The Birth of the Clinic and the Advent of Reproduction: Pregnancy,Pathology and the Medical Gaze in Modernity

Introduction

This paper explores the increasing visualization of the pregnant interior within the context of the development of modern medical discourse. ¹ The making visible the interior of the body, particularly the female body, is an extension of the 18th-century process of, as Barbara Stafford has argued in her Body Criticism, ‘making the invisible visible’ (1991/1993). The effort to medicalize the body itself involved the disappearance of the patient, with his/her list of complaints, histories, family location and emotive processes. In discussing the advances of medical research in the 19th century, Thomas Laqueur summarizes this aim: ‘The power of the anatomical-pathological model … lay in its capacity to strip away individual differences, affective and material, so as to perceive the essence of health or disease in organ tissues. The autopsy, not the interview, was the moment of truth’ (1990/1992: 188). As I will argue, the efforts to make the interior of the pregnant body visible followed a similar trajectory. As pregnancy increasingly came under the surveillance of the medical gaze in modernity, the aims of medicine in relation to the sick body were increasingly used in studying the pregnant body. In the 19th century, this led to an overlap of the pregnant with the pathological. From its inception as a standardized form of knowledge with a universal aim, the language of medical science has sought to be voice of the body without interference from the patient; this was true in both studies of pathology and in the gradual medicalization of pregnancy.

I am particularly concerned, in this paper, to explore the increased visualization of the fetus in modern pregnancy. As many feminist scholars have argued, the visualization of the fetus carries with it the risk of the elision of the mother’s body in visual culture. ² As I will argue, the increased visualization of the bodily interior, in medical discourse, ties pathology and pregnancy together as interior processes, read through the signs on the body. The innovations of 20th-century medical imaging technologies, on the one hand, reinforce this link; on the other hand, pregnancy in the late 20th century is increasingly divorced from pathology, insofar as there is a ‘norm’ created for pregnancy that opposes pathology. ³

In my reading of the pregnant body, I employ Foucault’s Birth of the Clinic (1973/1994) as a guiding template for discussing pregnancy, pathology, and visualization. First, I will demonstrate how the pregnant body functions as the absent and yet central figure in Foucault’s drama of the emergence of the medical gaze in forensic pathology. In this demonstration, I will argue that the pregnant body is the corpse’s double, a double which, like the corpse, retains the secret of life in its tissues and functions. Second, I will use Foucault’s tracing of the medical gaze in order to demonstrate the overlap between pregnancy and pathology in terms of reading bodily signs: the clinical gaze represents a fundamental shift in how bodily signs were interpreted, between early and later modernity. In explicating this reading of the interior, I will demonstrate how the overlap between pregnancy and pathology affected medical understandings of pregnancy; in essence, there was a conceptual shift in early modernity from pregnancy as generation to pregnancy as reproduction, but this was always incomplete, precisely because of this overlap. Third, I will discuss the impact of visualizing pregnancy in the 20th century, particularly in relation to surveillance, and the implications of this reading for feminist theory, insofar as the surveillance of the pregnant body is not only a question of controlling women’s reproduction, but also a fundamental component in understanding modern femininity as it is experienced by women. The gendered aspects of sex as a biological construct revealed by feminist and queer theory authors is one of the most important areas of current scholarship; no longer the overlay of socially constructed behaviors onto biological material, gender is now thoroughly understood as having figured in biological constructs from the 18th century on, that is, from the inception of biology as a distinct form of knowledge. ⁴

The development of the procedures of the medical gaze has been best described by Michel Foucault in The Birth of the Clinic (1973/1994) while his The Order of Things (1970/1994) describes the epistemological shifts of early modernity that led to the development of biology (among other disciplines) as a form of knowledge. From a body with permeable boundaries and moving, humorous organs, the modern medical body came to be understood as a collection of overlapping systems, each of which had its place and purpose within the living organism. The medical gaze with which we are familiar, particularly its manifestations in imaging technology, has its roots not only in advances in technology, but in the modern epistemological arrangement of the body and the birth of biology as the study of life. With regard to the Clinic, I am arguing that the female reproductive subject, though barely mentioned, is in fact at the heart of this text, and its centrality affects the overall feminization of the modern medical subject. The modern medical body is from its inception figured as a site of interior knowledge that must be excavated in order to be made functional; the metaphorical matter on which this operation is performed is female. In his The Body Emblazoned, Jonathan Sawday (1995/1996) argues that the anatomized body in early modern Europe is feminine, insofar as the female body serves as the figurative terrain to be partitioned and scrutinized in anatomy, in blazon poetry and in colonization. In reading the Clinic, I am making the claim that the dead body, whose interior processes are mapped, calculated and systematized, serves as a double for the pregnant body, and the methods used to make the dead body an object of knowledge are another version of medicine’s effort to do the same regarding the female body in its capacity for conception.

Foucault’s hugely influential Birth of the Clinic traces the development of the modern clinical gaze, a gaze that emerged from comparative pathological anatomy in Revolutionary France. In doing so, Foucault describes changes in the relationship between sight and representation in western medicine; that is, the gaze of the clinician became the privileged reader of the medical body, and the body of the patient became the epistemological terrain on which the new theories of ‘life’ were founded.

Foucault repeatedly uses the term ‘life’ in the Clinic, and in The Order of Things, with no mention of the social and cultural metaphors that linked women in particular to ‘life’ in very specific ways throughout the 19th and 20th centuries. Although the ‘life’ described in the Clinic is an automated function, one with no specific connection to particular bodies (or even human bodies, for that matter), I cannot help but suspect that Foucault’s choice of this term indicates something about the bodies that he is describing. In particular, the corpse that is central to the drama of the clinical gaze reads as a maternal body. Alice E. Adams (1994) has also deduced this. She points out that the metaphors used in the Clinic are maternal, and that the body opened to the clinical gaze is a pregnant body. In particular, she highlights a passage from the Clinic to explain the relationship between the corpse and the pregnant body:

Foucault says in Birth of the Clinic that at the dawn of the modern medicine, death– ‘the great analyst’ – ‘bursts open the wonders of genesis in the rigors of decomposition’. He writes, ‘The slow, natural death of the old man resumes in inverse direction the development of life in the child, in the embryo’. Death … recapitulates the events of gestation in reverse order. (1994: 136)

The next sentence in the Clinic is a quote from Bichat: ‘The state of the animal that natural death annihilates is close to that in which it found itself inside its mother, and even to that of the vegetable that lives only within itself and for whom all nature is silent’ (Foucault, 1973/1994: 143). The maternal metaphor being used is Bichat’s own, which Foucault employs in order to describe the workings of the clinical gaze: this is a gaze that seeks life within death, and the origin of that life in the death of the body. This metaphor governs the anatomists' project even before the emergence of a properly clinical gaze. As Jonathan Sawday (1995/1996) has argued, the anatomists of early modernity feminized the corpse in the very act of opening and investigating its interior. Further, this investigation had the character of an exploration, thus linking the feminizing anatomy project to global exploration and conquest. ⁵

In my own reading of the maternal metaphor in the Clinic, I focus on a different passage, one that links pathology and pregnancy in explicit ways. This link demonstrates the overlap between pregnancy and pathology in terms of reading bodily signs. That is, the signs of the interior of the body were interpreted quite differently in early modernity; using pregnancy as an example of this interpretation, we can discern how the pregnant body became legible in modern medicine as both overlapping with, and yet distinct from, the pathological body.

The Birth of the Clinic: Foucault Reads the Clinical Gaze

The production of signs manifests the body in Foucault as both visible and decipherable. Visibility and legibility are the same in The Birth of the Clinic, in that what appears to the clinician is produced by his inquiry. Instead of presenting the practitioner with a bewildering array of symptoms which must be classified according to established categories in the old nosological tradition (much like the old zoological tradition of categorizing species on the basis of particular external similarities, as Foucault describes in The Order of Things), the body available to Foucault’s clinical gaze offers legible signs of its interior processes. These various signs are elements or signifiers in a new discursive form for medicine. This form then allows the elements to be compared, differentiated and combined in order to produce a diagnosis.

Foucault (1973/1994) compares the older system of classifying illnesses to that of portraiture, which is based on the exhaustive and compiled description of minute details, descriptions which, when added together, compose a complete illustration of a disease. In the emerging clinical method, this pictorial means of diagnosis gives way to a reading of the particular processes of the body designated as signifiers. These might include temperature, pulse, and breathing rates, so a high fever, irregular pulse and labored breathing would be signs of the underlying presence of disease, now made visible through this reading of the body’s processes. Because the signs of disease are now simply irregularities in the general signs of the body, a norm of the healthy body is thereby produced. A sick body is simply a deviation from the norm. The clinical gaze does not simply diagnose on the basis of what is immediately visible; it is a form of seeing in which sight and language are one and the same. The sick body is no longer a pictogram which must be recognized and classified; instead, it speaks to the practitioner through a perfectly legible code of physical signs. The very basis of medicine shifts from a pictorial paradigm to a visual one based on the rules of discourse. As Foucault argues, ‘Beneath a gaze that is sensitive to difference, simultaneity or succession, and frequency, the symptom therefore becomes a sign – a spontaneously differential operation, devoted to totality and to memory’ (1973/1994: 94). The symptom is no longer a detail of a portrait: it is a sign which, in tandem with others, allows the disease to announce itself through the normal operations of the body. As Lisa Cartwright argues, the modern medical gaze involves a ‘change on the relationship between representations and things … Whereas the grid of natural history brought living beings to full knowledge, biological representation seeks to get at what cannot be seen in a process that makes all the more evident the disjuncture between representation and “object”’ (1993: 10).

Just as disease comes to be figured as variation in the state of health of the body, death is also refigured as a physical variation of its own. Anatomical studies repositioned death in medical discourse as a new terrain on which the origins and functions of life could be discovered. No longer simply opposed to life, or considered the absence of life, death in medical knowledge takes on new value as the condition under which pathology and its operations may be rooted out and followed. The clinical method of determining constants and variables in health and disease is taken up in anatomy studies, in which dissected body parts are broken down into elemental ‘tissues'. These elemental tissues then form the basis of the various systems of the organism, such as the pulmonary system, the digestive system, and so on. Relations between the systems may be traced by following the course of the disease through the dead body; one can discover a relation between the heart and the lungs based on the lesions common to both in pulmonary disease, for example. In other words, medical discourse begins to follow a structural model, whereby the singularity of the parts is elided in favor of their relationships and functions.

In anatomy studies, the body provides a wealth of information on the location and progress of disease: where did the lesion take root, what effect did it have on multiple organs and tissues, what form did it take in its movement? Anatomical studies adopt the clinical method in this new language of medicine, offering to the gaze the ability to trace the organic processes of the body by charting the development of disease through its elemental units. As Foucault notes, pathology makes visible the systems of the body because these are its means of growth: ‘Anatomy could become pathological only insofar as the pathological spontaneously anatomizes. Disease is an autopsy in the darkness of the body, dissection alive’ (1973/1994: 131). This marks the birth of localization; what was once a general condition or array of symptoms with no unifying organization is now a deviation from the general state of health that has as its starting point a specific place in the body and a specific course of development. Foucault is describing the general paradigm for understanding how the body works in order to diagnose its complaints: from a pictogram to be recognized, to a language to be deciphered, to a visual discourse of the body’s operations, in which healthy, sick, and dead bodies become points on a continuum, rather than states which are absolutely opposed to one another. The use of corpses in anatomy studies, from the 13th century through the Renaissance, which Sawday has characterized as ‘the anatomizing age’, testifies to this ongoing dependence on the dead body for information regarding the living, though previously this had been used mainly to either bolster Galenic theories of physiology ⁶ or to establish the basis of gross anatomy rather than secondary organization of the body’s systems.

Life in Foucault

As Foucault argues, life itself came to be the governing ideology of medicine in the 19th century, replacing that of nature. The epistemological shift from nature and its categories to that of life with its processes and systems with specific functions produced a modern body with a purpose: to defend itself against death and disease, and to reproduce. ⁷

Foucault mentions pregnancy as an example of a bodily state whose signs must be deciphered in early modernity, but it does not figure largely in his later descriptions of the anatomical-clinical methods and the changes they wrought. There are obvious reasons for this: pregnancy may require a diagnosis but it is not a pathology, and the clinician who discovers it knows well what the outcome will, or should, be. Additionally, the relationship between the interior processes of the body and pathology is an intimate one, as Foucault is at pains to demonstrate; the one yields an image of the other. The same is not true for pregnancy, which comes to be localized and fixed in one particular system.

However, by reading the pathological body as a double for the pregnant body, we can begin to understand the impact of the clinical gaze, and its focus on pathology, on the changes in how pregnant bodies were read in the 19th century. The importance of the relations between tissues, the new purposes of the body that were assigned on the basis of their processes, the increasing importance of the visibility of the interior of the body, and the assignment of the ‘seat of origin’ in diagnosis, were all factors in the modernization of pregnancy. The effort to ‘fix’ the seat of pathology mimics the effort to ‘fix’ the moment of conception and the role of the female body in gestation, an effort that was the subject of raging debates through early modern Europe, and continued through the 20th century. ⁸ The fluidity of the early modern maternal body, which might mark its child, was subject to emotional storms that endangered the fetus, and contained the womb, an organ understood as ‘animal’ and passionate, would eventually come to be anchored in a discourse that allowed no room for the autonomy or will of an organ, nor for the supposed powers of the maternal imagination. ⁹ Instead, the reproductive system in late modernity came to be rooted in an automated functionality whose mechanized workings characterized not just the body that contained them but the purpose of being female in general. ¹⁰

In the next passage, pregnancy is described as another example of the language of the interiority of the body. The diagnosis of pregnancy in the 17th century is illustrated by Foucault as another example of how calculation played a role in recognizing the portrait of conception:

Thus the certainty of pregnancy in a woman may be divided into eight degrees: the disappearance of menstruation; nausea and vomiting in the first month; an increase in the size of the womb in the second month; a much greater increase of the womb in the third month; the extension of the womb over the pubic bones; the projection of the whole hypogastric region in the fifth month and the spontaneous movement of the foetus, which kicks against the internal surface of the womb; lastly, at the beginning of the last month, the movements of tossing and displacing. Each of these signs, therefore, carries within itself one eighth of certainty; the succession of the first four constitutes a half-certainty. (Foucault, 1973/1994: 104)

For Foucault, then, pregnancy in itself is subject to the same diagnostic conditions as pathological states, but does not in itself require explanation in terms of understanding the female body under the medical gaze or the language that it speaks. However, this desire to read the signs of pregnancy casts the pregnant body in the same mold as that of the pathological, as an interior density that requires a reading.

Pregnancy and Fluidity in the Early Modern Female Body

Pregnancy has undergone radical changes in the last few centuries, accompanied by the emergence of the fetus as a subject of medical knowledge. These developments have been brought to a head with the use of technologies such as ultrasound and amniocentesis, but their epistemological roots can be traced to early modernity, prior to the era that Foucault describes. Indeed, as Adrian Wilson argues, ‘the medicalization of childbirth came too early’ (1995: 5) in relation to Foucault’s medical gaze. ¹¹ The medical gaze that at once describes, breaks down, compares, calculates and predicts pathology attempted to do the same for conception. A crucial difference is that where pathology spreads and moves throughout the body, pregnancy was fixed in one system, and the uterus, which had an earlier tendency to wander, was anchored in one place.

We are now conditioned to recognize the absence of menses as a sign of conception, now considered an absolute event. It has either occurred or it has not: one is either pregnant or one is not. This view of pregnancy is radically dissimilar from its predecessors, in which the absence of menses did not necessarily signal conception, and pregnancy did not guarantee the birth of a child. In particular, the retention of the menses was in itself a cause of disease, often understood as the surplus or ‘bad’ blood which was normally expunged by the female body (Renne and van de Walle, 2001: 12). ¹² As we have seen from Foucault’s above paragraph, the diagnosis of pregnancy was not given until the body had completed its appearance as a portrait of the condition. Instead, the mature female body was caught up in a fluctuating series of symptoms and aberrations, which might include false pregnancy, menstrual retention, internal disorder, and changes in body parts. As Foucault argues, these fluctuations lent themselves to interpretation on the basis of probability, in which each detail was added to the others in order to build up the portrait of pregnancy; in this older version, the absence of menses is no more or less important than the extension of the womb.

That pregnancy became an absolute state that signaled the isolated event of conception can also be traced to the importance of localization in modern medicine. The diagnosis of particular diseases, for example, can only be determined through the discovery of their seat of origin in the body. Before that, the signs of disease, such as coughing or fever, can indicate ill health but cannot specify the exact nature of the affliction. Pathology is reduced by anatomical studies from a series of complaints and signs to a point of origin, the ‘seat’ of the disease which then spreads itself throughout the body via points of contact. As Foucault notes, ‘It [assignment of origin] is directed towards the future of the disease rather than to its past; the seat [of the disease] is the point from which the pathological organization radiates. Not the final cause, but the original site’ (1973/1994: 140).

Obviously early moderns understood pregnancy as taking place within the womb. But the increasing specificity of bodily operations lent itself to a more circumscribed understanding of pregnancy, when nausea, vomiting, and so on became side-effects of conception, rather than part of a general array of symptoms. Conception was tied to a specific set of organs and a particular system in the body, even though this system, and particularly the work of ovulation, was not thoroughly subject to medicalization until the 20th century. ¹³ The erratic movement of pathology through the body became legible through localization; simultaneously, pregnancy was fixed and contained, tied to the female reproductive organs which no longer capriciously romped through the female form, ¹⁴ but were tied to a specific place and, indeed, a specific purpose.

As Gail Paster notes in The Body Embarrassed (1993), the very distinction between pregnancy and pathology was not made in early modernity, and the one was easily mistaken for the other. In early modernity, the menses were understood as obeying a cycle, but that cycle was part of the larger circuit of blood that the menses supposedly relieved. The menses cleansed and purged the female body of impurities that were not solely related to the reproductive system, which had yet to be isolated. The female body was impure because it required this cleansing, not because it was capable of reproduction. The technique of bleeding the sick was part and parcel of this philosophy. Illness was often attributed to bad blood. Blood could be agitated by strong emotion, it could collect at various points of the body, which must then be drained, it could spread sickness from one area to another (Duden, 1991). Menstruation figured as an example of the imprecision and fluidity of the female body; a halt in the cycle might signal conception, or it could indicate stagnation, the blood having stilled for mysterious reasons. As van de Walle (in Renne and van de Walle, 2001) has argued in her analysis of ancient Greek authors of medicine, menstrual retention was extremely dangerous, and was understood as the cause of many illnesses, rather than being the symptom of some underlying condition.

According to Barbara Duden, early moderns in Germany did not refer to miscarriages as such until after the third or fourth month of term; prior to this, they were referred to as ‘cleansings', in which the expulsion of blood, growths or ‘molas' was interpreted as a sign of recovering health. Indeed, should a woman stagnate with little or no indication to the practitioner that a healthy pregnancy was under way, she might be given an expulsive prescription in order to purify the womb. Duden has ample evidence that many women requested this remedy from their local doctors.

The fluid interior of the female body lent itself to beliefs concerning the impressionable nature of the fetus; it might be physically marked by the strong emotions or experiences of the mother. ¹⁵ The pregnant body was a porous space where not only substance but event could make its mark on the ‘fruit’ within. And, like a fleshy mirror, signs on the mother’s body could be read as indications of whether or not that fruit were present and, if so, what its nature might be. The list of how to determine the sex of a child from signs on the pregnant body, for example, is extensive. The only sign of pregnancy that was universally accepted among early moderns was that of ‘quickening’, when a woman reported feeling the child within her move. This is a fundamentally different sign from the ones recognized in modern medicine for two main reasons. One, it relied on internal sensation rather than visibility. Two, as it was not visible and could not be ‘read’, the authoritative voice in pregnancy was that of the woman herself. ¹⁶

Pregnancy and the Clinical Gaze

By employing the work of Foucault, we can ascertain that the anatomical-clinical method isolated and contained bodily systems, in that organs and processes were assigned a proper place from which they might interact with other bodily functions but from which they would not deviate or interfere with the others. The lesions that appear on the heart do not appear on the ovaries; the pulmonary system does not take part in reproduction. Obviously this does not mean that heart disease cannot affect pregnancy. What it does mean is that specific organs and systems have specific purposes that they carry out in order to sustain the organism.

One effect of localization on the pregnant body was to isolate and contain both reproduction and the systems that worked to sustain it; from this moment on, generation changed to reproduction. As Laqueur notes in his Making Sex, ‘The word reproduction came to be distinguished from the older term generation only during the course of the nineteenth century, when the production of new parts of individuals (regeneration) was understood as fundamentally different from the making of new individuals' (1990/1992: 285). From here, the reproductive organs could be considered the defining organs of the female body. At the same time, the female body becomes a container for these organs, their carrier, as it were. Pregnancy was no longer the fruitful potential of the fluid female body; instead it was the result of the mechanical operations of a functioning system. Emily Martin’s (1987/1989) reading of 20th-century gynecological texts that present the uterus as a muscle or machine exemplifies the results of this process. The result was twofold. On the one hand, pregnancy and reproduction can be considered separately from the female body. ¹⁷ On the other, the female body was specified solely on the basis of its role in reproduction; other considerations or factors of the female body are secondary or merely effects of this role.

Just as the pulmonary system evolved through a series of observations of relations between bodily elements and their networks, the reproductive system in human females evolves as a motivated aspect of physicality. Other systems and factors in being female exist in order to support it. That birth occurs in healthy women differs from the new modern perspective that the purpose of the female body is to reproduce the species. Menstruation is no longer a general aspect of being female; it is a sign that the female reproductive system is at work. When that sign disappears, the modern interpretation is that something has taken place in that system.

While the life of disease and the life of the patient are embedded in one another, the life of the mother and that of the fetus is more complex. Pregnancy may cause the demise of the mother, and the fetus in turn is at the mercy of the body which carries it. While it is clear from the theory of the impressionable nature of the fetus (that of ‘mother’s marks') that the pregnant woman was potentially dangerous to the ‘fruit’ within her in early modern Europe, it is also evident that the fetus was capable of endangering the mother. It was, as Gelis describes, a creature of nature and therefore potentially alien to the body in which it grew. Difficult deliveries were often blamed on the child: ‘When the labor did not proceed normally, the entourage was indeed tempted to seek a cause for this. … The readymade culprit was the child: it was accused of having made a bad job of its “dive”, or of being too lazy and making no effort to set its mother free’ (Gelis, 1991: 230). Although pregnant women were given plenty of advice in terms of protecting the child from their own bodies, ¹⁸ there was an accompanying belief that the fetus had a nature all its own.

As stated earlier, the only sure sign of early modern pregnancy that was collectively recognized was the report of a quickening. Quickening relies on internal sensation, available solely to the women themselves. As Mary Fissell (2004) argues, male writers of 17th-century England made the pregnant body an object of male speculation and discussion in popular print, marking a dramatic shift in gendered attitudes towards pregnancy. Women and their desires, particularly sexual desires, became a matter of public discourse. The particularly influential Directory for Midwives of 1651 by Nicholas Culpeper cast doubt on women’s abilities to determine exactly when they had become pregnant. In this instance, the desire to ‘fix’ the moment of conception was tied to, first, changes in whose speech counted in terms of pregnancy, with male practitioners claiming a more accurate form of knowledge about generation than women. Second, women’s pregnancies became a matter of public (male) discussion, in effect setting the stage for women’s interiors to become a matter of public visibility (Fissell, 2004).

This twinning of masculine medical discussion and feminine bodily interiors developed, in England and America, into the practice of gynecology. As Ornella Moscucci (1990) makes abundantly clear, the creation of the science of gynecology in England was based on the premise that because the female body was capable of reproduction, it was subject to disease in ways that the male body was not. The isolation of the systems of the body and their assigned functions did not erase the taint of pathology from pregnancy; instead, women became pathological because they were capable of becoming pregnant. As she explains,

As part of an integrated whole, the sexual organs constantly interacted with the rest of the female organism. Both the vascular and the nervous systems were emphasized as the elements which mediated the relationship between organs, bridging the physical and the mental aspects of the female organization…Gender differences were represented in terms of a different weighting between the controlling and automatic sectors of the nervous system; while the higher intellectual faculties played the dominant role in men, an imbalance of physical over mental events was posited in women. (pp. 104–5)

Nineteenth-century gynecologists were no closer to understanding the process of conception than their predecessors. Yet, the clinical gaze that traced and explained the relationship between tissues, organs, and systems was taken up in the actual practice of natural science in order to fix women firmly in a position not only subordinate to men, but at the mercy of the reproductive system as a whole. ¹⁹

Visualizing the Fetus

The concept of the species as a general category was developed in tandem with the increasing ability to isolate and locate the individual as a variation on the universal. For Foucault, the ability to scrutinize and categorize the individual in comparison with its fellows is the crowning achievement of modern techniques of power/knowledge, and holds a distinguished place in his major works. In terms of fetal development, the ability of the modern medical gaze to monitor and isolate the fetus had traditionally been met by the obstacle of the mother’s body. No longer a porous space through which one could glimpses the ‘fruit’ within, the pregnant body from the 18th century on became a visual obstruction to a clear understanding of its internal processes.

Pregnancy was of great interest to anatomists. From Jacques Gelis's study of early modern attitudes towards pregnancy, ‘in their desire for further knowledge, surgeons seized every opportunity to perform autopsies on the corpses of aborted babies … The aim was clear: to reconstruct the chain from the first days and weeks of life to full term’ (1991: 219). The English pioneer of obstetrics William Smellie complained in 1779, ‘the modus of conception is altogether uncertain, especially in the human species, because opportunities of opening pregnant women so seldom occur’ (Laqueur, 1990/1992: 182). The modus of conception would remain invisible until the 20th century. But medical curiosity about the fetus led to the study of embryology, begun in the late 19th century.

The effort to construct the ‘chain of life’, or the process of organic human development, emerged in the late 19th century. As notes Lynne Morgan (2009), anatomist and embryologist Wilhelm His ‘began to promote the idea that human development could be understood as a sequence of demonstrable, predictable steps' (pp. 8–9, quoting Hopwood). In the United States, a student of His, Franklin Paine Mall, was instrumental in establishing a tradition of embryo-collecting, from which the visual narrative of the ‘development of life’ would emerge. The ability to visualize the fetus, to study and place it within a ‘chain’, was undertaken, but without the pregnant body at all – a point to which I will return later. ²⁰

The effort to visualize the fetus was born of a desire to clearly distinguish pregnancy from pathology; that is, to read the signs of the body without interference from the woman. ²¹ In doing so, the clinical gaze established a distinction between the woman and her pregnancy. It intensified the idea that interior states may only be read through the clinical gaze. In doing so, the clinical gaze inadvertently reinforced the overlap between pregnancy and pathology, by positioning the pregnant body as requiring a reading.

The x-ray was used on pregnant women starting in 1896, though there were dangers associated with the lengthy time of exposure. The fetus did not appear in early radiographs at all until the fetus was six weeks old, making them useless for detecting the early stages of pregnancy. The ‘rabbit test’ (in which a rabbit was injected with female human urine and then later dissected in order to ascertain changes in the ovaries, which only a pregnant woman’s hormones could cause) appeared in 1931, making visualization in detection unnecessary. X-rays were used to monitor the fetus in problematic cases until the linking of radiation with cancer and abnormal fetal development in the 1950s, which effectively ended its use on pregnant women (Kelves, 1997).

Ultrasound, the use of soundwaves to produce images, was first used to tackle another gap left by x-ray, that of the brain, which x-ray cannot penetrate. Ultrasound was not used in obstetrics until the 1950s by a Scottish doctor who set about measuring the various sizes of fetuses (already we have the appearance of the unborn being measured and compared) (Kelves, 1997). By the 1980s ultrasound was a regular practice in pregnancy, one fueled not by medical necessity but the desire of pregnant women to see their babies. Ultrasound is in some ways a perfect medium for visualizing the modern fetus because it can capture movement: it was successfully paired with real time computer technology in 1975 (Kelves, 1997). As we have seen, when ‘nature’ became ‘life’, the fetus could easily be cast as its most potent expression. Our belief in life is confirmed when its expression is in motion.

Ultrasound itself has to be read. In her Naked to the Bone: Medical Imaging in the Twentieth Century, Kelves begins her chapter on ultrasound with the story of Cecil Jacobsen, a fertility doctor who duped patients into believing they were pregnant by injecting them with a hormone that ‘imitates pregnancy on blood tests' (Kelves, 1997: 229). He then showed his patients sonograms of their ‘babies'. Kelves's point is that sonograms are difficult to decipher and require a trained eye in order to be read, an eye that knows what to look for. Rather than a transparent window into the womb, accessible to all, ultrasound is an extension of the specifically medical gaze in which sight and medical discourse are one and the same. The advancement that ultrasound represents is the ability to interpret the signs of the fetus without having to read them through the surface of the mother’s body, or relying on her testimony as an ‘unreliable source’. ²² This is the radical implication of ultrasound: not the putting of a human face on the embryo, but the ability to register the signs emitted by the embryo independently of the mother. This is in fact the ultimate aim of western medicine as regards the bodily interior: to read that interior without interference from the subject. The patient in modern medicine is only so much ‘noise’ which has the potential to block a clear reading of the body; in ultrasound, we find not only western medicine’s aim of surveying life without the maternal, but the body in general without the patient.

This entails a separation of the mother and fetus which recalls the old tradition of attributing will and intention to the unborn. We have in some ways come full circle; the fetus was, at one time, a creature of nature, announcing its presence through signs in and on the pregnant body, and whose presence could not be ascertained with certitude except by the pregnant woman herself. It later become a subject of research in the new philosophy of life and a product of the female reproductive system, but that system was still the means through which the living fetus was read and, in many ways, was subordinate to. ²³ Kelves argues, ‘Before ultrasound there was no way to see eggs, a developing embryo, or a fetus at an early stage of development. Gynecologists and obstetricians were apt to regard the fetus as a kind of uterine tumor’ (1997: 247). ²⁴ Pathology and pregnancy were still linked in the minds of some medical practitioners.

Conclusion: Medical Visualization and the Pregnant Body

By examining the ways the pregnant body was submitted to the clinical gaze in medical discourse, and so tied to reproduction as a philosophy of human species-behavior, we can see how pregnancy was positioned by medicine as both a state foreign to the body which experiences it, and the very purpose of the body capable of producing it. I here wish to conclude this paper by exploring some of the implications of these findings for modern western pregnancy, particularly in the USA.

The localization and isolation of the female reproductive system does not automatically lead to a simple reduction of this system for the body which experiences it. Instead, the entire female body comes to be caught up in this concept; the female human body is designed by and for reproduction in a way that the male is not. This has the dual effect of giving women more perceived control over reproduction (as an internal system that can be potentially monitored and controlled, although that control is tightly bound to social privilege), while at the same time rendering that system external, in that the interior of the body becomes a thing to be known, an object of a discourse that assigns that interior a place and a function in the philosophy of species-being. The bodily interior has been positioned by medical discourse as a site of mystery for some time, something to be excavated and known. The excavation for women, however, has resulted in that interior being rendered a site of public discourse. ²⁵ The stirrings of this externalization of women’s interiors begins in the 17th century, as women’s bodies become the source of public speculation and medical theory concerning women’s desires and the process of conception. ²⁶

This radical externalization is an integral component of modern biological sex. If, in Foucault’s The Order of Things (1970/1994), ‘man’ becomes external to himself through the discourses that yield ‘him’ knowledge of how ‘he’ functions, then ‘woman’ is rendered both external to herself, and yet more intimately tied to that external interiority. ‘Woman’ comes to be an alienated persona not simply because the term itself is a relative one (insofar as ‘woman’ is defined on the basis of what ‘man’ is not) but because western medical discourse produces this body in particular as both fundamentally interior (its most important purpose is buried deep inside) and, at the same time, as already explained, described, and therefore not only knowable, but a matter of public discourse. The demand for ultrasound on the part of pregnant women who choose to be mothers is also a public demand; visualizing the interior of the pregnant body is part of what Mitchell and Georges (1998) call the ‘cultural script’ that North American pregnant women are expected to follow. ²⁷

The effect of the medical gaze on the pregnant female body is to produce an experience of internal partition, not on the basis of empirical fact, but as a permanent and necessary disjunction between the experience of the body and the discourse which renders it knowable, a disjunction made all the more acute by the assigned role of the female in reproduction. ²⁸ The fetal image represents this disjuncture, insofar as it is produced as a matter of course for pregnant women, and because it is used in order to promote a bonding. That is, the discourse assumes that a visual dimension is necessary in order for a pregnant woman to be a ‘mother’, or to desire to be a mother. ²⁹ Recently, there have been extensive efforts on the part of US lawmakers to force pregnant women seeking abortions to view ultrasounds prior to the procedure (see Sack, 2010). 3D ultrasounds have been developed as a designer alternative to 2D ultrasound and are advertised as offering ‘first looks' at the fetus. ³⁰

The fetal image is here represented as a bridge, between the pregnant interior and external visualization. However, that bridge is predicated on a division, that is to say, on the assumption that the image is necessary to ‘bridge’ the gap between the pregnant woman and the fetus. The fetal image perpetuates the dialectic, or ‘contest’, between pregnant women and the clinical gaze. Just as the effort to visualize the fetus inadvertently reinforced the overlap between pregnancy and pathology, the fetal image, on the one hand, renders the bodily interior ‘knowable’. This knowledge, however, comes at a price, insofar as it further envelops the pregnant body in a visual field which requires medical interpretation, and therefore public discourse. The anatomical-clinical method requires that the female body be read in order to more firmly position it within a discourse on species-production, both the very secret heart of humanity and its alien other.