Could Quacks Thrive Pre-Legalization?

"Most illegal medical abortionists will not handle a case when the pregnancy is beyond the twelfth week, but there are no doubt some exceptions. The technique of the well-accredited criminal abortionist is usually good. They have to be good to stay in business, since otherwise they would be extremely vulnerable to police action."
— Planned Parenthood President Alan Guttmacher, M.D. Babies by Choice or by Chance, 1959

"Call them what you will, abortionists or anything else, they are still physicians, trained as such; and many of them are in good standing in their communities. They must do a pretty good job if the death rate is as low as it is."
— Planned Parenthood Medical Director Mary Calderone, M.D. "Illegal Abortion as a Public Health Problem," American Journal of Public Health, July, 1960

Abortion-rights activists insist that the Philadelphia "house of horrors" operated by Dr. Kermit Gosnell without let or hindrance was not the result of lax oversight in the age of legal abortion, but was caused by oppressive oversight. And, they insist, were abortion again criminalized, practitioners like Gosnell would become the norm.

If this was the case, it certainly was somehow invisible to Planned Parenthood, even though they held a massive conference on induced abortion in 1955. The participants in this conference included doctors Guttmacher and Calderone, as well as public health physicians, professors in obstetrics and gynecology, New York Chief Medical Examiner Milton Helpern, and even criminal abortionist Dr. George Lottrell Timanus, who gave a detailed report on his own thriving practice. The conference found the practice of abortion to be primarily the work of physicians like Timanus, with the serious damage done in the minority of abortions perpetrated by non-physicians.

I have been studying abortion mortality, both legal and criminal, since 1996, and what I have found anecdotally supports the findings of the conference. Any criminal abortionist who drew attention to himself or herself by harming a patient would be, at the very least, severely inconvenienced by an arrest and investigation even if no prosecution went forward. Prosecution was stressful and expensive and might result in the loss of one's medical license even if it did not result in a prison sentence. If convicted, the abortinoist could expect to go to prison for at least five years, perhaps for life. This reality gave these practitioners, as Dr. Guttmacher pointed out, motive to refrain from taking appalling risks with their patients' lives. Patient deaths were, more often than not, related not to quackery, but to the state of medicine in general. No matter who performed the abortion, or how carefully, an infection was a far more deadly complication in the era before antibiotics, and a laceration far more deadly before blood typing and transfusions.

In fact, it was these improvements in medical care, and not the legal status of abortion, that caused maternal mortality in general, and abortion mortality in particular, to plummet decades before abortion was legalized, as you can see in below. (I have yet to account for the leveling-off in the 1950s.)

As far as I can see from seventeen years or research into criminal abortion deaths, the primary factor in the degree of quackery that went on in abortion practice hinged, as it does today, on the will of public officials and the legal system. In times and places where abortion was seen as an abomination, quack abortionists were quickly taken out of circulation. In times and places where abortion was seen as a victimless crime, practitioners were freed to ply their trade with only the annoyance of an occasional trip to the police station for a scolding.

Chicago in the late 19th and early 20th century seemed to be as keen on enforcing abortion laws as Pennsylvania has been recent decades. The authorities were so tolerant of abortion that perhaps the most deadly quack abortionist of all time, Dr. Lucy Hagenow, fled there in 1889 to avoid trouble after she'd been repeatedly prosecuted over a string of abortion deaths in San Fransisco.

Hagenow found Chicago's permissive attitude congenial. Advertising quite openly, as was the norm for Chicago abortionists of the era, Hagenow managed to kill five women before being incarcerated in 1900. Even then, she was only kept out of circulation a single year before being paroled, allowing her to kill three more women. She was sentenced to prison in 1907 but released after serving only ten years. This prison stint seemed to cow Hagenow somewhat, and although she continued to perpetrate abortions, she managed not to kill any of her patients until something finally snapped in 1925 and she turned deadly again, killing six patients before the end of 1926. She was prosecuted and jailed one last time. Hagenow appealed her case and in 1929 won a new trial. However, the judge dismissed the case, noting that there's been no new evidence gathered during Hagenow's incarceration and that at the age of 81 she was so old that she probably wouldn't case any more trouble. "You had better make your peace with God, Lucy Hagenow," the judge told her. "I do not think your months on earth are many." Hagenow, the Associated Press noted, was nearly deaf and "may not have heard. She muttered something, and shambled laboriously from the room." She faded into obscurity and died in 1933.

In Hagenow's era, as in our own, how much damage an abortionist was able to do hinged not on the law, but on the degree to which abortion is accepted and embraced by those with the power to put an end to the quackery by holding abortionists accountable for their crimes.