March 7, 1978: High-Risk Abortion at a Birthing Center

SUMMARY: Gloria Jeanie Small, age 34, died March 7, 1978 after an abortion performed by Ronald Tauber at his Orlando Birthing Center in Orlando, FL.

Dr. Ronald Tauber's Background

Dr. Ronald Tauber

Dr. Ronald Tauber considered himself a maverick. He was a risk-taker. He lost his medical privileges over an abortion he'd performed at Florida Hospital. The administration wasn't too upset that the baby in question had been between 23 and 24 weeks of gestation -- teetering on the cusp between Constitutionally protected second-trimester abortions and illegal third-trimester abortions. Rather, he had raised the ire of the hospital administrators, as one said, because he had performed the abortion on the medical ward. As an administrator said, "There was the possibility of delivering a live fetus and the nurses were afraid to work the case. It also would have been a problem to put the patient on the obstetrical floor where babies are born... the nurses here were very upset about the entire situation and Dr. Tauber didn't settle the problem."

Long story short: The problem wasn't the age of the fetus Tauber aborted. It was that he put the nurses in a bad situation and the administration backed the nurses.

Shortly after losing his privileges at Florida Hospital, he lost his privileges and position at Orlando General Hospital. He had been Chairman of the Department of Obstetrics and Gynecology. Tauber said that the move was part of a conspiracy between the two hospitals to persecute him for performing late second-trimester abortions at Florida Hospital. Orlando General Hospital's president, however, said, "Dr. Tauber was suspended from our staff because he didn't meet the standards of practice as held by this hospital."

Tauber's New Idea

Orlando Birthing Center

Tauber responded by opening the Orlando Birthing Center in Orlando, Florida. Tauber said that he wanted to provide a more family-centered and lower-cost birthing experience. Though he lacked privileges to admit any of his patients to a fully-equipped hospital, he said that he had arrangements with local physicians who did have privileges and would admit any of his patients who needed such care. 

All might have gone well had he stuck with delivering living babies. But he also decided that he was just as interested in making sure fetuses came out dead as in helping them emerge alive. As a space to do the abortions, as well as tubal ligations and C-sections, Tauber converted a concrete building adjacent to the gracious birthing center into a surgical ward.

Tauber's birthing center, like his last abortion at Florida Hospital, danced in a gray zone of legality. Tauber intended to keep fewer than three patients at a time overnight, and thus his center didn't qualify as a hospital. He also didn't fall under the category for ambulatory surgical centers. A consultant for the Florida Health and Rehabilitative Services Office of Licensure and Certification said, "As long as Tauber says his facility is a doctor's office, we have no jurisdiction."

And it was into the gray zone that Gloria Jeanie Small walked one spring day.

Gloria's Choice

Gloria was a 34-year-old mother of six children, ages 3 to 19. She had done her best to supplement welfare payments with work at a fern farm and occasional cleaning jobs at the nearby Brass Rail Bar. Neighbors described the family as very close-knit. 

But in January of 1977 she had a positive pap smear and was diagnosed with sarcoidosis, Her doctor, Stephen Spore, described her as "a pulmonary cripple," and noted that just trying to converse left her gasping for breath. As her health deteriorated she could no longer work. 

As if the breathing problems weren't enough to deal with, Gloria suffered from arthritis and ulcers. She spent a year in and out of West Volusia Hospital for bone and liver scans, barium tests, and x-rays.

Then, in February of 1978, Gloria discovered that she was pregnant. She scheduled an abortion at Women's Health Center in Orlando, but before the appointment she developed double pneumonia and was hospitalized once again.

She had discussed her abortion plan with Dr. Spore. He believed that Gloria's health would be at risk whether she decided to give birth or to undergo an abortion. However, he advised her that her medications had likely injured her unborn baby. After this consultation, Gloria decided that "under no circumstances" would she carry her baby to term. 

Spore believed that Gloria should have her abortion in a hospital, where she could be closely monitored by physicians familiar with her medical history. But none of the doctors affiliated with the hospital wanted to abort Gloria's baby. Spore told Gloria that she should therefore go ahead and have the abortion at Women's Health Center.

But by then, Gloria was 14 weeks into her pregnancy. Though abortions past 13 weeks were legal, there were not any clinics in the area that would perform them that late.

Women's Health Center discussed Gloria's options for her. One doctor in Miami would do the abortion, but it would cost $600, and Gloria would have to pay for travel expenses. An out-of-state facility would be even ore expenses. So Women's Health Center referred Gloria to Orlando Birthing Center and the care of Ronald Tauber.

Consultation at the Birthing Center

When she was around 15 weeks pregnant when she made her first visit to Orlando Birthing Center on March 2, 1978. She had a consultation with Tauber, who noted, "She discussed her need for sterilization and stated that she didn't want any further children." He noted that Gloria was struggling to support her six children. Gloria reportedly told Tauber that she couldn't afford the full fee, and that if Tauber didn't perform the abortion she'd do it herself, and if she failed to dislodge the unwanted fetus she'd just kill herself.

 

Tauber agreed to reduce the fee and scheduled Gloria to return for a combination of abortion and tubal ligation on March 6.

What Were Her Realistic Options?

A prolife center also could have taken a holistic approach to Gloria's sad predicament. She was struggling financially. With her health problems she was probably also struggling to manage a household with so many children, even though the oldest were old enough to help take care of the youngest. The fact that she was raising her six children on her own indicates that she may have lacked the skills to identify reliable men that would help to support the children they sired. Her work skills seemed to be limited to more physical labor that her health wouldn't allow. Help finding a sedentary job would have resolved some of her problems. Abortion doesn't require a holistic approach but focuses on getting rid of the fetus and leaving the woman in her same unfavorable circumstances.

Dr. Spore expressed awareness that Gloria was a high-risk patient, either for an abortion or for carrying to term. But news coverage doesn't indicate that he referred her to a high-risk ob/gyn who would have been able to give her more realistic guidance. Was Spore so focused on the idea that the baby might have health problems that he fixated on the idea that the child should be aborted? Or was he just stuck thinking in that direction because Gloria had previously scheduled an abortion?

What would a high-risk ob/gyn have done? By the late 1970s, he or she certainly would have had access to ultrasound to better assess the health of Gloria's unborn baby. He or she would have had a better idea of the comparative risks of carrying to term versus aborting. If a high risk ob/gyn believed that an abortion was indeed the best option, Gloria would almost certainly have been admitted to a hospital for the procedure, and her medical assistance would have paid for it as medically necessary. Sending her to an abortion clinic was a shortcoming on Dr. Spore's part.

The Abortion and the First Signs of Trouble

Going into the abortion, Gloria's vital signs were good. Her blood pressure at 11:45 pm was 122/84 and her pulse was 84. Tauber was assisted by registered nurse Carolyn MacArthur and OR tech Cynthia LaGree.

Gloria's surgery was started at 12:05 pm. About 45 minutes into the procedure, there was a sudden gush of blood. Tauber inserted a scope through Gloria's navel to try to identify the source of the bleeding. LaGree said later that she observed through the scope as Tauber completed the abortion. The only injury she saw was a hole about half in inch long on the lower right side of the uterus. This nick was not enough to account for the amount of blood loss Gloria seemed to be suffering.

The surgery was completed at 1:25 pm, nearly an hour and a half after it was started. By then, Gloria's blood pressure had fallen to 80/60 and her pulse had risen to 96. This was a sign of internal bleeding. Tauber packed Gloria's uterus with medical gauze, which appeared to have controlled the bleeding. By this point, though, Gloria had lost an estimated 1500 cc's -- 3 units -- of blood. Tauber documented Gloria's condition as "borderline." He administered IV fluids, continued cardiac monitoring, and ensured that she was being attended by a nurse. 

Delays and Transfusions

Tauber hand-wrote a note on her chart: "Plan -- Observe and transfuse. If deteriorates, transfer for hysterectomy." He ordered blood from Central Florida Blood Bank at 4:30 pm.

While waiting for the blood to arrive, Tauber called Orlando Regional Medical center. The resident on call instructed him to call the attending obstetric physician. So around 5:30 or 6:00 pm, Tauber called Dr. A. J. Herran to get clearance to admit her to ORMC. Dr. Herran approved the transfer. But Tauber decided to try to stabilize his patient at the birthing center.

Also at around 6 pm, Gloria's friend LeRoy Feaster came by with Gloria's two youngest children, expecting to take her home. By then, the first blood had arrived and Gloria was getting a transfusion. He was told that she would have to be kept overnight. LeRoy went back to speak to her. She reassured him that there had just been a problem with her blood pressure that was being addressed. She smiled as LeRoy gave her a goodbye kiss on the cheek. 

Tauber administered a second transfusion, concluded that Gloria was recovering, and left his patient in the care of a crisis nurse and nurse MacArthur. 

Gloria Seemed Stable

Tauber came back at around 9:30 on the morning of March 7. Gloria's vital signs had remained stable since the previous night. Though Gloria was sitting up on the side of the bed and had gotten up and showered, she still reported abdominal pain. Tauber attributed this to the laparoscopic surgery and kept Gloria for observation.  

Nurse LaGree said that all signs of the bleeding had stopped. Gloria's abdomen was soft and not tender. She spent the afternoon watching TV and chatting with the nurse. She showed off pictures of her children and told LaGree that her oldest son had just gotten back from Job Corps and was going to be a help to the family. 

At around 5:30, LeRoy Feaster came by again, expecting to take Gloria home. He looked into her room but decided not to disturb her because she was sleeping. He never saw her alive again.

The Final Catastrophe Plays Out

At around 6 pm, Gloria walked to the operating room to have the packing removed. Tauber removed it slowly, but about 3/4 of the way through the process there was a sudden massive gush of blood, and Gloria's blood pressure plunged. Tauber ordered meds to contract the uterus and told his staff to call 911 and to cancel an ordered unit of blood from the blood bank so that it would be available for the hospital.

While waiting for the ambulance, Tauber packed Gloria's uterus and vagina with more gauze. Nurse B.J. Caruth lowered Gloria's head so it was lower than her feet to direct more blood and oxygen to her brain. "Mrs. Small was looking around quietly, but obviously frightened, obviously in pain. She was instinctively trying to roll over. We reminded her to lie still and she said, 'OK, OK, OK.'"

The staff who contacted the ambulance dispatch gave contradictory instructions. She said she said that she that there was an hemorrhage and used the words "stat" and "emergency," but also said "to come without making a commotion about it."

This led to the ambulance being dispatched as "routine transfer -- no lights, no siren." It was half an hour until, light and sires blaring, the ambulance headed from the birthing center to the hospital. Gloria arrived, accompanied by Tauber, at 6:52 pm. EMS said that awake and talking, alert, but lethargic and weak.

Chaos at the Hospital

Reports of what happened next are unclear. Dr. Herran said that he was notified that Gloria was being transferred and began his drive towards the hospital. While on the way he got a notice on his pager that Gloria had arrived at the emergency room and gone into cardiac arrest. Different hospital staff give different accounts of whether the internal bleeding was diagnosed promptly, but though Gloria's blood pressure was 82/56 at 7 pm. 

Tauber, not part of the hospital staff, was no longer able to provide care. He reported that he kept telling hospital staff that he'd ordered two units of blood that were at the blood bank across the street, but that hospital policy said they couldn't use blood that had been ordered based on type matching done at another facility. 

Things were chaotic. Gloria's condition was clearly deteriorating rapidly. She went into cardio-respiratory arrest and was provided with resuscitation efforts. Her pulse was restored by the time she got her transfusion at 7:40 pm, but she was still being "bagged" to keep air going in and out of her lungs as she was brought into the operating room at 7:47 pm. 

Herran arrived at the hospital and was briefed by staff as he prepared to operate. Another doctor, R. O. Vandyke, arrived to assist. The surgery began at 7:55 pm. Gloria's uterus was distended from all the gauze packing, which was poking out through a 1 1/2 inch tear. A resident photographed the damaged uterus as Herran surgically removed it. During the surgery, that lasted more than an hour, Gloria received five units of blood, but Herran estimated that this only made up for about a quarter of the blood the patient had lost.

Gloria was barely clinging to life as she was taken to the Intensive Care Unit at 9:50 pm.

Five minutes later she was dead.

The Immediate Aftermath

Some time after midnight the morning of March 8, Gloria's 19-year-old son, Terry, was called by a nurse and told to come to the hospital as soon as possible. Terry called LeRoy Feaster, telling him that the hospital had called. He had to get off work early, then, confused, he went to the birthing center rather than to the hospital. The receptionist directed him to the hospital. The hospital sent him to the medical examiner's office. 

Assistant Medical Examiner Judith Bunker hemmed and hawed and finally told LeRoy that Gloria had died. As LeRoy broken down, he later recalled, Bunker told him that Tauber kept Gloria at the center too long and should have brought her to the hospital for surgery right away. 

LeRoy contacted Gloria's sister, Shirley Johnson, who lived in DeLeon Springs.

On March 10, the medical examiner's office and police department met to discuss the case. But somebody at the state attorney's office leaked the story to WDBO, Channel 6 news. This led to concerns that Tauber would have a chance to destroy records to cover his tracks. A Channel 6 reporter said that he "sat in a van across the street [from the birthing center] with a sixpack of beer for four hours, waiting for the raid." 

When it came at 11:25 that night, the media rushed up to the search party as they entered the birthing center, where three women were in labor. 

The medical examiner said that Gloria's medical history should have precluded performing an abortion in an outpatient setting. The medical board faulted Tauber with failing to transfer to a hospital as soon as he'd had the bleeding stabilized with packing, and with trying to remove the packing in a setting where there was no blood available for a transfusion. 

A court-appointed panel found Tauber negligent in Gloria's death.

The Consequences for Tauber

The repercussions for the 31-year-old Tauber were astonishing, given the legality of Gloria's abortion. He was dismissed from the staff of two hospitals, had his medical license suspended, and was charged with manslaughter. However, I have found no record that the case ever went to trial. Tauber relocated to Detroit, where he finally got around to completing a residency in obstetrics and gynecology, and went to work at the Scottsdale Medical Clinic abortion facility.

Gloria, like other Black women, faced a higher risk of abortion death than a white woman.

Watch High-Risk Abortion at a Birthing Center on YouTube.

Watch High-Risk Abortion at a Birthing Center on Rumble.

Sources:

• "An innovative concept, a controversial innovator," Orlando Sentinel Star, March 16, 1978
• "Doctor returning for hearing in abortion case," Sentinel Star, January 28, 1979
• "Autopsy: The tragic story of Gloria Small (page 1)," Orlando Sentinel Star, March 18, 1979
• "Autopsy: The tragic story of Gloria Small (page 2)," Orlando Sentinel Star, March 18, 1979
• "'Facts Omitted' in article on Gloria Small," Orlando Sentinel Star, April 1, 1979

March 6, 1945: Beatrice's Journey to Sudden Death

SUMMARY: Beatrice Fisher, age 36, died on March 6, 1945 after an abortion perpetrated by Dr. Frank Hart in his Seattle, WA practice.

Starting the Fatal Journey

Beatrice Fern Fisher, age 36, operated a gas station and grocery store with her husband, Lyle, in Snohomish county, about seventeen miles north of Seattle. The couple had three children, aged 14, 13, and 4. Around 1937, Beatrice had successfully sought an abortion, performed by the same Seattle doctor who had delivered her oldest child. Around March 4 of 1945, Beatrice informed her husband that she was pregnant, and that she intended to return to Seattle for an abortion to be performed by the woman who'd done the first abortion. Her husband wasn't happy with the plan, but left the matter to his wife.

On March 5, Beatrice took her four-year-old daughter and $100 in cash and drove to Seattle to seek her former physician. On the way to Seattle, Beatrice stopped at the home of her mother-in-law, Ethel Howard. Mrs. Howard was a practical nurse. While at her mother-in-law's house, Beatrice called a "Dr. T" and spoke to him about having an abortion done. This was the first Mrs. Howard learned of the pregnancy.

At some point that morning, Beatrice called her husband and said that she'd not been able to talk to her doctor, but that the nurse at the doctor's office had referred her to "Dr. T" in Seattle.

Seeking "Doctor T"

Beatrice, her mother-in-law, and the little girl went to Seattle, to Dr. T's office. They arrived at around noon. Dr. T was not available, but his nurse gave Beatrice a business card from Dr. T. On the back, she wrote the name of 58-year-old Dr. Frank C. J. Hart, along with the address of his office in the Joshua Green building in Seattle.

Beatrice and her companions went to Hart's office, where they found a waiting room full of women but no nurse. Later, Hart came into the waiting room and announced, "Five of you women that came in just now leave and those that were here yesterday remain." Mrs. Howard left with the little girl, but Beatrice stayed.

The Trip Back Home

On the drive home, at about 5:00, Beatrice stopped at her mother-in-law's home. She said she had a severe headache. She was perspiring heavily. Mrs. Howard, following Dr. Hart's instructions, gave her daughter-in-law black tea and put a hot water bottle under her back. That was when she noticed that Beatrice's genitals were bandaged.

Beatrice stayed in bed for about 45 minutes, then got up for dinner with her in-laws. She left for home at about 8:30, stopping at the gas station to pick up her husband.

The Next Day

The following morning, Beatrice told her husband that she was returning to Dr. Hart to have "blood clots" removed. She looked tired. She took her daughter with her again, stopping again at her mother-in-law's house. The three went into Seattle, ate lunch, then went to Hart's office. During the trip, Beatrice reported chest and arm pain, and her face was flushed deep red.

At Hart's office, the women again found a waiting room full of women, but no nurse. Again, Hart made the announcement that those who were there for the first time were to leave, and the rest were to remain. He told Beatrice to proceed into the office. Mrs. Howard told Hart that she was very concerned about Beatrice. Hart told her, "This is no place for relations and children. Meet her downstairs in the lobby."

A Dreadful Surprise

Expecting her daughter-in-law to be ready to leave in about 20 minutes, Mrs. Howard went to do some shopping. On returning to the building, she found a crowd of people gathered in the lobby near the flower shop. Mrs. Howard approached the group and found Beatrice lying dead. She had collapsed and died on the spot.

The autopsy determined that Beatrice had been about two months pregnant. There were clear signs that somebody had performed a curettage. The uterine wall had been gouged in several places. Clots had formed over these gouges. The coroner concluded that one of these clots had formed an embolism that had lodged in Beatrice's lung, causing her death.

The Doctor Arrested

On March 7, Hart was arrested. He showed authorities through his premises and gave instruments into evidence, including sponge-forceps and irrigating curettes. When questioned, Hart said that he kept no patient records and didn't give receipts.

When the case went to trial, Hart insisted that he had only been treating Beatrice for complications of a self-induced abortion. Lyle signed a statement saying that two other doctors had refused to perform an abortion, asserting that it was too risky. This would indicate that Beatrice was willing to persist in finding a physician rather than resorting to a self-induced abortion.

Hart was convicted of abortion and manslaughter in Beatrice's death and was sentenced to concurrent sentences of 5 years and 20 years. He appealed but his conviction was upheld.

Hart died in the State Penitentiary in Walla Walla from "heart block" on September 29, 1948

Beatrice's Death in Context

Beatrice's abortion was typical of illegal abortions in that it was performed by a physician.

During the 1940s, while abortion was still illegal, there was a massive drop in maternal mortality from abortion. The death toll fell from 1,407 in 1940, to 744 in 1945, to 263 in 1950. Most researches attribute this plunge to the development of blood transfusion techniques and the introduction of antibiotics. 

Watch Doctor's Efforts and Sudden Death on YouTube.

Watch Doctor's Efforts and Sudden Death on Rumble.

Sources: 

• 178 Wash. 290, 34 P.2d 914; Supreme Court of Washington. State v Martin No. 25153.July 23, 1934
• "Seattle Doctor Faces Abortion Charge on Death of Woman," The Bellingham (WA) Herald, March 7, 1945
• "Seattle Physician Is Released on Bail," Port Angeles (WA) Evening News, March 8, 1945
• "Dr. Hart Loses on Two Points," The Seattle Star, October 2, 1945
• "Hart Plans to Appeal Verdict," The Seattle Star, October 3, 1945
• "Doctor Sentenced," The Bellingham (WA) Herald, December 23, 1945
• "Doctor Hart Loses State Court Appeal," The Seattle Star, December 27, 1946
• Washington State Penitentiary Commitment Record No. 21508
• Washington State Department of Health Certificate of Death No. 16260

March 6, 1970: A Lingering Death After Safe and Legal Abortion

A 16-year-old girl underwent a second-trimester saline abortion on August 26, 1969. A journal article on her death identifies her as "F.S." Life Dynamics identifies her as "Fay" on their "Blackmun Wall" as having been killed by a legal abortion.

Faye developed an infection and symptoms of meningitis after her abortion. She continued to be treated for ten days before she was transferred to another hospital in San Francisco for further treatment.

Doctors performed two heart valve replacements for Faye, and had scheduled her for yet another before she died on March 6, 1970. The cause of death was severe congestive heart failure and pneumonia.

Source: "Medical and Surgical Complications of Therapeutic Abortions," Stewart, Goldstein, Obstetrics and Gynecology, 40:4, October 1972, 547

March 5, 1907: Woman Implicates Midwife on Deathbed

On March 5, 1907, Mrs. Ella Brunswick, age 24, died at St. Elizabeth's hospital in Chicago from complications of a criminal abortion performed that day. In a deathbed statement, Ella implicated a 35-year-old midwife named Kunigundi Hardman.

Ella's abortion was typical of Chicago abortions of the era in that it was perpetrated by a medical professional. Physician-abortionists and midwife-abortionists were very common.

Note, please, that with issues such as doctors not using proper aseptic techniques, lack of access to blood transfusions and antibiotics, and overall poor health to begin with, there was likely little difference between the performance of a legal abortion and illegal practice, and the aftercare for either type of abortion was probably equally unlikely to do the woman much, if any, good.

Watch Chicago Midwife's Fatal Work on YouTube.
Watch Chicago Midwife's Fatal Work on Rumble.

Sources: 

• Homicide in Chicago Interactive Database
• "Police Search for Midwife," Chicago Daily Tribune, March 6, 1907

March 5, 1980: Hospital Abortion Immediately Kills Patient

Gwendolyn Cliett, age 29, was about to undergo a safe, legal abortion and tubal ligation at Presbyterian Hospital in Philadelphia on March 5, 1980. She was 8 to 10 weeks pregnant. Before the procedure could be done, Gwendolen reacted to the anesthesia and died. Gwendolyn, being a Black woman, was at higher risk of abortion death than a white woman would have been.

---

Source: Pennsylvania Death Certificate # 029586

March 5, 1900: Possible Lay Abortion in Chicago

On March 5, 1900, Mrs. Alice Koester died in German Hospital from complications of an illegal abortion evidently performed there that day by Maria Janke.

Janke was arrested March 10, and held by Coroner's Jury on March 11. She was sentenced by Judge Clifford to Joliet Penitentiary.

Janke's employment status is listed as "professional", but nothing more specific is indicated to clarify why she would be performing an illegal abortion in a hospital.

Note, please, that with overall public health issues such as doctors not using proper aseptic techniques, lack of access to blood transfusions and antibiotics, and overall poor health to begin with, there was likely little difference between the performance of a legal abortion and illegal practice, and the aftercare for either type of abortion was probably equally unlikely to do the woman much, if any, good.

Source: Homicide in Chicago Interactive Database

March 4, 1921: Dr. Millikin's Killing Spree

Summary: Nineteen-year-old Francis Karies was one of five deaths attributed to Dr. Charles Waldstein Millikin in Akron, Ohio.

Background

Dr. C. W. Millikin

Charles Waldstein Millikin was a trained, licensed physician and very highly respected in his community. It's important to grasp this as we look at what he did with his training and license over a six-month period from October of 1920 through March of 1921.

The sixth son of Thomas and Tamar (Clark) Milliken, C.W. was born April 17, 1856 in Johnston, Trumbull County, Ohio. Milliken was an 1880 graduate of the University of Pennsylvania School of Medicine in Philadelphia. He was licensed as an allopath in Ohio in 1896 after having served a residency at Harrisburg Hospital and Philadelphia Hospital in Pennsylvania. 

Millikin moved to Akron, Ohio in 1882.

In 1887, Milliken served as secretary of the 64th quarterly meeting of the Northeastern Ohio Medical Association. 

Things started going wrong when Milliken was around 64 years old, nearing retirement age.

He should have retired.

September and October, 1920 

Around September 23, 1920, Milliken performed a criminal abortion on 19-year-old Francis Karies (also sometimes spelled Kerris) at his Akron practice. I've been unable to determine anything about Francis's whereabouts or condition in the following weeks. 

However, Millikin was keeping busy. He performed an abortion on Maud Sporn, alias Spohr, on October 2. Had Millikin known that Francis was ailing when he turned his instruments on Maud? I've been unable to find out. But it should have been clear to Millikin that his ministrations were dubious when Maud died in Akron on October 13.

Somehow Francis ended up in Chicago, where she died at Swedish Covenant Hospital on October 23. The coroner recommended Milliken's arrest, but there is no record if any legal action was taken against him for Francis's death until, sadly, too much later. In fact, as far as I know, no authorities outside of Chicago seemed to take notice. The deaths of both Maud and Francis somehow flew under the radar.

February Through March, 1921

No ill seems to have befallen any other women at Milliken's hands in November or December. Even January of 1921 got off to a good start. But things started going wrong in Millikin's practice in February.

Millikin was 65 in 1921 when Iva Jean Tripplett, nee Isner, age 28, wife of Artie George Tripplett of Akron went to his practice for a criminal abortion on March 1. I've been unable to determine if she took ill right away, or the details of where she died. I have only a date, March 9, and that Millikin falsified her death certificate. He claimed that Iva had died of acute tuberculosis.

Funeral services at Billows' mortuary chapel interrupted on afternoon of October 10. Family had been planning to transport Ida's body to West Virginia for burial.

Coroner Kent performed post-mortem.

Millikin filed death certificate indicating acute tuberculosis. Health department issued burial certificate. Coroner found Ida's lungs in perfect condition but found evidence of septicemia. Removed organs and preserved them for prosecution.

Artie said he hadn't know about the abortion until Ida took ill and told him. Four young children. "Doyle stated tat the death of Mrs. Tripplett makes four in seven days all from the same causes, and each of them charged against Dr. Millikin.

Milliken was free on March 1 or 2, 1921 when he performed an abortion on Iva J. Triplett at his home office at 365 E. Market St. in Akron. Immediately after the abortion, Ida took ill. Millikin attended to her until her death from septicemia and peritonitis at 7:00 on the morning of March 9, leaving behind a husband and children. That was the third death in a week reported to Doyle.

Florence Cobb

As Ida lay dying under Milliken's care, he performed another criminal abortion which resulted in the March 6 death of 22-year-old telegraph operator Florence Heath Cobb, wife of Thomas Cobb of Kenmore, who worked for Goodyear Tire and Rubber. Died at Akron Hospital at 1:00 the afternoon of Sunday, March 6, 1921. Florence and Thomas had married only on the 22nd of the previous June. Her family brought her body to her home town of Salt Lake City for burial. Millikin arrested on the 5th while Florence was still alive, a few hours after the illness was reported to Doyle. Assistant prosecutors Scheck and Wanamaker visited Florence Cobb at City hospital on Saturday the 5th. She made a dying declaration saying Milliken had performed the fatal abortion. Her husband agreed. An autopsy showed that Florence had died as the result of an abortion. Florence, a graduate of the LDS University in Salt Lake City, had been a swimming instructor at Desert Gymnasium before moving to Akron, where she married Thomas Cobb on June 22, 1920.

"Doyle stated that when the first reports came to him he was loathe to place any credence on them inasmuch as the physician is reputed to be one off the best in Summit county and one, through his long residence and wide practice here has earned the reputation of being a man of high ideals." Had to order bodies exhumed.

"The physician who has practiced for 40 years or more in Akron and is well known to most of the older residents of the city and vicinity was arrested Saturday night when Doyle had been informed of the serious condition of Mrs. Cobb, and he was released on bond furnished by himself and A. G. Miller." Doyle wanted to await the April grand jury to present the four deaths.

On March 15, 1921, five more indictments were handed to the judge by the grand jury, for a total of seven at that point, some for the abortions, some for falsification of documents to cover up the abortions.

Louise Marie Vogt, 19, died of peritonitis on March 5, 1921 after an abortion perpetrated on February 26.

And what became of the illustrious Dr. C. W. Millikin after all of these deaths? He pleaded guilty for the death of Louise Marie Vogt in exchange for a suspended sentence, dismissal of the indictments for the four other deaths, and revocation of his medical license. Three judges, Anderson, C. P. Kennedy, and F. J. Rockwell pushed for clemency on the grounds that Millikin was old, a first-time offender, and an all-around great guy.

Judge Anderson further stated, "Courts have made the practice of late years of giving young first offenders that benefit of a parole, and we feel that this is a case where the court can do likewise. It is extremely hard at his age for this defendant to be in such trouble as he now finds himself in. This young woman was in trouble. He had treated the members of her family for 30 years, and when she came to him begging him to assist her he did so in order to protect her good name and that of the family. He is not really guilty, although technically he is. I have known him for a great many years, and have never known him to do an unkind act. The appeal of the woman in distress affected him, and he was justified, morally, in doing what he did. Although the publicity given him has caused the loss of his good name, he will always enjoy the confidence of his friends."

Judge Ahern chimed in, "Dr. Millikin has admitted his guilt, however, but on account of his past record and his many manifestations of public spiritedness the court feels that he is entitled to a suspended sentence."

Prosecutor Doyle merely commented that legally the judges had the authority to turn Millikin loose. His rather tight-lipped comments to reporters tend to indicate that he did not take kindly to the leniency granted to a man who had cost five young women their lives.

Milliken remained in Akron until his death from cerebral hemorrhage and chronic myocarditis on April 13, 1929. "Last Rites For Dr. Millikin To Be Held Tuesday," announced the April 15, 1929 Akron Beacon Journal. The notice sang his praises as a political and social figure. "Dr. Millikin's Death," published in another edition that same day, praised him to the skies: "In the death of Dr. C. W. Millikin this community loses another fine type of the old-time physician whose fifty years of service here spanned the interesting transit of Akron from village to city class. .... He was chief of staff of the City Hospital in 1915. He was a lover of nature and a member of the National Audubon society and the National Society of Natural Research Next to his professional work and his devotion to his friends, public service held his chief interest. This was expressed through his association with the Democratic party, of whose local organization he was often chairman. He sought no preferment for himself. Having no children of his own he sent many a student to and through college. He was a lover of children and of young people. One so kindly and gentle in character will be deeply missed in the circles where he was best known and highly regarded."

He likely was not so nearly highly regarded by the loved ones of Iva Triplet, Maud Sporn, Louise Marie Vogt, Florence Cobb, and Francis Karris. 

Sources:

• "Akron Doctors in Other Fields," Summit County (OH) Beacon, May 18, 1887
• "Woman's Death Brings Arrest of Physician," Akron (OH) Beacon Journal, March 7, 1921
• "Funeral Stopped By Prosecutor's Orders; Post Mortem Held," Akron (OH) Beacon Journal, March 11, 1921
• "Dr. Millikin is Facing 5 More Counts," Akron (OH) Beacon Journal, March 15, 1921
• "Claims Death Was Due to Unnecessary Operation," Elyria (OH) Telegram, May 4, 1921
• "Dr. C. W. Millikin Pleads Guilty," Akron (OH) Beacon Journal, May 27, 1921
• "Dr. Millikin Has License Revoked By Medical Board," Akron (OH) Beacon Journal, July 9, 1921
• 110 Ohio St. 381 144 N.E. 264 MILLIKEN v. HEDDESHEIMER. No. 18278. Supreme Court of Ohio. May 27, 1924

March 4, 2000: Kermit Gosnell's Other Dead Woman

Summary: 22-year-old Se'mika Shaw died a painful death on March 4, 2000 from complications of an abortion performed by Kermit Gosnell at his "house of horrors" in Philadelphia

Authorities Notified; Respond Lackadaisically 

Kermit Gosnell

On April 29, 2004, Mark Greenwald, a prosecuting attorney for the Pennsylvania Board of Medicine filed a one-paragraph "Prosecution Evaluation" in a matter referred to the Board concerning Dr. Kermit Barron Gosnell, who for decades had operated a filthy, dangerous abortion clinic in Philadelphia:

Brief Factual Summary: The file was opened as a result of a Medical Malpractice Payment Report. The underlying malpractice case involved the death of a 22 year old female following the termination of her 5th pregnancy. Following a seemingly routine procedure on 3/1/02, the patient was taken to the ER at the University of Pennsylvania with complaints of pain and heavy bleeding. The patient underwent surgery but the surgeon was unable to locate any perforation and the patient died from infection and sepsis. Although the incident is tragic, especially in light of the age of the patient, the risk was inherent with the procedure performed by Respondent [Gosnell] and administrative action against respondent’s license is not warranted.

RECOMMENDATION: Z-02, Prosecution not Warranted

An Agonizing Death 

Se'mika Shaw

The "22 year old female" in question was Se'mika Shirelle Shaw*. Most of what little we know about her is from her cousin, PA State Representative Margo L. Davidson. 

Margo believed that Se'mika, whom the family called Mika, sought an abortion because she already had two young children. She and her same-age cousins were the best of friends and were preparing to set up housekeeping together.

She underwent her abortion on March 1, 2000, five months into her pregnancy.

Mika called the facility the next day to say that she was bleeding profusely. According to court records she was not instructed to seek care. 

Two days later, March 4, Mika collapsed on the floor of her family home in the presence of some of her cousins. One of those young cousins later called Margo to tell her that Mika was dead. 

Margo was bewildered because Mika had been young and healthy. Margo went to the house to join the grieving relatives and started to hear the story. Mika had been bleeding profusely, writhing and screaming in pain on the floor. The young cousins tried to convince her to go to the hospital. They were afraid to call the clinic because at some point they'd been told not to call if there was a problem. 

Screenshot of Margo Davidson
from "Institutional Denial," 
3801 Lancaster, 2014

Mika's continued agony overcame their fear, and one of them tried to call Women's Medical Society, but was unable to reach anybody. 

Then Mika's mother, Linda, arrived and saw the condition her daughter was in. She took Mika to the hospital, but by then it was too late to save her.

Margo was later told that the abortion had been incomplete; part of the placenta had been left behind. Her young cousin had died from a perforated uterus and sepsis. 

Margo was also a minister and did the eulogy at Mika's funeral. The young cousins were hysterical, trying to pull their friend from the casket and bring her back to life. Margo didn't allow the young cousins to go the the cemetery because she was afraid they'd try to jump into the grave.

They Already Knew About Gosnell

To get an idea of how slovenly the Medical Board's investigation was, please note that Semika underwent the fatal abortion in March of 2000. The Board didn't even get the year right when reviewing this death before blowing the entire matter off, just over four years after the fact. 

The Grand Jury Report on Kermit Gosnell noted:

Before Department of State prosecutors decided not to investigate the 22-year-old patient’s death, they had been told of Gosnell’s many illegal practices. What makes these prosecutors’ inaction even more astonishing is that they did know more than the bare facts included in the Board attorney’s evaluation of the case. On the same day in 2004 that they decided not to do anything about Semika Shaw’s death, these same two prosecutors also closed the investigation into the complaint brought to the Department of State more than two years earlier by Marcella Stanley Choung. That was the complaint that had alerted the Board of Medicine – eight years before Karnamaya Mongar died – to almost all of the same violations revealed by this Grand Jury’s investigation.

Police photo of one of the cats at Gosnell's clinic

In December of 2001, Ms. Choung had filed a detailed, written complaint about Gosnell to the Department of State. In March of 2002, she testified in a follow-up interview. As the Grand Jury Report noted:

She informed the department investigator that Gosnell was using unlicensed workers (including herself) to give IV anesthesia to patients when he was not at the clinic; that his facility was filthy; that two sick, flea-infested cats roamed freely in the procedure rooms, vomiting throughout; that Gosnell ate in the procedure rooms; that the autoclave used to sterilize instruments was broken; that he reused single-use curettes; that there were no licensed nurses at the facility when IV anesthesia was administered; that Gosnell allowed one patient to use her cousin’s insurance card to pay for an abortion; that Gosnell performed abortions on “underage children” against their will if their mothers asked him to; and that he performed other abortions without consent forms.

The "investigation" into Ms. Choung's report consisted of three phone calls. Nobody visited the clinic. Nobody interviewed the employees. Nobody contacted the patient who had given Ms. Choung permission to share her contact information with the state. All that came of it was a recommendation -- which was never followed up -- that the Department of Health should inspect the facility.

More of the Same

Drug dosage chart created c. 1995 by 15-year-old
Ashley Baldwin for use by other staff at Gosnell's clinic.

Not that forwarding information to the Department of Health would have accomplished anything: The DOH had first inspected and given a 12-month license to Gosnell's clinic in 1979, in spite of numerous and alarming shortcomings, and didn't review the clinic again until 1989, when it was again permitted to stay open in spite of multiple shortcomings that clearly endangered patients. They repeated this type of review in 1992, again approving the facility in spite of appalling conditions, and in 1993 they reported that previous deficiencies had been corrected, despite continuing deplorable conditions, because of a new politically-motivated policy not to inspect abortion clinics unless they'd gotten a complaint.

They did not enter the clinic again until they were invited to do so by the DEA and Philadelphia DA for the drug raid in 2010. In the 16 years since the new head-in-the-sand policy, they had failed to investigate after receiving at least 6 serious complaints including two reports of patient deaths.

A Pattern of Enabling Quackery

Gosnell was able to get away with what he did because of calculated decisions by abortion-rights activists to turn a blind eye. I've dubbed this phenomenon "the Compton-Carr Effect," after its most straightforward proponent: Janis Compton-Carr of the Florida Abortion Council. After the Miami Herald exposed a nasty abortion mill featuring many of the same kinds of deplorable conditions found at Gosnell's clinic -- dirty instruments, untrained staff, illegal peddling of narcotics -- Compton-Carr said, "In my gut, I am completely aghast at what goes on at that place. But I staunchly oppose anything that would correct this situation in law."

Fortunately, thanks to the internet and crowdfunding, we can bypass the abortion lobby's cheerleaders in Hollywood and the mainstream media. Filmmakers Phelim McAleer and Ann McElhinney, along with journalist Magdalena Segieda, raised $2.1 million to produce Gosnell: The trial of America's biggest serial killer, a movie that closely follows the real story. I highly recommend both this film, and the documentary 3801 Lancaster. 

*Most documents spell her name "Semika," without the apostrophe. It is pronounced "sha-MEE-kah."

For more background on Gosnell and how he got away with his crimes for so long, read:

• Verified: Gosnell Got Snipping Idea at NAF Seminar
• Gosnell Clinic Even Nastier than Grand Jury Reported
• The Gosnell Patient Who Barely Escaped With Her Life 
• Kermit Gosnell and the Milgram Experiment 
• Gosnell: The One That Got Away, and Hope for Others 
• Gosnell and Viability: Where's the Line?
• Gosnell and Post-Viability Abortions
• Gosnell: Location Can Mean Misdemeanor vs. Murder 
• Gosnell: The Grand Jury Convened
• Why "Gosnell" Must be Told: The Compton-Carr Effect
• Why the Left must Censor us on Gosnell: The "Outlier" Lie
• "Snipping" and why the Left Must Silence Us on Gosnell

Watch Prochoice Oversight Leads to Agonizing Death on YouTube.
Watch Prochoice Oversight Leads to Agonizing Death on Rumble.

Sources:

• Kermit Gosnell Grand Jury Report
• "Gosnell Timeline -- what took the state so long to inspect this house of horrors?" Saynsumthn's Blog, May 7, 2013
• "Institutional Denial," 3801 Lancaster, 2014

March 3, 1984: Teen Dies after Five-Hour Abortion at Allred Clinic

The National Abortion Federation, an organization of abortion practitioners and their for-profit and non-profit abortion facilities, is highly reputable in abortion-rights circles. Sixteen-year-old Patricia Chacon lost her life after placing her trust in one of those NAF members. 

Patricia had no way of knowing, as she climbed onto the abortion table at Avalon Hospital, that 24-year-old Denise Holmes had died at Avalon in December of 1970. She also had no way of knowing that she would become the second of more than a dozen women for whom a safe, legal abortion at Family Planning Associates would be the last choice she would ever make.

Edward Allred

Patricia, 24 weeks pregnant, underwent a safe and legal abortion at the hands of Edward Allred, assisted by Leslie Orleans at Allred's Avalon Hospital in Los Angeles on the morning of March 3, 1984. The abortion took five hours to complete.

Patricia retained fetal tissues, so she was scheduled for a second procedure that afternoon to complete the abortion.

 
There are conflicting stories as to what happened next. Allred pronounced Patricia dead at 4:30 pm, saying that Patricia died of an embolism during the second surgery.  Patricia's parents claim that their child bled to death while left unattended.

An autopsy found numerous catgut sutures in Patricia's vagina and hemorrhage in her uterus. Death was attributed to disseminated intravascular coagulopathy (DIC, a clotting disorder) due to abortion-induced amniotic fluid embolism (amniotic fluid in the bloodstream).  

Patricia's parents sued Allred and Orleans for their daughter's death. Since one of the things DIC causes is massive hemorrhage, Patricia's parents are probably correct in blaming her death on blood loss. They also asserted that Patricia had been given substandard care due to Allred's racism. Given Allred's public statemen about wanting to set up an abortion clinic in Calexico so that he could abort the babies of women crossing the border from Mexico, they might have had a point.

Avalon Hospital was part of Edward Allred's Family Planning Associates Medical Group, a National Abortion Federation member facility. Allred claimed that Patricia had been the first dead patient at one of his clinics, overlooking the fact that he had owned the hospital where Denise Holmes had died from abortion complications in 1970.

Other women known to have died after abortion at the chain of facilities founded by Allred include:

Mary Pena, age 43, 1984

Josefina Garcia, age 37, 1985

Laniece Dorsey, age 17, 1986

Joyce Ortenzio, age 32, 1988

Tami Suematsu, age 19, 1988

Susan Levy, age 30, 1992

Deanna Bell, age 13, 1992

Christine Mora, age 18, 1994

Ta Tanisha Wesson, age 24, 1995

Nakia Jorden, 1998

Maria Leho, 1999

Kimberly Neil, 2000

Maria Rodriguez, age 22, 2000

Chanelle Bryant, age 22, 2004

"Kyla Ellis," age 23, 2014

Watch Callousness or Racism? on YouTube.

Newly added sources:

• "Racism charged in girl's death during abortion," Chico (CA) Enterprise Record, March 3, 1985
• "$14 million suit filed in abortion death," The Press-Democrat, March 4, 1985
• "Teen's family sues over abortion," The Camarillo (CA) Daily News, March 4, 1985
• "DA probes two deaths after abortions," San Pedro (CA) News-Pilot, December 6, 1985

March 2, 1994: Quack's Satellite Clinic Causes Agonizing Death for Teen

Of all the justifications for the current state of abortion in the United States, this is the one that probably steams me the most, personally is the argument that abortion has to be legal to prevent gruesome back-alley deaths. I've reviewed about 6,000 abortion injury and death cases. I've gone through boxes of nothing but autopsy reports on young women and girls dead for no good reason. The idea that it's okay to kill some women legally in order to prevent other women from being killed illegally gets to me.

We can start with Jammie Garcia, aka Jammie Garcia Yanez-Villegas.

When the documents for Lime 5 were pouring in, I was an abstracting machine. I had a three to four foot stack of documents in my office on any given day that I had to plow through, skim, highlight, read, summarize. I learned to be very detached and clinical, to just get the words and ideas and not let it get to me. But Jammie Garcia got to me.

The first document I reviewed was a March 1994 report on an inspection done in response to a patient death in a clinic owned by Dr. Moshe Hachamovitch. The report said that the staff were inadequately trained in how to properly sterilize instruments. The administrator was evidently aware of the fact that the autoclave used to sterilize instruments was not functioning properly. As for the instruments themselves, "two loop forceps, two tenaculums and one curette were found to have small particles of dried brownish-dark red material on them. Three speculums were found to have small particles of dried clear material on them." "The only sterilized abortion tray in the procedure room was found to contain a curette with a loop whose edge was visibly jagged instead of smooth." 

Untrained staff? Dirty instruments? Indifferent administration? That's not enough to even get my attention. I'd read one report in which the inspectors asked the staff to demonstrate that the emergency generator was functioning properly. The generator caught fire. I'd seen reports of dogs in clinics, bloody bare mattresses, drunken abortionists falling on the floor. So Moshe Hachamovitch's little abortion mill didn't stand out for its flaws.

Then there was the case of the patient whose death had brought on the inspection. She was identified as 15-year-old "J.G." "J.G." had her abortion performed by John Coleman at Hachamovitch's A to Z abortion facility on February 18, 1994. Four days later, on February 23, she was admitted to the Intensive Care Unit of a Houston hospital, with spiking fever, chills, nausea, pain, respiratory distress, a distended abdomen, low blood oxygen levels, and foul-smelling discharge. An examination revealed inflammation and a tear in her cervix.

"J.G." died on March 2.

This was all tragic, very sad, but again, typical for what I'd see in an abortion death. I dutifully wrote up the case while Mona tried to get more information. She got a copy of the autopsy report.

When I hear about how we need legal abortion to prevent those horrible back-alley abortions, I can see Mona and me sitting and reading that autopsy report. Mona came across the hall with Jammie's autopsy report in one hand, and another autopsy report in another. She wanted me to really grasp how swollen and boggy Jammie's organs were. Jammie's liver and lungs weighed twice what they should have weighed.

Then Mona and I sat down together and read the rest of the autopsy report. By the time we were done, we were both crying, telling each other, "She was unconscious by then. She had to have been unconscious."

Jammie's body was wracked with abscesses, spreading infection that had entered her body through the damage the abortion had done to her uterus. Her brain was swollen. As near as Mona and I could figure, Jammie's fetid fluids had made their way up through her damaged bowels and into her lungs.

Nobody can convince me that Jammie's death was an improvement on the old back-alley abortions. No drunken, trenchcoat-clad pervert with a rusty coathanger could have done more damage, could have killed her any more horribly.

I will never understand the stubborn instance that when a pregnant woman faces challenges, somebody has to die. Why? Why, with so many adoptive homes for her child, did Jammie have to die? Why, with so many prolife pregnancy centers standing by to help her, did Jammie have to die?

Abortion laws didn't kill Jammie Garcia. An abortionist did. Does the fact that he did it in a legally operating "clinic," with medical instruments instead of with a coathanger, make her any less dead?

Women -- and teenage girls like Jammie Garcia -- will continue to die, as long as they continue to perceive abortion as an escape. And they will continue to perceive it as an escape as long as there is a multi-million-dollar advertising campaign shouting from the rooftops the wonders and benefits of safe-n-legal abortion.

NOTE:
Five other patients are known to have died either under Hachamovitch's direct care or under the care of an employee at one of his clinics.

Tanya Williamson
This young woman was inadequately monitored in recovery and allowed to lapse into respiratory arrest. She died on in September of 1996

Luz Rodriguez
Allowed to bleed to death in 1986 under Hachamovitch's direct care in the Bronx.

Christina Goesswein
Hachamovitch brought her to his office at 4 a.m. to treat grave complications. She died in October of 1990.

Lisa Bardsley
Bled to death on the way home from her safe, legal abortion at one of Hachamovitch's facilities in Arizona in 1995. 

Lou Ann Herron

Lou Anne Herron
Her pleas for help went unheeded as she bled to death in Hachamovitch's Arizona abortion clinic in 1998.

Sources:

• Travis County District Court Cause No. 94-07517
• "History of trouble at clinics," Arizona Republic, January 17, 1999