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A LANGE medical book
Ganong’s Review of
Medical Physiology
TWENTY-FIFTH EDITION
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Dedication to
William Francis Ganong
W
illiam Francis (“Fran”) Ganong was an outstanding remarked on and admired whenever the book came up for dis-
scientist, educator, and writer. He was completely cussion among physiologists. He was an excellent writer and
dedicated to the field of physiology and medical ed- far ahead of his time with his objective of distilling a complex
ucation in general. Chairman of the Department of Physiology subject into a concise presentation. Like his good friend, Dr.
at the University of California, San Francisco, for many years, Jack Lange, founder of the Lange series of books, Fran took
he received numerous teaching awards and loved working with great pride in the many different translations of the Review of
medical students. Medical Physiology and was always delighted to receive a copy
Over the course of 40 years and some 22 editions, he was of the new edition in any language.
the sole author of the best selling Review of Medical Physiology, He was a model author, organized, dedicated, and enthusi-
and a co-author of 5 editions of Pathophysiology of Disease: An astic. His book was his pride and joy and like other best-selling
Introduction to Clinical Medicine. He was one of the “deans” authors, he would work on the next edition seemingly every
of the Lange group of authors who produced concise medical day, updating references, rewriting as needed, and always ready
text and review books that to this day remain extraordinarily and on time when the next edition was due to the publisher. He
popular in print and now in digital formats. Dr. Ganong made did the same with his other book, Pathophysiology of Disease:
a gigantic impact on the education of countless medical stu- An Introduction to Clinical Medicine, a book that he worked on
dents and clinicians. meticulously in the years following his formal retirement and
A general physiologist par excellence and a neuroendo- appointment as an emeritus professor at UCSF.
crine physiologist by subspecialty, Fran developed and main- Fran Ganong will always have a seat at the head table of
tained a rare understanding of the entire field of physiology. the greats of the art of medical science education and commu-
This allowed him to write each new edition (every 2 years!) nication. He died on December 23, 2007. All of us who knew
of the Review of Medical Physiology as a sole author, a feat him and worked with him miss him greatly.
Bowman’s
Fenestrations
space
Capillary lumen
Basal lamina
FIGURE 37–2 Structural details of glomerulus. A) Section through vascular pole, showing capillary loops. B) Relation of mesangial cells
and podocytes to glomerular capillaries. C) Detail of the way podocytes form filtration slits on the basal lamina, and the relation of the lamina
to the capillary endothelium. D) Enlargement of the rectangle in C to show the podocyte processes. The fuzzy material on their surfaces is
glomerular polyanion.
about 12 m2. The volume of blood in the renal capillaries at any glomerular filtration rate (GFR) and is claimed to enhance and
given time is 30–40 mL. prolong anuria in acute kidney injury (AKI).
More than LYMPHATICS INNERVATION OF
600 full-color The kidneys have an abundant lymphatic supply that drains
via the thoracic duct into the venous circulation in the thorax.
THE RENAL VESSELS
The renal nerves travel along the renal blood vessels as they
illustrations CAPSULE enter the kidney. They contain many postganglionic sym-
pathetic efferent fibers and a few afferent fibers. There also
The renal capsule is thin but tough. If the kidney becomes appears to be a cholinergic innervation via the vagus nerve,
edematous, the capsule limits the swelling, and the tissue but its function is uncertain. The sympathetic pregangli-
pressure (renal interstitial pressure) rises. This decreases the onic innervation comes primarily from the lower thoracic
Taste exhibits after reactions and contrast phenomena 2. A 37-year-old female was diagnosed with multiple sclerosis.
that are similar in some ways to visual after images and con- One of the potential consequences of this disorder is
trasts. Some of these are chemical “tricks,” but others may be diminished taste sensitivity. Taste receptors
true central phenomena. A taste-modifier protein, miraculin, A. for sweet, sour, bitter, salt, and umami are spatially separated
has been discovered in a plant. When applied to the tongue, on the surface of the tongue.
this protein makes acids taste sweet. B. are synonymous with taste buds.
C. are a type of chemoreceptor.
Animals, including humans, form particularly strong
D. are innervated by afferents in the facial, trigeminal, and
aversions to novel foods if eating the food is followed by ill-
glossopharyngeal nerves.
ness. The survival value of such aversions is apparent in terms E. All of the above.
of avoiding poisons.
3. Which of the following does not increase the ability to
discriminate many different odors?
CHAPTER SUMMARY A. Many different receptors
■
B. Pattern of olfactory receptors activated by a given
Olfactory sensory neurons, supporting (sustentacular) cells, odorant
and basal stem cells are located in the olfactory epithelium C. Projection of different mitral cell axons to different parts of
■
within the upper portion of the nasal cavity.
The cilia located on the dendritic knob of the olfactory
sensory neuron contain odorant receptors that are coupled to
the brain
D. High β-arrestin content in olfactory neurons
E. Sniffing
End-of-chapter review
G-proteins. Axons of olfactory sensory neurons contact the
dendrites of mitral and tufted cells in the olfactory bulbs to
form olfactory glomeruli.
4. As a result of an automobile accident, a 10-year-old boy suffered
damage to the brain including the periamygdaloid, piriform, questions help you assess
■
and entorhinal cortices. Which of the following sensory deficits
Information from the olfactory bulb travels via the lateral
olfactory stria directly to the olfactory cortex, including
the anterior olfactory nucleus, olfactory tubercle, piriform
is he most likely to experience?
A. Visual disturbance
B. Hyperosmia
your comprehension
cortex, amygdala, and entorhinal cortex.
■
C. Auditory problems
Taste buds are the specialized sense organs for taste and are D. Taste and odor abnormalities
composed of basal stem cells and three types of taste cells (dark, E. No major sensory deficits
light, and intermediate). The three types of taste cells may
5. Which of the following are incorrectly paired?
represent various stages of differentiation of developing taste
cells, with the light cells being the most mature. Taste buds are A. ENaC : Sour taste
located in the mucosa of the epiglottis, palate, and pharynx and B. Gustducin : Bitter taste
in the walls of papillae of the tongue. C. T1R3 family of GPCRs : Sweet taste
■
D. Heschel sulcus : Smell
There are taste receptors for sweet, sour, bitter, salt, and
E. Ebner glands : Taste acuity
umami. Signal transduction mechanisms include passage
through ion channels, binding to and blocking ion channels, 6. A 9-year-old boy had frequent episodes of uncontrollable nose
and GPCRs requiring second messenger systems. bleeds. At the advice of his clinician, he underwent surgery
■
to correct a problem in his nasal septum. A few days after the
The afferents from taste buds in the tongue travel via
surgery, he told his mother he could not smell the cinnamon
the seventh, ninth, and tenth cranial nerves to synapse
rolls she was baking in the oven. Which of the following is true
in the NTS. From there, axons ascend via the ipsilateral
about olfactory transmission?
medial lemniscus to the ventral posteromedial nucleus
of the thalamus, and onto the anterior insula and frontal A. An olfactory sensory neuron expresses a wide range of
operculum in the ipsilateral cerebral cortex. odorant receptors.
B. Lateral inhibition within the olfactory glomeruli reduces
the ability to distinguish between different types of odorant
MULTIPLE-CHOICE QUESTIONS receptors.
C. Conscious discrimination of odors is dependent on the
For all questions, select the single best answer unless otherwise pathway to the orbitofrontal cortex.
directed. D. Olfaction is closely related to gustation because odorant and
1. A young boy was diagnosed with congenital anosmia, a rare gustatory receptors use the same central pathways.
disorder in which an individual is born without the ability to E. All of the above.
smell. Odorant receptors are 7. A 31-year-old female is a smoker who has had poor oral
A. located in the olfactory bulb. hygiene for most of her life. In the past few years she has
B. located on dendrites of mitral and tufted cells. noticed a reduced sensitivity to the flavors in various foods
C. located on neurons that project directly to the olfactory which she used to enjoy eating. Which of the following is not
cortex. true about gustatory sensation?
D. located on neurons in the olfactory epithelium that project A. The sensory nerve fibers from the taste buds on the anterior
to mitral cells and from there directly to the olfactory cortex. two-thirds of the tongue travel in the chorda tympani
E. located on sustentacular cells that project to the olfactory bulb. branch of the facial nerve.
S E C T I O N
13 Autonomic Nervous System 255
Cellular & Molecular
ix
S E C T I O N S E C T I O N
Gastrointestinal
IV Physiology 451
VI Respiratory Physiology 619
S E C T I O N
VII Renal Physiology 669
Cardiovascular
V Physiology 517 37 Renal Function & Micturition 671
31 Blood as a Circulatory Fluid & the Dynamics Answers to Multiple Choice Questions 719
of Blood & Lymph Flow 553
Index 721
32 Cardiovascular Regulatory Mechanisms 585
xi
The detailed study of physiologic system structure and In the second part of this introductory section, we take a
function has its foundations in physical and chemical laws cellular approach to lay a groundwork of understanding
and the molecular and cellular makeup of each tissue and groups of cells that interact with many of the systems dis
organ system. This first section provides an overview of the cussed in future chapters. The first group of cells presented
basic building blocks that provide the important frame contribute to inflammatory reactions in the body. These
work for human physiology. It is important to note here that individual players, their coordinated behavior, and the net
these initial sections are not meant to provide an exhaustive effects of the “open system” of inflammation in the body are
understanding of biophysics, biochemistry, or cellular and discussed in detail. The second group of cells discussed are
molecular physiology, rather they are to serve as a reminder responsible for the excitatory responses in human physiol
of how the basic principles from these disciplines contrib ogy and include both neuronal and muscle cells. A funda
ute to medical physiology discussed in later sections. mental understanding of the inner workings of these cells,
and how they are controlled by their neighboring cells
In the first part of this section, the following basic building helps the student to understand their eventual integration
blocks are introduced and discussed: electrolytes; carbohy into individual systems discussed in later sections.
drates, lipids, and fatty acids; amino acids and proteins; and
nucleic acids. Students are reminded of some of the basic In the end, this first section serves as an introduction,
principles and building blocks of biophysics and biochemi refresher, and quick source of material to best understand
stry and how they fit into the physiologic environment. systems physiology presented in the later sections. For
Examples of direct clinical applications are provided in detailed understanding of any of the chapters within this
the Clinical Boxes to help bridge the gap between build section, several excellent and current textbooks that pro
ing blocks, basic principles, and human physiology. These vide more in depth reviews of principles of biochemistry,
basic principles are followed up with a discussion of the biophysics, cell physiology, muscle and neuronal physiol
generic cell and its components. It is important to realize ogy are provided as resources at the end of each individ
the cell is the basic unit within the body, and it is the collec ual chapter. Students who are intrigued by the overview
tion and fine-tuned interactions among and between these provided in this first section are encouraged to visit these
fundamental units that allow for proper tissue, organ, and texts for a more thorough understanding of these basic
organism function. principles.
Energy Production in
Medical Physiology
INTRODUCTION
In unicellular organisms, all vital processes occur in a single products of metabolism; a reproductive system to perpetuate
cell. As the evolution of multicellular organisms progressed, the species; and nervous and endocrine systems to coordinate
various cell groups organized into tissues and organs have and integrate the functions of the other systems. This book is
taken over particular functions. In humans and other vertebrate concerned with the way these systems function and the way each
animals, the specialized cell groups include a gastrointestinal contributes to the functions of the body as a whole. This first
system to digest and absorb food; a respiratory system to take chapter focuses on a review of basic biophysical and biochemical
up O2 and eliminate CO2; a urinary system to remove wastes; principles and the introduction of the molecular building blocks
a cardiovascular system to distribute nutrients, O2, and the that contribute to cellular physiology.
Cell membrane
fluid: K+
20% body 15% body weight
mEq/L H2O
Capillaries
weight Na+ Cl−
100 Cl−
Na+
Na+
Intracellular fluid:
50 HCO3− Prot−
40% body weight
K+ K+ HCO3− HCO3−
Prot−
0
A B Cl−
FIGURE 1–1 Organization of body fluids and electrolytes into compartments. A) Body fluids can be divided into intracellular and
extracellular fluid compartments (ICF and ECF, respectively). Their contribution to percentage body weight (based on a healthy young adult
male; slight variations exist with age and gender) emphasizes the dominance of fluid makeup of the body. Transcellular fluids, which constitute
a very small percentage of total body fluids, are not shown. Arrows represent fluid movement between compartments. B) Electrolytes and
proteins are unequally distributed among the body fluids. This uneven distribution is crucial to physiology. Prot–, protein, which tends to have a
negative charge at physiologic pH.
the H+, that is, the negative logarithm of the [H+]. The pH of
water at 25°C, in which H+ and OH– ions are present in equal
CLINICAL BOX 1–2
numbers, is 7.0 (Figure 1–2). For each pH unit less than 7.0,
the [H+] is increased 10-fold; for each pH unit above 7.0, it is Acid–Base Disorders
decreased 10-fold. In the plasma of healthy individuals, pH Excesses of acid (acidosis) or base (alkalosis) exist when
is slightly alkaline, maintained in the narrow range of 7.35– the blood is outside the normal pH range (7.35–7.45). Such
7.45 (Clinical Box 1–2). Conversely, gastric fluid pH can be changes impair the delivery of O2 to and removal of CO2 from
quite acidic (on the order of 3.0) and pancreatic secretions tissues. There are a variety of conditions and diseases that can
can be quite alkaline (on the order of 8.0). Enzymatic activ- interfere with pH control in the body and cause blood pH to fall
ity and protein structure are frequently sensitive to pH; in outside of healthy limits. Acid–base disorders that result from
any given body or cellular compartment, pH is maintained respiration to alter CO2 concentration are called respiratory aci
to allow for maximal enzyme/protein efficiency. dosis and respiratory alkalosis. Nonrespiratory disorders that
Molecules that act as H+ donors in solution are consid- affect HCO3– concentration are referred to as metabolic acido
ered acids, while those that tend to remove H+ from solu- sis and metabolic alkalosis. Metabolic acidosis or alkalosis can
tions are considered bases. Strong acids (eg, HCl) or bases be caused by electrolyte disturbances, severe vomiting or diar
(eg, NaOH) dissociate completely in water and thus can most rhea, ingestion of certain drugs and toxins, kidney disease, and
diseases that affect normal metabolism (eg, diabetes).
10−3 3
10−4 4 ders are encountered. Treatment of respiratory acido
10−5 5 sis should be initially targeted at restoring ventilation,
10−6 6 whereas treatment for respiratory alkalosis is focused
For pure water,
10−7 7
[H+] = 10−7 mol/L on the reversal of the root cause. Bicarbonate is typi
10−8 8
10−9 9 cally used as a treatment for acute metabolic acido
ALKALINE
change the [H+] in solution. In physiologic compounds, most If H+ is added to a solution of carbonic acid, the equilib-
acids or bases are considered “weak,” that is, they contribute rium shifts to the left and most of the added H+ is removed
or remove relatively few H+ from solution. Body pH is stabi- from solution. If OH– is added, H+ and OH– combine, tak-
lized by the buffering capacity of the body fluids. A buffer ing H+ out of solution. However, the decrease is countered by
is a substance that has the ability to bind or release H+ in more dissociation of H2CO3, and the decline in H+ concentra-
solution, thus keeping the pH of the solution relatively con- tion is minimized. A unique feature of HCO3– is the linkage
stant despite the addition of considerable quantities of acid between its buffering ability and the ability for the lungs to
or base. Of course there are a number of buffers at work in remove CO2 from the body. Other important biologic buffers
biologic fluids at any given time. All buffer pairs in a homog- include phosphates and proteins.
enous solution are in equilibrium with the same [H+]; this
is known as the isohydric principle. One outcome of this
principle is that by assaying a single buffer system, we can DIFFUSION
understand a great deal about all of the biologic buffers in
Diffusion is the process by which a gas or a substance in a
that system.
solution expands, because of the motion of its particles, to fill
When acids are placed into solution, there is dissociation
all the available volume. The particles (molecules or atoms)
of some of the component acid (HA) into its proton (H+) and
of a substance dissolved in a solvent are in continuous ran-
free acid (A–). This is frequently written as an equation:
dom movement. A given particle is equally likely to move into
or out of an area in which it is present in high concentration.
HA H+ + A−
|
pH = pKa + log[A−]/[HA]
L e g u a n e n , II 30.
L e p e l a a r , zie Platalea.
L e p e l a a r , II 57;
wisseling van gevederte bij den Chineeschen —, II 170.
Lepidoptera, 575;
getalsverhouding der seksen bij —, 488;
kleuren der —, 576;
oogvlekken der —, II 128.
L e p i d o s i r e n , 280, 288.
L i c h a a m s k r a c h t , zie S p i e r k r a c h t .
L i e f d e , moederlijke —, 117;
bij dieren, 117;
ouderlijke en kinderlijke — gedeeltelijk het gevolg van natuurlijke teeltkeus, 190.
Linaria, II 171.
Linyphia, 525.
L i p v i s s c h e n , zie Labrus.
L o n g s l a k k e n , zie Pulmonata.
L o o p k e v e r s , zie Carabidae.
L o o p v o g e l s , zie Cursores.
L o s b a n d i g h e i d , 220;
groote — der wilden, 205;
de — een beletsel van den aanwas der bevolking, 77.
L i j s t e r , Woud—, II 206.
L i j s t e r , zwarte, zie M e r e l .
M a c c u l l o c h , Kol., over een Indisch dorp zonder een enkel vrouwelijk kind, II
344.
M a i l l a r d , M., over de verhouding der seksen in een soort van Papilio van
Bourbon, 488.
M a i n e , de heer, over het samensmelten [450]van den eenen stam met den
anderen, 238;
over het gebrek aan begeerte naar verbetering, 244.
M a l l e , Dureau de la, over een hond, door een kat grootgebracht, 121;
over valken, 121.
M a n e n s c h a a p , zie Ammotragus.
M a n t e l l , W., over het wegnemen der mooie meisjes door de opperhoofden van
Nieuw-Zeeland, 362.
Marsupialia, 279;
tepels der —,285;
hun afstamming van de Monotremata, 288;
baarmoeder der —,67;
ontwikkeling van het membrana nictitans bij de —, 24;
buidels der —, 435;
betrekkelijke grootte der seksen bij de —, II 244;
kleuren der —, II 277.
M a r t e l i n g e n , ongevoeligheid der Amerikaansche wilden voor —, 205.
M a r t i n , W. C. L., over den schrik van een orang op het gezicht van een
schildpad, 120;
over het haar bij Hylobates, 271;
over het wijfje van een Amerikaansch hert, II 243;
over de stem van Hylobates agilis, II 268;
over Semnopithecus nemaeus, II 300. [451]
M a r t i n s , C., over den dood ten gevolge der ontsteking van het wormvormig
aanhangsel, 28.
M a u d s l e y , Dr., over den invloed van den reuk bij den mensch, 25;
over Laura Bridgman, 138;
over de ontwikkeling der stemorganen, 140;
over de behaardheid van idioten, 64.
M c N e i l l , de heer, over het gebruik van het gewei der herten, II 239;
over den Schotschen hertenhond, II 246;
over de lange haren aan de keel van het hert, II 252;
over het loeien der herten, II 267.
M e c k e l , over correlatie tusschen de spieren van den arm en het been, 73;
over polydactylisme, 66.
M e e k r a p v l i n d e r , 587.
M e e z e n , zie Parinae.
M e l k k l i e r e n , 435, 284.
Meloë, verschil in kleur bij de seksen van een soort van —, 555.
M e m n o n , de jonge —, 332.
M e n s c h e n o f f e r s , 148, 258.
M e n s c h e n r i j k , 265.
M e r g h e u v e l s , 393.
M e s t t o r r e n , zie Copris.
M e y e r , Dr. L., over het verschil tusschen de ooren van den man en die van de
vrouw, 453;
over het Darwinsche spitsoor, 22.
M e y e r , over een samengerold lichaam aan het einde van den staart bij een
Macacus en een kat, 30.
M e y e r , Dr. A., over het paren van Phryganidae van verschillende soorten, 532.
M i l l i o e n p o o t e n , 528.
M i l n e E d w a r d s , H., over het gebruik der vergroote knijpers van het mannetje
van Gelasimus, 520.
„M i m i c k r y ”, 597;
bij vlinders, 597.
M i s d a d i g e r s , 249.
M o n o g e n i s t e n , 341.
Monotremata, 279;
ontwikkeling van de membrana nictitans bij de —, 24;
melkafscheidende klieren der —, 284;
verbinding der zoogdieren met de reptielen door de —, 288.
M o n s t r u o s i t e i t e n , overeenkomstig den mensch en de lagere dieren, 57;
veroorzaakt door stilstand in ontwikkeling, 65;
correlatie van —, 73;
overplanting van —, 337.
M o r i n e l , — Plevier, II 192.
M o r r i s , F. O., over een verlaten havik die door andere haviken gevoed werd, II
103.
M o s d i e r e n , zie Polyzoa.
M u g g e n , langbeenige, 538.
M ü l l e r , Dr. Hermann en Fritz, over de verhouding der seksen bij de bijen, 493,
494.