Patterns of Practice
Historians have generally treated midwives and doctors separately, but these two groups of practitioners did not practice in two separate worlds.[75] It is important to see the similarities and connections between them as well as their differences. Midwives and doctors provided reproductive health care services in an era when health care was practiced primarily in the practitioner's office or the patient's home rather than in a hospital. Because of the location and structure of care at the turn of the century, their style of practice shared certain characteristics. The Times uncovered the availability of abortion in Chicago; other records of actual abortion cases in the Chicago area, drawn from legal records and newspaper accounts, permit a closer examination of actual turn-of-the-century abortion practices.[76]
The abortion practice, like other obstetrical practices, seems to have been split between doctors and midwives. In 1915, midwives delivered about half of Chicago's babies,[77] and the available evidence suggests that midwives and doctors performed abortions in approximately equal numbers at the turn of the century as well. A 1917 study of women who came to the Washington University Dispensary in St. Louis found that physicians and midwives had "an equal share in the nefarious practice" of illegal abortion. Of fifty-one women who had had induced abortions, physicians and midwives each had induced 24 percent of them.[78] A New York study of the patient histories of 10,000 working-class women found that physicians had induced almost four times as many abortions as had midwives,[79] while a study of III convictions for illegal abortion in New York between 1925 and 1950 found that the abortion-
ists were midwives in 22.5 percent of the cases and doctors in 27.9 percent.[80] Investigators of midwives in Chicago, New York, Boston, and Baltimore suspected that 5 percent to more than 50 percent of midwives practiced illegal abortion.[81] Though studies conducted at the time estimated the proportion of midwives involved in abortion, they never asked the same question of the medical profession, an omission that reveals the investigators' automatic respect for the medical profession and automatic suspicion of midwives. There is no way to determine what proportion of either group performed abortions, but patient histories and mortality data indicate that both midwives and doctors did.
Emily Projahn was thirty-three years old and had given birth to four children, two of whom survived. In August of 1916 her period did not come. It did not show up in September. After having missed her period for two months, she and her husband visited a doctor whom her husband had seen previously, Dr. C. W. Mercereau at 4954 Milwaukee Avenue. It was a Friday evening and they spoke to him of their trouble. Dr. Mercereau agreed to do the operation and told them the fee would be $10 and $2 for calling on her afterwards. They paid half the fee that night. Mr. Projahn later explained that the doctor "asked me to be quiet and not say anything more about it. I said I would." The doctor then shut the door and prepared to perform the operation. He had his patient lie in a surgical chair and used an instrument. Mrs. Projahn called the instrument a "womb opener." Her husband described it as "nickel-plated, silver-like" and "ten or twelve inches long." The doctor told her to "stay on her feet until she got sick enough to go to bed." When they got home that evening, Mrs. Projahn was bleeding. A week later she called Dr. Mercereau, who came to their home and prescribed medicine. He visited her at home twice. After three weeks of chills and fever, she called in a second doctor, who hospitalized her.[82]
Emily Projahn's abortion was not atypical. The operation was performed in the physician's office, and the doctor followed up by visiting her at home and prescribing medications. Apparently, most physicians performed abortions in their offices.[83] A number of physicians saw their patients one or more times after the operation. Both the patients and their abortionists expected doctors to provide continuing care, as they would with any other health problem. Repeated visits, as in the case of one woman whose doctor saw her five additional times, indicated the procedure had gone badly.[84]
Some physician-abortionists managed their own hospitals. The existence of these hospitals emphasizes the ubiquity of abortion and sug-
gests that some practiced rather openly without fear of trouble. In the 1920s in Chicago, Dr. Amante Rongetti, a regularly licensed physician and surgeon, performed abortions in his own Ashland Boulevard Hospital with beds for twenty-five patients. Dr. Justin L. Mitchell was the medical head of the Michigan Boulevard Sanitarium, where he performed illegal abortions.[85]
Physician fees for abortion varied widely in this period, ranging from $10 to $175. On average, physicians received $48; the most frequently paid amount was $50.[86] Dr. Mercereau charged the Projahns a low fee. Several doctors received less than they asked for. One doctor demanded $150 for the abortion he performed on Ester Reed. When her mother objected, he cruelly told her to sell her furniture and clothing to get the money. Reed's mother gave him $50, and, though he complained, he began the procedure and two days later finished it at their home.[87]
Doctors induced abortions by methods described in medical texts. There were three ways to induce an abortion: by ingesting drugs, a method generally viewed as dangerous or ineffective by the medical profession; by introducing something, such as a rubber catheter, a gauze tampon, or other object, into the cervix to irritate it, bring on contractions, and cause the woman to miscarry; or by dilating the cervix with metal dilators or gauze tampons and then using a curette, a spoon-shaped instrument, to scrape fetal and placental tissue out of the uterus (preferably with the woman under anesthesia). The latter was known as a dilation and curettage, or "D & C."[88] Probably most physicians used instruments to induce abortions.[89] Dr. Mercereau may have induced Mrs. Projahn's miscarriage by introducing through the cervix a uterine sound, a slender, pointed instrument for measuring the depth of the uterus. Three Chicago physicians introduced catheters to bring about abortions. Four sold drugs. Pills were cheaper than an operation, which made them a popular first attempt. If they failed, however, the woman faced a later (more risky, and possibly more expensive) abortion. At least one doctor used chloroform during the operation, and two used gauze. According to Edna Lamb's statement in 1917, Dr. Charles Kline-top packed her cervix with gauze in order to induce an abortion.[90] In the words of one nurse, she and the doctor made it look "just like a woman just having a miscarriage.[91]
The majority of the Chicago physician-abortionists I have identified were Regulars, and a third belonged to the AMA. Over a third belonged to the Chicago Medical Society or the Illinois State Medical Society. Five of the physician-abortionists were Homeopaths, one an
Eclectic. Of this group of thirty-eight physician-abortionists, most were men, seven were women. Although these findings cannot be extended to the universe of physician-abortionists, they establish the involvement of regular, mainstream physicians in abortion.[92]
The women who went to midwives for abortions were mostly of a different class than the women who found physician-abortionists. Native-born, middle-class women were most likely to see physicians; immigrant and working-class women were more likely to go to immigrant midwives. Most of Chicago's midwives and their clients in delivery or abortion cases were white, European immigrants. Over 97 percent of the city's midwives were foreign-born. The few native-born white or black midwives practicing in Chicago may have performed abortions as well, but they have not appeared in the sources.[93] Immigrant women probably preferred immigrant midwives when they needed abortions for the same reasons they preferred them during childbirth—midwives were female, foreign-born, and cheap.
In 1916, Rosie Kawera of Chicago asked a friend to go with her to visit Mrs. Wilhelmina Benn, a licensed midwife. Kawera explained to her friend that "she had a little baby; she wanted to get some medicine to get it out." Kawera was twenty-nine years old, Russian-born, married to a "moulder," mother of an eleven-month-old baby, and two months pregnant. She borrowed $10 from her brother and went to Mrs. Benn's. While her friend waited in the kitchen, Kawera went into the bedroom, where Mrs. Benn inserted what Kawera called "a little pipe." Mrs. Benn told Kawera to keep it in overnight and to phone whenever she got "sick."[94]
Midwives sympathized with women who faced unwanted pregnancies. When the male reporter for the Times approached Mme. Schoenian, she told him, "I feel so sorry for the poor things and do all I can for them." The reporter concluded that Schoenian expressed the feelings of most of Chicago's midwives: they felt "sympathy for the 'poor girl'" and considered performing abortions "a benevolent undertaking." The reporter seemed to suggest that midwives had a feminist analysis of abortion, believing that "the necessity for secrecy came from 'man's inhumanity to man'—or woman rather."[95] It is unlikely that immigrant women who refused to be attended by male doctors during childbirth considered going to men for abortions.[96]
Not only did midwives identify with their patients as women, they shared their culture and language. Rosie Kawera and her midwife, Mrs. Benn, were both Russian-born. Frauciszka Gawlik, Austrian-born and
married to a Polish man, went to a Polish- and German-speaking midwife for her abortion.[97] Though the majority of native-born, white women had physicians attend them during childbirth, some, knowing of midwives' reputation for being abortionists, may have looked for midwives when they needed abortions.
Finally, midwives charged about half as much as doctors, whether for performing an abortion or delivering a baby. Both midwives and doctors, however, charged twice as much for abortions as they did for deliveries. Midwives charged about $10 for attending a birth; doctors charged $20 to $25. A 1910 investigation found midwives' average fee for an abortion was almost $28.[98] My sample of Chicago midwives and physicians who performed abortions at the turn of the century indicates that midwives charged, on the average, $20 for an abortion.[99]
Once a woman found a midwife willing to perform an abortion and they agreed upon a price, they had to decide when and where the procedure would be performed. Midwives provided abortions and after-care in several different locations: in the homes of their patients, in their own offices or homes, or in the homes of other women who acted as nurses. The different places in which midwives worked reflected the variety in the location of medical care in the early twentieth century. Some midwives performed abortions at their own homes. Mrs. Kawera went to Mrs. Benn's home for her abortion. Mrs. Jennie Carantzalis, a licensed midwife and nurse, had an office with a receptionist in her own home. Other midwives induced abortions at their patients' homes, as did Mrs. Babetta Newmayer. Midwives visited their abortion patients at home to check on their recovery just as midwives checked up on patients following a delivery.[100]
Some midwives had their abortion patients stay with them or at another woman's home for a few days so that they could oversee their recovery. For some patients, particularly single women who wanted to keep their pregnancies secret, being able to abort and recover for a few days somewhere other than their own homes was a distinct advantage. One 1910 investigation reported that half of the midwives who agreed to perform an abortion (six of twelve midwives) wanted to keep the patient in their homes for a few days after the procedure. One midwife, who used drugs to induce abortions, reportedly "said the patient could stay with her so she could watch the case." When Esther Stark went to midwife Mary Groh for an abortion, Groh arranged to have her board with Mrs. Scholtes for a few days after her "treatment." Midwives could not practice in hospitals, but, in a sense, some midwives created
their own informal "hospitals" when they arranged for other women to nurse abortion patients in a setting that was neither the patient's home nor the practitioner's office.[101]
A few midwives had busy abortion practices and seemed to work almost exclusively as abortionists. The Chicago Vice Commission found four women waiting for abortions in one midwife's basement apartment. Another midwife, the commission reported, "said she had a patient in the house and another one who had just had an operation was in the next room."[102] For the women having abortions, it may have been reassuring to recover surrounded by other women sharing the same experience.
Midwives used drugs and instruments to induce abortions. Studies of Chicago midwives in 1908 and 1913 found both in their possession. One investigator commented, "A midwife who has in her equipment a speculum, uterine sounds, dilators, curettes and wired gum catheters, is beyond all question or doubt carrying on a criminal practice." Some midwives, like Hattie Chlevinski and Mrs. Veronica Ripczynski, gave their abortion patients special teas. Midwife Sophie Mann advised her patient to take hot baths, to use a hot water bottle on her stomach, and to use some other remedy "concerning vinegar" (perhaps a douche? ).[103]
Midwives Cecilia Styskal, Catherine Haisler, and Jennie Carantzalis all used rubber catheters to induce abortions for their patients. Mrs. Wilhelmina Benn, who inserted "a little pipe" in her patient, may have been using a catheter too. Inducing abortions by inserting a catheter into the cervix to irritate the uterus and induce labor was a common method—used both by physicians and by women at home. At a 1931 trial for criminal abortion, a sixteen-year-old woman described in detail the abortion induced for her by Jennie Carantzalis. She recalled that the midwife had her lie down on a table and inserted "an instrument that opens up" into her vagina (perhaps a dilator?). "She started turning it around there, and it hurt me. . .. I started bleeding and then she took a long instrument that looked like a scissors and she put cotton in them." The woman explained that the midwife "dipped [the cotton] in some liquid and put it in my vagina and was cleaning it out. . .. Then she put a long rubber tube un [sic ] me." The midwife inserted more cotton and then, the woman recalled, "she gave me something to put around me, because I was flowing real fast. . .. She said, sit down on the chair a few minutes, and you will be all right." Carantzalis prescribed quinine pills to be taken every three hours, told her to walk around, and instructed that the tube "was supposed to be taken out within
24 hours, the next day at 4:00 o'clock." The next day the young woman was feverish, had "terrific pains," and aborted the fetus.[104]
The Chicago case study shows that midwives and doctors practiced abortion in similar ways. Both prescribed drugs and used catheters to induce miscarriages. Physicians used instruments most frequently, though a few midwives carried curettes in their bags. Some physicians and midwives, as the 1888 exposé made evident, worked together. However, doctors charged twice as much as midwives for abortion services, a pricing structure that matched the class of the practitioners and their patients.
As a general rule, midwives and physicians cared for different patient populations. Midwives primarily served poor, immigrant women, while doctors primarily attended native-born and more affluent women. Both shared class, ethnicity, and culture with their patients; shared backgrounds probably eased women's anxieties. Some women may have crossed these boundaries of background and neighborhood in order to find strangers, whom they believed likelier to perform an abortion or found easier to consult because they did not personally know them.
Midwives shared the experiences of womanhood with their patients, which male physicians could not. Though women who wanted abortions often tried to get them from female physicians, expecting that gender identity would produce aid, many female doctors refused. Some women physicians did perform abortions, and they may have understood this in terms of gender, but there is no way to discover whether, in terms of their relative numbers, more male or more female physicians provided abortions. Contrary to the expectations of women then and some feminists now, the evidence does not allow us to assume that female physicians were more likely to respond to women's demands and perform abortions. The evidence for the turn of the century, suggests the opposite, since feminists abhorred abortion and many, many male physicians provided abortions. As midwives disappeared from northern cities by the 1930s,[105] poor women lost a group of practitioners who identified with their gender, culture, and class and provided a range of reproductive services.
This chapter has emphasized the availability of abortion and its ongoing, successful practice, yet the safety of illegal abortions needs to be considered. Even though most women survived their abortions, many died. In 1910, for example, the Cook County coroner recorded the deaths of fifty-two women due to abortion. Seventeen, or 33 per-
cent, had been caused by self-induced abortions, suggesting the dangers of self-reliance. Eight, or 15 percent, followed criminal abortions. In twenty-seven deaths, the cause was unknown—some may have been miscarriages, some illegal abortions. The proportion of deaths known to be caused by criminal abortions was typical.[106] No doubt additional abortion-related deaths were ascribed to other causes.[107] Some abortionists were truly terrible. Dr. Lucy Hagenow, for example, provided abortions in her offices on the north side of Chicago and caused the deaths of (at least) six women due to abortion in 1896, 1899, 1905, 1906, and 1907 and, after being imprisoned for a number of years, operated on another woman who died in 1926.[108] This list of deaths caused by one person is stunning. It is important to remember abortionists such as this one while keeping in mind that the available records overemphasize abortion deaths. Hagenow's imprisonment protected women who sought abortions for several years.
The mortality associated with abortion must be assessed within the context of overall maternal mortality. Childbearing was dangerous, and pregnant women feared dying during childbirth. In the 1920s, observers believed that at least 20,000 women died each year in the United States due to puerperal causes. In 1930, the United States still had one of the highest maternal mortality rates in the world, and this rate did not fall until the late 1930s.[109] The U.S. Children's Bureau's scrupulous study of maternal mortality in fifteen states found that induced abortions were responsible for at least 14 percent of the maternal deaths, and the rate was higher in urban areas.[110] It is impossible to determine the risk associated with the abortion procedure itself since we do not know the total number of abortions induced or the number of abortion- related deaths. Most likely abortion was more dangerous than childbirth since it always required intervention with instruments and hands that could introduce infections, whereas some women delivered without interference. Nor can we ascertain the relative responsibility of different practitioners without knowing who performed abortions and with what results.
Nonetheless, I suspect that midwives and doctors had comparable safety records for abortions. I do not think we should assume, as most contemporary observers did, that midwives were necessarily more dangerous than physicians. Medical studies of maternal mortality from the 1910s, 1920s, and 1930s repeatedly showed that midwives had lower mortality rates than physicians.[111] Of course, skill at delivering babies does not automatically translate into skill in performing abortions. Other evidence shows that midwives and physicians were responsible
Plate 2. Perforation of the uterus with the curette was one of the hazards of abortion: it
could occur during an induced abortion or as a result of a physician's attempt to
treat an abortion. Illustration by Robert Latou Dickinson in Frederick J. Taussig,
Abortion, Spontaneous and Induced: Medical and Social Aspects
(St. Louis: C.V. Mosby, 1936), 231. Courtesy C. V. Mosby Co.
for similar numbers of abortion-related deaths. Cook County coroner's records of women's deaths resulting from abortion between 1905 and 1915 showed that out of over one hundred cases where women had died because of criminal abortions, midwives were responsible in fifty-four cases; physicians, in forty-nine. In Milwaukee between 1903 and 1908, of thirty-two abortion-related fatalities, seven of the abortions were performed by doctors, three by midwives, and four were self-induced; in the remaining eighteen cases, who performed the abortions was unknown. A Minneapolis study of abortion-related deaths between 1927 and 1936 found physicians responsible for more than twice as many deaths as midwives.[112]
Finally, physicians' growing use of the curette in abortion cases contributed to the number of abortion-related deaths. (See plate 2.) One expert in obstetrics and abortion, Frederick J. Taussig, observed that as physicians increasingly performed abortions and attended miscarriages, where they did emergency curettements as recommended by most
specialists, the rate of uterine perforations and deaths as a result of perforation rose steadily. "The agent most frequently responsible for this injury, it must be confessed, is the physician," Taussig concluded. "The midwife and lay abortionist are relatively less responsible."[113]
As the problem of perforation makes clear, operations performed by physicians at the turn of the century could be quite risky for the woman patient. And though skilled physicians could perform therapeutic abortions safely,[114] not all physicians were competent. Surgery expanded steadily after 1880 with the development of antiseptic and aseptic technique, and the growing number of operations performed by general practitioners, rather than specialists in surgery, became an issue of concern to specialists and the public.[115] As physicians increasingly intervened in pregnancy, whether to deliver a baby, induce an abortion, or curette an incomplete abortion (spontaneous or induced), they sometimes introduced infections and injured their patients.
Answering the question "Who was better, doctors or midwives?" is less important than recognizing that the great variation in education and skill of medical practitioners and the lack of oversight over their practices at the turn of the century meant that the safety of obstetrical procedures varied a great deal. The risk associated with an abortion depended on the technical expertise of the individual practitioner—whether midwife or doctor. [116] Some of the midwives and physicians who induced abortions were quite talented at the operation; others were incompetent and injured or killed their patients. The privacy and autonomy of medical practice that allowed doctors to perform abortions for their patients in this period also allowed every general practitioner, regardless of skill or training, to perform surgical operations such as curettages. The very conditions that permitted the widespread practice of abortion added to the risks of abortion.