RUPTURE OF THE UTERUS

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RUPTURE OF THE UTERUS Powered By Docstoc
					  28 Augustus 1948              S.A.    TYDSKRIF VIR GENEESKUNDE                                                509

marked angulation at these levels suggesting that        \ras effected. Immediately after clipping, there was
an intrathecal, space-occupying lesion was present.      a complete alteration in the colour of the whole
  1yelography was performed by the lumbar route          zone of malformation-the whole zone became paler
and 3 C.c. of Pantopaque were injected. \¥ith the        and the large loops which were lifted free were
patient in the Trendelenburg position, at the level      excised.
of the I st lumbar vertebra it was noted that there         Haemostasis was carried out and the closure
 was an obstruction to the flow of the Pantopaque        undertaken.
column which fragmented, and the whole appearance          Since the operation, there has been a gradual but
 was that of irregular tortuous filling effects (Figs.   definite improvement in the muscular tone of both
 I and 2).    These defects were continuous. Some        lower limbs and the patient has noted a definite
Pantopaque was able to flow past the lesion but          improvement in the power of both the lower limbs.
some remained as small globules in this site. A            Comrrnents. The clinical symptoms in this case
cisternal myelography carried out by Mr. Krynau\\'       pointed to a space-occupying lesion of the spinal
confirmed these findings.                                cord. It was not possible to reach a more accurate
   The radiological differential diagnosis lay between   diagnosis clinically. There were no igns of any
(a) a venous angioma of the pinal column and (b) a       telangiectasia or of angiomatous malformation in
localised arachnoiditis.                                 the skin or in the mucous membranes to suggest a
   The worm-like appearance (Fig. 2) of the filling      possible angiomatous etiology of the tumours.
defect was thought to be more in favour of the             From a radiological standpoint, the appearances
diagnosis of a venous haemangioma rather than a          are considered to be fairly characteristic of a venous
localised arachnoiditis and a pre-operative diagnosis    angioma.
of a haemangioma was made. It is of interest to
                                                                                  SUMMARY
note, that Buchanan and Walker 6 maintain that
differentiation of these two conditions radiologically      I. A case of variocosities of the spinal vems IS
is not possible. To quote from their own article:        described .
. We cannot concur with the opinion that it is patho-       2. Emphasis is placed on the value of the myelo-
gnomonic for we have seen myelograms similar to          g-raphic findings in making a pre-operative diagnosis.
that of the patient in the present case, which were         3. The literature is reviewed and the extreme
taken of patients with adhesive arachnoiditis of the     \'ariability of the clinical picture is discussed.
spinal cord which were identical.'
   The operation was performed by Mr. Krynauw.             "Ve are indebted to NIL Krvnauw for permission to quote
A laminectomy of the nth and 12th thoracic and the       from the operative findings. .
1st and 2nd lumbar vertebrae was done.             The
                                                                                 REFERENCES
operation revealed a complex arterio-venous mal-
formation extending from the conus upwards for           1 Sargent, P. (1925): Brain. 48. 259.
8 cm. Careful dissection of the dilated vessels was      2 Globus, J. H., and Doshay, L. J. (1929): Surg. Gynec.
made to free them from the cord. The origin of                Obst. 48. 345.
                                                         3 Black, W. C., and Faber, H. K. (1935): J. Amer. Med.
the vessels appeared to be at the internal foramina           Assoc. 104. 1889.
at the level of the 2nd lumbar \·ertebra. The vessels    4 Gray (1946) : Anatomy.     Longman & Sons. 28th ed.
were clipped at their Source and were excised. A         5 EIsburg. C. A.. Dyke, C. G., and Wolf, A: Surgical
control of the blood supply was obtained by a clip           Diseases 01 tlte Sp'inal Cord, Mem.branes and Nerve Roots.
                                                              London: H. K. Lewis & Co.
placed on the posterior descending vein and              6 Buchanan. D. ~., and \Valker, A. E. (1941): Amer. J. Dis.
occlusion of this vessel where it entered the conus           Childh. 61. 928.




                                   RUPTURE OF THE UTERUS
                                        NOTES ON THREE CASES
                                           C. MARKs, M.B., CH.B.
                                              Kimberley, C.P.
       adequa!e ante-natal
W ITH uterus very rarely services, rupture of
   the               IS    encountered, but in
                                                                                    CASE 1

the past six months three cases of spontaneous rup-        E. S., a Native-female, 32 years old, was admitted
ture of the uterus have. been treated at the Kimberley   to General Surgical Ward on 15 November 1947.
Hospital. The mortahty of ruptured uterus is stated        History. Three days before admission she
to vary from 25-50 %. The three cases noted here         developed sudden, slight, vaginal bleeding for one
recovered completely.                                    day. The next day she experienced a dull pain in
  510                                    S.A.   MEDICAL JOURNAL                                 28 August 1948

the left iliac fossa and felt very weak and faint.        inches; (b) Intercristal, 9.5 inches; (c) External
Abdominal distension then commenced gradually,            Conjugate, 7 inche .
till it reached the present degree. She vomited three        A bd01ninal E:mrninatioll. A right paramedian
to four times during this time; the vomitus was           operation scar. The uterus extended up to the
small in quantity and consisted of clear fluid. Her       xiphisternum. It "'as tense, tender, hard and non-
bowels acted regularly until the day before               contracting.
admission.       Her last menstrual period was 18            Right Occipito-Anterior Position. The head
months ago.         One year ago she had a pelvic         was high and mobile; the foetal heart was heard at
operation in Johannesburg after having been               150 per minute.
amenorrhoeic for eight months. Since the operation           Vaginal Exami1lGtion. The cervix was three
she had not menstruated .until she had the vaginal        fingers dilated. 10 a.m. Ko advance at 10 a.m. but
loss before admission.                                    the general condition was unchanged.
     On General Examination. There was marked                Diagnosis. 'Silent' rupture of an old Caesarean
 pallor of the mucous membranes. Temperature,             scar of the uterus. Un·der gas, oxygen and ether
102° F.      Pulse rate, 140 per minute. Respiration      anaesthesia the old abdominal scar was excised and
rate, 30 per minute. Blood pressure cj5/s0 mm. Hg.        the abdomen opened through dense fibrous tissue.
Blood Hb., 25%. Red cell count, 2 million per             As this was di\"ided the placenta presented through
c.mm. C.r.,0.6. White cell count, 16,000 per c.mm.        a rent in the uterus. The foetus was removed and
Polymorphs, 78%; Lymphocytes, 22%.                        it immediately cried.
    Cardio-vascular, Respiratory and NerJous Sys-            It was found that the longitudinal rupture in the
tems. Normal.                                             uterus had been sealed off by adherence to the
    A bdomen. Marked distension, with tenderness          anterior abdominal wall. The anterior abdominal
over the whole abdomen, especially in the hypo-           wall was dissected off the uterus and as the patient's
gastrium. Dullness to percussion in both flanks.          condition wa still good, a subtotal hysterectomy
:\! 0 borborygmi.      Midline subumbilical operation     was performed.
scar.                                                        I A pril.  Mother and child were both well and
     Vaginal Examination. A mass was palpable in          were di charged from hospital.
the pouch of Douglas, pushing the cervix upwards.
    Provisional Diagnosis. Infected pelvic haema-                                CASE   3
tocele after a ruptured ectopic pregnancy. The case
,,"as treated for five days with blood transfusions and       S. c., a Natiye female, aged 23 years, was
penicillin. With Wangcnsteen gastric suction the           admitted to the Maternity Ward at 12.30 a.m. on
abdominal distension resolYed and a large mass             16 May 1948. She was at full term.
became palpable in the left iliac fossa. On three             History. Labour pains commenced four hours
separate occasions the patient suddenly felt faint         before with a slight show.       Caesarean section
and the pulse became feeble but she rallied.              August 1946, for disproportion.
     20 Nove'111lber 1947.  A pelvic laparotomy was           On General Examination. Slight pallor of the
performed under gas, oxygen and ether anaesthesia.        mucous membranes. Temperature, cj50 F. Pulse,
A ruptured uterus was found and several layers of          120 per minute. Respiration 24 per minute. Blood
dense blood clot.       Both tubes were intact. No        pressure, 96/60 mm. Hg.
foetus or lithopaedion was present. A subtotal               Cardio-vaswlar, Respiratory and Nervous sys-
hysterectomy was performed.                               tems. Normal.
    15 December. The patient was discharged in a             Abdomel1. The uterus was contracting and
good general condition.                                   tender. A breech presented at the brim of the
                                                          peh·is. :\To foetal heart was heard.
                        CASE 2
                                                             Per R ectU1J1. The cervix admitted one finger.
                                                             3.30 a.111. The patient complained of abdominal
  S. NI., Native female, aged 24 years, was admitted      pain and increased vaginal bleeding.        She was
to the Maternity Ward at 8 p.m. on 24 March 1948.          shocked and collapsed, with a p.ulse of IS0 per
She was a second para, at term.                           minute and thready. Blood pressure, 60/20 mm. Hg.
  Previous Pregnancy. She had had a Caesarean                A bdomel1. The foetus was palpable free in the
section in 1944 for disproportion.                        upper abdomen lying transversely across it; a hard
  Present Pregnancy. Labour pains commenced 12            tense uterus was palpable beneath the foetus.
hours before admission \yith good, strong, regular           The patient was treated expectantly with morphine
pams.                                                     and blood transfusions, and at 8 a.m. a laparotomy
  On General Examination. Temperature, 98-40              was performed under gas, oxygen and ether
F. Pulse, 92 per minute. Respiration, 20 per              anaesthesia.
minute.                                                      The· child \yas found with the membranes intact
  Cardio-vascu.lar Respiratm"y and Nervous S:ys-          lying free in the peritoneal cavity and it wa~
tems. Normal.                                             removed. The placenta was also removed. Very
  Blood pressure. 1I6/64 mm. Hg.                          little free blood was present and the uterus was
  External measurements. (a) Interspinous, 8.5            found contracted despite a 3.5 inch longitudinal
  28 Augustus 1948                 S.A.    TYDSKRIF VIR GENEESKUNDE                                                511

perforation. In yiew of the patient's poor condition            2. In the first case quoted there \\'as no evidence
the ruptured uterus \\'as repaired by suture and the          of pregnancy, but nevertheless rupture of the uterus
abdomen closed after sterilizing the patient.                 had occurred, The other cases ruptured during
  26 Ma)'. The patient \vas discharged in good                labour.
condition.                                                      3. A unique feature is the fact that in case 2
                       COMMEXTS                               a live child was deli\'ered a fter rupture of the uterus
  Several points of interest may be mentioned:-               had occurred.
  1. Each of these cases had previously had a
                                                                Thanks are extended to Mr. N. Kretzmar and Dr. B. Bishop
Caesarean section of the classical varietv and each           of the Kimberley Hospital Honorary Staff, for permission to
subsequently ruptured.                   .                    publish this series of cases.




                              PSYCHONEUROSIS IN THE SOLDIER *
                                ITS PSYCHOPATHOLOGY AND AETIOLOGY
                                             DAVID PERK, M.D., D.P.M.
                                                     Johannesburg

                                               1. PSYCHOPATHOLOGY

THOUGH psychoneurosis is mostly predetermined                 true in reference to psychoneurotic break-dO\n1S in
     by inborn constitution and by the development            action.
in life of the psyche, current external circumstances            The drama of human life is played out in succes-
have an important bearing on the timing of the                sive attachments that human beings form and in the
neurotic break-down. In adding a further stress to            separations that follow. Some occur in the natural
the inner stresses afflicting the indiyidual. an              course of the individual's psycho-sexual maturation
environmental situation is often the means of pre-            and growth of physical independence, and some
cipitating a psychoneutosis.       This effect throws         are forced upon him by circumstances. The less
light on the composition of stresses within the               emotional independence he has achieved in growing
psyche. Because the soldier had to face em,iron-              up. the less he is prepared to absorb enforced
mental situations peculiar to his calling, the aetiology      separations, or put differently, the more fixated the
of the psychoneuroses from which he suffered had              is in his emotional attachments the more keenly he
a different construction from that of the civilian            feels separations. Suddenly removed from his home
psychoneuroses, especially of peacetime.             The      and either parents or wife. and set down in the midst
aetiology of psychoneurosis in the soldier illuminates        of a host of strangers and in unfamiliar surr-oundings,
the psychopathology of both military and civilian             the iJllmature person, on enlistment. felt not only a
psychoneurosis,                                               sense of loss of vital psychical props, but a positiye
                                                              threat of annihilation. as he reeled and floundered in
                  IXTER:,<AL SITUATION                        the novel and regulation-ridden environment. In
  If World V/ar I produced the label' shell shock.'           contrast, the Ilormal type of person soon found his
World War II gave birth to ' separation neurosis '.           bearings and made fresh attachments. Not infre-
In the early days of the War the cliche tlsed \vas            quently. however, a soldier who had experienced
, mother fixation', to be replaced later by the term          separation from his mother or wife or sweetheart,
'separation neurosis'. Applied to describe the                from his home and all that it meant to him. from
unhappiness experienced by the soldier \vho has to            hi to\\"n and country, and from individuals and units
leave his mother or his wife, to whom he was                  in the service to whom he had £!TO\\'n attached. \,"ith
excessively attac.hed; ?r t.he anxiety of the soldier         no more than a passing sense of emptiness and ,,'ith
confronted by difficulties 111 service life and threats       unruffled philosophy, might yet break down. This
to his safety, and feeling in the circumstances a             resulted from the dependence needs he experienced
resurgence of dependence needs, it was valid enouo-h.         in his terrifying loneliness. on going into action.
It tended, however, to oye~simplify the psycho-                  The intensitv of an attachment varies with the
pathology of psychoneurOSIS 111 the soldier when. as          dependence needs of the individual and it is thus seen
sometimes happened, it was advanced as a o'eneraI             in different strengths in different persons. Some feel
explanation of the condition. This is particularly            a keener frustration in separation than others. Even
                                                              the less susceptible may, however, feel an addt>d
  * The section or. psychopatholo~y formed the subject of a   keenness in separation under specially stre. sful
lectme delivered at Tara Hospital.                            conditions,

				
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