child in whom the anus was imperforate, and the rectum
opened into the membranous portion of the urethra.
" An opening was made into the neck of the bladder, as
was supposed, and the operation was, in as far as circum-
stances would admit, perfectly successful. The boy lived
and throve till he was six years old, when he died of disease
of the lungs. Although it may be doubtful if there was a
sphincter or levator muscle here originally, he had the com-
mand over the aperture and the urinary apparatus that chil-
dren usually^ possess. Occasionally when his bowels were
loose, a few dro]3s of faeces would come by the urethra, and
he w^as wont also to discharge part of the urine by the artifi-
cial opening. On several occasions, small hard urinary de-
posits were discliarged from the anus, and I had to extract
one about the size of a hazel-nut. Often his mother had to
remove small seeds and barley pickles from the orilice of the
urethra, and once she extracted a small j)ortion of a bone
which he had swallowed in his food.
262 Tin-: bixth species of malfokmation.
" On inspecting the parts after deatli, I found that the
bowel terminated in the membranons portion of the nrethra
by an aperture, about the size of a lancet puncture, and not
in the upper end of the bladder, as was originally imagined,"
{A Sy stein of Practical Surgery. 4:th American JEdit.,p. 545.
Philadelphia : 1853. Also., Edhiburgk Medical and Surgi-
cal Journal. Vol. XXX VI., p. ^Q'd. 1831.)
Case CLXXIII. — Dr. Nagel, Professor of Surgery at Clau-
senbourg, communicated, on the 25th of August, 1855, to the
" Society of Practical Medicine of Berlin,''^ the following
case of imperforate anus, with an abnormal opening of the
rectum in the urethra.
" This was the case of a male infant in whom no anus
existed. A small tumor a little elevated above the skin was
the only indication of an anus. The meatus urinarius was
immediately in front of the scrotum. Hypospadias and
imperforation of the anus therefore existed at the same time.
Through the meatus urinarius small cylinders of fsecal matter
passed from time to time, mingled with the urine, which
sometimes however passed unmixed. A curved sound intro-
duced by this passage could easily be so turned that its ter-
minal extremity was felt in the normal position of the anus.
An incision was made upon the sound, the wound was
dilated, and a pasteboard cylinder was introduced into the
rectum. During severral days a small quantity of fgecal
matter passed by the urinary meatus, and of urine by
the anus. At the end of some months the child was doing
well, the anal opening M'as sufficiently large, and the urine
passed by the urethra alone, and the Isecal matter by the
anus." {liecherches Cliniques et Critiques sur VAnus Artifi-
ciel. Par le Dr. Hermann Friedherg. Archives Generales de
Medecine de Paris. Mai, 1857,^. 580.)
Case CLXXIV. — M. Godard, a resident Hospital student
of Paris, presented to the " Societe de Biologie de Paris^'' in
July, 1855, three anatomical preparations and six drawings,
relating to three cases of congenital imperforation. of the anus,
which came under his observation at the Hospital Necker, and
at the Hospital des Enfants Malades, wathin the year 1855.
These cases are highly interesting in several respects. They
all occurred within a short period of each other; they were
all male children ; the rectum in each terminated very smgu-
larly in the urethra by a narrow, pipe-like prolongation, and
the operations in each were soon followed by death. I have
presented these cases almost entire, translated from the origi-
THE SIXTH 8PECIKS OK M.M.I ( (UMATION. 203
rial. Tlie iolldwinoj is M. (iodunrs tliiid case; his fust aiul
second cases will he touiid in tlie chapter on yl/^Aw//?*^//? yl/'//-
ficial Anus. [ Vide Cases CCLXXIX—CiJLXX XI 1 1.^
" Charles rr(isj)er Drcel was Ixini on the 2Tth of June, IS.");').
On ihe day after his birth tlie midwife discovered that he had
no anus, and tluit tlie mcconiuni jiassed by the nrethra willi
the urine. Tiiis child was admitted into the hall Saint Come
of the Hospital des Enfanis MahiJcs^ on the 21>th of June;
on this day, as well as on the i)recedin<i;, it had several times
vomited a peculiar matter, having the odor and the ai»j)ear-
ance of meconium. Pressure upon the al)domen caused the
meconium to be discharged in jets from the urethra. M.
Guersant, the surgeon of the hospital, made an incision in the
pcrinaium, three-eightlis of an inch long, and then pushed in
a trocar in the direction of the sacrum, and at once the meco-
nium flowed through the camila. This opening was erdarged
and an elastic sound was inserted. On tlie 3Uth of June the
vomiting ceased and the intestinal matters passed both by the
nrethra and by the canula. On the first of July there was no
change in the condition of the child, and on the third it died,
"•Tlie autopsy was made on the fourth of July, and gave
the following results: — The peritoneum was slightly vascular,
and in the pelvic cavity at the left of the rectum it presented
a wound, apparently owing to the puncture of the trocar.
The su])erior extremity of the rectum was normal, and passed
obliquely from above downward, and from left to right; it
adhered behind to the sacrum and coccyx, and in front was
directed towards the bladder and to the prostate, both of
which it touched. <,)n the left, the rectum was adjacent to an
abscess, which, as in the first case, was the result of the punc-
tures of the trocar ; the wound in the peritonaeum proves this.
On the right there was nothing in the rectum w^orthy of no-
tice. The inferior extremity of the rectum terminated in a
sack-like dilatation, and presented on its left side an oldong
openins:, whose greatest axis was directed from before back-
wards. "" At the circumference of this orifice a fibrous cylinder
was sent off, which extended as far as the anal region. This
cylinder was formed by a condensation of the cellular tissue
of the part, and was the result of the operation. Around this
canal the external sphincter could be dissected ; tlie fibres
composing it were in layers and very distinct. This muscle
was three-eighths of an inch in height. The dilated portion
of the rectum being laid open, a funnel-shaped orifice was
observed on its ant'erior wall, which led into a small canal
which passed under the prostate and opened in the urethra
just in front of the urethral crest. The peritonaium descended
264 TiiK SIXTH srivCiES or malformation.
as usual along the niiterior face of- the rectum, flexed upon
the bladder, and at the point of reflection was seven-eigliths
of an inch distant from the cutaneous surface of the perin-
aeum." {Oazette MedicaU de Par'is. A7inee l^bh. No. 44.
p. 700.)
In relation to the cause of the formation of i\\Q filjrous cylin-
der mentioned in the preceding case, M. Friedberg, of 13erlin,
in the pathological pait of his invaluable Essay on Artificial
Anus, makes the following comment: " M. Godard considers
this cylinder the result of the operation. I contest this opin-
ion for two reasons — First, a flbrous cord could not form, by
condensation of celluhir tissue, in four days after a wound.
Second, M. Godard says that he found the external sphincter
very clearly developed around this cylinder, as well as fibres
covering it to the height of three-eigiiths of an inch. It evi-
dently follows that this fibrous cylinder descending from the
corrugated part of the rectum, was actually the end of this
intestine which had been obliterated, and upon which the
movable intestinal canal was extended, when it was dilated
with the accumulation of meconium."
Friedberg is doubtless correct.
(3.) Cases in which the Rectum Terminated in the Yagina.
Cask CLXXV. — Benivenius describes tlie case of a girl
who had an imperforate anus wdtli an abnormal opening of
the rectum. This girl, two days after her birth, commenced
to discharge her faeces per vaginam, and continued to do so
until she died, which event took place in her sixteenth yeai'.
She died with most excruciating colic pains, doubtless in con-
sequence of obstinate constipation and induration of the fieces,
tor she usually had but one alvine evacuation in eight days.
{Lihellus de Ahditis nonnvllis ac tniixindis Morhorum Sana-
tionum Causis. cap. 86. Basil: 1529.)
Cask CLXXVI. — Van Swieten relates the case of a young
woman who was afflicted with the same disgusting malforma-
tion as the one mentioned by Betiivenius. There was in this
case an iniperforation of the anus with an abnormal opening
of the rectum.
No surgical operation is said to have been performed either
in the case of Benivenius nor in this of Van Swieten. {Com-
THE SIXTH SPKCIES OF MALFORMATION. 20;
m
enla/'id in Ihnnainu Boerhaave Aphorisinos do cognoHccuilis
et curandis MorVis. Lib. IV. Aph. 1340, p. 575. Ludo. But.
1785.) ^ •"
Cask CLXXVII. — Mcrcuriulis reliUcs the rciiKirkiiMc c.-isc
of a ytHiiiiJj Jewess, the diiir'^litcr of a i\-si<KMit of I'adiia,
iiaiiUMl Teiitouicus, who was born without an anus, and (lis
chai'iiX'd tlie feces altogether through the vagina. i^De Mor-
huH Pnerot'iun. Lib. 1. c. 9, Ve)ietu.s\ 178.3. 4:(<t.)
In this curious and fai - faini'(l ease of that day, there was
an iiu]ierforate anus with un abnormal opening of the rectum
into the vagina, tlirough which tlio fiecal matter was dis-
chai'ged ; yet strange to say, that tliis remarkable patient,
with this great affliction, attained to the extraordinary age of
a whole century, as Morgani testifies. lie also says that Mer-
curial is pei'formed no o])eration himself in this case, and ad-
vised the father of the girl never to suffer one to be perfoi'med
bv any one. {De Sidlbus et Causls Morborxim Epist.
XXXII. Art. 3. Venellis 1761. 2 (o)n. Folia.)
Case CLXXVIII. — De Jessieu mentions the case of a girl
seven years old, whom he knew, who had an imperforate
anus with an abnormal opening of the rectum. Tiiis girl
from infancy had always discharged her fiEces per vaginam.
No operation is mentioned as having been performed. {^Ilis-
toire de V Academic des Science. AnnSe 1719. p. 42.)
Cask CLXXIX. — Htesbart says that he saw a .young
woman, twenty years of age, who passed her faeces altogether
per vaginam, the anus being imperforate. She always had
excellent health. No operation was performed. (Jfiseel-
lanea curiosa svm ephem. acad. natur curiosor, decur. II.
anil. X. Observ. 1^. p. 132. 1691.)
Case CLXXX. — Dodonpens records the case of a child in
whom the anus was imperforate and the rectum opened into
the vagina. [Anjiotationes ad jBeneviuin, cap. IX.)
Case CLXXXI. — Amatns Lnsitanus records a case of a
female infant in whom no natural anus existed, and the
rectum communicated freely with the vagina. [Ouratlonum
Medicinalium. Cent. II. curat. 10. Venet : 1653.)
Case CLXXXII. — Schenck also reports a case of a female
child in whom no normal anus was ]^resent, and in whom the
i-ectum opened in the vagina. {Opus ciiatum. Lib. III.
Sect. I obs. 258. p)- 458.)
266 THE SIXTH SPKCIKS OF MALFOKMATION.
Case CLXXXIII. — Peteriiiann observed a child in wlioin
iu> imtnral anus existed, and in whom the rectum opened
into the va<2;ina. {Observationes Medlcm, dec. II. Ohs. 2.
Lipsm : 1707.)
Case CLXXXIV. — Ilartmann saw a child that was in
excellent liealtli and growing rapidly, who presented an
imperforate anns, and who passed the faeces altogether per
\ aginam, {Miscellanea curiosa she ephem,. acad, noiur curi-
osor, decur. II. ann. 1691. />.279.)
Case CLXXXY. — Alix saw a chikl in whom no anus
existed naturally, who by an abnormal anus, discharged the
feces through the vagina. [Ohservat'iones ChirurgiccB, tome
III p. 203. Altenhurg : 1774.)
Case CLXXXYI. — Papendorf observed a female infant in
M-liom no normal anus existed, whose rectum communicated
with the vagina by two abnormal orifices, and through which
all the fsecal matter was passed. {Abhandlung von der angeh-
ohrnen Yerschlicssung des Afters hey Kind r en. Leipzig:
1783.)
Case CLXXXYII. — ^Wandermonde saw a female child in
whom all the faeces were passed by the vagina, there being
no natural anus. {Recueil Periodigue de la Societe de Medi-
cine de Paris, tome VI. p. 128.)
Case CLXXXYIII. — Arand relates the case of a female
child in whom there was an imperforate anus and a communi-
cation ol the rectum in the vaginal canal, through which the
fiEces were passed. {Ohservat. Med. Chirurg. obs. IV. jp. 28.)
Case CLXXXIX. — Fiirst re2:>orts the case of a female child
who presented an imperforate anus, with the rectum opening
into the vagina. {Miscellanea curiosa sive ephcTn. acad. natur
curiosor. decur. II. arm III ohs. 112.)
Case CXC. — Bonn records a case in which the anus was
imperforate and the rectum opened into the vagina. (Papen-
dorf. Opus citatum.)
Case CXCI. — Kirsten saw a child whose anus was imper-
forate and the rectum tei'minated in the vagina. {Act nat.
vur, Llh. IX. ohs. XI. p. 24.)
THK SIXTH SPKCIKS OF MALKcjltMATION. 267
Cask CXCII. — Ilocliard oLsorvt'd the cnno of a fcinalo
iuttint in whom tlie {uius was iinpcrfonitc aii<l tin; rL-ctuiii
coimnuiucated with tlie vagina, {Jtmrnal de Medicine, Ch'ir-
xirgie, Pharmacie. tome LXXXV. p. 3 TO.)
Case CXCIII. — M. Fournier relates a very interesting case
in which he was called to consult, of a woman who had been
five days in lal)or. On making an examination, he discovered
no trace whatever of an anus in its natural situation, it l)ein'>-
congenitally imperforate ; the rectum he found tilled with
foeces, compressing the uterus, and tliat the abnormal opening
of the rectum which M^as large, entered the vagina. He
administered an enema, after which the fieces were evacuated,
and the acconchement safely terminated. {Dictlonnaire des
Sciences Jledicales. tome IV. p. 155-6.)
Case CXCIY. — Mr. Cooke, whilst attending a woman in
labor, who was nearly forty years of age, discovered that with
the descent of the foetal head, excrementitious matters escaped
per vaginam ; and also that a congenital communication
existed between the vagina and the rectum, sufficiently large
to admit two fingers. {English Translation of Moryagni.
Vol. II. I). 110. Boston : 1824.)
Case CXCV. — Mr. Cooke reports the case of a female
infant wdiich was brought to him, in which the rectum com-
municated with the vagina, through wdiicli all the faeces Avere
discharged. An anus indeed existed at the natural situation,
but so rigidly contracted that a small probe could scarcely be
introduced. {Opus citatum.)
Case CXCVI. — Mr. Howship reports the following case of
imperforate anus with an anormal opening of the rectum in
the vagina.
" In 1815, I was requested by my friend, Dr. Samnel Merri-
man, to examine the body of a young woman, aged seventeen,
who had died of a scrofulous disease, and who from birth had
evacuated her stools by the vagina ; although there Avas in
this case no w^ant of power of retention.
'â– '- Post-Mortem Examination. There was an external mark
in the natural situation of the anus, but no opening. Upon
laying open the abdomen, the intestine rectum was traced
down to the posterior part of the vagina, to which it was
adherent.
"The vagina being removed and laid open, the intestine was
found to open upon its surface, by a very vascular and prom-
268 Tii;<; sixth species of malformation.
inent sort of papilla, situated witliin the vagina, near the os
externum.'" {^Practical Ohservatlons in Surgery and Morhid
Anatomy. />. 321. London: 1816.)
Cask CXCVII. — The following liighly interesting case in
whicli the rectum terminated, by an abnormal opening, in
the vagina, was communicated to the ''Medioal Recorder'' by
the able and distinguished surgeon, J. Rhea Barton, M.D.,
formerly surgeon of the Pennsylvania Hospital, and of the
Philadelphia Alms-House Infirmary.
"Tiie subject of this imperfection was a female infant,
already six weeks old. Upon examining the part, not the
slicjhtest trace of an anus was to be seen ; but I soon observed
tiie faeces, says Dr. Barton, with much suneringto the patient,
simultaneously voided with the urine jy^'r vaginam. A minute
inspection of this part, led to the discovery of a fistulous
aperture through the recto-vaginal septum, and communicat-
ing with some part of the intestine. The mother evinced
that degree of distress at the unhappy deformity of her off-
spring, and commiseration for its sufferings that might be
expected from a tender parent, and was extremely solicitous
for its relief. Accordingly, the operation, as is usually
directed in cases of imperforate anus, was performed ;
namely, by making an incision through the parts where the
anus should be, tt:c., &c. The instrument passed into the
rectum, and upon withdrawing it, fffices esca])ed freely. The
part was then plugged with patent lint dipped in sweet oil,
to prevent re-union. Not many days before the wound be-
gan to granulate and rapidly cicatrize ; to prevent, therefore,
its closure, a piece of bougie was introduced, and brouglit
out of the vagina through the original opening into it. Tliis
tent caused much irritation and suffering; but as it was
deemed advisable, its use was persisted in for several weeks.
The mother, wiio in the meantime had left the city with her
infant, findino; it productive of no good effect removed it ; and
the part soon closing up, rendered the opei'ation abortive.
"When the infant had attained the age of nine months, the
father called upon me, and announced the increased sufferings
of his child, owing to the still existing defect, and greater re-
tention of faeces, from their becoming more consistent as the
patient grew older, stating also, that without tlie effect of
aperient medicines, there would be an evacuation not oftener
than once in four or five days, and sometimes prolonged to a
period threatening death.
" In taking the case into further considei'ation, the following
mode of operating suggested itself to me, as one promising
TIIK SIXTH SPKCIES OF MALFORMATION. 2(^9
SUCC0S8. To tak(^ tor 1113' i^Miido into tlio n-ctniii tliu ojx'iiiii:,'
coniiuunicatini^ witli the v;i<,Mnu; to iiitroducu into it adinjctor,
and with a bistoury to lay open the vagina and inti-^runu'iits
as far l)ack as the pai't where the amis should he ; ihcic in
remove! a small pt»rtion of the inte:^'uments, if necessary, and
to dissect down until I came to the tei-minatiou of the i;ur,
and to open it freely. By this operation the antei-ior houndary
of the incision would be the listulous openini>; in the vaL;'ina,
and posteriorly it would terminate where the natural outier.
ou^ht to be found. The subsequent ti'eatment t(^ consist in
endeavorini; to ])romote granulations and the cicatrizinir of
the original opening, and so much of the anterior ])ortion of
i'.utislon as rendered the vagina incomj)lete ; in the mean time,
to keej) the remainder open until this shall have been etfected.
This plan was pursued, and I had the pleasure to succeed
most ])erfectly in all my views. The integuments around the
incision retracted, and thereby obviating the necessity of re-
moving them. The original aperture closed up with that
])art of the incision connected with it. The vagina became
complete, and a route direct from the rectum was established,
havino; no communication whatever with the vaii-ina.
" In this case there was no sjjlimcter ani muscle ; in conse-
quence of which I had nearly been deterred from the
operation, by the opinion of some of my medical friends, wlii>
nuiintained that even thouii-h I should succeed in establishin<^
a direct outlet from the rectum, the patient would throughoiir
life, labor under the lamentable misfortune of being uiuible
to control the evacuations, tor want of a sphincter muscle.
Reflecting, however, upon cases of fistula in ano, where this
muscle had been divided by the bistoury, I recollected that
the patients even there were enabled to exercise a limited
degree of restraint over the part by the action of the general
muscular coat of the rectum, or, as it is sometimes described,
the internal sphincter muscle. Under a belief, therefore that
this part of the structure, from continued use, would in time
assume the functions of a proper sphiircter, I operated with
confidence of success, and was not disappointed. The little
patient never found any difficulty from that source." {Med-
ical Recorder, Vol. V'lLp.2,bY. P/u7. 182i.)
Case CXCYIII. — The following interesting case, similar
to that operated on by Dr. Barton, was communicated to the
~" Medical Recorder,^^ by Dr. Satchell, then House Surgeon to
the Pennsylvania Hospital. The late and lamented Di'.
Parrish, of Philadelphia, was the successful operator in this
case.
270 THE SIXTH SPECIES OF MALFORMATION,
" Jane Dimraick, aged about fifteen montlis, was admitted
into the Pennsylvania Hospital on the 6th of February, 1823,
durin£:; Dr. Parrish's tour of duty. Slie was afflicted with
imperforate anus, the fseces being passed per vaginam
through a small opening situated about lialf an inch from the
OS externum. The depression in wliich the anus should have
existed, was quite smooth, and exhibited no mark whatever
of the proper structure. The child passed her faeces with
considei-able pain, at intervals of ten days or two weeks,
which were fluid or of a very soft consistence.,
" Under the impression that the rectum terminated in a cul-
de-sac, Dr. Parrish, on the 18th of February, performed the
following operation. A probe, having a curvature suited to
the purpose, was introduced into the vagina, thence through
the orifice of communication into the rectum, so as to pro-
trude the integuments in the place where the anus should
liave been. An incision was then made upon the point of
the probe with a small scalpel through tlie integuments, and
the opening thus formed was freely enlarged both anteriorly
and posteriorly, by means of a bistoury, until it was supposed
that the intestine was opened, no discharge of fseces being
the only circumstance of evidencing tlie contrary. Presum-
ing, however, that the rectum was freely opened, a silver
tube somewhat in the form of a nipple, with a curvature
adapted to the bowel, and with shoulders, anteriorly and
posteriorly, for the purpose of confining it in its situation by
means of tape, was introduced with the view of obviating a
closure of the wound, and at the same time of allowing the
evacuation of the faeces. But in the course of two or three
days, it was positively ascertained that tlie rectum had not
been opened, and that even if it had been opened, it would
have been utterly impossible to have prevented a reclosure
of the gut.
" The disease, or rather the malformation being unique in
the practice of the institution, it elicited a good deal of atten-
tion and interest, and it was ultimately agreed to attempt a
mode of cure, which had proved entirely successful in a very
similar case that had occui'red to Doctor J. R. Barton. Encour-
aged by the success of this case. Dr. Parrish performed a like
operation upon his little patient, and liad the pleasure of
succeeding to the extent of bis wishes. A very large quan-
tity of impacted faeces was found to occupy tliQ rectum, and
by means of the handle of a teaspoon, enemeta, and repeated
doses of the Olei Picini, the bowels were thoroughly emptied.
" On the 6th of March, two days after the last operation, the
child voided an unaltered water-melon seed, which must hav
TIIR SIXTH SPKCIKS OF MALKOUMATK >X. liTl
been in the bowels since tlie ]»recc(lin<; full ; and inilccij
there is reason to believe that she never passed jmy solid
excrement. The faeces were at first of a dark color, and
very offensive, bnt soon acquired the natural yellow appear-
ance. The wound healed; and on the 'JTtli of March, three
weeks and two days after the second operation, the child was
discdiarii'ed cured. At the time of her disciiar<ije, she
appeared to possess considerable jjowcr over the anus, and
indeed she could retain or discliari^e her faeces at pleasure.
'• We have every reason to believe, that the rectum termin-
ated in this case, in the vagina, and not in a cul-de-sac, as
was at tirst presumed. I will merely add, that no dressings
were used, but the linger lubi'icated with simple cerate was
introduced every day or two, in order to do away any ten-
dencv which the opening mii^ht have to heal." {Medical
Recorder, Vol. VII. p. 359. PA^/. .' 182J-.)