A CONTRIBUTION TO THE STUDY OF 
ICTERUS NEONATORUM. 
By FREDERICK P. HENRY, M.D., 
PH I LADELPHUVr- 
THE following observations were made with the object 
of throwing further light upon the pathology of 
icterus neonatorum, and more particularly to determine the 
question of its hsemic or hepatic origin. 
By the term icterus neonatorum I mean a discoloration of 
the skin, appearing from two to five days after birth, vary- 
ing in hue from a slight sallowness to a decided yellow, dis- 
appearing gradually in about two weeks, and unattended by 
any marked symptoms of constitutional disturbance. In 
the milder cases the urine does not contain bile pigment, at 
least in sufficient quantity to stain the child's clothing, 
while in the more pronounced cases the napkins are decid- 
edly stained by it. This definition excludes all cases of 
congenital imperfection of the biliary passages, all inflam- 
matory affections of the liver, and gastro-duodenal catarrh; 
in a word, all cases of jaundice by obstruction. This being 
the case, it remains to consider whether there is any other 
form of mechanical jaundice than that by obstruction, and, 
if so, whether icterus neonatorum can be classed under it. 
A few words are here necessary as to the classification of 
jaundice from the point of view of its etiology. 
Reprinted from the Archives of Medicine, Vol. x, No. 2, October, 1883. 2 
FREDERICK P. HENR Y. 
I.- The mechanical or hepatogenic form. 
This is universally recognized, in so far as it is produced 
by any agency increasing the pressure in the bile ducts, and 
thereby favoring the entrance of the bile into the lymph- 
and blood-vessels. The converse of this, namely, that 
icterus may be caused by diminished blood-pressure in the 
portal vein, is by no means so generally acknowledged. 
Pylethrombosis, which is sometimes brought forward as a 
typical cause of the latter form of jaundice, is so in a theo- 
retical sense only, for it is extremely doubtful whether such 
thrombosis is ever primary. 
The occurrence of jaundice in fasting animals has been 
attributed to diminished blood-pressure in the portal vein, 
due to enfeebled action of the heart, and, therefore, classed 
under the head of hepatogenic or mechanical jaundice ; but 
there is quite as good reason for classifying such cases 
under the head of haematogenic jaundice, for in them a 
rapid diminution in the number of the red blood cells can 
be demonstrated, while the diminished portal pressure is 
only inferential. 
II.-Hcematogenic or chemical jaundice. 
Opinions are divided as to the existence of a form of 
jaundice in which the abnormal hue of the tissues is derived 
directly from the coloring matter of the blood. Neverthe- 
less, there is very convincing evidence, both experimental 
and clinical, to be adduced in support of such a variety of 
the disease. For example, the injection into the veins of 
substances which are known to disintegrate the red blood 
cells, is followed by jaundice. The simplest of these sub- 
stances is water. The red blood cells, when submitted to 
the action of water outside of the body, lose their coloring 
matter; and corresponding with this observation is the fact 
that injection of water in considerable quantity into the THE STUDY OF ICTERUS NEONATORUM. 
3 
veins, is followed by jaundice. The same result is produced 
by the vapors of chloroform and ether when brought in con- 
tact with blood contained in a gas chamber ; and jaundice 
occasionally, though it must be admitted very rarely, fol- 
lows prolonged anaesthesia by these agents in the human 
subject. 
The jaundice of acute phosphorus poisoning, of malarial 
haematuria, and that occurring after the bites of venomous 
reptiles, is probably haematogenic; although in the first- 
mentioned variety, owing to the fact that phosphorus is an 
irritant to the gastro-duodenal mucous membrane, it is the 
opinion of some that the jaundice is hepatogenic or 
mechanical. In a case of acute phosphorus poisoning, which 
was recently under my care at the Episcopal Hospital, there 
was an intense degree of icterus; nevertheless, at the autopsy 
the gall-bladder was found empty, which would certainly 
not have been the case had the jaundice been of mechanical 
origin. 
III.-faundice by suppression. 
Harley is the most prominent advocate of such a variety 
of icterus. He considers that the bile pigment, like choles- 
terin, is preformed in the blood, and is merely separated 
by the liver. E. Wagner 1 regards the opinion that there 
is such a form of jaundice as no longer tenable, and refers 
to experiments upon the removal of the liver by Muller, 
Kunde, and Moleschott. The question may be regarded 
as still open, although the advocates of this form of icterus 
will probably admit that there are two forms of jaundice by 
suppression ; one in which the accumulation of pigment is 
due to imperfect action of the liver, therefore hepatogenic ; 
another in which more pigment is formed in the blood 
than can be separated by even a healthy liver, therefore 
1 " Manual of General Pathology," Am. ed., p. 557. 4 
FREDERICK P. IIENR Y. 
hamatogenic. The advantage, therefore, of this supposed 
variety is by no means apparent. 
From the foregoing remarks it is, I trust, manifest that I 
hold to the division of cases of jaundice into hepatogenic or 
mechanical and haematogenic or chemical, and believe that 
further study will settle cither the exclusive or, at least, the 
preponderating influence of one or other of these causes in 
every case of icterus. 
To produce experimentally the first of these two forms of 
icterus, it would be necessary to increase the bile-pressure 
absolutely by ligature of the hepatic or common bile-duct, or 
to increase it relatively by cutting off a portion of the por- 
tal blood-supply. Now, this latter experiment is performed 
in the case of every human being by ligature of the umbili- 
cal cord. The portal blood-pressure is suddenly and mark- 
edly diminished ; abnormal conditions of osmosis are estab- 
lished, and when jaundice ensues it is only necessary to 
prove that the number of the pigment-carriers, i. c., the red 
blood cells, has not been reduced, in order to settle the 
question of the mechanical origin of icterus neonatorum. 
This is what I have done, by counting the blood cells in 
a few new-born children, and because, so far as I can as- 
certain, it has never before been done ; there is scarcely an 
affection of which the etiological status is more uncertain.1 
The following observations were made at the Maternity 
Hospital2 in the autumn of 1881. 
Case i.-Oct. 19, 1881. Alice K., born at 8 a.m. Count 
made at 10:30 a.m. The child was of average size and not cya- 
nosed. Labor had been natural and easy. No symptoms of sus- 
pended animation. Child crying lustily when born. Weight, 8% 
1 I refer, of course, to counting the blood cells in the neonatus with especial 
reference to the cause of icterus neonatorum, although unaware of its having 
been done for any purpose. 
8 Formerly called the State Hospital for Women and Infants. For the 
opportunity of making these observations, I am indebted to the courtesy of the 
officials of the institution, and particularly to Dr. J. V. Ingham. THE STUDY OF ICTERUS NEONATORUM. 
5 
lbs. The blood was obtained by puncture of the great toe, and 
was venous-looking. (The average number of red blood cells per 
cubic millimetre is, in the adult, at least 5,000,000.) 
Number of red cells per cubic mm., 6,410,000. 
No white in specimen examined. 
Oct. 20th, 10:30 a.m. Second count in the same case. Child 
thriving. 
Number of red cells per cubic mm., 5,810,000. 
Oct. 22d. Third count in the case of Alice K. Child doing 
well ; no appearance of jaundice. 
Number of red cells per cubic mm., 5,680,000. 
The above case proves that a rapid and great diminution 
in the number of the red blood cells may occur during the 
first few days after birth, without the supervention of jaun- 
dice. That this diminution in the number of cells per cubic 
mm. was not caused by the absorption of water, is proved 
by the following facts: The child before birth is suspended 
in the amniotic fluid, and therefore in a condition far 
more favorable to the absorption and retention of water in 
the system than after its removal from the body of the 
mother. During the examinations of the blood, the only fluid 
ingested by this infant was that obtained from its mother's 
breasts, and this, the colostrum, was of small amount. 
On the other hand, water passed freely out of the system 
through the kidneys and skin, so that the conditions were 
eminently favorable to the production of an increased per- 
centage of blood cells, a kind of spurious plethora, through 
diminution in the normal amount of water in the blood. 
Nevertheless, the percentage of red blood cells was reduced, 
and therefore they must have been destroyed. 
Case 2.-John G., born Oct. 20th, at 12 (mid-day). Labor easy 
and natural. Child not asphyxiated ; weight, 8 lbs. Count No. 
1 made at n A.M.,Oct. 21st. 
Number red cells per cubic mm., 5,925,000. 
This count corresponds closely with count No. 2, in case .No. 1, 
which was made about the same time after birth. 6 
FREDERICK P. HENRY. 
Count No. 2, Oct. 23rd. 
Number red cells per cubic mm., 5,520,000. 
Faint yellowish tint of skin. 
Count No. 3, Oct. 25th. 
Number red cells per cubic mm., 4,870,000. 
Child deeply jaundiced. 
Case 3.-Mary C., born 5:20 a.m., Nov. 5th. Count made at 
2:30 p.m., Nov. 6th. Child weighed lbs. at birth. Labor 
natural. 
Number red cells per cubic mm., 3,625,000. 
Proportion of white cells to red, 1 to 145. 
This case was undoubtedly one of congenital anaemia. 
The child's only appearance of mal-nutrition was a shrivelled 
state of the integuments of the feet and a less rosy color of 
the skin than normal. For a new-born child it was deci- 
dedly pale. This shrivelled state of the skin emphatically 
negatives the idea of a relative anaemia from excess of fluid. 
The blood was probably deficient in quantity (oligaemia) as 
well as defective in quality (oligocythaemia). There was 
also a decided increase in the number of the white cells. 
Careful inquiry proved that there had been no hemorrhage 
from the cord. As possibly bearing upon the congenital 
imperfection of this child, I may mention the facts that the 
parents were themselves immature-the father being seven- 
teen and the mother eighteen years old. But one exam- 
ination could be obtained in this interesting case, and 
therefore it has but a remote bearing upon my subject. I 
introduce it for its own inherent interest. 
Case 4.-Wm. S., born Nov. 6th, 5 a.m.; weight, lbs. 
Count No. 1, Nov. 7th. Number red cells per cubic mm., 
4,520,000. 
White cells to red, 1 to 904. 
Count No. 2, Nov. 8th, 11 a.m. Number red cells per cubic 
mm., 5,335>OO°- 
White cells to red, 1 to 711. 
Child slightly yellow. THE STUDY OF ICTERUS NEONATORUM. 
7 
Case 5.-Sela F., female, born Nov. 17th, 8:15 a.m.; weight, 7 
lbs.; labor rapid and natural ; child healthy-looking. 
Count No. 1, Nov. 19th, 10:30 a.m. 
Number red cells per cubic mm., 5,185,000. 
Number white cells to red, 1 to 350. 
Count No, 2, Nov. 21st, 4 p.m. 
Number red cells per cubic mm., 5,495,000. 
Number white cells to red, 1 to 628. 
Slight icteric hue of skin. 
From the foregoing observations no argument can be ad- 
vanced in favor of the haematogenic origin of icterus neona- 
torum ; for while it is true that in case 2, the only one in 
which there was marked jaundice, this condition coincided 
with a rapid and great diminution of red cells, it is also true 
that in case i there was a very decided loss in red cells 
without the occurrence of jaundice, and that in cases 4 
and 5, with a slight degree of icterus there was an increase 
in the number of red cells. 
The next questions which naturally arise in connection 
w'ith this subject are : If this icterus is not haematogenic, 
why does it not invariably occur, since the umbilical vein is 
ligatured in all new-born infants, and why has the statement 
been made and corroborated by excellent observers, that it 
is more frequently met with in delicate children than in the 
robust ? 
I admit both of the facts implied in the above questions, 
and propose the following explanation: 
The degree of immediate interference with the portal cir- 
culation produced by ligature of the umbilical cord, depends 
both upon the anastomoses of the umbilical vein with the 
veins of the abdominal wall, and upon the vigor of the car- 
diac contractions. Where there is free anastomosis and a 
vigorous heart, the intravascular blood-pressure in the 
hepatic lobules may be maintained to such an extent as to 
prevent the absorption of bile, and vice versd. 1 may here 8 
FREDERICK P. HE NR Y. 
mention, as bearing upon this subject, that the size of the 
heart, which in the adult is as 1 to 160, in the foetus is as 1 
to 120. This preponderance of cardiac force in the new-born 
child is a provision of nature for the establishment of new 
circulatory channels, rendered necessary by the ligature of 
the cord and the beginning of respiration. 
Facts are not wanting to show that the umbilical vein 
often continues pervious through life, but it is to be regretted 
that they are not given with more attention to detail. 
Thierfelder states that it continues patulous in " most 
human beings." Bamberger has " frequently found the 
umbilical vein in adults pervious to a fine sound"; and 
Hoffmann has reported a case of cirrhosis, in which he de- 
monstrated an anastomosis between the greatly dilated um- 
bilical vein and the inferior epigastric. In cases of cirrhosis, 
a patulous condition of the umbilical vein and anastomoses 
with veins of the abdominal wall, may, through the estab- 
lishment of a reverse venous current, be in a high degree 
conservative. 
It is true that Sappey has denied that a vein frequently 
found in the ligamentum teres is identical with the um- 
bilical vein, but there can be no doubt regarding the case of 
Hoffmann, for he traced the vessel to its communication in 
the transverse fissure with the portal vein, and through 
the open ductus venosus, with the vena cava inferior? 
As an instance of the confusion attending the subject of 
icterus neonatorum, I may mention, that while one set of 
observers attribute its causation to the sudden diminution 
of blood-pressure in the hepatic vessels produced by liga- 
ture of the cord, Dr. West 2 states that " in many instances 
of it the foetal passages are still pervious, and the blood 
1 For reference to cases of patulous umbilical vein, see Ziemssen's Cyclopaedia, 
Am. ed., vol. ix, p. 185. 
2 " Lectures on the Diseases of Infancy and Childhood." THE STUDY OF ICTERUS NEONATORUM. 
9 
circulates in part through channels which ought to have 
been closed from the time of birth." 
The knowledge that the umbilical vein continues pervious 
in " many instances " of icterus, can only have been obtained 
by means of autopsies, and it is to be regretted that the 
general statement is not supported by some particular facts. 
Since none such are given, I am not inclined to accept it. 
For the umbilical vein to continue pervious after ligature 
of the cord, there must be anastomoses with veins of the 
abdominal wall, and in order that this collateral venous cir- 
culation be at once established, there must be a certain 
degree of vigor on the part of the heart. Where one or 
other of these factors is wanting, thrombosis will occur in 
the vein, and, therefore, the unsupported statement that the 
umbilical vein continues pervious in many instances of 
icterus, is opposed to the undoubted fact that the affection 
is most common in weakly infants. 
In my argument I, of course, assume that the current of 
blood in the umbilical vein, when this remains patulous after 
birth, is, as before, toward the liver. This, although not 
susceptible of proof, is much more reasonable than to suppose 
a reversed current, as in cases of cirrhosis. 
In cases in which the umbilical vein does not remain per- 
manently patulous, the usual period of its obliteration may 
be prolonged, owing to the above-mentioned anastomoses, 
and this more gradual obliteration may prevent the occur- 
rence of this form of mechanical jaundice. 
The fact of varying degrees of icterus neonatorum, har- 
monizes completely with the theory of a venous anastomosis 
more or less extensive, and a cardiac contraction more or 
less powerful; while on the theory of a haematogenic icterus, 
it is impossible to explain why, of new-born children under 
precisely similar conditions, some should be the victims of a 
blood dyscrasia, whose only sign or symptom is a discolora- 10 
FREDERICK P. HENRY. 
tion of the skin, while others should present nothing of the 
sort. 
As to the frequency of icterus neonatorum, opinions vary 
from the one extreme of denying its existence to the other 
of believing that it is more or less present in all new-born 
children, its lighter grades escaping detection because they 
are not carefully looked for. I cannot concur in this latter 
opinion. While it is true that there are none so blind as 
they who will not see, it is also true that the willingness to 
see is at least as productive of positive results as is the un- 
willingness to see, of negative. Leaving the will, however, 
out of the question, it is undoubtedly the case that icterus 
neonatorum is far more common than is generally supposed. 
Harley does not consider the affection a form of jaun- 
dice at all, and objects strenuously to the term icterus 
neonatorum, which he calls a " learnedly sounding name," 
and proposes for it that of chlorosis neonatorum, which, to 
the ear of the writer, has quite as learned a sound, and con- 
veys impressions concerning the pathology of the affection 
which are not substantiated by a single fact. 
The known fact that the portal blood-pressure is suddenly 
diminished by ligature of the umbilical cord, and the 
further facts recorded above as to the number of the blood 
globules in the neonatus, lead me to the conclusion that 
icterus neonatorum is of the mechanical or hepatogenic 
form, and that the term chlorosis neonatorum, proposed by 
Harley for this affection, is a misnomer.