Fundamentals of Anatomy &

Physiology 10th Edition Frederic H.

Martini
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Chapters Clinical Cases

1 An Introduction to Anatomy and Physiology 1 Using A&P to Save a Life 2

2 The Chemical Level of Organization 26 What is Wrong with my Baby? 27

3 The Cellular Level of Organization 64 When Your Heart is in the Wrong Place 65

4 The Tissue Level of Organization 113 The Rubber Girl 114

5 The Integumentary System 150 Skin Cells in Overdrive 151

6 Osseous Tissue and Bone Structure 178 A Case of Child Abuse? 179

7 The Axial Skeleton 206 Knocked Out 207

8 The Appendicular Skeleton 241 The Orthopedic Surgeon’s Nightmare 242

9 Joints 263 What’s Ailing the Birthday Girl? 264

10 Muscle Tissue 289 A Real Eye Opener 290

11 The Muscular System 332 The Weekend Warrior 333

12 Neural Tissue 385 Did Franklin D. Roosevelt Really Have Polio? 386

13 The Spinal Cord, Spinal Nerves, and Spinal Reflexes 429 Prom Night 430

14 The Brain and Cranial Nerves 461 The Neuroanatomist’s Stroke 462

15 Sensory Pathways and the Somatic Nervous System 508 Living with Cerebral Palsy 509

16 The Autonomic Nervous System and The First Day in Anatomy Lab 532
Higher-Order Functions 531

17 The Special Senses 563 A Chance to See 564

18 The Endocrine System 608 Stones, Bones, and Groans 609

19 Blood 652 A Mysterious Blood Disorder 653

20 The Heart 684 A Needle to the Chest 685

21 Blood Vessels and Circulation 723 Did Ancient Mummies Have Atherosclerosis? 724

22 The Lymphatic System and Immunity 781 Isn’t There a Vaccine for That? 782

23 The Respiratory System 830 How Long Should a Cough Last? 831

24 The Digestive System 880 An Unusual Transplant 881

25 Metabolism and Energetics 935 The Miracle Supplement 936

26 The Urinary System 972 A Case of "Hidden" Bleeding 973

27 Fluid, Electrolyte, and Acid–Base Balance 1015 When Treatment Makes You Worse 1016

28 The Reproductive System 1050 A Post-Game Mystery 1051

29 Development and Inheritance 1095 The Twins That Looked Nothing Alike 1096
Spotlight Figures

1–1 Levels of Organization 1–10 Diagnostic Imaging Techniques

2–3 Chemical Notation

3–1 Anatomy of a Model Cell 3–7 Protein Synthesis, Processing, and Packaging 3–22 Overview of Membrane Transport
3–23 DNA replication 3–24 Stages of a Cell’s Life Cycle
4–20 Inflammation and Regeneration
5–3 The Epidermis

6–11 Endochondral Ossification 6–16 Types of Fractures and Steps in Repair

7–4 Sectional Anatomy of the Skull
8–10 Sex Differences in the Human Skeleton
9–2 Joint Movement
10–9 Events at the Neuromuscular Junction 10–10 Excitation-Contraction Coupling
10–11 The Contraction Cycle and Cross-Bridge Formation
11–3 Muscle Action
12–9 Resting Membrane Potential 12–14 Generation of an Action Potential 12–15 Propagation of an Action Potential
13–8 Peripheral Distribution of Spinal Nerves 13–14 Spinal Reflexes
14–4 Formation and Circulation of Cerebrospinal Fluid
15–6 Somatic Sensory Pathways
16–2 Overview of the Autonomic Nervous System

17–2 Olfaction and Gustation 17–13 Refractive Problems 17–16 Photoreception

18–2 Structural Classification of Hormones 18–3 G Proteins and Second Messengers 18–18 Diabetes Mellitus
18–20 The General Adaptation Syndrome
19–1 The Composition of Whole Blood 19–8 Hemolytic Disease of the Newborn
20–10 Heart Disease and Heart Attacks 20–14 Cardiac Arrhythmias
21–33 Congenital Heart Problems
22–28 Cytokines of the Immune System
23–15 Respiratory Muscles and Pulmonary Ventilation 23–25 Control of Respiration
24–15 Regulation of Gastric Activity 24–27 Chemical Events of Digestion
25–11 Absorptive and Postabsorptive States
26–16 Summary of Renal Function
27–18 The Diagnosis of Acid-Base Disorders
28–12 Regulation of Male Reproduction 28–24 Regulation of Female Reproduction
29–5 Extraembryonic Membranes and Placenta Formation
F U N D A M E N TA L S O F

Anatomy&Physiology
Tenth Edition

Frederic H. Martini, Ph.D.

University of Hawaii at Manoa

Judi L. Nath, Ph.D.

Lourdes University

Edwin F. Bartholomew, M.S.

William C. Ober, M.D. Claire E. Ober, R.N. Kathleen Welch, M.D. Ralph T. Hutchings
Art Coordinator and Illustrator Illustrator Clinical Consultant Biomedical Photographer

Clinical Cases by:

Ruth Anne O’Keefe

Boston Columbus Indianapolis New York San Francisco Upper Saddle River
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Notice: Our knowledge in clinical sciences is constantly changing. The authors and the publisher of
this volume have taken care that the information contained herein is accurate and compatible with
the standards generally accepted at the time of the publication. Nevertheless, it is difficult to ensure
that all information given is entirely accurate for all circumstances. The authors and the publisher
disclaim any liability, loss, or damage incurred as a consequence, directly or indirectly, of the use
and application of any of the contents of this volume.

Copyright © 2015, 2012 by Frederic H. Martini, Inc., Judi L. Nath, LLC, and Edwin F. Bartholomew,
Inc. Published by Pearson Education, Inc., publishing as Pearson Benjamin Cummings, 1301
Sansome St., San Francisco, CA 94111. All rights reserved. Manufactured in the United States of
America. This publication is protected by Copyright and permission should be obtained from the
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Many of the designations used by manufacturers and sellers to distinguish their products are
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of a trademark claim, the designations have been printed in initial caps or all caps.

MasteringA&P®, A&P Flix™, Practice Anatomy Lab™ (PAL™), and Interactive Physiology® are trade-
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Library of Congress Cataloging-in-Publication Data

Martini, Frederic, author.
Fundamentals of anatomy & physiology/Frederic H. Martini, Judi L. Nath, Edwin F. Bartholomew;
William C. Ober, art coordinator and illustrator; Claire E. Ober, illustrator; Kathleen Welch, clinical
consultant; Ralph T. Hutchings, biomedical photographer. — Tenth edition.
p.; cm.
Fundamentals of anatomy and physiology
Includes bibliographical references and index.
ISBN-13: 978-0-321-90907-7
ISBN-10: 0-321-90907-0
I. Nath, Judi Lindsley, author. II. Bartholomew, Edwin F., author. III. Title.
IV. Title: Fundamentals of anatomy and physiology.
[DNLM: 1. Anatomy. 2. Physiology. QS 4]
QP34.5
612—dc23 2013037105
1 2 3 4 5 6 7 8 9 10—DOW—17 16 15 14 13
0-321-90907-0 (Student edition)
978-0321-90907-7 (Student edition)
0-321-93968-9 (Exam Copy)
978-0321-93968-5 (Exam Copy)
Text and Illustration Team
Frederic (Ric) H. Martini, Ph.D.
Author
Dr. Martini received his Ph.D. from
Cornell University in comparative and
functional anatomy for work on the
pathophysiology of stress. In addition to
professional publications that include
journal articles and contributed chapters, technical reports,
and magazine articles, he is the lead author of ten undergradu-
ate texts on anatomy and physiology or anatomy. Dr. Martini is
currently affiliated with the University of Hawaii at Manoa and
has a long-standing bond with the Shoals Marine Laboratory,
a joint venture between Cornell University and the University
of New Hampshire. He has been active in the Human Anatomy
and Physiology Society (HAPS) for over 20 years and was a
member of the committee that established the course curricu-
lum guidelines for A&P. He is now a President Emeritus of HAPS
after serving as President-Elect, President, and Past-President
over 2005–2007. Dr. Martini is also a member of the American
Physiological Society, the American Association of Anato-
mists, the Society for Integrative and Comparative Biology, the
Australia/New Zealand Association of Clinical Anatomists,
the Hawaii Academy of Science, the American Association for
the Advancement of Science, and the International Society of
Vertebrate Morphologists.
Edwin F. Bartholomew, M.S.
Author
Edwin F. Bartholomew received his
undergraduate degree from Bowling
Green State University in Ohio and his
M.S. from the University of Hawaii.
Mr. Bartholomew has taught human
anatomy and physiology at both the secondary and undergrad-
uate levels and a wide variety of other science courses (from
botany to zoology) at Maui Community College and at his-
toric Lahainaluna High School, the oldest high school west of
the Rockies. He is a coauthor of Visual Anatomy & Physiology,
Essentials of Anatomy & Physiology, Visual Essentials of Anatomy
& Physiology, Structure and Function of the Human Body, and The
Human Body in Health and Disease (all published by Pearson).
Mr. Bartholomew is a member of the Human Anatomy and
Physiology Society (HAPS), the National Association of Biol-
ogy Teachers, the National Science Teachers Association, the
Hawaii Science Teachers Association, and the American Asso-
ciation for the Advancement of Science.
Judi L. Nath, Ph.D.
Author
Dr. Judi Nath is a biology professor at
Lourdes University, where she teaches
anatomy and physiology, pathophysi-
ology, and medical terminology. She
received her Bachelor’s and Master’s
degrees from Bowling Green State University and her Ph.D.
from the University of Toledo. Dr. Nath is devoted to her stu-
dents and strives to convey the intricacies of science in captivat-
ing ways that are meaningful, interactive, and exciting. She has
won the Faculty Excellence Award—an accolade recognizing
effective teaching, scholarship, and community service—multiple
times. She is active in many professional organizations, no-
tably the Human Anatomy and Physiology Society (HAPS),
where she has served several terms on the board of direc-
tors. Dr. Nath is a coauthor of Visual Anatomy & Physiology,
Visual Essentials of Anatomy & Physiology, and Anatomy & Physi-
ology (all published by Pearson), and she is the sole author
of Using Medical Terminology. Her favorite charities are those
that have significantly affected her life, including the local
Humane Society, the Cystic Fibrosis Foundation, and the
ALS Association. On a personal note, Dr. Nath enjoys family
life with her husband and their dogs.
William C. Ober, M.D.
Art Coordinator and Illustrator
Dr. Ober received his undergraduate
degree from Washington and Lee
University and his M.D. from the
University of Virginia. He also studied
in the Department of Art as Applied
to Medicine at Johns Hopkins Univer-
sity. After graduation, Dr. Ober completed a residency in Fam-
ily Practice and later was on the faculty at the University of
Virginia in the Department of Family Medicine and in the
Department of Sports Medicine. He also served as Chief of
Medicine of Martha Jefferson Hospital in Charlottesville, VA.
He is currently a Visiting Professor of Biology at Washington
and Lee University, where he has taught several courses and
led student trips to the Galapagos Islands. He was on the
Core Faculty at Shoals Marine Laboratory for 24 years, where
he taught Biological Illustration every summer. Dr. Ober
has collaborated with Dr. Martini on all of his textbooks in
every edition.
iii
iv Text and Illustration Team
Claire E. Ober, R.N.
Illustrator
Claire E. Ober, R.N., B.A., practiced fam-
ily, pediatric, and obstetric nursing be-
fore turning to medical illustration as a
full-time career. She returned to school
at Mary Baldwin College, where she re-
ceived her degree with distinction in studio art. Following a
five-year apprenticeship, she has worked as Dr. Ober’s partner
in Medical & Scientific Illustration since 1986. She was on the
Core Faculty at Shoals Marine Laboratory and co-taught the
Biological Illustration course with Dr. Ober for 24 years. The
textbooks illustrated by Medical & Scientific Illustration have
won numerous design and illustration awards.
Kathleen Welch, M.D.
Clinical Consultant
Dr. Welch received her B.A. from the
University of Wisconsin–Madison, her
M.D. from the University of Washington
in Seattle, and did her residency in Fam-
ily Practice at the University of North
Carolina in Chapel Hill. Participating in the Seattle WWAMI
rural medical education program, she studied in Fairbanks,
Anchorage, and Juneau, Alaska, with time in Boise, Idaho, and
Anacortes, Washington, as well. For two years, she served as
Director of Maternal and Child Health at the LBJ Tropical
Medical Center in American Samoa and subsequently was a
member of the Department of Family Practice at the Kaiser
Permanente Clinic in Lahaina, Hawaii, and on the staff at Maui
Memorial Hospital. She has been in private practice since 1987
and is licensed to practice in Hawaii and Washington State.
Dr. Welch is a Fellow of the American Academy of Family
Practice and a member of the Maui County Medical Society
and the Human Anatomy and Physiology Society (HAPS).
With Dr. Martini, she has coauthored both a textbook on anat-
omy and physiology and the A&P Applications Manual. She and
Dr. Martini were married in 1979, and they have one son.
Ralph T. Hutchings
Biomedical Photographer
Mr. Hutchings was associated with the
Royal College of Surgeons for 20 years.
An engineer by training, he has focused
for years on photographing the struc-
ture of the human body. The result
has been a series of color atlases, including the Color Atlas of
Human Anatomy, the Color Atlas of Surface Anatomy, and The
Human Skeleton (all published by Mosby-Yearbook Publishing).
For his anatomical portrayal of the human body, the Interna-
tional Photographers Association has chosen Mr. Hutchings as
the best photographer of humans in the twentieth century. He
lives in North London, where he tries to balance the demands
of his photographic assignments with his hobbies of early
motor cars and airplanes.
Ruth Anne O’Keefe, M.D.
Clinical Contributor
Dr. O’Keefe did her undergraduate stud-
ies at Marquette University, attended
graduate school at the University of
Wisconsin, and received her M.D. from
George Washington University. She
was the first woman to study orthopedics at The Ohio State
University during her residency. She did fellowship training in
trauma surgery at Loma Linda University in California. In ad-
dition to her private orthopedic practice, she has done ortho-
pedic surgery around the world, taking her own surgical teams
to places such as the Dominican Republic, Honduras, Peru,
New Zealand, and Burkina Faso. She serves on the board of
Global Health Partnerships, a group that partners with a clinic
serving 35,000 people in remote Kenya. Dr. O’Keefe has al-
ways enjoyed teaching and now supervises medical students
from the University of New Mexico doing ongoing research
in Kenya. She lives in Albuquerque with her Sweet Ed. She
is mother of four, grandmother of nine, and foster mother
to many.
Preface
The Tenth Edition of Fundamentals of Anatomy & Physiology is a
comprehensive textbook that fulfills the needs of today’s stu-
dents while addressing the concerns of their professors. We fo-
cused our attention on the question “How can we make this
information meaningful, manageable, and comprehensible?”
During the revision process, we drew upon our content knowl-
edge, research skills, artistic talents, and years of classroom ex-
perience to make this edition the best yet.
The broad changes to this edition are presented in the New
to the Tenth Edition section below, and the specific changes
are presented in the Chapter-by-Chapter Changes in the
Tenth Edition section that follows.
New to the Tenth Edition
In addition to the many technical changes in this edition, such
as updated statistics and anatomy and physiology descriptions,
we have made the following key changes:
NEW 50 Spotlight Figures provide highly visual one- and
two-page presentations of tough topics in the book, with
a particular focus on physiology. In the Tenth Edition, 18
new Spotlight Figures have been added for a total of 50
across the chapters. There is now at least one Spotlight
Figure in every chapter, as well as one Spotlight Figure cor-
responding to every A&P Flix.
NEW 29 Clinical Cases get students motivated for their
future careers. Each chapter opens with a story-based Clini-
cal Case related to the chapter content and ends with a
Clinical Case Wrap-Up that incorporates the deeper con-
tent knowledge students will have gained from the chapter.
NEW The repetition of the chapter-opening Learning
Outcomes below the coordinated section headings
within the chapters underscores the connection between
the HAPS-based Learning Outcomes and the associated
teaching points. Author Judi Nath sat on the Human
Anatomy and Physiology Society (HAPS) committee that
developed the HAPS Learning Outcomes, recommended
to A&P instructors, and the Learning Outcomes in this
book are based on them. Additionally, the assessments in
MasteringA&P are organized by these Learning Outcomes.
As in the previous edition, full-sentence section headings,
correlated with the Learning Outcomes, state a core fact or
concept to help students readily see and learn the chapter
content; and Checkpoints, located at the close of each sec-
tion, ask students to pause and check their understanding
of facts and concepts. If students cannot answer these ques-
tions within a matter of minutes, then they should reread
the section before moving on. The Checkpoints reinforce
the Learning Outcomes, resulting in a systematic integra-
tion of the Learning Outcomes over the course of the
chapter. Answers to the Checkpoints are located in the blue
Answers tab at the back of the book.
Easier narrative uses simpler, shorter, more active sen-
tences and a reading level that makes reading and studying
easier for students.
Improved text-art integration throughout the illustration
program enhances the readability of figures. Several tables
have been integrated directly into figures to help students
make direct connections between tables and art.
Eponyms are now included within the narrative, along
with the anatomical terms used in Terminologia Anatomica.
NEW Assignable MasteringA&P activities include the
following:
NEW Spotlight Figure Coaching Activities are highly
visual, assignable activities designed to bring interac-
tivity to the Spotlight Figures in the book. Multi-part
activities include the ranking and sorting types that ask
students to manipulate the visuals.
NEW Book-specific Clinical Case Activities stem from
the story-based Clinical Cases that appear at the begin-
ning and end of each chapter in the book.
NEW Adaptive Follow-up Assignments allow instruc-
tors to easily assign personalized content for each in-
dividual student based on strengths and weaknesses
identified by his or her performance on MasteringA&P
parent assignments.
NEW Dynamic Study Modules help students acquire,
retain, and recall information quickly and efficiently.
The modules are available as a self-study tool or can be
assigned by the instructor. They can be easily accessed
with smartphones.
Chapter-by-Chapter Changes in the
Tenth Edition
This annotated Table of Contents provides select examples of
revision highlights in each chapter of the Tenth Edition. For
a more complete list of changes, please contact the publisher.
v
vi Preface
Chapter 1: An Introduction to Anatomy and Physiology
• New Clinical Case: Using A&P to Save a Life
• New Spotlight Figure 1–10 Diagnostic Imaging Techniques
• New Clinical Note: Autopsies and Cadaver Dissection
• New Clinical Note: Auscultation
• Figure 1–7 Directional References revised
• Figure 1–8 Sectional Planes revised
• Figure 1–9 Relationships among the Subdivisions of the Body
Cavities of the Trunk revised
Chapter 2: The Chemical Level of Organization
• New Clinical Case: What Is Wrong with My Baby?
• New Clinical Note: Radiation Sickness
• Clinical Note: Fatty Acids and Health revised
• Section 2-2 includes revised Molecular weight discussion
• Figure 2–4 The Formation of Ionic Bonds revised
• Figure 2–5 Covalent Bonds in Five Common Molecules revised
• Table 2–3 Important Functional Groups of Organic Compounds
revised (to clarify structural group and R group)
• Protein Structure subsection includes new discussion of amino
acids as zwitterions
• Figure 2–21 Protein Structure revised
Chapter 3: The Cellular Level of Organization
• New Clinical Case: When Your Heart Is in the Wrong Place
• New information added about cholesterol and other lipids
• New overview added about roles of microtubules
• Figure 3–5 The Endoplasmic Reticulum revised
• Clinical Note on DNA Fingerprinting revised
• Figure 3–13 The Process of Translation revised
• Figure 3–14 Diffusion revised
• Figure 3–17 Osmotic Flow across a Plasma Membrane revised
• New Spotlight Figure 3–22 Overview of Membrane Transport
incorporates old Figures 3–18, 3–19, and 3–21 and old
Table 3–2
• New Spotlight Figure 3–23 DNA Replication incorporates old
Figure 3–23
• Spotlight Figure 3–24 Stages in a Cell’s Life Cycle revised
Chapter 4: The Tissue Level of Organization
• New Clinical Case: The Rubber Girl
• Intercellular Connections subsection updated
• Figure 4–2 Cell Junctions revised
• Figure 4–8 The Cells and Fibers of Connective Tissue Proper
revised
• Adipose Tissue subsection includes updated discussion
of brown fat
• Figure 4–10 Loose Connective Tissues revised
• Spotlight Figure 4–20 Inflammation and Regeneration revised
Chapter 5: The Integumentary System
• New Clinical Case: Skin Cells in Overdrive
• Figure 5–1 The Components of the Integumentary System revised
• New Figure 5–2 The Cutaneous Membrane and Accessory
Structures
• New Spotlight Figure 5–3 The Epidermis incorporates old
Figures 5–2 and 5–3
• New Figure 5–5 Vitiligo
• New Figure 5–6 Sources of Vitamin D3
• Clinical Note: Decubitus Ulcers revised with new photo
• New Figure 5–8 Reticular Layer of Dermis
• Figure 5–10 Dermal Circulation revised
• Figure 5–12 Hair Follicles and Hairs revised
• New Figure 5–11 Hypodermis
Chapter 6: Osseous Tissue and Bone Structure
• New Clinical Case: A Case of Child Abuse?
• Figure 6–1 A Classification of Bones by Shape revised
• New Figure 6–2 An Introduction to Bone Markings incorporates
old Table 6–1
• New Spotlight Figure 6–11 Endochondral Ossification incor-
porates old Figure 6–10
• New Figure 6–12 Intramembranous Ossification
• Spotlight Figure 6–16 Types of Fractures and Steps in Repair
revised
• Clinical Note: Abnormal Bone Development revised
Chapter 7: The Axial Skeleton
• New Clinical Case: Knocked Out
• New Clinical Note: Sinusitis
• Figure 7–2 Cranial and Facial Subdivisions of the Skull revised
• Figure 7–3 The Adult Skull revised to incorporate old Table 7–1
• New Spotlight Figure 7–4 Sectional Anatomy of the Skull
incorporates old Figure 7–4 and parts of old Table 7–1
• Figure 7–6 The Frontal Bone revised
• Figure 7–14 The Nasal Complex revised
• Figure 7–22 The Thoracic Cage revised
Chapter 8: The Appendicular Skeleton
• New Clinical Case: The Orthopedic Surgeon’s Nightmare
• New Clinical Note: Hip Fracture
• New Clinical Note: Runner’s Knee
• New Clinical Note: Stress Fractures
• Carpal Bones subsection now lists the 8 carpal bones in two
groups of 4 (proximal and distal carpal bones)
• Figure 8–6 Bones of the Right Wrist and Hand revised
• New Spotlight Figure 8–10 Sex Differences in the Human
Skeleton incorporates old Figure 8–10, old Table 8–1, and
old bulleted list in text
• Clinical Note: Carpal Tunnel Syndrome includes new illustration
• Figure 8–14 Bones of the Ankle and Foot revised
• Clinical Note: Congenital Talipes Equinovarus includes
new photo
Chapter 9: Joints
• Chapter title changed from Articulations to Joints
• New Clinical Case: What’s Ailing the Birthday Girl?
• New Clinical Note: Dislocation and Subluxation
• New Clinical Note: Damage to Intervertebral Discs
• Table 9–1 Functional and Structural Classifications of Articula-
tions redesigned
• Spotlight Figure 9–2 Joint Movement incorporates old Figures
9–2 and 9–6 and subsection on Types of Synovial Joints
• Revised discussion of synovial fluid function in shock absorption
• Figure 9–6 Intervertebral Articulations expanded
• Figure 9–7 The Shoulder Joint revised
• Figure 9–10 The Right Knee Joint rearranged and revised
• Clinical Note: Knee Injuries revised

Chapter 10: Muscle Tissue
• New Clinical Case: A Real Eye Opener
• New subsection Electrical Impulses and Excitable Membranes
added in Section 10-4
• New Spotlight Figure 10–10 Excitation–Contraction Coupling
incorporates old Figures 10–9 and 10–10
• New Figure 10–13 Steps Involved in Skeletal Muscle Contraction
and Relaxation incorporates old Table 10–1
• Treppe subsection includes new discussion of treppe in cardiac
muscle
• Motor Units and Tension Production subsection includes new
discussion of fasciculation
• Figure 10–20 Muscle Metabolism revised
• Table 10–2 Properties of Skeletal Muscle Fiber Types revised to
make column sequences better parallel text discussion
Chapter 11: The Muscular System
• New Clinical Case: The Weekend Warrior
• Figure 11–1 Muscle Types Based on Pattern of Fascicle Organiza-
tion revised
• Figure 11–2 The Three Classes of Levers revised
• New Spotlight Figure 11–3 Muscle Action
• Figure 11–14 An Overview of the Appendicular Muscles of the
Trunk revised
• Figure 11–18 Muscles That Move the Hand and Fingers revised
• Figure 11–22 Extrinsic Muscles That Move the Foot and Toes
revised
Chapter 12: Neural Tissue
• New Clinical Case: Did President Franklin D. Roosevelt Really
Have Polio?
• New Figure 12–1 A Functional Overview of the Nervous System
• Figure 12–7 Schwann Cells, Peripheral Axons, and Formation of
the Myelin Sheath revised and new part c step art added
• New Spotlight Figure 12–9 Resting Membrane Potential incor-
porates old Figure 12–9
• Figure 12–10 Electrochemical Gradients for Potassium and
Sodium Ions revised
• Added ligand-gated channels as an alternative term for chemi-
cally gated channels
• New Spotlight Figure 12–15 Propagation of an Action
Potential incorporates old Figures 12–6 and 12–15
• New Figure 12–16 Events in the Functioning of a Cholinergic
Synapse incorporates old Figure 12–17 and old Table 12–4
Chapter 13: The Spinal Cord, Spinal Nerves, and Spinal Reflexes
• New Clinical Case: Prom Night
• New “Tips & Tricks” added to Cervical Plexus subsection
• Figure 13–7 Dermatomes revised
• New information on the Jendrassik maneuver added to Section 13-8
• New Figure 13–10 The Cervical Plexus incorporates old Table 13–1
and old Figure 13–11
• New Figure 13–11 The Brachial Plexus incorporates old Table 13–2
and old Figure 13–12
• New in-art Clinical Note: Sensory Innervation in the Hand added
to Figure 13–11
• New Figure 13–12 The Lumbar and Sacral Plexuses incorporates
old Table 13–3 and old Figure 13–13
• New in-art Clinical Note: Sensory Innervation in the Ankle and
Foot added to Figure 13–12
Preface vii
• New Spotlight Figure 13–14 Spinal Reflexes incorporates old
Figures 13–15, 13–17, 13–19, and 13–20
Chapter 14: The Brain and Cranial Nerves
• New Clinical Case: The Neuroanatomist’s Stroke
• New Spotlight Figure 14–4 Formation and Circulation of
Cerebrospinal Fluid incorporates old Figure 14–4
• Figure 14–5 The Diencephalon and Brain Stem revised
• New Figures 14–6 The Medulla Oblongata and 14–7 The Pons
incorporate old Figure 14–6 and old Table 14–2
• New Figure 14–8 The Cerebellum incorporates old Figure 14–7
and old Table 14–3
• New Figure 14–9 The Midbrain incorporates old Figure 14–8, old
Table 14–4, and a new cadaver photograph
• New Figure 14–11 The Hypothalamus in Sagittal Section incorpo-
rates old Figure 14–10 and old Table 14–6
• New Figure 14–12 The Limbic System incorporates old
Figure 14–11 and old Table 14–7
• Figure 14–14 Fibers of the White Matter of the Cerebrum revised
• Figure 14–15 The Basal Nuclei revised
• Figure 14–16 Motor and Sensory Regions of the Cerebral Cortex
revised
• New information on circumventricular organs added to Section 14-2
Chapter 15: Sensory Pathways and the Somatic Nervous System
• New Clinical Case: Living with Cerebral Palsy
• New Figure 15–1 An Overview of Events Occurring along the
Sensory and Motor Pathways
• New Figure 15–3 Tonic and Phasic Sensory Receptors
• Spotlight Figure 15–6 Somatic Sensory Pathways revised
• Figure 15–8 Descending (Motor) Tracts in the Spinal Cord
reorganized
Chapter 16: The Autonomic Nervous System and Higher-Order
Functions
• New Clinical Case: The First Day in Anatomy Lab
• New Spotlight Figure 16–2 Overview of the Autonomic
Nervous System incorporates old Figures 16–3 and 16–7
• Figure 16–3 Sites of Ganglia in Sympathetic Pathways revised
• Figure 16–4 The Distribution of Sympathetic Innervation revised
Chapter 17: The Special Senses
• New Clinical Case: A Chance to See
• Figure 17–1 The Olfactory Organs revised
• Spotlight Figure 17–2 Olfaction and Gustation revised
• Figure 17–3 Gustatory Receptors revised
• Figure 17–22 The Middle Ear revised
• Figures 17–23, 17–24, and 17–25 revised to indicate different
orientations of maculae in the utricle and saccule
• Figure 17–32 Pathways for Auditory Sensations revised
Chapter 18: The Endocrine System
• New Clinical Case: Stones, Bones, and Groans
• New Spotlight Figure 18–3 G Proteins and Second Messengers
incorporates old Figure 18–3
• Figure 18–7 The Hypophyseal Portal System and the Blood
Supply to the Pituitary Gland revised
• Figure 18–11 The Thyroid Follicles revised
• New Figure 18–14 The Adrenal Gland incorporates old
Figure 18–14 and old Table 18–5
viii Preface
Chapter 19: Blood
• New Clinical Case: A Mysterious Blood Disorder
• Figure 19–3 The Structure of Hemoglobin revised
• Table 19–4 includes revised names for Factors IX and XI and
source of Factor X
Chapter 20: The Heart
• New Clinical Case: A Needle to the Chest
• Figure 20–3 The Superficial Anatomy of the Heart revised
• Figure 20–6 The Sectional Anatomy of the Heart revised
• Figure 20–12 Impulse Conduction through the Heart revised
• Figure 20–16 Phases of the Cardiac Cycle revised
• Figure 20–21 Autonomic Innervation of the Heart revised
• Figure 20–24 A Summary of the Factors Affecting Cardiac Output
revised
Chapter 21: Blood Vessels and Circulation
• New Clinical Case: Did Ancient Mummies Have
Atherosclerosis?
• Figure 21–2 Histological Structures of Blood Vessels revised
• Figure 21–8 Relationships among Vessel Diameter, Cross-
Sectional Area, Blood Pressure, and Blood Velocity within the
Systemic Circuit revised
• Figure 21–9 Pressures within the Systemic Circuit revised
• Figure 21–11 Forces Acting across Capillary Walls revised
• Figure 21–20 Arteries of the Chest and Upper Limb revised
• Figure 21–25 Arteries of the Lower Limb revised
• Figure 21–29 Flowcharts of Circulation to the Superior and Infe-
rior Venae Cavae revised
• Figure 21–30 Venous Drainage from the Lower Limb revised
Chapter 22: The Lymphatic System and Immunity
• New Clinical Case: Isn’t There a Vaccine for That?
• Figure 22–6 The Origin and Distribution of Lymphocytes revised
• Figure 22–11 Innate Defenses revised
• Complement System subsection – includes revised number of
complement proteins in plasma (from 11 to more than 30)
• Figure 22–18 Antigens and MHC Proteins revised
Chapter 23: The Respiratory System
• New Clinical Case: How Long Should a Cough Last?
• Figure 23–1 The Structure of the Respiratory System reorganized
• Figure 23–3 The Structures of the Upper Respiratory System revised
• Figure 23–5 The Glottis and Surrounding Structures revised
• Figure 23–7 The Gross Anatomy of the Lungs revised
• Figure 23–9 The Bronchi, Lobules, and Alveoli of the Lung revised
• Figure 23–10 Alveolar Organization revised
• Figure 23–13 Mechanisms of Pulmonary Ventilation revised
• New Spotlight Figure 23–15 Respiratory Muscles and Pulmonary
Ventilation incorporates old Figure 23–16
• Figure 23–16 Pulmonary Volumes and Capacities revised
• Spotlight Figure 23–25 Control of Respiration revised
Chapter 24: The Digestive System
• New Clinical Case: An Unusual Transplant
• Figure 24–10 The Esophagus revised
• Figure 24–12 The Stomach revised
• Figure 24–16 Segments of the Intestine revised
• Figure 24–21 The Anatomy and Physiology of the Gallbladder
and Bile Ducts revised
Chapter 25: Metabolism and Energetics
• New Clinical Case: The Miracle Supplement
• Figure 25–9 Lipid Transport and Utilization revised
• Figure 25–12 MyPlate Plan revised
• Figure 25–14 Mechanisms of Heat Transfer revised
Chapter 26: The Urinary System
• New Clinical Case: A Case of “Hidden” Bleeding
• Revised all relevant figure labels by replacing “Renal lobe” with
“Kidney lobe”
• Figure 26–6 The Functional Anatomy of a Representative Neph-
ron and the Collecting System revised
• Spotlight Figure 26–16 Summary of Renal Function revised
Chapter 27: Fluid, Electrolyte, and Acid–Base Balance
• New Clinical Case: When Treatment Makes You Worse
• Figure 27–2 Cations and Anions in Body Fluids revised
• Figure 27–3 Fluid Gains and Losses revised
• Figure 27–11 The Role of Amino Acids in Protein Buffer Systems
revised (to emphasize amino acids as zwitterions)
• Figure 27–13 Kidney Tubules and pH Regulation revised
• New Spotlight Figure 27–18 The Diagnosis of Acid–Base
Disorders incorporates old Figure 27–18
Chapter 28: The Reproductive System
• New Clinical Case: A Post-Game Mystery
• Figure 28–1 The Male Reproductive System revised
• Figure 28–3 The Male Reproductive System in Anterior View
revised and reorganized
• Figure 28–4 The Structure of the Testes revised
• Figure 28–7 Spermatogenesis revised
• Figure 28–13 The Female Reproductive System revised
• Figure 28–15 Oogenesis revised
• Figure 28–18 The Uterus revised
Chapter 29: Development and Inheritance
• New Clinical Case: The Twins That Looked Nothing Alike
• Revised all relevant chapter text by replacing “embryological”
with “embryonic” for simplification
• New Spotlight Figure 29–5 Extraembryonic Membranes and
Placenta Formation incorporates old Figure 29–5
• Table 29–2 An Overview of Prenatal Development includes
revised sizes and weights at different gestational ages
• Figure 29–8 The Second and Third Trimesters revised
• Figure 29–9 Growth of the Uterus and Fetus revised
• Figure 29–13 Growth and Changes in Body Form and Proportion
revised
Appendix
• New periodic table
• New codon chart
Acknowledgments
This textbook represents a group effort, and we would like to
acknowledge the people who worked together with us to create
this Tenth Edition.
Foremost on our thank-you list are the instructors who
offered invaluable suggestions throughout the revision process.
We thank them for their participation and list their names and
affiliations below.
Lisa Conley, Milwaukee Area Technical College
Theresa G. D’Aversa, Iona College
Danielle Desroches, William Paterson University
Debra Galba-Machuca, Portland Community College–Cascade
Lauren Gollahon, Texas Tech University
Gigi Goochey, Hawaii Community College
Mark Haefele, Community College of Denver
Anthony Jones, Tallahassee Community College
William L’ Amoreaux, College of Staten Island
J. Mitchell Lockhart, Valdosta State University
Scott Murdoch, Moraine Valley Community College
Louise Petroka, Gateway Community College
Cynthia Prentice-Craver, Chemeketa Community College
S. Michele Robichaux, Nicholls State University
Susan Rohde, Triton College
Yung Su, Florida State University
Bonnie Taylor, Schoolcraft College
Carol Veil, Anne Arundel Community College
Patricia Visser, Jackson College
Theresia Whelan, State College of Florida – Manatee-Sarasota
Samia Williams, Santa Fe College
The accuracy and currency of the clinical material in this
edition and in the A&P Applications Manual in large part reflect
the work of Kathleen Welch, M.D. Her professionalism and
concern for practicality and common sense make the clinical
information especially relevant for today’s students. Addition-
ally, our content expert on the Clinical Cases, Ruth Anne O’Keefe,
M.D., provided constant, useful feedback on each chapter.
Virtually without exception, reviewers stressed the impor-
tance of accurate, integrated, and visually attractive illustra-
tions in helping readers understand essential material. The
revision of the art program was directed by Bill Ober, M.D.
and Claire E. Ober, R.N. Their suggestions about presentation
sequence, topics of clinical importance, and revisions to the
proposed art were of incalculable value to us and to the project.
The illustration program for this edition was further enhanced
by the efforts of several other talented individuals. Jim Gibson
designed most of the new Spotlight Figures in the art program
and consulted on the design and layout of the individual fig-
ures. His talents have helped produce an illustration program
that is dynamic, cohesive, and easy to understand. Anita Im-
pagliazzo helped create the new photo/art combinations that
have resulted in clearer presentations and a greater sense of re-
alism in important anatomical figures. We are also grateful to
the talented team at Imagineering (imagineeringart.com) for
their dedicated and detailed illustrative work on key figures for
this edition. The new color micrographs in this edition were
provided by Dr. Robert Tallitsch, and his assistance is much ap-
preciated. Many of the striking anatomy photos in the text and
in Martini’s Atlas of the Human Body are the work of biomedical
photographer Ralph Hutchings; his images played a key role in
the illustration program.
We also express our appreciation to the editors and sup-
port staff at Pearson Science.
We owe special thanks to Executive Editor, Leslie Berriman,
for her creativity and dedication. Her vision helped shape
this book in countless ways. Leslie’s enthusiasm for publish-
ing the highest quality material spills over onto the author/
illustrator team. She is our biggest advocate and is always
willing to champion our cause—despite the challenges of
working with authors. We are appreciative of all her efforts
on our behalf.
Assistant Editor, Cady Owens, and Associate Project Editor,
Lisa Damerel, are unquestionably the very finest at what they
do. While it is expected that editors pay attention to details and
keep projects moving forward, Cady and Lisa are true profes-
sionals and extremely skilled at not only preparing our ma-
terial for publication, but making sure it is the best it could
possibly be. This past year could not have happened without
them.
Annie Reid, our Development Editor, played a vital role in
revising the Tenth Edition. Her unfailing attention to readabil-
ity, consistency, and quality was invaluable to the authors in
meeting our goal of delivering complex A&P content in a more
student-friendly way.
We are grateful to Mike Rossa for his careful attention to
detail and consistency in his copyedit of the text and art.
This book would not exist without the extraordinary
dedication of the Production team, including Caroline Ayres,
who solved many problems under pressure with unfailing
good cheer. Norine Strang skillfully led her excellent team at
S4Carlisle to move the book smoothly through composition.
ix
x Acknowledgments
The striking cover and clear, navigable interior design were
created by tani hasegawa. Thanks also to Mark Ong, Design
Manager, and Marilyn Perry, who devised innovative solutions
for several complex design challenges.
Thanks to our photo researcher, Maureen Spuhler, and
photo editor, Donna Kalal, for finding, obtaining, and coordi-
nating all the photos in the photo program.
Thanks are also due to Sharon Kim, Editorial Assistant,
who served as project editor for the print supplements for
instructors and students and coordinated the administrative
details of the entire textbook program. Dorothy Cox and Shan-
non Kong worked tirelessly to shepherd the print and media
supplements through production. Thanks also to Stacey Wein-
berger for handling the physical manufacturing of the book.
We are also grateful to Joe Mochnick, Content Producer,
and Liz Winer, Executive Content Producer, for their creative
efforts on the media package, most especially MasteringA&P.
We would also like to express our gratitude to the fol-
lowing people at Pearson Science: Paul Corey, President, who
continues to support all our texts; Barbara Yien, Director of De-
velopment, who kindly kept all phases moving forward under
all circumstances; Allison Rona, Senior Marketing Manager;
and the dedicated Pearson Science sales representatives for
their continuing support of this project. Special thanks go to
Frank Ruggirello, Vice President and Editorial Director, for
working closely with Leslie in ensuring we have the resources
necessary to publish what students need to succeed. And, a
round of applause goes to Derek Perrigo, Senior A&P Special-
ist, our biggest cheerleader.
To help improve future editions, we encourage you to send
any pertinent information, suggestions, or comments about
the organization or content of this textbook to us directly,
using the e-mail addresses below. We warmly welcome com-
ments and suggestions and will carefully consider them in the
preparation of the Eleventh Edition.
Frederic (Ric) H. Martini
Haiku, Hawaii
martini@pearson.com
Judi L. Nath
Sandusky, Ohio
nath@pearson.com
Edwin F. Bartholomew
Lahaina, Hawaii
bartholomew@pearson.com
Contents

Preface v
2 The Chemical Level of
Organization 26
UNIT 1 LEVELS OF ORGANIZATION
An Introduction to the Chemical Level of Organization 27
1 An Introduction to Anatomy 2-1 Atoms are the basic particles of matter 27
and Physiology 1 Atomic Structure 27
Elements and Isotopes 28
An Introduction to Studying the Human Body 2 Atomic Weights 29
Electrons and Energy Levels 30
1-1 Anatomy and physiology directly affect
your life 2 2-2 Chemical bonds are forces formed by atom
interactions 31
1-2 Anatomy is structure, and physiology is function 3
Ionic Bonds 31
1-3 Anatomy and physiology are closely integrated 4 Covalent Bonds 34
Anatomy 4 Hydrogen Bonds 35
Physiology 5 States of Matter 35
1-4 Levels of organization progress from molecules 2-3 Decomposition, synthesis, and exchange reactions are
to a complete organism 6 important chemical reactions in physiology 36
1-5 Homeostasis is the state of internal balance 7 Basic Energy Concepts 36
1-6 Negative feedback opposes variations from normal, Types of Chemical Reactions 37
whereas positive feedback exaggerates them 10 2-4 Enzymes catalyze specific biochemical reactions by
The Role of Negative Feedback in Homeostasis 10 lowering the energy needed to start them 38
The Role of Positive Feedback in Homeostasis 12 2-5 Inorganic compounds lack carbon, and organic
Systems Integration, Equilibrium, and Homeostasis 13 compounds contain carbon 39
1-7 Anatomical terms describe body regions, anatomical 2-6 Physiological systems depend on water 39
positions and directions, and body sections 14 The Properties of Aqueous Solutions 40
Superficial Anatomy 14 Colloids and Suspensions 41
Sectional Anatomy 16
2-7 Body fluid pH is vital for homeostasis 41
1-8 Body cavities of the trunk protect internal organs
and allow them to change shape 18 2-8 Acids, bases, and salts are inorganic compounds with
important physiological roles 42
The Thoracic Cavity 22
Salts 43
The Abdominopelvic Cavity 22
Buffers and pH Control 43
Chapter Review 23
Spotlights 2-9 Carbohydrates contain carbon, hydrogen, and oxygen
Levels of Organization 8
in a 1:2:1 ratio 43
Diagnostic Imaging Techniques 20 Monosaccharides 44
Clinical Case Disaccharides and Polysaccharides 45
Using A&P to Save a Life 2 2-10 Lipids often contain a carbon-to-hydrogen ratio
Clinical Notes of 1:2 46
Autopsies and Cadaver Dissection 5 Fatty Acids 46
Auscultation 14 Eicosanoids 47
Glycerides 48
Steroids 48
Phospholipids and Glycolipids 49

xi
xii Contents

2-11 Proteins contain carbon, hydrogen, oxygen, and 3-6 Carrier-mediated and vesicular transport assist
nitrogen and are formed from amino acids 51 membrane passage 94
Protein Structure 51 Carrier-Mediated Transport 94
Protein Shape 52 Vesicular Transport 96
Enzyme Function 54 3-7 The membrane potential results from the unequal
Glycoproteins and Proteoglycans 56 distribution of positive and negative charges across
2-12 DNA and RNA are nucleic acids 56 the plasma membrane 100
Structure of Nucleic Acids 56 3-8 Stages of a cell’s life cycle include interphase, mitosis,
RNA and DNA 56 and cytokinesis 101
2-13 ATP is a high-energy compound used by cells 58 DNA Replication 101
Interphase, Mitosis, and Cytokinesis 101
2-14 Chemicals and their interactions form functional units
The Mitotic Rate and Energy Use 103
called cells 59
Chapter Review 60 3-9 Several growth factors affect the cell life cycle 103
Spotlights 3-10 Tumors and cancers are characterized by abnormal cell
Chemical Notation 32 growth and division 106
Clinical Case 3-11 Differentiation is cellular specialization as a result of
What Is Wrong with My Baby? 27 gene activation or repression 108
Clinical Notes Chapter Review 109
Radiation Sickness 29
Spotlights
Fatty Acids and Health 48
Anatomy of a Model Cell 66
Protein Synthesis, Processing, and Packaging 78
Overview of Membrane Transport 98

3 The Cellular Level

DNA Replication 102
Stages of a Cell’s Life Cycle 104
of Organization 64 Clinical Case
When Your Heart Is in the Wrong Place 65
An Introduction to Cells 65 Clinical Notes
3-1 The plasma membrane separates the cell from its Inheritable Mitochondrial Disorders 80
surrounding environment and performs various DNA Fingerprinting 84
functions 65 Mutations 86
Membrane Lipids 68 Drugs and the Plasma Membrane 90
Telomerase, Aging, and Cancer 107
Membrane Proteins 69
Parkinson’s Disease 108
Membrane Carbohydrates 70
3-2 Organelles within the cytoplasm perform particular
functions 70
The Cytosol 70 4 The Tissue Level
The Organelles 71 of Organization 113
3-3 The nucleus contains DNA and enzymes essential for
controlling cellular activities 82 An Introduction to the Tissue Level of Organization 114
Contents of the Nucleus 83 4-1 The four tissue types are epithelial, connective,
Information Storage in the Nucleus 83 muscle, and neural 114
3-4 DNA controls protein synthesis, cell structure, and cell 4-2 Epithelial tissue covers body surfaces, lines cavities
function 84 and tubular structures, and serves essential
The Role of Gene Activation in Protein Synthesis 84 functions 114
The Transcription of mRNA 84 Functions of Epithelial Tissue 115
Translation and Protein Synthesis 86 Specializations of Epithelial Cells 115
How the Nucleus Controls Cell Structure and Function 87 Maintaining the Integrity of Epithelia 116
3-5 Diffusion is a passive transport mechanism that assists 4-3 Cell shape and number of layers determine the
membrane passage 87 classification of epithelia 118
Diffusion 89 Classification of Epithelia 119
Diffusion across Plasma Membranes 91 Glandular Epithelia 123
 Contents xiii

4-4 Connective tissue provides a protective structural Stratum Spinosum 153

framework for other tissue types 126 Stratum Granulosum 155
Classification of Connective Tissues 126 Stratum Lucidum 155
Connective Tissue Proper 126 Stratum Corneum 155
4-5 Cartilage and bone provide a strong supporting 5-2 Factors influencing skin color are epidermal
framework 133 pigmentation and dermal circulation 155
Cartilage 133 The Role of Epidermal Pigmentation 156
Bone 136 The Role of Dermal Circulation 157
4-6 Tissue membranes are physical barriers of four types: 5-3 Sunlight causes epidermal cells to convert a steroid
mucous, serous, cutaneous, and synovial 137 into vitamin D3 158
Mucous Membranes 137 5-4 Epidermal growth factor has several effects on the
Serous Membranes 137 epidermis and epithelia 159
The Cutaneous Membrane 139 5-5 The dermis is the tissue layer that supports the
Synovial Membranes 139 epidermis 160
4-7 Connective tissue creates the internal framework Dermal Strength and Elasticity 160
of the body 139 Cleavage Lines 161
4-8 The three types of muscle tissue are skeletal, cardiac, The Dermal Blood Supply 161
and smooth 140 Innervation of the Skin 161
Skeletal Muscle Tissue 140 5-6 The hypodermis connects the dermis to underlying
Cardiac Muscle Tissue 142 tissues 162
Smooth Muscle Tissue 142 5-7 Hair is composed of keratinized dead cells that have
4-9 Neural tissue responds to stimuli and propagates been pushed to the surface 163
electrical impulses throughout the body 142 Hair Production 165
4-10 The response to tissue injury involves inflammation The Hair Growth Cycle 165
and regeneration 144 Types of Hairs 165
Inflammation 144 Hair Color 165
Regeneration 144 5-8 Sebaceous glands and sweat glands are exocrine
4-11 With advancing age, tissue repair declines and cancer glands found in the skin 166
rates increase 144 Sebaceous Glands 166
Aging and Tissue Structure 144 Sweat Glands 167
Aging and Cancer Incidence 146 Other Integumentary Glands 168
Chapter Review 146 Control of Glandular Secretions and the Homeostatic
Spotlights Role of the Integument 168
Inflammation and Regeneration 145 5-9 Nails are keratinized epidermal cells that protect the
Clinical Case tips of fingers and toes 169
The Rubber Girl 114 5-10 Several phases are involved in repairing the
Clinical Notes integument following an injury 169
Exfoliative Cytology 120 5-11 Effects of aging include skin thinning, wrinkling,
Marfan’s Syndrome 129 and reduced melanocyte activity 172
Chapter Review 175
Spotlights
UNIT 2 SUPPORT AND MOVEMENT The Epidermis 154
Clinical Case
Skin Cells in Overdrive 151
5 The Integumentary Clinical Notes
Skin Cancer 158
System 150 Decubitus Ulcers 161
Liposuction 163
An Introduction to the Integumentary System 151 Burns and Grafts 171
5-1 The epidermis is composed of layers with various Skin Abnormalities 172
functions 153
Stratum Basale 153
xiv Contents

6 Osseous Tissue and Bone 7 The Axial Skeleton 206

Structure 178
An Introduction to the Axial Skeleton 207
An Introduction to the Skeletal System 179 7-1 The 80 bones of the head and trunk
6-1 The skeletal system has five make up the axial skeleton 207
primary functions 179 7-2 The skull is composed of 8 cranial bones and
6-2 Bones are classified according to shape and structure, 14 facial bones 207
and they have a variety of surface markings 180 7-3 Each orbital complex contains an eye, and the nasal
Bone Shapes 180 complex encloses the nasal cavities 223
Bone Markings 181 The Orbital Complexes 223
Bone Structure 182 The Nasal Complex 223
6-3 Bone is composed of matrix and several types of 7-4 Fontanelles are non-ossified areas between cranial
cells: osteocytes, osteoblasts, osteogenic cells, bones that allow for brain growth in infants and small
and osteoclasts 182 children 224
Bone Matrix 183 7-5 The vertebral column has four spinal curves 226
Bone Cells 183 Spinal Curvature 226
6-4 Compact bone contains parallel osteons, and spongy Vertebral Anatomy 227
bone contains trabeculae 184 7-6 The five vertebral regions are the cervical, thoracic,
Compact Bone Structure 185 lumbar, sacral, and coccygeal regions 228
Spongy Bone Structure 186 Cervical Vertebrae 229
The Periosteum and Endosteum 187 Thoracic Vertebrae 232
6-5 Bones form through ossification and enlarge through Lumbar Vertebrae 232
appositional growth and remodeling 189 The Sacrum 232
Endochondral Ossification 189 The Coccyx 235
Intramembranous Ossification 192 7-7 The thoracic cage protects organs in the chest and
The Blood and Nerve Supplies to provides sites for muscle attachment 235
Bone 192 The Ribs 235
6-6 Bone growth and development depend on a balance The Sternum 236
between bone formation and bone resorption 192 Chapter Review 238
6-7 Exercise, hormones, and nutrition affect bone Spotlights
development and the skeletal system 194 Sectional Anatomy of the Skull 212
The Effects of Exercise on Bone 194 Clinical Case
Nutritional and Hormonal Effects on Bone 194 Knocked Out 207
6-8 Calcium plays a critical role in bone physiology 196 Clinical Notes
The Skeleton as a Calcium Reserve 196 Temporomandibular Joint Syndrome 222
Sinusitis 225
Hormones and Calcium Balance 196
Craniostenosis 226
6-9 A fracture is a crack or break in a bone 198 Kyphosis, Lordosis, and Scoliosis 229
6-10 Osteopenia has a widespread effect on aging skeletal
tissue 199
Chapter Review 203
Spotlights
8 The Appendicular
Endochondral Ossification 190
Skeleton 241
Types of Fractures and Steps in Repair 200
Clinical Case An Introduction to the Appendicular Skeleton 242
A Case of Child Abuse? 179 8-1 The pectoral girdles—the clavicles and scapulae—
Clinical Notes attach the upper limbs to the axial skeleton 242
Heterotopic Bone Formation 188 The Clavicles 244
Abnormal Bone Development 196 The Scapulae 244
 Contents xv

8-2 The upper limbs are adapted for free movement 245 9-5 The shoulder is a ball-and-socket joint, and the elbow
The Humerus 245 is a hinge joint 276
The Ulna 247 The Shoulder Joint 276
The Radius 247 The Elbow Joint 278
The Carpal Bones 247 9-6 The hip is a ball-and-socket joint, and the knee is a
The Metacarpal Bones and Phalanges 248 hinge joint 279
8-3 The pelvic girdle—two hip bones—attaches the lower The Hip Joint 279
limbs to the axial skeleton 250 The Knee Joint 280
The Pelvic Girdle 250 9-7 With advancing age, arthritis and other degenerative
The Pelvis 250 changes impair joint mobility 283
8-4 The lower limbs are adapted for movement and 9-8 The skeletal system supports and stores energy and
support 254 minerals for other body systems 284
The Femur 254 Chapter Review 286
The Patella 254 Spotlights
The Tibia 256 Joint Movement 270
The Fibula 256 Clinical Case
The Tarsal Bones 257 What’s Ailing the Birthday Girl? 264
The Metatarsal Bones and Phalanges 258
Clinical Notes
8-5 Sex differences and age account for individual skeletal Bursitis and Bunions 268
variation 258 Dislocation and Subluxation 268
Chapter Review 260 Damage to Intervertebral Discs 275
Knee Injuries 283
Spotlights
Sex Differences in the Human Skeleton 253
Clinical Case
The Orthopedic Surgeon’s Nightmare 242 10 Muscle Tissue 289
Clinical Notes
Carpal Tunnel Syndrome 249 An Introduction to Muscle Tissue 290
Hip Fracture 254
Runner’s Knee 254 10-1 Skeletal muscle performs six major functions 290
Stress Fractures 258
Congenital Talipes Equinovarus 258
10-2 A skeletal muscle contains muscle tissue, connective
tissues, blood vessels, and nerves 291
Organization of Connective Tissues 292
Blood Vessels and Nerves 292
9 Joints 263 10-3 Skeletal muscle fibers have distinctive features 292
The Sarcolemma and Transverse Tubules 292
An Introduction to Joints 264 Myofibrils 293
9-1 Joints are categorized according to their range The Sarcoplasmic Reticulum 294
of motion or structure 264 Sarcomeres 295
9-2 Synovial joints are freely movable joints containing Sliding Filaments and Muscle Contraction 298
synovial fluid 266
Articular Cartilage 266
10-4 The nervous system communicates with skeletal
muscles at the neuromuscular junction 299
Synovial Fluid 267
Electrical Impulses and Excitable
Accessory Structures 267 Membranes 302
Factors That Stabilize Synovial Joints 267 The Control of Skeletal Muscle Activity 302
9-3 The structure and function of synovial joints enable Excitation–Contraction Coupling 302
various skeletal movements 268 Relaxation 308
Types of Movements at Synovial Joints 269
10-5 Sarcomere shortening and muscle fiber stimulation
9-4 Intervertebral discs and ligaments are structural produce tension 308
components of intervertebral joints 274 Tension Production by Muscle Fibers 308
Intervertebral Discs 274 Tension Production by Skeletal Muscles 312
Intervertebral Ligaments 275 Motor Units and Tension Production 312
Vertebral Movements 275
xvi Contents

10-6 ATP provides energy for muscle contraction 316 11-4 Descriptive terms are used to name skeletal
ATP and CP Reserves 316 muscles 339
ATP Generation 317 Location in the Body 339
Energy Use and the Level of Muscular Activity 318 Origin and Insertion 339
Muscle Fatigue 318 Fascicle Organization 339
The Recovery Period 318 Position 339
Hormones and Muscle Metabolism 320 Structural Characteristics 339
Action 340
10-7 Muscle performance capabilities depend on muscle
fiber type and physical conditioning 320 Axial and Appendicular Muscles 341
Types of Skeletal Muscle Fibers 320 11-5 Axial muscles are muscles of the head and neck,
Muscle Performance and the Distribution of Muscle vertebral column, trunk, and pelvic floor 341
Fibers 321 Muscles of the Head and Neck 341
Muscle Hypertrophy and Atrophy 321 Muscles of the Vertebral Column 351
Physical Conditioning 322 Oblique and Rectus Muscles 354
10-8 Cardiac muscle tissue differs structurally and Muscles of the Pelvic Floor 356
functionally from skeletal muscle tissue 324 11-6 Appendicular muscles are muscles of the shoulders,
Structural Characteristics of Cardiac Muscle Tissue 324 upper limbs, pelvis, and lower limbs 358
Functional Characteristics of Cardiac Muscle Tissue 325 Muscles of the Shoulders and Upper Limbs 358
10-9 Smooth muscle tissue differs structurally and Muscles of the Pelvis and Lower Limbs 369
functionally from skeletal and cardiac muscle 11-7 With advancing age, the size and power of muscle
tissue 325 tissue decrease 379
Structural Characteristics of Smooth Muscle Tissue 326
11-8 Exercise produces responses in multiple body
Functional Characteristics of Smooth Muscle Tissue 327 systems 379
Chapter Review 328 Chapter Review 381
Spotlights Spotlights
Events at the Neuromuscular Junction 300 Muscle Action 338
Excitation–Contraction Coupling 303
Clinical Case
The Contraction Cycle and Cross-Bridge Formation 304
The Weekend Warrior 333
Clinical Case
Clinical Notes
A Real Eye Opener 290
Intramuscular Injections 344
Clinical Notes Hernia 378
Tetanus 306
Rigor Mortis 308
Delayed-Onset Muscle Soreness 323
UNIT 3 CONTROL AND REGULATION

11 The Muscular System 332

12 Neural Tissue 385
An Introduction to the Muscular System 333
An Introduction to Neural Tissue 386
11-1 Fascicle arrangement is correlated with muscle power
and range of motion 333 12-1 The nervous system has anatomical and functional
Parallel Muscles 333 divisions 386
Convergent Muscles 333 The Anatomical Divisions of the Nervous System 386
Pennate Muscles 334 The Functional Divisions of the Nervous System 387
Circular Muscles 335 12-2 Neurons are nerve cells specialized for intercellular
communication 388
11-2 The three classes of levers increase muscle
efficiency 335 The Structure of Neurons 388
The Classification of Neurons 390
11-3 Muscle origins are at the fixed end of muscles, and
insertions are at the movable end of muscles 336 12-3 CNS and PNS neuroglia support and protect neurons 392
Origins and Insertions 336 Neuroglia of the Central Nervous System 392
Actions 337 Neuroglia of the Peripheral Nervous System 397
Neural Responses to Injuries 398
 Contents xvii

12-4 The membrane potential is the electrical potential of
the cell’s interior relative to its surroundings 398
The Membrane Potential 398
Changes in the Membrane Potential 402
Graded Potentials 404
13-3 Gray matter integrates information and initiates
commands, and white matter carries information from
place to place 435
Organization of Gray Matter 437
Organization of White Matter 437

12-5 An action potential is an electrical event 406 13-4 Spinal nerves form plexuses that are named according
The All-or-None Principle 406 to their level of emergence from the vertebral
canal 437
Generation of Action Potentials 406
Anatomy of Spinal Nerves 437
Propagation of Action Potentials 407
Peripheral Distribution of Spinal Nerves 438
12-6 Axon diameter, in addition to myelin, affects Nerve Plexuses 438
propagation speed 412
13-5 Interneurons are organized into functional groups
12-7 At synapses, communication occurs among neurons called neuronal pools 447
or between neurons and other cells 413
Synaptic Activity 413 13-6 Reflexes are rapid, automatic responses to
stimuli 449
General Properties of Synapses 413
The Reflex Arc 449
Cholinergic Synapses 414
Classification of Reflexes 452
12-8 Neurotransmitters and neuromodulators have various
functions 416 13-7 Spinal reflexes vary in complexity 453
The Activities of Other Neurotransmitters 416 Monosynaptic Reflexes 453
Neuromodulators 417 Polysynaptic Reflexes 454
How Neurotransmitters and Neuromodulators 13-8 The brain can affect spinal cord–based reflexes 455
Work 420 Voluntary Movements and Reflex Motor Patterns 456
12-9 Individual neurons process information by integrating Reinforcement and Inhibition 456
excitatory and inhibitory stimuli 421 Chapter Review 457
Postsynaptic Potentials 421 Spotlights
Presynaptic Inhibition and Presynaptic Facilitation 423 Peripheral Distribution of Spinal Nerves 440
The Rate of Generation of Action Potentials 423 Spinal Reflexes 450
Chapter Review 425 Clinical Case
Spotlights Prom Night 430
Resting Membrane Potential 400 Clinical Notes
Generation of an Action Potential 408 Anesthesia 435
Propagation of an Action Potential 410 Shingles 439
Clinical Case Sensory Innervation in the Hand 444
Did Franklin D. Roosevelt Really Have Polio? 386 Sensory Innervation in the Ankle and Foot 447

Clinical Notes
Rabies 390
Tumors 392
Demyelination 395
14 The Brain and Cranial
Nerves 461

An Introduction to the Brain and Cranial Nerves 462

13 The Spinal Cord, Spinal Nerves, 14-1 The brain has several principal structures, each with
and Spinal Reflexes 429 specific functions 462
Major Brain Regions and Landmarks 462
An Introduction to the Spinal Cord, Spinal Nerves, Embryology of the Brain 464
and Spinal Reflexes 430 Ventricles of the Brain 464
13-1 The brain and spinal cord make up the central nervous 14-2 The brain is protected and supported by the cranial
system (CNS), and the cranial nerves and spinal nerves meninges, cerebrospinal fluid, and the blood–brain
make up the peripheral nervous system (PNS) 430 barrier 465
13-2 The spinal cord is surrounded by three meninges and The Cranial Meninges 465
carries sensory and motor information 431 Cerebrospinal Fluid 467
Gross Anatomy of the Spinal Cord 431 The Blood Supply to the Brain 469
Spinal Meninges 433
xviii Contents

14-3 The medulla oblongata is continuous with the spinal 15-4 Separate pathways carry somatic sensory and visceral
cord and contains vital centers 470 sensory information 518
14-4 The pons contains nuclei and tracts that carry or relay Somatic Sensory Pathways 518
sensory and motor information 472 Visceral Sensory Pathways 523
14-5 The cerebellum coordinates learned and reflexive patterns 15-5 The somatic nervous system is an efferent division that
of muscular activity at the subconscious level 473 controls skeletal muscles 523
14-6 The midbrain regulates auditory and visual reflexes The Corticospinal Pathway 524
and controls alertness 475 The Medial and Lateral Pathways 525
The Basal Nuclei and Cerebellum 526
14-7 The diencephalon integrates sensory information with
motor output at the subconscious level 477 Levels of Processing and Motor Control 527
The Thalamus 477 Chapter Review 528
The Hypothalamus 478 Spotlights
Somatic Sensory Pathways 520
14-8 The limbic system is a group of tracts and nuclei that
function in emotion, motivation, and memory 480 Clinical Case
Living with Cerebral Palsy 509
14-9 The cerebrum, the largest region of the brain, contains
motor, sensory, and association areas 482 Clinical Notes
Assessment of Tactile Sensitivities 517
The Cerebral Cortex 482
Amyotrophic Lateral Sclerosis 526
The White Matter of the Cerebrum 482 Cerebral Palsy 527
The Basal Nuclei 482
Motor and Sensory Areas of the Cortex 486
14-10 Cranial reflexes involve sensory and motor fibers
of cranial nerves 503 16 The Autonomic Nervous
Chapter Review 504 System and Higher-Order
Spotlights Functions 531
Formation and Circulation of Cerebrospinal Fluid 468
Clinical Case An Introduction to the Autonomic Nervous System and
The Neuroanatomist’s Stroke 507 Higher-Order Functions 532
Clinical Notes 16-1 The autonomic nervous system is involved in the
Epidural and Subdural Hemorrhages 467 unconscious regulation of visceral functions and has
Disconnection Syndrome 488 sympathetic and parasympathetic divisions 532
Aphasia and Dyslexia 489 Organization of the ANS 532
Divisions of the ANS 533
16-2 The sympathetic division consists of preganglionic
15 Sensory Pathways and neurons and ganglionic neurons involved in using
energy and increasing metabolic rate 536
the Somatic Nervous Organization and Anatomy of the Sympathetic
System 508 Division 537
Sympathetic Activation 540
An Introduction to Sensory Pathways and the Somatic Nervous 16-3 Stimulation of sympathetic neurons leads to the
System 509 release of various neurotransmitters 540
15-1 Sensory information from all parts of the body is Sympathetic Stimulation and the Release of
routed to the somatosensory cortex 509 NE and E 541
15-2 Sensory receptors connect our internal and external Sympathetic Stimulation and the Release of
environments with the nervous system 510 ACh and NO 541
The Detection of Stimuli 510 Summary: The Sympathetic Division 542
The Interpretation of Sensory Information 511 16-4 The parasympathetic division consists of preganglionic
Adaptation 512 neurons and ganglionic neurons involved in
conserving energy and lowering metabolic rate 542
15-3 General sensory receptors are classified by the type of
stimulus that excites them 513 Organization and Anatomy of the Parasympathetic
Division 542
Nociceptors 513
Parasympathetic Activation 542
Thermoreceptors 514
Mechanoreceptors 514
Chemoreceptors 517
 Contents xix

16-5 Stimulation of parasympathetic neurons leads to the 17-4 Photoreceptors respond to light and change it into
release of the neurotransmitter ACh 544 electrical signals essential to visual physiology 581
Neurotransmitter Release 544 Visual Physiology 581
Membrane Receptors and Responses 544 The Visual Pathways 587
Summary: The Parasympathetic Division 544 17-5 Equilibrium sensations originate within the internal
16-6 The sympathetic and parasympathetic divisions ear, while hearing involves the detection and
interact, creating dual innervation 545 interpretation of sound waves 590
Anatomy of Dual Innervation 545 Anatomy of the Ear 590
Autonomic Tone 546 Equilibrium 593
Hearing 596
16-7 Visceral reflexes play a role in the integration and
control of autonomic functions 549 Chapter Review 604
Visceral Reflexes 549 Spotlights
Higher Levels of Autonomic Control 550 Olfaction and Gustation 566
Refractive Problems 582
The Integration of SNS and ANS Activities 551
Photoreception 584
16-8 Higher-order functions include memory and states of Clinical Case
consciousness 552
A Chance to See 564
Memory 552
Clinical Notes
States of Consciousness 554
Diabetic Retinopathy 574
16-9 Neurotransmitters influence brain chemistry and Detached Retina 574
behavior 556 Glaucoma 577
Motion Sickness 593
16-10 Aging produces various structural and functional
changes in the nervous system 557
Chapter Review 559
Spotlight
Overview of the Autonomic Nervous System 534
18 The Endocrine System 608
Clinical Case An Introduction to the Endocrine System 609
The First Day in Anatomy Lab 532
18-1 Homeostasis is preserved through intercellular
Clinical Notes communication 609
Amnesia 553
Categorizing Nervous System Disorders 555 18-2 The endocrine system regulates physiological
Alzheimer’s Disease 557 processes through the binding of hormones to
receptors 611
Classes of Hormones 611
Secretion and Distribution of Hormones 612
17 The Special Senses 563 Mechanisms of Hormone Action 614
Control of Endocrine Activity by Endocrine Reflexes 616
An Introduction to the Special Senses 564 18-3 The bilobed pituitary gland is an endocrine organ that
17-1 Olfaction, the sense of smell, involves olfactory releases nine peptide hormones 619
receptors responding to chemical stimuli 564 The Anterior Lobe of the Pituitary Gland 619
Olfactory Receptors 564 The Posterior Lobe of the Pituitary Gland 623
Olfactory Pathways 565 Summary: The Hormones of the Pituitary Gland 625
Olfactory Discrimination 565 18-4 The thyroid gland lies inferior to the larynx and
17-2 Gustation, the sense of taste, involves taste receptors requires iodine for hormone synthesis 626
responding to chemical stimuli 568 Thyroid Follicles and Thyroid Hormones 626
Taste Receptors 568 Functions of Thyroid Hormones 628
Gustatory Pathways 568 The C Cells of the Thyroid Gland and Calcitonin 629
Gustatory Discrimination 569 18-5 The four parathyroid glands, embedded in the
17-3 Internal eye structures contribute to vision, while posterior surface of the thyroid gland, secrete
accessory eye structures provide protection 570 parathyroid hormone to elevate blood Ca2 630
Accessory Structures of the Eye 570 18-6 The adrenal glands, consisting of a cortex and medulla,
The Eye 573 cap the kidneys and secrete several hormones 631
The Adrenal Cortex 631
The Adrenal Medulla 634
xx Contents

18-7 The pineal gland, attached to the roof of the third 19-4 The ABO blood types and Rh system are based on
ventricle, secretes melatonin 634 antigen–antibody responses 664
18-8 The pancreas is both an exocrine organ and endocrine Cross-Reactions in Transfusions 666
gland 635 Testing for Transfusion Compatibility 666
The Pancreatic Islets 636 19-5 The various types of white blood cells contribute to the
Insulin 637 body’s defenses 667
Glucagon 637 WBC Circulation and Movement 667
18-9 Many organs have secondary endocrine Types of WBCs 670
functions 639 The Differential Count and Changes in WBC
The Intestines 639 Profiles 671
The Kidneys 639 WBC Production 672
The Heart 640 19-6 Platelets, disc-shaped structures formed from
The Thymus 640 megakaryocytes, function in the clotting process 674
The Gonads 641 Platelet Functions 675
Adipose Tissue 643 Platelet Production 675

18-10 Hormones interact to produce coordinated 19-7 Hemostasis involves vascular spasm, platelet plug
physiological responses 643 formation, and blood coagulation 675
Role of Hormones in Growth 644 The Vascular Phase 675
Aging and Hormone Production 644 The Platelet Phase 676
Chapter Review 648 The Coagulation Phase 677
Spotlights Fibrinolysis 679
Structural Classification of Hormones 613 Chapter Review 680
G Proteins and Second Messengers 615 Spotlights
Diabetes Mellitus 638 The Composition of Whole Blood 654
The General Adaptation Syndrome 645 Hemolytic Disease of the Newborn 668
Clinical Case Clinical Case
Stones, Bones, and Groans 609 A Mysterious Blood Disorder 653
Clinical Notes Clinical Notes
Diabetes Insipidus 623 Collecting Blood for Analysis 656
Endocrine Disorders 642 Plasma Expanders 657
Hormones and Athletic Performance 646 Abnormal Hemoglobin 660

UNIT 4 FLUIDS AND TRANSPORT

20 The Heart 684

An Introduction to the Cardiovascular System 685

19 Blood 652 20-1 The heart is a four-chambered organ, supplied by the
coronary circulation, that pumps oxygen-poor blood
An Introduction to Blood and the Cardiovascular to the lungs and oxygen-rich blood to the rest of the
System 653 body 686
19-1 Blood has several important functions and unique The Pericardium 686
physical characteristics 653 Superficial Anatomy of the Heart 686
19-2 Plasma, the fluid portion of blood, contains significant The Heart Wall 686
quantities of plasma proteins 656 Cardiac Muscle Tissue 689
Plasma Proteins 656 Internal Anatomy and Organization 689
19-3 Red blood cells, formed by erythropoiesis, contain Connective Tissues and the Cardiac Skeleton 695
hemoglobin that can be recycled 657 The Blood Supply to the Heart 695
Abundance of RBCs 657 20-2 The conducting system distributes electrical impulses
Structure of RBCs 658 through the heart, and an electrocardiogram records
Hemoglobin 659 the associated electrical events 697
RBC Formation and Turnover 660 Cardiac Physiology 697
RBC Production 661 The Conducting System 697
 Contents xxi

The Electrocardiogram 702 The Cardiovascular Response to Hemorrhaging 751

Contractile Cells 703 Vascular Supply to Special Regions 752
20-3 Events during a complete heartbeat make up a cardiac 21-5 The pulmonary and systemic circuits of the
cycle 706 cardiovascular system exhibit three general functional
Phases of the Cardiac Cycle 707 patterns 753
Pressure and Volume Changes in the Cardiac Cycle 708 21-6 In the pulmonary circuit, deoxygenated blood enters
Heart Sounds 710 the lungs in arteries, and oxygenated blood leaves the
lungs by veins 754
20-4 Cardiodynamics examines the factors that affect
cardiac output 711 21-7 The systemic circuit carries oxygenated blood from
Overview: Factors Affecting Cardiac Output 711 the left ventricle to tissues and organs other than
the pulmonary exchange surfaces, and returns
Factors Affecting the Heart Rate 712
deoxygenated blood to the right atrium 755
Factors Affecting the Stroke Volume 715
Systemic Arteries 755
Summary: The Control of Cardiac Output 717
Systemic Veins 763
The Heart and the Cardiovascular System 718
Chapter Review 719 21-8 Modifications of fetal and maternal cardiovascular
systems promote the exchange of materials, and
Spotlights independence occurs at birth 772
Heart Disease and Heart Attacks 698
Placental Blood Supply 772
Cardiac Arrhythmias 704
Fetal Circulation in the Heart and Great Vessels 772
Clinical Case
Cardiovascular Changes at Birth 773
A Needle to the Chest 685
Clinical Note 21-9 Aging affects the blood, heart, and blood vessels 775
Abnormal Conditions Affecting Cardiac Output 708 Chapter Review 777
Spotlight
Congenital Heart Problems 774
Clinical Case
21 Blood Vessels Did Ancient Mummies Have Atherosclerosis? 724
and Circulation 723 Clinical Notes
Arteriosclerosis 728
An Introduction to Blood Vessels and Circulation 724 Edema 741
21-1 Arteries, arterioles, capillaries, venules, and veins differ
in size, structure, and functional properties 724
The Structure of Vessel Walls 725
Differences between Arteries and Veins 726
22 The Lymphatic System
Capillaries 729
and Immunity 781
Veins 732
An Introduction to the Lymphatic System
The Distribution of Blood 733
and Immunity 782
21-2 Pressure and resistance determine blood flow and
22-1 Surface barriers and internal defenses make up
affect rates of capillary exchange 734
innate defenses, and lymphocytes provide adaptive
Pressure 734 defenses 782
Total Peripheral Resistance 734
22-2 Lymphatic vessels, lymphocytes, lymphoid tissues, and
An Overview of Cardiovascular Pressures 736 lymphoid organs function in body defenses 783
Capillary Pressures and Capillary Exchange 739 Functions of the Lymphatic System 784
21-3 Cardiovascular regulatory mechanisms involve Lymphatic Vessels 784
autoregulation, neural mechanisms, and endocrine Lymphocytes 787
responses 742
Lymphoid Tissues 790
Autoregulation of Blood Flow within Tissues 742
Lymphoid Organs 790
Neural Mechanisms 743
The Lymphatic System and Body Defenses 794
Hormones and Cardiovascular Regulation 746
22-3 Innate (nonspecific) defenses do not discriminate
21-4 The cardiovascular system adapts to physiological between potential threats and respond the same
stress and maintains a special vascular supply to the regardless of the invader 796
brain, heart, and lungs 749
Physical Barriers 796
The Cardiovascular Response to Exercise 749
Phagocytes 796
xxii Contents

Immune Surveillance 798

Interferons 799 UNIT 5 ENVIRONMENTAL EXCHANGE
Complement System 799
Inflammation 801
Fever 802 23 The Respiratory System 830
22-4 Adaptive (specific) defenses respond to individual
threats and are either cell-mediated or antibody- An Introduction to the Respiratory System 831
mediated 802
23-1 The respiratory system, organized into an upper
Forms of Immunity 803
respiratory system and a lower respiratory system, has
Properties of Adaptive Immunity 804 several basic functions 831
An Introduction to the Immune Response 804 Functions of the Respiratory System 831
22-5 T cells play a role in initiating, maintaining, and Organization of the Respiratory System 832
controlling the immune response 805
23-2 Located outside the thoracic cavity, the upper
Antigen Presentation 805 respiratory system consists of the nose, nasal cavity,
Antigen Recognition 806 paranasal sinuses, and pharynx 835
Activation of CD8 T Cells 808 The Nose, Nasal Cavity, and Paranasal Sinuses 835
Activation of CD4 T Cells 809 The Pharynx 837
22-6 B cells respond to antigens by producing specific 23-3 Composed of cartilages, ligaments, and muscles, the
antibodies 810 larynx produces sound 837
B Cell Sensitization and Activation 810 Cartilages and Ligaments of the Larynx 837
Antibody Structure 811 Sound Production 838
Primary and Secondary Responses to Antigen The Laryngeal Musculature 839
Exposure 814
23-4 The trachea and primary bronchi convey air to and
Summary of the Immune Response 815 from the lungs 839
22-7 Immunocompetence enables a normal immune The Trachea 839
response; abnormal responses result in immune The Primary Bronchi 840
disorders 818
The Development of Immunocompetence 818
23-5 Enclosed by pleural cavities, the lungs are paired
organs containing alveoli, which permit gaseous
Cytokines of the Immune System 818 exchange 841
Immune Disorders 818 Lobes and Surfaces of the Lungs 841
Stress and the Immune Response 823 The Bronchi 841
22-8 The immune response diminishes as we age 825 The Bronchioles 841
22-9 The nervous and endocrine systems influence the Alveolar Ducts and Alveoli 843
immune response 825 The Blood Supply to the Lungs 846
Chapter Review 826 The Pleural Cavities and Pleural Membranes 846
Spotlight 23-6 External respiration and internal respiration allow
Cytokines of the Immune System 820 gaseous exchange within the body 847
Clinical Case 23-7 Pulmonary ventilation—the exchange of air between
Isn’t There a Vaccine for That? 782 the atmosphere and the lungs—involves pressure
Clinical Notes changes, muscle movement, and respiratory rates and
Cancer and the Lymphatic System 788 volumes 848
Graft Rejection and Immunosuppression 806 The Movement of Air 848
AIDS 819 Pressure Changes during Inhalation and Exhalation 849
The Mechanics of Breathing 852
Respiratory Rates and Volumes 854
23-8 Gas exchange depends on the partial pressures of
gases and the diffusion of molecules 856
The Gas Laws 856
Diffusion and Respiratory Function 858
 Contents xxiii

23-9 Most oxygen is transported bound to hemoglobin; 24-4 The esophagus is a muscular tube that transports
and carbon dioxide is transported in three ways: as solids and liquids from the pharynx to the
carbonic acid, bound to hemoglobin, or dissolved in stomach 895
plasma 860 Histology of the Esophagus 895
Oxygen Transport 860 Swallowing 896
Carbon Dioxide Transport 863
24-5 The stomach is a J-shaped organ that receives the
Summary: Gas Transport 864 bolus from the esophagus and aids in chemical and
23-10 Neurons in the medulla oblongata and pons, along mechanical digestion 897
with respiratory reflexes, control respiration 864 Anatomy of the Stomach 897
Local Regulation of Gas Transport and Alveolar Regulation of Gastric Activity 901
Function 865 Digestion and Absorption in the Stomach 901
The Respiratory Centers of the Brain 866
24-6 The small intestine digests and absorbs nutrients,
Respiratory Reflexes 870 and associated glandular organs assist with digestive
Voluntary Control of Respiration 872 processes 901
Changes in the Respiratory System at Birth 872 The Small Intestine 901
23-11 Respiratory performance declines with age 873 Histology of the Small Intestine 904
Intestinal Secretions 906
23-12 The respiratory system provides oxygen to, and
eliminates carbon dioxide from, other organ Intestinal Movements 907
systems 873 The Pancreas 907
Chapter Review 876 The Liver 909
Spotlights The Gallbladder 914
Respiratory Muscles and Pulmonary Ventilation 853 The Coordination of Secretion and Absorption 914
Control of Respiration 868 24-7 The large intestine is divided into three parts with
Clinical Case regional specialization 916
How Long Should a Cough Last? 831 The Cecum 917
Clinical Notes The Colon 917
Breakdown of the Respiratory Defense System 834 The Rectum 919
Pneumothorax 852 Histology of the Large Intestine 919
Decompression Sickness 858
Physiology of the Large Intestine 920
Blood Gas Analysis 860
Carbon Monoxide Poisoning 863 24-8 Digestion is the chemical alteration of food that allows
Emphysema and Lung Cancer 875 the absorption and use of nutrients 922
The Processing and Absorbing of Nutrients 922
Carbohydrate Digestion and Absorption 922

24 The Digestive System 880 Lipid Digestion and Absorption 925

Protein Digestion and Absorption 925
Water Absorption 926
An Introduction to the Digestive System 881
Ion Absorption 926
24-1 The digestive system, consisting of the digestive tract
and accessory organs, has overlapping food utilization 24-9 Many age-related changes affect digestion and
functions 881 absorption 928
Functions of the Digestive System 882 24-10 The digestive system is extensively integrated with
The Digestive Organs and the Peritoneum 883 other body systems 928
Histology of the Digestive Tract 885 Chapter Review 930
The Movement of Digestive Materials 886 Spotlights
Control of Digestive Functions 887 Regulation of Gastric Activity 902
Chemical Events of Digestion 923
24-2 The oral cavity contains the tongue, salivary glands,
Clinical Case
and teeth, each with specific functions 889
An Unusual Transplant 881
The Tongue 890
Clinical Notes
Salivary Glands 890
Peritonitis 883
The Teeth 892
Epithelial Renewal and Repair 886
24-3 The pharynx is a passageway between the oral cavity Mumps 890
and esophagus 894 Gastritis and Peptic Ulcers 897
xxiv Contents

Pancreatitis 907 Dietary Fats and Cholesterol 951

Cirrhosis 909 Vitamins 960
Colorectal Cancer 917 Alcohol 962
Inflammatory and Infectious Disorders of the Digestive System 920 Induced Hypothermia 965
Thermoregulatory Disorders 967

25 Metabolism and
Energetics 935 26 The Urinary System 972

An Introduction to Metabolism and Energetics 936 An Introduction to the Urinary System 973

25-1 Metabolism refers to all the chemical reactions 26-1 The kidneys, ureters, urinary bladder, and urethra
in the body, and energetics refers to the flow and make up the urinary system, which has three primary
transformation of energy 936 functions 973

25-2 Carbohydrate metabolism involves glycolysis, ATP 26-2 Kidneys are highly vascular organs containing
production, and gluconeogenesis 939 functional units called nephrons, which filter, reabsorb,
and secrete 974
Glycolysis 939
Sectional Anatomy of the Kidneys 975
Mitochondrial ATP Production 939
Blood Supply and Innervation of the Kidneys 976
Energy Yield of Glycolysis and Cellular Respiration 945
The Nephron 978
Gluconeogenesis 946
26-3 Different segments of the nephron form urine by
25-3 Lipid metabolism involves lipolysis, beta-oxidation,
filtration, reabsorption, and secretion 983
and the transport and distribution of lipids as free fatty
acids and lipoproteins 947 Basic Processes of Urine Formation 983
Lipid Catabolism 947 26-4 Hydrostatic and colloid osmotic pressures influence
Lipid Synthesis 949 glomerular filtration pressure, which in turn affects the
glomerular filtration rate 987
Lipid Transport and Distribution 949
Filtration Pressures 988
25-4 Protein catabolism involves transamination and
The Glomerular Filtration Rate 989
deamination, whereas protein synthesis involves
amination and transamination 952 Control of the GFR 989
Amino Acid Catabolism 952 26-5 Countercurrent multiplication, antidiuretic
Protein Synthesis 952 hormone, and aldosterone affect reabsorption and
secretion 992
25-5 The body experiences two patterns of metabolic
Reabsorption and Secretion at the PCT 992
activity: the absorptive and postabsorptive
states 956 The Nephron Loop and Countercurrent
Multiplication 993
25-6 Adequate nutrition is necessary to prevent deficiency Reabsorption and Secretion at the DCT 996
disorders and ensure physiological functioning 957
Reabsorption and Secretion along the Collecting
Food Groups and a Balanced Diet 957 System 997
Nitrogen Balance 957 The Control of Urine Volume and Osmotic
Minerals 959 Concentration 997
Vitamins 960 The Function of the Vasa Recta 1001
Diet and Disease 961 The Composition of Normal Urine 1001
25-7 Metabolic rate is the average caloric expenditure, and 26-6 Urine is transported by the ureters, stored in the
thermoregulation involves balancing heat-producing bladder, and eliminated through the urethra, aided by
and heat-losing mechanisms 962 the micturition reflex 1004
Energy Gains and Losses 962 The Ureters 1005
Thermoregulation 964 The Urethra 1006
Chapter Review 969 The Micturition Reflex and Urination 1007
Spotlight 26-7 Age-related changes affect kidney function and the
Absorptive and Postabsorptive States 954 micturition reflex 1009
Clinical Case 26-8 The urinary system is one of several body systems
The Miracle Supplement 936 involved in waste excretion 1011
Clinical Notes
Carbohydrate Loading 947
 Contents xxv

Chapter Review 1011 Metabolic Acidosis 1041

Spotlight Metabolic Alkalosis 1043
Summary of Renal Function 1002 The Detection of Acidosis and Alkalosis 1043
Clinical Case 27-7 Aging affects several aspects of fluid, electrolyte, and
A Case of “Hidden” Bleeding 973 acid–base balance 1045
Clinical Notes Chapter Review 1046
Analysis of Renal Blood Flow 977 Spotlight
Glomerulonephritis 982 The Diagnosis of Acid–Base Disorders 1044
Diuretics 997
Urinary Obstruction 1008
Clinical Case
Renal Failure and Kidney Transplant 1009 When Treatment Makes You Worse 1016
Clinical Notes
Water and Weight Loss 1023
Athletes and Salt Loss 1027
27 Fluid, Electrolyte, and
Acid–Base Balance 1015
UNIT 6 CONTINUITY OF LIFE
An Introduction to Fluid, Electrolyte, and Acid–Base
Balance 1016
27-1 Fluid balance, electrolyte balance, and acid–
base balance are interrelated and essential to
28 The Reproductive
homeostasis 1016 System 1050
27-2 The ECF and ICF make up the fluid compartments,
which also contain cations and anions 1017 An Introduction to the Reproductive System 1051
The ECF and the ICF 1017 28-1 Basic reproductive system structures are gonads,
Basic Concepts in the Regulation of Fluids and ducts, accessory glands and organs, and external
Electrolytes 1019 genitalia 1051
An Overview of the Primary Regulatory Hormones 1020 28-2 Spermatogenesis occurs in the testes, and hormones
The Interplay between Fluid Balance and Electrolyte from the hypothalamus, anterior lobe of the
Balance 1021 pituitary gland, and testes control male reproductive
functions 1052
27-3 Hydrostatic and osmotic pressures regulate the
The Testes 1052
movement of water and electrolytes to maintain fluid
balance 1021 Spermatogenesis 1056
Fluid Movement within the ECF 1021 Mitosis and Meiosis 1056
Fluid Gains and Losses 1022 The Anatomy of a Spermatozoon 1060
Fluid Shifts 1022 The Male Reproductive Tract 1061
The Accessory Glands 1062
27-4 Sodium, potassium, calcium, magnesium, phosphate,
and chloride balance is essential for maintaining Semen 1064
homeostasis 1024 The External Genitalia 1064
Sodium Balance 1025 Hormones and Male Reproductive Function 1066
Potassium Balance 1027 28-3 Oogenesis occurs in the ovaries, and hormones
Balance of Other Electrolytes 1028 from the pituitary gland and gonads control female
reproductive functions 1068
27-5 In acid–base balance, regulation of hydrogen ions in
body fluids involves buffer systems and respiratory The Ovaries 1069
and renal compensatory mechanisms 1030 The Uterine Tubes 1074
The Importance of pH Control 1030 The Uterus 1075
Types of Acids in the Body 1030 The Vagina 1079
Mechanisms of pH Control 1032 The External Genitalia 1080
Maintenance of Acid–Base Balance 1035 The Mammary Glands 1081
Hormones and Female Reproductive Function 1081
27-6 Respiratory acidosis/alkalosis and metabolic
acidosis/alkalosis are classes of acid–base balance 28-4 The autonomic nervous system influences male and
disturbances 1038 female sexual function 1087
Respiratory Acidosis 1038 Male Sexual Function 1087
Respiratory Alkalosis 1041 Female Sexual Function 1088
xxvi Contents

28-5 With age, decreasing levels of reproductive hormones the uterus undergoes structural and functional
cause functional changes 1088 changes 1112
Menopause 1088 Pregnancy and Maternal Systems 1112
The Male Climacteric 1089 Structural and Functional Changes in the Uterus 1114
28-6 The reproductive system secretes hormones affecting 29-6 Labor consists of the dilation, expulsion, and placental
growth and metabolism of all body systems 1089 stages 1115
Chapter Review 1092 Stages of Labor 1115
Spotlights Premature Labor 1117
Regulation of Male Reproduction 1067 Difficult Deliveries 1117
Regulation of Female Reproduction 1084 Multiple Births 1117
Clinical Case 29-7 Postnatal stages are the neonatal period, infancy,
A Post-Game Mystery 1051 childhood, adolescence, and maturity, followed by
Clinical Notes senescence 1118
Dehydroepiandrosterone (DHEA) 1066 The Neonatal Period, Infancy, and Childhood 1118
Prostatic Hypertrophy and Prostate Cancer 1068 Adolescence and Maturity 1120
Ovarian Cancer 1074 Senescence 1122
Cervical Cancer 1075
Breast Cancer 1083 29-8 Genes and chromosomes determine patterns of
inheritance 1122
Patterns of Inheritance 1123
Sources of Individual Variation 1126
29 Development and Sex-Linked Inheritance 1128
Inheritance 1095 The Human Genome Project and Beyond 1129
Chapter Review 1131
An Introduction to Development and Inheritance 1096 Spotlight
29-1 Development, marked by various stages, is a Extraembryonic Membranes and Placenta Formation 1104
continuous process that occurs from fertilization to Clinical Case
maturity 1096 The Twins That Looked Nothing Alike 1096
29-2 Fertilization—the fusion of a secondary oocyte and a Clinical Notes
spermatozoon—forms a zygote 1097 Abortion 1114
The Oocyte at Ovulation 1097 Chromosomal Abnormalities and Genetic Analysis 1130
Oocyte Activation 1099
29-3 Gestation consists of three stages of prenatal Appendix
development: the first, second, and third The Composition of Minor Body Fluids A-1
trimesters 1099 The Chemistry of Blood, Cerebrospinal Fluid, and Urine A-2
The Periodic Table A-3
29-4 Cleavage, implantation, placentation, and
Codon Chart A-4
embryogenesis are critical events of the first
trimester 1100 Answers to Checkpoints, End-of-Chapter Questions,
Cleavage and Blastocyst Formation 1101 and Clinical Case Wrap-Ups AN-1
Implantation 1101
Glossary G-1
Placentation 1106
Embryogenesis 1107 Credits C-1
29-5 During the second and third trimesters, maternal Index I-1
organ systems support the developing fetus, and
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flickering flame, before an image of the Virgin. At sight of it she
repressed a sob.
“You see, my child,” said the Mother Superior poetically, “it must
have been waiting for you. Anyhow it is empty. Perhaps it may have
known you were coming.”
She spoke softly so that the long rows of sleepers might not be
disturbed, then proceeded to turn down the coverlets.
“Oh, Mother,” Madeleine suddenly whispered softly as she stood
by the bed, “won’t you let me stay always? I never want to go out
any more. I have had such a hard time. I will work so hard for you if
you will let me stay!”
The experienced Sister looked at her curiously. Never before had
she heard such a plea.
“Why, yes, my child,” she said. “If you wish to stay I’m sure it can
be arranged. It is not as we usually do, but you are not the only one
who has gone out in the past and come back to us. I am sure God
and the Blessed Virgin will hear your prayer for whatever is right. But
now go to bed and sleep. You need rest. I can see that. And to-
morrow, or any time, or never, as you choose, you may tell me what
has happened.”
She urged her very gently to enter and then tucked the covers
about her, laying finally a cool, wrinkled hand on her forehead. For
answer Madeleine seized and put it to her lips, holding it so.
“Oh, Mother,” she sobbed as the Sister bent over her, “don’t ever
make me go out in the world again, will you? You won’t, will you? I’m
so tired! I’m so tired!”
“No dear, no,” soothed the Sister, “not unless you wish it. And now
rest. You need never go out in the world again unless you wish.”
And withdrawing the hand from the kissing lips, she tiptoed silently
from the room.
 II
THE HAND

D AVIDSON could distinctly remember that it was between two

and three years after the grisly event in the Monte Orte range—
the sickening and yet deserved end of Mersereau, his quondam
partner and fellow adventurer—that anything to be identified with
Mersereau’s malice toward him, and with Mersereau’s probable
present existence in the spirit world, had appeared in his life.
He and Mersereau had worked long together as prospectors,
investors, developers of property. It was only after they had struck it
rich in the Klondike that Davidson had grown so much more apt and
shrewd in all commercial and financial matters, whereas Mersereau
had seemed to stand still—not to rise to the splendid opportunities
which then opened to him. Why, in some of those later deals it had
not been possible for Davidson even to introduce his old partner to
some of the moneyed men he had to deal with. Yet Mersereau had
insisted, as his right, if you please, on being “in on” everything—
everything!
Take that wonderful Monte Orte property, the cause of all the
subsequent horror. He, Davidson—not Mersereau—had discovered
or heard of the mine, and had carried it along, with old Besmer as a
tool or decoy—Besmer being the ostensible factor—until it was all
ready for him to take over and sell or develop. Then it was that
Mersereau, having been for so long his partner, demanded a full half
—a third, at least—on the ground that they had once agreed to work
together in all these things.
Think of it! And Mersereau growing duller and less useful and
more disagreeable day by day, and year by year! Indeed, toward the
last he had threatened to expose the trick by which jointly, seven
years before, they had possessed themselves of the Skyute Pass
Mine; to drive Davidson out of public and financial life, to have him
arrested and tried—along with himself, of course. Think of that!
But he had fixed him—yes, he had, damn him! He had trailed
Mersereau that night to old Besmer’s cabin on the Monte Orte, when
Besmer was away. Mersereau had gone there with the intention of
stealing the diagram of the new field, and had secured it, true
enough. A thief he was, damn him. Yet, just as he was making safely
away, as he thought, he, Davidson, had struck him cleanly over the
ear with that heavy rail-bolt fastened to the end of a walnut stick, and
the first blow had done for him.
Lord, how the bone above Mersereau’s ear had sounded when it
cracked! And how bloody one side of that bolt was! Mersereau
hadn’t had time to do anything before he was helpless. He hadn’t
died instantly, though, but had turned over and faced him, Davidson,
with that savage, scowling face of his and those blazing, animal
eyes.
Lying half propped up on his left elbow, Mersereau had reached
out toward him with that big, rough, bony right hand of his—the right
with which he always boasted of having done so much damage on
this, that, and the other occasion—had glared at him as much as to
say:
“Oh, if I could only reach you just for a moment before I go!”
Then it was that he, Davidson, had lifted the club again. Horrified
as he was, and yet determined that he must save his own life, he
had finished the task, dragging the body back to an old fissure
behind the cabin and covering it with branches, a great pile of pine
fronds, and as many as one hundred and fifty boulders, great and
small, and had left his victim. It was a sickening job and a sickening
sight, but it had to be.
Then, having finished, he had slipped dismally away, like a jackal,
thinking of that hand in the moonlight, held up so savagely, and that
look. Nothing might have come of that either, if he hadn’t been
inclined to brood on it so much, on the fierceness of it.
 No, nothing had happened. A year had passed, and if anything
had been going to turn up it surely would have by then. He,
Davidson, had gone first to New York, later to Chicago, to dispose of
the Monte Orte claim. Then, after two years, he had returned here to
Mississippi, where he was enjoying comparative peace. He was
looking after some sugar property which had once belonged to him,
and which he was now able to reclaim and put in charge of his sister
as a home against a rainy day. He had no other.
But that body back there! That hand uplifted in the moonlight—to
clutch him if it could! Those eyes.

II—June, 1905

Take that first year, for instance, when he had returned to

Gatchard in Mississippi, whence both he and Mersereau had
originally issued. After looking after his own property he had gone
out to a tumble-down estate of his uncle’s in Issaqueena County—a
leaky old slope-roofed house where, in a bedroom on the top floor,
he had had his first experience with the significance or reality of the
hand.
Yes, that was where first he had really seen it pictured in that
curious, unbelievable way; only who would believe that it was
Mersereau’s hand? They would say it was an accident, chance, rain
dropping down. But the hand had appeared on the ceiling of that
room just as sure as anything, after a heavy rain-storm—it was
almost a cyclone—when every chink in the old roof had seemed to
leak water.
During the night, after he had climbed to the room by way of those
dismal stairs with their great landing and small glass oil-lamp he
carried, and had sunk to rest, or tried to, in the heavy, wide, damp
bed, thinking, as he always did those days, of the Monte Orte and
Mersereau, the storm had come up. As he had listened to the wind
moaning outside he had heard first the scratch, scratch, scratch, of
some limb, no doubt, against the wall—sounding, or so it seemed in
his feverish unrest, like some one penning an indictment against him
with a worn, rusty pen.
 And then, the storm growing worse, and in a fit of irritation and
self-contempt at his own nervousness, he had gone to the window,
but just as lightning struck a branch of the tree nearest the window
and so very near him, too—as though some one, something, was
seeking to strike him—(Mersereau?) and as though he had been
lured by that scratching. God! He had retreated, feeling that it was
meant for him.
But that big, knotted hand painted on the ceiling by the dripping
water during the night! There it was, right over him when he awoke,
outlined or painted as if with wet, gray whitewash against the
wretched but normally pale-blue of the ceiling when dry. There it was
—a big, open hand just like Mersereau’s as he had held it up that
night—huge, knotted, rough, the fingers extended as if tense and
clutching. And, if you will believe it, near it was something that
looked like a pen—an old, long-handled pen—to match that scratch,
scratch, scratch!
“Huldah,” he had inquired of the old black mammy who entered in
the morning to bring him fresh water and throw open the shutters,
“what does that look like to you up there—that patch on the ceiling
where the rain came through?”
He wanted to reassure himself as to the character of the thing he
saw—that it might not be a creation of his own feverish imagination,
accentuated by the dismal character of this place.
“’Pears t’ me mo’ like a big han’ ’an anythin’ else, Marse Davi’son,”
commented Huldah, pausing and staring upward. “Mo’ like a big fist,
kinda. Dat air’s a new drip come las’ night, I reckon. Dis here ole
place ain’ gonna hang togethah much longah, less’n some repairin’
be done mighty quick now. Yassir, dat air’s a new drop, sho’s yo’
bo’n, en it come on’y las’ night. I hain’t never seed dat befo’.”
And then he had inquired, thinking of the fierceness of the storm:
“Huldah, do you have many such storms up this way?”
“Good gracious, Marse Davi’son, we hain’t seed no sech blow en
—en come three years now. I hain’t seed no sech lightnin’ en I doan’
know when.”
 Wasn’t that strange, that it should all come on the night, of all
nights, when he was there? And no such other storm in three years!
Huldah stared idly, always ready to go slow and rest, if possible,
whereas he had turned irritably. To be annoyed by ideas such as
this! To always be thinking of that Monte Orte affair! Why couldn’t he
forget it? Wasn’t it Mersereau’s own fault? He never would have
killed the man if he hadn’t been forced to it.
And to be haunted in this way, making mountains out of mole-hills,
as he thought then! It must be his own miserable fancy—and yet
Mersereau had looked so threateningly at him. That glance had
boded something; it was too terrible not to.
Davidson might not want to think of it, but how could he stop?
Mersereau might not be able to hurt him any more, at least not on
this earth; but still, couldn’t he? Didn’t the appearance of this hand
seem to indicate that he might? He was dead, of course. His body,
his skeleton, was under that pile of rocks and stones, some of them
as big as wash-tubs. Why worry over that, and after two years? And
still—
That hand on the ceiling!

III—December, 1905

Then, again, take that matter of meeting Pringle in Gatchard just at

that time, within the same week. It was due to Davidson’s sister. She
had invited Mr. and Mrs. Pringle in to meet him one evening, without
telling him that they were spiritualists and might discuss spiritualism.
Clairvoyance, Pringle called it, or seeing what can’t be seen with
material eyes, and clairaudience, or hearing what can’t be heard with
material ears, as well as materialization, or ghosts, and table-
rapping, and the like. Table-rapping—that damned tap-tapping that
he had been hearing ever since!
It was Pringle’s fault, really. Pringle had persisted in talking. He,
Davidson, wouldn’t have listened, except that he somehow became
fascinated by what Pringle said concerning what he had heard and
seen in his time. Mersereau must have been at the bottom of that,
too.
At any rate, after he had listened, he was sorry, for Pringle had
had time to fill his mind full of those awful facts or ideas which had
since harassed him so much—all that stuff about drunkards,
degenerates, and weak people generally being followed about by
vile, evil spirits and used to effect those spirits’ purposes or desires
in this world. Horrible!
Wasn’t it terrible? Pringle—big, mushy, creature that he was, sickly
and stagnant like a springless pool—insisted that he had even seen
clouds of these spirits about drunkards, degenerates, and the like, in
street-cars, on trains, and about vile corners at night. Once, he said,
he had seen just one evil spirit—think of that!—following a certain
man all the time, at his left elbow—a dark, evil, red-eyed thing, until
finally the man had been killed in a quarrel.
Pringle described their shapes, these spirits, as varied. They were
small, dark, irregular clouds, with red or green spots somewhere for
eyes, changing in form and becoming longish or round like a jellyfish,
or even like a misshapen cat or dog. They could take any form at will
—even that of a man.
Once, Pringle declared, he had seen as many as fifty about a
drunkard who was staggering down a street, all of them trying to
urge him into the nearest saloon, so that they might re-experience in
some vague way the sensation of drunkenness, which at some time
or other they themselves, having been drunkards in life, had
enjoyed!
It would be the same with a drug fiend, or indeed with any one of
weak or evil habits. They gathered about such an one like flies, their
red or green eyes glowing—attempting to get something from them,
perhaps, if nothing more than a little sense of their old earth-life.
The whole thing was so terrible and disturbing at the time,
particularly that idea of men being persuaded or influenced to
murder, that he, Davidson, could stand it no longer, and got up and
left. But in his room upstairs he meditated on it, standing before his
mirror. Suddenly—would he ever forget it—as he was taking off his
collar and tie, he had heard that queer tap, tap, tap, right on his
dressing-table or under it, and for the first time, which Pringle said,
ghosts made when table-rapping in answer to a call, or to give
warning of their presence.
Then something said to him, almost as clearly as if he heard it:
“This is me, Mersereau, come back at last to get you!
Pringle was just an excuse of mine to let you know I was
coming, and so was that hand in that old house, in
Issaqueena County. It was mine! I will be with you from
now on. Don’t think I will ever leave you!”
It had frightened and made him half sick, so wrought up was he.
For the first time he felt cold chills run up and down his spine—the
creeps. He felt as if some one were standing over him—Mersereau,
of course—only he could not see or hear a thing, just that faint tap at
first, growing louder a little later, and quite angry when he tried to
ignore it.
People did live, then, after they were dead, especially evil people
—people stronger than you, perhaps. They had the power to come
back, to haunt, to annoy you if they didn’t like anything you had done
to them. No doubt Mersereau was following him in the hope of
revenge, there in the spirit world, just outside this one, close at his
heels, like that evil spirit attending the other man whom Pringle had
described.

IV—February, 1906

Take that case of the hand impressed on the soft dough and
plaster of Paris, described in an article that he had picked up in the
dentist’s office out there in Pasadena—Mersereau’s very hand, so
far as he could judge. How about that for a coincidence, picking up
the magazine with that disturbing article about psychic
materialization in Italy, and later in Berne, Switzerland, where the
scientists were gathered to investigate that sort of thing? And just
when he was trying to rid himself finally of the notion that any such
thing could be!
 According to that magazine article, some old crone over in Italy—
spiritualist, or witch, or something—had got together a crowd of
experimentalists or professors in an abandoned house on an almost
deserted island off the coast of Sardinia. There they had conducted
experiments with spirits, which they called materialization, getting the
impression of the fingers of a hand, or of a whole hand and arm, or
of a face, on a plate of glass covered with soot, the plate being
locked in a small safe on the center of a table about which they sat!
He, Davidson, couldn’t understand, of course, how it was done,
but done it was. There in that magazine were half a dozen pictures,
reproductions of photographs of a hand, an arm and a face—or a
part of one, anyhow. And if they looked like anything, they looked
exactly like Mersereau’s! Hadn’t Pringle, there in Gatchard, Miss.,
stated spirits could move anywhere, over long distances, with the
speed of light. And would it be any trick for Mersereau to appear
there at Sardinia, and then engineer this magazine into his presence,
here in Los Angeles? Would it? It would not. Spirits were free and
powerful over there, perhaps.
There was not the least doubt that these hands, these partial
impressions of a face, were those of Mersereau. Those big knuckles!
That long, heavy, humped nose and big jaw! Whose else could they
be?—they were Mersereau’s, intended, when they were made over
there in Italy, for him, Davidson, to see later here in Los Angeles.
Yes, they were! And looking at that sinister face reproduced in the
magazine, it seemed to say, with Mersereau’s old coarse sneer:
“You see? You can’t escape me! I’m showing you how
much alive I am over here, just as I was on earth. And I’ll
get you yet, even if I have to go farther than Italy to do it!”
It was amazing, the shock he took from that. It wasn’t just that
alone, but the persistence and repetition of this hand business. What
could it mean? Was it really Mersereau’s hand? As for the face, it
wasn’t all there—just the jaw, mouth, cheek, left temple, and a part of
the nose and eye; but it was Mersereau’s, all right. He had gone
clear over there into Italy somewhere, in a lone house on an island,
to get this message of his undying hate back to him. Or was it just
spirits, evil spirits, bent on annoying him because he was nervous
and sensitive now?

V—October, 1906

Even new crowded hotels and new buildings weren’t the protection
he had at first hoped and thought they would be. Even there you
weren’t safe—not from a man like Mersereau. Take that incident
there in Los Angeles, and again in Seattle, only two months ago
now, when Mersereau was able to make that dreadful explosive or
crashing sound, as if one had burst a huge paper bag full of air, or
upset a china-closet full of glass and broken everything, when as a
matter of fact nothing at all had happened. It had frightened him
horribly the first two or three times, believing as he did that
something fearful had happened. Finding that it was nothing—or
Mersereau—he was becoming used to it now; but other people,
unfortunately, were not.
He would be—as he had been that first time—sitting in his room
perfectly still and trying to amuse himself, or not to think, when
suddenly there would be that awful crash. It was astounding! Other
people heard it, of course. They had in Los Angeles. A maid and a
porter had come running the first time to inquire, and he had had to
protest that he had heard nothing. They couldn’t believe it at first,
and had gone to other rooms to look. When it happened the second
time, the management had protested, thinking it was a joke he was
playing; and to avoid the risk of exposure he had left.
After that he could not keep a valet or nurse about him for long.
Servants wouldn’t stay, and managers of hotels wouldn’t let him
remain when such things went on. Yet he couldn’t live in a house or
apartment alone, for there the noises and atmospheric conditions
would be worse than ever.

VI—June, 1907

Take that last old house he had been in—but never would be in
again!—at Anne Haven. There he actually visualized the hand—a
thing as big as a washtub at first, something like smoke or shadow in
a black room moving about over the bed and everywhere. Then, as
he lay there, gazing at it spellbound, it condensed slowly, and he
began to feel it. It was now a hand of normal size—there was no
doubt of it in the world—going over him softly, without force, as a
ghostly hand must, having no real physical strength, but all the time
with a strange, electric, secretive something about it, as if it were not
quite sure of itself, and not quite sure that he was really there.
The hand, or so it seemed—God!—moved right up to his neck and
began to feel over that as he lay there. Then it was that he guessed
just what it was that Mersereau was after.
It was just like a hand, the fingers and thumb made into a circle
and pressed down over his throat, only it moved over him gently at
first, because it really couldn’t do anything yet, not having the
material strength. But the intention! The sense of cruel, savage
determination that went with it!
And yet, if one went to a nerve specialist or doctor about all this,
as he did afterward, what did the doctor say? He had tried to
describe how he was breaking down under the strain, how he could
not eat or sleep on account of all these constant tappings and
noises; but the moment he even began to hint at his experiences,
especially the hand or the noises, the doctor exclaimed:
“Why, this is plain delusion! You’re nervously run down, that’s all
that ails you—on the verge of pernicious anemia, I should say. You’ll
have to watch yourself as to this illusion about spirits. Get it out of
your mind. There’s nothing to it!”
Wasn’t that just like one of these nerve specialists, bound up in
their little ideas of what they knew or saw, or thought they saw?

VII—November, 1907

And now take this very latest development at Battle Creek recently
where he had gone trying to recuperate on the diet there. Hadn’t
Mersereau, implacable demon that he was, developed this latest
trick of making his food taste queer to him—unpalatable, or with an
odd odor?
 He, Davidson, knew it was Mersereau, for he felt him beside him
at the table whenever he sat down. Besides, he seemed to hear
something—clairaudience was what they called it, he understood—
he was beginning to develop that, too, now! It was Mersereau, of
course, saying in a voice which was more like a memory of a voice
than anything real—the voice of some one you could remember as
having spoken in a certain way, say, ten years or more ago:
“I’ve fixed it so you can’t eat any more, you—”
There followed a long list of vile expletives, enough in itself to
sicken one.
Thereafter, in spite of anything he could do to make himself think
to the contrary, knowing that the food was all right, really, Davidson
found it to have an odor or a taste which disgusted him, and which
he could not overcome, try as he would. The management assured
him that it was all right, as he knew it was—for others. He saw them
eating it. But he couldn’t—had to get up and leave, and the little he
could get down he couldn’t retain, or it wasn’t enough for him to live
on. God, he would die, this way! Starve, as he surely was doing by
degrees now.
And Mersereau always seeming to be standing by. Why, if it
weren’t for fresh fruit on the stands at times, and just plain, fresh-
baked bread in bakers’ windows, which he could buy and eat quickly,
he might not be able to live at all. It was getting to that pass!

VIII—August, 1908

That wasn’t the worst, either, bad as all that was. The worst was
the fact that under the strain of all this he was slowly but surely
breaking down, and that in the end Mersereau might really succeed
in driving him out of life here—to do what, if anything, to him there?
What? It was such an evil pack by which he was surrounded, now,
those who lived just on the other side and hung about the earth, vile,
debauched creatures, as Pringle had described them, and as
Davidson had come to know for himself, fearing them and their ways
so much, and really seeing them at times.
 Since he had come to be so weak and sensitive, he could see
them for himself—vile things that they were, swimming before his
gaze in the dark whenever he chanced to let himself be in the dark,
which was not often—friends of Mersereau, no doubt, and inclined to
help him just for the evil of it.
For this long time now Davidson had taken to sleeping with the
light on, wherever he was, only tying a handkerchief over his eyes to
keep out some of the glare. Even then he could see them—queer,
misshapen things, for all the world like wavy, stringy jellyfish or coils
of thick, yellowish-black smoke, moving about, changing in form at
times, yet always looking dirty or vile, somehow, and with those
queer, dim, reddish or greenish glows for eyes. It was sickening!

IX—October, 1908

Having accomplished so much, Mersereau would by no means be

content to let him go. Davidson knew that! He could talk to him
occasionally now, or at least could hear him and answer back, if he
chose, when he was alone and quite certain that no one was
listening.
Mersereau was always saying, when Davidson would listen to him
at all—which he wouldn’t often—that he would get him yet, that he
would make him pay, or charging him with fraud and murder.
“I’ll choke you yet!” The words seemed to float in from somewhere,
as if he were remembering that at some time Mersereau had said
just that in his angry, savage tone—not as if he heard it; and yet he
was hearing it of course.

“I’ll choke you yet! You can’t escape! You may think you’ll die a
natural death, but you won’t, and that’s why I’m poisoning your food
to weaken you. You can’t escape! I’ll get you, sick or well, when you
can’t help yourself, when you’re sleeping. I’ll choke you, just as you
hit me with that club. That’s why you’re always seeing and feeling
this hand of mine! I’m not alone. I’ve nearly had you many a time
already, only you have managed to wriggle out so far, jumping up,
but some day you won’t be able to—see? Then—”

The voice seemed to die away at times, even in the middle of a

sentence, but at the other times—often, often—he could hear it
completing the full thought. Sometimes he would turn on the thing
and exclaim:
“Oh, go to the devil!” or, “Let me alone!” or, “Shut up!” Even in a
closed room and all alone, such remarks seemed strange to him,
addressed to a ghost; but he couldn’t resist at times, annoyed as he
was. Only he took good care not to talk if any one was about.
It was getting so that there was no real place for him outside of an
asylum, for often he would get up screaming at night—he had to, so
sharp was the clutch on his throat—and then always, wherever he
was, a servant would come in and want to know what was the
matter. He would have to say that it was a nightmare—only the
management always requested him to leave after the second or third
time, say, or after an explosion or two. It was horrible!
He might as well apply to a private asylum or sanatorium now,
having all the money he had, and explain that he had delusions—
delusions! Imagine!—and ask to be taken care of. In a place like that
they wouldn’t be disturbed by his jumping up and screaming at night,
feeling that he was being choked, as he was, or by his leaving the
table because he couldn’t eat the food, or by his talking back to
Mersereau, should they chance to hear him, or by the noises when
they occurred.
They could assign him a special nurse and a special room, if he
wished—only he didn’t wish to be too much alone. They could put
him in charge of some one who would understand all these things, or
to whom he could explain. He couldn’t expect ordinary people, or
hotels catering to ordinary people, to put up with him any more.
Mersereau and his friends made too much trouble.
 He must go and hunt up a good place somewhere where they
understood such things, or at least tolerated them, and explain, and
then it would all pass for the hallucinations of a crazy man,—though,
as a matter of fact, he wasn’t crazy at all. It was all too real, only the
average or so-called normal person couldn’t see or hear as he could
—hadn’t experienced what he had.

X—December, 1908

“The trouble is, doctor, that Mr. Davidson is suffering from the
delusion that he is pursued by evil spirits. He was not committed
here by any court, but came of his own accord about four months
ago, and we let him wander about here at will. But he seems to be
growing worse, as time goes on.
“One of his worst delusions, doctor, is that there is one spirit in
particular who is trying to choke him to death. Dr. Major, our
superintendent, says he has incipient tuberculosis of the throat, with
occasional spasmodic contractions. There are small lumps or
calluses here and there as though caused by outside pressure and
yet our nurse assures us that there is no such outside irritation. He
won’t believe that; but whenever he tries to sleep, especially in the
middle of the night, he will jump up and come running out into the
hall, insisting that one of these spirits, which he insists are after him,
is trying to choke him to death. He really seems to believe it, for he
comes out coughing and choking and feeling at his neck as if some
one has been trying to strangle him. He always explains the whole
matter to me as being the work of evil spirits, and asks me to not pay
any attention to him unless he calls for help or rings his call-bell; and
so I never think anything more of it now unless he does.
“Another of his ideas is that these same spirits do something to his
food—put poison in it, or give it a bad odor or taste, so that he can’t
eat it. When he does find anything he can eat, he grabs it and almost
swallows it whole, before, as he says, the spirits have time to do
anything to it. Once, he says, he weighed more than two hundred
pounds, but now he only weighs one hundred and twenty. His case
is exceedingly strange and pathetic, doctor!
 “Dr. Major insists that it is purely a delusion, that so far as being
choked is concerned, it is the incipient tuberculosis, and that his
stomach trouble comes from the same thing; but by association of
ideas, or delusion, he thinks some one is trying to choke him and
poison his food, when it isn’t so at all. Dr. Major says that he can’t
imagine what could have started it. He is always trying to talk to Mr.
Davidson about it, but whenever he begins to ask him questions, Mr.
Davidson refuses to talk, and gets up and leaves.
“One of the peculiar things about his idea of being choked, doctor,
is that when he is merely dozing he always wakes up in time, and
has the power to throw it off. He claims that the strength of these
spirits is not equal to his own when he is awake, or even dozing, but
when he’s asleep their strength is greater and that then they may
injure him. Sometimes, when he has had a fright like this, he will
come out in the hall and down to my desk there at the lower end,
and ask if he mayn’t sit there by me. He says it calms him. I always
tell him yes, but it won’t be five minutes before he’ll get up and leave
again, saying that he’s being annoyed, or that he won’t be able to
contain himself if he stays any longer, because of the remarks being
made over his shoulder or in his ear.
“Often he’ll say: ‘Did you hear that, Miss Liggett? It’s astonishing,
the low, vile things that man can say at times!’ When I say, ‘No, I
didn’t hear,’ he always says, ‘I’m so glad!’”
“No one has ever tried to relieve him of this by hypnotism, I
suppose?”
“Not that I know of, doctor. Dr. Major may have tried it. I have only
been here three months.”
“Tuberculosis is certainly the cause of the throat trouble, as Dr.
Major says, and as for the stomach trouble, that comes from the
same thing—natural enough under the circumstances. We may have
to resort to hypnotism a little later. I’ll see. In the meantime you’d
better caution all who come in touch with him never to sympathize,
or even to seem to believe in anything he imagines is being done to
him. It will merely encourage him in his notions. And get him to take
his medicine regularly; it won’t cure, but it will help. Dr. Major has
asked me to give especial attention to his case, and I want the
conditions as near right as possible.”
“Yes, sir.”

XI—January, 1909

The trouble with these doctors was that they really knew nothing of
anything save what was on the surface, the little they had learned at
a medical college or in practise—chiefly how certain drugs, tried by
their predecessors in certain cases, were known to act. They had no
imagination whatever, even when you tried to tell them.
Take that latest young person who was coming here now in his
good clothes and with his car, fairly bursting with his knowledge of
what he called psychiatrics, looking into Davidson’s eyes so hard
and smoothing his temples and throat—massage, he called it—
saying that he had incipient tuberculosis of the throat and stomach
trouble, and utterly disregarding the things which he, Davidson,
could personally see and hear! Imagine the fellow trying to persuade
him, at this late date, that all that was wrong with him was
tuberculosis, that he didn’t see Mersereau standing right beside him
at times, bending over him, holding up that hand and telling him how
he intended to kill him yet—that it was all an illusion!
Imagine saying that Mersereau couldn’t actually seize him by the
throat when he was asleep, or nearly so, when Davidson himself,
looking at his throat in the mirror, could see the actual finger prints,—
Mersereau’s,—for a moment or so afterward. At any rate, his throat
was red and sore from being clutched, as Mersereau of late was
able to clutch him! And that was the cause of these lumps. And to
say, as they had said at first, that he himself was making them by
rubbing and feeling his throat, and that it was tuberculosis!
Wasn’t it enough to make one want to quit the place? If it weren’t
for Miss Liggett and Miss Koehler, his private nurse, and their
devoted care, he would. That Miss Koehler was worth her weight in
gold, learning his ways as she had, being so uniformly kind, and
bearing with his difficulties so genially. He would leave her something
in his will.
 To leave this place and go elsewhere, though, unless he could
take her along, would be folly. And anyway, where else would he go?
Here at least were other people, patients like himself, who could
understand and could sympathize with him,—people who weren’t
convinced as were these doctors that all that he complained of was
mere delusion. Imagine! Old Rankin, the lawyer, for instance, who
had suffered untold persecution from one living person and another,
mostly politicians, was convinced that his, Davidson’s, troubles were
genuine, and liked to hear about them, just as did Miss Koehler.
These two did not insist, as the doctors did, that he had slow
tuberculosis of the throat, and could live a long time and overcome
his troubles if he would. They were merely companionable at such
times as Mersereau would give him enough peace to be sociable.
The only real trouble, though, was that he was growing so weak
from lack of sleep and food—his inability to eat the food which his
enemy bewitched and to sleep at night on account of the choking—
that he couldn’t last much longer. This new physician whom Dr.
Major had called into consultation in regard to his case was insisting
that along with his throat trouble he was suffering from acute
anemia, due to long undernourishment, and that only a solution of
strychnin injected into the veins would help him. But as to Mersereau
poisoning his food—not a word would he hear. Besides, now that he
was practically bedridden, not able to jump up as freely as before, he
was subject to a veritable storm of bedevilment at the hands of
Mersereau. Not only could he see—especially toward evening, and
in the very early hours of the morning—Mersereau hovering about
him like a black shadow, a great, bulky shadow—yet like him in
outline, but he could feel his enemy’s hand moving over him. Worse,
behind or about him he often saw a veritable cloud of evil creatures,
companions or tools of Mersereau’s, who were there to help him and
who kept swimming about like fish in dark waters, and seemed to
eye the procedure with satisfaction.
When food was brought to him, early or late, and in whatever form,
Mersereau and they were there, close at hand, as thick as flies,
passing over and through it in an evident attempt to spoil it before he
could eat it. Just to see them doing it was enough to poison it for
him. Besides, he could hear their voices urging Mersereau to do it.
“That’s right—poison it!”
“He can’t last much longer!”
“Soon he’ll be weak enough so that when you grip him he will
really die!”
It was thus that they actually talked—he could hear them.
He also heard vile phrases addressed to him by Mersereau, the
iterated and reiterated words “murderer” and “swindler” and “cheat,”
there in the middle of the night. Often, although the light was still on,
he saw as many as seven dark figures, very much like Mersereau’s,
although different, gathered close about him,—like men in
consultation—evil men. Some of them sat upon his bed, and it
seemed as if they were about to help Mersereau to finish him,
adding their hands to his.
Behind them again was a complete circle of all those evil,
swimming things with green and red eyes, always watching—
helping, probably. He had actually felt the pressure of the hand to
grow stronger of late, when they were all there. Only, just before he
felt he was going to faint, and because he could not spring up any
more, he invariably screamed or gasped a choking gasp and held his
finger on the button which would bring Miss Koehler. Then she would
come, lift him up, and fix his pillows. She also always assured him
that it was only the inflammation of his throat, and rubbed it with
alcohol, and gave him a few drops of something internally to ease it.
After all this time, and in spite of anything he could tell them, they
still believed, or pretended to believe, that he was suffering from
tuberculosis, and that all the rest of this was delusion, a phase of
insanity!
And Mersereau’s skeleton still out there on the Monte Orte!
And Mersereau’s plan, with the help of others, of course, was to
choke him to death, there was no doubt of that now; and yet they
would believe after he was gone that he had died of tuberculosis of
the throat. Think of that.

XII—Midnight of February 10, 1909

The Ghost of Mersereau (bending over Davidson): “Softly!

Softly! He’s quite asleep! He didn’t think we could get him—that I
could! But this time,—yes. Miss Koehler is asleep at the end of the
hall and Miss Liggett can’t come, can’t hear. He’s too weak now. He
can scarcely move or groan. Strengthen my hand, will you! I will grip
him so tight this time that he won’t get away! His cries won’t help him
this time! He can’t cry as he once did! Now! Now!”
A Cloud of Evil Spirits (swimming about): “Right! Right! Good!
Good! Now! Ah!”
Davidson (waking, choking, screaming, and feebly striking out):
“Help! Help! H-e-l-p! Miss—Miss—H—e—l—p!”
Miss Liggett (dozing heavily in her chair): “Everything is still. No
one restless. I can sleep.” (Her head nods.)
The Cloud of Evil Spirits: “Good! Good! Good! His soul at last!
Here it comes! He couldn’t escape this time! Ah! Good! Good! Now!”
Mersereau (to Davidson): “You murderer! At last! At last!”

XIII—3 A.M. of February 17, 1909

Miss Koehler (at the bedside, distressed and pale): “He must
have died some time between one and two, doctor. I left him at one
o’clock, comfortable as I could make him. He said he was feeling as
well as could be expected. He’s been very weak during the last few
days, taking only a little gruel. Between half past one and two I
thought I heard a noise, and came to see. He was lying just as you
see here, except that his hands were up to his throat, as if it were
hurting or choking him. I put them down for fear they would stiffen
that way. In trying to call one of the other nurses just now, I found
that the bell was out of order, although I know it was all right when I