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
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
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.
W ITH uterus very rarely services, rupture of
the IS encountered, but in
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.
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.
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,