ANS REVIEW NOTES D.
The autonomic motor neurons regulate
Introduction
A. The autonomic nervous system (ANS)
regulates the activity of smooth muscle,
cardiac muscle, and certain glands.
B. Operation of the ANS to maintain
homeostasis, however, depends on a
continual flow of sensory afferent input,
from receptors in organs, and efferent motor
output to the same effector organs.
1. Structurally, the ANS includes autonomic
sensory neurons, integrating centers in the
CNS, and autonomic motor neurons.
2. Functionally, the ANS usually operates
without conscious control.
C. The ANS is regulated by centers in the
brain, mainly the hypothalamus and medulla
oblongata, which receive input from the
limbic system and other regions of the
COMPARISON OF SOMATIC AND AUTONOMIC
NERVOUS SYSTEMS
cerebrum.
A. The somatic nervous system contains
both sensory and motor neurons.
B. The somatic sensory neurons receive
input from receptors of the special and
somatic senses.
1. These sensations are consciously
perceived.
C. Somatic motor neurons innervate skeletal
muscle to produce conscious, voluntary
movements.
1. The effect of a motor neuron is
always excitation.
D. The autonomic nervous system contains
both autonomic sensory and motor neurons.
1. Autonomic sensory neurons are
associated with interceptors.
a. Autonomic sensory input is not
consciously perceived.
2. The ANS also receives sensory
input from somatic senses and special
sensory
neurons.
visceral activities by either increasing
(exciting) or
decreasing (inhibiting) ongoing activities of
cardiac muscle, smooth muscle, and glands.
F. Most autonomic responses cannot be
consciously altered or suppressed.
G. All autonomic motor pathways consists
of two motor neurons in series
1. The axon of the first motor
neuron of the ANS extends from the CNS
and synapses in
a ganglion with the second neuron.
2. The second neuron synapses on
an effector. Preganglionic fibers release
acetylcholine and postganglionic fibers
release acetylcholine or norepinephrine.
3. The output (efferent) part of the
ANS is divided into two principal parts: the
sympathetic and the parasympathetic
divisions. Organs that receive impulses from
both sympathetic and parasympathetic fibers
are said to have dual innervation.
4. summarize the similarities and
differences between the somatic and
autonomic nervous systems.
ANATOMY OF AUTONOMIC MOTOR
PATHWAYS
A. Anatomical Components
1. The first of two autonomic motor neurons is called
a preganglionic neuron
a. Its cell body is in the brain or spinal cord.
b. Its myelinated axon, called a
preganglionic fiber, passes out of the CNS as
part of a cranial or spinal nerve, later
separating from the nerve and extending to
an autonomic ganglion where it synapses
with the postganglionic neuron.
2. The postganglionic neuron, the second neuron in
the autonomic motor pathway, lies entirely outside
the CNS.
a. Its cell body and dendrites are located in
an autonomic ganglion, where it makes
 synapses with one or more preganglionic
fibers.
b. The axon of a postganglionic neuron, the
postganglionic fiber, is unmyelinated and
terminates in a visceral effector.
B. Preganglionic Neurons
1. The cell bodies of sympathetic preganglionic
neurons are in the lateral gray horns of the 12
thoracic and first 2 or 3 lumbar segments.
a. This division is called the thoracolumbar
division.
1. The axons of the sympathetic preganglionic
neurons are known as the thoracolumbar
outflow.
2. The cell bodies of parasympathetic
preganglionic neurons are in cranial nerve
nuclei (III, VII, IX, and X) in the brain stem
and lateral gray horns of the second through
fourth sacral segments of the cord.
3. The parasympathetic division is known as
the craniosacral division.
a. The axons of the parasympathetic
preganglionic neurons are referred to as
the craniosacral outflow.
C. Autonomic Ganglia
1. Sympathetic Ganglia
a. These ganglia include the sympathetic
trunk or vertebral chain or paravertebral
ganglia that lie in a vertical row on either
side of the vertebral column.
b. Other sympathetic ganglia are the
prevertebral or collateral ganglia that lie
anterior to the spinal column and close to
large abdominal arteries. They include the
celiac, superior mesenteric, and inferior
mesenteric ganglia.
c. Sympathetic preganglionic neurons
synapse with postganglionic neurons in
ganglia of the sympathetic trunk or
prevertebral ganglia
2. Parasympathetic Ganglia
a. Parasympathetic ganglia are the terminal
or intramural ganglia that are located very
close to or actually within the wall of a
visceral organ.
1. Examples include the ciliary, pterygopalatine,
submandibular, and otic ganglia
2. Parasympathetic preganglionic neurons synapse
with postganglionic neurons in terminal ganglia.
D. Autonomic Plexuses
1. These are tangled networks of
sympathetic and parasympathetic neurons.
2. Major autonomic plexuses include the
cardiac, pulmonary, celiac, and hypogastric.
E. Structure of the Sympathetic Division
1. White rami communicans (plural - the
white rami communicants) connect the
anterior ramus of the thoracic and first 2 or 3
lumbar spinal nerves with the ganglia of
the sympathetic trunk.
2. The gray ramus communicans is the
structure containing the postganglionic
fibers
that connect the ganglion of the sympathetic
trunk to the spinal nerve.
3. Preganglionic fibers that pass through the
sympathetic trunk without terminating in
the trunk form nerves beyond the trunk
known as splanchnic nerves.
4. Developmentally, the adrenal medulla is a
modified sympathetic ganglion and its
cells are similar to sympathetic
postganglionic neurons.
5. Clinical Connection: In Horner’s
syndrome, the sympathetic innervation to
one side of the face is lost.
F. Structure of the Parasympathetic Division
1. The cranial outflow consists of
preganglionic axons that extend from the
brain stem in four cranial nerves. The cranial
outflow components are four pairs of ganglia
and the plexuses associated with the vagus
nerve.
2. The sacral outflow consists of
preganglionic axons in anterior roots of the
second through fourth sacral nerves.
3. Compare the Anatomical features of the
sympathetic and parasympathetic

ANS NEUROTRANSMITTERS AND
RECEPTORS
A. Cholinergic Neurons and Cholinergic
Receptors
1. Cholinergic neurons release the neurotransmitter
acetylcholine and include all sympathetic and
parasympathetic preganglionic neurons, all
parasympathetic postganglionic neurons, and
sympathetic postganglionic neurons that innervate
most sweat glands.
a. Cholinergic receptors are integral
membrane proteins in the postsynaptic
plasma membrane. The two types of
cholinergic receptors are nicotinic and
muscarinic receptors
b. Activation of nicotinic receptors causes
excitation of the postsynaptic cell.
c. Activation of muscarinic receptors can
cause either excitation or inhibition
depending on the cell that bears the
receptors.
B. Adrenergic Neurons and Adrenergic Receptors
1. The adrenergic neurons release norepinephrine
and include most sympathetic postganglionic
neurons.
2. The main types of adrenergic receptors are alpha
and beta receptors.
a. These receptors are further classified into
subtypes.
1. Depending on the subtype,
activation of the receptor can result
in either excitation or inhibition.
3. Effects triggered by adrenergic neurons typically
are longer lasting than those triggered by cholinergic
neurons.
4. describes the location of the subtypes of
cholinergic and adrenergic receptors and summarize
the responses that occur when each type of receptor
is activated.
C. Receptor Agonists and Antagonists
1. An agonist is a substance that binds to and
activates a receptor, mimicking the effect of a
natural neurotransmitter or hormone; an antagonist is
a substance that binds to and blocks a receptor,
preventing a natural neurotransmitter or hormone
from exerting its effect.
2. Different drugs can serve as agonists or
antagonists to selectively activate or block ANS
receptors.
PHYSIOLOGICAL OF THE ANS
A. Most body structures receive dual innervation,
that is, fibers from both the sympathetic and
parasympathetic divisions. Usually, one division
causes excitation and one causes inhibition resulting
in autonomic tone.
B. The sympathetic responses prepare the body for
emergency situations (the fight-or-flight responses).
1. Sympathetic responses are stimulated by the four
E’s (Emergency, Embarrassment, Exercise,
Excitement)
2. The effects of sympathetic stimulation are longer-
lasting and more widespread than those of the
parasympathetic stimulation.
a. Norepinephrine is degraded more slowly
than Ach.
b. There are more postganglionic neurons in
this division.
3. Specific sympathetic responses include:
a. Pupils dilate
b. heart rate and blood pressure increase.
c. Blood flow to the kidneys and
gastrointestinal tract diminishes
d. Blood flow to the skeletal muscles, liver,
heart and adipose tissue increases
e. Liver cells release glucose and adipose
cells break down fat to increase available
energy
 f. The parasympathetic division regulates
activities that conserve and restore body
A. this section depicts relationships between the
energy (energy conservation-restorative
nervous system and other systems.
system).
C. Parasympathetic responses are stimulated during
periods of rest and relaxation. HOMEOSTATIC DISORDERS
1. The effects of parasympathetic stimulation are
last for a shorter time and are less widespread than
those of the sympathetic stimulation. A. Raynaud’s disease is due to excessive
a. Acetylcholine is degraded more rapidly sympathetic stimulation of arterioles within the
than NE. fingers and toes resulting in diminished blood flow
to the digits.
b. There are more postganglionic neurons in
this division. B. Autonomic dysreflexia is an exaggerated response
of the sympathetic division of the ANS that occurs in
2. Parasympathetic responses include about 80% of individuals with spinal cord injury at
or above the level of T6. It occurs due to interruption
a. Salivation
of the control of the ANS by higher centers.
b. Lacrimation
c. Urination
d. Digestion
e. defecation (collectively known as
“SLUDD”).
f. also decreased heart rate
g. decreased airway diameter
h. decreased pupil diameter.
D. summarize the responses of glands, cardiac
muscle, and smooth muscle to stimulation by the
ANS.

PHYSIOLOGICAL OF THE ANS

A. Autonomic Reflexes
1. A visceral autonomic reflex adjusts the activity of
a visceral effector, often unconsciously.
2. A visceral autonomic reflex arc consists of a
receptor, sensory neuron, association
neuron, autonomic motor neurons, and visceral
effector.
B. Autonomic Control by Higher Centers
1. The hypothalamus controls and integrates the
autonomic nervous system. It is connected to both
the sympathetic and the parasympathetic divisions.
2. Control of the ANS by the cerebral cortex occurs
primarily during emotional stress.
FOCUS ON HOMEOSTASIS: THE NERVOUS SYSTEM

BLOOD REVIEW NOTES
INTRODUCTION
A. Blood inside blood vessels, interstitial fluid
around body cells, and lymph inside lymph vessels
constitute one’s internal environment.
B. To obtain nutrients and remove wastes, cells must
be serviced by blood and interstitial fluid.
1. Blood, a connective tissue, is composed of
plasma and formed elements.
2. Interstitial fluid bathes body cells.
C. The branch of science concerned with the study of
blood, blood-forming tissues, and the disorders
associated with them is called hematology.
FUNCTION OF BLOOD
A. Blood transports oxygen, carbon dioxide,
nutrients, heat, wastes, and hormones.
B. It helps regulate pH, body temperature, and water
content of cells.
C. It prevents blood loss through clotting and
combats toxins and microbes through certain
phagocytic white blood cells or specialized plasma
proteins.
FUNCTION OF BLOOD
A. Physical characteristics of blood include a
viscosity greater than that of water; temperature,
38°C (100.4°); and a pH of 7.35 to 7.45.
B. Blood constitutes about 8% of body weight;
volume ranges from 4 to 6 liters.
C. Blood samples for laboratory testing may be
obtained by venipuncture, finger-stick, or arterial
stick (Clinical Connection)
COMPONENTS OF BLOOD
A. Blood consists of 55% plasma and 45% formed
elements
B. Blood plasma consists of 91.5% water and 8.5%
solutes.
1. Principal solutes include proteins
(albumins, globulins, fibrinogen), nutrients,
enzymes, hormones, respiratory gases,
electrolytes, and waste products.
2. Summarize the chemical composition of
plasma.
C. Formed Elements
1. The formed elements in blood include
erythrocytes (red blood cells or RBCs),
leukocytes (white blood cells or WBCs), and
thrombocytes (platelets)
2. The percentage of total blood volume
occupied by red blood cells is called the
hematocrit. A hematocrit measures the
percentage of red blood cells in whole blood.
a. A significant drop in hematocrit
indicates anemia, due to a lower-
than-normal number of RBCs.
b. In polycythemia the percentage of
RBC is abnormally high with a
higher-than-normal hematocrit.
FORMATION OF BLOOD CELLS
A. Blood cells are formed from pluripotent
hematopoietic stem cells
1. Originating from the pluripotent stem
cells are the myeloid stem cells and
lymphoid stem cells.
a. Myeloid stem cells give rise to
RBCs, platelets, and all WBCs
except for lymphocytes.
b. Lymphoid stem cells give rise to
lymphocytes.
2. Myeloid stem cells differentiate into
progenitor cells or precursor cells (blast
 cells) which will develop into the actual a. The gaseous hormone NO binds to hemoglobin.
formed elements of blood.
b. Hemoglobin can release NO
3. Lymphoid stem cells differentiate into
c. Released NO causes vasodilation which improves
pre-B and prothymocytes which develop
blood flow and enhances oxygen delivery to the
into B-lymphocytes and T-lymphocytes,
area.
respectively.
D. RBC Life Cycle
B. This process of hemopoiesis (or hematopoiesis) is
stimulated by several hematopoietic growth factors. 1. Red blood cells only live about 120 days because
These hematopoietic growth factors stimulate of the wear and tear on their plasma membranes as
differentiation and proliferation of the various blood they squeeze through blood capillaries.
cells.
2. In the RBC life cycle, after phagocytosis of worn-
1. Erythropoietin increases the number of out RBCs by macrophages, hemoglobin is recycled
RBC precursors. the globin portion is split from the heme with the
amino acids being reused for protein synthesis. The
2. Thrombopoietin increases the number of
iron in the heme portion is reclaimed with the rest of
platelet precursors.
the heme molecule; the rest becomes a component of
3. Cytokins (colony-stimulating factors and bile in the digestive process.
interleukins) increase the number of WBC
3. Under normal conditions plasma contains almost
precursors.
no free iron. If the amount of iron present in the
C. Bone marrow examination is a way to diagnose body builds up, iron overload results causing
blood diseases. (Clinical Connection) diseases of the liver, heart, pancreatic islets, and
gonads. Iron overload also permits iron dependent
D. Growth factors, available through recombinant
microbes to flourish (Clinical Connection).
DNA technology, hold great potential for use in
patients who cannot normally form the blood cells. E. Erythropoiesis: Production of RBCs
(Clinical Connection)
1. Erythrocyte formation, called erythropoiesis,
occurs in adult red bone marrow of certain bones
RED BLOOD CELLS
2. The main stimulus for erythropoiesis is hypoxia
A. Red blood cells or erythrocytes (RBCs) contain
3. A reticulocyte count (average 0.5 - 1.5% of all
the oxygen-carrying protein hemoglobin and number
RBCs) is a diagnostic test that indicates the rate of
about 5.4 million cells/microliter of blood.
erythropoiesis and is useful in diagnosing and
B. RBCs anatomy
WHITE BLOOD CELLS
1. are biconcave discs without nuclei that contain treating anemia. (Clinical Connection).
hemoglobin
2. The cytosol of RBCs contains hemoglobin
molecules; these important molecules are
synthesized before loss of the nucleus during RBC
A. Leukocytes (white blood cells or WBCs) are
production and constitute about 33% of the cell’s
nucleated cells and do not contain hemoglobin. Two
weight.
principal types are granular (neutrophils,
C. RBC Physiology eosinophils, basophils) and agranular (lymphocytes
and monocytes
1. The function of the hemoglobin in RBCs is to
transport oxygen and some carbon dioxide. B. Granular leukocytes include eosinophils,
Hemoglobin molecules are specialized components basophils, and neutrophils based on the straining of
of the red blood cell plasma membrane that combine the granules.
with oxygen (as oxyhemoglobin) or with carbon
C. Agranular leukocytes do not have cytoplasmic
dioxide (as carbaminohemoglobin) in this transport
granules and include the lymphocytes and
process.
monocytes, which differentiate into macrophages
2. Hemoglobin also functions in blood pressure (fixed and wandering).
regulation.
D. Leukocytes have surface proteins, as do
erythrocytes. They are called major
histocompatibility antigens (MHC), are unique for
each person (except for identical siblings), and can
be used to identify a tissue.
E. Function of WBCs
1. White blood cells usually live for only a
few hours or a few days. Normal blood contains
5,000-10,000 leukocytes/mm3.
a. Leukocytosis refers to an increase in the
number of WBCs.
b. Leukopenia refers to an abnormally low
number of WBCs.
2. The general function of leukocytes is to combat
inflammation and infection.
a. WBCs leave the blood stream by
emigration
b. Some WBCs, particularly neutrophils and
macrophages, are active in phagocytosis.
c. The chemical attraction of WBCs to a
disease or injury site is termed chemotaxis.
d. Different WBCs combat inflammation
and infection in different ways.
1. Neutrophils and wandering or
fixed macrophages (which develop
from monocytes) do so through
phagocytosis.
2. Eosinophils combat the effects of
histamine in allergic reactions,
phagocytize antigen-antibody
complexes, and combat parasitic
worms.
3. Basophils develop into mast cells
that liberate heparin, histamine, and
serotonin in allergic reactions that
intensify the inflammatory response.
4. B lymphocytes, in response to the
presence of foreign substances
called antigens, differentiate into
tissue plasma cells that produce
antibodies.
5. T lymphocytes destroy foreign invaders directly.
i. A differential white blood cell count is a
diagnostic test in which specific white blood
cells are enumerated. Because each type of
WBC plays a different role, determining the
percentage of each type in the blood assists
in diagnosing the condition.
ii. Research the significance of elevated or
depressed counts of the various WBCs.
PLATELETS
A. Thrombopoietin stimulates myeloid stem cells to
produce platelets.
1. Myeloid stem cells develop into
megakaryocyte-colony-forming cells that
develop into megakaryoblasts.
2. Megakaryoblasts transform into
megakaryocytes which fragment.
3. Each fragment, enclosed by a piece of cell
membrane, is a platelet (thrombocyte).
B. Normal blood contains 250,000 to 400,000
platelets/mm3. Platelets have a life span of only 5 to
9 days; aged and dead platelets are removed by fixed
macrophages in the spleen and liver.
C. Platelets help stop blood loss from damaged
vessels by forming a platelet plug. Their granules
also contain chemicals that promote blood clotting.
D. A complete blood count (CBC) is a test that
screens for anemia and various infections. It usually
includes counts of RBCs, WBCs, and platelets per
μL of whole blood; hematocrit and differential white
blood cell count. The amount of hemoglobin in
grams per ml is also determined (Clinical
Connection)
E. Summarize the formed elements in blood.
STEM CELL TRANSPLANTS FROM BONE
MARROW AND CORD BLOOD
A. Bone marrow transplants may be used to treat
several types of anemia, leukemia, and numerous
other blood disorders. However, residual host T cells
can reject the transplant and transplanted T cells can
attack the host.
HEMOSTASIS
B. Cord blood transplants are from the host so
transplant rejection is not an issue.

A. Hemostasis refers to the stoppage of bleeding.
When blood vessels are damaged or ruptured, the
hemostatic response must be quick, localized to the
region of damage, and carefully controlled.
B. It involves vascular spasm, platelet plug
formation, and blood coagulation (clotting).
1. In vascular spasm, the smooth muscle of a
blood vessel wall contracts to stop bleeding.
2. Platelet plug formation involves the
clumping of platelets around the damage to
stop the bleeding
3. A clot is a gel consisting of a network of
insoluble protein fibers (fibrin) in which
formed elements of blood are trapped
4. The chemicals involved in clotting are
known as coagulation (clotting) factors;
most are in blood plasma, some are released
by platelets, and one is released from
damaged tissue cells
5. Blood clotting involves a cascade of
reactions that may be divided into three
stages: formation of prothrombinase
(prothrombin activator), conversion of
prothrombin into thrombin, and conversion
of soluble fibrinogen into insoluble fibrin
6. The clotting cascade can be initiated by
either the extrinsic pathway or the intrinsic
pathway.
C. Normal coagulation requires vitamin K and also
involves clot retraction (tightening of the clot) and
fibrinolysis (dissolution of the clot).
1. The fibrinolytic system dissolves small,
inappropriate clots and clots at a site of
damage once the damage is repaired.
2. Plasmin (fibrinolysin) can dissolve a clot
by digesting fibrin threads and inactivating
substances such as fibrinogen, prothrombin,
and factors V, VIII, and XII.
D. Homeostatic Control Mechanisms
1. Clots are generally localized due to fibrin
absorbing thrombin into the clot, clotting
factors diffusing through blood, and the
production of prostacyclin, a powerful
inhibitor of platelet adhesion and release.
2. Substances that inhibit coagulation, called
anticoagulants, are also present in blood. An
example is heparin.
3. Patients who are at increased risk of
forming blood clots may receive an
anticoagulant drug such as heparin or
warfarin. To prevent clots in donated blood,
a substance that removes Ca+2 such as
EDTA or CPD may be added to the blood
(Clinical Connection)
4. Despite the anticoagulating and
fibrinolytic mechanisms, blood clots
sometimes form within the cardiovascular
system.
5. Clotting in an unbroken blood vessel is
called thrombosis.
6. A thrombus (clot), bubble of air, fat from
broken bones, or piece of debris transported
by the bloodstream that moves from its site
of origin is called an embolus.
7. At low doses aspirin inhibits vasoconstriction and
platelet aggregation thereby reducing the chance of
thrombus formation. Thrombolytic agents are
injected into the body to dissolve clots that have
already formed. Streptokinase or tissue plasminogen
activator (TPS) are thrombolytic agents (Clinical
Connection)
BLOOD GROUPS AND BLOOD TYPES
A. The surfaces of red blood cells contain
genetically determined blood group antigens, called
agglutinogens or isoantigens.
1. Blood is categorized into different blood
groups based on the presence or absence of
various isoantigens.
2. Within a blood group there may be two or
more different blood types.
3. Major blood groups are the ABO and Rh
groups. Other blood groups include the
Lewis, Kell, Kidd, and Duffy systems.
B. ABO Group
1. In the ABO system, agglutinogens
(antigens) A and B determine blood types
2. Plasma contains agglutinins (antibodies),
designated as a and b, that react with
agglutinogens that are foreign to the
individual.
C. Rh Blood Group
1. In the Rh system, individuals whose
erythrocytes have Rh agglutinogens are
 classified as Rh+. Those who lack the
antigen are Rh-.
2. Research for the incidence of ABO and
Rh blood types
D. A disorder due to Rh incompatibility between
mother and fetus is called hemolytic disease of the
newborn; it is treatable, but also preventable
(Clinical Connection).
E. Transfusions
C. Hemophilia is an inherited deficiency of clotting
in which bleeding may occur spontaneously or after
only minor trauma.
D. Acute leukemia is a malignant disease of blood-
forming tissues characterized by uncontrolled
production and accumulation of immature
leukocytes. In chronic leukemia, there is an
accumulation of mature leukocytes in the
bloodstream because they do not die at the end of
their normal life span.

1. Knowledge of blood types is essential to MEDICAL TERMINOLOGY

safe transfusion of blood and may also be
used in proving or disproving paternity,
linking suspects to crimes, or as a part of List as many as you can the medical terms associated
anthropology studies to establish a with blood.
relationship among races. substance that
removes Ca+2 such as EDTA or CPD may
be added to the blood (Clinical Connection)
2. Summarize the interactions of the
blood types of the ABO system.
F. Typing and Cross-Matching Blood for
Transfusion
1. The Rh and ABO blood groups
may be detected by a simple medical
test, blood typing, in which a sample
of blood is mixed with serum
containing agglutinins to each of the
major agglutinogens (AB, B, and
Rh).
2. Typing is the determination of
blood types, whereas cross-matching
is the mixing of donor and recipient
blood for compatibility.

DISORDERS: HOMEOSTATIC IMBALANCES

A. Anemia is a condition in which the oxygen-

carrying capacity of the blood is reduced; it is a sign,
not a diagnosis and is usually characterized by a
decreased erythrocyte count or hemoglobin
deficiency. Kinds of anemia include iron-deficiency,
pernicious, hemorrhagic, hemolytic, Thalassemia,
and aplastic.
B. Sickle-cell disease is an inherited disorder due to
an abnormal kind of hemoglobin. RBCs show a
characteristic sickle shape, rupture easily, and show
a reduced oxygen carrying capacity which results in
hemolytic anemia.
 C. Protective Covering of the Brain
1. The brain is protected by the cranial bones and the
cranial meninges
a. The cranial meninges are continuous with
the spinal meninges and are named dura
mater, arachnoid, and pia mater.
1. Three extensions of the dura
mater separate parts of the brain: the
falx cerebri, falx cerebelli, and the
tentorium cerebelli.
D. Blood Flow and the Blood-Brain Barrier
1. Blood flows to the brain mainly via blood
vessels that branch from the cerebral arterial
circle (circle of Willis) at the base of the
brain the veins that return blood from the
head to the heart.

BRAIN AND CNs REVIEWER NOTES

2. Although the brain comprises only about
2% of the total body weight, it utilizes about

INTRODUCTION

20% of the oxygen used by the entire body.

A. The brain is the center for registering sensations, The brain is one of the most metabolically
correlating them with one another and with stored active organs of the body, and the amount of
information, making decisions, and taking action. oxygen it uses varies with the degree of
mental activity.
1. It is also the center for intellect, emotions,
behavior, and memory. a. Any interruption of the oxygen
supply to the brain can result in
2. It also directs our behavior towards weakening, permanent damage, or
others. death of brain cells. Interruption of
the mother’s blood supply to a child
3. In this chapter we will consider the
during childbirth before it can
principal parts of the brain, how the brain is
breathe may result in paralysis,
protected and nourished, and how it is mental retardation, epilepsy, or
related to the spinal cord and to the 12 pairs death.
of cranial nerves.
b. Because carbohydrate storage in
BRAIN ORGANIZATION, PROTECTION AND the brain is limited, the supply of
glucose to the brain must be
BLOOD SUPPLY
continuous. Glucose deficiency may
produce mental confusion, dizziness,
convulsions, and unconsciousness.
A. The brain and spinal cord arise from
embryological tissue (ectoderm) beginning as a c. A blood-brain barrier (BBB)
hollow, neural tube. protects brain cells from harmful
substances and pathogens by serving
B. The major parts of the brain are the brain stem, as a selective barrier to prevent
diencephalon, cerebrum, and cerebellum passage of many substances from
the blood to the brain.
 - Clinical Connection: An
injury to the brain due to trauma,
inflammation, or toxins causes a
breakdown of the BBB, permitting
the passage of normally restricted
substances into brain tissue. The
BBB may also prevent entry of
drugs that could be used as therapy
for brain cancer or other CNS
disorders, so research is exploring
ways to transport drugs past the
BBB
A. Cerebrospinal fluid (CSF) is a clear, colorless
liquid that protects the brain and spinal cord against
chemical and physical injuries and carries oxygen,
glucose, and other needed chemicals from the blood
to neurons and neuroglia.
1. There are four CSF filled cavities within
the brain called ventricles.
2. CSF contributes to hemostasis by
providing mechanical protection, chemical
protection, and circulation.
3. CSF is formed by filtration from networks
of capillaries called choroid plexuses (found
in the ventricles) and circulates through the
subarachnoid space, ventricles, and central
canal.
4. Materials entering CSF from the choroid
capillaries cannot leak between the
surrounding ependymal cells; these
constitute the blood-cerebrospinal fluid
barrier, which permits certain substances to
enter the fluid but excludes others and
protects the brain and spinal cord from
harmful elements.
5. Most of the fluid is absorbed by the
arachnoid villi of the superior sagittal blood
sinus this absorption normally occurs at the
same rate at which CSF is produced in the
choroid plexuses, thereby maintaining a
relatively constant CSF volume and
pressure.
a. Clinical Connection: If CSF
cannot circulate or drain properly
due to some obstruction in the
ventricles or subarachnoid space, a
condition called hydrocephalus
develops. The fluid buildup that
occurs causes increased pressure on
the brain, either internally or
externally, depending on where the
blockage is present. Surgically
draining the ventricles and diverting
the flow of CSF by an implanted
shunt can positively and
dramatically affect the individual’s
prognosis.
A. Medulla Oblongata
1. The medulla oblongata, or just medulla, is
continuous with the upper part of the spinal cord and
contains portions of both motor and sensory tracts
2. It also contains the nuclei of origin for cranial
nerves VIII (cochlear and vestibular branches)
through XII
3. Structural regions of the medulla include the
pyramids and the inferior olivary nucleus
a. Decussation of pyramids results in
neurons in the left cerebral cortex
controlling skeletal muscles on the right side
of the body and neurons in the right cerebral
cortex controlling skeletal muscles on the
left side.
b. Inferior olivary neurons relay impulses
from proprioceptors to the cerebellum.
4. Functional regions include nuclei that are reflex
centers for regulation of heart rate, respiratory rate,
vasoconstriction, swallowing, coughing, vomiting,
sneezing, and hiccupping; the first three are
considered vital reflexes.
a. Clinical Connection: Injury to the medulla
can be fatal or lead to serious problems.
B. Pons
1. The pons is located superior to the medulla. It
connects the spinal cord with the brain and links
parts of the brain with one another by way of tracts
2. It relays nerve impulses related to voluntary
skeletal movements from the cerebral cortex to the
cerebellum.
3. The pons also contains the pneumotaxic and
apneustic areas, which help control respiration along
with the respiratory center in the medulla
4. It contains nuclei for cranial nerves V through VII
and the vestibular branch of VIII
C. Midbrain
1. The midbrain conveys motor impulses from the
cerebrum to the cerebellum and spinal cord, sends
sensory impulses from the spinal cord to the
thalamus, and regulates auditory and visual reflexes
2. Structures within the midbrain include the cerebral
peduncles, the corpora quadrigemina, the left and
right substantia nigra, the left and right red nucleus,
and the medial lemniscus.
3. It also contains nuclei of origin for cranial nerves
III and IV.
D. Reticular formation.
1. The reticular formation consists of small areas of
gray matter interspersed among fibers of white
matter and has both sensory and motor functions.
2. It helps regulate muscle tone, alerts the cortex to
incoming sensory signals (reticular activating
system, or RAS) and is responsible for maintaining
consciousness and awakening from sleep.
3. The functions of the brain stem, and other brain
structures, are summarized in Table 14.2.
THE CEREBELLUM
A. The cerebellum occupies the inferior and
posterior aspects of the cranial cavity and consists of
two hemispheres and a central, constricted vermis
1. It is attached to the brain stem by three pairs of
cerebellar peduncles
2. The cerebellum functions in the coordination of
skeletal muscle contractions and in the maintenance
of normal muscle tone, posture, and balance
a. Clinical Connection: Injury or impairment
of the cerebrum results in ataxia.
THE DIENCEPHALON
A. Thalamus
1. The thalamus is located superior to the midbrain
and contains nuclei that serve as relay stations for all
sensory impulses, except smell, to the cerebral
cortex
2. There are seven major groups of thalamic nuclei
on each side
3. It also registers conscious recognition of pain and
temperature and some awareness of light touch and
pressure.
4. It plays an essential role in awareness and the
acquisition of knowledge, which is termed cognition.
B. Hypothalamus
1. The hypothalamus is found inferior to the
thalamus, has four major regions (mammillary,
tuberal, supraoptic, and preoptic), controls many
body activities, and is one of the major regulators of
homeostasis
2. The hypothalamus has a great number of
functions.
a. It functions in regulation of emotional and
behavioral patterns.
b. It regulates eating and drinking through
the feeding center, satiety center, and thirst
center.
c. It aids in controlling body temperature.
d. It regulates circadian rhythms and states
of consciousness.
C. Epithalamus
1. The epithalamus lies superior and posterior to the
thalamus and contains the pineal gland and the
habenular nuclei
2. The pineal gland secretes melatonin to influence
diurnal cycles in conjunction with the hypothalamus.
3. The habenular nuclei are involved in olfaction,
especially emotional responses to odors.
D. Circumventricular Organs
1. Parts of the diencephalon, called
circumventricular organs (CVOs), can monitor
chemical changes in the blood because they lack a
blood-brain barrier.
2. CVOs include part of the hypothalamus, the pineal
gland, the pituitary gland, and a few other nearby
structures.
a. They function to coordinate homeostatic
activities of the endocrine and nervous
systems.
b. They are also thought to be the site of
entry into the brain of HIV.

E. summarize the functions of the parts of the
diencephalon.
THE CEREBRUM
A. Cerebral cortex
1. The cerebral cortex, is 2-4 mm thick and is
composed of gray matter. The cortex contains
billions of neurons
2. The cortex contains gyri (convolutions), deep
grooves called fissures, and shallower sulci.
3. Beneath the cortex lies the cerebral white matter,
tracts that connect parts of the brain with itself and
other parts of the nervous system.
4. The cerebrum is nearly separated into right and
left halves, called hemispheres, by the longitudinal
fissure. Internally communication between the
hemispheres occurs via the corpus callosum, a
bundle of transverse white fibers.
B. Lobes
1. Each cerebral hemisphere is further subdivided
into four lobes by sulci or fissures.
2. The cerebral lobes are named the frontal, parietal,
temporal, and occipital.
3. A fifth part of the cerebrum, the insula, lies deep
to the parietal, frontal, and temporal lobes and
cannot be seen in an external view of the brain.
C. White Matter
1. The white matter is under the cortex and consists
of myelinated axons running in three principal
directions
a. Association fibers connect and transmit
nerve impulses between gyri in the same
hemisphere.
b. Commissural fibers connect gyri in one
cerebral hemisphere to the corresponding
gyri in the opposite hemisphere.
c. Projection fibers form ascending and
descending tracts that transmit impulses
from the cerebrum to other parts of the brain
and spinal cord.
D. Basal Nuclei
1. The basal nuclei are paired masses of gray
matter in each cerebral hemisphere
a. They are the globus pallidus, which is
closer to the thalamus
2. putamen which is closer to the cerebral
a. The claustrus is a thin sheet of gray matter
situated lateral to the putamen. It is
considered by some to be a subdivision of
the basal nuclei. The function of the
claustrum in humans has not been clearly
defined, but it may be involved in visual
attention.
3. The third of the basal nuclei is the caudate nucleus
E. Limbic System
1. The limbic system is found in the cerebral
hemispheres and diencephalon
2. It functions in emotional aspects of behavior and
memory, and is associated with pleasure and pain.
F. Clinical Connection: Brain Injuries
1. Lapse in memory is one of many effects resulting
from brain injuries; brain injuries are commonly
associated with head injuries and result, in part, from
displacement and distortion of neuronal tissue at the
moment of impact and in part from the release of
disruptive chemicals from injured brain cells.
2. Various degrees of brain injury are described by
the term’s concussion, contusion, and laceration.
FUNCTIONAL ORGANIZATION OF THE
CEREBRAL CORTEX
A. Specific types of sensory, motor, and
integrative signals are processed in certain
cerebral regions
1. Sensory Areas
 a. The sensory areas of the cerebral cortex
are concerned with the reception and
interpretation of sensory impulses.
b. Some important sensory areas include the
primary somatosensory area, primary visual
area, primary auditory area, and primary
gustatory area.
2. Motor Areas
a. The motor areas are the regions that
govern muscular movement.
b. Two important motor areas are the
primary motor area and Broca’s speech area.
3. Association Areas
a. The association areas are concerned with
complex integrative functions such as
memory, emotions, reasoning, will,
judgment, personality traits, and
intelligence.
b. Association areas include the
somatosensory association area, visceral
association area, auditory association area,
Wernicke’s (posterior language)
area, common integrative area,
premotor area, frontal eye field area,
and language areas.
1. Clinical Connection: Injury to the
association or motor speech areas
results in aphasia, an inability to use
or comprehend words.
B. Hemispheric Lateralization
1. The two hemispheres of the cerebrum are not
bilaterally symmetrical, either anatomically or
functionally, with the functional asymmetry called
hemispheric lateralization.
a. The left hemisphere is more important for
right-handed control, spoken and written
language, and numerical and scientific skills.
b. The right hemisphere is more important
for left-handed control, musical and artistic
DEVELOPMENTAL ANATOMY OF THE NERVOUS
awareness, space and pattern perception,
insight, imagination, and generating mental
images of sight, sound, touch, taste, and
smell.
c. Table 14.3 summarizes some of the
distinctive functions that are more likely to
reside in the left or right hemisphere.
AGING AND THE NERVOUS SYSTEM
C. Brain Waves
1. Electrical potentials generated by brain cells are
called brain waves.
2. Brain waves generated by the cerebral cortex are
recorded as an electroencephalogram (EEG)
a. Alpha
b. Beta
c. Theta
d. delta
3. An EEG may be used to diagnose epilepsy and
other seizure disorders, infectious diseases, tumors,
trauma, hematomas, metabolic abnormalities,
degenerative diseases, and periods of
unconsciousness and confusion; it may also provide
useful information regarding sleep and wakefulness.
a. An EEG may also be one criterion in
confirming brain death (complete absence of
brain waves in two EEGs taken 24 hours
CRANIAL NERVES
apart).
A. Twelve pairs of cranial nerves originate from the
brain
B. The pairs are named primarily on the basis of
distribution and numbered by order of attachment to
the brain.
C. Some cranial nerves (I, II, and VIII) contain only
sensory fibers and are called sensory
nerves. The rest are mixed nerves because they
contain both sensory and motor fibers.
D. illustrate the distribution of many of the cranial
nerves.
E. present a summary of cranial nerves, including
SYSTEM
clinical applications related to their dysfunction.
F. Clinical Connection: Anesthesia during dental
procedures involves cranial nerves
A. The development of the nervous system begins
with a thickening of the ectoderm called the neural
plate
1. The parts of the brain develop from
primary and secondary vesicles
A. Age-related effects involve loss of neurons and
decreased capacity for sending nerve impulses to and
from the brain; processing of information also
diminishes.
B. Other effects include decreased conduction
velocity, slowing of voluntary motor movements,
and increased reflex time.
C. Degenerative changes and disease states
involving the sense organs can alter vision, hearing,
taste, smell, and touch
C. Alzheimer’s disease (AD) is a disabling
neurological disorder that afflicts about 11% of the
population over age 65.
1. Its causes are unknown, its effects are
irreversible and devastating, and it has no
cure at the present time.
2. It involves widespread intellectual
impairment, personality changes, sometimes
delirium, and culminates in dementia, the
loss of reason and ability to care for oneself.
3. A person with AD usually dies of some
complication that affects bedridden patients,
such as pneumonia.
4. Brains of AD victims show three distinct
structural abnormalities:
a. Great loss of neurons in specific
regions (e.g., hippocampus and

AGING AND THE NERVOUS SYSTEM

cerebral cortex).
A. The most common brain disorder is a
cerebrovascular accident (CVA or stroke). b. Plaques of abnormal proteins
deposited outside neurons (amyloid
1. CVAs are classified into two principal
plaques).
types: ischemic (the most common type),
due to a decreased blood supply, or c. Tangled protein filaments within
hemorrhagic, due to a blood vessel in the neurons (neurofibrillary tangles).
brain that bursts.
2. Common causes of CVAs are MEDICAL TERMINOLOGY
intracerebral hemorrhage, emboli,
and atherosclerosis.
3. CVAs are characterized by abrupt onset of List the medical terminologies associated with the
persisting neurological symptoms that arise central nervous system.
from destruction of brain tissue (infarction).
B. A transient ischemic attack (TIA) is an episode of
temporary cerebral dysfunction caused by impaired
blood flow to the brain.
1. Symptoms include dizziness, weakness,
numbness, or paralysis in a limb or in half of
the body; drooping of one side of the face;
headache; slurred speech or difficulty
understanding speech; or a partial loss of
vision or double vision.
2. Onset is sudden and a TIA usually persists
for only a few minutes, rarely lasting as long
as 24 hours.
3. Causes of the impaired blood flow include
blood clots, atherosclerosis, and certain
blood disorders; TIAs commonly are
forerunners of future CVAs.

HEART REVIEW NOTES
INTRODUCTION
A. The cardiovascular system consists of the blood,
heart, and blood vessels.
B. The heart is the pump that circulates the blood
through an estimated 75,000 miles of blood vessels.
C. The study of the normal heart and diseases
associated with it is known as cardiology.
ANATOMY OF THE HEART
A. Location of the heart
1. The heart is situated between the lungs in the
mediastinum with about two-thirds of its mass to the
left of the midline.
2. Because the heart lies between two rigid
structures, the vertebral column and the sternum,
external compression on the chest can be used to
force blood out of the heart and into the circulation.
(Clinical Connection)
B. Pericardium
1. The heart is enclosed and held in place by the
pericardium.
a. The pericardium consists of an outer
fibrous pericardium and an inner serous
pericardium.
b. The serous pericardium is composed of a
parietal layer and a visceral layer.
c. Between the parietal and visceral layers of
the serous pericardium is the pericardial
cavity, a potential space filled with
pericardial fluid that reduces friction
between the two membranes.
d. An inflammation of the pericardium is
known as pericarditis. Associated bleeding
into the pericardial cavity compresses the
heart (cardiac tamponade) and is potentially
lethal (Clinical Connection).
C. Layers of the Heart Wall
1. The wall of the heart has three layers: epicardium,
myocardium, and endocardium.
2. The epicardium consists of mesothelium and
connective tissue, the myocardium is composed of
cardiac muscle, and the endocardium consists of
endothelium and connective tissue.
3. Inflammations of the myocardium and
endocardium are myocarditis and endocarditis,
respectively (Clinical Connection)
D. Chambers of the Heart
1. The chambers of the heart include two upper atria
and two lower ventricles.
2. On the surface of the heart are the auricles and
sulci.
a. The auricles are small pouches on the
anterior surface of each atrium that slightly
increase the capacity of each atrium.
b. The sulci are grooves that contain blood
vessels and fat and separate the chambers.
E. Right Atrium
1. The right atrium receives blood from the superior
and inferior vena cava and the coronary sinus
2. In the septum separating the right and left atria is
an oval depression, the fossa ovalis, which is the
remnant of the foramen ovale.
3. Blood passes from the right atrium into the right
ventricle through the tricuspid valve.
F. Right Ventricle
1. The right ventricle forms most of the anterior
surface of the heart.
2. Blood passes from the right ventricle to the
pulmonary trunk via the pulmonary semilunar valve.
G. Left Atrium
1. The left atrium receives blood from the pulmonary
veins.
2. Blood passes from the left atrium to the left
ventricle through the bicuspid (mitral) valve.
H. Left Ventricle
1. The left ventricle forms the apex of the heart.
2. Blood passes from the left ventricle through the
aortic semilunar valve into the aorta.
3. During fetal life the ductus arteriosus shunts blood
from the pulmonary trunk into the aorta. At birth the
ductus arteriosus closes and becomes the
ligamentum arteriosum.
I. Myocardial Thickness and Function
1. The thickness of the myocardium of the four
chambers varies according to the function of each
chamber.
2. The atria walls are thin because they deliver blood
to the ventricles.
3. The ventricle walls are thicker because they pump
blood greater
a. The right ventricle walls are thinner than
the left because they pump blood into the
lungs, which are nearby and offer very little
resistance to blood flow.
b. The left ventricle walls are thicker
because they pump blood through the body
where the resistance to blood flow is greater.
J. Fibrous Skeleton of the Heart
1. The fibrous skeleton of the heart forms the
foundation for which the heart valves attach, serves
as points of insertion for cardiac muscle bundles,
prevents overstretching of the valves as blood passes
through them, and acts as an electrical insulator that
prevents direct spread of action potentials from the
atria to the ventricles.
HEART VALVES AND CIRCULATION OF BLOOD
A. Valves open and close in response to pressure
changes as the heart contracts and relaxes.
B. Operation of the atrioventricular valves
 1. Atrioventricular (AV) valves prevent
blood flow from the ventricles back into the
atria.
2. Back flow is prevented by the contraction
of papillary muscles tightening the chordae
tendinae which prevent the valve cusps from
everting.
C. Operation of the semilunar valves
1. The semilunar (SL) valves allow ejection
of blood from the heart into arteries but
prevent back flow of blood into the
ventricles.
2. Semilunar valves open when
pressure in the ventricles exceeds the
pressure in the arteries.
3. Heart valve disorders affect blood flow
through the heart. (Clinical Connection)
D. Systemic and Pulmonary Circulations
4. When blockage of a coronary artery
deprives the heart muscle of oxygen,
reperfusion may damage the tissue further.
This damage is due to free radicals. Drugs
that lessen reperfusion damage after a heart
attack are being developed.
5. Low levels of oxygen carried to the
myocardium may result in weakened heart
cells (or myocardial ischemia), and if the
damage is permanent then this is called
myocardial infarction (MI) or heart attack
(Clinical connection)
CARDIAC MUSCLE AND THE CARDIAC
CONDUCTION SYSTEM
A. Histology of Cardiac Muscle
1. Compared to skeletal muscle fibers, cardiac
muscle fibers are shorter in length, larger in
diameter, and squarish rather than circular in
transverse section. They also exhibit branching.

1. The left side of the heart is the pump for
the systemic circulation. It pumps
oxygenated blood from the lungs out into the
vessels of the body.
2. The right side of the heart is the pump for
the pulmonary circulation. It receives
deoxygenated blood from the body and
sends it to the lungs for oxygenation.
3. reviews the route of blood flow through
the chambers and valves of the heart and the
pulmonary and systemic circulations.
E. Coronary Circulation
1. The flow of blood through the many
vessels that pierce the myocardium of the
heart is called the coronary (cardiac)
circulation; it delivers oxygenated blood and
nutrients to and removes carbon dioxide and
wastes from the myocardium
2. The principal arteries, branching from the
ascending aorta and carrying oxygenated
blood, are the right and left coronary
arteries.
3. Deoxygenated blood returns to the right
atrium primarily via the principal vein, the
coronary sinus.
2. Cardiac muscles have the same arrangement of
actin and myosin, and the same bands, zones, and Z
discs as skeletal muscles.
3. They do have less sarcoplasmic reticulum than
skeletal muscles and require Ca+2 from extracellular
fluid for contraction.
4. They form two separate functional networks in the
heart: the atrial and the ventricular networks.
a. Fibers within the networks are connected
by intercalated discs, which consist of
desmosomes and gap junctions.
b. The intercalated discs allow the fibers in
the network to work together so that each
network serves as a functional unit.
c. Regeneration of heart cell has much
potential in treating heart problems (Clinical
connection)
B. Autorhythmic Cells: The Conduction System
1. Cardiac muscle cells are autorhythmic cells
because they are self-excitable. They
repeatedly generate spontaneous action potentials
that then trigger heart contractions.
 a. These cells act as a pacemaker to set the
rhythm for the entire heart.
b. They form the conduction system, the
route for propagating action potential
through the heart muscle.
2. Components of this system are the sinoartrial (SA)
node (pacemaker), atrioventricular (AV) node,
atrioventricular bundle (bundle of His), right and left
bundle branches, and the conduction myofibers
(Purkinje fibers)
3. Signals from the autonomic nervous system and
hormones, such as epinephrine, do modify the
heartbeat (in terms of rate and strength of
contraction), but they do not establish the
fundamental rhythm.
4. Artificial pacemakers stimulate heart muscle and
provide a normal rhythm (Clinical Connection).
C. Action potential and contraction of contractile
fibers
1. An impulse in a ventricular contractile fiber is
characterized by rapid depolarization,
plateau, and repolarization
2. The refractory period of a cardiac muscle fiber
(the time interval when a second contraction cannot
be triggered) is longer than the contraction itself
D. ATP production in cardiac muscle
1. Cardiac muscle relies on aerobic cellular
respiration for ATP production.
2. Cardiac muscle also produces some ATP from
creatine phosphate
3. The presence of creatine kinase (CK) in the blood
indicates injury of cardiac muscle usually caused by
a myocardial infarction.
E. Electrocardiogram
1. Impulse conduction through the heart generates
electrical currents that can be detected at the surface
of the body. A recording of the electrical changes
that accompany each cardiac cycle (heartbeat) is
called an electrocardiogram (ECG or EKG).
a. The ECG helps to determine if the
conduction pathway is abnormal, if the heart
is enlarged, and if certain regions are
damaged.
b. In a typical Lead II record, three clearly
visible waves accompany each heartbeat.
2. Correlation of ECG waves with atrial and
ventricular systole
a. A normal ECG consists of a P wave (atrial
depolarization - spread of impulse from SA
node over atria), QRS complex (ventricular
depolarization - spread of impulse through
ventricles), and T wave (ventricular
repolarization).
b. The P-Q (PR) interval represents the
conduction time from the beginning of atrial
excitation to the beginning of ventricular
excitation.
c. The S-T segment represents the time when
ventricular contractile fibers are fully
depolarized, during the plateau phase of the
impulse.
d. Figure 20.13 illustrates the timing and
route of action potential depolarization and
repolarization through the conduction
system and myocardium
THE CARDIAC CYCLE
A. A cardiac cycle consists of the systole
(contraction) and diastole (relaxation) of both atria,
rapidly followed by the systole and diastole of both
ventricles
B. Pressure and volume changes during the cardiac
cycle
1. During a cardiac cycle atria and ventricles
alternately contract and relax forcing blood
from areas of high pressure to areas of lower
pressure.
2. Read the relation between the ECG and
changes in atrial pressure, ventricular
pressure, aortic pressure, heart sounds.
ventricular volume and cycle phases during
the cardiac cycle.
C. The act of listening to sounds within the body is
called auscultation, and it is usually done
with a stethoscope. The sound of a heartbeat comes
primarily from the turbulence in blood flow caused
by the closure of the valves, not from the contraction
of the heart
1. The first heart sound (lubb) is created by blood
turbulence associated with the closing of the
atrioventricular valves soon after ventricular systole
begins.
2. The second heart sound (dupp) represents the
closing of the semilunar valves close to the end of
the ventricular systole.
3. A heart murmur is an abnormal sound that
consists of a flow noise that is heard before,
between, or after the lubb-dupp or that may mask the
normal sounds entirely. Some murmurs are caused
by turbulent blood flow around valves due to
abnormal anatomy or increased volume of flow. Not
all murmurs are abnormal or symptomatic, but most
indicate a valve disorder (Clinical Connection).
A. Since the body’s need for oxygen varies with
the level of activity, the heart’s ability to
discharge oxygen-carrying blood must also be
variable. Body cells need specific amounts of
blood each minute to maintain health and life.
B. Cardiac output (CO) is the volume of blood
ejected from the left ventricle (or the right
ventricle) into the aorta (or pulmonary trunk)
each minute.
1. cardiac output equals the stroke volume,
the volume of blood ejected by the ventricle
with each contraction, multiplied by the
heart rate, the number of beats per minute.
2. Cardiac reserve is the ratio between the
maximum cardiac output a person can
achieve and the cardiac output at rest.
C. Regulation of Stroke Volume
1. Three factors regulate stroke volume: preload, the
degree of stretch in the heart before it contracts;
contractility, the forcefulness of contraction of
individual ventricular muscle fibers; and afterload,
the pressure that must be exceeded if ejection of
blood from the ventricles is to occur.
a. Preload: Effect of Stretching
1. According to the Frank-Starling law of the
heart, a greater preload (stretch) on cardiac
muscle fibers just before they contract
increases their force of contraction during
systole.
2. The Frank-Starling law of the heart
equalizes the output of the right and left
ventricles and keeps the same volume of
blood flowing to both the systemic and
pulmonary circulations.
b. Myocardial contractility, the strength of
contraction at any given preload, is affected by
positive and negative inotropic agents.
1. Positive inotropic agents increase
contractility and negative inotropic agents
decrease contractility.
2. Thus, for a constant preload, the stroke
volume increases when positive inotropic
agents are present and decreases when
negative inotropic agents are present.
HELP FOR FAILING HEARTS
c. The pressure that must be overcome before a
semilunar valve can open is the afterload.
1. In congestive heart failure, blood begins
to remain in the ventricles increasing the
preload and ultimately causing an
overstretching of the heart and less forceful
contraction (Clinical Connection).
D. Regulation of Heart Rate
1. Cardiac output depends on heart rate as well as
stroke volume. Changing heart rate is the body’s
principal mechanism of short-term control over
cardiac output and blood pressure. Several factors
contribute to regulation of heart rate.
2. Autonomic regulation of the heart
a. Nervous control of the cardiovascular
system stems from the cardiovascular center
in the medulla oblongata (Figure 20.16).
b. Proprioceptors, baroreceptors, and
chemoreceptors monitor factors that
influence the heart rate.
c. Sympathetic impulses increase heart rate
and force of contraction; parasympathetic
impulses decrease heart rate.
3. Chemical regulation of heart rate
a. Heart rate affected by hormones
(epinephrine, norepinephrine, thyroid
hormones).
b. Ions (Na+, K+, Ca+2) also affect heart
rate.
 c. other factors such as age, gender, physical
fitness, and temperature also affect heart
rate.
d. Figure 20.17 summarizes the factors
B. The endothelial tubes develop into the four-
influencing both stroke volume and heart
rate in the overall increase of cardiac
DISORDERS: HOMEOSTATIC IMBALANCES
output.
chambered heart and great vessels of the heart
EXERCISE AND THE HEART
A. Sustained exercise increases oxygen demand in
muscles.
B. Among the benefits of aerobic exercise (any
activity that work large body muscles for at least 20
minutes, preferably 3-5 times per week) are
increased cardiac output, increased HDL and
decreased triglycerides, improved lung function,
decreased blood pressure, and weight control.
A. a heart fails, a person’s mobility decreases. Heart
transplants may help such individuals. Other
possibilities include cardiac assist devices and
surgical procedures.
Please describe several devices and procedures.
DEVELOPMENT OF THE HEART
A. The heart develops from mesoderm before the
end of the third week of
A. Coronary artery disease (CAD), or coronary heart
disease (CHD), is a condition in which the heart
muscle receives an inadequate amount of blood due
to obstruction of its blood supply. It is the leading
cause of death in the United States each year. The
principal causes of obstruction include
atherosclerosis, coronary artery spasm, or a clot in a
coronary artery.
1. Risk factors for development of CAD
include high blood cholesterol levels, high
blood pressure, cigarette smoking, obesity,
diabetes, “type A” personality, and sedentary
lifestyle.
2. Atherosclerosis is a process in which
smooth muscle cells proliferate and fatty
substances, especially cholesterol and
triglycerides (neutral fats), accumulate in the
walls of the medium-sized and large arteries
in response to certain stimuli, such as
endothelial damage
3. Diagnosis of CAD includes such
procedures as cardiac catherization and
cardiac angiography.
4. Treatment options for CAD include drugs
and coronary artery bypass grafting.
NERVOUS SYSTEM NOTES
INTRODUCTION

A. The components of the brain interact to receive

sensory input, integrate and store the information,
and transmit motor responses.
B. To accomplish the primary functions of the
nervous system there are neural pathways to transmit
impulses from receptors to the circuitry of the brain,
which manipulates the circuitry to form directives
that are transmitted via neural pathways to effectors
as a response.

SENSATION

A. Sensation is a conscious or unconscious

awareness of external or internal stimuli.
Perception is the conscious awareness and
interpretation of sensations.

B. Sensory Modalities
1. Sensory Modality is the property by which one
sensation is distinguished from another.
2. In general, a given sensory neuron carries only
one modality.
3. The classes of sensory modalities are general
senses and special senses.
a. The general senses include both somatic
and visceral senses, which provide
information about conditions within internal
organs.
b. The special senses include the modalities
of smell, taste, vision, hearing, and
equilibrium.

C. The Process of Sensation

1. For a sensation to arise, four events must occur,
these are stimulation, transduction, conduction, and
translation.
 a. A stimulus, or change in the environment,
capable of initiating a nerve impulse by the
nervous system must be present.
b. A sensory receptor or sense organ must
pick up the stimulus and transduce (convert) SOMATIC SENSATIONS (Summarize the Receptors
it to a nerve impulse by way of a generator
potential.
c. The impulse(s) must be conducted along a
neural pathway from the receptor or sense
organ to the brain
d. A region of the brain or spinal cord must
translate the impulse into a sensation.
D. Sensory Receptors
1. Types of Sensory Receptors
2. On a microscopic level, sensory receptors are free
nerve endings, encapsulated nerve endings at the
dendrites of first-order sensory neurons, or separate
cells that synapse with first order sensory neurons
3. When stimulated the dendrites of free nerve
endings, encapsulate nerve endings, and the
receptive part of olfactory receptors produce
generator potentials.
a. The specialized cells that act as receptors
for the special senses of vision, hearing,
equilibrium, and taste produce receptor
potentials in response to stimuli.
4. Generator and receptor potentials are graded, local
potentials; generator potentials trigger action
potentials, whereas receptor potentials doe not.
5. According to location, receptors are classified as
exteroceptors, interceptors (visceroceptors), and
proprioceptors.
6. On the basis of type of stimulus detected,
receptors are classified as mechanoreceptors,
thermoreceptors, nociceptors, photoreceptors,
chemoreceptors, and osmoreceptors.
7. Table 16.1 summarizes the classification of
sensory receptors.
E. Adaptation in Sensory Receptors
1. A characteristic of many sensations is adaptation,
i.e., a change in sensitivity (usually a decrease) to a
long-lasting stimulus.
2. Receptors vary in how they adapt
a. Rapid adaptor
b. Slow adaptors
3. The receptors involved are important in signaling
for somatic sensation)
information regarding steady states of the body.
A. Tactile Sensations
1. Tactile sensations are touch, pressure, and
vibration plus itch and tickle.
a. Tactile receptors include corpuscles of
touch (Meissner’s corpuscles), hair root
plexuses, type I (Merkel’s discs) and type II
cutaneous (Ruffini’s corpuscles)
mechanoreceptors, lamellated (Pacinian)
corpuscles, and free nerve endings
2. Touch
a. Crude touch refers to the ability to
perceive that something has simply touched
the skin; fine touch provides specific
information about a touch sensation such as
location, shape, size, and texture of the
source of stimulation.
b. Receptors for touch include corpuscles of
touch (Meissner’s corpuscles) and hair root
plexuses; these are rapidly adapting
receptors.
c. Type I cutaneous mechanoreceptors
(tactile or Merkel discs) and type II
cutaneous mechanoreceptors (end organs of
Ruffini) are slowly adapting receptors for
touch
d. Pressure and Vibration
1. Pressure sensations generally
result from stimulation of tactile
receptors in deeper tissues and are
longer lasting and have less
variation in intensity than touch
sensations; pressure is a sustained
sensation that is felt over a larger
area than touch.
2. Receptors for pressure are type II
cutaneous mechanoreceptors and
lamellated (Pacinian) corpuscles.
 i. Like corpuscles of touch,
lamellated corpuscles adapt
rapidly.
3. Vibration sensations result from rapidly
repetitive sensory signals from tactile
receptors; the receptors for vibration
sensations are corpuscles of touch and
lamellated corpuscles, which detect low-
frequency and high-frequency vibrations,
respectively.
e. Itch and Tickle
1. Itch and tickle receptors are free nerve
endings.
2. Tickle is the only sensation that you may
not elicit on yourself.
f. Phantom pain is the sensations of pain in a limb
that has been amputated. (Clinical Connection)
B. Thermal Sensations
1. Thermoreceptors are free nerve endings.
2. Separate thermoreceptors respond to hot and cold
stimuli.
C. Pain Sensations
1. Pain is a vital sensation because it provides us
with information about tissue-damaging stimuli and
with signs that may be used for diagnosis of
disease or injury.
SOMATIC SENSORY PATHWAYS
2. Pain receptors (nociceptors) are free endings that
are located in nearly every body tissue; adaptation is
slight if it occurs at all.
3. Localization of pain
a. Two kinds of pain are recognized in the
parietal lobe of the cortex: somatic
(superficial and deep) and visceral; visceral
pain, unlike somatic pain, is usually felt in or
just under the skin that overlies the
stimulated organ – the pain may also be felt
in a surface area far from the stimulated
organ in a phenomenon known as referred
pain
4. Analgesic drugs block pains sensations (Clinical
Connection).
D. Proprioceptive Sensations
1. Receptors located in skeletal muscles, in tendons,
in and around joints, and in the internal ear convey
nerve impulses related to muscle tone, movement of
body parts, and body position. This awareness of the
activities of muscles, tendons, and joints and of
balance or equilibrium is provided by the
proprioceptive or kinesthetic sense.
2. Muscle spindles:
a. proprioceptors in skeletal muscles that
monitor changes in the length of skeletal
muscles and participate in stretch reflexes
b. muscle spindle consists of several slowly
adapting sensory nerve endings that wrap
around 3 to 10 specialized muscle fibers,
called intrafusal muscle fibers
c. The main function of muscle spindles is to
measure muscle Length
3. Tendon Organs
a. located at the junction of a tendon and a
muscle
b. protects tendons and their associated
muscles from damage due to excessive
tension
4. Joint Kinesthetic receptors
a. responds to acceleration and deceleration
of joints during movement
A. Somatic sensory pathways relay information from
somatic receptors to the primary somatosensory area
in the cerebral cortex.
1. The pathways consist of first-order,
second-order, and third-order neurons.
2. Axon collaterals of somatic sensory
neurons simultaneously carry signals into
the cerebellum and the reticular formation of
the brain stem.
B. Posterior Column-Medial Lemniscus Pathway to
the Cortex
1. The nerve impulses for conscious
proprioception and most tactile sensations
 ascend to the cortex along a common
pathway formed by three-neuron sets
2. Impulses conducted along this pathway
are concerned with discriminative touch,
stereognosis, proprioception, and vibratory
sensations.
C. Anterolateral Pathways to the Cortex
1. The anterolateral or spinothalamic
pathways carry mainly pain and temperature
impulses
2. They also relay the sensations of tickle
and itch and some tactile impulses.
D. Trigeminothalamic Sensory Pathways to the
Cortex
1. The trigeminothalamic pathways carry
mainly tactile sensations, pain and
temperature impulses from the face
2. They relay the sensations to the
somatosensory area via the same side
thalamus.
E. Mapping the Primary Somatosensory Area
1. Specific areas of the cerebral cortex
receive somatic sensory input from
particular parts of the body and other areas
of the cerebral cortex provide output
instructions for movement of particular parts
of the body
2. Precise location of somatic sensations
occurs at the primary somatosensory area
F. Somatic Sensory Pathways to the Cerebellum
1. The posterior spinocerebellar and the
anterior spinocerebellar tracts are the major
routes whereby proprioceptive impulses
reach the cerebellum.
2. The Cuneo cerebellar and rostral
spinocerebellar tracts convey impulses from
proprioceptors of the trunk and upper limbs.
G. summarize the major sensory tracts in the spinal
cord and pathways in the brain.
H. Tertiary syphilis causes a progressive
degeneration of the posterior portions of the spinal
cord resulting in lost somatic sensations and
proprioception failure. (Clinical Connection)
SOMATIC MOTOR PATHWAYS
A. Lower motor neurons extend from the brain stem
or spinal cord to skeletal muscles.
B. Four distinct neurons participate in control of
movement by providing input to lower motor
neurons
C. Local circuit neurons are located close to lower
motor neuron cell bodies in the brain stem and spinal
cord.
1. Local circuit neurons and lower motor
neurons receive input from upper motor
neurons.
2. Neurons of the basal ganglia provide input
to upper motor neurons.
3. Cerebellar neurons also control activity of
upper motor neurons.
D. Organization of Upper Motor Neuron Pathways
1. The primary motor area in the precentral
gyrus of the frontal lobe is a major control
region for voluntary movements
2. Direct, or pyramidal, motor pathways
provide input to lower motor neurons from
the cortex
3. Indirect motor pathways provide input to
lower motor neurons from motor centers in
the brain stem
E. Direct motor pathways.
1. The various tracts of the pyramidal system
convey impulses from the cerebral cortex
that result in precise muscular movements.
2. The direct pathways include the
corticospinal tracts and corticobulbar tracts
3. The corticospinal tracts promote voluntary
movements of the limbs and trunks
4. The corticobulbar tracts are tracts that
promote voluntary movements of the head
5. Damage or disease of lower motor
neurons produces flaccid paralysis of
muscles on the same side of the body. Injury
or disease of upper motor neurons results in
spastic paralysis of muscles on the opposite
side of the body. (Clinical Connection)
6. Amyotrophic Lateral Sclerosis (ALS) is a
disease that attacks motor areas of the
IN
 cerebral cortex, axons of upper motor
neurons and cell bodies of lower motor
neurons. It causes progressive muscle
weakness (Clinical Connection).
F. Indirect Pathways
1. Indirect or extrapyramidal pathways
include all somatic motor tracts other than
the direct (corticospinal and corticobulbar)
tracts.
a. Indirect pathways involve the
motor cortex, basal ganglia,
thalamus, cerebellum, reticular
formation, and nuclei in the brain
stem (Table 16.4).
b. Major indirect tracts are the
rubrospinal, tectospinal,
vestibulospinal, and reticulospinal
tracts.
c. Summarize the major motor
tracts, their functions, and pathways
in the brain.
G. Role of the Basal Ganglia
1. The basal ganglia help program habitual
or automatic sequences and set an
appropriate level of muscle tone.
2. They also selectively inhibit other motor
neuron circuits that are intrinsically active or
excitatory.
3. Impairment of the basal ganglia results in
uncontrollable, abnormal body movements,
often accompanied by muscle rigidity and
tremors. A number of diseases, including
Parkinson disease, Huntington disease,
Tourette Syndrome basal ganglia disorders
(Clinical Connection).
H. Modulation of Movement by the Cerebellum
1. The cerebellum is active in both learning
and performing rapid, coordinated, highly
skilled movements and in maintaining
proper posture and equilibrium.
2. The four aspects of cerebellar function are
monitoring intent for movement, monitoring
actual movement, comparing intent with
actual performance, and sending out
corrective signals
A. The integrative functions include sleep
and wakefulness, memory, and emotional
responses (discussed in Chapter 14 of
Tortora).
B. Wakefulness and Sleep
1. Reticular Activating System (RAS)
2. Sleep and wakefulness are integrative functions
that are controlled by the reticular activating system
3. Arousal, or awakening from a sleep, involves
increased activity of the RAS.
a. Once the RAS is activated, the cerebral
cortex is also activated and arousal occurs.
b. The result is a state of wakefulness called
consciousness.
4. Sleep
a. During sleep, a state of altered
consciousness or partial unconsciousness
from which an individual can be aroused by
different stimuli, activity in the RAS is very
low.
b. Normal sleep consists of two types: non-
rapid eye movement sleep (NREM) and
rapid eye movement sleep (REM).
1. Non-rapid eye movement or slow
wave sleep consists of four stages,
each of which gradually merges into
the next. Each stage has been
identified by EEG recordings.
2. Most dreaming occurs during
rapid eye movement sleep.
C. Learning and Memory
1. Learning is the ability to acquire new knowledge
or skills through instruction or experience. Memory
is the process by which that knowledge is retained
over time.
2. For an experience to become part of memory, it
must produce persistent functional changes that
represent the experience in the brain.
3. The capability for change with learning is called
plasticity.
4. Memory is the ability to recall thought and is
generally classified into two kinds based on how
long the memory persists: short-term and long-term
memory.
5. A memory trace in the brain is called an engram (a
change in the brain that represents the experience).
a. Short-term memory lasts only seconds or
RESPIRATORY SYSTEM NOTES
hours and is the ability to recall bits of
information; it is related to electrical and
chemical events.
b. Long-term memory lasts from days to
years and is related to anatomical and
biochemical changes at synapses.
c. Loss of memory is called amnesia
(Clinical Connection)
A. Parkinson’s disease is a progressive degeneration
of CNS neurons of the basal nuclei region due to
unknown causes that decreases dopamine
neurotransmitter production.
1. This condition produces motor
coordination problems of involuntary tremor
and/or rigidity.
2. Motor performance can be described as
bradykinesia (slow) and hypokinesia
(limited).
3. Limited treatment is provided with L-
dopa, a precursor to dopamine, or through
acetylcholine inhibitors.
MEDICAL TERMINOLOGY
List as many as you can the medical
terminology associated with the sensory,
motor and integrative systems.
INTRODUCTION
A. The two systems that cooperate to supply O2 and
eliminate CO2 are the cardiovascular and the
respiratory system.
1. The respiratory system provides for gas
exchange.
2. The cardiovascular system transports the
respiratory gases.
3. Failure of either system has the same
effect on the body: disruption of homeostasis
and rapid death of cells from oxygen
starvation and buildup of waste products.
B. Respiration is the exchange of gases between the
atmosphere, blood, and cells. It takes place in three
basic processes: ventilation (breathing), external
(pulmonary) respiration, and internal (tissue)
respiration.
RESPIRATORY SYSTEM ANATOMY
A. The respiratory system consists of the nose,
pharynx, larynx, trachea, bronchi, and lungs
1. The upper respiratory system refers to the
nose, pharynx, and associated structures.
The lower respiratory system refers to the
larynx, trachea, bronchi, and lungs.
2. The conducting system consists of a series
of cavities and tubes - nose, pharynx, larynx,
trachea, bronchi, bronchiole, and terminal
bronchioles - that conduct air into the lungs.
The respiratory portion consists of the area
where gas exchange occurs - respiratory
bronchioles, alveolar ducts, alveolar sacs,
and alveoli.
3. The branch of medicine that deals with the
diagnosis and treatment of diseases of the
 ear, nose, and throat is called
otorhinolaryngology.
B. Nose
1. The external portion of the nose is made
of cartilage and skin and is lined with
mucous membrane. Openings to the exterior
are the external nares.
2. The external portion of the nose is made
of cartilage and skin and is lined with
mucous membrane
3. The bony framework of the nose is
formed by the frontal bone, nasal bones, and
maxillae
4. The interior structures of the nose are
specialized for warming, moistening, and
filtering incoming air; receiving olfactory
stimuli; and serving as large, hollow
resonating chambers to modify speech
sounds.
5. The internal portion communicates with
the paranasal sinuses and nasopharynx
through the internal nares.
6. The inside of both the external and
internal nose is called the nasal cavity. It is
divided into right and left sides by the nasal
septum. The anterior portion of the cavity is
called the vestibule.
7. (Please study the surface anatomy of the
nose.)
8. Rhinoplasty (“nose job”) is a surgical
procedure in which the structure of the
external nose is altered for cosmetic or
functional reasons. (Clinical Connection)
C. Pharynx
1. The pharynx (throat) is a muscular tube
lined by a mucous membrane
2. The anatomic regions are the
nasopharynx, oropharynx, and
laryngopharynx.
3. The nasopharynx functions in respiration.
Both the oropharynx and laryngopharynx
function in digestion and in respiration
(serving as a passageway for both air and
food).
4. A Tonsillectomy is the surgical removal
of the tonsils (Clinical Connection)
D. Larynx
1. The larynx (voice box) is a passageway
that connects the pharynx with the trachea.
2. It contains the thyroid cartilage (Adam’s
apple); the epiglottis, which prevents food
from entering the larynx; the cricoid
cartilage, which connects the larynx and
trachea; and the paired arytenoid,
corniculate, and cuneiform cartilages
E. The Structures of Voice Production
1. The larynx contains vocal folds (true
vocal cords), which produce sound. Taunt
vocal folds produce high pitches, and
relaxed vocal folds produce low pitches
2. Sound originates from the vibration of the
vocal folds, but other structures are
necessary for converting the sound into
recognizable speech.
3. Laryngitis is an inflammation of the
larynx that is usually caused by respiratory
infection or irritants. Cancer of the larynx is
almost exclusively found in smokers
(Clinical Connection).
F. Trachea
1. The trachea (windpipe) is anterior to the
esophagus
2. It extends from the larynx to the primary
bronchi
3. It is composed of smooth muscle and C-
shaped rings of cartilage and is lined with
pseudostratified ciliated columnar
epithelium.
a. The cartilage rings keep the
airway open.
b. The cilia of the epithelium sweep
debris away from the lungs and back
to the throat to be swallowed.
 4. Two methods of bypassing obstructions
from the respiratory passageways are
tracheostomy and intubation. (Clinical
Connection)
G. Bronchi
1. The trachea divides into the right and left
pulmonary bronchi
2. The bronchial tree consists of the trachea,
primary bronchi, secondary bronchi, tertiary
bronchi, bronchioles, and terminal
bronchioles.
3. Changes in histology reflect changes in
function is the structures of the bronchial
tree.
a. The mucus membrane changes
from ciliated pseudostratified
epithelium with many goblet cells
(in the largest bronchi) to non-
ciliated cuboidal epithelium in the
smallest bronchioles.
b. The c-rings of the trachea are
replaced by plates of cartilage (in
the bronchi) and eventually cartilage
disappears completely in the
bronchioles.
c. As the amount of cartilage
decreases the amount of smooth
muscle increases.
H. Lungs
1. Lungs are paired organs in the thoracic
cavity; they are enclosed and protected by
the pleural membrane
a. The parietal pleura is the outer
layer which is attached to the wall of
the thoracic cavity.
b. The visceral pleura is the inner
layer, covering the lungs
themselves.
c. Between the pleurae is a small
potential space, the pleural cavity,
which contains a serous lubricating
fluid secreted by the membranes.
d. The lungs extend from the
diaphragm to just slightly superior
to the clavicles and lie against the
ribs anteriorly and posteriorly.
e. Injuries to the chest wall that
allow air to enter the intrapleural
space either from the outside or
from the alveoli cause
pneumothorax, filling the pleural
cavity with air. (Clinical
Connection).
2. The right lung has three lobes separated
by two fissures; the left lung has two lobes
separated by one fissure and a depression,
the cardiac notch
a. The secondary bronchi give rise to
branches called tertiary (segmental)
bronchi, which supply segments of
lung tissue called bronchopulmonary
segments.
b. Each bronchopulmonary segment
consists of many small
compartments called lobules, which
contain lymphatics, arterioles,
venules, terminal bronchioles,
respiratory bronchioles, alveolar
ducts, alveolar sacs, and alveoli
3. Alveoli
a. Alveolar walls consist of type I
alveolar (squamous pulmonary
epithelial) cells, type II alveolar
(septal) cells, and alveolar
macrophages (dust cells)
b. Type II alveolar cells secrete
alveolar fluid, which keeps the
alveolar cells moist and which
contains a component called
surfactant. Surfactant lowers the
surface tension of alveolar fluid,
preventing the collapse of alveoli
with each expiration.
c. Gas exchange occurs across the
alveolar-capillary membrane
4. The lungs have a double blood supply.
a. Blood enters the lungs via the
pulmonary arteries (pulmonary
circulation) and the bronchial
arteries (systemic circulation). Most
of the blood leaves by the
pulmonary veins, but some drains
into the bronchial veins.
b. In the lungs vasoconstriction in
response to hypoxia diverts
pulmonary blood from poorly
ventilated areas to well ventilated
 areas. This phenomenon is known
as ventilation – perfusion coupling.
PULMONARY VENTILATION
A. Respiration occurs in three basic steps:
pulmonary ventilation, external respiration, and
internal respiration.
B. Inhalation (inspiration) is the process of bringing
air into the lungs.
1. The movement of air into and out of the
lungs depends on pressure changes governed
in part by Boyle’s law, which states that the
volume of a gas varies inversely with
pressure, assuming that temperature is
constant
2. The first step in expanding the lungs
involves contraction of the main inspiratory
muscle, the diaphragm
3. Inhalation occurs when alveolar
(intrapulmonic) pressure falls below
atmospheric pressure. Contraction of the
diaphragm and external intercostal muscles
increases the size of the thorax, thus
decreasing the intrapleural (intrathoracic)
pressure so that the lungs expand. Expansion
of the lungs decreases alveolar pressure so
that air moves along the pressure gradient
from the atmosphere into the lungs
4. During forced inhalation, accessory
muscles of inspiration
(sternocleidomastoids, scalenes, and
pectoralis minor) are also used.
5. Make a summary of inhalation.
C. Exhalation (expiration) is the movement of air out
of the lungs.
1. Exhalation occurs when alveolar pressure
is higher than atmospheric pressure.
Relaxation of the diaphragm and external
intercostal muscles results in elastic recoil of
the chest wall and lungs, which increases
intrapleural pressure, decreases lung volume,
and increases alveolar pressure so that air
moves from the lungs to the atmosphere.
There is also an inward pull of surface
tension due to the film of alveolar fluid.
2. Exhalation becomes active during labored
breathing and when air movement out of the
lungs is impeded. Forced expiration employs
contraction of the internal intercostals and
abdominal muscles
3. Make a summary of expiration
D. Other factors that affecting pulmonary ventilation
1. In the lungs, surface tension causes the
alveoli to assume the smallest diameter
possible.
a. During breathing, surface tension
must be overcome to expand the
lungs during each inspiration. It is
also the major component of lung
elastic recoil, which acts to decrease
the size of the alveoli during
expiration.
b. The presence of surfactant, a
phospholipid produced by the type II
alveolar (septal) cells in the alveolar
walls, allows alteration of the
surface tension of the alveoli and
prevents their collapse following
expiration.
2. As a result of inadequate surfactant, the
alveoli of premature babies cannot remain
open. This disorder, called Respiratory
Distress Syndrome, results in blue skin color
and labored breathing. (Clinical Connection)
E. Compliance is the ease with which the lungs and
thoracic wall can be expanded. Any condition that
destroys lung tissue causes it to become filled with
fluid, produces a deficiency in surfactant, or in any
way impedes lung expansion or contraction,
decreases compliance.
F. The walls of the respiratory passageways,
especially the bronchi and bronchioles, offer some
resistance to the normal flow of air into the lungs.
Any condition that obstructs the air passageway
increases resistance, and more pressure to force air
through is required.
G. Breathing Patterns and Modified Respiratory
Movements
1. Breathing Patterns
a. Eupnea is normal variation in
breathing rate and depth.
b. Apnea refers to breath holding.
c. Dyspnea relates to painful or
difficult breathing.
 d. Tachypnea involves rapid
breathing rate.
e. Costal breathing requires
combinations of various patterns of
intercostal and extracostal muscles,
usually during need for increased
ventilation, as with exercise.
f. Diaphragmatic breathing is the
usual mode of operation to move air
by contracting and relaxing the
diaphragm to change the lung
volume.
2. Modified respiratory movements are used
to express emotions and to clear air
passageways. lists some of the modified
respiratory movements.
LUNG VOLUMES AND CAPACITIES
A. Air volumes exchanged during breathing and rate
of ventilation are measured with a spirometer, or
respirometer, and the record is called a spirogram
B. Among the pulmonary air volumes exchanged in
ventilation are tidal (500 ml), inspiratory reserve
(3100 ml), expiratory reserve (1200 ml), residual
(1200 ml) and minimal volumes. Only about 350 ml
of the tidal volume actually reaches the alveoli, the
other 150 ml remains in the airways as anatomic
dead space.
C. Pulmonary lung capacities, the sum of two or
more volumes, include inspiratory (3600 ml),
functional residual (2400 ml), vital (4800 ml), and
total lung (6000 ml) capacities
D. The minute volume of respiration is the total
volume of air taken in during one minute (tidal
volume x 12 respirations per minute = 6000 ml/min).
EXCHANGE OF OXYGEN AND CARBON DIOXIDE
A. To understand the exchange of oxygen and
carbon dioxide between the blood and alveoli, it is
useful to know some gas laws.
1. According to Dalton’s law, each gas in a mixture
of gases exerts its own pressure as if all the other
gases were not present.
TRANSPORT OF OXYGEN AND CARBON
a. The partial pressure of a gas is the
pressure exerted by that gas in a mixture of
gases. The total pressure of a mixture is
calculated by simply adding all the partial
pressures. It is symbolized by P.
b. The partial pressures of the respiratory
gases in the atmosphere, alveoli, blood, and
tissues cells are shown in the text.
c. The amounts of O2 and CO2 vary in
inspired (atmospheric), alveolar, and expired
air.
2. Henry’s law states that the quantity of a gas that
will dissolve in a liquid is proportional to the partial
pressure of the gas and its solubility coefficient (its
physical or chemical attraction for water), when the
temperature remains constant.
a. Nitrogen narcosis and decompression
sickness (caisson disease, or bends) are
conditions explained by Henry’s law.
b. A major clinical application of Henry’s
law is hyperbaric oxygenation. This
technique uses pressure to cause more
oxygen to dissolve in the blood and is used
to treat anaerobic bacterial infections (such
as tetanus and gangrene) and a number of
other disorders and injuries (Clinical
connection)
B. External and Internal Respiration
1. In internal and external respiration, O2 and CO2
diffuse from areas of their higher partial pressures to
areas of their lower partial pressures
2. External respiration results in the conversion of
deoxygenated blood (depleted of O2 but higher in
CO2 ) going to the lungs, to oxygenated blood
(saturated with O2 and lower in CO2) returning
from the lungs to the heart.
3. External respiration depends on partial pressure
differences, a large surface area for gas exchange, a
small diffusion distance across the alveolar-capillary
(respiratory) membrane, and the solubility and
molecular weight of the gases.
4. Internal (tissue) respiration is the exchange of
gases between tissue blood capillaries and tissue
cells and results in the conversion of oxygenated
blood into deoxygenated blood.
5. At rest only about 25% of the available oxygen in
oxygenated blood actually enters tissue cells. During
exercise, more oxygen is released.
DIOXIDE IN THE BLOOD
A. Oxygen Transport
1. In each 100 ml of oxygenated blood, 1.5% of the
O2 is dissolved in the plasma and 98.5% is carried
with hemoglobin (Hb) inside red blood cells as
oxyhemoglobin (HbO2)
a. Hemoglobin consists of a protein portion
called globin and a pigment called heme.
b. The heme portion contains 4 atoms of
iron, each capable of combining with a
molecule of oxygen.
c. Hemoglobin and Oxygen Partial Pressure
d. The most important factor that determines
how much oxygen combines with
hemoglobin is PO2.
e. The relationship between the percent
saturation of hemoglobin and PO2, the
oxygen-hemoglobin dissociation curve.
f. The greater the PO2, the more oxygen will
combine with hemoglobin, until the
available hemoglobin molecules are
saturated.
g. Other Factors Affecting Hemoglobin
Affinity for Oxygen
1. In an acid (low pH) environment,
O2 splits more readily from
hemoglobin. This is referred
to as the Bohr effect.
2. Low blood pH (acidic conditions)
results from high PCO2.
3. Within limits, as temperature
increases, so does the amount of
oxygen released from hemoglobin.
Active cells require more oxygen,
and active cells (such as contracting
muscle cells) liberate more acid and
heat. The acid and heat, in turn,
stimulate the oxyhemoglobin to
release its oxygen.
4. BPG (2, 3-biphosphoglycerate) is
a substance formed in red blood
cells during glycolysis. The greater
the level of BPG, the more oxygen
is released from hemoglobin.
5. Fetal hemoglobin has a higher
affinity for oxygen because it binds
BPG less strongly and can carry
more oxygen to offset the low
oxygen saturation in maternal blood
in the placenta.
6. Because of the strong attraction of
carbon monoxide (CO) to
hemoglobin, even small
concentrations of CO will reduce the
oxygen carrying capacity leading to
hypoxia and carbon monoxide
poisoning. (Clinical Connection)
B. Carbon Dioxide Transport
1. CO2 is carried in blood in the form of dissolved
CO2 (7%), carbaminohemoglobin (23%), and
bicarbonate ions (70%)
2. The conversion of CO2 to bicarbonate ions and
the related chloride shift maintains the ionic balance
between plasma and red blood cells
C. Summary of Gas Exchange and Transport in
Lungs and Tissues
1. CO2 in blood causes O2 to split from hemoglobin.
2. Similarly, the binding of O2 to hemoglobin causes
a release of CO2 from blood.
3. Make a summary of all reactions that occur during
gas exchange.
CONTROL OF RESPIRATION
A. Respiratory Center
1. The area of the brain from which nerve impulses
are sent to respiratory muscles is located bilaterally
in the reticular formation of the brain stem. This
respiratory center consists of a medullary
rhythmicity area (inspiratory and expiratory areas),
pneumotaxic area, and apneustic area.
2. Medullary Rhythmicity Area
a. The function of the medullary rhythmicity
area is to control the basic rhythm of
respiration.
b. The inspiratory area has an intrinsic
excitability of autorhythmic neurons that
sets the basic rhythm of respiration.
c. The expiratory area neurons remain
inactive during most quiet respiration but are
probably activated during high levels of
ventilation to cause contraction of muscles
used in forced (labored) expiration.
3. Pneumotaxic Area
 a. The pneumotaxic area in the upper pons
helps coordinate the transition between
inspiration and expiration.
b. The apneustic area sends impulses to the
inspiratory area that activate it and prolong
inspiration, inhibiting expiration.
B. Regulation of the Respiratory Center
1. Cortical Influences
a. Cortical influences allow conscious
control of respiration that may be needed to
avoid inhaling noxious gasses or water.
b. Breath holding is limited by the
overriding stimuli of increased [H+] and
[CO2].
2. Chemoreceptor Regulation of Respiration
a. Central chemoreceptors (located in the
medulla oblongata) and peripheral
chemoreceptors (located in the walls of
systemic arteries) monitor levels of CO2 and
O2 and provide input to the respiratory
center.
1. Central chemoreceptors respond
to change in H+ concentration or
PCO2, or both in cerebrospinal
fluid.
2. Peripheral chemoreceptors
respond to changes in H+, PCO2,
and PO2 in blood.
b. A slight increase in PCO2 (and thus H+), a
condition called hypercapnia, stimulates central
chemoreceptors.
1. As a response to increased PCO2,
increased H+ and decreased PO2,
the inspiratory area is
activated and EXERCISE AND THE RESPIRATORY SYSTEM
hyperventilation, rapid and
deep breathing, occurs
2. If arterial PCO2 is lower than 40
mm Hg, a condition called
hypocapnia, the chemoreceptors are
not stimulated and the inspiratory
area sets its own pace until CO2
accumulates and PCO2 rises to 40
mm Hg.
c. Severe deficiency of O2 depresses activity of the
central chemoreceptors and respiratory center.
d. Hypoxia refers to oxygen deficiency at the tissue
level and is classified in several ways (Clinical
Connection).
1. Hypoxic hypoxia is caused by a
low PO2 in arterial blood (high
altitude, airway obstruction, fluid in
lungs).
2. In anemic hypoxia, there is too
little functioning hemoglobin in the
blood (hemorrhage, anemia, carbon
D
monoxide poisoning).
3. Stagnant hypoxia results from the
inability of blood to carry oxygen to
tissues fast enough to sustain their
needs (heart failure, circulatory
shock).
4. In histotoxic hypoxia, the blood
delivers adequate oxygen to the
tissues, but the tissues are unable to
use it properly (cyanide poisoning).
5. Proprioceptors of joints and
muscles activate the inspiratory
center to increase ventilation prior to
exercise induced oxygen need.
6. The inflation (Hering-Breuer)
reflex detects lung expansion with
stretch receptors and limits it
depending on ventilatory need and
prevention of damage.
7. Other influences include blood
pressure, limbic system,
temperature, pain, stretching the
anal sphincter, and irritation to the
respiratory mucosa.
8. Summarize the changes that
increase or decrease ventilation rate
and depth.
A. The respiratory system works with the
cardiovascular system to make appropriate
adjustments for different exercise intensities and
durations.
B. As blood flow increases with a lower O2 and
higher CO2 content, the amount passing through the
lung (pulmonary perfusion) increases and is matched
by increased ventilation and oxygen diffusion
capacity as more pulmonary capillaries open.
C. Ventilatory modifications can increase 30 times
above resting levels, in an initial rapid rate due to
neural influences and then more gradually due to
chemical stimulation from changes in cell
metabolism. A similar, but reversed, effect occurs
with cessation of exercise.
D. Smokers have difficulty breathing for a number
of reasons, including nicotine, mucous,
DISORDERS: HOMEOSTATIC IMBALANCES
irritants, and that fact that scar tissue
replaces elastic fibers (Clinical Connection)
A. Asthma is characterized by the following: spasms
of smooth muscle in bronchial tubes that result in
A. The respiratory system begins as an outgrowth of partial or complete closure of air passageways;
endoderm called the laryngotracheal bud, part of inflammation; inflated alveoli; and excess mucus
which divides into two lung buds that grow into the production. A common triggering factor is allergy,
bronchi and lungs. but other factors include emotional upset, aspirin,
exercise, and breathing cold air or cigarette smoke.
B. The smooth muscle, cartilage, and connective
tissue of the bronchial tubes and pleural sacs develop
MEDICAL TERMINOLOGY
from mesenchyma (mesodermal) cells.

B. Chronic obstructive pulmonary disease (COPD)

AGING AND THE RESPIRATORY SYSTEM
A. Aging results in decreased vital capacity,
decreased blood oxygen level, diminished alveolar
macrophage activity, and decreased ciliary action of
the epithelium lining the respiratory tract.
B. Elderly people are more susceptible to
pneumonia, bronchitis, emphysema, and other
pulmonary disorders.
A. Examine the role of the respiratory system in
maintaining homeostasis.
is a type of respiratory disorder characterized by
chronic and recurrent obstruction of air flow,
which increases airway resistance.
1. The principal types of COPD are
emphysema and chronic bronchitis.
2. Bronchitis is an inflammation of the
bronchial tubes, the main symptom of which
is a productive (raising mucus or sputum)
cough.
C. In bronchogenic carcinoma (lung cancer),
bronchial epithelial cells are replaced by cancer cells
after constant irritation has disrupted the normal
FOCUS ON HOMEOSTASIS: THE RESPIRATORY
SYSTEM
growth, division, and function of the epithelial cells.
Airways are often blocked and metastasis is very
common. It is most commonly associated with
smoking.
D. Pneumonia is an acute infection of the alveoli.
The most common cause in the pneumococcal
bacteria but other microbes may be involved.
Treatment involves antibiotics, bronchodilators,
oxygen therapy, and chest physiotherapy.
E. Tuberculosis (TB) is an inflammation of pleurae
and lungs produced by the organism Mycobacterium
tuberculosis. It is communicable and destroys lung
tissue, leaving nonfunctional fibrous tissue behind.
F. Coryza (common cold) is caused by viruses and
usually is not accompanied by a fever, whereas
influenza (flu) is usually accompanied by a fever
greater than 101°F.
G. Pulmonary edema refers to an abnormal
accumulation of interstitial fluid in the interstitial
spaces and alveoli of the lungs. It may be pulmonary
or cardiac in origin.
H. Cystic fibrosis is an inherited disease of secretory
epithelia that affects the respiratory passageways,
pancreas, salivary glands, and sweat glands.

SPECIAL SENSES NOTES

I. Asbestos-related diseases result from inhalation of
asbestos particles.
J. Sudden Infant Death Syndrome is the sudden
death of an apparently healthy infant, usually
occurring during sleep. The cause is unknown but
may be associated with hypoxia, possibly INTRODUCTION
resulting from sleeping position. As such, it
is recommended that infants sleep on their
backs for the first six months. A. Receptors for the special senses - smell, taste,

K. Acute respiratory distress syndrome is a form of GUSTATION: SENSE OF TASTE

respiratory failure characterized by excessive
leakiness of respiratory membranes and severe
hypoxia.
Make a list of the medical terms associated with the
respiratory system.
vision, hearing, and equilibrium - are housed in
complex sensory organs.
B. Ophthalmology is the science that deals with the
eye and its disorders.
C. Otorhinolaryngology is the science that deals with
disorders of the ear, nose and throat.

INTRODUCTION

A. Both smell and taste are chemical senses.

B. Anatomy of olfactory receptors
1. The receptors for olfaction, which are
bipolar neurons, are in the nasal epithelium
in the superior portion of the nasal cavity
a. They are first-order neurons of the
olfactory pathway.
b. olfactory hairs are the parts that
respond to the olfactory stimulus
2. Supporting cells are epithelial cells of the
mucous membrane lining the nose.
 3. Basal stem cells produce new olfactory
receptors.
C. Physiology of Olfaction
1. Genetic evidence suggests there are
hundreds of primary scents.
2. In olfactory reception, a generator
potential develops and, through a
transduction process, triggers one or more
nerve impulses
3. Adaptation to odors occurs quickly, and
the threshold of smell is low: only a few
molecules of certain substances need be
present in air to be smelled.
4. Olfactory receptors convey nerve
impulses to olfactory nerves, olfactory
bulbs, olfactory tracts, and the cerebral
cortex and limbic system.
5. Clinical Connection: Hyposmia, a reduced
ability to smell, affects half of those over
age 65 and 75% of those over 80. It can be
caused by neurological changes, drugs, or
the effects of smoking.
A. Taste is a chemical sense.
1. To be detected, molecules must be
dissolved.
2. Taste stimuli classes include sour, sweet,
bitter meaty, and salty.
3. Other “tastes” are a combination
of the five primary taste sensations plus
olfaction,
B. Anatomy of Taste Buds and Papillae
1. The receptors for gustation, the gustatory
receptor cells, are located in taste buds
2. Taste buds consist of supporting cells,
gustatory receptor cells, and basal cells.
3. Taste buds are found on the margins of
papillae.
4. The papillae include circumvallate,
fungiform, and foliate papillae.
a. Filiform papilla cover the tongue
but act as tactile receptors instead of
taste receptors
C. Physiology of Gustation
1. When a tastant is dissolved in saliva it can
make contact with the plasma membrane
of gustatory receptor cells.
2. Receptor potentials developed in
gustatory hairs cause the release of
neurotransmitter that gives rise to nerve
impulses.
a. Receptor potentials develop in
response to chemicals in the food (ie
sodium or hydrogen)
D. Taste Thresholds and Adaptation
1. Taste thresholds vary for each of the
primary tastes with the threshold for bitter
being the lowest, then sour, and finally the
other primary tastes.
2. Adaptation to taste occurs quickly.
3. Gustatory receptor cells convey nerve
impulses to cranial nerves V, VII, IX, and S,
the medulla, the thalamus, and the parietal
lobe of the cerebral cortex (Figure 17.3).
4. Clinical Connection: Taste aversion
causes individuals to avoid foods which
upset their digestive system. Because cancer
treatments cause nausea, cancer patients may
lose their appetites because they develop
taste aversion for most food.
VISION
1. More than half the sensory receptors in the human
body are located in the eyes.
2. A large part of the cerebral cortex is devoted to
processing visual information.
3. Visible light (wavelengths between 400 and 700
nm) is the only part of the spectrum of
electromagnetic radiation that can be detected by the
eyes
B. Accessory Structures of the Eyes
1. Eyelids
a. The eyelids shade the eyes during sleep, protect
the eyes from excessive light and foreign objects,
and spread lubricating secretions over the eyeballs
b. From superficial to deep, each eyelid consists of
epidermis, dermis, subcutaneous tissue, fibers of the
orbicularis oculi muscle, a tarsal plate, tarsal glands,
and conjunctiva
1. The tarsal plate gives form and support to
the eyelids.
i. The tarsal glands secrete a fluid to
keep the eye lids from adhering to
each other.
c. The conjunctiva is a thin mucous membrane that
lines the inner aspect of the eyelids and is reflected
onto the anterior surface of the eyeball.
d. Eyelashes and eyebrows help protect the eyeballs
from foreign objects, perspiration, and the direct rays
of the sun
e. The lacrimal apparatus consists of structures that
produce and drain tears
f. The six extrinsic eye muscles move the eyeballs
laterally, medially, superiorly, and inferiorly
C. Anatomy of the Eyeball
1. The eye is constructed of three layers
a. The fibrous tunic is the outer coat of the eyeball. It
can be divided into two regions: the posterior sclera
and the anterior cornea. At the junction of the sclera
and cornea is an opening known as the scleral
venous sinus or canal of Schlemm
1. The sclera, the “white” of the eye, is a
white coat of dense fibrous tissue that covers
all the eyeball, except the most anterior
portion, the iris; the sclera gives shape to the
eyeball and protects its inner parts. Its
posterior surface is pierced by the optic
nerve.
2. The cornea is a nonvascular, transparent,
fibrous coat through which the iris can be
seen; the cornea acts in refraction of light.
b. The vascular tunic is the middle layer of the
eyeball and is composed of three portions: choroid,
ciliary body, and iris
1. The choroid absorbs light rays so that they
are not reflected and scattered within the
eyeball; it also provides nutrients to the
posterior surface of the retina.
2. The ciliary body consists of the ciliary
processes and ciliary muscle.
i. The ciliary processes consist of
protrusions or folds on the internal
surface of the ciliary body where
epithelial lining cells secrete
aqueous humor.
ii. The ciliary muscle is a smooth
muscle that alters the shape of the
lens for near or far vision.
3. The iris is the colored portion seen
through the cornea and consists of circular
iris and radial iris smooth muscle fibers
(cells) arranged to form a doughnut-shaped
structure.
i. The black hole in the center of the
iris is the pupil, the area through
which light enters the eyeball.
ii. A principal function of the iris is
to regulate the amount of light
entering the posterior cavity of the
eyeball
c. The third and inner coat of the eye, the retina
(nervous tunic), lines the posterior three-quarters of
the eyeball and is the beginning of the visual
pathway
1. The surface of the retina is the only place
in the body where blood vessels can be
viewed directly and examined for
pathological changes
2. The optic disc is the site where the optic
nerve enters the eyeball.
3. The vessels of the retina are the central
retinal artery and vein. They are bundled
together with the optic nerve with branches
across the retinal surface.
4. The retina consists of a pigment
epithelium (nonvisual portion) and a neural
portion (visual portion).
i. The pigment epithelium aids the
choroid in absorbing stray light rays.
ii. The neural portion contains three
zones of neurons that are named in
the order in which they conduct
nerve impulses: photoreceptor
neurons, bipolar neurons, and
ganglion neurons
 5. The photoreceptor neurons are called rods
or cones because of the differing shapes of
their outer segments.
i. Rods are specialized for black-
and-white vision in dim light; they
also allow us to discriminate
between different shades of dark and
light and permit us to see shapes and
movement.
ii. Cones are specialized for color
vision and sharpness of vision (high
visual acuity) in bright light; cones
are most densely concentrated in the
central fovea, a small depression in
the center of the macula lutea.
1. The macula lutea is in the
exact center of the posterior
portion of the retina,
corresponding to the visual
axis of the eye.
iii. The fovea is the area of sharpest
vision because of the high
concentration of cones.
iv. Rods are absent from the fovea
and macula and increase in density
toward the periphery of the retina.
v. Clinical Connection: A detached
retina may result in visual
distortions or blindness
vi. Clinical Connection: Age related
macular disease is a degenerative
disorder of the retina and the
pigmented layer in persons 50 years
of age or older
2. The eyeball contains the nonvascular lens, just
behind the pupil and iris. The lens fine tunes the
focusing of light rays for clear vision.
3. The interior of the eyeball is a large space divided
into two cavities by the lens: the anterior cavity and
the vitreous chamber
a. The anterior cavity is subdivided into the
anterior chamber (which lies behind the
cornea and in front of the iris) and the
posterior chamber (which lies behind the iris
and in front of the suspensory ligaments and
lens).
1. The anterior cavity is filled with a
watery fluid called the aqueous
humor that is continually secreted
by the ciliary processes behind the
iris.
2. The aqueous humor flows
forward from the posterior chamber
through the pupil into the anterior
chamber and drains into the scleral
venous sinus (canal of Schlemm)
and then into the blood.
3. The pressure in the eye, called
intraocular pressure, is produced
mainly by the aqueous humor. The
intraocular pressure, along with the
vitreous body, maintains the shape
of the eyeball and keeps the retina
smoothly applied to the choroid so
the retina will form clear images.
4. Excessive intraocular pressure,
called glaucoma, results in
degeneration of the retina and
blindness.
b. The second, and larger,
cavity of the eyeball is the
vitreous chamber (posterior
cavity). It lies between the
lens and the retina and
contains a gel called the
vitreous body. It is formed
during embryonic life and is
not replaced thereafter.
c. Summarize the structures
associated with the eyeball.
D. Image formation on the retina involves refraction
of light rays by the cornea and lens, accommodation
of the lens, and constriction of the pupil.
1. The bending of light rays at the interface of two
different media is called refraction; the anterior and
posterior surfaces of the cornea and of the lens
refract entering light rays so they come into exact
focus on the retina
2. Images are focused upside-down (inverted) on the
retina and also undergo mirror reversal these
inverted images are rearranged by the brain to
produce perception of images in their actual
orientation.
3. The lens fine tunes image focus and changes the
focus for near or distant objects.
E. Accommodation and Near Point of Vision
1. Accommodation is an increase in the curvature of
the lens, initiated by ciliary muscle contraction,
which allows the lens to focus on near objects. To
focus on far objects, the ciliary muscle relaxes and
the lens flattens.
2. The near point of vision is the minimum distance
from the eye that an object can be clearly focused
with maximum effort.
3. Clinical Connection: With aging the lens loses
elasticity and its ability to accommodate resulting in
a condition known as presbyopia.
F. Refraction Abnormalities
1. Myopia is nearsightedness.
2. Hyperopia is farsightedness.
3. Astigmatism is a refraction abnormality due to an
irregular curvature of either the cornea or lens.
4. Clinical Connection: LASIK surgery can be
utilized to correct the above conditions.
G. Constriction of the pupil means narrowing the
diameter of the hole through which light enters
the eye; this occurs simultaneously with
accommodation of the lens and functions to
prevent light rays from entering the eye through
the periphery of the lens.
1. In convergence, the eyeballs move
medially so they are both directed toward an
object being viewed; the coordinated action
of the extrinsic eye muscles bring about
convergence.
Physiology of Vision
A. The first step in vision transduction is the
absorption of light by photopigments (visual
pigments) in rods and cones (photoreceptors)
1. Photopigments are colored proteins that undergo
structural changes upon light absorption.
a. The single type of photopigment in rods is
called rhodopsin. A cone contains one of
three different kinds of photopigments so
there are three types of cones.
b. All photopigments involved in vision
contain a glycoprotein called opsin and a
derivative of vitamin A called retinal.
1. Retinal is the light absorbing part
of all visual photopigments.
c. There are four different opsins, one for
each cone photopigment and another for
rhodopsin.
d. Research how photopigments are
activated and restored.
e. Bleaching and regeneration of the
photopigments accounts for much but not all
of the sensitivity change during light and
dark adaptation.
2. Once receptor potentials develop in rods and
cones, they release neurotransmitters that induce
graded potentials in bipolar cells
3. light adaptation —your visual system adjusts in
seconds to the brighter environment by decreasing
its sensitivity.
4. dark adaptation— sensitivity increases slowly
over many minutes.
5. Clinical Connection: Most forms of
colorblindness (inability to distinguish certain
colors) result from an inherited absence of or
deficiency in one of the three cone photopigments
and are more common in males. A deficiency in
rhodopsin may cause night blindness (nyctalopia).
B. The Visual Pathway
1. Bipolar cells transmit excitatory signals to
ganglion cells, which depolarize and initiate nerve
impulses
2. Impulses from ganglion cells are conveyed
through the retina to the optic nerve, the optic
chiasma, the optic tract, the thalamus, and the
occipital lobes of the cortex
C. Brain pathway and Visual Fields
1. Axons of the optic nerve pass through the optic
chiasm where some crossover to to the other side,
while some remain on the same side, before
continuing to the thalamus.
2. The visual field, defined as the area which the
eyes can see, have a central half and a peripheral
half.
HEARING AND EQUILIBRIUM
A. The ear consists of three anatomical
subdivisions.
1. The external (outer) ear collects sound waves and
passes them inwards; it consists of the auricle
(pinna), external auditory canal (meatus), and
tympanic membrane (eardrum)
a. Ceruminous glands in the external
auditory canal secrete cerumen (earwax) to
help prevent dust and foreign objects from
entering the ear.
b. Excess cerumen may become impacted,
causing temporary partial hearing loss
before it is removed.
2. The middle ear (tympanic cavity) is a small, air-
filled cavity in the temporal bone that is lined by
epithelium. It contains the auditory (Eustachian)
tube, auditory ossicles (middle ear bones, the
malleus, incus, and stapes), the oval window, and the
round window
3. The internal (inner) ear is also called the labyrinth
because of its complicated series of canals.
Structurally it consists of two main divisions: an
outer bony labyrinth that encloses an inner
membranous labyrinth.
4. The bony labyrinth is a series of cavities in the
petrous portion of the temporal bone.
a. It can be divided into three areas named
on the basis of shape: the semicircular canals
and vestibule, both of which contain
receptors for equilibrium, and the cochlea,
which contains receptors for hearing.
b. The bony labyrinth is lined with
periosteum and contains a fluid called
perilymph. This fluid, chemically similar to
cerebrospinal fluid, surrounds the
membranous labyrinth.
c. The membranous labyrinth is a series of
sacs and tubes lying inside and having the
same general form as the bony labyrinth.
1. The membranous labyrinth is
lined with epithelium.
2. It contains a fluid called
endolymph, chemically similar to
intracellular fluid.
d. The vestibule constitutes the oval central
portion of the bony labyrinth. The
membranous labyrinth in the vestibule
consists of two sacs called the utricle and
saccule.
e. Projecting upward and posteriorly from
the vestibule are the three bony semicircular
canals. Each is arranged at approximately
right angles to the other two.
1. The anterior and posterior
semicircular canals are oriented
vertically; the lateral semicircular
canal is oriented horizontally.
2. One end of each canal enlarges
into a swelling called the ampulla.
f. The portions of the membranous labyrinth
that lie inside the semicircular canals are
called the semicircular ducts (membranous
semicircular canals).
g. The vestibular branch of the
vestibulocochlear nerve consists of
ampullary, utricular, and saccular nerves.
h. Anterior to the vestibule is the cochlea,
which consists of a bony spiral canal that
makes almost three turns around a central
bony core called the modiolus
B. Cross sections through the cochlea show that it
is divided into three channels by partitions that
together have the shape of the letter Y
1. The channel above the bony partition is the scala
vestibuli, which ends at the oval window.
2. The channel below is the scala tympani, which
ends at the round window. The scala vestibuli and
scala tympani both contain perilymph and are
completely separated except at an opening at the
apex of the cochlea called the helicotrema.
3. The third channel (between the wings of the Y) is
the cochlear duct (scala media). The vestibular
membrane separates the cochlear duct from the scala
vestibuli, and the basilar membrane separates the
cochlear duct from the scala tympani.
4. Resting on the basilar membrane is the spiral
organ (organ of Corti), the organ of hearing
a. Projecting over and in contact with the
hair cells of the spiral organ is the tectorial
membrane, a delicate and flexible gelatinous
membrane.
C. Sound waves result from the alternate
compression and decompression of air molecules.
1. The sounds heard most acutely by human ears are
from sources that vibrate at frequencies between
1000 and 4000 Hertz (Hz; cycles per minute).
a. The frequency of a sound vibration is its
pitch; the greater the intensity (size) of the
 vibration, the louder the sound (as measured
in decibels, dB).
b. Clinical Connection: Exposure to loud
sounds can damage hair cells of the cochlea
and possibly lead to deafness.
Physiology of Hearing
A. The events involved in hearing
1. The auricle directs sound waves into the
external auditory canal.
2. Sound waves strike the tympanic
membrane, causing it to vibrate back and
forth.
3. The vibration conducts from the tympanic
membrane through the ossicles (through the
malleus to the incus and then to the stapes).
4. The stapes moves back and forth, pushing
the membrane of the oval window in and
out.
5. The movement of the oval window sets up
fluid pressure waves in the perilymph of the
cochlea (scala vestibuli).
6. Pressure waves in the scala vestibuli are
transmitted to the scala tympani and
eventually to the round window,
causing it to bulge outward into the
middle ear.
7. As the pressure waves deform the walls of
the scala vestibuli and scala tympani, they
push the vestibular membrane back and forth
and increase and decrease the pressure of the
endolymph inside the cochlear duct.
8. The pressure fluctuations of the
endolymph move the basilar membrane
slightly, moving the hair cells of the spiral
organ against the tectorial membrane; the
bending of the hairs produces receptor
potentials that lead to the generation of
nerve impulses in cochlear nerve fibers.
9. Pressure changes in the scala tympani
cause the round window to bulge outward
into the middle ear.
B. Differences in pitch are related to differences in
the width and stiffness of the basilar membrane and
sound waves of various frequencies that cause
specific regions of the basilar membrane to vibrate
more intensely than others.
1. High-frequency or high-pitched sounds
cause the basilar membrane to vibrate near
the base of the cochlea.
2. Low-frequency or low-pitched sounds
cause the basilar membrane to vibrate near
the apex of the cochlea.
C. Hair cells convert a mechanical force (stimulus)
into an electrical signal (receptor potential); hair
cells release neurotransmitter, which initiates nerve
impulses.
D. The cochlea can produce sounds called
Physiology of Hearing
otoacoustic emissions. They are caused by vibrations
of the outer hair cells that occur in response to sound
waves and to signals from motor neurons.
A. Nerve impulses from the cochlear branch of the
vestibulocochlear nerve pass to the cochlear nuclei
in the medulla. Here, most impulses cross to the
opposite side and then travel to the midbrain, to the
thalamus, and finally to the auditory area of the
temporal lobe of the cerebral cortex.
1. Clinical Connection: Cochlear implants are
devices that translate sounds into electronic signals
that can be interpreted by the brain.
Physiology of Equilibrium
A. There are two kinds of equilibrium.
1. Static equilibrium refers to the
maintenance of the position of the body
(mainly the head) relative to the force of
gravity.
2. Dynamic equilibrium is the maintenance
of body position (mainly the head) in
response to sudden movements, such as
rotation, acceleration, and deceleration.
B. Otolithic Organs: Saccule and Utricle
1. The maculae of the utricle and saccule are
the sense organs of static equilibrium; they
also contribute to some aspects of dynamic
equilibrium
2. The maculae consist of hair cells, which
are sensory receptors, and supporting cells.
C. Membranous Semicircular Ducts
1. The three semicircular ducts, along with
the saccule and utricle maintain dynamic
equilibrium
 2. The cristae in the semicircular ducts are
the primary sense organs of dynamic
equilibrium.
D. The Equilibrium Pathway
1. Most vestibular branch fibers of the
vestibulocochlear nerve enter the brain stem
and terminate in the medulla; the remaining
fibers enter the cerebellum (Figure 17.26)
2. Various pathways between the vestibular
nuclei, cerebellum, and cerebrum enable the
cerebellum to play a key role in maintaining
static and dynamic equilibrium.
3. Clinical Connection: Motion Sickness
4. Summarize the structures related to
hearing and equilibrium.
DEVELOPMENT OF THE EYES AND EARS
A. Eyes
1. Eyes begin to develop when the ectoderm
of the lateral walls of the prosencephalon
bulges to form a pair of optic grooves
2. As the neural tube closes the optic
grooves enlarge and move toward the
surface of the ectoderm and are known as
optic vesicles.
A. Changes in vision, that occur with age include:
loss of lens elasticity; loss of transparency of lens;
discoloration of the sclera; weakening of the
extrinsic muscles; less responsive irises; lowered tear
production; and, lessening of color vision.
B. Changes in hearing, that occur with age include;
hearing loss of high-pitched sounds; loss of hair
cells; degeneration of the auditory pathway and an
increase in tinnitis.
DISORDERS: HOMEOSTATIC IMBALANCES
A. A cataract is a loss of transparency of the lens that
can lead to blindness.
B. Glaucoma is abnormally high intraocular
pressure, due to a buildup of aqueous humor inside
the eyeball, which destroys neurons of the retina. It
is the second most common cause of blindness (after
cataracts), especially in the elderly.
C. Deafness is significant or total hearing loss. It is
classified as sensorineural (caused by impairment of
the cochlear or cochlear branch of the
vestibulocochlear nerve) or conduction (caused by
impairment of the external and middle ear
mechanisms for transmitting sounds to the cochlea).

3. When the optic vesicles reach the surface,
the surface ectoderm thichens to form the
lens placodes and the distal portions of the
optic vesicles invaginate to form the optic
cups.
4. The optic cups remain attached to the
prosencephalon by the optic stalks.
B. Ears
1. Inner ear develops from a
thickening of surface ectoderm
called the otic placode
2. Otic placodes invaginate to form otic pits.
D. Meniere’s syndrome is a malfunction of the inner
ear that may cause deafness and loss of equilibrium.
E. Otitis media is an acute infection of the middle
ear, primarily by bacteria. It is characterized by pain,
malaise, fever, and reddening and outward bulging
of the eardrum, which may rupture unless prompt
treatment is given. Children are more susceptible
than adults.
MEDICAL TERMINOLOGY
List as many as you can the medical terminologies
associated with the special senses.

3. Optic pits pinch off from the surface

ectoderm to form otic vesicles
4. Otic vesicles will form structures
associated with the membranous labyrinth of
the inner ear.
5. Middle ear develops from the first
pharyngeal (branchial) pouch.

AGING AND THE SPECIAL SENSES

SPINAL CORD & SPINAL NERVE NOTES

INTODUCTION

A) The spinal cord and spinal nerves mediate

reactions to environmental changes.
B) The spinal cord has several functions.
1) It processes reflexes.
2) It is the site for integration of EPSPs and
IPSPs that arise locally or are triggered by
nerve impulses from the periphery and brain.
3) It is a conduction pathway for sensory, to
the brain, and motor impulses to effectors.

SPINAL CORD ANATOMY

A) The spinal cord is protected by two connective

tissue coverings, the meninges and vertebra, and
a cushion of cerebrospinal fluid.
1) The vertebral column provides a bony covering of
the spinal cord
2) Meninges
(a) The protective meninges are three
coverings that run continuously around the
spinal cord and brain
(b) The outermost layer is the dura mater
(c) The middle layer is the arachnoid.
(d) The innermost meninge is the pia mater,
(1) Denticulate ligaments are
thickenings of the pia mater that
suspend the spinal cord in the
middle of its dural sheath.
3) The subarachnoid space carries cerebrospinal
fluid, (CSF).
4) Clinical Connection: A spinal tap is done to
withdraw CSF for diagnostic purposes
B) External Anatomy of the Spinal Cord
1) The spinal cord begins as a continuation of the
medulla oblongata and terminates at about the
second lumbar vertebra in an adult
2) It contains cervical and lumbar enlargements that
serve as points of origin for nerves to the extremities.
3) The tapered portion of the spinal cord is
the conus medullaris, from which arise the filum
terminale and cauda equina.
C) Internal Anatomy of the Spinal Cord
1) The anterior median fissure and the posterior
median sulcus penetrate the white matter of the
spinal cord and divide it into right and left sides
2) The gray matter of the spinal cord is shaped like
the letter H or a butterfly and is surrounded by white
matter.
(a) The gray matter consists primarily of
cell bodies of neurons and neuroglia and
unmyelinated axons and dendrites of
association and motor neurons.
3) The white matter consists of bundles of
myelinated axons of motor and sensory neurons
4) The gray commissure forms the cross bar of the
H-shaped gray matter.
(a) In the center of the gray commissure is
the central canal, which runs the length of
the spinal cord and contains cerebrospinal
fluid.
(b) Anterior to the gray commissure is the
anterior white commissure, which connects
the white matter of the right and left sides of
the spinal cord.
5) The gray matter is divided into horns, which
contain cell bodies of neurons.
6) The white matter is divided into columns.
7) Each column contains distinct bundles of nerve
axons that have a common origin or destination and
carry similar information.
(a) These bundles are called tracts.
(1) Sensory (ascending) tracts
conduct nerve impulses toward the
brain.
(2) Motor (descending) tracts
conduct impulses down the cord.
8) The internal organization of the spinal cord allows
reflexes to be processed and to inform the brain of
the results of those reflexes
9) review the cross section of the spinal cord at
different segments.
SPINAL NERVE
A) Spinal nerves connect the CNS to sensory
receptors, muscles, and glands and are part of the
peripheral nervous system.
1) The 31 pairs of spinal nerves are named and
numbered according to the region and level of the
spinal cord from which they emerge
(a) There are 8 pairs of cervical nerves, 12
pairs of thoracic nerves, 5 pairs of lumbar
nerves, 5 pairs of sacral nerves, and 1 pair of
coccygeal nerves.
2) Spinal nerves are the paths of communication
between the spinal cord and most of the body.
3) Roots are the two points of attachment that
connect each spinal nerve to a segment of the spinal
cord
 (a) The posterior or dorsal (sensory) root
contains sensory nerve fibers and conducts
nerve impulses from the periphery into the
spinal cord; the posterior root ganglion
contains the cell bodies of the sensory
neurons from the periphery.
(b) The anterior or ventral (motor) root
contains motor neuron axons and conducts
impulses from the spinal cord to the
periphery; the cell bodies of motor neurons
are located in the gray matter of the cord.
B) Connective Tissue Covering of Spinal Nerves
1) Spinal nerve axons are grouped within connective
tissue sheathes
2) A fiber is a single axon within an endoneurium.
3) A fascicle is a bundle of fibers within a
perineurium.
4) A nerve is a bundle of fascicles within an
epineurium.
5) Numerous blood vessels are within the coverings.
C) Distribution of Spinal Nerves
1) Shortly after passing through its intervertebral
foramen, a spinal nerve divides into several
branches; these branches are known as rami
(a) Branches of a spinal nerve include the
dorsal ramus, ventral ramus, meningeal
branch, and rami communicantes.
(1) The anterior rami of spinal
nerves T2-T12 do not enter into the
formation of plexuses and are
known as intercostal or thoracic
nerves.
(i) These nerves directly
innervate structures they
supply in the intercostal
spaces.
(2) Their posterior rami supply the
deep back muscles and skin of the
posterior aspect of the thorax.
(3) The ventral rami of spinal
nerves, except for T2-T12, form
networks of nerves called plexuses
(4) The cervical plexus supplies the
skin and muscles of the head, neck,
and upper part of the shoulders;
connects with some cranial nerves;
and supplies the diaphragm
(5) Emerging from the plexuses are
nerves bearing names that are often
descriptive of the general regions
they supply or the course they take.
(6) Damage to the spinal cord above
the origin of the phrenic nerves (C3-
C5) causes respiratory arrest.
(7) Clinical Connection: Breathing
stops because the phrenic nerves no
longer send impulses to the
diaphragm
D) The brachial plexus constitutes the nerve
supply for the upper extremities and a number of
neck and shoulder muscles
1) A number of nerve disorders may result from
injury to the brachial plexus
(a) Clinical Connection: Among these
injuries are Erb-Duchene palsy or waiter’s
tip palsy, ulnar and radial injuries, wrist
drop, claw hand, and winged scapula
E) The lumbar plexus supplies the anterolateral
abdominal wall, external genitals, and part of the
lower extremities
1) The largest nerve arising from the lumbar plexus
is the femoral nerve.
(a) Clinical Connection: Injury to the
femoral nerve is indicated by an inability to
extend the leg and by loss of sensation in the
skin over the anteromedial aspect of the
thigh.
(b) Clinical Connection: Obturator nerve
injury is a common complication of
childbirth and results in paralysis of the
adductor muscles of the leg and loss of
sensation over the medial aspect of the thigh.
F) The sacral plexus supplies the buttocks,
perineum, and part of the lower extremities
1) The largest nerve arising from the sacral plexus
(and the largest nerve in the body) is the sciatic
nerve.
(a) Clinical Connection: Injury to the sciatic
nerve (common peroneal portion) and its
branches results in sciatica, pain that extends
from the buttock down the back of the leg
 (1) Sciatic nerve injury can occur
due to a herniated (slipped) disc,
dislocated hip, osteoarthritis of the
lumbosacral spine, pressure from the
uterus during pregnancy, or an
improperly administered gluteal
injection
G) Sacral and Coccygeal Plexus
1) Situated in the anterior sacrum
1) Supplies buttocks, perineum, and lower limbs
B) Dermatomes
1) The skin over the entire body is supplies by spinal
nerves that carry somatic sensory nerves impulses
into the spinal cord.
2) All spinal nerves except C1 innervate specific,
constant segments of the skin; the skin segments are
called dermatomes
3) Knowledge of dermatomes helps a physician to
determine which segment of the spinal cord or which
spinal nerve is malfunctioning.
A) The spinal cord has two principal functions.
1) The white matter tracts are highways for nerve
impulse conduction to and from the brain.
2) The gray matter receives and integrates incoming
and outgoing information to perform reflexes.
B) Sensory and Motor Tracts
1) Read the principal sensory and motor tracts in the
spinal cord.
2) Sensory information from receptors travels up the
spinal cord to the brain along two main routes on
each side of the cord: the spinothalamic tracts and
the posterior column tract.
3) Motor information travels from the brain down
the spinal cord to effectors (muscles and glands)
along two types of descending tracts: direct
pathways and indirect pathways.
C) Reflexes and Reflex Arcs
1) The spinal cord serves as an integrating center for
spinal reflexes. This occurs in the gray matter.
2) A reflex is a fast, predictable, automatic response
to changes in the environment that helps to maintain
homeostasis.
3) Reflexes may be spinal and cranial in location,
and somatic, or autonomic in function.
D) Reflex Arc
1) A reflex arc is the simplest type of pathway;
pathways are specific neuronal circuits and thus
include at least one synapse.
2) The five functional components of a reflex arc are
the receptor, sensory neuron, motor neuron,
integrating center neuron, and effector
3) Reflexes help to maintain homeostasis by
permitting the body to make exceedingly rapid
adjustments to homeostatic imbalances.
4) Somatic spinal reflexes include the stretch reflex,
tendon reflex, flexor (withdrawal) reflex, and
crossed extensor reflex; all exhibit reciprocal
innervation.
(a) Stretch Reflex
(1) The stretch reflex is ipsilateral and is
important in maintaining muscle tone and
muscle coordination during exercise
(2) A two-neuron or monosynaptic reflex
arc contains one sensory neuron and one
motor neuron. A stretch reflex, such as the
patellar reflex, is an example.
(i) It operates as a feedback
mechanism to control muscle length
by causing muscle contraction.
(b) Tendon Reflex
(1) The tendon reflex is ipsilateral and
prevents damage to muscles and tendons as a
result of stretching
(2) It operates as a feedback mechanism to
control muscle tension by causing muscle
relaxation when muscle force becomes too
extreme.
(c) Flexor and Crossed Extensor Reflexes
(1) The flexor (withdrawal) reflex is
ipsilateral and is a protective withdrawal
reflex that moves a limb to avoid pain
(2) This reflex results in contraction of
flexor muscles to move a limb to avoid
injury or pain.
 (3) It works with the crossed extensor C) Poliomyelitis (infantile paralysis or polio) is a
reflex to maintain balance. viral infection characterized by fever, headache, stiff
neck and back, deep pain and weakness, and loss of
(i) Crossed Extensor Reflex
certain somatic reflexes. Paralysis is produced when
1. This is a balance- the virus destroys motor neuron cell bodies.
maintaining reflex that
causes a synchronized
extension of the joints of
one limb and flexion of the
joints in the opposite limb
2. The crossed extensor
reflex, which is
contralateral, helps to
maintain balance during the
flexor reflex.
a. Clinical Connection:
Reflexes are often used for
diagnosing disorders of the
nervous system and locating
injured tissue.
i. If a reflex is
absent, or abnormal,
the damage may be
somewhere along a
particular
conduction
pathway.
ii. Among the
clinically important
reflexes are the
Patellar reflex,
Achilles’ reflex,
Babinski reflex,
Abdominal reflex
and Pupillar reflex.

SPINAL CORD PHYSIOLOGY

A) The damage that results from Traumatic injuries
depends on the degree of spinal cord section, and or
compressions and the segments involved. Complete
transection results in paralysis of a variety of forms.
Lessor effects include incomplete paralysis to loss of
sensation and motor function. Spinal shock often
occurs immediately after injury with associated
swelling. Administration of corticosteroids is one
treatment to reduce the swelling.
B) Shingles is an acute infection of the peripheral
nerves by the herpes zoster virus; the virus migrates
down peripheral nerves, causing pain, skin
discoloration, and a characteristic line of skin
blisters.