FOR several years it has been known that the amount of female sex hormone, estrin, as well as the amount of gonad stimulating hormone from the anterior pituitary, prolan, were increased in the blood during pregnancy. Mazers theory as given by Bland, First and Roeder is 1 that the luteal hormone which is stimulated by prolan prepares the endometrium to take care of the pregnancy and is therefore found early in the blood while estrin governs growth and vasculation of the uterus and is not needed early- in fact, will in large quantities produce abortion. The kidneys therefore act as governors in attempting to keep these substances in physiologic balance.
It remained for Aschheim and Zondek 2 in 1927, to propose an accurate experimental method of determining the presence of an excess of this pituitary hormone in the urine of pregnant women, using immature female white mice. Their results were quite accurate from the beginning and they were able to report over 98 per cent correct diagnoses in early urine pregnancy. Later they reported the efficiency of the test in hydatid mole, chorio-epithelioma, ectopic pregnancy and teratoma of the testicle. Moreover, they showed that the reaction became negative shortly after the placental tissue died or was removed from contact with the maternal circulation.
Although most of the literature covers the detection of an excess of the pituitary hormone, Mazer and Hoffman have designed a test which will verify the presence of an excess of the ovarian hormone. Bland, First and Roeder, who reported a comparison of these test, felt that both examinations should be made, claiming a larger percentage of correct positives could be obtained with the Aschheim-Zondek test and a smaller percentage of false positive with the Mazer -Hoffman test.
The original Aschheim-Zondek test consisted of the injection subcutaneously into the back of varying amounts of the urine of the patient from 0.2 to 0.4 cubic centimeters twice daily for six injections,into give immature female mice weighing between five and eight grams. One hundred house after the first injection, the mice were killed and the ovaries were examined. In positive cases the ovaries were enlarged, hyperemic, and showed haemorrhagic spots and yellow elevations.
The haemorrhagic spots and yellow elevations. Follicles,and the yellow protrusions are due to the formation of corpora luteal. In most cases, microscopic examination is required to make an accurate diagnosis. The formation of he follicles with haemorrhages is frequently called the I and II reaction, while the formation and is necessary for the diagnosis of pregnancy. This test in the hands of various investigators has shown an accuracy of 85 to 98 per cent in the diagnosis of pregnancy.
Although the test is rather simple, and very accurate, there are several drawbacks, and for these reasons, modifications have been developed have been developed to made the test of grater clinical value. The most important drawback is the need for five mice of certain ages and weights. For practical purposes, this would necessitate the keeping of a large number of mice at varying ages in the clinical laboratory. Other defects are the 100 hours of waiting before the results of the test are known and the smallness of the ovaries in the mice, which makes the diagnosis difficult microscopic examination.
The various modifications of he Aschheim-Zondek test depend on the same basic principles. Brown 3 claimed almost 100 per cent correct results in one month the time required by the Aschheim-Zondek test by using blood serum intravenously in rabbits. Davis and Ferrill 4 used thirty-five-to forty-day-old immature male rats and claimed 98 per cent correct results.
Jones and Murgrage 5 found less than 3 per cent of error in using female rats instead of mice and further stated that the specimens could be preserved in toluol for one week so they could be preserved in toluol for one week so they could be shipped long distances . Reinhart and so they could be shipped long distances. Reinhart and Acott,6 in their report, although using the rabbit as the test animal, stated that the ferret and cat could be used.
Of all the modifications, the one outlined by Maurice H. Friedman7 in 1929 seemed to be the most practical. By 1931 he had refined the technique and he gave as his reasons for preference of his test, first, the availability of the animals, and second, the time required for completion of the test. He stated that any female rabbit which was not pregnant could be used after three weeks isolation and that the test could be read in from thirty six to forty eight hours after injecting the urine.
At that time he reported ninety-two followed cases without an error. Wilson and Corner 9 reported a series of cases the same year and stressed the use of large rabbits (four pounds or over). They also made the statement that a positive specimen would remain so for months.
The Friedman test consists of the injection into the ear vein of a suitable rabbit of five to seven cubic centimeters of suitable urine and killing th habit in thirty six to fifty eight hours. A suitable rabbit is one weighing four pounds or over. A suitable specimen of urine is a morning specimen collected following a dry diet the night before. The specimen should have a specific gravity of 1.015 or more and should be filtered before injection.
A positive test is shown by the presence of corpora haemorrhagica and corpora luteal on the ovaries. In the negative test, the ovaries will be small, grayish yellow and may show a few small clear cysts.
Reinhart and Scott, 10 in confirming the work of Friedman, made the statement that the samples of urine from nonpregnant women were utterly without effect on the rabbit ovary, no matter how injected. They reported two errors in 150 cases. On 1931 also, Magath 11 and Randall reported a case of chorio-epithelioma in which the test was positive before and negative after the operation.
Up to this item, the most careful check of the time after termination of the pregnancy when the tests became negative was made by Schneider .12. He ran tests on women during the puerperium and found that no tests were positive four days after delivery. He used this evidence to stress the usefulness of the test in retained decidual tissue following labor of incomplete abortion. He also reported three cases which gave positive tests twelve to twenty days after coitus, two of them before the expected next menstrual period.
In 1933, Ferguson 17 showed that quantitative test s could be devised, which he used to study the effects of treatment of teratoma testis. He showed a quantitative decrease following treatment with a rise following recurrences of the tumors.
Later reports by Reinhart 13 did not tend to discredit the accuracy which the early workers attributed to the test. He reported five false positives and fifteen false negatives in 1,002 cases. Sondern and Silverman 14 where able to raise the percentage of correct diagnosis even in ectopic pregnancy by running both the Aschheim Zondek and Friedman tests on 487 cases. They reported, as did all workers, 100 per cent correct diagnoses in hydatid mole.
The best summary of the accuracy of the Friedman test is given in the American Journal of Clinical Pathology 15 where 5,759 cases tested 152 erroneous results, or a percentage of 2.63.
We have been using a modification of the Friedman test set forth by Dr. Young 16 of Mt. Sinani Hospital of Cleveland. In this method, of animals are operated upon before the test of examine the ovaries and determine their condition before the suspected urine is injected. The operation is carried on under morphine anesthesia with one-half grain of morphine injected intravenously. The abdomen is opened under sterile precautions and the ovaries examined. If the ovaries are negative at this time of inspection, the abdomen is closed and fifteen to twenty five cubic centimeters of urine are injected intravenously. In Youngs communication, she advocated the injection of fifteen cubic centimeter amounts twice at four-hour intervals.
Many of our tests were done in this way and others had only a single injection of twenty to twenty-five cubic centimeters of urine. Forty-eight hours after the first urine injection, the animal is again opened under morphine anesthesia and the ovaries examined. If there is any doubt as to the reaction, an ovary is removed and microscopic examination performed with the frozen section method of hasten the results. The presence of luteinization is considered a positive pregnancy reaction.
Young has also advocated the injection of known positive urine into the rabbits, giving a negative result to make sure that the rabbit can satisfactorily react to the prolan as there are a certain number of rabbits suffering from some type of endocrine imbalance which prevents them from reacting to the test. She believes that some of the false negative results are due to this factor. In her method, all positive ovaries are sectioned and luteinization looked for, as it is possible for certain non pregnant conditions to give haemorrhagic follicle formation without luteinization.
The essential steps in the method used in the cases reported in this paper consist first in obtaining satisfactory sample of urine. The patient is instructed not to take fluids after 6:00 P.M. the night before to insure is then used for the rest. The rabbit which has been previously isolated for at least two days is opened under morphine anesthesia and the ovaries examined. If negative, fifteen to twenty-five cubic centimeters are injected, depending on the specific gravity of the urine.
A urine of specific gravity of less than 1.015 is considered unsatisfactory, although we have obtained several definite positive results with urines of specific gravity of meters are injected intravenously and the rabbits kept isolated for the next forty-eight hours, following which another laparotomy is performed and the ovaries again inspected. The presence of large corpora haemorrhagica and lutein body formation indicates a positive test. In the negative tests the ovaries remain small, gay, and may have a few small translucent cysts.
The test in our hands has been far more valuable as a means of differential diagnosis than in ascertaining, early, whether of not the patient was pregnancy, We have has to cases of teratoma of the testicle and no chorio epitheliomata of hydatid moles, and negative test has served in three instances to set us at ease, where we would otherwise have been in doubt.
As outline of twenty-one cases of the ninety reported will serve to show how the test has been of service in our hospital.
(1) Mrs. T., aged thirty. Amenorrhea, question of fibroid or pregnancy. Test positive. Abortion two months.
(2) Mrs. S., aged forty-three. Amenorrhoea, question of menopause or fibroid. Test positive three times. Delivered.
(3) Mrs. W., aged twenty-four .Amenorrhoea, with pain. Test negative. Operated,cystic ovary.
(4) Mrs. B., aged twenty-seven. Amenorrhea. Test positive. D and C showed placental tissue. Test negative in two days.
(5) Mrs. S., aged thirty-five. Enlarging uterus, with regular menstruations for five months. Test positive. Delivered.
(6) Miss C., aged seventeen. Rapidly enlarging uterus to full term size. Irregular bleeding. Test negative. Operated and pathologic diagnosis: proliferating fibromyoma with early malignant change.
(7) Miss M., aged twenty-five. Amenorrhoea, suspect ectopic. Test negative. Operated and pathologic diagnosis: tubo-ovarian abscess.
(8) Mr. M., aged twenty. Suspected pituitary tumor. Test negative. Autopsy showed cerebellar tumor.
(9) Mrs. V., aged twenty-eight. Suspected ectopic pregnancy. Test positive. Left hospital with indefinite diagnosis, questionable false positive.
(10) Miss B., aged twenty-seven. Aborted at home, bleeding two days after curettage. Test negative. Haemorrhage stopped two days later.
(11) Mrs. M., aged forty. Irregular menses, suspect fibroid or pregnancy. Test negative. No enlargement after five months.
(12) Mrs. W., aged thirty-five. Very obese and abdomen enlarging, endocrine dysfunction. Test positive. Near term.
(13) Mrs. Z., aged thirty-seven. Amenorrhea, tubes tied off in previous cesarean operation. Test positive three times. Therapeutic abortion revealed pregnancy. Since delivered full term.
(14) Mrs. W., aged thirty-give. Irregular bleeding two months, pain right tube. Test negative. Found to have atresia of cervix after coagulation.
(15) Mrs. P., aged forty-eighty. Suspect menopause. Test positive. Delivered.
(16) Mr.J., aged nineteen. Tumor of testicle. Test negative. Proven to be inflammatory.
(17) Miss R., aged twenty-four. Amenorrhea nine days past time for period. Intact hymen. Test positive. Delivered.
(18) Miss B., aged seventeen. Coitus fourteenth intermenstrual day, amenorrhea three weeks. Test negative twice. Menstruated three and one- half weeks late.
(19) Mrs. A.,aged forty-five. Amenorrhea and hot flushes. Test positive. Delivered.
(20) Mrs. J.M, aged forty-four. Amenorrhea and hot flashes twenty- two years after last pregnancy. Test positive. Criminal abortion, menstruate regularly since.
(21) Mrs. N., aged twenty-give. Bleeding after delivery for two months. Test negative. Treatment of endocervicitis Stopped bleeding.
In the ninety cases which we are reporting we had two possible errors, one false negative, which was checked in two weeks and found to be strongly positive and one questionable false positive which we have Portland above in Case 9. The table of results is as follows:
41 Negative .
1 False negative Female.
1 False positive.
We have tried to give a short history of the evolution of the Friedman test, as well as outline the technique of both the Aschheim-Zondek and Friedman tests. We have abstracted in a very superficial ways few of the available articles to show the results and opinions of others who have had longer experience and many more cases than we in order to add weight to our opinions.
We have outlined the Young technic, which we believe is the best method of doing the Friedman test yet to appear in literature, and we have given a summary of a few of the more interesting cases in order to show the importance of the use of this tests in confirming normal pregnancy and deferentially diagnosing the more or less acute abdominal conditions, such as ectopic gestation, hydatid mole and chorio-Epithelioma.
Finally, we have tried to show the importance of the test on ascertaining the completeness of removal of the products of gestation and have made mention of its usefulness in tumors of the pituitary and testicle.