[Reprinted from the New York Journal of Gynaecology and Obstetrics 
for May, 1894. 
THE RELATION OF HYSTERECTOMY TO CONSERVA- 
TIVE OPERATIONS UPON THE APPENDAGES. 
William M. Polk, M. D. 
I find that I have been criticised for what has been called incon- 
sistency, the ground of complaint resting upon a comparison of my 
utterances relative to certain procedures designed to preserve the 
appendages, with those recently expressed upon the subject of abla- 
tion of the uterus for salpingitis. I am too deeply interested in the 
welfare of both subjects to permit anything said by me to stand as a 
stumbling block to either ; but as I am confident that a correct read- 
ing of my utterances will fail to reveal inconsistency, I beg leave to- 
present the necessary extracts. 
Speaking upon the subject of "curettage and subsequent depletion 
by means of drainage with gauze packing," which I strongly advo- 
cated, I said to the New York Academy of Medicine, December 3,, 
1891 (see Transactions, 1891) : 
"The conditions to which the method has been applied include 
acute as well as chronic inflammation of the uterus and its append- 
ages, parturient and non-pregnant. . . . 
" It is to be hoped that no one will misunderstand me in reference 
to the treatment of chronic salpingitis and infer, because I favor 
attacking the interior of the uterus in certain cases, that I oppose 
direct operation upon the appendages in appropriate cases. Such 
is far from being the attitude I maintain. I favor attacking the in- 
terior of the uterus in chronic metritis and endometritis, because by 2 
William M. Polk, M. P. 
so doing we can prevent the extension of disease into sound append- 
ages, and in the diseased tube modify the disease so as to limit the 
damage that may be done. This is of special value in cases where 
already one set of appendages are diseased, and yet the other remains 
healthy. Cases in other words in which at the present time, were we 
to open the abdomen we would not only remove the diseased member 
but the sound one as well, because experience teaches that in such 
cases the unaffected organs soon become diseased. This I believe to 
be solely due to the absence of efficient treatment of the interior of 
the uterus. I likewise favor this measure in the presence even of 
double chronic salpingitis, because there are some patients who, with 
a full knowledge of all the dangers and inconveniences of the disease, 
prefer to take their chances rather than submit to mutilation, and yet 
their condition is such as to demand treatment at our hands. . . . 
" I beg leave to present at the end of this paper a synopsis of the 
histories of some of these patients. In one it will be noted that a 
laparotomy was done, and then the uterus was attacked. The charts 
cover several of these cases; they represent instances in which, hav- 
ing freed the appendages from all adhesions, or the ovary from a 
cyst, I attacked an associated metritis or endometritis at the same 
sitting." 
Two months later I presented a paper upon the same subject to 
the New York Obstetrical Society (see The New York Journal of 
Gynaecology and Obstetrics, May, 1892) in which, after again strongly 
advocating the measure, I said : 
" I wish here, Mr. President, to make the statement that, this 
method, in common with every human endeavor, has its failures as 
■well as its successes. The failures, however, have never left my pa- 
tients in worse condition than before, but have simply fallen short of 
that degree of relief which would justify one in stating to the patient 
that she had escaped the certainties of laparotomy. 
"Granting then, that we have our failures, what do they signify? 
In every instance, the result obtained has been a diminution in the 
size of the peri-uterine mass. Our knowledge of these masses in gen- 
eral, teaches us that in the main, they are composed of the tube. The 
diminution then, implies an attempt on the part of the tube, to return 
to its normal state. The exact condition of such appendages can, of 
course, only be determined by exploratory incisions, but, given a case 
of salpingitis, peritonitis, ovaritis, in which the inflammatory process 
is active and possibly excessive, and subject that case to the prelimi- 
nary treatment here mapped out, so as to obtain as much improve- Hysterectomy and Conservative Operations upon the Appendages. 
3 
ment as can be had, is it not fair to assume that, should we then be 
obliged to open the abdomen, we would find the appendages in far 
better condition for conservative operation than had we operated 
sooner. 
" It is obvious then, that whatever may be our ultimate course, 
this preliminary treatment is a necessity. . . . 
"To sum up the points which I desire to bring before you in this 
paper, I would say that I first wish to call attention to the advisa- 
bility of extending our treatment of peri-uterine inflammation by 
scraping and packing the inside of the uterus-by selecting for this 
treatment, the period immediately antecedent to menstruation. In 
case this does not give a sufficient degree of cure, making it necessary 
to go further, that we operate in such a way as to save the patient all 
or as much of the appendages as their condition will warrant, bearing 
in mind always that the essential object of our procedure is the main- 
tenance, as far as possible, of the function of menstruation. . . 
In April, 1893, I again said, before the New York County Medi- 
cal Society (Intra-uterine Treatment by the Curette and by packing 
with Gauze in Salpingitis and its Complications) : "The purpose of 
this paper is to formulate as far as possible this method of treatment 
in the disease in question-and to that end it is my purpose to group 
the varieties of the disorder as they have come before me. The dif- 
ferentiation of conditions present in each case has been made as the 
result of a thorough examination under ether, after a careful inquiry 
into the previous history. The method of physical examination em- 
ployed being the bimanual method, both by vagina and rectum. The 
uterus being steadied with the volsella, and the method of examina- 
tion mentioned carried out in every instance with all the care and 
thoroughness of which I am capable. 
" None of the cases presented any special obstacle to the examina- 
tion, so that the conclusions (diagnostic and therapeutic) reached 
were in all of them satisfactory to me and to the gentlemen who hap- 
pened to be assisting me. 
"This statement is made at the outset, because there being no 
doubt in my mind as to the deductions, I wish, as far as your faith 
in me as an observer will permit, to secure first your acceptance of 
my premises and thus permit you the more easily to follow to my 
conclusions. For convenience of study I have arranged the condi- 
tions under four headings or groups : 
" Group A.-Lesser degrees of salpingitis, the lesion confined 
mainly to the tubes. 4 
William M. Polk, M. D. 
" Case I.-This case represents a minor degree of tubal disease 
in which there is probably no closure of the infundibula, but thicken- 
ing of the walls throughout. The appendages being non-adherent. 
And yet because of this condition, there is loss of elasticity in the 
corresponding upper border of the broad ligament with consequent 
shortening, and of necessity some check upon the mobility of the 
uterus on that side. 
"Curetted and packed November io, 1892. Result as determined 
four months later, good symptomatically and anatomically. 
" Case If.-Aged twenty-seven ; married. In good general health, 
with the sole exception of pain in menstruation, and sterility. Dating 
her ailment from a mild attack of pelvic inflammation following a 
forced abortion three years ago. Appendages thickened and ad- 
herent to posterior-face of broad ligament, the right being attached 
so low, as probably to rest upon the lateral fossa of Douglas's. 
"Curetted and packed May 1, 1892. Result as determined one 
year later. Nothing remains but enlarged ovary on right, this now 
movable. Sterility same as before. Result symptomatically and ana- 
tomically-good. 
"Case III.-Miscarriage two years ago; no special discomfort at 
the time nor since, with the exception that she has more weight and 
fullness in the pelvis at menstruation, than before the miscarriage and 
is sterile. The condition of the appendages is much the same as in 
the second case, with the exception that the infundibula of the left 
tube is prolapsed and rests on the floor of Douglas's cul-de-sac. 
"Operated February 20, 1893. Result. 
"April 10, 1893.-Free on right; a small mass in Douglas's cul- 
de-sac. Connected with left appendages. 
"Group B represents distinct instances of pyosalpinx (pus tubes). 
" Case I.-Mrs. P., aged twenty-four, married, three children, last, 
two years ago,-following this birth pelvic inflammation,-slow re- 
covery, ill-health ever since. Anaemic, weak, flows excessively at the 
menstrual period. Uterus enlarged, retroverted, adherent to floor of 
pelvis. Appendages on both sides enlarged, the one on the left the 
more so,-this one representing a mass as large as a walnut. 
"Curetted and packed April, 1892. The uterus lifted to the nor- 
mal position easily and held there by a pessary. Examination six 
months after the operation : her general health good, uterus in nor- 
mal position. No thickening appreciable on right side ; on the left 
side the mass diminished one half, menstruation normal, and the pel- 
vic pain which had been so persistent as to almost forbid locomotion. Hysterectomy and Conservative Operations upon the Appendages. 
5 
has entirely disappeared, so that the patient is able to attend easily to 
her household duties which are by no means light. 
"April, 1894.-Improvement has continued. Local condition 
about the same as April, 1892. 
"Case 11.-E. M. This case was operated upon October, 1891. 
The uterus measured four inches and a half, was sensitive, soft, with 
a mass about half the size of the enlarged uterus situated on the left 
side. This mass when pressed upon, diminished slightly in size, and, 
at the same time, there was a free discharge of pus from the cervical 
canal. 
"'Fhe case was curetted and packed on the 19th of October, the 
cavity re-packed on the 26th. On November 3d the canal of the 
uterus was three inches and a quarter, there was no pain on pressure, 
the mass on the left side was half the dimension which it had had at 
the outset, and the patient was discharged on November 14th in 
such comfortable condition that she declined all further treatment. 
" Case III.-B. H. Here we have an instance of pelvic inflamma- 
tion, in which the uterus was imbedded in a mass of exudate which 
sprung evidently from the double salpingitis which existed. The masses, 
on either side were fully as large as the body of the uterus. The uterus 
was fixed, although in an anterior position. In Douglas's cul-de-sac 
there was fluctuation, and examination from the rectum revealed the 
intimate relation of the left appendages. The patient's temperature 
ranged from ioo° to 102°. 
" All the evidences of a pelvic abscess being present, it was deter- 
mined to open into the fluctuating regions in the posterior vaginal 
fossa. This was done, and about two ounces of turbid serum escaped. 
Passing the finger into the opening made, the rounded outline of the 
inflamed appendages was easily made out. 
" Four days after this operation the uterus was curetted and 
packed. 
"On April 24th, twenty days after this last operation, examination 
shows that the uterus is of abdut normal size, the masses on either 
side have so largely subsided that they are about one third the dimen- 
sions on entering, and the patient, from having been bedridden from 
pain and weakness on admission, is now so well that she insists upon 
her discharge. 
" Group C represents long-continued cases in which the adhesions 
are well organized and dense. Cases, therefore, in which, because of 
the organization of the inflammatory product, but little improvement 
is to be expected from any treatment which looks to resolution. 6 
William M. Polk, M. D. 
" Case I.-Mrs. K., aged thirty-one, married, United States. Oper- 
ated upon in March, 1892. 
" The patient complains of constant vaginal discharge,-of painful 
menstruation. In other respects, her health is good. She dates her 
ailment from a miscarriage six years ago. Following this miscarriage 
she had pelvic inflammation, and was ill with pelvic pains, and distress 
in menstruation, which interfered with exercise. 
" The mobility of the uterus was found to be somewhat impaired ; 
hard masses existed on both sides, but most markedly on the left ; 
there was a good deal of pelvic tenderness, which was greatly in- 
creased when upward pressure was made upon the uterus. 
" It was evidently an old case of pyosalpinx in which the discharge 
was largely from a pus tube. The case was curetted and packed. 
Convalescence was smooth, but two weeks after the operation violent 
pelvic pains supervened, and examination showed that there was a 
large inflammatory mass behind the uterus. This was opened, and 
about two ounces of sero-purulent fluid evacuated. It was evidently 
the inside of the tube, because the same material as was obtained 
from this cavity exuded from the uterus prior to the operation when 
the mass was pressed upon. 
"Case II.-The patient had suffered from pelvic peritonitis two 
years ago in consequence of treatment for posterior displacement. 
Never had children. The uterus was retroverted, was adherent 
slightly, and a hard, slightly sensitive mass existed at the base of the 
right broad ligament, posteriorly. 
" The uterus was first forced forward as far as possible, and was 
then curetted and packed. 
"Four months after the operation there was slight diminution in 
the size of the mass as well as of the pelvic pains from which the 
patient had suffered. The amount of benefit derived, however, 
seemed to be no more than would have sprung from counter-irrita- 
tion from pelvic massage and attention to the general health. 
" Group D.-Irregular Cases. 
" Case I.-In this case the patient gave the history of having suf- 
fered from menstrual pain for nine months, which was constantly on 
the increase. This pain had lasted through the intermenstrual 
periods, and for a month before operation she was incapacitated for 
her usual work, that of a domestic. 
" Examination showed that there was no special enlargement of 
the uterus, which measured only two inches and three quarters, but 
on either side of the uterus there were masses, showing very clearly Hysterectomy and Conservative Operations upon the Appendages. 
7 
that there was considerable implication of the appendages, the masses 
being about two thirds the size of the uterus itself. 
" The uterus was curetted and packed on the 30th of January 
last, but she experienced no relief; if anything, she was in more pain 
than before. 
" On February 24th, the size of the uterus and of the masses on the 
two sides was about the same as at the operation three weeks before. 
Laparotomy was therefore performed. It was then found that, in 
addition to salpingitis, with marked thickening of the tubes, there 
was a purulent infiltration of both ovaries, each of these organs con- 
taining cavities filled with pus. It is needless to say that the ap- 
pendages on both sides were removed. 
"Case II.- Here a considerable mass was situated on the right 
side of the uterus; with thickening of the broad ligament on the left 
side. The mass on the right side being movable, it was diagnosti- 
cated as a case of purulent salpingitis on the right, with adhesions and 
thickening of the appendages on the left. The uterus was about the 
normal length, but from the freedom with which the sound moved 
about in its cavity, was evidently enlarged. 
"The patient was operated upon by laparotomy on the 27th of 
June, 1891, and the appendages on the right side were removed, the 
mass on that side proving to be a haematoma. Upon the left side 
the end of the tube was open, but it, together with the ovary, was 
adherent to the posterior face of the broad ligament. These 
appendages were freed from their attachments and allowed to 
remain. 
" The interesting feature of the case is that the patient returned to 
the hospital in February, 1892, when she complained of pain on the 
left side, and was found to have a mass in the region of the left 
appendages, which mass had not existed there before, and the cavity 
of the uterus now measured three inches and a half instead of two 
inches and three quarters, as before. 
"This case was curetted and packed on the 8th of February, 
aid was discharged on the 25th of the same month with about the 
same amount of thickening on the left side as had existed prior to the 
laparotomy in the previous June ; with a uterus measuring three 
inches, and without pelvic pain. 
" This case should have been curetted and packed at the time 
that the laparotomy was done. The endometritis which originated the 
tubal disease, was no doubt present at that time, and subsequently 
lighted up and produced the recurrent salpingitis which was responsi- 8 
William M. Polk, M. D. 
ble for the patient's pain and discomfort, and for the evident enlarge- 
ment which existed on the left side. 
" The good result which was obtained in consequence of the op- 
eration done at this late date, proves what might have been accom- 
plished if curetting and packing had been done originally. 
" Group D is introduced to illustrate, first, the shortcomings of the 
operation, as in Case I, and the need for its prompt application, as 
shown in Case II. In Case I we were dealing with a suppuration in 
the ovaries, in addition to suppuration in the tubes. The suppurative 
process in the ovaries was clearly uninfluenced by the treatment, which 
is in exact accordance with what we would expect. The suppuration 
here being in a connective-tissue space, having no direct connection 
with the uterus, its behavior would be identical with inflammation in 
any other connective-tissue space or glandular organ, no matter in 
what part of the body it might be situated, and would, therefore, be 
benefited but little by anything which might be done upon the interior 
cf the uterus. 
"The same remark, no doubt, holds true in reference to the sup- 
purative process when it exists in the cavity of the peritonaeum, which 
enables us to state that suppuration in an ovary or in the cavity of the 
peritonaeum, would in no way be benefited by the process of uterine 
depletion which results from the curetting and drainage. 
" Conclusions.-The legitimate conclusions to be drawn from 
these cases are. therefore, the following : 
" i. The effect of the operation upon the uterus and annexae which 
are intimately and directly connected with it through its vascular and 
lymphatic supply (the Fallopian tubes and the broad ligaments), is to 
cause depletion and diminution in size. 2. Properly done it will not 
excite inflammatory reaction. 3. In the lesser degrees of inflamma- 
tion of the tubes, and as far as has at present been observed, in cases 
of pyosalpinx, with enlargement of the uterus, the anatomical result 
of the operation is a diminution in the bulk of the inflamed structures, 
which clearly points to the occurrence of more or less resolution. 
Symptomatically, the operation causes a decided improvement in the 
sensations of these patients. In cases of long-standing salpingitis, 
especially if there be no particular enlargement of the uterus-cases 
in which, in all probability, organization of the inflammatory products 
has taken place, the operation produces neither anatomical nor 
symptomatic improvement. 
"Then again, cases in which the inflammatory products exist in 
the free peritoneal cavity or in the ovary in the shape of pus or in Hysterectomy and Conservative Operations upon the Appendages. 
9 
the shape of organized material, would not be benefited by the 
operation. 
"We, therefore, conclude that, all things being equal, the treat- 
ment is most efficacious in the more recent cases. In view of the fact 
that in no case where it has been properly applied ill results have fol- 
lowed, we also conclude that in every case of endometritis and me- 
tritis with tubal disease, in which the conditions favorable to resolution 
are present, the curetting and packing of the cavity of the uterus 
should be employed before the radical operation of removing the 
appendages is broached. And we maintain this attitude, not only 
because of the possibility of such relief being obtained as will satisfy 
the demands of the patient, but because of the opportunity offered for 
such an amount of resolution as will place these appendages in a con- 
dition more favorable for conservative operation than if no such treat- 
ment as that advocated above were employed." 
The extracts thus far presented relate to efforts at relief and cure 
short of laparotomy. In reference to those advocated by me after 
laparotomy I will present the following extract from a paper read 
before the American Gynaecological Society May 16, 1893, which fully 
represents my attitude : 
" I now formulate the propositions of this paper in order that you 
may the more easily grasp the points for criticism. 
"1. As a rule, women are the better mentally and physically for 
the maintenance of menstruation and ovulation up to the period of 
Nature's menopause. 
" 2. The minor discomforts which pertain to the function even 
though they be clearly dependent upon the ovary and tube do not 
require removal of these organs. 
"3. The appendages may be operated upon to the promotion of 
child-bearing (four cases out of eighty). 
" 4. Disease of the appendages does not always demand complete 
removal; certain conditions permitting partial removal. • 
"5. The condition of the ovary should be the chief factor in de- 
termining the question of procedure. 
6. If the ovary contains pus, it and the associated tube should 
be removed ; it being the rule that whenever an ovary is removed the 
tube must accompany it. 
" 7. If the tube contains pus, the ovary being free from pus or 
disseminated degeneration, the operator is at liberty to amputate the 
tube and leave the ovary; the same rule may apply in cases of hydro- 
salpinx and hematosalpinx. 10 
William M. Polk, M. D. 
"8. Cysts of the ovary do not demand its removal, provided they 
are not general throughout the organ and can be enucleated-haema- 
toma of the ovary being a possible exception. 
" 9. Tubes with open infundibula, even though adherent and 
affected with parenchymatous inflammation and endosalpingitis, do 
not demand removal except when one opens into a pus cavity. 
" 10. A tube whose outer end is closed and yet otherwise is in 
good condition may be opened, cleansed, and its inner and outer 
coats coaptated, and then be returned to the abdominal cavity, pro- 
vided it does not contain pus; possibly the same may apply to old 
blood. 
"11. Adhesions do not demand the removal of the tubes and 
ovaries, unless they be so dense that in breaking them the append- 
ages are seriously injured. This presupposes that the appendages 
in themselves are not sufficiently diseased to demand removal. 
'12. In all cases of subacute or chronic tubal disease, it is of the 
first importance to treat the interior of the uterus. Curetting it with 
the sharp curette and then firmly packing it with gauze being the best 
method of treatment." 
The extracts given so far, prove my faith in the kind of intra-uter- 
ine treatment specified for certain forms of salpingitis, and they prove 
also my faith in the so-called " conservative " operations upon the 
appendages. It is evident, however, that I clearly indicate, if I do 
not specify, certain diseased conditions which contraindicate the 
measures aforesaid, which conditions render necessary removal of 
the appendages. It is evident that the limit within which I advocate 
ablation of the appendages is much narrower than that so far permit- 
ted by the average operator, and it is equally evident that the phrase, 
" when it is necessary to remove the appendages " possesses a signifi- 
cance with me which differs no little from that belonging to it when 
used by the average operator. Bearing this in mind I now present 
extracts from my article upon Ablation of the Uterus for Salpingitis, 
which was read before the New York Obstetrical Society, October, 
1893 (see New York Journal of Gynaecology and Obstetrics, December, 
i893): 
" It is my purpose in this paper to bring before the society the 
advantages connected with the removal of the entire uterus when it is 
necessary to remove the appendages. This radical step is familiar to 
you chiefly through the writings and work of Segond of Paris who has 
advocated this procedure in all cases of diseased appendages. As I 
understand, he recommends the operation in every case where other Hysterectomy and Conservative Operations upon the Appendages. 
11 
surgeons now content themselves with the simpler process of mere 
removal of the appendages. 
" The position which I hold upon the latter question places me, as 
you well know, in antagonism to the one more generally held. For I 
claim that while operation in these cases is necessary, yet the degree 
of operative interference should not always extend to complete removal 
or in some cases, even to partial removal, as for instance in simple ad- 
hesions (see Transactions of the American Gynecological Society, page 
182, vol. xiii, or New York Journal of Gynecology and Obstetrics, Au- 
gust, 1893). 
" It is evident, therefore, that I do not accept Segond's proposal in 
whole, because by so doing, one necessarily abandons all idea of con- 
servative surgery in dealing with diseased appendages. Conditions of 
disease, which according to my beliefs, may be-reduced by operation 
to a status in keeping with health and usefulness, are by his plan con- 
demned to sacrifice, his proposal in this particular antagonizing my 
proposals in the same degree as do most operators of the present day 
-who having diseased appendages before them see no better way of 
dealing with them than amputation. . . . 
" In presenting the subject propounded in the title of this paper it 
is necessary to subdivide the question as follows: 
" 1. Shall those of us who repudiate 'conservative' operations 
upon the appendages, content ourselves with mere amputation, or 
shall we extend the operation to the removal of the uterus as well? 
" 2. Shall those of us who accept ' conservative ' operations upon 
the appendages extend the principle to the uterus when deprived of its 
appendages or shall we remove the uterus when compelled to remove 
the appendages ? 
" The answer to both questions can be found in the same direction 
and turns, First, Upon the relation of the emasculated uterus (borrow- 
ins a term applicable to the opposite sex) to the individual possessor : 
Second, Upon the dangers of the added operation." 
After presenting matter in evidence the paper concluded : 
"We find then, First, That with the removal of the appendages the 
uterus becomes a useless, vexatious and perhaps a dangerous organ ; 
Second, That the vital conditions of the patient being such as are 
usually presented in case of salpingitis, the dangers attending its re- 
moval are not sufficient to forbid this step. Accepting these state- 
ments as a working basis, we can say to those who repudiate conserva- 
tive operations upon the appendages that complete work demands the 
removal of the uterus along with the appendages ; and to those who 12 
William M. Polk, M. D. 
accept conservative operations upon the appendages that when these 
organs are sacrificed the principles of conservatism do not apply to the 
uterus which then should be removed. 
" There is an aspect of this question of dealing with diseased ap- 
pendages which should now be noticed. When one speaks to a woman 
of taking out the ovaries, she may contemplate the sacrifice with feel- 
ings of regret, but when one speaks of taking out the uterus-apart 
from the question of added danger which has been dealt with above- 
one is met by opposition which is based upon the idea that in the 
uterus centers her womanhood. As a fact, we know that it centers in 
her ovaries, and if we were candid with ourselves we would admit 
that her idea is the result of our own false teaching. Until this fact 
can be brought home to her. we may expect greater opposition to the 
complete operation than to the amputation of the appendages, when 
in fact it should be the reverse. And again, just so long as we shirk 
this question, just so long will we ignore the advantages to be gained 
along the lines of operations which have for their primary object the 
saving of the ovaries. The ovary is the organ to be considered- 
that is, the organ about which the maintenance of woman's position 
revolves. It is not the uterus, and from my standpoint I would rather 
sacrifice every uterus without its ovaries than one ovary that could 
be saved by any known process of surgery or medicine. 
" Turning now to the kind of hysterectomy which should be 
adopted, I will say that to one repudiating 'conservative' operations 
upon the appendages, the logical procedure may lie in vaginal hys- 
terectomy, although I question whether so good an operation can be 
done from below as from above the pubis. 
" To one belonging to the class which accepts ' conservative ' op- 
erations upon the appendages, the essential procedure is supra-pubic 
hysterectomy, because with such an operator the key to the problem is 
the condition of the appendages as revealed by close visual inspec- 
tion, and this can only be made by approaching the organs from 
above. His operation is primarily in the nature of an exploratory 
procedure, and he expects at the outset to be able to save a part or 
the whole of the ovaries and at least part, and perhaps all, of both 
tubes. But should the condition from his standpoint forbid such 
action, he is then in position to follow his more radical brother and 
make a clean sweep of all the organs-ovaries, tubes, and uterus."