BLOOD Hippocrates mentioned that blood is a physical representation of the four humours. That is, the red portion denotes the sanguinous humour, the watery component represents the phlegmatic humour, the froth represents the bilious humour and the residue which sinks to the bottom is the melancholic humour. BLOOD According to Tibb, humours are produced in the liver. Therefore, the efficient functioning of the liver is essential for maintaining the ideal integrity of blood constituents. Whilst the physical production of blood cells may be in the bone marrow, blood disorders are invariably the result of inadequate humours produced in the liver. BLOOD The concept of haematology from the Tibb perspective relates not only to the qualities they possess but also within the physical parameters that these qualities translate into. These include the viscosity of the blood, the temperature of the blood, the moisture content and the purity of the blood. THE NATURE AND FUNCTION OF BLOOD Blood is the red, thick, viscous specialized fluid which is pumped by the heart around the body via the arteries, capillaries and veins of the cardiovascular system. The main function is the provision of nutrients to the cells as well as the elimination of by-products of metabolism. Provides the vehicle by which an immense variety of different substances are transported between the various organs and tissues. Blood is fundamentally important in assisting Physis. Function of blood Blood serves the body in three ways: 1. Transportation-of O2 from the lungs, nutrients and vitamins absorbed from the digestive system, waste products such as urea, uric acid, creatinine and CO2 from the tissues and hormones from the endocrine glands. 2. Regulation-blood helps maintain the acid-base balance (pH) of body fluids; the amount of fluid in the tissues is adjusted by altering osmotic pressure; heat generated in the muscles is transmitted to other parts of the body. 3. Protection- a) immune system; b) antibodies; c) coagulation STATISTICS Blood accounts for approximately 8% of body weight Total volume of approximately 5L in an adult male (rather less in an adult female) 250millilitres in a new-born baby Blood makes a complete circuit of the body in about one minute Blood is classified as connective tissue because nearly half is made up of cells. Blood varies in colour from bright scarlet to dark red, depending on how much O2 it is carrying. COMPOSITION OF BLOOD PLASMA- contains proteins such as albumins, globulins and fibrinogen, nutrients, hormones, mineral electrolytes and metabolic end products. Blood cells are mostly in the bone marrow-the soft tissue found in the centre of bones and this process is called erythropoiesis. Some blood cells are also made in the spleen. In children, blood cells are mainly made in the marrow of the long bones. In adults, most production takes place in the flatter bones e.g. the pelvis RED BLOOD CELLS- make up around 99% of all blood cells, contain the O2 carrying protein haemoglobin. WHITE BLOOD CELLS- include the granulocytes,neutrophils, eosinphils and basophils. These have segmented nuclei. Also included are the monocytes and lymphocytes. These have single nuclei. The white blood cells are all involved in various aspects of the body’s defence against micro-organisms and the immune system. PLATELETS- are small blood cells crucially important for blood coagulation. They are also formed from the stem cell system. Red blood cell platelets White blood cell FORMATION OF BLOOD All blood cells are derived form stem cells present in the bone marrow. Both red & white blood cells are produced in the bone marrow, and broken down by the spleen. In addition, white blood cells are formed in the liver, spleen and lymph nodes. Red blood cells enter blood vessels via the nutrient circulation. Vitamin B12, vitamin C and folic acid are vitally important for the synthesis of red blood cells. The elements iron, cobalt and copper are also essential. Red blood cell production is controlled by a hormone secreted by the kidney-erthyropoietin-which stimulates bone marrow. Red blood cells are made at an astonishing rate-literally billions per day. The reason is simply the fact that their survival time is short, as they are worn out very rapidly. THE NATURE OF PLASMA This clear fluid occupies around 55 % of blood volume. The main components are: 1. 90% water 2. 7% proteins (mainly albumin, globulins, fibrinogen) & lipoproteins 3. 3% small molecules (mostly salts, vitamins, hormones, urea, amino acids) 4. 0.1% glucose The proteins help maintain the osmotic pressure, to hold fluid within the circulation and counteract the blood pressure that forces it out of the capillaries. The gamma globulins defend the body against infection. Nature of Plasma the plasma proteins include: Albumin-is synthesized by the liver. It maintains the osmotic pressure of the blood Gamma globulin- this contains the various antibodies needed by the immune system Blood clotting factors- fibrinogen, plasminogen and other proteins Complement- a group of enzymes which helps antibodies fight against pathogens. Nutrients found in the plasma 1. Glucose- a simple sugar absorbed by the capillaries in the intestine following digestion 2. Amino acids- the products of protein digestion; they too are absorbed from the digestive tract through the intestinal capillaries. 3. Lipids- used as a source of energy, or stored in fat deposits for reserve energy. Serum is the same as plasma, but without the fibrinogen. RED BLOOD CELLS • A red blood corpuscle is circular, bi-concave in shape & about 7.5 microns in diameter. • There are approximately 5 to 6 million per cubic millimetre of blood normally • The red blood cells contain the red pigment haemoglobin, an iron- containing protein which carries O2 throughout the CVS. The red blood cells have only one function in the body- THE TRANSPORT OF O2 • This is achieved by combining O2 reversibly with haemoglobin. • Healthy men have about 15g of haemoglobin per 100ml blood; and females 13g per 100ml • The red blood cell survives for about 80 to 120 days in the CVS • Approximately two million die every second • Old and damaged red blood cells are removed by the reticulo- endothelial system which is present in the liver and spleen. WHITE BLOOD CELLS There are normally about 8000 of these per cubic millimetre of blood (1% of blood volume) There are two basic groups: Granulocytes- also called polymorphonuclear leucocytes. These make up about 65% of the white blood cell population. They survive for less than a week, they destroy invaders (allergens, bacteria, parasites etc.) & remove dead and damaged tissue cells. There are three different types of granulocytes: Eosinophils- cells are involved in defence against parasites, and in the allergic reaction Basophils- known to be involved in the allergic reaction as they contain histamine. They can also ingest foreign particles. In tissues, they change into mast cells. Neutrophils- are involved in killing bacteria and provide a defence against infection. Agranulocytes-lymphocytes and monocytes. They are formed in the marrow, lymph glands, spleen and thymus. They help to maintain the immune system. The monocytes are larger cells, distinct from lymphocytes and function mainly by phagocytosis. In tissues, monocytes change into macrophages. PLATELETS These are found in the bone marrow They are cytoplasmic fragments of much larger cells called megakaryocytes. They do not have cell nuclei or DNA & do not divide. They do contain mitochondria and enzymes Platelets are extensively involved in the blood clotting (coagulation) process. They contain two contractile proteins, actin and myosin which are brought into play during clot retraction and wound healing. Platelets survive for 7 to 10 days in the bloodstream. HAEMOSTASIS Blood flows freely in intact blood vessels due partly to an excess of naturally occurring anti-coagulants. However, if the blood vessel wall breaks, a series of chemical reactions begin to stop the bleeding (haemostasis). Without this process, even a simple cut would result in the bleeding to death. Although we can lose up to 15% of our blood without serious ill-effects, a greater loss can be severe, leading to shock and even death. Loss of blood (haemorrhage) internally or externally can lead to anaemia in the long term. HAEMOSTASIS EVENTS IN HAEMOSTASIS INCLUDE: 1. Vasoconstriction- contraction of the smooth muscles in the blood vessel wall. In the short term, this markedly reduces the flow of blood and loss from the rupture in the blood vessel wall. 2. Platelet plug- any damage to the blood vessel activates platelets, which become sticky and adhere to each other and to the damaged area, forming a temporary plug. 3. Blood clotting- the platelet plug is reinforced with a fibrin meshwork across the wound. Red & white blood cells are trapped within this mesh, forming the familiar blood clot. This process is called blood coagulation. BLOOD COAGULATION The formation of a blood clot is a very complicated process involving over 30 chemicals. Some of these, called coagulation factors, enhance clot formation. 13 coagulation factors are involved in clotting which occurs in injured tissue. The end product of this sequence is thromboplastin This is an enzyme which catalyses the conversion of a plasma protein, prothrombin, into a smaller protein called thrombin. Calcium and other factors are involved. Thrombin, in its turn, catalyses the joining of fibrinogen molecules present in the plasma to produce the typical fibrin mesh. It is this mesh that traps blood cells (red and white blood cells, platelets) in the blood vessel wall. Once the clot solidifies, the top layer of cells dies, forming the scab. The large number of chemical steps involved in the clotting process means that coagulation must be tightly controlled. This is extremely important, because unnecessary clotting can be very dangerous, especially if it blocks a blood vessel (thrombosis), in a major organ. When blood is removed from the body, it will automatically clot on contact with a surface than the blood vessel lining. The fluid remaining after clotting is the serum. Serum contains all the components of blood plasma except the clotting factors. FIBRINOLYSIS Once the tissue has healed, after 2 to 3 days, the fibrin mesh which holds the clot together is dissolved. This process , called Fibrinolysis, is catalysed by the enzyme plasmin, which is produced from the plasma protein plasminogen. Plasminogen molecules are incorporated into the blood clot during its formation. Here they lie dormant until activated by the healing process. Most of the body’s plasmin is restricted to the blood clot Normally, a fine balance between blood coagulation and Fibrinolysis is maintained by the body. STEM CELLS These are the ancestors of all blood cells. All types of blood cells are derived from the stem cells, which may go on to form red blood cells, white blood cells and platelets. There are two basic properties of stem cells: 1. They are potentially immortal, able to divide indefinitely 2. They can develop into adult types of cells. Poor nutrition or a poorly balanced diet will obviously result in an imbalance in humours. In addition, poor elimination would result in accumulation of toxins, low O2 levels, either in the blood or at the vascular level. Predisposing factors People who have a dominant Phlegmatic temperament will be inclined to the haematological disorders. This is an outcome which could be predicted from a lack of heat and/or lack of dryness Most of the conditions associated with blood disorders will invariably proceed along pathway 2. However, there are exceptions-if the clinical condition is genetic, or if there is a sudden and excessive loss of blood due to trauma, surgical procedures or menorrhagia. The approach to treating disorders of the blood generally revolve around restoring the efficiency of the liver, by means of proper nutrition. Any deficiencies in the food consumed, either in mineral or other component, can be rectified by advising the sufferer to adhere to a food regimen that includes a balance of nutrients & minerals required for the proper synthesis of haemoglobin, red blood cells, white blood cells and platelets. ANAEMIA C+M frame, excess phlegmatic humour, pathway 2 Anaemia is a reduction in the blood’s ability to carry O2, due to a decrease in either a) the number of red blood cells or b) the amount of haemoglobin they contain. According to Tibb, anaemia can be the result of a C+M imbalance. Iron-deficiency anaemia is the most common form All age groups and both sexes are affected but anaemia is more common in younger women. Clinical features The initial signs of developing anaemia may be: Loss of appetite Constipation Amenorrhoea Irritability Difficulty in concentrating Coldness of the hands and feet Signs and symptoms of anaemia Symptoms Tiredness & lethargy Dyspnoea Dizziness Heart palpitations Signs Pale inner eyelids Sore tongue (glossitis) Cracking of the side of the mouth (angular stomatitis) Brittle hair and pallid skin Brittle nails (koilonychia) Older patients-chest pain & swollen ankles Causes and risk factors Around 50% of cases of anaemia in the developing world occur in people with hookworm infestation. Anaemia arises from a number of reasons, depending on the type. The major ones include: 1. Chronic inflammation in the body-this often appears with chronic diseases, such as infections, carcinomas, connective tissue disorders and kidney failure. 2. Dietary factors-e.g. Low iron content of the food regularly consumed and a dietary deficiency in folic acid. Also, a lack of intrinsic factor (substance that gastric glands produce to promote absorption of vitamin B12) absorption resulting from auto-immune damage to the stomach lining. 3. Excessive loss of blood from gastrointestinal disorders (e.g. Peptic ulcers, alcoholism and piles) 4. Gynaecological disorders-repeated childbirth and heavy menstrual bleeding 5. Disease-liver damage, thyroid disorders, bone marrow disorders, haemophilia, sickle cell disease, thalassaemia, kidney failure Discuss treatment plan as well as medication for this condition with regard to Tibb philosophy. Angular stomatitis & angular cheilitis There are several types and classifications of anaemia. This is a condition in which the body lacks the amount of red blood cells to keep up with the body's demand for oxygen. Understanding the different classifications can help to recognise the symptoms and also to avoid anaemia in the first place... Iron deficiency anaemia Iron deficiency anaemia is a condition in which the body has too little iron in the bloodstream. This form of anaemia is more common in adolescents and in women before menopause. Blood loss from heavy periods, internal bleeding from the gastrointestinal tract, or donating too much blood can all contribute to this disease. Other causes can be from poor dietary habits or from chronic intestinal diseases. The signs and symptoms of this disease are: 1. Paleness 2. Headache 3. Irritability Symptoms of more severe iron deficiency anaemia include: 1. Dyspnoea 2. Rapid heartbeat 3. Brittle hair and nails Treatment usually takes the form of oral iron supplements and dietary modifications. Folic Acid Deficiency Anaemia This form of anaemia is characterised by a lack of folic acid, one of the B group of vitamins, in the bloodstream. This is usually caused by an inadequate intake of folic acid, usually found in vegetables or by the overcooking of the vegetables. Alcoholism can also be a contributing factor in this form of anaemia. During pregnancy when the folic acid is used more or in infancy, this disease can also manifest itself. It can also be caused as a side effect of other blood disorders. Symptoms of the disorder include: 1. Weakness 2. Fatigue 3. Memory lapses 4. Irritability This condition can be avoided by including foods with folic acid in the diet. Such foods include beef liver, asparagus, and red beans. Pernicious anaemia Pernicious anaemia usually affects people between the ages of 50 and 60 and is a result of a lack of vitamin B12. The disease can be hereditary but some forms of the condition can be autoimmune diseases. People who have any autoimmune diseases are more likely to contract pernicious anaemia. Symptoms of this form of anaemia may include: 1. Fatigue 2. Dyspnoea 3. Heart palpitations 4. Numbness or tingling in extremities Aplastic anaemia Aplastic anaemia is caused by an absence or reduction of red blood cells. This can happen through injury where the blood forming tissue in the bone marrow is destroyed. Because of this, the sufferer is unable to fight infection and is likely to be a heavy bleeder. Symptoms include: 1. Lethargy 2. Paleness 3. Purpura 4. Bleeding 5. Rapid heartbeat 6. Infections 7. Congestive heart failure There is no definite known cause for aplastic anaemia but it is thought to be caused by exposure to certain toxins and also to the hepatitis virus. Polycythemia Vera This disease is more common in middle aged men and is characterised by an increase in red blood cells, leucocytes, and thrombocytes. There is a very fast and intense reproduction of cells and the bone marrow cells mature more rapidly than usual. The cause of this condition is unknown. Symptoms are: 1. Purplish coloured skin 2. Bloodshot eyes 3. Headache 4. Dizziness 5. Enlarged spleen Although the signs and symptoms of anaemia may seem overwhelming, the good news is that most forms can be effectively controlled with medication and dietary changes. Sickle Cell Anaemia This form of anaemia is of a hereditary nature and is a result of an abnormal type of red blood cells. Sickle cell anaemia is a life threatening disease and there is no prevention. Symptoms of this condition include: 1. Painful attacks in arms, legs and stomach 2. Jaundice in whites of the eyes 3. Fever 4. Chronic fatigue 5. Rapid heartbeat 6. Paleness Complications include leg ulcers, shock, cerebral haemorrhage, and orthopaedic disorders. What is fibrinogen? Fibrinogen, also called Factor I, is a blood plasma protein produced by the liver that plays an important role in blood coagulation. Blood coagulation is a process in which several components of the blood form a clot. When blood escapes from a rupture in a blood vessel, coagulation is triggered. Several proteins, called coagulation factors, go into action to produce thrombin. The thrombin then converts fibrinogen to fibrin. Fibrin produced from fibrinogen is the main protein in a blood clot. It surrounds the cells in the blood and plasma and helps form the clot. The resulting clot, which is stabilized by Factor XIII, remains intact from 10 to 14 days, the time required for healing to take place. When there is a problem with fibrinogen, i.e., either it is missing or it does not function properly, the clot has difficulty forming. This can result in haemorrhaging or thrombosis. The normal volume of fibrinogen in the blood is from 2 to 4 g/l (grams/litre). The amount of fibrinogen in blood can be measured from a blood sample. Types of Fibrinogen Deficiency There are three types of deficiency: Afibrinogenaemia: (absence of fibrinogen) In this type of factor I deficiency, there is a complete absence of fibrinogen. The fibrinogen level is <0.2 g/l of plasma. about 5 people out of 10 million are affected by it. of the three types, this one causes the most serious bleeding. Hypofibrogenaemia: (lower than normal level) In this anomaly, fibrinogen is present, but at a lower level than normal, between 0.2 g/l and 0.8 g/l. This anomaly is less frequent than Afibrinogenaemia. Bleeding problems may be mild, moderate or severe. Dysfibrinogenaemia: (malfunctioning) In Dysfibrinogenaemia, the fibrinogen level is normal, which means between 2 and 4 g/l, but the fibrinogen does not function properly. About 1 person in 1 million is affected by this condition. More than 100 different types of Dysfibrinogenaemia have been reported. Those affected rarely suffer from haemorrhaging problems. They may even present the opposite condition: thrombosis (blood coagulates in the blood stream). Transmission of Fibrinogen Deficiency Fibrinogen deficiency is a very rare inherited bleeding disorder. It is transmitted from parent to child at conception. The disorder is caused by an abnormal gene. It affects both men and women, as well as people of all races and ethnic origins. Every cell of the body contains chromosomes. A chromosome is a long chain of a substance called DNA. DNA is organized in 30,000 units: these are called genes. The genes determine physical characteristics, such as eye colour. In the case of fibrinogen deficiency, one of the genes involved is defective. The defective gene in fibrinogen deficiency is located on a chromosome that is not responsible for the child’s sex (autosomal). As a result, both girls and boys can be affected equally. Afibrinogenaemia (absence of fibrinogen) This is a recessive disorder, which means that both parents must be carriers. In order for a person to inherit fibrinogen deficiency, he must receive two defective genes, one from the mother and the other from the father. A carrier is a person who has only one of the two defective genes, but is not affected by the disorder: the second gene enables just enough fibrinogen to be made for good coagulation. The fibrinogen level will be lower than normal, but there will be no symptoms of the disorder. Hypofibrinogenemia and Dysfibrinogenaemia These are inherited disorders that can be either dominant or recessive. Dominant means that a single parent can transmit the disorder if he or she is a carrier. Recessive means that both parents must be carriers of the disorder in order to transmit it. Symptoms Afibrinogenaemia (absence of fibrinogen) In congenital Afibrinogenaemia (fibrinogen level <0.2 g/l), bleeding can vary, from slight to severe. many patients have very long intervals between bleeding episodes. a diagnosis of Afibrinogenaemia is generally made postnatally, usually because of bleeding from the umbilical cord and/or a haemorrhage following circumcision. Other types of bleeding have been described: • bruises • bleeding from the gums • epistaxis (nosebleeds) • gastrointestinal haemorrhage • genito-urinary haemorrhage • intra-cranial haemorrhage • rupture of the spleen and haemorrhage in the spleen About 20% of those suffering from Afibrinogenaemia present hemarthroses (bleeding in the joints). Because of this particular feature, the disorder may be confused with haemophilia A or B. Hypofibrinogenemia (lower than normal level) Bleeding in Hypofibrinogenemia is much like what is seen in Afibrinogenaemia. It can be more or less serious, depending on fibrinogen levels, which can vary from 0.2 to 0.8 g/l of plasma. The higher the fibrinogen level, the less bleeding. The lower the fibrinogen level, the more bleeding. Dysfibrinogenaemia (improper functioning) In Dysfibrinogenaemia, the quantity of fibrinogen is normal, which means between 2 and 4 g/l. Bleeding can vary depending on how the fibrinogen is functioning. Bleeding may: be absent (no symptoms); show a tendency toward haemorrhage (as described in Afibrinogenaemia); show a tendency toward thrombosis. FIBRINOGEN DEFICIENCY Also called Afibrinogenaemia C+M frame due to excess phlegmatic humour, Pathway2 Fibrinogen is an important factor in the coagulation of blood. This kind of deficiency can lead towards disorder of low coagulation. Treatments Many people who have Hypofibrinogenemia or a Dysfibrinogenaemia do not need treatment. To control or prevent bleeding, all that’s required is to increase the fibrinogen level in the blood with blood products or substitutes. This kind of treatment is called factor replacement treatment. The aim of the treatment is to increase the fibrinogen level to 1 g/L when there is minor bleeding, and 2 g/L for serious bleeding or for surgery. Fibrinogen concentrate can be administered by drip: • at the time of surgery; • to the mother during childbirth or after delivery; • after a trauma; • before dental surgery; • as prophylaxis (prevention) for subjects with Afibrinogenaemia to prevent bleeding. At the present time, the most frequently used treatment in Canada is fibrinogen concentrate. The concentrate is obtained from human plasma and contains fibrinogen only. The concentrate undergoes a viral inactivation process, which eliminates viruses such as HIV and hepatitis A, B and C. It is impossible to completely eliminate the risk of transmitting infections that are currently unknown. There are other options that can be considered for treatment: • plasma • cryoprecipitate (a precipitate produced by freezing and thawing under controlled conditions. An example of a cryoprecipitate is the residue obtained from fresh frozen blood plasma that has been thawed at 4 degrees Celsius . This residue is extremely rich in clotting factor. However, their use is not recommended much nowadays for various reasons, such as: slight risk of viral transmission; possible serious allergic reactions because of the large number of different substances contained in these products in addition to fibrinogen. Anticoagulants are sometimes used to reduce the risk of thrombosis among patients with Dysfibrinogenaemia. THROMBOCYTOPENIA C+M frame due to excess Phlegmatic humour, Pathway2 This condition refers to a severe reduction in the quantity of platelets (thrombocytes) in the bloodstream. It arises either from a) an abnormally low production rate or b) an excessive destruction of thrombocytes. As a result there is a greater tendency for unexplained bruising and bleeding to occur especially in the skin and mucous membranes, as the blood is less able to clot. Anaemia and an enlarged spleen may develop Causes include cirrhosis of the liver, an enlarged spleen, alcoholism and a number of allopathic drugs.
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