Population Problems and Efforts to Combat Infertility

In France, as in other comparable countries, infertility was the object of popular practices and cultural traditions dating back to ancient times. In the nineteenth century, various physicians and quacks offered a wide range of methods, rooted in pre-scientific conceptions and beliefs, claiming not only to ‘cure’ infecundity, but also to determine the sex of the child.3 The emergence of gynaecology as a specialism within medicine in the early nineteenth century reflected heightened concerns about the female reproductive body, including female infertility.4 The rising medical interest in involuntary childlessness may also be due to the involvement of French ‘middle-class medicine’ in bourgeois marital fertility, as physicians attempted to address male anxiety and ward off social decline.5 However, until the late nineteenth century, medical treatments for infertility were still only available on a private basis, and therefore probably limited to well-off female patients. This means that the story of responses to the problem of involuntary childlessness is complicated: we need to explain the coexistence of increased interest in infertility and lack of attention to collective methods of tackling the problem.

On the one hand, there was undoubtedly an increase in published medical literature on the topic. These works mostly related to gynaecology and obstetrics, but also to physiology, forensic science, female hygiene, and water cures. Some of the most famous and scientifically and politically influential gynaecologists and obstetricians in France, such as Jacques Doleris (1852-1938), Adolphe Pinard (1844-1934), and Charles Pajot (1816-96), conducted important investigations into infertility, based on both their own clinical practice and international medical research on the topic.6 A search of the digital catalogue of the Bibliotheque interuniversitaire de Sante/Medicine in Paris, one of the most important medical reference libraries in the world, reveals that between 1800 and 1914, approximately 60 books or theses with the term ‘sterilite’ (infertility) in the title were published.7 As the Google Ngram computations below show (Figs. 1 and 2), from the 1880s onwards there was a rise in discussion of ‘sterilite involontaire’ (involuntary sterility), and after 1930 the number of publications with the terms ‘sterilite involontaire’, ‘sterilite conju- gale or ‘ sterilite pathologique’ rose sharply once again. 8 These figures suggest a dramatic increase in medical attention devoted to the problem of involuntary childlessness, with sharp explosions of interest in the decades around the turn of the century, and then again from 1930 to around the mid-century.

On the other hand, for many reasons, the social conditions necessary for recognition of involuntary childlessness as a collective issue were not yet in place. From the 1870s, there was intense concern about the slow rate of population growth in France, fuelled partly by anxieties about the after-effects of defeat in the Franco-Prussian war of 1870-71. It was widely believed that a large and healthy population would be needed both to defeat Germany in any future war, and for imperial expansion. In this context, the rise offeminism and neo-Malthusianism both induced moral panics, while campaigns to promote

Ngram of incidence of terms sterilite conjugate, sterilite involontaire, and sterilite pathologique, 1800-1980. (Source

Fig. 1 Ngram of incidence of terms sterilite conjugate, sterilite involontaire, and sterilite pathologique, 1800-1980. (Source: Ngram Culturomics Search: http://books. google.com/ngrams [accessed 6 December 2016]. For the purposes of reproduction in this volume, the results of these Ngram searches have been adapted into black-and- white line illustrations by Kirsty Harding.)

Ngram of combined incidence of terms sterilite conjugale, sterilite involuntaire, and sterilite pathologique, 1800-1980. (Source

Fig. 2 Ngram of combined incidence of terms sterilite conjugale, sterilite involuntaire, and sterilite pathologique, 1800-1980. (Source: Ngram Culturomics Search: http:// books.google.com/ngrams [accessed 6 December 2016]. For the purposes of reproduction in this volume, the results of these Ngram searches have been adapted into black-and-white line illustrations by Kirsty Harding.)

population growth became more common. At the centre of these efforts was the Alliance nationale contre la depopulation, a lobbying group founded in 1896 by the statistician Jacques Bertillon (1851-1922).9 There was, then, widespread agreement that management of the population was an urgent issue, but far less consensus on what means should be chosen to ‘repopulate’ the nation. There were always great difficulties in simultaneously convincing government decisionmakers, pronatalist pressure groups, pro-family associations, social hygienists and physicians of the worth of particular interpretations of the cause of relative population decline, or of proposed measures to tackle it.10 Internal dissension among these collective stakeholders, as well as between them, about the aim of political programmes, their most urgent priorities, and the means by which these aims would be best achieved, made it even more difficult to address the problem of involuntary childlessness.

Of course, one of the main reasons that medical and other pressure groups paid comparatively little attention to involuntary childlessness was that few believed this was an important contributory factor in the decline in the birth rate. Physicians and statisticians had wondered for several decades to what extent the fall of the French birth rate was due to a physiological decrease in reproductive capacity, whether because of venereal diseases, tuberculosis, excessive alcohol consumption, or other ‘diseases of civilization’. Using the number of childless households listed in the 1896 census as the proxy for infertility, in the belief that very few couples want no children, Jacques Bertillon calculated that the rate of involuntary childlessness could not exceed 15% of the adult population.11 Like other pronatalist experts and lobbyists, Bertillon believed that ‘physiological causes’ played only a marginal role in the population decline: according to the most respected observers, the main culprits were ‘Malthusian behaviours’ (use of birth control) and, especially from the physicians’ standpoint, ‘criminal abor- tion’.12 This interpretation of the reasons for the declining birth rate resulted in the passing of legislation in 1920 which banned the dissemination of contraceptives, propaganda around birth control, and incitement to abortion. In 1923, even harsher measures against abortion were introduced, including making it illegal to recommend an abortionist; an important aspect of this legislation was reclassifying abortion as a minor offence, which in effect made it possible to secure more prosecutions for procuring or performing the operation.13 In the same year, the adoption of abandoned or orphaned children was legalized, in recognition of the increased numbers of such children following the 1914-18 war. Although this was not its main purpose, by providing a potential social solution to the difficulties of infertile couples, this law also provided a means of bypassing the medical aspect of the problem.

The belief that birth control and abortion were the main factors behind the population decline led to the belief that the best way to prevent reproductive disorders, including involuntary childlessness, was to reduce gynaecological infections induced by abortion by eliminating abortion itself. Doctors frequently highlighted the association between abortion and secondary infertility. In 1927, a small number of participants in the Kiev Congress of Gynaecology had decried the effects of the 1920 legalization of abortion in the Soviet Union on women’s health. In the early 1930s, the Alliance nationale contre la depopulation disseminated discussions from the Congress on the dire demographic consequences of legal abortion without any critical commentary.14 Lobbying groups interpreted medical evidence presented at the Congress as demonstrating that even when practised by physicians, induced abortion often led to metritis (inflammation of the uterus), salpingitis (infection and inflammation of the fallopian tubes), and post-abortion curettage which damaged reproductive capacity.

Because there was so much anxiety around voluntary childlessness, whether by means of birth control or abortion, as the cause of the declining birth rate, venereal disease was not awarded the central place among explanations of the causes of involuntary childlessness that it held in Britain (for further discussion of approaches to this issue in Britain, see Anne Hanley’s chapter in this volume). French physicians did worry about men transmitting venereal disease (which they had supposedly contracted from sex workers) to their wives, and thereby causing an increase in miscarriages and acquired infertility, but most tended to emphasize the likelihood that venereal disease would result in the production of ‘inferior’ offspring.15 These fears increased during the First World War, when social hygienist discourse on the sexual health of French soldiers generated fevered debates on the future of regulated prostitution, stimulated the introduction of a totally new health policy to tackle venereal disease (based on the creation of VD dispensaries), and even led to the army taking direct control of brothels across the country.16 In subsequent decades, physicians incorporated awareness of the effects of venereal disease to differing extents in their accounts of male and of female infertility. By the end of the Second World War it was widely accepted that gonorrhoeal epididymitis (inflammation of the epididymis) was the main cause of male physiological infertility.17 However, although physicians were progressively aware of the links between syphilis and spontaneous abortion, and especially between gonorrhoea and tubal infertility, they continued to emphasize the effects of post-abortion complications on female infertility.

All this shows that involuntary childlessness was not framed as an autonomous public health problem (in fact, if we use government involvement as an index, infertility did not achieve this status until the late 1930s). This helps to explain why, in the 1920s, the first significant initiatives in medical treatments for infertility were isolated undertakings, on the margins of the public health system. After the First World War, a number of Parisian gynaecologists and obstetricians combined their desire to relieve patients’ suffering with their interests in medical experimentation and the qualitative and quantitative ‘betterment’ of the French population. Around this time, a handful of doctors who believed that providing assistance to childless couples was more fruitful than hunting down the women who aborted attempted to set up specialized hospital treatments for infertility. The physicians Louis Devraigne (1876-1946) and Jean Dalsace (1893-1970) were influential figures in the attempt to construct medical and social models to address infertility, and to provide practical help for all those who suffered from this problem.

Louis Devraigne was a leader of the puericulture movement, which Pinard described in 1896 as concerned with ‘research and application of knowledge useful to the reproduction, preservation and improvement of the species’.18

This movement, often perceived as a French version of eugenics, mixed social hygiene and pronatalism in campaigns for the modernization of hospital maternity wards. Devraigne believed it was essential to rationalize procreation in order to strengthen the social body, and he presented puericulture, denatalite (the decline in the birth rate), and sterilite as inseparable issues. Jean Dalsace was a different kind of character. He belonged to the more liberal end of the biopolitical spectrum: a member of the French Communist Party, he was also an early advocate of sexology (a discipline which might be viewed as operating at the crossroads of gynaecology, eugenics and psychoanalysis), sex reform, and birth control, which he viewed as both a reproductive right and a necessary measure to protect women from post-abortion diseases. For Dalsace, medical treatments for infertility were, as in the puericulture model, a matter of social importance, but he believed the problem of involuntary childlessness could only be resolved if physicians were able to foster individual well-being, in particular in sexual and reproductive life. As this 1937 poster (Fig. 3), used to attract patients to his dispensary in Suresnes, shows, Dalsace saw infertility (sterilite) as connected to eugenics (eugenique). Dalsace believed, as did many other doctors and later demographers, that only motivated couples would ask for reproductive assistance, and that this self-selection for infertility treatment had potential eugenic benefits. By definition, couples who sought

A poster announcing Dalsace’s clinic in Suresnes

Fig- 3 A poster announcing Dalsace’s clinic in Suresnes (1937). By permission of the Archives municipales de Suresnes (Q 66) treatment must really want to have children, and it was thought that if children were greatly desired, they would be better raised.19 Like Devraigne’s project, Dalsace’s work greatly influenced the creation of sites and practices for infertility medicine in interwar France.

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