By Lukas Engelmann
What is specifically medical about medical photographs? The clinical photograph – a still image of disease symptoms – is usually considered the typical medical photograph, both historically and in the present. But if we understand the expansive archive of photographs of the third plague pandemic (1894–1959) as an integral part of the history of this genre, it takes on a different shape and invites renewed question as to how a photograph visualizes a disease in the history of medicine. I will challenge the traditional analytical frame of medical photography to question how the photographic genre incorporates images beyond those that visualize patients bearing the stigmata of disease.
The first picture for consideration was taken in 1904 at the Seamen’s Hospital in Jurujuba, Rio de Janeiro. It depicts a patient being treated for bubonic plague by clinical staff who seem to be posing with the patient, presenting his body to the camera. They represent the medical professionalism in their uniformed attendance and are presumably carrying out or staging daily tasks for the patient’s care. The patient himself is exposed with his gown positioned to offer sufficient concealment of his genitals to keep the picture decent. The picture’s focus is directed to the patient’s groin where we see an inguinal bubo, one of the characteristic symptoms of bubonic plague. The patient’s foot is held up in a helpful manner so as to demonstrate another recognizable sign in the lesion near his ankle.
One could say the picture appears in the manner of a ‘typical’ medical photograph. It has two of the classic features of medical photography at the turn of the 20th century: the representation of the medical profession at work, and the visualization and classification of a particular disease entity. Contextualized within a specific historical and geographical setting – Brazil in 1904 – this vision of medical practice is attached to an ideal of modernism in which the postcolonial national identity of the largest state in South America was committed to large sanitary campaigns. The fight against epidemics was conceived as a prominent symbol of progress, and accordingly its representations regularly shifted into triumphalist registers. Doctors were seen to be conquering the pre-modern, almost medieval world of infectious diseases. In terms of the recorded provenance of the picture, it forms part of an album created by Dr Camillo Terni in 1904, called “Studies in Plague.” A note affixed to the back of the photograph notes it as Observation No. 289, and includes a description of the patient’s typical features of plague: “simple femoral-inguinal and iliac-buboes, with plague ulcer on the instep.” Its aim, then, was to capture a characteristic appearance, and serve as a guiding representation of a disease entity to its viewer.
This second photograph was taken in 1900 in Honolulu, Hawaii. The then-famous photographer Frank Davey took it just after a devastating plague outbreak ravaged through the Chinese and Japanese quarters of the island’s capital. The photograph is one of a series. The number 215 indicates this image’s position in the series, while the numbers on the buildings refer to either legal or medical case files related perhaps to the residents of the building. This series was officially ordered by the Board of Health on Honolulu and was filed as a record of the bubonic plague in the Hawaiian State Archive. Seemingly accidentally, they provide a near-complete photographic account of a now-lost built community, as the Chinese settlements were almost completely destroyed in flames after what was supposed to be a controlled burning of a few plague-infected houses spiralled out of control. Rather than signs of plague as a disease appearing on the human body, this set of photographs shows its audience an inconspicuous scene of urban housing in 1900 Honolulu, which on face value has little to do with the epidemic.
Yet is it possible to talk about both featured images as medical photographs of plague? While the first clearly fits within popular expectations of what medical photographs should look like, the street scene from Hawaii taken out of its context seems irrelevant to the historical event of plague, and could easily be overlooked as a state photograph, an analogue prototype of Google maps for example, an artistic snapshot or a document of a crime scene. But the fact that the photograph from Hawaii was taken under order of the Board of Health changes its significance. The photographer’s intention was to demonstrate factors potentially relevant to the outbreak of plague, to capture an aspect assumed to be significant for doctors involved in containing the threat, or for the sanitary officers carrying out their work to quarantine the epidemic. Given the importance of these photographs to epidemiological prevention strategies, how could we not grant the status of a medical photograph to this kind of picture?
The ERC-research project on the “Visual Representation of the Third Plague Pandemic” (http://www.crassh.cam.ac.uk/programmes/visual-representations-of-the-third-plague-pandemic), of which my research is a part, and which is led by Christos Lynteris, has aggregated a global database of photographs of plague, and has debated the conditions and characteristics of images that can be thought to belong. Our preliminary findings suggest that clinical photographs – capturing symptoms of people with plague – constitute just a fraction of plague’s archive. Browsing the collection of over 5000 images, it is evident that the focus of doctors, epidemiologists and government officials was fixed largely on the locales, the environment and the buildings in which plague cases appeared or threatened to arrive. The photographic focus of plague images was emphatically the epidemic’s ecology.
If the pictures were to be assessed purely on the basis of their visual content, stripped of contextual information, only the first photograph can confidently be described as a medical picture. The patient’s visible lesions and the hospital setting ensure its recognition as such, regardless of time and place. To the trained eye, the symptoms might suggest a plague diagnosis; some observers might even identify the uniforms and nationality of the medical staff. Meanwhile the photograph of a Honolulu street indicates nothing specifically medical; it could have easily lost its place in history and its link to plague; just another suburban scene with buildings typical of late 19th century Hawaii.
Comparing the two photographs prompts the question if medical photographs should be defined through the medical circumstances of their production, or through recognizable signs of a disease in their visual frame. Both approaches have certain limitations but also provide benefits for historical scholarship. Focusing on the context of a picture’s production, the photographer’s intention or profession, the photograph’s arrangement, its circulation, publication and the way in which it is archived – what Elizabeth Edwards has called a photograph’s “social biography” – draws a viewer’s eye to the conditions under which a picture comes into being. The picture from Rio de Janeiro delivers an impression of the Brazilian context in which plague appeared in isolated cases, arriving through the seaport. The Hawaiian picture suggests stories of how plague was perceived once it was established in Honolulu, considered to be a problem complicated by the built environment and the unsanitary state of certain housing districts. In both cases, these photographs earn their place as medical images in the archive, embedded as pictures of plague through metadata and contextual information.
While considering the social biography of photographs and thereby broadening medical photography’s archive is exciting, we quickly encounter the problem that potentially any photograph could become medical. Private collections of landscape pictures taken by doctors could have been inspired by medical interests and agendas; photographs snapped by patients might indicate individual strategies of coping with illness. A misplaced or mis-labelled box in an archive might open new, hitherto unimagined ways of seeing a disease in its history. Focusing solely on context and the social and cultural conditions under which a photograph might be framed as medical risks such historical relativism, and the visual content of the photograph might be denied its own weight and merit. A photograph’s significance would come to rest solely in frameworks of interpretation and contextualization.
Heeding just the signs of disease and the trappings of medical institutional spaces on the surface of photographs, on the other hand, risks judging past situations with the clinical standards and expectations of the twenty-first century. Our current diagnostic routines can only take us so far with photographs of the medical past. We cannot assume that disease has always been framed and photographed in similar ways, with the same intentions (even if they share the same historical moment). Diagnostic routines do not enjoy stable forms across time and place, nor do the elements we consider today to be of significance necessarily have equal or any importance at the time of plague in Brazil. Photographs like the one from Hawaii would entirely escape our notice as components of bubonic plague history, and we would miss the dominance of these representations of plague’s ecology in the global archive of the Third Plague Pandemic. We would also lose sight of a way of seeing plague in which the clinical representation was less significant than we might have expected. Assuming stable diagnostic categories over time might obscure the local niches and historical conditions under which bubonic plague appeared – and mattered – in subtly and markedly different ways.
The work of Elisabeth Edwards can help us arrive at an understanding of medical photography beyond the limitations of seemingly mutually exclusive perspectives. Medical photography first and foremost must be viewed as a practice of medical knowledge production. Medical photographs were taken to make sense of a disease in its particular circumstances, to clarify the classification of symptoms, etiology and causes; to interrogate the theories about why a disease appeared in one place and not in another. The picture serves epidemiological and classification purposes, shows an external object and is not an object in and of itself. This ‘functional’ mode of photography embodies a constant tension between the photographer’s deliberate choices and the ways in which photographs have been used and assembled in publications, albums, archives and collections. Photographs cannot be understood as mere representations of a historical fact, nor do they demonstrate simply what they were originally intended to show. They accrue meaning. They are complicated entities in which their original purpose to capture this disease or that ecology became entangled with what they show and what was assumed to be uncertain, unusual and unknown. A disease threatens the bodily integrity of a single patient but also that of a space, an environment and a way of life, a niche in which an epidemic flourished. Consequently, Edwards argues, photographic collections should not be positioned as constituting certain facts, but as archives of uncertain knowledge.
Analysing the commonalities of our two very different photographs of plague, then, raises important questions for future research and historical analysis. Both photographs have been taken to visualize a state of affairs related to a disease that had appeared unexpectedly. Both images place the disease in relation to a particular locale: the anatomical body, and the urban social space. But neither photograph is able to make claims about how exactly this relation between disease and body/space is construed. Neither photograph hypothesises a cause for plague, only a relation, an association, an assemblage, maybe a disease ecology. But each photograph on its own is unable to disclose what is driving the relationship between disease and the body or the urban spacewhat has caused the disease to show itself on this body or in this spatial configuration. In other words, photographs leave the work of making sense of symptoms on a body or the significance of particular kinds of housing to the captions, to archives, to text accompanying the publication in which they appear about plague, so as to awaken interpretations of the observer.
Medical photographs picture what is uncertain and unusual. They show a body that has its integrity threatened, and they capture ‘infected’ alleyways. As such, photographs prompt questions by displaying fragments of the messy situation on the ground, the interruption that does not neatly fit into existing systems and categories of knowledge: the moment of uncertainty. To paraphrase George Canguilhem, who compared health to the silence and innocence of the organs, photographs in medicine might be best understood as a medium that seeks to capture the moment in which innocence has been replaced by uncertainty. Medical photographs show us a certain innocence that might be found as much on a healthy body as it can be found on an unremarkable street, an innocence that has already been lost. Knowledge of the disturbance needs to be gained in order to re-establish that kind of innocence.
I acknowledge the support of the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007-2013)/ERC Grant Agreement n.336564.
Lukas Engelmann is a historian of medicine. His PhD on the visual medical history of AIDS is the foundation for the forthcoming book AIDS Unseen and a recently published article on “Photographing AIDS”. Since May 2014, he is a post-doctoral research associate at CRASSH, working on the visual representations of plague in North and South America. Profile: http://www.crassh.cam.ac.uk/people/profile/LukasEngelmann
 Presentations of inguinal buboes, one of the common symptoms of plague, were conventionally photographed with the genitals covered. However, in some cases, decency seems to have presented less of a concern to the photographers.
 Nísia Trindade Lima, “Doctors, Social Scientists, and Backlands Peoples: Continuity and Change in Representations of Brazil’s Rural World,” Canadian Journal of Latin American and Caribbean Studies 35, no. 69 (2010): 39–67.
 Christos Lynteris, Ethnographic Plague: Configuring Disease on the Chinese-Russian Frontier (Palgrave Macmillan, 2016); Christos Lynteris, “The Prophetic Faculty of Epidemic Photography: Chinese Wet Markets and the Imagination of the Next Pandemic,” Visual Anthropology 29, no. 2 (March 14, 2016): 118–32, doi:10.1080/08949468.2016.1131484.
 Elizabeth Edwards, Raw Histories: Photographs, Anthropology and Museums (London: Bloomsbury Academic, 2001).
 Eduardo Vilela Thielen and Anthony Zineski, eds., Science Heading for the Backwoods: Images of the Expeditions Conducted by the Oswaldo Cruz Institute Scientists to the Brazilian Hinterland, 1911/1913 (Rio de Janeiro: Oswaldo Cruz Foundation, Casa de Oswaldo Cruz, 1991).
 Elizabeth Edwards, “Photographic Uncertainties: Between Evidence and Reassurance,” History and Anthropology 25, no. 2 (March 15, 2014): 171–88, doi:10.1080/02757206.2014.882834.