If a woman experienced poor reproductive outcomes, then it was assumed that she had lived a pre-pregnant lifestyle not conducive with healthful reproduction. In another 1824 article in the New England Journal of Medicine and Surgery, a physician recounted an experience with a woman who had an early spontaneous abortion. Reporting that “her health was not very good at any time, and had not improved during her pregnancy,”21 the physician explained that to treat a spontaneous abortion is also to treat “the patient before a second conception”—that is, in this physician’s view, the times between reproductive events blended together and should be seen as preventive care in preparation for the next (healthier) time.22 The nineteenth-century medical literature was peppered with these types of assessments of general pre-pregnancy health and ideas about how to intervene medically. Physicians were puzzled when healthy women experienced poor reproductive outcomes, tying such events to lifestyle and moral behavior.
In another medical article on spontaneous abortion, for example, a physician tried to explain how such an event could happen in women who seem otherwise very healthy. The physician attributed spontaneous abortion to life choices that were made in the pre-pregnancy phase, arguing that sometimes these women “are married late in life; have been luxurious livers . . . [and] have good health.”23 The physician conjectured that this variety of abortion belongs to a type in which “the general health is too good for healthy pregnancy.”24 In this appraisal, top-notch pre-pregnancy health actually could be detrimental—some white women’s life of luxury had not situated them well for motherhood, but it was all in the service of expositing what was deemed “proper” pre-pregnancy lifestyles. Physicians thus were clearly enamored with women’s lifestyle choices such as age at marriage and first pregnancy—likening any desires that deviated from early marriage and motherhood as potentially damaging to their future reproductive outcomes.
Physicians also were interested in whether certain physiological reproductive risks were present during the pre-pregnancy period. In 1887, writing about a rare case of a pregnancy taking place within a uterus that had structural abnormalities, a physician discussed the patient’s reproductive history prior to her pregnancy and emphasized the idea that the uterine position was likely laterally flexed prior to pregnancy, which of course was not diagnosed prior to the pregnancy.25 In accounts of Bright’s disease from the same time, physicians accentuated that having the condition prior to pregnancy exacerbated the seriousness of disease during pregnancy.26 Similarly, the cause of a case of puerperal eclampsia was “probably from an endometriosis existing prior to conception.”27 In 1895, in a piece on metritis (inflammation of uterine wall) as a cause of miscarriage, a physician highlighted that treatments might be best before pregnancy, writing, “As to the treatment, I may say at once that it is very difficult to treat an endometritis as long as pregnancy is going on. The only good practice is the preventive treatment which is undertaken when the uterine cavity is empty in cases in which an inflammation of the uterine mucosa has occurred before the pregnancy or when it has already produced miscarriages.”28 In many of these instances, physicians mentioned how pre-pregnancy care might have helped the woman’s circumstances, but there was no organized idea about proper medical care prior to conception. Pre-pregnancy health discussions were rather mostly reflective of general concerns over women’s social behaviors leading up to marriage and motherhood as well as speculations about physiological abnormalities prior to pregnancy that might pose medical risks to a woman’s reproductive capacity and future reproductive outcomes. Discussions over venereal diseases serve as good examples of just how intermingled were the worlds of social concern and medical concern, of social policy and ideas about reproductive health care interventions. The following section briefly considers the prolific medical literature on syphilis as illustrative.
VENEREAL DISEASE AS AN EARLY HUB OF
PRE-PREGNANCY DISCOURSE
Syphilis was a public-health menace around the turn of the twentieth century. A common topic in the medical literature regarding the potential health of future offspring, syphilis was usually discussed vis-à-vis social and moral interventions as well as medical interventions. One article by Abner Post in an 1889 issue of the Boston Medical and Surgical Journal was titled “Some Considerations Concerning Syphilis and Marriage” and asked the question of whether two syphilitics should marry and, by extension, reproduce. For the man in question, Post’s answer was that nothing would be worsened because he was already syphilitic, but for the woman the concern was about future pregnancies. Post’s answer to syphilitic couples wanting to conceive was to wait until they experience two full years of symptom-free living, at which point he also prescribed a course of mercury treatment before conception.29 Dr. Post’s recommendation served as an early example of a precise pre-pregnancy medical intervention.
In 1912, the article “Epitome of Current Medical Literature” in the British Medical Journal discussed a case of syphilis in terms of its “conceptional” basis, highlighting the prophylactic promise of “preconceptional treatment” with regard to syphilis to produce “healthy children and to avoid conceptional infection of the wife.”30 In one of the first medical mentions of a pre-pregnancy “treatment regime,” the focus remained on both the maternal and paternal influences on the quality of the conceptus. In fact, much of the literature on syphilis focused on men and their responsibilities. Many physicians in the nineteenth century accepted Colles’s Law, which posited that syphilis was passed from sperm to fetus, completely bypassing the mother.31
The pre-pregnancy discussions around syphilis and other “conditions” were concerned mostly with leading a “proper lifestyle” and with social concerns endemic to the pre-pregnancy period, such as marital fidelity or the spread of sexually transmitted disease. In his history of venereal disease, historian Allan Brandt notes that “these themes had particular resonance for American physicians, who were already concerned about the future of the family.”32 Many physicians during this time who were concerned about how venereal diseases were impacting the family allied with the eugenics movement, seeing venereal diseases as impacting the future of “the race.”33 Indeed, declining birth rates of whites were seen as a sign of the demise of American values, and reproductive matters were front and center not only for public health purposes but also for population concerns. Many states passed “eugenic marriage laws” whereby only the prospective husband had to undergo a physician assessment and “receive a certification of health”34 before getting married and thus, presumably, before procreating. Near the turn of the twentieth century, physicians thus believed it was in their province—as both medical and moral leaders—to advise patients against entering into “hasty marriages.”35
Thomas Parran, surgeon general under Franklin Delano Roosevelt, further sought to make venereal disease a national concern, and pre-pregnancy interventions were at the forefront of his agenda. One of Parran’s suggestions included mandatory blood tests prior to marriage as well as in early pregnancy.36 Beginning with Connecticut in 1935, as Brandt recounts, in many states a premarital blood test became a standard requirement for a couple prior to obtaining a marriage license.37 In Connecticut in particular, if either the bride or groom was found to be infected, the couple had to wait—sometime years—before procuring a marriage license, until the said individual was found to be infection free,38 a process that certainly reflected government