The above image, dating from 1831, is a diagram of a vaginal speculum designed and manufactured by John Weiss, a well-known maker of surgical instruments in London in the 18th and 19th centuries. The company in fact still operates to this day. Intended for direct vision of the cervix via the vagina, the first vaginal specula were used by the ancient Greeks and Romans.[1] However, the invention of the ‘modern’ speculum that is familiar to us today is largely credited to the American James Marion Sims, a well-known gynaecologist in the 19th century.
Specula vary in their design and the material used, depending on their intended use, whether it be in the operating theatre or in the examination room. The most common style of speculum that is used in the vagina is the bivalved speculum, in which the two blades are hinged and are ‘closed’ when the speculum is inserted to facilitate its entry and ‘opened’ in its final position, where they can be held open by a screw mechanism, so that the user’s hands are free to perform other tasks.[2] While perhaps more heavy and industrial-looking than their modern-day counterparts, these mid-19th century specula appear to be based on similar basic design principles to 20th and 21st century versions. Perhaps the most striking difference, however, is that modern versions usually have two blades, not three. Also, according to the description of the version pictured above, one should turn the handle in order to open the blades of the instrument, rather than there being a screw mechanism to do so.
Thomas R Mitchell, author of Practical remarks on the use of the speculum in the treatment of diseases of females, which was published in 1849, describes several different variations on specula design that were available at the time, of which ‘some are very ingenious’.[3] He describes, for example, one design which ‘consists of five blades, which are made to dilate by means of a string attached to a central peg’,[4] and another ‘furnished with an air cushion of bladder or the crop of a fowl, to facilitate its introduction’.[5] Described in the front matter of the book as a Fellow and Licentiate of the Royal College of Surgeons in Ireland and as a lecturer in midwifery, Mitchell considers the speculum to be nothing short of revolutionary in terms of its impact on the sphere of women’s health. He writes, ‘I look upon the introduction of the Speculum into general practise, as one of the greatest improvements in the treatment of disease since the discovery of the stethoscope’.[6] Indeed, he implies that the speculum is nothing short of life-saving since, prior to its invention, he writes, ‘many went to the grave with the seat of disease undiscovered’.[7]
However, for many of Mitchell’s contemporaries, the potential to preserve life was far outweighed by the moral implications of the instrument’s use. The anonymous author of The speculum: its moral tendencies, writes that he believes ‘the workmanship of the Creator to be as perfect now as of yore, and that the modern and multitudinous disorders attributed to the uterine system are wicked inventions, put forth to sanction unnecessary interferences’.[8] For some, the idea of men being allowed to view women’s vaginas in any capacity was a social abomination that was symptomatic of a morally degenerate society. The author of Hints to husbands: a revelation of the man-midwife’s mysteries, for example, deplores the practice of ‘man-midwifery’ and aims in his writing to ‘fearlessly unveil and drag into the light its indecent mysteries’.[9]
In taking such a tone of outraged morality, these two authors transgress the perception of the clinician as an objective observer. The implication is that men are deriving private enjoyment from viewing female genitalia, under the guise of performing medical examinations. This view completely subverts the ideal of the ‘clinical gaze’ as described by Michel Foucault. Foucault writes of the attempts ‘on the part of clinical thought to define its methods and scientific norms’,[10]over which ‘hovers the great myth of a pure Gaze that would be pure Language: a speaking eye. It would scan the entire hospital field, taking in and gathering together each of the singular events that occurred within it.’[11] This gaze would be ‘turned into speech that states and teaches; the truth’.[12] In short, this speaking eye ‘would be the servant of things and the master of truth’.[13] If the clinical gaze is to be realised, for the benefit of medical and scientific knowledge, then the physician – who, in a historical context was usually male – must in a sense become an impassive observer, immune to sexual desire when viewing a woman’s genitalia. In effect, the female patient must become an object to the male observer (the physician). The speculum facilitates this transition since, by its appearance it is clear that the instrument is, first and foremost, designed for the doctor’s easy access, and less concern is given to the patient’s comfort. It enables the user to directly view and examine inside the vagina without the need for digital insertion, distancing the physician from the body of the patient and transforming it into a clinical specimen. The benefits of this to the progression of women’s healthcare are clear, however, the ‘clinical gaze’ as described by Foucault rouses some problematic issues relating to the operation of medical culture within patriarchal society.
If the clinical gaze in one sense is beneficial for women in removing a layer of morality from the observation of their bodies and allowing hitherto ‘hidden’ disease to be uncovered, in another sense it can be understood that the ‘medical gaze of the professional, taken to be the true source of medical knowledge, has consistently been privileged over the voice of the patient’.[14] This suggests that the power resides with the physician, rather than the patient. This view can be seen as stemming primarily from the fact that medicine is a male-dominated profession, therefore, in an gynaecological examination setting, it is likely to be a male doctor observing a female patient. A pure Foucauldian ‘clinical gaze’ may debatably be the ideal in attempting to advance medical science, but in practice it can be argued that in the patient examination setting, the clinical gaze merely upholds the power imbalance between the genders that underlies patriarchal society. Taking the speculum as symbolic of this, we can see that the instrument’s usefulness and value lies in its ability to increase men’s knowledge of women’s bodies. As Kaspalis writes, the speculum is another example of male power over women, making ‘visible the inner recesses of the female body, just as the telescope enabled a view of the outer depths of space’.[15] In Kaspalis’s view, ‘the speculum was like a compass in that it helped guide the physician into this unknown terrain. In this rhetorical construction, the female body is metaphorically produced as raw natural territory awaiting discovery and cultivation by the hands of male medical culture.’[16] The implication of this is that the examination of women’s bodies by men serves only the purpose of increasing men’s knowledge and therefore power, reducing the female patient’s body to a passive resource awaiting exploitation.
The speculum as an historical object is interesting in that it raises a number of questions around issues of women’s health and the fact that, worldwide, this is still an area where more research and knowledge is needed, particularly in some developing countries. It is true that many lives have been saved through the use of the speculum, particularly in detecting cervical cancer through the introduction of cervical screening programmes, which are part of many healthcare systems in countries in the west. However, there are wider cultural and social issues at play that make the issue more complex. First, in the tone of moral outrage adopted by some commentators in the 19th century who saw the use of the speculum as indicative of a morally corrupt society. It is notable that, in both examples presented (The speculum: its moral tendencies and Hints to husbands: a revelation of the man-midwife’s mysteries) the authors are both male, again reducing the female patient to a silent, passive object. Second, the imbalance of power in the examination setting between the doctor and patient can be seen as reflecting the gender imbalance in society at large. In effect, the speculum represents an object that perpetuates gender inequality in its intended use as a means by which to view the female as an object, thereby facilitating the ‘clinical gaze’, which by default equates to the ‘male gaze’. As an object of historical interest, therefore, the speculum carries the weight of complex social and cultural concerns, making its an analysis crucial to an understanding, not only of the history of medicine, but to the advancement of women’s healthcare in the future.
[1] Ralph Jackson, ‘Roman doctors and their instruments: recent research into ancient practice’, Journal of Roman Archaeology, 3 (1990), pp. 5–27 (p.9)
[2] Marion Edward Clark, Diseases of women, (Democrat Print, Kirksville, 1901), p. 68
[3] Thomas R Mitchell, Practical remarks on the use of the speculum in the treatment of diseases of females, (Fannin, Dublin, 1849), p. 13
[4] Mitchell, p. 13
[5] Mitchell, p. 13
[6] Mitchell, p. 11
[7] Mitchell, p. 12
[8] A Fellow of the Royal College of Surgeons, The speculum: its moral tendencies, (Bosworth and Harrison, London, 1857), p. 5–6
[9] George Morant, Hints to husbands: a revelation of the man-midwife’s mysteries, (Simpkin Marshall & Co, London, 1857), p. 5
[10] Michel Foucault, The Birth of the Clinic, (Taylor and Francis, Oxford, 1989), p. 140
[11] Foucault, p. 140–141
[12] Foucault, p. 141
[13] Foucault, p. 141
[14] Kirsti Malterud, Lucy Candib, Lorraine Code, ‘Responsible and responsive knowing in medical diagnosis: the medical gaze revisited’, Nordic Journal of Feminist and Gender Research, 12.1 (2004), pp. 8–19 (p.8)
[15] Terri Kapsalis, Public privates: Performing gynecology from both ends of the speculum, (Duke University Press, Durham and London, 1997), p. 39
[16] Kapsalis, p. 39
