[Reprinted fi-om The American Journal of Obstetrics and Diseases of Women and 
Children, Vol. XVIII., March, 1885.] 
TWO CASES OF CONGENITAL IMPERFORATE ANUS WITH 
FECAL FISTULA IN THE ADULT FEMALE. 
BY 
CLARA MARSHALL, M.D., 
Professor of Materia Medica and General Therapeutics, in the Woman's Medical College 
of Pennsylvania ; one of the Accoucheurs to the Philadelphia Hospital. 
Congenital malformations of the rectum and anus, of such a 
nature as to interfere with the function of defecation, are, for- 
tunately, of rare occurrence. And yet by its very rarity such 
an unnatural conformation may entirely escape the notice of 
the accoucheur, or may tax to the utmost the resources of the 
surgeon. 
Among these malformations may be mentioned the simple 
occlusion of the anus by a thin layer of integument, or semi- 
mucous membrane, a rectum of unusually small calibre, or the 
still graver defect of an absence of a portion, or even the 
whole of the rectum, with or without a communication with 
the surface by some unnatural channel. These various devia- 
tions from nature have from time to time suggested a variety 
of surgical procedures, among which the simple crucial incision 
over the anus for the mildest type of deformity; the thrusting 
of a trocar into the perineum (in cases of imperforate rectum) 
in the hope of striking somewhere a bulging rectal cul-de-sac 
(" making an exploratory puncture into anatomical darkness "); 
the more careful dissections with the scalpel on a like voyage 
of discovery; or the still graver operations of inguinal and 
lumbar colotomy, are associated with the names of Littre, 
Callisen, Amussat, and others of high authority in the pro- 
fessional world. In this brief paper reference will be made 
only to such cases as are allied to those which have come un- 
der the personal observation of the writer, the general charac- 
ter of which is indicated in its title. 
Case I.-Ella H., set. 19; born in Ireland; domestic; mar- 2 
Marshall : Two Cases of 
ried; primipara. Her family history is good, and she herself is 
stoutly built, and has always had good health. She was admitted 
to the Philadelphia Hospital, March 3d, 1884, and after a normal 
pregnancy was delivered, at full term, of a female child weighing 
six pounds. The labor was very slow, the head not being delivered 
until six hours after the membranes had ruptured. 
At the time when the messenger was sent for me, the condition, 
as described by the interne in charge, was as follows: "The 
pelvis is roomy, presentation that of the vertex with the occiput 
to the left and anterior, the os well dilated; but as the uterine 
contractions are very feeble, delivery by the forceps seems to be 
indicated." 
Upon arriving, I found the woman in good condition; the fetal 
pulsations were distinctly audible, and the head was upon the 
perineum. I noticed that, although the head was distending the 
perineum so that the anus seemed to be distinctly outlined, yet 
there was not that eversion of the mucous membrane of the rec- 
tum usually seen at this stage of labor. 
As the physician in charge of the case reported considerable 
progress in the labor during the absence of the messenger, a short 
time was allowed in which to see what could be accomplished 
without the aid of instruments. It was during this time, when 
introduction of the finger into the rectum, to favor extension of 
the head was suggested, that the deformity was discovered. The 
anus was found to be imperforate, and what appeared to be an 
anus was simply a depression surrounded by an imperfectly de- 
veloped sphincter. Upon introducing a finger within the vagina, 
and making pressure against the posterior wall, an opening was 
found about four inches from the vulva, leading directly into the 
rectum. When the child was born, its thighs and hips were cov- 
ered with fecal matter; much had also escaped with the liquor 
amnii. When questioned, the woman stated that the deformity 
was congenital, and had never given her any inconvenience ex- 
cept when constipated, at which times she had some difficulty in 
expelling the fecal mass-a state of affairs which might easily 
occur in one not so deformed. The labor was soon terminated 
without instrumental interference; the infant was well-formed in 
every respect, and the lying-in was normal. 
Some weeks after her delivery, the patient was examined by 
my colleague, Dr. Wm. H. Parish, and by Dr. Robert P. Harris; 
Drs. Bliss and Matson, who were with the patient during her con- 
finement, were also present. Upon this occasion, the fistulous 
opening between the vagina and rectum, which had so plainly 
existed during the labor, could not be found-the rectum open- 
ing upon the vulva just within the fourchette. This abnormal 
anus, which might better be described as a slit, had no sphincter 
in the strict sense of that term, and its anterior and posterior 
walls were in such close apposition as to render an examination 
by the touch alone quite deceptive, the finger readily passing- 
over the perineum and into the vaginal canal (after the usual Congenital Imperforate Anus. 
3 
method of making a digital examination) without detecting any- 
thing abnormal. 
Not in every case of imperforate anus does the onset of labor 
lead to the discovery of its existence, for Le Fort tells us of 
"A married woman who, upon rectal examination, was found 
to have an imperforate anus, the rectum opening obliquely into 
the back part of the vagina. The command of the feces was so 
perfect that no inconvenience resulted, and neither she, nor her 
husband, nor the accoucheur who had delivered her three, times, 
were aware that there was any peculiarity of the sexual organs." 
[Holmes' System of Surgery.] 
In the case now reported, the " anus " was drawn upwards dur- 
ing the labor, simulating a recto-vaginal fistula, the contents of 
the rectum being discharged into the vagina fully four inches 
above the entrance. In such a case as this, any obstetrical proce- 
dure requiring the introduction of the hand within the cavity of 
the uterus would be likely to result in the introduction of fecal 
matter also, which, by its absorption, might' endanger the safety 
of the patient. There is also the possibility of the feces becom- 
ing impacted, and acting as a serious obstruction to the pro- 
gress of the labor, as in the following case: 
M. Fournier (1813) was called in consultation in the case of a 
woman who had been in labor for five days, and whose bowels 
had not been moved for a week. The case proved to be one of im- 
perforate anus, the vagina being filled with hardened feces which 
had entered from an opening within the vulva. Copious injec- 
tions removed this hardened mass from the rectum and vagina, 
after which the labor was speedily and safely terminated ("Dic- 
tionnaire des Sciences Medicales," Tome IV., p. 155). 
Case II.-This case I was enabled to examine through the cour- 
tesy of Dr. D. D. Richardson and his assistant, Dr. Alice Avery, 
of the Insane Department of the Philadelphia Hospital. Dr. 
Avery has kindly furnished me the following notes from her case- 
book. 
Mary L , admitted to the hospital May 6th, 1884, was born 
in Philadelphia, is seventeen years of age, single, and without 
occupation. Her father is living and healthy, her mother died 
of phthisis pulmonalis, and a younger sister of convulsions. Her 
general physical condition is not good, as she is somewhat ane- 
mic, though the thoracic and abdominal viscera appear to be 
healthy; the pulse, temperature, and urine are normal. The 
mental condition is that of dementia. 
There exists a congenital malformation, by which the rectum 
terminates within the vagina. The recto-vaginal opening is low 
down upon the posterior wall of the vagina, of sufficient size to 4 
Marshall : Two Cases of 
allow of free evacuation of the bowel, and surrounded by a 
sphincter, by means of which it is almost completely closed. 
When the finger is introduced into this "anus," it may be passed 
backward into a rectal cul-de-sac, the bottom of which is sepa- 
rated from the usual anal site by not more than a quarter of an 
inch of tissue. (In Case No. I. no such rectal pouch exists, but 
in both there is the same attempt at the development of a sphinc- 
ter ani.) The other pelvic organs are apparently normal, except 
that the uterus is unusually high (being partly au abdominal or- 
gan), and is displaced to the left. 
The control over the evacuation of the bowel posessed by 
both the above-mentioned patients may at first thought seem 
remarkable, but it is no more so than the fact of the 
small proportion of cases in which division of the sphincter 
ani for fistula in ano is followed by incontinence of feces; 
nor is it more remarkable than is the same state of affairs where 
colotomy has been performed for congenital malformations of 
the rectum. "The physiology of the act of defecation goes 
far to explain why there should be a certain warning of the 
approach of an evacuation. . . . The control spoken of will 
be found in most cases to mean rather a consciousness of an 
approaching movement, a warning given in sufficient time to 
allow the patient to make necessary arrangements, rather than 
an ability to absolutely prevent the evacuation which is about 
to take place " (Kelsey, on " Diseases of the Rectum and 
Anus"). There may arise a question as to the advisability of 
surgical interference. In case No. I., the patient is so per- 
fectly healthy in every respect that it would seem the most 
sensible course to " let well enough alone." The same conclu- 
sion is warranted in the case of the young girl in the insane 
department of the hospital. Indeed, it is obvious that opera- 
tive interference is not so imperatively demanded in this class 
of cases as it is in those in which there exists no outlet what- 
ever to the bowel. Yet even the more favorable cases, as a 
rule, suffer great discomfort, and in a certain proportion, sooner 
later death results. Even if trouble does not come on at 
the birth of the child, as soon as it begins to take solid food 
there is a liability to constipation of the most obstinate and 
dangerous character. 
Benivenius (1529) reports the case of a girl who had an imper- 
forate anus, with au opening between the rectum and vagina, 
through which the feces were expelled. This abnormal opening Congenital Imperforate Anus. 
5 
proved insufficient; the feces were usually voided only once in 
eight days, and death finally occurred at the age of sixteen from 
obstinate constipation with impaction of the feces ("Libellus de 
Abditis Nonnullis ac Mirandis Morborum Sanationum Causis," 
Cap. 86, Basil., 1529). 
In order to avoid so dangerous a complication, as well as to 
save the individual from the constant sense of what is in many 
instances a disgusting deformity, in the majority of cases 
operative interference is indicated, either in infancy (if the 
symptoms are urgent) or in early childhood. 
The method of operating can best be described by calling 
attention to some recorded cases successfully treated by ope- 
rative measures. 
In 18-, in Philadelphia, Dr. J. Rhea Barton performed two 
operations upon the same child at the ages of six weeks and nine 
months; the first by incision through the anal depression upward 
into the rectum. This failed, as the parts soon united. He 
then introduced a director into the recto-vaginal opening, and 
cut downward, laying open the tissues to the anal depression, and 
then upward to the bowel. The newly formed route from the 
rectum to the anus was kept open, and the remainder healed by 
granulation, the result being a rectum and vagina each complete. 
Moreover, tlie absence of the sphincter-ani muscle did not pre- 
vent the patient's having control over the evacuations (Medical 
Recorder, Vol. VII., p. 357. Philadelphia, 1824). 
Following the example of Dr. Barton, Dr. Joseph Parish oper- 
ated with entire success Feb. 18th, 1823, upon achild aged fifteen 
months, who was suffering from the malformation under consid- 
eration. 
In this case, Prof. Dieffenbach performed the following opera- 
tions. He introduced a grooved director, considerably curved, 
into the recto-vaginal orifice, thrust a pointed bistoury imme- 
diately below the "fossanavicularis" outside of the vagina into the 
groove of the director, and divided all the cellular and muscular 
tissues between the point of the puncture and the coccyx. lie 
then dissected off the end of the rectum from the abnormal open- 
ing, and isolated it for some distance from the surrounding parts: 
this enabled him to draw down the free end of the bowel, and 
attach it to each edge of the cleft perineum. The cut edges of 
the rectum united to the skin, and the recto-vaginal aperture 
closed very completely, only having been occasionally touched 
with nitrate of silver. Three weeks later, by a second operation, 
the perineum was restored. The cure was complete. (Boden- 
hamer on " Congenital Malformations of the Rectum and Anus.") 
Other parallel cases are on record, among which are the 
following: 6 
Marshall : Two Cases of 
M. J. Hgesbart saw a young woman, set. twenty years, with a 
similar malformation. Her health was excellent, and no opera- 
tive measures had ever been instituted ("Miscellanea curiosa 
decur," II., Ann. X., Observ. 75, p. 132, 1691). 
1791. One of the most remarkable cases on record is that of 
a Jewess, a resident of Padua, described by Mercurialis and 
Morgagni. In this young woman, there existed the deformity 
already described, and we are told that she lived to the advanced 
age of one hundred years, without any aid from the stirgeon; in- 
deed, Mercurialis advised against operative procedure ("De 
Sedibus et Causis Morborum," Epist. xxxii., Art. 3, Venetiis, 
1761, 2 Tome, Folio). 
1785. Van Sweiter reports the case of a young woman with the 
same deformity (Boerhave, Book iv., 1340, p. 575). 
1822. Mr. William Cooke, while attending a case of labor in 
a woman aged forty, discovered that the feces were escaping from 
the vagina; this led to the discovery of a congenital communica- 
tion between the rectum and vagina, large enough to admit of 
two fingers (English translation of Morgagni, Vol. ii., p. 110, 
Boston, 1824). 
1826. Switzer reports the case of a woman who complained of 
no pain in defecation, and who claimed ability to secure entire 
cleanliness by sponging out the vulva after each fecal evacuation 
(" Annotationes in Colotomiam," p. 79, Hafnie, 1826). 
1833. Ricord describes a most interesting case of deformity in 
a woman twenty-two years of age. Upon introducing the 
vaginal speculum, he was surprised to find it passed so far with- 
out meeting the neck of the uterus, when a lump of fecal matter 
was brought into view which he at first mistook for the os tineas; 
also some grape seeds, at first thought to be granulations; a more 
thorough examination, however, revealed the fact that the vagina 
was acul-de-sac, the uterus being absent, the anus imperforate, and 
the feces voided through a recto-vaginal opening, over which she 
had control, except so far as the expulsion of flatus was con- 
cerned. Menstruation had never occurred in any form. Injec- 
tions after defecation had secured cleanliness, and the deformity 
had never been suspected by others (Jour. Univer. et Hebdom. de 
Med., Tome xii., p. 167, Paris, Oct., 1883). 
1860. Dr. Berrut operated successfully upon an infant with 
this deformity. Up to seven years of age, she was subject to 
diarrhea, but at twenty was healthy and well-developed, and had 
diurnal evacuations. 
The number of recorded cases of this deformity is, com- 
paratively speaking, very small, many cases being lost to 
statistics through the carelessness of midwives. Dr. Lohrer, of 
Vienna, met with only two cases of imperforate anus in fifty 
thousand new-born children. Mr. Collins, during his master- 
ship of the Dublin Lying-In Hospital, observed only one in- Congenital Imperforate Anus. 
7 
stance in 16,645 births. (West's lecture on "Diseases of In- 
fancy and Childhood.") 
But the rarity of these cases does not excuse the accoucheur 
from the important duty of examining every infant immedi- 
ately after birth, or from ascertaining, at a subsequent visit, 
whether there has been a passage of meconium. The nurse 
must be cautioned not to administer purgative medicines ex- 
cept under direction, and such direction .must not be given 
until all question of malformation is set at rest. 
If unhappily a deformity exist, fortunate is the obstetrician, 
who, being forewarned, is at the same time forearmed.