GEMOGRAMMA (Greek haima blood + gramma of the devil, line, image; synonym general clinical blood test) — results of a quantitative and qualitative research of composition of blood. Includes data on quantity of erythrocytes, them morfol, features, quantity of reticulocytes, the general hemoglobin content in blood, a color indicator, quantity of leukocytes, a ratio of their different types, quantity of thrombocytes, and also about some indicators of coagulant system of blood and physical. - chemical indicators of blood. Depending on the contingent of patients the range of indicators can be expanded. In 1972. The all-Union research laboratory center M3 of the USSR developed the new Scheme.
For the first time the term «gemogramm» was offered by V. Shilling in 1931 for the characteristic only of leukocytic composition of blood, namely for definition of a percentage ratio of different types of leukocytes, including neutrophilic leukocytes with various form of a kernel (see. Leukocytic formula).
Blood for a research is recommended to be taken in the morning on an empty stomach or in an hour after a light breakfast. In laboratory practice investigate usually capillary blood (it is possible to take blood from a vein). Blood is taken by a prick a needle of pulp of a finger or a lobe of an ear, and children of early age — pulp have heels. It is necessary to use needles scarificators with removable copies or feathers scarificators (fig. 1 and 2) which after work boil in a sterilizer or place for 2 hours in a drying oven at a temperature of 180 °.
Skin on site of a prick is consistently wiped with two tampons: at first the moistened alcohol, then ether. At such processing of skin the drop of blood acting from a puncture does not blur. The injection needs to be given sideways where the capillary network is more dense, on depth of 2 — 3 mm depending on thickness of skin that blood followed freely. At strong pressing to blood the intercellular lymph will be added that can affect results of the analysis. It is important to observe the sequence of capture of blood for a research of separate indicators: after removal (cotton wool) of the first drop gather blood for definition of ROE, for determination of amount of hemoglobin, for calculation of total quantity of erythrocytes, for calculation of total quantity of leukocytes, do smears (usually two) for the purpose of calculation of a leukocytic formula and studying of morphology of erythrocytes; for calculation of reticulocytes smears do on specially prepared glasses.
For definition of a blood clotting time and duration of bleeding, and also make separate punctures of skin for calculation of quantity of thrombocytes.
Determination of amount of hemoglobin it is possible to make in various ways. In laboratory practice for this purpose use gemometr like Sali more often (see. Gemoglobinometriya ).
Norms of hemoglobin for men of 14,5 g of % (fluctuation of 13,0 — 16,0 g of %) and for women of 13,0 g of % (fluctuation of 12,0-14,0 of %).
Reduction of concentration of hemoglobin in blood is observed at anemias of various etiology (at blood loss, deficit of polyneuramin 12 , gland, increased hemolysis of erythrocytes, etc.). Increase in concentration of hemoglobin meets at an erythremia, secondary, or symptomatic, hyperglobulias. At a pachemia there can occur relative increase in concentration of hemoglobin.
Total quantity of erythrocytes count in 1 mkl blood. Capture of blood can be made melanzherny (in mixing pipettes or mixers) or a probirochny method (in test tubes, on H. M. Nikolaev) with the subsequent calculation of erythrocytes in a cytometer under a microscope (see cytometers). Count erythrocytes and in a photo-electric eritrogemometr, and also by means of a tselloskop.
The quantity of erythrocytes are normal at men 4 000 000 — 5 000 000 in 1 mkl of blood, at women 3 700 000 — 4 700 000. Increase in quantity of erythrocytes is usually noted at diseases of which increase in concentration of hemoglobin is characteristic (e.g., a polycythemia, secondary hyperglobulias, etc.). Reduction of quantity of erythrocytes is observed at decrease in erythroblastic function of marrow (hypo - and aplastic processes), at patholologically the changed marrow (leukoses, a multiple myeloma, metastasises of malignant tumors, etc.), owing to the strengthened erythrocytolysis (hemolitic anemias), at deficit in an organism of iron, polyneuramin 12 , at bleedings.
Color indicator — the indicator expressing abundance of hemoglobin in one erythrocyte in terms of Sali. If the hemoglobin content is measured in gram-percent, then the color indicator is calculated by division of the trebled indicator of amount of hemoglobin in gram-percent on the first two figures of an indicator of number of erythrocytes (e.g., hemoglobin of 14,0 g of %, number of erythrocytes 4 200 000; color indicator = 1,0). If the hemoglobin content is expressed in terms of Sali, then this indicator is divided into the doubled first two figures of an indicator of maintenance of erythrocytes (e.g., hemoglobin of 84 units, number of erythrocytes — 4 200 000; a color indicator 84 / (2 • 42) = 1,0). Normal the color indicator fluctuates from 0,85 to 1,15. The size of a color indicator matters during the definition of a form of anemias: a color indicator lower than 0,85 — hypochromia, a color indicator 0,85 — 1,15 — normokhrom-ny, a color indicator higher than 1,15 — hyperchromic.
The average content of hemoglobin in one erythrocyte in abs. calculation it is accepted to designate in pikogramma (pg). It is defined by division of an indicator of a hemoglobin content in 1 mkl blood on quantity of erythrocytes in the same volume. E.g., the average size of maintenance of erythrocytes in 1 mkl blood — 5 000 000; the average size of a hemoglobin content — 16,7 g of % that makes 0,000167 g, or 167 000 000 pg in 1 mkl blood. Therefore, the hemoglobin content in one erythrocyte will make 167000000/5000000 = 33,4 pg.
Almost average size of a hemoglobin content in one erythrocyte can be received by multiplication of amount of hemoglobin in gram-percent on 10 and divisions of the work of these numbers into number of erythrocytes in 1 ml of blood: 16,7 • 10/5 = 33,4 pg. The average content of hemoglobin in a separate erythrocyte at adults fluctuates from 27 to 33,4 pg.
A hyperchromasia (see. Hyperchromasia , the hypochromatism) depends on increase in volume of erythrocytes (macrocytes, megaloytes), but not from saturation rate their hemoglobin and is an indicator of an abnormal liver function, disturbance of exchange of polyneuramin 12 or its lack of an organism (Pernicious anemia). In these cases the hemoglobin content in one erythrocyte raises to 50 pg. The hypochromatism is observed at reduction of volume of erythrocytes (microcytes) or reduction of a hemoglobin content in an erythrocyte, normal on volume. The average content of hemoglobin in one erythrocyte goes down to 20 pg.
Blood sedimentation rate (SOE, see. Sedimentation of erythrocytes ) it is expressed in millimeters of the plasma settling within 1 hour. Normal at women it makes up to 14 — 15 mm an hour, at men — to 10 mm an hour.
Change of a blood sedimentation rate is not specific to any disease. However acceleration of sedimentation of erythrocytes always indicates existence patol, process.
Quantity of reticulocytes count in blood smears, it is intravital the painted 1% solution to a brilliantkrezilbla in abs. alcohol. On in advance prepared slide plates (preparation consists in drawing on well washed up, fat-free and warmed up glass of paint in the form of a smear) do thin blood smears and at once place glass in a moist chamber (a Petri dish, at the edges the cut is stacked by the moistened rollers from a gauze or cotton wool). The camera is put in the thermostat at t ° 37 ° for 3 — 5 min. Then smears dry up on air. Count quantity of reticulocytes on 1000 erythrocytes; results of a research express in per mille. Normal contents them in peripheral blood makes 2 — 10 ‰.
Reticulocytes are young erythrocytes in which by means of supravital coloring granular and mesh substance comes to light. The reticulocyte after escaping of marrow in peripheral blood turns into a mature erythrocyte. Consider that their final maturing is made within several hours.
Quantity of thrombocytes it is possible to count by various methods.
1. In smears of peripheral blood quantity of thrombocytes count on 1000 erythrocytes. Blood for smears is taken from a finger. To the place of a prick previously put a drop of 14% of solution of magnesium sulfate; the allocated drop of blood is mixed with magnesium sulfate and do a smear on glass; smears paint across Romanovsky 2 — 3 hours; knowing quantity of erythrocytes in 1 mkl blood, calculate quantity of thrombocytes in 1 mkl blood. E.g., at calculation on 1000 erythrocytes 60 thrombocytes met; the quantity of erythrocytes in 1 mkl blood — 5 000 000, therefore, will make quantity of thrombocytes 60x5000, or 300 000.
2. In a cytometer thrombocytes count after a preliminary lizirovaniye of erythrocytes with use of the phase-contrast microscope.
3. The quantity of thrombocytes can be counted by means of automatic counters, napr, a tselloskopa.
At adults and at children of advanced age the quantity of thrombocytes makes 180 000 — 320 000 in 1 mkl. At Verlgof's disease and symptomatic trombotsitopeniye the number of thrombocytes can sharply decrease up to total disappearance.
Quantity of leukocytes count as well as quantity of erythrocytes. The average quantity of leukocytes at the adult fluctuates from 4000 to 9000 in 1 mkl blood. Children have it slightly more, at newborns — to 15 000 — 30 000. At significant increase in quantity of leukocytes it is possible to speak about leukocytosis (see), at reduction — about leukopenias (see).
The leukocytic formula is investigated in the painted blood smears.
Sizes of a hematocrit define in a hematocrit or, using Van-Slayka's nomogram, on concentration of hemoglobin in blood (see. Gematokritny number ). The Gematokritny number shows a volume ratio of uniform elements of blood and plasma. Results of a research express or fractional number, in numerator to-rogo the volume of uniform elements, and in a denominator — the volume of plasma, or as a percentage, the uniform elements showing the attitude of volume to the volume of the taken blood. Normal amounts of a hematocrit at men 40/60 — 48/52 (or 40 — 48%), at women 36/64 — 42/58 (or 36 — 42%). Increase in volume of erythrocytes is observed at hyperglobulias, reduction — at anemias.
Morphology of erythrocytes (as well as leukocytes) it is investigated in the painted blood smears. Blood smears before coloring process the fixing liquids (e.g., methyl alcohol) for the purpose of prevention of destruction of uniform elements of blood in the course of coloring. There are many ways of coloring of the blood smears based on chemical affinity of elements of a cell to certain aniline paints. During the studying of blood smears under a microscope gain an impression about the size, a form and coloring of erythrocytes which can change at patol, states. The sizes of erythrocytes determined with the help eyepiece micrometer (see), at healthy people vary in the known limits. It is so-called fiziol, an anisocytosis of erythrocytes. An exact impression about distribution of erythrocytes in size is gained measurement of their diameter and curve plotting of an anisocytosis (see. Eritrotsitometriya ), the State, at Krom erythrocytes of various size find, call an anisocytosis that can be, e.g., at anemias. The absolute majority of erythrocytes has to dia. 7 — 8 microns. Erythrocytes to dia, call less than 6,5 microns microcytes, and a state, at Krom they prevail — a microcythemia (e.g., at deficit of iron, at microspherocytic hemolitic anemia). Erythrocytes to dia, call more than 8 microns macrocytes. Their detection at newborns is considered as fiziol, the phenomenon, macrocytes disappear to two-month age. The macrocytosis at the strengthened regeneration of blood is found, cancer and polyps of a stomach, the lowered function of a thyroid gland, a myelomatosis. Erythrocytes to dia, call more than 12 microns megaloytes. They can have the oval form. Except big size, the hyperchromia, lack of a dvoyakovognutost (lack of the central gleam) and big thickness are characteristic of them. Megalotsitoz find at a lack of an organism of vitamin B 12 .
Change of a form of erythrocytes is called a poikilocytosis. Erythrocytes can become oval, pear-shaped, star-shaped, jagged, etc. Erythrocytes with sharply expressed oval form are called dipsotherapies of which 5 — 10% (G. A. Alekseev) are normal.
Polychromophils (see. Polychromatophilia ) — these are the unripe erythrocytes containing the remains of basphilic substance along with hemoglobin. Depending on amount of hemoglobin polychromatophilous erythrocytes in the usual smears (painted across Romanovsky) have various shades, from blue till pinkish-gray color. In the usual smears painted by aniline paints also reticulocytes are polychromatophilous. Count polychromophils in a thick drop. Smears with a thick drop are painted across Romanovsky without fixing, at the same time mature erythrocytes are hemolyzed, and young, unripe, shown bazofilno by the painted reticulum of bluish-violet color. Normal in a thick drop find 1 — 2 erythrocyte with a basphilic reticulum not in each field of vision, and designate it as P+, at 3 — 5 polychromophils — P ++, at 5 — 10 — P +++, at more significant amount of polychromophils — P ++++. This method inexact, but gives an idea of increase or reduction of quantity of young erythrocytes. The polychromatophilia is an indicator of regeneration of an erythrogenesis and meets at blood losses, the strengthened hemolysis of erythrocytes, etc. Normal a large amount of polychromophils meets in the first days after the birth and quickly decreases after two weeks.
At the changed regeneration of marrow in peripheral blood there are normoblasts, and at pernicious anemia megaloblasts can be found.
Nuclear forms of elements of an erythroidal sprout in peripheral blood at adults are observed only at severe forms of anemia, emergence them — a sign patol. regenerations. In similar cases also the remains of a kernel in the form of a thin ring, a loop, the eight of violet-blue color (Cabot's ring), round formations of violet-red color of 1 in size — 2 microns (Joly's little body) or in the form of basophilic stippling in erythrocytes can be observed.
At malaria in erythrocytes find shyuffnerovsky granularity — the small rose-red inclusions filling almost all erythrocyte or 10 — 15 inclusions, various by the size; the last sometimes call Maurer's maculation.
At the patients with heavy intoxications (phenylhydrazine, nitrobenzene, aniline, potassium chloride, nitroglycerine, toluoldiaminy, etc.) treated by streptocides and also at the persons working in the chemical industry it is necessary to investigate blood by a method of Deysi for the purpose of identification in erythrocytes of little bodies Heinz — Ehrlich — roundish inclusions of purple-red color; sometimes they are found vnekletochno.
Resistance of erythrocytes — property of erythrocytes to resist to destructive influences: osmotic, mechanical, thermal, etc. In a wedge, practice usually investigate osmotic resistance of erythrocytes: a number of test tubes with solution of sodium chloride on the increasing concentration — from 0,28 to 0,56% is formed. Normal the minimum resistance of erythrocytes of adults (when the first erythrocytes begin to collapse) fluctuates between 0,48 and 0,44% of sodium chloride, maximum (all erythrocytes are destroyed) — between 0,32 — 0,28%.
Morphology of leukocytes can change at infectious diseases, influence of chemical substances, diseases of the hemopoietic device, action of ionizing radiation.
The anisocytosis (various size) of leukocytes is found and is normal. However the expressed anisocytosis is a display of pathology.
Structural changes are found both in a kernel, and in cytoplasm of a leukocyte. In a kernel there can be following changes: a) hypersegmentations of a kernel (the term «hypersegmentation» is more often used for designation of increase in quantity of segments of segmentoyaderny leukocytes which detection has diagnostic value at pernicious anemia, a radial illness); b) hromatinoliz — dissolution of chromatin of a kernel with preservation of its contour; c) karioliz — dissolution of a part of a kernel at safety of structure of the rest of a kernel; d) fragmentoz — separation from a kernel of 1 — 5 fragments sometimes connected with a kernel threads of basichromatin; e) pycnosis — a kernel becomes unstructured owing to consolidation of the main chromatin; at the same time the size of a kernel decreases; e) a karyorrhexis - disintegration of a kernel on the piknotichny parts of rounded shape and various size which are not connected among themselves.
Toxicogenic granularity in cytoplasm of neutrophils in the smears painted by mixes of an azur and eosine comes to light insufficiently reliably. At special colourings (across Freyfeld, across Momsen, according to Shmelyov) in cytoplasm the bluish reticulum with transitions to large lumps is found; sometimes all cell is covered with small powdered kernels. Toxicogenic granularity of neutrophils is observed at the purulent processes, diseases connected with intoxication at infections (diphtheria, measles, chicken pox, scarlet fever, a rubella, pneumonia). The account of neutrophils with toxicogenic granularity is made in relation to number counted (but not on 100) neutrophils. E.g., all neutrophils — 70%, including neutrophils with toxicogenic granularity — 45%.
A cytolysis — disintegration of a cell. Lack of cytoplasm, a kernel with indistinct contours is characteristic of a cytolysis more often, the structure of a kernel is kept, sometimes about such kernel there is a granularity. The specified changes can meet also in normal blood, being signs of involution of a cell, but at their detection in a significant amount are considered as pathology.
Morphology of thrombocytes it is studied in the thin blood smears taken without stabilizer (magnesium sulfate), painted by mix of an azur and eosine (on Nokhta).
Detection in a smear of units from 5 — 6 thrombocytes is noted as a good agglyutinabelnost. In thrombocytes the central granular part (granulomer) and a peripheral homogeneous part (hyalomere) is visible. Granulomer consists of azurophilic grains with a lilacky shade. It is possible to distinguish also thinner details of structure of thrombocytes — vacuoles, pseudopodiums, thin shoots antennas, coming from a granulomer. On the basis morfol, features of thrombocytes the platelet formula is formed, edges can change at pathology (see. Thrombocytes ).
Viscosity of blood depends on viscosity of plasma, quantity of erythrocytes, hemoglobin, content of carbonic acid in blood (see Viscosity, viscosity of blood). Is defined in the viscometer (fig. 3). The principle of definition is based on comparison of speed of advance of blood and a dist, waters in strictly identical capillaries and at identical vacuum in system of the viscometer. The ways passed by liquids in capillaries at the same time are inversely proportional viscosity of these liquids. Therefore viscosity is expressed the relation of length of the way passed a dist, water to length of the way passed by blood. As blood is gathered to a tag, viscosity of blood will be equal to length of the way passed by water for the same time; length of a way is counted on a scale. Viscosity of blood at men makes from 4,3 to 5,3, at women — from 3,9 to 4,9.
Causative agents of malaria can be found also in usual blood smears, but at the directed research on a plasmodium of malaria it is necessary to take still so-called. thick drop (see), edges gives the chance to find parasites even at their small number. The next way of preparation of a thick drop is recommended: on a slide plate prepare a usual blood smear and while it is still wet, touch with it the drop of blood which again acted on site a prick. The drop of blood on a wet smear evenly spreads the correct circle that excludes need of its spreading. To a thick drop allow to dry about half an hour on air in horizontal position. Unlike a usual smear, the thick drop should not be fixed, it is painted as usual with azur-eosin mixes. From erythrocytes during the coloring hemoglobin is leached (owing to lack of fixing) therefore it is possible to distinguish only «shadows» of erythrocytes. In a thick part of a smear the probability of detection of the activator is more, but sometimes they are worse painted, than the parasites located on edge of a drop.
Bibliography: Kassirsky I. A. and Alekseev G. A. Clinical hematology, M., 1970; The Guide to clinical laboratory trials, under the editorship of E. A. Kost and L. G. Smirnova, page 44, M., 1964; With about to about l about in V. V. and r ib about in and I. A. Indicators of peripheral blood at healthy people, Laborat, business, No. 5, page 259, 1972; The Reference book on clinical laboratory methods of a research, under the editorship of E. A. Kost, M., 1975; The Reference book on functional diagnosis, under the editorship of I. A. Kassirsky, page 304, M., 1970; T about d about r about in Y. Clinical laboratory trials in pediatrics, the lane with bolg., page 271, Sofia, 1968.
D. N. Ishmukhametova.