make anesthesia dangerous. If débris be removed from the uterus, it should be thoroughly examined and its character noted. If free hemorrhage is present, the womb may be tamponed, with advantage, with sterile gauze. If the womb is so large that the finger of the physician cannot thoroughly explore it, a blunt-edged douche-curet should be gently inserted, and the wall of the womb thoroughly but gently scraped and irrigated. The constitutional treatment of the patient calls for active stimulation, purgation, the use of cold over the abdomen, abundant nourishment, and surgical nursing. In deciding upon operation in these cases care must be taken that the indications for such interference are clear. The physician must remember that he should cooperate with justice to secure the conviction of the perpetrator. Should operation be hastily resorted to without positive indication, the defense might allege, in the interests of the perpetrator, that the physician's operation, and not the abortionist, should be held responsible for the death of the patient. Cases of criminal abortion should at once be reported to the proper authorities, who will secure all possible evidence before the patient's condition necessitates an operation from which she may not recover. The operations necessary in the treatment of this condition are those usually employed in puerperal septic infection. Thorough curetting and disinfection of the uterus under anesthesia, opening and draining pelvic and abdominal abscesses, the removal of diseased Fallopian tubes and ovaries, and hysterectomy may be indicated. Such patients are often unfavorable subjects for operation by reason of their depressed and depleted condition following hemorrhage and nervous shock. The mortality-rate of such operations is necessarily high, and the utmost resources of surgery are often severely taxed in the effort to save the patient's life. So long, however, as the patient can take food and stimulants she may recover, and the most desperate cases sometimes result in a slow and imperfect convalescence. Many attempts have been made to lessen the frequency of criminal abortion; in countries where the decrease of population has alarmed the government, stringent measures have been taken and every inducement offered for the legitimate increase in the population. The establishment of foundling asylums has, it is claimed, lessened this evil by caring for illegitimate offspring and thus removing the temptation for their destruetion. In countries having large standing armies, where the marriage of soldiers is prohibited until a certain amount of property is possessed, illegitimate pregnancy is frequent, but the hospital cares for the mother, while the government, in the foundling asylum, assumes charge of the child. However far this may be from an ideal state of affairs, it is true that criminal abortion is not excessively frequent under these conditions. In the United States, with few foundling asylums and with many laws of Puritan origin in effect, the temptation to criminal abortion to those illegitimately pregnant must be great. It is undoubtedly true that much can be done by intelligent philanthropy to lessen criminal abortion. Cases of illegitimate pregnancy should be taken in hand as soon as possible, and the unfortunate woman be given kind and intelligent care. She should have an opportunity to work so long as her strength permits, when she can seek confinement in a suitable maternity hospital. After her recovery, ample time should be given to her to gain strength, and the child should be kept with her. She should then either obtain employment with the child, or so arrange its care that she can see it frequently and contribute to its support. There exist in our cities societies for the aid of such cases, so that few need be without help. means A most essential reform in the prevention of abortion could be brought about by the press. There is scarcely a paper, religious or secular, which does not contain the advertisement of a to procure abortion. In the papers of great cities the names and addresses of those who will undertake this crime are daily published and widely circulated. Few publishers have the moral courage of the late George W. Childs, who would at any time expunge from his paper an improper advertisement. Few such passed his critics, but where one had eluded their vigilance and its character became known to Mr. Childs, he instantly ordered its expulsion. Ecclesiastic law among some sects is a distinct prevention of abortion. The Rev. Dr. Breen sets forth the teaching of the church of Rome. No scientific procedure proved to be a therapeutic necessity is refused by the Church. The destruction, however, of the living embryo ecclesiastic authority unites in condemning. The writings of the Jesuits, the Edict of the Baltimore Council, and other edicts are of like nature. Veit and other medical writers upon the subject have urged that physicians should report all cases of abortion. This course is not, however, followed in many countries, and commonly only those cases are reported in which wrong-doing is suspected or in which a fatal result occurs. This brings up the very interesting question of the responsibilities. of the medical attendant in these cases. They They are well set forth by Ballantyne.3 Attention has been called to this subject in recent years by the celebrated case of Kitson vs. Playfair. Here action was brought for alleged slander in statements made in confidence regarding a person seen in consultation. The question of illegitimate pregnancy was raised by these statements. During the trial it was held that the physician was guilty, and that he should not have revealed the results of his professional observations. The case was not appealed. The writer is indebted to Russell Duane, Esq., of the Philadelphia Bar, for information regarding the laws of the United States upon this point. The statements of a physician regarding his patients concerning information acquired by him in a professional capacity fall under two heads: those statements made in a court of justice and those made out of court. Regarding the former, we have in England the trial of the 1 Medical Record, New York, 1895, No. 48, page 71. 2 Deutsche medicinische Zeitung, 1888. 3 British Medical Journal, January 22, 1898. Duchess of Kingston. Mr. Cæsar Hawkins, who had attended the Duchess of Kingston as surgeon, was asked whether he knew of a marriage between the Duchess and another. Held by Lord Mansfield that witness must answer question: "If a surgeon was voluntarily to reveal these secrets, to be sure he would be guilty of a breach of honor and of great indiscretion; but to give that information in a court of justice, which by the law of the land he is bound to do, will never be imputed to him as any indiscretion whatever." In the State of Pennsylvania the following act is operative: "An Act to prevent physicians and surgeons from testifying in civil cases to communications made to them by their patients. "SECTION I.-Be it enacted, etc., that no person authorized to practice physic or surgery shall be allowed in any civil case to disclose any information which he acquired in attending a patient in a professional capacity, and which was necessary to enable him to act in that capacity, which shall tend to blacken the character of his patient, without his consent." Confidential communications made by a patient to his physician were not privileged at common law, but the following states have provided by statute that communications made by a patient to his physician or surgeon, and information acquired by him while attending a patient in a professional capacity, are privileged, and such physician or surgeon cannot be compelled to testify to any such facts in subsequent legal proceedings. The following states have legislated to the above effect by the Acts mentioned: Arkansas, Stat. 1883, p. 625, Sec. 2862; California, Code C. P., 1885, Sec. 1881; Colorado, G. S., 1883, p. 1062, Sec. 4; Dakota, Comp. Laws, 1887, p. 910, Sec. 5313; Idaho, R. S., 1887, p. 679; Indiana, R. S., 1887, p. 679, Sec. 497; Iowa, Rev. Code, 1884, p. 860; Kansas, Comp. Laws, 1885, p. 645, Sec. 323; Michigan, G. S., 1882, p. 1889, Sec. 7516, Sec. 86; Minnesota, Gen. Stat., 1881, p. 792, ch. 73, tit. 1, Sec. 10; Missouri, R. S., 1879, p. 690, Sec. 4017; Montana, Comp. Stat., 1887, p. 230, Civ. Code, Sec. 650; Nevada, Gen. Stat., 1885, p. 833, Sec. 3406, Sec. 84; New York, Code of Civ. Proc. (4 Rev. Stat. p. 164), Sec. 834; Ohio, Rev. Stat., 1884, p. 1096, Sec. 5241; Oregon, Gen. Laws, 1872, p. 251; Pennsylvania Act of 18th June, 1895, P. L. 195; Utah, Comp. Laws, 1876, p. 506; Washington, Code, 1881, p. 102, Sec. 392; Wisconsin, Rev. Stat., 1878, p. 992, Sec. 4075; Wyoming, Rev. Stat., 1887, p. 590, Sec. 2589. Aside from the absolutely legal requirements of the case, the physician has a distinct duty to his patient and to the public. He must not violate his patient's confidence, and his effort should be not only to save her life and health, but, if possible, her character. Much can be done 120 State Trials, 355, 572, 573; trial for bigamy. For a full discussion of the celebrated Playfair case the reader is referred to an article, entitled "The Medicolegal Consideration of the Playfair Case," by Andrew J. Hirsch, Esq., of the Chicago Bar, Medicolegal Journal, 1896, vol. xiv., page 455. in this way by those who see many women as patients by setting. forth clearly the moral and physical dangers of criminal abortion. Too much stress cannot be laid upon the fact that the crime is equally notorious whether performed in the first weeks of pregnancy or when the ovum has become a child. The absolute refusal of the physician to entertain such a proposition has its influence for good. A physician should be able to direct unfortunate women to those who can help them, and to warn and to protect them against the practice of abortion. It is a despicable act to take from these poor creatures their little savings under pretense of admitting them to some hospital for a fee; and yet we regret to say that on several occasions unmarried women have come to hospitals, having paid a fee to some physician under the belief that he had secured their admission. It is the duty of each physician to coöperate with reputable charitable institutions to secure care for these patients. Our large cities contain numerous private lying-in hospitals and midwives' houses whose sole purpose it is to deprive the patient of her money, and, if possible, her offspring of its life. When, however, a physician is summoned to a case of criminal abortion, he has a duty to fulfil to the community as well as to the patient. Each coroner and city official may interpret his duty differently. In the main, however, it may be stated that without revealing the patient's name, he may with propriety acquaint the proper authority with the existence of the case and ask their counsel. It is often the case that only the patient knows the name of the perpetrator, and it will usually be found that she will not reveal his identity. If she recovers, the secret remains hers, and the fact of the abortion is known to her physician. If she dies or is in danger of death, upon his information the authorities will intervene. Reputable physicians may be made the subjects of blackmail and falsely accused of committing abortion. This but emphasizes the rule which careful physicians follow, namely, to make no examination of the pelvic and abdominal organs of unknown women without the presence of a third and known person. A designing woman may induce a physician to commit abortion by describing symptoms pointing to some disease of the womb which requires an instrumental examination. In former times, when the use of the uterine sound was common, a physician might introduce this instrument to measure the length of the womb and thus rupture the sac of the ovum, producing abortion. At present, among those best qualified, the uterine sound is rarely employed, and the interior of the uterus is never invaded without stringent necessity and every precaution. The possibility of pregnancy must never be lost sight of in conducting any pelvic or abdominal examination, and if this be kept in mind, accidental or unwitting abortion will rarely be produced by physicians. INFANTICIDE. By infanticide is understood the unlawful destruction of the newborn child. The question at once arises as to whether the destruction of the child during the process of birth is infanticide. Is the product of conception at this time still a portion of the mother's body, or is it a separate individual? An illustration may be found in a case described by Blöttner. A physician was called to attend a case of confinement, and found the fetus in transverse presentation. He failed to turn the child, and then endeavored to remove the child piecemeal. He was unsuccessful in this, and another physician terminated the labor. The mother died as the result of her injuries, and the first physician was subjected to arrest. In his defense it was urged that he had not been guilty of infanticide, but simply of careless and inefficient practice. As the child was not born, it was not a separate individual, but a part of the mother's body. For the prosecution, the attorney recognized the contention of the defense, but urged that as the child was partly delivered when the first physician was summoned, it could not be regarded as anything but a separate entity. The subsequent decision of the Court was in favor of the physician, and he was simply fined for negligent and un-kilful practice. The precise determination of what constitutes individual life has been a matter of repeated discussion by the courts of various countries. Ordloff lays stress upon the fact that the fetus does not become an independent being until it has breathed the external air into its lungs. This is the opinion of most medicolegal authorities. It can readily be seen that important issues may turn upon this point. If the fetus be destroyed purposely before birth, it might be claimed that its destruction was accidentally due to unsuccessful efforts at delivery. If the fetus died in birth, the question as to whether it can inherit property may decide the disposition of an estate. The writer recalls the case of a mother dying from convulsions, upon whom, at the moment of death, the physician in attendance performed Cesarean section. The child did not breathe, and hence by the terms of the will the mother's fortune was not inherited by the child nor its father, but passed directly to an institution. Had the child breathed in the presence of witnesses it would have inherited, and upon its death the property would have passed in whole or in part to its father. Strictly speaking, infanticide is the intentional destruction of the new-born child and the destruction of the fetus during birth. The latter 1 Klinische medicinische Wochenschrift, 1887, p. 81. * Vierteljahresschrift für gerichtliche Medicin, 1889. |