The Invention of New Public Instruments in the Interwar Period
During the 1920s, many French hospitals and dispensaries, guided by the aims of the puericulture movement, began to emphasize preventative and social medicine in their prenatal and postnatal medical provision, often targeting the lower classes.20 The first specialized consultation clinics for infertile women and men were organized in this context. In 1925, Devraigne had opened a prenatal clinic in the maternity ward of the Hopital Lariboisiere, a major Parisian hospital, and after lengthy negotiation with the Parisian Hospitals administration managed to obtain authorization to open an infertility unit.21 A dozen other infertility units were then set up in Paris on the same model.22 These modest units did not receive specific budgets, and their status as ‘outpatient consultation clinics’ prevented practitioners from admitting patients to hospital beds.23 Dalsace took a different route into the provision of treatments for infertility, and instead experimented with his own project in the suburban town of Suresnes, the first garden city created in France. He convinced the mayor, the socialist reformer Henri Sellier (1883-1943), to make a room available in one of the municipal child nurseries for a weekly consultation with infertile patients. This ‘infertility and eugenics’ clinic opened in 1937. Although it has proved very difficult to find archival sources on Dalsace’s activities in Suresnes, there is some evidence that his practice differentiated between ‘healthy’ women who needed help to become pregnant and ‘unhealthy’ women, such as victims of syphilis or mental disorders, or the wives of alcoholics. These ‘unhealthy’ women were encouraged to use the pessaries that Dalsace brought illegally from Britain.24 In both public and private spheres, then, eugenic concerns helped to determine medical attitudes towards the desirability of ‘curing’ infertility.
These pioneer physicians sought to convince both the authorities and public opinion that science provided a credible answer to infertility by proving their professional skill and technical efficiency. Implicitly, this meant demonstrating their superiority over ‘amateurs’ and ‘improvisers’, and avoiding interventions perceived as inappropriate, such as artificial insemination without clear therapeutic justification. At this time, although some doctors in private practice carried out artificial insemination using the husband’s sperm, this remained controversial. In a notorious case of 1884, the physician Oscar Lajartre was convicted by the Tribunal civil de Bordeaux for violating the confidentiality of the doctor-patient relationship in order to pursue costs from a patient who refused to pay for failed artificial insemination. However, artificial fertilization in itself was not condemned.25 Significantly, Lajartre was able to continue publishing advertisements for his ‘miraculous’ treatments in the newspapers.26 Even after the Sanctum Officium (the administrative arm of the Roman Catholic Church, which oversaw Catholic doctrine) pronounced a non licere on artificial insemination in 1897, after several years of internal debate on the matter, physicians continued to practise the technique.27 By avoiding such practices, Devraigne and Dalsace hoped to bolster the case for a scientific approach to the understanding and treatment of infertility.
Both this ethos, and the substantial resources of the hospital environment, led to important advances in the diagnosis and treatment of infertility. Practitioners developed an array of laboratory techniques to diagnose and identify the cause of infertility. These included systematic methods to detect mechanical obstacles to fertilization, especially examination of the fallopian tubes (which were frequently infected). Dalsace played a significant role in introducing tubal insufflation to France, as well as contrast radiography (based on Lipiodol injections) which revealed the presence of lesions, malformations, tumours, or fibroids responsible for infertility. During the Nazi Occupation of France (1940-44), Raoul Palmer (1904-85) developed the innovative exploratory surgical technique of coelioscopy (a medical procedure for examining the abdomen, in order to directly observe and possibly treat the fallopian tubes). Finally, after researchers identified the relationship between ovulation, the menstrual cycle, and fertility capacity in the 1920s, physicians were able to bring analysis of male and female genital secretions into their array of diagnostic practices.28
As the number of laboratory techniques potentially available expanded, and the scientific status of this branch of medicine was consolidated, physicians working in infertility medicine began to face a new set of problems. Now, they not only needed consulting rooms in which to examine patients, but they had to obtain the necessary human and material resources to carry out lengthy and expensive investigations. The battery of clinical investigations - gynaecological, urological, and, increasingly, psychological - required time and money. There was also a growing need for specialized staff and equipment in the spheres of biochemistry, endocrinology, cytology, and radiology. New scientific knowledge brought the need for new kinds of practical organization: for example, the need to examine sperm immediately after ejaculation meant that ejaculate could no longer be brought from the patient’s home to the laboratory. Physicians had to find creative solutions to this restriction. Each new clinical and scientific advance in the diagnosis of infertility generated new difficulties to be overcome, without concomitant increases in funding or personnel.
There were fewer advances in therapeutic techniques in the interwar period, although the nature of the debates around the necessity, desirability, and consequences of interventions did shift. Physicians usually sought to pragmatically identify the most appropriate methods of treatment for different diagnoses. Although artificial insemination was now less often criticized for moral reasons, at least in official discourse, it was still perceived as unsafe and unpre- dictable.29 It was not until the 1950s that this practice, sometimes associated with clandestine sperm donation, was really taken seriously. Instead, it seems that in the interwar years physicians mainly attempted to ‘cure’ infertility through prescribing drugs to treat hormonal disorders or genital infections. Indeed, the most significant improvement in reproductive medicine during the 1940s was probably the introduction of antibiotics to cure both post-abortion and gonococcal infections. There were also some more radical interventions available, although physicians were often reluctant to resort to these, partly because they would deter clients. Nevertheless, surgery to remove genital obstructions was often unavoidable.30
In their publications, French physicians acknowledged that the treatment process was arduous, involving numerous unpleasant examinations and often invasive interventions, and they knew that many individuals or couples gave up before the end of the medical process. These texts constitute an indirect historical source about the experience of infertility, and the human suffering of these men and women. The gender dynamics of infertility treatment were complex. Many physicians believed that informing a man that he was permanently sterile could lead to psychological destruction, or even suicide. At the same time, one of the consequences of medical intervention in infertility was to challenge the social taboo attached to male infecundity.31 Here we see another example of the way in which medical and social attitudes to infertility were changing, but in unpredictable directions.
Physicians took great pains to statistically analyse the results of their therapeutic experiments, with the aims of both legitimating their activities and sharing their practical observations. They claimed success rates of between 10% and 20%, but often defined ‘success’ in very different ways, ranging from improved spermatogenesis to conception or birth. As a result, the ultimate significance of such statistics is never obvious. Apart from anything else, it is extremely difficult to assess whether these treatments were even successful on the terms defined by individual physicians. This perhaps demonstrates that the causes and consequences of the medicalization of reproduction cannot be fully measured using statistical approaches to the successful treatment of infertility. As several physicians have suggested, the problem is not only the effectiveness of medical activities, but also the physician’s capacity to provide care, to listen, and to convince patients of the benefits of medical processes.32 To understand the reasons for the cultural change that led men and women to seek professional help when difficulties arose, and the context in which health-seeking behaviour took place, we need to consider wider shifts in attitudes to medicine, infertility, and public health. The remainder of this chapter addresses some of these issues by examining failed attempts to create a national system of medical provision for the diagnosis and treatment of infertility from the late 1930s onwards.