THE IMPORTANCE OF THE FRACTIONAL SERUM BILIRUBIN DETERMINATION IN CLINICAL MEDICINE

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Abstract
The history and present status of knowledge of the van den Bergh reaction is discussed with special reference to the work of Cole et al.on the polar and norupolar behavior of the direct and indirect types of serum bilirubin. van den Bergh''s original emphasis on the prompt character of the direct reaction and its essential difference from the delayed direct (and indirect) is upheld on the basis of comparative study of the time reaction curve of hemolytic jaundice serum and the proportion of polar bilirubin by the Cole-Lathe method. The delayed direct measured at 30[image] included non-polar bilirubin, while the 1[image] value is in better agreement with the small polar fraction in such serum. Bilirubin exhibits a red color reaction with H2SO4, in the absence of water. On shaking the CHCl3 reaction mixture with water the red color disappears, that of bilirubin returning and entering the aqueous phase. In addition to its non-polar behavior it exhibits a prompt direct van den Bergh reaction, thus being similar to the bilirubin of the bile, and that of blood serum and urine in cases of obstructive jaundice. Billing and Lathe and Schmid have shown independently that this is a glucuronide. Studies of the fractional serum based on 884 determinations in 702 cases emphasize; (1) Values for bilirubin ratio (1[image] prompt direct x 100) less than 40% are strongly indicative of parenchymal and total or hemolytic jaundice. Values less than 35% are almost never due to mechanical obstructive causes, if the total bilirubin is more than 1.5. Values less than 20% are characteristic of hemolytic jaundice in the Gilbert type of constitutional jaundice. The chronic idiopathic jaundice of Dubin-Johnson exhibits much higher ratios. (2) Increase of the 1[image] (prompt direct) fraction within a normal total, increased the value of the serum bilirubin determination in diagnosis. Though not specific this finding aids in pointing to an hepatic or biliary tract disturbance. In the present series it was encountered in 80 cases, including common duct stone, cirrhosis, hepatitis, and hepatic carcinomatosis.