Chapter 5
Expansion and Specialization

"My husband has been out of work for over six months and no help is in sight," wrote one mother to Margaret Sanger and the American Birth Control League; "I can't afford more children." Every year she performed two abortions upon herself, and she reported, "I have just now gotten up from an abortion and I don't want to repeat it again."^[1] The disaster of the Great Depression touched all aspects of women's lives, including the most intimate ones, and brought about a new high in the incidence of abortion. As jobs evaporated and wages fell, families found themselves living on insecure and scanty funds. Many working people lost their homes; tenants had their belongings put out on the street.^[2] Married couples gave up children to orphanages because they could not support them.^[3]

As women pressured doctors for help, the medical practice of abortion, legal and illegal, expanded during the 1930s. Physicians granted, for the first time, that social conditions were an essential component of medical judgment in therapeutic abortion cases. Medical recognition of social indications reveals the ways in which political and social forces shaped medical thinking and practice. A handful of radical physicians, who looked to Europe as a model, raised the possibility of liberalizing the abortion law. During these years, abortion became more concentrated in the hands of physicians in both hospitals and private offices as a result of structural changes in medicine.

If we move away from the dramatic narratives about abortion produced at inquests or in newspapers, which tell of the deaths and dan-

gers of abortion, and step into the offices of physician-abortionists, a different story can be discerned. Abortion was not extraordinary, but ordinary. The proverbial "back-alley butcher" story, of abortion over-emphasizes fatalities and limits our understanding of the history of illegal abortion.^[4] Case studies of the "professional abortionists" and their practices in the 1930s provide a unique opportunity to analyze the experiences of the tens of thousands of women who went to physician-abortionists. Many women had abortions in a setting nearly identical to the doctors' offices where they received other medical care. These doctors specialized in a single procedure, abortion. They used standard medical procedures to perform safe abortions routinely and ran what may be called abortion clinics. Furthermore, abortion specialists were an integral part of regular medicine, as the network of physicians who referred patients to these physician-abortionists demonstrates. The physician-abortionists represent the expansion of abortion during the Depression decade.

The Depression years make vivid the relationship between economics and reproduction. Women had abortions on a massive scale. Married women with children found it impossible to bear the expense of another, and unmarried women could not afford to marry. As young working-class women and men put off marriage during the Depression to support their families or to save money for a wedding, marriage rates fell drastically. Yet while they waited to wed, couples engaged in sexual relations, and women became pregnant. Many had abortions.^[5]

During the Depression, married women were routinely fired on the assumption that jobs belonged to men and that women had husbands who supported them. Discrimination against married women forced single women to delay marriage and have abortions in order to keep their jobs. One such woman was a young teacher whose fiancé was unemployed. As her daughter recalled fifty years later, "She got pregnant. What were her choices? Marry, lose her job, and bring a child into a family with no means of support? Not marry, lose her job and reputation, and put the baby up for adoption or keep it?" As this scenario makes clear, she had no "choice." Furthermore, it points to the limitations of the rhetoric of "choice" in reproduction; social forces condition women's reproductive options. The teacher's boyfriend found a local physician who helped her in his office; then she went to a hotel to miscarry. Two years later she married a different man, who had a job, and eventually bore seven children.^[6]

That almost a thousand New Jersey women purchased a type of

abortion "insurance" in 1936 demonstrates that abortion was a recurring and common need for many. New Jersey police uncovered a "Birth Control Club" of eight hundred dues-paying and card-carrying members. Membership in the club "entitled them to regular examinations and to illegal operations, when they needed them, at a further fee of $75 and upward." Most of the members were "girl clerks" who worked in Newark's downtown offices. Just as working people made small regular payments for life insurance and funeral coverage, these working women bought a form of health insurance through dues paid to this "club." These women expected to have abortions in the future. The club provided a means of blunting the expense of abortions and other gynccological care.^[7] When the New York Times covered this incident, birth control leaders immediately attacked the headline dubbing this a "birth control" club. The medical director of the American Birth Control League explained that the birth control movement "opposed" abortion and that the two were not the same.^[8]

The Depression helped legitimate contraceptives. American society increasingly accepted birth control during the 1930s. Condoms sold briskly in drug stores and gas stations. In 1930, the American Birth Control League had fifty-five birth control clinics in fifteen states; by 1938 there were over five hundred clinics. Hostility toward welfare payments and "relief babies" helped win support for providing birth control to the poor. The federal government quietly sponsored, for the first time, provision of birth control services in the late 1930s. As courts began to overturn the Comstock Laws on contraceptives, they allowed the medical profession to prescribe birth control devices. One 1937 poll found that nearly 80 percent of American women approved of birth control use. That year the AMA finally abandoned its official opposition to birth control. The medical profession had been pushed by the birth control movement into accepting responsibility for contraception.^[9] Contraceptives were not foolproof, however.

Greater availability of contraceptives could not alone meet the increased need for control over childbearing. The recognized expert on abortion, Frederick J. Taussig, reported that the number of abortions had grown "throughout the world." He believed it was "due less to [a] laxity of morals than to underlying economic conditions." A New Orleans physician who studied the septic abortion cases at the Charity Hospital found that the number of criminal abortions among poor, white patients rose 166 percent between 1930 and 1931. This surge reflected, he suggested, "the financial pressure . . . on this type of charity patient." Studies of Cincinnati, Minneapolis, New York, and Phila-

delphia showed that the use of abortion swelled in the early 1930s.^[10]

Medical studies and sex surveys demonstrated that women of every social strata turned to abortion in greater numbers during the Depression. Comparative studies by class and race appeared for the first time in the 1930s. Induced abortion rates among white, middle- and upper-class, married women rose during the Depression years. The Kinsey Institute for Sex Research, led by Paul H. Gebhard, analyzed data from over five thousand married, white, mostly highly educated, urban women.^[11] The researchers found that "the depression of the 1930's resulted in a larger proportion of pregnancies that were artificially aborted." For every age group of women, born between 1890 and 1919, the highest induced abortion rate occurred during "the depth of the depression." White, married women were determined to avoid bearing children during the Depression: they reduced their rate of conception as well.^[12]

In the early years of the Depression, married women aborted more of their first pregnancies than had women of earlier generations. Dr. Regine K. Stix discovered this pattern after interviewing almost a thousand women at a New York City birth control clinic in 1931 and 1932, all of whose incomes were severely reduced by the Depression. The young married woman who had an abortion did so "because she was the bread-winner in the family and could not afford to lose her job, much less produce another mouth to feed. A year or two later," Stix explained, "if her husband was working, she gave up her job and planned a baby or two." The findings of Kinsey researchers suggest that aborting first pregnancies early in marriage might have been a growing trend, particularly among more educated, urban white women.^[13]

Married black women, like their white counterparts, used abortion more during the Depression. Since African American women lost their jobs in disproportionate numbers, their need may have been greater than that of white women.^[14] Unfortunately, Kinsey researchers did not collect data from black women before 1950, but others documented black women's resort to abortion during the 1930s. Dr. Charles H. Garvin, an esteemed black surgeon from Cleveland, commented in 1932 "that there has been a very definite increase in the numbers of abortions, criminally performed, among the married." The African American press reported on black women's use of abortion.^[15] In 1935, Harlem Hospital, which cared for mostly poor black patients, opened a separate ward, "The Abortion Service," to treat the women who came for emergency care following illegal abortions.^[16]

A number of studies showed that white and black married women of

the same class had abortions at the same rate. A study of reproductive histories collected from forty-five hundred women at a New York clinic between 1930 and 1938 suggested that when class was controlled, working-class women, black and white alike, induced abortions at the same rate. The researchers found that "the incidence of pregnancies and spontaneous and induced abortion [among black women] was identical with that obtained for the entire group."^[17] A Houston study found that approximately equal proportions of Mexican, African American, and white women had abortions.^[18] Studies like these of women of the same class suggest that any racial differences in overall abortion rates may be explained best by class differences.

The evidence on the practice of abortion by class is somewhat contradictory, but it seems that affluent women had higher abortion rates than did working-class women, but working-class and poor women actually had a greater number of abortions because they were pregnant more often. The Kinsey group of upper- and middle-class white women aborted 24.3 percent of their pregnancies in 1930 and 18.3 percent in 1935. In contrast, the working-class black and white women in the New York clinic study aborted at about half that rate, or 11.5 percent.^[19]

The key difference between black and white women was in their response to pregnancy outside of marriage, not their use of abortion. Unmarried white women who became pregnant were more likely to abort their pregnancies than were African American women in the same situation. Instead, more black women bore children out of wedlock and did so without being ostracized by their families and community. Dr. Virginia Clay Hamilton discovered important differences in abortion behavior between white and black single women during interviews with over five hundred low-income women who entered New York's Bellevue Hospital in 1938 and 1939 following the interruption of pregnancy, whether by miscarriage or induced abortion. Hamilton promised confidentiality and found that "the group showed surprisingly little reluctance to discuss the intimate questions which were put to them." Both white and black unmarried women had higher rates of induced abortion than did married women, but 64 percent of the unmarried white women told of having deliberately induced their abortions compared to only 40 percent of the unmarried black women. "Still more striking," commented Hamilton, was the racial difference in abortion behavior among the previously married. Divorced and widowed black women, "behav[ed] essentially like those still married," while divorced and widowed white women returned to the behavior of

unmarried women when faced with illegitimate pregnancies. The level of induced abortions among previously married white women approached the high level of abortions among single white women. The Kinsey report found the same racial differences in the behavior of unmarried women.^[20]

The tolerance of illegitimacy among African Americans was tempered by class. As African Americans advanced economically, they held their unwed daughters and sons to more rigid standards of chastity. Similarly, by the time the Kinsey Institute interviewed black women in the 1950s, there were clear class differences in the use of abortion by unmarried black women: those with more education (and presumably more affluence) aborted at a higher rate than those with less education.^[21]

Women's religious background made little difference in their abortion rates, though religiosity did make a difference. A study of working-class women in New York in the 1930s found almost identical abortion rates among Catholic, Jewish, and Protestant women.^[22] However, researchers found striking differences in the reproductive patterns followed by women of different religious groups, a finding that seems to reflect class differences. Catholic and Jewish women tended to have their children earlier in their lives and began aborting unwanted pregnancies as they got older; Protestant women tended to abort earlier pregnancies and bear children later.^[23] The Kinsey Report found for both married and unmarried white women, the more devout the woman, the less likely she was to have an abortion; the more religiously "inactive" a woman, the more likely she was to have an abortion.^[24]

Access to physician-induced abortions and reliance upon self-induced methods for abortion varied greatly by class and race. Most affluent white women went to physicians for abortions, while poor women and black women self-induced them. Physicians performed 84 percent of the abortions reported by the white, urban women to Kinsey researchers. Fewer than 10 percent of the affluent white women self-induced their abortions, though black women and poor white women, because of poverty or discrimination in access to medical care, often did so. According to the Kinsey study on abortion, 30 percent of the lower-income and black women reported self-inducing their abortions.^[25] Sara Brooks, a black Alabama midwife, recalled her own attempt at abortion in the 1930s. A friend told her to go visit "Annie" to get herself out of "trouble." Annie gave Brooks a mixture of camphor gum and nutmeg. When Brooks took it, she recalled, "It made me so sick." The doctor who was called gave her warm baking soda to force

her to vomit. She believed she would have otherwise died, as her own mother had after taking turpentine to induce an abortion.^[26]

Low-income women's and black women's greater reliance upon self-induced methods of abortion meant that the safety of illegal abortion varied by race and class. Self-induced abortions caused more complications and hospitalization than did those induced by physicians or midwives. Since poor women and black women were more likely to try to self-induce abortions and less likely to go to doctors or midwives, they suffered more complications. Dr. Regine K. Stix learned from interviewing almost a thousand women in 1931 and 1932 that self-induced abortions, as compared to midwife- or physician-induced abortions, had the highest rates of infection and hemorrhage. Women reported having no complications after their abortions in 91 percent of the abortions performed by doctors and 86 percent of those performed by midwives. In contrast, only 24 percent of the self-induced abortions were without complications. Of the women who entered the county hospital in Portland, Oregon, after illegal abortions, more than two-thirds had induced their abortions themselves. It is worth noting that although the majority of complications occurred in self-induced abortions, physicians performed the majority of abortions.^[27]

As more women had abortions during the Depression, and perhaps more turned to self-induced measures because of their new poverty, growing numbers of women entered the nation's hospitals for care following their illegal abortions. The Depression deepened an earlier trend toward the hospitalization of women who had abortion-related complications in public hospitals. As childbirth gradually moved into the hospital, so too did abortion.^[28] Hospitals separated their abortion cases from other obstetrical cases because of the danger of spreading infection and devoted entire wards to caring for emergency abortion cases. At Cook County Hospital, physicians sent all patients with septic abortions or other obstetrical infections to Ward 41.^[29] One intern at Cook County Hospital recalled that in 1928 she saw at least thirty or forty abortion cases in the month and a half she worked there; or, one woman a day and several hundred women a year entered the hospital because of postabortion complications. In 1934, the County Hospital admitted 1,159 abortion cases, and reported twenty-two abortion-related deaths that year. Both black and white patients entered the nation's hospitals for care following illegal abortions.^[30]

Doctors and public health reformers began to realize the importance of illegal abortion as a contributor to maternal mortality. The maternal mortality study conducted by the Children's Bureau, first reported on

in 1931, spotlighted the magnitude of maternal mortality due to illegal abortion. This study, of over seven thousand maternal deaths in fifteen states in 1927 and 1928, found that illegal abortion was responsible for at least 14 percent of the nation's maternal mortality.^[31] Another major study of maternal mortality in New York City by the New York Academy of Medicine found that 12.8 percent of maternal deaths were the result of septic abortion. The New York study also showed that abortion had increased as a cause of death both in absolute numbers and in proportion to other causes of maternal mortality. Taussig estimated that approximately fifteen thousand women died every year in the United States because of abortion.^[32]

A few physicians began to talk of reform, and even repeal, of the abortion laws. In 1933, two radical physicians published books favoring the decriminalization of abortion in the United States.^[33] Both of the physician-authors, Dr. William J. Robinson and Dr. A. J. Rongy, were Jewish immigrants from Russia who were active in politically radical circles as well as members of mainstream medical organizations. Both belonged to the AMA and the New York State and County Medical Societies. For over thirty years Robinson tried to persuade physicians to provide contraceptives. In 1911, he advocated the legalization of abortion, along with a few others, but the rest of the medical profession quickly dismissed such ideas.^[34] When Robinson published his book, he considered the time "ripe" for change. In The Law against Abortion: Its Perniciousness Demonstrated and Its Repeal Demanded , Robinson contrasted the poisonings, injuries, and deaths of women who had illegal abortions in the United States with the safety record of more than a decade of legal abortions performed by physicians in the Soviet Union.^[35]

Rongy offered a different tactic in his book, Abortion: Legal or Illegal? He advocated an expansion of the legitimate reasons for therapeutic abortions, which would come close to legalizing abortion. The American public, Rangy argued, already accepted abortion as a "social necessity." "No matter how callous the average physician appears to be," Rongy contended, "he is not left unaffected by the pathetic and often pitiful pleadings of the woman to whom a new pregnancy. is a genuine cause of distress." Because of such experiences, most doctors, Rongy declared, privately supported liberalizing the abortion laws. Yet physicians feared to voice publicly their support for legal change. Rongy argued that the legal exception for therapeutic abortions set a precedent that could be used. The indications for abortions should be expanded.^[36]

Although Rongy's book "evoked a controversy," a serious public de-

bate on the merits of liberalizing the abortion laws did not develop.^[37] One reason it did not was that it was censored. Rongy complained that "the august New York Times refused to allow the publisher to advertise" his book.^[38] Open discussion of abortion frightened publishers, some of whom opted for silence on the subject. One magazine had its staff of fourteen discuss whether an article on abortion should be published, then protected itself further by giving the article to "several hundred women" who were asked whether it was objectionable. None of the women objected, but before publishing the article, the editors deleted certain graphic paragraphs as a result of reader comments. Though the author of the article referred to Rongy's book, she did not say a word about his proposal to liberalize access to abortion. Instead, she emphasized the dangers of abortion and advised, "Have your baby!"^[39] Another reporter discovered that citizens who relied upon libraries for information would have a difficult time learning anything about abortion. The New York Public Library possessed no literature on abortion except the sections included in the Children's Bureau maternal mortality study, and the Academy of Medicine refused to allow nonphysicians to see books on contraception and abortion.^[40] American medical publications similarly avoided open debate on the question of reforming the criminal abortion laws. A JAMA reviewer described both books as "omens of an expansion in the United States of the demand for sex freedom" and criticized them for ignoring "the evils that may follow . . . repeal or relaxation" of the criminal abortion laws.^[41]

The reviewer may have feared that the United States would see, as Europe had, the rise of a feminist and socialist movement for legal abortion. The Soviet Union had legalized abortion in 1920, and socialists and feminists had made the legalization of abortion an issue in Germany, Austria, Switzerland, and England.^[42] In England, a movement for the legalization of abortion arose out of the organizing of leftist-feminists active in the birth control movement. In the 1920s these feminists learned that working-class women used abortion as their form of birth control. Furthermore, studies showed that deaths because of illegal abortion contributed greatly to maternal mortality. In 1936, a group of middle-class feminists committed to the interests of the working class and socialism formed an organization, the Abortion Law Reform Association (ALRA), to demand that abortion be made legal and accessible. The ALRA found support among working-class women in England and helped bring them to speak on their own behalf at parliamentary hearings on abortion.^[43]

A widespread and vocal political movement for the legalization of abortion never developed in the United States, as it did in England and in Europe. Nonetheless, the challenge to the status quo by a small group of radicals in the 1930s and earlier should not be overlooked. The movements to legalize abortion in the 1960s and 1970s had their roots in earlier efforts during the Depression era. Birth controllers, reformers, physicians, and a small segment of the general public were aware of the possibility of decriminalizing abortion. The birth control movement reported on the Soviet Union and on European efforts to legalize abortion, as did medical journals and some popular magazines,^[44] and a handful of leftist women authors addressed the topic of abortion in their fiction.^[45]

Though a few M.D.s advocated greater access to abortion in the Depression years, birth controllers continued to treat abortion as taboo. Occasionally birth control clinic staff quietly helped women find abortions,^[46] but publicly birth controllers adamantly rejected abortion. The birth controllers were no more brave than mainstream physicians when it came to abortion. A surprising legislative attempt to legalize abortion proves the point. In 1939 a Colorado physician-legislator, Senator George A. Glenn, introduced a bill that would have legalized abortion in his state. How much support he had is unknown. He may have been inspired by radicals within his profession or by a recent case in England that allowed therapeutic abortions to be performed for a greater number of reasons. Margaret Sanger's secretary wrote privately that she believed Sanger would agree with Glenn "that women should be free to terminate pregnancies where it is not desired—but . . . she believes that abortion always represents a physical risk and that contraception is infinitely preferable." When Glenn publicly referred to abortion as "birth control" in his bill, however, Sanger's secretary, frantically sent a telegram and letters urging him to change the wording of his bill because they did not want contraception equated with abortion.^[47] Birth controllers' fear of abortion underlines the radicalism of women's claim to reproductive rights.

Popular abortion reform movements developed in Europe in the 1920s and 1930s; why not in the United States? In the U.S. as in England, working-class women constantly made it clear to birth controllers that they relied upon abortion, but no organization comparable to the ALRA formed to demand the decriminalization of abortion in the United States. The weakness of working class and socialist movements in this country—and the weak links between feminists, birth controllers, and socialists—hampered the development of a similar po-

litical movement around abortion. The red scare after World War I devastated the women's movement and the left, which had actively supported the early birth control movement and which, in Europe, nurtured the movement to legalize abortion.^[48] As the American birth control movement withdrew from the left and became a movement of middle-class professionals, the association of legal abortion with Soviet socialism surely tainted the notion among American birth control supporters, who were themselves under assault. The U.S. birth control movement maintained an antiabortion stance and argued for the legitimacy of contraceptives by arguing that birth control could eliminate illegal abortion (a position shared with the more mainstream birth control movement in England). The refusal of American birth controllers to engage in a discussion about liberalizing access to abortion ensured that a public discussion of the idea never developed.^[49]

In 1936, a third physician published a book on abortion in the U.S., advocating more moderate reform of the nation's abortion laws than that envisioned by radical thinkers. Dr. Frederick J. Taussig, an obstetrician-gynecologist, wrote a treatise on the subject, which the National Committee on Maternal Health published. The detailed scientific and medical content of Taussig's book, together with its moderate political stance, made it the standard authority on abortion for decades.^[50] Taussig offered a model law more socially conservative than Rongy's and less radical than the legalization demanded by Robinson. Taussig had criticized Rongy for being too lenient, asserting that a "lowering of moral tone" would result if unmarried women and widows were allowed to obtain legal abortions.^[51] Taussig suggested that modifying state abortion laws to allow physicians to perform a few more therapeutic abortions would not arouse much opposition. At the same time, his reform would restrict physicians' practices. Regular physicians would be allowed to perform therapeutic abortions only after consultation with another physician and in a licensed hospital. Taussig's reform law would allow abortions for rape victims, for retarded women, for girls under sixteen years of age, and for poor women with burdensome household responsibilities.^[52]

Many who felt they needed abortions would not be covered. Taussig did not design his proposal to serve all the women already obtaining illegal abortions. He excluded women whose reasons for abortion would offend social conservatives—such as married women who wanted to delay childbearing or did not want to give up their jobs. His proposal denied abortions to unwed women over sixteen years old and to divorced

or widowed women who hoped to avoid the shame of bearing an illegitimate child. Taussig felt confident that his law would decrease "the number of secret abortions," while the provisions requiring medical consultation and practice in a hospital would prevent "abuse."^[53]

Taussig had called on the medical profession to push for reform, but despite his prominence and the support of the National Committee on Maternal Health, the profession as a whole did not seek liberalization of the nation's abortion laws in the 1930s. The prestige of exclusive medical groups could not erase the association of abortion law reform with radicalism and feminism nor overcome physicians' hostility to being allied with these groups. Furthermore, such a limited model law that rejected women's own perceptions of when they needed abortions and that lacked support from the birth control movement had little chance of gaining popular support.

Although few physicians joined the political challenge of the laws, physicians nonetheless liberalized access to "therapeutic" abortion. During the 1930s, individual physicians and the profession as a whole accepted a de facto expansion of the accepted indications for therapeutic abortions along exactly the social lines proposed by Taussig. In fact, Taussig's proposed legal reform encompassed the broadened indications for therapeutic abortions that he believed to be already accepted by "current medical practice and public opinion" and "in agreement with 'mass opinion.'"^[54] A 1939 poll of the nation's medical students confirmed the medical acceptance of abortion. The majority of the medical students, 68 percent, were willing to perform abortions if they were legal.^[55]

Therapeutic abortion for women who had tuberculosis illustrates how social conditions entered medical judgment. Tuberculosis of the lungs was the most frequent reason for therapeutic abortion, though there was disagreement over this indication. At the turn of the century, physicians observed that the condition of women who had tuberculosis declined with pregnancy. Physicians urged women with tuberculosis to avoid pregnancy and agreed that when a tubercular woman became pregnant, a therapeutic abortion should be performed to prevent her decline and death. Over the course of thirty years, physicians learned the benefits of rest, saw that the effects of pregnancy on tuberculosis depended on whether the woman had active or latent tuberculosis, and began to revise their views. Typically, Taussig reported, physicians believed latent cases of tuberculosis did not justify abortions, but active cases did.^[56]

As Taussig noted, the decision whether to abort the pregnant woman with tuberculosis "is intimately bound up with the social-economic status of the patient." Although doctors disagreed on when tuberculosis made an abortion necessary, they agreed each case had to be examined "from all angles, social as well as medical" before a decision could be made. Long-term bed rest and treatment in a sanatorium could bring a woman with active tuberculosis to a safe delivery. Few could pay for sanatorium care, however, and in those cases, Taussig believed that abortion was justified. He explained how the number of children, housework, and poverty entered into the physician's assessment of proper treatment in these cases. His explanation demonstrates how an affluent woman's desire for a baby, or a poor woman's distress at the prospect, could be incorporated into the physician's decision regarding the necessity of therapeutic abortion.^[57]

In a poorly nourished woman with a large family, we must regard the saving of fetal life with less concern than in the woman who can and will carry out sanatorium treatment for the required period of time during and after her pregnancy, and for whom the saving of the child is a matter of great concern. In such women with but one or no children we may, even in active cases, refrain from intervention, while in those whose external conditions make the pregnancy and the subsequent care of the child a serious burden, we would incline more readily, even in latent cases, to an interruption.^[58]

The desperate poverty and hunger of many Americans during the Depression similarly entered medical diagnosis. Taussig rejected the Soviet policy of providing abortions for women who already had large families, but reached the same conclusion by medicalizing the problems of large, low-income families. A large family, he suggested, could be detrimental to the health of both a woman and her family. On that basis, an abortion could be medically justified. Abortions in cases of asthma, weight loss, and physical depletion were legitimate, according to Taussig, when the woman had "heavy household duties" and children whom she could not care for or feed adequately. Taussig admitted that conservatives would disagree and that American laws did not allow abortions until a woman's health had already declined, but he favored allowing physicians to perform therapeutic abortions in order "to preserve the health of the mother and the integrity and well being of the family."^[59]

As medical advances made it increasingly possible for physicians to bring pregnancies to term for patients with threatening diseases, deter-

mining whether an abortion should be performed became more complicated. Changes in the treatment of tuberculosis, heart disease, and vomiting made it possible for more women with these conditions to deliver babies. With adequate rest, women with tuberculosis or heart disease could successfully go through labor. In cases of excessive vomiting, glucose and vitamin feedings could remove the threat of death. Cesarean section had replaced abortion as the response to contracted pelvis. All of these were important advances for women who wanted children. For those who did not, they might prefer abortion and to avoid risks to their own health. The ambiguity of medicine and the ambiguity of the social situation made determining the correct decision difficult.^[60]

Taussig's acceptance of broadening the medical indications for therapeutic abortions to include social and economic reasons helped legitimate what was already accepted practice among many doctors. Taussig explained that since the world war "there have been two movements running counter to each other" in terms of their medical and political views of therapeutic abortion: on the one hand, some advocated the liberalization of indications for therapeutic abortion to include social indications; on the other hand, socially conservative doctors argued that therapeutic abortion should be done rarely and never for social reasons.^[61] The latter group rejected looking to the circumstances of the patient as part of medicine. Taussig's belief in the necessity of considering the pregnant woman's social situation favored and strengthened one stream of medical thought.

The debate was not only about abortion specifically, but about the nature of medical practice and the relationship between the patient's social world and sickness and health. Should medical decisions be made exclusively on the basis of medical facts about the patient's body and scientific knowledge? Or did the physician have to take into account the person and his or her family, work responsibilities, capacities, and interests? Though the discussion was not framed this way, these issues lay at the heart of divergent medical beliefs about therapeutic abortion. The opposing responses are different methods for dealing with ambiguity in medical knowledge and practice. On one side, physicians recognize the ambiguity inherent in medicine, acknowledge that there are choices to be made, and advocate looking at the larger picture in order to help make the appropriate decision. On the other, physicians handle ambiguity by denying it. When there is doubt, they suggest, there is but one answer. They present a rule to be followed in all cases and in-

sist that all other information is irrelevant. Taussig's discussion of tuberculosis showed, however, that although a physician might take the conservative medical stance that a tubercular woman should get rest in an institution and carry the pregnancy to term, the social issues were inescapable. A low-income woman was unable to follow the doctor's prescription to spend months in an institution.

Even though Taussig believed social conditions, family need, and income should be considered by the doctor, he resisted addressing the question of what the patient herself wanted. Physicians who debated the indications for therapeutic abortion all shared the assumption that doctors would make decisions for patients. Radical physicians like Robinson and Rongy, in contrast, assumed that women themselves would determine when an abortion was necessary. Although mainstream medical thinking assumed that abortion decisions were under physicians' control, plenty of physicians listened to their patients and helped them obtain abortions. Allowing physicians to treat social reasons as legitimate medical reasons created some space in which women and their families could make their preferences known and physicians could listen.

Despite the objections of some, physicians did perform therapeutic abortions for economic reasons. An editorial comment in JAMA confirmed that physicians performed abortions out of sympathy for destitute patients. "Poverty," the editor asserted, "does not constitute an indication for abortion." Yet, he admitted, "there is no doubt that in the United States many abortions are performed for borderline cases in which there is a strong ethical indication plus a more or less minor medical ailment." ^[62] The expansion of therapeutic abortions benefited women who wanted abortions and who found doctors who could, and would, justify them on combined medical and social grounds.

Because patients with complications from illegal abortions increasingly went to hospitals, the problem of illegal abortion became visible to doctors in an unprecedented way. The suffering that so many doctors witnessed made many willing to help women seeking abortions. In previous years many doctors had privately observed the horrible results of illegal abortion and tried to cope with them individually in patients' homes or their own offices. In the Depression decade, as interns, residents, staff, and specialists in hospitals, doctors observed, on a larger scale, the continuous stream of patients needing emergency care as a result of illegal abortions. From his days as a hospital intern, Dr. Rongy recalled a young woman who was hospitalized following her abortion

and her mother who stayed by her side for ten days until her daughter died of septicemia. This "tragedy . . . left a profound impression." ^[63] A physician who interned at Freedmen's Hospital in Washington, D.C., in the 1930s later recalled attending a hemorrhaging woman who "still had the straightened-out coat hanger hanging from her vagina." ^[64] In hospital wards, doctors saw women with septic infections, perforations of the uterus, hemorrhages, and mutilation of intestines and other organs caused by self-induced abortions or ineptly performed operations.

The hospital atmosphere, one surmises, made more doctors aware of medical participation in underground abortion services and the stretching of indications to perform therapeutic abortions. In past decades, almost every general practitioner or specialist in obstetrics had been approached at least once by a woman seeking an abortion. The demand generated by the disaster of the Depression increased the number of women knocking on doctors' doors for help. Hospitals concentrated abortion and physicians in one place. In the hospital, doctors could observe each other, talk informally, and spread rumors about physicians' involvement in abortion. Such an atmosphere, I suspect, helped forge a liberal consensus within a section of the medical profession about the horrors of self-induced and poorly performed criminal abortions, together with an acceptance of performing abortions for needy patients or referring them to abortionists.

Abortion Specialists and Clinics

"The demand of women to have abortions," Dr. Rongy observed in 1933, "has become so insistent" that physicians had become more tolerant. A few, he reported, were now "specialists in abortion, who devote themselves to that work to the exclusion of any other part of medical activity." As the Depression damaged physicians' finances, more became interested in abortion practice.^[65] The disappearance from northern cities of immigrant midwives added to the pressure upon physicians to perform abortions.

Labeling these physician-abortionists "specialists" referred not to postgraduate education or board certification, but to an exclusive practice and expertise.^[66] Even in this unrecognized specialty, however, some physicians obtained additional training in abortion procedures in the United States and Europe. Several abortionists, like their counter-

parts in other specialties, devised their own instruments and techniques.^[67] Rongy believed that as physicians made abortion their "specialty," the dangers of illegal abortion diminished because doctors purchased equipment, used anesthesia and antiseptic procedures, and gained skill in performing abortions.^[68]

The medical profession unofficially recognized this specialty by referring patients to physician-abortionists. The specialization in abortion benefited not only the women who wanted abortions, but also physicians who did not themselves perform abortions. Patients could go to skilled practitioners, and physicians could send their patients to colleagues whom they trusted. Numerous doctors avoided performing abortions themselves but participated in abortion by sending patients to specialists. These physician-abortionists were not isolated, but often well-connected and highly regarded by their peers.

Most cities had several physicians who "specialized" in abortion, and many small towns had at least one physician-abortionist. New York's medical examiner knew of "75 physicians" who "specialize exclusively in boot-leg abortions."^[69] In the mid-1930s one businessman set up a chain of abortion clinics in cities on the West Coast.^[70] Doctors Gabler, Keemer, and Timanus, of Chicago, Detroit, and Baltimore respectively, were physician-abortionists who performed abortions for tens of thousands of women during the 1930s. The decades-long existence of these specialty practices points to the tolerance and accessibility of abortion during these years.

Physician-abortionists practiced in a legally and medically gray area. It was not always clear whether they performed illegal abortions or legal, therapeutic abortions. As physicians, the law allowed them to perform therapeutic abortions in order to preserve a woman's life, but abortion was illegal and frowned upon by the profession. What made physician-abortionists different from other doctors was the volume of abortions performed, often to the exclusion of other medical practice. As long as these physicians received referrals from other physicians, practiced safely, and avoided police interference, they might consider the abortions to be therapeutic. Yet any physician who regularly performed abortions also knew that the procedure was criminal and that he or she practiced on a fine line. Most probably realized that they had crossed that line into illegality.

It is difficult for the historian to gain access to patient records, and this is particularly true for an illegal procedure. Yet I have uncovered records of abortion patients and have reconstructed, for the first time,

the daily practice of an underground abortion clinic and the characteristics of its clientele. Seventy patient records of women who had abortions at a Chicago clinic owned by Dr. Josephine Gabler have been preserved in legal documents. These records are a rare find. Analysis of these patient records illuminates the inner workings of a health-care institution that provided crucial reproductive services to thousands of women for decades. The Gabler clinic (later run by Ada Martin) serves as a case study of a specialty practice and reveals the abortion experiences of many women who found physician-abortionists.^[71]

Dr. Josephine Gabler was a major source of abortions for Chicago women and other Midwesterners in the 1930s. She graduated from an Illinois medical school in 1905 and received her Illinois medical license that year.^[72] She established herself as a specialist in abortion by the late 1920s, perhaps earlier. Over eighteen thousand abortions were performed at her State Street office between 1932 and 1941.^[73] In other words, the clinic provided approximately two thousand abortions a year—about five a day, if it operated seven days a week.^[74] Dr. Gabler, and other doctors who worked at the State Street office, provided needed abortion services to women from the entire region, including patients from Illinois, Indiana, Michigan, and Wisconsin.^[75]

The abortion practice at 190 North State Street in the heart of downtown Chicago was busy and well connected to the Chicago medical community. In January 1940, after more than a decade of business, Dr. Gabler sold her abortion practice to her receptionist, Ada Martin. Gabler retired to Florida, and Martin thereafter managed the practice, arranging for physicians like Dr. Henry James Millstone to perform the abortions.^[76] Some of the patients discussed here had abortions before 1940, when Dr. Gabler practiced; others had abortions after Martin purchased the practice.

Numerous women found their way to the State Street office through physicians. Although the medical profession officially condemned abortion, this does not mean that physicians did not participate in illegal abortion.^[77] In fact, Dr. Gabler's practice and doctors' referrals to her reveal that many women sought help from physicians—and received it. The Gabler-Martin clinic demonstrates that doctors have been more responsive to the demands of their female patients—even demands for an illegal procedure—than previously suspected. Over two hundred doctors, including some of Chicago's most prominent physicians and AMA members, referred patients to Gabler and Martin for abortions.^[78] Of the patients where the person who referred the women can be

identified, nearly half had been referred by a doctor.^[79] When Mrs. Helen B. learned of her pregnancy in 1940, she wanted an abortion. She "finally persuaded" her doctor that she needed an abortion and was given Dr. Josephine Gabler's business card.^[80] The use of business cards itself emphasizes the openness of abortion practice in this period. After Gabler's retirement, the business still used her name and doctors still referred to her. Pharmacists, nurses, and beauty shop operators sent patients as well.^[81] As the referrals indicate, women who needed abortions appealed to health-care workers at all levels and visited an exclusive female institution, the beauty salon, for information.

Gabler and Martin showed their appreciation for referrals—and encouraged their colleagues and allies to keep referring—by paying commissions to those who sent patients. Investigators reported that the payments were usually fifteen dollars each, which was about a quarter of the average fee for abortion.^[82] When other specialists worked out this type of mutually beneficial arrangement, medical leaders called it "fee-splitting" and deplored it as unethical. Nonetheless, fee-splitting was common among early-twentieth-century doctors, partly because specialists earned so much more than general practitioners.^[83]

The other major path to an abortionist's office was through women's personal networks. An abortionist's name and address were critical information, which women shared with each other. In this sample, of the cases where the source of the referral is identifiable, almost a third of the patients found their way to the clinic through friends.^[84] Two others knew of the clinic through female relatives, a sister and a sister-in-law. Several had been there before. Every woman who went to 190 North State Street for an abortion became a potential source of information for others in the same predicament. The process of finding a connection could take time; and as time slipped away, the abortion became more difficult, dangerous, and costly. Access to Dr. Gabler and other abortionists depended upon a woman's fortune in tapping into a knowledgeable network. Some never found a safe abortionist.^[85]

Women fortunate enough to obtain Gabler's name and address went to the sixth floor of 190 North State Street and checked in with a receptionist.^[86] The receptionist (who was first Martin, and later Josephine Kuder) collected information from the patient on a medical record, determined how far the pregnancy had progressed by asking when the woman had last menstruated, told the woman the price of the abortion procedure, and arranged an appointment. On the day of the abortion, the woman was told to undress and put on "a white

apron." Mrs. Martin then took her into the operating room, where she was laid on a table, her arms strapped down and her legs raised, and her "private part" shaved, the standard medical procedure in childbirth as well. Mrs. Martin covered the woman's eyes with a towel and then gave her gas to put her to sleep during the operation. One woman woke up during the procedure and felt someone "scraping" her womb. After the operation, the patient rested for about forty-five minutes, received printed instructions from Mrs. Martin outlining how she should care for herself following the abortion, and then went home. Another recalled being given "a card with instructions . . . about hot baths and not to take them. It is similar to the things when you are pregnant and you have a baby in the hospital and about not having anything to do with your husband for so many days afterwards." Finally, Martin admonished the patients not to call anyone else if they had problems, but to call the office, which had a twenty-four-hour answering service. Patients were scheduled to return for a checkup; some came the next day, others ten days or six weeks later.^[87]

In many ways, the experience of getting an abortion at the State Street clinic was like going into any other doctor's office for medical care. Referrals from physicians, note taking by a receptionist, women dressed in white uniforms, instruments and delivery tables, and the instructions for after-care were all typical in a doctor's office—and familiar to women who had previously delivered babies in hospitals. The women received anesthesia and, apparently, a dilation and curettage of the uterus—the same procedure they would have had if they had a legal, therapeutic abortion in the hospital.^[88]

Nonetheless, the criminality of abortion made its practice clandestine. Two safeguards designed to shield the people performing abortions made the procedures in Martin's office different from legal, hospital procedures: covering the eyes of patients in order to make identifying the physician-abortionist impossible and warning women not to go to anyone else if they experienced complications. The clinic did not abandon its clients if problems developed following the abortion, but they did not want them going to physicians or local hospitals who might alert authorities.

The majority of women in the State Street patient records were married when they had their abortions. The data for the clinic's patients match the findings of studies that suggest that the majority of women who had abortions before World War II were married.^[89] Fifty-six of the seventy women, or a full 80 percent, were married when they had their

abortions. Only fourteen were unmarried, though the proportion of unmarried women may be understated.^[90]

The married women having abortions followed different patterns to control the timing and number of their children. Over half of the married women (thirty-two women, or 57 percent) had children.^[91] Over a third of these women had children under two years old. Mothers seemed strongly motivated to avoid having two babies in diapers at once. Some did not expect to have any more children, like Victoria M., who had three adult children aged twenty-six, twenty-four, and eighteen years old.^[92] A second, and large, group of the married women (twenty-four, or 4-3 percent) had no children at all. This is not what we would expect; we have learned that married women used birth control and abortion after they had children, not before. Unfortunately, the records do not reveal what personal, economic, or social reasons induced these particular women to have abortions, but this group of childless, married women who had abortions is an interesting one that suggests differences in reproductive behavior. Some could be lying, as at least one unmarried woman did, but I know that two were indeed married and childless.^[93] Could they represent a significant number of married couples who intended to have no children at all? Since the records do not say how long they had been married, it is possible that these were abortions of prebridal pregnancies. Perhaps some worried about extra-marital affairs. Some may have been college students or married to students. Perhaps they needed an abortion because they could not risk losing their jobs. Probably most who had abortions in the early years of their marriages had children later. Class could shape reproduction in complicated ways. Working women and more affluent college women found it necessary to delay childbearing for different reasons and at different times.

The age range of the State Street patients reflected the diversity of women's reproductive patterns and needs. The ages of the women having abortions in this sample ranged from eighteen to forty-eight years, but the majority of women were in their twenties. Their average age was twenty-seven years, but over half were under twenty-five.^[94] In 1992, for comparison, most of the women who had abortions were unmarried and under twenty-five years old.^[95] Women having abortions in the 1930s and early 1940s were about the same age that they are today. The difference is that most of the women in the Martin case records ended their pregnancies within the context of marriage: 80 percent of the Gabler-Martin clinic patients were married; now, 80 percent are un-

married. Today, most of the women who have abortions do so when they are single and finishing high school or college and expect to bear children later. As Rosalind Petchesky argues, this change marks a "rejection of early marriage as the defining objective in women's lives, and . . . an expectation of economic independence." ^[96]

It is difficult to determine the class of the women who made up the patients at 190 North State Street, but it seems to have been a mixed group. The records of this office show that we cannot assume that working-class women were never able to get safe abortions from physicians. The availability of safe, illegal abortions depended on more factors than one's class background. Information about income or the occupation of the woman's husband, if married, was not included in the patient records, but the records show that at least a third of the women worked for wages. Most of the married women seem to have been homemakers, but one quarter of the married women (fourteen) worked outside of the home. The group of working women included professional women such as teachers and nurses as well as working-class women such as a waitress, a "wrapper" at a baking company, and a sausage maker. Two women who lived in Evanston and Skokie, Chicago suburbs, may have been more affluent. The various referral networks suggest that women of different classes learned of the State Street clinic.

The racial composition of the women who relied upon the abortion services of Dr. Gabler is even more obscure. There is no racial information in the patient records. Newspaper photos, however, show that Martin and Kuder were white, and the lack of racial identification of witnesses and most of the people charged in the case suggest that most were white, since legal opinions and newspapers at the time often identified black individuals. One person in the Martin case was identified as an African American: Mrs. Roberta Powell, a "colored" nurse from the south side of Chicago, was charged along with Martin.^[97] If black women sought connections to abortionists through black nurses, which seems likely, some African Americans may have found Gabler through Powell. This is the only hint regarding black women in this case, and, unfortunately, Powell never reemerged in the records.

Most of the women who went to the State Street office for an abortion did so early in their pregnancies. The largest number came for help when they had missed two periods and there was no more hope that they were somehow just off one month. Over 80 percent went to the office for an abortion within two months of their last period; in current terminology, 96 percent of the abortions were during the first trimester.

This pattern matches that of the present; today most abortions are performed in the first eight weeks of pregnancy.^[98] Women then and now have tended to have very early abortions.

The fees charged for abortion at 190 State Street ranged between $35 and $300. For the sixty-nine cases with fees noted on the patient record, the mean price—the average—was $67 and the modal price—the price most frequently paid—was $50. Remarkably, the Kinsey study on abortion also found that the average fee for an abortion in the 1903s was $67.^[99] These charges were considerable: the average working woman's wage was approximately $20 per week.^[100] Nonetheless, an abortion cost less than physician and hospital fees for childbirth.^[101]

The prosecutor in the trial of Martin and Kuder charged that the prices "for this criminal operation varied with whatever the traffic would bear,"^[102] but my analysis of the office's patient records finds that different factors determined price. One was the length of pregnancy—the further along a woman was, the higher the price. Another was bargaining by patients to lower the price. The more expensive abortions generally occurred at a later point in the pregnancy; the cost of the operation reflected the greater difficulty and risk associated with a later abortion. Of the six abortions that cost over one hundred dollars in this sample, five were of advanced pregnancies.^[103] Georgina W. paid one of the highest prices for her abortion, $200, but Martin called hers an "unusual case" because her pregnancy was four months along. In addition, the office arranged for nursing care at an apartment on the south side of Chicago, where she rested for several days. Even Georgina W., however, negotiated the original price down fifty dollars.^[104] Paula F., who went to Dr. Gabler for an abortion in 1939, recalled in court that when the receptionist (Kuder) asked how long she had been pregnant, she lied and said "three or four weeks at the most" instead of saying it had been two and a half months. She lied, she explained, because "I know they do charge according to the length of period you have missed and your condition, . . . I knew it would make a big difference in the price." Not only did Paula F. try to cut the price by hiding the progress of her pregnancy, she told the receptionist that she could not afford the quoted price and offered $35 instead. When Kuder told her that "they couldn't think of doing it like that," Paula F. started to walk out, but Kuder stopped her and told her "Well, that will be all right." ^[105] Some of the variation in prices may have been a result of fitting the fee to the customer, as the prosecutor accused, but this was common among doctors. Physicians accepted lower fees from lower-income patients and collected higher fees from wealthier patients.^[106]

The successful bargaining indicates that women did not feel as desperate or as ashamed about abortion as we might expect. Many of the women who walked into the abortionist's office had an idea of what a "fair" price for an abortion should be. Women's willingness to bargain suggests that at least some knew of other abortionists and had other options. The evidence suggests that these women believed they had some control over their illegal abortions. This is really quite remarkable given the criminality of abortion at the time. Gabler and Martin negotiated with their patients and accepted partial payments.^[107] Of the twenty-four patients who testified at the trial of Martin and Kuder, over a third told of getting the fees lowered.^[108] When Helen N. heard the fee was $65, she objected because she had paid $50 on her previous visit. Her fee for the second abortion was lowered to $50. Some women, like Charlotte B., paid a lower price for their abortions because friends had told them what they had paid. Charlotte B. initially agreed to pay $65 for her abortion when she made her appointment, but when she learned that a "lady friend" had paid less, Charlotte complained and paid only $50.^[109] The clinic seemed to be trying to raise its prices, but without success.

Gabler and Martin could provide illegal abortions openly because they paid for protection from the law. Bribery of police and prosecutors underpinned the abortion practice. We only know of the corruption of legal authorities in Chicago because police officer Daniel Moriarity tried to kill Martin in order to silence her. Moriarity hoped to keep his own bribe taking a secret by killing Martin; after mistakenly killing Martin's daughter, he confessed to his own role in illegal abortion. He declared that Martin had paid at least two police officers and two assistant state's attorneys to "fix" any investigations into her business.^[110] Moriarity met Martin at a tavern each month, where she "slipped him a $100 note." The payments added up to almost half of his annual income, an enticing sum. In return, Moriarity made sure that attempts to prosecute Mrs. Martin or her associates were bungled. Moriarity reflected, "I always managed to keep the heat off her pretty well until this latest investigation." ^[111] Hired police protection of abortionists may not have been unusual. One woman who traveled from Wisconsin to Chicago for an abortion by a well-known physician saw a policeman near the physician's office. At first, she recalled, "my fears were that he was a spy; later on I realized he was a paid look-out and protector." ^[112]

The office at 190 North State Street where thousands of women obtained abortions from a skilled practitioner was not a rarity.^[113] Few reputable physicians would induce abortions, but, one New York physician

observed, few "would refuse to supply the name and address of one of these abortionists to a patient who applied to them in distress." ^[114] In Detroit, African American physicians might refer patients to Dr. Edgar Bass Keemer Jr. Dr. Keemer's education, professional career, and social circle were within the African American medical profession. He graduated from Meharry Medical College in Nashville, Tennessee, in 1936, interned at Freedmen's Hospital in Washington, D.C., and took over the practice of a deceased black general practitioner in Indiana. When he moved to Detroit, black physicians helped him open his practice. Keemer was not isolated from other black physicians as an abortionist, but relied upon. Throughout his career as an abortionist, which lasted into the 1970s, Keemer served primarily poor women and black women. In thirty-five years, he performed over thirty thousand abortions.^[115]

Dr. Keemer performed his first abortion in 1938. As Keemer told the story, he had refused to perform an abortion for an unmarried woman, who then committed suicide. After this tragedy, Keemer resolved to make amends by performing an abortion for someone else. Within months another woman sought help. She explained, he recalled, that she needed an abortion because she had seven children, her husband earned little, "and we can't hardly feed 'em." Keemer agreed to do the abortion and then realized he did not know how. He contacted the physician-abortionist he knew in Washington to learn the techniques he never learned in medical school.^[116]

Keemer's wife, also a physician, played a key role in convincing him to perform abortions. She had wanted to help the first woman, who had come to her expecting a female physician to understand, but Keemer overruled his wife. She was furious. She favored performing abortions because she had had an abortion herself while the couple completed their medical internships. She pointed out Keemer's hypocrisy to him. Although she pushed her husband to do abortions, it is not clear whether Keemer's wife joined the abortion practice.^[117]

Keemer's new mentor had performed the abortion for Keemer's wife. "Dr. G." was known as "one of the best practitioners of the forbidden art on the East Coast." This doctor showed Keemer how to use Leunbach's Paste to induce abortions. The advantages of the Leunbach method compared to doing a dilation and curettage, according to Keemer, were in its safety and minimal pain. A dilation and curettage took more time, required extreme care during the curettage to avoid perforation of the uterus, and, if done without anesthesia, was "murderously painful." With the new method, the physician filled a bulb sy-

ringe with the paste, a potassium soap solution, and carefully expelled all air in order to avoid introducing an air bubble into the bloodstream, which could kill the patient. Once the air had been removed, the physician introduced the syringe into the cervix, injected the paste into the uterus, and packed the vagina with sterile gauze. The Leunbach method required only "ten minutes on the doctor's table," another advantage of the method, and then the woman could go home. Eighteen hours later, she removed the gauze tampon and a miscarriage occurred with "minimal cramps." Two aspirin, Keemer claimed, usually blunted any pain.^[118]

The Leunbach method stimulated the practice of abortion during the 1930s and quickly gained a reputation as dangerous. Keemer had adopted the quintessential abortion method of the decade. A German physician promoted Leunbach's Paste and sold it through the mail to doctors with promises that with it they could safely and easily induce therapeutic abortions instead of performing major operations. A writer for JAMA attacked the paste as dangerous, both as a method and because it could easily be used to induce illegal abortions. The chief danger was having a patient die from an air embolism or poisoning; German medical journals had reported twenty-five deaths following the use of this paste. The author warned that abortionists "will turn to such pastes, because of their simplicity." Furthermore, he conceded, "some reputable physicians, now in dire financial straits, may be tempted to use this simple means for inducing abortion." ^[119] The ease with which Leunbach's paste could be used in the privacy of a doctor's own office helped pull physicians into the abortion trade. When a federal crackdown in the early 1940s dried up Keemer's supply of Leunbach's paste, his abortion practice almost ended. Keemer approached his father, a pharmacist in Nashville, for help. He sent his father a sample, told him why he needed it, and asked him to manufacture it for him. Keemer soon received the paste along with a "note wishing me good luck." ^[120]

When women came to Keemer's office in Detroit, he took their medical histories, explained the procedure, then performed the brief operation using the Leunbach method to induce a miscarriage. Keemer sent his patients home with printed instructions on caring for themselves and told them to call at any time if they needed help. Keemer or a nurse visited the women at home the next day and did a checkup two weeks later as well. The fee Keemer charged for his first abortion in the late 1930s was $15; by the 1960s he charged on a sliding scale up to $125. If the procedure failed, Keemer returned the fee. In the unusual case

where a dilation and curettage was needed, Keemer sent the woman to the hospital, called in a specialist, and paid all fees as well as any money lost by the patient in missing work.^[121] Keemer protected his patients by providing after-care; his sense of financial responsibility protected him from complaints and legal interference.

In Baltimore, reputable physicians referred their patients to Dr. George Loutrell Timanus, one of two well-known physician-abortionists in Baltimore. Dr. Timanus had a close relationship to Baltimore's white medical elite at Johns Hopkins University, where the faculty taught Timanus's techniques to their students and called him a friend. Timanus received his M.D. from the University of Maryland Medical School in 1914. From the mid-1920s to his retirement in 1951, he specialized in abortion and provided abortions for women living on the East Coast.^[122]

Dr. Timanus's practice was nearly identical to those of Doctors Gabler and Keemer. At Dr. Timanus's office at 1307 Maryland Avenue, patients were greeted by a receptionist and attended by a nurse. Timanus, however, required them to have a letter of referral from a physician. He charged $400, though a referring physician could ask him to lower the fee for less affluent patients, used anesthesia, and performed dilation and curettages. Like Keemer and Gabler, he provided his patients with after-care and phone numbers to call if they had any problems. Timanus's patients seem to have been mostly affluent, probably mostly white, women.^[123]

Like Dr. Keemer, Dr. Timanus heard the distress of women faced with pregnancies they could not bear. As chief physician at public playgrounds in Baltimore, he came into contact with working-class mothers of large families and unmarried, pregnant teens. "Schoolteachers," Timanus later recalled, intervened on behalf of schoolgirls, "pleading pitifully for girls who would be banished from school and home if they produced an illegitimate birth." Timanus empathized with the difficulties of poor married women and unmarried girls and began performing abortions in the mid-1920s.^[124]

The experiences that moved Doctors Keemer and Timanus to aid women who sought abortions were not exceptional. Most doctors encountered women patients seeking abortions who told similar stories of poverty, excessive childbearing, and illegitimacy. Numerous individual physicians violated the official medical norms that condemned abortion because they could not ignore the dilemmas described by their patients. Many referred them to someone else; only a few doctors bravely

turned their sympathy into practice. It is difficult to trace precisely the motivations of those who became abortionists. Money motivated some, as it motivated some to become physicians. Others acted on the political conviction that women had the right to control their own reproduction.^[125]

Doctors Gabler, Keemer, and Timanus represent a larger pattern of medical involvement in illegal abortion and an expansion of the medical provision of abortions during the 1930s. Each of these physicians specialized in abortion and had open, busy practices. Hundreds of physicians in their areas trusted them and relied upon them as a resource for abortion services. Their practices were not temporary, but established; they were not located on back alleys, but on main streets. Dr. Gabler had a business card; Dr. Timanus was listed in the phone book and his office had a sign in front.^[126] Gabler, Keemer, and Timanus were three of many doctors who performed abortions and were probably among the best available.

Thousands of women obtained abortions from physicians in conventional medical settings and suffered no complications afterwards. Middle-class women, through their private doctors, may have had the best access to the physicians who specialized in abortion. But these specialty abortion practices were not exclusive. A mixed group of patients—working-class and middle-class women, white and black—reached these trusted physicians. The Depression heightened women's need for abortions. The expansion of abortion featured both the acceptance of a wider array of indications for therapeutic abortion and the rise of abortion as a specialty. Women's increased demand for abortions drew the medical profession into providing abortion services.