It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a fæcal fistula which had followed an oöphorectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube passed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble.
If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or cæcum he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.)
=Intestinal obstruction.= It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:--
2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.
3. Strangulation around an adventitious band.
4. Obstruction due to an overlooked cancer in the colon.
5. Strangulation in a sac formed by a yielding cicatrix.
The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.
The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.
From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up like a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the supravaginal cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.