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.