and very feeble, and had but little continuous or quiet sleep,
" After it was weaned, its diet consisted of milk and barley
flour, and the fseces, no doubt in consequence of the change
in the food, had become of much greater consistence. The
contents of the bowels were forced out by violent straining in
small pieces, quite solid, about the size of a duck shot.
" On examining the parts, I found that the outlet of the
bowel w^as but little, if any larger than when I saw it before,
and the large end of a probe did not pass very readily into it.
The moment, however, that it was introduced, strong convul-
sive efibrts followed, and it was evident that there was a
great accumulation of ftecal matter in the intestine, lying in
ilie hollow of the sacrum.
"As it was apparent that the child would not live long in
this way, I suggested the expediency of attempting to relieve
it by an operation ; though i confess that I was not very san-
guine as to its success, nor did I give a very favorable prog-
nosis to the parents as to the result. They consented, how-
220 THE FIFTH SPECIES OF MALFORMATION.
ever, and on the following day. Jan. 26tli, 1853, I performed
it in the following way :
" The child, having been rendered insensible by the inhal-
ation of rectified snlplmric ether, was laid on a table. A
"iirector of the smallest size was introduced, thongh with dif-
ficulty, about an inch into the bowel, with the groove towards
the sacrum. With a very narrow knife passed into the
groove, I enlai'ged the external opening of the bowel suffi-
ciently to admit my fore-linger, and continued the incision
upwards nearly to the end of the director; I then found that
I could pass my finger readily into the bowel, which aj^peared
to be of the usual size, till within about an inch of its outlet,
where it had been contracted into a small canal, certain! v not
one fourth as large as the bowel above.
" I did not consider it necessary to carry the incision any
farther ; nor did I deem it safe ; partly from the fear of hem-
orrhage, and in part from an apprehension that if I did so I
sliould destroy the retentive power of the bowel, as sometimes
happens from an operation for fistula in ano, where it has
been found necessary to divide the parts high up.
" Lint was applied to the edges of the wound, and a cloth
wet in cold water laid over it. There was no bleeding, ex-'
cept a slight oue at the time ; the child was evidently re-
lieved, though the fiiecal matter was not discharged till castor
oil was administered on the following day.
"In two days after the operation I introduced a moderate-
sized rectum bougie, of a diameter as large as that of the
bowel, and this has been done daily to the present time. In
a very few days the wound healed, and the child has appa-
rently sufi'ered no inconvenience since. It has regular evac-
uations of a proper consistence without the use of medicine.
It has the entire control of the bowel, and has regained its
health. It is now vigorous and active as female children of
that age nsuallv are.
" I examined the parts very recently, four months after the
operation. The anus can now be seen without separating the
labia ; but the perina?um is covered with the same delicate
mucous membrane that lines the vagina. Whether this will
ever be productive of inconvenience, it is not perhaps easy to
say ; it is probable that this membrane niay lose some of its
sensibility, but there is no reason to suppose, that it will
ac(piire the properties of the ordinary covering of the body.
" This case must be regarded as a favorable one of mal-
formation of this kind. In some that have been described,
the <»pening into the vagina was as large as the diameter of
the bowel, and there was no sphincter ; while here the lower
THE FIFTH SI'KUIKS OF MA[,F(»K.\r Air< »N'. 2:^1
pjirf of the rectum was contmetiMl into a narrow canal, fiir-
iiislu'd with lunscuhir power sulHcieiit to prevnit the invohiii-
tary (lisehari;-e of the fa'ces. WJiere there is no provision of
this kind, tlie nialfonuatiou must of course be oho of the most
(lisgustin<j^ character." {The Virginia Mcdiml and Sanjical
Jiiiu'ital, Vol. I., p. ^iy'^. Richmond: 1S53.)
Cask CXXIII. — Professor Nagel reUites the followiui!^ case
of imperforate anus, being the second, though of a ditferciit
species, M'hich he communicated to the " ^Society of Practical
Meilicinc of BerlinP
'' Tills second case of Dr. Nagel's occurred in a female child
six months old. There was imperforate anus and an abnormal
opening of the rectum at the entrance of the vagina, at the
point ol the lower commissure; a small tono-ue with its edire
l):-esented to the front completely closed this opening. A
sound could not only be introduced with ease into the rec-
tum, but could also be pushed against the perina^um, and IV-lt
in front. The child although doing well, often sutfered with
colic and tenesmus, especially when fruit-stones, green goose-
berries covered wath their skin, or similar bodies were re-
tained in the narrow anal aperture, or when impacted fieces
were collected in the false passage behind the orifice. Consti-
pation became more and more frequent, and the means
hitherto employed to obtain liquid stools continued ineffectual.
Nagel then decided upon an operation, which he performed
by the process of Dieftenbach. By means of a hollow bent
sound he easily formed the new anus ; the muc<ius coating of
the open intestine was joined to the skin. In the part of the
rectum situated in front of this new anus, that is to say, in
the canal which opened at the point of the posterior commis-
sure of the vagina, Nagel introduced, eight days after, a red-
hot iron, but without succeeding in obliterating it, A small
([uantity of fsecal matter still continued to pass therefrom.
Nagel feared to divide the cutaneous bridge which separated
the artificial from the abnormal anus, considering the section
of the circular fibres of the sphincter going to the vagina, and
the incontinence of ffecal matter, consequent upon the section
of the canal, as a still greater inconvenience." [Recherches
Clinques et Critiques sur IJAnus Artijiciel. Par le Dr.
Ilerinann Friedherg. Archives Genercdes de Medicine de
Paris. Jfai, 1857. p. 581.)
Case CXXIY. — ^Tlie following case was communicated to
J. C. Lettsom, M. D., by Mr. T. Mantell, of Dover, England,
in a letter dated, Dover, May 25th, 1789 :
222 THE FIFTH SPECIES OF MALFOKMATION.
" JVIrs. S was delivered of a female child in September,
1786. A few days after I was informed, that no proper
evacuation of meconium had taken place, and that some small
quantity of faeces had come away with the urine. On exam-
ination I found that a malformation was the cause, there not
being any anus, or the least appearance of one. The infant,
in other respects, was well formed : the vagina was perfect,
and the water passed naturally by the urethra ; the health of
the child was bad ; she appeared generally in great pain, was
very costive, and, by violent forcings, a little quantity of hard
fteces were driven out, in the form of small spiral strings, per
vaginam.
" On acquainting the parents with the danger of the case,
and proposing, as the only relief, to make an incision through
to the intestine, and by that means endeavor to obtain a natu-
ral mode of evacuation, they requested me to do whatever I
thought proper.
" As I had no direction by an impulse of the foeces against
the skiu, I chose the usual natural distance from the vagina,
and made a deep but small incision, and, by passing a curved
probe by the vagina, through the aperture into the rectum, I
soon felt it, and was guided by that to proceed till the dis-
charge of fieces came plentifully through the new aperture ;
the haemorrhage was not great, and tlie child was imme-
diately relieved. To prevent constipation, and avoid pain by
the expulsion of hard faeces, I gave laxative medicines, and
my young patient felt little inconvenience, though there still
continued some small discharge, as before, per vaginam. At
the month's end it removed with its mother to town, and I
saw no more of them till the spring of 1788, when I was
informed by Mrs. S that the child had been very un-
healthy, that it had sutfered from many disorders, and was
still troubled (particularly when costive) in voiding the faeces ;
and that the orifice I had formerly made had been so much
closed as to render it necessary for a surgeon to dilate it, and
yet it was now again very confined, which made such a con-
stant use of purging medicines necessary, as to debilitate the
constitution of the emaciated little subject.
" I had formerly been afraid of making the aperture large,
lest, if I did, the powers of retention would be lost ; but there
now being a kind of stricture at the part, induced me to think
the levatores and sphincter muscles were not deficient ; and
that no mischief would ensue, if I enlarged the orifice.
Accordingly I made a large incision, and afte*' this no further
difiiculties arose, the child became healthy, and I have the
satisfaction of finding, near a year since the last operation,
TIIK FIFTH SPECIES OF MAI.lOIiMATIt iN. 223
tliat slio contiiinos perfectly well." (M' ntoirs <>f the Mxlical
fSocliii/ of London., Vol. I J I.., Art. XIX.., v. 389. London :
1792.)
Cask CXXV. — The late and lamented Dr. Miitter, lorinerlv
the able and distini»;uishe<l Professor of Surgery in tlie Jefler-
sou Medical Oolle<^e of Philadel])hia, conuuunicated to Dr.
Meigs the following interesting case, in a letter dated October
4th, 1844 :
" In compliance with your rerpiest, I send a Ijrief notice of
the case of Imperforate Anus, of which you s])oke the other
day. About the last of April, 1844, I was requested by Dr.
Jewell to visit, in consultation, the female infant (two weeks
old) of one of his patients. On examination, the following
condition of things was observed : The rectum terminated in
a cul-de sac, which extended to within three or four lines of
the natural position of the orifice of the gut, which spot was
occupied by dense cellular tissue and common integument,
and no trace of the anal opening could be distinguished. We
were told that the child was in the habit of passing its faeces
through the va'/ina, and that each evacuation was attended
with violent efforts, while the fiscal matter was moulded into
snuill threads. Separating the labia, an opening about the size
of a small duck-shot was discovered just withhi the fourchette,
and above it, a well-formed hymen. Through this opening a
probe was readily passed into the rectum, and also through
the hymen into the vagiiui, and both canals appeared perfectly
normal, with the exception, of course, of the defect already
described. The indication was obvious, and I at once pro-
posed the following operation. With the view of establishing
a proper channel for the faeces, and, at the same time, dispose
the orifice between the rectum and vagina to contract and
thus heal. Passing a small grooved director from the vagina
into the rectum, 1 forced out the tissues forming its lower
extremity, and then thrust a trocar down to the director and
directly tlirough the spot usually occupied by the natural ori-
fice of the intestine. Withdrawing both instruments, I next,
with a probe-pointed bistoury, enlarged the opening made by
the trocar, and as soon as this was accomplished, the child
passed an immense quantity of ftecal matter, apparently with
much relief. A sponge-tent was then introduced into the rec-
tum, and the nurse instructed as to its objects and use.
" Being on the eve of sailing for Europe, I did not see the
child again, but suggested the continued use of the sponge-
tent, until the opening made had lost all disposition to
contraction ; and, after this, if the orifice in the vagina did
224 THE FIFTH SPECIES OF MALFORMATION.
not heal of its own accord, in consequence of the natural
channel for the fasces being established, that it should be
touched occasionally with tlie argent nitrat.
" I did not deem this a case in which the operation
of Aniussat was advisable, nor Avas it one that indicated
(ituu.noii of the tissues occupying the position of the anal
oritice, nor could any operation upon the fistulous open-
ing between the rectum and vagina be with propriety pro-
posed. I preferred the trocar to a sharp-pointed hisfoury^ for
performing the operation, for the simple reason that wounds
nuitle with the former instrument are much less prone to heal
by the first intention than when the latter is em^^loyed ;
and as it was one object, of course, to prevent the close of the
gut again, an event by no means uncommon, when a simple
conical incision is made with a bistoury, I adopted the plan
of operating described. I have not seen the child since
my return, but understand from Dr. Jewell that there is some
contraction of the orifice, and that, in all prol)al)ility, it will
be necessary again to divide its margins."' {^A Treatise on tlm
Diseases and Special Hygiene of Females. By Colomhat De
Vlsere. Translated from the French., hy Charles D. Meigs.,
M. D. p. 116. Philadelphia : 1845.)
CHA^r^TER VII.
THE SIXTH SPECKS OF MALFORMATION.
SECTION I.
DESCRIPTION.
1. This species is recognized by the rectum terminating by
an abnormal anus, either in the bladder, the urethra, the
vagina, the uterus, or in a cloaca in the perinseum with
the urethra and the vagina. There is generally neither
a natural anus nor the sign of one present ; yet sometimes,
though rarely, a small contracted orifice indeed exists, at the
natural situation, simulating the normal anus, which permits
the introduction of the end of a small probe for a few lines.
Mr. Cooke and Mr. Lucas have each seen and reported a case
of this description. [ Vide Oases CXXXYI—CXG F/.]
2. This preternatural alliance of the digestive, the urinal
and the generative systems, which is analogous to the normal
formation of some animals, comprises that division of the con-
genital malformations of the anus and the rectum which
Meckel very appropriately denominates — " Cloaca Congenital,''''
and which is the ^''Atresia Ani Vesicalis, Urethralis and
Yaglnalis''' of Papendorf.
3. The variety of this species of congenital vice in which
the rectum opens into the bladder, is much more common in
the male than in the opposite sex. Tliere are indeed but few
cases of the latter on record, and even those few are by no
means well authenticated. Tlie celebrated Morgagni reports a
case from mere hearsay. [ Yide Case CXXIX.^
15
226 THE SIXTH SPECIES OF MALFOKMATION.
Aristotle gives the singular instance of a cow wliicli pre-
sented not tlie slio-htest trace of an anus in situ naturali. He
sa3's, in this case, that "Me excretnentitious jmHs of the food,
heing attenuated., were discharged through the bladder^ {De
Generatione Animalium. Lib. IV., C. 4, in Jin,)
4. There are but few cases on record of the variety of this
species of malformation, in which the rectum oj^ens into the
female urethra. Licetus and Delesalle report each a case.
[ Vide Cases CLI—GLIIL ]
5. Some of the instances in which the rectum communi-
cates with the bladder in the male, are accompanied with an
imperfect development of the penis, especially occlusion of
the prepuce and urethra. M. Desgenettes records a case of
this charactei-. [ Vide Case CXXXII?\
6. The rectum, in the majority of instances, instead of com-
municating directly with the bladder by simply an orilice,
terminates obliquely in this viscus, between the insertion of
the ureters, by a short conical canal, the vesical orifice of
which being sometimes so small in diameter as scarcely to
admit the end of the smallest sized probe. This narrow con-
ical duct or rectal extremity, the base of which corresponds
to the superior extremity of the rectum, or inferior extremity
of the colon, and which is observed, in these cases, to connect
the rectum and the l>ladder, is said by Dr. J. B. S. Jackson,
of Boston, to resemble very much the ductus arteriosus.
{Recoi'ds of tlie Boston Society for Medical Iinprovement,
VoK III., J)' 158. Boston: 1859.)
7. The rectum, wlieu it terminates in the urethra, does so
by a narrow conical canal, and quite small orifice, as it does
in the bladder, and in the largest number of instances opens
into the membranous portion of the urethra.
8. When the rectum terminates in the vagina the recto
vaginal orifice is generally mucli larger than when it opens
into the urinary passages. In some few instances, however,
it terminates by a canal which becomes gradually narrowed
THE SIXTH STKOIES OF MALI-UlCMATloN. 227
as it approaches tlio vagina, luilil it is quite small. The va-
ginal anus will nsiuilly be found situated htw down in some
part of tlie posterior or lateral parietes of the vaginal canal.
[ Vide Plate IX, Figure 1.]
Papendorf reports a case in which the rectum terminated at
two [)oints in the vagina. S. F. Ainsworth, M. D., of our own
country, records a similar case. [ Vide Cases CLXXXVl—
CCIIL]
9. Physical Signs — Diagnosis. Should the abnormal open-
ing of the rectum be vesical, its existence will be manifested
by the thickness of the urine, and by its greenish appearance,
which it acquires from being blended and tinged with the
meconium previous to its expulsion from the bladder; and
by its passing only at the time of urinating. These evidences
are sufficient to show that the abnormal opening is entero-
vesical, but they are not sufficient to indicate the direction, or
the precise point of the termination of the rectum. This is
often quite difficult, if not impossible to determine. When
the urine is so much mixed with the meconium as to become
semi-fluid, it is an evidence that the recto-vesical opening is
large ; when on the contrary it merely tinges the napkins, it
is evident that the abnormal opening is small. Besides the
passage of the meconium through the bladder and urethra,
gas is also often expelled through the same medium.
Should the abnormal opening of the rectum be urethral,
the meconium will often escape unmixed wath the urine,
either constantly in small quantities, or at intervals, or a
small jet will always precede the passage of the urine. The
meconium is sometimes also forced out in small cylindrical or
spiral bodies. It is also difficult in these cases to determine
at what point the rectal opening enters the urethra, wliether
at a short distance from the glans penis, or deeper down near
the perinseum.
10. Prognosis. The prognosis in those cases in which the
rectum communicates with the bladder or the urethra of the
228 THE SIXTH SPECIES OF MALFORMATION.
male is always very unfavorable, and unless such cases are
relieved by prompt surgical measures, as a general rule, they
soon end in death. In these instances the great danger and
difficulty are at once obvious, when we take into considera-
tion the smallness of the recto-vesical opening generally, and
the length, narrowness and flexure of the male urethra. The
extremely delicate and highly sensitive mucous lining too, of
the bladder and the urethra, is not capable of sustaining for a
length of time, without imminent danger of fatal cystitis, the
immediate contact of the highly irritating stercoraceous mat-
ters ; and when the recto-vesical orifice is so small that noth-
ing but the thinnest portions of the meconium can pass
through it, the great danger then is from the accumulation
and the retention of the excrementitious matters. Should the
child even under these unfavorable circumstances continue to
survive for several months, as soon as the fseces increase in
quantity and acquire a certain degree of consistence, and ac-
cumulate, the life of the unfortunate little patient could no
longer be sustained.
11. Much the same difficulties and dangers attend those
cases in which the rectum terminates in the male urethra.
It was declared by M. Bertin, many years ago, that this
particular malformation — that is, that in which the rectum
opens either into the bladder or the urethra of the male —
uniformly resulted in death. {Memoire de V Academic des
Sciences. AfinSe 1Y71. j:). 496.) This opinion is still held by a
number of surgeons of the present day, but it is not altogether
tenable, for it will be seen that several cases have been
reported in which life has been prolonged for months and
even for years. M. Bravais mentions the case of a i)oj four
years old. [ Vide Case CZIL] Flajani reports an interesting
case of a child four months old. [Vide Case CZIV.] M.
PouUetier saw a boy three years old, who passed all his fseces
through a preternatural opening of the rectum into the ure-
thra. [ Vide Case CL Vin.~\ Professor Gross, of Philadel-
THE BIXTII SPECIK8 OF MALKOltMATION. 229
pliia, luinies two cases. One a very reinarkaljlc one. [ Vide
Case aZ.]
12. The prognosis is somewliat more favoraLle wlicii tlic
rectnm communicates with the bUidikM- or tlio urethra of the
lemale, in consef|ueuce of the shortness and the straightness of
the uretlira, and its great susceptibility of diUitation.
13. The prognosis is much more favorable when the rectum
communicates with the vagina than when it opens into the
urinary passages, in consequence of the greater amplitude of
the recto-vaginal aperture generally in these cases, and the
width and the straightness of the vaginal canal which tluis
affords an ample passage for the easy egress of the ficcal
dejections. The vaginal anus wdien large, as is usually the
case, does not give rise to fatal results, does not compromise
the life of the patient, neither does it in after life interfere
with, nor prevent the functions of the vagina and the uterus.
Several instances have been recorded of such patients having
grown up to womanhood, and even of having been capable of
becoming pregnant and of bearing children, without any very
serious impediment to life or inconvenience, excej)t the very
disgusting nature of the infirmity itself. M. Fournier cites
the case of a woman who became a mother, who had a con-
genital imperforate anus with an abnormal opening of the
rectum in the vagina. [Vide Case CXCIII.] Kicord
reports the singular case of a courtesan twenty-two years of
age, who presented a congenital imperforation of the anus
with an abnormal opening of the rectum in the vagina. A
similar case to this in almost every respect, is related
l)y Switzer. [Vide Cases CCI—CCII.] Morgagni records
the cas© of a woman who from birth was afflicted with this
infirmity, and who attained the extraordinary age of one
hundred years. [ Vide Case CZXXVII.]
14. Although we have shown that the unfortunate subjects
of this affliction are generally in no immediate danger of
death, yet the imperfection is one of a peculiarly delicate
9
230 THE SIXTH SPECIES OF MALFORMATION.
cluaracter, and one that, should life be spared and prolonged,
would only entail miseiy upon the unfortunate victim of it.
The manner in which such a malformation would operate
upon the mind, should the patient thus afflicted arrive at the
age of reflection, can well be imagined, when we take into
consideration the disgusting and the repulsive nature of the
deformity itself.
' 15. All the cases in which the rectum opened into the
vagina were until of late years considered liopelessly incura-
ble, and even many surgeons still consider them so. They are
the opprobrium medicoruTn. Surgery, however, must remedy
this repulsive infirmity hereafter, and thus wipe out this dis-
grace. This she has already to a considerable extent accom-
plished.
16. In some of the cases under consideration, however, the
mucous membrane of the vagina sooner or later becomes
excoriated, indurated and fungated from the neglect of clean-
liness, and abscesses often form in the adjacent cellular tissue.
Such cases generally, are deplorably hopeless.
17. With regard to the prognosis of those extremely rare
cases in which the rectum, together with the genito-urinary
organs terminates in a cloaca in the perinseum, as observed
in the monotremata, in birds, in reptiles and in many fishes,
it is useless to conjecture. Such cases would seem, as a mat-
ter of course, to be beyond all hope of remedy. Only one
such case in the human subject, as far as my reading extends,
is recorded, and that one was observed by Saviard, and which
I have presented entire. [ Vide Case CCIY.^
Martin saw a malformation of this nature in a full-grown
bitch. {Annates de Societe Natur. tome XII.)
Hartmann observed a lusus of this character in a heifer.