TOXOPLASMOSIS—The Protean Manifestations of the Condition and Their Significance in Pregnancy and in Newborn Infants

Toxoplasmosis is a relatively common and generally mild parasitic infection which can, however, produce fatal and crippling complications under certain conditions — particularly when a human fetus or a newborn infant is infected. In this instance, the infection is the result of a spread of the acquired disease which may occur in the mother in the last six months of pregnancy. Although the infection of adults can be dangerous and fatalities have been reported, the danger to the nervous system, eyes and other structures of the newborn infant can be devastating—blindness, brain damage and mental deficiency, particularly as the result of an obstruction to the flow of circulating cerebrospinal fluid within the brain.This report covers a number of differing features of the disease which have been described separately by other authors in specialty journals and in the foreign literature. If present, these signs should suggest toxoplasmosis, particularly in pregnancy, in the newborn infant and in still-born infants.Early diagnosis is of paramount interest in view of the poor response which may be obtained in the treatment of subacute and chronic phases of the illness. Difficulties in diagnosis stem from the manifestations of toxoplasmosis which closely resemble the symptoms of other infectious diseases.The clinical laboratory diagnosis is made by the isolation of the organism or by the demonstration of immune protein in the patient''s serum.     

VOMITING AS A SYMPTOM OF SERIOUS DISEASE IN INFANTS AND CHILDREN

Vomiting or its lesser stages—anorexia, nausea—is a prime symptom of the most serious surgically curable diseases of childhood.In the newborn, when vomitus is green, abdomen scaphoid, and erect roentgen view shows air-fluid levels in stomach and duodenum with gas beyond, partial duodenal obstruction is present and midgut volvulus with malrotation is likely enough to justify immediate exploration.In infancy, vomiting is a clear sign of intussusception when associated with intermittent colicky pain, palpable mass and “currant-jelly” feces. These symptoms are not always present, and if there is blood in the feces, barium enema study must follow. In further doubt, exploration may be justified.In childhood, a common early symptom of appendicitis is vomiting accompanied by pain without any complete remission. Constipation is frequent but diarrhea may occur and contribute to an impression of gastroenteritis. Complete and repeated physical examination, with a history of the above symptoms, should lead to correct diagnosis.     

INTESTINAL ATRESIA OR STENOSIS IN THE NEWBORN—Associated with Fibrocystic Disease of the Pancreas

In a review of cases of intestinal atresia or stenosis in the newborn at Children''s Hospital of Los Angeles it was noted that in approximately 10 per cent there was clinical or anatomic evidence of fibrocystic disease of the pancreas. Histologic sections of the bowel in all these cases showed the alterations of the mucosa commonly found in fibrocystic disease. Extensive ulceration, foreign body reaction and calcium deposition in the bowel wall were observed in five cases. Sections through the site of obstruction in one patient showed narrowing of the diameter of the bowel with preservation of muscular layers, but replacement of the central portion by a vascular, fibrous diaphragm in which giant cells, hemosiderin and calcium were prominent. This suggested that in certain instances obstruction of the intestine may be caused by fibrosis secondary to injury of the mucosa by abnormal meconium.Awareness of the common association of intestinal obstruction and fibrocystic disease of the pancreas and recognition of the histologic change in the bowel in fibrocystic disease may lead to early diagnosis of this disorder in some infants with intestinal obstruction.     

Pancreatic Disease in Infancy and Childhood—Surgical Implications

Surgeons whose practice involves many infants and children should be acquainted with all abnormalities of pancreatic malformation and function. Conditions amenable to surgical treatment are few, but serious.Trauma to the pancreas in childhood is most commonly diagnosed by fever, leukocytosis, rectus spasm and elevated serum amylase. Drainage of the lesser sac and debridement of devitalized tissue may prevent the sequelae of pseudocyst formation which seems to follow the untreated injury. True congenital cysts are characterized by an epithelial lining.Mucoviscidosis complicated by meconium ileus remains a challenging disease of the newborn that requires early operation. Ten per cent of infants with cystic fibrosis may be threatened by intestinal obstruction from this cause. Some children surviving the newborn period go on to develop obstruction later.Annular malformation of pancreas may produce upper intestinal (duodenal) obstructive symptoms immediately after birth. Surgical correction by duodenojejunostomy should be postponed only long enough to correct severe fluid or electrolyte imbalances.Idiopathic spontaneous hypoglycemia has the most serious prognosis if convulsions are allowed to recur. Increased metabolic rates in infants increase the need for control of blood sugar levels by either administration of cortisone or pancreatic resection. If adenoma is the cause, a conservative resection of the tumor suffices. If serial frozen section fails to reveal either tumor or hypertophy of insulin-producing cells, blind pancreatectomy may be indicated, for irreversible brain damage develops early in uncontrolled hypoglycemia.     

INTESTINAL OBSTRUCTION IN THE NEWBORN

Any newborn who continues to vomit in the first few days of life, particularly if the vomitus contains bile and if the abdomen is distended, should have immediate investigation because intestinal obstruction in the newborn is a fatal condition unless promptly recognized and surgically corrected. The most common cause of obstruction at this age is atresia and the simplest possible surgical procedure which adequately corrects this deformity should be done. It is also possible to successfully correct the obstruction caused by other congenital deformities such as annular pancreas and meconium ileus.Although prematurity is a definite factor in the outcome, intestinal obstruction in the newborn can be corrected with a surprisingly low mortality. Occasionally unusual methods are needed to tide these infants over the critical period of postoperative care.     

Isolation of Exophiala jeanselmei associated with esophageal pathology — Three cases,laboratory and clinical features

Exophiala jeanselmei was isolated from three esophageal cultures over an 11-month period at Lutheran General Hospital. We believe this provides evidence for a new site of isolation, since previous reports of the organism's incidence were confined to skin and lung. Case 1 is an eight-year-old female with a three-year history of gagging and vomiting. Esophagoscopy revealed a mass biopsied as vegetable material. Case 2 is a 66-year-old retired male with a history of obesity, diabetes and spinal stenosis. Following back surgery, the patient developed odynophagia. Esophageal biopsies showed ulceration and bacterial colonies with no evidence of fungus. Case 3 is a 62-year-old male gardener who is also a nail biter. Esophagoscopy revealed a gastro-esophageal stricture with reflux and evidence of a hiatus hernia. Material biopsied was consistent with Barrett's esophagus and evidence of fungi was seen. The esophageal mass of case 1 and the esophageal brushings of case 2 and 3 grew E. jeanselmei. Aspiration, reflux, and mechanical disruption of the esophageal mucosa are possible predisposing factors in colonization of esophageal lesions by this ubiquitous, normally low virulence organism.     

DIVERTICULITIS OF THE COLON—Surgical Treatment

Appropriate surgical treatment of diverticulitis of the colon can result in a highly satisfactory proportion of permanent cures, with an operative mortality of 2 to 5 per cent.Colostomy is a valuable emergency procedure for the control of severe infection or the relief of obstruction but is not a satisfactory definitive treatment for the cure of diverticulitis. Definitive surgical treatment requires resection of the involved segment of colon.Three indications for surgical intervention in “uncomplicated” diverticulitis are: (1) continued or repeated attacks, (2) persistent deformity as seen by x-ray examination, and (3) persistent blood in the stools.Although a three-stage operation is usually considered a safer procedure, one-stage resections may be safely and satisfactorily employed in many instances.     

A Clinical Classification of the Mechanisms of Perinatal Wastage

A clinical classification of perinatal morbidity and mortality should be based upon the pathophysiological mechanisms which affect the fetus and newborn infant, resulting in this morbidity and mortality. Each mechanism is a distinctive disturbance which may be regarded as the common pathway for expression of insults to the fetus and newborn infant arising from a wide variety of obstetric abnormalities and specific disease entities. The following classification of mechanisms incorporating the whole spectrum of perinatal problems is proposed: (1) developmental abnormality; (2) immaturity and prematurity; (3) chronic fetal insufficiency; (4) acute fetal insufficiency; (5) newborn respiratory failure; (6) blood group incompatibility; (7) infection, and (8) trauma.     

DIAGNOSIS OF INTESTINAL OBSTRUCTION IN THE NEWBORN,A Review of the Literature with a Report of Eight Additional Cases

Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made.In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth—a sign which may be helpful in diagnosis.Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal.The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance.     

ROENTGEN THERAPY OF INTRATHORACIC NEOPLASMS

The results of treatment of carcinoma of the esophagus, whether by operation or radiation, are equally poor: At best 3 to 5 per cent 5-year survival in larger series. Likewise, the palliative results as judged from short-term survival after 1, 2, and 3 years are approximately the same. The cause of failure is usually that metastatic deposits are already present in the paraesophageal and mediastinal nodes by the time diagnosis is made. Control of these nodes is impossible either by surgical or by radiation therapy, but in about half of the patients adequate irradiation therapy will be palliative and will satisfactorily re-establish esophageal function, but entail less morbidity than surgical operation.Carcinoma of the lung yields little to radiotherapy. Cure is rare, but specific aims of palliation may be achieved. Anaplastic tumors can be controlled locally by irradiation, but they metastasize so rapidly that the chief aim of radiotherapy is to relieve pulmonary embarrassment due to rapid enlargement of mediastinal lymph nodes. Epidermoid carcinomas and adenocarcinomas may be treated at points of bronchial obstruction by intense irradiation, but diffuse thoracic pain is better palliated by sympathetic nerve block.     

Coin ingestion,an unexpected finding at colonoscopy: case report

Gastrointestinal tract ingested foreign bodies are common problems, particularly in children. The most common ingested foreign bodies are coins. Once foreign bodies have passed through the esophagus and into the stomach, 80% will pass through the gastrointestinal tract unimpeded, with the remainder requiring endoscopic or surgical removal. It is rare to find ingested foreign bodies at routine colonoscopic examination, in particular in an adult without any prior history of ingestion.     

Congenital tuberculosis associated with maternal disseminated miliary tuberculosis

Untreated tuberculosis during pregnancy presents a serious risk for transmission of disease to the newborn and can result in adverse perinatal and obstetrical outcomes. Tuberculosis during pregnancy and congenital tuberculosis are infrequent conditions and are difficult to diagnose due the non-specificity of the symptoms. A case report is presented of a woman who had no children previously with disseminated miliary tuberculosis. Tuberculosis symptoms appeared immediately after birth of the first child, with a clinical diagnosis on the second month after childbirth, whereupon the patient died. The son, a premature infant, showed disease symptoms from the first day, with primary pulmonary complex and persistent atelectasis due to bronchial obstruction. The obstruction was due to thoracic lymphadenitis and coinfection with cytomegalovirus. The infant received standard treatment and his condition improved.     

成人肾恶性横纹肌样瘤的研究:1例报告及文献复习

应用组织化学、免疫组织化学及电镜技术对我国首例成人肾恶性横纹肌样瘤（ｍ ａｌｉｎｇａｎｔｒｈａｂｄｏｉｄｔｕｍ ｏｒ, ＭＲＴ） 进行了研究, 与婴幼儿ＭＲＴ相比本例有以下临床病理特点： （１） 以血尿为早期和唯一症状,肿块缺乏特征性ＣＴ 改变; （２） 光镜下大量ＰＡＳ阳性嗜酸性球形小体多位于细胞外, 电镜下细胞外小体由微丝构成并有界膜包绕; （３） 免疫组化显示肿瘤细胞向神经外胚层、横纹肌和组织细胞多向性分化; （４） 肿瘤侵袭力较低, 高度表达ｎｍ ２３－Ｈ１ 蛋白, 随访１８个月术后化疗效果佳, 提示其恶性度较婴幼儿ＭＲＴ 低。     

Decidual reaction of the cervix; a review of 27 cases

Decidual reaction of the cervix is a benign growth produced by the hormones of pregnancy. These reactions or changes in the cervix are present in about 20 per cent of normal pregnant women. They may look like cancer but are not cancer. They are benign lesions. Bleeding is a common symptom and may occur at any stage of pregnancy. The presence of decidual reaction does not predispose to spontaneous miscarriage. In most cases no treatment is required; in a few light cauterization may be needed to control bleeding. Any suspicious lesion should be biopsied to rule out malignancy. By microscopic examination any experienced pathologist can differentiate a decidual reaction from cancer. The consensus of opinion is to let the pregnant woman deliver, normally, with this benign lesion, for it disappears after the baby is born. If cancer is found during pregnancy, it should be actively treated.     

The diagnosis of intestinal obstruction in the newborn; a review of the literature with a report of eight additional cases

Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made. In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth-a sign which may be helpful in diagnosis. Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal. The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance.     

Action of Douglas Fir Tussock Moth Larvae and Their Microflora on Dietary Terpenes

A single type of bacterium, tentatively identified as a member of the genus Bacillus, was isolated from 2 of 20 midguts of Douglas fir tussock moth larvae being fed a diet of fir needles. No bacteria could be isolated from most midguts. Although spherically shaped bodies were present in the food bolus, these bodies, if microorganisms, could not be distinguished from spherical bodies associated with the plant tissue. The Douglas fir tussock moth dietary terpenes were altered during their passage through the insects, with two new terpenes being detected in the feces. One of these was identified as isoborneol. The relative significance of the insect and gut microflora with respect to terpene modification is unresolved. The well-established toxicity of terpenes may account for the near absence of common gut microflora in the insects.     

ELECTRON MICROSCOPY AND X-RAY SCANNING MICROANALYSIS OF NEEDLE BIOPSY MATERIAL FROM HUMAN LIVER

A study has been made of the fine structure of hepatic parenchymal cells of human biopsy material in a case of pancreatic tumor with obstructive jaundice. Dense particles about 60 A in diameter have been found in the cytoplasm, which are considered to be ferritin molecules by electron microscopy. They are encountered throughout the cytoplasmic matrix and are often aggregated in electron-transparent areas, most of which are enclosed by an apparently single-layered membrane. Identification of the elemental iron has been pursued by the application of the x-ray scanning microanalyser which reveals a quantitative value within 1.0 per cent of the pure iron sample. The use of x-ray scanning microanalysis enables one to obtain accurate data from extremely small and precisely defined volumes of biological specimens.     

THE RESISTANCE OF INSECT PARASITOIDS TO THE DEFENCE REACTIONS OF THEIR HOSTS

Some of the following propositions are to be read as suggestions or hypotheses, supported by circumstantial or direct evidence, but not yet rigorously demonstrated. An estimate of the significance to be attached to each should be gathered from the body of the paper rather than from the following brief statements. 1.The problem is posed: how do endophagous parasitoids counteract the haemocytic defence reactions of their usual hosts? 2.It has been demonstrated that the egg and young first-instar larva of Nemeritis canescens have a coating on their surface which enables them to escape the attention of the haemocytes of their usual host, and to develop without exciting a defence reaction. The coating is applied to the egg before it is laid, and to the cuticle of the larva before it hatches. A little evidence suggests that some other ichneumon wasps of the subfamily Ophioninae may use this mechanism of resistance. 3.Older first-instar larvae, and the second and later instars, of many parasitoids, both hymenopterous and dipterous, probably overcome the haemocytic reaction of their host by rapid feeding, which depletes its blood both of cells and of nutrients, and so drains its resources that haematopoiesis is prevented and encapsulation becomes impossible. 4.The common habit of parasitoids of lingering in the first instar, before ingesting much food, while the host goes on developing to another stage or undergoes diapause, may enable the larva to retain a protective coating that would have become ineffective if it had grown. When at length the larva does feed and grow, the preceding mechanism (3) comes into play. 5.The teratocytes and pseudogerms formed by many species in several families of Hymenoptera absorb nutrients on a large scale from the blood of the host. They act quickly, as soon as the larva hatches. I suggest that by their attrition of the host's reserves of food, and its consequent debility, they prevent an effective haemocytic reaction to the young parasitoid. 6.Some dipterous and hymenopterous parasitoids first inhabit the intestine of their host, and do not penetrate the body cavity until they are ready to overwhelm the defence reactions by rapid and gross feeding. 7.Parasitoids that live temporarily inside an organ of the host may there acquire a coating which protects them from reaction by the blood cells. 8.Species of parasitoids that occupy an organ of the host for a long period, and develop inside it, escape a defence reaction because they live within the connective tissue covering the organ, to which the blood cells do not react. 9.Eggs of hymenopterous parasitoids laid within the embryos of their hosts may be treated by the embryonic blood cells as a developing organ, and become covered with connective tissue as those organs are. Thereafter they would not be recognized as foreign bodies. 10.Parasitoid eggs laid in the eggs or the young larvae of their host may be coated with host substances, or covered by connective tissue (9), before the blood of the host be comes capable of vigorousdefence reactions. They would there after escape recognition as foreign bodies. This may be the advantage of the habit of the so-called egg-larval parasitoids. 11.Reasons have been given by Schneider (1950) for his belief that the serosa of the ichneumon wasp Diplazon fissorius secretes something that locally inhibits the defence reactions of its hosts. The trophamnion and pseudoserosa of some parasitoid eggs may have this function. 12. Some parasitoids, especially second- and third-instar larvae of Tachinidae, physically repulse the haemocytes of their host, moulding them into a capsule that serves the maggot as a respiratory sheath.     

COMPLICATIONS FOLLOWING SUBTOTAL GASTRECTOMY

Four hundred consecutive cases in which subtotal gastrectomy was done for duodenal and gastric ulcer were reviewed. The mortality rate was 3.5 per cent. There were 57 complications, an incidence of 14 per cent. Of the fatal complications, duodenal stump disruption was the most common and serious—11 cases and 7 deaths. The other fatal complications included various types of obstruction, pulmonary embolus, hemorrhagic pancreatitis and separation of the abdominal incision. Of the nonfatal complications, obstruction of the stoma, anastomotic bleeding, pneumonia, venous thrombosis and wound infection were the most common.Catheter duodenostomy is helpful in the closure of a difficult duodenal stump. Where this was done in the present series there were no fatalities.Electrolyte balance, correction of protein deficiencies, blood replacement and the judicious use of antibiotics are important prophylactic factors against postoperative complications.