KA I\GE

THE ICTERUS INDEX AS A MEASURE OF THE SERUM BILIRUBIN CONCENTRATION

Author(s): BERTIL JOSEPHSON
Source: Acta Genetica et Statistica Medica, Vol. 4, No. 2/3 (1953), pp. 231-235
Published by: S. Karger AG
Stable URL: https://www.jstor.org/stable/45103179
Accessed: 21-10-2022 16:37 UTC

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 Josephson 231

LITERATUR
Bonnier, G. and A. Han,ıon: Hered. 2, 1-27, 1948. - Falconer, D. S. and
M. Laıyszewski: J. Genet. 51, 67-80, 1952. - Fisher, R. A.: Brit. agric. Bull. 4,
217-218, 1951. -Hammond, J.: Biol.Rev. 22, 195-213, 1947. - Johansson, I.: Anim.
Breed. Ahstr. 18, 1-12, 1950. - Johansson, I. and A. Hansson: Causes of Variation
in Milk and Butterfat Yield of Dairy Cows. K. Lantbr. Akad. Handl. Stockholm
1940. - Lush, J. L.: Heritability of Quantitative Characters in Farın Animals. Proc.
8th inter. Congr. Genet. Hered. Suppl. 356-375, 1949. - Mahadevan, P.: J. agric.
Sci. 41, 80-88, 94-97, 1951. - Winsor, C. P. and G. L. Clarke: J.Marine Research
3, 1-34, 1940.

Jo,.pMOn. B.: A, ta genel. 4, 231-235, 19~3

From the Central Clinical Laboratory, St. Erik's Hospital, Stockholm

THE ICTERUS INDEX AS A MEASURE OF THE

SERUM BILIRUBIN CONCENTRATION

By BERTiL JOSEPHSON

Since Meulengracht [1920] descrihed his method for comparing

the intensity of the colour of plasma or serum with that ofa standard
dichromate solution the method has heen extensively used in routine
clinical work as an estimation of the degree of icterus. Previously
Nyström [1915] had descrihed a similar method for estimating the
serum colour hy comparison with a solution of FeCl3 containing a
trace of safranin. Nyström was aware of the influence of the hile
pigmente on the colour but he was interested only in the "normal"
colour in patients without jaundice.
The presence of hile pigmente in the hlood was first demonstrated
in horse serum hy O. Hammarsten [1878]. The corresponding de-
monstration in normal human serum was puhlished hy Hannema
[1915]. it is well known that beside the hile pigments several
coloured suhstances are present in the normal human plasma such as
lutein, "lipochrom" carotenes, ete. Their concentration, however, is
-except under rare, pathological conditions-so low that their

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232 J osephson, The lcterus lndex

infiuence on the colour of plasma from jaundiced patients is con-

sidered to be negligible. On the other hand, the infiuence of these
substances on the plasma colour of non-icteric subjects in comparison
to the infiuence of the bile pigments is not known. Only one statistical
comparison between icterus index and chemically determined
bilirubin seems to have been published (Sterner and Cusack [1945]).
Their material was 429 patients with icterus indices from normal up
to 25. The results from icteric and non-icteric subjects were treated
in common. They determined the icterus index after precipitation of
the serum proteins with acetone which is known to co-precipitate a
very considerable part of the bile pigments (Newburger [1937]).
As thedetermination ofthe icterus index ismuch less complicated
and takes a shorter time to carry out than the determination of the
bile pigments by the diazo reaction it was considered useful to
examine the infiuence of the concentration of these pigments on the
icterus index in the healthy man. This infiuence was compared with
that in jaundiced patients.

Material and ieclınique.

196 healthy men, 164 healthy women and 40 jaundiced patients 1
were examined (cf. table 1). 193 of the healthy subjects were less
than 50 years old and 167 were over 60 years. The normal subjects and
the laboratory results from these were the same as those used by
Joseplıson and Dalılberg [1952] and the control of the health of the
subjects is described in their paper. lcterus index was determined
according to Meulengracht [1921] and bilirubin according to Jendras-
sik and Grof [1938]. Both determinations were carried out on serum.
in neither method are the proteins precipitated. The diagnoses, age
and sex of the icterus patients were not considered to be of interest.

Statistical methods.
The means, their standard errors and the. standard variations
are calculated as in the paper of Josephson and Dahlberg [1952]. The
correlation coefficients and regression lines are calculated according
to Bravais-Pearson as described by Dalılberg [1940]2.
1 Dr. J. Ström, physician in chief of the Hospital for Epidemic Diseases of
Stockholın, has kindly provided me with serum samples from patiente with epidemic
hepatitis. Some sera were from patients with non-infectious liver diseases treated
in St. Erik's Hospital.
9 I owe many thanks to Dr. E. Lander who has helped me with the statistical

treatment of the results in a very kind way.

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 as a Measure of the Serum Bilirubin Concentration 233

Table 1. The mean valueıı, M, the standard errors of the meanı, e(M), and the ıtand­
ard variationı, 11, of the icterus index and the bilirubin eoneentration. The eoeffi.eients,
r, and their ıtandard errors, e(r), for the correlation between ieterus index and bilirubin
coneentration.
State Icterus index Bilinıbin Correlation
of Sex Age Number coef&cient
yearı
health M ± a(M) 1
o M± a(M)
1
o •± •(r)

< 50 83 6,45±0,25 2,27 0,929±0,053 0,483 0,83±0,034

healthy men > 60 113 5,46±0,16 1,66 0,740±0,029 0,311 0,64±0,056
total 196 5,88±0,14 2,00 0,820±0,029 0,404 0,77±0,029

< 50 110 5,80±0,12 1,29 0,788±0,026 0,276 0,53±0,069

healthy women > 60 54 4,37±0,13 0,97 0,766±0,033 0,244 0,59±0,089
total 164 5,33±0,11 1,37 0,780±0,021 0,266 0,49±0,059

< 50 193 6,08±0,13 1,81 0,848±0,028 0,386 0,75±0,032

healthy both > 60 167 5,10±0,12 1,56 0,749±0,023 0,292 0,58±0,052
total 360 5,63±0,09 1,76 0,802±0,018 0,349 0,69±0,027

jaundieed both 40 35,1±6,4 40,6 5,36±1,10 6,98 0,84±0,047

Results.
The means, v ariations and correlation coefficients are demonstrated
in table 1. The results from the healthy men are plotted in fig. 1 and
from the jaundiced patients in fig. 2. The results from the healthy women
3.e+-------------~-
3.4

~3.o
t2.s
Q.

E
·_g 1.8
::J
~1.4
Fig. 1. The icterus indices and m
bilirubin eoncentrationı of the 1.o
196 healthy men. The line cı re-
0.6
presentı the ieterus index aı a
fıınction of the bilirubin con- o.
eentrations and the line b the
bilirubin coneentration as a 2 4 s e 10 12 14 1s 1e
function of the ieterus indices. ıcterusindex

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234 J osephson, The lctenıs Index

34
30
c
t26
~2
r1a
:!14
2
~10
6
2
20 40 60 80 100 120 140 160 180 200
lcterus iıdex
Fig. 2. The ictenıs indices and bilirubin concentrations of 40 jaundiced patients.

are not recorded as they did not differ very much from those of the
men. In fig. 1 the regression lines are drawn showing the icterus
index as a function of the bilirubin concentrations (a) and the bili-
rubin concentration as a function of the icterus indices (b).
The calculation of these lines gave the following results for the
mutual dependence of icterus index (I) and bilirubin concentra-
tion (B) on each other.
Formen I - 3,81 B + 2,76 ± 1,28
B - 0,155 I - 0,09 ± 0,26
For women I - 2,53 B + 3,35 ± 1,20
B - 0,095 I + 0,27 ± 0,23

Discussion.
As the table demonstrates, there was a fairly good correlation
between icterus index and serum bilirubin concentration in all the
groups of normal subjects. The correlation coefficient was markedly
high in the group of youngıtr men. It was rather good in the icteric
patients too. This was to be expected, as the discoloration of their
serum must have been due to its high concentration.ofbile pigments.
The fairly good correlation in the healthy subjects shows that the
bile pigments have considerable influence on the serum colour even

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 as a Measure of the Serum Bilirııhin Coneentration 235

under normal conditions. On the other hand the correlation is not

so good that one is permitted to draw any defınite conclusions on the
bilirubin concentration of a serum sample from its index fıgure.
A better correlation was to be expected in the jaundiced patients
than the one obtained. The fact that the correlation coeffıcient in
this group was only 0,84 may be explained partly by the obvious
possibility of individual errors in estimation of the icterus index and
partly by the fact that several different bile pigments, not identical
with bilirubin, may appear in the serum of jaundiced patients. A few
of the icteric sera were turbid which is the probable reason why their
fıgures went very much astray.
The fact that the regression lines for the icterus indices as a
variable of the bilirubin concentrations do not point towards the
origin but extrapolate towards a value of 2 to 4 at a bilirubin con-
centration of Zero is of interest. This observation indicates that
approximately 2 to 4 units of the index fıgures are due to coloured
substances in the serum, which are not bilirubin.

Summary.
The eorrelation hetween the ieterus index aeeording to Meulengracht [1920]
and the serum hilirııhin eoneentration was examined in 360 healthy suhjeete and
in 40 jaundieed patients. in the normal suhjeets the eorrelation eoefficient was
0,69 and in the patients it was 0,84.

Ruume.
La eorrelation entre l'index d'iet~re selon Meulengracht [1920] et la eoneentra•
tion de hilirııhine dans le serum a ete analysee ehez 360 personnes hien portantes et
ehez 40 malades ayant la jaunisse. Chez les personnes normales le eoefficient de
correlation 6tait de 0,69 et chez les malades de 0,84.

Zusammenfaısung.
Die Korrelation zwisehen dem Ikterusindex naeh Meulengraclıt [1920] und
ıler Konzentration von Bilirııhinserum ist hei 360 gesunden Individuen und 40
Gelhsuehtpatienten untersueht worden. Für die normalen Individuen hetrug der
Korrelationskoeffizient 0.69 und für die Patienten 0.84.

REFERENCES
Dahlberg, G.: Statistieal Methods, London 1940. - Hammarsten, O.: Malys Jh.
Thier Chem. 8, 129, 1878. - Hannema, L. G.: Malys Jh. Thier Chem. 45, 88, 1915. -
Jendrassik, L. und P. Grof: Bioehem. Z. 297, 81, 1938. -Josephson, B. and G. Dahl·
berg: Seand. J. elin. Lah. Invest. 4, 216, 1952. - Meulengracht, E.: Dtseh. Arch.
klin. Med. 132, 285, 1920; Ugeskr. Laeg. 20, 1, 1921. - Newburger, R.: J. Lah. elin.
Med. 22, 1192, 1937. - Nyström, B.: Finska LiikSöllsk. Manadst. 57, 1649, 1915. -
Sterner, J. and M. Cusack: Amer. elin. Patlı. 15 (teehn. seet. 9), 7, 1945.

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