Lu many cases there is a partially formed external sphincter ring, and this should be carefully searched fur, as the anal orifice may be inside of it (Fig. 29, Plate 4).
If the rectum cannot be located by advancing up to promon tory, it would be permissible, following the procedure of McLeod, to resort to laparotomy on the left side, making the smallest possible incis ion, through which the rectum may be pushed toward the perineal incision.
In cases where even this procedure does not lead to the desired result, the creation of an artificial anus in the lateral abdominal incision is the last, though very undesirable resource, its function leaving very much to be desired.
In an eight-months-old child with anus vestibularis I made an arch-like incision around the anal fossa which showed outwardly visible function, dissected the rectum with its funnel-shaped vestibular end from its surroundings, perforated the anal fossa and pulled the rectal tube through the existing sphincter ring, thus following a process similar to that in hypospadias. Then followed closing of the pelvis by perineal plastic. The operation was followed by complete function which was verified six months later (Fig. 301), Plate 5).
The same result was attained in an infant (Fig. 3], Plate 5). In all eases, however, the rectum should lie close to the skin incision without tension, as otherwise the sutures will cut into the parts and the rectum retract into the traumatic funnel, the anal portion developing into a eicatricial canal which would easily cause symptoms of stenosis. Should
there still be any accessory fistular ducts, these are best treated by open incision, although they would soon become obliterated if fecal matter no longer passes through them (Fig. 31, Plate 5).
The results of this proctoplastic method (Dieffenbach) are far more favorable as to mortality than operations through the abdominal cavity, t he proportion of recoveries being from 22 to 63 per cent. (Ashhurst). Of course, the unfavorable statistical figures for the abdominal operations are not quite fair, because front the first the cases submitted to them are grave and unfavorable, but prolonged operations in the abdominal cavity, such as are always involved in plastic procedures, are well known to be borne badly by infants, quite aside from the fart that the deep anesthesia required is another injurious factor.
\oTE.—For other congenital dilatations and constrictions of the intestine, such as IIirschsprung's disease and intestinal stenosis and atresia, see R. Fisch], vol. iii. For their surgical treatment, see "Intes tinal Operations."