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 Essentials of

Human

Second Edition
Disease
Leonard V. Crowley, MD
Biology Department
Century College
University of Minnesota Medical Center, Fairview
Minneapolis, Minnesota

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 Chapter 3 Autoimmune Disease Manifestations and
Mechanisms of Tissue Injury 59
Inflammation and Repair 38 Connective-­Tissue (Collagen) Diseases 59
The Inflammatory Reaction 38 Lupus Erythematosus 59
Chemical Mediators of Inflammation 41 Chapter Review 62
The Role of Lysosomal Enzymes in the
Inflammatory Process 42 Chapter 5
Inflammation Caused by Antigen–Antibody
Interaction 42
Pathogenic Microorganisms, Fungi,
Harmful Effects of Inflammation 42 and Animal Parasites 65
Infection 43 Types of Harmful Microorganisms 65
Terminology of Infection 43 Bacteria 66
Factors Influencing the Outcome of an Classification of Bacteria 66
­Infection 43 Major Classes of Pathogenic Bacteria 67
Chronic Infection 44 Antibiotic Treatment of Bacterial Infections 72
Chapter Review 44 Antibiotic Sensitivity Tests 73
Adverse Effects of Antibiotics 74
Chlamydiae 75
Chapter 4
Rickettsiae and Ehrlichiae 75
Immunity, Hypersensitivity, Allergy,
and Autoimmune Diseases 47 Mycoplasmas 75
Viruses 75
The Body’s Defense Mechanisms 47
Classification of Viruses 75
Immunity 48 Mode of Action 76
The Role of Lymphocytes in Acquired- Defenses Against Viral Infections 79
Immunity 48 Treatment with Antiviral Agents 80
Development of the Lymphatic System 48 Fungi 80
Response of Lymphocytes to Foreign Superficial Fungal Infections 80
Antigens 49
Highly Pathogenic Fungi 81
The Role of Complement in Immune Other Fungi of Medical Importance 81
Responses 52
Treatment of Systemic Fungal Infections 82
Antibodies (Immunoglobulins) 52 Animal Parasites and Their Host 82
Hypersensitivity Reactions: Immune System–Related Protozoal Infections 82
Tissue Injury 54 Malaria 83
Type I. Immediate Hypersensitivity Reactions: Babesiosis 83
Allergy and Anaphylaxis 54 Amebiasis 83
Type II. Cytotoxic Hypersensitivity Genital Tract Infections Caused by
Reactions 56 Trichomonads 84
Type III. Tissue Injury Caused by Immune Giardiasis 84
Complexes (“Immune Complex Disease”) 56 Toxoplasmosis 84
Type IV. Delayed (Cell-­Mediated) Cryptosporidiosis 85
Hypersensitivity Reactions 57 Pulmonary Pneumocystis Infection 86
Suppression of the Immune Response 57 Metazoal Infections 86
Reasons for Suppression 57 Roundworms 86
Methods of Suppression 57 Tapeworms 89
Tissue Grafts and Immunity 58 Flukes 89
Autoimmune Diseases 58 Chapter Review 91

viii Contents

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 Chapter 6 Autosomal Recessive Inheritance 120
Codominant Inheritance 121
Communicable Diseases 96 X-­Linked Inheritance 121
Methods of Transmission and Control 96 Intrauterine Injury 121
Methods of Transmission 96 Harmful Drugs and Chemicals 121
Methods of Control 97 Radiation 123
Immunization 97 Maternal Infections 123
Identification, Isolation, and Treatment of Multifactorial Inheritance 125
Infected Persons 97 Prenatal Diagnosis of Congential Abnormalities 125
Control of Means of Indirect Transmission 97
Amniocentesis 126
Requirements for Effective Control 97
Chorionic Villus Sampling 127
Sexually Transmitted Diseases 98
Chapter Review 127
Syphilis 99
Gonorrhea 100
Herpes 101 Chapter 8
Genital Chlamydial Infections 102 Tumors 131
Human Immunodeficiency Virus Infections and
Tumors: Disturbed Cell Growth 132
AIDS 103
HIV and Its Target 103 Tumors 132
Manifestations of HIV Infection 103 Classification and Nomenclature 132
Measurement of Viral RNA and CD4+ Comparison of Benign and Malignant
Lymphocytes as an Index of Disease Tumors 132
Progression 104 Benign Tumors 134
Complications of AIDS 104 Malignant Tumors 134
Prevalence of HIV Infection and AIDS in H
­ igh-­ Variations in Terminology 135
Risk Groups 105 Necrosis in Tumors 138
Treatment of HIV Infection 106 Noninfiltrating (in Situ) Carcinoma 139
Prevention and Control of HIV Infection 107 Precancerous Conditions 139
Case Studies 107 Etiologic Factors in Neoplastic Disease 140
Chapter Review 108 Viruses 140
Gene and Chromosomal Abnormalities 140
Failure of Immunologic Defenses 142
Chapter 7 Heredity and Tumors 143
Congenital and Hereditary Diagnosis of Tumors 144
Diseases 111 Early Recognition of Neoplasms 144
Causes of Congenital Malformations 111 Cytologic Diagnosis of Neoplasms 144
Frozen-­Section Diagnosis of Neoplasms 145
Chromosomal Abnormalities 112 Tumor-­Associated Antigen Tests 145
Chromosome Nondisjunction During
Gametogenesis 112 Treatment of Tumors 146
Chromosome Deletions and Translocations Surgery 146
During Gametogenesis 112 Radiotherapy 146
Chromosome Nondisjunction in the Hormone Therapy 146
Zygote 114 Anticancer Drugs 147
Sex Chromosome Abnormalities 114 Adjuvant Chemotherapy 147
Autosomal Abnormalities 117 Immunotherapy 147
Genetically Transmitted Diseases 118 Leukemia 148
Autosomal Dominant Inheritance 119 Classification of Leukemia 148

Contents ix

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 Clinical Features and Principles of
Treatment 148
Precursors of Leukemia: The Myelodysplastic
Syndromes 149
Multiple Myeloma 149
Survival Rates in Neoplastic Disease 150
Chapter Review 152
Chapter 9
Blood Coagulation
Abnormalities and Circulatory
Disturbances 155
Hemostasis 156
Factors Concerned with Hemostasis 156
Blood Vessels and Platelets 156
Plasma Coagulation Factors 156
Coagulation Inhibitors and Fibrinolysins
Calcium and Blood Coagulation 158
Clinical Disturbances of Blood Coagulation
Abnormalities of Small Blood Vessels 158
Abnormalities of Platelet Numbers or
Function 158
Deficiency of Plasma Coagulation Factors 158
Liberation of Thromboplastic Material into the
Circulation 160
Laboratory Tests to Evaluate Hemostasis 160
Case Studies 161
Circulatory Disturbances: Thrombosis and
Embolism 163
Venous Thrombosis and Pulmonary Embolism
Large Pulmonary Emboli 163
Small Pulmonary Emboli 165
Diagnosis of Pulmonary Embolism 165
Treatment of Pulmonary Embolism 166
Arterial Thrombosis 167
Intracardiac Thrombosis 167
Thrombosis Caused by Increased Blood
Coagulability 167
Thrombosis in Patients with Cancer 168
Embolism as a Result of Foreign Material 168
Fat Embolism 168
Amnionic Fluid Embolism 168
Air Embolism 168
Edema 168
x Contents
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Factors Regulating Fluid Flow Between
Capillaries and Interstitial Tissue 169
Pathogenesis and Classification of Edema 169
Shock 170
Chapter Review 172
Chapter 10
The Cardiovascular System 176
Cardiac Structure and Function 177
Normal Cardiac Function 177
Cardiac Chambers 177
Cardiac Valves 177
Blood Supply to the Heart 178
Conduction System of the Heart 179
The Cardiac Cycle 179
Blood Vessels 180
Blood Pressure 180
158 The Electrocardiogram 181
Cardiac Arrhythmias 181
158 Atrial Fibrillation 181
Treatment of Atrial Fibrillation 181
Ventricular Fibrillation 182
Heart Block 182
Heart Disease as a Disturbance of Pump Function 182
Congenital Heart Disease 183
Cardiac Development and Prenatal Blood
Flow 183
Pathogenesis and Manifestations of Congenital
Heart Disease 183
Common Cardiovascular Abnormalities 185
163 Patent Ductus Arteriosus 185
Patent Foramen Ovale 185
Atrial and Ventricular Septal Defects 185
Pulmonary or Aortic Valve Stenosis 185
Coarctation of the Aorta 186
The Tetralogy of Fallot and Transposition of the
Great Arteries 186
Prevention of Congenital Heart Disease 187
Valvular Heart Disease 187
Rheumatic Fever and Rheumatic Heart
Disease 187
Nonrheumatic Aortic Stenosis 189
Mitral Valve Prolapse 191
Infective Endocarditis 192
Coronary Heart Disease 194
Risk Factors 195
8/16/12 11:00 AM
 Manifestations 195
Diagnosis of Coronary Artery Disease 196
Coronary Disease Manifestations with
Apparently Normal Coronary Arteries 196
Treatment of Coronary Artery Disease 197
Severe Myocardial Ischemia and Its Complications:
A “Heart Attack” 198
Cardiac Arrest 199
Myocardial Infarction 200
Location of Myocardial Infarcts 200
Major Complications of Myocardial
Infarcts 200
Survival After Myocardial Infarction 201
Diagnosis of Myocardial Infarction 201
Evaluation and Treatment of Patients with
Suspected Myocardial Infarction: The Acute
Coronary Syndrome Classification 203
Restoring Blood Flow Through a Thrombosed
Coronary Artery 204
Subsequent Treatment of Myocardial
Infarction 205
Case Studies 205
Taking Aspirin to Reduce the Risk of Cardiovascular
Disease 207
Cocaine-Induced Arrhythmias and Myocardial
Infarcts 207
Blood Lipids and Coronary Artery Disease 207
Neutral Fat 207
Cholesterol 208
Transport of Cholesterol by Lipoproteins
Alteration of Blood Lipids by Change in
Diet 209
Hypertension and Hypertensive Cardiovascular
Disease 209
Primary Hypertension 209
Secondary Hypertension 210
Isolated Systolic Hypertension 210
Treatment of Hypertension 210
Primary Myocardial Disease 210
Myocarditis 210
Cardiomyopathy 210
Heart Failure 211
Pathophysiology and Treatment of Heart
Failure 211
Comparison of Systolic and Diastolic
Dysfunction in Heart Failure 212
Acute Pulmonary Edema 212
Aneurysms 213
Arteriosclerotic Aneurysm 213
Dissecting Aneurysm of the Aorta 214
Diseases of the Veins 217
Venous Thrombosis and
Thrombophlebitis 217
Varicose Veins of the Lower Extremities 217
Chapter Review 219
Chapter 11
The Hematopoietic and Lymphatic
Systems 223
The Hematopoietic System 223
Composition and Function of Human
Blood 223
Normal Hematopoiesis 225
Development, Maturation, and Survival of Red
Cells 225
Regulation of Hematopoiesis 226
Anemia 226
Etiologic Classification of Anemia 226
Morphologic Classification of Anemia 226
Iron Metabolism and Hematopoiesis 227
Iron Deficiency Anemia 228
Vitamin B12 and Folic Acid Deficiency 230
Acute Blood Loss 231
Accelerated Blood Destruction 231
Diagnostic Evaluation of Anemia 234
208
Polycythemia 235
Secondary Polycythemia 235
Primary Polycythemia 235
Complications and Treatment of
Polycythemia 235
Iron Overload: Hemochromatosis 235
Thrombocytopenia 236
The Lymphatic System 236
Diseases of the Lymphatic System 237
Inflammation of the Lymph Nodes
(Lymphadenitis) 237
Infectious Mononucleosis 237
Neoplasms Affecting Lymph Nodes 238
Alteration of Immune Reactions in Diseases of
the Lymphatic System 238
The Enlarged Lymph Node as a Diagnostic
Problem 238

Contents xi

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 The Role of the Spleen in Protection Against
Systemic Infection 239
Chapter Review 239
Chapter 12
The Respiratory System 241
Oxygen Delivery: A Cooperative Effort 241
Structure and Function of the Lungs 242
Bronchi, Bronchioles, and Alveoli 242
Ventilation 244
Gas Exchange 244
Pulmonary Function Tests 245
The Pleural Cavity 245
Pneumothorax 246
Atelectasis 248
Obstructive Atelectasis 248
Compression Atelectasis 249
Pneumonia 250
Classification of Pneumonia 250
Clinical Features of Pneumonia 251
Pneumocystis Pneumonia 251
Tuberculosis 251
Course of a Tuberculous Infection 251
Miliary Tuberculosis and Tuberculous
Pneumonia 254
Extrapulmonary Tuberculosis 254
Diagnosis and Treatment of Tuberculosis
Bronchitis and Bronchiectasis 255
Chronic Obstructive Lung Disease 255
Derangements of Pulmonary Structure and
Function 256
Pathogenesis of Chronic Obstructive Pulmonary
Disease 257
Prevention and Treatment 258
Bronchial Asthma 259
Respiratory Distress Syndrome 259
Respiratory Distress Syndrome of Newborn
Infants 259
Adult Respiratory Distress Syndrome 260
Pulmonary Fibrosis 260
Lung Carcinoma 261
Chapter Review 263
xii Contents
43898_FMxx_FINAL.indd 12
Chapter 13
The Breast and Female
Reproductive System 268
The Breast 269
Structure and Physiology of the Breast 269
Mammograms 269
Abnormalities of Breast Development 270
Accessory Breasts and Nipples 270
Unequal Development of the Breasts 271
Breast Hypertrophy 272
Gynecomastia 272
Benign Cystic Change in the Breast 272
Fibroadenoma 272
Carcinoma of the Breast 273
Breast Carcinoma Risk Related to Hormone
Treatment 273
Breast Carcinoma Susceptibility Genes 273
Classification of Breast Carcinoma 274
Evolution of Breast Carcinoma 274
Clinical Manifestations 274
Treatment 276
Examination of Axillary Lymph Nodes: The Role
of the Sentinel Node 276
Estrogen and Progesterone Receptors in Breast
Carcinoma 276
HER-2 Gene Amplification in Breast
Carcinoma 277
Adjuvant Therapy for Breast Carcinoma 278
254 Treatment of Recurrent and Metastatic
Carcinoma 278
Sarcoma of the Breast 278
A Lump in the Breast as a Diagnostic Problem 278
Female Reproductive System 279
Infections of the Female Genital Tract 279
Vaginitis 279
Cervicitis 279
Salpingitis and Pelvic Inflammatory
Disease 279
Condylomas of the Genital Tract 280
Endometriosis 280
Cervical Polyps 282
Cervical Dysplasia and Cervical Carcinoma 282
HPV Vaccine 282
Diagnosis and Treatment 283
Endometrial Hyperplasia, Polyps, and Carcinoma 283
8/16/12 11:00 AM
 Uterine Myomas 283
Irregular Uterine Bleeding 285
Dysfunctional Uterine Bleeding 285
Other Causes of Uterine Bleeding 286
Diagnosis and Treatment 286
Dysmenorrhea 286
Cysts and Tumors of the Ovary 286
Diseases of the Vulva 289
Vulvar Dystrophy 289
Carcinoma of the Vulva 289
Toxic Shock Syndrome 289
Contraception 289
Emergency Contraception 290
Chapter Review 291
Chapter 14
Prenatal Development and Diseases
Associated with Pregnancy 296
Fertilization and Prenatal Development
Fertilization 297
Early Development of the Fertilized Ovum
Stages of Prenatal Development 300
Duration of Pregnancy 301
Decidua, Fetal Membranes, and Placenta
The Decidua 301
The Chorion and Chorionic Villi
The Amnionic Sac 302
The Yolk Sac 302
The Placenta 302
Amnionic Fluid 304
Polyhydramnios and Oligohydramnios 304
Hormone-Related Conditions in Pregnancy 304
Nausea and Vomiting During Early
Pregnancy 304
Hyperemesis Gravidarum 304
Gestational Diabetes 304
Spontaneous Abortion (“Miscarriage”)
Ectopic Pregnancy 306
Consequences of Tubal Pregnancy
Abnormal Attachment of the Placenta 307
Placenta Previa 307
Twins and Multiple Pregnancies 307
Fraternal Twins 307
Identical Twins 308
Determination of Zygosity of Twins from
Examination of Placenta 308
Twin Transfusion Syndrome 309
Vanishing Twins and Blighted Twins 311
Conjoined Twins 312
Disadvantages of Twin Pregnancies 312
Preeclampsia and Eclampsia: Toxemia of
Pregnancy 312
Hydatidiform Mole and Choriocarcinoma 313
Benign Hydatidiform Mole 313
Invasive Mole 314
Choriocarcinoma 314
Treatment of Gestational Trophoblast
Disease 314
Hemolytic Disease of the Newborn (Erythroblastosis
Fetalis) 314
Changes in Hemoglobin and Bilirubin After
Delivery 314
Rh Hemolytic Disease 315
Diagnosis of Hemolytic Disease in the Newborn
Infant 315
297 Treatment of Hemolytic Disease 316
Fluorescent Light Therapy for
298 Hyperbilirubinemia 317
Prevention of Rh Hemolytic Disease with
Rh-Immune Globulin 317
ABO Hemolytic Disease 318
301
Chapter Review 320
301
Chapter 15
The Urinary and Male Reproductive
Systems 324
Structure and Function of the Urinary System 325
The Kidneys 325
The Ureters 325
The Bladder and Urethra 325
Function of the Kidneys 326
The Nephron 326
305 Renal Regulation of Blood Pressure and Blood
Volume 328
Requirements for Normal Renal Function 329
306
Developmental Disturbances 329
Glomerulonephritis 330
Immune-Complex Glomerulonephritis 330
Anti-GBM Glomerulonephritis 331
Nephrotic Syndrome 331

Contents xiii

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 Arteriolar Nephrosclerosis 332 Treatment 355
Diabetic Nephropathy 333 Carcinoma of the Testis 356
Gout-Associated Nephropathy 333 Carcinoma of the Penis 356
Infections of the Urinary Tract 333 Chapter Review 357
Cystitis 334
Pyelonephritis 334
Vesicoureteral Reflux and Infection 335 Chapter 16
Calculi 335 The Liver, Biliary System, and
Foreign Bodies 336 Pancreas 363
Obstruction 337 Structure and Function of the Liver 364
Renal Tubular Injury 339 Bile 366
Formation and Excretion 366
Renal Cysts 339 Composition and Properties 366
Solitary Cysts 339
Congenital Polycystic Kidney Disease 339
Causes and Effects of Liver Injury 367
Tumors of the Urinary Tract 340 Viral Hepatitis 367
Renal Cortical Tumors 340 Clinical Manifestations and Course 368
Transitional Cell Tumors 340 Hepatitis A 368
Hepatitis B 369
Nephroblastoma (Wilms Tumor) 340
Hepatitis C 371
Diagnostic Evaluation of Kidney and Urinary Tract Hepatitis D (Delta Hepatitis) 372
Disease 341 Hepatitis E 372
Urinalysis 341 Other Hepatitis Viruses 372
Clearance Tests 341 Sexually Transmitted Hepatitis 372
Additional Techniques 342 Fatty Liver 372
Renal Failure (Uremia) 342 Alcoholic Liver Disease 372
Acute Renal Failure 342 Cirrhosis 374
Chronic Renal Failure 342 Derangements of Liver Structure and
Hemodialysis 343 Function 375
Peritoneal Dialysis 344 Procedures to Treat Manifestations of
Renal Transplantation 345 Cirrhosis 378
Structure and Function of the Male Reproductive Biliary Cirrhosis 378
System 346 Reye Syndrome 380
Gonorrhea and Nongonococcal Urethritis 348 Cholelithiasis 380
Prostatitis 348 Factors Affecting the Solubility of Cholesterol
in Bile 380
Benign Prostatic Hyperplasia 348
Complications of Gallstones 381
Carcinoma of the Prostate 350 Treatment of Gallstones 381
Cryptorchidism 351 Cholecystitis 382
Testicular Torsion 352 Tumors of the Liver and Gallbladder 382
Scrotal Abnormalities 353 Jaundice 382
Hydrocele 353 Hemolytic Jaundice 383
Varicocele 353 Hepatocellular Jaundice 383
Erectile Dysfunction 354 Obstructive Jaundice 383
Physiology of Penile Erection 354 Biopsy of the Liver 383
Causes of Erectile Dysfunction 354 The Pancreas: Structure and Function 383

xiv Contents

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 Pancreatitis 384 Inflammatory Diseases of the Intestine 406
Acute Pancreatitis 384 Acute Enteritis 406
Chronic Pancreatitis 384 Chronic Enteritis 406
Cystic Fibrosis of the Pancreas 385 Crohn Disease 407
Antibiotic-Associated Colitis 408
Diabetes Mellitus 385 Appendicitis 408
Type 1 Diabetes Mellitus 386 Meckel Diverticulum 409
Type 2 Diabetes Mellitus 387
Pregnancy-Associated Diabetes 387 Disturbances of Bowel Function 409
Diabetes and the Metabolic Syndrome 388 Food Intolerance 409
Irritable Bowel Syndrome 410
Actions of Insulin on Metabolic Processes 388
Fat Metabolism and Formation of Ketone Eating Disorders 410
Bodies 388 Obesity 410
Biochemical Disturbances in Diabetes 389 Causes of Obesity 410
Monitoring Control of Diabetes 390 Health Consequences of Obesity 411
Treatment of Diabetes 391 Treatment of Obesity 411
Complications of Diabetes 391
Anorexia Nervosa and Bulimia Nervosa 412
Other Causes of Hyperglycemia 391
Anorexia Nervosa 412
Hypoglycemia 392 Bulimia Nervosa 413
Tumors of the Pancreas 393 Binge Eating Disorder 413
Chapter Review 393 Diverticulosis and Diverticulitis of the Colon 414
Intestinal Obstruction 415
Chapter 17 Adhesions 416
Hernia 416
The Gastrointestinal Tract 399 Volvulus and Intussusception 417
Structure and Functions 400 Tumors of the Bowel 417
Cleft Lip and Cleft Palate 400 Mesenteric Thrombosis 418
Abnormalities of Tooth Development 400 Hemorrhoids 419
Missing Teeth and Extra Teeth 400
Abnormalities of Tooth Enamel Caused by Diagnostic Evaluation of Gastrointestinal
Tetracycline 400 Disease 420
Dental Caries and Its Complications 401 Chapter Review 420
Prevention and Treatment 402
Periodontal Disease 402 Chapter 18
Inflammation of the Oral Cavity 402 Nutrition and Disease 424
Tumors of the Oral Cavity 402 Nutrient Requirements and Their Functions 424
Diseases of the Esophagus 402 Food and Water 425
Cardiac Sphincter Dysfunction 403 Vitamins and Minerals 426
Gastric Mucosal Tears 403 Achieving a Balanced Diet: Food Groups and Food
Esophageal Obstruction 404 Guides 426
Gastritis 404 Malnutrition 426
Acute Gastritis 404 Causes of Malnutrition 426
Chronic Gastritis and Its Complications: The Malnutrition in Children 427
Role of Helicobacter pylori 404 Malnutrition in Adults 427
Peptic Ulcer 405 Alcohol: Its Role in Malnutrition 428
Carcinoma of the Stomach 406 Vitamins: Their Sources and Functions 428

Contents xv

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 Fat-Soluble Vitamins 428 Pituitary Hypofunction 448
Water-Soluble Vitamins 430 Pituitary Tumors 449
Minerals 431 Overproduction of Growth Hormone 449
Overproduction of Prolactin 450
Chapter Review 432
The Thyroid Gland 450
Goiter 451
Chapter 19 Hyperthyroidism 452
Fluids and Electrolytes 434 Hypothyroidism 453
Chronic Thyroiditis and Hashimoto
Body Water and Electrolytes 434
Thyroiditis 453
Interrelations of Intracellular and Extracellular Tumors of the Thyroid 454
Fluid 435 The Parathyroid Glands and Calcium Metabolism 455
Units and Concentration of Electrolytes 435 Hyperparathyroidism 456
Regulation of Body Fluid and Electrolyte Hypoparathyroidism 456
Concentration 435 The Adrenal Glands 456
The Adrenal Cortex 456
Disturbances of Water Balance 435
Disturbances of Adrenal Cortical Function 457
Dehydration 435
Overhydration 436 The Adrenal Medulla 458
Disturbances of Electrolyte Balance 436 Tumors of the Adrenal Medulla 458

Acid–Base Balance 436 The Pancreatic Islets 460

Buffers 436 The Gonads 460
Control of Carbonic Acid by the Lungs 437 Hormone Production by Nonendocrine Tumors 461
Control of Bicarbonate Concentration by the
Kidneys 437 Stress and the Endocrine System 461
Relationship Between pH and Ratio of Buffer Acute Stress Response 461
Components 437 Chronic Stress Response 461
Disturbances of Acid–Base Balance 438 Chapter Review 462
Compensatory Mechanisms Responding to
Disturbances in pH 438 Chapter 21
Metabolic Acidosis 439
Compensatory Mechanisms 440 The Nervous System 465
Respiratory Acidosis 440 Structure and Function 466
Metabolic Alkalosis 441
Respiratory Alkalosis 441
Development of the Nervous System 467
Diagnostic Evaluation of Acid–Base Muscle Tone and Voluntary Muscle Contraction 467
Balance 442 Muscle Paralysis 468
Chapter Review 443 Cerebral Injury 468
Neural Tube Defects 469
Chapter 20 Anencephaly 469
The Endocrine Glands 445 Spina Bifida 470
Endocrine Functions and Dysfunctions 445 Prenatal Detection of Neural Tube Defects 471

The Pituitary Gland 446 Hydrocephalus 471

Pituitary Hormones 447 Stroke 473
Anterior Lobe Hormones 447 Cerebral Thrombi and Emboli 474
Physiologic Control of Pituitary Hormone Stroke Caused by Arteriosclerosis of Extracranial
Secretion 447 Arteries 475

xvi Contents

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 Cerebral Hemorrhage 476 Arthritis 496
Manifestations of Stroke 476 Rheumatoid Arthritis 496
Rehabilitation of the Stroke Patient 477 Osteoarthritis 498
Transient Ischemic Attack 477 Gout 499
Cerebral Aneurysm 477 Fracture 501
Infections of the Nervous System 479 Osteomyelitis 501
Meningitis Caused by Bacteria and Fungi 479 Hematogenous Osteomyelitis 501
Viral Infections 480 Osteomyelitis as a Result of Direct Implantation
Manifestations of Nervous System Virus of Bacteria 501
Infection 480 Clinical Manifestations and Treatment 501
Arbovirus Infections 480 Tumors of Bone 501
Creutzfeldt–Jakob Disease 481 Osteoporosis 502
Mad Cow Disease 481 Structure and Function of the Spine 503
Alzheimer Disease 482 Chest Wall Abnormalities 504
Multiple Sclerosis 482 Pectus Excavatum 504
Parkinson Disease 483 Marfan Syndrome: Connective Tissue Disease 504
Scoliosis 505
Huntington Disease 484
Intervertebral Disk Disease 506
Degenerative Diseases of Motor Neurons 484
Structure and Function of Skeletal Muscle 506
Tumors of the Nervous System 484 Contraction of Skeletal Muscle 506
Tumors of the Peripheral Nerves 484 Factors Affecting Muscular Structure and
Tumors of the Brain 485 Function 507
Tumors of the Spinal Cord 485
Inflammation of Muscle (Myositis) 507
Peripheral Nerve Disorders 485 Localized Myositis 507
Polyneuritis (Peripheral Neuritis) 485 Generalized Myositis 507
Neurologic Manifestations of Human Immunodeficiency Muscular Atrophy and Muscular Dystrophy 507
Virus Infections 486
Myasthenia Gravis 508
HIV Infections of the Nervous System 486
Opportunistic Infections of the Nervous Chapter Review 509
System 486
AIDS-Related Tumors 486 General References 513
Chapter Review 487
Answers to Interactive
Chapter 22 Activities 515
The Musculoskeletal System 491
Structure and Function of the Skeletal System 491 Glossary 519
Bone Formation 492
Bone Growth 493
Congenital Malformations 494 Index 531
Abnormal Bone Formation 494
Congenital Clubfoot (Talipes) 494

Contents xvii

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43898_FMxx_FINAL.indd 18 8/16/12 11:00 AM
 Preface
Purpose and Scope of the Book
Essentials of Human Disease is a consolidated and
modified version of the very successful An Intro-
duction to Human Disease, now in its ninth edition.
This book is designed to appeal to allied health
and health education students who have limited
time to master basic disease concepts. Despite
time limitations, these students want to learn the
essential structural and functional characteristics
of common and important diseases, as well as the
principles of diagnosis and treatment, and they
want the material presented in a user-friendly,
non-intimidating manner. In order to accomplish
these objectives, some diseases considered in An
Introduction to Human Disease had to be eliminated
or reduced in content. On the other hand, other
items of interest were added to appeal to students,
and the format was modified in order to encour-
age students to take an active role in the learning
process.
Most students have had some previous exposure
to anatomy and physiology, and they are often
pleasantly surprised to find the basic concepts
relating to human disease are quite straightforward,
easy to understand, and extremely interesting.
Every organ system has key structural features
and physiologic functions, which are reviewed at
the beginning of most chapters. All is well when
these systems perform properly, but when they
do not function correctly students discover that
disease may be the culprit. Moreover, when the
student understands the anatomic and physio-
logic changes associated with a given disease, it is
not difficult to deduce the clinical manifestations
of the disease and how to formulate appropriate
treatment that favorably influences the course and
outcome of the disease.
Many students derive tremendous satisfaction
from watching their knowledge base relating to
human disease grow by leaps and bounds through-
out the course. Many students who have taken a
human disease course have gone on to careers in
biology, medicine, nursing, and other health fields.
Each chapter in the book begins with learning
objectives, followed in most cases by a brief review
of the anatomy and physiology of the organ system
43898_FMxx_FINAL.indd 19
discussed in the chapter, which leads into a sys-
tematic survey of the pathology, pathophysiology,
clinical manifestations, and principles of treatment
of the specific diseases covered.
Each chapter ends with a chapter summary,
questions for review, student exercises, and an
annotated bibliography that summarizes the con-
cepts in the articles cited.
Features that will facilitate learning include the
following:
• In-text key terms are set in bold and defined
in the margin of the page where the term
appears, as well as in the glossary at the end
of the book.
• Tables are used to reinforce and summarize
key material in the text. For example,
essential features of bacterial, fungal, and
parasitic diseases, characteristics of various
types of congenital heart disease, and
principles of diagnosis and treatment of
heart attacks.
• Chapters dealing with similar or related
subjects are consolidated, and a separate
chapter on nutrition and disease is
included.
• “A Closer Look” boxes are included in some
chapters. These boxes discuss important
physicians and scientists who made key
contributions to the diagnosis or treatment
of specific diseases.
• Interactive Activities are included at the end
of each chapter. They consist of multiple-
choice, matching, true or false, and fill-
in-the-blank questions. Critical thinking
questions raise a “real world” question
about a disease-related subject as would
be proposed by a fellow student, parent,
or friend. This format requires students
to evaluate their knowledge of the subject
and then come up with an appropriate,
scientifically based answer to the question.
Answers to odd-numbered questions
are provided at the back of the book.
(Instructors may obtain electronic access to
all answers.) The questions and answers can
serve as a focus for classroom discussion.
xix
8/16/12 11:00 AM
 Organization
The book is organized into two main sections.
The first section, comprising the first 9 chapters,
deals with general concepts and diseases affecting
the body as a whole. The second section, which
includes the remaining 13 chapters, considers the
various organ systems and the primary diseases
associated with each.
In the first section, Chapter 1 discusses mani-
festations of disease, classification, diagnosis, and
principles of treatment. Chapter 2 considers the
organization and basic function of cells and tissues,
genes, chromosomes, cell division, and chromo-
some analysis, as well as the HLA system and its
relationship to disease. Chapters 3 and 4 consider
the body’s defenses, the inflammatory reaction, the
immune system, and their major disorders.
Chapters 5 and 6 are concerned with the vari-
ous pathogenic microorganisms, fungi, parasites,
and the diseases they cause. Chapter 7 considers
congenital and hereditary diseases, and Chapter 8
deals with tumors. Chapter 9 describes coagulation
of the blood and the conditions that occur when
blood does not clot normally or when blood clots
too readily and its complications—thrombosis and
embolism.
In the second section, the final 13 chapters, indi-
vidual organ systems are considered in a systematic
manner, with emphasis on the more common and
critical diseases. Basic pathophysiology, pathol-
ogy, and principles of diagnosis and treatment
are discussed.
Chapter 10 describes diseases of the cardio-
vascular system and related aspects, including
the acute coronary syndrome classification of
coronary heart disease. Diseases of the hema-
topoietic and lymphatic systems are considered
together in Chapter 11, followed by diseases of
the respiratory system in Chapter 12. Chapters 13
and 14 are best considered as a unit: diseases of
the breast, the female reproductive system, pre­
natal development, and diseases associated with
pregnancy. Chapter 15 considers kidney diseases
and the closely associated diseases of the male
reproductive system, which are best considered
together as a unit.
xx Preface
43898_FMxx_FINAL.indd 20
Chapter 16 describes derangements of the liver,
biliary system, and pancreas, including diabetes
mellitus. Gastrointestinal tract diseases follow in
Chapter 17, including sections on eating disorders
and their treatment, and Chapter 18 deals with
nutrition and disease. Chapter 19 departs from
the organ system approach and considers distur-
bances in fluid, electrolyte, and acid–base balance,
which follows the discussion in earlier chapters of
the diseases in which these conditions occur. The
final three chapters deal, respectively, with major
diseases of the endocrine glands, nervous system,
and musculoskeletal system.
New to the Second Edition
• Chapter 1 contains current information on
ultrasounds.
• Chapter 6 contains updated information on
AIDS, HIV prevention, and mother-to-infant
transmission of HIV.
• Chapter 15 includes new text on renal
transplantations.
• Chapter 18 reflects the newest BMI data
updated from the 2010 USDA Dietary
Guidelines.
• Chapter 22 has new sections on Pectus
Excavatum and Marfan Syndrome.
• Tables and figures have been updated
throughout the text with the latest data and
statistics.
Study Aids and Special Features
Various learning and study aids are included to
enhance the usefulness of the book. Learning
objectives, review questions, and chapter sum-
maries are provided for each chapter. Literature for
further study is listed at the end of each chapter,
and a listing of general references is included at
the end of the book. These additional resources
should prove useful to students who wish to pur-
sue a subject in greater detail. A glossary with a
pronunciation guide is appended to the end of the
text. This may provide extra support to students
who have not had a course in medical terminology
and can serve as a convenient reference for other
students who wish to have a quick review of a
8/16/12 11:00 AM
 particular term. Words appearing in the glossary
are set in boldface type in the text.
Additional Resources
Student Companion Website:
go.jblearning.com/CrowleyEssentials
The website to accompany Essentials of Human
Disease offers the following resources to enhance
student learning and comprehension: Anatomy
and Physiology Review, Chapter Outlines, Web
Links, Practice Quizzes, an Interactive Glossary,
Flashcards, and Crossword Puzzles.
Instructor’s Media CD
The Instructor’s Media CD includes PowerPoint
Presentations and an extensive PowerPoint Image
and Table Bank. For more information about these
resources, please contact your sales representative.
Acknowledgments for the Second Edition
Jones & Bartlett Learning would like to extend
a warm thank you to Dr. Jim Van Elsywk for his
work in reviewing this text and accompanying
ancillaries throughout the production process.
Acknowledgments from the First Edition
Many people helped with the initial edition of
Introduction to Human Disease, on which the Essen-
tials of Human Disease is based. Several colleagues
with whom Dr. Crowley practiced at hospitals
43898_FMxx_FINAL.indd 21
in Minneapolis and St. Paul made helpful sug-
gestions, as did colleagues in the Department
of Laboratory Medicine and Pathology, and the
Department of Family Practice and Community
Health at the University of Minnesota, College of
Medicine. Staff members at the West Side Com-
munity Health Center in St. Paul were also very
helpful, and some of the case studies used in the
book were based on these clinical contacts.
Judie Coulter, the senior departmental secretary
in the Biology Department at Century College,
provided invaluable assistance in converting the
ninth edition of Introduction to Human Disease to
the new Essentials book, by organizing the book
chapters and preparing the book for publication.
It would have been very difficult to accomplish
this task without her help.
Reviewers of the First Edition of
Essentials of Human Disease
Jeanne M. Clerc, EdD, MT(ASCP)SH
Western Illinois University
Dorothy M. Hendrix, PhD, RHIT
East Los Angeles Community College
Sara S. Plaspohl, DrPH, MHS, CIM, CIP
Armstrong Atlantic State University
Peter C. Sayles, PhD
North Country Community College
Preface xxi
8/16/12 11:00 AM
43898_FMxx_FINAL.indd 22 8/16/12 11:00 AM

General Concepts of
Disease: Principles
of Diagnosis
1. Define the common terms used to describe dis-
ease, such as lesions, organic and functional disease,
symptomatic and asymptomatic disease, etiology, and
pathogenesis.
2. List the major categories of human disease.
Characteristics of Disease
Any disturbance of structure or function of the body
may be regarded as disease. A disease is often asso-
ciated with ­well-­defined, characteristic structural
changes, called lesions, that are present in various
organs and tissues. One can recognize lesions by exam-
ining the diseased tissue with the naked eye, which is
called a gross examination, or with the aid of a micro-
scope, which is called a histologic examination. Some-
times histologic examinations are supplemented by
specialized studies that evaluate the properties of the
43898_CH01_6204.indd 1
Chapter
1
3. Explain the approach that a practitioner uses to make
a diagnosis and decide on a patient’s treatment.
4. Describe the various types of diagnostic tests and
procedures that can help the practitioner in making
a diagnosis and deciding on proper treatment.
cell membranes and the proteins within the cells. A
disease associated with structural changes is called an
organic disease. In contrast, a functional disease is
one in which no morphologic abnormalities (morphe =
structure or shape) can be identified even though body
functions may be profoundly disturbed. However, as
we develop new methods for studying cells, we can
sometimes identify previously unrecognized abnor-
malities that disturb cell functions. Consequently,
many of the traditional distinctions between organic
and functional disease are no longer as sharply defined
as in the past.
8/16/12 8:54 AM
 Pathology is the study of disease, and a pathologist is Congenital and Hereditary
a physician who specializes in diagnosing and classify-
ing diseases primarily by examining the morphology
Diseases
Congenital and hereditary diseases are the result of
of cells and tissues. A clinician is any physician or
disease developmental disturbances. They may be caused by
Any other health practitioner who cares for patients.
genetic abnormalities, abnormalities in the numbers
disturbance A disease may cause various subjective
of the structure
and distribution of chromosomes, intrauterine injury
manifestations, such as weakness or pain,
or function of the as a result of various agents, or an interaction of genetic
in an affected individual: These are called
body. and environmental factors. Hemophilia, the w ­ ell-­known
symptoms. A disease may also produce
lesion (le´shun) Any hereditary disease in which blood does not clot properly,
objective manifestations, detectable by
structural abnormality and congenital heart disease induced by the German
or pathologic change. the clinician, that are called signs or
measles virus are examples of diseases in this category.
physical findings. In many diseases,
organic disease A
disease associated with the quantity of blood cells in the cir-
structural changes in the culation may change, and so may the Inflammatory Diseases
affected tissue or organ. biochemical constituents in the body Inflammatory diseases are those in which the body
pathology The study of the fluids. These alterations are reflected reacts to an injurious agent by means of inflammation.
structural and functional as abnormal laboratory test results. Many of the diseases characterized by inflammation,
changes in the body caused
A disease that causes the affected such as a sore throat or pneumonia, are caused by
by disease.
individual no discomfort or dis- bacteria or other microbiologic agents. Others, such as
etiology (e-te-ol´o-je) The
cause, especially the cause ability is called an asymptomatic “hay fever,” are a manifestation of an allergic reaction
of a disease. disease or i­ llness. A disease is often or a hypersensitivity state in the patient. Some ­diseases
pathogenesis (path- asymptomatic in its early stages. If in this category appear to be caused by antibodies formed
o-jen´e-sis) Manner the disease is not treated, however, against the patient’s own tissues, as occurs in some
in which a ­disease it may progress to the stage where uncommon diseases classified as autoimmune diseases.
develops. it causes subjective symptoms and The etiology of still other inflammatory diseases has
pathogen (path- abnormal physical findings. Therefore, not been determined.
o-jen´) A
disease-​causing
the distinction between asymptomatic
bacterium or and symptomatic disease is one of degree, Degenerative Diseases
other harmful depending primarily on the extent of the In degenerative diseases, the primary abnormality is
organism. disease. degeneration of various parts of the body. In some
The term etiology means cause. A disease of cases, this may be a manifestation of the aging pro-
unknown etiology is one for which the cause is not cess. In many cases, however, the degenerative lesions
yet known. Unfortunately, many diseases fall into this are more advanced or occur sooner than would be
category. If the cause of a disease is known, the agent expected if they were age related, and they are distinctly
responsible is called the etiologic agent. The term abnormal. Certain types of arthritis and “hardening of
pathogenesis refers to the manner by which a disease the arteries” (arteriosclerosis) are common examples
develops, and a pathogen is any microorganism, such of degenerative diseases.
as a bacterium or virus, that can cause disease.
Metabolic Diseases
Classifications of Disease The chief abnormality seen in metabolic diseases is a
disturbance in some important metabolic process in
Diseases tend to fall into several large categories, the body. For example, the cells may not be utilizing
although the diseases in a specific category are not nec- glucose normally, or the thyroid gland may not prop-
essarily closely related. Rather, the lesions produced by erly regulate the rate of cell metabolism. Diabetes,
the various diseases in a category are morphologically disturbances of endocrine glands, and disturbances of
similar or have a similar pathogenesis. Diseases are fluid and electrolyte balance are common examples of
conveniently classified in the following large groups: metabolic diseases.
1. Congenital and hereditary diseases
2. Inflammatory diseases Neoplastic Diseases
3. Degenerative diseases Neoplastic diseases are characterized by abnormal cell
4. Metabolic diseases growth that leads to the formation of various types of
5. Neoplastic diseases benign and malignant tumors.

2 Chapter 1 General Concepts of Disease: Principles of Diagnosis

43898_CH01_6204.indd 2 8/16/12 8:54 AM

 Health and Disease:
A Continuum
Health and disease may be considered two extremes of
a continuum. At one extreme is severe, l­ ife-­threatening,
disabling illness with its corresponding major effect on
the physical and emotional ­well-­being of the patient.
At the other extreme is ideal good health, which may
be defined as a state of complete physical and mental
­well-­being. The healthy person is emotionally and
physically capable of leading a full, happy, and pro-
ductive life that is free of anxiety, turmoil, and physi-
cal disabilities that limit activities. Between these two
extremes are many gradations of health and disease,
ranging from mild or ­short-­term illness that limits
activities to some extent through moderate good health
that falls short of the ideal state. The midpoint in this
continuum may be considered a “neutral” position in
which one is neither ill nor in ideal good health. In
this continuum, most of us are somewhere between
midposition and the ideal state.
The goal of traditional medicine is to cure or amelio-
rate disease. This is accomplished by various means,
ranging from administering an antibiotic to cure an
infection to very complex ­“high-­technology” treat-
ments such as kidney transplants and heart surgery.
The advances of modern medicine have done much
to relieve suffering and advance human welfare, but
modern medicine does not guarantee good health.
Health is more than an absence of disease; it is a condi-
tion in which body and mind function efficiently and
harmoniously as an integrated unit. Consequently,
we must take an active part in achieving good health
by assuming some responsibility for our own physical
and emotional ­well-­being. This means practicing such
commonsense measures as eating properly, exercising
moderately, and avoiding harmful excesses such as
overeating, smoking, heavy drinking, or using drugs,
which can disrupt physical or emotional w ­ ell-­being.
Taking responsibility for one’s health also requires
using one’s mind constructively, expressing emotions,
and feeling good about oneself. Positive mental atti-
tudes are essential for good health because negative
feelings may be reflected in disturbed bodily functions
that are manifested as disease.
Principles of Diagnosis
The determination of the nature and cause of a patient’s
illness by a physician or other health practitioner is
called a diagnosis. It is based on the practitioner’s
evaluation of the patient’s subjective symptoms, the
43898_CH01_6204.indd 3
physical findings, and the results of vari-
ous laboratory tests, together with diagnosis
other appropriate diagnostic pro-
cedures. When the practitioner
The determination
of the nature and cause of
a patient’s illness.
has reached a diagnosis, he or
she can then offer a prognosis: prognosis The probable
outcome of a disease or a
an opinion concerning the even- ­disorder; the outlook
tual outcome of the disease. Then for recovery.
a course of treatment is instituted.
The History
The clinical history is a very important part of the
evaluation. It consists of several parts:
1. The history of the patient’s current illness
2. The past medical history
3. The family history
4. The social history
5. The review of systems
The history of the present illness elicits details con-
cerning the severity, time of onset, and character of the
patient’s symptoms. Many diseases have characteristic
symptoms. The patient’s description of the oppressive
substernal pain of a heart attack or the pain and uri-
nary disturbances associated with a bladder infection,
for example, may provide very helpful information
that suggests the correct diagnosis. The past medical
history provides details of the patient’s general health
and previous illnesses. These data may shed light on
the patient’s current problems as well. The family
history provides information about the health of the
patient’s parents and other family members. Some
diseases, such as diabetes and some types of heart
disease, tend to run in families. The social history
deals with the patient’s occupation, habits, alcohol
and tobacco use, and similar data. This information
may also relate to the patient’s general health and cur-
rent problems. The review of systems inquires as to
the presence of symptoms other than those disclosed
in the history of the present illness; such symptoms
might suggest disease affecting other parts of the body.
For example, the practitioner inquires about such
symptoms as pain or burning on urination, which sug-
gest an abnormality of the urinary tract, and coughing,
shortness of breath, or chest pain, which may indicate
disease of the respiratory system. In this way, possible
dysfunctions of other organ systems are evaluated by
systematic inquiry.
The Physical Examination
The physical examination is a systematic examina-
tion of the patient. The practitioner places particular
Principles of Diagnosis 3
8/16/12 8:54 AM
 emphasis on the part of the body affected by the
illness, such as the ears, throat, chest, and lungs in
the case of a respiratory infection. Any abnormalities
detected on the physical examination are correlated
with the clinical history. At this point, the practitioner
begins to consider the various diseases or conditions
that would fit with the clinical findings. Sometimes,
more than one possible diagnosis needs to be consid-
ered. In a differential diagnosis the practitioner consid-
ers a number of diseases that are characterized by the
patient’s symptoms. For example, if a patient complains
of shortness of breath and abnormalities are detected
when the lungs are examined with a stethoscope, the
practitioner may consider both chronic lung disease
and chronic heart failure in the differential diagnosis.
Often the practitioner can narrow the list of diag-
nostic possibilities and arrive at a correct diagnosis
by using selected laboratory tests or other specialized
diagnostic procedures. In difficult cases, the clinician
may also wish to obtain the opinion of a medical con-
sultant, who is a physician with special training and
experience in the type of medical problem presented
by the patient.
Treatment
After the diagnosis has been established, a course of treat-
ment is initiated. There are two different types of treat-
ment: specific treatment and symptomatic treatment.
A specific treatment is one that exerts a highly spe-
cific and favorable effect on the basic cause of the
disease. For example, an antibiotic may be given to
a patient who has an infection that is responsive to
the antibiotic, or insulin may be given to a patient
with diabetes. Symptomatic treatment, as the name
implies, makes the patient more comfortable by alle-
viating symptoms but does not influence the course
of the underlying disease. Examples are the treatment
of fever, pain, and cough by means of appropriate
medications. Unfortunately, there are no specific treat-
ments for some diseases. Consequently, the clinician
must be content with treating the manifestations of
the disease without being able to influence its ultimate
course.
When dealing with patients who have ­long-­standing
chronic disease such as chronic heart, kidney, or lung
disease, or some types of cancer, the physician may
be assisted by a disease management team composed
of a group of persons with special skills that are use-
ful in the care and treatment of patients with these
diseases. The management team may include persons
who can explain to patients the nature of their disease,
the goals of treatment, and how patients can contrib-
4 Chapter 1 General Concepts of Disease: Principles of Diagnosis
43898_CH01_6204.indd 4
ute to their own care. Other health-care team mem-
bers such as dieticians, nurse clinicians, physician’s
assistants, respiratory therapists, physiotherapists, and
pharmacists can bring their own special skills to help
physicians care for patients with chronic illnesses who
require ­long-­term care and who have special needs.
Often the team approach to management of patients
with chronic diseases reduces the long-term costs of
medical care, improves the patient’s satisfaction with
the quality of his or her medical care, and contributes
to a more favorable response to treatment.
Screening Tests for Disease
Purpose and Requirements for
Effective Screening
Many diseases that respond to treatment are asymp-
tomatic initially. If untreated, however, the disease
often progresses slowly, causing gradual but progres-
sive organ damage until eventually the person is seri-
ously ill with far advanced organ damage caused by the
disease. Unfortunately, treatment of l­ ate-­stage disease
is often much less effective and may not be able to
restore the function of the organs that have been dam-
aged. Had the disease been identified and treated in
its early asymptomatic stage, the d
­ isease-­related organ
damage could have been prevented or minimized, and
the affected person would have been spared the dis-
comfort, disability, and shortened survival associated
with ­late-­stage disease.
A successful screening program should fulfill the
following requirements:
1. A significant number of persons must be at risk
for the disease in the group being screened.
2. A relatively inexpensive noninvasive test must be
available to screen for the disease that does not
yield an excessively high number of ­false-­positive
or ­false-­negative results.
3. Early identification and treatment of the disease
will favorably influence the health or welfare of
the person with the disease.
Groups Suitable for Screening
Screening tests should target a group of persons in
whom there is a relatively high frequency of disease,
and tests should also target the age group in whom
the disease is likely to be present. If the disease, for
example, has its onset in middle age, then screening
adolescents and children in the target group would
not be productive.
8/16/12 8:54 AM
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 Hän seisoo vielä, korva ei enää niin kuuntele, mutta sydän jyskää
ja riemu pauhaa hänessä, niin että ruumis värisee…

— Pelastettu! Poikani! Poikani!

Ilta yhä pimenee, päivän kajastus on sammunut, taivas käynyt

pilveen…
Ei kuulu liikettä maalta eikä joelta, ei mistään päin…

Nyt hän kuulee Isonkosken kohinan, joka tuntuu olevan vallan

likellä…

Huutaako riemullisesti vai tuskallisestiko?

Karoliina kuuntelee. Tohisee… tohisee… on väliin kuin riemastuisi,

väliin kuin valittaisi…

»Ei valitusta, ei valitusta!»

Hän työntää veneen vesille ja lähtee soutamaan takaisin Ruotsin

puolelle. Hän ei ajattele mitään selvästi eikä loppuun, tuntuu vain
hyvältä olla. Ei paina mikään eikä sydämessä pakota. Ei ajattele
tulevaisuutta eikä menneisyyttä. On vain nyt niin hyvä olla.

Mutta puolijoessa hän muistaa Oskarin vanhat vaatteet, jotka ovat

jääneet veneeseen, kun on uudet pojan ylle pukenut. Hän kokoaa ne
yhteen myttyyn ja heittää myötävirralle…

Koski huutaa nyt kuin riemuissaan, Karoliina soutaa lujasti, ja pian

vene töksähtää Ruotsin rantatörmään.

Hän lähtee nousemaan rantapolulle ja kävelee sitä pitkin, saapuen

saunalle. Siinä seisahtuu ja katselee virran veteen, joka nyt hohtaa
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sekaisin, ja ruumis tuntuu kihelmöivän joka paikasta. Tuntuu, että
jalat tärisevät, ja käsissä on kuin suonenveto.

Niin tulee hän kuin tietämättään taloon, nousee kuistille, lyö ovet
lukkoon ja menee sisälle. Hän saa pirtissä kynttilän palamaan ja nyt
hän taas jaksaa ajatella ja tuntee tointuvansa.

Mutta juuri kun hän on alkanut selvästi ajatella, kuuluu pihalta

puhelua ja niittyneuvojen kolinaa. Hän arvaa, että niittymiehet ovat
tulleet, ja pannen kaiken voimansa liikkeelle nousee hän avaamaan
tulijoille kuistin ovea.

Väki onkin hyvien poutien vallitessa ehtinyt saada niityn tehdyksi

päivää ennen kuin tavallisesti.

Isäntä on hyvällä tuulella eikä hoksaa kysyä, miksi emäntä valvoo

näin yöllä. Muistaa kuitenkin poikaansa ja sanoo:

»Oskari on tietenkin jo nukkumassa… Antaapa pojan rauhassa

maata…
Huomenna aiotaankin tuumailla kouluun lähtöä.»

Isäntä ei huomaa emännässä mitään muutosta eikä varro

emännän vastauksia. Puhelee sitä, tätä.

Mutta Mantan katse viipyy kauan emännässä, jonka silmissä palaa

niin kummallinen, outo tuli. Semmoisena Manta ei muista emäntää
ennen nähneensä.
XII

Aamu vaikeni kirkkaana, kastehelmisenä ja lämpöisenä. Öinen usva

laskeusi maille ja vesille. Suuri, sininen taivas oli pilvetön.

Portaankorvan isäntä oli aikaisin liikkeellä.

Hän oli kahdesti kysynyt emännältä Oskaria, mutta ei ollut saanut

mitään vastaukseksi. Mutta kun hän kolmannen kerran kysyi eikä
emäntä sittenkään vastannet, luuli hän pojan vielä nukkuvan ja riensi
emännän makuukamariin.

Kummankin vuode oli tyhjä, eikä niissä näyttänyt kukaan

nukkuneenkaan.

Olisiko poika Väylänpäässä kyläilemässä?

Hän arveli niin olevan ja meni pirttiin. Rengit ja kesämies istuivat

penkillä, vielä väsyneinä raskaasta työstä. Emäntä seisoi selin, joelle
katsellen. Yhtäkkiä leimahti isännän viha, ja hän karjaisi:

»Missä Oskari on? Oletko päästänyt hänet Väylänpäähän, vaikka

kielsin?»
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kasvoiltaan, ja silmät paloivat kuin tulen liekki. Ei kukaan ollut häntä
sellaisena nähnyt. Mutta isäntä ei häneen katsonutkaan.

»Missä poika on?» karjaisi hän uudelleen, niin että pirtti jymisi.

»Olipa missä hyvänsä… Mitä sinä hänestä…»

Emännän ääni tuntui soinnuttomalta, ja hän oli kalpea kuin

kuolema.

Siinä samassa syöksyi Manta pirttiin, Oskarin vettätippuva

arkilakki kädessä.

»Hyvä Jumala! Mihin Oskari on joutunut, kun lakki löytyi padon

päältä?»

Miehet ja isäntä riensivät lakkia tunnustelemaan, mutta emäntä ei

liikahtanut paikaltaan.

Se oli Oskarin lakki.

»Missä on poikani? Mitä olet, onneton, tehnyt pojalleni?»

Isännän silmät pyörivät kuin mielipuolen päässä.

»Sinunko poikasi», sanoi emäntä nyt pitkään ja pilkallisesti.

»Sinun poikasi! Etkö tiedä, että se poika on paremmista paikoista
lähtöisin…»

»Mitä sinä puhut?» sähähti isäntä ja tarttui ensimmäiseen

esineeseen, joka hänen eteensä sattui.
 Mutta silloin emäntä singahti kuin luoti keskelle lattiaa, ja
vuosikausia hillitty viha syöksyi kauhealla pauhulla lähteistään. Kuin
hullu hän asettui isännän eteen, heristi nyrkkiään ja kiljaisi:

»Sinunko poikasi! Etkö sinä vaivainen räkänokka ymmärrä, ettet

sinä semmoista poikaa ole ikänäsi saanut… Minun on poikani…»

Isännän häntä kohti heittämä jakkara lensi sivuikkunasta ulos,

hipaisten emännän ohimoa.

Silloin isäntä alkoi hakea uutta asetta. Miehet nousivat seisomaan,

ja
Manta huusi.

Emäntä ponnahti pystyyn lattialta, johon oli kaatunut, ja syöksyi

ovesta ulos juuri kun isännän tähtäämä kirves lensi ovipieleen…

Miehet kävivät isäntään kiinni, mutta hän heitti heidät syrjään ja

kasvoillaan hirmuinen vimma rynnisti emännän perään. Miehet
riensivät jälkeen.

Emäntä juoksi jo lähellä saunaa, avopäin, tuuhea tukka hulmuten

tuulessa…

»Herra Jumala! Herra Jumala!» huusi Manta ja juoksi ohi miesten,

saavutti isännänkin ja juoksi hänen edelleen…

Miehet näkivät emännän rientävän saunalle, porhaltavan

pysähtymättä padolle ja suistuvan pää edellä virtaan…

Isäntä ehti juuri saunalle ja Manta törmän alle — kun kuulivat

kimakan parkaisun ja näkivät emännän uppoavan…
 Aapeli töksähti istualleen kuin salaman satuttamana, silmät
ummessa.

Manta juoksi padolle ja miehet rannalle mihin ehtivät.

Keskellä jokea, jo alempana, he näkivät ihmiskäden nousevan

virrasta, liikkuvan kuin apuun pyytäen…

»Lautta tulee!» huudettiin Mantalle.

Suuri tukkilautta oli tulossa korvan yläpuolelta. Se oli joutunut

väärälle reitille ja tuli epäilemättä törmäämään patoon… Manta älysi
vaaran, ja juuri kun hän ehti ensimmäiselle rantakivelle, rysähti lautta
koko painollaan patoa vasten, nostaen sen kokonaan kohoksi
pohjasta asti ja painaen alleen… Hetken päästä se jo kulki siinä
kohden, missä emännän käsi oli pinnalle noussut.

Aapeli istui retkallaan kivellä, kädet silmillä.

Manta nousi törmälle. Hän näki lautan vihaista vauhtia painuvan

Isoonkoskeen, joka aamuvarhaisella huusi ja ulvoi…

Kun lautta oli kadonnut näkyvistä ja kosken ulvonta kuin hiljennyt,

ymmärsi Manta, että se peto nyt oli saanut kitaansa hänet, jota
toistakymmentä vuotta oli houkutellut…

Padon paikalla pyöri virta vaahtoisena, valkoisia pyöryläisiä

seljemmäksi kuljetellen.
 *** END OF THE PROJECT GUTENBERG EBOOK
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