A letter to Professor Donald
This letter was inspired by the Early Ultrasound Scan, in the Royal College Of Physicians & Surgeons of Glasgow Archive (Catalogue number: RCPSG 65/3/1-2)
Dear Professor Donald,
When I saw the ultrasound scan, I thought of you: Ian Donald, obstetric pioneer from Glasgow. There are a few things I would like to tell you. As a pregnant patient of a recurrent miscarriage clinic, I underwent ultrasound examinations every fortnight until the twentieth week of gestation, a series of visual introductions, if you like, to a liminal life. The ultrasound suite, a place I had come to associate with dread and bad news, took on a numinous quality.
Entering the darkened room, removing my shoes, and observing silence until I heard my baby’s heartbeat, gave me the sense of partaking in something sacred, even magical. Pulling my top up, my jeans down, baring my midriff, lying on the bed, half my body now exposed, the other half draped in hospital sheets, I felt like the magician’s assistant whose role is to lie still in a box on stage, during the illusion “sawing the lady in half”. The cold gel on the ultrasound probe enabled a virtual bisection, allowing the obstetric spectators to look inside my body. I’ve since learned you used olive oil, but whatever the lubricant, before your invention Professor Donald, this view was only possible when a woman was physically cut open.
As weeks passed and my pregnancy developed, it became less comfortable to lie still on my back. During those scans, the inconvenience of my consciousness, my involuntary acts of breathing, the small movements I made when shifting from an uncomfortable position to a more comfortable one, seemed to irritate the sonographer and slowed down her work of scanning. When I was chastened, reminded to lie still, to hold my breath until instructed to exhale, I imagined my sisters: the unconscious women who lay perfectly and conveniently still, cadaverous or under anaesthesia while their uterus and foetus were cut out and then preserved in pickling jars in museums of pathology.
Too dramatic? Don’t you agree, Professor Donald, that there is a theatrical aspect to the ultrasound examination? It begins with entering the dimly lit room, taking centre-stage on the examining couch, and continues with the ritual drawing back of the concertina-folded curtains surrounding the bed, and culminates in the audience of parents and professionals gazing at the screen. The dimmed, cinematic lighting serves as a further invitation to project hopes and plans for the unborn onto the image on the screen.
In order to better understand the significance of ultrasound in mediating my feelings towards my body and towards my unborn child, I read about you, Professor Donald. I learned that in the 1950s, you left your post as an obstetric senior registrar and reader in a prestigious London teaching hospital and took up a consultant post in Glasgow, where it was your ambition to build a new maternity hospital. During the Second World War, you had been drafted into the Royal Air Force. Your bravery was mentioned in Dispatches. Before the war, you had invented a paediatric respirator.
Mere months after taking up the new chair in Glasgow, working with the engineer Tom Brown, you adapted the reflection of high-frequency sound waves known as ultrasound, from a technology that was used to detect industrial flaws in deep-sea submarines, and used it to examine the uterine contents of pregnant women. For the first time, a foetus was visible while still growing inside her mother.
In your paper in the Lancet (1958), now lauded as a medical classic, you describe clinical ultrasound imaging that involves bouncing sound waves above the audible range of human hearing, at human tissues, and detecting the echoes that bounce back. Those echoes are used to make the now-familiar monochrome images of foetuses that sparked my maternal fantasies. I don’t think, Professor, that it’s just me who feels this way. Women posting first-trimester ultrasounds on Facebook write, “I’m having a baby”. Nobody is gestating a ball of cells, or even a foetus. Your sonar made us mothers-in-waiting. But your invention took something from us too, and that’s why I am writing to you. After your invention, the mystery of a pregnant woman’s body became a medically interesting case, subject to ultrasonic-scrutiny. The once-sacred maternal site became a site of medical enquiry.
I don’t think that you had malign intentions. Your development was one of the most important discoveries in obstetrics and you wanted to make the care of pregnant women safer. By visualising the unborn conceptus, you hoped to be alerted early to factors that might cause difficulty during birth, for example: the position of the placenta, the lie of the baby, and signs which might indicate a foetus in distress, whose life could be saved by being delivered prematurely by caesarean section.
As a patient of the recurrent miscarriage clinic, I was grateful for your safety net. I was surprised to learn that even when frequent ultrasound scanning is the only medical intervention in a high-risk pregnancy, the chances of miscarriage diminish. Could you have foreseen that, Professor Donald? Frequent ultrasonic surveillance is literally lifesaving, for mothers and their unborn children.
Did you consider though, when you wrote the Lancet paper, that the material products of your surveillance, the scan images, would be seen in the context of each woman’s visual cultural background? When I saw my own ultrasound images, there was something uncanny about seeing an immortalised infant, illuminated by a single shaft of light from the omniscient ultrasound probe. In some of my images, the light forms a kind of halo around the head, where the sound waves have bounced off the foetal skull bone. In the sixteenth century, there was a proliferation of nativity scenes, known as adoration paintings, perhaps most famously exemplified by The Adoration of the Kings, by Pieter Bruegel the Elder, heralding the arrival of new life, new hope, and a new story unfurling. These paintings are clearly of an infant of significance, illuminated in a single shaft of light that appears to come from above, in some paintings forming an obvious halo, in others just the faint suggestion of one. Adoration paintings persist in reproductions on cards arriving during Christmastide, fluttering through the letterboxes of even secular households. The nativity tableau is one of the first pieces of theatre that most British children perform. Nursery nativity plays, where the infant-King is deified, are a rite of passage.
In this particular cultural context, it ought not to surprise you that for many British women, their small prints of ultrasound images become cherished icons of life. These are the pictures that a woman waits for, in those twelve nail-biting weeks before the so-called “dating scan”, living in that limbo of socially-undeclared pregnancy, a state of expectant-expecting.
Did you imagine, Professor Donald, that your invention would result in a significant shift in clinical focus? Your development of routine obstetric ultrasound offered a new testimony of pregnancy, replacing the woman’s story of her changing body. The obstetric gaze which had been sharply focussed, certainly in early pregnancy, on the woman is now an embryo-centric gaze, leaving pregnant women in the shadows. Your ultrasound probe turns the art of obstetric care into a discipline guided by visualising technology that inevitably separates the foetus from her mother.
In the obstetric-maternal power dynamic, ultrasound is a high-stakes intervention. For medical professionals, clinical ultrasound is now seen as more valid and less prone to error than women’s clinical histories. It is in the scanning room that authority, including authority over the woman’s body, is channelled by custom, including the custom of calculating the baby’s estimated due date from ultrasonographic measurements, even when this estimate is in conflict with the mother’s account of her date of conception. According to my “dating scan”, I conceived on a date when my husband and I were in different countries. When I suggested my scan-informed date may be incorrect, I was told, “we always go by the scan dates, not by the woman’s. An ultrasound scan is inevitably more accurate.” The scanning room became a space where the performance of medical power was enacted. My knowledge was afforded no lines in my obstetric record. A mother, in the ultrasonic context, is a voyeur.
The technical ability that you pioneered to visualise an ultrasonographic image of a foetus is entangled with other ethical complexities. How much thought did you give to this? You were, by all accounts, an active and outspoken pro-life campaigner. Professor Geoffrey Chamberlain, former professor and academic head of the department of obstetrics and gynaecology at St George’s Hospital, London, who at the time of writing was Editor-in-Chief of the British Journal of Obstetrics and Gynaecology and president of the Royal College of Obstetricians and Gynaecologists wrote:
Donald was selfish for all he believed in, and fought valiantly for it. Others could write of the strongly held Christian faith of the man and how it ruled his culture and attitudes to contraception and abortion and the battles this led him into.
Professor Donald, you must have known that seeing foetal images had the potential to evoke maternal emotions. Instead of using this realisation to benefit women, you used it to advance moral arguments against abortion and contraception. What a complex legacy. Your repurposed military kit was used to suppress women’s agency over our own bodies and you sought to limit our reproductive choices. Ever since ultrasound became widespread in the 1980s, campaigners from the pro-life movement have demonstrated outside abortion clinics with foetal images. These campaigners co-opt clinical images as political propaganda props.
And yet, despite my anger about this, I also feel a debt of gratitude. Your invention was a physically intimate experience, but also a socially transfigurative one. After many miscarriages, I first saw my daughter as a foetal pole on an ultrasound scan at four weeks gestation, one Christmas Eve. Your sonar made me an eyewitness to her existence. Carrying her not only inside my body, but also on a monochrome printout in my bag, gave her a materiality of her own. As my due date drew closer, I felt that I knew her.
For all these gains in maternal knowledge, don’t you find it ironic that your development has seen the proof of pregnancy shift from the woman’s embodied sense of quickening, to the technological assessment of a viable foetus? A woman in contemporary Britain is not able to declare herself pregnant to primary health care services without first proving her claim with a positive pregnancy test, or by lying still to be probed in a darkened room, so that an ultrasonically-generated image of her embryo or foetus can be produced. This shift increases the risk that an expectant mother’s account of her body is discounted or disregarded. Too many women die in childbirth, too many babies die during birth, despite your efforts to make obstetrics safer. In the inquiries into maternal deaths and stillbirths, there is a tragic, recurring theme: clinicians need to listen to pregnant women. Your colleagues forget, sometimes, that the scanned uterus also has a head, a voice, a maternal instinct.
I’d like to impress on you, and on all who use your sonar, that the image women see on ultrasound changes our lives. The heartbeat we don’t hear in ultrasound rooms is a silence that we hear forever. While your ultrasound image gives vital scientific information to clinicians, it also scaffolds women’s fantasies of mothering, giving our feelings strength and durability. Ultrasound shapes maternal desires and, mysteriously, magically, mediates maternal-foetal emotional bonds, including grief for those scanned with stilled hearts.
Thank you for conveying this to all who use your invention.
Yours sincerely,
An Obstetric Ultrasound Patient
Image credits: Labour and birth, Heather Spears, by kind permission from the Wellcome Collection, London
Works consulted:
Bunduki, Victor, Marcelo Zugaib. “Neural Tube Defects.” In Atlas of Fetal Ultrasound, V. Bunduki and M. Zugaib. New York: Springer, 2018.
Chamberlain, Geoffrey. “Ian Donald: a Memoir.” Journal of the Royal Society of Medicine 98, no. 3 (2005): 133.
Deborah, Kirklin. “The role of medical imaging in the abortion debate.” Journal of Medical Ethics 30 (2004): 426.
Donald, Ian, MacVicar John, Brown Thomas. “Investigation of abdominal masses by pulsed ultrasound.” Lancet 1 (1958): 1188–95.
Fraiberg, Selma, Edna Adelson, Vivian Shapiro. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships.” Journal of the American Academy of Child Psychiatry 14, no. 3 (1975): 387-421.
Rose, Gillian. Visual Methodologies: An Introduction to Researching with Visual Materials. 3rd ed. London ; Thousand Oaks, Calif: SAGE, 2012.
Winnicott, Donald W. Babies and their Mothers. London: Free Association Books, 1988.
—–. “(1952) Letter to Roger Money-Kyrle, 27th November.” In The Spontaneous Gesture : Selected Letters of D.W. Winnicott. Edited by Robert Rodman. London: Karnac Books, 1999.