STUDIES ON ICTERUS NEONATORUM

Transcription

1 STUDIES ON ICTERUS NEONATORUM THE PRODUCTION OF ICTERUS IN ANIMALS FOLLOWING PROLONGED ANOXAEMaA' BY ALTON GOLDBLOOM AND RUDOLF GOTTLIEB (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 icterus neonatorum, we demonstrated the readiness with which the blood of a newly born infant haemolysed as compared with the blood of an older child or an adult. We showed also that the morphologic pattern of the blood of the new born was considerably different; for instance the presence of a polycythaemia and the increase in the number of nucleated red cells and reticulocytes. We showed too, that reduction of the polycythaemia and of the number of immature cells in the circulation coincided with an increase in the bilirubin in the serum, the development of icterus and the development of a normal resistance of the red cells in varying concentrations of salt solution. We showed also that the diminished resistance of the red cells of the newly born to salt solution is due to the immature cells in the circulation, namely that these cells haemolyse even in normal salt solution, and that the cells remaining after these immature forms have been destroyed, show normal resistance. In attempting to explain the nature of icterus neonatorum, we reasoned that, in view of the admixture of arterial and venous blood, the right to left shunt existing in ante natal life, the foetus, was comparable to any other individual living in a state of diminished oxygen supply. That immediately after birth, with the cessation of admixture in, normal infants, the necessity for polycythaemia no longer This research was made possible by a grant from the Cooper Fund. 375

2 376 EXPERIMENTAL ICTERUS FOLLOWING ANOXAEMIA DM - n2 84.,-, - E 8 cd w) M3. Uf) o -S IUf4 ZIU I.- > d ca bo t~~~~~cd rae 4) C~~~~~~~~~~~~~(JI.~~~~~~~~~~~oC Cd d Cf) ~~~~~~~~~4 C b4b Ob t txb Ob It I.. t:. Ile b w r....a m j -.4.". E. ts 4' N pq zz zzzzz z zzzzzz (statlju) X9PUx :pual: -4- '- d 'N Vo ' N e- NC4- i ) -iuqi,d j qo Su cd d YCd d dc' d d c YCd cd'd - E - E i - E - E- E z z z zz z zz z zz z zz zz z *Y~pa4vpnN (ourpl'uh) Us) t) U) \ C14.t.o U) U) C ) C)C cq CU4 U)U. ) \ \ \o o -ardi-h Tod z9quinu q3d* oe Cl cedc c WdC u> do '3WuPo3fl C) C) ( Cf) If C)) 4' If If) 8 S;uno~~~~yg~~~~C) 4 1 ) l \C 4.ld $ *J 4-4 > C-d.4- o bo Cd bo bo bo bo o ooicb bo boo bo :)4)4)4)4laql:puax >4 c u )u4) O)4 4 )4 If UX,e~ 1fBf e' V ~~~~~~-t\-v ~~~~- e m C14\Veq14ro C C U)~~~~~~~C c w~c cu~c (Uw wv asv lbuizuv jo j2qmnki NO _

3 Ot4t a,z,oboo x x U) M M ~~~~~~~~~~3 N es N N N N 4 U) Xo X ALTON GOLDBLOOM AND RUDOLF GOTTLIEB 377 C E - c ~~~~~~~~A E -E * cc > g > ot ab S.obOw Cd b ~ ~~~~ ~ eddcd c dcdcxdasco d ci d sd Cd dzu C Z;b;oZZ NZ; Z; Ct; NZ; a t; tk Z; to;cz; CZ; CZ; ; ;N; 4) v Os ON O1 O~ O O Ol Os ON O% O ON - C1 uzl u4 u4 (V %Os o o o ~~o ol oca oooooo o~ oio o~~~~~~~ o- ~~~ 8~~~~~~~~~~ U) U) U )U )U C8 \ o a U) a' 8~~ ~ ~~~~ o o C o W. m nc \ O' ~~~~~C4 t_ U - tnu)4 4 >+NSs s, \\U d Cac >, co :> cldo;~ e co co Ca id co Cga.-~~~~~~Csc _e _ N X X X~~~~~~~~~~~~~~~~N

4 378 CZ EXPERDIENTAL ICTERUS FOLLOWING ANOXAEMIA en E:4 _, cd 5 o Eo o oot 4) z 4u) Z)4 C) Z;:D.. (A (StABa) Xapul sllal3i n C) N N N ; N N ~~~~e > t t c C.oo a o C.) C) c i C)qSl3., 2 wa t C)Ce C)CX C) ce ce) ) q C) bobobob -- bbcbobo CNe. >[palelnolaa>[: ~ o ~ ~ + nnoe hon ~~~~c o 8 O o% (ourpitii) at C C>a C -1uamJad uiqolouiah e' eq C4 - - q C ' cdc oe d c CdC C CdCd Cd Cd CdCd Cd o YW~LJXTT1S~I W~~~~~~~ C B zz zzz z z z "Iz zz z zz z -Dy-a paplopnn C) ) ) ) ) C) C 'X' id iaqumnu '3~parain3! aui ~ o" > ) ) sluno:) a~ C C) QOC,I') e ) f) C) U kn~~~~~~~~~~~~~ 3 e ~ -c' es I) ~ ~~C1 oqe ce ~ ~ ~ ~ ~ ICI~~~~~~~~~4- I Um8 ZaqWnf

5 o~ u) ALTON GOLDBLOOM ADRUOLF GOTTLIEB fl~~~~~~~~~~~~~~~~~~~' - ~ ~~~ O toc d~~~~b Cd cos Ca co.q co Cd Cd co Cd u;j c o ce U cd C e + o ootk ov oo ooob bo eso cd t _- C14 C14 C C4 _- o o E 4 _, _C14 N CD CPI c\ o 2 _ - _- oo e eoeod od 1tt ttttt4tt tt o o o o o o o o ooo o o oo o o o o ooooo o z z Xo o z z z o z U) o Xo z z z o o o o o z U) z x oo oo oo o 888 o o ooooo o g >gg>> > > >e oo bo + + o 9 ocoo oo o co oe ol CI oe o o o O C-4 Q vot-4 m ve-c1, O-4-4 t- m \ O sk sk -I Ce b In m O m \ C1 it WI (D -i qd \ \ u uu uu )v 379 ce co cdc oc dca cd co C dc ec dcs

6 a 1 >~3 1. a,v w!tuiu jo jaquinn _4t) oo _n u) mt o ee ) Ncs c qe tf) to) Cl Cs Ul) C4Mm e \~~~~~~~~~~~~~~~ oq C1 q v) v o oo_ C:.4 SS M j Cl Cd co _e C e ON 38 EXPERTMENTAL ICTERUS FOLLOWING ANOXAEMIA I.U. ed 8 - E Co U) o I~~~~~~~~~~ - 4.)~~ ~ ~ ~ t ce e.>>.>.>.> > >.>... = d Cd -14 e1s -4U d SC)4.CC) m d ba ~ bodw C bo bo)blobo)b) bo bobobob (Qu,epleH) as Co oo C) % C% ON C71 ON Co + C CCdC C Cd ce Cd CceCC.. z z z z z z z z z % % z z z z *Yf~IP'~PlN *DdH qpolsapnx Oo e ooo o C'l C O ou) O OOo u f^f) ~ u (SrASQ) xaput PI eq Ifo -14-1doonad ut ol2ouwah ~OOC EC sc ooc sc -iqa~du~o~ou~ *!Id-H.iod jaquinu toolco ) '

7 Cho C> _D ) oo o -D (D o U) OW+\ o t O a to WI m4do c 1 gg 1rRS }}}i RE ztzta t t z z A t A t z t t t z ~~to U) bl) W ~~~~~~~~~~~~~~~~ ALTON GOLDBLOOM AND RUDOLF GOTTLIEEB 381 to o be 9) g,vb o bo g~~~~~~~c co db m B w- 6 s s o o oi oo-c O (2%( ''v e4 No In (Or \ v- \ -4 \ )u m tn \ ooc ci o ooooc o ooo 4 Jt -- -t-t A4-4 Jt e. e e CD% % % m 1-to_

8 382 EXPERIMENTAL ICTERUS FOLLOWING ANOXAEMIA ol I oe o to 4~~ Cd ~ ~ Cd >oo ~~Q U2~~~~~~~~~~~~~~~~~~~~~~~ o <X.~~~~~~~>. >.> >.>.>.> > > > >.> o (siasq) xapr 3ta3 N~ i - ~ *s-a~~~~~~~~~~~~~~~- a1lhl 4-,.6-4i -gg -4- Gg (auwpjsh)a ~O O\ c 4Cs1 \ \ --u-d *D-g-E paealonx \ o~bi) o to bo o oo bo bo o bo bo o bo o Z ;z;;z; zzz ZZZ ZZ 3fflI[PaW9PlNaza (OUIPH)sig ) ZC q U)If ) O o ' o (SJA'U(dJaQOUI 'DadJoAsu -4--{ CSC S -44 4_-4 > C _ o- oc N C C % % % [:wjuh jaojium m t 't n )C U -'-U) t'oo% ' awb os IVURUV 1 jaquinn %

9 g:.- E r *; > ae > o s w.s b w,.], a,_.,.. FV;-F. X or. *. XW W W viz a #.i~~~~~~~~~~ ALTON GOLDBLOOM AND RUDOLF GOTTLI:EB 383 1':*-1_ [' *.~~~~~~~~~~~ K - -.'~~~~~~~~~~~~~~~~~~~~~~U. _. - s,^,..._#.~~~~~~~p

10 384 EXPERIMENTAL ICTERUS FOLLOWING ANOXAEMIA existed, leading to destruction of the excess of red cells and thus to icterus neonatorum. We felt therefore that if these theories are correct it should be possible not only to produce a polycythaemia by keeping animals under reduced atmospheric pressure but also to produce some degree of jaundice in these animals shortly after the pressure is restored to normal. Accordingly we have attempted to produce a polycythaemia in FIG. 2. BONE MARROW OF A NORMAL GUINEA PIG guinea pigs by keeping them under reduced atmospheric pressure by means of a specially devised apparatus (see fig. 1). Tube 1 connects a glass jar, which is fixed air tight to a glass plate, with a vacuum pump. Tube connects the jar with a manometer. Tube 3 allows air to enter, the amount of which could be regulated by a stop cock. Eighteen young guinea pigs were used for this experiment, thirteen of them were kept from 2 to 4 weeks under reduced atmospheric pres-

11 ALTON GOLDBLOOM AND RUDOLF GOTTLIEB 385 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 begun to show an increase in the number of red blood cells. Sections of the bone marrow of this animal were made and showed increased activity. A sixth control animal was killed at the beginning of the experiment for bone marrow studies. The pressure in the apparatus was gradu- FIG. 3. BONE MARROW OF A GUINEA PIG AFTER 4 WEEKS EXPOSURE TO REDUCED ATMOSPHERIC PRESSURE ally reduced to 3 mm. below normal atmospheric pressure and then kept constant at this level, which corresponds to an altitude of about 18, feet. Food was introduced daily through the top opening; for that reason and on account of the blood studies the pressure had to be increased every day for a few minutes. A total of about 2 minutes of normal atmospheric pressure was necessary during the

12 ,386 EXPERIMENTAL ICTERUS FOLLOWING ANOXAEMIA whole experiment. The blood of the animals was examined every 48 hours. The examinations were made of the number of red blood corpuscles, the percentage of haemoglobin, the number of reticulated and nucleated red blood cells, the fragility of the red blood cells, the icteric index, and the van den Bergh reaction. The blood for the examination was taken by puncture of the ear, except for the van den Bergh reaction, for which.5 cc. was taken by heart puncture. Nu4h^TrvV PmsXsumc- mmhg. 2 8 s E CRETUt" TO Aryosrmcw Pmttit kua 3F, I *~~~~~~~~~~~~~~~~~~~~~~~~ FIG. 4.aSHOWING AVERAGE PERCENr1LE CHANGE OF RED BLOOD CEILS AND.~~~~~~~~~~~~~~~~~~~~~~~~ D^Y8~~~~~~~ FIG. 4. SHOWiNG AVERAGE PERCENTILE CHANGE OF RED BLOOD CELLS AND HEMOGLOBIN, INCREASE IN UNITS OF THE VAN DEN BERGH AND THE PRESSURE AT WHICH THE ANIMALS WERE KEPT, PLOTTED AGAINST DAYS OF THE EXPERIMENTS Red blood cell counts and haemoglobin percentage The number of the red blood cells and the percentage of haemoglobin increased rapidly, reaching an average maximum increase of about 3 per cent within 1 days. Five to eight days after the animals were removed to normal atmospheric pressure again, the number of red blood cells and the percentage of haemoglobin returned to their original figures. The chart (fig. 4) shows the average percentile rise of the red blood cells and the haemoglobin, which always ran parallel.

13 ALTON GOLDBLOOM AND RUDOLF GOTTLIEB 387 Reticulated red blood cells Reticulated red blood cells were not present in the blood of the animals at normal atmospheric pressure. Three to four days after exposure of the animals to reduced atmospheric pressure, reticulated red blood cells began to appear, reaching in one week the maximal number of 5 to 6 per high power field in thick smears. Within one week after the removal of the animals to normal atmospheric pressure the 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 the red 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 the van den Bergh reaction was always negative. The icteric index and the van den Bergh reaction remained unchanged as long as the animals were in the chamber under reduced atmospheric pressure. About 48 hours after the animals were removed from the apparatus to normal atmospheric pressure, the icteric index began to rise and the indirect van den Bergh reaction became positive, both reaching their maximum within 24 hours, an icteric index of from 7 to 9, and an indirect van den Bergh reaction of from 1 to 2 units. Both icteric index and the van den Bergh reaction remained high for about 8 days and then came gradually down to normal, reaching nonnal values in 3 to 5 days after the red blood cell count had returned to nonnal. The table gives a synopsis of the events during the whole experiment. THE BONE MARgROW The sections made from the bone marrow of the confined animals showed greater activity than that of the controls (figs. 2 and 3). SUMMARY OF FINDINGS 1. Guinea pigs were kept under reduced atmospheric pressure. A polycythaemia developed rapidly, reaching its maximum in about 1 days. The average increase of the red blood cells as well as the haemoglobin was about 3 per cent above the original values. Return to

14 388 EXPEKIMENTAL ICTERUS FOLLOWING ANOXAEMIA normal took place in about 5 to 8 days after the pressure was increased to normal. 2. There was with the polycythaemia a marked increase in reticulated red blood cells, 5 to 6 per high power field. When the pressure was increased to normal the reticulated cells disappeared in about one week. 3. There was an increase in the icteric index and an appearance of positive indirect van den Bergh reactions after the animals were removed from the low atmospheric pressure chamber. The icteric index ranged from 7 to 9 (normal 1 to 3) and the van den Bergh reaction from 1 to 2 units (normal ). COMMENT Our previous work demonstrated that the infant develops icterus neonatorum as a result of haemolysis of red blood cells in the course of a period of postnatal re-adjustment, during which the polycythaemia disappears. The above experiments were designed to produce a polycythaemia in animals through a prolonged diminution of their oxygen supply, and to observe whether icterus occurred during their period of readjustment from polycythaemia to the normal red cell count. Polycythaemia was successfully produced. As in new born infants, the animals released from the environment of lowered atmospheric pressure, very soon showed an increasing icteric index and a positive indirect van den Bergh reaction together with a reduction of the polycythaemia and the disappearance of the reticulated cells. Thus an icterus, similar to icterus teonatorum, was produced in animals. The period of re-adjustment was of somewhat shorter duration than in the human foetus. No nucleated red blood cells were found in these animals and the fragility of their red cells showed no changes. It would therefore appear quite reasonable to conclude that icterus neonatorum is a haemolytic icterus which is the result of a postnatal re-adjustment from a condition of oxygen unsaturation to a normal oxygen saturation. BIBLIOGRAPHY 1. Goldbloom, A., and Gottlieb, R., Am. J. Dis. Child., 1929, xxxviii, 57. Icterus Neonatorum.