A CASE IN WHICH FOR OVER THIRTY-FIVE YEARS A WOMAN 
DEFECATED AND URINATED, AND FOR ELEVEN 
YEARS MENSTRUATED BY THE RECTUM 
By William W. Keen, M.D. 
of Philadelphia 
EMERITUS PROFESSOR OF SURGERY, JEFFERSON MEDICAL COLLEGE; LATE MAJOR, M. C., U. S. ARMY 
A case in which for over thirty-five years a woman defecated and 
urinated, and for eleven years menstruated by the rectum is worthy of a 
final record as an evidence of the possibilities of surgery and especially 
of the conclusive evidence it affords that the rectum can be utilized as a 
common cloaca for the urine and the menstrual flow as well as for the 
faeces for an indefinite period. 
The condition necessitating this novel use of the rectum was a case 
of extensive and incurable vesico-vaginal and recto-vaginal fistulae caused 
by sloughing as a complication of typhoid fever. Ultimately I entirely closed 
the vaginal outlet. 
I first reported the case publicly in my Toner lecture delivered at 
the Smithsonian Institution in Washington on February 17, 1876. It 
appeared in print in March, 1877. 
In February, 1876, she had been entirely cured for seven weeks. When 
the lecture was printed she had remained cured for fifteen months. At her 
death, May 24, 1911, she had been cured for thirty-five years and five 
months. 
In Surgery, Gynaecology and Obstetrics (1917, vol. xxv, p. 391) Reuben 
Peterson has assembled 38 other similar cases in addition to two of his own, 
making 41 in all. 
When my Toner lecture was delivered, February 17, 1876, only one 
similar case, by I. Baker Brown, had ever been published {Trans. Obstet. 
Soc., London, 1864, v, p. 25). Of this I was ignorant. So far as I then 
knew I was the pioneer. I first learned of Baker Brown's case in January, 
1919, when I found it in Peterson's paper. 
In 1851, Maisonneuve had performed this operation for the first time, 
but it was not published until 1889. Rose had operated on three cases in 
1872, 1883, and 1886, but they were published, one case in 1878, and the other 
two in 1903. 
In 1898, in my " Surgical Complications and Sequels of Typhoid Fever," 
p. 80, I republished the case bringing the history up to the end of 1897. The 
present record carries it down fourteen years longer and up to the time of 
her death. 
It is the only one of the 41 cases caused by typhoid fever. In 33 cases in 
* Read before the American Surgical Association in Atlantic City, June, 1919. 
607 WILLIAM W. KEEN 
which the cause of the condition was stated, 25 resulted from childbirth, 
and 4 from operations for cancer. 
A brief abstract of the case as published in my Toner lecture in 1876 and 
in my book on the surgery of typhoid fever in 1898 and my later notes is 
as follows: 
Mrs. M. D., thirty-five years old, first came under my observation in 
St. Mary's Hospital, Philadelphia, in 1873. i&72 she nursed her hus- 
band in a fatal attack of typhoid fever and then fell ill of the same 
disease. About the fourth week the labia minora sloughed away and 
both urine and faeces escaped through the vagina. In October, 1872, 
she entered the hospital under the care of my colleague Doctor Grove. 
He tried three times unsuccessfully to close the fistulae by plastic opera- 
tions. When I succeeded to his service I also made three equally un- 
successful attempts. In December, 1875, being convinced of the impos- 
sibility of success, I proposed to her a, to me, wholly novel operation, 
•viz., the absolute closure of the vagina, leaving the fistulae wide open. 
This would compel the urine and the menstrual blood to be voided 
through the rectum. I explained the operation and its consequences 
to herself physically and as to marriage very frankly to her. She at 
once accepted my proposition. 
The operation was a success except at the anterior end of the 
cicatrix, which held everywhere else but failed at the internal end 
of what was left of the urethra, the vesical end of which had sloughed 
away. Several minor but always unsuccessful operations were done 
here. Finally, on December 28, 1875, I excised this small remnant of 
the urethra. This was her twelfth operation and was entirely success- 
ful. She had urinated, menstruated and defecated with entire comfort 
for seven weeks when I delivered the Toner lecture and described her 
case in full, February 17, 1876. 
She had been a nurse and for nearly four years had been unable 
to earn a living. She had been socially and professionally a pariah 
by reason of the disgusting atmosphere in which she lived and 
moved. This successful operation restored her to her social world 
and to her means of earning a living. She urinated once or twice at 
night and five or six times during the day. Menstruation ceased in 
1887, over eleven years after the operation. 
After the operation fistulae in the cicatrix broke out in 1877, 1896, 
and 1904, i.e., at intervals of 2, 19, and 8 years, respectively. Usually 
they caused only a little leakage and only when in the erect posture. 
Once the fistula healed spontaneously, once after a minor operation. 
The third occurred in 1904 as follows: 
In 1904, another small fistula appeared. However, as she was so 
slightly inconvenienced and as the escaping urine caused no odor 
about her person she did not consult me for two years. In October, 
1906, at my suggestion, she entered the Jefferson Hospital under the 
care of Dr. Francis T. Stewart and Dr. F. FI. Maier. They laid open 
several small pockets containing urinary concretions. This entirely 
relieved her. 
608 PERMANENT RECTAL CLOACA 
In December, 1888, thirteen years after the vaginal closure, she 
sought my help and stated that the escape of urine was intermittent. 
Digital examination by the rectum showed that the recto-vaginal 
fistula had so contracted that it would only admit the tip of the finger. 
It also showed that there was a calculus in the vagina which acted 
like a ball valve and explained the intermittent urinary flow. By 
inserting a curved haemostatic forceps I easily crushed the calculus. 
This consisted of urinary salts deposited on a small mass of faeces. 
At the date of her death on May 24, 1911, at the age of seventy- 
three, she had remained dry and well, with the exception noted, for 
thirty-five years and five months after the closure of the vaginal out- 
let. During all this long period she urinated only once or twice at 
night and five or six times during the day. She was wholly satisfied 
with the result of her persistent optimism. 
No ascending renal, vesical or uterine infection occurred at any time, 
nor did mucous membrane of the rectum at any time resent the con- 
stant presence of the urine or the periodical presence of the menstrual 
blood. 
609