meiosis (my-OH -sis) nu lear divisi n in whi h the number hr -
m s mes are redu ed t hal their riginal number; pr du es
gametes
Meissner corpuscle (MYZ-ner KOR-pus-ul) a sens ry re ept r
l ated in the skin l se t the sur a e that dete ts light t u h;
als kn wn as tactile corpuscle
melanin (MEL-ah-nin) br wn skin pigment
melanocyte (MEL-ah-n h-syte) spe ialized ells in the pigment
layer that pr du e melanin
melanocyte-stimulating hormone (MSH) (MEL-ah-n h-syte
S IM-y -lay-ting H O R-m hn) resp nsible r a rapid in-
rease in the synthesis and dispersi n melanin granules in
spe ialized skin ells
melanoma (mel-ah-NO H -mah) a malignant ne plasm ( an er)
the pigment-pr du ing ells the skin (melan ytes); als alled
malignant melanoma
melatonin (mel-ah- O H -nin) imp rtant h rm ne pr du ed by the
pineal gland; believed t regulate the nset puberty and the
menstrual y le; als re erred t as the third eye be ause it re-
sp nds t levels light and is th ught t be inv lved with the
b dys internal l k
membrane (MEM-brane) thin layer r sheet
membranous labyrinth (MEM-brah-nus LAB-eh-rinth) a mem-
bran us sa that ll ws the shape the b ny labyrinth and is
lled with end lymph
memory cell (MEM- h-ree sel) ell that remains in reserve in the
lymph n des until its ability t se rete antib dies is needed
menarche (meh-NAR-kee) beginnings the menstrual un ti n
Mnire disease (men-ee-AYR dih-ZEEZ) hr ni inner ear dis r-
der hara terized by tinnitus, pr gressive nerve dea ness, and
vertig
meninges (meh-NIN-jeez) (sing., meninx) f uid- ntaining mem-
branes surr unding the brain and spinal rd
meningitis (men-in-JYE-tis) inf ammati n the meninges aused
by a variety a t rs in luding ba terial in e ti n, my sis, viral
in e ti n, and tum rs
meniscus (meh-NIS-kus) (pl., menis i) arti ular artilage disk
menopause (MEN- h-pawz) terminati n menstrual y les
menses (MEN-seez) menstrual f w
menstrual cramp (MEN-str -al kramp) pain ul ntra ti n the
uterine mus le during menstruati n
menstrual cycle (MEN-str -al SYE-kul) the y li al hanges in
the uterine lining
mesentery (MEZ-en-tayr-ee) a large d uble ld perit neal tissue
that an h rs the l ps the digestive tra t t the p steri r wall
mesoderm (MEZ- h-derm) the middle layer the primary germ
layers
messenger RNA (mRNA) (MES-en-jer R N A) a dupli ate py
a gene sequen e n the DNA that passes r m the nu leus t the
yt plasm
metabolic (met-ah-BOL-ik) related t metab lism, the hemi al
rea ti ns the b dy
metabolic acidosis (met-ah-BOL-ik as-ih-DOH -sis) a disturban e
a e ting the bi arb nate element the bi arb nate arb ni
a id bu er pair; bi arb nate de it
metabolic alkalosis (met-ah-BO L-ik al-kah-LO H -sis) disturban e
a e ting the bi arb nate element the bi arb nate arb ni
a id bu er pair; bi arb nate ex ess
metabolism (meh- AB- h-liz-em) mplex pr ess by whi h nu-
trients are used by a living rganism
730 GLOSSARY
metacarpal (met-ah-KAR-pal) the part the hand between the
wrist and ngers
metallic (meh- AL-ik) relating t metal, as in metallic taste
metaphase (ME -ah- ayz) se nd stage mit sis, during whi h
the nu lear membrane and nu le lus disappear
metastasis (meh- AS-tah-sis) pr ess by whi h malignant tum r
ells all a primary tum r, then migrate t a new tissue t l -
nize a se ndary tum r
metatarsal arch (met-ah- AR-sal) the ar h that extends a r ss the
ball the t; als alled the transverse arch
metatarsals (met-ah- AR-salz) any the ve b nes that rm the
t; arti ulate with tarsal b nes pr ximally and the rst r w
t e phalanges distally
metazoan (met-ah-ZO H -an) (pl., metaz a) animals (large multi el-
lular rganisms) that an s metimes ause r transmit disease
meter (MEE-ter) a measure length in the metri system; equal t
ab ut 39.5 in hes
methylation (meth-il-AY-shun) hemi al pr ess in whi h a methyl
gr up (CH 3) is added t a m le ule, as in adding methyl t DNA
t regulate gene a tivity
microbe (MY-kr be) any mi r s pi rganism
microbiologist (my-kr h-bye-O L-uh-jist) s ientist spe ializing in
the study mi r rganisms su h as ba teria
microbiome (my-kr h-BYE- hm) all the intera ting e systems
mi r bes (ba teria, ungi, et .) that live n r in the human b dy;
als alled the human microbiome r human microbial system
microcephaly (my-kr h-SEF-ah-lee) a ngenital abn rmality in
whi h an in ant is b rn with a small head
microglia (my-KRO G-lee-ah) ne type nne tive tissue und
in the brain and spinal rd
micron (MY-kr n) measurement that equals 1/1000 millimeter;
1/25,000 in h
micronutrient (MY-kr h-NO O-tree-ent) nutrient needed by the
b dy in very small quantity, su h as vitamins and minerals
microtubule (my-kr h- O O B-y l) thi k ell ber ( mpared t
mi r lament); h ll w tube resp nsible r m vement sub-
stan es within the ell r m vement the ell itsel
microvilli (my-kr h-VIL-ee) brushlike b rder made up epithelial
ells und n ea h villus in the small intestine and ther areas
the b dy; in reases the sur a e area (as r abs rpti n nutrients)
micturition (mik-t -RISH -un) urinati n, v iding ( bladder)
midbrain (MID-brayn) ne the three parts the brainstem
middle ear (MID-ul eer) a tiny and very thin epithelium-lined av-
ity in the temp ral b ne that h uses the ssi les; in the middle
ear, s und waves are ampli ed
midsagittal plane (mid-SAJ-ih-tal) a ut r plane that divides the
b dy r any its parts int tw equal halves
mineral (M IN-er-al) in rgani element r salt und naturally in
the earth that may be vital t the pr per un ti ning the
b dy
mineralocorticoid (MC) (min-er-al- h-KOR-tih-k yd) h rm ne
that inf uen es mineral salt metab lism; se reted by adrenal r-
tex; ald ster ne is the hie mineral rti id
minor duodenal papilla (MYE-ner d - h-DEE-nul [ r d -AH -
de-nul] pah-PIL-ah) small mus ular bump in lining du de-
num where the a ess ry pan reati du t enters
mitochondria (my-t h-KON-dree-ah) plural rm mitochondrion
mitochondrial D NA (my-t h-KO N-dree-al D N A) DNA l ated
in the mit h ndria ea h ell, nstituting a single hr m -
s me; als alled mtDNA r mDNA
mitochondrion (my-t h-KO N-dree- n) rganelle in whi h A P
generati n urs; ten termed p werh use ell
mitosis (my- OH -sis) indire t ell divisi n inv lving mplex
hanges in the nu leus
mitral valve (MY-tral valv) heart valve l ated between the le t
atrium and ventri le; als kn wn as the bicuspid valve
mitral valve prolapse (MVP) (MY-tral valv PROH -laps) nditi n
in whi h the bi uspid (mitral) valve extends int the le t atrium,
ausing in mpeten e (leaking) the valve
mode (m hd) ateg ry sensati n dete ted by a sens ry re ept r;
als alled modality
molar see tricuspid
mold large ungus ( mpared t a yeast, whi h is a small ungus)
molecule (MOL-eh-ky l) parti le matter mp sed ne r
m re smaller units alled atoms
monoclonal antibody (m n- h-KLO NE-al AN-tih-b d-ee) spe-
i antib dy pr du ed r m a p pulati n identi al ells
monocyte (MON- h-syte) largest type white bl d ell; a type
agranul yte; ten inv lved in phag yt sis abn rmal ells r
parti les
mononucleosis (MAH N- h-NO O -klee-OH -sis) nditi n har-
a terized by an in rease in the number m n nu lear leuk -
ytes; an be aused by the Epstein-Barr virus (EBV); als m-
m nly alled mono
monosaccharide (m n- h-SAK-ah-ryde) a simple sugar m-
p sed nly a single sa haride gr up (C 6H 12O 6); examples
in lude glu se, ru t se, gala t se
monosomy (MO N- h-s h-mee) abn rmal geneti nditi n in
whi h ells have nly ne hr m s me where there sh uld be a
pair; usually aused by n ndisjun ti n ( ailure hr m s me
pairs t separate) during gamete pr du ti n
monozygotic twins (mahn- h-zye-GO -ik twinz) twins that de-
vel p r m a single zyg te that has split during early devel pment
int tw separate, but geneti ally identi al, spring; see also
identical twins
mons pubis (m nz PYO O -bis) skin- vered pad at ver the
symphysis pubis in the emale
morbidity (m r-BID-ih-tee) illness r disease; the rate in iden e
a spe i illness r disease in a spe i p pulati n
mortality (m r- AL-ih-tee) death; the rate deaths aused by a
spe i disease within a spe i p pulati n
morula (MOR-y -lah) a s lid mass ells rmed by the divisi ns
a ertilized egg
motility (m h- IL-ih-tee) ability t m ve
motor neuron (MO H -ter NO O-r n) neur n that transmits nerve
impulses r m the brain and spinal rd t mus les and glandular
epithelial tissues
motor unit (MOH -ter YO O-nit) a single m t r neur n al ng with
the mus le ells it innervates
mouth (m wth) ral avity
mucocutaneous junction (my -k h-ky - AY-nee-us JUNK-shun)
the transiti nal area where the skin and mu us membrane meet
mucosa (my -KOH -sah) mu us membrane
mucous membrane (MYO O -kus MEM-brane) epithelial mem-
branes that line b dy sur a es pening dire tly t the exteri r and
se rete a thi k, slippery material alled mucus
mucus (MYO O -kus) thi k, slippery material that is se reted by the
mu us membrane and keeps the membrane m ist
multiple myeloma (MUL-tih-pul my-LO H -mah) an er plasma
ells
multiple neuro bromatosis (MUL-tih-pul n -r h- ye-br h-
mah- OH -sis) dis rder hara terized by multiple, s metimes
dis guring, benign tum rs the S hwann ells (neur glia) that
surr und nerve bers

multiple sclerosis (MS) (MUL-tih-pul skleh-ROH -sis) the m st
mm n primary disease the entral nerv us system; a myelin
dis rder
muscle ber (MUS-el FYE-ber) the spe ialized ntra tile ells
mus le tissue that are gr uped t gether and arranged in a highly
rganized way
muscle strain (MUS-el strayn) mus le injury resulting r m verex-
erti n r trauma and inv lving verstret hing r tearing mus-
le bers
muscle tone (MUS-el t hn) t ni ntra ti n; hara teristi
mus le a n rmal individual wh is awake
muscular dystrophy (MUS-ky -lar DIS-tr h- ee) a gr up mus-
le dis rders hara terized by atr phy skeletal mus le with ut
nerve inv lvement; D u henne mus ular dystr phy (DMD) is the
m st mm n type
muscular system (MUS-ky -lar SIS-tem) the mus les the b dy
muscularis (mus-ky -LAYR-is) tw layers mus le surr unding
the digestive tube that pr du e wavelike, rhythmi ntra ti ns
alled peristalsis, whi h m ve d material
musculotendinous unit (mus-ky -l h- EN-din-us YO O -nit) the
un ti nal unit rmed by a skeletal mus les mus le tissue, ten-
d n, and the jun ti n between the tw tissues
mutagen (MYO O-tah-jen) agent apable ausing mutati n (al-
terati n) DNA
myalgia (my-AL-jee-ah) general term re erring t the sympt m
pain in mus le tissue
myasthenia gravis (my-es- H EE-nee-ah GRAH -vis) aut immune
mus le dis rder hara terized by pr gressive weakness and
hr ni atigue
mycotic in ection (my-KO -ik in-FEK-shun) ungal in e ti n
myelin (MY-eh-lin) lip id substan e und in the myelin sheath
ar und s me nerve bers
myelinated ber (MY-eh-lih-nay-ted FYE-ber) ax ns utside the
entral nerv us system that are surr unded by a segmented wrap-
ping myelin
myeloid (MY-eh-l yd) relating t b ne marr w
myeloid neoplasm (MY-eh-l yd NEE- h-plaz-em) abn rmal pr -
li erati n myel id tissue r myel id pre urs r ells ten as-
s iated with an er us trans rmati n
myeloid tissue (MY-eh-l yd ISH -y ) tissue that makes up b ne
marr w
myeloma (my-eh-LO H -mah) malignant tum r b ne marr w
myocardial in arction (MI) (my- h-KAR-dee-al in-FARK-shun)
death ardia mus le ells resulting r m inadequate bl d
supply, as in r nary thr mb sis
myocardium (my- h-KAR-dee-um) mus le the heart
myo lament (my- h-FIL-ah-ment) any the ultrami r s pi ,
threadlike stru tures und in my brils; tw types: thick and
thin
myoglobin (my- h-GLOH -bin) a red, xygen-st ring pr tein pig-
ment similar t hem gl bin und in mus le bers
myoma (my-O H -mah) benign tum r sm th mus le mm nly
urring in the uterine wall; see also bromyoma
myometrium (my- h-MEE-tree-um) mus le layer in the uterus
myopathy (my-OP-ah-thee) general term re erring t any mus le
disease
myopia (my-O H -pee-ah) re ra tive dis rder the eye aused by an
el ngated eyeball; nearsightedness
myosin (MY- h-sin) ntra tile pr tein und in the thi k my la-
ments skeletal mus le
myositis (my- h-SYE-tis) general term re erring t mus le inf am-
mati n, as in in e ti n r injury
GLOSSARY 731
myxedema (mik-seh-DEE-mah) nditi n aused by de ien y
thyr id h rm ne in adults
N
nail body (BOD-ee) the visible part the nail
nail root the part the nail hidden by the uti le
nanometer (NAN- h-mee-ter) a measure length in the metri
system; ne billi nth a meter
nares (NAY-reez) (sing., naris) n strils
nasal (NAY-zal) relating t the n se
nasal cavity (NAY-zal KAV-ih-tee) the m ist, warm avities lined
by mu sa l ated just bey nd the n strils; l a t ry re ept rs are
l ated in the mu sa
nasal polyp (NAY-zal PAH -lip) painless, n n an er us tissue
gr wth that pr je ts r m nasal mu sa
nasal septum (NAY-zal SEP-tum) a partiti n that separates the
right and le t nasal avities
nasopharynx (nay-z h-FAYR-inks) the upperm st p rti n the
tube just behind the nasal avities
natural killer cell (NK cell) (NACH -er-ul KIL-er sel) type lym-
ph yte that kills many types tum r ells
nausea (NAW-zee-ah) unpleasant sensati n the gastr intesti-
nal tra t that mm nly pre edes the urge t v mit; upset
st ma h
neck (nek) the b dy regi n nne ting head t th rax; the narr w,
nne ting part a stru ture, as in the regi n the t th that
j ins r wn t r t
necrosis (neh-KRO H -sis) death ells in a tissue, ten resulting
r m is hemia (redu ed bl d f w)
needle biopsy (NEE-dil BYE- p-see) type bi psy in whi h a
spe imen is withdrawn r m the b dy thr ugh a h ll w needle;
see biopsy
negative eedback (NEG-ah-tiv FEED-bak) h me stati ntr l
system in whi h in rmati n eeding ba k t the ntr l enter
auses the level a variable t be hanged in the dire ti n p-
p site t that the initial stimulus
nematode (NEM-ah-t hd) r undw rmslarge parasites apable
in esting humans
neonatal period (nee- h-NAY-tal PEER-ee-id) stage early hu-
man devel pment that rresp nds t appr ximately the rst
4 weeks a ter birth
neonate (NEE- h-nayt) an ther name r an in ant during the rst
4 weeks a ter birth; see neonatal period
neonatology (nee- h-nay- O L- h-jee) diagn sis and treatment
dis rders the newb rn in ant
neoplasm (NEE- h-plaz-em) an abn rmal mass pr li erating
ells that may be either benign r malignant; a tum r
neoplastic (nee- h-PLAS-tik) relating t tum rs (ne plasms)
nephritis (neh-FRY-tis) general term re erring t inf ammat ry r
in e ti us nditi ns renal (kidney) tissue
nephron (NEF-r n) anat mi al and un ti nal unit the kidney,
nsisting the renal rpus le and the renal tubule
nephron loop (NEF-r n l p) extensi n the pr ximal tubule
the kidney; als kn wn as loop o Henle r Henle loop
nephropathy (neh-FRO P-ah-thee) kidney disease
nephrotic syndrome (neh-FRO -ik SIN-dr hm) gr up symp-
t ms and signs that ten a mpany gl merular dis rders the
kidney: pr teinuria, hyp albuminemia, and edema
nerve (nerv) lle ti n nerve bers
nerve impulse (nerv IM-puls) signals that arry in rmati n al ng
the nerves
732 GLOSSARY
nervous system (NER-vus SIS-tem) b dy system made up the
brain, spinal rd, and nerves
nervous tissue (NER-vus ISH -y ) nsists neur ns and neu-
r glia and pr vides rapid mmuni ati n and ntr l b dy
un ti n
neuralgia (n -RAL-jee-ah) general term re erring t nerve pain
neurilemma (n -rih-LEM-mah) nerve sheath
neuritis (n -RYE-tis) general term re erring t nerve inf ammati n
neuroblastoma (n -r h-blas- OH -mah) malignant tum r
sympatheti nerv us tissue, und mainly in y ung hildren
neurogenic bladder (n -r h-JEN-ik BLAD-der) nditi n in
whi h the nerv us ntr l the urinary bladder is impaired,
ausing abn rmal r bstru ted f w urine r m the b dy
neurogenic shock (n -r h-JEN-ik sh k) ir ulat ry ailure (sh k)
aused by a nerve nditi n that relaxes (dilates) bl d vessels
and thus redu es bl d f w; literally nerve- aused sh k
neuroglia (n -ROH -glee-ah) supp rting ells nerv us tissue;
als alled simply glia
neurohypophysis (n -r h-hye-POF-ih-sis) p steri r pituitary gland
neurologist (n -RO L-uh-jist) physi ian spe ializing in the treat-
ment nerv us system dis rders
neuroma (n -ROH -mah) general term r nerv us tissue tum rs
neuromuscular junction (NMJ) (n -r h-MUS-ky -lar JUNK-
shun) the p int nta t between the nerve endings and mus le
bers
neuron (NO O -r n) nerve ell, in luding its pr esses (ax ns and
dendrites)
neuroscientist (n -r h-SYE-en-tist) s ientist spe ializing in re-
sear h n erning the stru ture and un ti n the nerv us
system
neurotransmitter (n -r h-trans-MI -ter) hemi als by whi h
neur ns mmuni ate
neutral (NO O -truhl) 1. relating t a s luti n having a pH 7, be-
ing neither a id n r base; 2. having n ele tri al harge
neutron (NO O-tr n) ele tri ally neutral parti le within the nu leus
an at m
neutrophil (NO O-tr h- l) white bl d ell that stains readily with
neutral dyes
nevus (NEE-vus) (pl., nevi) small, pigmented benign tum r the
skin (e.g., a m le)
nitric oxide (NO) (NYE-trik AW K-side) mp und mp sed
ne nitr gen and ne xygen at m in ea h m le ule, ten a ting
as a small-m le ule neur transmitter
nitrogen (NYE-tr h-jen) ne the hemi al elements und in
great quantity in the human b dy, espe ially in nu lei a ids
(DNA, RNA), pr teins, and amin a ids; symb lized by N, as in
NH 3 (amm nia)
nitroglycerin (nye-tr h-GLIS-eh-rin) heart medi ati n that dilates
r nary bl d vessels thus impr ving supply xygen t
my ardium
Nobel prize (n h-BEL) internati nal award reated by the late
Al red N bel and awarded ea h year t up t three re ipients in
ea h several ateg ries su h as hemistry, physi s, and medi-
ine r physi l gy (ea h N bel laureate [prizewinner] re eives a
dipl ma, a medal, and a ash prize at a erem ny in St kh lm,
Sweden)
nodes o Ranvier (rahn-vee-AY) indentati ns und between adja-
ent S hwann ells
nodule (NO D-y l) see lymph nodule
nondisjunction (n n-dis-JUNK-shun) urs during mei sis when
a pair hr m s mes ails t separate
nonelectrolyte (n n-ee-LEK-tr h-lyte) mp und that d es n t
diss iate int i ns in s luti n; r example, glu se
non-Hodgkin lymphoma (n n-H O J-kin lim-FO H -mah) type
lymph ma (malignant lymph tum r) hara terized by swelling
lymph n des and pr gressing t ther areas
nonspeci c immunity (n n-spih-SIH - k ih-MYO O N-ih-tee) the
pr te tive me hanisms that pr vide immediate, generi pr te -
ti n against any ba teria, t xin, r ther injuri us parti le; als
alled innate immunity
nonsteroid hormone (n n-S AYR- yd H O R-m hn) general type
h rm ne that d es n t have the lipid ster id stru ture (derived
r m h lester l) but is instead a pr tein r pr tein derivative;
als s metimes alled protein hormone
norepinephrine (NE) (n r-ep-ih-NEF-rin) h rm ne se reted by
adrenal medulla; released by sympatheti divisi n; als kn wn as
noradrenaline
normal saline (SAY-leen) s dium hl ride s luti n is t ni with
b dy f uids
nose artilagin us respirat ry rgan the a e
nosocomial in ection (n h-z h-KOH M-ee-al in-FEK-shun) in-
e ti n that begins in the h spital r lini
NSAID (EN-sayd) a r nym r n nster idal anti-inf ammat ry
drug, the term is applied t aspirin, ibupr en, a etamin phen,
and many ther anti-inf ammat ry agents that d n t ntain
ster id h rm nes r their derivatives
nuclear envelope (NO O -klee-ar AH N-vel- hp) the b undary a
ells nu leus, made up a d uble layer ellular membrane
nuclear medicine technologist (NO O -klee-ar MED-ih-sin tek-
NOL-uh-jist) medi al pr essi nal wh prepares and administers
radi a tive drugs r ther substan es
nuclear membrane (NO O-klee-ar MEM-brane) membrane that
surr unds the ell nu leus
nucleic acids (n -KLAY-ik AS-ids) the tw nu lei a ids are rib -
nu lei a id (RNA), und in the yt plasm, and de xyrib nu-
lei a id (DNA), und in the nu leus and mit h ndri n; made
up units alled nucleotides that ea h in lude a ph sphate, a
ve- arb n sugar, and a nitr gen base
nucleolus (n -KLEE- h-lus) inter ellular stru ture riti al t pr -
tein rmati n be ause it pr grams the rmati n rib s mes
in the nu leus
nucleoplasm (NO O -klee- h-plaz-im) a spe ial type yt plasm
und in the nu leus
nucleotide (NO O -klee- h-tyde) m le ule that nne ts t ther
nu le tides t rm a nu lei a id su h as DNA r RNA; ea h
nu le tide has three parts: a ph sphate gr up, a sugar (rib se r
de xyrib se), and a nitr gen us base (adenine, thymine [ r ura-
il], guanine, r yt sine)
nucleus (NO O-klee-us) spheri al stru ture within a ell; a gr up
neur n ell b dies in the brain r spinal rd; entral re the
at m, made up pr t ns and (s metimes) neutr ns
nurse (nurs) health- are pr essi nal trained t are r the si k and
injured
nursing assistant (NURS-ing ah-SIS-tent) health- are w rker un-
der the supervisi n a nurse t are r patients nutrition (n -
RIH -shun) d (nutrients), vitamins, and minerals that are
ingested and assimilated int the b dy
nutritionist (n - RISH -en-ist) pr essi nal nsultant spe ializ-
ing in diet and d
nyctalopia (nik-tah-LOH -pee-ah) nditi n aused by retinal de-
generati n r avitamin sis A and hara terized by the relative
inability t see in dim light; night blindness
 GLOSSARY 733

oral (OR-al) relating t the m uth

O
oral candidiasis see thrush
obesity ( h-BEES-ih-tee) nditi n hara terized by abn rmally oral cavity (O R-al KAV-ih-tee) m uth
high pr p rti n b dy at oral rehydration therapy (OR ) treatment in ant diarrhea by the
oblique racture ( h-BLEEK FRAK- hur) b ne ra ture hara ter- administrati n a liberal d se sugar and salt s luti n
ized by a ra ture line that is diag nal t the l ng axis the orbicularis oculi ( r-bik-y -LAYR-is OK-y -lye) a ial mus le
br ken b ne that auses a squint
oblique plane ( h-BLEEK playn) imagined f at plane that runs di- orbicularis oris ( r-bik-y -LAYR-is O R-is) a ial mus le that
ag nally t an axis the b dy r ne its parts, pr du ing a pu kers the lips
slanted, blique se ti n r ut orbital (OR-bih-tal) relating t rbit the eye (s - alled eye
obstetric nurse ( b-S E -rik nurs) nurse spe ializing in pregnan y, s ket)
lab r, and delivery are orchitis ( r-KYE-tis) inf ammati n the testes, ten aused by
obstetrician ( b-steh- RISH -an) physi ian spe ializing in preg- in e ti n
nan y, lab r, and delivery are organ (OR-gan) gr up several tissue types that per rms a spe ial
occipital ( k-SIP-it-al) relating t the area at the ba k the l wer un ti n
skull organ o Corti (KOR-tee) see spiral organ; als Corti organ
occipital bone ( k-SIP-it-al b hn) p steri r and in eri r b ne organelle ( r-gah-NELL) inter ell rgan; r example, the
the skull rib s me
occupational therapist (ak-y -PAY-shun-al H AYR-ah-pist) organic compound ( r-GAN-ik KOM-p wnd) mp und wh se
health pr essi nal wh treats injuries r dis rders t devel p r large m le ules ntain arb n and that in lude C O C b nds
re ver everyday living skills and/ r C O H b nds
old age li e y le phase a ter early and middle adulth d; see senescence organism (OR-gah-niz-em) an individual living thing
older adulthood see old age and senescence organization ( r-gan-ih-Z AY-shun) the hara teristi the b dy
olecranal ( h-LEK-rah-nal) relating t le ran n (ba k elb w) being rganized, that is, stru tured in di erent levels m-
olecranon ( h-LEK-rah-n n) the large b ny pr ess the ulna; plexity and rdinated in un ti n; the human b dy is ten said
mm nly re erred t as the tip the elb w; s metimes alled t be rganized int di erent levels rganizati n: hemi al,
olecranon process ell, tissue, rgan, system, and b dy
olecranon ossa ( h-LEK-rah-n n FO S-ah) a large depressi n n organ o Corti (OR-gan v KOR-tee) the rgan hearing l ated
the p steri r sur a e the humerus in the hlea and lled with end lymph; als alled Corti organ
ol action ( hl-FAK-shun) sense smell r spiral organ
ol actory receptor ( hl-FAK-t r-ee ree-SEP-t r) hemi al re ep- organogenesis ( r-gah-n h-JEN-eh-sis) rmati n rgans r m
t rs resp nsible r the sense smell; l ated in the epithelial the primary germ layers the embry
tissue in the upper part the nasal avity origin (OR-ih-jin) the atta hment a mus le t the b ne, whi h
oligodendrocyte ( hl-ih-g h-DEN-dr h-syte) a ell that h lds d es n t m ve when ntra ti n urs, as distinguished r m
nerve bers t gether and pr du es the myelin sheath ar und ax- inserti n
ns in the CNS oropharynx ( r- h-FAYR-inks) the p rti n the pharynx that is
oligospermia ( hl-ih-g h-SPER-mee-ah) l w sperm pr du ti n l ated behind the m uth
oliguria ( hl-ih-GO O-ree-ah) s anty am unts urine orthodontics ( r-th h-D O N-tiks) dental spe ialty dealing with
oncogene (ON-k h-jeen) gene (DNA segment) th ught t be re- diagn sis and treatment mal lusi n the teeth
sp nsible r the devel pment a an er orthopedic surgeon ( r-th h-PEE-dik SUR-jen) physi ian trained
oncology ( ng-KOL- h-jee) study tum rs and an er; bran h the medi al spe ialty orthopedics, dealing with skeletal injury and
medi ine n erned with diagn sis and treatment an er disease
onycholysis (ahn-ik- h-LYE-sis) separati n nail r m the nail orthopnea ( r- H O P-nee-ah) dyspnea (di ulty in breathing) that
bed that begins at the distal r ree edge the a e ted nail is relieved a ter m ving int an upright r sitting p siti n
oocyte (O H - h-syte) immature stage the emale sex ell os coxae ( s KOK-see) hip b nes; see also coxal bone
oogenesis ( h- h-JEN-eh-sis) pr du ti n emale gametes osmosis ( s-MO H -sis) m vement a f uid thr ugh a semiperme-
oophorectomy ( h- -eh-REK-t h-mee) surgi al pr edure t re- able membrane
m ve the varies ossicle (OS-sih-kul) any the little b nes (malleus, in us, stapes)
oophoritis ( h- -eh-RYE-tis) inf ammati n the varies und in the ears
open racture (OH -pen FRAK- hur) mp und ra ture; b ne osteitis de ormans ( s-tee-AYE-tis deh-FO R-manz) see Paget
ra ture in whi h b ne ragments pier e the skin disease
ophthalmic ( - H AL-mik) relating t the eye osteoarthritis ( s-tee- h-ar- H RY-tis) degenerative j int disease; a
ophthalmologist ( -thal-MO L-eh-jist) physi ian spe ializing in n ninf ammat ry dis rder a j int hara terized by degenera-
treating dis rders the eye and visi n ti n arti ular artilage
ophthalmoscope ( - H AL-mah-sk hp) lighted instrument tted osteoblast (OS-tee- h-blast) b ne- rming ell
with pti al devi es t permit examinati n the retina and in- osteoclast (OS-tee- h-klast) b ne-abs rbing ell
ternal eye stru tures osteocyte (O S-tee- h-syte) b ne ell
opposition ( p- h-ZISH -un) m ving the thumb t t u h the tips osteogenesis imper ecta ( s-tee- h-JEN-eh-sis im-per-FEK-tah)
the ngers; the m vement used t h ld a pen il t write d minant, inherited dis rder nne tive tissue hara terized
optic disk (OP-tik disk) the area in the retina where the pti nerve by imper e t skeletal devel pment, resulting in brittle b nes
bers exit and there are n r ds r nes; als kn wn as a blind spot osteoma ( s-tee-O H -mah) benign b ne tum r
734 GLOSSARY
osteomalacia ( s-tee- h-mah-LAY-shah) b ne dis rder usually
aused by vitamin D de ien y and hara terized by l ss min-
eral in the b ne matrix; the adult rm ri kets
osteomyelitis ( s-tee- h-my-eh-LYE-tis) ba terial (usually staphy-
l us) in e ti n b ne tissue
osteon (AH S-tee- n) stru tural unit mpa t b ne tissue made
up n entri layers (lamellae) hard b ne matrix and b ne
ells ( ste ytes); als alled Haversian system
osteoporosis ( s-tee- h-p h-ROH -sis) b ne dis rder hara terized
by l ss minerals and llagen r m b ne matrix, redu ing the
v lume and strength skeletal b ne
osteosarcoma ( s-tee- h-sar-KO H -mah) b ne an er
otitis ( h- YE-tis) general term re erring t inf ammati n r in e -
ti n the ear; titis media inv lves the middle ear
otitis media ( h- YE-tis MEE-dee-ah) a middle ear in e ti n
otologist ( h- OL-uh-jist) physi ian spe ializing in treating dis r-
ders the ear
otosclerosis ( h-t h-skleh-RO H -sis) inherited b ne dis rder in-
v lving stru tural irregularities the stapes in the middle ear and
hara terized by tinnitus pr gressing t dea ness
otoscope (OH -t h-sk hp) lighted devi e used t examine external
ear anal and eardrum
ova (O H -vah) (sing., vum) emale sex ells
oval window (OH -val W IN-d h) a small, membrane- vered pen-
ing that separates the middle and inner ear
ovarian cyst ( h-VAYR-ee-an SIS ) sm th f uid- lled sa that
rms in varian tissue
ovarian ollicle ( h-VAYR-ee-an FO L-ih-kul) ea h ntains an
yte
ovary (OH -var-ee) emale g nad that pr du es va ( emale sex
ells)
overactive bladder (O H -ver-ak-tiv BLAD -der) nditi n
requent urinati n hara terized by sensati n urgen y and
pain
overhydration ( h-ver-hye-DRAY-shun) t mu h f uid input in
the b dy, whi h an put a burden n the heart
oviduct (OH -vih-dukt) als alled uterine tube r allopian tube; see
uterine tube r de niti n
ovulation ( v-y -LAY-shun) release an vum r m the vary
ovum (OH -vum) (pl., va) egg; emale sex ell ( emale gamete)
oxygen (O 2) (AH K-sih-jen) ne the hemi al elements und in
great quantity in the human b dy; symb lized by O, as in H 2O
(water) r O 2 ( xygen gas)
oxygen concentrator (AH K-sih-jen KON-sen-tray-t r) a devi e
used in health are that in reases the pr p rti n xygen gas in
the air the r m in whi h it is pla ed; s metimes used in treat-
ment pers ns in respirat ry distress and in ther su h ndi-
ti ns that pr du e hyp xia (l w xygen n entrati n in the
bl d)
oxygen debt (AH K-sih-jen det) ntinued in reased metab lism
that urs in a ell t rem ve ex ess la ti a id that resulted r m
exer ise
oxygen therapy (AH K-sih-jen) administrati n xygen gas t in-
dividuals su ering r m l w xygen n entrati n in the bl d
(hyp xia)
oxyhemoglobin (H bO 2) (ahk-see-hee-m h-G LOH -bin) hem gl -
bin mbined with xygen
oxytocin (O ) (ahk-see- O H -sin) h rm ne se reted by the p ste-
ri r pituitary gland in a w man be re and a ter she has delivered
a baby; th ught t initiate and maintain lab r and als auses the
release breast milk int the mammary du ts t pr vide n ur-
ishment r the baby
P
P wave ele tr ardi gram def e ti n that represents dep larizati n
the atria
p-arm (PEE-arm) the sh rt segment a hr m s me that is di-
vided int tw segments by a entr mere
pacemaker (PAYS-may-ker) see sinoatrial node
Pacini corpuscle (pah-CH EE-nee KOH R-pus-ul) a re ept r und
deep in the dermis that dete ts pressure n the skin sur a e; als
alled pacinian corpuscle r lamellar corpuscle
Paget disease (PAJ-et dih-ZEEZ) steitis de rmans; a mm n,
ten mild b ne dis rder hara terized by repla ement n rmal
sp ngy b ne with dis rganized b ne matrix
pain receptor (payn ree-SEP-t r) sens ry neur n that dete ts pain-
ul stimuli; als alled nociceptor
palate (PAL-let) the r the m uth; made up the hard (ante-
ri r p rti n the m uth) and s t (p steri r p rti n the
m uth) palates
palatine tonsil see tonsil
paleontologist (pay-lee-un- O L-uh-jist) s ientist that studies r-
ganisms that lived in the an ient past
palmar (PAH L-mar) relating t the palm the hand
palpable (PAL-pah-bul) an be elt r t u hed
palpebral ssure (PAL-peh-bral FISH -ur) pening between the
tw eyelids
pancreas (PAN-kree-as) end rine gland l ated in the abd minal
avity; ntains pan reati islets that se rete glu ag n and
insulin
pancreatic islet (pan-kree-A -ik eye-let) ne the mi r s pi ,
is lated end rine p rti ns the pan reas; made up alpha and
beta ells, am ng thers; als alled islet o Langerhans
pancreatitis (pan- ree-ah- YE-tis) inf ammati n the pan reas
pandemic (pan-DEM-ik) re ers t a disease that a e ts many pe -
ple w rldwide
Papanicolaou test (pah-peh-nik- h-LAH - ) an er-s reening
test in whi h ells brushed r m the lining the uterine
ervix are smeared n a glass slide and examined r abn rmali-
ties; als alled Pap smear r Pap test
papilla (pah-PIL-ah) (pl., papillae) small, nipple-shaped elevati n
papilloma (pap-ih-LO H -mah) benign skin tum r hara terized by
ngerlike pr je ti ns (e.g., a wart)
papule (PAP-y l) raised, rm skin lesi n less than 1 m in
diameter
paracrine [agent or hormone] (PAYR-ah-krin [AY-jent r H O H R-
m hn]) h rm ne that regulates a tivity in nearby ells within the
same tissue as their s ur e
paralysis (pah-RAL-ih-sis) l ss the p wer m ti n, espe ially
v luntary m ti n
paramedic (payr-ah-MED-ik) health- are w rker trained t assist a
physi ian r t give are in the absen e a physi ian, ten as
part a rst-resp nder team
paranasal sinus (payr-ah-NAY-zal SYE-nus) ur pairs sinuses
that have penings int the n se
paraphimosis (para- h-MOH -sis) nditi n in whi h the male
reskin ann t be easily repla ed a ter being retra ted away r m
the glans penis
paraplegia (payr-ah-PLEE-jee-ah) paralysis (l ss v luntary mus-
le ntr l) b th legs
parasite (PAYR-ah-syte) any rganism that lives in r n an ther
rganism (a h st) t btain its nutrients; parasites may be harm-
less t the h st, r they may disrupt n rmal b dy un ti ns the
h st and thus ause disease

parasympathetic division (payr-ah-sim-pah- H E -ik dih-VIZH -
un) part the aut n mi nerv us system that ntr ls many
vis eral e e t rs under n rmal maintenan e nditi ns; ganglia
are nne ted t the brainstem and the sa ral segments the
spinal rd ( rani sa ral segments)
parasympathetic postganglionic neuron (payr-ah-sim-pah- H E -
ik p st-gang-glee-ON-ik NO O-r n) ANS neur n in whi h den-
drites and ell b dy are in a parasympatheti gangli n and ax n
travels t a variety vis eral e e t rs
parasympathetic preganglionic neuron (payr-ah-sim-pah- H E -
ik pree-gang-glee-ON-ik NO O -r n) ANS neur n in whi h
dendrites and ell b dy are l ated in the gray matter the
brainstem and sa ral rd segments; ax n terminates in a para-
sympatheti gangli n
parathyroid gland (payr-ah- H YE-r yd) set end rine glands
l ated in the ne k n the p steri r aspe t the thyr id gland;
se rete parathyr id h rm ne (P H )
parathyroid hormone (P H) (payr-ah- H YE-r yd H OR-m hn)
h rm ne released by the parathyr id gland that in reases the
n entrati n al ium in the bl d
parenteral (pah-REN-ter-al) utside the intestinal tra t; parenteral
therapy is administrati n nutrients, spe ial f uids, and/ r ele -
tr lytes by inje ti nthus bypassing intestinal abs rpti n
parietal (pah-RYE-ih-tal) the walls an rgan r avity
parietal bone (pah-RYE-ih-tal) ranial b ne the t p and side
the ranium
parietal pericardium (pah-RYE-ih-tal payr-ih-KAR-dee-um) peri-
ardium surr unding the heart like a l se- tting sa k t all w
the heart en ugh r m t beat
parietal peritoneum (pah-RYE-ih-tal payr-ih-t h-NEE-um) se-
r us membrane that lines and is adherent t the wall the ab-
d minal avity
parietal pleura (pah-RYE-ih-tal PLO O -rah) ser us membrane that
lines and is adherent t the wall the th ra i avities
parietal portion (pah-RYE-ih-tal POR-shun) ser us membrane
that lines the walls a b dy avity
Parkinson disease (PD ) (PARK-in-s n dih-ZEEZ) a hr ni dis-
ease the nerv us system hara terized by a set signs alled
parkinsonism that results r m a de ien y the neur transmit-
ter d pamine in ertain regi ns the brain that n rmally inhibit
verstimulati n skeletal mus les; parkins nism is hara terized
by mus le rigidity and trembling the head and extremities,
rward tilt the b dy, and shu ing manner walking
parotid duct (per-AH -tid dukt) either the du ts the par tid
salivary glands; als kn wn as Stensen duct
parotid gland (per-AH -tid) paired salivary gland that lies just bel w
and in r nt ea h ear at the angle the jaw
partial pressure (P) (PAR-shal) pressure exerted by any ne gas in a
mixture gases r in a liquid
partial-thickness burn term used t des ribe b th min r burn in-
jury and m re severe burns that injure b th epidermis and dermis
(see rst-degree burn) (see second-degree burn)
parturition (pahr-t -RIH -shun) a t giving birth
passive transport ellular pr ess in whi h substan es m ve thr ugh
a ellular membrane with the energy supplied dire tly by the ell
r its membrane
patella (pah- EL-ah) small, shall w pan; the knee ap
pathogenesis (path- h-JEN-eh-sis) pattern a diseases
devel pment
pathologist (pah- H OL-uh-jist) s ientist wh studies disease
pr esses
pathology (pah- H O L- h-jee) the s ienti study disease
GLOSSARY 735
pathophysiology (path- h- z-ee-OL- h-jee) study the underly-
ing physi l gi al aspe ts disease
patient care technician (PAY-shent kayr tek-NISH -en) health- are
w rker wh pr vides pers nal are t patients under the supervi-
si n nurses, physi ians, and ther pr essi nals
pectoral girdle (PEK-t h-ral G IRD-el) sh ulder girdle; the s apula
and lavi le, whi h nne t the upper extremities t the axial
skelet n
pectoralis major (pek-teh-RAH -liss MAY-j r) maj r f ex r the arm
pedal (PEED-al) relating t the t
pedigree (PED-ih-gree) hart used in geneti unseling t illus-
trate geneti relati nships ver several generati ns
pelvic (PEL-vik) relating t the pelvis r hip b nes, r t the nearby
anat mi al regi n
pelvic cavity (PEL-vik KAV-ih-tee) the in eri r p rti n the ven-
tral avity kn wn as the abd min pelvi avity
pelvic girdle (PEL-vik GIRD-el) ring b ne rmed by the pelvi
b nes that nne t the l wer extremities t the axial skelet n
pelvic in ammatory disease (PID ) (PEL-vik in-FLAM-aht r-ee
dih-ZEEZ) a ute inf ammat ry nditi n the uterus, all pian
tubes, and/ r variesusually the result a sexually transmitted
in e ti n (S I)
pelvis (PEL-vis) basin- r unnel-shaped stru ture
penicillin (pen-ih-SIL-in) antibi ti derived r m pr du ts a spe-
i type m ld; dis vered in the lab Alexander Fleming
penis (PEE-nis) (pl., penes r penises) stru ture that rms part
the male genitalia; when sexually ar used, be mes sti t enable
it t enter and dep sit sperm in the vagina
pepsin (PEP-sin) pr tein-digesting enzyme the st ma h
pepsinogen (pep-SIN- h-jen) mp nent gastri jui e that is
nverted int pepsin by hydr hl ri a id
peptidase (PEP-tyd-ayz) intestinal enzyme that breaks apart pep-
tide b nds in p lypeptide strands that remain r m pr tein
digesti n
peptide bond (PEP-tyde) valent b nd linking amin a ids within
a pr tein m le ule
per use (per-FYO OZ) t f w thr ugh, as in f w bl d thr ugh
a tissue
pericardial ef usion (pair-ih-KAR-dee-all e -FYO O -shen) a u-
mulati n peri ardial f uid, pus, r bl d in the spa e between
the tw peri ardial layers
pericarditis (payr-ih-kar-DYE-tis) nditi n in whi h the peri ar-
dium be mes inf amed
pericardium (payr-ih-KAR-dee-um) membrane that surr unds the
heart
perilymph (PAYR-ih-lim ) a watery f uid that lls the b ny laby-
rinth the ear
perinatal in ection (payr-ih-NAY-tal in-FEK-shun) in e ti n
passed r m a m ther t an in ant during the time the birth
pr ess
perineal (payr-ih-NEE-al) relating t the area between the anus and
genitals (the perineum)
perineum (payr-ih-NEE-um) the area between the anus and
genitals
perineurium (payr-ih-NO O-ree-um) nne tive tissue that en ir-
les a bundle ( as i le) nerve bers within a nerve
periodontal membrane (payr-ee- h-DON-tull MEM-brayn) -
br us tissue that lines ea h t th s ket and serves t atta h the
t th t underlying b ne
periodontitis (payr-ee- h-d n- YE-tis) inf ammati n the peri-
d ntal membrane (peri d ntal ligament) that an h rs teeth t
jaw b ne; mm n ause t th l ss am ng adults
736 GLOSSARY
periosteum (payr-ee-O S-tee-um) t ugh, nne tive tissue vering
the b ne
peripheral (peh-RIF-er-al) relating t an utside sur a e
peripheral nervous system (PNS) (peh-RIF-er-al NER-vus SIS-
tem) the nerves nne ting the brain and spinal rd t ther
parts the b dy
peripheral resistance (PR) (peh-RIF-er-al) resistan e (bl ked e -
rt) t bl d f w en untered in the peripheral arteries (arteries
that bran h the a rta and pulm nary arteries)
peristalsis (payr-ih-S AL-sis) wavelike, rhythmi ntra ti ns
the st ma h and intestines that m ve d material al ng the
digestive tra t
peritoneal space (payr-ih-t h-NEE-al) small, f uid- lled spa e be-
tween the vis eral and parietal layers that all ws the layers t slide
ver ea h ther reely in the abd min pelvi avity
peritoneum (payr-ih-t h-NEE-um) large, m ist, slippery sheet
ser us membrane that lines the abd min pelvi avity (parietal
layer) and its rgans (vis eral layer)
peritonitis (payr-ih-t h-NYE-tis) inf ammati n the ser us
membranes in the abd min pelvi avity; s metimes a seri us
mpli ati n an in e ted appendix
permanent teeth (PER-mah-nent teeth) set 32 teeth that re-
pla es de idu us teeth; als alled adult teeth
permeable membrane (PER-mee-ah-bul MEM-brayn) a mem-
brane that all ws passage substan es
permease system (PER-mee-ayz SIS-tem) a spe ialized ellular
mp nent that all ws a number a tive transp rt me hanisms
t ur
pernicious anemia (per-NISH -us ah-NEE-mee-ah) de ien y
red bl d ells aused by a la k vitamin B12
peroneal muscles (per- h-NEE-al MUS-els) plantar f ex rs and
evert rs the t; the per neus l ngus rms a supp rt ar h r
the t; see peroneus (muscle) group
peroneus (muscle) group (per- n-EE-uss gr p) gr up lateral
mus les the leg that a t t pr nate the t, r tating it t ward
the midline, and plantar f ex the t, pulling it t es-d wnward;
als alled the bularis (muscle) group
perspiration (per-spih-RAY-shun) transparent, watery liquid re-
leased by glands in the skin that eliminates amm nia and uri
a id and helps maintain b dy temperature; als mm nly
kn wn as sweat
pH (p H ) mathemati al expressi n relative H n entrati n
(a idity); pH value higher than 7 is basi , pH value less than 7 is
a idi , pH value equal t 7 is neutral
phagocyte (FAG- h-syte) white bl d ell that engul s mi r bes
and digests them
phagocytosis ( ag- h-sye- OH -sis) ingesti n and digesti n par-
ti les by a ell
phalanges ( ah-LAN-jeez) the b nes that make up the ngers and
t es
pharmacist (FAR-mah-sist) health- are w rker trained t dispense
drugs and edu ate patients in their pr per use
pharmacologist ( ar-mah-KAH L-uh-jist) s ientist spe ializing in
the study drug a ti ns
pharmacology ( arm-ah-KAH L-ah-jee) study drugs and their
a ti ns in the b dy
pharmacy technician (FAR-mah-see tek-NISH -en) health- are
w rker trained t dispense drugs under the supervisi n
pharma ist
pharyngeal tonsil see adenoid
pharyngitis ( ayr-in-JYE-tis) s re thr at; inf ammati n r in e ti n
the pharynx
pharynx (FAYR-inks) rgan the digestive and respirat ry systems;
mm nly alled the throat
phenylketonuria (PKU) ( en-il-kee-t h-NO O-ree-ah) re essive,
inherited nditi n hara terized by ex ess phenylket ne in
the urine, aused by a umulati n phenylalanine (an amin
a id) in the tissues; may ause brain injury and death i phenylala-
nine intake is n t managed pr perly
phimosis ( h-MOH -sis) abn rmal nditi n in whi h the prepu e
( reskin) ts tightly ver the glans the penis
phlebitis (f eh-BYE-tis) inf ammati n a vein
phlebotomist (f eh-BO - h-mist) health- are w rker spe ializing
in drawing bl d r m veins r lab rat ry analysis r d nati n
phospholipid ( s- h-LIP-id) ph sphate- ntaining lipid ( at)
m le ule
photodynamic therapy ( h-t h-dye-NAM-i ) use laser energy
t trigger ph t sensitizing drugs in spe ialized treatment su-
per ial an ers and wet age-related ma ular degenerati n
photopigments ( h-t h-PIG-ments) hemi als in retinal ells that
are sensitive t light
photoreceptor (FOH -t h-ree-sep-t r) spe ialized nerve ell stimu-
lated by light
photore ractive keratectomy (PRK) (FO H -t h-ree- rak-tiv kayr-
ah- EK-t h-mee) re ra t ry eye surgery that uses an ex imer r
l laser t vap rize rneal tissue in treating mild t m derate
nearsightedness; als alled excimer laser surgery
phrenic nerve (FREN-ik nerv) the nerve that stimulates the dia-
phragm t ntra t
physical education (FIS-ik-al ed-y -KAY-shun) tea hing dis i-
pline that uses n health, tness, and sp rts
physical therapist (FIS-ik-al H AYR-ah-pist) health pr essi nal
wh helps patients impr ve b dy m vements and manage pain
physician ( h-ZISH -en) health- are pr essi nal, usually h lding a
d t rate in medi ine r related dis ipline, li ensed t pr vide
and supervise medi al are
physiology ( z-ee-O L- h-jee) the study b dy un ti n
pia mater (PEE-ah MAH -ter) the vas ular innerm st vering
(meninx) the brain and spinal rd
pigment (PIG-ment) l red substan e
pigment layer (PIG-ment LAY-er) the layer the epidermis that
ntains the melan ytes that pr du e melanin t give skin its
l r; stratum basale r basal layer
pineal gland (PIN-ee-al gland) end rine gland l ated in the third
ventri le the brain; pr du es melat nin; als kn wn as pineal
body
pinna (PIN-nah) f ap the external ear
pinocytosis (pin- h-sye- OH -sis) a tive transp rt me hanism used
t trans er f uids r diss lved substan es int ells
pitting edema (pit-ing eh-DEE-mah) depressi ns in sw llen sub u-
tane us tissue that d n t rapidly re ll a ter exerted pressure is
rem ved
pituitary gland (pih- O O-ih-tayr-ee) end rine gland l ated in the
skull; made up the aden hyp physis and the neur hyp physis
pivot joint (PIV-it j ynt) type diarthr ti syn vial j int in whi h
a pr je ti n r m ne b ne arti ulates with a ring r n t h in
an ther b ne, all wing r tati nal m vement
placenta (plah-SEN-tah) an h rs the devel ping etus t the uterus
and pr vides a bridge r the ex hange nutrients and waste
a pr du ts between the m ther and devel ping baby
placenta previa (plah-SEN-tah PREE-vee-ah) abn rmal nditi n
in whi h a blast yst implants in the l wer uterus, devel ping a
pla enta that appr a hes r vers the ervi al pening; pla enta
previa inv lves the risk pla ental separati n and hem rrhage

plane (o body) (playn) any mpletely f at ut thr ugh the b dy r
any its parts; a b dy plane an be riented in any several
dire ti ns (e.g., sagittal, midsagittal, r ntal [ r nal], transverse
[h riz ntal]) and is used t visualize the b dy r m di erent
perspe tives; see also section (o body)
plantar (PLAN-tar) relating t the s le the t polycythemia (pahl-ee-sye- H EE-mee-ah) an ex essive number
plantar ex (PLAN-tar f eks) t m ve the ankle s that the b tt m
the t is dire ted in eri rly
plantar exion (PLAN-tar FLEK-shun) m vement in whi h the
b tt m the t is dire ted d wnward; this m ti n all ws a
pers n t stand n tipt e
plaque (plak) raised skin lesi n greater than 1 m in diameter
plasma (PLAZ-mah) the liquid part the bl d
plasma cell (PLAZ-mah sel) ell that se retes pi us am unts
antib dy int the bl d; als alled ef ector cell
plasma membrane (PLAZ-mah MEM-brayn) membrane that sep-
arates the ntents a ell r m the tissue f uid; en l ses the
yt plasm and rms the uter b undary the ell
plasma protein (PLAZ-mah PRO H -teen) any several pr teins
n rmally und in the plasma; in ludes albumins, gl bulins, and
brin gen
plasmid (PLAS-mid) small ir ular ring ba terial DNA
platelet (PLAY -let) see thrombocyte
platelet plug (PLAY -let) a temp rary a umulati n platelets
(thr mb ytes) at the site an injury; it pre edes the rmati n
a bl d l t
platyhelminth (plat-ih-H EL-minth) f atw rm r f ukeanimal
parasite apable in esting humans
pleura (PLO O R-ah) (pl., pleurae) the ser us membrane in the th -
ra i avity
pleural (PLO OR-al) relating t the pleura r t the side the
th rax
pleural cavity (PLO O R-al KAV-ih-tee) a lateral subdivisi n the
th rax; avity in whi h ea h lung is l ated
pleural space (PLO O R-al) the spa e between the vis eral and pari-
etal pleurae lled with just en ugh ser us (pleural) f uid t all w
them t glide e rtlessly with ea h breath
pleurisy (PLO OR-ih-see) inf ammati n the pleura
plexus (PLEK-sus) mplex netw rk rmed by nverging and
diverging nerves, bl d vessels, r lymphati vessels
plica (PLYE-kah) (pl., pli ae) multiple ir ular lds
pneumocystosis (n -m h-sis- OH -sis) a pr t z an in e ti n,
m st likely t invade the b dy when the immune system has been
mpr mised
pneumonectomy (n -m h-NEK-t h-mee) surgi al pr edure in
whi h an entire lung is rem ved
pneumonia (n -MO H -nee-ah) abn rmal nditi n hara terized
by a ute inf ammati n the lungs in whi h alve li and br n hial
passages be me plugged with thi k f uid (exudate)
pneumothorax (n -m h- H OH -raks) abn rmal nditi n in
whi h air is present in the pleural spa e surr unding the lung,
p ssibly ausing llapse the lung
podiatrist (p h-DYE-uh-trist) physi ian wh spe ializes in health
are the t, ankle, and leg
polar body (POH -lar BOD-ee) small, n n un ti nal ell pr du ed
during mei ti ell divisi ns (mei sis) in the rmati n emale
sex ells (gametes); in apable being ertilized
poliomyelitis (p l-ee- h-my-eh-LYE-tis) viral disease that dam-
ages m t r nerves, ten pr gressing t paralysis skeletal
mus les
polycystic kidney disease (PKD ) (pahl-ee-SIS-tik KID-nee dih-
ZEEZ) m st mm n geneti dis rder in humans, in whi h large
GLOSSARY 737
f uid- lled p kets ( ysts) devel p in the epithelium the kid-
ney tubules
polycystic ovary syndrome (PCOS) (pahl-ee-SIS-tik O H -var-ee
SIN-dr hm) nditi n that is hara terized by varies usually
twi e the n rmal size and that are studded with f uid- lled ysts
red bl d ells
polydipsia (pahl-ee-DIP-see-ah) ex essive and ng ing thirst
polyendocrine disorder (PAH L-ee-EN-d h-krin dis-OR-der) dis-
rder aused by m re than ne end rine mal un ti n r inv lv-
ing m re than ne h rm ne
polysaccharide (pahl-ee-SAK-ah-ryde) bi m le ule made up
many sa haride sugars (m n sa harides)
polyuria (p l-ee-YO O -ree-ah) unusually large am unts urine
pons (p nz) the part the brainstem between the medulla bl n-
gata and the midbrain
popliteal (p p-lih- EE-al) relating t the area behind the knee
pore (p r) pinp int-size penings n the skin that are utlets
small du ts r m the e rine sweat glands
portal hypertension (POR -al hye-per- EN-shun) high bl d
pressure aused by bl kage bl d f w in the liver ( r m an-
er r irrh sis)
port-wine stain pigmented, benign tum r the skin present at
birth and ranging in l r r m pale red t a deep reddish purple;
als alled nevus ammeus (see nevus)
positive eedback (POZ-it-iv FEED-bak) h me stati ntr l sys-
tem in whi h in rmati n eeding ba k t the ntr l enter
auses the level a variable t be pushed arther in the dire ti n
the riginal deviati n, ausing an ampli ati n the riginal
stimulus; rdinarily this me hanism is used by the b dy t am-
pli y a pr ess and qui kly nish it, as in lab r ntra ti ns and
bl d l tting
posterior (p hs- EER-ee- r) l ated behind; pp site anterior
posterior pituitary gland (p hs- EER-ee- r pih- O O-ih-tayr-ee)
neur hyp physis; pr du es h rm nes ADH and xyt in
postganglionic neuron (p st-gang-glee-O N-ik NO O-r n) aut -
n mi neur n that ndu ts nerve impulses r m a gangli n t
ardia r sm th mus le r glandular epithelial tissue
postherpetic neuralgia (p st-her-PE -ik n -RAL-jee-ah) pain
( ten severe) al ng nerve pathways previ usly a e ted by an
utbreak shingles (herpes z ster)
postnatal period (PO S -nay-tal PEER-ee-id) the peri d begin-
ning a ter birth and ending at death
postsynaptic neuron (p st-sih-NAP-tik NO O -r n) a neur n situ-
ated distal t a synapse
posture (POS- hur) p siti n the b dy
precapillary sphincter (pree-CAP-pih-layr-ee SFINGK-ter)
sm th mus le ells that guard the entran e t the apillary
preeclampsia (pree-ee-KLAMP-see-ah) syndr me abn rmal
nditi ns in pregnan y un ertain ause; syndr me in ludes
hypertensi n, pr teinuria, and edema; als alled toxemia o preg-
nancy, it may pr gress t e lampsiasevere t xemia that may
ause death
preexisting condition (pree-ig-ZIS -ing k n-DISH -un) dis rder
r health state that has be me established be re an ther ndi-
ti n urs; als alled a primary nditi n
preganglionic neurons (pree-gang-glee-ON-ik NO O-r ns) aut -
n mi neur ns that ndu t nerve impulses between the spinal
rd and a gangli n
premature (cardiac) contraction (pree-mah- UR [KAR-dee-ak]
k n- RAK-shun) ntra ti ns the heart wall that ur be-
re expe ted; extrasyst les
738 GLOSSARY
premenstrual syndrome (PMS) (pree-MEN-str -al SIN-dr hm)
syndr me psy h l gi al hanges (su h as irritability) and
physi al hanges (l alized edema) that ur be re menstrua-
ti n in many w men
premolar see bicuspid
prenatal period (PREE-nay-tal PEER-ee-id) the peri d a ter n-
epti n until birth
prepuce see oreskin
presbycusis (pres-bih-KYO O -sis) pr gressive hearing l ss ass i-
ated with advan ed age
presbyopia (pres-bee-OH -pee-ah) arsightedness ass iated with
advan ing age
presynaptic neuron (pree-sih-NAP-tik NO O-r n) a neur n situ-
ated pr ximal t a synapse
primary bronchi (PRYE-mayr-ee BRAH N-kye) (sing., br n hus)
rst bran hes the tra hea (right and le t primary br n hi)
primary ollicle (PRYE-mayr-ee FO L-ih-kul) varian lli le pres-
ent at puberty; lined with granul sa ells
primary germ layer (PRYE-mayr-ee jerm LAY-er) any the three
layers germ ells that give rise t de nite stru tures as the
embry devel ps
primary protein (PRYE-mayr-ee PROH -teen) the preliminary
stru ture a pr tein: the sequen e amin a ids held t gether
with peptide b nds (this stru ture will then ld t be me the
se ndary pr tein stru ture)
primary spermatocyte (SPER-mah-t h-syte) spe ialized ell that
underg es mei sis t ultimately rm sperm
prime mover the mus le resp nsible r pr du ing a parti ular
m vement
principle o independent assortment geneti prin iple that states as
hr m s me pairs separate, the maternal and paternal hr m -
s mes redistribute themselves independently the ther hr -
m s me pairs
prion (PREE-ahn) sh rtened rm the term PRO teina e us
IN e ti us parti le; path geni pr tein m le ule that nverts
n rmal pr teins the b dy int abn rmal pr teins, ausing ab-
n rmalities un ti n (the abn rmal rm the pr tein als
may be inherited by spring an a e ted pers n); see also
bovine spongi orm encephalopathy
product any substan e rmed as a result a hemi al rea ti n
progeria (pr h-JEER-ee-ah) rare, geneti nditi n in whi h a per-
s n appears t age rapidly as a result abn rmal, widespread
degenerati n tissues; adult and hildh d rms exist, with the
hildh d rm resulting in death by age 20 r s
progesterone (pr h-JES-ter- hn) h rm ne pr du ed by the rpus
luteum; stimulates se reti n the uterine lining; with estr gen,
helps t initiate the menstrual y le in girls entering puberty
prognosis (pr g-NOH -sis) in medi ine, the pr bable ut me a
disease
prolactin (PRL) (pr h-LAK-tin) h rm ne se reted by the anteri r
pituitary gland during pregnan y t stimulate the breast devel p-
ment needed r la tati n; als alled lactogenic hormone
prolactinoma (pr h-LAK-tih-n h-mah) benign aden ma (epithe-
lial tum r) the anteri r pituitary, pr du ing hyperse reti n
pr la tin (and exaggerated pr la tin e e ts); is usually small and
urs m st ten in emales
proli erative phase (PROH -li -eh-rah-tiv aze) phase menstrual
y le that begins a ter the menstrual f w ends and lasts until
vulati n
pronate (PRO H -nayt) t make a r tati nal m vement the re-
arm (turning the palm medially t a e ba kward) r the leg
and ankle (turning the t s t es p int utward and the medial
edge the s le hits the gr und); pp site supinate
pronation (PRO H -nay-shun) a ti n in whi h the rearm r leg
and ankle pronates; pp site supination
prone used t des ribe the b dy lying in a h riz ntal p siti n a ing
d wnward
prophase (PRO H - ayz) rst stage mit sis during whi h hr m -
s mes be me visible
proprioceptor (pr h-pree- h-SEP-t r) stret h re ept r l ated in
the mus les, tend ns, and j ints; all ws the b dy t re gnize its
p siti n
prostaglandin (PG) (pr s-tah-GLAN-din) any a gr up natu-
rally urring atty a ids that a e t many b dy un ti ns
prostatectomy (pr s-tah- EK-t h-mee) surgi al rem val part r
all the pr state gland
prostate cancer (PROS-tayt KAN-ser) malignan y the pr state
gland
prostate gland (PROS-tayt) lies just bel w the bladder; se retes a
f uid that nstitutes ab ut 30% the seminal f uid v lume;
helps a tivate sperm and helps them maintain m tility; als
kn wn simply as the pr state
prostate-speci c antigen (PSA) (PRO S-taytspeh-SIF-ik AN-tih-
jen) a pr tein (antigen) pr du ed by pr state tissue that may be
elevated in the bl d men with pr state an er
prostatectomy (pr s-tah- EK-t h-mee) surgi al rem val all r
part the pr state gland
prosthesis (pr s- H EE-sis) an arti ial b dy part r devi e that
assists the un ti ning a b dy part; used m re narr wly, the
term applies nly t arti ial limbs r limb extensi ns
protease (PROH -tee-ayz) pr tein-digesting enzyme
protein (PRO H -teen) ne the basi nutrients needed by the
b dy; a nitr gen- ntaining rgani mp und mp sed a
lded strand amin a ids
protein-calorie malnutrition (PCM) (PROH -teen-KAL- r-ee
mal-n - RISH -un) abn rmal nditi n resulting r m a de -
ien y al ries in general and pr tein in parti ular; likely t
result r m redu ed intake d but may als be aused by in-
reased nutrient l ss r in reased use nutrients by the b dy
protein hormone (PRO H -teen H OR-m hn) a n nster id; see
nonsteroid hormone
proteinuria (pr h-teen-YO O-ree-ah) presen e abn rmally high
am unts plasma pr tein in the urine; usually an indi at r
kidney disease
proteoglycan (PROH -tee- h-GLYE-kan) large m le ule made up
a pr tein strand that rms a ba kb ne t whi h are atta hed
many arb hydrate m le ules
proteome (PRO H -tee- hm) the entire gr up pr teins en ded
by the gen me; see genome
proteomics (pr h-tee-OH -miks) the endeav r that inv lves the
analysis the pr teins en ded by the gen me, with the ultimate
g al understanding the r le ea h pr tein in the b dy
prothrombin (pr h- H ROM-bin) a pr tein present in n rmal
bl d that is required r bl d l tting
prothrombin activator (pr h- H ROM-bin AK-tih-vay-t r) m-
binati n l tting a t rs and ir ulating plasma pr teins that
initiates nversi n pr thr mbin t thr mbin in the l tting
me hanism
prothrombin time (P ) (pr h- H ROM-bin tyme) time it takes r
a bl d sample t l t a ter tissue thr mb plastin (pr thr mbin
a tivat r) is addeda way t assess e ien y a pers ns extrinsi
l tting me hanism; see also international normalized ratio (INR)

proton (PROH -t n) p sitively harged parti le within the nu leus
an at m
protozoan (pr h-t h-ZOH -an) (pl., pr t z a) single- elled rgan-
isms with nu lei and ther membran us rganelles that an in-
e t humans
proximal (PROK-sih-mal) next r nearest; l ated nearest the en-
ter the b dy r the p int atta hment a stru ture; pp site
distal
proximal convoluted tubule (PC ) (PRO K-sih-mal k n-v h-
LO O-ted O OB-y l) the rst segment a renal tubule
pseudo (SO O-d h) alse
pseudogene (SO OD- h-jeen) p ssibly n n un ti nal br ken ge-
neti de und in junk DNA l ated between the un ti ning,
ding genes a DNA m le ule
pseudohypertrophy (s -d h-hye-PER-tr h- ee) literally, alse
mus le gr wth; an ther name r D uchenne muscular
dystrophy (D MD )
pseudostrati ed epithelium (SO OD- h-S RA -ih- yde ep-ih-
H EE-lee-um) type tissue similar t simple lumnar epithe-
lium that rms a membrane made up a single layer ells
that are tall and narr w but that are squeezed t gether in a way
that pushes the nu lei int tw layers and thus gives an initial
impressi n that it is strati ed (having m re than ne layer
ells); mpare t simple columnar epithelium
psoriasis (s h-RYE-ah-sis) hr ni , inf ammat ry skin dis rder
hara terized by utane us inf ammati n and s aly plaques
psychiatrist (sye-KYE-uh-trist) physi ian spe ializing in mental
health
psychogenic (sye-k h-JEN-ik) relating t anything aused by psy-
h l gi al me hanisms; r example, psy h geni dis rders are
ten aused by stress r ther psy h l gi al trauma
psychologist (sye-KOL-uh-jist) s me ne wh studies mental pr -
esses r treats mental nditi ns thr ugh unseling r related
therapies
puberty (PYO O-ber-tee) stage ad les en e in whi h a pers n
be mes sexually mature
pubis (PYO O -bis) j int in the midline between the tw pubi b nes
public health (PUB-lik helth) br ad, interdis iplinary eld aimed at
pr m ting health and wellness all pe ple
puerperal ever (py -ER-per-al FEE-ver) nditi n aused by
ba terial in e ti n in a w man a ter delivery an in ant, p ssibly
pr gressing t septi emia and death; als alled childbed ever
pulmonary artery (PUL-m h-nayr-ee AR-ter-ee) artery that ar-
ries de xygenated bl d r m the right ventri le t the lungs
pulmonary circulation (PUL-m h-nayr-ee ser-ky -LAY-shun)
ven us bl d f w r m the right atrium t the lung and then t
the le t atrium
pulmonary embolism (PUL-m h-nayr-ee EM-b h-liz-em) bl kage
the pulm nary ir ulati n by a thr mbus r ther matter; may
lead t death i bl kage pulm nary bl d f w is signi ant
pulmonary semilunar valve (PUL-m h-nayr-ee sem-ih-LO O-nar
valv) valve l ated at the beginning the pulm nary artery
pulmonary vein (PUL-m h-nayr-ee vayn) any vein that arries xy-
genated bl d r m the lungs t the le t atrium
pulmonary ventilation (PUL-m h-nayr-ee ven-tih-LAY-shun)
breathing; pr ess that m ves air in and ut the lungs
pulse (puls) alternating expansi n and re il the arterial walls
pr du ed by the alternate ntra ti n and relaxati n the ven-
tri les; travels as a wave away r m the heart
Punnett square (PUN-it skwayr) grid used in geneti unseling t
determine the pr bability inheriting geneti traits
GLOSSARY 739
pupil (PYO O-pill) the pening in the enter the iris that regu-
lates the am unt light entering the eye
Purkinje bers (pur-KIN-jee FYE-bers) spe ialized ells l ated in
the walls the ventri les; relay nerve impulses r m the AV n de
t the ventri les, ausing them t ntra t
purpura (PUR-pah-rah) nditi n in whi h small hem rrhages
ause purplish dis l rati ns in the skin, mu us membranes,
and ther b dy sur a es
pus a umulati n white bl d ells, dead ba terial ells, and dam-
aged tissue ells at the site an in e ti n
pustule (PUS-ty l) small, raised skin lesi n lled with pus
P wave def e ti n n an ECG that urs with dep larizati n the
atria
pyelonephritis (pye-eh-l h-neh-FRY-tis) in e ti us nditi n
hara terized by inf ammati n the renal pelvis and nne tive
tissues the kidney
pyloric sphincter (pye-LO R-ik SFING K-ter) sphin ter that pre-
vents d r m leaving the st ma h and entering the
du denum
pyloric stenosis (pye-LOR-ik steh-NO H -sis) anat mi al abn r-
mality in whi h the pening thr ugh the pyl rus r pyl ri
sphin ter is unusually narr w
pylorospasm (pye-LO H R- h-spaz-um) spasm pyl ri sphin ter
st ma h
pylorus (pye-LO R-us) the small narr w se ti n the st ma h that
j ins the rst part the small intestine
pyramids (PEER-ah-mids) triangular-shaped divisi ns the me-
dulla the kidney; see renal pyramid
pyrogen (PYE-r h-jen) any systemi inf ammat ry hemi al that
auses the therm stati ntr l enters the hyp thalamus t
pr du e a ever
pyruvic acid (pye-RO O -vik AS-id) pr du t the gly lysis
glu se, an energy- ntaining m le ule that enters the mit -
h ndri n r urther atab lism and generati n A P
Q
q-arm (KYU-arm) the l ng segment a hr m s me that is di-
vided int tw segments by a entr mere
QRS complex (Q R S KOM-pleks) def e ti n n an ECG that -
urs as a result dep larizati n the ventri les
quadrant (KWO D-runt) see abdominal quadrants
quadriceps emoris (KWOD-reh-seps eh-MO R-is) extens r mus-
le the leg
quadriplegia (kw d-rih-PLEE-jee-ah) paralysis (l ss v luntary
mus le ntr l) in all ur limbs
quaternary protein (KWA -er-nayr-ee PROH -teen) the urth
level stru ture in a pr tein rmed when tw r m re tertiary
(third-level) pr teins unite t rm a larger pr tein m le ule
quickening (KW IK-en-ing) when a pregnant w man rst eels
re gnizable m vements the etus
R
radial keratotomy (RK) (RAY-dee-al KAR-ah-tah-t h-mee) surgi-
al pla ement six r m re radial slits in a sp kelike pattern
ar und the rnea; f attens rnea and impr ves us
radiation (ray-dee-AY-shun) f w heat waves away r m the
bl d
radiation sickness (ray-dee-AY-shun SIK-nes) illness aused by ell
damage r m high levels radiati n; sympt ms may in lude
740 GLOSSARY
diarrhea, heada he, ever, dizziness, weakness, hair l ss; als alled
radiation poisoning r acute radiation syndrome
radiation therapy (ray-dee-AY-shun H AYR-ah-pee) treatment
ten used r an er in whi h high-intensity radiati n is used t
destr y an er ells; als alled radiotherapy
radical mastectomy (RAD-ih-kal mas- EK-t h-mee) surgi al pr -
edure in whi h a an er us breast is rem ved al ng with nearby
mus le tissue and lymph n des
radioactive isotope (ray-dee- h-AK-tiv AYE-s h-t hp) rm an
element in whi h at ms have a unique at mi number and als
release parti les r waves radiati n (see also isotope)
radiography (ray-dee-O G-rah- ee) imaging te hnique using x-rays
that pass thr ugh s me tissues m re easily than thers, all wing
an image tissues t rm n a ph t graphi plate r ther
sensitive sur a e; invented by W ilhelm Rntgen in 1895
radiological technologist (ray-dee- h-LO J-ih-kul tek-NOL-uh-
jist) health- are w rker wh per rms diagn sti imaging pr e-
dures, su h as x-rays and C r MRI s ans
radiologist (ray-dee-AH L-uh-jist) physi ian wh spe ializes in di-
agn sis using medi al imaging su h as x-rays and C r MRI
s ans
radius (RAY-dee-us) ne the tw b nes in the rearm; l ated
n the thumb side the rearm
Raynaud phenomenon (ray-NO h-NOM-eh-n hn) dis rder
hara terized by sudden de reases in ir ulati n in the digits
( ngers r t es), ten in resp nse t stress r temperature hange
reabsorption (ree-ab-SORP-shun) pr ess abs rbing again that
urs in the kidneys
reactant (ree-AK-tant) any substan e entering (and being hanged
by) a hemi al rea ti n
receiving chambers (ree-SEE-ving CH AYM-bers) atria the
heart; re eive bl d r m the superi r and in eri r venae avae
receptor (ree-SEP-t r) peripheral beginning a sens ry neur ns
dendrite
recessive (ree-SES-iv) in geneti s, the term recessive re ers t genes
that have e e ts that d n t appear in the spring when they are
masked by a d minant gene (re essive rms a gene are repre-
sented by l wer ase letters); mpare with dominant
reconstructive surgery (ree-k n-S RUK-tiv SUR-jeh-ree) any
surgi al pr edure in whi h anat mi al stru tures are rebuilt t a
di erent rm
rectum (REK-tum) distal p rti n the large intestine
rectus abdominis (REK-tus ab-DOM-ih-nus) mus le that runs
d wn the middle the abd men; pr te ts the abd minal vis era
and f exes the spinal lumn
red blood cell (RBC) see erythrocyte
red bone marrow (red b hn MAR- h) b ne marr w (myel id tis-
sue) und in the ends l ng b nes and in f at b nes; un ti ns
in the pr du ti n bl d ells
re erred pain (re-FERD payn) pain that riginates in a di erent
l ati n in the b dy r m where it is per eived by the brain
re ex (REE-f eks) inv luntary a ti n
re ex arc (REE-f eks ark) all ws an impulse t travel in nly ne
dire ti n
re ux (REE-f uhks) ba kf w, as in f w st ma h ntents ba k
int es phagus
re raction (ree-FRAK-shun) bending a ray light as it passes
r m a medium ne density t ne a di erent density
regeneration (ree-jen-er-AY-shun) the pr ess repla ing missing
tissue with new tissue by means ell divisi n
regulation (reg-y -LAY-shun) pr ess ntr l b dy un ti ns
regulator cell ( -reg) lymph yte the immune system that
suppresses B- ell di erentiati n int plasma ells, all wing ne-
tuning antib dy-mediated immune resp nses; als alled sup-
pressor cell
rejection reaction (ree-JEK-shun re-AK-shun) immune resp nses
t a d nated r gra ted tissue r rgan; see also alloimmunity
releasing hormone (RH) (ree-LEE-sing H OR-m hn) h rm ne
pr du ed by the hyp thalamus gland that auses the anteri r
pituitary gland t release its h rm nes
remission (ree-MISH -un) stage a disease during whi h a temp -
rary re very r m sympt ms urs
renal calculi (REE-nal KAL-ky -lye) kidney st nes
renal colic (REE-nal KO L-ik) pain aused by the passage a kid-
ney st ne
renal column (REE-nal KOL-um) extensi n rti al tissue that
dips d wn int the medulla the kidney between the renal
pyramids
renal corpuscle (REE-nal KOR-pus-ul) the part the nephr n
l ated in the rtex the kidney and made up the gl merulus
and gl merular (B wman) apsule
renal cortex (REE-nal KO R-teks) (pl., rti es) uter p rti n the
kidney
renal ailure (REE-nal FAIL-y r) a ute r hr ni l ss kidney
un ti n; a ute kidney ailure is ten reversible, but hr ni kid-
ney ailure sl wly pr gresses t t tal l ss renal un ti n (and
death i kidney un ti n is n t rest red thr ugh a kidney trans-
plant r use an arti ial kidney)
renal medulla (REE-nal meh-D UL-ah) (pl., medullae r medullas)
inner p rti n the kidney
renal papilla (REE-nal pah-PIL-ah) (pl., papillae) nipplelike p int
a renal pyramid, r m whi h urine drips ut the kidney
tubules
renal pelvis (REE-nal PEL-vis) basinlike upper end the ureter
that is l ated inside the kidney
renal ptosis (REE-nal OH -sis) nditi n in whi h ne r b th
kidneys des end, ten be ause l ss the at pad that sur-
r unds ea h kidney
renal pyramid (PIR-ah-mid) triangular-shaped divisi n the me-
dulla the kidney
renal threshold (REE-nal H RESH -h ld) when the am unt a
substan e that is n rmally ully reabs rbed r m tubular f uid
(su h as glu se) in reases ab ve this thresh ld level, the kidney
tubules are unable t reabs rb all it and the substan es spill
ver int the urine
renal tubule (REE-nal O O B-y l) ne the tw prin ipal parts
the nephr n
renin (REE-nin) enzyme pr du ed by the kidney that atalyzes the
rmati n angi tensin, a substan e that in reases bl d
pressure
renin-angiotensin-aldosterone system (RAAS) (REE-ninan-jee-
h- EN-sinal-DAH -stayr- hn SIS-tem) auses hanges in
bl d plasma v lume and bl d pressure mainly by ntr lling
ald ster ne se reti n
repolarization (ree-p h-lah-rih-Z AY-shun) begins just be re the
relaxati n phase ardia mus le a tivity
reproductive system (ree-pr h-DUK-tiv SIS-tem) pr du es h r-
m nes that permit the devel pment sexual hara teristi s and
the pr pagati n the spe ies
residual volume (RV) (reh-ZID-y -al VO L-y m) the air that
remains in the lungs a ter the m st r e ul expirati n
respiration (res-pih-RAY-shun) breathing r pulm nary ventilati n

respiratory acidosis (RES-pih-rah-t r-ee as-ih-DOH -sis) a respi-
rat ry disturban e that results in a arb ni a id ex ess
respiratory alkalosis (RES-pih-rah-t r-ee al-kah-LOH -sis) a res-
pirat ry disturban e that results in a arb ni a id de it
respiratory arrest (RES-pih-rah-t r-ee ah-RES ) essati n
breathing with ut resumpti n
respiratory control center (RES-pih-rah-t r-ee k n- RO L SEN-
ter) nerve regulat ry enter l ated in the medulla and p ns that
stimulates the mus les respirati n
respiratory distress syndrome (RD S) (RES-pih-rah-t r-ee dih-
S RESS SIN-dr hm) di ulty in breathing aused by absen e
r ailure the sur a tant in f uid lining the alve li the lung;
IRDS is in ant respirat ry distress syndr me; ARDS is adult
respirat ry distress syndr me
respiratory membrane (RES-pih-rah-t r-ee MEM-brayn) the sin-
gle layer ells that makes up the wall the alve li
respiratory mucosa (RES-pih-rah-t r-ee my -KO H -sah)
mu us- vered membrane that lines the tubes the respira-
t ry tree
respiratory muscle (RES-pih-rah-t r-ee MUS-el) any the mus-
les resp nsible r the hanging shape the th ra i avity that
all ws air t m ve in and ut the lungs
respiratory system (RES-pih-rah-t r-ee SIS-tem) the rgans that
all w the ex hange xygen r m the air with the arb n di x-
ide r m the bl d
respiratory therapist (RES-pih-rah-t r-ee H AYR-ah-pist) health
pr essi nal wh helps patients in rease respirat ry un ti n and/
r ver me r pe with the e e ts respirat ry nditi ns
respiratory tract (RES-pih-rah-t r-ee trakt) the tw divisi ns the
respirat ry system are the upper and l wer respirat ry tra ts
reticular ormation (reh- IK-y -lar r-MAY-shun) l ated in
the medulla where bits gray and white matter mix intri ately
reticular tissue (reh- IK-y -lar) meshw rk netlike tissue that
rms the ramew rk the spleen, lymph n des, and b ne
marr w
retina (RE -ih-nah) innerm st layer the eyeball; ntains r ds
and nes and ntinues p steri rly with the pti nerve
retinal detachment (RE -ih-nal) nditi n that urs when part
the retina alls away r m the tissue supp rting it
retrograde endoscopic cholangiography (RE -r h-grayd en-d h-
SKAH P-ik k hl-an-jee-O G -rah- ee) x-ray imaging the bile
du t system using an end s pe threaded thr ugh the maj r du -
denal papilla t inje t ntrast material
retroperitoneal (reh-tr h-payr-ih-t h-NEE-al) area utside the
perit neum
retrovirus (ret-r h-VYE-rus) ateg ry virus that uses its RNA t
trans ribe ba kward t pr du e the viruss primary geneti de
and insert it int the h sts DNA gen me
Rh system lassi ati n bl d based n the presen e (Rh ) r
absen e (Rh ) a unique antigen n the sur a e RBCs
rhabdomyolysis (RAB-d h-mye-O L-ih-sis) seri us, a ute ndi-
ti n resulting r m damaged mus le bers releasing their n-
tents int the bl dstream
rheumatic heart disease (r -MA -ik hart dih-ZEEZ) ardia
damage (espe ially t the end ardium, in luding the valves) re-
sulting r m a delayed inf ammat ry resp nse t strept al
in e ti n
rheumatoid arthritis (RA) (RO O -mah-t yd ar- H RY-tis) an au-
t immune inf ammat ry j int disease hara terized by syn vial
inf ammati n that spreads t ther tissue
rhinitis (rye-NYE-tis) inf ammati n the nasal mu sa ten
aused by nasal in e ti ns
GLOSSARY 741
Rh-negative (R H NEG-ah-tiv) red bl d ells that d n t ntain
the antigen alled Rh actor
RhoGAM (RO H -gam) an inje ti n a spe ial pr tein given t an
Rh-negative w man wh is pregnant t prevent her b dy r m
rming anti-Rh antib dies, whi h may harm an Rh-p sitive
baby
Rh-positive (R H POZ-ih-tiv) red bl d ells that ntain an anti-
gen alled Rh actor
rib (rib) any the 24 paired f at b nes rming part the rame-
w rk the th ra i wall
ribonucleic acid (RNA) (rye-b h-n -KLAY-ik AS-id) a nu lei
a id und in the yt plasm that is ru ial t pr tein synthesis
ribosomal RNA (rye-b h-SO H M-al R-N-A) als alled rRNA, it
is a rm RNA that makes up m st the stru tures (subunits)
the rib s me rganelle the ell
ribosome (RYE-b h-s hm) rganelle in the yt plasm ells that
synthesizes pr teins; als kn wn as a protein actory
rickets (RIK-ets) hildh d rm ste mala ia, a b ne-s tening
nditi n aused by vitamin D de ien y
Rickettsia (rih-KE -see-ah) small ba terium that in e ts human
ells as an bligate parasite
right lymphatic duct (lim-FA -ik) main lymphati du t that drains
lymph int the right sub lavian vein
rigor mortis (RIG- r MO R-tis) literally sti ness death, the
permanent ntra ti n mus le tissue a ter death aused by the
depleti n A P during the a tin-my sin rea ti npreventing
my sin r m releasing a tin t all w relaxati n the mus le
risk actor (FAK-t r) predisp sing nditi n; a t r that puts ne at
a higher than usual risk r devel ping a parti ular disease
RNA (ar en ay) see ribonucleic acid
RNA inter erence (RNAi) (ar en ay in-ter-FEER-ens) a regulat ry
pr ess the ell in whi h a small m le ule dsRNA (d uble-
stranded RNA) alled siRNA (small inter ering RNA) j ins with
a RISC (RNA-indu ed silen ing mplex) pr tein stru ture t
break d wn a spe i mRNA (messenger RNA) trans ript and
thus e e tively silen e the gene en ded by the mRNA; RNAi is
a natural regulat ry pr ess th ught t be inv lved with regulat-
ing gene expressi n, as in inhibiting viral in e ti ns, but is als
used as a resear h te hnique t study the human gen me (RNA
rib nu lei a id)
RNAi therapy (ar en ay aye H AYR-ah-pee) any medi al pr edure
in whi h RNAi te hniques are used t silen e (disable) the e e ts
a disease- ausing gene; see also RNA inter erence (RNAi)
rod type light re ept r l ated in the retina resp nsible r m n -
hr me, dim-light visi n
root blunt tip the t ngue; p rti n the t th that ts int the
s ket the alve lar pr ess either the upper r l wer jaw
rotate (r h- AY ) m ve in a ir le ar und a entral p int
rotation (r h- AY-shun) m vement ar und a l ngitudinal axis; r
example, shaking y ur head n
rugae (RO O-gee) (sing., ruga) wrinkles r lds
rule o nines a requently used meth d t determine the extent a
burn injury; the b dy is divided int 11 areas 9% ea h t help
estimate the am unt skin sur a e burned in an adult
S
sacrum (SAY-krum) b ne the l wer vertebral lumn between
the last lumbar vertebra and the yx, rmed by the usi n
ve sa ral vertebrae
saddle joint (SAD-el j ynt) type diarthr ti j int rmed by tw
saddle-shaped sur a es, all wing m vement in tw di erent axes
742 GLOSSARY
sagittal (SAJ-ih-tal) l ngitudinal; like an arr w
sagittal plane (SAJ-ih-tal playn) a l ngitudinal se ti n r f at ut
extending r m r nt t ba k, dividing b dy r b dy part int
right and le t subdivisi ns
salivary amylase (SAL-ih-vayr-ee AM-ih-layz) digestive enzyme
und in the saliva that begins the hemi al digesti n arb hy-
drates (begins nversi n star h t smaller arb hydrate
m le ules)
salpingitis (sal-pin-JYE-tis) inf ammati n the uterine ( all pian)
tubes
salt mp und rmed when an a id and a base mbine; s metimes
spe i ally re ers t the mm n salt, s dium hl ride (NaCl)
saltatory conduction (SAL-tah-t r-ee k n-DUK-shun) when a
nerve impulse en unters myelin and jumps r m ne n de
Ranvier t the next
sarcoma (SAR-k h-mah) tum r mus le tissue
sarcomere (SAR-k h-meer) ntra tile unit mus le; length a tik) any the external physi al hara teristi s sexual maturity
my bril between tw Z bands
SARS-associated coronavirus (SARS-CoV) (SARZ as-OH -see-
ayt-ed k h-ROH -nah-vye-rus [SARZ k h-VEE]) a type r -
navirus sh wn t be the ause severe a ute respirat ry syndr me
(SARS); see also severe acute respiratory syndrome (SARS) and
coronavirus
satiety center (sah- YE-eh-tee SEN-ter) luster ells in the hy-
p thalamus that send impulses t de rease appetite s that an
individual eels satis ed
scabies (SKAY-bees) ntagi us skin nditi n aused by the it h
mite (Sarcoptes scabiei)
scapula (SKAP-y -lah) sh ulder blade
scar (skahr) thi kened mass tissue, usually br us nne tive tis-
sue, that remains a ter a damaged tissue has been repaired
Schwann cell (shw n r shv n sel) large nu leated ell that rms
myelin sheath ar und peripheral neur ns
sciatica (sye-A -ih-kah) neuralgia (pain) the s iati nerve
scienti c method (sye-en- IF-ik ME H - dd) any l gi al and
systemati appr a h t dis vering prin iples nature, ten
inv lving testing tentative explanati ns alled hypotheses
sclera (SKLEER-ah) white uter at the eyeball
scleroderma (skleer- h-DER-mah) rare dis rder a e ting the ves-
sels and nne tive tissue skin and ther tissues, hara terized
by tissue hardening
scoliosis (sk h-lee-OH -sis) abn rmal lateral (side-t -side) urva-
ture the vertebral lumn
scotoma (sk h- O H -mah) l ss the entral visual eld aused by
nerve degenerati n, it s metimes urs with neuritis ass iated
with multiple s ler sis
scrotum (SKROH -tum) p u hlike sa that ntains the testes
scurvy (SKER-vee) nditi n aused by avitamin sis C (la k vi-
tamin C), whi h impairs the n rmal maintenan e llagen-
ntaining nne tive tissues, ausing bleeding and ul erati n
the skin, gums, and ther tissues
sebaceous gland (seh-BAY-shus) il-pr du ing glands und in the
skin
sebum (SEE-bum) se reti n seba e us glands
second-degree burn burn injury that is m re severe than a rst-
degree burn and ten inv lves damage t the dermis; see also
partial-thickness burn
second messenger (SEK-und MES-en-jer) m le ule that pr vides
mmuni ati n within the target ell a hemi al signal su h as
a h rm ne; r example, y li AMP
second-messenger mechanism (SEK-und MES-en-jer MEK-an-
iz-em) a system ellular mmuni ati n (signal transdu ti n)
in whi h a m le ule pr vides a mmuni ati n link within the
target ell a hemi al signal su h as a h rm ne; r example,
y li AMP links the external signal (arrival the h rm ne r
neur transmitter) t the internal ellular pr esses that pr du e
hanges in the target ell
secondary bronchi (SEK-un-dayr-ee BRAH N-kye) (sing., br n-
hus) smaller br n hial bran hes that result r m divisi n the
primary br n hi
secondary in ection (SEK- n-dayr-ee in-FEK-shun) in e ti n that
urs as a nsequen e the weakened state the b dy r
damage aused by a previ usly existing disease
secondary protein (SEK- n-dayr-ee PRO H -teen) se nd level
pr tein stru ture rmed by the lding the primary pr -
tein (string amin a ids) int heli es (spirals) and pleated
lds
secondary sex characteristic (SEK- n-dayr-ee seks kayr-ak-ter-IS-
resulting r m the a ti n the sex h rm nes; r example,
gr wth male and emale patterns b dy hair and at distribu-
ti n, external genital stru tures
secretion (seh-KREE-shun) in kidney un ti n re ers t a tive
m vement substan es su h as ele tr lytes, waste pr du ts, r
drugs thr ugh kidney tubule ells int the urine; in ells, se reti n
is the pr ess m ving a substan e ut the ell
secretory phase (SEEK-reh-t h-ree ayz) phase menstrual y le
that begins at vulati n and lasts until the next menses begins
section (SEK-shun) a ut, rdinarily f at, thr ugh the b dy r any
b dy part; see also plane (o body)
segmentation (seg-men- AY-shun) urs when digestive ref exes
ause a rward-and-ba kward m vement within a single regi n
the G I tra t
seizure (SEE-zhur) sudden nset abn rmal b dy un ti n, as in a
brain seizure when a sudden disrupti n in the n rmal ring
neur ns in the brain auses mild t severe neur l gi al sympt ms
su h as inv luntary mus le spasms, hanges in ns i usness, r
abn rmal sensati ns
sella turcica (SEL-lah ER-sih-kah) small depressi n the sphe-
n id b ne that ntains the pituitary gland
semen (SEE-men) male repr du tive f uid r seminal uid
semicircular canal (sem-ih-SIR-ky -lar kah-nal) any three
membran us, f uid- lled, urved tubes l ated in the inner ear;
ntains a sens ry re ept r alled crista ampullaris that generates
a nerve impulse n m vement the head
semilunar (SL) valve (sem-ih-LO O -nar valv) valve l ated between
the tw ventri ular hambers and the large arteries that arries
bl d away r m the heart; any the valves und in the veins r
lymphati vessels
seminal uid (SEM-ih-nal FLO O -id) see semen
seminal vesicle (SEM-ih-nal VES-ih-kul) paired, p u hlike glands
that ntribute ab ut 60% the seminal f uid v lume; ri h in
ru t se, whi h is a s ur e energy r sperm
semini erous tubule (seh-mih-NIF-er-us O OB-y l) l ng, iled
stru ture that rms the bulk the testi ular mass
senescence (seh-NES-enz) phase human li e y le that nsti-
tutes lder adulth d; pr ess aging
sense organ (sens O R-gan) any stru ture that dete ts hanges in the
internal r external envir nment the b dy
sensor (SEN-s r) part a h me stati eedba k l p that dete ts
(senses) hanges in the physi l gi al variable that is regulated by
the eedba k l p
sensory neuron (SEN-s r-ee NO O-r n) neur n that transmits
impulses t the spinal rd and brain r m any part the b dy

sensory receptor (SEN-s h-ree ree-sep-t hr) neur n in skin, inter-
nal rgans, and mus les that all ws b dy t dete t vari us stimuli
( hanges)
septic shock (SEP-tik sh k) ir ulat ry ailure (sh k) resulting
r m mpli ati ns septi emia (t xins in bl d resulting r m
in e ti n)
serosa (see-ROH -sah) uterm st vering the digestive tra t;
mp sed the parietal pleura in the abd minal avity
serotonin (sayr- h- OH -nin) a neur transmitter that bel ngs t a
gr up mp unds alled catecholamines
serous (SEE-rus) watery; re ers t lear ser us f uid r the type
membrane that pr du es it
serous membrane (SEE-rus MEM-brayn) a tw -layer epithelial
membrane that lines b dy avities and vers the sur a es
rgans
serum (SEER-um) bl d plasma minus its l tting a t rs, still
ntains antib dies
severe acute respiratory syndrome (SARS) (seh-VEER ah-
KYO O res-pir-ah- O R-ee SIN-dr hm [sarz]) viral in e ti n
hara terized by pneum nia and sympt ms ever, dry ugh,
dyspnea (sh rtness breath), heada he, hyp xia (l w xygen
n entrati n in the bl d), and s metimes pr gressing t death
due t respirat ry ailure aused by damage t alve li the lungs
severe combined immune de ciency (SCID ) (seh-VEER k m-
BYNED ih-MYO O N deh-FISH -en-see) nearly mplete ail-
ure the lymph ytes t devel p pr perly, in turn ausing ailure
the immune systems de ense the b dy; very rare ngenital
immune dis rder
sex chromosome (seks KROH -m h-s hm) either a pair hr -
m s mes in the human gen me that determine gender; n rmal
males have ne X hr m s me and ne Y hr m s me (XY),
whereas n rmal emales have tw X hr m s mes (XX)
sex hormone (seks H O R-m hn) any h rm ne that has a dire t e -
e t n sexual stru ture r un ti n, su h as test ster ne (male)
and estr gens ( emale)
sex-linked trait (seks-linked trayt) n nsexual, inherited trait g v-
erned by genes l ated in a sex hr m s me (X r Y); m st
kn wn sex-linked traits are X-linked
sexually transmitted disease (S D ) (SEKS-y -al-ee trans-MIH -
ted dih-ZEEZ) any mmuni able disease that is mm nly
transmitted thr ugh sexual nta t; mpare t sexually
transmitted in ection (S I)
sexually transmitted in ection (S I) (SEKS-y -al-ee trans-MIH -
ted in-FEK-shun) any in e ti n that is mm nly transmitted
thr ugh sexual nta t and that may r may n t pr du e symp-
t ms; a sexually transmitted in e ti n that pr du es sympt ms
(makes a pers n si k) may als be alled a sexually transmitted
disease (S D )
sha t see diaphysis
shingles (SH ING-guls) see herpes zoster
sickle cell anemia (SIK-ul sel ah-NEE-mee-ah) severe, p ssibly
atal, hereditary disease aused by an abn rmal type
hem gl bin
sickle cell trait (SIK-ul sel trayt) nditi n in whi h nly ne de e -
tive gene is inherited and nly a small am unt hem gl bin
that is less s luble than usual is pr du ed
sigmoid colon (SIG-m yd KOH -l n) S-shaped segment the
large intestine that terminates in the re tum
sign (syne) bje tive deviati n r m n rmal (per eived by an exam-
iner) that marks the presen e a disease
signal transduction (tranz-DUK-shen) term that re ers t the
wh le pr ess getting a hemi al signal (su h as a h rm ne r
GLOSSARY 743
neur transmitter) t the inside a ell; in a way, signal transdu -
ti n is really signal translati n by the ell
simple (SIM-pel) single, n t mplex
simple columnar epithelium (SIM-pel k h-LUM-nar ep-ih-
H EE-lee-um) type tissue that rms a membrane made up
a single layer ells that are taller than they are wide
simple cuboidal epithelium (SIM-pel KYO O -b yd-al ep-ih-
H EE-lee-um) type tissue that rms a membrane made up
a single layer ubelike ells
simple goiter (SIM-pel GOY-ter) nditi n in whi h the thyr id
enlarges be ause i dine is la king in the diet
simple squamous epithelium (SIM-pel SKWAY-mus ep-ih-
H EE-lee-um) type tissue that rms a membrane made up
a single layer f attened ells
single-gene disease disease aused by individual mutant genes in
nu lear DNA that pass r m ne generati n t the next
sinoatrial (SA) node (sye-n h-AY-tree-al) the hearts pa emaker;
where the impulse ndu ti n the heart n rmally starts; l -
ated in the wall the right atrium near the pening the su-
peri r vena ava
sinus (SYE-nus) a spa e r avity inside s me stru tures the b dy,
as inside the ranial b nes (paranasal sinuses) and inside a lymph
n de; s me large veins are als alled sinuses
sinus dysrhythmia (SYE-nus dis-RI H -mee-ah) variati n in the
rhythm heart rate during the breathing y le (inspirati n and
expirati n)
sinusitis (sye-ny -SYE-tis) sinus in e ti n
skeletal muscle (SKEL-et-tal MUS-el) mus le tissue under willed
r v luntary ntr l; als kn wn as voluntary muscle
skeletal muscle tissue see skeletal muscle
skeletal system (SKEL-et-tal SIS-tem) the b nes, artilage, and
ligaments that pr vide the b dy with a rigid ramew rk r sup-
p rt and pr te ti n
Skene gland (skeen gland) see lesser vestibular gland
skin see cutaneous membrane
skin gra t surgi al implantati n transplanted skin t repla e
burned r therwise injured r rem ved skin
skull b ny stru ture the head
sliding lament model (SLY-ding FIL-ah-ment MAH -del) n-
ept in mus le physi l gy des ribing the ntra ti n a mus le
ber in terms the sliding mi r s pi pr tein laments past
ea h ther within the my brils in a manner that sh rtens the
my brils and thus the entire mus le
small intestine (in- ES -in) part GI tra t that in ludes du de-
num, jejunum, and ileum
smooth muscle (MUS-el) mus le tissue that is n t under ns i us
ntr l; als kn wn as involuntary r visceral muscle; rms the
walls bl d vessels and h ll w rgans su h as the st ma h and
small intestine
smooth muscle tissue see smooth muscle
snuf dippers pouch pre an er us leuk plakia (white pat hes)
in ld between heek and gum aused by use sm keless
t ba
sodium-potassium pump (SOH -dee-um p h- AS-ee-um) a sys-
tem upled i n pumps that a tively transp rts s dium i ns
ut a ell and p tassium i ns int the ell at the same time
und in all living ells
so t palate (s t PAL-let) s t, mus ular p steri r p rti n the r
the m uth
solute (SO L- t) substan e that diss lves int an ther substan e;
r example, in saltwater the salt is the s lute diss lved in
water
744 GLOSSARY
solution (suh-LO O -shun) liquid made up a mixture m le ule
types, usually made s lutes (s lids) s attered in a s lvent (liq-
uid), su h as salt in water
solvent (SO L-vent) substan e in whi h ther substan es are
diss lved; r example, in saltwater the water is the s lvent r
salt
somatic nervous system (s h-MAH -tik NER-vus SIS-tem) the
m t r neur ns that ntr l the v luntary a ti ns skeletal
mus les
spastic paralysis (SPAS-tik pah-RAL-ih-sis) l ss v luntary mus-
le ntr l hara terized by inv luntary ntra ti ns a e ted
mus les
special senses (SPESH -ul SEN-sez) senses dete ted by re ept rs in
spe i l ati ns ass iated with mplex stru tures and inv lve
m des smell, taste, visi n, hearing, r equilibrium
speci c immunity (spih-SIH - k ih-MYO O -nih-tee) the pr te tive
me hanisms that pr vide spe i pr te ti n against ertain types
ba teria r t xins
sperm (pl., sperms r sperm) the male spermat z n; sex ell
spermatid (SPER-mah-tid) resulting daughter ell r m the pri-
mary spermat yte underg ing mei sis; a spermatid has nly hal
the geneti material and hal the hr m s mes regular b dy
ells
spermatogenesis (sper-mah-t h-JEN-eh-sis) pr du ti n sperm
ells
spermatogonia (sper-mah-t h-GOH -nee-ah) sperm pre urs r ells
spermatozoon (sper-mah-tah-ZOH -an) (pl., spermat z a) sperm
ell r male sex ell (male gamete)
sphenoid bone (SFEE-n yd b hn) entral keyst ne b ne the
f r the ranium; resembles a bat
sphincter (SFINGK-ter) ring-shaped mus le
sphygmomanometer (s g-m h-mah-NOM-eh-ter) devi e r stent (stent) metal spring r mesh tube inserted int an a e ted ar-
measuring bl d pressure in the arteries a limb
spinal cavity (SPY-nal KAV-ih-tee) the spa e inside the spinal l-
umn thr ugh whi h the spinal rd passes
spinal nerve (SPY-nal nerv) any the nerves that nne t the spi-
nal rd t peripheral stru tures su h as the skin and skeletal
mus les
spinal tract (SPY-nal trakt) any the white lumns the spinal
rd that pr vide tw -way ndu ti n paths t and r m the
brain; ascending tract arries in rmati n t the brain, whereas
descending tracts ndu t impulses r m the brain
spindle ber (SPIN-dul FYE-ber) a netw rk mi r s pi tubules
rmed in the yt plasm between the entri les as they are m v-
ing away r m ea h ther during mit sis
spine (spyne) the vertebral lumn; a p inted ridge
spiral organ (SPY-rel O R-gun) the rgan hearing l ated in the
hlea with iliated sens ry re ept r ells; als alled organ o
Corti
spirometer (spye-ROM-eh-ter) an instrument used t measure the
am unt air ex hanged in breathing
spleen largest lymph id rgan; lters bl d, destr ys w rn- ut red
bl d ells, salvages ir n r m hem gl bin, and serves as a bl d
reserv ir
splenectomy (spleh-NEK-t h-mee) surgi al rem val the spleen
splenic exure (SPLEN-ik FLEK-shur) p int at whi h the de-
s ending l n turns d wnward n the le t side the abd men;
als alled splenic colic exure r le t colic exure
splenomegaly (spleh-n h-MEG-ah-lee) nditi n enlargement
the spleen
spongy bone (SPUN-jee) p r us b ne in the end the l ng b ne,
whi h may be lled with marr w
spontaneous abortion (sp n- AY-nee-us ah-BOR-shun) mis ar-
riage; l ss an embry r etus be re the twentieth week
gestati n ( r etus under a weight 500 g)
spore (sp r) n nrepr du ing rm a ba terium that resists adverse
envir nmental nditi ns; sp res revert t the a tive multiplying
rm when nditi ns impr ve
sporozoan (sp r- h-ZOH -an) (pl., sp r z a) idia; parasiti
pr t z an that enters a h st ell during ne phase a tw -part
li e y le
sprain (sprayn) an a ute injury t s t tissues surr unding a j int,
in luding mus le, tend n, and/ r ligament
sputum (SPYO O-tum) material spit r ughed r m the m uth
squamous (SKWAY-mus) s alelike
squamous cell carcinoma (SKWAY-mus sel kar-sih-NO H -mah)
malignant tum r the epidermis; sl w-gr wing an er that is
apable metastasizing; the m st mm n type skin an er
squamous suture (SKWAY-mus SO O- hur) the imm vable j int
between the temp ral b ne and the sphen id b ne
stapes (S AY-peez) tiny, stirrup-shaped b ne in the middle ear
staph (sta ) a sh rt w rd rm r Staphylococcus, a ateg ry ba -
teria that an in e t the skin and ther rgans, s metimes
seri usly
static equilibrium (S A -ik ee-kwih-LIB-ree-um) sense the
p siti n the b dy relative t gravity
statin (S A -in) ateg ry drugs that help ntr l bl d n en-
trati n h lester l
stem cell ell apable dividing t pr du e new ell types
stenosed valve (steh-NOSD valv) ardia valve that is narr wer than
n rmal, sl wing bl d f w r m a heart hamber
Stensen duct (S EN-sen dukt) a du t the par tid salivary glands;
als kn wn as parotid duct
tery t keep it pen
sterility (steh-RIL-ih-tee) as applied t humans, the inability t
repr du e
sternoclavicular joint (ster-n h-klah-VIK-y -lar j ynt) the dire t
p int atta hment between the b nes the upper extremity
and the axial skelet n
sternocleidomastoid (stern- h-klye-d h-MAS-t yd) the diag nal
strap mus le l ated n the anteri r aspe t the ne k
sternum (S ER-num) breastb ne
steroid (S AYR- yd) any a lass lipids related t ster ls and
rming numer us repr du tive and adrenal h rm nes
steroid hormone (S AYR- yd H O R-m hn) a type lipid-s luble
h rm ne that passes inta t thr ugh the ell membrane the
target ell and inf uen es ell a tivity by a ting n spe i genes
stillbirth (S IL-berth) delivery a dead etus (a ter twentieth
week gestati n; be re 20 weeks it is termed a spontaneous
abortion)
stimulus (S IM-y -lus) (pl., stimuli) agent that auses a hange in
the a tivity a stru ture
stoma (S O H -mah) an pening, su h as the pening reated in a
l st my pr edure
stomach (S UM-uk) an expansi n the digestive tra t between
the es phagus and small intestine
stork bite (st rk byte) type birthmark
strabismus (strah-BIS-mus) abn rmal nditi n in whi h la k
rdinati n , r weakness in, the mus les that ntr l ne r
b th eyes ause impr per using images n the retina, thus
making depth per epti n di ult
strain (strayn) injury inv lving any mp nent the mus ul ten-
din us unit; alth ugh mus le is usually inv lved, the tend n, the

jun ti n between the tw , as well as their atta hments t b ne,
als may be inv lved
strati ed (S RA -ih- yde) arranged in multiple layers
strati ed squamous epithelium (S RA -ih- yde SKWAY-mus ep-
ih- H EE-lee-um) type tissue that rms a membrane made
up several layers ells, with f attened ells in the sur a e
layer(s)
strati ed transitional epithelium (S RA -ih- yde tran-ZISH -en-
al ep-ih- H EE-lee-um) type tissue that rms a membrane
made up several layers ells that an stret h ut and f atten
with ut breaking
stratum corneum (S RAH -tum KO R-nee-um) the t ugh uter
layer the epidermis; ells are lled with keratin
stratum germinativum (S RAH -tum jer-min-ah- IV-um) the in-
nerm st layer the tightly pa ked epithelial ells the epider-
mis; ells in this layer are able t repr du e themselves
strawberry hemangioma (hem-an-jee-OH -mah) mm n pig-
mented and generally transient birthmark aused by a lle ti n
dilated bl d vessels
strength training (strengkth RAYN-ing) ntra ting mus les
against resistan e t enhan e mus le hypertr phy
stress (stres) a tual r per eived threat t h me stati balan e r the
physi l gi al resp nses t su h threat; pressure r l ad (me hani-
al stress)
Stretta procedure (S RE -ah pr h-see-jur) pr edure using an
end s pe t deliver radi requen y energy t burn, tighten, and
redu e the size the lumen the l wer es phageal sphin ter in
a pers n with gastr es phageal ref ux disease (GERD)
striae (S RYE-ee) (sing., stria) stret h marks aused by stret hing
the skin bey nd its ability t reb und
striated muscle (S RYE-ay-ted MUS-el) see skeletal muscle
stroke volume (SV) (str hk VO L-y m) the am unt bl d that
is eje ted r m the ventri les the heart with ea h beat; ten
expressed as mL/min (milliliters per minute)
structural protein (S RUK-shur-al PRO H -teen) pr tein that has
the r le building stru tures in the b dy, su h as llagen bers
r keratin bers; mpare t unctional protein
subcutaneous injection (sub-ky - AY-nee-us in-JEK-shun) in-
je ti n liquid r pelleted material int the sp ngy and p r us
sub utane us layer beneath the skin
subcutaneous tissue (sub-ky - AY-nee-us ISH -y ) see
hypodermis
subendocardial branch (sub-en-d h-KAR-dee-al bran h) see Pur-
kinje ber
sublingual gland (sub-LING-gwal gland) salivary gland that drains
saliva int the f r the m uth
subluxation (sub-luks-AY-shun) abn rmal, partial separati n the
b nes in a j int; als alled incomplete dislocation
submandibular gland (sub-man-DIB-y -lar gland) salivary glands
that drain saliva int the m uth n either side the lingual
renulum
submucosa (sub-my -KOH -sah) nne tive tissue layer ntain-
ing bl d vessels and nerves in the wall the digestive tra t
sucrase (s -krays) enzyme that atalyzes the hydr lysis su r se
int glu se and ru t se; als alled invertase r saccharase
sucrose (SO O-kr hs) sugar made a d uble sa haride m le ule
made up a glu se unit and ru t se unit
sudden in ant death syndrome (SID S) unexpe ted death un-
kn wn rigin in apparently n rmal in ants; s metimes alled
rib death
sudori erous gland (s -d h-RIF-er-us) glands that se rete sweat;
als re erred t as sweat glands
GLOSSARY 745
sulcus (SUL-kus) (pl., sul i) urr w r gr ve
super cial (s -per-FISH -al) near the b dy sur a e
super cial ascia (s -per-FISH -al FAH -shah) hyp dermis; sub u-
tane us layer beneath the dermis
superior (s -PEER-ee- r) higher; pp site in erior
superior vena cava (s -PEER-ee- r VEE-nah KAY-vah) ne
tw large veins returning de xygenated bl d t the right atrium
supinate (s -pih-NAY ) t make a r tati nal m vement the
rearm (turning the palm laterally t a e rward) r the leg
and ankle (turning the t s t es p int inward and the lateral
edge the s le hits the gr und); pp site pronate
supination (s -pih-NAY-shun) a ti n in whi h the rearm r leg
and ankle supinates; pp site pronation
supine (SO O -pyne) des ripti n the b dy lying in a h riz ntal
p siti n a ing upward
supraclavicular (s -prah-klah-VIK-y -lar) area ab ve the lavi le
sur actant (sur-FAK-tant) a substan e vering the sur a e the
respirat ry membrane inside the alve lus; it redu es sur a e ten-
si n and prevents the alve li r m llapsing
suture (SO O- hur) imm vable j int
sweat (swet) see perspiration
sweat gland (swet) see sudori erous gland
sympathetic division (sim-pah- H E -ik dih-VIZH -un) part
the aut n mi nerv us system; ganglia are nne ted t the th -
ra i and lumbar regi ns the spinal rd; un ti ns as an emer-
gen y system
sympathetic postganglionic neurons (sim-pah- H E -ik p st-
gang-glee-O N-ik NO O -r ns) dendrites and ell b dies are in
sympatheti ganglia and ax ns travel t a variety vis eral
e e t rs
sympathetic preganglionic neuron (sim-pah- H E -ik pree-
gang-glee-O N-ik NO O -r n) nerve ell wh se dendrites and
ell b dies are l ated in the gray matter the th ra i and
lumbar segments the spinal rd; leaves the rd thr ugh a
ventral r t a spinal nerve and terminates in a llateral
gangli n
symptom (SIMP-tum) subje tive deviati n r m n rmal that marks
the presen e a disease (per eived by a patient)
synapse (SIN-aps) jun ti n between adja ent neur ns
synaptic cle t (sin-AP-tik kle t) the spa e between a synapti kn b
and the plasma membrane a p stsynapti neur n
synaptic knob (sin-AP-tik n b) a tiny bulge at the end a terminal
bran h a presynapti neur ns ax n that ntains vesi les with
neur transmitters
synarthrosis (sin-ar- H RO H -sis) a j int in whi h br us nne -
tive tissue j ins b nes and h lds them t gether tightly; m-
m nly alled sutures
syndrome (SIN-dr hm) lle ti n signs r sympt ms, usually
with a mm n ause that de nes r gives a lear pi ture a
path l gi al nditi n
synergist (SIN-er-jist) mus le that assists a prime m ver
synovial uid (sih-NOH -vee-al FLO O-id) the thi k, l rless lu-
bri ating f uid se reted by the syn vial membrane
synovial membrane (sih-NOH -vee-al MEM-brayn) nne tive tis-
sue membrane lining the spa es between b nes and j ints that
se retes syn vial f uid
system (SIS-tem) gr up rgans arranged s that the gr up an
per rm a m re mplex un ti n than any ne rgan an per-
rm al ne
systemic circulation (sis- EM-ik ser-ky -LAY-shun) bl d f w
r m the le t ventri le t all parts the b dy and ba k t the
right atrium
746 GLOSSARY
systemic lupus erythematosus (SLE) (sis- EM-ik LO O-pus er-
ih-them-ah- O H -sus) hr ni inf ammat ry disease aused by
widespread atta k sel -antigens by the immune system (aut -
immunity); hara terized by a red rash n the a e and ther signs
systole (SIS-t h-lee) ntra ti n the heart mus le
systolic blood pressure (sis- OL-ik blud PRESH -ur) r e with
whi h bl d pushes against artery walls when ventri les ntra t
T
cell (tee sel) see lymphocyte
lymphocyte (tee LIM - h-syte) ells the immune system
that have underg ne maturati n in the thymus; pr du es ell-
mediated immunity
wave ele tr ardi gram def e ti n that ref e ts the rep larizati n
the ventri les
tachycardia (tak-ih-KAR-dee-ah) rapid heart rhythm (greater than
100 beats/minute)
tactile corpuscle ( AK-tyle KO R-pus-ul) a sens ry re ept r l -
ated in the skin l se t the sur a e that dete ts light t u h; als
kn wn as Meissner corpuscle
talus ( AY-lus) se nd largest tarsal (ankle) b ne and arti ulates
with the tibia at the ankle j int
target cell ( AR-get sel) ell that is a ted n by a parti ular h r-
m ne ( r ther signaling m le ule) and then resp nds t it
target organ ( AR-get OR-gan) rgan ntaining target cells that
are a ted n by a parti ular h rm ne ( r ther signaling m le-
ule) and then resp nds t it
tarsal ( AR-sal) relating t a f at plate r spe i ally t the heel; any
the seven b nes the heel and ba k part the t; the cal-
caneus is the largest tarsal b ne
tarsal gland ( AR-sal gland) see meibomian gland
taste bud t ngue stru ture h using hemi al re ept rs that dete t
the sense taste
ay-Sachs disease ( AY-saks dih-ZEEZ) re essive, inherited n-
diti n in whi h abn rmal lipids a umulate in the brain and
ause tissue damage that leads t death by age 4
telemetry (tel-EM-eh-tree) te hn l gy by whi h data, su h as heart
a tivity m nit red by an ele tr ardi graph, an be sent t a re-
m te l ati n thr ugh teleph ne wires, radi waves, r ther
mmuni ati n pathway
telophase ( EL- h- ayz r EE-l h- ayz) last stage mit sis in
whi h the ell divides
temporal ( EM-p h-ral) relating t time r t the side the head;
mus le that assists the masseter in l sing the jaw
temporal bone ( EM-p h-ral b hn) ranial b ne l ated n l wer
side ranium and part its f r
tendon ( EN-d n) band r rd br us nne tive tissue that
atta hes a mus le t a b ne r ther stru ture
tendon sheath ( EN-d n sheeth) tube-shaped stru ture lined with
syn vial membrane that en l ses ertain tend ns
tenosynovitis (ten- h-sin- h-VYE-tis) inf ammati n a tend n
sheath
teratogen ( ER-ah-t h-jen) any envir nmental a t r that auses a
birth de e t (abn rmality present at birth); mm n terat gens
in lude radiati n (e.g., x-rays), hemi als (e.g., drugs, igarettes,
r al h l), and in e ti ns in the m ther (e.g., herpes r rubella)
tertiary protein ( ER-shee-ayr-ee PRO H -teen) third level pr -
tein stru ture rmed by urther lding the se ndary pr tein
stru ture
testis ( ES-tis) (pl., testes) male g nad resp nsible r pr du ti n
male sex ells r gametes (sperm) and test ster ne
testosterone (tes- O S-teh-r hn) male sex h rm ne pr du ed by
the interstitial ells in the testes; the mas ulinizing h rm ne
tetanic contraction (teh- AN-ik k n- RAK-shun) sustained n-
tra ti n mus le
tetanus ( E -ah-nus) state sustained mus ular ntra ti n
thalamus ( H AL-ah-mus) l ated just ab ve the hyp thalamus; its
un ti ns are t help pr du e sensati ns, ass iate sensati ns
with em ti ns, and play a part in the ar usal me hanism
thalassemia (thal-ah-SEE-mee-ah) any a gr up inherited he-
m gl bin dis rders hara terized by pr du ti n hyp hr mi ,
abn rmal red bl d ells
theory ( H EE-ah-ree) an explanati n a s ienti prin iple that
has been tested experimentally and und t be true; mpare t
hypothesis and law
thermoreceptor (ther-m h-ree-SEP-t r) sens ry re ept r a tivated
by heat r ld
thermoregulation (ther-m h-reg-y -LAY-shun) maintaining h -
me stasis b dy temperature
third-degree burn inv lves mplete destru ti n b th epidermis
and dermis with injury extending int sub utane us tissue; see
ull-thickness burn
thoracic (th h-RAS-ik) relating t the hest area the b dy (upper
trunk)
thoracic cavity (th h-RAS-ik KAV-ih-tee) rgan- ntaining spa e
inside the rib age r hest the b dy that in ludes the medias-
tinum and le t and right pleural avities
thoracic duct (th h-RAS-ik dukt) largest lymphati vessel in the
b dy
thorax ( H O R-aks) b ny age the upper t rs rmed by 12
pairs ribs, the sternum, and th ra i vertebrae; als alled the
chest
threshold stimulus ( H RESH -h ld S IM-y -lus) minimal level
stimulati n required t ause a mus le ber t ntra t
thrombin ( H ROM-bin) pr tein imp rtant in bl d l tting
thrombocyte ( H RO M-b h-syte) type bl d ell that plays a
r le in bl d l tting; als alled platelet
thrombocytopenia (thr m-b h-sye-t h-PEE-nee-ah) general term
re erring t an abn rmally l w bl d platelet unt
thrombophlebitis (thr m-b h-f eh-BYE-tis) vein inf ammati n
(phlebitis) a mpanied by l t rmati n
thrombosis (thr m-BO H -sis) rmati n a l t in a bl d vessel
thromboxane (thr m-BOKS-ayne) pr staglandin-like substan e in
platelets that plays a r le in hem stasis and bl d l tting
thrombus ( H RO M-bus) stati nary bl d l t
thrush andidiasis m uth (m uth in e ti n) hara terized by
white, reamy pat hes exudate n inf amed ral mu sa and
t ngue; aused by yeastlike ungal rganism
thymine ( H YE-meen) ne several nitr gen- ntaining bases
that make up nu le tides, whi h in turn make up nu lei a ids
su h as DNA (but n t RNA); in the ell, it an bind t an ther
nitr gen us base, adenine (A r a), t rm a m re mplex stru -
ture r in translating geneti des; symb lized by the letter r
t; see also guanine, adenine, cytosine, uracil
thymosin ( H Y-m h-sin) h rm ne pr du ed by the thymus that is
vital t the devel pment and un ti ning the b dys immune
system
thymus see thymus gland
thymus gland ( H Y-mus) end rine gland l ated in the mediasti-
num; vital part the b dys immune system; ten alled simply
the thymus
thyroid ollicle ( H Y-r yd FO L-lih-kul) p ket thyr id ll id
(suspended, st red rm thyr id h rm ne) in the thyr id gland

thyroid gland ( H Y-r yd) end rine gland l ated in the ne k that
st res its h rm nes until needed; thyr id h rm nes regulate el-
lular metab lism
thyroid-stimulating hormone ( SH) ( H Y-r yd S IM-y -lay-
ting H O R-m hn) a tr pi h rm ne se reted by the anteri r pi-
tuitary gland that stimulates the thyr id gland t in rease its se-
reti n thyr id h rm ne
thyroxine ( 4) (thy-RO K-sin) thyr id h rm ne that stimulates el-
lular metab lism
tibia ( IB-ee-ah) shinb ne
tibialis anterior (tib-ee-AL-is an- EER-ee- r) d rsif ex r the t
tic douloureux (tik d -l -RO O ) see trigeminal neuralgia
tidal volume ( V) ( YE-dal VOL-y m) am unt air breathed
in and ut with ea h breath
tinea ( IN-ee-ah) ungal in e ti n the skin
tinea pedis ( IN-ee-ah PED-is) a ungal in e ti n the skin the
t hara terized by redness and it hing; als alled athletes oot
tinnitus (tih-NYE-tus r IN-it-us) abn rmal sensati n ringing
r buzzing in the ear
tissue ( ISH -y ) gr up similar ells that per rm a mm n
un ti n
tissue uid ( ISH -y FLO O-id) a dilute saltwater s luti n that
bathes every ell in the b dy; als alled interstitial uid
tissue hormone ( ISH -y H O R-m hn) pr staglandins; pr du ed
in a tissue and di used nly a sh rt distan e t a t n ells within
the tissue
tissue plasminogen activator ( PA or tPA) ( ISH -y plaz-MIN-
h-jen AK-tih-vay-t r) naturally urring substan e that a ti-
vates plasmin gen and nverts it t the a tive enzyme plasmin,
whi h in turn diss lves brin bl d l ts
tissue typing ( ISH -y YE-ping) a pr edure used t identi y
tissue mpatibility be re an rgan transplant
lymphocytes ( LIM- h-sytes) ells that are riti al t the un -
ti n the immune system; pr du e ell-mediated immunity
tone (t hn) tensi n; baseline ntra ti n any mus le
tonic contraction ( AH N-ik k n- RAK-shun) sustained, baseline
skeletal mus le ntra ti n used t maintain p sture
tonsil ( AH N-sil) mass lymph id tissue; pr te ts against ba te-
ria; three main sets: palatine t nsils, l ated n ea h side the
thr at; pharyngeal t nsils (aden ids), near the p steri r pening
the nasal avity; and lingual t nsils, near the base the t ngue
tonsillectomy (tahn-sih-LEK-t h-mee) surgi al pr edure used t
rem ve the t nsils
tonsillitis (tahn-sih-LYE-tis) inf ammati n the t nsils, usually
aused by in e ti n
tophus ( OH - us) (pl., t phi) st nelike gr wths r dep sits in tis-
sues r ar und j ints; may ntain urate rystals in patients with
g ut
total metabolic rate ( MR) ( O H -tal met-ah-BOL-ik rayt) t tal
am unt energy used by the b dy per day
toxicologist (t k-sih-KOL-uh-jist) s ientist wh studies the e e ts,
treatments, and dete ti n p is ns
trabecula (trah-BEK-y -lah) (pl., trabe ulae) bran hed, needlelike
thread tissue ( r example, b ne) that rms a netw rk
spa es
trachea ( RAY-kee-ah) the windpipe; the tube extending r m the
larynx t the br n hi
tracheostomy (tray-kee-O S-t h-mee) medi al pr edure inv lving
the utting an pening int the tra hea
trachoma (trah-KOH -mah) hr ni in e ti n the njun tiva
vering the eye aused by the ba terium Chlamydia trachomatis;
als alled chlamydial conjunctivitis
GLOSSARY 747
tract (trakt) a single nerve pathway made up several bundles
ax ns and extending thr ugh the entral nerv us system; m-
pare t nerve
tragus ( RAY-gus) pr minent bump skin- vered artilage the
auri le (external ear) that lies just anteri r the pening t the
a usti anal (ear anal)
transaminase (trans-AM-ih-nayz) enzyme released r m damaged
tissues; high bl d n entrati n may indi ate a heart atta k r
ther path l gi al event
transcellular uid (tranz-SEL-y -lar FLO O -id) part the extra-
ellular f uid that in ludes erebr spinal f uid (CSF), f uids the
eyeball, and the syn vial j int f uids (but n t bl d plasma r
interstitial f uid)
transcription (trans-KRIP-shun) a ti n that urs when the d uble-
stranded DNA m le ule unwinds and be mes a template t rm
mRNA, thus making a py a gene
trans er RNA ( RANS- er R N A) type rib nu lei a id (RNA)
that temp rarily binds t spe i amin a ids and trans ers them
t spe i sequen es ( d ns) n a messenger RNA (mRNA)
m le ule; als kn wn as tRNA
transitional (tranz-IH -shen-al) relating t a hange r s mething
apable hange, as in transitional epithelium (whi h an hange
ell shape as the tissue stret hes)
transitional epithelium (tranz-IH -shen-al ep-ih- H EE-lee-um)
type epithelial tissue that rms membranes apable stret h-
ing with ut breaking, as in the urinary bladder; ells in this type
tissue an stret h r m a r ughly lumnar shape ut t a f at-
tened (squam us) shape and ba k again with ut sustaining dam-
age; als alled strati ed transitional epithelium
translation (trans-LAY-shun) the synthesis a pr tein by rib -
s mes (by translating geneti de)
transplant (trans-PLAN ) tissue r rgan gra t; pr edure in whi h
a tissue (e.g., skin, b ne marr w) r an rgan (su h as kidney,
liver) r m a d n r is surgi ally implanted int a re ipient
transport maximum ( max) ( RANZ-p rt MAKS-im-um) the
largest am unt any substan e that an be m ved by a ellular
transp rter (pump r arrier) at ne time, determined mainly by
the number available transp rters that substan e
transport process ( RANZ-p rt PRO H -ses) pr ess arrying
materials within the b dy, ten a r ss membranes and within
f uids
transverse arch ( RANS-vers) see metatarsal arch
transverse canal (tranz-VERS kah-NAL) mmuni ating anal
between entral (H aversian) anals that ntains vessels t arry
bl d t the ste ns; als arries nerves and lymphati vessels;
als alled Volkmann canal
transverse colon (tranz-VERS KO H -len) divisi n the l n that
passes h riz ntally a r ss the abd men
transverse racture ( RANS-vers FRAK- hur) b ne ra ture har-
a terized by a ra ture line that is at a right angle t the l ng axis
the b ne
transverse plane (tranz-VERS playn) a f at ut thr ugh the b dy ( r
a b dy part) that is h riz ntal r r sswise and thus divides the
b dy ( r b dy part) int upper and l wer p rti ns; see also section
(o body)
transversus abdominis (trans-VER-sus ab-DAH -min-us) the in-
nerm st layer the anter lateral abd minal wall
trapezium (trah-PEE-zee-um) the arpal b ne the wrist that
rms the saddle j int that all ws the pp siti n the thumb
trapezius (trah-PEE-zee-us) triangular mus le in the ba k that el-
evates the sh ulder and extends the head ba kward
traumatic (truh-MA -ik) relating t injury (trauma)
748 GLOSSARY
triceps brachii ( RY-seps BRAY-kee-aye) extens r mus le the
elb w
tricuspid (try-KUS-pid) des ribes anything having three angles r
p ints ( usps)
tricuspid tooth (try-KUS-pid) t th with rather large f at sur a e
with tw r three grinding usps; als alled molar
tricuspid valve (try-KUS-pid valv) the valve l ated between the
right atrium and ventri le
trigeminal neuralgia (try-JEM-ih-nal n -RAL-jee-ah) pain in ne
r m re ( three) bran hes the th ranial nerve (trigeminal
nerve) that runs al ng the a e; als alled tic douloureux
triglyceride (try-GLIH -ser-ayed) lipid that is synthesized r m
atty a ids and gly er l r r m ex ess glu se r amin a ids;
st red mainly in adip se tissue ells
trigone ( RY-g n) triangular area n the wall the urinary
bladder
triiodothyronine ( 3) (try-aye- h-d h- H Y-r h-neen) thyr id
h rm ne that stimulates ellular metab lism
trimester three-m nth segments the gestati n peri d
(pregnan y)
triple therapy ( RIP-pul H AYR-ah-pee) treatment ul ers us-
ing a mbinati n bismuth subsali ylate (Pept -Bism l) and
tw antibi ti s
triplegia (try-PLEE-jee-ah) paralysis (l ss v luntary mus le n-
tr l) in three limbs, ten tw legs and ne arm
trisomy ( RY-s h-mee) abn rmal geneti nditi n in whi h ells
have three hr m s mes (a triplet) where there sh uld be a pair;
usually aused by n ndisjun ti n ( ailure hr m s me pairs t
separate) during gamete pr du ti n
tropic hormone ( ROH -pik H O R-m hn) h rm ne that stimu-
lates an ther end rine gland t gr w and se rete its h rm nes
true ribs the rst seven pairs ribs, whi h are atta hed t the
sternum
trypsin ( RIP-sin) pr tein-digesting enzyme (pr tease)
tubal pregnancy ( O O-bal PREG-nan-see) e t pi pregnan y that
urs in a uterine ( all pian) tube
tuberculosis ( B) (t -ber-ky -LO H -sis) hr ni ba terial (ba il-
lus) in e ti n the lungs r ther tissues aused by M ycobacte-
rium tuberculosis rganisms
tumor ( O O-mer) gr wth tissues in whi h ell pr li erati n is
un ntr lled and pr gressive
tumor suppressor gene gene that w rks against the devel pment
an er us ells
tunica albuginea ( O O -nih-kah al-by -JIN-ee-ah) a t ugh,
whitish membrane that surr unds ea h testis and enters the gland
t divide it int l bules
tunica externa ( O O-nih-kah eks- ER-nah) the uterm st layer
und in bl d vessels
tunica intima ( O O -nih-kah IN-tih-mah) end thelium that lines
bl d vessels; als alled tunica interna
tunica media ( O O -nih-kah MEE-dee-ah) the mus ular middle
layer und in bl d vessels; the tuni a media arteries is m re
mus ular than that veins
turbinate ( UR-bih-nayt) see concha
turgor ( UR-ger) resilien y r f uid pressure in the ells the skin,
ten l st during dehydrati n
urner syndrome ( UR-ner SIN-dr hm) geneti dis rder aused
by m n s my the X hr m s me (XO ) in emales; hara ter-
ized by immaturity sex rgans ( ausing sterility), webbed ne k,
ardi vas ular de e ts, and learning dis rders
wave def e ti n n an ele tr ardi gram that urs with rep lar-
izati n the ventri les
twitch a qui k, jerky resp nse t a single stimulus
tympanic (tim-PAN-ik) drumlike
tympanic membrane (tim-PAN-ik MEM-brayn) eardrum; mem-
brane that separates external ear anal r m middle ear
type 1 diabetes mellitus (dye-ah-BEE-teez mel-AYE-tus) a ndi-
ti n in whi h the pan reati islets se rete t little insulin, result-
ing in in reased levels bl d glu se; rmerly kn wn as
juvenile-onset diabetes r insulin-dependent diabetes mellitus
type 2 diabetes mellitus (dye-ah-BEE-teez mel-AYE-tus) a ndi-
ti n in whi h ells the b dy be me less sensitive t the h r-
m ne insulin and perhaps the pan reati islets se rete t little
insulin, resulting in in reased levels bl d glu se; rmerly
kn wn as maturity-onset diabetes r noninsulin-dependent diabetes
mellitus
U
ulcer (UL-ser) a ne r ti pen s re r lesi n
ulna (UL-nah) ne the tw rearm b nes; l ated n the little
nger side
ulnar deviation (UL-nur dee-vee-AY-shun) de rmity the hands
as a result rheumat id arthritis
ultrasonogram (ul-trah-SO H N- h-gram) a re rd btained by us-
ing s und t pr du e images
ultrasonography (ul-trah-s n-O G-rah- ee) an imaging te hnique
in whi h high- requen y s und waves are ref e ted tissue t
rm an image
umami ( -MOM-ee) meaty r sav ry taste pr du ed by gluta-
mati a id (an amin a id)
umbilical (um-BIL-ih-kul) relating t the navel r umbili us, a
stru ture made up bl d vessels nne ting the devel ping
etus t the pla enta
umbilical artery (um-BIL-ih-kul AR-ter-ee) tw small arteries that
arry xygen-p r bl d r m the devel ping etus t the pla enta
umbilical cord (um-BIL-ih-kul) f exible stru ture nne ting the
etus t the pla enta, whi h all ws the umbili al arteries and vein
t pass
umbilical region (um-BIL-ih-kul REE-jun) the very enter regi n
the abd min pelvi avity, near the umbili us (navel) and be-
tween the le t and right lumbar regi ns; termin l gy used when
the abd min pelvi avity is visualized as being subdivided int
nine regi ns as in a ti -ta -t e grid
umbilical vein (um-BIL-ih-kul vayn) a large vein arrying xygen-
ri h bl d r m the pla enta t the devel ping etus
universal donor blood bl d type O ( r O )
universal recipient blood bl d type AB ( r AB )
upper esophageal sphincter (UES) (eh-s -eh-JEE-al SFING K-
ter) ring mus ular tissue (sphin ter) l ated between laryng -
pharynx and pr ximal end es phagus
upper GI (UGI) (upper jee aye) the st ma h and es phagus; an
x-ray study the l wer es phagus, st ma h, and du denum,
pr du ed with the aid a ntrast medium and used t dete t
ul erati ns, tum rs, inf ammati ns, r anat mi al malp siti ns
su h as hiatal hernia
upper respiratory in ection (URI) (RES-pih-rah-t ree) in e ti n
l alized in the mu sa the upper respirat ry tra t (primarily
the n se, nasal sinuses, and/ r pharynx)
upper respiratory tract (UP-er res-PYE-rah-t r-ee trakt) divisi n
respirat ry tra t utside the th rax that is mp sed the
n se, pharynx, and larynx
uracil (YO O R-ah-sil) ne several nitr gen- ntaining bases that
make up nu le tides, whi h in turn make up nu lei a ids su h as

RNA (but n t DNA); in the ell, it an hemi ally bind t an-
ther nitr gen us base, adenine (A r a), t rm a m re mplex
stru ture r in translating geneti des; symb lized by the letter
U r u; see also guanine, adenine, thymine, cytosine
urea (y -REE-ah) nitr gen- ntaining waste pr du t
uremia (y -REE-mee-ah) nditi n in whi h bl d urea n en-
trati n is abn rmally elevated, expressed as a high BUN (bl d
urea nitr gen) value; uremia is ten aused by renal ailure; als
alled uremic poisoning
uremic poisoning (y -REE-mik POY-z n-ing) see uremia
ureter (YO O-reh-ter) mus ular tube that ndu ts urine r m the
kidney t the urinary bladder
urethra (y -REE-thrah) passageway r eliminati n urine; in
males, als a ts as a genital du t that arries sperm t the exteri r
urethritis (y -reh- H RY-tis) inf ammati n r in e ti n the
urethra
urinalysis (y r-in-AL-is-is) lini al lab rat ry testing urine
samples
urinary bladder (YO OR-ih-nayr-ee BLAD-er) llapsible sa like
rgan that lle ts urine r m the kidneys and st res it be re
eliminati n r m the b dy
urinary incontinence (YO OR-ih-nayr-ee in-KON-tih-nens) n-
diti n in whi h an individual v ids urine inv luntarily; mpare
t incontinence
urinary meatus (YO O R-ih-nayr-ee mee-AY-tus) external pening
the urethra
urinary retention (YO OR-in-ayr-ee ree- EN-shun) nditi n in
whi h n urine is v ided
urinary suppression (YO O R-in-ayr-ee sup-PRESH -un) nditi n
in whi h kidneys d n t pr du e urine
urinary system (YO OR-ih-nayr-ee SIS-tem) system resp nsible r
ex reting liquid waste r m the b dy
urinary tract in ection (U I) (YO OR-ih-nayr-ee trakt in-FEK-
shun) in e ti n the mu sa that lines the urinary tra t
urination (y r-ih-NAY-shun) passage urine r m the b dy;
emptying the bladder
urine (YO OR-in) f uid waste ex reted by the kidneys
urologist (y -ROL-uh-jist) s ientist r physi ian spe ializing in
urine and the ur genital tra t and its dis rders
urticaria (er-tih-KAYR-ee-ah) an allergi r hypersensitivity re-
sp nse hara terized by raised red lesi ns; als re erred t as hives
uterine tube (YO O-ter-in t b) either a pair tubes that n-
du t the vum r m the vary t the uterus; als alled allopian
tube r oviduct
uterus (YO O-ter-us) h ll w, mus ular rgan where a ertilized egg
implants and gr ws
uvula (YO O-vy -lah) ne-shaped pr ess hanging d wn r m
the s t palate that helps prevent d and liquid r m entering
the nasal avities
V
vaccine (VAK-seen) appli ati n killed r attenuated (weakened)
path gens ( r p rti ns path gens) t a patient t stimulate
immunity against that path gen
vagina (vah-JYE-nah) internal tube r m uterus t vulva
vaginitis (vaj-ih-NYE-tis) inf ammati n the vagina
variant Creutz eldt-Jakob disease (vCJD ) (VAYR-ee-ant
KROY S- elt YAH -k hb dih-ZEEZ) a degenerative disease
the entral nerv us system aused by pri ns (pr teina e us in e -
ti us parti les) that nvert n rmal pr teins the nerv us sys-
tem int abn rmal pr teins, ausing l ss un ti n; see prion
GLOSSARY 749
varicose vein (VAYR-ih-k hs vayn) enlarged vein in whi h bl d
p ls; als alled varix
varix (VAYR-iks) (pl., vari es) see varicose vein
vas de erens (vas DEF-er-enz) (pl., vasa de erentia) see ductus
de erens
vasectomy (va-SEK-t h-mee) surgi al severing the vas de erens
t render a male sterile
vasoconstriction (vay-s h-k n-S RIK-shun) redu ti n in vessel
diameter aused by in reased ntra ti n the mus ular at
(sm th mus le)
vasodilator (vay-s -DYE-lay-t r) lass drugs that trigger the
sm th mus les arterial walls t relax, ausing the arteries t
dilate
vasomotor mechanism (vay-s h-MOH -t r MEK-ah-niz-em) a -
t rs that ntr l hanges in the diameter arteri les by hang-
ing the tensi n sm th mus les in the vessel walls
vastus (VAS-tus) wide; great size
vector (VEK-t r) arthr p d that arries an in e ti us path gen
r m ne rganism t an ther
vein (vayn) vessel arrying bl d t ward the heart
venous return (VEE-nus) am unt bl d returned t the heart by
the veins
ventral (VEN-tral) r near the belly; in humans, r nt r
anterior; pp site dorsal r posterior
ventral body cavity (VEN-tral BO D -ee KAV-it-ee) rgan-
ntaining spa e in the anteri r trunk the b dy; r example,
the th ra i and abd min pelvi avities; mpare with dorsal
body cavity
ventricle (VEN-trih-kul) any small avity r spa e
ventricular brillation (VF or V- b) (ven- RIK-y -lar b-ril-
LAY-shun) li e-threatening nditi n in whi h the la k ven-
tri ular pumping suddenly st ps the f w bl d t vital tissues;
unless ventri ular brillati n is rre ted immediately by de bril-
lati n r s me ther meth d, death may ur within minutes; see
also automatic external de brillator
venule (VEN-y l) small bl d vessels that lle t bl d r m the
apillaries and j in t rm veins
vermi orm appendix (VERM-ih- rm ah-PEN-diks) a tubular
stru ture atta hed t the e um and mp sed lymph id
tissue
vertebra (VER-teh-bra) (pl., vertebrae) any the b nes that make
up the spinal (vertebral) lumn
vertebral column (ver- EE-bral KOL-um) the spinal lumn,
made up a series separate vertebrae that rm a f exible,
urved r d
vertebroplasty (ver-tee-br h-PLAS-tee) rth pedi pr edure used
t treat the vertebral mpressi n ra tures that ur in ste p -
r sis; inv lves inje ting b ne ement, but with ut using a
ball n
vertigo (VER-tih-g ) abn rmal sensati n spinning; dizziness
vesicle (VES-ih-kul) a lini al term re erring t blisters, f uid- lled
skin lesi ns
vestibular nerve (ves- IB-y -lar nerv) a divisi n the vestibul -
hlear nerve (the eighth ranial nerve)
vestibule (VES-tih-by l) l ated in the inner ear; the p rti n ad-
ja ent t the val wind w between the semi ir ular anals and
the hlea
vestibule o the vulva (VES-tih-by l) the area between the labia
min ra; the lit ris and the ri e the urethra are l ated in
the vestibule
villus (VIL-us) (pl., villi) any the s t, ngerlike pr je ti ns that
ver the pli ae ( lds) the small intestine
750 GLOSSARY
Vincent in ection (VIN-sent in-FEK-shun) ba terial (spir hete)
in e ti n the gum, pr du ing gingivitis; als alled Vincent
angina and trench mouth
virilizing tumor (VEER-il-aye-zing O O M-er) ne plasm the
adrenal rtex that stimulates verpr du ti n test ster ne and
there re an in rease in mas ulinizati n, even w men
virus (VYE-rus) mi r s pi , parasiti entity nsisting a nu lei
a id b und by a pr tein at and s metimes a lip pr tein envel pe
visceral (VIS-er-al) relating t the vis era r internal rgans
visceral ef ector (VIS-er-al ee-FEK-t r) any mus le r gland (e e -
t r) und within the avities the b dy and ntr lled by the
aut n mi nerv us system; examples in lude ardia mus le tis-
sue, sm th mus le tissue, and internal glands
visceral muscle (VIS-er-al MUS-el) see smooth muscle and
involuntary muscle
visceral pericardium (VIS-er-al payr-ih-KAR-dee-um) the peri ar-
dium that vers the heart; als alled epicardium
visceral peritoneum (VIS-er-al payr-ih- OH N-ee um) ser us
membrane that vers and is adherent t the abd minal vis era
visceral pleura (VIS-er-al PLO O-rah) ser us membrane that vers
and is adherent t the sur a e the lungs
visceral portion (VIS-er-al PO R-shun) ser us membrane that v-
ers the sur a e rgans und in the b dy avity
vital capacity (VC) (VYE-tal kah-PAS-ih-tee) largest am unt air
that an be m ved in and ut the lungs in ne inspirati n and
expirati n
vitamin (VYE-tah-min) rgani m le ule needed in small quanti-
ties t help enzymes perate e e tively r t therwise regulate
metab lism in the b dy
vitiligo (vit-ih-LYE-g ) pat hy areas light skin aused by a -
quired l ss epidermal melan ytes
vitreous humor (VI -ree-us H YO O -m r) the jellylike f uid und
in the eye, p steri r t the lens
vocal cords (VOH -kull k rds) bands tissue in larynx resp nsible
r pr du ti n s und (spee h)
voiding (VO YD-ing) emptying the bladder
volar (VOH -lar) relating t the palm r s le
voluntary muscle (VO L-un-tayr-ee MUS-el) see skeletal muscle
vulva (VUL-vah) lds and ther stru tures that t gether make up
the external genitals the emale
vulvitis (vul-VYE-tis) inf ammati n the vulva (the external e-
male genitals)
W
wart raised bump that is a benign ne plasm (tum r) the skin
aused by viruses
water intoxication (WAH -ter in- OK-sih-kay-shen) p ssibly li e-
threatening neur l gi al impairment aused by severe verhydra-
ti n and a mpanying ele tr lyte imbalan e
West Nile virus (WNV) (nyle VY-rus) s metimes atal viral in e -
ti n aused by a type f avivirus transmitted t humans by an
inse t ve t r su h as a m squit , sand f y, r ti k; hara terized by
sudden nset ever and ten a mpanied by malaise, an-
rexia, nausea/v miting, eye pain, heada he, myalgia (mus le
pain), rash, sw llen lymph n des, and s metimes pr gressing t
severe neur l gi al disease
wheal (weel) raised red skin lesi n ten ass iated with severe it h-
ing, as in hives
white blood cell (WBC) see leukocyte
white matter (MA -ter) tissue made up nerve tra ts vered with
white myelin
withdrawal re ex (with-DRAW-al REE-f eks) a ref ex that m ves a
b dy part away r m an irritating stimulus
X
xeroderma pigmentosum (zeer- h-DER-mah pig-men- OH -
sum) rare geneti dis rder hara terized by the inability skin
ells t repair geneti damage aused by the ultravi let (UV) ra-
diati n in sunlight
Y
yeast (yeest) single- elled ungus ( mpared t m ld, whi h is a
multi ellular ungus)
yellow bone marrow (YEL- h b hn MAYR- h) atty tissue und
inside the medullary avity a l ng b ne
yellow ever (YEL- h FEE-ver) viral illness aused by a type
f avivirus (literally yell w virus) arried by m squit ve t rs and
hara terized by ever
yolk sac (y hk sak) in humans, inv lved with the pr du ti n
bl d ells in the devel ping embry
Z
Z disk disklike stru ture separating ne stru tural unit (sar mere)
the my bril r m the next unit the my bril, ten seen as
a dark band (Z line) in mi r graphs the my brils skeletal
mus le bers; als alled Z line
Z line see Z disk
Zika virus (ZEE-kah VYE-rus) viral illness aused by a type
f avivirus arried by m squit ve t rs r transmitted sexually and
hara terized by ever; kn wn t ause birth de e ts su h as
mi r ephaly
zona asciculata (ZO H -nah as-si -y -LAY-tah) middle z ne
the adrenal rtex that se retes glucocorticoids
zona glomerulosa (ZOH -nah gl h-mayr-y -LOH -sah) uter
z ne the adrenal rtex that se retes mineral rti ids
zona reticularis (ZOH -nah reh-tik-y -LAYR-is) inner z ne
the adrenal rtex that se retes small am unts sex h rm nes
zygomatic (zye-g h-MA -ik) heek b ne (malar b ne) r related t
the heek b ne and nearby area
zygomaticus (zye-g h-MA -ik-us) mus le that elevates the rners
the m uth and lips; als kn wn as the smiling muscle
zygote (ZYE-g ht) a ertilized vum
Illus tration/Photo Cre dits
Ch a p t e r 1
1-2, 1-6, 1-7: Barbara C usins; 1-4: Redrawn r m Mus lin JE:
Know the body: muscle, bone, and palpation essentials, St L uis, 2012,
M sby; S ien e Appli ati n b x (M dern Anat my, art): J e Kulka;
S ien e Appli ati n b x (M dern Anat my, ph t ): Nati nal Li-
brary Medi ine (Nati nal Institute H ealth).
Ch a p t e r 2
2-1: Fr m Sugim t Y et al: Chemi al identi ati n individual
sur a e at ms by at mi r e mi r s py, Nature 446:64-67, 2007;
S ien e Appli ati n b x (Bi hemistry, art): J e Kulka.
Ch a p t e r 3
3-4A: C urtesy Charles Fli kinger, University Virginia; 3-4B:
Lennart Nilss n, Albert B nniers F rlag AB, St kh lm Sweden;
3-12: Fr m F rbes CD, Ja ks n W F: Color atlas and text o clinical
medicine, ed 3, L nd n, 2003, Elsevier; 3-16: Fr m Stevens A,
L we J: Pathology, ed 2, St L uis, 2000, M sby; able 3-2: Netw rk
Graphi s.
Ch a p t e r 4
4-1, Adapted r m Faw ett DW: Bloom and Fawcetts a textbook o
histology, ed 11, Philadelphia, 1986, Saunders, In G artner LP, H iatt
JL: Concise histology, Philadelphia, 2011, Saunders; 4-2, 4-3B, 4-4B,
4-6B, 4-8B: Barbara C usins; 4-3A, 4-4A, 4-6A,4-8A, 4-15A: Fr m
Gartner LP, H iatt JL: Color textbook o histology, ed 3, Philadelphia,
2007, Saunders; 4-5: Fr m Erlandsen SL, Magney J: Color atlas o
histology, St L uis, 1992, M sby; 4-7A, 4-10, 4-11, 4-12, 4-13, 4-14,
4-16A, 4-18A, 4-19: Dennis Strete; 4-17A: Fr m Gartner LP:
extbook o histology, ed 4, Philadelphia, 2017, Elsevier; 4-20: Fr m
Callen JP, Paller AS, Greer KE, et al: Color atlas o dermatology,
Philadelphia, 1993, Saunders; S ien e Appli ati n b x (Mi r s py,
art): J e Kulka; S ien e Appli ati n b x (Mi r s py, M dern
C mp und Light Mi r s pe, art):J e Kulka.
Ch a p t e r 5
5-2, 5-6: Barbara C usins; 5-14: Fr m Markstedt K, Athanasi s M,
urnier I, et al: 3D Bi printing human h ndr ytes with
nan ellul se-alginate bi ink r artilage tissue engineering appli-
ati ns, Biomacromolecules 16:1489-96, 2015; S ien e Appli ati n
b x (Radi graphy, drawing): J e Kulka; S ien e Appli ati n b x
(Radi graphy, x-ray lm): Ph t Resear hers, In .
Ch a p t e r 6
6-1, 6-3: Centers r Disease C ntr l and Preventi n, Atlanta, GA;
6-4: Barbara C usins; 6-5A: Fr m ravis J: D rugs unter mad w
agent in ells, Science News 160(7):100, 2001, Fred C hen; 6-5B:
Centers r Disease C ntr l and Preventi n/ eresa H ammett; 6-6,
6-7A-B: David M Phillips/Visual Unlimited; 6-8: Fr m S huster
FL, Visvesvara GS: Free-living am ebae as pp rtunisti and n n-
pp rtunisti path gens humans and animals, Int J Parasitol
34(9):1001-1027, 2004; 6-9: Getty Images; 6-10, 6-11: R lin
Graphi s; 6-12A: Fr m Le reut AL: M ammography, St L uis, 1991,
M sby; 6-12B: Fr m W illiams AL, H aught n VM: Cranial
computed tomography, St L uis, 1985, M sby; 6-12C: Fr m Runge
VM: Enhanced magnetic resonance imaging, St L uis, 1989, M sby;
6-12D: Fr m H agen-Ansert SL: extbook o diagnostic ultrasonogra-
phy, ed 6, St L uis, 2006, M sby; 6-13 inset: Fr m B l gnia JL,
S ha er JV: Dermatology essentials, St L uis, 2014, Saunders;
able 6-7, Fig 1: C urtesy Nati nal Center r Veterinary Parasit l-
gy at O klah ma State University; able 6-7, Fig 2: Centers r
Disease C ntr l and Preventi n/D r. Amanda L tis, D r. W illiam
Ni h ls n, D r. W ill Reeves, D r. Chris Padd k; able 6-7, Figs 3, 4:
Centers r Disease C ntr l and Preventi n/Anna Perez; able 6-7,
Fig 5: Centers r Disease C ntr l and Preventi n; able 6-7, Fig 6:
Centers r Disease C ntr l and Preventi n/Andrew J Br ks; Re-
sear h, Issues, and rends b x (Centers r Disease C ntr l and
Preventi n, ph t ): Centers r Disease ntr l and Preventi n:
Publi H ealth Image Library: Image ID: 19388 (http://phil. d .g v/
phil/details.asp); Clini al Appli ati n b x (Lab rat ry Identi ati n
Path gens, images): Fr m G ering RV, D krell H M,
Z u kerman M, et al: M ims M edical M icrobiology, ed 5, Elsevier, Ltd,
2012; S ien e Appli ati ns b x (Publi H ealth, art): J e Kulka;
S ien e Appli ati ns b x (Publi H ealth, ph t ): US Dept H ealth
& H uman Servi es, http://www.usphs.g v/newsr m/gallery/
adayintheli e.aspx; Resear h, Issues, and rends b x (Disease as a
Weap n): Fr m Bee hing NJ, Nye FD: Diagn sti pi ture tests in
lini al in e ti us diseases, St L uis, 1996, M sby; Clini al Appli a-
ti n b x (Medi al Imaging the B dy, A,B,C): Ph t Resear h-
ers, In .; Clini al Appli ati n b x (Medi al Imaging the B dy, D):
Fr m Ballinger PW et al: M errills atlas o radiographic positions &
radiologic procedures, ed 10, St L uis, 2003, M sby.
Ch a p t e r 7
7-4: Edward Res hke; 7-5: C urtesy James A Is hen, MD, Bayl r
C llege Medi ine; 7-6: C pyright Kevin Patt n, Li n Den In ,
Weld n Spring, MO ; 7-7, 7-21B: Fr m H abi P: Clinical dermatol-
ogy, ed 6, St L uis, 2016, M sby; 7-9: Fr m G ldstein B, edit r:
Practical dermatology, ed 2, St L uis, 1997, M sby; 7-11A, 7-12:
Fr m H abi : Clinical dermatology, ed 3, St L uis, 1996, M sby;
7-11B, 7-20B: Fr m H abi P: Clinical dermatology, ed 4, St L uis,
2004, M sby; 7-13: Fr m Callen JP, Paller AS, Greer KE, et al: Color
atlas o dermatology, ed 2, Philadelphia, 2000, Saunders; 7-15:
H kenberry-W ils n: Wongs nursing care o in ants and children, ed 9,
St L uis, 2013, M sby; 7-18: C urtesy Mi hael Pe k, MD, Univer-
sity N rth Car lina Burn Center, Chapel H ill, In C pstead-
Kirkh rn L, Banasik J: Pathophysiology, ed 2, St L uis, 1999,
Saunders; 7-20A: Fr m Em nd R D, Welsby PD, R wland H AK:
Colour atlas o in ectious diseases, ed 3, L nd n, 1995, M sby;
7-20C,D: C urtesy Jaime A s hen, MD, Department Derma-
t l gy, Bayl r C llege Medi ine, H ust n, X; 7-21A: Fr m
P tter P, Perry A: Fundamentals o nursing, ed 7, St L uis, 2009,
M sby; 7-21C: Fr m H abi P: Clinical dermatology, ed 5, St L uis,
2010, M sby; 7-20D: Fr m Kumar V, Abbas A, Faust N: Robbins
and Cotran pathologic basis o disease, ed 8, Philadelphia, 2010,
Saunders; 7-22A: Fr m G ldman L, S ha er AI: Goldmans Cecil
medicine, ed 24, Philadelphia, 2012, Saunders; 7-22B: Fr m N ble J,
Greene H L: extbook o primary care medicine, St L uis, ed 3, M sby,
C-1
C-2 Illus tration/Photo Cre dits
2001; 7-22C: Fr m wnsend C, Beau hamp RD, Evers BM,
Matt x K: Sabiston textbook o surgery, ed 18, Philadelphia, 2008,
Saunders; 7-22D: Fr m Rakel R: extbook o amily medicine, ed 7,
Philadelphia, 2007, Saunders; S ien e Appli ati n b x (Se rets
the Skin, art): J e Kulka; S ien e Appli ati n b x (Se rets the
Skin, ph t ): C urtesy Angies List, www.angieslist. m/arti les/
what-expe t-laser-tatt -rem val.htm.
Ch a p t e r 8
8-4, 8-5: Dennis Strete; 8-6: Adapted r m M Can e K, H uether S:
Pathophysiology, ed 7, St L uis, 2014, M sby; 8-8: Netw rk Graph-
i s; 8-10B: Barbara C usins; 8-12: C urtesy D r. N. Blevins,
New England Medi al Center, B st n; 8-16: Adapted r m
D rake R, V gl W, Mit hell AW M: Grays anatomy or students, ed 3,
Philadelphia, 2015, Chur hill Livingst ne; 8-17: Fr m H kenberry
MJ: Wongs essentials o pediatric nursing, ed 9, St L uis, 2013, M sby;
8-18D: Fr m Barkauskas V, Baumann L, St ltenberg-Allen K,
Darling-Fisher C: Health and physical assessment, ed 2, St L uis,
1998, M sby; 8-18E: C urtesy Nan y Lyn h; 8-20C,F, 8-21B,
8-22B,D: Fr m Vidi B, Suarez FR: Photographic atlas o the human
body, St L uis, 1984, M sby; 8-24: Yv nne Wylie Walst n; 8-30A,B:
Damjan v I, Linder J, Anders n WAD: Andersons pathology, ed 10,
St L uis, 1996, M sby; 8-31: Fr m Kumar V, Abbas A, Faust N:
Robbins and Cotran pathologic basis o disease, ed 7, Philadelphia, 2005,
Saunders; 8-32, 8-35: Fr m Kumar V: Robbins basic pathology, ed 9,
Philadelphia, 2013, Saunders; 8-33: Fr m Br wner B, Jupiter J,
ra t n P: Skeletal trauma: basic science, management, and reconstruc-
tion, ed 3, Philadelphia, 2003, Saunders; 8-34: Fr m Canale S :
Campbells operative orthopaedics, ed 9, St L uis, 1998, M sby;
8-38: Fr m Swartz MH : extb k physi al diagn sis, ed 6,
Philadelphia, 2010, Saunders; 8-39A: Fr m Callen JP, Paller AS,
Greer KE, et al: Color atlas o dermatology, ed 2, Philadelphia, 2000,
W B Saunders; 8-39B: Fr m H abi P: Clinical dermatology, ed 5,
St L uis, 2010, M sby; Clini al Appli ati n b x ( tal H ip Re-
pla ement, g): Fr m Canale S : Campbells operative orthopaedics, ed
10, St L uis, 2003, M sby; H ealth and Well-Being b x (T e Knee
J int, Fig A): R lin Graphi s; S ien e Appli ati n b x (B nes and
J ints, art): J e Kulka; S ien e Appli ati n b x (B nes and J ints,
ph t ): Fr m Cummings N, Stanley-Green S, H iggs P: Perspectives
in athletic training, St L uis, 2009, M sby; Clini al Appli ati n b x
(Arthr s py, Fig A): Fr m Miller MD, H ward RF, Plan her KD:
Surgical atlas o sports medicine, Philadelphia, 2003, Saunders; Clini al
Appli ati n b x (Arthr s py, Fig B): Fr m J hns n LL: Diagnostic
and surgical arthroscopy, ed 2, St L uis, 1981, M sby.
Ch a p t e r 9
9-3C: C urtesy D r. H .E. H uxley; 9-5B: C urtesy D r. Paul C.
Let urneau, Department Anat my, Medi al S h l, University
Minnes ta, MN; 9-10, 9-11, 9-12: J hn V. H agen; 9-13 (Ph t ):
C urtesy Kellie W hite; 9-14: CD C: Publi H ealth Image Library:
Image ID: 6373, http://phil. d .g v/phil/details.asp; S ien e
Appli ati n b x (Mus le Fun ti n, art): J e Kulka; Clini al Appli a-
ti n b x (Intramus ular Inje ti ns, ph t inset): Fr m Perry AG,
P tter PA, O stend r W R: Clinical nursing skills and techniques, ed 8,
St L uis, 2014, M sby.
Ch a p t e r 10
10-2C: Dennis Strete; 10-5: Fr m Feldman M, Friedman L, Brandt
L: Sleisenger & Fordtrans gastrointestinal and liver disease, ed 8,
Philadelphia, 2006, Saunders; 10-13, 10-14 (ph t ): Fr m Vidi B,
Suarez FR: Photographic atlas o the human body, St L uis, 1984,
M sby; 10-15: Fr m Z itelli BJ, Davis H W: Atlas o pediatric physical
diagnosis, ed 5, Philadelphia, 2007, M sby; 10-16: James King-
H lmes and S ien e Ph t Library; 10-17A: Fr m Chipps EM,
Clanin NJ, Campbell VG: Neurologic disorders, St L uis, 1992,
M sby; 10-26: Fr m H abi P: Clinical dermatology, ed 2, St L uis,
1990, M sby; Clini al Appli ati n b x (T e Bl d-Brain Barrier,
g): C urtesy J hn N lte, PhD, University Ariz na C llege
Medi ine; Clini al Appli ati n b x (Antidepressants, ph t ): C py-
right Adzi hi iek (st k ph t r m Shutterst k. m); Clini al
Appli ati n b x (Lumbar Pun ture, g): Fr m F rbes CD, Ja ks n
W D: Color atlas and text o clinical medicine, ed 3, L nd n, 2003,
M sby; S ien e Appli ati n b x (Neur s ien e, art): J e Kulka.
C h a p t e r 11
11-4: Fr m Newell FW: Ophthalmology: principles and concepts, ed 7,
St L uis, 1992, M sby; 11-5C: Fr m Swartz MH : extbook o physi-
cal diagnosis, ed 7, Philadelphia, 2014, Saunders; 11-8: Fr m Swartz
MH : extbook o physical diagnosis, ed 6, Philadelphia, 2010,
Saunders; 11-9: Fr m Newell FW: Ophthalmology: principles and
concepts, ed 8, St L uis, 1996, M sby; 11-10: Seidel H et al: M osbys
guide to physical examination, ed 3, St L uis, 2002, M sby; 11-11:
Fr m Ishiharas tests or colour de ciency, ky , Japan, 1973, Kanehara
rading C , C pyright Isshinkai F undati n; 11-13A: Fr m Ball
JW, Dains JE, Flynn JA: Seidels guide to physical examination, ed 8,
St L uis, 2015, M sby; 11-13C,D: Fr m Bingham BJG, H awke M,
Kw k P: Atlas o clinical otolaryngology, St L uis, 1992, M sby-Year
B k; H ealth and Well-Being b x (Swimmers Ear, ph t ): Fr m
Z itelli, Davis: Atlas o pediatric physical diagnosis, ed 5, Philadelphia,
2007, Elsevier, C urtesy Mi hael H awke, MD; S ien e Appli ati ns
b x (Senses, art): J e Kulka.
Ch a p t e r 1 2
12-5A: C urtesy R bert F Gagel, MD, and Ian M Cut he n, MD,
University exas M.D. Anders n Can er Center, H ust n, exas,
In Bla k JM, H awks JH : M edical-surgical nursing: clinical manage-
ment or positive outcomes, ed 8, St L uis, 2009, M sby; 12-5B, 12-11,
12-16: Fr m F rbes CD, Ja ks n W F: Color atlas and text o clinical
medicine, ed 3, Edinburgh, 2003, M sby; 12-9: Fr m Seidel NM,
Ball JW, Dains JE, Benedi t GW: M osbys guide to physical examina-
tion, ed 4, St L uis, 1999; 12-10: Fr m Swartz MH : extbook o
physical examination, ed 6, Philadelphia, 2010, Saunders; 12-15:
C urtesy G wer Medi al Publishers; Clini al Appli ati n b x (Syn-
theti H uman Insulin, ph t ): C urtesy Medtr ni , pl ; Clini al
Appli ati n b x (Syntheti H uman Insulin, art): Fr m C per K,
G snell K: Adult H ealth Nursing, ed 7, St L uis, 2015, M sby; S i-
en e Appli ati ns b x (End rin l gy, art): J e Kulka.
Ch a p t e r 1 3
13-1: Barbara C usins; 13-3A,B,C: Fr m Bevelander G , Ramalay
JA: Essentials o histology, ed 8, St L uis, 1979, M sby; 13-3D: Fr m
Z akus SM: Clinical procedures or medical assistants, ed 3, St L uis,
1995, M sby; 13-5: Fr m Carr J, R dak B: Clinical hematology atlas,
ed 2, St L uis, 2004, Elsevier; 13-6 (ph t s): Fr m Bel her AE:
Blood disorders, St L uis, 1993, M sby; 13-8: C urtesy D r. R bert
W. M Kenna, Department Path l gy, University exas S uth-
western Medi al S h l, Dallas, X, In Kumar V, Abbas AK:
Robbins and Cotran pathologic basis o disease, ed 8, Philadelphia,
Saunders, 2010; 13-9: Dennis Strete; 13-12, 13-16: Fr m Kumar V:
Robbins basic pathology, ed 9, Philadelphia, 2013, Saunders; 13-13:
C urtesy D r. JV Mel ; 13-14: C urtesy D r. R bert W M Kenna,
Department Path l gy, University exas S uthwestern Medi-
al S h l, Dallas, X, In Kumar V et al: Robbins basic pathology,
ed 9, Philadelphia, 2013, Saunders; 13-15: Fr m H brand AV,

Pettit JE: Clinical haematology illustrated, Edinburgh/L nd n, 1987,
Chur hill Livingst ne/G wer Medi al Publisher; 13-17B: C py-
right Dennis Kunkel Mi r s py, In ; 13-18: Fr m Kumar V, Abbas
AK, Faust N: Robbins and Cotran pathologic basis o disease, ed 8,
Philadelphia, 2010, Elsevier; Clini al Appli ati n b x (Cardia
Bl d ests, g): Fr m Warek is R, R bins n R: Phlebotomy, ed 2,
St L uis, 2007, Saunders; S ien e Appli ati n b x (H emat l gy,
g): J e Kulka.
Ch a p t e r 14
14-4: Fr m Kumar V, Abbas AK, Faust N: Robbins and Cotran
pathologic basis o disease, ed 8, Philadelphia, 2010, Elsevier; 14-12:
Barbara C usins; 14-14: Fr m Libby P, B n w RO, Mann DL,
Z ipes DP: Braunwalds heart disease: a textbook o cardiovascular
medicine, ed 8, Philadelphia, 2008, Saunders; 14-17: C urtesy
Patri ia Kane, Indiana University Medi al S h l; Clini al Appli a-
ti n b x (E h ardi graphy, ph t ): Fr m F rbes, CD: Color atlas
and text o clinical medicine, ed 3, Edinburgh, 2003, M sby; Clini al
Appli ati n b x (Angi graphy, g): Fr m G ldman L, Ausiell D:
Cecil textbook o medicine, ed 23, Philadelphia, 2008, Saunders;
S ien e Appli ati n b x (Cardi l gy, art): J e Kulka; Unn
14-3B:Fr m http://www.bls.g v/ h/health are/diagn sti -medi al-
s n graphers.htm#tab-3.
Ch a p t e r 15
Clini al Appli ati n b x (Raynaud Phen men n, ph t ): Fr m
Barkauskas VH , Baumann LC, Darling-Fisher CS: Health and
physical assessment, ed 3, St L uis, 2002, M sby; S ien e Appli a-
ti ns b x (Cir ulati n the Bl d, art): J e Kulka; S ien e Appli a-
ti ns b x (Cir ulati n the Bl d, ph t ): Fr m Warek is, R,
R bins n, R: Phlebotomy: worktext and procedures manual, ed 3,
St L uis, 2012, Saunders.
Ch a p t e r 16
16-1, inset: D rake RL et al: Grays anatomy or students, ed 3,
Philadelphia, 2015, Chur hill-Livingst ne; 16-3: C urtesy Walter
unnesen, MD, T e Ameri an B ard Pediatri s, Chapel H ill, NC;
16-4: Fr m Z itelli B, M Intire SC, N walk AJ: Atlas o pediatric
physical diagnosis, ed 6, Philadelphia, 2012, M sby; 16-5: Fr m
G ldstein B, edit r: Practical dermatology, ed 2, St L uis, 1997,
M sby; 16-7: Fr m Ballinger P, Frank E: M errills atlas o radio-
graphic positions and radiologic procedures, v l 1, ed 11, St L uis, 2007,
M sby; 16-8: Fr m Ball JW, Dains JE, Flynn JA, et al: Seidels guide
to physical examination, ed 8, St L uis, 2015, M sby; 16-14: C urtesy
D r. Y-J Liu, MD, Anders n Can er Center, H ust n, X, In
Abbas A, Li htman A: Cellular and molecular immunology, ed 8,
Philadelphia, 2015, Saunders; 16-15: C pyright Dennis Kunkel
Mi r s py In .; 16-19: Fr m Ceri R, Ja ks n W F: Colour atlas o
allergic skin disorders, L nd n, 1992, M sby-W l e; 16-20: Fr m
H abi P: Clinical dermatology: a color guide to diagnosis and therapy,
ed 3, St L uis, 1996, M sby; Clini al Appli ati n b x (Inter er n,
ph t s): Nati nal Can er Institute; S ien e Appli ati n b x (Va -
ines, art): J e Kulka.
Ch a p t e r 17
17-1: Barbara C usins; 17-6C: Fr m C x JD: R adiation oncology,
ed 9, Philadelphia, 2010, M sby; 17-8: Netw rk Graphi s; 17-13:
Fr m Kumar V, Abbas A, Faust N: Robbins and Cotran pathologic
basis o disease, ed 8, Philadelphia, 2010, Saunders; Clini al Appli a-
ti n b x (Keeping the ra hea Open, gs): C urtesy Andrew P.
Evan, Indiana University S h l Medi ine; S ien e Appli ati n
b x (Respirat ry Medi ine, art): J e Kulka.
Illus tration/Photo Cre dits C-3
Ch a p t e r 18
18-9A: Fr m Regezi JA, S iubba JJ, P grel MA: Atlas o oral and
maxillo acial pathology, Philadelphia, 2000, Saunders; 18-9B: Fr m
Callen JP, Paller AS, Greer KE, et al: Color atlas o dermatology, ed 2,
Philadelphia, 2000, W B Saunders; 18-9C: Fr m Grundy JR, J nes
JG: A color atlas o clinical operative dentistry: crowns and bridges, ed 2,
L nd n, 1993, M sby-W l e; 18-9D: Fr m Christensen GJ: A con-
sumers guide to dentistry, ed 2, St L uis, 2002, M sby; 18-9E: Fr m
Em nd R D, Welsby PD, R wland H AK: Colour atlas o in ectious
diseases, ed 4, Edinburgh, 2003, M sby; 18-10A: Fr m W ils n SF,
Giddens JF: Health assessment or nursing practice, ed 2, St L uis,
2001, M sby; 18-10B: Fr m Greig JD, Garden OJ: Color atlas o
surgical diagnosis, L nd n, 1996, imes Mirr r Internati nal Pub-
lishers; 18-13: C pyright Kevin Patt n, Li n Den In , Weld n
Spring, MO ; 18-17B: Fr m Weir J, Abrahams PH , Spratt JD,
Salk wski LR: Imaging atlas o human anatomy, ed 4, M sby Elsevier
Ltd, 2011; 18-17C, 18-18 (x-ray nly): Fr m Abrahams PH , B n
JM, Spratt JD, et al: M cM inns color atlas o human anatomy, ed 6,
Edinburgh, 2008, M sby; 18-19: C urtesy T mps n JM, W ils n
SF: Health assessment or nursing practice, St L uis 1996, M sby;
18-20: Fr m Kumar V, Abbas AK, Faust N: Robbins and Cotran
pathologic basis o disease, ed 6, Philadelphia, 1999, Elsevier; 18-21:
Fr m Vidi B, Suarez RF: Photographic atlas o the human body, St
L uis, 1984, M sby; 18-22B: Fr m Abrahams PH , B n JM, Spratt
JD, et al: M cM inns color atlas o human anatomy, ed 6, Edinburgh,
2008, M sby; 18-22C: Fr m H euman DM, Mills AS, M G uire
H H : Gastroenterology, Philadelphia, 1997, Saunders; 18-22D:
Fr m Z itelli BJ, Davis H W: Atlas o pediatric physical diagnosis, ed 3,
Philadelphia, 1997, M sby; 18-24 (ph t ): Fr m Swartz MH : ext-
book o physical diagnosis, ed 6, Philadelphia, 2010, Saunders; 18-25:
Barbara C usins; Clini al Appli ati n b x (Mumps, ph t ): C ur-
tesy GDW M Kendri k, In Zitelli BJ, Davis H W: Atlas o pediatric
physical diagnosis, ed 5, Philadelphia, 2007, M sby; Clini al Appli a-
ti n b x (Upper Gastr intestinal X-ray Study, ph t ): Ph t
Resear hers, In .; S ien e Appli ati n b x (Gastr enter l gy, art):
J e Kulka.
Ch a p t e r 19
19-1: Fr m the U.S. Department Agri ulture, Center r
Nutriti n P li y and Pr m ti n, USDAs MyPlate (website):
www. h semyplate.g v, a essed August 29, 2016; 19-4: Adapted
r m Carr ll R: Elseviers integrated physiology, Philadelphia, 2007,
M sby; 19-6: Fr m M rgan SL, Weinsier RL: Fundamentals o
clinical nutrition, ed 2, St L uis, 1998, M sby; 19-8A: C urtesy
D r. J nathan Spe t r, B st n, MA, In Z itelli BJ, M Intire SC,
N walk AJ: Z itelli and Davis atlas o pediatric physical diagnosis, ed 6,
Philadelphia, 2012, M sby; 19-8B: Fr m Z itelli BJ, M Intire SC,
N walk AJ: Z itelli and Davis atlas o pediatric physical diagnosis, ed 6,
Philadelphia, 2012, M sby; H ealth and Well-Being b x (Carb hy-
drate L ading, ph t ): i-st k; S ien e Appli ati n b x (F d
S ien e, art): J e Kulka.
Ch a p t e r 2 0
20-1B: Fr m Abrahams P, H ut hings R , Marks SC: M cM inns color
atlas o human anatomy, ed 5, St L uis, 2003, M sby; 20-2B: Fr m
Abrahams P, Marks S, H ut hings R: M cM inns color atlas o human
anatomy, ed 6, Philadelphia, 2008, M sby; 20-4: C urtesy Andrew P.
Evan, Indiana University S h l Medi ine; 20-10: Fr m elser A,
Y ung J, Baldwin K: Elseviers integrated histology, Philadelphia, 2008,
M sby; 20-12: Fr m Kumar V, Abbas A, Faust N: Robbins and
Cotran pathologic basis o disease, ed 8, Philadelphia, 2010, Saunders;
20-13: C urtesy D r. E. M sher, Brigham and W mens H spital,
C-4 Illus tration/Photo Cre dits
B st n, MA, In Kumar V, Abbas AK, Faust N: Robbins and Cotran
pathologic basis o disease, ed 8, Philadelphia, 2010, Elsevier; 20-14B:
C urtesy B. Bra ken, MD, Cin innati, Ohi , In Weiss MA, Mills
SE: Atlas o genitourinary tract disorders, Philadelphia, 1988, J.B.
Lippin tt/G wer Medi al Publishing; 20-15: Fr m Kumar V,
Abbas AK, Faust N, Mit hell RN: Robbins basic pathology, ed 7,
Philadelphia, 2007, Saunders; able 20-2 (ph t ): Fr m B newit-
West K: Clinical procedures or medical assistants, ed 8, St L uis,
Saunders, 2011; S ien e Appli ati n b x (Fighting In e ti n, art):
J e Kulka; S ien e Appli ati n b x (Fighting In e ti n, ph t ):
C pyright M sbys Clini al Skills: Essentials C lle ti n.
Ch a p t e r 2 1
21-6: C pyright Kevin Patt n, Li n Den In , Weld n Spring, MO ;
21-8: Fr m Fritz S: M osbys undamentals o therapeutic massage, ed 5,
St L uis, 2013, M sby; 21-11: M di ed r m G ldman L, S ha er
AI: Goldmans Cecil medicine, ed 24, Philadelphia, 2012, Saunders;
Clini al Appli ati n b x (Edema, ph t ): Fr m Bl m A, Ireland J:
Color atlas o diabetes, ed 2, St L uis, 1992, M sby; S ien e Appli a-
ti ns b x (T e C nstan y the B dy, art): J e Kulka; S ien e
Appli ati ns b x (T e C nstan y the B dy, ph t ): C pyright
M sbys Clini al Skills: Essentials C lle ti n.
Ch a p t e r 2 2
S ien e Appli ati ns b x (T e B dy in Balan e, art): J e Kulka;
S ien e Appli ati ns b x (T e B dy in Balan e, ph t ): US Navy,
www.navy.mil/view_image.asp?id=6952.
Ch a p t e r 2 3
23-2A: Lennart Nilss n, Albert B nniers F rlag AB, St kh lm
Sweden; 23-5A: Car lyn C ulam and J hn A M Intyre; 23-6: Fr m
Abraham PH , B n JM, Spratt JD: M cM inns clinical atlas o human
anatomy, ed 6, Edinburgh, 2008, M sby; 23-7B: Fr m Vidi B,
Suarez FR: Photographic atlas o the human body, St L uis, 1984,
M sby; 23-8: Fr m Z itelli BJ, M Intire SC, N walk AJ: Atlas o
pediatric diagnosis, ed 6, Philadelphia, 2012, M sby; 23-16: Fr m
Kumar V, Abbas AK, Faust N: Robbins and Cotran pathologic basis
o disease, ed 8, Philadelphia, 2010, Saunders; 23-17: C urtesy
D r. Edmund S Cibas, Department Path l gy, Brigham & W m-
ens H spital, B st n, In Kumar V, Abbas AK, Faust N: Robbins and
Cotran pathologic basis o disease, ed 8, Philadelphia, 2010, Elsevier;
S ien e Appli ati n b x (Repr du tive S ien es, art): J e Kulka.
Ch a p t e r 2 4
24-1B, 24-6: Lennart Nilss n, Albert B nniers F rlag AB,
St kh lm Sweden; 24-3: C urtesy Lu inda L Vee k, J nes Insti-
tute r Repr du tive Medi ine, N r lk, VA; 24-5B: Fr m Kumar
V, Abbas AK, Faust N: Robbins and Cotran pathologic basis o disease,
ed 7, Philadelphia, 2005, Elsevier; 24-12: C urtesy Karen urner;
24-13A: Fr m H kenberry MJ, W ils n D: Wongs essentials o pedi-
atric nursing, ed 8, St L uis, 2009, M sby; 24-13B, Resear h, Issues,
and rends b x (Antenatal Diagn sis and reatment, gs A,B,C):
C pyright Kevin Patt n, Li n Den In , Weld n Spring, MO; 24-14:
Fr m Mahan LK, Es tt-Stump S: Krauses ood & nutrition therapy,
ed 12, St L uis, 2008, Elsevier; Resear h, Issues, and rends b x
(Freezing Umbili al C rd Bl d, ph t ): C urtesy Craig B r k,
St Paul Pi neer Press; Resear h, Issues, and rends b x (Fetal
Al h l, ph t ): C urtesy Claus Sim n/Mi hael Janner; Re-
sear h, Issues, and rends b x (Pr geria, ph t ): C urtesy the
Pr geria Resear h F undati n; Peab dy, Massa husetts http://www
.pr geriaresear h. rg; S ien e Appli ati n b x (Embry l gy, art):
J e Kulka.
Ch a p t e r 2 5
Q u te (p. 685): Matt Ridley: Genome: the autobiography o a species in
23 chapters; 25-9A: C urtesy L is M G avran, Denver Childrens
H spital; 25-9B: Fr m Z itelli BJ, Davis H W: Atlas o pediatric physi-
cal diagnosis, ed 5, Philadelphia, 2007, M sby; 25-10, 25-11B: C ur-
tesy Nan y S Wexler, PhD, C lumbia University; 25-11A: Fr m
Llewellyn-J nes D, O ats J, Abraham S: Fundamentals o obstetrics and
gynaecology, ed 9, Edinburgh, 2010, M sby; S ien e Appli ati n b x
(Geneti s and Gen mi s, art): J e Kulka.
All hapter pening art used by permissi n Shutterst k. m.
Index
A A r s me, 621 Age gr up, p pulati n pr je ti ns by, 665t
ABCDE rule, r malignant melan ma, 164t A ti n p tential, 256 Age-related ma ular degenerati n (AMD),
Abd men A tive immunity, 438 302
arteries in, 410t A tive transp rt pr esses, 5355, 54t Agglutinated bl d, 356
veins in, 411t A ute ba terial njun tivitis, 300 Aging, 667670
Abd minal a rta, 410 , 413 , 556 A ute br n hitis, 470471 e e ts , 668670
Abd minal regi n, 12t A ute gl merul nephritis, 570571 me hanisms , 667668
Abd minal thrusts, 467b A ute lymph yti leukemia, 363364, 364 Aging pr ess, 16
Abd min pelvi quadrants, 9, 10 A ute myel id leukemia, 364 Agranular leuk ytes, 361 , 362
Abd min pelvi regi ns, 10 A ute renal ailure, 571572 Air ex hange, in pulm nary v lume, 474
Abdu ens nerve (CN VI), 271t, 272 A ute - ell lymph yti leukemia Albinism, e10t, 150, 687t
Abdu ti n, 228 (A LL), e1t inheritan e , 682, 683
j int, 199t Adams apple, 464, 464 Albumin
Abdu t rs, 229t Adaptati n, 309 n rmal values, e19t
Abn rmal bl d l ts, 365 Adaptive immunity, 436t, 437438 as plasma v lume expander, 350
Abn rmal nail stru ture, 154 types , 438, 438t in urine, e22t
ABO system, 355356, 356 Addis n disease, 334, 334 Ald ster ne, 322323t, 332, 563, 587, 587
Ab rti n, sp ntane us, 662 as aut immune disease, e9t Ald ster nism, e7t
Abrasi n burn, e6t as end rine nditi ns, e7t Alkaline ph sphatase, n rmal values, e19t
Abrupti pla entae, 662, 662 Addu ti n, 228 Alkal sis, 31, 607
Abs rpti n, 494495, 495t, 519520 j int, 199t Allergy, 445
me hanisms , 519520, 519 Addu t r l ngus, 231 , 234t All immunity, 446447
in small intestine, 508 Addu t r magnus, 231 Al pe ia, 152
sur a e area and, 520 Addu t r mus les, 229t, 234, 234t Al pe ia areata (AA), 152
A ess ry nerve (CN XI), 271t, 272 Adenine, 35 Alpha ells (A ells), 334335, 335
A ess ry repr du tive rgans Aden ar in ma, 129, 512 Alve lar du t, 460
emale, 627t Aden br ma, 129 Alve lar sa , 467, 467
male, 618t Aden hyp physis, 326 Alve li, 460 , 467468, 467 , 468 , 631632,
A ess ry sex glands Aden ids, 435, 463 632
emale, 631632 Aden ma, 129 Alzheimer disease (AD), e1t, 265, 265
male, 623, 623 Aden sine deaminase (ADA) de ien y, 693 Amebas, 123
A idents, e1t Aden sine diph sphate (ADP), 35, 536 Amebiasis, e5t
A etabulum, 191193 Aden sine triph sphate (A P), 35, 35 , 47 Amebi dysentery, e5t
A et a etate, in urine, e22t aging and, 668 Amen rrhea, 635
A et ne, in urine, e22t in arb hydrate metab lism, 535536, 536 in emale athletes, 636b
A etyl C A, 535 heat pr du ti n and, 224 Amin a ids, 33, 538
A etyl gr ups, 688 mus le ntra ti n and, 222 Amm nia, in urine, e22t
A etyl h line (ACh), 257258 Aden virus, 118 Amni entesis, 690691, 692
A id-base balan e, 600615 Adip se tissue, 78, 78 , 79t Amni ti avity, 654656
bu ers, 603606 Ad les en e, gr wth and devel pment, 666 Amni ti sa , 660
pH in Adrenal rtex, 331333 Amphiarthr ses, 196197
b dy f uids, 601602 h rm nes , 322323t Ampulla, 306, 306
imbalan es , 607 Adrenal glands, 96 , 331334, 332 Anab li ster ids, 227, 325b
respirat ry me hanisms ntr l r, 606 h rm nes , 322323t Anab lism, 533
urinary me hanisms ntr l r, Adrenal medulla, 333334 glu se, 536
606607 Adrenal sex h rm nes, 333 Anaer bi ba teria, 120
A id ph sphatase, n rmal values, e19t Adrenergi bers, 278, 278 Anal anal, 512513
A idi hyme, 506 Adren rti tr pi h rm ne (AC H ), Anal sphin ter, 514
A idi ati n urine, 606 322323t, 326 Anaphase, 60
A id sis, 31, 607 Adult p ly ysti kidney disease, 573 Anaphyla ti sh k, 421
A ids, 30 Adult respirat ry distress syndr me (ARDS), Anaplasia, 61 , 61t, 62
indigesti n, 503 469 Anat mi al mpass r sette, 8
A ne, 155, 155 Adult stem ells, 61b Anat mi al dire ti ns, 78
A quired immune de ien y, 448 Adulth d, gr wth and devel pment, 666667 Anat mi al dis rders, upper respirat ry tra t,
A quired immun de ien y syndr me Aer bi ba teria, 120 465466
(AIDS), e1t, 640t A erent arteri le, 557, 558 Anat mi al p siti n, 7, 7
A r megaly, e7t, 327, 327 A erent lymphati vessel, 433, 433 Anat my, 3
Age m dern, 6b
and kidney un ti n, 560b Andr gen insensitivity, e10t
Page numbers ll wed by b, t, and indi ate as risk a t r r disease, 117 Andr gens, 322323t
b xes, tables, and gures, respe tively. r le in ausing an er, 130 Andr pause, 670

I-1
I-2 Index

Anemia, 358361 Ar h a rta, 380 , 410 Auri le, 302, 303

aplasti , 359 Ar haea, 122 atrial, 380 , 381
de ien y anemias, 359360 Ar hes, t, 194 Aut immunity, 116, 445446
hem lyti , 360361 Are la, 150, 632 Aut mati external de brillat rs (AEDs), 392
hem rrhagi , 358 Are lar nne tive tissue, 78, 78 Aut n mi ndu ti n paths, 276, 276
si kle ell, 360, 360 Are lar glands, 632 Aut n mi nerv us system, 274279
Aneurysm, 406407 Arm aut n mi ndu ti n paths, 276
Angina pe t ris, 386 arti ial, 103 aut n mi neur transmitters, 277278
Angi graphy, 386b, 386 mus les , gr uped a rding t un ti n, dis rders , 278279
Angi plasty, 406 229t un ti nal anat my, 275
ball n, 407 right, 191 parasympatheti divisi n, 277
Animal star h, 536 Arre t r pili mus le, 153 sympatheti divisi n, 276277
Ani ns, 589, 590 Arterial bl d gas analysis, 610b, 610t Aut psy, 12b
An rexia, 505 Arteries, 404 Aut s mes, 681
An rexia nerv sa, 543 dis rders , 406407 Avitamin sis, 539
Antebra hial regi n, 12t umbili al, 413 Avitamin sis K, e10t
Antenatal medi ine, 663b, 663 Arteri les, 405 Avulsi n ra tures, 196b, 196 , 205
Anteri r dire ti n b dy, 7, 8 a erent, 557, 558 Axial skelet n, 180189, 181t
Anteri r pituitary gland h rm nes, 326327, e erent, 557, 558 , 559 skull, 181185
328 pulm nary, 467 spine (vertebral lumn), 186189
Anteri r tibial artery, 410 Arteri s ler sis, 406, 407 , 669 th rax, 189
Anteri r tibial vein, 411 Arthritis Axillary artery, 410
Anthrax, e2t, 128b, 128 g uty, 206207 Axillary lymph n des, 430
Antibi ti drugs, 127128 in e ti us, 207 Axillary regi n, 12t
Antibi ti resistan e, 127 rheumat id, 205 Axillary vein, 411
Antib dies, 439440 types , 206 Axis, 186, 187
in bl d typing, 355, 358t Arthr p ds, 124, 124t Ax n, 83, 250, 253
de niti n , 439 Arthr s py, 208b, 208 demyelinated, 252
un ti ns , 439440, 439 Arti ular artilage, 177, 198
Antib dy-mediated immunity, 439 Arti ular pr esses, lumbar vertebra, 186 B
Antib dy titer, 447 Arti ulati ns. see J ints B ells, 442443
Anti agulant therapy, 365366 Arti ial rgans, 101104 devel pment , 442
Anti agulants, 394b Arti ial pa emaker, 390, 392 un ti n , 443
Anti nvulsive drugs, 266 As ariasis, e5t B- mplex vitamins, 540t
Antidepressants, 258b Ascaris rganisms, 124t B lymph ytes, 351t, 362
Antidiureti h rm ne (ADH ), 262, 322323t, As ending a rta, 380 , 413 Ba illi, 121, 121t
328, 563, 587 As ending l n, 412 , 512513 Ba teria
Antigen, 439 As ending tra ts, spinal rd, 267, 268 disease aused by, 120122, 121 , 121t,
in bl d typing, 355, 358t As ites, 517, 517 127t
Antigen-presenting ells (APCs), 441 As rbi a id, 540t in urine, e22t
Antiplatelet agents, 394b Aspergill sis, e4t Ba terial njun tivitis, a ute, e2t
Antisepsis, 125t Aspergillus rganisms, 123 , 123t Balan e
Antiviral drugs, 128 Aspirati n bi psy yt l gy (ABC), 352 a id-base. see A id-base balan e
Anuria, 563 Assimilati n, 533 b dy un ti ns, 1416
Anus, 99 , 619 , 628 Asthma, 472473 Balantidiasis, e5t
A rta, 97 , 104 Astigmatism, 299 Ball-and-s ket j ints, 198
abd minal, 410 , 556 Astr ytes, 251 Ball n angi plasty, 407
ar h , 380 Atele tasis, 470 Banting, Frederi k, 338
A rti semilunar valve, 381 , 383 Ather s ler sis, 33, 33b, 406, 407 , 669 Bariatri s, 510
Apex, ardia , 379380, 380 Athletes t, 158159t Barrett es phagus, 503
Apgar s re, 661 Atlas, 186, 187 Barth lin gland, 633
Api al heart beat, 380 At mi mass, 25 Basal ell ar in ma, 164, 164
Aplasti anemia, 359 At mi number, 25 Basal metab li rate (BMR), 541
Apnea, 478t At ms, 2526, 26 Basal nu lei, 262
Ap rine, 154 Atria, ardia , 380381, 381 Basement membrane, 146
Ap rine sweat glands, 154 Atrial ablati n, 392 veins, 404
Ap pt sis, 667 Atrial ntra ti n, 382 Bases, 30
Appendages, 145 premature, 390 Basili vein, 411
Appendi itis, 516 Atrial brillati n, 390, 391 Bas phils, 351t, 362
Appendi ular skelet n, 180, 181t, 190194 Atrial f utter (AFL), 392 n rmal values, e19t
upper extremity, 190191 Atrial natriureti h rm ne (ANH ), 322323t, Beaum nt, W illiam, 520
Appendix, 99 , 412 , 513 , 515516 339, 563, 587 Beds re, 158159t, 161162
Appetite, a t rs that inf uen e, 542t Atr phy, 13, 61, 61 , 61t Bee tapew rm in estati n, e5t
Aque us hum r, 296297 disuse, 228 Bell palsy, 273
Aque us s luti n, 29 skin, 158159t Benign pr stati hypertr phy (BPH ), 625
Arachnida rganisms, 124t Atta hments skeletal mus le, 221 Benign tum rs, 62
Ara hn id mater, 268, 269 Audit ry ass iati n area, 263 mpared with malignant tum rs, 128129,
Arb r vitae, 260, 261 Audit ry tube, 303 , 304 129t
 Index I-3

Benign uterine tum rs, 637 red bl d ells (RBCs), 352358 B ne ement, in vertebr plasty, 188b
Beriberi, e10t white bl d ells (W BCs), 361362 B ne ra tures, e6t, 204
Bernard, Claude, 593 Bl d d ping, 354b repair , 205
Best, Charles, 338 Bl d f w types , 203204
Beta-adrenergi bl kers, 394b hanges in, during exer ise, 417b B ne marr w
Beta ells (B ells), 334335, 335 resistan e t , 416 red, 98 , 176, 352, 430
Bi arb nate, n rmal values, e19t thr ugh heart, 384385 transplant, 352
Bi arb nate i ns (H CO 3 ), 481 Bl d gases, h me stasis , 475 yell w, 176
Bi arb nate l ading, 606b Bl d plasma, 349, 350351 B ne tissue stru ture, 177
Bi eps bra hii mus le, 95 , 229t, 231 , 233t Bl d pressure B nes, 79t, 80, 80 , 208b, 208
Bi eps em ris, 231 , 234t apillary, 588, 590b arti ulati n , 196
Bi uspid valve, 381 , 383 de niti n , 414 devel pment , 177180
Bi uspids, 497 a t rs that inf uen e, 414416, 416 gr ss stru ture , 176177
Bilateral symmetry, 7 f u tuati ns in, 417418 in e ti n, 202
Bile readings, 418b, 418 making and rem deling, 177179
s dium- ntaining, 591 Bl d pressure gradient, 414 mi r s pi stru ture , 177, 178
in urine, e22t Bl d pr teins, 534 rem deling, 179
Biliary li , 510 Bl d serum, 351 skull, 181185, 183t
Bilirubin, in urine, e22t Bl d tests tum rs, 200, 200
Bi hemistry, 25, 36b r an er, 132133 vertebral lumn, 187t
Bi psy, 132 ardia , 351b B ny labyrinth, 304, 305
aspirati n bi psy yt l gy (ABC), 352 CBC, 353b B ny landmarks, palpable, 192b
r kidney, 569 WBC unt, 362 Borrelia burgdor eri, 127t
Bi terr rism, 128b Bl d tissue, 79t, 80, 81 B tulism, e2t
Bi tin, 540t Bl d types, 355358 B u hard n des, 205
Birth, 658661 ABO system, 355356, 356 B vine sp ngi rm en ephal pathy (BSE),
de e ts , 663 Rh system, 356 120
multiple, 661, 661 Bl d urea nitr gen (BUN) test, 572 B wman apsule, 557, 558
parturiti n, 658, 660 Bl d values, e19t Bra hial artery, 410 , 419
stages lab r, 660 , 661 Bl d vessels, 403406 Bra hial regi n, 12t
Birthmarks, 151 diseases , e1t Bra hial veins, 411
Bites, e5t dis rders , 406408 Bra hialis, 231 , 233t
Bladder arteries, 406407 Bra hi ephali artery, 410
neur geni , 566567 veins, 408 Bra hi ephali veins, 411
vera tive, 570 un ti ns , 405406 Bra hytherapy, 625
Bladder an er, 567, 570 heart, 380 Brady ardia, 390, 391
Blast yst, 654, 655 , 656 stru ture , 404405 Brain, 96 , 260264
Blast my sis, e4t types , 403404 verings and f uid spa es, 268270
Bleeding, dys un ti nal uterine, 635636 water utput, 586 divisi ns , 260
Blind sp t, nding, 297b, 297 Bl d v lume, 414415 Brain dis rders
Bl d, 348377 B dy, 223 destru ti n brain tissue, 264266
ir ulati n , 402427, 420b, 420 nstan y , 593b, 593 seizure dis rders, 266
etal, 412414, 413 rgan systems , 93100, 102103t Brainstem, 260, 264t
hepati p rtal, 409410, 412 st ma h, 504 respirat ry ntr l enters, 475
systemi and pulm nary, 408409, 409 uterus, 628 Breasts, 100 , 631632
disease, me hanisms , 352 as a wh le, 101 an er, 637638
ex hange b dy f uids by, 588 B dy avities, 911, 9 , 10t emale, 632
n rmal and agglutinated, 356 rgans , 11 lymphati drainage , 434
pH , 602 B dy f uids lymphedema a ter breast surgery, 434b
transp rtati n gases, 480481 mpartments, 584585 milk-se reting ells, 631632, 632
umbili al rd, reezing , 659b, 659 imp rtan e ele tr lytes, 589 Breathing
vis sity , 416 i ns in, 28t me hani s , 473474, 475
Bl d-brain barrier (BBB), 256b, 256 pH , 601602 patterns, 477478
Bl d asts, in urine, e22t ntr l me hanisms, 602603 Bree h birth, 658
Bl d l tting, 366 v lumes, 584, 584 Brittle b ne disease, 202
platelets and, 365 B dy membranes, 145147 Br a area, 263
in skin repair, 157 types , 146 Br n hi, 98
Bl d l tting dis rders, 365368 B dy pr p rti ns, devel pmental hanges in, primary, 460 , 466
abn rmal bl d l ts, 365 664665, 664 se ndary, 467
hem philia, 366368 B dy regi ns, 1113 Br n hial tree, 466467
thr mb yt penia, 368 B dy sur a e area, estimating, 161 Br n hi les, 460 , 467
vitamin K de ien y, 368 B dy temperature, 544546 Br n hitis
Bl d mp siti n, 349352 abn rmal, 545546 a ute, 470471
bl d tissue, 349350 range , 546 hr ni , 472, 472
lasses bl d ells, 351t therm regulati n in, 544545, 544 , 545 Br wn at, 79t
rmed elements, 349, 351 B hr, Christian, 482b, 482 Bru ell sis, e2t
lip pr teins, 33b B ils, 161 Bruising skin, 155
plasma, 349, 350351 B lus, 497, 502 Bu al regi n, 12t
I-4 Index

Bu ers, 31, 603606 Carb hydrate digesti n, 518 Cell-mediated immunity, 443
Bu y at, 353 Carb hydrate l ading, 536b Cell membranes, 5056
Bulb id rpus le (Krause rpus le), 292t Carb hydrate metab lism, 535537 a tive transp rt pr esses, 5355, 54t
Bulb urethral gland, 565 , 619 , 623 A P, 535536, 536 ell transp rt and disease, 5556
Bulb us rpus les (Ru ni rpus le), 292t glu se anab lism, 536 passive transp rt pr esses, 5153, 51t
Bulimarexia, 543 glu se atab lism, 535, 535 Cells, 4269
Bulimia, 543 regulati n , 536537, 537 mp siti n , 44
Burns, e6t Carb hydrates, 31, 31 des ripti n , 6
lassi ati n and severity, 157161 Carb n di xide, n rmal values, e19t un ti n and stru ture, 50
depth lassi ati n , 160 Carb n di xide (CO 2) immune system, 440443
Bursae, 147, 220 in bl d ir ulati n, 385 innate and adaptive immunity, 436t
Bursitis, 236 bl d transp rtati n , 481 nerv us system, 250253
in hem gl bin, 354 parts , 4450
C partial pressure, 478 size and shape, 4344
Ca hexia, 133 transp rt , 481 stru ture , 45
Cal aneus, 193 Carb ni a id, bu ering a ti n , 604 Census Bureau, p pulati n pr je ti ns, 665t
Cal i er l, 540t Carb ni anhydrase (CA), 602603 Centers r Disease C ntr l and Preventi n
Cal it nin (C ), 322323t, 329, 330331, Car in gens, r le in ausing an er, 130 (CD C), 114b
331 Cardia arrest, and respirat ry a id sis, 609b Central nerv us system (CNS), 95, 259270,
Cal ium, 541t Cardia dysrhythmia, 389392 260
imbalan e, 592593, 592t Cardia enzymes, 351b aging e e ts, 669
n rmal values, e19t Cardia mus le tissue, 82, 82t, 83 , 95, 220 Central sul us, 263
st rage in b nes, 176 Cardia utput, 392394, 393 Central ven us bl d pressure, 418
in urine, e22t Cardia tamp nade, 382 Centri les, 46t, 48
Cal ium- hannel bl kers, 394, 394b Cardia tr p nins, 351b Centr s me, 48
Cal ium i ns, thin laments and, 222 Cardia vein, 380 Cephali regi n, 12t
Cal uli Cardi geni sh k, 421 Cephali vein, 411
renal, 567, 569 Cardi l gy, 392b, 392 Cerebellum, 260261, 261 , 264t
Stagh rn, 567 Cardi my pathy, e9t, 394 Cerebral rtex, 261 , 262
Callus, 204, 205 Cardi pulm nary resus itati n (CPR), 380 ntr l respirati n, 476
Cal rie, 537b Cardi vas ular system, 9697, 97 Cerebral palsy, 264265, 265
Calyx, 557 aging e e ts in, 669 Cerebr spinal f uid spa es, 269270, 269 , 270
Canali uli, 177 bl d f w thr ugh, 385 , 409 Cerebr vas ular a ident (CVA), 264, 407
Can ell us b ne, 79t, 80, 177 Car tid artery, 419 Cerebrum, 262264, 263 , 264t
Can er, e1t, e6t, 62 , 637638 Car tid b dy re ept rs, 477 Cerumen, 303, 304
bladder, 567, 570 Carpal b nes, 94 , 190t Cerumin us glands, 303
breast, 637638 Carpal regi n, 12t Cervi al an er, e1t
auses , 130131 Carpal tunnel syndr me, 236 Cervi al lymph n des, 430
dete ting, 131133 Carrier, geneti , 682683 Cervi al regi n, 12t
rms , 130t Cartilage, 79t, 80, 80 Cervi al vertebrae, 182 , 267
geneti basis , 688b arti ular, 177 Cervix, 628 , 660
lung, 473 stal, 189 Cesarean se ti n, 658
in m uth, 499500 mi r s pi stru ture, 177 CF transmembrane ndu tan e regulat r
varian, 638 thyr id, 464 (CF R), 686
path genesis , 131134 tissue, 178 Chambers, heart, 380381
pr state, 625 stru ture, 177 Chan r id, 640t
s reening, 101b tum rs, 200201 Chemi al b nding, 2728
skin, 163165 Carver, Ge rge Washingt n, 539 valent b nds, 2728, 28
stages and grades , 133 Catab lism, 533 hydr gen b nds, 28, 29
st ma h, 506 glu se, 535 i ni b nds, 27, 28
testi ular, 625 nutrients, 538 Chemi al digesti n, 517, 518t
treatment, 133134 tissue, 586 Chemi al rmula, 27
Candida rganisms, 123t, 501 water rmed by, 586t Chemi al level rganizati n, 5
Candidiasis, e4t, 640t Catara ts, 300, 300 , 669 Chemi al rganizati nal levels, 2527
Canine teeth, 497 Cate h lamines, 257258 at ms, 2526
Cann n, Walter Brad rd, 603b, 603 Catheterizati n, urinary, 566b, 566 elements, m le ules and mp unds, 2627
Capillaries, 405 Cati ns, 589, 590 Chemi al rea ti ns, 29
lymphati , 431 Cavity, 500 Chemi als, innate and adaptive immunity,
neur glia and, 251 Ce um, 512 436t
peritubular, 559 Celia artery, 410 Chemistry
Capillary beds, 404 Cell bi l gy, 62b in rgani , 2931
Capillary bl d pressure, 588, 590b Cell b dy, 250, 251 li e, 2441
Capillary ex hange, 405406, 406 Cell divisi n, 60 rgani , 3135
Capitulum, 191 abn rmal, 130 Chem re ept rs, 292
Capsule Cell extensi ns, 4849, 49 inf uen ing respirati n, 476
gl merular, 557, 560 Cell gr wth, 5659 Chem ref exes, 476477
kidney, 557 hanges in, 6062, 61 Chem therapy, 133134
Carbamin hem gl bin (H bCO 2), 354, 481 Cell li e y le, 59, 60 r breast an er, 637
 Index I-5

Cheyne-St kes respirati n (CSR), 478, 478t Cisterna hyli, 430 , 432 C nne tive tissue, 7681, 79t
Chi kenp x (vari ella), e1t Citri a id y le, 535 bl d tissue, 79t, 80, 81
Childbed ever, 663 Claude, Bernard, 593b b ne, 79t, 80, 80
Childh d, gr wth and devel pment, 666 Clavi le, 94 , 190, 190t artilage, 80, 80
Chlamydia, 640t Cle t lip, 501, 501 ells and matrix, 78
Chlamydia trachomatis, 300 Cle t palate, 501, 501 atty, in heart, 381
Chlamydial njun tivitis r tra h ma, 300 X-linked rm, e10t br us, 7880
Chl ride, n rmal values, e19t Clit ris, 628 , 633, 633 hemat p ieti tissue, 79t, 81
Chl ride i n, 27 Cl ne, 442 membranes, 146, 147
Chl rine (Cl), 541t Cl sed ra tures, 203 types , 78, 79t
Ch king, ve-and- ve res ue r, 467b, 467 Cl tting time, bl d, e19t C nstipati n, 514
Ch le yste t my, 510 C balt (C ), 541t C nta t dermatitis, 163, 163 , 446
Ch le ystitis, 509 C i, 121, 121 , 121t C ntinu us ambulat ry perit neal dialysis
Ch led h lithiasis, 510 Coccidioides rganisms, 123t (CAPD), 572b, 572
Ch lelithiasis, 509 C idi id my sis, e4t C ntra ti n
Ch lera, e2t, 56 C ygeal nerve, 267 atrial, 382
Ch lester l, 33, 44, 539b, 539 C yx, 186187, 267 heart, strength , 415
Ch linergi bers, 277278, 278 C hlea, 304, 305 mus le, 222 , 227
Ch ndr ytes, 177, 178 C hlear implant, 103 is metri , 226
Ch ndr ma, 129 C d minan e, 683 is t ni , 226
Ch ndr sar ma, 200201 C litis, 514 twit h and tetani , 225226
Ch rdae tendineae, 381 , 383 C llagen, 72 premature, 390
Ch ri n, 337 C lle ting du t (CD), 558, 559 , 560 ventri ular, 382 , 386
devel ping, 654655, 656 C ll id, 329 C ntr l enters, 14
Ch ri ni g nad tr pin, 322323t, 337 C l n, 512 respirat ry, 475, 477
Ch ri ni villi, 654655 C l r, urine, e22t, 568t C ntr l gr up, 4
Ch ri ni villus sampling, 690691 C l r blindness, 302, 302 C ntusi n, e6t, 235
Ch r id, 295 C l re tal an er, 515 C nve ti n, 544, 544
Ch r id plexus, 269 C l st my, 515b, 515 C nvergent squint, 301
Chr matids, 59 C lumnar epithelium tissues, 75, 75 C nversi n a t rs (SI units), e23t
Chr matin, 50 C mbined ABO -Rh system, 357358, 358t C nvex urvatures, 187188
Chr matin strand, 680 C mm n bile du t, 508 , 509 C pper (Cu), 541t
Chr m s mal geneti diseases, 686 C mm n ar tid artery, 410 n rmal values, e19t
Chr m s mes, 50, 680682 C mm n ld, e1t, 118 C r pulm nale, 394395, 394
distributi n t spring, 681682 C mm n ilia artery, 97 , 104 , 413 C rnea, 294 , 295
in human gen me, 681 C mm n ilia vein, 411 C r nal plane. see Fr ntal plane
Chr ni br n hitis, 472, 472 C mpa t b ne, 79t, 80, 177, 178 C r nal suture, 185, 197
Chr ni gl merul nephritis, 571 C mpensated metab li a id sis, 610 C r nary angi plasty, 386
Chr ni l wer respirat ry diseases, e1t C mplement-binding sites, 439440 C r nary arteries, 380 , 386
Chr ni lymph yti leukemia, 363, 363 C mplement as ade, 439440, 439 , 440 C r nary bypass surgery, 386, 387
Chr ni myel id leukemia, 364, 364 C mplement pr teins, 440 C r nary veins, 387
Chr ni bstru tive pulm nary disease C mplementary base pairing, 56 C r navirus (C V), 119, 119t
(CO PD), e6t, 471472 C mplete bl d ell unt, 353, 353b C r n id ssa, 191
Chr ni renal ailure, 572573 C mplete ra tures, 203 C rpus all sum, 261 , 262
stages , 573 C mp unds C rpus avern sum, 624
Chr ni traumati en ephal pathy (C E), 266 des ribed by hemi al rmula, 26 C rpus luteum, 336, 628, 634 , 655
Chv stek sign, 593 rgani , 3135, 31 , 32t C rpus sp ngi sum, 624
Cilia, 46t, 49, 49 urine, 568t C rti al nephr ns, 558559
Ciliary es alat r, 461 C mpressi n ra tures, 201 C rti ids, 332
Ciliary mus le, 294 , 295296 C mputed t m graphy (C ), 131, 131 C rtis l (hydr rtis ne), 322323t, 332333
Ciliates, 123, 123t C n ave urvatures, 187188 C stal artilage, 189
Cir ulati n, 402427 C n entri ntra ti n, 226 C st sternal arti ulati n, 189
etal, 412414, 413 C n entri lamella, 177 C unseling, geneti , 689691
hepati p rtal, 409410, 412 C n ha, nasal, 462 C valent b nds, 2728, 28
pH ntr l me hanisms and, 604 C n ussi n, 264 C wper gland, 619 , 623
pla ental, 656 C ndu ti n, 544, 544 C wp x, 118
pulm nary, 384, 385 C ndu ti n impairment, 307 C xal b ne, 191, 194t
r utes , 408414 C ndu ti n paths, aut n mi , 276 Cramps, 235
systemi , 384, 385 C ndu ti n system, heart, 388, 389 menstrual, 635
systemi and pulm nary, 408409, 409 C ndyl id j ints, 199 Cranial b nes, 183t
Cir ulat ry sh k, 421 C ndyl id pr ess mandible, 184 Cranial avity, 9, 463
Cir ulat ry system, 9697, 102103t C nes, 296 Cranial nerves, 96 , 270, 271t, 272
Cir um isi n, male, 624b C ngenital de e ts, in m uth, 501, 501 Cranial regi n, 12t
Cir umdu ti n, 228 C ngenital immune de ien y, 447448 Crani sa ral system. see Parasympatheti
j int, 199t C ngenital inguinal hernia, 626, 627 divisi n, aut n mi nerv us system
Cir umf ex artery, 380 C ngestive heart ailure (CH F), 395 Creatinine
Cir umvallate papillae, 307 C njun tiva, 295 n rmal values, e19t
Cirrh sis, 511, 511 C njun tivitis, 300, 300 in urine, e22t
I-6 Index

Creatinine learan e, urine, e22t Dehydrati n, 588 Digesti n, 494495, 495t, 517519, 519
Creatinine ph sph kinase (CPK), n rmal testing r, 589 arb hydrate, 518
values, e19t Dehydrati n synthesis, 29, 29 hemi al, 517, 518t
Crenati n, 53b Delt id mus le, 95 , 229t, 231 , 232, 233t end pr du ts , 519
Cretinism, e7t, 330 Dementia, 265, 669 lipid, 519
Creutz eldt-Jak b disease, variant, 120 Dendrites, 83, 250, 251 me hani al, 517
Cribri rm plate, 463 Dendriti ell (D C), 440, 441 verview , 517
Cri id artilage, 464 Dense br us nne tive tissue, 7980, 79 , pr tein, 518519
Crista ampullaris, 306, 306 79t in small intestine, 508
Cr hn disease, 514515 Dental applian es, 501 Digestive system, 9899, 99 , 492531, 494
Cr ssbridges, my sin-a tin, 223 Dental aries, e2t, 500 appendix, 515516
Cr ssing- ver, 682, 682 Dental nditi ns, 500501, 500 digestive tra t, wall , 495496, 495
Cr up, 465 De xyrib nu lei a id (DNA), 35, 35 , 35t, es phagus, 502503
Cr wn, t th, 498, 498 50, 5657 gallbladder, 509511
Crural regi n, 12t repli ati n, 59 large intestine, 512515, 513
Crus penis, 624 virus, 118 , 119t liver, 509511
Crush injury, 235 Dep larizati n, 256 rgans , 494t
Crush syndr me, e6t Depth lassi ati n burns, 157160 pan reas, 511512
Crushing injuries, skeletal tissue, 85 Dermal-epidermal jun ti n, 148 , 150 perit neum, 516517, 516
Crust, 158159t, 160 Dermal ridges, 150151 pharynx, 501502, 502
Crypt r hidism, 625 Dermat mes, 273, 274 primary me hanisms , 495t
Crystals, in urine, e22t Dermis, 150151 small intestine, 506509, 507
C ells, 330 Des ending a rta, 380 st ma h, 504506, 504
Cubital regi n, 12t Des ending l n, 412 , 512513 Digital regi n, 12t
Cub id b ne, 194 Des ending tra ts, spinal rd, 267, 268 Digital veins, 411
Cub idal epithelium, simple, 75 Devel pment, 652677 Digitalis, 394b
Cultures, 122b ad les en e, 666 Diphtheria, e2t
Cunei rm b nes, 194 adulth d, 666667 Dire ti nal terms, 7
Cupula, 306 aging, 667670 Disa harides, 31
Curvatures, spinal, 187189 birth, 658661 Disease
abn rmal, 188189, 189 hildh d, 666 av iding risk , 117
in in ant, 188 , 665, 666 dis rders pregnan y, 662664 ell transp rt and, 5556
Curved r spiral r ds, 121, 121t early stages , 655 mbined risk a t rs , 117
Cushing disease, e7t in an y, 665666 drug therapy r, 127128
Cushing syndr me, e7t, 334, 334 peri ds , 656 epidemi l gy, 114
Cuspids, 497 p stnatal peri d, 664667 geneti me hanisms , 116
Cutane us b dy regi n, 12t prenatal peri d, 654658 inf ammat ry, 135136
Cutane us membrane, 146. see also Skin Devel pmental pr esses, 16 me hanisms , 115117
Cuti le, 153 Deviated septum, 465 path geni rganisms and parti les in,
Cyan balamin, 540t Diabetes insipidus, e7t, 328 117124
Cyan sis, 149, 413 Diabetes mellitus (DM), e1t, 325 patterns , 114115
Cy li AMP (aden sine m n ph sphate), and bl d glu se levels, 562 preventi n and ntr l , 125128
321 signs and sympt ms , 337 preventi n and treatment strategies r,
Cysti br sis (CF), e10t, 55, 55 , 512, 686, Diabeti ket a id sis, 607b 126127
687t Diabeti retin pathy, 299 , 301 pr gressi n, 114
Cystitis, 565, 569570 Diagn sti imaging, r early signs an er, pr tein synthesis and, 5859
interstitial, 570 131132 risk a t rs r, 117
Cysts, varian, 637 Dialysis, 52, 53 sexually transmitted, 640t
Cyt kines, 438439 kidney, 103104 signs and sympt ms, 113114
Cyt kinesis, 60 Diaphragm, 98 , 233t, 380 , 473 spread , st pping, 115
Cyt plasm, 44, 4549 Diaphysis, 176, 179 stress-indu ed, 278279
Cyt sine, 35 Diarrhea, 514 studying, 113115
Cyt skelet n, 46 due t hemi al agents, e6t termin l gy, 113114
Cyt t xi ells, 443 in ant, 514b tra king, 114115
Diarthr ses, 197199 as weap n, 128b
D un ti n , 198199 Disin e ti n, 125t
Dantr lene, 545546 stru ture , 197198 Disse ti n, 3
Darwin tuber le, 303 Diarthr ti j int Diss lved CO 2, 481
De idu us teeth, 497, 666 stru ture, 198 Distal nv luted tubule (D C ), 558, 558 ,
De ubitus ul ers, 161162 types, 198 559 , 560 , 562t
Deep, de niti n , 7 Diast le, 383 Distal dire ti n b dy, 7, 8
Deep em ral artery, 410 Diast li bl d pressure, 418, 420 Distal phalanx, 194
De brillat rs, implantable ardi verter, 392 Dien ephal n, 261262, 264t Disuse atr phy, 228
De ien y anemias, 359360 Di erential W BC unt, 362 Diureti s, 591b
Degenerati n, tissues, 116117 Di usi n, 5152, 51 , 51t al h l as, 591b
Degenerative disease, 265266 ex hange gases by, 478 a eine as, 591b
Degenerative j int disease, 204205 m vement respirat ry gases by, 480 Divergent squint, 301
Deglutiti n, 502 thr ugh membrane, 52 Diverti ulitis, 514
 Index I-7

Divisi ns skelet n, 180 Ele tr ardi gram (ECG), 388389, 390 Enteritis, 508
Dizyg ti twins, 661 dysrhythmia, 391 Enter biasis, e5t
DNA analysis, 691b, 691 e e ts hyp kalemia, 592 Enterobius rganisms, 124t
DNA ngerprinting, 691b Ele tr en ephal gram (EEG), 266, 266 Enuresis, 566
D minan e, 682683 Ele tr lytes, 27, 589 Envir nmental nta t, path gens spread by,
D minant gene, 682, 683 balan e, 583 125
D nated rgans and tissue, s reening , 81b in b dy f uids, imp rtan e , 589591 Envir nmental a t rs
D n rs bl d, 356 un ti ns , 589591 and disease risk, 117
D pamine, 257258 h me stasis , 591 r le in ausing an er, 130131
D rsal, de niti n , 7 imbalan es, 591593, 592t Enzyme a ti n, 34
D rsal b dy avities, 9 Ele tr n transp rt system, 535 Enzymes, 34, 34
D rsal regi n, 12t Ele tr ph resis, 691b, 691 ardia , 351b
D rsal respirat ry gr up (DRG), 475476 Elements, 2627, 27t hemi al digesti n and, 517518
D rsal r t gangli n, 254 , 268 Elephantiasis, 432, 432 E sin phils, 351t, 362
D rsalis pedis artery, 419 Eliminati n, 495, 495t n rmal values, e19t
D rsif exi n, 229, 230 Emb lism, pulm nary, 366 , 408 Epi ardium, 381, 381
D uble helix, 35 Emb lizati n, uterine artery, 637 Epidermis, 148, 149150
D wagers hump, 201 Embry , 656, 657 Epidermophyton rganisms, 123t
D wn syndr me, e10t, 688, 689 Embry l gy, 654, 670b Epididymis, 619 , 620 , 622
Drew, Charles Ri hard, 367 Embry ni phase, 656 Epigastri regi n, 10
Drugs, immun suppressive, 104105 Embry ni stem ells, 61b Epigeneti s, 685
D u henne mus ular dystr phy (DMD), e10t, Emesis, 505 nditi ns in, 688
236, 687t Emphysema, 472 Epigl ttis, 463 , 464
D u tus arteri sus, 413 Emptying ref ex, 566 Epigl ttitis, e2t, 465
D u tus ven sus, 412413, 413 En apsulated nerve endings, 292t Epilepsy, 266
D u denum, 412 , 506 End arditis, 381 Epinephrine (Epi), 322323t, 333
D ura mater, 268, 269 End ardium, 381, 381 Epineurium, 253
D war sm, 327 End h ndral ssi ati n, 179, 180 Epiphyseal ra tures, 196b, 196
pituitary, e7t End rine gland, 75 Epiphyseal line, 179
D ynami equilibrium, 306, 306 End rine system, 96, 96 , 318347 Epiphyseal plate, 179
D ys un ti nal uterine bleeding, 635636 adrenal glands, 331334, 332 Epiphyses, 177
D ysmen rrhea, 635 disease me hanisms, 322323t, 325 Epispadias, 626
D ysplasia, mammary, 632b un ti n , thr ugh ut the b dy, 338339 Epistaxis, 465466
D yspnea, 478 glands, 320, 320 , 322323t Epithelial asts, in urine, e22t
h rm ne se reti n regulati n, 324325 Epithelial membranes, 146147
E hyp thalamus, 320 , 328329 mu us, 147
Ear, 302304, 303 me hanisms h rm ne a ti n, 320321, types , 146
aging e e ts in, 669 321 Epithelial tissues, 7276, 72t
external, 302304, 303 pan reati islets, 334336, 335 arrangement ells, 73
inner, 303 , 304 parathyr id glands, 329 , 331 lassi ati n , 73
middle, 303 , 304 pineal gland, 338 lumnar epithelium, 75, 75
Ear b nes, 183t pituitary gland, 326328 ub idal epithelium, 74 , 75, 75
Eardrum, 303, 303 pla enta, 337338 pseud strati ed epithelium, 76, 77
Earwax, 303 pr staglandins, 325326 shape ells, 73
Eating dis rders, 543544 sex glands, 336 squam us epithelium, 7374, 74
E entri ntra ti n, 226 thymus, 320 , 337 transiti nal epithelium, 76
E rine sweat glands, 154 thyr id gland, 320 , 329331, 329 strati ed, 76, 77
E h ardi graphy, 384b, 384 End rin l gists, 325 transiti nal epithelium, ureteral, 564, 565
E lampsia, 662 End rin l gy, 325, 338b Epstein-Barr virus (EBV), e1t, 119t
E t derm, 657, 658t End derm, 657, 658t Equilibrati n, 52
E t pi pregnan y, 631b End lymph, 304, 305 Equilibrium, 52, 306307
E zema, 162163 End metrial ablati n, 636 dis rders, 307
Edema, 590, 590b End metri sis, 637 Ere tile dys un ti n, 626
ass iated with nephr ti syndr me, End metrium, 631 Ernest Everett Just, 62b, 62
570 End neurium, 253 Erythr blast sis etalis, 356, 357 , 361
pitting, 590b, 590 End plasmi reti ulum (ER), 46t, 47 Erythr ytes, 351t
E e t r, 14 mus le ell, 222 Erythr p ietin, 560
E e t r ells, 442443 End rphins, 258 Es phageal inf ammati n, 503
E erent arteri le, 557, 558 , 559 End s pe, 503 Es phagus, 99 , 463 , 502503
E erent lymphati vessels, 433, 433 End steum, 177 Essential amin a ids, 538, 538t
Ehrlichia ewingii, 127t End thelium Estr gens, 322323t, 629, 634
Ehrli hi sis, 207 ardi vas ular, 405 Ethm id air ells, 462
Einth ven, W illem, 392 lymphati , 431 Ethm id b nes, 183t, 184
Eja ulat ry du t, 619 , 623 End tra heal intubati n, 465b, 465 ribri rm plate , 463
Elasti artilage, 79t, 80 Enduran e training, 228 Eupnea, 478t
Elasti bers, 78 Energy, measuring, 537b Eusta hian tube, 303 , 304, 463
Elasti tissue, artery, 404 Energy levels rbitals, 2526 Evap rati n, 544, 544
Elastin, 72 Enkephalins, 258 Eversi n, 229, 230
I-8 Index

Ex ess p st-exer ise xygen nsumpti n, 225 Feedba k l p, 14 Flagellates, 123, 123t
Ex riati n, 158159t ald ster ne me hanism, 587 Flat b nes, 177
Ex reti n negative, 15, 15 stru ture , 177
by skin, 156 p sitive, 1516, 16 Flat t, 195
by sweat, 586 Female repr du tive system, 100, 100 , Flatulen e, 514
Exer ise 627635 Flatus, 514
hanges in bl d f w during, 417b breasts, 631632 Flavivirus, 119120, 119t
e e ts dis rders , 635639 Fleming, Alexander, 571b, 571
n immunity, 438b h rm nal and menstrual, 635636 Flexi n, 228
n skeletal mus le, 226228 in e ti n and inf ammati n, rearm, 229
f uid intake and, 509b 636637 j int, 198, 199t
pr teinuria a ter, 567b in ertility, 638639 Flex r retina ulum, 236
skin and, 156b, 156 tum rs and related nditi ns, Flex rs, 229t
type 1 diabetes mellitus and, 335b 637638 Fl ating ribs, 189
Ex rine glands, 75, 499 essential rgans, 627, 627t Fl ra, 513
Ex phthalm s, 330, 330 external genitals, 632633, 633 Fluid balan e, 582599, 584
Experimental ntr ls, 4 menstrual y le, 633635, 633 maintenan e , 585588
Experimentati n, 4 varies, 627628, 628 Fluid mpartments, 584585
Expirati n, 474 uterine tubes, 630, 630 ele tr lytes in, 590
Expirat ry reserve v lume (ERV), 475 uterus, 630631, 630 Fluid h me stasis, r le lymphati system
Extensi n, 228 vagina, 628 , 631 in, 431
rearm, 229 vestibular glands, 631632, 633 , 640t Fluid imbalan e, 588589
j int, 198, 199t Female skelet n, 194 dehydrati n, 588
Extens rs, 229t Fem ral artery, 97 , 410 , 419 verhydrati n, 589
External abd minal blique mus le, 95 , Fem ral regi n, 12t Fluid intake, regulati n, 587588
231 Fem ral vein, 97 , 411 Fluid utput
External ear, 302304, 303 Femur, 94 , 194t regulati n , 586587
External genitals Fertilizati n, 654, 654 , 655 r utes , 586587, 586t
emale, 632633 implantati n and, 654, 655 Fluid shi t, 588
male, 623624, 624 Fetal al h l syndr me, 664b Fluid uptake, exer ise and, 509b
External ilia vein, 411 Fetal ir ulati n, 412414 F late de ien y anemia, e10t, 359
External jugular vein, 411 Fetal death, 662 F li a id, 540t
External blique, 233 , 233t Fetal-maternal ABO in mpatibility, 361 F lli le, hair, 152
External respirati n, 478 Fetal phase, 656 F lli le-stimulating h rm ne (FSH ),
External urinary meatus, 619 , 624 Fetus, 656, 657 322323t, 326, 619, 635
Extra ellular f uid, 585, 585 , 585t, 587 Fever, 135136, 545 F lli ular ysts, 637
Extra ellular matrix, 72, 72 puerperal, 663 F ntanels, 179, 185
Eye, 96 Fever blisters, 118 F d guide, 533, 534
aging e e ts in, 669 herpes and, e1t F d intake, regulati n , 541
blind sp t, 297b Fibrillati n, 390392 F d s ien e, 539b
stru ture and un ti n , 294 , 295297 Fibrin, 365 F ds, water in, 586 , 586t
Fibrin mesh, 366 F t
F Fibrin gen, 365, 366 ar hes , 195
Fa e b nes, 183t Fibr artilage, 79t, 80 b nes , 193
Fa ial artery, 410 , 419 Fibr ysti disease, 632b mus les , gr uped a rding t un ti n,
Fa ial expressi n, mus les , 232 Fibr id, 637 229t
Fa ial nerve (CN VII), 271t, 272 Fibr sar ma, 129 right, 194
Fa ial regi n, 12t Fibr us layer, eye, 295 F t pr esses, neur glia and, 251
Fa ial vein, 411 Fibr us netw rk, 151 F ramen magnum, 260
Fa t r VIII, absen e , in hem philia A, Fibula, 94 , 191193, 194t F ramen vale, 413, 413
367 Fibular (per neal) vein, 411 F rearm, 191
Fall pian tubes, 628 , 630 Fibular vein, 411 f exi n and extensi n , 229
False ribs, 189, 190t Fibularis brevis, 229t, 231 F reskin
Farsightedness, 299, 300 Fibularis l ngus, 229t, 231 emale, 633
Fas ia, skeletal mus le, 221 Fibularis tertius, 229t male, 619
Fas i les Filtrati n, 51t, 53 F rmed elements, 349, 350 , 351
ax ns bundled int , 253 bi l gi al, by lymph n des, 433434 F vea entralis, 294 , 296
skeletal mus le, 221 urine, 560561 Fra tures
Fasciola rganisms, 124t Fimbriae, 630, 654, 655 b ne, 203204, 204
Fat First-degree burns, 157 mpressi n, 201
metab lism , 537538, 538 Fish tapew rm in estati n, e5t epiphyseal and avulsi n, 196b, 196
within nerve, 253 Fissures Fragile X syndr me (FXS), e10t, 688
Fat-st ring ells, h rm nes , 322323t erebrum, 262 Franklin, R salind, 36b, 36
Fatigue, mus le ntra ti n and, 224225 dermal, 158159t Fraternal twins, 661
Fatty a ids, n rmal values, e19t lungs, 469 Fre kles, 150, 158159t
Fatty tissue Fitness, tissues and, 84b, 84 Free edge nail, 153
nne tive, in heart, 381 Five-and- ve res ue r h king, 467b Free nerve endings, 292t
sub utane us, 148 Flagella, 46t, 49, 49 Free-radi al the ry aging, 668
 Index I-9

Free radi als, 668 Geneti diseases, 684689 n rmal values, e19t
Frenulum, 497 hr m s mal, 688689 reabs rpti n , 562
Fri ti n ridges, 150 me hanisms , 684686 in tubule ltrate, 562
Fr nt teeth, 497 hr m s mal, 685686 in urine, e22t
Fr ntal b nes, 183t, 185 single-gene, 685 Gluteal regi n, 12t
Fr ntal l be, 263 preventi n , 689693 G luteus maximus, 229t, 231 , 234, 234t, 237
Fr ntal mus le, 232, 232 , 232t single-gene, 686688, 687t G luteus medius, 229t, 237
Fr ntal plane, 8 , 9 treating sympt ms , 692 G ly er l, 32
Fr ntal regi n, 12t treatment , 692693 Gly gen, 31, 536
Fr ntal sinus, 185 , 462 , 463 Geneti a t rs Gly gen l ading, 536b
Fr stbite, 546 r an er, 130 Gly genesis, 536
Full-thi kness burns, 160 r disease, 117 Gly gen lysis, 335, 536
Fun ti nal pr teins, 34 Geneti mutati ns, 684 G ly lysis, 535
Fundus Geneti predisp siti n, 685 G ly suria, 336, 562
st ma h, 504, 504 Geneti variati n, 682 G ly sylated hem gl bin, e19t
uterus, 628 , 630 Geneti s, 694b G blet ells, 75
Fungal in e ti ns, tinea, 161 human disease and, 679680 G iter
Fungi, path geni , 123, 123 , 123t Genital herpes, 640t as de ien y diseases, e10t
Furun les, 161 Genital warts, e1t, 640t as end rine nditi ns, e7t
Genitals, external G lgi apparatus, 46t, 47
G emale, 632633 G lgi tend n rgan, 292t
G pr tein, 320b, 321 male, 623624, 624 G nad tr pin-releasing h rm ne (GnRH ),
Gallbladder, 99 , 508 , 509511 Gen me, 59b 619, 635
Gallst nes, 509510, 510 human, 681 G nads, 618
Gametes, 681 Gen mi s, 680, 694b G n rrhea, e2t, 640t
Gangli n, 254 Germ layers, primary, 657, 658t G uty arthritis, 206207
sympatheti , 276 German measles. see Rubella G raa an lli le, 628
Gangli n ells, 296, 298 Ger nt l gy, 667 G ra ilis, 231
Gangrene, 406 Gestati n peri d, 656 G ra t-versus-h st reje ti n, 447
Gas ex hange, in lungs, 478481, 479 Gestati nal diabetes mellitus, e7t, 662 G ra ts, skin, 155, 155
Gastri jui e, pH , 602 Ghrelin, 322323t, 338339 G ram staining te hnique, 120121
Gastri se reti ns, s dium- ntaining, Giardiasis, e5t, 640t G ranular asts, in urine, e22t
591 Gigantism, e7t, 327, 327 G ranular leuk ytes, 361 , 362
Gastri ul er, 505506, 505 Gingiva, 498 G raves disease, 330
Gastri vein, 412 Gingivitis, 501 as aut immune diseases, e9t
Gastritis, 505 Glands, 75. see also speci c glands as end rine nditi ns, e7t
Gastr nemius, 229t, 231 , 234, 234t end rine, 322323t G ray matter, 253, 254 , 260, 268
Gastr enteritis, e2t sex Great ardia vein, 411
Gastr enter l gy, 505, 520b emale, 631632 Great saphen us vein, 411
Gastr epipl i vein, 412 male, 623, 623 G reater urvature, 504
Gastr es phageal ref ux disease (GERD), skin, 154155 Greater mentum, 516517
503 vis eral e e t rs, 277t G reater tr hanter, 193 , 237
Gastr intestinal (GI) tra t Glans penis, 624 G reater tuber le, 191
h rm nes , 322323t Glau ma, 296297, 301, 669 G reensti k ra tures, 203
upper x-ray study, 506b, 506 Glia, 250252 Gr wth, 652677
Gene, 56 entral, 250252, 251 ell, hanges in, 5659, 6062, 61
un ti ns , 56 un ti n , 250 Gr wth h rm ne (GH ), 322323t, 326327
Gene augmentati n, 692693 peripheral, 252 G uanine, 35
Gene expressi n, 682684 Gliding j ints, 199 G um, 498
hereditary traits, 682683 Gli ma, 250 G ustat ry ells, 307, 308
sex-linked traits, 683684 Gl bulins, 350 G yri, 262
Gene linkage, 682 n rmal values, e19t
Gene pairs, 682 Gl merular- apsular membrane, 560 H
Gene repla ement, 692 Gl merular apsule, 557, 560 , 562t H air, 151153
Gene therapy, 692693, 693 Gl merular ltrati n, 561 gr wth, 152
p tential , 693 Gl merular ltrati n rate (GFR), 573 l ati n , 151152
General senses, 291, 292t, 293294, 293 Gl merul nephritis, e9t, 570 l ss, 152153
dis rders inv lving, 294 a ute, 570571 H air lli le, 148
m des sensati n and, 293294 hr ni , 571 H amstrings, 229t, 231 , 234, 234t
re ept rs, distributi n , 293, 293 Gl merulus, 557, 558 , 559 , 560 , 562t H and
Genes, 680682 Gl ss pharyngeal nerve (CN IX), 271t, 272 arti ial, 103
human gen me, 680 Glu ag n, 322323t right and wrist, 192
l ati n , in disease, 685, 686 G lu rti ids (G Cs), 332 H antavirus, e1t
me hanisms gene un ti n, 680 Glu ne genesis, 332, 537538 H antavirus pulm nary syndr me, e1t
r le , in disease, 684685 G lu se H ard palate, 463 , 496497
Geneti basis an er, 688b anab lism, 536 H arvey, W illiam, 420, 420
Geneti de, 56 atab lism, 535 H ashim t disease, e7t
Geneti unseling, 689691 metab lism , 535 H aversian systems, 177, 178
I-10 Index

H ead H epatitis, 510511 H yaline asts, in urine, e22t

arteries in, 410t H epatitis A, 510 H ydr ephalus, 271
mus les , 232, 232 , 232t H epatitis A virus, e1t H ydr hl ri a id (H Cl), 505, 518
sagittal se ti n, 463 H epatitis B, 510 H ydr gen b nds, 28, 29
veins in, 411t H epatitis B virus, e1t H ydr gen i ns (H ), 601
H eada he, e6t H epatitis C, e1t, 511 H ydr lysis, 29, 517
H earing, 304306, 305 H epatitis viruses, 119t, 640t H ydr nephr sis, 567, 569
dis rders, 307 H ereditary traits, 682683 H ydr stati pressure, 53
H earing impairment, e6t H ernias, inguinal, ngenital, 626, 627 H ydr xide i ns (OH ), 601
H eart, 97 , 378401, 470 H erniated disk, 197, 197 H ymen, 633, 633
a ti n , 382 , 383 H erpes simplex 1, e1t H y id b ne, 183t, 185, 185 , 463
arti ial pumps, 103 H erpes simplex 2, e1t H yper al emia, 331, 592593
atria, h rm nes , 322323t H erpes simplex virus, 118 H yper h lester lemia, e10t, 539b, 687t
bl d f w thr ugh, 384385 genital, 640t H yper hr mi RBCs, 354, 355
ardia y le , 387, 388 H erpes z ster, e1t, 273, 274 . see also Shingles H ypergly emia, 327
ardia utput , 392394, 393 H ex saminidase, 688 H yperkalemia, 592
hambers , 380381 H iatal hernia, 503, 504 H ypernatremia, 592
ndu ti n system , 388, 389 H igh-density lip pr tein (H DL), 33 H yper pia, 299, 300
ardia dysrhythmia, 389392 n rmal values, e19t H yperparathyr idism, e7t
ele tr ardi graphy, 388389 H ilum, 556557, 557 H yperplasia, 61, 61 , 61t
r nary ir ulati n , 385 H inge j ints, 198 H yperse reti n, 325
verings , 381 H ip, 94 H ypersensitivity, immune system, 444447
diseases , e1t arti ial j int, 103 H ypersensitivity rea ti n, e6t
peri ardium , 381382 t tal hip repla ement, 200b H ypertensi n (H N), 419421, 669
strength , ntra ti n , 415 H ipp rates, 208 lassi ati n , 420
stress-indu ed disease and, 279 H ist genesis, 658 de niti n , 419420
valves , 383 Histoplasma rganisms, 123t risk a t rs , 420421
H eart bl k, 389390, 391 H ist plasm sis, e4t H yperthyr idism, e7t, 330, 330
H eart ailure, 394395 H ives, 162, 163 H ypert ni s luti n, 53b
H eart implants, 395 drug-sensitivity, 158159t H ypertr phy, 61, 61 , 61t
H eart murmurs, 384 H dgkin disease, 435 H yperventilati n, 477, 478t
H eart rate, 393, 415416 H me stasis, 14, 14 , 101, 603b, 603 H ypervitamin sis, 539
H eart s unds, 380, 384 disturban es , 115116, 116 H yp albuminemia, 570
H eart transplant, 395 f uid, r le lymphati system, 431 H yp al emia, 593
H eartbeat, 277t H m ysteine, n rmal values, e19t H yp hr mi RBCs, 354, 355
H eartburn, 503 H riz ntal ssure, 469 H yp gastri regi n, 10
H eat ramps, 546 H riz ntal plane. see ransverse plane H yp gl ssal nerve (CN XII), 271t, 272
H eat exhausti n, 546 H riz ntal se ti n, 6 H yp gly emia, 327
H eat pr du ti n, mus le ntra ti n and, 224 H rm ne repla ement therapy (H R ), 630b, H yp kalemia, 592
H eatstr ke, 546 670 H yp se reti n, 325
H eberden n des, 205 H rm nes, 320 H yp spadias, 625626
H eight, gr wth in, 666 a ti n, me hanism , 320321 H yp thalamus, 96 , 261262, 320 , 328329
H eimli h, H enry, 467 un ti n , 322323t h rm nes , 322323t
H eimli h maneuver, 467b se reti n, regulati n , 324325 r le in menstrual y le, 634
H elper ells, 443 H st-versus-gra t reje ti n, 447 H yp thermia, 546
H emangi ma, strawberry, 151, 151 H uman engineered hr m s me (H EC), H yp thesis, 4
H emat rit (H t), 353, 353 692693 H yp thyr idism, e7t, 330
in anemia, 359t H uman gen me, 59b, 680, 681 H yp t ni s luti n, 53b
n rmal values, e19t H uman Gen me Pr je t (H G P), 680 H yp ventilati n, 477, 478t
H emat l gy, 367b H uman granul yti ehrli hi sis, 127t H yp v lemi sh k, 421
H emat p iesis, 176, 352, 657, 659b H uman gr wth h rm ne (hGH ), 327 H yp xia, 472
H emat p ieti tissue, 79t, 81 H uman immun de ien y virus (H IV), H ystere t my, 631
H emiplegia, 265 118119, 118 , 119t, 448
H em dialysis, 572b, 572 dementia and, 266 I
H em dynami s, 414418 H uman lymph yte antigens (H LAs), 447 Identi al twins, 661
H em gl bin, e19t, 354, 354 H uman rganism, 6 Ide gram, 680, 681
in anemia, 359t H uman papill mavirus (H PV), e1t, 119t, 131, Ile e al valve, 512
H em gl bin A1 , e19t 638 Ilia rest, 237
H em lyti anemias, e9t, 360361 H uman skelet n, 182 Ili ps as, 229t, 231 , 234, 234t
H em philia, e10t, 366368, 687t H uman -lymph tr pi virus 1 (H LV-1), Ilium, 191
H em rrhagi anemia, 358 e1t Immune mem ry, 437
H em rrh ids, 408 H umerus, 94 , 190, 190t, 191 Immune system, 9798, 98 , 436438
H enle l p, 557558, 558 , 559 , 560 , 562t H um ral immunity, 439 adaptive immunity , 436t, 437438
H eparin, 362 H untingt n disease (H D), e10t, 266, 687t, antib dies in, 439440, 439
H epati f exure, 512513 690 ells , 440443
H epati p rtal ir ulati n, 409410, 511 H ut hins n-Gil rd pr geria syndr me, 667b mplement pr teins in, 440
H epati p rtal vein, 411 , 412 , 413 H uxley, Andrew, 223b, 223 de ien y , 447448
H epati veins, 411 , 412 H yaline artilage, 79t, 80, 466 un ti n , 436
 Index I-11

hypersensitivity , 444447 Inguinal hernia, ngenital, 626, 627 Iris, 295

innate immunity , 436437, 436t Inguinal lymph n des, 430 Ir n de ien y anemia, e10t, 359360, 360
lymph ytes in, 441443, 442 Inguinal regi ns, 10, 10 , 12t Ir n (Fe)
m le ules , 438440 Inhibiting h rm nes (IH s), 322323t, in hem gl bin, 354
phag ytes in, 440441 328329 n rmal values, e19t
Immunizati n, 447b Inje ti ns Irritable b wel syndr me, 514515
Immun gl bulins (Igs), 439 intramus ular, 237b Is hemia, 406
Rh GAM, 356 sub utane us, 152b Is hium, 191
Immun l gi al tests, 122b Injuries Islets Langerhans, 334, 511
Immun suppressive drugs, 104105 knee j int, 206207b, 206 Is immunity, 446
Immun therapy, 134 mus le, 235 Is lati n, in disease preventi n, 125t
Impetig , 161 traumati Is metri ntra ti n, 226
Implantable ardi verter de brillat rs (ICDs), brain, 264 Is sp riasis, e5t
392 n ninf ammat ry j int pr blems due t , Is t ni ntra ti n, 226
Implantati n, 654 205 Is t ni s luti n, 53b
devel pment and, 656 Innate immunity, 436437, 436t, 437t Is t pes, 26b
dis rders, 662, 662 Inner ear, 303 , 304 It h mite, 161
ertilizati n and, 654, 655 Inner layer, eye, 296 IV te hni ians, 420
Implants, heart, 395 Innervati n, target rgans, by ANS, 275
Imprinting, 685 In rgani hemistry, 2931 J
In vitr ertilizati n (IVF), 657b, 685b Inse ta, 124t Jaundi e, 509510
In is rs, 497 Inserti n, mus le, 221 , 232t Jenner, Edward, 448b, 448
In mpetent valves, 383 Inspirati n, 473474 J hns n, Virginia, 639b, 639
In mplete ra tures, 203 Inspirat ry reserve v lume (IRV), 475 J ints, 197 , 208b, 208
In ntinen e, urinary, 566 Insulin, 322323t amphiarthr ses, 196197
In us, 183t, 304 in arb hydrate metab lism, 536537, 537 arthritis, 205
Independent ass rtment, prin iple , 682 Insulin in usi n devi e, 103 diarthr ses, 197199
In an y, gr wth and devel pment, 665666 Insulin sh k, e7t dis rders, 204207
In ant diarrhea, 514b Integument, 145 m vement types, 199t
In ant respirat ry distress syndr me (IRDS), Integumentary system, 9394, 94 , 145 n ninf ammat ry j int disease,
468469 Interaryten id n t h, 464 , 465b 204205
In e ti ns Inter alated disks, 82 synarthr ses, 196
b nes, 202 in ardia mus le ber, 220 J ule ( J), 537b
emale repr du tive tra t, 636 Inter stal mus les, 233 Just, Ernest Everett, 62b, 62
l wer respirat ry tra t, 470471 Inter er ns (IFs), 446b, 446 Juvenile rheumat id arthritis ( JRA), 205
m uth, 501 Interleukins, 438439 Juxtagl merular apparatus, 559560, 559
mus le, 235, 235 Internal ilia artery, 104 , 413 Juxtamedullary nephr n, 558559, 558
n s mial, 571b Internal ilia vein, 104 , 411
sexually transmitted, 640 Internal jugular vein, 411 K
skin, 161, 162 Internal blique, 233 , 233t Kap si sar ma, 164 , 165, 446
upper respirat ry tra t (URI), 460461, Internal respirati n, 480 Kary type, 681 , 690691
464465 Internati nal n rmalized rati (INR), 366 Kel id, 84, 84
In e ti us arthritis, 207 Interneur ns, 250 Keratin, 149
In e ti us me hanisms, disease, 116 Interpe t ral (R tter) n des, 434 Keratitis, 295
In e ti us m n nu le sis, e1t, 364, 364 Interphase, 59 Ket nuria, 607
In eri r dire ti n b dy, 7, 8 Interstitial ystitis, 570 Kidney dis rders/diseases, e1t
In eri r mesenteri artery, 410 , 412 Interstitial f uid, 430431 gl merular, 570571
In eri r mesenteri vein, 411 v lume values, 584 , 585t kidney ailure, 571572
In eri r nasal n ha, 183t Interstitial spa e, lung, 468 bstru tive, 567569
In eri r vena ava, 97 , 104 , 380 , 411 , 413 Interventri ular septum, 381 Kidney st nes, 567
In ertility, 638639 Intestinal glands, 508 Kidneys, 99 , 413 , 555, 556560
Inf ammati n, 134136 Intestinal se reti ns, s dium- ntaining, 591 arti ial, 572b, 572
a ute and hr ni , 136 Int xi ati n, water, 589 ntr l urine v lume and, 563
me hanisms , 134135 Intra ellular f uid, 585 dialysis, 103104
s iati nerve, 273 v lume values, 584 , 585t external anat my , 556557
systemi , 135 Intramembran us ssi ati n, 179180 un ti n , 559560
Inf ammati n mediat rs, 134 Intramus ular inje ti ns, 237b gr ss stru ture , 556557
Inf ammat ry nditi ns, in large intestine, Intrapleural spa e, 470 internal anat my , 557
514515 Intubati n, end tra heal, 465b, 465 l ati n , 556
Inf ammat ry j int disease, 205207 Inversi n, 229, 230 mi r s pi stru ture , 557559
Inf ammat ry me hanisms, disease, 116 Inv luti n, 435 pH ntr l me hanisms and, 604 , 606
Inf ammat ry resp nse, 134135, 134 , 135 , I dine (I), 541t reabs rpti n, 561562
436437, 437 I n pump, 54, 54t se reti n, 562
Inf ammat ry skin dis rders, 163 I ni b nds, 27, 28 transplantati n, 104
Inf uenza, e1t, e1t I ns water utput, 586
Inf uenza viruses, 119t in b dy f uids, 28t, 589 Kil al rie, 537b
Ingesti n, 494, 495t al ium, thin laments and, 222 Kline elter syndr me, e10t, 689, 689
Inguinal anal, 233 reabs rpti n, 561 Knee-jerk ref ex, 254
I-12 Index

Knee j int hr ni lymph yti , 363, 363 Lupus erythemat sus, 445, 446
b nes , 193 hr ni myel id, 364, 364 Luteal ysts, 637
injuries t , 206207b, 206 Leuk ytes, 350 Luteinizati n, 326
K h, R bert, 126 agranular, 362 Luteinizing h rm ne (LH ), 322323t, 326,
K r tk s unds, 418 granular, 362 619, 635
Krebs y le, 535 in human bl d smears, 361 Lyme disease, e2t, 127t, 207, 207
Kwashi rk r, e10t Leuk yt sis, 362 Lymph, 430431
Kyph sis, 188 Leuk penia, 362 Lymph n des, 98 , 433434, 433
Leuk plakia, 499500 Lymph spa e, 253
L Levels rganizati n, 46, 5 Lymph vessels, 98
Labia maj ra, 633 Levi-M ntal ini, Rita, 670b, 670 Lymphadenitis, 433
Labium majus, 628 Lev d pa, 259 Lymphangi gram, 433, 433
Labium minus, 628 Li e span, extending, 669b Lymphangitis, 432, 432
Lab r, stages , 660 , 661 Li estyle, as risk a t r r disease, 117 Lymphati du t, right, 98
Lab rat ry identi ati n path gens, 122b, Ligaments, 198 Lymphati system, 9798, 98 , 429436, 430
122 Limited- eld radiati n, 638 Lymphati venules, 431432
Lab rat ry tests Linear ra tures, 204 Lymphati vessels, 431432
results r types anemia, 359t Lingual t nsils, 435, 435 , 463 Lymphedema, 432, 432
urinalysis, 567 Lip an er, 500 Lymph ytes, 362, 441443, 442
La erati n, e6t Lipase, 518 n rmal values, e19t
La rimal b ne, 183t Lipids, 3233 Lymph granul ma venereum (LGV), e2t,
La rimal gland, 295 digesti n, 519 640t
La rimal sa , 185 , 462, 462 n rmal values, e19t Lymph id rgans, 432436
La teals, 432, 508 Lip ma, 129 Lymph id tissue, 352
La ti a id, 604, 605 Lip pr tein, 33b, 33 Lymph ma, 129, 435436
La ti dehydr genase (LDH ), n rmal values, Liquid ingesti n, 586 , 586t Lys s mes, 46t, 4748
e19t Lith tripsy, 569b
La ti er us du ts, 632 Lith tript r, 569b M
La t se int leran e, 518, 664 Liver, 99 , 412 , 509511 Ma r yti RBCs, 355
La una(e), 177, 178 metab li un ti n , 534 Ma r nutrients, 534538, 534t
Lambd idal suture, 184 , 185 Liver f uke in estati n, e5t arb hydrate metab lism in, 535537
Lamellar rpus le (Pa ini rpus le), 292t L bar pneum nia, 471, 471 at metab lism in, 537538, 538
Lamellar (Pa ini) rpus le, 154 L bes pr tein metab lism in, 538
Lapar s pe, 657b, 660 brain, 263 Ma r phages, 362, 440, 468
Large intestine, 99 , 512515 lung, 469 Ma ula, 306
dis rders , 514515 L k-and-key m del, 34, 320321 Ma ula lutea, 294 , 296
un ti n , 513514 L ewi, O tt , 279b, 279 Ma ule, 158159t
stru ture , 512513, 513 L ng b nes, 176 Mad w disease, 120
water utput, 586 stru ture , 176177 Magnesium (Mg), 541t
Laryngitis, 465 type b nes, 176 Magneti res nan e imaging (MRI), 131, 131
Laryng pharynx, 460 , 463 L ng th ra i vein, 411 Malabs rpti n syndr me, 509
Larynx, 98 , 460, 460 , 463 , 464, 464 L se br us nne tive tissue, 78, 78 , 79t Malaria, e5t
Laser therapy, 134 L rd sis, 188 Maldigesti n, 509
Lateral axillary (bra hial) n des, 434 L w- arb diets, 537b Male- emale skeletal di eren es, 194195
Lateral dire ti n b dy, 7, 8 L w-density lip pr tein (LDL), 33 Male repr du tive system, 100, 100 , 618624
Lateral epi ndyle, 191 , 193 n rmal values, e19t a ess ry rgans, 618619, 618t, 619
Lateral ssure, 263 L wer es phageal sphin ter (LES), 502 bulb urethral glands, 623
Latissimus d rsi, 229t, 232, 233 , 233t L wer extremity, 191194 dis rders, 624627
Leber hereditary pti neur pathy, e10t, arteries in, 410t in ertility and sterility, 624625
685b b nes, 191194, 194t penis and s r tum, 625627
Le t atri ventri ular valve, 381 mus les , 234, 234t pr state, 625
Le t heart ailure, 395 veins in, 411t testes, 625
Le t hyp h ndria regi n, 10 L wer respirat ry tra t, 460, 460 , 466473 essential rgans, 618, 618t
Le t ilia regi n, 10 in e ti n, 470471 external genitals, 623624, 624
Le t lumbar regi n, 10 lung an er, 473 pr state gland, 623
Le t ventri ular assist systems (LVAS), 104 bstru tive pulm nary dis rders, 471473 repr du tive tra t, 618
Leg restri tive pulm nary dis rders, 471 seminal vesi les, 619 , 623
b nes, 193 Lumbar pun ture, 272b, 273 testes, 619622
f exi n and extensi n , 229 Lumbar regi n, 12t, 17 Male skelet n, 194
mus les , gr uped a rding t un ti n, Lumbar vertebrae, 186 , 267 Malignant hyperthermia (MH ), 545546
229t Lumpe t my, 637 Malignant melan ma, 164, 164
Legi nnaires disease, e2t Lungs, 98 , 380 , 413 , 469, 469 warning signs, 164t
Lens, 294 , 295296 an er, 473 Malignant tum rs, 62
Leptin, 322323t, 339 ex hange gases in, 473 mpared with benign tum rs, 128129,
Lesser urvature, 504 pH ntr l me hanisms and, 604 129t
Leukemia, 363364 and pleurae, 469470 Malleus, 183t, 304
a ute lymph yti , 363364, 364 water utput, 586 Mal lusi n, 499b, 499
a ute myel id, 364 Lunula, 153 Mammary dysplasia, 632b
 Index I-13

Mammary glands, 100 Mental ramen, 184 M ns pubis, 632

Mammary regi n, 12t Mesentery, 496, 516 M n a e, 334
Mandible, 94 , 183t Mes derm, 657, 658t M rbillivirus, e1t
Manganese (Mn), 541t Messenger RNA (mRNA), 35, 57t M rula, 654, 655
Manubrium, 189 Metab li a id sis, 607 M tility, 494, 495t
Marasmus, e10t Metab li alkal sis, 607 M tility dis rders, 514
Massage, mus le, 228b Metab li b ne diseases, 201202 M ti n si kness, 307
Masseter, 232 , 232t ste p r sis, 201 M t r neur ns, 225, 250, 254
Maste t mies, 434 Paget disease, 202, 202 s mati , 276
Master gland, 326 ri kets and ste mala ia, 201202 M t r unit, 225, 226
Masters, W illiam, 639b, 639 Metab li dis rders, 542544 M uth, 99 , 496501
Masti ati n, 497 Metab li imbalan es, 542543 dis rders , 499501, 500
mus les , 232 Metab li me hanisms, disease, 116 salivary glands in, 498499, 499
Mastitis, 663664 Metab li rates, 541542, 542 stru ture , 496497, 497
Mast id pr ess temp ral b ne, 184 Metab lism teeth in, 497498, 498
Mast iditis, 181, 185 arb hydrate, 535537 M vement
Matrix, 72 at, 537538 pr du ed by mus les, 223224
b ne, 179 nutriti n and, 532553 v luntary mus ular, 223
Matter, 25 pr tein, 538 Mu utane us jun ti n, 147
Maxilla, 94 , 183t Meta arpal b nes, 94 , 190191, 190t Mu sa
Maxillary sinus, 185 , 462 Metaphase, 5960 digestive tra t, 495 , 496
Maximum xygen nsumpti n (VO 2 max), Metastasis, 129, 130 respirat ry, 461, 461
480b, 480 Metatarsal b nes, 94 , 193, 194t, 195 Mu sal immunity, 445b
M Burney p int, 516 Metaz a, path geni , 124 Mu us membranes, 147
Mean rpus ular v lume, bl d, e19t Methyl gr ups, 688 urethral, 564
Measles, e1t Metri system, 4b Multiple births, 661, 661
Me hani al digesti n, 517 Mi r bi me, 513 Multiple myel ma, 363, 363
Me hanisms disease, 115117 Mi r ephaly, 664b Multiple neur br mat sis, e10t, 252 , 253,
Me han re ept rs, 292 Mi r yti RBCs, 355 687t
Medial dire ti n b dy, 7, 8 Mi r glia, 251252, 251 Multiple s ler sis (MS), e9t, 225, 252253,
Medial epi ndyle, 191 , 193 Mi r nutrients, 538541 252
Median ubital vein, 411 minerals in, 540541, 541t Mumps, e1t, 500b, 500
Median nerve, 236, 236 vitamins in, 538540, 540t Murmurs, heart, 384
Mediastinum, 9, 469 Mi r s pi stru ture Murray, J seph E, 165
Medi al imaging, b dy, 132 , 133b, 133 b nes, 177 Mus le bers
Medi al ma hines, r rgan repla ement, kidneys, 557559 ntra ti n , 222
103104 Mi r s py, 76b, 76 sl w and ast, 224b, 224
Medi al terms M icrosporum rganisms, 123t stru ture , 221222
mbining v wels in, e12 Mi r villi, 4849, 508 Mus le hypertr phy, 228
learning and using, e12, e12t Mi turiti n, 565566 Mus le spindle, 292t
pluralizati n , e12, e12t Midbrain, 261 , 264t Mus le stimulus, 225
pre x , e12, e13t Middle n ha ethm id, 184 Mus le tissue, 8183
r t , e12, e16t Middle ear, 303 , 304 ardia , 82, 82t, 83 , 220
su x , e12, e14t Middle phalanx, 192 skeletal, 8182, 82 , 82t, 220
Medulla, h rm nes , 322323t Midsagittal plane, 9 sm th, 8283, 82t, 83 , 220
Medulla bl ngata, 260, 261 , 264t Milliequivalent (mEq), 590 Mus le t ne, 222223, 224
Medullary avity, 177 Mineral rti ids (MCs), 332 Mus les, 9495
Medullary rhythmi ity area, 475476 Minerals, 540541, 541t un ti n , 223b
Mei sis, 681, 682 Mis arriage, 662 Mus ular dis rders, 235237
Melanin, 149, 295 Mit h ndria, 46t, 47 in e ti ns, 235
Melan ytes, 149 aging and, 668 injury, 235
Melan ma, 129, 164 Mit h ndrial DNA, 685b, 685 mus ular dystr phy, 236237
Melat nin, 262, 322323t, 338 Mit h ndrial inheritan e, 685b, 685 myasthenia gravis, 237
Membranes, 144173 Mit h ndri n, 251 Mus ular dystr phy (MD), 236237
b dy, 145147 Mit sis, 5960 Mus ular system, 9495, 95 , 218247
lassi ati n , 145146 Mitral valve Mus ularis, 495 , 496
Membran us labyrinth, 304, 305 pr lapse, 383, 383 Mutagens, 684
Mem ry, innate and adaptive immunity, 436t sten sis, 383 Mutati ns, geneti , 684
Mem ry ells, 442 , 444 M des sensati n, 293294 Myalgia, 235
Menar he, 633 M lars, 497 Myasthenia gravis (MG), e9t, 237
Mendel, Greg r, 694b, 694 M le ules, 2627 My sis, e4t
Mnire disease, 307 hydr gen, 28, 29 Myelin sheath, 251
Meninges, 268269 M n l nal antib dies, 440 Myel id tissue, 352
Meningitis, e2t, 269 M n ytes, 351t, 362 Myel ma, 129
Men pause, 631, 670 n rmal values, e19t My ardial in ar ti n, 406
Menstrual y le, 633635, 633 M n sa haride, 31 My ardium, 381, 381
ntr l , 634 , 635 M n s my, 686 My laments, thi k and thin, 221, 221
phases , 634, 634 M n zyg ti twins, 661 My metrium, uterus, 630631
I-14 Index

My pia, 299, 300 Neur mus ular jun ti n (NMJ), 225 O upati nal health pr blems, 236b
My sin-a tin r ssbridges, 223 Neur ns, 250 O ular albinism, e10t
My sitis, 235 aut n mi , 275 O ul m t r nerve (CN III), 271t, 272
Myxedema, 330, 330 stru ture , 250, 251 O d r, urine, e22t, 568t
as aut immune diseases, e9t types , 250 O spring, pr du ing, 617618
as end rine nditi ns, e7t Neur s ien e, 279b O lder adulth d, gr wth and devel pment,
Neur transmitters, 257258 667, 667
N aut n mi , 277278, 278 O le ranal regi n, 12t
Naegleria owleri, 124 Neutr phils, 351t, 362 O le ran n pr ess, 191
Nails, 153154 n rmal values, e19t O l a t ry nerve (CN I), 271t, 272
variati ns in, 153154, 153 Nevus, 129 O l a t ry re ept rs, 308, 308
Naris, 463 Newb rn O lig dendr ytes, 251 , 252
Nasal b ne, 183t, 184 , 463 b ne devel pment in, 180 O lig spermia, 625
Nasal avity, 98 , 460 hem lyti disease , 361 O liguria, 563
Nasal regi n, 12t Nia in, 540t O n genes, 130, 688b
Nasal septum, 462 Night blindness, e10t, 301 O ny h lysis, 153154, 154
Nas pharynx, 460 , 462, 463 Nitri xide (NO ), 258 O genesis, 628629, 629
Natural killer ells, 442 Nitrite, in urine, e22t O ph re t my, 629
Nausea, e6t, 505 Nitr gen base, 35 O pen ra tures, 203
Navi ular b ne, 194 Nitr gly erin, 394b O phthalmi regi n, 12t
Nearsightedness, 299, 300 N turnal enuresis, 567 O phthalm s pe, 296, 299
Ne k N de Ranvier, 251 O pp rtunisti invasi n, path gens spread by,
arteries in, 410t N n-genital herpes vesi les, 158159t 125
mus les , 232, 232 , 232t N n-H dgkin lymph ma, 435 O pti disk, 297, 299
sagittal se ti n, 463 N ndisjun ti n, 685686, 687 O pti nerve (CN II), 271t, 272
t th, 498, 498 N ninf ammat ry j int disease, 204205 O ral avity, 98 , 185 , 462 , 496497
Needle bi psy, r kidney, 569 N nspe i immunity, 436 O ral regi n, 12t
Negative eedba k, 15, 15 , 324, 324 N nster id h rm nes, 320321 O rbi ularis uli, 232 , 232t
Nemat des, 124t N nster idal antiinf ammat ry drugs O rbi ularis ris, 232, 232 , 232t
Ne natal devel pment, riti al peri ds , 659 (NSAIDs), r gastri ul er, 505 O rbital regi n, 12t
Ne natal peri d, 665, 665 N repinephrine (NE), 257258, 322323t, O rbitals, energy levels , 2526
Ne nat l gy, 665 333 O rgan C rti, 304, 305
Ne plasms, 62, 116 N rm yti RBCs, 354, 355 O rgan repla ement, 101105
benign and malignant, 128130, 129 N se, 462 arti ial rgans, 101104
Nephritis, 570 N s mial in e ti ns, 571b n nvital, 101103
Nephr n l p, 557558, 558 , 559 , 560 , 562t Nu lear envel pe, 50 vital, 103104
Nephr ns, 557, 558 Nu lear p res, 50 O rgan systems, 93100
and urine rmati n, 560, 560 , 562t Nu lei a ids, 35 applying n epts in, 101
Nephr ti syndr me, 570 Nu le lus, 46t, 50 ardi vas ular, 9697, 97
Nerve endings, 292t Nu le plasm, 50 digestive, 9899, 99
Nerve ber Nu le tides, 56 end rine, 96, 96
myelinated, 257 mp nents , 35t gr uping , 102103t
unmyelinated, 257 Nu leus, 25 integumentary, 9394, 94
Nerve gr wth a t r (NGF), dis very , ell, 46t, 4950, 251 lymphati and immune system, 9798,
670b Nutrients, dietary s ur es , 534535 98
Nerve impairment, 307 Nutriti n mus ular, 9495, 95
Nerve impulses, 255256, 255 de niti n , 533 nerv us, 95, 96
Nerve signals, 253259 metab lism and, 532553 repr du tive, 99100, 100
Nerves, 253 Ny tal pia, e10t, 301. see also Night blindness respirat ry, 98, 98
spinal, 267 skeletal, 94, 94
Nerv us system, 95, 96 , 248289 O urinary, 99, 99 , 554581
ells , 250253 O besity, 543 O rganelles, 44
nerve impulses, 255256 O bligate intra ellular parasites, 121 O rgani hemistry, 3135
rgans and divisi ns , 249250, 250 O blique earl be reases (Franks sign), 303 O rganism, 5
ref ex ar s, 253255 O blique ssure, 469 O rgan genesis, 658
synapses, 256259 O blique ra ture, 204 O rgans
Nerv us tissue, 82t, 83, 84 O blique planes, 9 des ripti n , 6
dis rders , 252253 O bstru tive kidney dis rders, 567569 engineered, 104, 104
regenerati n and, 85 renal al uli, 567, 569 innervati n , by ANS, 275
Neuralgia, trigeminal, 273 tum rs, 567569 maj r b dy avities, 11
Neurilemma, 251 O bstru tive pulm nary dis rders, 471473, male repr du tive, 618t
Neur blast ma, 279 472 sense. see Sense rgans
Neur end rine system, 102103t O ipital artery, 410 urinary system, 556
Neur geni sh k, 421 O ipital b ne, 94 , 183t, 184 , 185 vital/n nvital, 101
Neur glia, 250 O ipital l be, 263 O rigin mus le, 221 , 232t
Neur hyp physis, 326 O ipital regi n, 12t O r pharynx, 460 , 463
Neur ma, 253 O ipital vein, 411 O rth d nti s, 499b
 Index I-15

Osm lality Pan reati veins, 412 Pelvi inf ammat ry disease (PID), e2t, 636,
bl d, e19t Pan reatitis, 511512 640t
urine, e22t Pant theni a id, 540t Pelvi regi n, 12t
Osm sis, 51t, 52, 52 Papani la u test, 132, 638, 638 Pelvis, male and emale, 194195, 195
Osm ti balan e, 52, 53b, 53 Papilla(e), 307, 497 Peni illin, 571b
Osm ti pressure, 52 ir umvallate, 307 Penis, 100 , 619 , 624
Ossi les, 304 dermal, 150 dis rders , 625626
Ossi ati n, end h ndral, 179, 180 du denal Pepsin, 518
Osteitis de rmans, 202 maj r, 506 Pepsin gen, 518
Oste arthritis, 204205, 206 min r, 506 Peptide b nds, 33
Oste blasts, 177179 renal, 557 Per rating bers, b ne, 178
Oste lasts, 177179 Papillary layer skin, 150151 Peri ardial e usi n, 382
Oste ytes, 179 Papillary mus le, 381 Peri ardial spa e, 381
Oste genesis imper e ta, e10t, 202, 203 , 687t Papill ma, 129 Peri arditis, 381382
Oste ma, 129 Papule, 155, 158159t Peri ardium, 381382
Oste mala ia, e10t, 201202 Para rine, 325 Perilymph, 304, 305
Oste myelitis, 202, 204 Paralysis, spasti , 265 Perineal regi n, 12t
Oste ns, 177, 178 Paramammary n des, 434 Perineum, 633, 633
Oste p r sis, e7t, 201, 201 Paramyx virus, e1t, 119t Perineurium, 253
Oste sar ma, 129, 200 Paranasal sinuses, 185 , 462, 462 Peri d ntal ligament, 501
O titis, external, e2t, 303b Paraphim sis, 624 Peri d ntal membrane, 498
O titis media, 304, 304 Paraplegia, 265 Peri d ntitis, 501
O t s ler sis, 307 Parasternal lymph n des, 430 Peri steum, 177
O t s pe, 303304, 304 Parasternal n des, 434 Peripheral nerve bers, 253
O va, 681 Parasympatheti divisi n, aut n mi Peripheral nerv us system (PNS), 95, 260 ,
O varian lli les, 336, 627 nerv us system, 277 270274
O varies, 96 , 100 , 320 , 655 Parathyr id glands, 329 , 331 ranial nerves, 270
an er, 637 Parathyr id h rm ne (P H ), 176, 322323t, dis rders , 273274
un ti ns , 628629 331, 331 spinal nerves, 270273
h rm nes , 322323t Parathyr ids, 96 Peristalsis, 496, 496
r le in menstrual y le, 634 Parietal b ne, 94 , 183t Perit neal spa e, 516
stru ture and l ati n , 627628, 628 Parietal l be, 263 Perit neum, 516517, 516
O vera tive bladder, 570 Parietal peri ardium, 381, 381 Perit nitis, 517
O verf w in ntinen e, 566 Parkins n disease, e10t, 259 Permanent teeth, 497, 666
O verhydrati n, 589 Parkins nism, 259, 259 Perni i us anemia, 359
O vulating h rm ne. see Luteinizing h rm ne Par tid glands, 499 as aut immune diseases, e9t
(LH ) Parr t ever, e2t as de ien y diseases, e10t
O vulati n, 634635, 634 , 655 Partial pressure (P), 478 Per neus brevis, 231
O vum, 655 Partial-thi kness burns, 160, 160 Per neus l ngus, 231
O xygen Parturiti n, 658, 660 Perpendi ular plate ethm id, 184
in bl d ir ulati n, 385 Passive immunity, 438 Pers n-t -pers n nta t, path gens spread
bl d transp rtati n , 481 Passive transp rt pr esses, 5153, 51t by, 125
O xygen debt, 225 di usi n, 5152, 51 , 51t Pertussis, e2t
O xyhem gl bin (H bO 2), 354 thr ugh membrane, 52 pH , 30
O xyt in (O ), 322323t, 328 ltrati n, 51t bl d, e19t
Pat h, dermal, 158159t b dy f uids, 601602
P Patella, 94 , 191193, 194t ntr l
P-arm, 680 Patellar ligament, 254 integrati n , 603
P wave, 389 Path geni rganisms and parti les, in disease, me hanisms r, 602603
Pa emaker, 103 117124 imbalan es , 607
Pa emaker, arti ial, 390, 392 ba teria, 120122, 121 , 121t mpensati n r, 609610
Pa ked- ell v lume (PCV) test, 353 ungi, 123, 123 , 123t unit, 602
Paget disease, 202, 202 path geni animals, 124, 124t, 125 urine, e22t, 568t
Pain re ept rs, 292 pri ns, 120, 120 pH s ale, 30
Palate, 435 pr t z a, 123124, 123t, 124 use , 601602, 602
hard, 463 viruses, 118120, 118 , 119t Phag ytes, 440441
s t, 463 Path l gy, 3 Phag yt sis, 5455, 54t, 55 , 362 , 439 , 441
Palatine b ne, 183t Path physi l gy, disease, 115117 Phalanges, 190t, 194t
Palatine t nsils, 435, 435 , 463, 463 Patterns disease, 114115 t, 193
Palmar regi n, 12t Pco 2, bl d, e19t hand, 94 , 190191
Palpable b ny landmarks, 192b Pe tineus, 231 Pharyngeal t nsils, 435, 435 , 463
Pan reas, 99 , 412 , 511512, 512 Pe t ralis maj r mus le, 95 , 229t, 231 , 232, Pharyngitis, 465
Pan reati islets, 96 , 334336, 335 , 511 233t Pharynx, 98 , 99 , 460, 460 , 462464, 501502
h rm nes , 322323t Pedal regi n, 12t un ti n , 502
Pan reati jui e, 511 Pedigree, 690, 690 stru ture , 501502, 502
Pan reati se reti ns, s dium- ntaining, Pellagra, e10t Phases menstrual y le, 634, 634
591 Pelvi girdle, 190 Phenylalanine hydr xylase, 686687
I-16 Index

Phenylket nuria (PKU), e10t, 686688, P ly ysti kidney disease (PKD), 572573, Presby usis, 307
687t 573 Presby pia, 299300, 669
Phim sis, 624 adult, 573 Pressure gradient, in bl d f w, 415
Phlebitis, 408 P ly ysti vary syndr me (PCOS), 637, 637 Pressure s re, 158159t
Phleb t mists, 420 P ly ythemia, 358, 416 Presynapti neur n, 256
Ph sphate, 32 P lydipsia, 562 Primary amen rrhea, 635
Ph sph lipid bilayer, 32, 33 P lyend rine dis rders, 325 Primary audit ry area, 263
Ph sph lipids, 44 P lyps, nasal, 462 Primary dysmen rrhea, 635
n rmal values, e19t P lysa harides, 31, 72 Primary germ layers, 657
Ph sph rus (P), 541t P lyuria, 563 Primary s mati sens ry area, 263
n rmal values, e19t P ns, 260, 261 Primary spermat yte, 620, 621
Ph t pigment, 301 respirat ry ntr l enters, 476 Primary taste area, 263
Ph t re ept r ells, 297, 298 P ntine respirat ry gr up (PRG), 476 Pri ns, 120, 120
Ph t re ept rs, 292 P pliteal artery, 97 , 410 , 419 Pr geria, 667, 667b, 667
Physi al allergy, e6t P pliteal lymph n des, 430 Pr gerin, 667b
Physi l gy, 3 P pliteal regi n, 12t Pr gester ne, 322323t, 629, 634
Pia mater, 268, 269 P pliteal vein, 411 Pr la tin (PRL r la t geni h rm ne),
Pigment layer skin, 155 P pulati n pr je ti ns, by age gr up, 665t 322323t, 327
Pineal gland, 96 , 261 , 262, 264t, 338 P rk tapew rm in estati n, e5t Pr la tin ma, 327
h rm nes , 322323t P rt-wine stain, 151 Pr lapse, mitral valve, 383, 383
Pinna, 302, 303 P rtal hypertensi n, 511 Pr nati n, 228, 230
Pin yt sis, 54t, 55 P sitive eedba k, 1516, 16 , 324 Pr ne, 7
Pinw rm in estati n. see Enter biasis P sitr n emissi n t m graphy (PE ) s an, 26 Pr phase, 59
Pitting edema, 590b, 590 P st n ussi n syndr me, 264 Pr pri ept rs, 293
Pituitary dwar sm, e7t P steri r dire ti n b dy, 7, 8 Pr staglandin therapy, 326b
Pituitary gland, 96 , 261 , 320 , 326328 P steri r pituitary gland h rm nes, 328, 328 Pr staglandins (PGs), 325326
h rm nes , 322323t P steri r tibial artery, 419 Pr state an er, 625
anteri r pituitary, 326327 P steri r tibial vein, 411 dete ting, 626b
p steri r pituitary, 328 P stgangli ni neur ns, 275 Pr state gland, 100 , 565 , 619 , 623
r le in menstrual y le, 634 P stnatal peri d, 664667 dis rders , 625
stru ture , 326 adulth d, 666667 Pr state t my, 625
Pituitary stalk, 326 hildh d, 666 Pr stati hypertr phy, benign, 625
Piv t j ints, 199 in an y, 665666 Pr stheses, 103
Pla enta, 337338, 654656, 656 , 660 lder adulth d, 667 Pr tein- al rie malnutriti n, e10t, 543544,
etal side , 413 P stpartum dis rders, 663664 543t, 544
h rm nes , 322323t P stsynapti neur n, 256 Pr tein exp rt system, 48
maternal side , 413 P sture, 224 Pr teins, 3334, 34
Pla enta previa, 662, 662 P tassium i ns, urine v lume, 562 bl d, 350
Planes b dy, 89, 8 P tassium (K), 541t mplement, 440
Plantar f exi n, 229, 230 imbalan e, 592, 592t digesti n , 518519
Plantar regi n, 12t n rmal values, e19t metab lism , 538, 538
Plaque, 406 in urine, e22t n rmal values, e19t
ather s ler ti , 407 , 539 Pre apillary sphin ters, 404 plasma membrane, 44
dermal, aused by ri ti n, 158159t Pre entral gyrus, 263 synthesis , 5759, 58
Plasma Pree lampsia, 662 disease and, 5859
antib dies, 356 Preexisting nditi ns, as risk a t r r Pr teinuria, 570
bl d, 349, 350351 disease, 117 a ter exer ise, 567b
v lume values, e19t, 584 , 585t Pre x, medi al terms, e12, e13t Pr te gly ans, 72
Plasma ells, 362, 442443 Pre r ntal ass iati n area, 263 Pr te me, 680
Plasma membrane, 4445, 44 , 46t Pregangli ni neur ns, 275 Pr te mi s, 680
sele tively permeable, 52 Pregnan y Pr thr mbin a tivat r, 365, 366
Plasma pr teins, 534, 588 antenatal diagn sis and treatment, 663b, Pr thr mbin time (P ), 366
Plasmids, 692693 663 Pr t z a, path geni , 123124, 123t, 124
Platelet unt, bl d, e19t dis rders , 662664 Pr ximal nv luted tubule (PC ), 557, 558 ,
Platelet plug, 365, 366 e t pi , 631b 559 , 560 , 562t
Platelets, 365 in rease in skin pigmentati n, 150 Pr ximal dire ti n b dy, 7, 8
Platyhelminths, 124, 124t, 125 length, 658b Pr ximal phalanx, 194
Pleura, lungs and, 469470 stages lab r, 660 , 661 Pseud genes, 680
Pleurisy, 146, 470 Premature ntra ti ns, 390 Pseud strati ed lumnar epithelium, 77
Pli ae, 508 Premenstrual syndr me (PMS), 636 Pseud strati ed epithelium, 76, 77
Pluralizati n, medi al terms, e12, e12t Prem lars, 497 iliated, 461
Pneum nia, e1t, e2t, e6t, 471 Prem t r area, 263 Psitta sis. see Parr t ever
Pneum th rax, 470, 470 Prenatal peri d, 654658 Ps riasis, 162
Po 2, bl d, e19t ertilizati n t implantati n, 654, 655 Pteryg id pr ess sphen id, 184
P is ning, e6t rmati n primary germ layers, 657 Pubi angle, 195
P larizati n, 255256 hist genesis and rgan genesis, 658 Pubi ( rab) li e, 640t
P li myelitis, e1t, 235 peri ds devel pment, 656 Pubis, 191
P li virus, 118 Prepu e, 619 Publi health, 126b
 Index I-17

Puerperal ever, 663 hem gl bin, 354 external genitals, 632633, 633
Pulm nary arteries, 481 RBC unt, 353 all pian tubes, 630
Pulm nary artery, 97 , 380 , 381 , 410 n rmal values, e19t menstrual y le, 633635, 633
Pulm nary apa ities, 476t in urine, e22t varies, 627628, 628
Pulm nary ir ulati n, 384, 385 , 408409 stru ture and un ti n , 352353 stru tural plan, 627
Pulm nary emb lism, 366 , 408 Red bers, 224 uterus, 630631, 630
Pulm nary gas ex hange, 478479 Red-green l r blindness, e10t, 684, 687t vagina, 628 , 631
Pulm nary semilunar valve, 381 , 383 Re erred pain, 296297b, 296 Repr du tive system, male, 618624, 619
Pulm nary stret h ref exes, 477 Ref ex a ess ry glands, 623, 623
Pulm nary trunk, 413 , 470 emptying, 566 dis rders, 624627
Pulm nary veins, 380 , 381 , 411 , 470 , 479 knee-jerk, 254 in ertility and sterility, 624625
Pulm nary ventilati n, 473478 Ref ex ar s, 253255 penis and s r tum, 625627
v lumes, 476 Ref ex in ntinen e, 566567 pr state, 625
Pulm nary v lumes, 474475, 476t Ref ux, 503, 503 testes, 625
Pulse, 419, 419 Re ra ti n, 297, 300 eja ulat ry du t and urethra, 619 , 623,
Punnett square, 690, 692 Re ra ti n dis rders, 297301 623
Pupil, 295, 295 Regenerati n, tissue and, 8384 epididymis, 620 , 622
Pustule, 155, 158159t Regi ns b dy, 13 external genitals, 623624, 624
Pyel nephritis, 570 Regulati n, 495t, 502 stru tural plan , 618619
a ute, 570 Regulat ry ells, 443 testes, 619622
hr ni , 570 Reje ti n vas de erens, 619 , 622623
Pyl ri nditi ns, 505 gra ted tissues, 447 Residual v lume (RV), 475, 476
Pyl ri sphin ter, 504 , 505 immune, transplants, 104105 Resistan e
Pyl ri sten sis, 505 Reje ti n syndr me, 446447 antibi ti , 127
Pyl r spasm, 505 Relative nstan y, 14 t bl d f w, 416
Pyl rus, st ma h, 504, 504 Relaxati n, ventri ular, 386 Respirati n
Pyrid xine, 540t Releasing h rm nes (RH s), 322323t, brainstem ntr l , 475476
328329 breathing patterns, 477478
Q Renal artery, 104 , 410 , 559 ex hange gases, in lungs, 473
Q angle, 206207b, 206 Renal al uli, 567, 569 me hani s breathing, 473474
Q-arm, 680 Renal ell ar in mas, 567 verview , 474
Q ever, e2t Renal li , 567 regulati n , 477
QRS mplex, 389 Renal lumns, 557 r le in ntr lling pH , 606
Q uadri eps em ris mus le gr up, 229t, 231 , Renal rpus le, 557, 558 , 559 Respirat ry a id sis, 608
234, 234t Renal rtex, 557 and ardia arrest, 609b
Q uadri eps mus le, 254 Renal insu ien y, 573 Respirat ry alkal sis, 609
Q uadriplegia, 265 Renal medulla, 557 Respirat ry distress syndr me, 468469
Renal papilla, 557 Respirat ry medi ine, 482b
R Renal pelvis, 557 Respirat ry ref exes, 476477
Rabies, e1t Renal pyramids, 557 Respirat ry system, 98, 98 , 458491
Radial artery, 410 , 419 Renal sinuses, 557 aging e e ts in, 669670
Radial pulse, 419 Renal thresh ld, 562 alve li, 467468, 467 , 468
Radial tuber sity, 191 Renal tubule, 557558 bl d transp rtati n gases, 480
Radial vein, 411 Renal tum rs, 569 br n hi les, 467, 467
Radiati n, 544, 544 Renal vein, 104 , 411 , 556 , 559 larynx, 460, 460 , 463 , 464
Radiati n si kness, 26b, e6t, Renin-angi tensin-ald ster ne system lungs and pleura, 470
Radiati n therapy, 134 (RAAS), 563, 564 n se, 462
Radi a tive is t pes, 26b, 26 Rep larizati n, 256 pharynx, 462464
Radi requen y ablati n, 636 ventri ular, 389 respirat ry mu sa, 461, 461
Radi graphy, 105b, 131, 131 Repr du ti n, 99100 stru tural plan , 460461, 460
Radius, 94 , 190, 190t, 191 ellular, 5960 systemi gas ex hange, 480
Ramn y Cajal, Santiag , 309b, 309 hanges in, 6062, 61 tra hea, 466, 466
Rash, in SLE, 446 sexual, 617618 Respirat ry tra t, 460461
Rati nal drugs, 133134 Repr du tive du ts l wer, 460, 460
Raynaud phen men n, 414b, 414 emale, 630631 in e ti n, 470471
Reabs rpti n, in urine rmati n, 561562 male, 622623 lung an er, 473
Re ept rs, 258259 Repr du tive in ertility, e9t bstru tive pulm nary dis rders,
in skin, 151154 Repr du tive system, 99100, 100 , 616651 471473
Re essive gene, 682 aging e e ts in, 670 restri tive pulm nary dis rders, 471
Re essiveness, 682683 anal g us eatures , 639, 639t upper
Re tum, 99 , 512513, 619 , 628 Repr du tive system, emale, 627635, 628 anat mi al dis rders, 465466
Re tus abd minis mus le, 95 , 231 , 233 , 233t a ess ry glands, 627t, 628 , 631632 in e ti ns (URI), 460461, 464465
Re tus em ris mus le, 95 , 229t, 234t dis rders , 635639 Respirat ry virus, 118
Red bl d ells (RBCs), 352358, 352 h rm nal and menstrual, 635636 Restri tive pulm nary dis rders, 471
abn rmalities , 354355, 355 in e ti n and inf ammati n, 636637 Reti ular rmati n, 260, 261
dis rders , 358361 in ertility, 638639 Reti ular layer, skin, 151
anemia, 358361 tum rs and related nditi ns, Reti ular tissue, 78, 79 , 79t
p ly ythemia, 358 637638 Reti ul yte unt, bl d, e19t
I-18 Index

Retina, 296, 298 Salm nell sis, e2t Sens ry re ept rs, 291
dis rders , 301302 Saltat ry ndu ti n, 257 respirat ry ntr l enters, 476, 477
Retinal degenerati n, 301302 Salts, 31 skin, 154
Retinal deta hment, 299 , 301 San J aquin ever. see C idi id my sis types , 292293
Retinitis pigment sa, e10t Sar mas, 129 Septi sh k, 421
Retr perit neal l ati n Sar mere, 221222 Septi emia, e1t
de niti n , 516 SARS-ass iated r navirus (SARSC V), Ser sa, 495 , 496
kidneys, 556 119 Ser t nin, 257258
Rh in mpatibility, 361 Sart rius mus le, 95 , 229t, 231 , 234t Ser t nin-spe i reuptake inhibit rs (SSRIs),
Rh-negative bl d, 356 Saturated atty a ids, 32 258
Rh-p sitive bl d, 356 S ab, 158159t Ser us membranes, 146147, 147
Rh system, 356 S abies, 161, 640t Serum hepatitis, 510
Rheumati ever S apula, 94 , 190, 190t Serum values, e19t
as aut immune diseases, e9t S ars, 8384 Severe a ute respirat ry syndr me (SARS),
as ba terial nditi ns, e2t Schistosoma rganisms, 124t 119
as viral nditi ns, e1t S hist s miasis, e5t Severe mbined immune de ien y (SCID),
Rheumati heart disease, 383 S hwann ell, 226 , 250, 253 e10t, 447, 687t, 693
Rheumat id arthritis, e9t, 205 multiple tum rs , 252 Severity burns, 157, 161
Rhinitis, 464465 S iati nerve, 237 Sex hara teristi s, se ndary, 666
Rhin virus, e1t, 118 , 119t inf ammati n , 273 Sex hr m s mes, 681
Rib, 94 S ienti meth d, 4, 4 Sex determinati n, 683
Rib f avin, 540t S lera, 295 Sex glands, 336
Rib nu lei a id (RNA), 35, 35t, 57 S ler derma, 162 emale, 631632
regulat ry, 57 S li sis, 188 male, 623, 623
types , 57t S rat h, 158159t Sex h rm nes, 332
Rib nu lei a id (RNA) virus, 118 , 119t S reening, an er, 101b Sex-linked inheritan e, 684
Rib s mal RNA, 57t S r tum, 100 , 619, 619 Sex-linked traits, 683684
Rib s mes, 46t, 47 dis rders , 626627, 627 Sexual repr du ti n, 617618
Ribs, 189, 473474, 556 S urvy, e10t, 539, 540 Sexually transmitted diseases (S Ds), 640t
Ri kets, e10t, 201202, 201 Seas nal a e tive dis rder (SAD), 338 Sexually transmitted in e ti n (S I), 640
Rickettsia rickettsii, 127t Seba e us glands, 154155 Shape and size
Right atri ventri ular valve, 381 Sebum, 154 ba teria, 121
Right li f exure, 512513 Se nd-degree burns, 157160 ells, 4344
Right heart ailure, 394 Se nd-messenger systems, 320b Shigell sis, e2t
Right hyp h ndria regi n, 10 Se nd messengers, 321 Shingles, e1t, 273
Right ilia regi n, 10 me hanism, 320321 Sh k, ir ulat ry, 421
Right lumbar regi n, 10 Se ndary amen rrhea, 635 Si kle ell anemia, e10t, 360, 360 , 683, 687t
Rig r m rtis, 223b Se ndary dysmen rrhea, 635 Si kle ell trait, e10t, 360, 687t
Risk a t rs Se ndary sex hara teristi s, 666 Sigm id l n, 512513
r disease, 117 Se reti ns, 494495, 495t Signal transdu ti n, 320b
r hypertensi n, 420421 gastri , 591 Signs and sympt ms, ti k-b rne diseases,
RNA inter eren e, 693 intestinal, 591 127t
R ky M untain sp tted ever, e2t, 127t pan reati , 591 Silent gallst nes, 509
R ds in urine rmati n, 562 Simple lumnar epithelium, 75, 75
ba terial, 121t Segmentati n, 496, 496 Simple ub idal epithelium, 75, 75
ph t re ept rs, 296 Seizure dis rders, 266 Simple g iter, 330, 330
Rntgen, W ilhelm, 105 Sel -antigens, 445 Simple squam us epithelium, 73
R t Sel -examinati n, r early signs an er, Single-gene diseases, 685, 686688
medi al terms, e12, e16t 131 Sinus dysrhythmia, 390, 391
t ngue, 497 Sella tur i a, 326 Sinuses, 181185
t th, 498, 498 Semen, 336 paranasal, 185 , 462, 462
R tati n, 228 Semi ir ular anals, 304, 305 renal, 557
j int, 199, 199t Semimembran sus, 231 , 234t Sinusitis, 462
R ugh end plasmi reti ulum, 47 Seminal vesi le, 619 Skeletal mus le, 220
R undw rm in estati n. see As ariasis Semitendin sus, 231 , 234t ntra ti n
Rubella, e1t Senes en e, 667 is metri , 226
Rugae, 504, 565, 565 Sensati n is t ni , 226
Rules nines, 161, 161 m des , 293294 m vements pr du ed by, 228230
by skin, 156 twit h and tetani , 225226
S Sense rgans, aging e e ts in, 669 e e ts exer ise n, 226228
Sa rum, 186187, 267 Senses, 290317, 309b un ti n , 222225
Saddle j ints, 199 lassi ati n , 291293 atigue, 224225
Sagittal plane, 8 , 9 general, 291, 292t, 293294, 293 heat pr du ti n, 224
Saliva integrati n , 309 integrati n with ther b dy systems,
pH , 602 sens ry pathways and, 293 225
s dium- ntaining, 591 spe ial, 292, 293t, 294309 m vement, 223224
Salivary amylase, 499 Sens r, 14 p sture, 224
Salivary glands, 99 , 498499, 499 Sens ry neur ns, 250 m t r unit, 225

mus le stimulus, 225
stru ture
mus le bers, 221222
mus le rgans, 220221
Skeletal mus le tissue, 8182, 82 , 82t
Skeletal system, 94, 94 , 174217
age di eren es, 195
aging e e ts, 668
dis rders , 200207
envir nmental a t rs, 195196
un ti ns , 175176
j ints, 196199
mi r s pi stru ture b nes, 177
m vement , 176
pr te ti n , 176
st rage , 176
types b nes, 176
Skeletal variati ns, 194196
Skelet mus ular system, 102103t
Skelet n, main parts , 181t
Skene glands, 631
Skin, 144173, 165b, 165
a ess ry stru tures
hair, 151153
nails, 151154
re ept rs, 151154
aging e e ts, 668
burns, 157161
an er, 163165
lesi ns, 164
l r hanges, 149150
dis rders , 156165
un ti ns , 155156
in e ti ns, 161, 162
lesi ns, 156157, 158159t
mi r s pi view , 148
ph t mi r graph , 149
pr te ti n in, 155
re ept rs, 154
repair, 157
seba e us glands, 154155
sense rgan a tivity, 155
stru ture , 148155
sweat glands, 154
synthesis vitamin D, 156
temperature regulati n, 155156
thi k and thin, 151
turg r , 588
vas ular and inf ammat ry dis rders,
161163
water utput, 586
Skull, 181185, 184 , 261
b nes , 183t
regi ns , 181
Sliding lament m del, 222
Small ba teria, 121, 121t
Small ardia vein, 411
Small intestine, 99 , 412 , 506509
stru ture , 506508, 507 , 508
Smallp x, 115, 115
Sm th end plasmi reti ulum, 47
Sm th mus le, 220, 277t
tra healis, 466
ureteral, 565
vein, 404
Sm th mus le tissue, 8283, 82t, 83
Snail ever. see S hist s miasis
Snu dippers p u h, 499500
Index I-19
S dium (Na), 541t Spleni vein, 411 , 412
imbalan e, 592, 592t Splen megaly, 435
internal se reti ns ntaining, 591 Sp ngy b ne, 80, 177, 178
n rmal values, e19t Sp ntane us ab rti n, 662
reabs rpti n , 561 Sp res, 122
in urine, e22t anthrax, 128b
S dium bi arb nate, 499 Sp r z a, 123124
bu ering a ti n , 605 Sprain, 235
S dium hl ride, 27, 28 Spread path gens
S dium-p tassium pump, 54, 54 envir nmental nta t, 125
S t palate, 463 , 496497 pp rtunisti invasi n, 125
S leus, 229t, 231 , 234t pers n-t -pers n nta t, 125
S lutes, 29 transmissi n by ve t r, 126
S luti ns, 29 Squam us ell ar in ma, 164, 164
S mati sens ry ass iati n area, 263 Squam us epithelium, 7374
S unds simple squam us epithelium, 73
heart, 380, 384 strati ed, 461
K r tk , 418 strati ed squam us epithelium, 7374, 74
Spasti paralysis, 265 Squam us suture, 184 , 185
Spe ial senses, 292, 293t, 294309 Stages hr ni renal ailure, 573
hearing and equilibrium as, 302307 Stages lab r, 660 , 661
smell as, 308309 Stagh rn al uli, 567
taste as, 307308, 308 Staining pr perties, ba teria, 120121
visi n as, 294297 Stapes, 183t, 304
Spe i gravity Staphyl al in e ti n, e2t
n rmal values, e19t Star h, 31
urine, 568t Stati equilibrium, 306, 306
Spe i immunity, 437 Statins, 539b
Spe i ity, innate and adaptive immunity, Stem ells, 61b, 61 , 657
436t r m rd bl d, 659b
Speed rea ti n, innate and adaptive in - ell devel pment, 444
immunity, 436t Sten sed valves, 383
Sperm, 620621, 621 Sten sis, mitral valve, 383
human, 622 Stents, 406
pr du ti n, redu ed, 625 Sterility, e7t
Spermatids, 620 Sterilizati n, in disease preventi n, 125t
Spermat genesis, 619620, 621 Stern lavi ular j int, 190
Spermat g nia, 619 Stern leid mast id mus le, 95 , 231 , 232,
Spermat z a, 619, 655 , 681 232 , 232t
Sphen id b ne, 183t, 184 Sternum, 94 , 189, 190t, 470
Sphen id sinus, 185 , 462 , 463 Ster id abuse, 325b
Sphin ters, 502 Ster id h rm nes, 33, 321, 321
anal, 514 Ster ids, 33, 33
es phageal, 502 Stillbirth, 662
pre apillary, 404 Stings, e5t
pyl ri , 504 , 505 St ma h, 99 , 412 , 504506, 504
urinary, 565, 565 an er, 506
Sphygm man meter, 418 dis rders , 505506, 505
Spinal avity, 9 un ti n , 505
Spinal rd, 96 , 261 , 266268 stru ture , 504
verings and f uid spa es, 268270, 269 Strabismus, 300301, 301
un ti ns , 268 Strains
stru ture , 266268, 267 , 268 mus le, 235, 235
Spinal nerves, 96 , 270273 mus ul tendin us unit, 205
Spinal tap, 272 Strati ed squam us epithelium, 7374, 74 ,
Spindle bers, 59 461
Spine, 186189 Strati ed transiti nal epithelium, 76, 77
Spin us pr ess Stratum rneum, 148 , 149
lumbar vertebra, 186 Stratum germinativum, 148 , 149
vertebral, 556 Strawberry hemangi ma, 151, 151
Spiral ra ture, 204 Strength, mus le, enhan ement , 227b
Spiral rgan, 304, 305 Stress, 332333, 333
Spir grams, 478t mus le tensi n indu ed by, 235
Spir meter, 474 as risk a t r r disease, 117
Spleen, 98 , 412 , 430 , 435 Stress ardi my pathy, 394
Splene t my, 435 Stress in ntinen e, 566
Spleni artery, 410 Stret h re ept r, 254
Spleni f exure, 512513 Stret h re ept r, pulm nary, 477
I-20 Index

Striae, skin, 158159t Systemi ir ulati n, 384, 385 T rax, 189

Striati ns Systemi gas ex hange, 480 arteries in, 410t
in ardia mus le ber, 220 Systemi inf ammati n, 135 b nes , 190t
in skeletal mus le ber, 220 Systemi lupus erythemat sus (SLE), e9t, 445 veins in, 411t
Str ke, e1t, 264, 407 Systems, des ripti n , 6 T readw rm in estati n. see ri hin sis
Str ke v lume, 393394 Syst le, 383 T ree-neur n ar s, 253254
Str ng a id, 3031 Syst li bl d pressure, 418, 420 T r mb yte, 351t, 365
Stru tural pr teins, 34 T r mb yt penia, 368
Stru ture- un ti n relati nships, ellular, 50 T T r mb phlebitis, 408
Stru ture skeletal mus le ells, 435, 443 T rush, 501
mus le bers, 221222 devel pment , 443, 444 T umb, m bility , 199
mus le rgans, 220221 un ti ns , 443 T ymine, 35
Stru ture skin, 148155 lymph yte, 351t, 362 T ym sin, 322323t, 337, 435
dermal-epidermal jun ti n, 148 , 150 wave, 389 T ymus gland, 96 , 98 , 320 , 337, 430 ,
dermis, 150151 a hy ardia, 390, 391 434435
epidermis, 149150 a tile rpus le (Meissner rpus le), 154, h rm ne un ti n and dys un ti n,
papillary layer, 150151 292t 322323t
pigment, 149150 alus, 194 T yr id artilage, 463 , 464
reti ular layer, 151 arget ell, 320 T yr id lli les, 329
stratum germinativum, 149 arget rgans, innervati n , by ANS, 275 T yr id gland, 96 , 320 , 329331, 329 , 464
sub utane us tissue, 151 arsal b nes, 94 , 194t h rm nes , 322323t, 329330
Styl id pr ess temp ral, 184 arsal regi n, 12t T yr id-stimulating h rm ne ( SH ),
Subat mi parti les, 25 aste buds, 307, 308 , 497 322323t, 326
Sub lavian arteries, 410 ay-Sa hs disease, e10t, 687t, 688 T yr xine ( 4), 321, 322323t
Sub lavian artery, 97 eeth, 497498, 498 ibia, 94 , 191193, 194t
Sub lavian vein, 411 , 430 typi al, 498, 498 ibial tuber sity, 193
Sub utane us tissue, 151 el phase, 60 ibialis anteri r mus le, 95 , 229t, 234, 234t
Sublingual glands, 499 emperature regulati n, by skin, 155156 i d ul ureux, 273
Submandibular glands, 499 emp ral b ne, 183t, 184 i k-b rne diseases, 127t
Submu sa emp ral l be, 263 idal v lume ( V), 474
digestive tra t, 495 , 496 emp ral mus le, 232 , 232t inea, e4t, 161
small intestine, 507 emp ral regi n, 12t issue h rm ne, 325
st ma h, 504 end n sheath, 220221 issue plasmin gen a tivat r ( PA r tPA),
Subs apular n des, 434 in arpal tunnel, 236 365, 394b
Sudden in ant death syndr me (SIDS), 478b end ns, 95, 95 , 220 issue typing, 45, 81b, 447
Sud ri er us glands, 154 extens rs ngers, 236 issues, 7091
Su x, medi al terms, e12, e14t en syn vitis, 236 bl d, 349350
Sunburn, and skin an er, 163b erat gens, 663 nne tive. see C nne tive tissue
Sunstr ke, 546 ermin l gy, disease, 113114 degenerati n , 116117
Super ial, de niti n , 7 est gr up, 4 des ripti n , 6
Super ial temp ral artery, 419 estes, 96 , 100 , 619622 elasti , 404
Superi r dire ti n b dy, 7, 8 dis rders , 625 engineered, 104, 104
Superi r mesenteri artery, 410 un ti ns , 619622 epithelial, 7276
Superi r mesenteri vein, 411 , 412 stru ture and l ati n , 619, 619 , 620 tness and, 84b, 84
Superi r vena ava, 97 , 380 , 381 , 411 , 413 esti ular an er, 625 maj r systemi arteries in, 410t
Supinati n, 228, 230 estis, h rm nes , 322323t maj r systemi veins in, 411t
Supine, 7 est ster ne, 227, 322323t, 336, 619 mus le, 8183, 220
Supplemental xygen, 462 pr du ti n , 621622 nerv us, 83
Supra lavi ular n des, 434 etani ntra ti ns, 225226 repair, 8385
Supra lavi ular regi n, 12t etanus, e2t pher l, 540t
Sur a e area, abs rpti n and, 520 T alamus, 262, 264t ngue, 99
Sur a tant-pr du ing ell, 468 T alassemia, e10t, 360361 base , 464
Surgery, r nary bypass, 386, 387 T erm re ept rs, 292 nsille t my, 463464
Sutures, 185 T erm regulati n, 544545, 544 nsillitis, 435, 463, 463
Sweat glands, 154 eedba k ntr l , 545 nsils, 98 , 430 , 435, 435 , 463
Swimmers ear, e2t, 303b. see also O titis, T iamine, 540t th de ay, 500
external T igh, mus les , gr uped a rding t phi, 303
Sympatheti divisi n, aut n mi nerv us un ti n, 229t tal lung apa ity, 476
system, 276277 T ird-degree burns, 160 tal metab li rate ( MR), 541, 542
Symphysis pubis, 196, 628 T irst, me hanism, 588 xi sh k syndr me, e2t, 421
Sympt mati gallst nes, 509 T ra i a rta, 410 xi l gists, 420
Synapses, 256259, 258 T ra i avity, ser us membranes , 146 x plasm sis, e5t
Synapti le t, 256 T ra i du t, 98 , 430 rabe ulae, 177, 178
Synapti kn b, 256 T ra i regi n, 12t ra hea, 98 , 380 , 460, 463 , 466, 466
Synarthr ses, 196 T ra i vertebrae, 186 , 187t, 189, 267 ra he br n hitis, 470471
Syn vial membranes, 147, 220 T ra lumbar system. see Sympatheti ra he st my, 465b, 465
Syntheti human insulin, 336b, 336 divisi n, aut n mi nerv us ra h ma, e2t
Syphilis, e2t, 640t system ra ts, 253
 Index I-21

ragus, 303, 303 in nerv us system, 253 Urethra, 99 , 100 , 565

raits renal, 569 emale, 628
hereditary, 682683 testi ular, 625 male, 619 , 623
sex-linked, 683684 types , 129130 Urethral syndr me, 569570
ransaminase, n rmal values, e19t urinary system, 567569 Urethritis, 569
rans ellular f uid, 585, 585t virilizing, the adrenal rtex, 334 Urge in ntinen e, 566
rans ripti n, 57 uni a albuginea, 619, 620 Uri a id
rans er RNA, 5758, 57t uni a externa, 404, 404 n rmal values, e19t
ransiti nal epithelium, 76 uni a intima, 404405, 404 in urine, e22t
strati ed, 76, 77 uni a media, 404, 404 Urinalysis, 567
ureteral, 564, 565 urbinates, 462 Urinary bladder, 99 , 565, 619 , 628
ranslati n, 5758 urg r, skin, 588 Urinary in ntinen e, 566
ransmissi n, me hanisms , 125126 urner syndr me, e10t, 689, 690 Urinary retenti n, 566
ransplant winning, 661 Urinary suppressi n, 566
b ne marr w, 352 wit h, 225226 Urinary system, 99, 99 , 554581
heart, 395 w -p int dis riminati n, 293 aging e e ts in, 670
reje ti n syndr me, 446447 ympani membrane, 303, 303 anteri r view rgans, 556
ransp rt maximum, 562 ype 1 diabetes mellitus, 335 mi turiti n, 565566
ransverse ar h, 194 as aut immune diseases, e9t renal and urinary dis rders, 567573
ransverse l n, 512513 as end rine nditi ns, e7t Urinary tra t in e ti ns (U Is), 569570
ransverse ra tures, 204 exer ise and, 335b treatment , 571b, 571
ransverse plane, 8 , 9 ype 2 diabetes mellitus, e7t, 335 Urine
ransverse pr ess yph id ever, e2t a idi ati n , 606
lumbar, 187 hara teristi s , 568t
vertebrae, 267 U mp nents , e22t
ransversus abd minis, 233 , 233t Ubiquitin, 688 eliminati n , 564567
rapezius, 231 , 232, 232 , 232t, 237 Ul er rmati n , 560563, 560
raumati injury de ubitus, 161162 utput, abn rmalities , 566567
brain, 264 dermal, 158159t v lume
n ninf ammat ry j int pr blems due t , Ul erative litis, e9t, 514515 abn rmalities , 563
205 Ulna, 94 , 190, 190t ntr l , 563
raumati me hanisms, disease, 116 Ulnar artery, 410 Ur genital system, 102103t
ravelers diarrhea. see Giardiasis Ulnar deviati n, in rheumat id arthritis, Urs de xy h li a id (A tigall), 510
ri eps bra hii, 229t, 231 , 232, 233t 205 Urti aria, 162
richinella rganisms, 124t Ulnar vein, 411 Uterine artery emb lizati n, 637
ri hin sis, e5t Ultras n graphy, 132 Uterine tube, 100
ri h m niasis, e5t, 640t in antenatal medi ine, 663b, 663 Uterus, 100 , 630631, 630 , 660
ri uspid valve, 381 , 383 rem val kidney st nes using, 569b an er, 638
ri uspids, 497 Ultravi let radiati n, r le , 163 Uvula, 463 , 497
rigeminal nerve (CN V), 271t, 272 Umami, 308
rigeminal neuralgia, 273 Umbili al rd, 413 , 660 , 665 V
rigly erides, 32, 32 Umbili al rd bl d, reezing , 659b, 659 Va inati n, disease and, 126127
n rmal values, e19t Umbili al hernia, 663 Va ines, 447, 448b
rig ne, 565 Umbili al regi n, 10, 10 , 12t Va inia virus, 118
rii d thyr nine ( 3), 322323t Umbili al vein, 413 Vagina, 100 , 628 , 660
rimesters, 656 Umbili us, 233 Vaginitis, 637
riple therapy, 506 Un mpensated metab li a id sis, 610 Vagus nerve (CN X), 271t, 272
riplegia, 265 Universal d n r bl d, 357 Valves, heart, 383
ris my, 685686 Universal re ipient bl d, 357 van Leeuwenh ek, Ant nie, 76b, 76
ris my 21, 688689 Unsaturated atty a ids, 32 Variant Creutz eldt-Jak b disease (vCJD),
r hlear nerve (CN IV), 271t, 272 Upper es phageal sphin ter (UES), 502 120
r hlear n t h, 190 Upper extremity, 190191 Vari ella z ster virus (VZV), e1t
r ph blast, 656 arteries in, 410t Vari es, 408
r p nins test, 351b b ne, 190191, 190t Vari se veins, 408, 408
rue ribs, 190t mus les , 232, 233t Vas de erens, 100 , 619 , 622623
runk, mus les , 233, 233 veins in, 411t Vas ular layer, eye, 295296
rypsin, 518 Upper respirat ry in e ti ns (URIs), e1t Vase t my, 623b
uber ul sis ( B), e2t, 127, 471 Upper respirat ry tra t, 460 , 462466 Vas nstri ti n, 365
ubules, renal, 557558 anat mi al dis rders, 465466 Vas dilat rs, 406
um r suppress r genes, 688b in e ti n (URI), 460461, 464465 Vas m t r me hanism, 416, 417
um rs Urea, in urine, e22t Vastus intermedius, 234t
benign and malignant, 128129, 129t Urea learan e, urine, e22t Vastus lateralis, 231 , 234t
benign uterine, 637 Uremia, 555, 573 Vastus medialis, 231 , 234t
b ne, 200, 200 Uremi p is ning, 555 Ve t r, transmissi n by, path gens, 126,
and an er, 128134 Uremi syndr me, 573 127t
artilage, 200201 Ureters, 99 , 104 , 557 , 564565, 564 , 565 Veins, 404
emale repr du tive tra t, 637638 emale, 628 dis rders , 408
ne plasms, 128130 male, 619 Ven us valve un ti n, 405
I-22 Index

Ventilati n, regulati n , 475477 Visual a uity, 298b, 298 W heals, 158159t, 162
Ventral, de niti n , 7 Visual ass iati n area, 263 W hite bl d ells (W BCs), 361362
Ventral b dy avities, 9 Visual rtex, 263 agranular leuk ytes, 362
Ventral respirat ry gr up (VRG), 475476 Visual impairment, e6t dis rders , 363365
Ventri les, ardia , 380381, 380 , 381 Visual pathway, 297, 299 in e ti us m n nu le sis, 364, 364
Ventri ular ntra ti n, 382 , 386 Vital apa ity (VC), 475, 476 leukemia, 363364
premature, 390 Vitamin A, 540t multiple myel ma, 363, 363
Ventri ular brillati n, 390, 391 Vitamin B12, in anemia, 359t granular leuk ytes, 362
Ventri ular relaxati n, 386 Vitamin C, 540t phag yti , 440
Venule, pulm nary, 467 Vitamin D, 540t types , 362
Venules, 406 de ien y, 201 WBC unt, 362
Vermi rm appendix, 515 synthesis by skin, 156 n rmal values, e19t
Vertebra(e), 94 , 187 Vitamin E, 540t in urine, e22t
Vertebral lumn, 186189, 186 Vitamin H , 540t W hite at, 79t
b nes , 187t Vitamin K, 540t W hite bers, 224
Vertebral disk, herniated, 197 in bl d l tting, 365 W hite matter, 253, 260
Vertebral ramen, 187 de ien y, 368 W h ping ugh. see Pertussis
Vertebr plasty, 188b, 188 Vitamins, 538540, 540t W indburn, e6t
Vesalius, Andreas, 6b, 6 imbalan es in, 539540 W inter depressi n, e7t
Vesi le, 158159t Vitilig , 149, 150 , 158159t
n n-genital herpes, 158159t Vitre us hum r, 296297 X
Vesi le, seminal, 619 V al rds, 463 , 464 X-linked inherited dis rders, hem philia,
Vestibular glands, 631 V lar regi n, 12t 366367
Vestibular nerve, 306 V lkmann anals, 177 X-linked traits, 683684
Vestibule, 304, 305 , 633, 633 V mer, 183t, 184 X-ray study, upper gastr intestinal, 506b,
Vestibul hlear nerve (CN VIII), 272 , 306 V miting, 608b, 608 506
Villi, 508 V wels, mbining, in medi al terms, e12 Xer derma pigment sum, 688b
Viral en ephalitis, e1t Vulva, 100 Xiph id pr ess, 189 , 190t
Viral in e ti ns XO, 689
shingles, 273 W XXY, 689
warts, 161 Warning signs
Virilizing tum r, the adrenal rtex, 334 an er, 131t Y
Viruses malignant melan ma, 164t Yeast ells, 123
path geni , 118120, 118 , 119t Warts, e1t, 158159t, 161 Y lk sa , 654
r le in ausing an er, 131 genital, 640t
Vis eral e e t rs, aut n mi un ti ns , 277t Water, 2930 Z
Vis eral peri ardium, 381, 381 in b dy, 584 Z disk, 222
Vis eral perit neum, 496 utput by b dy, 589 Z lines, 221
Vis eral pleura, 470 reabs rpti n , 561 Z in (Zn), 541t
Vis sity Water-based hemistry, 29 de ien y, e10t
bl d, 416 Water int xi ati n, 589 Zyg mati b nes, 183t, 184
n rmal values, e19t Weak a id, 3031 Zyg mati regi n, 12t
Visi n, 294297 Werni ke area, 263 Zyg mati us, 232, 232 , 232t
dis rders , 297302 West Nile virus (W NV), 120 Zyg te, 618, 654, 655 , 656

In t ro d u c t io n
A mplete understanding human anat my and physi l gy
requires an appre iati n r h w stru tures within the b dy
relate t ne an ther. Su h appre iati n r anat mi al stru -
ture has be me espe ially imp rtant in the twenty- rst en-
tury with the expl si n in the use diverse meth ds medi-
al imaging that rely n the ability t interpret se ti nal views
the human b dy.
T e best way t devel p y ur understanding verall ana-
t mi al stru ture is t are ully disse t a large number male
and emale human adaversthen have th se disse ted spe i-
mens handy while reading and learning ab ut ea h system
the b dy. O bvi usly, su h multiple disse ti ns and nstant
a ess t spe imens are impra ti al r nearly every ne. H w-
ever, the experien e a simple disse ti n an be appr ximated
by layering several partially transparent, tw -dimensi nal ana-
t mi al diagrams in a way that all ws a student t virtually
disse t the human b dy simply by paging thr ugh the layers.
T is Clear View o the Human Body pr vides a handy
t l r disse ting simulated male and emale b dies. It als
pr vides views several di erent parts the human b dy in
a variety r ss se ti ns. T e many di erent anteri r and
p steri r views als give y u a perspe tive n b dy stru ture
that is n t available with rdinary anat mi al diagrams. T is
Clear View is an always-available t l t help y u learn the three-
dimensi nal stru ture the b dy in a way that all ws y u t
see h w they relate t ea h ther in a mplete b dy. It will
always be right here in y ur textb k, s pla e a b kmark
here and re er t the Clear View requently as y u study ea h
the systems the human b dy.
Cle ar Vie w o the
Hum an Bo dy
Developed by
KEVIN PATTON and
PAUL KRIEGER
Illustrated by
Drago n y Me dia Gro up
Hin t s o r U s in g t h e C le a r Vie w
o t h e Bo d y
1. Starting at the rst page the Clear View, sl wly li t the
page as y u l k at the anteri r view the male and e-
male b dies. Y u will see deeper stru tures appear, as i
y u had disse ted the b dy. As y u li t ea h su essive
layer images, y u will be l king at deeper and deeper
b dy stru tures. A key t the labels is und in the gray
sidebar.
2. Starting with the se nd se ti n the Clear View, n ti e
that y u are l king at the p steri r aspe t the male and
emale b dy. Li t ea h layer r m the edge t reveal b dy
stru tures in su essive layers r m the ba k t the r nt.
T is very unique view will help y u understand stru tural
relati nships even better.
3. O n ea h page the Clear View, l k at the transverse se -
ti n represented in the sidebar. T e se ti n y u are l king
at n any ne page is r m the l ati n sh wn in the larger
diagram as a red line. In ther w rds, i y u ut the b dy at
the red line and tilted the upper part the b dy t ward
y u, y u w uld see what is sh wn in the se ti n diagram.
N ti e that ea h se ti n has its wn labeling system that is
separate r m the labels used in the larger images.
CV1
KEY 47. Peri ardium 95. Right lung 145. Fem ral artery and vein
48. Liver 96. Le t lung 146. Addu t r magnus m.
1. Epi ranius m. 49. Gallbladder 97. Pulm nary artery 147. Patella
2. emp ralis m. 50. St ma h 98. Right atrium 148. Fibula
3. O rbi ularis uli m. 51. ransverse l n 99. Right ventri le 149. ibia
4. Masseter m. 52. Small intestines 100. Le t atrium 150. Fibularis l ngus m.
5. O rbi ularis ris m. 53. Bi eps bra hii m. 101. Le t ventri le 151. Spinal rd
6. Pe t ralis maj r m. 54. Bra hi radialis m. 102. C ra bra hialis m. 152. Nerve r t
7. Serratus anteri r m. 55. Addu t r l ngus m. 103. In eri r vena ava 153. Platysma m.
8. Basili vein 56. Sart rius m. 104. Des ending a rta 154. Splenius apitis m.
9. Bra hial as ia 57. Q uadri eps em ris m. 105. Right kidney 155. Levat r s apulae m.
10. Cephali vein 58. Patellar ligament 106. Le t kidney 156. Rh mb ideus m.
11. Re tus sheath 59. ibialis anteri r m. 107. Right ureter 157. In raspinatus m.
12. Linea alba 60. Sup. extens r retina ulum 108. Re tum 158. eres maj r m.
13. Re tus abd minis m. 61. In . extens r retina ulum 109. Urinary bladder 159. Lumb d rsal as ia
14. Umbili us 62. Cerebrum brain 110. Pr state gland 160. Ere t r spinae m.
15. Abd minal blique m., 63. Cerebellum 111. Ilia artery and vein 161. Serratus p st. in . m.
external 64. Brainstem 112. Uterus 162. Latissimus d rsi m.
16. Abd minal blique m., 65. Maxillary sinus 113. Parietal b ne 163. Gluteus medius m.
internal 66. Nasal avity 114. Fr ntal sinus 164. Gluteus maximus m.
17. ransverse abd minis m. 67. ngue 115. Sphen idal sinus 165. Ili tibial tra t
18. Inguinal ring, external 68. T yr id gland 116. O ipital b ne 166. Flex r arpi ulnaris m.
19. F ssa valis 69. H eart 117. Palatine pr ess 167. Extens r arpi ulnaris m.
20. Fas ia the thigh 70. H epati veins 118. Cervi al vertebrae 168. Extens r digit rum m.
21. Great saphen us vein 71. Es phagus 119. C rpus all sum 169. Carpal ligament, d rsal
22. Parietal b ne 72. Spleen 120. T alamus 170. Inter sse us m.
23. Fr ntal b ne 73. Celia artery 121. rapezius m. 171. Gluteus minimus m.
24. emp ral b ne 74. P rtal vein 122. A r mi n pr ess 172. Piri rmis m.
25. Zyg mati b ne 75. D u denum 123. C ra id pr ess 173. Gemellus sup. m.
26. Maxilla 76. Pan reas 124. H umerus 174. O bturat r internus m.
27. Mandible 77. Mesenteri artery 125. Subs apularis m. 175. Gemellus in . m.
28. Stern leid mast id m. 78. As ending l n 126. Delt id m. ( ut) 176. Q uadratus em ris m.
29. Stern hy id mus le 79. ransverse l n 127. ri eps m. 177. Bi eps em ris m.
30. Om hy id mus le 80. Des ending l n 128. Bra hialis m. 178. Gastr nemius m.
31. Delt id m. 81. Sigm id l n 129. Bra hi radialis m. 179. Cal aneal (A hilles)
32. Pe t ralis min r m. 82. Mesentery 130. Radius tend n
33. Sternum 83. Appendix 131. Ulna 180. Cal aneus b ne
34. Rib ( stal) artilage 84. Inguinal ligament 132. Diaphragm 181. Sub utane us at
35. Rib 85. Pubi symphysis 133. T ra i du t 182. C rpus sp ngi sum
36. Greater mentum 86. Extens r arpi radialis m. 134. Q uadratus lumb rum m. 183. C rp ra avern sa
37. Fr ntal l be 87. Pr nat r teres m. 135. Ps as m. 184. Umbili al ligaments
38. Parietal l be 88. Flex r arpi radialis m. 136. Lumbar vertebrae 185. Epigastri artery and vein
39. emp ral l be 89. Flex r digit rum 137. Ilia us m. 186. Right testis
40. Cerebellum pr undus m. 138. Gluteus medius m. 187. ransverse th ra i m.
41. Nasal septum 90. Q uadri eps em ris m. 139. Ili em ral ligament 188. Parietal pleura
42. Bra hi ephali vein 91. Extens r digit rum 140. Sa ral nerves 189. C mm n bile du t
43. Superi r vena ava l ngus m. 141. Sa rum 190. Lesser mentum
44. T ymus gland 92. T yr id artilage 142. C yx 191. Flex r digit rum
45. Right lung 93. ra hea 143. Femur pr undus
46. Le t lung 94. A rti ar h 144. Vastus lateralis m. 192. Epigl ttis

CV2
 He ad - Trans ve rs e S e c tio n

A
b B
a C

a D
d E
c

c
e F

A
R L
P
f
g A. Vitreous body of eye
h
f
B. Ethmoidal cells
i i C. Temporalis m.
h
D. Optic nerve
n g E. Sphenoidal sinus
F. Brain

o j
j
o

Ante rio r Vie w

p
k a. Frontal region (forehead)
k
b. Cranial region (upper skull)
q p
l c. Facial region
l r
d. Pinna of ear
s e. Cervical (neck) region
m
m f. Axilla (armpit)
t g. Breast
S h. Nipple and areola
t
R L i. Brachial region (arm)
j. Antebrachial region (forearm)
I
k. Carpal region (wrist)
l. Palmar or volar region
m. Digital or phalangeal region
(fingers)
n. Abdomen
o. Umbilicus or navel
p. Pubic region with pubic hair
q. Penis (circumcised)
r. Scrotum
u s. Vulva
t. Femoral region (thigh)
u
u. Crural region (leg)
v. Tarsal region (ankle)

v v

CV3
 Po s te rio r View
1
2
1. Epicranius m.
1 3
2. Temporalis m.
3. Orbicularis oculi m.
4
4. Masseter m. 3 5
5. Orbicularis oris m. 5 4
6. Pectoralis major m.
7. Serratus anterior m. 153
8. Basilic vein
11. Rectus sheath 153
12. Linea alba
13. Rectus abdominis m.
14. Umbilicus 6
15. Abdominal oblique m., external 6
17. Transverse abdominis m.
19. Fossa ovalis 8 8
21. Great saphenous vein 7
153. Platysma m. 7
181. Subcutaneous fat
182. Corpus spongiosum 12
183. Corpora cavernosa 12
17
184. Umbilical ligaments 15
15
185. Epigastric artery and vein
17 11 11 14
186. Right testis
14
13

184 185
13 19
185 183
184
19 181
182

181 186
21 21

S
L R
I

CV4
 Lung s /He art - Trans ve rs e S e c tio n

G
F
1
D E
2
B
3 C

4
5 A
R L
P Abdo me n - Trans ve rs e S e c tio n

K
6 6
10
L
9 M
9 7
8
A
R L
P
12 2
155 133
A. Esophagus
111 166 111 15
13 . Descending aorta
14 17 166 C. Azygos vein
14
14
17
. Right lung
. Left lung
. Right atrium
1 . Right ventricle
H. Left atrium
8
I. Left ventricle
20 J. Liver
0 . Stomach
L. Pancreas
21 211 . Intervertebral disc
N. Left kidney
S
O. Spleen
R L
I

Ante rio r Vie w

1. Epicranius m.
2. Temporalis m.
3. Orbicularis oculi m.
4. Masseter m.
5. Orbicularis oris m.
6. Pectoralis major m.
7. Serratus anterior m.
8. Basilic vein
9. Brachial fascia
10. Cephalic vein
11. Rectus sheath
12. Linea alba
13. Rectus abdominis m.
14. Umbilicus
15. Abdominal oblique m., external
16. Abdominal oblique m., internal
17. Transverse abdominis m.
18. Inguinal ring, external
19. Fossa ovalis
0. Fascia of the thigh
1. Great saphenous vein

CV5
This pa ge inte ntiona lly le ft bla nk
 Male Pe lvis - Trans ve rs e S e c tio n

A
B
D G

E
F

377
222
39 3 Fe male Pe lvis - Trans ve rs e S e c tio n
41
0
25 A
26 D B
I
2
F E
288
29 A
43 300
R L
4
311 P
32 . Pectineus m.
B. Obturator externus m.
455 46 . Pubic symphysis
47 3
4 5 D. Neck of femur
53
3 . Rectum
533
F. Gluteus maximus m.
48
G. Prostate gland
499 50 . Urinary bladder
I. Vagina
54
4

5 36 Ante rio r Vie w

22. Parietal bone

23. Frontal bone
24. Temporal bone
25. Zygomatic bone
26. Maxilla
27. Mandible
5 5 28. Sternocleidomastoid m.
56 29. Sternohyoid muscle
566 30. Omohyoid muscle
5
577 31. Deltoid m.
S 32. Pectoralis minor m.
R L 33. Sternum
I 34. Rib (costal) cartilage
35. Rib
36. Greater omentum
37. Frontal lobe
38. Parietal lobe
58 39. Temporal lobe
588 40. Cerebellum
41. Nasal septum
42. Brachiocephalic vein
599 43. Superior vena cava
599
44. Thymus gland
45. Right lung
46. Left lung
47. Pericardium
60 600 48. Liver
600 49. Gallbladder
50. Stomach
611 61
61 51. Transverse colon
52. Small intestines
53. Biceps brachii m.
54. Brachioradialis m.
55. Adductor longus m.
56. Sartorius m.
57. Quadriceps femoris m.
58. Patellar ligament
59. Tibialis anterior m.
60. Sup. extensor retinaculum
61. Inf. extensor retinaculum

CV6
This pa ge inte ntiona lly le ft bla nk
 62
Ante rio r Vie w
62
3 64 66 2. erebrum of brain
3. erebellum
677 4. rainstem
677 5. axillary sinus
6. asal cavity
68 7. ongue
2