Dit artikel heeft als onderwerp de conventies in de medische fotografie, vanaf haar ontstaan 150 jaar geleden. Er wordt op gewezen dat juist de foto's die lijken te breken met deze conventies, zeer nuttig kunnen worden voor de geschiedschrijver van de geneeskunde. Vooral foto's van medische ingrepen die bedoeld waren voor een breder publiek van niet-professionals tonen vaak niet de medische activiteiten die de meeste tijd en energie vergen in de moderne geneeskunde, met name de behandeling van chronische aandoeningen. Foto's kunnen nuttig zijn bij het bestuderen van de spanning tussen de gezondheidszorgpolitiek en de dagelijkse geneeskundige praktijk.
Photographs of doctors and their patients began to be taken from the time of the invention of photography 150 years ago. Most people in medicine are aware of photographs of medicine but do not usually look at them closely. Photographs are so familiar to us that unless they are very special to us personally, we assume we know what is in them. Only a few people analyze photographs as documents that help to understand how people lived in the past or what is important to them in the present.
Please recall photographs of medical scenes that have been published in books of history or in articles about the history of medicine in journals such as this one. I would wager that some would see images of surgery (figure 1) or of gowned surgeons surrounding a patient who can hardly be seen. Others will recall images of patients, often of children in hospital beds, with a nurse standing nearby (figure 2). If the picture is old, it will have beds in rows, in a ward, with several nurses standing by (figure 3). Still others will recall snapshots of groups of doctors or nurses who trained or worked in the same hospital.
What is being recalled are what historians and critics of photographs call the conventions of medical photography. All means of representation use conventions: standard ways of communicating, for example, the conventions by which research reports in medical journals are constructed. Everybody knows the common division into abstract, problem statement, literature review, methodology, data presentation, discussion and conclusion. Knowing these conventions enables one to read quickly and critically.
What are the conventions of medical photography? They are such matters as where the photographer stands in relation to the subjects, how much light and darkness are acceptable, how the subjects of the picture sit, stand or move in relationship to each other, what people are doing when the photographer is permitted to take their picture (or unobtrusively takes photographs of them without permission) (figures 4 and 5). The conventions of most photographs of medicine, especially of those intended for other than professional use, are similar to those of photographs of other subjects taken at a particular time. That is, a photograph of a patient in a hospital bed with a nurse nearby will be similar to a photograph of a person in a public place, with an employee of that place nearby, taken at about the same time. A photograph taken at a party celebrating some medical event would look very much like a snapshot of a group of people at play. Photographs of medicine reveal the ways in which members of the medical community at a particular time visualized themselves in relation to other people and to objects in its environment. Photographers mainly take the pictures that people want them to take: if they are professionals, they want to be paid; if they are amateurs they want to show the pictures to friends and colleagues.
Occasionally, however, one sees unusual photographs. They look different. Most of the time, people ignore these photographs, because they do not expect to see them. Sometimes they are unusual because they misuse the conventions of the time: they are over-exposed or the people in them are in what, for the time, are awkward positions. Sometimes they break the conventions of the time: they show a doctor with blood on his gown, or a nurse whose face looks tired, or a patient resisting treatment (figure 6). These photographs are usually destroyed or hidden away; they surely do not appear in medical journals.
There are two other kinds of unusual medical photographs. One kind are photographs that are aesthetically pleasing. These pictures use the conventions of the fine arts of their time (figure 7). In the nineteenth century photography borrowed its conventions of beauty from painting. In the twentieth century, however, photography has evolved its own aesthetic conventions. In recent years photographers who are artists, have occasionally taken pictures in medical settings. These photographs are unusual and striking because they actively remind us that art is not life.
The second kind of unusual photography is of great importance to historians. They are photographs that suggest that there are contradictions between how people live and work and what they would prefer the photographer to see. Think about family photographs. Yours and mine probably look alike. Do any of them document, except accidentally, adolescent rebellion, or tensions between spouses?
The same point can be made about medical photography for a wider audience. Most of the photographs that one sees of medical encounters do not show patients experiencing pain or fear. Moreover, most of the photographs of medical intervention are images of acute intervention. But most people who have been close to medical practice know that most time is spent, by both patient and professional, managing the effects of chronic diseases, not intervening in acute situations.
What do we learn when we see some of the few photographs that depict pain or the management of chronic diseases? We learn that the stories that people want photographs to tell and the stories of how people live and work can be quite different. We learn about wishes and preferences and sometimes about anxiety and dreaden.
Photographs can help historians to document a tension in medicine, especially in the twentieth century. This tension has become quite important in my current research on past and contemporary health policy in the United States and the United Kingdom. Much of this recent research has been on the recognition of the importance of chronic degenerative disease. From about 1920, chronic disease has accounted for most of the mortality in industrial countries. But health policy – the ways services are organized and financed – in most countries has not given priority to managing chronic disease.
I slowly realized that photographs help me to document that the management of chronic disease has been a preoccupation of doctors and patients for most of this century, even though health policy had other priorities. Some of these photographs use the ordinary conventions of medical photography, in ordinary ways: but their subject matter is unusual, in comparison to the vast number of photographs of medicine that have been taken, saved and published. In addition, some of these photographs were taken by distinguished artist-photographers, whose discerning eyes found something unusual in the human struggle to cope with chronic disease. If one looks carefully, one can find photographs, taken between 1910 and 1990, that help us to understand this important contradiction in the history of medicine: that what preoccupied people engaged in medical encounters has been at variance with so much of our public policy.