STUDIES ON ICTERUS NEONATORUM

THE PRODUCTIONOF ICTERUS IN ANIMALS FOLLOWINGPROLONGEDANOXAEMaA'

BY ALTON GOLDBLOOMAND RUDOLFGOTTLIEB(From the Department of Medicine, McGill University Clinic, Royal Victoria Hospital,

Montreal)

(Received for publication October 9, 1929)

In a previous paper (1) in which we reported our studies on icterusneonatorum, we demonstrated the readiness with which the bloodof a newly born infant haemolysed as compared with the blood of anolder child or an adult. Weshowed also that the morphologic pat-tern of the blood of the new born was considerably different; for in-stance the presence of a polycythaemia and the increase in the num-ber of nucleated red cells and reticulocytes. We showed too, thatreduction of the polycythaemia and of the number of immature cellsin the circulation coincided with an increase in the bilirubin in theserum, the development of icterus and the development of a normalresistance of the red cells in varying concentrations of salt solution.Weshowed also that the diminished resistance of the red cells of thenewly born to salt solution is due to the immature cells in the circula-tion, namely that these cells haemolyse even in normal salt solution,and that the cells remaining after these immature forms have beendestroyed, show normal resistance.

In attempting to explain the nature of icterus neonatorum, wereasoned that, in view of the admixture of arterial and venous blood,the right to left shunt existing in ante natal life, the foetus, was com-parable to any other individual living in a state of diminished oxygensupply. That immediately after birth, with the cessation of admix-ture in, normal infants, the necessity for polycythaemia no longer

This research was made possible by a grant from the Cooper Fund.375

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existed, leading to destruction of the excess of red cells and thus toicterus neonatorum.

Wefelt therefore that if these theories are correct it should be pos-sible not only to produce a polycythaemia by keeping animals underreduced atmospheric pressure but also to produce some degree of jaun-dice in these animals shortly after the pressure is restored to normal.

Accordingly we have attempted to produce a polycythaemia in

FIG. 2. BONEMARROWOF A NORMALGUINEA PIG

guinea pigs by keeping them under reduced atmospheric pressure bymeans of a specially devised apparatus (see fig. 1). Tube 1 connectsa glass jar, which is fixed air tight to a glass plate, with a vacuumpump. Tube connects the jar with a manometer. Tube 3 allowsair to enter, the amount of which could be regulated by a stop cock.

Eighteen young guinea pigs were used for this experiment, thirteenof them were kept from 2 to 4 weeks under reduced atmospheric pres-

384

ALTON GOLDBLOOMAND RUDOLFGOTTLIEB

sure while the other five were kept as controls. One animal (no. 1)died at the end of one week in the apparatus, but had already begunto show an increase in the number of red blood cells. Sections of thebone marrow of this animal were made and showed increased activity.A sixth control animal was killed at the beginning of the experimentfor bone marrow studies. The pressure in the apparatus was gradu-

FIG. 3. BONEMARROWOF A GUINEA PIG AFTER4 WEEKSEXPOSURETO REDUCEDATMOSPHERICPRESSURE

ally reduced to 300 mm. below normal atmospheric pressure and thenkept constant at this level, which corresponds to an altitude of about18,000 feet. Food was introduced daily through the top opening;for that reason and on account of the blood studies the pressure hadto be increased every day for a few minutes. A total of about 200minutes of normal atmospheric pressure was necessary during the

385

EXPERIMENTALICTERUS FOLLOWINGANOXAEMIA

whole experiment. The blood of the animals was examined every 48hours. The examinations were made of the number of red bloodcorpuscles, the percentage of haemoglobin, the number of reticulatedand nucleated red blood cells, the fragility of the red blood cells, theicteric index, and the van den Bergh reaction. The blood for theexamination was taken by puncture of the ear, except for the van denBergh reaction, for which 0.5 cc. was taken by heart puncture.

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FIG. 4. SHOWiNGAVERAGEPERCENTILE CHANGEOF RED BLOODCELLS ANDHEMOGLOBIN, INCREASE IN UNITS OF THE VAN DEN BERGHAND THE

PRESSUREAT WHICHTHE ANIMALS WEREKEPT, PLOTTEDAGAINST DAYS OF THE EXPERIMENTS

Red blood cell counts and haemoglobin percentage

The number of the red blood cells and the percentage of haemoglobinincreased rapidly, reaching an average maximum increase of about 30per cent within 10 days. Five to eight days after the animals wereremoved to normal atmospheric pressure again, the number of redblood cells and the percentage of haemoglobin returned to their origi-nal figures. The chart (fig. 4) shows the average percentile rise ofthe red blood cells and the haemoglobin, which always ran parallel.

,386

ALTON GOLDBLOOMAND RUDOLFGOTTLIEB

Reticulated red blood cells

Reticulated red blood cells were not present in the blood of theanimals at normal atmospheric pressure. Three to four days afterexposure of the animals to reduced atmospheric pressure, reticulatedred blood cells began to appear, reaching in one week the maximalnumber of 5 to 6 per high power field in thick smears. Within oneweek after the removal of the animals to normal atmospheric pressurethe reticulated red blood cells disappeared again.

Nucleated red blood cells and fragility of the red blood cells

Nucleated red blood cells were at no time present. Fragility of thered blood cells did not show any change during the experiment.

The icteric index and the van den Bergh reaction

Normal guinea pigs showed ath icteric index of from 1 to 3, while thevan den Bergh reaction was always negative. The icteric index andthe van den Bergh reaction remained unchanged as long as the ani-mals were in the chamber under reduced atmospheric pressure. About48 hours after the animals were removed from the apparatus to normalatmospheric pressure, the icteric index began to rise and the indirectvan den Bergh reaction became positive, both reaching their maxi-mumwithin 24 hours, an icteric index of from 7 to 9, and an indirectvan den Bergh reaction of from 1 to 2 units. Both icteric index andthe van den Bergh reaction remained high for about 8 days and thencame gradually down to normal, reaching nonnal values in 3 to 5 daysafter the red blood cell count had returned to nonnal. The tablegives a synopsis of the events during the whole experiment.

THE BONEMARgROW

The sections made from the bone marrow of the confined animalsshowed greater activity than that of the controls (figs. 2 and 3).

SUMMARYOF FINDINGS

1. Guinea pigs were kept under reduced atmospheric pressure.A polycythaemia developed rapidly, reaching its maximum in about 10days. The average increase of the red blood cells as well as the haemo-globin was about 30 per cent above the original values. Return to

387

388 EXPEKIMENTAL ICTERUS FOLLOWINGANOXAEMIA

normal took place in about 5 to 8 days after the pressure was increasedto normal.

2. There was with the polycythaemia a marked increase in reticu-lated red blood cells, 5 to 6 per high power field. When the pressurewas increased to normal the reticulated cells disappeared in about oneweek.

3. There was an increase in the icteric index and an appearance ofpositive indirect van den Bergh reactions after the animals wereremoved from the low atmospheric pressure chamber. The ictericindex ranged from 7 to 9 (normal 1 to 3) and the van den Berghreaction from 1 to 2 units (normal 0).

COMMENT

Our previous work demonstrated that the infant develops icterusneonatorum as a result of haemolysis of red blood cells in the courseof a period of postnatal re-adjustment, during which the polycythae-mia disappears.

The above experiments were designed to produce a polycythaemiain animals through a prolonged diminution of their oxygen supply,and to observe whether icterus occurred during their period of re-adjustment from polycythaemia to the normal red cell count.

Polycythaemia was successfully produced. As in new born in-fants, the animals released from the environment of lowered atmos-pheric pressure, very soon showed an increasing icteric index and apositive indirect van den Bergh reaction together with a reductionof the polycythaemia and the disappearance of the reticulated cells.

Thus an icterus, similar to icterus teonatorum, was produced inanimals.

The period of re-adjustment was of somewhat shorter duration thanin the human foetus. No nucleated red blood cells were found in theseanimals and the fragility of their red cells showed no changes.

It would therefore appear quite reasonable to conclude that icterusneonatorum is a haemolytic icterus which is the result of a postnatalre-adjustment from a condition of oxygen unsaturation to a normaloxygen saturation.

BIBLIOGRAPHY1. Goldbloom, A., and Gottlieb, R., Am. J. Dis. Child., 1929, xxxviii, 57. Icterus

Neonatorum.