Albert Londe: radiographie d’une main sexdigitaire (x-ray of a sexdigital hand), aristotype, 17 x 11 cm, 1898. [X]

PICTURING THE PATIENT

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The Patient Record in Archives

I use the term patient photograph, as opposed to medical photograph to not only center the experience of the patient but to include all photographs taken of them. In this piece, I define medical photography as those not including the patient, such as photographs of physicians, medical equipment, or the buildings in which they operated. The impetus behind this paper lies in the thousands of patient-photographs that exist in archives with the impossibility to know what consent was given in the creation and dissemination of these images. Even photographs that record the mundane, daily life of patients in hospitals should be a source of archival care, as we begin to understand that consent of the sick cannot be taken for granted. Moreover, I would like this paper to illuminate the need to do history from the bottom-up, in which we situate the patient’s voice at the helm of our work.

Archivists (and earlier, historians) have naturally written on the unique sphere medical records hold in archives, though little has been said directly on their photographic collections. The first archival-specific scholarship seems to have begun as early as the 1960s, with historian Phillip D. Jordan noticing a growing interest in the history of medicine. Jordan calls for archivists to keep “the papers of nurses, dentists, researchers, and technicians” in a wide array of topics, such as mental health, disability, and indigenous affairs. Medical historian John B. Blake identically asks for archivists to preserve the documents of “at least some inconspicuous men” of their respective localities a few years later, as he noticed that the field of medical history was gaining interest with the public. He urges the archivist to understand “the potential value of medical records” in order “to help the innocent and floundering medical historian.” Later archivists, such as Barbara L. Craig finally address the medical photograph, writing briefly of their importance as documents of “long-term value”, while Nancy McCall and Lisa Mix write (perhaps a touch too removed) that “photographs of patients and specimens [are] a significant part of documentation.” Archival scholar Jeffrey Mifflin was the first to synthesize the true extent (and headache) of the archivist’s interaction with medical records, specifically its photography. Mifflin notes the often complicated custodial history, where “in hospitals, the survival of historical medical photography often depended on the efforts of committed individuals, usually doctors with historical interests, instead of organized institutional commitments.” These collections, like other long-forgotten documents, are usually unearthed in “neglected storage closets, tucked behind file cabinets, or hanging on walls.” Naturally, this disarray destroys the archival bond. According to Mifflin, this lost context can be rediscovered through studying the hospital’s past practices, but for the lone archivist, this act is undeniably time-consuming.

The Records Life Cycle

To understand the context of records that are relevant to these proposed privacy concerns, one may look at the frameworks of either the record life-cycle or continuum model. These two recordkeeping models attempt to understand and chart the existence of a record, from beginning to end. The life-cycle record relies on the natural metaphor of a linear birth, life, and death, while the latter takes a less sequential, more amorphous model based on time, space, and user-need.

Just as any other record-making body, medical establishments do not have the room to store every record they have created. Medical photograhphy today is largely for clinical use, taken for patient notes and securely stored with modern privacy laws in place, following the “birth” and “life” metaphor of the records model. With standard disposition and retention schedules ensuring these photographs are destroyed (“death”), some are innevitably saved for the archive (“the afterlife”).

Discussion by archivists about patient records have generally been about this in-between stage in the record life cycle. While no longer held by hospitals, archives that take documents containing private patient information must follow the appropriate laws in place. In Canada, the United States, and Great Britain, these privacy laws generally follow 20 years after the death of individual in the document, or if unknown, 100 years after its creation. This paper is interested when these privacy laws expire, and how archivists deal with sensitive patient images when they are no longer forced to by law.

History of Patient-Photography

The history of medical photography begins almost exactly in tandem with the history of photography itself. Due to its chemical foundation, mamy of the first photographers were themselves scientists and physicians, well-to-do men interested in the new technology that could further their field and their own understanding of the world. Owing to relative ease of sight, early photographs of patients usually documented malformations of the body and conditions of the skin. Psychiatric photography began with the nineteenth-century belief that mental conditions could be identifiable by the physiognomy of the patient, with the first psychiatrist to do so in earnest the British psychiatrist Dr. Hugh Welch Diamond. A founding member of the Royal Photographic Society, Welch published the paper “On the Application of Photography to Physiognomic and Mental Phenomena of Insanity” in 1856, arguing that his photographs could not only help in patient treatment but also “furnish a permanent record for medical guidance and physiognomic anlysis.” Thereafter, it was common for psychiatric patients to have a photograph taken of them at intake, an impulse from the tangential criminal mugshot (in order to see the criminal physiognomy) that began to become common industrial societies. Photographs of medical establishments began to be used in earnest for public-health initiatives starting in the early 1880s, furthering Progressive Era virtues and creating a new genre extolling the mental and physical architecture of new hospitals. This coincided with the advent of dry-plate photography by Dr. Richard Maddox, a physician frustrated with the cumbersome processes hitherto at his disposal. No longer bound to the sub-ten minutes between collodion-pouring, exposure, and development necessary for wet-plate pictures, the dry-plate could be bought and stored for later use, exposed wherever the photographer wished and developed whenever they returned to their studio. Physicians and scientists continued to be at the forefront of photographic advancement: much like life today, as these tools grew easier and easier to use, the photograph became more and more ubiquitous.

History of Photographic Objectivity

The photograph, since its first creation, has been noted for its “truth.” The epistemic virtues of the photograph lie for its readers in the mechanical, almost relentless documentation the camera and silver ions can capture. For theorists and semioticians, the photograph is a unique plain of depiction: this particular visual language is a message without a code. “What does the photograph transmit?” Barthes asks, “by definition, the scene itself, the literal reality.” In this, signified and signifier melt into a unique transparent phenomenon, where the viewer literally sees the physical world through the photograph. Even modern theorists can only admit that these conditions of truth are easier to fulfill than any other medium.

For most of the nineteenth century, the working sensitivity to light was incredibly low to film speeds possible later; wet-collodion plates, when shot today, are metered as an ISO of 1 (for comparison, the lowest nitrate film speed one can buy today sits at around 50). The lower the sensitivity to light, the smaller the silver halide grains that catch the light must be, in effect making the image sharper. Rather than viewing a grainy photograph, as we may expect from film photography today, the image is almost mirror-like.

In 1844, scientist William Henry Fox Talbot published the first book with photographs as illustrations. Entitled The Pencil of Nature, Talbot introduced the fist of six small volumes to his audience as something that had “been formed or depicted by optical and chemical means alone, and without the aid of any one acquainted with the art of drawing.” The title, a skeuomorphic, ironic reference to the lack of pencil, anticipated the concern with his salted paper prints—a photographic method made independently but concurrently of Daguerre but less detailed than the other man’s silver-plate process. Writing that the prints “will doubtless be brought much nearer to perfection; [...] both for completeness of detail and correctness of perspective,” Talbot attempted to assuage the viewer's concern for their less-than-perfect look. From the photograph’s inception then, the desire—almost need—for the most detailed, “accurate” image was necessary for correct use of the medium. Concerns of Talbot’s process would naturally come from technical improvement. To the nineteenth-century scientific mind then, to understand the photographic image was to submit fully to its mechanical pregnancy.

The truth-telling perceptions of medical photography can be traced to the history of scientific objectivity itself, beginning in the mid-nineteenth century (once again) from the creation of photography itself. Prior to the advent of photography, the expectation of the scientific image was the drawn and illustrated atlas. Artists labored to either find or collate an ideal specimen in which to teach others, coined by Daston and Galison as a “truth-to-nature” approach to scientific epistemology. After the camera, a strain of “hands-free” (mechanical) objectivity began to infect the scientific community. Scientific objectivity required the medical photographer to refrain from smuggling in “their own aesthetic and theoretical preferences” in order to guard itself against an attack of subjectivity, the persona non grata of science.

The proliferation of this idea abounds in medical texts involving photography during the period. A small article in The Lancet documents the language surrounding medical photography in the late 1850s, writing that:

“PHOTOGRAPHY is so essentially the Art of Truth—and the representative of Truth in Art—that it would seem to be the essential means of reproducing all forms and structures of which science seeks for the delineation. … [The Artist] draws the ideal rather than the actual. The great solar artist has no such preconceived notions, and invariably represents things to us as they are.”

By 1893, the photograph’s objective properties were solidified. Albert Londe, a photographer tasked with creating a studio within the female hysteric ward at la Salpêtrière hospital in Paris for especial ease of image-making, introduces the gains made in the field without even having to mention the idea of reality or truth. In the preface of his how-to manual for other medical photographers, Londe instead opts to simply praise the mechanical wonder at their fingertips: “qu’elle est devenue entre les mains [...] un merveilleux instrument de recherches et d’études”

Art historian John Tagg has written extensively on the growth of the evidentiary properties of photographs in the nineteenth century, arguing that the rise of industrialization created the perfect ecosystem for a society to privilege the power of truth to “mechanical means.” To Tagg, photography only functions “as a means of a record and a source of evidence” because the society says so. Regardless, photography furnished a chemical and scientifically sound “proof” predicated on the body as an object.

To this day, despite our prolific encounters with doctored or even AI images, seeing is still largely believing.

Unique Ethical Questions

The difficult history of medicine, when paired with the evidentiary properties of photographs, therefore pose difficult ethical concerns for the archivist. In looking for answers, the natural inclination is to parse Sontag—whose popular criticisms of both the photograph and illness seem tailor-made for questions such as this. Indeed, Sontag asks if only individuals “with the right to look at images of suffering of this extreme order are those who could do something to alleviate it—say, the surgeons at the military hospital where the photograph was taken—or those who could learn from it.” It is here we cross the ethical dilemma: one must either look or not—one must either be complicit or a coward. Thus established on the plane of objectification inherent to the medium, the patients in the photographs are “reduced to their powerlessness” from the very thing it wishes to capture: the illness. For Sontag (and even more so, Barthes), difficult photography cannot truly be ethically (see: accuratley) consumed. The transparency which creates image can can only be undercut, in part, by the inclusion of a caption: There cannot be “a dent in public opinion unless there is an appropriate context of feeling and attitude.” I am inclined to agree. When “the powerless are not named in the captions,” a photograph becomes complicit, in part, of the sin of inaction.

Photographer and theorist Allan Sekula has argued that photography of this nature resides in the “shadow archive”—a theoretical medical and juridical archive of the nineteenth century, held up by the “two tightly entwined branches” of physiognomy and phrenology. This archive relies almost entirely on the human body, and what is not, relies on the material infrastructure to retrieve the photographic data. The materials that make up the “shadow archive” are there in order to “see” the inner characteristics of the host, as photography was uniquely primed to see this body, as discussed earlier. Sekula references a letter by early Daguerre champion, statesmen François Arago, admiring that photography was a medium “in which objects preserve mathematically their forms.” Photography was thus a means of systematic scientification—to reduce all parts of the (sick) human body into a mathematical code with not only the potential to cure, but to also pathologize. While objectification occurred on the primal plane of these rhetoric, the camera (and its evidence) supplied the material building blocks of their theories. Archival objects of this kind then, which were made to be part of the mathematical and pathological “shadow archive” consequently carry a unique burden of care.

Further complicating matters, the bulk of medical photographs that we are attempting to protect (and the ones that arouse the most indignation) are, by law, over a hundred years old. Not only are the patients at the center of these records long gone, but the hospitals, just like any establishment, are prone to closure. This fact is overwhelmingly true with long-term sanitoria and psychiatric hospitals, the former entirely closing from medical breakthroughs and the latter from the late-twentieth century push for “deinstitutionalization.” The former sites of these photographs have either been revitalized into apartments, upscale hotels, or simply demolished after being left to deteriorate for decades. These buildings, a kind of synecdoche for the medical past in general, have become sites of mythology, horror, and distrust—not attributes unfortunately without merit, either. This occurrence has complicated the pursuit of humanization within these photographs, as yet another layer of objectification must be picked away in order to see the patient as human. We must contend with the cognitive dissonance that the nineteenth and twentieth centuries were a time of great medical achievements, a hopeful time where allopathic medicine began to gain the trust of the public, but that ultimately, the very patients it purported to help were easily sacrificed on that same bloody altar called “progress”.

As we parse the layered issues surrounding caring for patient-photography, we also face the issue of user-access. Should photographs, as a unique, transparent evidentiary record, always be available digitally? How do we ensure that users engage with these artifacts in a way that limits re-objectification, and how do we care for these experiences when the law no longer requires it? Medical art historian Suzannah Biernoff has tackled the ethical concerns raised in the changing context of viewing medical images, be it through art, museum, or even in research materials supplied by the archivist. Biernoff looks at the issue of this complicated photographic afterlife through the oeuvre of the WWI plastic surgeon Harold Gillies, whose often unsettling work has been reawakened in recent years through its inclusion in open-access online databases, art exhibitions, and even horror video games. She writes of the discomfort of the many questions that rise from showing her students these images, asking: “How will my students respond: with pity? With disgust? Fascination? Should I name the patient, or protect his anonymity? Would he, or his relatives, want the photograph to be shown in a non-medical context?” The author’s questions are answered in part from looking at the history surrounding their taking. Photographs of such profound facial disfigurements were not to be seen by the wider public; the potential effect on morale was too dangerous for the still-fighting soldiers and their families back home. Biernoff ultimately suggests that patient images “are one such frontier: an ethical borderland in which legal definitions of privacy, personhood and human rights compete with the contemporary politics of witnessing, memory and memorialisation.”

Art historian Susan Sidlauskas has likewise answered these questions by bringing up the nuanced context of care that occurs when patient photography is read accurately. Comparing the relatively non-objectified photographs within the casebooks for middle-class, short-term psychiatric patients from Holloway Sanatorium to other, more distressing patient portraits from sanitariums in the surrounding area, Sidlauskas argues that the original intent of dissemination, the role the patient had in their staging, and the accompanying context in which the photograph is held are both contributing factors in how to appropriately care for these images.

But even following these recommendations, cracks start to show. Some of the famous hysteria patient-photos of Albert Londe, with a graceful beauty and created with the precise objective to publish around the world, check these boxes at first glance; it is obvious to anyone who has learned the history of their creation though that they demand particular care. Londe took advantage of the jail-like institutionalization the patients could not leave, and the autonomy these women had in front of the camera (deduced from both personal reports and the overly glamorized images that left the studio) was still coerced: a fellow neurologist of Charcot admitted that not only were favors given to prime patient-actresses, but that their performances saved them from being transferred to the recesses of “incurables,” without a hope of leaving. As a testament to this photographic jail, Augustine, the most celebrated and photographed of Charcot’s teenage hysterics, ultimately escaped the Salpêtrière, after being sent to solitary confinement after refusing to perform her illness for live audiences and the camera.

Perhaps the most holistic approach, and the one most prescient to archivists, is to acknowledge and set-out to remedy the trauma that resides within the images. While most apparent in the faces of patients suffering from post-traumatic stress or on the pathologized body forced into undress, we must also remember the covered faces, cropped and diseased ligaments, and mundane posings that don’t immediately ask us to extend humanizing principles. Consent in the documentation of their bodies, except for clear cases such as at Holloway, cannot be assumed. Literature abounds on the unique surveillance-state of the hospital. Having experienced institutionalization myself, the floundering sense of self amid a necessarily sterile and watchful environment is taxing, regardless if it is a “good” or “bad” hospital. For the good it has done for me, I cannot pretend that the psychic stress of simply not being free did not affect me, nor can anyone I have spoken to about this shared experience.

When we speak of a trauma-informed archive then, we thus recognize the power-structure inherent to the creation of these images. It was the doctors and their photographers who overwhelmingly commissioned these photographs, without the need of patient consent. While photographs exist of mundane interior scenes, the trepidation of the chloroformed, half-naked patient ready for surgery in a crowded operating theater exist, as does the child’s face, destroyed beyond recognition from the effects of syphilis, not so much staring at the camera but gaping (for there are no eyes left to look). Patients, doomed to die (or close enough to), from the very parts of their body the camera celebrated.

I don’t intend to list off the various horrors sitting in archival boxes around the world: thousands of public-domain, antique photographs pulled from nameless publications are available today online as proof of this. The nineteenth-century fascination with the pathological certainly emphasized the teratological, but more importantly, I wish to speak on behalf of a holistic approach in caring for these photographs. As we become aware of the role of archives today as both memory-keeper, identify-finder, and community-builder. Rather than strictly being bastions of truth and evidence, the Jenkinsonian paradigm of the neutral truth keeper must sit alongside the growing expectation of archives as a repository of memory. Individuals, such as myself, who see themselves in the patient record and have used them for both emotional healing (from the experience of having a relatively rare illness) and material healing (when presenting these records to doctors for help in diagnosing) deserve to celebrate and solidify this new archival frontier.

What Is Being Done

The complicated issues surrounding the archival treatment of patient photography have begun to be discussed in recent years. Two of the first to recognize the important role medical and patient photographs play in its evidentiary properties, and to notice its bias in the archival record, were the archivist Barbara Craig and historian Gordon Dodds in 1980. Noting the fragmentary nature of photographs, as well as the inclination to use them “as catchy illustrations for texts,” Craig and Dodds set out to arrange 48 photos of Ontario hospitals, clinics, and health-services as “independent documents supported by captions.” The article, while broadly successful and important for starting the discussion at hand, nevertheless fails at proper patient-centering, particularly with the most uncomfortable images. An innocuous photograph of a physician with his clerk and a medical student posed in a well-to-do room fill 201 words; a photograph of two androgynous bodies with their chests (breasts?) bare, faces covered, somehow only inspire eight. Another photo, of a young body plastered with facial bandages not dissimilar to the photographs of WWI soldiers, eeks out only twelve, only mentioning that the figure is a boy, and that the bed had been donated. These instances of overt photographic objectification ideally need much more support than given by the pair, but are nevertheless an important starting point for material change. A similar, though stronger conclusion was made by the archivist Jeffrey Mifflin in 2007. Mifflin recreated the Craig and Dodds exercise with medical photography, this time lengthening the captions in his pursuit of ensuring the most historically-accurate contextualization.

Perhaps the most prescient work to look at then is with the archivists discussing radical empathy when working with traumatic records within the field. Michelle Caswell and Marika Cifor have proposed a feminist ethics approach to archival responsibility, a model in which “archivists are seen as caregivers, bound to records creators, subjects, users, and communities through a web of mutual affective responsibility.” This responsibility is borne from the idea of radical empathy, a learned practice in which an individual seeks to understand another through acknowledging their shared humanity and consequently into that other’s emotional and rational mind. Radical empathy’s emphasis on understanding others' emotions opens the doors to treating patient photography with more care, as the archivist’s role of record caretaker would ensure a human touch is still answering the ethical questions before us. Caswell and Cifor’s proposal that “takes bodies and the bodily into account” also speaks directly to the objectification of the patient’s body inherent in the photographic medium, centering the ethical crisis at hand and allowing the archivist an ample framework to support the records effectively.

A similar conclusion is made in Lorrain Dong’s 2015 dissertation, which looked at the social ecologies of records from a black psychiatric hospital in the American south. Using the framework of the actor-network theory, Dong concludes that medical records demand archival activism, as “the records are not so much tools but objects imbued with power, meaning, and agency” that is far “greater than the intentions or efforts of their human creators.” Specifically citing issues with private patient information, Dong suggests that archives that wish to have records digitized for online access have “portals” to ensure that both laws and ethical concerns are enacted.

Archives with sensitive photographic records have been slow to acknowledge the need for additional care. On a preliminary look, most medical archive collections do not have an access policy regarding patient records past the law required in their country. The American National Institute of Health’s (NIH) online collection has no discernable measures in place to place in context sensitive patient images: a simple search will reveal harrowing patient drawings and uncomfortable images of psychiatric patients with largely no contextual information available. Similar gaps in distressing content can be found on the online database for Archives Canada, especially regarding indigenous patients.

The best attempts I have come across to answer these ethical dilemmas come from the Manitoba Indigenous Tuberculosis History Project and the Wellcome Collection in London. The Manitoba Indigenous Tuberculosis History Project began in late 2019 “dedicated to the preservation, interpretation, and dissemination of” the thousands of photographs. Documenting the segregated TB hospitals for indigenous patients in Manitoba, the project operates a website and social media where images are regularly posted for survivors to aid in identifying. Moreover, the project’s website contains resources for individuals that may experience retraumatization, and actively centers the goal of reconciliation and healing. The Wellcome Collection, a British museum and library, has wide-ranging acknowledgment and guidelines for accessing sensitive content available to view on their website. Operating on seven different access levels, the images I have spoken about would mostly be under “open with advisory,” the second of the seven in order of severity. This level includes documents with “distressing or offensive content,” such as gore, nudity, people in severe pain, and corpses. For its online collection, one must click through an advisory warning, and download and licensing options are limited.

A non-medical imaging online collection I have found to treat sensitive information with care are the online repositories of the Tuol Sleng Genocide Museum, an archive working with a similar mission to the MITHP of identifying the thousands of images of murdered Khmer Rouge prisoners. Tuo Sleng does not allow users to view images “that could cause harm or embarrassment including images of torture, naked bodies and/or death” without providing “the reason why they are interested in seeing the full text of the restricted document(s).” Users that are permitted are then given expanded log-in credentials.

As we work to care for patient-photography, we must also recognize the institutional betrayal in medicine that still occurs within the medical field, and must anticipate the user’s needs to the best of our ability. To this day, many people’s institutionalized experience is a source of at least some psychic pain, if not trauma. In a similar vein, being aware of the potential of retraumatization, both for archivists themselves and their users has begun to be discussed. In creating a trauma-informed archive, we recognize then that there are multiplicitous sources of medical trauma that are inherent to not only the medicalized user but within the records themselves. Unbound by time but connected in experience, as the role of archives transforms into a repository of healing, our responsibility must too.

What More Can Be Done?

In the complicated balancing act of knowledge and censorship, we, as archivists, researchers, and humans must contend with the fact that many of these images were not made with the intention to be widely distributed, let alone openly accessible to view on a computer screen to anyone with an internet connection. Even those created to be published require the same empathetic model of care, as there is no way to know what consent patients had over the creation and dissemination of the images made from their bodies. As we have seen, art historians and cultural critics have the time and ability to write about the kind of images we as archivists may store, it’s our job to listen to them and try and reflect the lost context to anyone who wishes to interact with them.

I propose that, at the very least, at the highest level of description possible to make known not only the history behind these images creation but also the ethical concerns at hand. The language in the description should center the patient’s experience and have resources in place to address potential user discomfort. Online repositories that decide to digitize their sensitive photographs should have (if even minor) barriers in place for the most egregious, such as information click-through and/or required log-in credentials. Downloads should be limited. Institutions should have access and liscensing guidelines outlining issues of sensitivity at the discretion of their collections.

Just as archivists, “the photographer was thought to be an acute but non-interfering observer.” As still often the privileged first-stop between historians and their research, caring for the patient photograph is also a place to push back, no matter how subtly, on medical historians that do not center patient-humanity. Prior to 1900, medical history was largely written by the physicians themselves. Recent medical historiographic scholarship has singled out the “medical photograph” to be used in scholarship in order to “offer visualizations of unusualness and uncertainty.” As lamented in the 1859 Lancet article, patient and medical photography has been relegated to the spheres (and history) of medicine rather than the history of the photograph—and in doing so has escaped the Derridean potential for justice. It is a historical distortion to believe medical history begins and ends with the words of the practitioners: in more eloquent terms, “it takes two to make a medical encounter—the sick person as well as the doctor.”

As we tend to the orphaned photographic canon that has “sat uncomfortably between art and science,” stuck with a dehuminizing illness and a medium happy to objectify it, we must become—for their body’s first time—their caretakers.

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Around the world, archives hold the remnants of patient-photography. While the goriest of these have been the subject of wonderful and intense study by art and cultural critics alike, the archival responsibility within the field has been largely neglected. Images of patients from decades—or even centuries before—when viewed today frequently excite, disgust, and engender anxiety, often at the expense of the patient's full humanity. This phenomenon, I argue, is from the loss of original context, in which researchers (both professional and laymen) are at the mercy of archives without the grounding information that created these images. In trying to (re)create a more robust context for patient photographs, archivists should incorporate the methods of radical empathy and trauma-informed care for the sensitive collections that they steward.