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Human Diseases Marianne Neighbors
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Human Diseases
Sixth Edition Marianne Neighbors, EdD, RN
Ruth Tannehill-Jones, MS, RN
Australia ● Brazil ● Canada ● Mexico • S i n g a p o r e ● United Kingdom ● United States
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Ruth Tannehill-Jones
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Printed in the United States of America

Print Number: 01 Print Year: 2022
To my husband, Larry Butler, who is now with the Lord, and my
son Jeremy Neighbors, his wife Misty, and my grandson Kieran. I love
you all very much. Marianne
To my husband, Jim, the quiet, solid, love of my life for over

48 years, and to the other man in my life, my brother Bob Tannehill,
who has always loved and supported me, “his younger, little sister.” Ruth
Contents
List of Tables xii Hyperplasias and Neoplasms 15

Preface xiii Hyperplasias 15
Neoplasms 15
Reviewers xxi
Nutritional Imbalance 16
Malnutrition 16
Unit I Obesity 18
CONCEPTS OF HUMAN DISEASE 1 Vitamin or Mineral Excess or Deficiency 18
Impaired Immunity 18
Allergy 18
CHAPTER 1 Autoimmunity 18
Immunodeficiency 19
Introduction to Human Diseases 3
Aging 19
Disease, Disorder, and Syndrome 4 Death 20
Disease 4 Cellular Injury 20
Disorder 4 Cellular Adaptation 20
Syndrome 4 Atrophy 20
Pathology 4 Hypertrophy 21
Pathogenesis 4 Hyperplasia 21
Etiology 5 Dysplasia 21
Metaplasia 21
Predisposing Factors 6
Neoplasia 22
Age 6 Cell and Tissue Death 22
Sex 7 Organism Death 23
Environment 7
Summary 23
Lifestyle 7
Heredity 7 Review Questions 23
Diagnosis 7 Case Studies 24
Prognosis 8
Acute Disease 8 CHAPTER 3
Chronic Disease 8
Complication 9 Neoplasms 25
Mortality Rate 9 Terminology Related to Neoplasms and Tumors 26
Survival Rate 9 Classification of Neoplasms 26
Treatment 9 Appearance and Growth Pattern 26
Medical Ethics 10 Benign Neoplasm 26
Summary 11 Malignant Neoplasm 26
Tissue of Origin 27
Review Questions 11
Epithelial Tissue (Skin or Gland) 27
Case Studies 12 Connective Tissue (Bone, Muscle, or Fat) 27
Lymphatic or Blood-Forming Tissue 27
CHAPTER 2 Other Tissues 27
Growth of Benign and Malignant Neoplasms 27
Mechanisms of Disease 13 Benign Neoplasm Growth 28
Causes of Disease 14 Malignant Neoplasm Growth 28
Heredity 14 Hyperplasias and Neoplasms 29
Trauma 14 Hyperplasias 30
Inflammation and Infection 15 Neoplasms 30
v
vi Contents
Development of Malignant Neoplasms (Cancer) 30 Fibrinous Exudate 47

Invasion by and Metastasis of Cancer 31 Purulent Exudate 48
Inflammatory Lesions 48
Lymphatic System Metastasis 31
Abscesses 48
Bloodstream Metastasis 31
Ulcer 48
Cavity Metastasis 32
Cellulitis 49
Grading and Staging of Cancer 32
Tissue Repair and Healing 49
Grading 32
Tissue Repair 49
Staging 32
Regeneration 49
Causes of Cancer 32 Fibrous Connective Tissue Repair (Scar Formation) 49
Chemical Carcinogens 32 Tissue Healing 50
Hormones 33 Primary Union (First Intention) 50
Radiation 33 Secondary Union (Secondary Intention) 50
Viruses 34 Delayed Wound Healing 51
Genetic Predisposition 34 Complications of Wound Healing 51
Personal Risk Behaviors 34 Infection 52
Smoking and Tobacco Product Use 34
Frequency and Types of Infection 52
Diet 34
Bacteria 53
Alcohol Use 35
Viruses 54
Sexual Behavior 35
Fungi 55
Cancer Prevention 35 Rickettsiae 55
Frequency of Cancer 37 Protozoa 56
Diagnosis of Cancer 38 Helminths 57
Signs and Symptoms of Cancer 38 Testing for Infection 57
Pain 38 Summary 59
Obstruction 38 Review Questions 59
Hemorrhage 39 Case Studies 60
Anemia 39
Fractures 39 Unit II
Infection 39
Cachexia 39
COMMON DISEASES AND
Cancer Treatment 39 DISORDERS OF BODY SYSTEMS 61
Surgery 40
Chemotherapy 40 CHAPTER 5
Radiation 40
Hormone Therapy 41 Immune System Diseases and Disorders 63
Summary 41 Anatomy and Physiology 64
Review Questions 41 Common Signs and Symptoms 65
Case Studies 42 Diagnostic Tests 65
Common Diseases of the Immune System 66
CHAPTER 4 Hypersensitivity Disorders 67
Autoimmune Disorders 72
Inflammation and Infection 43 Isoimmune Disorders 78
Defense Mechanisms 44 Immune Deficiency Disorders 81
Physical or Surface Barriers (Nonspecific) 44 Trauma 83
Inflammation (Nonspecific) 44 Rare Diseases 83
Immune Response (Specific) 44
Severe Combined Immunodeficiency Disease (Scid) 83
Inflammation 45 Effects of Aging on the Immune System 85
The Inflammatory Process 45
Summary 85
Chronic Inflammation 46
Inflammatory Exudates 47 Review Questions 85
Serous Exudate 47 Case Studies 86
Contents vii
CHAPTER 6 Von Willebrand’s Disease 133

Lymphosarcoma 133
Musculoskeletal System Diseases Effects of Aging on the System 134
and Disorders 87 Summary 134
Anatomy and Physiology 88 Review Questions 134
Common Signs and Symptoms 90 Case Studies 136
Diagnostic Tests 90
Common Diseases of the Musculoskeletal System 91 CHAPTER 8
Diseases of the Bone 91
Other Diseases of the Bone 94 Cardiovascular System Diseases
Diseases of the Joints 96 and Disorders 137
Arthritis 96
Anatomy and Physiology 138
Joint Deformities 100
Diseases of the Muscles and Connective Tissue 101 Common Signs and Symptoms 140
Neoplasms 102 Diagnostic Tests 142
Trauma 103 Common Diseases of the Cardiovascular System 144
Fracture 103 Diseases of the Arteries 144
Types of Fractures 103 Diseases of the Heart 153
Treatment of Fractures 105 Coronary Heart Disease 154
Complications of Fractures 105 Diseases of the Veins 160
Strains and Sprains 106 Thrombophlebitis 160
Rare Diseases 115 Trauma 162
de Quervain’s Disease 115 Hemorrhage 162
Tuberculosis of the Bone 115 Shock 163
Paget’s Disease 116 Rare Diseases 163
Myasthenia Gravis 116
Malignant Hypertension 163
Effects of Aging on the System 116 Cor Pulmonale 163
Summary 116 Raynaud’s Disease 164
Review Questions 117 Buerger’s Disease 164
Case Studies 118 Polyarteritis Nodosa 164
Effects of Aging on the System 164
Summary 164
CHAPTER 7 Review Questions 165
Blood and Blood-Forming Organs Case Studies 168
Diseases and Disorders 119
Anatomy and Physiology 120 CHAPTER 9
Common Signs and Symptoms 121
Respiratory System Diseases
Diagnostic Tests 122
and Disorders 169
Common Diseases of the Blood
and Blood-Forming Organs 123 Anatomy and Physiology 170
Disorders of Red Blood Cells 123 Common Signs and Symptoms 171
Polycythemias 128 Diagnostic Tests 173
Disorders of White Blood Cells 129 Common Diseases of the Respiratory System 173
Mononucleosis 129
Diseases of the Upper Respiratory Tract 174
Lymphomas 130
Hay Fever (Allergic Rhinitis) 176
Disorders of Platelets 132
Diseases of the Bronchi and Lungs 178
Trauma 133 Diseases of the Pleura and Chest 189
Rare Diseases 133 Diseases of the Cardiovascular and Respiratory
Thalassemia 133 Systems 192
viii Contents
Trauma 193 Gluten-Induced Enteropathy 234

Pneumothorax and Hemothorax 193 Intestinal Polyps 234
Suffocation 193 Effects of Aging on the System 234
Rare Diseases 195 Summary 235
Pneumoconioses 195 Review Questions 235
Fungal Diseases 195 Case Studies 237
Legionnaires’ Disease 195
Effects of Aging on the System 196
CHAPTER 12
Summary 196
Review Questions 196 Liver, Gallbladder, and Pancreatic
Case Studies 197 Diseases and Disorders 239
CHAPTER 10 Common Signs and Symptoms 241
Lymphatic System Diseases
Common Diseases of the Accessory
and Disorders 199 Organs of Digestion 241
Anatomy and Physiology 200 Liver Diseases 241
Common Signs and Symptoms 201 Other Diseases of the Liver 244
Diagnostic Tests 201 Gallbladder Diseases 250
Pancreatic Diseases 252
Common Diseases of the Lymphatic System 201 Rare Diseases 253
Lymphoma 204
Primary Biliary Cirrhosis 253
Mononucleosis 204
Gilbert’s Syndrome 253
Rare Diseases 204 Hemochromatosis 253
Kawasaki Disease 204 Effects of Aging on the System 253
Effects of Aging on the System 204 Summary 253
Summary 204 Review Questions 254
Review Questions 205 Case Studies 255
Case Studies 205
CHAPTER 13
CHAPTER 11
Urinary System Diseases and Disorders 257
Digestive System Diseases Anatomy and Physiology 258
and Disorders 207 Common Signs and Symptoms 258
Anatomy and Physiology 208 Diagnostic Tests 259
Common Signs and Symptoms 209 Common Diseases of the Urinary System 260
Diagnostic Tests 210 Urethritis 264
Common Diseases of the Digestive System 213 Cystitis 264
Pyelitis 264
Diseases of the Mouth 213
Pyelonephritis 264
Diseases of the Throat and Esophagus 215
Diseases of the Kidney 265
Diseases of the Stomach 219
Diseases of the Bladder 272
Diseases of the Small Intestine 222
Diseases of the Colon 225 Trauma 275
Diseases of the Rectum 233 Straddle Injuries 275
Trauma 234 Rare Diseases 276
Trauma to the Mouth 234 Goodpasture Syndrome 276
Trauma to the Stomach and Intestines 234 Interstitial Cystitis 276
Rare Diseases 234 Effects of Aging on the System 276
Achalasia 234 Summary 277
Contents ix
Review Questions 277 Effects of Aging on the System 332

Case Studies 278 Summary 332
Review Questions 333
CHAPTER 14 Case Studies 334
Endocrine System Diseases
CHAPTER 16
and Disorders 279
Anatomy and Physiology 280 Eye and Ear Diseases and Disorders 335
Common Signs and Symptoms 282 Anatomy and Physiology 336
Diagnostic Tests 283 Eye 336
Common Diseases of the Endocrine System 284 Ear 337
Pituitary Gland Diseases 284 Common Signs and Symptoms 338
Thyroid Gland Diseases 286 Diagnostic Tests 338
Parathyroid Gland Diseases 289 Diagnostic Tests of the Eye 338
Adrenal Gland Diseases 290 Diagnostic Tests of the Ear 339
Hyperadrenalism 290 Common Diseases of the Eye 340
Other Diseases of the Adrenal Glands 292 Inflammation and Infection 344
Pancreatic Islets of Langerhans Diseases 292 Common Diseases of the Ear 350
Reproductive Gland Diseases 298
Infection 350
Trauma 299 Serous 350
Rare Diseases 299 Suppurative 350
Effects of Aging on the System 299 Deafness 354
Summary 299 Trauma 357
Review Questions 300 Rare Diseases 359
Case Studies 302 Retinoblastoma 359
Ménière’s Disease 359
Otitis Interna 359
CHAPTER 15 Effects of Aging on the System 359
Nervous System Diseases Summary 360
and Disorders 303 Review Questions 361
Case Studies 362
The Central Nervous System 304
The Peripheral Nervous System 305 CHAPTER 17
Common Signs and Symptoms 306
Reproductive System Diseases
and Disorders 363
Common Diseases of the
Nervous System 309 Anatomy and Physiology 364
Infectious Diseases 309 Female Anatomy and Physiology 364
Vascular Disorders 312 Male Anatomy and Physiology 365
Functional Disorders 315 Common Signs And Symptoms 366
Dementias 320 Diagnostic Tests 366
Sleep Disorders 324 Common Diseases of The
Tumors 325 Reproductive System 369
Trauma 326 Female Reproductive System Diseases 369
Rare Diseases 330 Other Female Reproductive
Amyotrophic Lateral Sclerosis 330 System Diseases and Disorders 374
Guillain–Barré Syndrome 330 Diseases of the Breast 381
Huntington’s Disease 330 Disorders of Pregnancy 384
Multiple Sclerosis 332 Male Reproductive System Diseases 387
x Contents
Sexually Transmitted Diseases 392

Acquired Immunodeficiency Syndrome 392
Unit III
Hepatitis 393 GENETIC AND DEVELOPMENTAL,
Sexual Dysfunction 398 CHILDHOOD, AND MENTAL
Trauma 401
Rape 401
HEALTH DISEASES AND
Rare Diseases 402 DISORDERS 445
Vaginal Cancer 402
Puerperal Sepsis 402 CHAPTER 19
Hydatidiform Mole 402
Effects of Aging on The System 402 Genetic and Developmental
Summary 403 Diseases and Disorders 447
Review Questions 403 Anatomy and Physiology 448
Case Studies 404 Common Signs and Symptoms 452
CHAPTER 18 Common Genetic and Developmental
Integumentary System Diseases Disorders 453
Musculoskeletal 453
and Disorders 405 Neurologic 455
Anatomy and Physiology 406 Cardiovascular 459
Common Signs and Symptoms 407 Blood 462
Sickle Cell Anemia 462
Hemophilia 462
Common Diseases of the Integumentary System 409 Digestive 462
Infectious Diseases 409 Urinary 465
Viral Diseases 409 Reproductive 467
Bacterial Diseases 412 Cryptorchidism 467
Fungal Diseases 416 Other Developmental Disorders 467
Parasitic Diseases 419 Multisystem Diseases and Disorders 468
Metabolic Diseases 421 Trauma 470
Hypersensitivity or Immune Diseases 423 Failure to Thrive 470
Scleroderma 425 Fetal Alcohol Syndrome 470
Idiopathic Diseases 425 Congenital Rubella Syndrome 470
Benign Tumors 427
Rare Diseases 470
Premalignant and Malignant Tumors 429
Abnormal Pigmented Lesions 432 Anencephaly 470
Diseases of the Nails 432 Achondroplasia 471
Diseases of the Hair 433 Tay-Sachs Disease 471
Trauma 434 Summary 471
Mechanical Skin Injury 434 Review Questions 471
Thermal Skin Injury 435 Case Studies 473
Electrical Injury 438
Radiation Injury 438
Pressure Injury 438 CHAPTER 20
Insect and Spider Bites and Stings 439
Childhood Diseases and Disorders 475
Rare Diseases 442
Elephantiasis 442 Infectious Diseases 476
Effects of Aging on The System 442 Viral Diseases 476
Bacterial Diseases 482
Summary 442
Fungal Diseases 484
Review Questions 443 Parasitic Diseases 485
Case Studies 444 Pediculosis 486
Contents xi
Respiratory Diseases 487 Narcotics 511

Digestive Diseases 490 Inhalants 512
Anabolic Steroids 512
Fluid Imbalances 490
Organic Mental Disorders 512
Food Allergies 490
Psychosis 514
Eating Disorders 490
Mood or Affective Disorders 516
Cardiovascular Diseases 491 Dissociative Disorders 518
Musculoskeletal Diseases 491 Anxiety Disorders 519
Blood Diseases 492 Somatoform Disorders 520
Neurologic Diseases 493 Personality Disorders 521
Gender Dysphoria 522
Eye and Ear Diseases 494 Sleep Disorders 523
Strabismus 494 Trauma 524
Trauma 494 Grief 524
Child Abuse 494 Suicide 524
Suicide 495 Rare Diseases 524
Drug Abuse 495
Poisoning 495 Mental Health Disorders in the Older Adult 524
Summary 498 Summary 525
Review Questions 498 Review Questions 525
Case Studies 500 Case Studies 527
CHAPTER 21 Appendix A:
References 529
Mental Health Diseases and Disorders 501
Common Signs and Symptoms 502 Appendix B:
Diagnostic Tests 502 Common Laboratory Values 537
Common Mental Health Diseases and Disorders 502
Developmental Mental Health Disorders 502 Appendix C:
Substance-Related Mental Disorders 506 Metric Conversion Tables 539
Methamphetamine Abuse 509
Caffeine and Nicotine Abuse 509
Sedatives or Depressants Abuse 510 Glossary 541
Amphetamine Abuse 510
Hallucinogen Abuse 510 Index 557
List of Tables
CHAPTER 1 CHAPTER 6
1–1 Types of Pathologists 4 6–1 Classification of Joints by Movement 89
1–2 xamples of Acute and Chronic Diseases/
E 6–2 Risk Factors for Osteoporosis 95
Disorders 5 6–3 Risk Factors for Osteoarthritis 97
1–3 Examples of Common Diagnostic Tests and
Procedures 8 CHAPTER 7
7–1 RBC Blood Donor and Recipient Chart 121
CHAPTER 2
7–2 Blood Cell Abnormalities and Associated
2–1 Classification of Hereditary Disease with Symptoms 122
Examples 14
7–3 CBC Normal Values 123
2–2 Examples of Neoplasms or Tumors 16
CHAPTER 13
CHAPTER 3
13–1 Urinalysis Values 259
3–1 Neoplasm vs. Nonneoplasm 26
3–2 Origins and Names for Benign and CHAPTER 14
Malignant Neoplasms 28 14–1 The Endocrine Glands: Their Hormones
3–3 Comparison of Benign and Malignant and Hormone Functions 281
Neoplasms 29 14–2 Emergency Treatment of Diabetic Coma or
3–4 Comparison of Carcinomas and Sarcomas 32 Insulin Shock 296
3–5 L ifetime Risk of Being Diagnosed with
Cancer—Both Sexes, All Races 37 CHAPTER 15
3–6 L ifetime Risk of Dying from Cancer—Both 15–1 The Cranial Nerves 306
Sexes, All Races 37
CHAPTER 21
CHAPTER 4 21–1 Genetic and Acquired Causes of Intellectual
4–1 ome of the Leading Causes of Death
S Disability 503
in the World Due to Infections 53 21–2 Physical Causes of Dementia and Delirium 514
4–2 Some Common Infections Caused by 21–3 Phobias 520
Microorganisms in Humans 53
21–4 Dr. Elisabeth Kübler-Ross’s Five Stages
of Grief/Death and Dying 524
CHAPTER 5
5–1 Types and Functions of Leukocytes 64
5–2 Types of Immunity 65
xii
Preface
A
llied health professionals are required to be and physiology before introducing the most common
knowledgeable about the common diseases and diseases related to each system and specialty area.
disorders health care providers see and treat. As Common diseases and disorders for each body system
the medical field continues to grow and change and new are presented consistently through a description of the
diseases emerge, the need for these careers will continue disease or disorder, the etiology, symptoms, diagnosis,
to expand. This book includes the most current research treatment, and prevention.
and reflects the latest practices from actual practice. Simulated real-world activities provide learn-
ers with hands-on experience applying key concepts
Conceptual Approach learned in the chapters into practice.
Several dilemmas immediately emerge when one
Many pathophysiology books have been written considers writing a textbook for such a large and diverse
to address the informational needs of the medical audience as the health care field. Questions arise as to
community, but learners in allied health professional how much content to include, what to exclude, how
programs require an essential pathophysiology detailed the content should be, and how to organize the
text geared specifically for these programs. Human content in the most understandable manner. Another
Diseases, Sixth Edition is designed and specifically common concern is the question of the appropriate
written for learners in health care programs pursuing reading level.
careers as allied health professionals, including but not In an attempt to resolve these dilemmas, it was
limited to medical assistants, medical coders, surgical decided to organize the book in such a way that blocks
technologists, respiratory therapist assistants, physical of material or even entire chapters could be omitted or
therapist assistants, radiologic technologists, medical covered in detail, depending on the format of the course
transcriptionists, emergency medical technicians, and needs of the learner. At the same time, informa-
nursing assistants. The book is intended to meet the tion on each disease is written in such a way that it can
needs of learners enrolled in an allied health career stand alone or be viewed as all inclusive. This concept
program as well as serve as a valuable resource for health allows the instructor, learner, or individual to select and
care professionals on the job. It is also ideal as a resource study only those specific diseases or individual disease
on basic diseases by anyone within the medical arena of interest. Not all health conditions are covered in the
or individuals interested in human diseases. Current text, so the conditions chosen to be included are those
information for this book was based on the authors’ own that are most common, along with the new and emerg-
experiences and research sought from current literature, ing diseases. A few rare conditions are also included. Of
books, Internet resources, and physician consultations. the conditions chosen for the text, only general infor-
Students will understand this text best if a basic mation is covered. The text is designed to be a basic
medical terminology or anatomy and physiology overview of common diseases and disorders, not an
course has been completed before this course of study. in-depth study. Thus, the diseases presented are not
However, this book is designed to make difficult patho- described on a cellular physiological level, which would
physiology concepts easier to understand by using a be too complex for the intended audience. The intention
consistent organization, and including pronunciations, also was to keep the reading level of the text at an easy-
boxed features, and full-color illustrations and photos to-read basic level to promote understanding. We did
of diseases and disorders. Organized into three units, not want to write beneath the level of the learner but, at
the book begins with basic concepts of human diseases, the same time, felt that a difficult reading level would
introduces common diseases and disorders of the only increase the complexity of the material and thus
body systems, followed by genetic and developmental, fail to promote understanding of the subject matter.
childhood, and mental health diseases and disorders. The boxed features within the chapters either add
Chapters progress through a basic review of anatomy interesting information about staying healthy, present
xiii
xiv Preface
new research on the chapter topics, or present infor- Appendices and Glossary
mation about alternative treatments. The pharmacology
Appendix A presents common laboratory values.
boxed features list some of the possible medications for
Appendix B includes metric conversion tables. The
diseases or disorders in the chapter. These drugs are
glossary includes key terms and their definitions.
listed with generic names only since there are many
trade names for the same generic medication. It is
not intended to be an exhaustive list of possible med- New to This Edition
ications, but just to give the reader some information
Changes to the sixth edition include:
about common medications that might be prescribed
for certain diseases or disorders reviewed in the chapter.
The “Consider This” feature presents interesting facts to Changes in All Chapters
engage learners in the material. Cengage is committed to providing quality and inclusive
learning materials. As we adapt our learning materials to
Organization of The Text the continually evolving areas of inclusion and diversity,
the below strategies were adopted for this edition.
Human Diseases, Sixth Edition, consists of 21 chapters,
two appendices, glossary, index, and bibliography. To ■ Use age and gender-appropriate terms with the fol-
gain the most benefit from your use of this text, take lowing exceptions:
advantage of the review questions and case studies that ■ Use the terms male and female when discussing
are included at the end of each chapter. anatomical structures and physiology based on
biological sex assignment to ensure alignment of
Unit I Chapters terminology learners see in other scientific courses.
Chapters 1 through 4 lay the foundation for some basic ■ Use the terms male(s) and female(s) when refer-
disease concepts, including mechanisms of disease, ring to different age groups based on biological
neoplasms, inflammation, and infection. sex assignment rather than using terms based on
various age groups (for example, a disease affects
female adolescents, women, and older adult).
Unit II and Unit III Chapters
■ Use terms that appear in ICD-10 coding as diagnosis
Unit II includes chapters 5-18 which are organized
codes to ensure consistency of the medical language
by body systems and begin with a basic anatomy and
learners are exposed to in the text and will see in
physiology review of each system before discussing
actual practice.
that system’s common diseases and disorders. Included
with this discussion, where appropriate, are common ■ In an effort to keep the text as current as possible, the
signs and symptoms, diagnostic tests, trauma, and rare Glimpse of the Future boxes were eliminated because
diseases. In addition, a unique section toward the end this content quickly becomes outdated.
of each chapter discusses the effects of aging on each
system to help learners understand the natural aging
Chapter-Specific Changes
process of the human body.
Unit III includes chapters 19 through 21 on spe- Chapter 1
cialty areas covering genetics, childhood diseases, and ■ Added the term healthcare-associated infection
mental health disorders. (HAI)
Each disease in Units II and III is broken down
(where applicable) into the following sections: ■ Added material to clarify the difference between an
Description, Etiology, Symptoms, Diagnosis, Treatment, epidemic and a pandemic
and Prevention. Although this may appear to be very
title-heavy when there is only a sentence or two in each Chapter 2
section, this breakdown will assist the learner to clearly ■ Updated the list of deaths caused by trauma
identify these components of each disease. It also main-
tains consistency throughout the textbook. ■ Updated the BMI scale
Preface xv
■ Updated Consumer Responsibility in Disease Pre- ■ Added a new Healthy Highlight: Increasing Iron in
vention Healthy Highlight to include COVID-19. the Diet
■ Added material on comorbidity ■ Updated the treatment section for aplastic anemia
■ Updated the treatment section for Hodgkin’s lym-
Chapter 3 phoma, Non-Hodgkin’s lymphoma, and multiple
■ Updated cancer statistics myeloma
■ Updated personal risk behaviors for cancer ■ Added a new Complementary and Alternative Ther-
apy: Hematologic Disorders Treated with Stem Cell
■ Updated material on smoking and tobacco product Transplants
use
■ Updated cancer prevention with the latest recom- Chapter 8
mendations from the American Cancer Society
■ Updated the Pharmacology Highlight
■ Updated the section on diagnosis of cancer
■ Added a new Complementary and Alternative Ther-
■ Added a new Complementary and Alternative Ther- apy: Quercetin for Cardiovascular Disease
apy: Kombucha Beverage for Some Forms of Cancer
■ Updated the Healthy Highlight: Prevent High Blood
Chapter 4 Pressure
■ Updated the treatment section for coronary artery
■ Added a new Healthy Highlight: Emerging Infectious disease
Diseases: How to Stay Healthy
Chapter 5 apy: Low Fat Diets: Are They Necessary?
■ Updated the section on common signs and ■ Added a new Complementary and Alternative Ther-
symptoms apy: Salidroside Use in Heart Disease
■ Added a new Healthy Highlight: The Importance of
Sleep to the Immune System Chapter 9
■ Updated the Pharmacology Highlight with the bio- ■ Updated the Healthy Highlight: Why Do I Sneeze?
logics category ■ Updated the Diagnostic Tests section
■ Added a new Healthy Highlight: There’s a Difference ■ Updated the Pharmacology Highlight with the anti-
Between Food Allergy and Food Intolerance cholinergics and mucolytics categories, added exam-
■ Added a new Complementary and Alternative Ther- ples of decongestants, and information on drugs used
apy: How to Boost the Immune System to treat COVID-19
■ Updated the section on Acquired Immunodeficiency ■ Added a new Complementary and Alternative Ther-
Syndrome (AIDS) apy: Echinacea for Colds and Influenza Prevention
Chapter 6 apy: Nutritional Supplements as a Treatment for
■ Added information on arthroscopy. COVID-19?
■ Added a new Complementary and Alternative Ther- ■ Added a Healthy Highlight: Coronavirus 2019
apy: Stem Cell Therapy for Knee Osteoarthritis (COVID-19)
■ Added a new Complementary and Alternative Ther- ■ Updated the pulmonary tuberculosis section
apy: Honey for Bone Health? ■ Updated the Healthy Highlight: The Harmful Effects
of Smoking
Chapter 7 ■ Added a Healthy Highlight: Are Electronic Cigarettes
■ Updated the Pharmacology Highlight with the anti- Safe?
coagulants and plasminogen activators category ■ Updated the Healthy Highlight: Abdominal Thrust
xvi Preface
Chapter 10 ■ Updated the renal calculi section
■ Updated the Pharmacology Highlight with the ■ Updated the renal failure section
immunotherapy category and added examples of ■ Added a new Complementary and Alternative Ther-
medications apy: Herbal Medicine for Incontinence
■ Added a new Complementary and Alternative Ther- ■ Updated the urinary incontinence section
apy: Acupuncture for Lymphedema Treatment
Chapter 14
Chapter 11 ■ Updated the Diagnostic Tests section
■ Updated the Diagnostic Tests section ■ Updated the Pharmacology Highlight with the
alpha-glucosidase inhibitors, thioglitazones, hor-
■ Updated the Pharmacology Highlight with the pro-
mone agonists, hormone antagonists, and anti-
motility agent category and updated the examples of
cancer agents categories, and updated the examples
medications
of medications
■ Updated the Healthy Highlight: What Does the
Tongue Tell You?
apy: Berberine for Hyperglycemia
■ Updated the Healthy Highlight: What You Need to
apy: Essential Oils for Relief of Nausea and Vomiting
Know About Type 2 Diabetes and Taking Dietary
■ Updated the Healthy Highlight: How to Tell Heart- Supplements
burn from a Heart Attack
■ Added a new Complementary and Alternative Ther- apy: Luteolin to Maintain Blood Glucose Levels
apy: Curcumin
■ Added a new Complementary and Alternative Ther- apy: Acupuncture for Diabetic Neuropathy
apy: Natural Therapies for Irritable Bowel Syndrome
Chapter 15
■ Updated the Healthy Highlight: Screening Tests for
Colon Cancer ■ Updated the Diagnostic Tests section
■ Updated the Pharmacology Highlight with the dopa-
Chapter 12 mine agonists category and added and updated the
■ Updated the Diagnostic Tests section examples of medications
■ Updated the Pharmacology Highlight with the alco- ■ Updated the treatment section for shingles
hol abuse treatment, kinase inhibitor, and immune ■ Updated the diagnosis section and added a new
system booster categories, and updated the examples image for cerebrovascular accident
of medications ■ Added a new Complementary and Alternative Ther-
■ Updated the Complementary and Alternative Ther- apy: Using Acupuncture for Dysphagia
apy: Dietary Supplements for Hepatitis C ■ Added a new Complementary and Alternative Ther-
■ Added a new Complementary and Alternative Ther- apy: Meditation for Dementia
apy: Liver Cancer Treatment ■ Updated the Healthy Highlight: Hand Tremors
■ Updated the Healthy Highlight: Brain Foods (New
Chapter 13
title: The MIND Diet for Brain Health)
■ Updated the Diagnostic Tests section ■ Added a new Complementary and Alternative Ther-
■ Updated the Pharmacology Highlight with the apy: Aromatherapy for Better Sleep
immunotherapy category and updated the examples
Chapter 16
of medications
■ Added a new Complementary and Alternative ■ Updated the Diagnostic Tests of the Eye section
Therapy: New Ways to Treat Lower Urinary Tract ■ Updated the example medications in the Pharmacol-
Problems ogy Highlight for eye disorders
Preface xvii
■ Updated the Diagnostic Tests of the Ear section Chapter 18

■ Updated the example medications in the Pharmacol- ■ Updated the Healthy Highlight: Collagen for Healthy
ogy Highlight for ear disorders Skin
■ Added a new Healthy Highlight: UV Light Exposure ■ Updated the Diagnostic Tests section
and Your Eyes
■ Updated the Pharmacology Highlight with the anti-
■ Updated the Healthy Highlight: What is a virals, enzyme inhibitors, and immunosuppressants
Blepharospasm? categories, and updated the examples of medications
■ Added a new Complementary and Alternative Ther- ■ Added a new Complementary and Alternative Ther-
apy: Nutrition for Eye Health apy: Therapies for Skin Conditions
■ Updated the Healthy Highlight: Foods to Help Dry ■ Updated the Complementary and Alternative Ther-
Eyes apy: Chamomile for Skin Conditions
■ Added a new Healthy Highlight: Some Drugs Can ■ Updated the Complementary and Alternative Ther-
Cause Ear Problems apy: Therapy for Scars
■ Updated the Healthy Highlight: Preserving and ■ Added a new Complementary and Alternative Ther-
Improving Your Hearing apy: The Lone Star Tick and Red Meat Food Allergies
■ Added a new Healthy Highlight: Natural Treatments
for Ear Problems Chapter 19
Chapter 17 ■ Added a new Healthy Highlight: Gene Mutations

■ Updated the Complementary and Alternative Ther-
■ Updated the Diagnostic Tests section apy: Using Meditation to Improve Health
■ Updated the Pharmacology Highlight for Female ■ Updated the Diagnostic Tests section
Reproductive Disorders with the Fertility drugs cat-
egory and updated the examples of medications ■ Updated the examples of medications in the Pharma-
cology Highlight
■ Updated the Pharmacology Highlight for Male
Reproductive Disorders with the Phosphodiesterase ■ Updated the Microcephaly section
inhibitors category and example medications ■ Updated the Huntington’s Disease section
■ Added a new Complementary and Alternative Ther- ■ Added a new Healthy Highlight: Genetic Testing
apy: The Chaste Tree Berry Benefits ■ Added a new Complementary and Alternative Ther-
■ Updated the section on breast cancer apy: Herbs for Treatment of Phenylketonuria (PKU)
■ Added a new Complementary and Alternative Ther- ■ Updated the Autism Spectrum Disorder section
apy: Art and Music Therapy to Improve Quality of
Life for Breast Cancer Patients Chapter 20
■ Updated the Complementary and Alternative Ther- ■ Updated the Acquired Immunodeficiency Syndrome
apy: Supplements for Men’s Health section
■ Added a new Complementary and Alternative Ther- ■ Updated statistics in the Diphtheria section
apy: Apitherapy for Benign Prostatic Hyperplasia
(BPH) ■ Updated the Healthy Highlight: Epinephrine for
Allergic Reactions
■ Updated the statistics in the genital herpes section
■ Updated the Healthy Highlight: Preventing Sexually apy: Managing Food Allergies
Transmitted Infections: Practice Safe Sex
■ Updated the Healthy Highlight: Some Facts about apy: Herbs for Children
Human Papillomavirus (HPV)
■ Updated statistics in the Suicide section
apy: Alternative Ways to Boost Testosterone Levels
xviii Preface
■ Updated the Healthy Highlight: Immunization ■ The Cognero® Test Bank includes 60 questions per
Schedule for Children chapter, including multiple-choice and scenario mul-
tiple-choice questions and feedback; true/false ques-
Chapter 21 tions were deleted.
■ Updated the Diagnostic Tests section
■ Added a new Healthy Highlight: Staying Positive to Mindtap
Improve Life
■ Updated the examples of medications in the Pharma- MindTap is a fully online, interactive learning
cology Highlight experience built upon authoritative Cengage Learning
content. By combining readings, multimedia, activities,
■ Updated the Intellectual Disability section
and assessments into a singular learning path, MindTap
■ Added a new Healthy Highlight: The National elevates learning by providing real-world application
Helpline for Mental Health and/or Substance Use to better engage students. Instructors customize the
Disorders learning path by selecting Cengage Learning resources
■ Updated the Caffeine and Nicotine Abuse section and adding their own content via apps that integrate
into the MindTap framework seamlessly with many
■ Added a new Healthy Highlight: Naloxone for
learning management systems.
Overdoses
■ To learn more, visit www.cengage.com/training
■ Added a new Healthy Highlight: Preventing Opioid /mindtap.
Overdoses
apy: Aromatherapy for Mood Elevation About the Authors
apy: Exercise for Relief from Depression Dr. Marianne Neighbors has been in nursing practice
and nursing education for more than 40 years. She
■ Added a section on Gender Dysphoria received her bachelor’s degree in nursing at Mankato
State, a master’s degree in health education at the
University of Arkansas, a master’s degree in nursing
Instructor and Student Resources at the University of Oklahoma, and a doctoral degree
in education with a focus on health science at the
Additional instructor and student resources for University of Arkansas. Dr. Neighbors has taught in
this product are available online. Instructor assets associate degree nursing education for 18 years, focusing
include an Instructor’s Manual, Educator’s Guide, on medical/surgical nursing, and in baccalaureate
PowerPoint® slides, Solution and Answer Guide, and a nursing education for 23 years, focusing on health
test bank powered by Cognero®. Student assets include promotion and community health. She also taught
PowerPoint® slides. Sign up or sign in at www.cengage advanced health promotion and nurse educator classes
.com to search for and access this product and its online at the master’s level. She has coauthored many research
resources. articles; four medical/surgical nursing texts, along with
■ The Instructor’s Manual includes a sample course two medical/surgical handbooks; a health assessment
syllabus and outline as a guide for setting up a course. handbook; and a home health handbook, in addition to
Additional materials for each chapter include detailed the six editions of Human Diseases. Dr. Neighbors has
content outlines, learning objectives, expanded chap- also written chapters for other nursing authors’ books.
ter summaries, discussion topics and learning activi- She is currently an Emeritus professor in the Eleanor
ties, and discussion questions. Mann School of Nursing at the University of Arkansas,
Fayetteville, Arkansas.
■ The Solution and Answer Guide includes answers to Ruth Tannehill-Jones worked as a registered
the text chapter review questions and case studies. nurse for more than 30 years. She began her nursing
The PowerPoint® slides include chapter objectives, education at the University of Arkansas, Fayetteville,
content and activity slides, and a self-assessment. with completion of an associate degree in nursing.
Preface xix
Ms. Tannehill-Jones was not a newcomer to this cam-

pus; some years previously, she had completed a bach-
Acknowledgments
elor’s degree in home economics. On receiving her A special thanks goes out to all our colleagues, friends,
RN license, she worked at St. Mary-Rogers Memorial and family members who have supported us throughout
Hospital in Rogers, Arkansas, in the capacities of staff this project.
nurse, head nurse, and nursing supervisor. Her other
nursing experience includes assisting orthopedic sur-
geons while employed by Ozark Orthopedic and Sports Feedback From The User(S)
Medicine Clinic located in the Northwest Arkansas The authors would like to hear from instructors, learners,
area. Ms. Tannehill-Jones gained experience in edu- or anyone using the textbook about its strengths and/
cation by working as an instructor of surgical technol- or suggestions for revisions. They are truly interested in
ogy while serving as the Divisional Chair of Nursing making the textbook user-friendly and comprehensive
and Allied Health Programs at Northwest Technical but not too detailed or too in-depth for the reader. The
Institute in Springdale, Arkansas. She obtained her authors want to know how the text is being used and
bachelor’s degree in nursing from Missouri Southern what features are most helpful. Please feel free to forward
State College in Joplin and her master’s degree in health comments to the authors through Cengage Learning or
service administration at Southwest Baptist University directly by e-mail to Dr. Neighbors at neighbo@uark
in Bolivar, Missouri. She worked for St. Mary’s— .edu and Ms. Tannehill-Jones at rjonesnwark@hotmail
Mercy Health System for more than 20 years in a vari- .com.
ety of nursing positions, with her last position being
Vice President of Patient Care Services, Chief Nurse Marianne Neighbors, EdD, RN
Executive. Ms. Tannehill-Jones retired from Regency Ruth Tannehill-Jones, MS, RN
Hospital of Northwest Arkansas in 2011.
Reviewers
We would like to thank all of the reviewers who have Nanette Mosser, RMA (AMT), BA
been an invaluable resource in guiding this book as it Program Director: Medical Assisting program,
has evolved. Their insights, comments, suggestions, MedQuest College
and attention to detail were extremely important in
Gloria Madison, MS, RHIA, CHDA, CHTS-IM
developing this textbook.
Program Director, Faculty: Health Information
Manuel F. Sanchez, M.D. Technology, Moraine Park Technical College
Faculty: St. Paul’s School of Nursing, Nursing and
Jennifer Pierce, CPC, CPC-I
Medical Assisting programs
Adjunct Professor: San Joaquin Valley College
Angela Campbell, MSHI, RHIA
HIT Instructor: San Juan College
Trena M. Soucy, MS
Biology Professor: Northern Maine Community College
Gladdi Tomlinson, RN, MSN
Professor of Nursing: Harrisburg Area Community
College
xxi
Unit I
Concepts of
Human Disease
1
Introduction to
Human Diseases
Key Terms
Acute (p. 5) Exacerbation (p. 8) Palliative (p. 10) Predisposing factors (p. 6)
Auscultation (p. 8) Fatal (p. 9) Palpation (p. 8) Prevalent (p. 7)
Chronic (p. 5) Holistic medicine (p. 9) Pandemic (p. 8) Preventive (p. 9)
Complication (p. 9) Homeostasis (p. 4) Pathogenesis (p. 4) Prognosis (p. 8)
Diagnosis (p. 7) Iatrogenic (p. 5) Pathogens (p. 4) Remission (p. 8)
Disease (p. 4) Idiopathic (p. 5) Pathologic (p. 4) Signs (p. 8)
Disorder (p. 4) Lethal (p. 9) Pathologist (p. 4) Symptoms (p. 8)
Epidemic (p. 8) Mortality rate (p. 9) Pathology (p. 4) Syndrome (p. 4)
Etiology (p. 5) Nosocomial (p. 5) Percussion (p. 8)
Learning Objectives
Upon completion of the chapter, the learner should be able to:
1. Define basic terminology used in the study 4. Identify the predisposing factors to human diseases.
of human diseases. 5. Explain the difference between the diagnosis and
2. Discuss the pathogenesis of a disease. the prognosis of a disease.
3. Describe the standard precaution guidelines 6. Describe some common tests used to diagnose
for disease prevention. disease states.
Overview
T he study of human diseases is important for understanding a variety of other topics in the health care
field. Diseases that affect humans can range from mild to severe and can be acute (short term) or chronic
(long term). Some diseases affect only one part of the body or a particular body system, whereas others affect
several parts of the body or body systems at the same time. Many factors influence the body’s ability to stay
healthy or predispose the body to a disease process. Some of these factors are controllable, but some are
strictly related to heredity. Diseases can be diagnosed by professional health care providers using a variety of
techniques and tests. ■
3
4 Chapter 1
TABLE 1–1 Types of Pathologists

Disease, Disorder,
and Syndrome Pathologist Role or Subject
In the study of human disease, several terms may be Experimental Research

similar and often used interchangeably but might not Academic Teaching
have identical definitions. Anatomic Clinical examinations
Autopsy Postmortem
Surgical Biopsies
Disease Clinical Laboratory examinations
Hematology Blood
Disease may be defined in several ways. It may be called
Immunology Antigen/antibodies
a change in structure or function that is considered to Microbiology Microorganisms
be abnormal within the body, or it may be defined as
any change from normal. It usually refers to a condi-
tion in which symptoms occur and a pathologic state is
present, such as in pneumonia or leukemia. Both defi- pathologist (pah-THOL-oh-jist) is one who studies dis-
nitions have one underlying concept: the alteration of ease. Using this strict definition of the word, even a stu-
homeostasis (ho-mee-oh-STAY-sis). dent studying diseases might be considered a pathologist.
Homeostasis is the state of sameness or normalcy There are many types of pathologists because there
the body strives to maintain. The body is remarkable are numerous ways to study disease. One of the more
in its ability to maintain homeostasis, but when this commonly known pathologists is the surgical pathol-
homeostasis is no longer maintained, the body is dis- ogist, who inspects surgical tissue or biopsies for evi-
eased or “not at ease.” dence of disease. The medical examiner or coroner can
be a pathologist who studies human tissue to determine
the cause of death and provide evidence of criminal
Disorder involvement in a death. Other types of pathologists are
Disorder is defined as a derangement or abnormal- outlined in Table 1–1.
ity of function. The term disorder can also refer to a The prefix patho- can be used in a variety of ways to
pathologic condition of the body or mind but more describe disease processes or the disease itself. Microor-
commonly is used to refer to a problem such as a ganisms or agents that cause disease are called pathogens
vitamin deficiency (nutritional disorder). It is also (PATH-oh-jens). These include some types of bacteria,
used to refer to structural problems such as a mal- viruses, fungi, protozoans, and helminths (worms). All
formation of a joint (bone disorder) or a condition pathogens have the ability to cause a disease or disor-
in which the term disease does not seem to apply, der. Fractures that are caused by a disease process that
such as dysphagia (swallowing disorder). Because weakens the bone, such as osteoporosis, would be called
disease and disorder are so closely related, they are pathologic (path-oh-LODGE-ick) fractures.
often used synonymously.
Pathogenesis
Syndrome
The pathogenesis (PATH-oh-JEN-ah-sis; patho = dis-
Syndrome (SIN-drome) refers to a group of symptoms, ease, genesis = arising) is a description of how a partic-
which might be caused by a specific disease but might ular disease progresses. Many of us are familiar with the
also be caused by several interrelated problems. Exam- pathogenesis of the common cold.
ples include Tourette’s syndrome, Down syndrome, A cold begins with an inoculation of the cold virus.
and acquired immunodeficiency syndrome (AIDS), This can occur following a simple handshake with some-
which are discussed later in the text. one who has a cold. Afterward, the target person might
rub their eyes or nose, allowing entry of the virus into
Pathology the body. After the inoculation period comes the incu-
bation time. During this period, the virus multiplies, and
Pathology (pah-THOL-oh-jee) can be broadly defined as the target person begins to have symptoms such as a
the study of disease (patho = disease, ology = study). A runny nose and itchy eyes. The pathogenesis of the cold
TABLE 1–2 Examples of Acute and Chronic

Diseases/Disorders Etiology
Acute Chronic The etiology (EE-tee-OL-oh-jee) of a disease means
the study of cause. The term etiology is commonly
Upper respiratory infections Arthritis used to mean simply “the cause.” One might say that
Lacerations Hypertension the cause is unknown or “of unknown etiology.” The
Middle ear infections Diabetes mellitus cause or etiology of pneumonia can be a virus or a
Gastroenteritis Low back pain bacterium. The etiology of athlete’s foot is a fungus
Pneumonia Heart disease named tinea pedis.
Fractures Asthma Another term used to mean “the cause is
unknown” is idiopathic (ID-ee-oh-PATH-ick). If an
individual is diagnosed as having idiopathic gastric
then moves into full-blown illness, usually followed by pain, it means the cause of the pain in the stomach
recovery and return to the previous state of health. is unknown.
The pathogenesis of a disease can be explained in Other terms related to cause of disease are
terms of time. An acute (a-CUTE) disease is short term iatrogenic (EYE-at-roh-JEN-ick) and nosocomial
and usually has a sudden onset. If the disease lasts for (NOS-oh-KOH-me-al). Iatrogenic (iatro = medicine,
an extended period or the healing process is progressing physician, genic = arising from) means that the prob-
slowly, it is classified as a chronic (KRON-ick) condition. lem arose from a prescribed treatment. An example of
See Table 1–2 for examples of acute and chronic diseases !. an iatrogenic problem is the development of anemia
Healthy Highlight
How Should You
Wash Your Hands
K eeping your hands clean through improved hand hygiene is one of the most
important steps we can take to avoid getting sick and spreading germs to others.
Many diseases and conditions are spread by not washing hands with soap and clean
water.
To wash your hands,
■ wet your hands with clean, running water (warm or cold), turn off the tap, and apply
soap.
■ lather your hands by rubbing them together with the soap. Be sure to lather the backs
of your hands, between your fingers, and under your nails.
■ scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday”
song from beginning to end twice.
■ rinse your hands well under clean, running water.
■ dry your hands using a clean towel or air-dry them.
It is important to wash
■ before eating or preparing food.
■ before touching your face.
■ after using the restroom.
■ after blowing your nose, coughing, or sneezing.
■ after handling a face mask.
■ after changing a diaper.
■ after caring for someone who is ill.
■ after touching animals.
Source: Centers for Disease Control and Prevention (2020).
6 Chapter 1
Healthy Highlight
Standard
Precautions
U sing standard precautions is recommended by the Centers for Disease Control and
Prevention for the care of all patients or when administering first aid to anyone.
These standards also include respiratory hygiene and cough etiquette, safe injection
techniques, and wearing masks for spinal insertions.
■ Handwashing Wash your hands after touching blood, body fluids, or both, even if
gloves are worn; use an antimicrobial soap.
■ Respiratory etiquette Cover your mouth, nose, or both with a tissue when coughing
and dispose of used tissue immediately. Wear a mask if possible. Maintain distance
from others, ideally greater than 3 feet. Wash hands after contact with secretions.
■ Gloves Wear gloves when touching blood, body fluids, and contaminated items;
change gloves after patient contact or contact with contaminated items; wash your
hands before and after.
■ Eyewear, mask, and face shield Wear protection for your eyes, mouth, and face when
performing procedures in which a risk of splashing or spraying of blood or body
secretions exists. This includes inserting catheters or injecting material into spinal or
epidural spaces. A mask should also be worn if the caregiver has a respiratory infection
but cannot avoid direct patient contact.
■ Gown Wear a waterproof gown to protect the clothing from splashing or spraying
blood or body fluids.
■ Equipment Wear gloves when handling equipment contaminated with blood or
body fluids; clean equipment appropriately after use; discard disposable equipment
in proper containers.
■ Environment control Follow proper procedures for cleaning and disinfecting the
patient’s environment after completion of a procedure.
■ Linen Use the proper procedure for disposing of linen contaminated with blood or
body fluids.
■ Blood-borne pathogens Do not recap needles; dispose of used needles and other
sharp instruments in proper containers; use a mouthpiece for resuscitation; keep a
mouthpiece available in areas where there is a likelihood of need.
in a patient undergoing chemotherapy treatments for factors are not the cause of the disease, and people with
cancer. predisposing factors do not always develop the dis-
Nosocomial is a closely related term; it implies that ease. These factors include age, sex, environment, life-
the disease was acquired from a hospital environment. style, and heredity. Some risk factors, such as lifestyle
A more comprehensive descriptor of a disease acquired behaviors, are controllable, whereas others such as age
in the hospital or in any health care facility is health are not.
care–associated infection (HAI). An example of a nos-
ocomial or HAI would be a postoperative patient devel-
oping an incisional staphylococcal infection. The best Age
way to prevent these infections is through the practice From the beginning of life until death, our risk of
of good handwashing. A good handwashing technique disease follows our age. Newborns are at risk of
is described in the Healthy Highlight box. disease because their immune systems are not fully
developed. On the other hand, older persons are
Predisposing Factors at risk because their immune systems are degen-
erating or wearing out. Girls in their early teens
Predisposing factors, also known as risk factors, make and women over the age of 30 are at high risk for
a person more susceptible to disease. Predisposing a difficult or problem pregnancy. The older we
become, the higher the risk for diseases such as

cancer, heart disease, stroke, senile dementia, and
Alzheimer’s disease. Consider This...
About 90% of diseases are partially caused
Sex or affected by stress.
Some diseases are more prevalent (occurring more
often) in one gender or the other. Men are more at risk
for diseases such as lung cancer, gout, and parkinson- Heredity
ism. Other disorders or diseases, including osteoporo-
sis, rheumatoid arthritis, and breast cancer, occur more Although one cannot change genetic makeup, being
often in women. aware of hereditary risk factors might encourage the
individual to change lifestyle behaviors to reduce the
risk of disease. For example, coronary heart disease has
Environment been shown to have a high familial tendency. Persons
Air and water pollution can lead to respiratory and with this family inheritance are compounding their
gastrointestinal disease. Poor sanitation, excessive chances if they smoke, have poor nutritional intake,
noise, and stress are also environmental risk factors. and do not exercise routinely.
Occupational diseases such as lung disease are high Breast cancer and cervical cancer also have famil-
among miners and persons working in areas with ial tendencies. Women with family members who have
increased amounts of dust or other particles in the been diagnosed with breast cancer or cervical cancer
air. are at a higher risk of developing these diseases. These
Farmers are considered to be at higher risk for dis- women should be screened routinely for evidence of
eases because of their increased exposure to dust, pes- cancer and should complete monthly breast self-exams.
ticides, and other pollutants. Farmers are also at higher With this knowledge about hereditary factors, individu-
risk for trauma injuries due to safety problems around als can choose to decrease their overall risk by improv-
farm machinery. People living in remote, rural areas ing their lifestyle health behaviors.
do not have health care availability comparable to that
enjoyed by people living in urban areas. This increases Diagnosis
their risk for chronic illnesses.
Diagnosis (die-ag-NO-sis) is the identification or
naming of a disease or condition. When an individual
Lifestyle
seeks medical attention, it is the duty of the physician
Lifestyle factors fall into a category over which the indi- to determine a diagnosis of the problem. A diagnosis is
vidual has some control. Choosing to improve health made after a methodical study by the physician, using
behaviors in these areas could lead to a reduction in risk data collected from a medical history, physical exam-
and thus a possibility of avoiding the occurrence of the ination, and diagnostic tests (Figure 1–1).
disease. Such factors include smoking, drinking alcohol,
poor nutrition (excessive fat, salt, and sugar and not
enough fruits, vegetables, fiber), a lack of exercise, and
stress.
Practicing health behaviors to prevent contami-
nation, and thus disease, is also an important lifestyle
behavior. The Centers for Disease Control and Pre-
vention recommends the use of standard precautions
when caring for any individual when there is a chance
of being contaminated with blood or body fluids (see
the Healthy Highlight box “Standard Precautions”).
This is an important measure to prevent transmission
of any disease that can be passed between humans in
blood or body fluids, such as hepatitis, Escherichia coli
infections, and AIDS. Figure 1–1 Physician checking a patient.
8 Chapter 1
A medical history is a systems review that might If an unusually large number of people in a region
include such information as previous illnesses, fam- are diagnosed with the same disease around the same
ily illness, predisposing factors, medication allergies, time, the disease is called an epidemic. During the
current illnesses, and current symptoms (SIMP-tums; late fall, winter, and early spring, influenza (flu) often
what patients report as their problem or problems). reaches epidemic numbers in various regions. If an epi-
Examples of symptoms might include stomach pain, demic affects an exceptionally large area, even as far
headache, and nausea. as worldwide, it is called a pandemic. Pandemics are
The physician proceeds with a head-to-toe phys- rare. The most recent being Coronavirus Disease 2019
ical examination of the patient, looking for signs of (COVID-19).
the disease. Signs differ from symptoms in that signs
are observable or measurable. Signs are what the
physician sees or measures. Examples of signs could Prognosis
include vomiting, elevated blood pressure, and ele- Prognosis (prawg-KNOW-sis) is the predicted or
vated temperature. expected outcome of the disease. For example, the prog-
In some cases, a patient’s concern might be con- nosis of the common cold would be that the individual
sidered as both a symptom and a sign. Some references should feel better in 7 to 10 days.
call this an objective or observable symptom, whereas
others state that it is also a sign. An example would be
a patient complaining of a runny nose. The runny nose Acute Disease
is the patient’s symptom, and because it is observable The duration of the disease can be described as acute in
to the physician, it is also a sign. nature. An acute disease is one that usually has a sud-
During the physical examination, the physician den onset and lasts a short amount of time (days or
might use other skills such as auscultation (aws- weeks). Most acute diseases are related to the respira-
kul-TAY-shun; using a stethoscope to listen to body tory system. Again, the common cold would be a good
cavities), palpation (pal-PAY-shun; feeling lightly example.
or pressing firmly on internal organs or structures),
and percussion (per-KUSH-un; tapping over vari- Chronic Disease
ous body areas to produce a vibrating sound). All the
results are compared to a normal standard to identify If the disease persists for a long time, it is considered
problems. chronic. Chronic diseases might begin insidiously
Diagnostic tests and procedures to assist in deter- (slowly and without symptoms) and last for the individ-
mining a diagnosis are numerous. The routine or most ual’s entire life. As one ages, the occurrence of chronic
common include urinalysis, complete blood count, disease increases. One of the most common chronic
chest X-ray, and electrocardiography (EKG or ECG). diseases is hypertension, or high blood pressure.
See Table 1–3 for examples of common diagnostic tests Chronic diseases often go through periods of
and procedures. remission and exacerbation (eg-ZAS-er-BAY-shun).
TABLE 1–3 Examples of Common Diagnostic Tests and Procedures
Test Description
Complete blood count (CBC) An examination of blood for cell counts and abnormalities
Urinalysis (UA) An examination of urine for abnormalities
Chest X-ray (CXR) X-ray examination of the chest cavity
Electrocardiography (ECG or EKG) A procedure for recording the electrical activity of the heart
Blood glucose A test of the blood to determine its glucose or sugar levels
Computerized axial tomography (CT or CAT) A special X-ray examination showing detailed images of body
structures and organs
Serum electrolytes An examination of blood serum to determine the levels of the common
electrolytes (sodium, potassium, chloride, and carbon dioxide)
Remission refers to a time when symptoms are dimin- to the individual with expected outcomes or progno-
ished or temporarily resolved. Exacerbation refers to a ses. The individual’s entire being should be taken into
time when symptoms flare up or become worse. Leu- consideration. The concept of considering the whole
kemia is a disease that progresses through periods of person rather than just the physical being is called
remission and exacerbation. Both acute and chronic holistic medicine.
diseases can range from mild to life-threatening. From a holistic viewpoint, there is an interac-
tion among the spiritual, cognitive, social, physical,
and emotional being. These areas do not work inde-
Complication pendently but have a dynamic interaction (Figure 1–2).
The prognosis might be altered or changed at times if Treatment interventions might include (a) medi-
the individual develops a complication. A complication cations, (b) surgery, (c) exercise, (d) nutritional mod-
is the onset of a second disease or disorder in an indi- ifications, (e) physical therapy, and (f) education.
vidual who is already affected with a disease. An indi- Individuals and family members should be educated
vidual with a fractured arm might have a prognosis of and involved in the treatment plan. Failing to involve
the arm healing in 6 to 8 weeks. If the individual suffers the individual and family can decrease compliance and
the complication of bone infection, the prognosis might lead to the plan failing.
change drastically. After the treatment plan is implemented, the
physician will follow up with the individual to deter-
Mortality Rate mine the plan’s effectiveness. The individual and
physician should work together to modify the plan
Mortality is defined as the quality of being mortal, that if it is found to be ineffective. Implementation of the
is, destined to die. Diseases commonly leading to the plan usually requires an entire health care team. The
death of an individual have a high mortality rate. The team can include nurses, a physical therapist, a social
mortality rate of a disease (also called death rate) is worker, clergy, and other health care professionals
related to the number of people who die with the dis- as needed.
ease in a certain amount of time. Other terms the med- The best treatment option is a preventive plan. In
ical community uses to refer to a deadly disease include preventive treatment, care is given to prevent disease.
fatal and lethal. Examples of preventive care are breast mammograms
Consider This... O N M
I R E
V
The ashes of the average cremated human N N
weigh approximately 9 pounds.
E
Physiological T
Survival Rate
A physician’s prognosis can also consider the survival Spiritual Psychological
rate. The survival rate is the percentage of people with
Individual
a particular disease who live for a set time. For example,
the 2-year survival rate of individuals with lung cancer
would be the percentage of people alive 2 years after
diagnosis. Intellectual Sociocultural
Treatment
After the diagnosis is established, the physician will
work with the individual to explain or outline a plan
of care. The physician might offer treatment options Figure 1–2 Holistic medicine.
10 Chapter 1
to screen for breast cancer, blood pressure screening When challenges concerning medical ethics arise
for hypertension, routine dental care to prevent dental in a health care facility, an ethics committee might be
caries, and a fecal occult blood test to screen for colon called on to make a decision. This committee might
cancer. involve one or more persons at each of these levels:
Other treatment plans might include palliative physician, nurse, ethicist, social worker, case manager,
(PAL-ee-ay-tiv) treatment. Palliative treatment is chaplain, legal representative, and administrator, or
aimed at preventing pain and discomfort but does director.
not seek to cure the disease. Treatment for end-term Groups or committees involved in decision-making
cancer and other serious chronic conditions can be might need to consider previous works of philosophy,
palliative. history, law, and religion to assist them in reaching a
Decisions concerning treatment plans can be very conclusion. Participation in ethical decision-making
difficult for the patient, the patient’s family, and the requires members to follow some basic rules, which
health care team. This is especially true when those can include
decisions involve palliative treatment and end-of-life
issues. During these times, professionals often seek ■ keeping the discussion focused and civil.
assistance in decision-making by using their knowledge ■ listening with an open mind to all opinions.
of medical ethics. ■ entertaining diverse ideas.
■ weighing out the pros and cons of each idea.
Medical Ethics ■ considering the impact of the decision on all per-
Webster’s Dictionary defines ethics as “the study of sons involved.
standards of conduct and moral judgment.” More
Every individual at some time or another will
simply put, ethics deals with the “rightness and wrong-
encounter or be called on to make a decision that is bio-
ness” or “goodness and badness” of human actions.
ethical in nature. Examples of these can include one’s
Ethics covers many areas of conduct and judgment in
willingness to
our society.
Bioethics is a branch of ethics concerned with ■ use a surrogate mother or father to have a bio-
what is right or wrong in bio (life) decisions. Because logical child.
bioethics is a study of life ethics, it covers or becomes
■ control the sex of children through chromosome
entwined with medical ethics. Medical ethics includes
selection.
the values and decisions in medical practice, including
relationships to patients, patients’ families, peer physi- ■ use fetal stem cells to grow new organs and tissues.
cians, and society. ■ use prescription stimulants in children.
Part of the ethical challenge in this age of rapidly ■ legalize abortion.
advancing technologies is actually determining what is
right or wrong, good or bad. New scientific discover- ■ use mood-altering drugs for older persons.
ies are challenging familiar or usual human behaviors, ■ clone humans.
leading to reconsideration of actions, thoughts, and ■ treat disease by replacing damaged or abnormal
emotions. Ethical dilemmas, once rare, are now com- genes with normal genes.
mon and often happen so quickly that society is unable
to understand completely the impact these decisions ■ use animal organs or tissues (xenotransplants) in
will have on the future. humans.
Bioethical decisions are often very difficult ■ support euthanasia.
because they touch the core of humanity in dealing ■ allow physician-assisted suicide.
with issues of birth, death, sickness, health, and dig-
nity. This generation and generations to come will Each of the preceding issues can be overwhelm-
be faced with ethical decisions formerly unknown to ing. Even so, yet another concern must be addressed,
humans. Many of these decisions will have a great involving the economics of these choices.
impact on medical ethics and will actually shape the Consider, for example, the economics of
future of humankind. human cloning. How will research, technology, and
intervention be funded? If costs are funded by individ-

uals, only wealthy individuals would be able to afford
clones. Is that fair or right? If costs are funded by the Consider This...
government, what criteria will be used for selection?
Will selection be based on intelligence, physical ability, A study in the Netherlands determined
or artistic skills? Who decides? that smokers and obese persons benefit
Medical ethics includes some very complicated a socialized health care system due to
life issues. Bioethical decision-making, or determin- earlier deaths. Health care costs for a
ing the rightness or wrongness of such issues, will lifetime for a healthy person will average
continue to be a challenge for society well into the $417,000, whereas the obese person will
future. cost $371,000 and the smoker will cost
$326,000.
Summary
T he study of human diseases is important to any health care or allied health professional. Disease can affect any body
system or organ and can range from mild to severe, depending on many factors. Several risk factors for disease can
be controlled to some extent by one’s lifestyle. Other diseases might not be preventable or controlled but need medical
intervention for treatment or cure. Diagnosing and treating a disease are usually accomplished by a team of health care
professionals led by the physician. Ethical decision-making has become a challenge in health care today, and as tech-
nology continues to grow and develop, medical ethics will become more challenging than ever.
Review Questions
Short Answer
1. Identify why it is important to study human diseases.
2. Describe the types of pathologists and their roles in the study of disease.
3. List the five predisposing factors for disease and one disease related to each factor.
Matching
4. Match the terms in the left column with the correct definition in the right column.
Pathogenesis a. The cause of a disease
Etiology b. Interventions to cure or control a disease
Diagnosis c. The development of a disease
Prognosis d. The identification or naming of a disease
Treatment e. The predicted or expected outcome of a disease
12 Chapter 1
Fill in the Blank

5. A common test used in determining a disease diagnosis that involves recording the electrical activity of the heart
is a/an _________.
Case Studies
■ Stan Cotton was accidentally tripped by another player while running down the field at a soccer game you
were coaching. He is able to walk to the sideline with assistance but has obvious bleeding on his legs and one
arm. You grab the first-aid box and go to his side. What do you do next? What equipment might you use to give
aid to Stan? What standard precautions should apply to this case?
■ Jane Swenson has been suffering from a cold for about a week and has missed 3 days of work. She decides
to return to work at the local community center for older adults. She is still coughing at intervals and has a runny
nose but has improved since last week. Should she still use some precautions to prevent spreading her illness?
If so, what should she do?
2
Mechanisms of
Disease
Key Terms
AIDS (p. 19) Cancer (p. 16) Infarct (p. 22) Neoplasms (p. 15)
Allergen (p. 18) Comorbidity (p. 23) Infection (p. 15) Oncology (p. 15)
Allergy (p. 18) Congenital (p. 14) Inflammation (p. 15) Organ rejection (p. 19)
Anoxia (p. 20) Degenerative (p. 19) Ischemia (p. 22) Parenteral (p. 17)
Antibodies (p. 18) Dysplasia (p. 20) Malignant (p. 16) Total parenteral
Antigens (p. 18) Encapsulated (p. 16) Metaplasia (p. 20) nutrition (TPN)
Atrophy (p. 20) Enteral (p. 17) Metastasize (p. 16) (p. 17)
Autoimmunity (p. 18) Gangrene (p. 22) Metastatic (p. 16) Trauma (p. 14)
Bariatrics (p. 18) Hyperplasias (p. 15) Morbidity (p. 23) Triage (p. 15)
Benign (p. 16) Hypertrophy (p. 20) Motor vehicle accidents Tumors (p. 15)
Body mass index Hypoxia (p. 20) (MVAs) (p. 14)
(BMI) (p. 18) Immunodeficiency Necrosis (p. 22)
Cachexia (p. 17) (p. 19) Neoplasia (p. 20)
Learning Objectives
1. Identify important terminology related to the 5. Compare the various types of impaired immunity.
mechanisms of human disease. 6. Identify the basic changes in the body occurring
2. Describe the causes of disease. in the aging process.
3. Identify disorders in each category of the causes 7. Describe the process of cell and tissue injury,
of disease. adaptation, and death.
4. Describe behaviors important to a healthy lifestyle.
Overview
T he human body is a complex machine that normally runs in an efficient, balanced manner, but when
changes occur in the body due to lifestyle behaviors, abnormal growths, nutritional problems, bacterial
invasion, or any other factor that upsets the balance, the result might be a disease process. Human disease
13
14 Chapter 2
can be very minor or life-threatening. Diseases are caused by a variety of factors; some are controllable, and
some are not. Even normal changes, such as aging, can put the individual at higher risk for developing dis-
ease. Many changes or alterations in cell and tissue structure can occur. Some of these changes are reversible,
but some might cause cellular, tissue, organ, or system death. ■
Chromosomal and genetic abnormalities might or

Causes of Disease might not be compatible with life. Some abnormalities
To gain a better understanding of the different causes might be present but cause no effect on the individual,
of diseases, it is usually helpful to classify or divide whereas others might lead to the death and sponta-
them into smaller groups. This classification can be neous abortion of the unborn child.
approached in several different yet logical ways. One More information related to hereditary diseases
commonly used approach is to divide the causes of dis- can be found in Chapter 19, “Genetic and Develop-
ease into the following six categories: mental, Childhood, and Mental Health Diseases and
Disorders.”
1. Heredity
2. Trauma Trauma
3. Inflammation and infection Traumatic diseases are caused by a physical injury
4. Hyperplasias and neoplasms from an external force. Trauma is the leading cause
5. Nutritional imbalance of death in children and young adults. The type of
trauma (TRAW-mah) or traumatic disease most
6. Impaired immunity
commonly affecting individuals varies with age, race,
and residence. For example, accidents, especially
Heredity falls, are a common cause of traumatic disorders
in older adults, whereas motor vehicle accidents
Hereditary diseases are caused by an abnormality in the
(MVAs) are the most frequent cause of injury and
individual’s genetic or chromosomal makeup. These dis-
death in young adults.
eases might or might not be apparent at birth. Hereditary
The National Safety Council lists deaths caused
diseases present at birth, even if not apparent, are called
by trauma, in order of prevalence (or occurrence), as
congenital (kon-JEN-ih-tahl) disorders. However, not
follows:
all congenital disorders are inherited. Some other causes
of congenital disorders include disease during pregnancy ■ Poisoning
(e.g., fetal alcohol syndrome) or difficulty with delivery ■ Falls
(e.g., cerebral palsy), to name only a couple.
Hereditary diseases are classified in three basic ways: ■ MVA
(1) a single-gene abnormality, (2) an abnormality of sev- ■ Choking
eral genes (polygenic), or (3) an abnormality of a chro- ■ Drowning
mosome (either entire absence of a chromosome or the
presence of an additional chromosome). See Table 2–1 Emergency management of trauma is often neces-
for the classification of hereditary diseases and examples. sary to prevent the complications of shock, hemorrhage,
TABLE 2–1 Classification of Hereditary Disease with Examples
Single Gene Polygenic Chromosomal
Cystic fibrosis Gout Klinefelter’s syndrome

Phenylketonuria Hypertension Turner’s syndrome
Sickle cell anemia Congenital heart anomalies Down syndrome
Mechanisms of Disease 15
and infection. On arrival at an emergency department,

patients are assessed according to signs and symptoms,
age, and medical history. Needs are then prioritized,
and care is given in order of severity of injury. This pri-
oritizing of care is called triage (tree-AZH) and incor-
porates an ABC prioritizing method, with A for airway,
B for breathing, and C for cardiac function. After these
areas are assessed, other areas of trauma such as bleed-
ing and fractures are addressed. An example of triage,
in general, would be giving priority care to a patient
who is not breathing before assisting a patient who has
a bleeding leg wound.
Types of trauma commonly occurring in each body
system are discussed in the specific system chapters.
Inflammation and Infection Figure 2–1 Inflammation of a finger.

Inflammation (in-flah-MAY-shun) is a protective
immune response that is triggered by any type of injury
or irritant. Even the slightest trauma can initiate the Hyperplasias and Neoplasms
inflammatory response. Signs of inflammation are red-
Hyperplasias (high-per-PLAY-zee-ahs; hyper 5 exces-
ness, heat, swelling, pain, and loss of motion. An exam-
sive, plasia 5 growth) and neoplasms (NEE-oh-pla-
ple of inflammation is sunburn. The tissue is red, warm
zms; neo 5 new, plasm 5 growth) are similar because,
to the touch, swollen, painful, and uncomfortable when
in both, an increase in cell number leads to an increase
moving. Although this area is inflamed, it is usually not
in tissue size.
infected.
Infection (in-FEK-shun) refers to the invasion of
microorganisms into tissue that causes cell or tissue Hyperplasias
injury. Inflammation and infection are often used syn- Hyperplasias differ from neoplasms in terms of cause
onymously even though they are quite different. A tis- and growth limits. Hyperplasias are overgrowths in
sue can be inflamed but not infected, as in sunburn, but response to some type of stimulus. An example of a
usually, infected tissue will also be inflamed. hyperplasia would be enlargement of the thyroid gland
For tissue to be infected or for an infection to occur, (goiter) in response to a hormone deficiency.
there has to be an invasion of microorganisms. Usually,
inflammation and infection go hand in hand. For exam- Neoplasms
ple, when the skin is cut, the tissue around the cut will Neoplasms (new growths) are commonly called
undergo a mild inflammation. As skin bacteria invade tumors. The Latin word tumor means “swelling” and
the cut tissue, the area becomes infected and usually originally was used in the description of the swelling
becomes even more inflamed due to the irritation to the related to inflammation. The Greek term for swelling
tissue caused by the bacteria (Figure 2–1). is onkos, which has been used to construct the word
Diseases that are related to inflammation are iden- oncology (ong-KOL-oh-jee; onco 5 tumor, logy 5
tified with the suffix -itis. Examples include appendicitis study of, or the study of cancer). Although all tumors
(inflammation of the appendix), gastritis (inflammation are not neoplasms, as described in more detail in
of the stomach), colitis (inflammation of the colon), Chapter 3, “Neoplasms,” the words are often used
and encephalitis (inflammation of the brain). In many synonymously.
cases, the inflammation will progress to an infection Diseases with tumor involvement usually end with
due to the presence of bacteria in the region. For exam- the suffix -oma. Examples include lipoma, carcinoma,
ple, appendicitis can be caused by an obstruction of melanoma, and sarcoma (Table 2–2). An exception to
the appendix. Because the bacteria Escherichia coli (E. this is the word hematoma, which is a clot of blood in
coli) are commonly found in the colon, the appendix an area. A hematoma on the head due to a blunt blow
becomes infected. would be an example.
16 Chapter 2
TABLE 2–2 Examples of Neoplasms or Tumors
Neoplasm/Tumor Description
Adenoma Usually benign tumor arising from glandular epithelial tissue
Carcinoma Malignant tumor of epithelial tissue
Fibroma Benign encapsulated tumor of connective tissue
Glioma Malignant tumor of neurologic cells
Lipoma Benign fatty tumor
Melanoma Malignant tumor of the skin
Sarcoma Malignant tumor arising from connective tissue such as muscle or bone
Neoplasms or tumors (-omas) may be classified as

benign (beh-NINE) or malignant (mah-LIG-nant).
Generally, benign tumors have limited growth, are
encapsulated (enclosed in a capsule) and thus easily
removed, and are not deadly. Malignant tumors are
just the opposite. These tumors grow uncontrollably;
have fingerlike projections into surrounding tissue,
making removal very difficult; and are usually deadly.
Malignant means deadly or progressing to death.
With these definitions, it is understandable why the
terms tumor, malignancy, and cancer bring fear to an
individual. Some -omas, or tumor diseases, are com-
monly called cancer. Cancer is defined as any malig-
nant tumor.
The fingerlike or crab-like projections that char-
acterize malignant tumors give cancer its name, from
the Greek karkinos, meaning “crab.” This character-
Courtesy of Mark L. Kuss

istic makes surgical removal of cancer quite difficult
(Figure 2–2). Another characteristic of malignant
neoplasms is that they metastasize (meh-TAS-tah-
sighz), or spread. Metastatic (MET-ah-STAT-ic)
cancers spread from a site of origin to a secondary
Figure 2–2 Crab-like appearance of cancer in a kidney.
site in the body. For example, lung cancer com-
monly metastasizes to the bone. Chapter 3 discusses
more detailed information about hyperplasias and
neoplasms.
Consider This...
Nutritional Imbalance Lack of water is the number one trigger of
Good nutrition is important in maintaining good health daytime fatigue.
and reducing the chance of disease. Nutritional disor-
ders can cause problems with physical growth, mental
and intellectual changes, and even death in extreme
cases. Most nutritional diseases are related to overcon- Malnutrition
sumption or under-consumption of nutrients. Specific Malnutrition can be due to inadequate nutrient intake
problems are malnutrition, obesity, and excessive or or to intake of an adequate amount with poor nutritive
deficient vitamins, minerals, or both. value. Diseases that cause a problem with the absorption of
Persons who are unable to eat enough to maintain

their body weight can receive nutritional supplements in
a liquid drink. Another way to supplement or provide
for total nutritional intake is not through the alimentary
canal or digestive system but through a parenteral (pah-
REN-ter-al; to administer by injection) route. Parenteral
routes can include subcutaneous (sub 5 under, cutane-
ous 5 skin), intramuscular (intra 5 within, muscular 5
muscle), or intravenous (intra 5 within, venous 5 vein)
administration. The intravenous route is the most com-
monly used parenteral route. Providing the total nutri-
tion needed by giving nutritive liquid through a venous
(vein) route is called total parenteral nutrition (TPN).

Nutrition can also be provided through an enteral
(small intestine) route. A nasogastric (naso 5 nose, gas-
tric 5 stomach) tube or a tube running through the nose
and into the stomach can be used for feedings if the sup-
plement is planned short term. For longer-term enteral
Figure 2–3 Cachexia. feeding, a gastrostomy (gastro 5 stomach, ostomy 5 open-
ing; opening into the stomach) procedure is performed
nutrients can also lead to malnutrition. Children and older to place a tube through the abdominal and stomach wall
persons are the age groups most affected by malnutrition. (Figure 2–4A). Enteral feeding, commonly called “tube
Persons suffering with cancer often experience prob- feeding,” is accomplished by this method (Figure 2–4B).
lems with malnutrition and develop cachexia. Cachexia
(ca-KECK-see-ah) is a term that describes any individual
who has an ill, thin, wasted appearance (Figure 2–3).
(B)
Gastrostomy
Rumruay/Shutterstock.com
(A) (C)
Figure 2–4 Gastrostomy. (A) Feeding. (B) Insertion site. (C) internal location.
18 Chapter 2
Obesity consume large amounts of vitamins for an extended

Although many individuals in the United States have time.
a nutritional deficiency, the most common problem Nutritional guidelines for a healthy lifestyle are dif-
is obesity, which is primarily due to overconsump- ficult to determine because they must cover a variety of
tion of nutrients and lack of exercise. According to ages and nutritional needs. Children, teens, and preg-
the American Heart Association, obesity is a national nant women have very specific nutritional needs. See
health concern, with nearly one in three (31.7%) U.S. the Healthy Highlight box “General Guidelines for a
children ages 2 to 19 being obese and more than one Healthy Lifestyle” for more information.
third (33.7%) of adults being obese. Obesity shortens
the life span of the individual by increasing the chance Impaired Immunity
for arteriosclerosis, leading to cardiovascular diseases.
The immune system of the body is a specialized group
It also affects the individual’s risk for developing bone
of cells, tissues, and organs designed to defend the
or joint problems due to the increased pressure on the
body against pathogenic attacks. The body’s first line
skeletal system.
of defense against pathogens is its normal structure and
Obesity is simply defined as too much body fat.
function, including intact skin, mucous membranes,
It is medically determined when an individual has a
tears, and secretions. The immune system protects the
body mass index (BMI) of greater than 29.9. BMI is
body in two additional ways, through
obtained by dividing the individual’s weight in pounds
by the square of their height, multiplied by 703. For 1. the inflammatory response, in which leukocytes
example, a person weighing 250 pounds who is 5 feet play a vital part in killing foreign invaders.
6 inches tall (66 inches) has a BMI of 40.3. This is cal-
2. the specific antigen–antibody reaction, in which
culated as 250 divided by (66 3 66) 3 703. This person
the body responds to antigens (AN-tih-jens) by
is considered extremely obese.
producing antibodies. Antigens are substances
A simple BMI scale uses these figures to determine
that cause the body some type of harm, thus
levels of obesity:
setting off this specific reaction. Antibodies,
BMI also called immune bodies, are proteins that
,18.5 underweight the body produces to react to the antigen and
18.5–,25 normal render it harmless.
25–,30 overweight Impaired immunity occurs when some part of this
30–,40 obese system malfunctions. Following are some common
.40 or higher extremely obese ways the system malfunctions.
Bariatrics (bear-ee-AT-tricks) is a branch of med-
icine that deals with the prevention and treatment of Allergy
obesity. First-line treatment for obesity often includes The immune response is too intense or hypersensitive to
diet, exercise, anti-obesity medication, and behavior an environmental substance. The allergen (environmen-
modification. These treatments in the severely obese tal substance that causes a reaction) in an allergy might
population often have poor long-term success. In these be such things as house dust, grass, pets, perfumes, or
cases, bariatric or weight loss surgery may be recom- insect bites, to name a few. These allergens do not usu-
mended. Gastric banding and gastric bypass are two of ally cause this type of reaction in most persons but do
the most common types of surgery. cause an allergic reaction in persons sensitive to them.
Obesity is one of the most preventable causes of
death. Worldwide, it is viewed as one of the most seri- Autoimmunity
ous public health problems of the twenty-first century. The immune response attacks itself. In autoimmunity
(auto 5 self), the body’s lymphocytes (white blood cells
Vitamin or Mineral Excess that produce antibodies) cannot identify the body’s own
or Deficiency self-antigens, which are harmless. In response, the lym-
Vitamin and mineral excesses and deficiencies are usu- phocytes form antibodies that then attack the body’s
ally related to diet, metabolic disorders, and some medi- own cells. Examples of autoimmune diseases include
cations. Hypervitaminosis can occur in individuals who rheumatoid arthritis and rheumatic fever.
Healthy Highlight
General Guidelines
for a Healthy
G eneral guidelines for a healthy lifestyle include the
following tips:
■ Maintain proper body weight.
Lifestyle ■ Eat a variety of foods.
■ Avoid excessive fat, salt, and sugar.
■ Eat adequate amounts of fiber.
■ Consume alcohol in moderation, no more than two drinks per day for men and one
for women.
■ Get enough rest and sleep, at least seven or more hours per day.
■ Always eat breakfast.
■ Maintain a moderate exercise schedule.
Immunodeficiency understood but is progressive and irreversible. Diseases

related to aging are often called degenerative diseases.
The immune response is unable to defend the body
Tissue degeneration is a change in functional activity
due to a decrease or absence of leukocytes, primarily
to a lower or lesser level. Examples of degenerative dis-
lymphocytes. Persons with immunodeficiency are
eases are degenerative joint disease and degenerative
usually asymptomatic (without symptoms) except for
disk disease.
recurrent infections. It is these recurrent infections
The mechanisms of aging are complex and thought
that often lead to death. An example of an immuno-
to include such factors as heredity, lifestyle, stress, diet,
deficiency disease is acquired immunodeficiency syn-
and environment. One might slow the process of aging
drome (AIDS). Immunodeficiency also can be caused
to some degree by living a healthy lifestyle and con-
by medications, chemotherapy, or radiation. Organ
trolling stress and environmental factors.
recipients are intentionally immunosuppressed or
Hereditary factors can include an increased life
immunodeficient to save their transplanted organ.
span related to an inherited ability to resist disease. Just
Without immunosuppressant medications, the body’s
as families have a history of disease patterns, they also
immune system would recognize the organ as for-
appear to have a pattern of longevity. Thus, individuals
eign and attack it, leading to organ death. This pro-
who have relatives who live to be in their nineties might
cess is called organ rejection. Cancer patients often
themselves live to that age. Individuals with a family
undergo chemotherapy and radiation treatments that
history of members who have died of heart disease in
can cause immunodeficiency. Some medications also
their early years might also suffer from the same prob-
affect the system by depressing its ability to function
lem. Although hereditary patterns cannot be controlled,
properly. Chapter 5, “Immune System Diseases and
longevity can be increased and disease decreased by
Disorders,” discusses the immune system and related
controlling lifestyle behaviors that increase the risk of
diseases in more detail.
chronic disease.
The body replaces and repairs itself throughout its
Aging lifetime, but with aging, this process slows. As early as
age 40, there are changes in skin, endocrine function,
There is no definite age in years when an individual vision, and muscle strength. Other changes in the aging
becomes aged. However, some statisticians consider process might include bone loss leading to osteoporo-
the retirement age of 65 as aged. An individual’s body sis, decreased melanin pigment production leading
actually begins to age at physical maturity, around to graying of the hair, decreased immunity leading to
age 18, in a complicated process that is not completely an increase in infections and possible development of
20 Chapter 2
Healthy Highlight
Consumer
Responsibility in
T oday’s consumer should be more health conscious than in the past. Individuals
are now expected to take charge of their health care needs and be more informed
about health choices. However, this may not be the case with many people. It is recom-
Disease Prevention mended that the consumer become more knowledgeable about diseases, medications,
and prevention. Unfortunately, many diseases are on the rise in the United States due
to a variety of causes. The public needs to be informed about these and to be active
in prevention. Diseases on the rise include pertussis, Shigella (especially in day-care
centers), salmonellosis, E. coli, meningococcal infection, tuberculosis, influenza, and
streptococcal infections, as well as new viral diseases, such as COVID-19. Epidemics
have been common in the past, but most people are not as familiar with pandemics. In
these circumstances, the public needs to be kept informed about lifestyle changes that
might be needed. Health care providers should help their patients find the most accu-
rate information about these diseases and help them incorporate prevention strategies
into their lifestyles.
cancer, a loss of brain and nerve cells that might lead The ability of the cell to survive depends on several fac-
to senile dementia, and a decrease in intestinal motility tors, including the amount of time the cell suffers and the
leading to constipation and possible diverticulosis. type of cell injury that occurred. If the cause of the injury is
short term, the cell has a greater chance of survival.
The type of cell also plays a part in its ability to
recuperate. The heart, brain, and nerve cells are eas-
Consider This... ily injured and often suffer death. This is particularly
important because these cells do not replace them-
After age 30, the brain loses 50,000 neu- selves. Even short-term injury might readily lead to
rons per day, causing a brain shrinkage death in these cells. Other cells are not as easily dam-
of approximately one-fourth of a percent aged. Connective and epithelial cells often recuperate
(0.25%) each year. and even readily replace themselves by mitosis (cell
division).
Cellular Adaptation
Death Cells that are exposed to adverse conditions often go
Humans are mortal, so eventually, everyone will die. through a process of adaptation. When the condi-
Even though we are unable to understand the aging tion is changed, these cells might be able to change
process fully, cellular, tissue, and organ deaths can be back to their normal structure and function. How-
reviewed in an effort to understand the death of the ever, some adaptations are permanent, so even if the
organism as a whole. condition improves, the cells are not able to return to
normal. Types of adaptation include atrophy (AT-tro-
fee), hypertrophy (high-PER-tro-fee), hyperplasia,
Cellular Injury dysplasia (dis-PLAY-zee-ah), metaplasia (met-ah-
Cellular injury and death can be due to some type of PLAY-zee-ah), and neoplasia (nee-oh-PLAY-zee-ah).
trauma, hypoxia (high-POCK-see-ah; not enough
oxygen), anoxia (ah-NOCK-see-ah; no oxygen), drug Atrophy
or bacterial toxins, or viruses. Cells can undergo near- Atrophy (a 5 without, trophy 5 growth) is a decrease
death experiences and actually recuperate in what is in cell size, which leads to a decrease in the size of the
considered reversible cell injury. tissue and organ (Figure 2–5). Atrophy is often due to
Normal Normal
Nucleus Nucleus
Basement membrane Basement membrane
Hyperplasia
Atrophy
Figure 2–5 Normal cell versus atrophied cell.

Figure 2–7 Normal tissue versus hyperplasia.
the aging process itself or to disease. An example of does not change with exercise; only the size of each
atrophy related to aging would be the smaller size of cell changes. To adapt to an increased workload, mus-
the muscles and bones of older people. As the female cle cells increase in size. Increased workload on the
ages, the breasts and female reproductive organs atro- skeletal muscles causes cellular hypertrophy and an
phy, especially after menopause. Examples of disease increase in muscle size. Heart muscle hypertrophy
or pathologic atrophy are usually related to decreased is usually seen in the left ventricle of the heart (left
use of the organ, especially muscles. Spinal cord inju- ventricular hypertrophy) when the left ventricle must
ries lead to an inability to move muscles. Without use, work harder to pump blood through diseased valves
muscle cells decrease in size, and the muscles atrophy. and arteries. To adapt to this need, the cells increase
in size and the left side of the heart enlarges.
Hypertrophy
Hypertrophy (hyper 5 excessive, trophy 5 growth) is Hyperplasia
an increase in the size of the cell leading to an increase Hyperplasia (hyper 5 increased, plasia 5 growth) is
in tissue and organ size (Figure 2–6). Skeletal muscle an increase in cell number that is commonly due to
and heart muscle cells do not increase in number by hormonal stimulation (Figure 2–7). Hyperplasia is dis-
mitosis. Literally, what an individual has at birth is cussed in more detail in Chapter 3.
what the individual has throughout life. This helps
explain why some athletes bulk up with exercise while
Dysplasia
others do not. The inherited number of muscle cells
Dysplasia (dys 5 bad or difficult, plasia 5 growth) usu-
ally follows hyperplasia. It is an alteration in size, shape,
Normal and organization of cells (Figure 2–8). Dysplastic cells
might change back to the normal cell structure if the
Nucleus irritant or stimulus is removed, but usually, these cells
progress to neoplasia.
Basement membrane Metaplasia

Hypertrophy Metaplasia (meta 5 changed, plasia 5 growth) is a cel-
lular adaptation in which the cell changes to another
type of cell (Figure 2–9). An example is the colum-
nar epithelial cells of the respiratory tree, which often
change to stratified squamous epithelial cells when
exposed to the irritants of cigarette smoking. This pro-
tective adaptation might be reversible if the individual
Figure 2–6 Normal cell versus hypertrophied cell. quits smoking.
22 Chapter 2
Normal Normal
Nucleus Nucleus
Basement membrane Basement membrane
Dysplasia Neoplasia
Figure 2–8 Normal tissue versus dysplasia. Figure 2–10 Normal tissue versus neoplasia.
Neoplasia Cellular death, called necrosis (neh-CROW-sis),

Neoplasia (neo 5 new, plasia 5 growth) is the develop- can involve a group of cells and, thus, tissue. When
ment of a new type of cell with an uncontrolled growth referring to dead cells or tissue, one would describe
pattern (Figure 2–10). Neoplasia is discussed in more the area as necrotic. When necrosis occurs due to
detail in Chapter 3. ischemia, the area of dead cells (ischemic necrosis) is
called an infarct (IN-farkt). Infarcts are commonly due
Cell and Tissue Death to obstruction of arteries. The most common infarct
affects tissues of the heart, leading to a myocardial
Cell death, as previously mentioned, can be caused infarction, or heart attack.
by trauma, hypoxia, anoxia, drug or bacterial toxins, Cells that are injured and not able to recover even-
or viruses. The most common causes of cell death are tually die. The cause of cell death can be determined by
hypoxia and anoxia. a pathologist because the gross (visible with the eye) and
Cell hypoxia caused by decreased blood flow is microscopic appearance of the tissue differs with the type
called ischemia (iss-KEE-me-ah; isch 5 hold back, of death. There are several types of necrosis, primarily
emia 5 blood). A cell without oxygen cannot produce named by the microscopic appearance of the dead cells.
needed energy and eventually dies. The most common type of necrosis is called coag-
ulation necrosis and is due to cellular anoxia. Coagula-
Normal tion necrosis is the type of cell death experienced with
myocardial infarction.
Nucleus A common alteration in necrosis occurs when sapro-
phytic (dead tissue–loving) bacteria become involved in
the necrotic tissue. With this occurrence, the necrotic tis-
Basement membrane sue is now described as gangrenous or having gangrene
(GANG-green). The type of gangrene can be wet, dry, or
Metaplasia gas, depending on the appearance of the necrotic tissue.
Wet gangrene usually occurs when the necrosis has
been caused by the sudden stoppage of blood flow, as in
the trauma of burning, freezing, or embolism.
Dry gangrene occurs when blood flow has been
slowed for a long period of time before necrosis
occurred, as in the case of arteriosclerosis and advanced
Basement membrane diabetes. In dry gangrene, the tissue is black, shriveled,
or mummified. This type of gangrene occurs on the
Figure 2–9 Normal tissue versus metaplasia. extremities only, primarily on the feet and toes.
Gas gangrene occurs with dirty, infected wounds. so extreme that the individual’s quality of life is severely
The tissue becomes infected with anaerobic (growing limited. This is often seen in cases of severe brain injury
without oxygen) bacteria that produce a toxic gas. This or even in some congenital disorders.
is an acute, painful, and often fatal type of gangrene. It is very common for individuals to have more than
one disease or condition at the same time. When two or
more conditions occur at the same time, this is called
Organism Death comorbidity and often complicates the individual’s abil-
Human death can be related to any of the aforemen- ity to heal or overcome the first or primary condition.
tioned causes of disease. The aging process leads to Prior to death, major organs such as the heart, lungs,
death due to a change in the normal structure of the and brain stop functioning. When the brain ceases
individual’s organs or a decrease in the ability to fight to function, the individual is considered brain dead.
disease. Diseases that would not be lethal in our younger Although death is difficult to define and difficult to deter-
years, such as respiratory infections, can be the cause of mine in some cases, one guideline used is that of brain
death in an older individual. death. The criteria for determining brain death include
According to the CDC, the most common cause ■ a lack of response to stimuli.
of death in the United States is heart disease, followed
by cancer and strokes (cerebrovascular accident). ■ a loss of all reflexes.
Although heart disease is the leading cause of death, ■ an absence of respiration or breathing effort.
stroke is the leading cause of serious, long-term disabil- ■ a lack of brain activity as shown by an electroen-
ity in the United States. (See Chapter 8, “Cardiovascular cephalogram.
System Diseases and Disorders,” for more information.)
Many times, the human organism—like the cell— This issue of defining death and when an individ-
does not die but becomes disabled. Disability is called ual is actually dead is still controversial in the medical
morbidity (state of being diseased). Often, morbidity is profession.
Summary
H uman diseases are caused by heredity; trauma; inflammation, infection, or both; hyperplasias, neoplasms, or both;
nutritional imbalances; impaired immunity; or some or all of these. Lifestyle behaviors can also be contributing
factors to disease development, as can the aging process. Eventually, all organisms die, and the process of death can occur
at the cellular, tissue, or whole-organism level.
Review Questions
Matching
1. Match the cause of diseases in the left column with the example of a disease for that category in the right column.
Heredity a. Pneumonia
Trauma b. Motor vehicle accident
Inflammation/infection c. Cancer
Hyperplasias/neoplasms d. Obesity
Nutritional imbalance e. Allergies
Impaired immunity f. Cystic fibrosis
True or False
2. T F In autoimmunity, the body’s immune system attacks itself.
3. T F Some medications used to prevent or cure some diseases can cause immunodeficiency.
24 Chapter 2
4. T F Diseases related to the aging process are called regenerative disorders.

5. T F All congenital disorders are easily recognized at birth.
6. T F Heart and brain cells are easily injured by hypoxia.
7. T F Heredity does not affect the aging process.
8. T F Cellular death occurs only in the event of hypoxia (lack of oxygen).
Short Answer
9. List the factors that affect a cell’s ability to survive after injury.
10. How do cells adapt when exposed to adverse conditions?
11. What are the definitions of the following terms?

a. Inflammation
b. Infection
c. Neoplasm
d. Immunity
12. What are two important habits for a healthy lifestyle?
a.
b.
Case Studies
■ Cann Ragland, age 29, was seriously injured in a motorcycle accident. He is comatose and on life support
equipment to maintain his breathing. He has not improved in 2 weeks with aggressive medical treatment. The
family is questioning whether he is alive or dead at this time. What criteria can be used to determine this? What
are the issues surrounding this determination? How could you help the family through this difficult time? What
resources are available to help people make decisions about end-of-life care?
■ Jessie Leher, age 69, is concerned about her aging status and loss of short-term memory at times. Her sister
told her to take Ginkgo biloba and CoQ10, over-the-counter herbal products. Jessie has high blood pressure
and some circulatory problems. She takes several prescription medications for these disorders and for a couple
of other problems, such as arthritis. Should she be cautioned about also taking the herbal remedies? How much
should she actually know about her medications? Should health care providers provide more education for
patients? Are consumers more interested in knowing about their health care treatments in today’s world than in
the past? Is that a good change?
3
Neoplasms
Key Terms
Anaplastic (p. 32) Carcinoma in situ (p. 31) Hematoma (p. 26) Neoplasm(s) (p. 26)
Angiogenesis (p. 29) Chemotherapy (p. 39) Hyperplasia(s) (p. 29) Palliative (p. 39)
Benign (p. 26) Curative (p. 39) Invasion (p. 26) Pap test (p. 37)
Biopsy (p. 32) Cytology (p. 38) Leukemia (p. 26) Preventive (p. 35)
Cachexia (p. 29) Differentiation (p. 28) Lymphomas (p. 27) Radiation (p. 30)
Carcinogen (p. 30) Dysplasia (p. 31) Malignant (p. 26) Sarcoma (p. 27)
Carcinogenesis (p. 32) Frozen section (p. 38) Metaplasia (p. 32) Staging (p. 32)
Carcinoma (p. 27) Grading (p. 32) Metastasis (p. 26) Tumor (p. 26)
Learning Objectives
1. Define basic terminology used in the study 6. Identify some common carcinogenic substances.
of neoplasms. 7. Identify high-risk behaviors for cancer
2. Explain the system used to classify neoplasms. development.
3. Compare hyperplasias to neoplasms. 8. State the frequency of cancer development in the
4. Identify the progression of cancer development. population.
5. State the signs and symptoms of cancer. 9. Describe the curative, palliative, and preventive
methods used in cancer treatment.
Overview
T housands of individuals are diagnosed with neoplasms each year. The diagnostic statement “You have a tumor”
often causes instant fear, dread, and tears for the individuals and families involved; few statements in our society
carry the emotional impact this one does. To most people, this diagnosis is equivalent to a pronouncement of death.
But not all tumors are malignant, and not all are deadly. However, more than 1.8 million individuals are diagnosed
with malignant neoplasms each year. This includes all types of cancers. Approximately 1,640 die each day, with
25
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II.
Lienalla ei olisi Matin reessä ollut varsin pitkälti kuljettavaa

kirkolle, mutta Matti kiusasi häntä lähtemään edelleen myllylle asti.
He olivat nuorempina usein leikkineet ja oleksineet yhdessä, vaikka
Matti olikin pari vuotta vanhempi.
"Mitäpä minulla siellä myllyllä olisi tekemistä?" vastusteli Liena.
"Siellähän kerron", tuumi Matti ja kiirehti hepoaan.
Piti kuitenkin pysähtyä suntion pihaan, että Liena ehti jättää

nyyttinsä ja sanoa, mihin menee, että kotiväki ei kaihoelisi, jos hän
vähän viivähtäisi enemmän, kuin Vaarassa käyntiin olisi aikaa
tarvinnut.
Edelleen ajaessa pysyi Matti alkumatkan harvapuheisena, tavasta

vain muistutellen hepoansa. Viimein hän yht'äkkiä virkahti:
"Kuulehan, Liena, tulisitko sinä meidän taloon miniäksi?"
"Mikolleko sitte vaiko Jussille?" ivasi Liena veitikkamaisesti

hymyillen.. "Maltahan kun sentään ajattelen. Ensinnäkin on teillä niin
kelvottoman siivotonta. Ulkona elukat oleksivat aivan rappusien
edessä, niiden nurkkia pureksien, jopa osa porstuassakin, kuten
tänään. Entäs se koko teidän pihanne! Jos minä sinne tulisin, pitäisi
ainakin kevät- ja syysajoiksi hankkia vene, jolla saisin rappusilta
läävään soutaa, ja sinä kai olisit soutajana, eikö niin? — Ja sisällä;
no, pitäisinpähän minä siellä parempaa järjestystä."
"Sinä vain kaikki leikiksi käännät. Totta minä tarkoitan. Minähän

sinusta vanhemmilleni miniän tekisin."
"Vai niin. No, pitäneehän minunkin sitte totta puhua. Kyllä minä
sinusta pidän, Matti. Vaan osaakohan sinuun oikein luottaa? Ne
siellä teillä tuntuvat niin pettelevän toisiaan. Mitenkä lieneekään
sinun vakavuutesi. Sanopas, mihin tuo pussi on menemässä!"
Liena osoitti sevältä heinäin alta pilkistävää pussin suuta.
"Senpähän kohta näet."
Samassa reki kääntyi myllypihaan.
Matti pysäytti hevosensa puodin eteen, joka oli melkein kiinni

maantiessä, ja pyysi Lienaa puotiin. Siellä hän otatti pöydälle koko
kasat huiveja, käski Lienaa niistä valitsemaan itselleen parasta,
kuiskasi puotimiehelle jotakin ja läksi puotipojan kanssa ulos, joka
näkyi jo asiat tajuavan. Pussi palasi tuota pikaa kauppiaan
makasiinista tyhjänä rekeen, ja Matti ajoi muun kuorman suoraa
päätä myllyn ovesta sisään.
Jauhattajia ei sattunutkaan olemaan muita kuin pari pussimiestä.

Matin riisuessa ja asettaessa hevostaan syömään loppuivat nekin
jauheet, joten hän pian selvisi joutilaaksi muutamaksi tunniksi.
Matti palasi puotiin, panetti eräästä laatikosta jotakin
paperitötteröön ja antoi sen Lienalle.
"Jos minun nyt välttämättä pitää ottaa jotakin, niin otanpahan sitte
tämän."
Liena näytti keskikokoista silkkihuivia.
"Onko sinulla muuta ostamista?"
"Ei itselleni, vaan äiti se käski ottamaan kahvia."
Matti punnitutti kaksi naulaa puolekkain ja Lienan yrittäessä

maksamaan iski silmää puotimiehelle, joka kohta selitti Lienalle, että
ei se mitään maksa.
Liena tiesi seudun tavat eikä ollut niin millänsäkään, sanoipahan

vain leikkisästi:
"Hyvinhän nyt myllypuoti on rikastunut, kun jo ilmaiseksi jakelee

tavaroitaan."
Matti läksi Lienaa saattamaan kotimatkalle jalkaisin. Jo pihalle

päästyä kysäsi Liena:
"Tähänkö se elopussi nyt hupeni?"
"Huvan pienihän se oli hupenemattakin."
"Kuulepas, Matti, tuskin vain minä sinuun uskallan luottaa.

Pettelethän sinäkin kotiväkeäsi."
"Harvoin se on tapahtunut enkä nytkään sitä olisi muuten tehnyt,

vaan näin sinun tulevan. Mitenpä täällä muuten minkään talon poika
saisi rahaa? Työtä kyllä saa tehdä kuin pahin renki, mutta älä
menekään isältä pyytämään, hän tarvitsee rahat muuhun. Jo olen
välistä arvellut lähteä muualle rengiksi, saisinhan silloin edes hyvän
palkan."
"On tuossa totta, mitä puhut. Vaan tosiaan, minä en voi tulla teille
miniäksi, niin kuin asiat nyt ovat. Sinä kun olet järkevä mies, puhu
sinä suoraan isäsi kanssa ja hän puhukoon äidillesi. Minä kyllä sitte
koetan pitää Anua Maijasta huolta.
"Onpa se Mikkokin jo aika velikulta.
"Hänet voitte varsin hyvin panna kouluun ja samoin Jussin, kuin

siksi varttuu.
"Jopa se Mikko alkaa olla liian suuri mies kouluun pantavaksi.

Jospa hän siellä vain oppii enemmän pahuutta, kun ei ole ketään
silmällä pitämässä. Kotona edes joskus saa kuria."
"Ole huoletta, kyllä siellä koulussa tehdään kaikki ihmisiksi",

vakuutti Liena, uskoen opetukseen pystyvän kelvottomiin yhtä
helposti kuin häneen itseensä, jolla oli ollut kunnon vanhemmat
kasvattajina.
Matti lupasi koettaa parastansa, vaan eivätpä siinä kaikki

vastukset olleet. Häntä itseäänkin oli ainiaan harmittanut
siivottomuus, mutta mitä sille kenkään voi tehdä. Karjopiha oli
luonnostaan niin vesinen, ja mitenpä niitä elukoita voikaan saada
pysymään poissa rappusilta. Ja kun kerran aivan rappusten edessä
oli likaa puolisääreen, niin siitähän ne likautuivat lattiatkin.
Lienalle johtui mieleen, että Vaaran vanhempi eli nykyinen
asuintupa aiottiin juuri keväällä purkaa ja että oli vedetty pitkin talvea
hirsiä rakennustarpeiksi.
"Kääntäkää koko tuparakennus toisin päin ja pankaa aita

pihamaan ja karjopihan välille."
"Tuleepa suotta maksamaan kylmän tuvan muutto."
"Eihän sitä tarvitsekaan muuttaa. Asettakaa uusi porstua ja

maitokammari kylmän tuvan toista sivuseinää vasten ja jatkakaa
kartanoa sinne päin niin tulevat rappuset pois karjopihasta."
"Ei tuo taitaisi hulluinta olla, jos vain kotiväki siihen suostuisi."
"Olisi hyvä aidata jokin kapanala pihamaaksi ja laittaa siihen pieni

kasvitarha. Siitäpä tulisikin oikein sievä laitos."
"Sinullahan nuo näkyvät kukat kotonasikin hyvin menestyvän ja

marjapensaat."
"Ja tehkää sitte uuden tuvan päähän kaksi pientä kammaria."
Mattia alkoi arveluttaa. Eiköhän vain Liena ruvennut jo vaatimaan

aivan mahdottomia.
"Jos sattuisi joku sairastumaan, olisi niin hyvä hänen olla rauhassa
muiden hälinältä."
Se naula veti. Matti oli itse ennen joulua ollut sairaana ja hän kyllä
muisti, miten lasten parku ja työn pauke olivat häntä vaivanneet.
Kotvasen he vielä siinä astuessaan rakensivat uutta tupaa

kammareineen, tasoittelivat ja täyttivät pihamaata, tekivät
kasvitarhaa ja panivat aitaa, kunnes saapuivat kirkkomäen alle, josta
Matti ei enää lähtenyt ylös astumaan.
Kätellee erottuaan Matista, jatkoi Liena iloisesti hyräillen

astuntaansa ylös pitäjäntuvalle. Iloinen hänen mielensä nyt
todellakin ole. Vähän tosin kammotti tuo Vaaran kotielämä, mutta
"tottapahan sitte yksin neuvoin selvitellään”, ajatteli hän.
"Mutta olenhan itsekin aivan samanlainen!" johtui hänelle sitte

mieleen. "Enkö ottanut vastaan salatavaraa Vaarassa ja nyt
uudestaan puodissa! Vaan vaikeahan on syrjästä päin sekautua
heidän asioihinsa. Pidänpähän vasta paremmin varani ja säilytän
omantuntoni puhtaana. Jospa vain Matti saisi lupauksensa
toteutumaan!"
Matti puolestansa riensi hyvää vauhtia takaisin myllylle ja läksi,

saatuaan elot jauhoina rekeen, hyvällä mielellä ajamaan kotiinsa.
Huudettuaan kotipihassa Mikon tuvasta korjaamaan hevosta, kun

näet ei jauhorekeä käynyt jättää ahnasten sikojen haltuun, sekä
kannettuaan säkit aittaan ja tyhjennettyään salvoon, astui Matti,
ajokalut käsivarrella, tupaan, jossa koko perhe istui iltapuhde-
töissään.
Isäntä veisteli kaplasta rekeen, joka oli leikkautunut ja seisoi

syrjällään penkin vieressä sulamassa.
Emäntä kehräsi villalepeitä vasusta, johon piika Tiina koetti niitä

kartata toisia sijaan.
Anna Maija neuloi sukkaa, Mikko koetti muka kiskoa päreitä ja

Jussi käpelehti isänsä vestolastujen parissa.
Kaikki istuivat piirissä päretulen ympärillä, joka paloi pihtiin
pistettynä uunin ulkonurkassa.
Matilla ei nyt ollut käsillä muuta työtä kuin Mikon kanssa yhteinen.
Siinä hänellä kyllä oli lomaa alkaa puhetta. Odotettuaan, kunnes
Tiina läksi karjaa illastamaan, sanoi hän äkisti:
"Kuulehan, isä, etkö rupeisi maksamaan minulle palkkaa, elossa

tai rahassa, sama se?"
Isäntä ja emäntä ällistyivät. Kotvanen kului ennen kuin isäntä

virkkoi:
"Jopa nyt hulluttelet, poika. Vai pitäisi tässä ruveta palkan

maksuun omille lapsilleen!"
"Oikein minä totta puhun. Enkä minä paljoa tahtoisikaan. Kunhan

edes vähänkään lupaisit, niin minun ei tarvitsisi omin luvin ottaa,
kuten tänäkin päivänä." Ja Matti huokasi syvään.
Isännältä pysähtyi työ. Hän luuli Matin laskevan leikkiä. Vaan

katsoessaan kyyrysistään häntä silmiin ja nähdessään tavallisen
leikin olevan niistä tällä kertaa kaukana nousi hän suoraksi istumaan
ja muuttui vakavaksi.
"Vai alat jo sinäkin niillä jäljillä kävellä? Akkaväen tehtäväähän se

toki tähän asti on ollut."
"Joko taas on akkaväki hampaissasi!" ärähti emäntä. "Mitenpä

tässä muuten työt teetettäisiin?"
Anna Maijalla ei näyttänyt olevan hyvää rauhaa. Hän oli ryhtynyt

Tiinan työtä jatkamaan, vaan siirtyi nyt punastuen edemmäksi tulen
valosta.
"Tahdotko ehkä sinäkin palkkaa? Jopa sitte pitäisi olla suuri

kukkaro."
"No, isä, koetetaan nyt selvittää asiat suuttumatta. Mikä menee

talon tarpeihin, samahan se, meneekö se rahassa vaiko muussa
tavarassa, vaikka tavarassa maksaminen taitaa sentään käydä
helpommaksi kuin rahassa. Eikä minun mielestäni tarvitsisi
salatakaan kehruuttamisia ja ompeluttamisia ja muuta sellaista, mitä
ei kotona ehditä eikä osata tehdä. Vaikka parempi olisi ollut käyttää
Anna Maijaa kansakoulussa, niin osaisihan nyt edes ommella
kotitarpeet, ja hänellähän siihen olisi aikaa. Tottapa se muukin oppi
edestä löytyisi elämän matkan varrelta."
Tämän puheen aikana olivat isännän kasvot osoittaneet milloin

tyytymättömyyttä, milloin mieltymystä. Nyt hän vastasi:
"Enhän minä ole kieltänytkään töitä teettämästä. Tuo elon ja voin

kantaminen puotiin kaikenlaisesta joutavasta räämästä, se se minua
suututtaa, kun sitä lisäksi vielä tehdään salaa ja varkain.
"Siinäpä se on juuri. Liika on tietysti aina liika, ja koreus ja ylpeys

käy lankeemuksen edellä. Mutta olisinpa tänään tarvinnut muutamia
markkoja, ja kun en rahaa kotoa saa, täytyi minun ottaa, mitä sain;
vein rukiita puotiin. Teenhän tässä työtä minäkin ja uskollisemmin
kuin mikään renki.
"No, mihinkä sinä nyt olisit niin rahaa tarvinnut? Etkö saattanut
pyytää?
"Metsässäpä olit, ja turha tuo on ennenkin ollut pyytö.

"Poika, poika, älä puolustele varkautta!" torui isä syvästi huoaten.
"Ei se sellainen menesty.
"Kylläpä sitte pian salvot tyhjenevät, jos pojat niitä rupeavat puotiin
vetämään oikein hevosella!” ihmetteli emäntä.
"Ikään kuin eivät salvoja muut puolentelisi kuin minä. — Mutta

varkaudelta se itsestäni tuntui tänään, ja hyvin koetin katsoa, että
saisin pussin salaa rekeen, vaikka toisa päin ajattelinkin, että
omaanihan siinä kannan.
"Näin minä ja näki suntion Lienakin, toimitti Anna Maija, unhottaen

omat jälkensä.
"Etkä virkkanut mitään, kun Jussi puhui pussista!” nuhteli emäntä.
"Mitenpä hän virkkoi, kun hänellä itselläänkin oli muuta mielessä.

Asialla se Liena täällä kävi."
"Kyllä tässä ihmeissä käsin ollaan! Kaikki vain taloa varastavat ja

vielä julkeavat noin ilmi puhua. Onhan tässä koetettu neuvoa ja
kurittaa; missä sitte lienee vika? Sinäkin, Matti, teet tuolla lailla,
vaikka olen sinuun aina luottanut. Etkö luule sen tuntuvan karvaalta
isäsi mielestä?"
"Isä, älähän nyt sentään minua ihan umpimähkään tuomitse!"
"Mihin sinä sitte tarvitsit rahaa? Vastaa siihen ensin ja puolustaudu

vasta sitte, jos osaat."
"Sitä en nyt tahtoisi sanoa tällä kertaa. Uskokaa, kun vakuutan,

että turhuuteen en pannut. Tuonempana kyllä kerron, ja silloin sen
itsekin hyväksytte."
"No, samahan tuo sitte oli, jos sait rahaa tai ruista; enkä minä niin
kovin moiti omin luvin otostakaan.
"Mutta minun omatuntoni moittii. Minä juuri tahtoisin päästä

salaamasta ja sen tähden minä pyysin palkkaa. Lupaa vaikka viisi-
tai vain neljäkin kymmentä markkaa. Jos elot riittää, myödään silloin,
kuin saadaan hintaa; jos eivät riitä myötäväksi, niin vähempihän
ainakin tarvitaan ostaa. Ei siitä talolle vahinkoa ole, vaan minulle
rauhallinen mieli; omaanihan saisin käyttää. Jos en kaikkea tarvitsisi,
niin talteenpahan jäisi minunkin taakseni."
Isäntä oli paikkakuntansa miehiä ja pysyi mielellään vanhoissa

tavoissa, mutta ei kuitenkaan ollut niin itsepäinen eikä
ymmärtämätön, että ei olisi taipunut järkevistä syistä: eihän hän ollut
keltään vaatinut tähänkään asti sokeaa tottelemista, vaan päin
vastoin hän olisi mielellään neuvotellut kaikista talon asioista
jokaisen kanssa, jos vain toiset olisivat siihen taipuneet. Mutta kun
varsinkin emäntä teki kaikki asiansa salaa ja ne kuitenkin aina tulivat
perästä päin tavalla tai toisella ilmi, tuli isäntä siitä usein
muistuttaneeksi. Tästä oli yksin suoravaisen Matinkin ja tietysti vielä
enemmin Anna Maijan mieleen kasvanut jonkinlaista kammoa, joka
heitä pakotti seuraamaan äitinsä esimerkkiä silloinkin, kuin ei ollut
tarviskaan salaella.
Nyt isäntä vähän aikaa mietiskeltyään virkkoi leppeästi:
"Et sinä, poika, näy tyhmimpiä olevan. Oudolta tuo tuntuu palkan
maksu omalle pojalleen, vaan parempi kuitenkin on maksaa sinulle
kuin rengille, joka saattaisi olla petollinen silmän palvelija."
"Sitähän juuri minäkin ajattelin. Ei minun nyt siis tarvitse miettiä

muuanne rengiksi lähtöä, kuten on välistä mieleeni jolahtanut."
"Ei sinun toki olisi tarvinnut edes ajatellakaan sellaisen häpeän
tekoa omalle kodillesi."
Näin oli Matin suhde sovitettu. Mutta ikään kuin korvatakseen

poikkeamistansa yleisestä tavasta kysyi isäntä vähän ivan sekaisella
äänellä, pitikö muillekin määrätä palkka.
Emäntä yritti suuttumaan ja Anna Maija jo salaa iloitsi, että ehkä

hänkin saa oman kukkaron.
Matti, tietäen sen toivon turhaksi ja katsoen itsekin niin moneen

palaan osittelemisen tarpeettomaksi, osasi selvittää asian kaikkein
mieliksi siten, että talon työt päätettiin teettää entiseen tapaan, vaan
salaamatta, ja että kukin sai välttämättömiin omiin tarpeihinsa pyytää
rahaa tai tavaraa isännältä, joka kuitenkin jo edeltä päin jyrkkään eitti
mitään antavansa mihinkään koreilemiseen, koska talon varat sitä
eivät kannattaneet.
Näin uskoivat kaikki nyt salailemisen ja petoksen olevan kotiväen

kesken kerrassaan haudatun, ja isäntä toivoi samassa suhteessa
myöskin kasvavan rehellisyyden ja suoruuden muita kohtaan.
Keskustelun päätyttyä Mikko isänsä käskystä etsi virsikirjan ja luki

iltarukouksen sekä Herran rukouksen ja siunauksen, kuten tavallista
oli Vaarassa, milloin isäntä itse ei päivää päättänyt siunauksella.
*****
Pahempi oli rakennus- ja siitä riippuva siivoasia selvitellä, jonka

Matti vasta toisena iltana otti puheeksi.
Tuvansijan muuttoa ja karjapihan aitaamista erilleen pihamaasta

ensin kaikki jyrkästi vastustivat. Kuka tuota viitsi ruveta aitain ylitse
joka kerran kapuamaan karjan asioille mennessä ja kuka muisti pitää
porttia kiinni, jos sellainen korukalu tehtäisiinkin. Ja kun viimein
ehdittiin jo vähän tottua näiden hankaluuksien ajatukseen, ilmestyi
muita vastuksia; milloin oli katto, milloin uunit esteenä.
Tätä neuvottelua kesti monta viikkoa. Sen verran Matti kuitenkin

sai aikaan, että vedettiin metsästä varalle enempi hirsiä ja kiviäkin
koottiin runsaammin.
Hauskalta nyt työ tuntui Matista. Hän raatoi kuin karhu,

vahvemmin kuin isänsä, vaikka hänkin vielä oli voimissaan. No,
Matillahan olikin mieleinen toivo tavoitettavana.
Moneen kertaan Matti mietiskeli ja jo ulkonakin lumeen

piirrustellen aprikoitsi, miten saisi kaikki kotiväen lukemattomat
estelyt kumotuksi.
Viimein hän eräänä sunnuntaina jäi kirkosta suntioon ja ryhtyi

Lienan kanssa asiaa perin pohjin harkitsemaan.
Liena oli koulussa oppinut piirrustelemaan kuvia monenkin laisia,

vaikka juuri ei rakennusten pohjapiirroksia. Se taito tuli nyt hyvään
tarpeesen. Illempana kotiin lähtiessään Matti pisti uuden
asuinkartanon pohjakuvan taskuunsa.
Siinä Lienan mestariteoksessa oli kaikki muut vastukset saatu

poistetuksi paitsi paikoilleen jäävän tuvan katon kääntäminen, joka
jäi tarpeettomaksi liikatyöksi. Oli siihen myöskin uuden tuvan jatkoksi
piirretty kaksi kammaria, jotka sentään voitiin jättää poiskin, jos
Vaaran isäntä hyvin jyrkästi pani vastaan.
Kotiin ehdittyänsä ja riisuuduttuansa levitti Matti paperin pöydälle
isänsä eteen, sanoen:
"Tuossa se nyt on uusi tuparakennus."
Siihenpä heti kaikki muutkin kokoutuivat ja Matin piti juurta jaksain

selittää kaikki tyyni, missä oli ovet, ikkunat ja uunit, rappuset ja muut
sellaiset.
"No, kylmiksikö ne nuo kammarit jätetäänkin?" kysyi emäntä.

"Kuka sairas niissä sitte voi elää?"
"Mitäpä niihin uuneista, kun ei ole tietoa seinäinkään teosta."
"Sen minä sanon, että jos kerran kartanon sijaa muutetaan, niin
kyllä ne pitää tehdä kammaritkin", päätti emäntä.
"No, no, vai sinä tässä rapeatkin rakentajaksi!" virkkoi isäntä.
Asia muuttui leikiksi ja samalla se oli päätetty.
Huomeisaamuna oli Matti vielä varemmin jalkeella. Kun isäntä

astui vaatteissaan ulos, olivat jo hevoset hirsirekien eteen valjastetut
ja Matti reessä istuen odottamassa.
III.
Seuraavana syksynä seisoi jo Vaaran tuparakennus uutuudesta

hohtavana, poikittain käännettynä ja muutenkin Lienan piirrustuksen
mukaan tehtynä, kammareinensa kaikkinensa valmiina.
Tietysti oli myöskin varsinaisia kirvesmiehiä ollut rakennustyössä,

mutta hyvää apuapa oli Matistakin ollut, milloin hän suinkin talon
töiltä jouti. Varsinkin kevätaikana oli Matti melkein nukahtamatta yöt
päivät kaivanut kivijalan sijaa veistellyt hirsiä ja tehnyt kaikkea
muuta, mihin vain yksin pystyi ja mihin hänen taitonsa riitti.
Suntion Lienalle oli hän jo kevätkorvalla tarkoilleen kertonut, miten

hänen oli ainakin aluksi onnistunut täyttää Lienan ehdot.
Kun vanha tupa lämpimämpäin ilmain tultua purettiin ja uusi

kivijalka seisoi valmiina sekä yhdet pohjahirret saatiin eräänä
lauantai-iltana kivien päälle paikoilleen, toi Matti pyhänä Lienan
Vaaraan ja kertoi kotiväelle, mitä varten hän oli rukiita puotiin vienyt,
vieläpä jäänyt vähän velkaankin, vaikka sen sittemmin jo oli kuitiksi
suorittanut.
Sattumalta, kenties salaisesta kutsustakin, kokoutui Vaaraan

muutakin nuorisoa ja suntion vanhukset, niin että voitiin vierasten
puolesta ryhtyä tupakaisten pitoon, ja ne silloin pitemmittä mutkitta ja
verukkeitta vietettiinkin nyt asuttavana olevassa ainoassa tuvassa.
Kuuliaiset jätettiin kesemmäksi, vaan usein Liena kävi Vaarassa

katsomassa, miten seinät kohoamistaan kohosivat, ja tinkimässä
kasvitarhan alaa sekä kylvämässä siksi erotetun hyvämaisen
peltokaistaleen ulkolaitaan, loitommaksi työmiesten jaloista, kukan
siemeniä.
Häät vietettiin jo uudessa tuvassa, vaikka siitä vielä silloin puuttui

uuni ja lattiakin oli vain hätävaraksi paikoilleen asetettu eikä
ikkunoita ollut hituakaan. Tarkenihan siinä kesäiltana ja yönä
tanssiessa niinkin.
Näissä häissä eräs siistipukuinen, vähän herrasmieheen vivahtava

nuorukainen hyvin ahkerasti piti tanssia vireillä, enimmäkseen,
melkeinpä yksinomaan tanssien vain talon tyttären Anna Maijan
kanssa ja hyvin ihastuneesti hänen silmiinsä katsellen.
Tämä nuorukainen oli Salonmökin Janne, joka äskettäin oli

kaupungissa päättänyt oppiaikansa ja valmiina nikkarimiehenä
palannut kotiseudulleen vähän levähtämään ja harrastelemaan.
Tosin hän oli aikonut parin viikon kuluttua lähteä suurempiin
työpaikkoihin, mutta Anna Maija hänet tänä iltana niin lumosi, että
hän vastustelematta suostui Vaaran isännän pyynnöstä jäämään
ikkunain ja ovien tekoon uuteen tupaan, vaikka hänelle siitä työstä ei
luvattukaan niin suurta palkkaa, kuin kaupunkipaikoista olisi saanut.
Niinpä hän seuraavana päivänä kävi salolta noutamassa työkalunsa
ja vanhan äitinsä ja asettui toistaiseksi riiheen asumaan ja
nikkaroimaan.
Syksymmällä ei enää muita ansiopaikkoja kuulunut
etäämmälläkään. Olihan siinä kyllin syytä pyytää Vaaran isännältä,
uuden tuvan valmistuttua, toista tupaa nikkarin työhuoneeksi ja,
isännän viimein vaikka vähän vastahakoisestikin suostuttua, asettua
siihen talvikaudeksi korjailemaa pitäjän herrasväen rikkinäisiä
huonekaluja, jopa tekemään uusiakin.
Liena, päästyään Vaaraan miniäksi, ryhtyi heti panemaan toimeen

parempaa järjestystä ensinnä maitokammarissa, jonka hoidon
emäntä mielellään jätti hänelle. Pääsihän hän siten siitä huolesta,
arveli emäntä itsekseen. Niinpä hävisivät sieltä kerrassaan kaikki
tomukasat.
Asuintuvan lattia ei vielä ollut ehtinyt varsin pahaksi mustua, ja

Liena nyt tietysti piti huolta, että se edelleen mustumaan ei
päässytkään. Tämä tosin tuntui välistä vähän liialliselta emännän
mielestä, niin että hän jo yritteli sanomaan: "mitä tuosta nyt joka
pyhäksi viitsit hangata? likautuuhan se kuitenkin." Mutta kun Liena
säveästi vastasi: "no, hyvä äiti, emmehän nyt rupea liassa elämään",
ei emäntä sentään lujemmin huolinut vastustaa, ajattelihan vain:
"kun ehtii ja viitsii, niin pesköön vaikka joka päivä."
Pitkään aikaan ei emännällä nyt ollut mitään salailemisen syitä.

Sisar Marin mies oli parannut, niin että he nyt kesäiseen aikaan
tulivat toimeen avuttakin. Isäntä toi kylliksi kahvia rukiitten sekaan,
sokuria ja muita talon tarpeita, eikä nyt myöskään enää tarvittu
teettää kylässä joka kohtaa, kuten ennen Lienan tuloa, sillä hän
osasi ja ehti itse paljon, opettipa vielä Anna Maijaakin.
Huomattuaan Lienan taitavaksi alkoi emäntä vähitellen kysellä

häneltä neuvoa, ensin tosin aristellen, että ei liiaksi luopuisi
emännän arvostaan, vaan sitte yhä useammin ja suorempaan, ja jos
Anna Maija jotakin kysyi äidiltään, neuvoi äiti häntä Lienan luo.
Kun tätä paitsi Matti aina ja usein isäntäkin neuvotteli Lienan

kanssa, kohosi hän tahtomattansa koko talon hallitsijaksi, ja hyvin
näytti kaikki käyvän, paremmin kuin Matti ja Liena olivat uskaltaneet
toivoakaan. Ei kellään ollut mitään valittamisen aihetta muusta kuin
että Mikko pyrki, milloin vain soveltui, sieppaamaan sokuripalaa tai
muuta mieluista.
Alkoipa siitä syksy lähestyä tai oikeastaan syyskuun alku ja Liena

tahtoi kaikin mokomin toimittaa Mikkoa kouluun. Hyvin isäntä ensin
vastusteli moista ajan ja tavaran tuhlausta, ei juuri itse opin tähden,
vaan varain riittämättömyyden pelosta. Mutta taipui hän sentään, kun
Liena huomautti tuota Mikossa jo näkemäänsä, isännälle
ennestäänkin tiettyä näpistelemiseen taipumusta ja lausui
toivovansa sen siellä koulussa katoavan.
Niinpä Mikko vietiin lähikaupungin kansakouluun ja pantiin evästä

mukaan muutamiksi viikoiksi sekä luvattiin kyllä ajoissa tuoda lisää.
Liianpa aikaisin Liena sentään alkoi riemuita työnsä

menestyksestä.
Nikkari Janne oli ensi hetkestä asti saavuttanut emännän suosion.

Olihan hän pulska poiki ja sitä paitsi mestarimies. Eipä siis ihme, että
emännän mielessä alkoi häilyä "nikkarin matamin" nimitys
sointuvampana kuin "talon emäntä", eikä hän malttanut olla sitä
huomauttamatta Anna Maijalle. Samaan aikaan hänestä rupesi
näyttämään Jannen äidin voipytty niin omaisen tutulta, että siihen
välistä livahti talon pytystä neljännes- tai puolinaulainen "siru".
Maitoa osui myöskin "tilkka" salatietä saman mummon haltuun. Ja
Jannen äiti puolestaan oli hyvin halukas ottamaan vastaan ilmaiseksi
annettua; siihenhän hän oli koko ikänsä tottunutkin köyhyydessä
eläessään.
Liena tätä välistä huomasi, mutta ei ryhtynyt emäntää opettamaan;

sehän toki olisi ollut sopimatonta. Matillensa hän kahden kesken
asian mainitsi ja pahoitteli, että arvattavasti Anna Maijakin eksyy
samalle tielle.
Joulun tullessa oli Matin lähdettävä noutamaan Mikkoa luvalle

kotiin luvun alottelusta.
Liena pyysi häntä tuomaan samalla kaupungista paperia, että saisi

ruveta kirjanpitoon tuloista ja menoista, jollaista hänelle ennen
koulussa oli vaikka hyvin niukastikin muutaman kerran vain
näyttämällä opetettu.
"Pääsenkö minä kanssasi?" kysyi Anna Maija, tullen juuri

keskeyttämään toisten tilisalaisuutta.
"Mitäpä sinulla on kaupungissa asiaa? Suotta vain lähtisit hevosen

vedettäväksi."
Seuraavana aamuna aikasin Anna Maija kuitenkin oli vaatteissaan

ja istahti Matin rekeen, johon emäntä sill'aikaa, kuin Matti vielä
ennen lähtöään pistihe tupaan piippuansa sytyttämään, toi salaa
muilta paitsi Anna Maijalta isonlaisen sijan reisikappaleen
kaupungissa tavaraan vaihdettavaksi.
Illan suussa palasi kaupunkimatkue.
Anna Maija juoksi hyvin tyytymättömänä ennen muita tupaan,

josta äitinsä heti vastaan tullen yritti käännyttämään häntä takaisin
porstuaan. Mutta Anna Maija vain äreästi alkoi riisuutua.
Korjattuaan hevosen saapui vähän ajan perästä Mattikin, kantaen

sijankinkkua kintusta, ja Mikko ilvehtien riensi jälestä.
"Katsokaas, millaisen lihakimpaleen minä siellä kaupungissa

löysin meidän reestä! Eikä sitä kukaan omistanut, vaikka minä kyllä
ilmoittelin."
"Eiköhän vain liene omia lihavaroja. Hyvinhän näyttikin

lihakorvossa suuri kolo olevan, kuin kävin siitä ottamassa
paistipalasta."
Liena se näin suoraan lausui arvelujansa, luullen vain Anna Maijaa

yksin syylliseksi, hän kun oli puoli väkisin sulloutunut lähtemään
kaupunkiin.
"Mikäs sen sinne kaupunkiin toi?" ilvensi Mikko.
"Eikö tuo lie hevonen vetänyt", tarttui nyt isäntä puheesen ja katsoi
terävästi Anna Maijaan, luullen hänkin tytärtänsä yksin syypääksi.
"No, hevonen sen tietysti vei, kun se täältä pantiin menemään.

Mutta miks'et sitä myönyt, Anna Maija?"
Tällä selityksellään emäntä tahtoi pelastaa tytärtänsä pulasta.
Anna Maija ryntäsi itku kurkussa ulos.
"Eikö sinulla ole muita kaupungin tuomisia?" kysyi isäntä Matilta,

ikään kuin ei olisi huomannutkaan emännän ilmoitusta. "Vai
ihastuitko sinä niin lihan löydöstä, että unhotit kaikki ostokset
sikseen?"
Matti pistäysi noutamaan ison kontin ja kaivoi siitä esiin pussin
toisensa perästä.
"En toki jättänyt; on niitä kontissa. Tässä on herrasryyniä, tässä

vehnäjauhoja, tässä kahvia ja tässä koko pikku pää sokuria. Onpa
tuossa teetäkin. Ja neuloja koko ropakko, kun kuulin äidin niitä
kaipaavan. No, Jussi, tulepas tänne osalle. Kas, tästä saat koko
kahmalosi täyteen oikeita sokurikakkuja. Mutta menepäs nyt
tarjoamaan isälle ja äidille; Lienan ja Anna Maijan pitää myöskin
saada, ja tehneehän se Mikonkin mieli, vaikka hänelle olisi parahiksi,
jos jäisikin ilman, kun jo kävi omin lupinsa pussissa."
"No, Anni, eikö näistä sinulle riitä?" kysyi isäntä.
"Kukapa tuota arvasi teidän niitä ostelevan."
"Senkö tähden piti niitä salaa muka hommata? Ikään kuin minä en
vanhastaan tietäisi, että vehnäsiä kuitenkin tavalla tai toisella laitat
jouluksi. Heitä sinä pois se salaamisen puuha. Nyt meillä on
kuitenkin monet silmät näkemässä.”
"Näkyypä olevan ja varsinkin Lienalla”, tuli emäntä äkeissään

lausuneeksi, ehtimättä ajatella, että ne sanat olisivat saattaneet
pahentaa hänen ja miniänsä väliä.
"Älä syytä Lienaa, kun on syy itsessäsi. Sano, että parempaa

miniää et olisi mistään saanut. Vai eikö pysty töihin taikka tekeekö
mitään salaa?"
Emännän täytyi mielessään väkisinkin tunnustaa isännän sana

todeksi, mutta julki hän ei sitä lausunut, eikä isäntäkään häntä enää

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Australia ● Brazil ● Canada ● Mexico • S i n g a p o r e ● United Kingdom ● United States

Learning Designer: Deb Myette-Flis

VP, Product Marketing: Jason Sakos

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To learn more about Cengage platforms and services, register or access

Notice to the Reader

Printed in the United States of America

To my husband, Jim, the quiet, solid, love of my life for over

List of Tables xii Hyperplasias and Neoplasms 15

Development of Malignant Neoplasms (Cancer) 30 Fibrinous Exudate 47

CHAPTER 6 Von Willebrand’s Disease 133

Trauma 193 Gluten-Induced Enteropathy 234

Review Questions 277 Effects of Aging on the System 332

Sexually Transmitted Diseases 392

Respiratory Diseases 487 Narcotics 511

Chapter 10 ■ Updated the renal calculi section

■ Updated the Diagnostic Tests of the Ear section Chapter 18

Chapter 17 ■ Added a new Healthy Highlight: Gene Mutations

Ms. Tannehill-Jones was not a newcomer to this cam-

TABLE 1–1 Types of Pathologists

In the study of human disease, several terms may be Experimental Research

TABLE 1–2 Examples of Acute and Chronic

become, the higher the risk for diseases such as

TABLE 1–3 Examples of Common Diagnostic Tests and Procedures

intervention be funded? If costs are funded by individ-

Fill in the Blank

Chromosomal and genetic abnormalities might or

TABLE 2–1 Classification of Hereditary Disease with Examples

Single Gene Polygenic Chromosomal

Cystic fibrosis Gout Klinefelter’s syndrome

and infection. On arrival at an emergency department,

Inflammation and Infection Figure 2–1 Inflammation of a finger.

TABLE 2–2 Examples of Neoplasms or Tumors

Neoplasms or tumors (-omas) may be classified as

Courtesy of Mark L. Kuss

Persons who are unable to eat enough to maintain

Courtesy of Mark L. Kuss

Obesity consume large amounts of vitamins for an extended

Immunodeficiency understood but is progressive and irreversible. Diseases

Basement membrane Basement membrane

Figure 2–5 Normal cell versus atrophied cell.

Basement membrane Metaplasia

Basement membrane Basement membrane

Neoplasia Cellular death, called necrosis (neh-CROW-sis),

4. T F Diseases related to the aging process are called regenerative disorders.

10. How do cells adapt when exposed to adverse conditions?

11. What are the definitions of the following terms?

Lienalla ei olisi Matin reessä ollut varsin pitkälti kuljettavaa

"Mitäpä minulla siellä myllyllä olisi tekemistä?" vastusteli Liena.

"Siellähän kerron", tuumi Matti ja kiirehti hepoaan.

Piti kuitenkin pysähtyä suntion pihaan, että Liena ehti jättää

Edelleen ajaessa pysyi Matti alkumatkan harvapuheisena, tavasta

"Kuulehan, Liena, tulisitko sinä meidän taloon miniäksi?"

"Mikolleko sitte vaiko Jussille?" ivasi Liena veitikkamaisesti

"Sinä vain kaikki leikiksi käännät. Totta minä tarkoitan. Minähän

Liena osoitti sevältä heinäin alta pilkistävää pussin suuta.

"Senpähän kohta näet."

Samassa reki kääntyi myllypihaan.

Matti pysäytti hevosensa puodin eteen, joka oli melkein kiinni

Jauhattajia ei sattunutkaan olemaan muita kuin pari pussimiestä.

TABLE 1–2 Examples of Acute and Chronic