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An intradermal test for pregnancy
AN INTRADERMAL TEST FOR PREGNANCY BENJAMIN Department
of Oncology and Experimenta
M.D.
GRUSKIN, PathoIogy,
PHILADELPHIA,
T
HE experimenta work of ZondekAschheim’ and Friedman,2 in the physioIogica1 fieId Ied to the deveIopment of tests for the determination of pregnancy. So much has been written and discussed in the Iiterature concerning these tests that repetition is unnecessary. However, they are of great interest, not 0nIy from a physiologica standpoint but aIso from their practica1 utiIization. The writer feeIs justified in introducing a new test for the determination of pregnancy which is based upon a new principIe and has the advantage of simpIicity of performance pIus quick resuIts obtained by its interpretation. The importance of this is easiIy seen in cases where a differentia1 diagnosis of ectopic pregnancy and other conditions is desired. This test is based on previous work,3,4,5 concerning the nature of homoIogous proteins producing an aIIergic reaction by the formation of pseudopodia when in jetted intradermaIIy *in positive cases of AaIignancy. The same principIe has been appIied in the determination of pregnancy, utiIizing pIacenta1 tissue as an antigen, which, when introduced intradermaIIy, causes pseudopod formation to take place at the site of in pregnant femaIes, but no injection, pseudopods appear when no pregnancy exists. That this reaction is pureIy the resuIt of the homoIogous nature of the prote_in is cIearIy shown by the foIIowing experiment: IsoIated young femaIe rabbits were injetted with the antigen folIowing the technique of the Friedman test. Corpora hemorrhagica appeared in the ovaries of the rabbits forty-eight hours after the first
Temple University
SchooI of Medicine
PA.
injection. The same antigen was then heated to 75’~. for thirty minutes and injected into another set of rabbits. No corpora hemorrhagica formed in the ovaries even after successive injections, whiIe the same heated antigen was stiI1 capable of producing pseudopodia when used as a test on pregnant women. There can be onIy one concIusion, that the hormone carried by the pIacenta may be destroyed by heating and pIays no part in this reaction and that it is pureIy due to the aIIergic response on the part of the individua1 to an homoIogous protein. TABLE
.;;zE=;D 134113
#34816
I
RhBBIrDATE INJECCED #II2
#III
11/20/34-s I/21/34--5
I I I/22/34
I l/20/34--5 11/21/34Y5
cc. cc. Lap. showed Grade positive Friedman.
~~?~~~~~ f/zH8. #34113
Lap. showed Grade positive Friedman.
II
II
RABBlT
%I 13
I x/27/34-5 I l/28/34--5
cc. cc.
1 I/29/34 ii34816
III
cc. EC.
1l/22/34 TABLE
RESOLr
#II4
11/27/34-s I l/28/34-5 1 t/29/34
Lap. showed Friedman.
negative
Lap. showed Friedman.
negative
cc. cc.
This reaction too, Iike the ZondekAschheim and Friedman tests, gives positive resuIts in teratomas, evidentIy on account of the feta1 character of this type of tumor, reacting homologousIy to the fetal tissue of the pIacenta. 59
60
American Journal of Surgery
Gruskin-Test
Method of performing the test: One-tenth of a cubic centimeter of the antigen is injected intradermaIIy with a 27 gauge needIe
for Pregnancy
JANUARY, 1936
soIution of hydrochloric acid plus a buffer, made up in the foIIowing manner: Buffer SoIution-0.05 Norma1 HCI. 2.27 grams KH2P04 per Iiter. The antigen is brought to pH of 6.9, to which six drops of a mixture, of two parts gIycerine to one of tricreso1, for every IO C.C. of the extract is added as a preservative. It is then pIaced in Pyrex containers, as we found that ordinary gIass gives up aIkaIies and changes the pH. The antigen is now ready for use. Results: In a series of 200 cases* the foIIowing resuIts were found :TABLE III
NUMBER OF
FIG. I.
and a I C.C. tuberculin syringe. Care must be taken that the injection shouId not be forced, so that no false pseudopods wiI1 be formed. In positive cases, a sIight area of inff ammation with pseudopod formation appears within ten minutes. In negative cases, no such reaction takes pIace. It is advisabIe to use a controI of physioIogic saIt soIution with each test. The controI must aIways be negative, showing no inAammation and no pseudopods. The bIeb after the injection must be perfectIy round and have the appearance of orange pee1 due to the hair foIIicIes, in which case one is sure that the test was done
CASES
IO
Negative.
IO
Negative.
105
Positive.
8 12 15 3 I
Negative. Positive. Positive. Positive. Positive.
4
Positive.
IO 3 I 4 I
Positive. Positive, Positive. Positive. Positive. Friedman test positive Positive.
I
Positive. Positive. Negative. Negative. Positive.
INTRADERMALLY.
Preparation of the antigen: PIacentas are obtained as soon as possibIe foIIowing deIivery, thereby avoiding any change in the protein which might take pIace by disintegration. The pIacentas are carefuIIy washed and cIeaned, and freed as much as possibIe from traces of bIood. It is then ground into puIp and pIaced into acetone, three times its voIume, for twenty-four hours. The acetone is then poured off, the tissue aIlowed to dry and the acetone evaporated. It is then extracted with a decinorma1 sodium hydroxide soIution for twenty-four hours and neutraIized with a
woman used BS control. Young man used BScontrol. FulI term pregnancy delivered. Not pregnant clinically. Incomplete abortion. Complete abortion. Therarxutic abortion. abortion (selfCriminal induced). Threatened abortion, discharged improved. Clinically pregnant. Ectopic, tubal, pregnancies. Abdominal pregnancy. Premature infant delivered. Hydatidiform mole.
Young
Patient died in diabetic coma, 3 mos. fetus found in the uterus st autopsy. Delivered a dead fetus, about 54/s mos. 2 weeks pregnancy, curettage done, villi found. Cervical erosion. Ca. of cervix uteri. Carcinoma of fundus with metastasis.
Positive. I
Positive. (Positive test for Ca.)
48
Positive.
II
Negative.
4
Positive.
Operated upon, dense pelvic adhesions. No pathoIogic exam. made. Clinically questionable pregnancy, believed to be Ca. of Fundus. Lost patients, never came back to clinic or delivered at this hospital 8s far as our records show. Lost patients, never came back to clinic or delivered at this hospital as far as our records show. Diagnosis, terstoma. as reported by Dr. EmanueI Schwartz6 and in our own hands.
* Under the cIinica1 supervision of Dr. J. 0. ArnoId, Professor and Head of the Department of Obstetrics at TempIe University HospitaI and his staff.
NEW SERIES VOL.XXXI, No.
I
Gruskin-Test
for Pregnancy
Contraindications: I. This test shouId not be done during the menstruation on account of the decidua1 invoIvement of that process which wiI1 respond to the homoIogous protein of the pIacenta1 extract, giving positive reactions. 2. Endocrine disturbances or hypersensitive skins which might respond to anything, even to saIine, as has been found. AIthough uncommon, it must be kept in mind so as to avoid performing the test upon such an individua1, as faIse positives may occur. Therefore it is advisable to use the saIine contro1 first, and if this shouId show pseudopod formation, the patient’s skin is not suitabIe for the test.
Journal
of Surgery
61
between ectopic pregnancy and other conditions. 4. The Iarge series of correct resuIts in positive and negative cases proves its reIiabiIity. Appreciation is here by expressed for the cooperation and clinica advice of Dr. J. 0. ArnoId, Professor and Head of the Department of Obstetrics at TempIe University HospitaI, and his staff in accompIishing this work. REFERENCES I. ZONDEK, B. and ASCHHEIM, S.: Die Schwangershaftsdiagnose aus dem Harn durch Nachweis des HypophysenvorderIappenhormons. Klin. Wcbnscbr. 7: 401, 1928. 2. FRIEDMAN, M. H.: Mechanism of ovulation in the rabbit; ovuIation produced by the injection of urine from pregnant women. Am. J. Pbysiol., 90.
SUMMAKY
617, 1929. 3. GRUSKIN, B. A serum test for the diagnosis of cancer based on a new theory of etiology. Am. J. Med. SC., ~01. 177: 476, 1929. 4. GRUSKIN, B. IntradermaI test for the determination of maIignancy. J. Lab. and Cl. Med., 17: 1237,
I.
An intraderma1 test for the determination of pregnancy, based upon a new principIe, has been introduced. 2. The ease of performance and quick reading of its resuIts proves its vaIue. 3. Its importance in cases where a quick diagnosis is desired, as the differentiation
REFERENCES
American
1932. 5. GRUSKIN, B. Allergic phenomena in malignancy. Penna. Med. J., 62: 573, 1933. 6. SCH~.~RTZ, EIIANUEI.. Persona1 communication.
OF
I I. HINTON, J. W., and CHURCH, R. E. The incidence of gastrojejuna1 ulcer following gastroenterostomy. Surg. Gynec. Obst., 60: 65-73 (Jan.) 1935. 12. IVY, A. C., RICHTER, O., MEYER, A. F., and GREENGARD, H. The reIation of gastrectomy to anemia. Am. J. Dig. Dis. 0 Nutrit., I: I 16 (Apr.) 1934. 13. JUDD, E. S. JejunaI ulcer. Surg., Gynec. Obst., 33: 120 (Aug.) 1921. 14. KLEIN, E., ASCHNER, P. W., and CROHN, B. B. The end-rest&s of partia1 gastrectomy for primary gastric and duodena1 uIcers. Tr. Am. Castro-Enterol. Assn., pp. 197-205, 1933. 15. LAHEY, F. H. Experiences with gastrojejuna1 uIcer and gastrojejunocoIic fistuIae. Presented at the annua1 meeting of the American Gastroenterologica1 Association, Atlantic City, June I I, ‘935. 16. LAPP and DIEBALD. Quoted by Eusterman, G. B. Discussion to papers on Physiologic studies subsequent to gastric resection for ulcer. Proc. Staff Meet. Mayo Chn., 9: 507 (Aug. 22) 1934. 17. LEWISOHN, R. The frequency of gastrojejuna1 UIcers. Surg. Gynec. Obst., p. 70 (Jan.) 1925. *Continued
DR.
JORDAN*
18. Q~TERBERG, A. E., and VANZANT, F. R. Determination of pepsin in the gastric content and its clinica significance in duodenal uIcer and Clin., pseudo-ulcer. Proc. Staff Meet. Mayo 7: 268, 1932. 19. PATERSON, H. J. JejunaI and gastrojejunal ulceration foIIowing gastrojejunostomy. Proc. Roy. Sot. Med., p. 238 (June) 1909. 20. VERBRUGGE, J. GastrojejunocoIic IistuIas. Arch. Surg., I I : 790, 1925. 21. VON REDWITZ, E., and Fvss, H. Quoted by Alvarez, W. C. Light from the Iaboratory and the clinic on the cause of peptic ulcer. Ax J. SURG., 18: 207 (Nov.) 1932. 22. WALTON, A. J. GastrojejunaI uIceration. Brit. J. Surg., 22: 33 (JuIy) 1934. 23. WEIR, J. F. Phenomena including recurrent ulcer following resection of benign Iesions. AM. J. SURG., 7: 505 (Oct.) 1929. 24. WRIGHT, G. Discussion on the remote resuhs of the surgical treatment of gastric and duodena1 uIcers. Proc. Roy. Sec. Med., p. 153 (May) 1920. 25. WRIGHT, G. CoIIective inquiry by the FeIIows of the into gastrojejunal Association of Surgeons ulceration. Brit. J. Surg., 22: 433, 1935. from p. 86.
of Oncology and Experimenta
M.D.
GRUSKIN, PathoIogy,
PHILADELPHIA,
T
HE experimenta work of ZondekAschheim’ and Friedman,2 in the physioIogica1 fieId Ied to the deveIopment of tests for the determination of pregnancy. So much has been written and discussed in the Iiterature concerning these tests that repetition is unnecessary. However, they are of great interest, not 0nIy from a physiologica standpoint but aIso from their practica1 utiIization. The writer feeIs justified in introducing a new test for the determination of pregnancy which is based upon a new principIe and has the advantage of simpIicity of performance pIus quick resuIts obtained by its interpretation. The importance of this is easiIy seen in cases where a differentia1 diagnosis of ectopic pregnancy and other conditions is desired. This test is based on previous work,3,4,5 concerning the nature of homoIogous proteins producing an aIIergic reaction by the formation of pseudopodia when in jetted intradermaIIy *in positive cases of AaIignancy. The same principIe has been appIied in the determination of pregnancy, utiIizing pIacenta1 tissue as an antigen, which, when introduced intradermaIIy, causes pseudopod formation to take place at the site of in pregnant femaIes, but no injection, pseudopods appear when no pregnancy exists. That this reaction is pureIy the resuIt of the homoIogous nature of the prote_in is cIearIy shown by the foIIowing experiment: IsoIated young femaIe rabbits were injetted with the antigen folIowing the technique of the Friedman test. Corpora hemorrhagica appeared in the ovaries of the rabbits forty-eight hours after the first
Temple University
SchooI of Medicine
PA.
injection. The same antigen was then heated to 75’~. for thirty minutes and injected into another set of rabbits. No corpora hemorrhagica formed in the ovaries even after successive injections, whiIe the same heated antigen was stiI1 capable of producing pseudopodia when used as a test on pregnant women. There can be onIy one concIusion, that the hormone carried by the pIacenta may be destroyed by heating and pIays no part in this reaction and that it is pureIy due to the aIIergic response on the part of the individua1 to an homoIogous protein. TABLE
.;;zE=;D 134113
#34816
I
RhBBIrDATE INJECCED #II2
#III
11/20/34-s I/21/34--5
I I I/22/34
I l/20/34--5 11/21/34Y5
cc. cc. Lap. showed Grade positive Friedman.
~~?~~~~~ f/zH8. #34113
Lap. showed Grade positive Friedman.
II
II
RABBlT
%I 13
I x/27/34-5 I l/28/34--5
cc. cc.
1 I/29/34 ii34816
III
cc. EC.
1l/22/34 TABLE
RESOLr
#II4
11/27/34-s I l/28/34-5 1 t/29/34
Lap. showed Friedman.
negative
Lap. showed Friedman.
negative
cc. cc.
This reaction too, Iike the ZondekAschheim and Friedman tests, gives positive resuIts in teratomas, evidentIy on account of the feta1 character of this type of tumor, reacting homologousIy to the fetal tissue of the pIacenta. 59
60
American Journal of Surgery
Gruskin-Test
Method of performing the test: One-tenth of a cubic centimeter of the antigen is injected intradermaIIy with a 27 gauge needIe
for Pregnancy
JANUARY, 1936
soIution of hydrochloric acid plus a buffer, made up in the foIIowing manner: Buffer SoIution-0.05 Norma1 HCI. 2.27 grams KH2P04 per Iiter. The antigen is brought to pH of 6.9, to which six drops of a mixture, of two parts gIycerine to one of tricreso1, for every IO C.C. of the extract is added as a preservative. It is then pIaced in Pyrex containers, as we found that ordinary gIass gives up aIkaIies and changes the pH. The antigen is now ready for use. Results: In a series of 200 cases* the foIIowing resuIts were found :TABLE III
NUMBER OF
FIG. I.
and a I C.C. tuberculin syringe. Care must be taken that the injection shouId not be forced, so that no false pseudopods wiI1 be formed. In positive cases, a sIight area of inff ammation with pseudopod formation appears within ten minutes. In negative cases, no such reaction takes pIace. It is advisabIe to use a controI of physioIogic saIt soIution with each test. The controI must aIways be negative, showing no inAammation and no pseudopods. The bIeb after the injection must be perfectIy round and have the appearance of orange pee1 due to the hair foIIicIes, in which case one is sure that the test was done
CASES
IO
Negative.
IO
Negative.
105
Positive.
8 12 15 3 I
Negative. Positive. Positive. Positive. Positive.
4
Positive.
IO 3 I 4 I
Positive. Positive, Positive. Positive. Positive. Friedman test positive Positive.
I
Positive. Positive. Negative. Negative. Positive.
INTRADERMALLY.
Preparation of the antigen: PIacentas are obtained as soon as possibIe foIIowing deIivery, thereby avoiding any change in the protein which might take pIace by disintegration. The pIacentas are carefuIIy washed and cIeaned, and freed as much as possibIe from traces of bIood. It is then ground into puIp and pIaced into acetone, three times its voIume, for twenty-four hours. The acetone is then poured off, the tissue aIlowed to dry and the acetone evaporated. It is then extracted with a decinorma1 sodium hydroxide soIution for twenty-four hours and neutraIized with a
woman used BS control. Young man used BScontrol. FulI term pregnancy delivered. Not pregnant clinically. Incomplete abortion. Complete abortion. Therarxutic abortion. abortion (selfCriminal induced). Threatened abortion, discharged improved. Clinically pregnant. Ectopic, tubal, pregnancies. Abdominal pregnancy. Premature infant delivered. Hydatidiform mole.
Young
Patient died in diabetic coma, 3 mos. fetus found in the uterus st autopsy. Delivered a dead fetus, about 54/s mos. 2 weeks pregnancy, curettage done, villi found. Cervical erosion. Ca. of cervix uteri. Carcinoma of fundus with metastasis.
Positive. I
Positive. (Positive test for Ca.)
48
Positive.
II
Negative.
4
Positive.
Operated upon, dense pelvic adhesions. No pathoIogic exam. made. Clinically questionable pregnancy, believed to be Ca. of Fundus. Lost patients, never came back to clinic or delivered at this hospital 8s far as our records show. Lost patients, never came back to clinic or delivered at this hospital as far as our records show. Diagnosis, terstoma. as reported by Dr. EmanueI Schwartz6 and in our own hands.
* Under the cIinica1 supervision of Dr. J. 0. ArnoId, Professor and Head of the Department of Obstetrics at TempIe University HospitaI and his staff.
NEW SERIES VOL.XXXI, No.
I
Gruskin-Test
for Pregnancy
Contraindications: I. This test shouId not be done during the menstruation on account of the decidua1 invoIvement of that process which wiI1 respond to the homoIogous protein of the pIacenta1 extract, giving positive reactions. 2. Endocrine disturbances or hypersensitive skins which might respond to anything, even to saIine, as has been found. AIthough uncommon, it must be kept in mind so as to avoid performing the test upon such an individua1, as faIse positives may occur. Therefore it is advisable to use the saIine contro1 first, and if this shouId show pseudopod formation, the patient’s skin is not suitabIe for the test.
Journal
of Surgery
61
between ectopic pregnancy and other conditions. 4. The Iarge series of correct resuIts in positive and negative cases proves its reIiabiIity. Appreciation is here by expressed for the cooperation and clinica advice of Dr. J. 0. ArnoId, Professor and Head of the Department of Obstetrics at TempIe University HospitaI, and his staff in accompIishing this work. REFERENCES I. ZONDEK, B. and ASCHHEIM, S.: Die Schwangershaftsdiagnose aus dem Harn durch Nachweis des HypophysenvorderIappenhormons. Klin. Wcbnscbr. 7: 401, 1928. 2. FRIEDMAN, M. H.: Mechanism of ovulation in the rabbit; ovuIation produced by the injection of urine from pregnant women. Am. J. Pbysiol., 90.
SUMMAKY
617, 1929. 3. GRUSKIN, B. A serum test for the diagnosis of cancer based on a new theory of etiology. Am. J. Med. SC., ~01. 177: 476, 1929. 4. GRUSKIN, B. IntradermaI test for the determination of maIignancy. J. Lab. and Cl. Med., 17: 1237,
I.
An intraderma1 test for the determination of pregnancy, based upon a new principIe, has been introduced. 2. The ease of performance and quick reading of its resuIts proves its vaIue. 3. Its importance in cases where a quick diagnosis is desired, as the differentiation
REFERENCES
American
1932. 5. GRUSKIN, B. Allergic phenomena in malignancy. Penna. Med. J., 62: 573, 1933. 6. SCH~.~RTZ, EIIANUEI.. Persona1 communication.
OF
I I. HINTON, J. W., and CHURCH, R. E. The incidence of gastrojejuna1 ulcer following gastroenterostomy. Surg. Gynec. Obst., 60: 65-73 (Jan.) 1935. 12. IVY, A. C., RICHTER, O., MEYER, A. F., and GREENGARD, H. The reIation of gastrectomy to anemia. Am. J. Dig. Dis. 0 Nutrit., I: I 16 (Apr.) 1934. 13. JUDD, E. S. JejunaI ulcer. Surg., Gynec. Obst., 33: 120 (Aug.) 1921. 14. KLEIN, E., ASCHNER, P. W., and CROHN, B. B. The end-rest&s of partia1 gastrectomy for primary gastric and duodena1 uIcers. Tr. Am. Castro-Enterol. Assn., pp. 197-205, 1933. 15. LAHEY, F. H. Experiences with gastrojejuna1 uIcer and gastrojejunocoIic fistuIae. Presented at the annua1 meeting of the American Gastroenterologica1 Association, Atlantic City, June I I, ‘935. 16. LAPP and DIEBALD. Quoted by Eusterman, G. B. Discussion to papers on Physiologic studies subsequent to gastric resection for ulcer. Proc. Staff Meet. Mayo Chn., 9: 507 (Aug. 22) 1934. 17. LEWISOHN, R. The frequency of gastrojejuna1 UIcers. Surg. Gynec. Obst., p. 70 (Jan.) 1925. *Continued
DR.
JORDAN*
18. Q~TERBERG, A. E., and VANZANT, F. R. Determination of pepsin in the gastric content and its clinica significance in duodenal uIcer and Clin., pseudo-ulcer. Proc. Staff Meet. Mayo 7: 268, 1932. 19. PATERSON, H. J. JejunaI and gastrojejunal ulceration foIIowing gastrojejunostomy. Proc. Roy. Sot. Med., p. 238 (June) 1909. 20. VERBRUGGE, J. GastrojejunocoIic IistuIas. Arch. Surg., I I : 790, 1925. 21. VON REDWITZ, E., and Fvss, H. Quoted by Alvarez, W. C. Light from the Iaboratory and the clinic on the cause of peptic ulcer. Ax J. SURG., 18: 207 (Nov.) 1932. 22. WALTON, A. J. GastrojejunaI uIceration. Brit. J. Surg., 22: 33 (JuIy) 1934. 23. WEIR, J. F. Phenomena including recurrent ulcer following resection of benign Iesions. AM. J. SURG., 7: 505 (Oct.) 1929. 24. WRIGHT, G. Discussion on the remote resuhs of the surgical treatment of gastric and duodena1 uIcers. Proc. Roy. Sec. Med., p. 153 (May) 1920. 25. WRIGHT, G. CoIIective inquiry by the FeIIows of the into gastrojejunal Association of Surgeons ulceration. Brit. J. Surg., 22: 433, 1935. from p. 86.