A CASE OF PREGNANCY 
COMPLICATED WITH 
Uterine Fibroids and Meas les- 
By D. W. CATHELL, M. D., 
OF BALTIMORE, MD. 
Reprint 
FROM TRANSACTIONS OF 
Metrical anti JFacuitp > 
of the State of Maryland. 
1886. STEAM PRE" OF 
GUGGENHEIMER; WEIL & CO. 
BALTIC Re. [Tieprint from 11 Transactions of the Medical and Chirurgical Faculty of 
Maryland" for 1886.] 
A CASE OF PREGNANCY COMPLICATED WITH UTE- 
RINE FIBROIDS AND MEASLES. 
By D. W. Cathell, M. D., 
Of Baltimore, Md. 
2\Irs. Lizzie S., American, aged 38 years, 5 feet G inches high, 
healthy and stoat, was married January 15, 1885. 
Menstruation, which had always been normal, continued to be 
regular for seven months after marriage, being last present from 
the 2d to the 6th of September, 1885. 
Its failure to return on September 30. and its continued absence 
after that date, created a belief that pregnancy had taken place. 
A slight discharge of blood from the vagina, early in December, 
accompanied by feeble uterine pains, caused fear that an abortion 
was threatened. A vaginal examination made at that time, dis- 
closed the fact that a hard, immovable fibroid mass, the size of 
an ordinary foetal head at term, occupied the whole of the lower 
portion of the pelvic cavity, displacing the cervix uteri forward 
and forcing the os uteri above the pubes, making it impossible to 
reach either the cervix or os with the finger. 
Careful examinations proved that this mass was not at all 
pedunculated, but grew in and formed a portion of the posterior 
walls of the uterus; in other words, was interstitial. 
A subserous fibroid, the size of a duck egg, was discovered on 
the left side of the fundus uteri, another about half that size was 
opposite to it on the right, with several others, still smaller, scat- 
tered here and there. 
With such conditions present, a positive diagnosis as to the 
existence or absence of pregnancy was, at that time, not possible. 
During December and January she was examined, at different 
times, by three prominent gynecologists, in each of whom the 
continued absence of menstruation excited a strong suspicion of 
pregnancy, although it was difficult to understand how impregna- 2 
D. W. CATHELL, M. T>. 
tion could be accomplished with the os uteri entirely away from 
its normal position, and in the face of such an obstruction as this 
pelvic mass presented. 
Early in February the belief that the patient was pregnant was 
strengthened by the darkening of the areola around the nipples, 
and the purplish blue color assumed by the vaginal mucous mem- 
brane. Later in February all doubts were dispelled by the move- 
ments of the foetus. 
As soon as the presence of pregnancy was undoubtable, consul- 
tations were held, during which the possibility and the advisability, 
of inducing abortion were earnestly discussed. Also, whether it 
would be better for the patient, to treat her at her home or in 
a hospital. 
It was finally determined to let her remain at her home, which 
was comfortable; also, not to attempt to produce abortion, 
because the hard immovable pelvic fibroid not only offered a very 
formidable obstacle to its induction, but would have completely 
prevented the discharge of the foetus, placenta and lochia; and 
bearing in mind the various resources that nature may bring to 
her aid during the latter part of gestation and during labor ; the 
certain loss of the child, and the very great danger to the mother 
that would attend an attempt to deliver prematurely, either by 
the vagina or through the abdominal walls, it was finally deter- 
mined not to interfere in any way previous to the beginning of 
natural labor. 
Careful preparations for this event were made by Dr. II. P. C. 
Wilson, Dr. A. F. Erich, Dr. Robert T. Wilson, the writer and 
his son, Dr. William T. Cathell, and the occurrence of labor was 
awaited with intense interest and anxiety. 
May 18, Mrs. S. was visited by a neighbor, who had a child 
in her arms suffering with the measles, which were very prevalent 
in the city at that time. The result was that Mrs. S. took a typical 
and severe case of measles. The eruption appeared on her June 
1, accompanied by a short, troublesome cough, with anorexia, 
nausea, etc., that greatly impaired her general health, and her 
spirits, which up to that time had both been excellent. 
The most distressing symptom accompanying the measles was 
a short, jerking cough, during a paroxysm of which at 1 o'clock, 
A. M., Saturday, June 5, the amniotic sac was accidentally rup- 
tured, eight days before the calculated time, which caused the SECTION ON OBSTETRICS AND GYNECOLOGY. 
3 
discharge of about one quart of amniotic fluid, and was followed 
by slight labor pains. 
An examination, two hours later, showed that the large tumor 
still occupied the pelvis, and that in consequence it was still 
impossible to touch the os. 
Distinct labor pains began at 3 o'clock, A. M., Sunday, June 
6, and gradually increased in severity and frequency till 4 o'clock 
that afternoon when, all the medical attendants being present, 
and the os uteri being still out of reach, it was agreed to admin- 
ister chloroform and make an examination. The patient was 
anaesthetized in the supine position and a hand was introduced 
into the vagina, but it was found impossible to pass the tumor, or 
to reach the os uteri with the patient (who weighed 225 pounds) 
in that position. 
For the purpose of getting the aid of gravity, etc., the patient 
was then placed in the genupectoral position and the hand was 
again introduced, resulting in the discovery of the os uteri, which 
lay to the left side, opposite the left obturator foramen ; that it 
was dilated to the size of a ten cent piece ; that the foetal head 
occupied the left anterior occipito-iliac position, and that the 
tumor, which was interstitial in the cervix uteri, could be lifted 
to a limited extent, but that pushing it up necessarily carried with 
it the whole of the cervix uteri, of which it constituted a part. 
It was also found, much to our relief, that the tissue constitu- 
ting the great hard mass had undergone very marked softening. 
Attempts to dilate the os with the fingers and hand were so suc- 
cessful that finally the os was almost fully dilated. The patient 
was then again placed in the supine position, and an attempt was 
made to apply the forceps to the foetal head, which failed because 
the uterine contractions had not been sufficient to fix the child's 
head, which was, of course, very high up. 
A determined and successful attempt was then made to enter 
the uterus and grasp the feet-version was accomplished, and a 
still-born female child, weighing about six pounds, was extracted. 
The delivery was accomplished with but little hemorrhage. 
There was a transverse laceration of the posterior wall of the 
vagina, adjacent to the tumor. 
A laceration of the perinseum, not extending into the rectum, 
was then closed with four wire sutures. A catheter passed into 
the bladder brought away half an ounce of urine. The vagina and 4 
1). W. CATHELL, M. 1). 
uterus were washed out with a solution of corrosive sublimate, 
7| grains to two quarts of water (1 to 4,000). A hypodermic of 
fluid extract of ergot was then given. The adherent placenta, 
which was attached to the fundus and posterior wall, was 
extracted manually, and the patient was allowed to emerge from 
the anaesthesia, which had been continued for an hour and a 
half. 
Prolapsus of the cord, which occurred during the act of turning, 
was the cause of the still-birth. 
The patient was left at 7 P. M. in a tolerably comfortable 
condition. Two hours later she was again seen and found to be 
complaining of considerable abdominal and vaginal soreness, which 
were aggravated by the measle cough that was still present. Other- 
wise she was comfortable and talkative. 
A cough mixture, containing morphia, gr. A to the dose, 
that she had been taking every two hours for several days, was 
ordered to be continued. About two ounces of urine were with- 
drawn with a male gum-elastic catheter. 
Four hours later, 1 A. M., Monday, I was summoned, and 
found her complaining greatly of a short, troublesome cough, with 
hoarseness and nausea. Also, great peritoneal and vaginal sore- 
ness. Pulse, 86 ; axillary temperature, 99|. Ordered morphia 
sulph. an eighth of a grain, to be taken every hour till the pain and 
soreness were relieved; also, ordered the usual remedies for nausea. 
Monday, June 7, 9 o'clock, A. M.-Pulse, 112; axillary tempera- 
ture, 99 ; respiration, 20. The patient feels sore and exhausted, 
and is still annoyed by the short racking cough; she passes urine 
normally. There has never been any lochial discharge and no 
odor is perceptible. A No. 8 (American) catheter, to which was 
attached a Davidson's syringe, was inserted about seven inches 
into the vagina, and one quart of a solution of corrosive sublimate, 
1 to 4,000, was injected. Continued the use of one-eighth of a 
grain of morphia sulph. every two hours; also, ordered cream, 
brandy, milk and broma to be given freely. 
Monday, 4 o'clock, P. M.-Pulse, 150; temperature in the 
axilla, 102; in the mouth, 101; respiration, 36. lias had two 
large diarrheic evacuations. The measle eruption, which is still 
present, has become very dusky and livid; the abdominal sore- 
ness and pain are worse. Ordered a fourth of a grain of morphia to 
be given every two hours until the pain and cough are controlled, SECTION ON OBSTETRICS AND GYNECOLOGY. 
5 
Monday, 9 o'clock, P. M.-Temperature in both the mouth and 
the axilla, 101; pulse, 150; respiration, 40; abdominal pain and 
soreness decreased. The patient has had but little sound sleep 
since the child was delivered. Gave her half a grain of morphia, to 
be followed by an eighth every two hours. She still has no lochial 
discharge. The catheter was inserted as before, and one quart of 
tepid water was injected, followed by one syringeful of a solution of 
corrosive sublimate, 1 to 1,000. 
Tuesday, 9 A. M.-Has had ten copious diarrheic passages since 
midnight; pulse, 164; temperature, in the mouth, 102; in the 
axilla, 98 ; in the rectum, 103 ; respiration, 34. She has, never- 
theless, slept five hours since the last visit; she is now awake and 
her mind is clear, but her countenance is pinched and greatly 
changed ; lips cyanotic, complexion altered from fair to a deep 
sallow. The measle eruption is nearly gone, except on the hips, 
thighs and back. There is still no lochial discharge ; she urinates 
freely; syringed with a pint of solution of corrosive sublimate, 
1 to 4,000. The frequency of the pulse, which seems due chiefly 
to the diarrhea, is the most discouraging feature of the case. 
Ordered an eighth of a grain of morphia, with an astringent, every 
two hours : also, earnestly impressed the necessity of pushing the 
administration of cream, brandy and milk. 
Tuesday, 4 o'clock P. M.-The patient is conscious but is sink- 
ing rapidly ; pulse, 180 ; temperature in axilla, 101 ; respiration, 
34 ; vomits a dark brownish fluid every few minutes ; she is unable 
to retain stimulants or food ; has no pain and but little abdominal 
soreness. Administered a fourth of a grain of morphia hypo- 
dermically, with the hope of arresting the vomiting. 
After the 4 o'clock visit, our patient sank rapidly, and expired 
at 9:15, fifty two hours after the delivery of the child. 
Permission to make a post-mortem examination could not be 
obtained. 
An astonishing feature of this case was that the patient had a 
dozen or more fibroids, which must have existed before conception, 
some interstitial, others subserous (none were submucous), one 
interstitial or intramural, large enough to fill the pelvic cavity, had 
displaced the os uteri upward and to the left until it faced the obtu- 
rator foramen of that side. Another subserous tumor as large as a 
duck egg existed on the left side of the fundus uteri; another, some- 
what smaller, was opposite to it on the right side of the fundus, and 6 
II. P. C. WILSON, M. D. 
the balance of the uterus was studded here and there with smaller 
ones ; and yet the patient was unaware of their presence until they 
were incidentally discovered by the medical attendant, who was 
examining for another purpo.se. 
I interrogated the patient very closely and at different times, 
and, from her answers, am satisfied that there never had been 
menorrhagia, or any other irregularity in menstruation, either as 
to the time or the quantity, up to the date of conception, which 
she believed took place September 7. 
There was no peritoneal soreness or irritability of either the 
rectum or the bladder ; neither frequent urination nor dysuria, 
no dragging pelvic or lumbar pains, no neuralgia of the crural 
nerves, absolutely nothing to disclose the fact that uterine fibroids 
were present, or to show how long they had been forming, and 
their discovery was left entirely to accident. 
At my request the following communications were written by 
two of the gentlemen connected with the case: 
THE COMPLICATION OF MEASLES. 
By II. P. C. Wilson, M. D. 
In the above mentioned case the occurrence of measles was 
undoubtedly the cause of labor coming on prematurely, and was 
the main factor in the fatal termination of the case. Earliest 
date for confinement was fixed at June 13. The disease was 
contracted May 18. The eruption appeared June 1, and came 
out most profusely, accompanied with a racking cough, which 
the remedies usually found efficient,' did not control. It was 
in one of these paroxysms that the membranes were ruptured, 
and the amniotic fluid discharged at 1 o'clock A. M., June 5, 
thereby bringing on the labor eight days before it was expected. 
Could she have had the benefit of these eight days, much of 
the measle poison would have been eliminated from the blood, 
and she would have rallied greatly from the depressing effects 
incidental to all blood poisons. 
When called to her, in labor, June 5, the measle eruption over 
the body was purplish, the countenance showed slight duskiness, 
and we realized that we were to go into an operation with the 
patient already poisoned. We put her under chloroform June 6, at 4 o'clock P. M. The 
uterus was dilated with the fingers and hand, and the child turned 
and delivered by 5 o'clock without very great difficulty, forty 
hours after the rupture of the amnion. There was a laceration of 
the cervix, along the line of union between the healthy uterus and 
the imbedded fibroid, but not extending into the peritoneal cavity. 
There was also a laceration of the perinaeum, but not down to the 
sphincter ani. These were such injuries as are constantly occur- 
ring in labor, without fatal results, and yet this woman died fifty- 
two hours after delivery. She had no peritonitis, no hemorrhage, 
no evidence of septicemia that she did not have before labor begun. 
She died of shock, superadded to the measle poison under which 
she was laboring. , 
Had the patient not had measles, or could her labor have been 
postponed eight or ten days longer, I have no doubt that she would 
have been alive to-day. There was nothing in her case during 
delivery, and nothing occurred after delivery that could otherwise 
explain her death. "It is the last straw that breaks the camel's 
back." 
SECTION ON OBSTETRICS AND GYNECOLOGY. 
7 
Observations by A. F. Erich, M. I). 
T'he most difficult question that came up in the management of 
the case was, "Whether an operation (Cesarean section, vaginal 
enucleation, etc.), should be performed at a selected time pre- 
vious to labor, or whether to wait until labor had set in ?" 
The tumor was so hard, and filled the pelvis so completely, that 
no one of the physicians in attendance had the remotest idea that 
the child could be delivered as long as the tumor remained in 
the pelvis. The slight possibility of lifting the tumor above the 
promontory of the sacrum, in the genupectoral position, with 
the aid of anaesthesia, could have been tried as well before as after 
labor had set in. It was finally, and as subsequent events proved, 
wisely decided to wait and see what nature would do in the matter. 
When the patient had been in labor for a number of hours, it 
was found that the large pelvic tumor had participated in the 
changes that usually take place in the walls of the uterus and the 
vagina at that time. The peculiar softening process it had under- 
gone would, I believe, have made it possible to deliver the child 
after version had been accomplished, without laceration of the 
vagina and the perinaeum, had we not been anxious to save the 8 
A. F. ERICH, M. D. 
life of the child, as well as that of the mother. The umbilical 
cord having come down with the feet of the child made it neces- 
sary to deliver rapidly. The transverse laceration of the poste- 
rior wall of the vagina must have occurred, as the same accident 
did in Dr. Chadwick's case, and described by him in the Transact. 
Am. Gyn. Society, Vol. I, page 266, as follows : "The extensive 
transverse laceration of the vagina, in my case, I suppose to have 
occurred at the time the head descended into the pelvis. I am con- 
vinced that the pelvis was not large enough to allow the passage of 
the head, as long as the fibroid was below the pelvic brim. The 
sudden advance of the head I can only explain by assuming that the 
fibroid, after a while, slipped above the brim; at the same time 
the head entered the pelvis, forcing the posterior vaginal wall into 
the hollow of the sacrum. As the vagina was already stretched 
longitudinally by the rise of the fibroid, it undoubtedly ruptured 
before the advancing head." Dr. Chadwick, in addition to his 
own case, describes eight cases of labor with fibroids, collected 
by himself. Six of these nine cases died, and three recovered. 
Suezzerott has collected one hundred and forty-seven cases, of 
which twenty proved fatal. Dr. Munde reports a case of intersti- 
tial cervical fibroid complicating labor, in the Transact. Am. Gyn. 
Society, Vol. 9, page 140, in which the obstruction was overcome 
by vaginal enucleation, lie has also collected nine cases, in which 
the same operation was resorted to, with the result of saving nine 
mothers; and of the children, of which six only were visible, four 
were saved. 
The lessons taught by this case are: That delivery ought not 
to be attempted in such cases until labor has fairly set in, and 
that forceps and version should always receive a thorough trial 
before more dangerous methods are resorted to.