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CRIMINAL ABORTION AND PROFESSIONAL SECRECY.
97 to make
sure
that
Imperfectburials polluting springs
no corpses remained are a’ source of great
unburied.
are rebuilding it will be necessary to watch the cubic air spaceallowed for the rooms, and the height of the buildings, and to see that acknowledged necessary modifications are introduced. Attention must also be paid to prophylaxis and treatment of disease, and to disinfection, for epidemics are especially to be feared among those in a lowered state of health. Attention to these ’matters is urgently demanded. A Gift in Memory of Dr. Reyntond. Madame Reymond, widow of the Senator Dr. Raymond, a medecin-major of the lst Class, who was mortally wounded during an aeroplane reconhaissance,1 has offered to the Army the flying machine with which that heroic officer practised during peace time. The offer has been accepted.
the villages
Obituary Notes. Professor Alfred Fournier died
recently
at the
age of 81. During his long career he added lustre to the chair of the dermatological clinic at the Hopital Saint Louis. A pupil of Ricord, he devoted himself to the study and treatment of syphilis.
descriptions
of this disease, hereditary or perfect. His entire teaching conacquired, cerning the effects of the disease on the different organs, and especially on the nervous centres, He pointed out remains correct to this day. the specific character of locomotor ataxy and established the certainty of a similar origin for progressive general paralysis. By making known their origin Fournier showed how to avoid them. At the Hopital Saint Louis he founded a school, organised a remarkable museum, and collected a huge number of precious specimens.-Last week also died another highly esteemed medical man whose name will live in French science, Dr. Lucien Jacquet. He was physician to the Hopital Saint Antoine and a specialist in dermatology, and had published important works on diseases of the skin. He demonstrated that alopecia was not an infectious disease, but a trophic disturbance affecting the nerves and local nutrition. He devised a method for combating baldness, wrinkles, fatigue, and premature senility. He made investigations into th$ importance of thorough mastication. He had recently applied his methods to’ the alleviation of fatigue in - troops after prolonged marches. For 20 years he carried on an ’intelligent and
His
are
alcdholism.’ discriminating campaign again-st ..’.:.
’ ’
Jan. 4th.
’
-
1
Correspondence.
danger by
For a long time the inhabitants must use only boiled water or water ,sterilised ’by the addition of hypochlorite of lime. The graves must be visited and covered with lime, and should’even be surrounded by a deep trench containing lime.’The fields of battle also must be sprinkled with. disinfectants, for they are -still covered with debris of all kinds. The dwellings that have been occupied by the enemy have the floors of the houses and the soil of the garden still strewn with foul débris. The pollution of the ’waters and the dust raised in cleaning up are also to be feared. The Bureau of Hygiene in the ’Ministry of the Interior has given the prefects the necessary instructions. Rigid surveillance of foodstuffs, milk and meat, must be practised. For the rebuilding of the destroyed dwellings it will be necessary at first to raise shelters, for often the basements are all that remain for those who return. Later, when and wells.
THE LANCET, Oct.
31st, 1914, p. 1065.
’’Audi alteram partem."
CRIMINAL ABORTION AND PROFESSIONAL SECRECY. To the Editor of THE LANCET.
SIR,-In your last issue you raised a very important and delicate question in a leading article
relating to the action of a medical practitioner as regards cases of abortion which may come underhis professional care. In considering this subject it is well to bear in mind that abortion from natural causes is an extremely common occurrence, and that cases of criminal abortion are fortunately of rare occurrence. Every medical practitioner attend-ing a case of abortion is perfectly’ justified im regarding the case as one of natural abortion unless. he has definite objective evidence to the contrary,. which he can see for himself without asking any ques-tions. In attending a case ’of abortion where thereis no conclusive objective evidence of criminal interference the medical practitioner will be wise to" regard the case as one of natural abortion, and any questioning on his part as to the possibility of any criminal cause is most strongly to be deprecated It is undoubtedly the medical man’s duty to do thebest he can for his patient, and any action on his. part in the nature of detective inquiry is to be condemned. The medical practitioner will wisely refrain from putting questions to his patient or receiving information from her which will throw upon him the difficult burden of " professional!
secrecy." If a patient desires
on her own account to: disclose certain facts it would be wise for themedical practitioner to caution his patient, and to allow her to take such steps on legal advice as shethinks fit, provided, of course, that her health is not. endangered.’. There is no need for the practitioner to be a party to these proceedings. A class of case sometimes occurs where the;’ medical practitioner cannot play a passive part, I refer to cases of abortion where there is conclusive, objective evidence of,criminal interference. Several such cases have come -to my notice. Examples-. of such cases are as follows. Visible perforating; wounds of the;, cervix uteri or of the roof,of the vagina. Marked .signs of the action of a corrosive: agent on the cervix uteri or vagina. Perforating wounds of the uterus or vagina revealed at opera, tion on the patient. In cases of this kind the: medical practitioner who takes no steps at all is unwisely throwing upon himself a grave responsibility which may lead to serious trouble to others. as well as to himself. In such cases the medicalpractitioner should insist on consultation with a
agree that there .is. of criminal interof any statements made by theference, patient, then undoubtedly some steps must be taken - e.g.,, in a desperate case, where there was no hope ; of recovery- on the part -of the patient, opportunity ,should be given the patient of making a dying : declaration. In less desperate cases, provided only is not detrimental to the health ! that this of the legal authorities should ’be-
specialist, and if they jointly objective evidence
conclusive
irrespective
procedure patient,, the
informed and opportunity given for a statutory to, be taken. In every case the health
doposition
andpossible recovery of the patient should occupy
98 the foremost place, and the medical practitioner in. charge of a patient will be right in permitting no steps to be taken which are dangerous to her life or detrimental to her condition of health. In cases of abortion where, after consultation with a specialist, it is decided that there is conclusive objective evidence of criminal interference,
small errors must always lead to waste of nerve energy, but in the robust it may never manifest itself, or the manifestation may be long delayed, but in those whose nervous organisation is of a more delicate character it very soon shows itself in some form of functional nerve disorderinsomnia, depression, suicide, drug taking, alcoholof statements made theism, any by quite irrespective dyspepsia, &c. patient, then there is no doubt that the duty rests Having found the defect-and in doing this the with the medical practitioner to inform the legal op.hthalmometer’is a priceless servant-the logical authorities. His duty to the public and to himself treatment is the prescription of the correction for must, I think, in such cases override any obligation constant use, and herein we perform a double good, of secrecy arising out of the confidential relationship :for not only do we remove the symptoms, but also to which a doctor stands towards a patient. the cause, for in the younger patients the removal I am, Sir, yours faithfully, ofthe eyestrain tends to, the disappearance of the error. I have heard it said that most of the cures W. H. WILLCOX, M.D., F.R.C.P. " Welbeck-street, W., Jan. 5th, 1915. are the result of suggestion "; it is possible that an occasional case does occur of such a class, but suppose suggestion were the cure in all, is that an INSOMNIA AND SUICIDE. argument against the treatment ?2 Is not our one To the Editor of THE LANCET. and ’only aim. to cure the patient ? It should be SIR,—The paper by Mr. C. E. Pronger under the remembered that the cases ’referred to above only above title in your issue of Dec. 12th, 1914, has occur very sparsely in hospital work, they must be brought into prominence what some of us have looked for in the upper classes, especially in the probeen preaching for years, and it has seemed as if fessional classes. Some of the most typical cases I the preaching were in vain. The medical profession have seen have been members of our own pro. allows that there is such a thing as eyestrain, and fession. Women at the climacteric are especially that the correction of errors of refraction may cure prone to this form of eyestrain, the oncoming presheadaches, and there many appear to stop, and do byopia added to the ’static error increasing the The opticians’ art has not realise that if eyestrain can cause headaches, trouble or starting it. a lasting benefit by inventing the invisible rendered not also numerous other forms of reflex irritawhy tion or waste of nerve energy-in fact, any bifocal glass, wherein the upper portion corrects " functional" nerve disorder ? When some years the static error and the lower portion the same, ago Gould, of Philadelphia, published his "Bio- plus the presbyopia. If the good that men do in this world is gauged graphic Clinics" and illustrated the enormous harm that uncorrected astigmatism could do and by the benefits it confers on the race then the had done, he was laughed at and called a madman, oculist who does his refraction work sensibly and and yet those who have followed in his footsteps carefully must have the consciousness of being a look up to him as a pioneer in ophthalmology large benefactor.-I am, Sir, yours faithfully, ERNEST CLARKE. Chandos-street, W., Jan. 1st, 1915. second only to the great Donders. If small errors of refraction may play such an important role it will be surely asked why the To the Editor of THE LANCET. profession generally have not accepted the fact, and the answer is because a large majority of the SIR,-If it be true, as suggested by Mr. C. Ernest oculists themselves have not done so. They laugh Pronger in THE LANCET of Dec. 12th, 1914, that at the man who corrects 0’12 D. of astigmatism or errors of refraction play a part in the production 0’25 D. of anisometropia, and almost infer that he is of habitual insomnia, it only affords another proof " next door " to a quack. We are so conservative in of the fact that this distressing condition is often the medical profession and forget that the only dependent upon trifling disturbances of physioform of conservatism for us is to conserve what is logical equilibrium. Nothing, for instance, is more good. As soon as one of us opens a new door and fatal to a good night’s rest than going to bed with lets in a new light it seems as if the whole a loaded rectum, especially in presence of a profession did their best to close the door instead tendency to flatulence, because this tends to excite of helping to open it wider. peristalsis and wakefulness. A , glycerine supThe explanation of this attitude is not far to pository or injection under these conditions will seek in the subject under discussion. It is that exert distinctly hypnotic effects. An empty stomach the " older school" have failed to recognise the is’ also adverse to sleep and should be combated paramount importance of the use of cycloplegics in by a biscuit or a cup of warm milk on retiring, this particular work. Very low errors of astig- these being far more efficacious than the customary matism or of anisometropia, such as 0’12D., 0’25 D., alcoholic nightcap. Then, too, there is the question 0’37 D., and possibly 0.5 D. play the chief role in of having the head high or low, which is a matter causing nervous disorder in a particular class of of personal idiosyncrasy. A cold bedroom is nerve patient. These low errors, and only these more conducive to sleep than one artificially heated, low errors, can be corrected unconsciously by the and free ventilation, provided no cold air impinge patient, and are only fully revealed when a cyclo- directly on the exposed surfaces, is favourable to plegic is used in all under 45 (and in some cases 50) deep, refreshing sleep. The use of a feather bed years of age. Homatropine generally suffices for or unduly thick, heavy bedclothes, by overheating the older patients, but atropine must be used for the body, produces restlessness, and in elderly men all up to the age of 25 or even 30. The masking of is apt to cause bladder irritability, with consequent the defect enables the patient to have apparently disturbance of rest. Another frequent cause of normal vision, and he is totally unconscious of, and troubled nights is the practice of taking a heavy very often indignant at the mere suggestion of, meal late in the day with too short an interval defective vision. This unconscious correction of between the meal and the hour for retiring to rest. ’
"
.
,
sure
that
Imperfectburials polluting springs
no corpses remained are a’ source of great
unburied.
are rebuilding it will be necessary to watch the cubic air spaceallowed for the rooms, and the height of the buildings, and to see that acknowledged necessary modifications are introduced. Attention must also be paid to prophylaxis and treatment of disease, and to disinfection, for epidemics are especially to be feared among those in a lowered state of health. Attention to these ’matters is urgently demanded. A Gift in Memory of Dr. Reyntond. Madame Reymond, widow of the Senator Dr. Raymond, a medecin-major of the lst Class, who was mortally wounded during an aeroplane reconhaissance,1 has offered to the Army the flying machine with which that heroic officer practised during peace time. The offer has been accepted.
the villages
Obituary Notes. Professor Alfred Fournier died
recently
at the
age of 81. During his long career he added lustre to the chair of the dermatological clinic at the Hopital Saint Louis. A pupil of Ricord, he devoted himself to the study and treatment of syphilis.
descriptions
of this disease, hereditary or perfect. His entire teaching conacquired, cerning the effects of the disease on the different organs, and especially on the nervous centres, He pointed out remains correct to this day. the specific character of locomotor ataxy and established the certainty of a similar origin for progressive general paralysis. By making known their origin Fournier showed how to avoid them. At the Hopital Saint Louis he founded a school, organised a remarkable museum, and collected a huge number of precious specimens.-Last week also died another highly esteemed medical man whose name will live in French science, Dr. Lucien Jacquet. He was physician to the Hopital Saint Antoine and a specialist in dermatology, and had published important works on diseases of the skin. He demonstrated that alopecia was not an infectious disease, but a trophic disturbance affecting the nerves and local nutrition. He devised a method for combating baldness, wrinkles, fatigue, and premature senility. He made investigations into th$ importance of thorough mastication. He had recently applied his methods to’ the alleviation of fatigue in - troops after prolonged marches. For 20 years he carried on an ’intelligent and
His
are
alcdholism.’ discriminating campaign again-st ..’.:.
’ ’
Jan. 4th.
’
-
1
Correspondence.
danger by
For a long time the inhabitants must use only boiled water or water ,sterilised ’by the addition of hypochlorite of lime. The graves must be visited and covered with lime, and should’even be surrounded by a deep trench containing lime.’The fields of battle also must be sprinkled with. disinfectants, for they are -still covered with debris of all kinds. The dwellings that have been occupied by the enemy have the floors of the houses and the soil of the garden still strewn with foul débris. The pollution of the ’waters and the dust raised in cleaning up are also to be feared. The Bureau of Hygiene in the ’Ministry of the Interior has given the prefects the necessary instructions. Rigid surveillance of foodstuffs, milk and meat, must be practised. For the rebuilding of the destroyed dwellings it will be necessary at first to raise shelters, for often the basements are all that remain for those who return. Later, when and wells.
THE LANCET, Oct.
31st, 1914, p. 1065.
’’Audi alteram partem."
CRIMINAL ABORTION AND PROFESSIONAL SECRECY. To the Editor of THE LANCET.
SIR,-In your last issue you raised a very important and delicate question in a leading article
relating to the action of a medical practitioner as regards cases of abortion which may come underhis professional care. In considering this subject it is well to bear in mind that abortion from natural causes is an extremely common occurrence, and that cases of criminal abortion are fortunately of rare occurrence. Every medical practitioner attend-ing a case of abortion is perfectly’ justified im regarding the case as one of natural abortion unless. he has definite objective evidence to the contrary,. which he can see for himself without asking any ques-tions. In attending a case ’of abortion where thereis no conclusive objective evidence of criminal interference the medical practitioner will be wise to" regard the case as one of natural abortion, and any questioning on his part as to the possibility of any criminal cause is most strongly to be deprecated It is undoubtedly the medical man’s duty to do thebest he can for his patient, and any action on his. part in the nature of detective inquiry is to be condemned. The medical practitioner will wisely refrain from putting questions to his patient or receiving information from her which will throw upon him the difficult burden of " professional!
secrecy." If a patient desires
on her own account to: disclose certain facts it would be wise for themedical practitioner to caution his patient, and to allow her to take such steps on legal advice as shethinks fit, provided, of course, that her health is not. endangered.’. There is no need for the practitioner to be a party to these proceedings. A class of case sometimes occurs where the;’ medical practitioner cannot play a passive part, I refer to cases of abortion where there is conclusive, objective evidence of,criminal interference. Several such cases have come -to my notice. Examples-. of such cases are as follows. Visible perforating; wounds of the;, cervix uteri or of the roof,of the vagina. Marked .signs of the action of a corrosive: agent on the cervix uteri or vagina. Perforating wounds of the uterus or vagina revealed at opera, tion on the patient. In cases of this kind the: medical practitioner who takes no steps at all is unwisely throwing upon himself a grave responsibility which may lead to serious trouble to others. as well as to himself. In such cases the medicalpractitioner should insist on consultation with a
agree that there .is. of criminal interof any statements made by theference, patient, then undoubtedly some steps must be taken - e.g.,, in a desperate case, where there was no hope ; of recovery- on the part -of the patient, opportunity ,should be given the patient of making a dying : declaration. In less desperate cases, provided only is not detrimental to the health ! that this of the legal authorities should ’be-
specialist, and if they jointly objective evidence
conclusive
irrespective
procedure patient,, the
informed and opportunity given for a statutory to, be taken. In every case the health
doposition
andpossible recovery of the patient should occupy
98 the foremost place, and the medical practitioner in. charge of a patient will be right in permitting no steps to be taken which are dangerous to her life or detrimental to her condition of health. In cases of abortion where, after consultation with a specialist, it is decided that there is conclusive objective evidence of criminal interference,
small errors must always lead to waste of nerve energy, but in the robust it may never manifest itself, or the manifestation may be long delayed, but in those whose nervous organisation is of a more delicate character it very soon shows itself in some form of functional nerve disorderinsomnia, depression, suicide, drug taking, alcoholof statements made theism, any by quite irrespective dyspepsia, &c. patient, then there is no doubt that the duty rests Having found the defect-and in doing this the with the medical practitioner to inform the legal op.hthalmometer’is a priceless servant-the logical authorities. His duty to the public and to himself treatment is the prescription of the correction for must, I think, in such cases override any obligation constant use, and herein we perform a double good, of secrecy arising out of the confidential relationship :for not only do we remove the symptoms, but also to which a doctor stands towards a patient. the cause, for in the younger patients the removal I am, Sir, yours faithfully, ofthe eyestrain tends to, the disappearance of the error. I have heard it said that most of the cures W. H. WILLCOX, M.D., F.R.C.P. " Welbeck-street, W., Jan. 5th, 1915. are the result of suggestion "; it is possible that an occasional case does occur of such a class, but suppose suggestion were the cure in all, is that an INSOMNIA AND SUICIDE. argument against the treatment ?2 Is not our one To the Editor of THE LANCET. and ’only aim. to cure the patient ? It should be SIR,—The paper by Mr. C. E. Pronger under the remembered that the cases ’referred to above only above title in your issue of Dec. 12th, 1914, has occur very sparsely in hospital work, they must be brought into prominence what some of us have looked for in the upper classes, especially in the probeen preaching for years, and it has seemed as if fessional classes. Some of the most typical cases I the preaching were in vain. The medical profession have seen have been members of our own pro. allows that there is such a thing as eyestrain, and fession. Women at the climacteric are especially that the correction of errors of refraction may cure prone to this form of eyestrain, the oncoming presheadaches, and there many appear to stop, and do byopia added to the ’static error increasing the The opticians’ art has not realise that if eyestrain can cause headaches, trouble or starting it. a lasting benefit by inventing the invisible rendered not also numerous other forms of reflex irritawhy tion or waste of nerve energy-in fact, any bifocal glass, wherein the upper portion corrects " functional" nerve disorder ? When some years the static error and the lower portion the same, ago Gould, of Philadelphia, published his "Bio- plus the presbyopia. If the good that men do in this world is gauged graphic Clinics" and illustrated the enormous harm that uncorrected astigmatism could do and by the benefits it confers on the race then the had done, he was laughed at and called a madman, oculist who does his refraction work sensibly and and yet those who have followed in his footsteps carefully must have the consciousness of being a look up to him as a pioneer in ophthalmology large benefactor.-I am, Sir, yours faithfully, ERNEST CLARKE. Chandos-street, W., Jan. 1st, 1915. second only to the great Donders. If small errors of refraction may play such an important role it will be surely asked why the To the Editor of THE LANCET. profession generally have not accepted the fact, and the answer is because a large majority of the SIR,-If it be true, as suggested by Mr. C. Ernest oculists themselves have not done so. They laugh Pronger in THE LANCET of Dec. 12th, 1914, that at the man who corrects 0’12 D. of astigmatism or errors of refraction play a part in the production 0’25 D. of anisometropia, and almost infer that he is of habitual insomnia, it only affords another proof " next door " to a quack. We are so conservative in of the fact that this distressing condition is often the medical profession and forget that the only dependent upon trifling disturbances of physioform of conservatism for us is to conserve what is logical equilibrium. Nothing, for instance, is more good. As soon as one of us opens a new door and fatal to a good night’s rest than going to bed with lets in a new light it seems as if the whole a loaded rectum, especially in presence of a profession did their best to close the door instead tendency to flatulence, because this tends to excite of helping to open it wider. peristalsis and wakefulness. A , glycerine supThe explanation of this attitude is not far to pository or injection under these conditions will seek in the subject under discussion. It is that exert distinctly hypnotic effects. An empty stomach the " older school" have failed to recognise the is’ also adverse to sleep and should be combated paramount importance of the use of cycloplegics in by a biscuit or a cup of warm milk on retiring, this particular work. Very low errors of astig- these being far more efficacious than the customary matism or of anisometropia, such as 0’12D., 0’25 D., alcoholic nightcap. Then, too, there is the question 0’37 D., and possibly 0.5 D. play the chief role in of having the head high or low, which is a matter causing nervous disorder in a particular class of of personal idiosyncrasy. A cold bedroom is nerve patient. These low errors, and only these more conducive to sleep than one artificially heated, low errors, can be corrected unconsciously by the and free ventilation, provided no cold air impinge patient, and are only fully revealed when a cyclo- directly on the exposed surfaces, is favourable to plegic is used in all under 45 (and in some cases 50) deep, refreshing sleep. The use of a feather bed years of age. Homatropine generally suffices for or unduly thick, heavy bedclothes, by overheating the older patients, but atropine must be used for the body, produces restlessness, and in elderly men all up to the age of 25 or even 30. The masking of is apt to cause bladder irritability, with consequent the defect enables the patient to have apparently disturbance of rest. Another frequent cause of normal vision, and he is totally unconscious of, and troubled nights is the practice of taking a heavy very often indignant at the mere suggestion of, meal late in the day with too short an interval defective vision. This unconscious correction of between the meal and the hour for retiring to rest. ’
"
.
,