her make up the cardi and blood vessels toze' aSCUlay te blood bear. er, we wll consider blood. The ear and Ying sae are discussed inthe next tO CHAPTER A dosely relied ten vessel in Chapter 17. . . js discussed it the lymphatic system, ¥ transport blood to all cells we em is designed t0 2 f Of the The caovaselar sem ATE oxygen ried by cls: ero body. Blood contains the body. This is accomplished by the he sete an, ius rach val Y etptyod wesels, which take blood from the hea Body cel ur bates cel i called intertrial i, aunts uenioed by blood and lymph. Blood picks vp orYE= fom the lng, aetts from the gastrointestinal tract, hormones from endocrine Blands, a he by. HE anspnts these, sabe i aaa? Prruse from microscopic blood vessels into interstg ie es wr ey ies 0 cles Sect Ol tw Hp and sweat glands for elimination from the body. Some wastes must be proceseg by the liver before they can be excreted (Chapter 19) Sometimes disease-causing organisms (pathogens) are able (o invade the blood ‘and interstitial fluid. The way in which the lymphatic system filters body fids to prevent the spread of pathogens throughout the body is discussed in Chaper V7. Blood inside blood vessels, interstitial fluid around body cells, and lymph inside lymph vessels constitute the body's internal environment. Because body cells ‘are too specialized to adjust to more than very limited changes in their environment, the intemal environment must be kept within normal physiological limits. Ths condition we have called homeostasis. In preceding chapters, we have discussed hhow the internal environment is kept in homeostasis. Now we will look at tha ‘environment itself, beginning with blood. “The branch of science concemed with the study of blood and blood-forming tissues and the disorders associated with them is called hematology (hém’-2-TOL- 8:8; hem = blood; logos = study of) a i gg FUNCTIONS OF BLOOD Blood is a liquid connective tissue that performs a number of critical functions. 1, It transports: oxygen from the lungs to the cells of the body; carbon dioxide from the cells to the lungs; nutrients from the digestive organs to the cells ‘waste products from the cells to the kidneys, lungs, and sweat glands; hormones from endocrine glands to the cells; heat from various cells. 2. It regulates: pH through buffers; normal body temperature through the hes absorbing and coolant properties of its water content; the water content of cells, principally through dissolved sodium ions (Na*). 3, It protects against: blood loss through the clotting mechanism; foreign microbes and toxins through phagocytic white bl li a sol ris eta lood cells or specialized plasma pro PHYSICAL CHARACTERISTICS OF BLOOD Blood is a viscous fluid: it is heavier, thicker, i visco ate. THe viscosity (adhesiveness or stickiness) pees coat temperature of blood, may be felt by touching it. aera al aC ea l00-4°P its pH range is 7.35 to 7.45 (slighty allies Sear mame rile yey ne , 0; an ay ras 4 to 5 lite Bioodconstiues about 8 percent of he oul ey need eSPONENTS OF BLOOD js composed of two portions: 45 won of formed elements (cells and eit y oi hime ia c (iquid containing di 8) and 55 ea is plasma ining dissolved substances ras orMED ELEMENTS te formed elements of the blood are (Figure 14.2): Exythrocytes (red blood cells) : Leucocytes (white blood cells) ‘A. Granular leucocytes (granulocytes) Components of Blood + 299 Origin The process by which blood cells are formed is called hemopoiesis (he-mé-poy-E-sis). In the adult, hemopoiesis takes place in red bone marrow of the humerus and femur, semum, ribs, vertebrae, s, and lymphoid tissue. Red blood cells, granular leucocytes, ‘and platelets are produced in red bone marrow. Agranular leucocytes arise from red bone marrow and lymphoid tissue in the spleen, tonsils, and lymph nodes. All blood cells originate from hemocytoblasts (hé'-md-Si-t3- blasts), immature cells that undergo differentiation into five types {LCE fom which the major types of blood cls develop Figure +2), Pelvis 1. Neutrophils 2. Eosinophils 3, Basophils H i oes) ‘Neutrophitis, 1. Lymphocytes oop Pe banat seamen c @! ) Eosinophils Famed {ERE 14-1 Components of blood in « normal adult. <=> EE septs Loans Thrombocytes tl Bho Monoztee > ae romeo eueweTs ‘euooerres (number per ove mieten (dierent wee ‘ood eal court) Prone Plasma a! Pr nine commer alse bun fad tives = tebuine som eat Fnigooen oss to VouUME BODY WEIGHT (het re the normal walves for ‘Soncentration? Percent PLASMA (woh Elctlyeegqireestes Red Blood Celis) Enythrocytes (€-RITH-+0. siracture F 18-88) of 1p a beoneve Acs averaging about § (at ood cts flor 2) Mature red blood cel ae quit simple in seer ave no nucleus or other organelles and cannot diva on extensive metabolic activities. Essentially, they cece ® selectively permeable plasma membrane, cytoplascy, at pigment called hemoglobin. Hemoglobin caries onjyen te weal and is responsible for the ed color of blood, Neem vies for hemoglobin are 14 0 20 g/100 ml of blood in inane, thio 15 g/100 mi in adult females, and 14 t0 16.5 g/100 mi ta saat males. As you will see later, certain proteins (antigens) oe sourtaces of red blood cells are responsible for the various tod groups such as ABO and Rh groups. 1s Functions The hemoglobin in erythrocytes combines with oxy- ferand with cazbon dioxide in order to then transport them through ood vessels. The hemoglobin molecule consists of four identical proieins called globin and four nonprotein pigments called hemes, {ach of which is attached to a protein and contains iron (Figure 143). As the erythrocytes pass through the lungs, each of the foar iron atoms in the hemoglobin molecules combines with a nolecule of oxygen to form oxyhemoglobin. The oxygen is trans- qored as oxyhemoglobin to other tissues ofthe body. Inthe tissues, the iro-oxygen reaction reverses, and the oxygen is released to foe into the interstitial fluid and cells. On the return trip, the bin portion combines with carbon dioxide from the interstitial fui to form carbaminohemoglobin, which is transported to the lungs, where the carbon dioxide is released and then exhaled. ‘though some carbon dioxide is transported by hemoglobin, the treater portion is transported in blood plasma (see Chapter 18). Since erythrocytes lack a nucleus, their capacity for carrying oxygen isincreased greatly. Moreover, since they lack mitochondria and ftnerate ATP anaerobically, they do not consume any of the oxygen that they transport. "Life Span and Number Red blood cells live only about 120 ays because of wear and tear on their fragile plasma membranes '% they squeeze through blood capillaries. Worm-out red blood cells are phagocytized by macrophages in the spleen, liver, and tone marrow, The red blood cell's hemoglobin is subsequently ‘eeycled (Figure 14-4). The globin is split from the heme portions ‘ad broken down into amino acids that may be reused by other stllsfor protein synthesis. The heme is broken down into iron 224 bliverdin. The iron is stored in the liver in two forms: ferritin ‘0d hemosidetin. Ferritin consists of iron bound to & protein te live called apoferitin. Hemosiderin isan extremely insoluble form of iron. Iron is transported in the blood by combining with ° rotein called transferrin. Transferrin combines with iron that been absorbed from the gastrointestinal tact or iron feesked from storage and transports it to bone marrow to be rane for exeplobin synthesis. Transferrin also transports iron to the HVT lsorge. The noniron portion of heme is converted into biliver~ 4%, greenish pigment, and then into bilirubin. Bilirubin's released “1 um = 125,000 ofan inch of 1/1000 of « milimeter es) Components of Blood * 301 FIGURE 14.3 Enjthrocytes. (c} Shape of an erythrocyte in surface view $9] and side view bottom). {b) Diagram of a hemoglobin molecule. Peer bi pce) partons of he mclacde or inde ie n ond blue o a -containing) portions are in the centr of ash glabin molecule re Surface view Side view (a) ‘Whot happens to hemoglobin after red blood into plasma and is transported to the liver to be excreted in bile, which passes from the liver to the small intestine. In the large intestine, bilirubin is converted by bacteria into urobilinogen, most of which is eliminated in feces in the form of a brown pigment (stercobilin), which gives feces its characteristic color. = Production The process by which erythrocytes are formed is called erythropoiesis (e-rith'10-poy-E-sis). It takes place in red ‘bone marrow (see Figure 14-2). Normally, erythropoiesis and red ‘load cell destruction proceed at the same pace. A healthy male has about 5.4 million red blood cells per cubic millimeter (mm*) fof blood, and a healthy female about 4.8 million. The higher value in the male is caused by higher levels of testosterone, which stimulate the production of red blood cells. To maintain normal quantities of erythrocytes, the body must produce mew mature Skis at the astonishing rate of 2 million per second. If the body suddenly needs more erythrocytes or if erythropoiesis is not keeping up with red blood cell destruction, a homeostatic mechanism steps tp production (Figure 14-5). The mechanism is triggered by the aduced supply of oxygen for body cells, called hypoxia (hi- POKS-é.2). If certain kidney (or liver) cells become oxygen-defi- tient, they release an enzyme called renal erythropoietic factor (REF) that conver a plasma protein into the hormone erythro poietin (poiem = to make). This hormone travels to the red bon Prrrow where it stimulates production of red blood cells. On Tnedical use of erythropoietin is to increase the amount of bloo« that can be collected by individuals who choose to donate thei ‘Gwn blood before surgery. Erythropoiesis increases at high altitude ‘where the air contains less oxygen and as a result of disease condi ions that produce hypoxia, such as pneumonia or the anemia (scussed later).Se 302 + Chapter 14 The Cardiovascular System: Blood FIGURE 14-4 Recydling of red blood cells 120 day Circulation for about Nh Reused for oe? as ae Ape a Red bone [oe] see] {ioe cs ed 72 -) Biirubin, oy) fre toe er ‘Macrophage in spieon, liver, oF red bone marrow taney //cUrobitn Urine aia | ees tar ‘ine tnogen Xeoceun Foes Trace how red blood cell components are recycled. In order for the bone marrow to produce adequate numbers of healthy red blood cells, individuals must consume adequate amounts of iron, protein, folic acid, and vitamin By2, and produce enough intrinsic factor (IF) in the stomach to absorb the vitamin By» Regular aerobic exercise also increases erythropoiesis. ‘The rate of erythropoiesis is measured by a procedure called a ‘reticulocyte (re-TIK-yoo-I6-si) count, Reticulocytes are an inter- ‘mediate cell in the development of a mature red blood cell (see Figure 14-2). Some reticulocytes are normally released in the blood- stream before they become mature red blood cells. The percentage of reticulocytes in a blood sample should range from 0.5 to 1.5. A hematocrit (Het) is the percentage of blood made up of the RBCs. In adult males the average is 40 to 54 percent; in females itis 38 to 46 percent (athletes may have somewhat higher values). The results of a hematocrit test help a doctor to determine the rate of hemopoiess. Leucocytes (White Blood Cells) © Structure and Types Unlike red blood cells, leucocytes (LOO- é-sits) or white blood cells (WBCs) have nuclei and do not contain hemoglobin (see Figure 14-2). Leucocytes fall into two major ‘groups. The first is granular leucocytes, They have large character- istic granules in their cytoplasm and possess lobed nuclei. The three kinds of granular leucocytes are identified on the basis of their specific granules and are called neutrophils (10 to 12 um in diameter), eosinophils (10 to 12 jum in diameter), and basophils @ to 10 um in diameter). ‘The second group is called agranular leucocytes because thet cytoplasmic granules do not stain easily and cannot be seen with ‘an ordinary light microscope. Lymphocytes (7 to 15 wm in diamete) ‘and monocytes (14 to 19 wm in diameter) are the two types in this group. Just as red blood cells have surface proteins, so do white bod cells and all other nucleated cells in the body. These proteins called HLA (human leucocyte associated) antigens, are uniget for each person (except for identical twins) and can be used © ‘identify tissue. If an incompatible tissue is transplanted, it ejected by the recipient as foreign, due, in part, to differences in donor and recipient HLA antigens. The HLA antigens are utd to type tissues to help prevent rejection '= Functions The skin and mucous membranes of the body & cone exposed to microbes and their toxins. Some of these microbes are capable of invading deeper tissues to cause disea® = they enter the body, itis the function of leucocytes f0 by phagocytosis or antibody production. Neutrophils a dispons ot at Sctively phagocytotic—they can ingest bacteria ispose of dead cells (see Figure 3-6a,b). Neutrophils (N¢«145 Production of red blood cal act Innibits * Lacs woreesed oxygen rapity to tissues <== |_ bow a ‘What are the three causes of hypoxia? fis) respond first to bacterial invasion, carrying on phagocytosis andreleasing the enzyme lysozyme, which destroys certain bacter Mooocytes (MON-6-sits) take longer to reach the site of infection ttan do neutrophils, but once they arrive, they do so in larger ‘tumbers and destroy more microbes. Monocytes that have migrated ‘o infected tissues are called wandering (tissue) macrophages. Trey clean up cellular debris following an infection. Most leuco- ‘tes possess, to some degree, the ability to crawl through minute ‘paces between the cells that form the walls of capillaries and ‘trough connective and epithelial tissue. This movement, like that famoebas, is called diapedesis (di'-a-pe-DE-sis). Exsinophils (€'-6-SIN-6-fils) are believed to release enzymes, ‘ach as histaminase, that combat the effects of ‘inflammation, aller- ‘icreactions, and certain parasitic worms. Thus, a high eosinophil Count frequently indicates an allergic condition or a parasitic infec- ‘ion, Eosinophils also phagocytize antigen-antibody complexes (0 ‘beexplained shortly). i Basophils (BA.s6-fls) re also believed to be involved inallersic Tatios. Once they leave the capillaries and enter the tissues, thy ae known as mast cells and function to liberate heparin, = and serotonin, substances that intensify the inflammatory ion (see Chapter 17). Iymphosytes (LIM-fo-sts) develop into cells that prodoe Antibodies (AN-ti-bod!-82) are proteins that inact "ips. An antigen (AN-tjen) is any substance that stimlates Components of Blood + 303 the production of antibodies and is capable of reacting specifically With the antibody. Most antigens are proteins, and most ae not synthesized by the body. Rather antigens make up the cell structures and enzymes of bacteria. They also make up the toxins released by bacteria. When antigens enter the body, they stimulate certain lymphocytes, called B cells, to become plasma eels (Figure 14-6). The plasma cells then produce antibodies, globulin-type Proteins that atach to antigens and inactivate them. This is called the antigen-antibody response. Eosinophils destroy the antigen antibody complexes. The antigen-antibody response is discussed in more detail in Chapter 17. Other lymphocytes are called T cells. One group of T cells, called eyotoxic (killer) T cells, that is activated by certain antigens react by destroying them directly or indirectly by recruiting other lymphocytes and macrophages. T cells are especially effective against bacteria, viruses, fungi, transplanted cells, and cancer cells ther types of T ces and their functions ae daeueed in Chap _ The antigen-antibody response helps us combat infection and ives us immunity to some diseases. It is also responsible for FIGURE 14.6 fibody response. An anfigen entering the body simulates B cello develop into anor plasma col The erodes atch tothe enige, cover ond render harm: less, Beat Covared antigen | ryld, eo. ; a /f AYA [LT What ore the five resus ofthe antigen-antibody response?304 = Chapter 14 The Cardiovascular System: Blood blood types, allergies, and the body's rejection of organs trans- Planted from an individual with a different genetic makeup. ‘An increase in the number of white blood cells present in the blood usually indicates an inflammation or infection. Because each type of white cell plays a different role, determining the percentage ‘of each type in the blood assists in diagnosing the condition. A differential white blood cell count is the number of each kind of White cell in 100 white blood cells. A normal differential blood ‘count falls within the following percentages: Neutrophils 60-70% Eosinophils 24% Basophils 0.51% Lymphocytes 20-25% ‘Monocytes 3.80% 100% Particular attention is paid to the neutrophils in a differential white blood cell count. A high neutrophil count usually indicates a response to invading bacteria. A high monocyte count generally indicates a chronic infection. Eosinophils and basophils are elevated a0 B B a BOL ee oo AB AB Neither A.B, ABs amar A.B, AB ° Neither ab ° Ano B baby is bom with this condition, blood i slowly agglutinins will act agunst the donated blood andasevere reaction NDet baby is ore, with Rh” blood. Iti even may occur. “The most common problem with Rh incompatibility may arise during pregnancy. During pregnancy, a small amount of the fetus's blood may leak from the placenta into the mother’s bloodstream, with the greatest possibility of transfer occurring at delivery. If the fetus is Rh’ and the mother is Rh~, she, upon exposure 10 the Rh* fetal cells or cellular fragments, will make anti-Rh ageluti- nins. If she becomes pregnant again, her anti-Rh agglutinins will cross the placenta and make their way into the bloodstream of the baby. Ifthe fetus is Rh, no problem will occur, singe Rh blood does not have the Rh agglutinogen. If the fetus is Rh*, hemolysis may occur in the fetal blood. The hemolysis brought ‘on by fetal-maternal incompatibility is called hemolytic disease of the newborn (HDN) ot erythroblastosis fetalis. COMMON DISORDERS Anemia Anemia is a condition in which the oxygen-carrying capacity ‘of the blood is impaired. There are several types of anemia (Gescribed next) and all lead to fatigue and intolerance to cold, both of which are related to lack of oxygen needed for energy ‘and heat production, and to paleness, which is due to low hemo- globin content. ‘Nutritional anemia arises from inadequate diet, one without sufficient amounts of iron, the necessary amino acids, or vitamin Bro Pernicious anemia is the insufficient production of erythro- cytes because of lack of vitamin B,2, resulting from an inability of the stomach to produce intrinsic factor, which allows absorp- tion of vitamin By ‘An excessive loss of erythrocytes through bleeding is called ‘hemorrhagic anemia. Hemolytic anemia is characterized by distortion in the shape of erythrocytes that are progressing toward hemolysis. The pre- ‘mature destruction of red blood cells may result from inherent defects, parasites, toxins, and antibodies from incompatible ‘blood (Rh mother and Rh* fetus, for instance). Destruction or inhibition of red bone marrow results in aplas- {nto the unborn child if the disease is a we jmportant, though, the. ésordercan eget ith an injection of anti-Rh gamma,-globulin preparation, vent tered to Rh™ mothers at 26 to 28 weeks of gestation a a eter delivery, miscarriage, ot abortion. These agglutinins te yp dhe fotal agglutinogens, if present, so the mother cannot respond to the foreign agglutinogens by producing agglutinins. Thus, fers of the next pregnancy is protected. In the case of an Rit mother, there are no complications, since she cannot make ani- Rh agglutinins. In cases where Rh incompatibility is not implicated in hemolytic disease of the newborn, incompatibility of other blood ‘groups such as the ABO group is frequently involved. tic anemic causes. ‘The erythrocytes of a person with sickle-cell anemia (SCA) ‘manufacture an abnormal kind of hemoglobin. When an erythro- cyte gives up its oxygen to the interstitial fluid, its hemoglobin tends to form long, stiff, rodlike structures that bend the erythro- cyte into a sickle shape. The sickled cells rupture easily. Pro- Jonged oxygen reduction may eventually cause extensive tissve damage. Furthermore, they tend to get stuck in blood vessels and can cut off blood supply to an organ altogether. Polycythemia ‘The term potyeythemia (pol'-é-si-THE-mé-a) refers to an aboot ‘mal increase in the number of red blood cells. Toxins, radiation, and certain medications are Infectious Mononucleosis (IM) Infectious mononucleosis (IM) mail n is a contagious disease primatl ite) lymphoid tissue throughout the body but also affecting blood. It is caused by the Epstein-Barr virus (EBV). comm inainly in children and young adults. The virus m5 commonly enters the body through intimate oral contact.| chronic Fatigue Syndrome eokemia inicaly, leukemia is classified on the basi Gi character of the disease, that is, acme °F t% duration wrote te fn resis (#FER-€-sis; aphairesis = remov: gate Peach blood is withdrawn from the ee are selectively separated, the undesirable component causing disease is removed, and the remainder is retumed to the body: Autologous intraoperative transfusion (AIT) Procedure in which blood lost during surgery is suctioned from the patient, treated with an anticoagulant, filtered of debris, and centri- fuged (spun at high speed) to recover the red blood cells. Then the red blood cells are washed in saline solution and returned to the patient Autologous (aw-TOL-o-gus; auto = self) transfusion (trans- FYOO-zhun) Donating one’s own blood for up to 6 weeks before elective surgery to ensure an abundant supply and also reduce transfusion complications such as those that may be associated with AIDS and hepatitis. Also called predona- tion. Blood bank A stored supply of blood for future use by the donor or other individuals. Since blood banks have now assumed additional and diverse functions (immunohematol- ogy reference work, continuing medical education, bone and tissue storage, and clinical consultation), they are more appro- rately referred to as centers of transfusion medicine. Citrated (SIT-rat-ed) whole blood Whole blood protected from coagulation by CPD (citrate phosphate dextrose) or a similar compound, Cyanosis (si'-4-NO-sis; cyano = blue) A reduced oxyhemoglo- bin in blood that causes a slightly bluish, dark purple discol- oration most easily seen in the nail beds and mucous mem- branes, Direct (immediate) transfusion (trans = through) Transfer of blood directly from one person to another without exposing the blood to a storage container. 2 Exchange inansjusion Removing blood from the recipient while altemately replacing it with donot blood. This method is Used for treating hemolytic disease of the newborn (HDN) and poisoning. This may be done intrauterine. ‘Medical Terminology and Conditions * 313 {etized by uncontrolled production and accumulation of immature leucocytes, In chronic leukemia, there is an accumulation of Mature leucocytes in the bloodstream because they do not die ‘at the end of their normal life span. The human T-cell leukemia- ‘bmphoma virus (HTLV-1 is strongly associated with some types of leukemia. Tn acute leckemia, anemia and bleding problems result from the crowding out of normal bone marrow cells by the overprodue- tion of immature cells, preventing normal production of red blood cells and platelets. The abnormal accumulation of imma- ture leucocytes may be reduced by using x-rays and antileukemic drugs. c MEDICAL TERMINOLOGY AND CONDITIONS incall Gamma globulin (GLOB-yoo-lin) Solution of globulins from nonhuman blood consisting of antibodies that react with spe- cific pathogens, such as measles, epidemic hepatitis, tetanus, and possibly poliomyelitis viruses. Hemochromatosis (hé-m0-kro'-ma-TO-sis; heme = iron; chroma = color) Disorder of iron metabolism characterized by excess deposits of iron in tissues, especially the liver ‘and pancreas, that result in bronze coloration of the skin, cirthosis, diabetes mellitus, and bone and joint abnormalities. Hemorrhage (HEM-or-ij; rrhage = bursting forth) Bleeding, either internal (from blood vessels into tissues) or external (from blood vessels directly to the surface of the body). Indirect (mediate) transfusion Transfer of blood from a donor to a container and then to the recipient, permitting blood to be stored for an emergency. ‘Multiple myeloma (rni'-e-LO-ma) Malignant disorder of plasma cells in bone marrow. Platelet (PLAT-Iet) concentrates A preparation of platelets ob- tained from freshly drawn whole blood and used for transfu- sions in platelet-deficiency disorders such as hemophilia, Reciprocal (re-CIP-10-cal) transfusion Transfer of blood from ‘a person who has recovered from a contagious infection into 1 patient suffering with the same infection. An equal amount of blood is retumed from the patient to the well person. Septicemia (sep'-ti-SE-m®-x; sep = decay; emia = condition ‘of blood) Toxins or disease-causing bacteria in the blood. Also called “blood poisoning.” Thrombocytopenia (throm'-bé-si'-t0-PE-né-a; thrombo = clot; ‘penia = poverty) Very low platelet count that results in a tendency to bleed from capillaries. Transfusion (tans-FYOO-zhun) Transfer of whole blood, blood ‘components (red blood cells only or plasma only), or bone ‘marrow directly into the bloodstream. Venesection (vén’-e-SEK-shun; veno = vein) Opening of a vein for withdrawal of blood. Whole blood Blood containing all formed elements, plasma, ‘and plasma solutes in natural concentration. eee