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Human Diseases
Sixth Edition Marianne Neighbors, EdD, RN
Ruth Tannehill-Jones, MS, RN
Australia ● Brazil ● Canada ● Mexico • S i n g a p o r e ● United Kingdom ● United States
Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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This is an electronic version of the print textbook. Due to electronic rights restrictions,
some third party content may be suppressed. Editorial review has deemed that any suppressed
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Important Notice: Media content referenced within the product description or the product
text may not be available in the eBook version.
Human Diseases, Sixth Edition Last three editions, as applicable: © 2023, © 2015, © 2010
Marianne Neighbors and Copyright © 2023 Cengage Learning, Inc. ALL RIGHTS RESERVED. WCN: 02-300
Ruth Tannehill-Jones
No part of this work covered by the copyright herein may be reproduced
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Notice to the Reader

Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection
with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain
and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt
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Printed in the United States of America

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

cancer, heart disease, stroke, senile dementia, and
Alzheimer’s disease. Consider This...
About 90% of diseases are partially caused
Sex or affected by stress.
Some diseases are more prevalent (occurring more
often) in one gender or the other. Men are more at risk
for diseases such as lung cancer, gout, and parkinson- Heredity
ism. Other disorders or diseases, including osteoporo-
sis, rheumatoid arthritis, and breast cancer, occur more Although one cannot change genetic makeup, being
often in women. aware of hereditary risk factors might encourage the
individual to change lifestyle behaviors to reduce the
risk of disease. For example, coronary heart disease has
Environment been shown to have a high familial tendency. Persons
Air and water pollution can lead to respiratory and with this family inheritance are compounding their
gastrointestinal disease. Poor sanitation, excessive chances if they smoke, have poor nutritional intake,
noise, and stress are also environmental risk factors. and do not exercise routinely.
Occupational diseases such as lung disease are high Breast cancer and cervical cancer also have famil-
among miners and persons working in areas with ial tendencies. Women with family members who have
increased amounts of dust or other particles in the been diagnosed with breast cancer or cervical cancer
air. are at a higher risk of developing these diseases. These
Farmers are considered to be at higher risk for dis- women should be screened routinely for evidence of
eases because of their increased exposure to dust, pes- cancer and should complete monthly breast self-exams.
ticides, and other pollutants. Farmers are also at higher With this knowledge about hereditary factors, individu-
risk for trauma injuries due to safety problems around als can choose to decrease their overall risk by improv-
farm machinery. People living in remote, rural areas ing their lifestyle health behaviors.
do not have health care availability comparable to that
enjoyed by people living in urban areas. This increases Diagnosis
their risk for chronic illnesses.
Diagnosis (die-ag-NO-sis) is the identification or
naming of a disease or condition. When an individual
Lifestyle
seeks medical attention, it is the duty of the physician
Lifestyle factors fall into a category over which the indi- to determine a diagnosis of the problem. A diagnosis is
vidual has some control. Choosing to improve health made after a methodical study by the physician, using
behaviors in these areas could lead to a reduction in risk data collected from a medical history, physical exam-
and thus a possibility of avoiding the occurrence of the ination, and diagnostic tests (Figure 1–1).
disease. Such factors include smoking, drinking alcohol,
poor nutrition (excessive fat, salt, and sugar and not
enough fruits, vegetables, fiber), a lack of exercise, and
stress.
Practicing health behaviors to prevent contami-
nation, and thus disease, is also an important lifestyle
behavior. The Centers for Disease Control and Pre-
vention recommends the use of standard precautions
when caring for any individual when there is a chance
of being contaminated with blood or body fluids (see
the Healthy Highlight box “Standard Precautions”).
This is an important measure to prevent transmission
of any disease that can be passed between humans in
blood or body fluids, such as hepatitis, Escherichia coli
infections, and AIDS. Figure 1–1 Physician checking a patient.
8 Chapter 1
A medical history is a systems review that might If an unusually large number of people in a region
include such information as previous illnesses, fam- are diagnosed with the same disease around the same
ily illness, predisposing factors, medication allergies, time, the disease is called an epidemic. During the
current illnesses, and current symptoms (SIMP-tums; late fall, winter, and early spring, influenza (flu) often
what patients report as their problem or problems). reaches epidemic numbers in various regions. If an epi-
Examples of symptoms might include stomach pain, demic affects an exceptionally large area, even as far
headache, and nausea. as worldwide, it is called a pandemic. Pandemics are
The physician proceeds with a head-to-toe phys- rare. The most recent being Coronavirus Disease 2019
ical examination of the patient, looking for signs of (COVID-19).
the disease. Signs differ from symptoms in that signs
are observable or measurable. Signs are what the
physician sees or measures. Examples of signs could Prognosis
include vomiting, elevated blood pressure, and ele- Prognosis (prawg-KNOW-sis) is the predicted or
vated temperature. expected outcome of the disease. For example, the prog-
In some cases, a patient’s concern might be con- nosis of the common cold would be that the individual
sidered as both a symptom and a sign. Some references should feel better in 7 to 10 days.
call this an objective or observable symptom, whereas
others state that it is also a sign. An example would be
a patient complaining of a runny nose. The runny nose Acute Disease
is the patient’s symptom, and because it is observable The duration of the disease can be described as acute in
to the physician, it is also a sign. nature. An acute disease is one that usually has a sud-
During the physical examination, the physician den onset and lasts a short amount of time (days or
might use other skills such as auscultation (aws- weeks). Most acute diseases are related to the respira-
kul-TAY-shun; using a stethoscope to listen to body tory system. Again, the common cold would be a good
cavities), palpation (pal-PAY-shun; feeling lightly example.
or pressing firmly on internal organs or structures),
and percussion (per-KUSH-un; tapping over vari- Chronic Disease
ous body areas to produce a vibrating sound). All the
results are compared to a normal standard to identify If the disease persists for a long time, it is considered
problems. chronic. Chronic diseases might begin insidiously
Diagnostic tests and procedures to assist in deter- (slowly and without symptoms) and last for the individ-
mining a diagnosis are numerous. The routine or most ual’s entire life. As one ages, the occurrence of chronic
common include urinalysis, complete blood count, disease increases. One of the most common chronic
chest X-ray, and electrocardiography (EKG or ECG). diseases is hypertension, or high blood pressure.
See Table 1–3 for examples of common diagnostic tests Chronic diseases often go through periods of
and procedures. remission and exacerbation (eg-ZAS-er-BAY-shun).
TABLE 1–3 Examples of Common Diagnostic Tests and Procedures
Test Description
Complete blood count (CBC) An examination of blood for cell counts and abnormalities
Urinalysis (UA) An examination of urine for abnormalities
Chest X-ray (CXR) X-ray examination of the chest cavity
Electrocardiography (ECG or EKG) A procedure for recording the electrical activity of the heart
Blood glucose A test of the blood to determine its glucose or sugar levels
Computerized axial tomography (CT or CAT) A special X-ray examination showing detailed images of body
structures and organs
Serum electrolytes An examination of blood serum to determine the levels of the common
electrolytes (sodium, potassium, chloride, and carbon dioxide)
Remission refers to a time when symptoms are dimin- to the individual with expected outcomes or progno-
ished or temporarily resolved. Exacerbation refers to a ses. The individual’s entire being should be taken into
time when symptoms flare up or become worse. Leu- consideration. The concept of considering the whole
kemia is a disease that progresses through periods of person rather than just the physical being is called
remission and exacerbation. Both acute and chronic holistic medicine.
diseases can range from mild to life-threatening. From a holistic viewpoint, there is an interac-
tion among the spiritual, cognitive, social, physical,
and emotional being. These areas do not work inde-
Complication pendently but have a dynamic interaction (Figure 1–2).
The prognosis might be altered or changed at times if Treatment interventions might include (a) medi-
the individual develops a complication. A complication cations, (b) surgery, (c) exercise, (d) nutritional mod-
is the onset of a second disease or disorder in an indi- ifications, (e) physical therapy, and (f) education.
vidual who is already affected with a disease. An indi- Individuals and family members should be educated
vidual with a fractured arm might have a prognosis of and involved in the treatment plan. Failing to involve
the arm healing in 6 to 8 weeks. If the individual suffers the individual and family can decrease compliance and
the complication of bone infection, the prognosis might lead to the plan failing.
change drastically. After the treatment plan is implemented, the
physician will follow up with the individual to deter-
Mortality Rate mine the plan’s effectiveness. The individual and
physician should work together to modify the plan
Mortality is defined as the quality of being mortal, that if it is found to be ineffective. Implementation of the
is, destined to die. Diseases commonly leading to the plan usually requires an entire health care team. The
death of an individual have a high mortality rate. The team can include nurses, a physical therapist, a social
mortality rate of a disease (also called death rate) is worker, clergy, and other health care professionals
related to the number of people who die with the dis- as needed.
ease in a certain amount of time. Other terms the med- The best treatment option is a preventive plan. In
ical community uses to refer to a deadly disease include preventive treatment, care is given to prevent disease.
fatal and lethal. Examples of preventive care are breast mammograms
Consider This... O N M
I R E
V
The ashes of the average cremated human N N
weigh approximately 9 pounds.
E
Physiological T
Survival Rate
A physician’s prognosis can also consider the survival Spiritual Psychological
rate. The survival rate is the percentage of people with
Individual
a particular disease who live for a set time. For example,
the 2-year survival rate of individuals with lung cancer
would be the percentage of people alive 2 years after
diagnosis. Intellectual Sociocultural
Treatment
After the diagnosis is established, the physician will
work with the individual to explain or outline a plan
of care. The physician might offer treatment options Figure 1–2 Holistic medicine.
10 Chapter 1
to screen for breast cancer, blood pressure screening When challenges concerning medical ethics arise
for hypertension, routine dental care to prevent dental in a health care facility, an ethics committee might be
caries, and a fecal occult blood test to screen for colon called on to make a decision. This committee might
cancer. involve one or more persons at each of these levels:
Other treatment plans might include palliative physician, nurse, ethicist, social worker, case manager,
(PAL-ee-ay-tiv) treatment. Palliative treatment is chaplain, legal representative, and administrator, or
aimed at preventing pain and discomfort but does director.
not seek to cure the disease. Treatment for end-term Groups or committees involved in decision-making
cancer and other serious chronic conditions can be might need to consider previous works of philosophy,
palliative. history, law, and religion to assist them in reaching a
Decisions concerning treatment plans can be very conclusion. Participation in ethical decision-making
difficult for the patient, the patient’s family, and the requires members to follow some basic rules, which
health care team. This is especially true when those can include
decisions involve palliative treatment and end-of-life
issues. During these times, professionals often seek ■ keeping the discussion focused and civil.
assistance in decision-making by using their knowledge ■ listening with an open mind to all opinions.
of medical ethics. ■ entertaining diverse ideas.
■ weighing out the pros and cons of each idea.
Medical Ethics ■ considering the impact of the decision on all per-
Webster’s Dictionary defines ethics as “the study of sons involved.
standards of conduct and moral judgment.” More
Every individual at some time or another will
simply put, ethics deals with the “rightness and wrong-
encounter or be called on to make a decision that is bio-
ness” or “goodness and badness” of human actions.
ethical in nature. Examples of these can include one’s
Ethics covers many areas of conduct and judgment in
willingness to
our society.
Bioethics is a branch of ethics concerned with ■ use a surrogate mother or father to have a bio-
what is right or wrong in bio (life) decisions. Because logical child.
bioethics is a study of life ethics, it covers or becomes
■ control the sex of children through chromosome
entwined with medical ethics. Medical ethics includes
selection.
the values and decisions in medical practice, including
relationships to patients, patients’ families, peer physi- ■ use fetal stem cells to grow new organs and tissues.
cians, and society. ■ use prescription stimulants in children.
Part of the ethical challenge in this age of rapidly ■ legalize abortion.
advancing technologies is actually determining what is
right or wrong, good or bad. New scientific discover- ■ use mood-altering drugs for older persons.
ies are challenging familiar or usual human behaviors, ■ clone humans.
leading to reconsideration of actions, thoughts, and ■ treat disease by replacing damaged or abnormal
emotions. Ethical dilemmas, once rare, are now com- genes with normal genes.
mon and often happen so quickly that society is unable
to understand completely the impact these decisions ■ use animal organs or tissues (xenotransplants) in
will have on the future. humans.
Bioethical decisions are often very difficult ■ support euthanasia.
because they touch the core of humanity in dealing ■ allow physician-assisted suicide.
with issues of birth, death, sickness, health, and dig-
nity. This generation and generations to come will Each of the preceding issues can be overwhelm-
be faced with ethical decisions formerly unknown to ing. Even so, yet another concern must be addressed,
humans. Many of these decisions will have a great involving the economics of these choices.
impact on medical ethics and will actually shape the Consider, for example, the economics of
future of humankind. human cloning. How will research, technology, and
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CHAPTER V
THE CHEYENNES HAVE SOME FUN
With a terrific jar Terry landed far in the brush and went ploughing
and rolling, topsy-turvy. He thought that he heard Shep yelp (as if
Shep had landed, too, somewhere); then he brought up, in a heap,
wedged at the bottom of a little wash.
He lay without moving, listening and wondering if any bones were
broken. No; he seemed to be all right. But there were chases,
through the brush, in the darkness; the Indians were riding hither-
thither, shouting and shooting. He heard it all—the shots, the yells of
triumph, a groan or two. The Indians were killing the handcar men!
It seemed to him a long time before that was over with, and every
moment he expected an Indian to ride on top of him. But the yelling
and shooting and scurrying died away. The Indians appeared to be
gathering at their fire.
Ah! What was that? He heard a faint rustle, near him. An Indian was
scouting about, on foot, looking for him? He scarcely dared to
breathe as he hugged the earth, and his heart thumped like a drum.
Then something paused, beside him; next something cold, like a
knife blade, pressed against his neck, and he heard a little whimper.
It was Shep, and Shep’s nose! Shep was alive and had found him.
Oh, Shep! Good old Shep! Be quiet, Shep. But Shep knew. He was
satisfied, and crouched close, only once in a while growling low in
his throat.
Here they were—the only ones left alive, Terry felt, from the handcar.
Now what could he do? The Indians were talking and laughing, at a
little distance. He gradually untangled himself, and inch by inch
raised his head, to see, in the direction of the fire. He had to crawl a
few feet, to the edge of his wash. He peeped over.
The Indians were collected around their fire, beside the track.
Between his place and the fire there was a narrow gully, bridged by a
wooden culvert; and upon the track over the culvert there was a tie,
fastened to the rails by wire, but knocked askew. That was what the
handcar had struck; and he had been thrown clear across to this
side and luckily had landed in this wash cut diagonally by the rains.
The sage was quite high here, too. He guessed he hadn’t been
counted on the handcar, because he had been lying down and the
four men had been standing.
He could just see the handcar, bottomside up, in the brush on the
slope of the gully. Now the Indians were leaving their fire and
trooping down track a little way. They began to pry at the rails, with
poles. They were planning another wreck. This one had been a
success, but it was only a small one. Perhaps they thought that a tie
would not wreck a train, and they wanted to wreck a train.
They pried and worked, loosening the rails. What could a fellow do?
That freight at Kearney might have got tired of waiting, and be along
any time. Or a passenger train might come. Terry thought upon
breaking for Willow Island, to give the alarm there. No, that wouldn’t
be the quickest way. If he might only get around the Indians, and run
to Plum Creek—it couldn’t be more than five or six miles, and he
might meet the train this side of it and stop it, somehow.
“Whisht! Come on, Shep. Careful, now,” he whispered. He started to
crawl. Shep crawled behind him. Once down in the gully, maybe they
could follow it up a way, and make a circuit around that gang. They
reached the bottom, and were about to do finely, when Terry heard a
groan.
It sounded from the brush, beyond the gully. He listened, and heard
it again. It was a groan in English. One of the handcar men was
alive. Well, he ought to go and see.
“’Elp!”
That was Bill Thompson! Bill was groaning for help. Oh, dear!
Up he crawled, seeking the place of the groans.
“Hello! Where are you?” he asked, cautiously. He was almost into
the fire-light.
“’Ere. Who are you?”
“Terry Richards. I’m coming.”
He kept crawling, and pretty soon he found Bill lying flat on his side,
with his head on his arm. In the faint glimmer of the flames a ghastly
thing he was.
“You bad hurt, Bill?”
“’Ello. They shot me through the h’arm an’ knifed me in the neck an’
scalped me, but I got the scalp.”
“What?”
“Yes. ’Ere ’tis, in my ’and. The bloomin’ beggar didn’t ’ang onto h’it.
’E dropped h’it. H’I saw ’im. Felt like the ’ole top o’ my ’ead was h’off,
but I got h’it when they wasn’t lookin’. D’ you think h’it’ll grow on me
again?”
“I dunno. We’d better get right out of here, though. He may come
looking for it.”
“’E ’asn’t missed it, I reckon. H’it was in ’is belt. What they doin’
now?”
“Tearing up the rails, so as to wreck a train. I’m going to try to make
Plum Creek. I’ll help you into that gully; then I’ve got to go.”
“H’all right,” groaned Bill. “You go. Never you mind me. H’I can
manage.”
“No,” said Terry. And suddenly he crouched lower. “Keep quiet, Bill.
They’re coming back.”
“Oh, the bloody villains,” groaned Bill. “Make a run for it, while you
can. Never mind me.”
“I can’t,” answered Terry. And even if he would, he didn’t dare. They
might see him; if they didn’t catch him, they’d find Bill——!
The whole body of Indians were roistering back, up track, for their
fire; probably to hide near it, as before, and wait. Some were afoot,
some on ponies; and a hideous sight they offered, to Terry, crouched
here on the outskirts of the fire-light, and daring to move not a
muscle. Cheyennes; that’s who they were: Cheyennes!
They began to scatter out, for ambush. Perhaps there’d be a chance
to risk it and crawl farther away. Ah! Oh, thunder! One of them was
coming across, straight this way, prowling through the brush.
“Lie low, Bill. Watch sharp.”
“What’s doin’?”
“They’re at the fire, but one of ’em’s coming.”
“’E’s lookin’ for ’is scalp,” Bill groaned.
They stiffened, motionless. Shep growled, and Terry nudged him
frantically. The Indian—he had feathers in his braids and a gun in his
hands—ranged right and left, and all the time drew nearer. At that
rate, he couldn’t miss them—not if he kept on. Terry didn’t know
whether to bolt or to stay. If Shep only would quit that growling——!
Or if the Indian would only turn aside. To be shot, or tomahawked,
would be awful. It took a great deal of nerve to stiffen, here, and hold
one’s breath, and wait and pray. There was just the chance that they
wouldn’t be discovered—but the Indian was coming, coming, in sure
and easy fashion, looking for that scalp!
Quit it, Shep! Bill was gasping, in his efforts to utter no sound. It was
worse for him, because he couldn’t see. Terry could see, with the
corner of an eye, through the brush—and he’d about made up his
mind that at the last moment he would bolt, and run, dodging, for the
open. He’d have to risk a bullet, and have to risk being overhauled;
but he might get away, and that would lead the Indian from Bill, too.
There wasn’t any use in the both of them being found, in this one
spot.
He was all braced, to make his dive, when on a sudden Shep took
matters into his own hand. The Indian was scouting about, in the
brush not more than twenty yards before—and out Shep charged,
with a furious snarly rush, in defense.
Terry had no time in which to grab him; and it would have been too
late, anyway. An instant more—so brief a space that the Indian was
taken by surprise—and out from the brush Shep had sprung for his
throat. He knocked the Indian backward. They staggered around
together, Shep snarling and snapping, the Cheyenne fighting him off.
Terry half sat up, to watch, his heart in his throat.
“It’s my dog,” he panted, to Bill.
The Cheyenne seemed to have Shep by the neck or jaw, and was
thrusting with his other arm, stabbing him. Shep yelped, snarlily. With
a kick and a fling the Cheyenne threw him aside; and as Shep
pluckily struggled to his feet and still snarling made for him again, the
Cheyenne quickly leveled rifle, and fired.
The bullet drove poor old Shep in a heap. He lay black and lax,
scarcely moving, except to lift his head, and drop it. He had
happened to land in a bare spot, and Terry could see him plainly.
Yes, he was dead.
Such a hot wrath surged into Terry’s brain and to his very finger-tips
that all he wanted now was a chance at that Indian, himself. If he but
had a gun—or if he might grab the Indian by the legs, drag him
down, and get atop of him! Anything, so as to avenge brave old
Shep. For the moment Terry was too hot to think of himself, or Bill, or
anybody except Shep, and that Cheyenne.
The Cheyenne stood over Shep, kicked him once or twice, and then
seemed about to come on again. Terry crouched, tense and alert.
Shep had not saved them, after all. Too bad.
“Is ’e comin’?” murmured Bill. “’E killed the dawg?”
“Sh!” warned Terry.
No! Hurrah! The Cheyenne stopped, and looked back. The Indians
by the fire had whooped to him, and were disappearing. The
Cheyenne turned and ran for them.
“He’s going, Bill!” Terry gasped. “It’s the train. That’s coming. I can
see the headlight. Oh, Bill!”
Bill struggled, to see also. Afar down the track there was a light,
wavering and flashing, and they could hear a dull rumble. Several of
the mounted Indians had dashed away, in that direction. The others
were scuttling and hiding.
“H’it’s the freight,” Bill groaned. “H’it’s the freight that was at Kearney.
Bully Brookes, ’e’s h’engine driver, ’Enshaw, ’e’s the stoker. H’it’ll be
a smash, an’ we can’t ’elp it. Is your dawg killed?”
“Yes, I guess so. But if he hadn’t run out the Cheyenne would have
found us and we’d have been killed, too.”
“’E was a good dawg, a sure-’nough ’ero. ’E stopped the h’Injun, but
we can’t stop that train.”
“There are two trains, Bill! I see another light, ’way behind the first
one!”
“H’it’ll be plain murder,” Bill groaned. “An’ we can’t do a thing. I wish
you’d never found me.”
“I couldn’t have got there in time, anyway,” said Terry.
The first light rapidly grew larger, the rumbling increased. Terry
stared, fascinated. He didn’t wish to see, but somehow he had to. If
Bully Brookes or his fireman, Henshaw, only would discover the lifted
rails and stop, in time, themselves. But it did not seem as though
they were going to stop or slacken. Flaring and wavering, the
headlight was coming on.
The engine began to whistle madly, with long shriek after long shriek.
Had it sensed its danger? But it did not slacken—it was coming
faster. And see! The Cheyennes were nagging it; by the glare from
the opened firebox as the fireman shoved in the cordwood sticks the
Indians were shown, racing on either side, brandishing their bows
and guns, egging the train on.
The engine jetted steam from its cylinder cocks; the whistle shrieked
and shrieked; the firebox glowed redly as the firemen stoked with the
cordwood, the Indians lashed their ponies and plied their arrows. It
was a wild scene, and terrible. Terry trembled with excitement. Bill
sank back, groaning.
“Tell me when she ’its,” he pleaded.
The engine was approaching the bonfire. It had not reached the tilted
rails, yet. Oh, would nobody see them?
They were seen, they were seen! Listen! The notes of the whistle
had changed to frantic yaps like those of a frightened animal. “Down
brakes, down brakes, quick!” the whistle was imploring. The engine
wheels spurted sparks, under reversed throttle. Too late. The racing
Cheyennes swerved apart, for safety; even while Terry gazed, and
before he had time to close his eyes, the engine rose right into the
air, with a roar and a plunge left the track, and dragging the tender
and car after car it went lurching into the prairie.
It toppled over, cars toppled, and in a moment everything seemed to
be piled in a long heap. The engine was almost buried from sight.
Out of the jangle there welled shouts. From the rear, men came
running; from the front the Cheyennes charged. One man with a
lantern—the conductor, maybe—arrived at the fore; the Indians
seemed to miss him, in the excitement, for he turned and ran fast,
again, down track, throwing his lantern away. He was going to the
train behind, and it looked as though he got off, safe.
The Cheyennes chased about, circled the engine heap, and danced
and whooped. Flames burst forth, licking up through the heap, and
the scene grew brighter and brighter.
“I think we’d better move, Bill,” Terry stammered. “They’ll see us
here, sure, as soon as the train gets to burning. We can hide in the
little gully where I was.”
“H’all right,” Bill groaned. “H’it’s a good time, while they’re murderin’
somebody h’else.”
That was a hard journey, with Bill hitching painfully through the
brush, using one arm and carrying his scalp and stopping every little
while to rest and pant. The wonder was, that he could move at all—a
man who had been shot and stabbed and scalped; but he had a lot
of will power, and was determined to live and make the scalp grow
on his head again, “to fool them bloody h’Injuns.”
At last he was settled in the gully, with Terry’s coat under his head.
Terry crawled up to the edge again, to lie shivering, and see what
more occurred. It wasn’t very likely, though, that the Indians would
leave the wreck until they had to.
No, they stayed there. One or two of the cars following the engine
and tender had been loaded with brick. They had landed right on top
of the engine, and the bricks were scattered all around. The Indians
were pelting the heap with the loose bricks; they acted like children;
but pretty soon the fire got too hot for that, so they withdrew, to squat
in a circle, and curiously watch.
The second train had backed down track, and was far distant, still
backing. Had gone to Plum Creek, probably, for help. Shivering Terry
and groaning Bill Thompson were left alone, with the Indians and the
blazing wreck. What a night! When would help come?
Terry never forgot this night. Up the track, and down the track
beyond the wreck nothing moved. The Indians stretched out and
seemed to sleep comfortably in the warmth of their big fire, as if
waiting until morning. In the gully Bill now and then groaned. On the
edge of the gully Terry huddled and nodded—but whenever he
started to doze, he woke with a jump, seeing things.
Poor old Shep! He had Shep in his mind a great deal. Yes, Shep was
a hero, and he should not be left there, for the coyotes to eat. That
would not be fair.
“H’are you ’ere?” Bill called up, faintly. “’Ello, lad.”
“I’m here,” Terry answered. “I’ll stay with you, Bill. I’m going to stay till
people come. I want to bury my dog.”
“’E was a fine dawg,” Bill agreed.
Finally Terry did manage to sleep, in spite of his shivering and his
bad dreams. He awakened stiff and bewildered. Where was he? Oh,
yes; here in the brush, still, outside the wreck. He might see about
him. The air was thin and gray, morning had come. He cautiously
raised higher, to look. The wreck was smoking, the Indians were
there—they were moving about, and flocking down track, and
climbing over the cars. No rescue had come yet. Oh, dear! The
telegraph wires had been used, for tying the tie that wrecked the
handcar, to the track, but why didn’t help come from Plum Creek
way?
Was Bill dead? No, he spoke.
“’Ello?”
“Hello. How are you?”
“Wish I had a drink. What’s doin’ now?”
“They’re robbing the wreck.”
“Yes, that’s what,” groaned Bill.
The Indians were enjoying themselves. They had broken into some
cars loaded with drygoods, and were strewing the stuff right and left.
As the morning brightened, that was an odd sight, down there. The
Cheyennes wrapped themselves in gay calico and gingham and red
flannel and other cloths; they tied whole bolts of the same cloth to
their saddle horns and their ponies’ tails, and darted hither-thither
over the plain, while the bolts unrolled and other riders chased after,
trying to step on the long streamers. They had so much plunder that
they seemed crazy.
Suddenly they all galloped to one side, to a little rise, and gathered
there, like a flock of magpies, gazing up track. Had they seen Terry?
He felt a thrill of fear, and huddled lower. Then he bethought to look
behind, up track, too—and he saw smoke!
It was a train! A train was coming, from the west. And how it did
come! A rescue train! Hurrah!
“Bill! A train’s coming! The Injuns are quitting!”
“Where from?”
“Up track.”
“’Ow’d they get word, thereabouts?”
“I dunno; but it’s coming, and coming lickity-split, as if it had
soldiers.”
“’Ooray!” Bill groaned. “An’ I ’ope it ’as a doctor, to stick this ’ere
scalp on me again.”
The engine shrieked, and the smoke poured blacker. The Indians
were getting restless. Then away they scoured. Terry stood up and
yelled and waved his arms, the train—a short train of box-cars—
pulled in and soldiers tumbled out. How good their blue coats looked!
Terry went stumbling and staggering to meet them. He saw
somebody he knew—the scout in buckskin who was leading the
soldiers, with the officer.
“Sol! Hello, Sol Judy! Oh, Sol!”
But Sol scarcely knew him.
“Who are you? What? For heaven’s sake, boy! You aren’t Terry
Richards?”
“Guess I am.” And Terry sank down. His legs had given out. “Oh,
Sol! They wrecked our handcar, and Bill Thompson’s in that gully
with his scalp gone, but he’s alive, and they killed Shep and then
they wrecked the freight and killed a lot more.”
In a moment he was surrounded and picked up. He had to tell his
story all over again, while some examined the wreck, and some got
Bill and carried him up, and the Cheyennes meanwhile made off.
They were soldiers from Fort McPherson, beyond Willow. A man had
ridden around the Indians, from Plum Creek, and taken the word.
“There aren’t enough of us to follow those fellows,” explained Sol.
“But the Pawnees are on the way from end o’ track. They’ll do the
business. Now you and Thompson can go back with this train.”
“I want to bury Shep, first,” Terry pleaded.
“Sure you do. He died fighting, like a soldier, and ‘Killed in action’ is
the report on him. A good U. P. hand he was, wasn’t he? So we’ll just
bury him right here, where he can watch the tracks.”
Nobody seemed to blame Terry any for crying, when he and Sol and
a couple of soldiers put Shep away. Sol understood; he had known
Shep a long time, himself.
The bodies of the handcar men and a brakeman (the engineer and
fireman had been burned) were placed aboard, for Willow. Taking Bill
Thompson and Terry, but leaving the soldiers on guard at the wreck,
the train backed up track. Bill’s scalp had been stowed in a bucket of
water, to keep it limber. It curled about, as it floated, and looked
exactly like a drowned rat. No doctor ever did succeed in planting it
and making it grow again on Bill’s head; but Bill got well and went to
work, wearing a skull-cap.
However, Terry went to work, the first, at end o’ track once more, the
next morning. Jenny was glad to see him. His father had been
mighty glad, too, and together they mourned the brave Shep.
“I hear tell ye lost your dog,” said Paddy Miles, kindly.
“Yes, that’s so,” Terry answered, with a gulp.
“Ah, well; ’twas a bad night, sure enough, for him an’ you an’ them
others,” mused Pat. “But him an’ they are not the only wans. There’s
many a grave beside the U. Pay., behind us, an’ there’s more on
ahead an’ more yet to be made, before the road goes through. ’Tis a
big job an’ a cruel job an’ a long road to travel; but ’tis sich a job as is
worth the dyin’ for anny day, say I—though I’d fair like to live jist to
see the Cintral baten into Salt Lake an’ the U. Pay. track stretchin’
out clane across Nevady.”
CHAPTER VI
MOVING DAY ALONG THE LINE
On marched the rails of the iron trail, at a giant’s stride of one to two
miles in a day, as if trying to catch the tie-layers and the graders. But
the tie-layers, planting their ties every two feet, managed to hold the
advance; and twenty, thirty, fifty miles in advance of them, the
graders followed the stakes of the engineers. Back and forth along
the grade toiled the wagons, distributing ties and provisions. From
Omaha to North Platte thundered the trains, bringing fresh supplies,
other rails and other ties, to be taken on by the construction-trains.
And into Omaha were pouring, by boat up from St. Louis and St.
Joe, and by wagon from Iowa, still other rails and ties and provisions,
from the farther east. It was said that if a double line of dollar bills
were laid, instead of rails, from Omaha across the plains, they would
not pay for the cost of the roadbed alone.
The Indians were still bad. They had not given up. They ambushed
grading parties whenever they could—killed stragglers and hunters,
and ran off stock. The Pawnee scouts and the regular cavalry and
infantry constantly patrolled the right-of-way, camped with the men,
and tried to clear the country, before and on either side. But the
construction-trains sometimes fought at full speed, or narrowly
escaped a wreck.
Every morning the track-layer gang of the boarding-train piled out at
reveille, the same as in the army; they marched to work, in columns
of fours, at a shoulder arms, under captains and sergeants, stacked
their guns, and were ready to spring to ranks again at the first order.
“B’ gorry, the same as a battalion o’ infantry, we are,” said Pat Miles.
“An’ there was no better battalion durin’ the war, either. From Gin’ral
Casement down to the chief spiker we got as good officers as ever
wore the blue, wid five years’ trainin’ behind ’em—an’ there’s many a
man usin’ a pick who’s fit to command a company, in a pinch.”
Little was heard from the engineering parties in the field. They were
scattered all through the mountains, from up in Wyoming down into
Colorado, and on across into Utah, beyond Salt Lake. In fact, last
year the surveys for the best routes had been pushed clear to
California—so as to be ready.
The parties that had come in, in the winter, to report and draw their
maps, had gone out again in early spring for another season’s work.
Some of the parties even had stayed out all winter, measuring the
snow falls and learning the weather at the passes.
General Sherman, commanding this Military Division of the Missouri,
which extended from the Mississippi River to the Rocky Mountains,
had issued orders that the military posts should furnish General
Dodge with all the soldiers who might be spared, so that the road
and the survey parties should be protected.
Just the same, the surveying job was a dangerous job; ten and
twelve miles of the survey lines were run, each day, and the chain-
men and rod-men sometimes were far separated from the soldiers—
and the chief of the party was supposed to go in the advance, to
discover the easiest country.
Last year the mountains and the deserts on either slope had been
pretty well covered. Now it was understood that the road was not to
turn south for Denver and the Colorado Rockies—no good passes
had been found; it was to turn for the northwest, instead, and cross
the Rockies in Wyoming, by a pass that General Dodge himself had
discovered in one of his Indian campaigns two years ago.
So onward marched the rails—that double line ever reaching
westward. Back and forth, hauling the truck, Terry rode old yellow
Jenny—and how many miles he traveled, to every one mile of track,
he never quite figured out, but seemed to him that he already had
ridden the distance to San Francisco.
“We’ll be after changin’ the base to a new Julesburg—as soon as the
rails reach yon,” said the men.
“Sure, if it’s base o’ supplies ye mane, that’ll be changed before ever
the rails get there,” was the answer. “Any day now they’ll be comin’
through—wid their gin mills an’ their skin-games an’ all on wheels, to
be set up an’ waitin’ for our pay-car.”
And that was true. The railroad followed up along the north side of
the South Platte River. The Overland Stage road followed up along
the south side, with the six-horse teams and the round Concord
stages plying over it between North Platte and Denver, on the Salt
Lake haul. And stage road and railroad grade headed westward
toward the old stage station at Julesburg.
It seemed likely that a new Julesburg would be the next supply base.
It was about the right distance from North Platte, the last base, or
ninety miles; for about every ninety or one hundred miles the supply
base was relocated, farther along, at end o’ track.
Sure enough. The middle of June, when old Julesburg itself was in
sight, two or three miles before, on the south side of the river there
appeared a long procession of wagons, buggies, horses, mules,
men, women and children.
“B’ gorry! Here they come, an’ there they go. Ain’t they kind, though,
to be all waitin’ for us?”
The wagons were loaded high with canvas, lumber, and goods; men
and women were perched atop, or riding in buggies, or upon saddle-
animals. The procession looked like a procession of refugees from a
war—there must have been over two hundred people. They certainly
raised a great cloud of dust.
The track-gang paused to cheer and wave; the women and the men
waved back. The graders on ahead waved and cheered, as the
procession passed them, to ford the river again at old Julesburg and
wait for end o’ track.
But Paddy Miles, the rugged Irishman, growled indignant.
“Bad cess to the likes of ’em. ’Tis hell on wheels, ag’in, movin’ on to
ruin many a man amongst us. Sure, if the Injuns’d only sweep the
whole lot from the face o’ the trail, I’d sing ‘Glory be! There’s a use
for the red nagurs, after all.’”
The way these new towns sprang up was wonderful. The railroad
sort of sowed them—and they grew over night like Jonah’s gourd or
the bean-stalk of Jack-the-Giant-Killer. There was North Platte.
Before the rails touched it, it had been nothing except a prairie-dog
village. But in three weeks it had blossomed into a regular town.
Now part of its people were moving along, to tag the pay-car. These
were the saloon keepers, gamblers, and speculators, in haste to
fleece the railroad workers. The track men and the graders got three
dollars a day, which meant rich picking for people bent upon selling
nothing for something.
The land agents of the railroad company had selected the site for the
next terminus town. Evidently it was across from old Julesburg, for
this evening lights beamed out, in a great cluster, up the grade,
where the “Hell on Wheels,” as the wrathful Pat Miles had dubbed it,
was settling down like a fat spider weaving a web.
In the morning there was revealed the tents set up, and the board
shanties going up—a mass of whity-brown and dingy dun, squatted
upon the gravelly landscape on the railroad side of the river.
Several graders had been killed, in shooting scrapes; the night at
new Julesburg had been a wild one; the track-layers who were
anxious to spend their money waxed impatient to arrive. As soon as
the rails reached the sprawling tent-and-shanty town, on the third
day, the terminus supplies were moving up, on flat-cars, from North
Platte.
The big building used by Casement Brothers, the contractors,
occupied a car by itself. It could be taken apart like a toy building of
blocks or cardboard. All the sections were numbered; and were
unjointed, piled upon a car, moved on, and set up again.
That was the case with a number of other buildings—stores and
offices, and the like. Some of them were painted to look as though
they had brick or stone fronts—but they were only flimsy wood. Why,
anybody who wished to erect a home on a lot could buy the house
for $300 in Chicago, and have it shipped, ready to be stuck together.
The railroad company owned the lands upon which these terminal
towns or “base” towns were located. The company land agents sold
or leased the town lots, and the speculators who acquired the lots
ran the figures up as high as $1000.
The rails paused a few days at this new Julesburg, while the
supplies from North Platte were brought up, and side-tracks were
laid for switching. After supper the first night in, Terry and little
Jimmie, his side-partner, went sight-seeing—like everybody else.
What a place—what an ugly, sprawling, dusty, noisy place, of tents
and shacks and jostling people, flannel-shirted, booted track-layers
and graders, blanketed Mexicans, even a few Arapaho Indians,
attracted hither-thither by the shouts and songs and revolver shots,
while candles, lanterns and coal-oil lamps tried to turn the dusk into
day.
“The man over there is yelling ‘Hurrah for the wickedest town in
America!’ Hear him?” half whispered Jimmie.
“It’s a heap worse than North Platte ever was,” Terry answered.
“North Platte’s a division point and will be a city; but Pat says this
town won’t last long. When the gamblers and whiskey-sellers move
on with the rails, there won’t be anything left.”
Suddenly he and Jimmie met, face to face, General Dodge himself,
with little General “Jack” Casement and a party, two of them in
military uniform. The generals stopped short.
“What are you boys doing here?”
“Jist lookin’ ’round, sorrs,” stammered Jimmie, in his best brogue,
with scrape of foot and touch of fingers to his ragged cap.
“You go back to the train. This is no place for boys,” General
Casement ordered sharply. “I think,” he added, to General Dodge,
“that I’ll instruct the police to keep all minors off the streets, at night,
unless with their parents or guardians.”
“A good idea,” agreed General Dodge. “But I’ll relieve you of one
boy, anyway. He goes along with me, I believe. You still want to go to
the very front, do you?” he asked, of Terry.
“Yes, sir, if I can.”
“Well, you can, with General Casement’s permission. I’m on my way
now. My party is camped a few miles out, beside the river. You’ll see
the tents, in the morning. And you’ll find an old friend of yours with
us: Sol Judy.”
That was good news.
“Is Sol going? Do you know Sol, sir?”
“Yes, indeed. Sol’s been my guide before. He mentioned you when
we got to talking over the Plum Creek massacre. That was a close
call, wasn’t it! And you lost your dog.”
“Yes, sir,” faltered Terry, with a little twinge in his heart. “I lost him.
But he saved Bill Thompson and me. I suppose losing those men
was worse.”
“They all gave their lives to the service,” said the general, gravely.
“People will never know what it costs to build this road and keep it
open. Now, we break camp at five o’clock tomorrow morning. You
report to me here at Casement Brothers’ headquarters at six o’clock.
Bring your campaign kit along, for we’ll be out all summer. We’ll
provide a horse for you.”
“Yes, sir. I’ll be there,” Terry exclaimed, rejoicing.
“How about this other lad?” pursued the general, a twinkle in his eye
as he scanned the red-headed Jimmie Muldoon. “Does he want to
go out into the Indian country?”
“No, sorr; plaze, sorr,” Jimmie apologized. “Sure, we have plinty
Injuns where we be, an’ I’ll stay wid the Irish. Me father’s chief spiker,
sorr, an’ me mother washes clothes, an’ me brother’s water carrier
an’ I’ve another brother who’s like to have Terry’s job; so it’s the
Muldoon family that’ll see the end o’ track through to Salt Lake.”
“All right,” the general laughed. “Stay ‘wid the Irish.’ You’ve a loyal
corps, Casement. But both you boys go back to your train and keep
out of trouble.”
With Jimmie, Terry was glad enough to beat a retreat to the
boarding-train, set out a little way in the cleaner brush and sand,
where the air was pure and the night was peaceful. A number of the
men, also, soon had enough of “town,” and were already turning in,
to sleep. But there was no sleep in new Julesburg. All night the
hubbub and hurly-burly continued, in spite of the police stationed by
General Casement.
However, tomorrow this would be left behind. Many a mile yet into
the north of west stretched the grade, waiting for the rails; and
beyond the grade itself stretched the surveyors’ location stakes; and
beyond the line of location stakes stretched widely the desert and
the mountains, where other stakes were being driven—and where
Terry Richards was about to explore, in company with Scout Sol
Judy and no less a personage than the bold General Dodge, chief
engineer of the whole road.
George Stanton, somewhere out there, having fun while he chopped
stakes and maybe even held the end of a surveyor’s chain, was
likely to get the surprise of his life.
CHAPTER VII
OUT INTO THE SURVEY COUNTRY
It was a tremendous large party. In fact, it looked like a regular

military excursion, instead of a survey trip, when in the early morning
it moved out from new Julesburg (the “roaring town” was dead tired
at this hour) and headed northwest up Lodge Pole Creek by the old
Overland Stage road on the Oregon Trail.
There were two companies, B and M, of the Second Cavalry, from
Fort McPherson, commanded by Captain (or Brevet Lieutenant-
Colonel) J. K. Mizner and First Lieutenant James N. Wheelan, to ride
the country and guard the long train of supply wagons. There was
Surgeon Henry B. Terry, of the army medical corps—a slender,
black-moustached, active man in major’s shoulder-straps. There
were the teamsters and farriers and wagoners and cooks and what-
not.
There were General Casement, and Construction Superintendent
Sam Reed, and Colonel Silas Seymour of New York (the consulting
engineer who was General Dodge’s assistant), and Mr. T. J. Carter, a
Government director of the road, and Mr. Jacob Blickensderfer, Jr.,
an engineer sent from Washington by the President, and Mr. James
Evans, the division engineer who was going out to examine the route
to the base of the Black Hills range. There were General William
Myers, chief quartermaster of the Department of the Platte, who was
to inspect the site of a new army post on the railroad survey, and
several surveyors who were to take the places of men that had been
killed by the Indians.
And there was General Dodge’s own party, with notables enough in
it to make a boy feel rather small.
Of course, the tall, lean man in buckskin was Scout Sol Judy, a real
rider of the plains, always ready for Indians or anything else. He
knew the country from Omaha to California.
The pleasant, full-bearded man who rode beside General Dodge
himself was none other than General John A. Rawlins, chief-of-staff
to General Grant, at Washington. General Rawlins was not well, and
General Grant had asked General Dodge if he might not be taken
along, sometime, on a trip, to see if roughing it in the Far West might
not do him good. So here he was. He and General Dodge had been
noted commanders in the Civil War, and were warm friends of each
other and of General Grant, too.
The alert trim-bearded man in corduroy coat was Mr. David Van
Lennep, the geologist, whose business was to explore for coal-fields
and minerals in the path of the survey.
The tall heavy-set, round-faced boyish-looking man was Captain and
Major William McKee Dunn, General Rawlins’ aide-de-camp, of the
Twenty-first Infantry.
Another round-faced boyish young man was Mr. John R. Duff from
Boston. His father was a director of the railroad company.
The tall slim man with side-whiskers was Mr. John E. Corwith, of
Galena, Illinois, who was a guest of General Rawlins.
For Terry to get the names and titles straight required most of the
day. General Dodge had introduced him in bluff fashion: “Gentlemen,
this is Terry Richards, one of the company men who are laying the
rails across continent. He’ll be one of us, on the trip.”
Beginning with General Rawlins, they all had shaken hands with him.
But it was young Mr. Duff who explained who they were, as on his
horse Terry fell in behind, to bring up the rear.
That was the place chosen by Mr. Duff and Mr. Corwith, the other
civilian guest.
“So you’re out to see the country, too, are you?” queried Mr. Duff,
genially. “What are you? Track inspector in advance?”
“I don’t know,” Terry admitted, a little uneasy in his faded old clothes.
But clothes seemed to make no difference. “General Dodge said I

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