CONGENITALLY IMPERFORATE RECTUM 
WITH A WELL-FORMED ANUS, 
IN AN INFANT AT TERM; RESTORATION OF THE ANAL 
OUTLET (PROCTOPLASTY) AFTER KRASKE’S OPERATION. 
CONVALESCENCE COMPLICATED BY WHOOPING-COUGH 
AND PROCIDENTIA OF THE RECTUM NECESSITATING 
EXCISION. RECOVERY WITH PARTIAL CONTROL OF 
BOWEL. 
By RUDOLPH MATAS, M. D., Professor of Surgery, Medical 
Department, Tulane University of Louisiana, Etc. 
Reprinted from the July, iBq7, number of the New Orleans Medical and Surgical Journal. 
On the morning of August 28, 1894, I delivered Mrs. H. W., 
uet. 23, 111-para, at term, of an apparently full grown male 
infant.* The delivery was affected without difficulty. As the 
child had an entirely normal appearance, no minute examination 
was made. The anus was well formed and the genitals pre- 
sented no abnormality on inspection. The next morning I was 
informed by the nurse in charge that though the baby had 
urinated freely, it had failed to pass meconium notwithstanding 
that it had taken the breast. As the external appearance of the 
anus was normal, I paid no special attention to these parts and 
advised that the baby be encouraged to take the breast, and, if 
there was no movement of the bowels by evening to administer 
two teaspoonfnls of sweet oil by enema. In the evening the 
nurse reported that notwithstanding repeated attempts, she had 
completely failed to inject the rectum, the enema being rejected 
as fast as it was injected; further, the child had grown restless, 
* It will be well to note, at this point, that Mrs. H. W. is of distinctly tubercular 
antecedents on her maternal side, her mother having died with pulmonary tuber- 
culosis. The husband, and father of the child, is distinctly tubercular, with cavi- 
ties in both lungs. These facts may have some relationship with the existing 
imperfections in the child. 2 
cried frequently, and the abdomen was more tense and full than 
usual. I immediately examined the rectum and found that a 
probe could be made to enter the anus a distance of three-quarters 
of an inch from the anal margin and no further. The little 
finger introduced into the anus revealed a complete membranous 
barrier, and confirmed the existence of an imperforate anal cul 
de sac. It was evident, therefore, that the proctodeum had been 
fully developed, but had failed to meet the mesenteron or rectal 
cul de sac, and that the distance separating the two remained, as 
usual, an unknown quantity that could only be ascertained by 
puncture or open section. 
The serious nature of the case was fully explained to the 
parents and an operation urged that would permit the establish- 
ment of an outlet through the normal anus or perineum or of an 
artificial anus elsewhere, if the exploration of the pelvis revealed 
such a condition that made the restoration of the intestinal canal 
at the anal region an impossibility. The parents at once con- 
sented. The general condition of the baby was excellent. The 
abdomen though slightly full and tense did not give evidence of 
intestinal paresis. The stomach retained a few teaspoonfuls of 
sweetened water without vomiting. 
At 11 P. m., forty hours after the birth of the baby, and with 
the valuable assistance of my friend, Dr. P. Michinard, and of 
Miss Little, trained nurse, the operation was begun. No anes- 
thetic was given. The parts were carefully prepared by a gen- 
eral warm bath, potash soap, and local compresses of warm 
carbolic solution (214 per cent.). The limbs were carefully 
wrapped in cotton and flannels to retain heat and prevent shock 
by exposure. Notwithstanding the late hour (11 p. m.) suffi- 
cient light was obtained by several lamps, so that no difficulty 
was experienced in the way of illumination. The infant was 
first placed on the back with the nates raised high, the thighs 
flexed and projecting beyond the edge of a hard pillow in an 
exaggerated lithotomy position. 
An attempt was first made to determine the depth of the rectal 
pouch by introducing a long needle, attached to an aspirating 
syringe, in the direction of the hollow of the sacrum and upward'. 
This was introduced a considerable depth, over two inches, by 
penetrating the rectal cul de sac, which, it must be stated, was 
not tense or bulged when the child cried. After repeating the 3 
exploration with negative results, the formal perineal section 
was begun. 
A grooved director was then introduced into the anus as far 
as it would go without perforating the cul de sac, and an incision 
was made in the median line through the posterior anal margin 
to the coccyx. As nothing appeared in the wound at this stage 
of the operation which could suggest the appearance of the rec- 
tal pouch, the incision was carried higher up to the base of the 
coccyx in the middle line, and the coccyx, which was cartilag- 
inous, was easily excised, by enucleation, without much 
disturbance to the soft parts. The removal of the coccyx left 
an opening which readily admitted the little finger for its whole 
length into the pelvis and greatly facilitated exploration. The 
lips of the wound and nates were now fully retracted and care- 
ful search made for the missing rectal pouch by dissecting the 
loose retro-peritoneal connective tissue. After this, a dark, 
brownish green, soft mass was indistinctly recognized as the 
occluded rectal pouch. An attempt was now made to seize this 
mass with hemostatic forceps and to drag it down to the edge of 
the perineo-coccygeal wound. As this opening was insufficient 
and it was evident that any forcible attempts at traction upon 
the mesenterou would end in a premature rupture of the gut and 
an inability to form a proper artificial anus, I decided to remove 
as much of the sacrum as would be required to permit of more 
direct exposure of the pelvic contents and permit the easy intro- 
duction of the finger or instruments into the pelvic cavity, with 
the view of clearing the high rectal end of its attachments, thus 
permitting me to drag it down to a safe anchorage at the sacral 
outlet. 
To resect the sacrum was a very simple procedure, as the bone 
was still cartilaginous and could be cut through with strong, 
blunt-pointed scissors with less difficulty than would be experi- 
enced in cutting through heavy card board. With a few clips 
of the scissors a considerable fragment of the sacrum was 
removed up to a point corresponding with the highest level of 
the fourth sacral vertebra. The sacral excision was central at the 
coccygeal line, but became marginal and to the left as it ad- 
vanced upward. A fenestrum was thus made in the posterior 
wall of the pelvis which permitted an easy exposure of the miss- 
ing bowel and peritoneum. By gently insinuating the index 4 
between the anterior surface ot the sacrum and the tissues in 
front of it, the rectal pouch -was sufficiently mobilized to permit 
it to appear at the sacro-coccygeal opening without dangerous 
traction. The peritoneum almost completely surrounded the 
gut, which presented a distended sausage-like appearance, of a 
dark bluish-black color. The peritoneal covering was particu- 
larly adherent at the lower end of the pouch, and here the serosa 
was unavoidably torn by my manipulations. The rent in the 
peritoneum was, however, easily closed by a few catgut stitches, 
before the small intestines had opportunity to prolapse through 
the opening. It was now recognized that the gap between the 
anus and rectum was considerable, and that there was no sign 
of the distinct cord that, according to some observers, sometimes 
connects the rectal and anal ends and represents the obliterated 
rectal portion. 
The dilated anal extremity of the mesenteron was now gently 
pulled down until it projected beyond the edges of the wound, 
and after securing it at opposite points with artery forceps, was 
freely opened with scissors in the intervening portion. A flood 
of meconium immediately covered the field, and continued to 
flow for some time afterward. In the meantime the parts were 
constantly irrigated with a douche of warm and weakly carbol- 
ized water. 
When the intestinal contents ceased flowing the parts were 
again douched, and the suturing of the mucous membrane to the 
skin was undertaken. It was now noticed that in consequence 
of the evacuation ot the bowel the tension of the rectal pouch 
had been entirely relieved, and that with very little effort it 
could be brought down quite low down in the perineal wound, 
and sufficiently so as to allow its apposition with the natural 
anus. The question which then arose was whether the original 
anal cul de sac should be removed and the mucous membrane of 
the bowel substituted in its place. I decided that I would not 
disturb the original anus for fear of injuring its sphincter 
muscles. The rectal pouch was sutured to the proctodeal cul de- 
sac in the manner shown in the accompanying diagram. The 
skin over the sacral region was then closed with a few silk 
sutures, and the mucous membrane carefully united to the skin 
immediately behind the anus in the ano-coccygeal region. 
This plastic operation would appear to be a very satisfactory restoration of the continuity of the rectal and anal tract, and 
leaves a well formed amis, but I have since concluded that it 
would be preferable, in a similar case, to excise the original 
mucous lining of the cul de sac down to the anal margin com- 
pletely ; paying special attention while so doing to respect all 
the underlying submucous structures with the view of preserv- 
ing the functions of the external sphincter and levator ani 
which has been cut through at its coccygeal attachments by the 
operation. The objection to leaving the original anus in situ is 
mainly that the interposition of the mucous membrane in its 
posterior segment is bound to act as a wedge of foreign tissue, 
which may interfere more or less permanently with the efficient 
contraction of the sphincter. 
Fio. I—Diagram showing cloaca resulting from anastomosis of procto- 
deum and mesenteron. 
(1) Peritoneal reflection. 
(2) Mesenteron or rectal cul de sac. 
(3) Proctodeum shaded to show line of junction with ampulla of mesen- 
teron. 
(4) Cloaca resulting from suture of enteron and proctodeum. 
After the operation the child was washed and soothed by a 
general immersion in a tub of warm water, after which the parts 
were dusted with iodoform powder and covered with gauze, 
Notwithstanding the extent of the operation the baby’s condi- 
tion was excellent. It kept up a continuous cry at first, but it 
subsequently intermitted with the less painful manipulations and 
procedures. After the final bath and dressing it went to sleep 
very quietly, as if nothing had happened. There was no loss of 6 
blood of any consequence. No vessels were ligated, and the 
precautions taken to keep the baby warm assisted in diminish- 
ing shock. 
The next morning, August 30, the temperature rose to 100.2-5 
deg. It was noticed that the child coughed occasionally. Next 
day the cough was more marked without any increase in the 
temperature. After this the cough continued to increase pro- 
gressively, much to the baby’s distress and to our discourage- 
ment until, in a few days, it became evident that the child had 
contracted whooping-cough. 
Locally, the wound progressed most favorably. The bowels 
moved regularly, there was scarcely any local irritation in the 
neighborhood of the anal margin notwithstanding the frequent 
contact of feces.* 
The whooping-cough, which was epidemic in the neighborhood 
at the time, and which thus manifested itself in the baby on the 
fourth day after birth, produced a marked effect on the child’s 
general condition, and threatened the final success of the opera- 
tion. 
The frequent paroxysms of violent cough unquestionably pre- 
cipitated a complication which would at least not have presented 
itself so soon after the operation. In consequence of the large 
pelvic outlet in the sacro-coccygeal region and the laxity of the 
anal orifice from weak sphincter control, the rectum began to 
protrude and not many days elapsed before three inches of pro- 
lapsed rectum remained constantly extruded from the anus. 
All attempts to control the escape of the bowel failed. The 
constant protrusion of the rectal mucosa caused irritation and 
tenesmus, which distressed the child exceedingly and prevented 
rest. 
None of the local applications had the least influence in pre- 
venting the recurrence of prolapse and it became necessary to 
operate. Having no faith in the palliative operations in such a 
case, I decided to excise the prolapse. Therefore, on September 20, 
1894, twenty-eight days after the first operation and again assisted 
by Dr. Michinard I amputated three inches of protruding bowel 
by the following method : 
*This was due to the watchfulness of the nurse, whose devotion to her charge 
contributed largely to the final recovery. 7 
The prolapsed bowel, which was deeply congested, reddish 
blue in color from anal constriction, was thoroughly washed with 
warm water, soap and a dilute peroxide of hydrogen solution. 
Very little chloroform was administered. The protruding bowel 
was seized with artery forceps at its apex, so as to stretch the 
prolapse to its utmost. The blades of a long Pean forceps were 
then introduced at three equidistant points up to the anal mar- 
gin, one blade within the canal and the other on the outside of 
it. Before closing the blades the whole prolapsed gut was firmly 
pressed with the fingers to exclude any coil of small bowel that 
might be lodged in the procidentia. This was not an unnecessary 
precaution, for the prolapse had a wide base, and the small 
intestine could be felt under the mucous membrane. After this 
the forceps compressed the mucous membrane together, and pre- 
vented the further descent of the small bowel. Now, holding the 
prolapsed mass steadily and preventing its retraction with the 
forceps, we proceeded to the next step, by which we were to 
secure the elastic constriction of the bowel at the point of divi- 
sion. A long needle threaded with a double elastic thread was 
made to transfix the prolapsus at the level closest to the skin, 
where two elastic threads were tied in a manner to constrict the 
bowel in two hemisections, thus : 
(1) Shaded part indicates peritoneal cavity communicating by diverti- 
cula with space in prolapse. The small intestine may escape into these 
spaces if precaution is not taken to prevent this occurrence by means indi- 
cated elsewhere. 
Fig. 2—Section of procidentia recti after Kraske’s operation. 
(2) Fixation pins to hold ligatures and prevent slipping during ampu- 
tation. 
(3) Elastic (sectional) ligatures. Fig. 3—Diagramatic section of procidentia recti and method of securing 
hemostasis and excluding peritoneal infection by fixation pins and elastic 
sectional ligatures. 
(1) Peritoneal spaces. 
(2) Lumen of bowel. 
(3) Section of prolapsed portion, after amputation 
(4) Fixation pin 
(5) Elastic ligatures. 
Fig 4—Diagramatic section of procidentia after suture; elastic ligature 
and fixation pin still in position. 
After thus securing the base of the prolapse by elastic liga- 
tures, the part beyond the line of constriction was amputated 
without the loss of a drop of blood, and without danger of injur- 
ing any important parts that might accidentally have slipped 
into the cavities of the prolapse. The elastic constriction also 
kept the mucous surfaces in perfect apposition and protected 
the peritoneum from contamination. The mucous membranes 
were then easily brought together by interrupted silk sutures.* 
*The procedure adopted in this case has close analogies with Kleberg’s method 
( Vide Kelsey’s Diseases of the Rectum, 1896, and Sajous’ Annual, Section D., p. 22, 
1891), though the author was not acquainted with Kleberg’s previous application 
of the principle of elastic constriction before he applied it in this case. 9 
After finishing this operation, we found it necessary to cir- 
cumcise the child on account of phimosis, which made urination 
painful. 
These operations were followed by no unpleasant conse- 
quences, and in ten days the child was entirely well, with the 
exception of an incipient inguinal hernia which became less 
troublesome as the cough diminished. It is also worthy of note 
that, in addition to the anal defects, the phimosis and the dispo- 
sition to hernia, the child was born a unilateral criptorchid—one 
testicle having failed to reach the scrotum. 
After this event, the child continued to grow and to do well, 
though he has always been pale, fretful, and not as vigorous as 
his other little brothers. Last summer, or about a year and a 
half after the operation, the baby was brought to the city, and I 
had the opportunity of examining it. 
The child had normally three or four bowel movements a 
day. It was difficult to ascertain whether there is much bowel 
control, but the finger feels a certain amount of resistance and 
contraction when it is introduced a short distance beyond the 
anal margin. The baby appears to be disposed to frequent 
diarrheal and dysenteric attacks, which are probably due to 
digestive disturbances. When these occur, the anal region 
becomes irritated, and has to be most carefully watched to pre- 
vent eczema and excoriations. It is also noticed that under 
these circumstances there is no fecal control. There is also a 
tendency to recurrence of the prolapsus recti, though in a much 
less degree than when this condition first existed. The prolapse 
now appears to be due to the tenesmus of dysentery. It is 
probable that the operative treatment will be required if the 
prolapse continues to increase. If such is the case, I shall 
advocate a simple rectopexy or anchoring of the rectum by 
Yerneuil’s m ethod. 
While the child has thus far survived, and is apparently in 
veiy fair condition, it is evident that it has had to travel over a 
very hard road, and that its future path is not likely to be 
strewn with roses. 
Commentary.—After a careful investigation of the literature 
of the subject, I find that this is the tenth in a list of twelve 
cases of ano-rectal imperforation in which relief has been 
attempted by Kraske’s method or its modifications. The cases 10 
are reported by Vincent of Lyons, two cases, in 1887; Ceci, of 
Genoa, 1890; Burrell, Boston, 1891; Chaput, Paris, 1892; 
Poisson, Nantes, 1892; Czerny, Heidelberg, 1893, two cases; 
Fochier, Lyons, 1894; the present case, New Orleans, 1894; 
Elliott, Boston, May, 1896; W. W. Keen, Philadelphia, Decem- 
ber, 1896. Of the twelve cases reported only two succumbed to 
causes directly connected with the operative treatment; and in 
one of these death was caused by peritonitis due to the infection 
of the peritoneum with an exploring needle previous to the sacral 
operation (Czerny’s second case). 
Eight out of the twelve cases died at variable periods, from a 
few days to two months after the operation, from diarrhea, 
marasmus, capillary bronchitis, and other conditions not directly 
connected with the operation. 
Four of the twelve cases had survived up to the time when 
they were reported. In Burrell’s case, four and a half years 
after operation; in Poisson’s, three years ; in the writer’s case, 
two years and nine months ; in Elliott’s case, six months after 
the operation. The relations of Kraske’s operation to other 
operative measures intended for the relief of imperforate infants 
are fully discussed in a paper which the writer has contributed 
to the transactions of the Second Pan American Congress held 
in Mexico City, November, 1896.