A Characteristic Picture of AIDS

Characteristic medical photographs taken to visualize common, typical and obvious signs of disease, but not the patient, comprised Farthing’s Colour Atlas of AIDS in 1986. The atlas was published as a culmination of the clinical experience of Farthing and his colleagues at Westminster Hospital in London as the epidemic was officially five years old. The number of infections had been constantly rising in the United States and the majority of Europe, while preliminary counts suggested an onset of the epidemic in the southern half of Africa.Footnote ⁴¹ The only available and partially effective treatment was AZT, approved and introduced a year later, while social profiling of risk groups was still focused on the four Hs: homosexual men, heroin users, Haitians and hemophiliacs. Disputes about the nature of the virus suspected to be the etiological agent were unresolved amongst several research teams, which argued for their chosen pathogenic candidate. Against this backdrop, the atlas editors attempted to produce the first total vision of the epidemic to date, made vivid as a characteristic rather than a definitive picture to its medical audience predominantly through photography.

In the mid-1980s, the state of knowledge about the epidemiology, immunology and virology of AIDS was sparse. Information given throughout the atlas remained vague, speculation is scattered throughout the chapters and many questions they posed remained unanswered. In this state of uncertainty, the resulting atlas appears more like bricolage than a systematized topology. But this seems to have been sufficient to fulfill the atlas’s aim to be a functional diagnostic instrument.

The photographs in the 1986 atlas were not included to strengthen a public empathy with persons who had developed AIDS, nor was their purpose to raise public awareness of the disastrous effects of the disease. As this example (Fig. 1.3) shows, bodies of different patients were depicted as an exchangeable canvas for similar lesions of the sarcoma. To guarantee anonymity, faces were cropped, patients were asked to assume an “anatomical position,” maximizing exposure of the body’s surface to the camera.Footnote ⁴² Clearly, the photographs do not follow aesthetic conventions of portrait photography: The face is absent unless it is directly affected. Where photographs showed lesions on the facial area, thick black lines were used to provide and secure anonymity for the patients. The background of almost every picture is white, the lighting even and bright and all are, as the title of the atlas promises, in color. Few of the photographs are anchored with a caption, and even if some specific background on what is seen in the photographs is given, no information is offered about the patients, their biography, their location or even their – at this stage improbable – chance for survival. Speculations about homosexual practices and lifestyles were not absent from the atlas but remained disconnected to individual photographs and could be found, for example, in the section on epidemiology.Footnote ⁴³

Fig. 1.3 A page from the section on KS in Farthing’s 1986 atlas of AIDS. The design of the page emphasizes again the focus on a characteristic appearance of widespread KS lesions on two different bodies, each positioned in an anatomical position to maximize the visible surface.

Source: Charles F. Farthing, Simon E. Brown, Richard C. D. Staughton, Jeffrey J. Cream, and Mark Mühlemann, eds., A Colour Atlas of AIDS: Acquired Immunodeficiency Syndrome (London: Wolfe Medical Publications, 1986), p. 26. Permission granted by Elsevier.

At the time of Farthing’s atlas production, the available method of analyzing blood samples (enzyme-linked immunosorbent assay [ELISA]) was complicated, expensive and sometimes unreliable.Footnote ⁴⁴ Diagnosing the immunodeficiency was often done by bedside clinical methods, and the occurrence of opportunistic infections were caught by the knowing eyes of doctors. Replicating the doctor’s trained gaze, the atlas’s photographs show the reader common diseases including KS, herpes, lymphoma and PCP. All these established diseases, however, now appeared in an unusual social group of bodies, unusual circumstances and, crucially, an unusual frequency and geographical density. These diseases were tied to a milieu in which most of them had never been seen before. The atlas’s first aim was to present a series of cases in which these known diseases had appeared out of their usual place.

This presentation of AIDS was almost exclusively dermatological. It builds on a long legacy of adequate representation of discrete patterns and unique shapes of symptoms on the exterior of the skin.Footnote ⁴⁵ The gaze rested, to use a Foucauldian phrase, largely on the surface of the body.Footnote ⁴⁶ It replicates those occurrences that catch the eye immediately and it catalogs the signs that everyone can see. The characteristic picture is construed through series of photographs, presentations of cases to the eyes of interested clinicians and students. The picture series mirrors the structure of the early World Health Organization (WHO) classification of AIDS, published in 1985.Footnote ⁴⁷ It provided a catalog of opportunistic infections and diseases, clustered into important, frequent and other signs of the immunodeficiency. Each sign was given a number, pneumopathy scored 2 while chronic or relapsing herpes were considered a 4. With several infections present reaching or exceeding a score of 12, the diagnosis of AIDS was established. According to the 1985 classification, generalized KS was counted on its own as 12. In the following years, the classification scheme was widely criticized for its shortcomings and vagueness and was replaced in 1994 with an updated international standard for the diagnosis of AIDS, now heavily reliant on serostatus.Footnote ⁴⁸

But photographs did more than just replicating the contested classifications of the time. Photography promised the benefit of an impartial perspective, a sober observation of clinical signs and the maintenance of an apparent indifference to the contested terrains of theory about causes, underlying ecologies and epidemiological profiles – the at-the-time-widely-popular investigation into the idea of patient zero, for example, is absent from the atlas.Footnote ⁴⁹ Contrary to Nixon’s photographs in the MoMA exhibition, the atlas’s series of clinical photographs were designed to visualize only specific aspects and effects of the syndrome. The underlying condition causing the symptoms to appear in the first place was implied as a diagnostic category; it remained a rubric that at this stage could only appear through long series of scattered signs. The clinical photographs did technically not show AIDS, but just isolated aspect of the syndromes disastrous effects.

Susan Sontag has called this absence of a unique signifier of AIDS an “inference.” Diseases like cancer and syphilis served as metaphorical reservoirs to help describe and interpret the new syndrome, indeed “the very definition of AIDS requires the presence of other diseases.”Footnote ⁵⁰ Instead of appearing as a radically new disease, yielding to unknown and unprecedented symptoms, AIDS instead acquired its unique quality by being a disposition of deficiency that lays the body vulnerable to a series of infections and diseases, and therefore is only accessible as an object of knowledge through the application of a new order of these known diseases and their appearances. The AIDS atlas’s editors used photography to act out this “inference” of AIDS, turning the unseen condition into something visible through a catalog of photographs of manifestations of discrete diseases that can then be seen as references to AIDS.

Another conclusion as to what photography had to offer medical knowledge production in the epidemic’s first decade offers itself here: Through photographs, Farthing’s atlas did not only express the unique shape of AIDS, but his commitment to clinical observation also reinstated medical authority where certainty and expertise were scarce. While the atlas’s first section is about the epidemiology of AIDS, which covered virology, immunology and practical details on accessible test kits, the body of the publication was concerned with a doctor’s bedside encounter with the patient. Rather than detailed descriptions about the agent’s biomedical structure, and in the absence of sufficient epidemiological data or distribution models, photographs seemed to allow a step back from the clamor and to ask its spectator to see rather than to speculate. Photography served as a first layer of careful abstraction, in which the repeated observation of cases was captured and recorded in an emphatically neutral or, rather, clinical way.

The Clinical Close-Up

A year after Farthing’s atlas was published, Paula Treichler delivered her famous essay on the “epidemic of signification.” Confronted with an unending stream of interpretations, beliefs and accusations against the populations at risk, she used this phrase to describe the vast distribution of suggested meanings for AIDS. These conjectures circled around the figure of the hypersexual homosexual male and inscribed those affected by implicating their lifestyle in theories of causation and guilt. By focusing on the continuum between biomedical practices and popular discourses, Treichler cites numerous theories that had at one time been shored up by biomedical knowledge. From the destructive power of sperm, or female immunity against infection, to lethal bacterial cocktails, acquired through many sexual encounters, debate about the true nature of AIDS was heated, despite broad agreement on a viral cause as of 1983. “We cannot therefore look ‘through’ language,” Treichler concludes, “to determine what AIDS ‘really’ is.”Footnote ⁵¹

Yingling, by comparison, claimed that the epidemic threatened the fabric of knowledge reaching far beyond the immune systems of risk groups.

Steven Epstein subsumed his analysis of these first years of the epidemic under the header “politics of lifestyle,” as the vast majority of medical knowledge on AIDS was acquired through epidemiological analysis of those affected, while biomedical interrogation lacked convincing explanations for the full range of appearances and occurrences associated with AIDS. Epidemiologists working on AIDS in the 1980s, as Oppenheimer argues, tended to conceptualize the syndrome as complex social phenomenon, inextricably linked to vague social behavior such as “promiscuity,” relations, networks and perceptions of communities.Footnote ⁵³ Lifestyle, sexual identity and communities became embroiled into equally vague definitions of the syndrome, exposing a toxic environment for stigmatization, exclusion and ignorant bigotry toward those considered at risk and perceived as a risk.Footnote ⁵⁴

In the eyes of many critics, language had provided inadequate to grapple with the emergence of AIDS; words seemed to fall short in the face of such an extent of individual, bodily loss enfolded within a social disaster, political crisis and with little progress in medical understanding. Or as Crimp summarized the crisis in 1987: “AIDS intersects with and requires a critical rethinking of all of culture: of language and representation, of science and medicine, of health and illness, of sex and death, of the public and private realms.”Footnote ⁵⁵ The perpetual crisis of AIDS led to a stream of metaphors of AIDS, which foregrounded racist stereotypes, conspiracy theories and religious angles alongside competing medical theories that rejected a viral cause.Footnote ⁵⁶ Looking back, Treichler would call her own collection of AIDS essays, published in 1999, “How to Have Theory in an Epidemic?” to emphasize the complicated ethical challenges of theorizing a disease of such devastating and deadly proportion. By even daring to speak of theory, cultural constructions or explanatory frameworks in the face of those dealing with the epidemic’s overwhelming demands, the immediacy of empirical approaches was appealing in and outside medicine.Footnote ⁵⁷

Social theory, cultural studies and literature were not the only places in which language seemed to fail grasping the epidemic. Farthing’s atlas is filled with indications and gestures of uncertainty. His captions reflect discussions about the commonality of certain symptoms and the frequency of their appearance. The reason for increased immunoglobulin production, for example, is described as “uncertain,”Footnote ⁵⁸ “progressive weight loss may be extremely marked in some patients,”Footnote ⁵⁹“the reason for the seborrheic dermatitis is as yet unclear”Footnote ⁶⁰ and the reason for the significant prevalence of KS in homosexual men with AIDS is “unknown.”Footnote ⁶¹

Alex Preda has described the ubiquitous practice of calling the appearance of KS and PCP “unusual” and “uncommon” in the early medical publications on AIDS. But for Preda the notion of unusualness and uncommon appearance is not an indication of the authors’ perplexity. Rather he suggests these notions of doubt served as instruments to enable new explanatory models, “signaling novelty and unusualness, redirecting the production of medical knowledge.”Footnote ⁶² And KS was presented in almost every early report and publication as the disease, whose unusual appearance and uncommon occurrence provided the framework to assume an underlying immunosuppression as its cause. In other words, Preda makes us aware that seeing KS and PCP in these new unusual appearances was the condition under which AIDS could be seen as an “unusual usual” syndrome.Footnote ⁶³ Photographs, which do not feature in Preda’s study of medical rhetoric, resembled this classification practice and presented the unusual appearances as a sign of AIDS.

A useful example of how photographs addressed uncertainty and unusualness is one of the many clinical close-ups from Farthing’s atlas (Fig. 1.4).Footnote ⁶⁴ Displayed in a diptych conformation a first photograph demonstrated the unusual extent of seborrhoeic dermatitis, spread across the patient’s chest, who is similar to the preceding picture (Fig. 1.3) positioned in an anatomical posture, while the second picture zoomed in to detail the follicular accentuation. The closer the lens got to the patient’s body, the less the patient appears a person and becomes instead a canvas. With higher magnification the appearance of follicles seemed removed from the individual body, from a person’s experience of illness and the dramatic development of the epidemic. Where the first picture tells of a posture of a person, at least partially naked and vulnerable to a frightening disease, the second picture has erased these affective residues of the portrait. Furthermore, the spread of skin disease is captioned as unusual, having moved beyond the commonly affected areas. In the process of cropping, arrangement and caption, these two photographs seem to move successfully from the unusual and confusing appearance of this skin disease to the representation of a disease, which has been marked as indicative of AIDS through its unusual patterns. The depiction “facifies” the symptom in the way that Ogdon describes the close-up as an isolation of the enhanced detail from social, historical and cultural circumstance.Footnote ⁶⁵ The closer the lens gets, the less contextualized appears the object in front of the camera.

Fig. 1.4 Two photographs of seborrhoeic dermatitis of chest from Farthing 1986. The close-up amplifies the gesture of abstraction with which clinical photography aims to arrive at characteristic representations of the unusual extent of the clinical sign of this skin disease that has been seen in patients with AIDS.

Source: Charles F. Farthing, Simon E. Brown, Richard C. D. Staughton, Jeffrey J. Cream, and Mark Mühlemann, eds., A Colour Atlas of AIDS: Acquired Immunodeficiency Syndrome (London: Wolfe Medical Publications, 1986), p. 58. Permission granted by Elsevier.

For O’Connor, clinical photography’s concern with superficial occurrences of pathology extends to a visualization practice as an “Art of Truth,” which alludes to the impression the photographs present “things as they are.” But this is less a description of the camera’s accuracy than a representation of the camera’s capacity to conflate surface and substance, to present visual clarity as the key to the deep truth of disease.Footnote ⁶⁶ For cases deemed exemplary of the ongoing epidemic, photographs gave a way of seeing AIDS that made the abundance of its metaphoric meanings and the uncertainty and resistance of AIDS as an object of medical knowledge for a while unseen. In this particular sense, clinical photography offered a way of seeing AIDS that moved beyond the epidemic of signification and provided an order in which uncertainty and unusualness were sustained rather than resolved.

With this use of photography, the AIDS atlas was built on an old fantasy of medicine, which put faith in an account of pathological phenomena free from speculation, assumption and theory. These photographs appeared to be the products of pure observation as well as accurate case description. Photography as “eyewitness” had been long trusted to translate observation into publication.Footnote ⁶⁷ In this way, the atlas photographs showed the clinician’s eye applied to AIDS and lent that same way of seeing to the reader. Committed to physical morphology and willfully impervious to the raging “epidemic of signification,” the atlas revealed AIDS as a series of discrete entities of medical knowledge appearing in a new order. To encounter the new epidemic through seeing familiar signs and diseases allowed for the rapid assertion of medical authority.Footnote ⁶⁸

But how exactly did clinical photography acquire this capacity to assert such authority in the absence of refined categories of AIDS epidemiology or any fundamental understandings of HIV and its microbiological mechanics? The longer history of visualizing disease in illustrations and photographs offers some indication as to how photography emerged as a unique professional medical practice. While it is tempting to see photography as part of the history of the empirical gaze applied to medical phenomena, such an approach forecloses other influences on the photographic picture of disease. Particular modes of analytical and diagnostic seeing were adapted by photography from the older genre of medical illustration, and what could tentatively be called a tradition of diagrammatic reasoning in medicine.

Analytical Visualization in the History of Medicine

The rejection and condemnation of theory was a recurring topic in medical thinking throughout the long nineteenth century. Already the pathologist and atlas-producer Jean Cruveilhier was concerned about systems, concepts and theories in the minds of the physicians around him in the 1820s as he favored an empirical account of disease entities, based on observation and illustration of clinical appearances. In this spirit, Cruveilhier declared the illustrations in his epic atlas to be timeless imprints of nature, resistant to the “back and forth of systems of thinking.”Footnote ⁶⁹ Instead of reading pedantic descriptions of skin rashes, he believed that seeing illustrations provided immediate and lasting impressions of the diseases in their actual state.Footnote ⁷⁰

Daston and Galison discuss concern about authorial subjectivity, part of which rested in the limited capacities of language to capture the spectacle of diseases in dense descriptions. To trust descriptions as accurate translations of appearances seen on a patient’s body became contested throughout the nineteenth century. Language was seen as untrustworthy, as it was perceived of leaning toward preconceived images and theoretical abstractions such as the archetype in German Naturphilosophie.Footnote ⁷¹ Not paying due diligence to techniques of observation and shrouding the doctor’s judgment, written words were conceived as obstacles to the clinicians’ ability to see and recognize the disease before their eyes.

Cruveilhier’s introduction to his atlas in 1824 provides an interesting starting point for situating illustration in the field of pathological anatomy. His rejection of language and appreciation of illustration as inerrable representation paved the way for the epistemic obstacles photography had to address half a century later. His atlas, the by-then largest collection of illustrations of pathological anatomy was published in 40 consignments between 1829 and 1842 in a design largely influenced by the Paris School of Medicine. Its wide distribution around Europe left a profound imprint on medical visualizations. The order of diseases did not follow abstract tables and classifications but was crafted around the anatomical location of pathological specimen within the human body. The atlas thus further established a way of thinking about disease based not on clusters of disparate signs across the body, but rather on the place of each appearance within or on the body’s surface.Footnote ⁷²

Cruveilhier’s stunning illustrations enhance their depth of meaning through weighted lines, careful coloring and exquisite detailing. Different types of melanoma, which comprised a large portion of the diseases included in the atlas, seem to almost pop out from the page, acquiring vividness and therefore achieving a lifelike truthfulness even to later audiences at the end of the twentieth century.Footnote ⁷³ Letters and numbers were integrated into the fine lines of the drawings and provided anchor points for references in accompanying texts, which delivered detailed description of the particular case history and the diagnosis, such as the names of patients and the circumstances of their arrival at the Hôpital Hôtel-Dieu. Cruveilhier’s drawings focused on the pathological forms and appearances, in the foreground of the pictures, while the surrounding normal anatomy occasionally appeared as a faded background. The malignant tumor depicted in “Maladies des Nerfs Ganglionnaires” (Fig. 1.5) draws particular attention to the color of the tissue, the morphology of the unusual growth and the position within the anatomy of the neck. The healthy anatomy appeared generic and exchangeable, through the absence of color, faded edges and the almost unnatural viewpoint. While the disease is displayed in its figural individuality, the physiological space is brought in as a repeatable background, like a generic stage set.

Fig. 1.5 Plate from the section “Maladies des Nerfs Ganglionnaires” in Cruveilhier’s atlas of pathological anatomy from 1824. The characteristic style of Cruveilhier pulls attention to the pathological specimen by drawing it in its place within a generic human anatomy.

Source: Jean Cruveilhier Anatomie pathologique du corps humain, ou descriptions, avec figures lithographieés et coloriées, des diverses altérations morbides (Paris: Baillière, 1829–42), Liv. 1, Plate III. Courtesy of the Staatsbibliothek zu Berlin.

Cruveilhier’s illustrations were rooted in the tradition of case description as well as the long history of visual anatomy.Footnote ⁷⁴ The ways in which cases have been described in medicine has been subject to much research in recent years, exposing a deep level of formalization in the translation of observation into text and illustration. Prudent observation enabled exhaustive description, which then meant the clinician could turn to systems and classes to compare practice with theory and forge new nosologies throughout the eighteenth and nineteenth century.Footnote ⁷⁵ But these new empirically based techniques of observation constantly confronted the problem of distinguishing between significant and random signs. When should an observed detail be considered as pertinent to the disease described? How might this decision be made and by whom, as depictions could not always rely on classes and theories of knowledge that preexisted the observation of appearances on a particular body?Footnote ⁷⁶ Cruveilhier’s visual contribution was precisely tuned to this problem. He wanted his illustrations to be concerned with capturing a characteristic impression of the disease, independent of the back and forth of the “Systèmes.”Footnote ⁷⁷

The first step in Cruveilhier’s analytical drawing method derived from Philipp Pinel’s commitment to disease observation.Footnote ⁷⁸ Pinel translated visible signs into exact written replica. The resulting text should be closely tied to what is seen, as if the disease could reveal itself, speaking its own, “native” language through the conduit of the describing clinical observer.Footnote ⁷⁹ Pinel’s method relied on an exchangeable relation between descriptive language and visual perception of symptoms. This suggested an economy of medical language that could include everything of relevance without losing significant details in its account of the visible stigmata of a disease. This ideal appealed to a stable and exact relation between what is seen and what is said, as Foucault described it for the early-nineteenth-century medicine. Knowing and seeing had become one in this endeavor and doctors imagined themselves to be naturally equipped with a “speaking eye.”Footnote ⁸⁰ Volker Hess wrote about this as the formation of a grammar of the language of diseases, in which the disease acquired a medical meaning only in the way in which it was enabled to reveal itself.Footnote ⁸¹ Reflecting on Pinel’s shortcoming, Cruveilhier criticized this analytical method as a theoretical deformation of the disease. He intervened by providing visualizations of pathological anatomy, which sought to capture nature as it really was.

Through his drawings he could address a most pressing problem of his time. Toby Gelfand described it in the following words: “Formal accounts did not (and could not if they wished to be of finite length and comprehensible) attempt a total picture of disease, replete with the multiple variations which occurred.”Footnote ⁸² The pathological could not be displayed by using the normative visual practice applied in anatomy atlases: The individuality of cases and appearances and their instances could not be so readily flattened into something so recognizable as a perfected “normal.” Cruveilhier used illustrations to establish the idea of a characteristic picture, a drawing that relies on a single case while it argues that this particular case should be seen as an exemplary case. Where anatomical atlases enjoyed an easy relationship to the individual bodies that might have served as models or templates to arrive at an average, the atlas of pathological anatomy needed to appreciate and integrate the notion of the single case. In its commitment to an empirical account of diseases, Cruveilhier’s drawings bore traces of mistrust to both the formal accounts of nosological tables and archetypical visual traditions of anatomy. The drawings established a way of visualizing pathology that lay somewhere in between, and Daston and Galison refer to Cruveilhier’s drawings as a unique way of arguing visually about diseases in which his approach resembled “a hybrid of the idealizing and the naturalizing modes.”Footnote ⁸³ The pathological object was kept as an individual object but related to a class of things placed in an atlas. This reinvented depicting of pathology at Cruveilhier’s time was needed, as neither the visual tradition of anatomy with its idealistic visualizations, nor the representation of an archetype, or pure phenomena were considered appropriate modes of seeing when it came to diseases.Footnote ⁸⁴ Intended to heavily supplement or even replace a language-based system, which had failed as a Grammatik of the disease, illustrations established a diagrammatical way of seeing and understanding pathological appearances.

After photography’s inception, illustration did by no means become an outdated technique of clinical visualization. It was and remained an artful diagrammatic of the pathological that embraced empirical yet structured accounts of the observed phenomenon. Similarly to how observations and descriptions were considered first orders of abstraction instead of preconditions for classification, did the art of illustration serve as a translation between the visible lesions and their systematic understanding as signs of disease.Footnote ⁸⁵

Illustration foreclosed the chance of seeing the unseen in visual representations. The pictures did not include the excess, the information discarded by the clinician’s eye. The unintended, accidental and overseen elements and aspects that might perhaps relate to the disease were routinely excluded from their visualization. Consequently, the reader of these drawn images could not expect to make additional discoveries and could not use the image to interrogate the visualized disease in its multifaceted shape. The viewer had to accept the illustration as the visual representation of an analytical gaze; someone had already decided what was significant for seeing a particular disease.

The AIDS atlas, published 150 years later, was also structured by an analytical perspective comparable to Cruveilhier’s publication. Editorial decisions had been made to include prominent opportunistic infections like KS, PCP, herpes, psoriasis, but not all. Photographs were taken of patients, whose cases had been decided to be characteristic appearances; these photographs were then cropped and captioned to make only those elements visible that were necessary to see the current picture of AIDS. Finally, the comparatively brief paragraphs of text throughout the atlas gave further guidelines for readers to learn how to see and recognize the syndrome in a certain way, but refrained from engagement with larger, contested matters in any systematic way.

However, unlike the illustration, a photograph cannot be so tightly controlled. The use of photography left room for other pictures to emerge. Most importantly, it allowed inclusion of uncertainty, of the unusualness of the appearance of infections in these particular bodies, and freed up an integration of the many unseen assumptions, theories and speculations about the young epidemic, although the overall impression was apparently somber and clinically neutral. Clinical photography was well-suited to present AIDS precisely for its faculty of offering a disease both as a standardized object of knowledge and as an excess of norms, classes and theories. This visual technology emphasized AIDS as crisis of medical knowledge while indicating the stability of medical authority.

Photography and Illustration

The history of clinical photography is still widely unwritten. Studies have analyzed representations produced by the medical use of photography as examples in larger arguments about the visual history of medicine, but no scholar has engaged systematically with this genre at large. Clinical photography’s history remains overshadowed by scholarship on the representation of medicine in society, on specific photographic practices in psychiatry in the case of Charcot and on the history of photography of physiological movement.Footnote ⁸⁶ Clinical photography has often been loosely included in the wider corpus of scientific photography, as researched by Tucker and others.Footnote ⁸⁷ But these perspectives tend to overlook a crucial point about clinical photography: As a visualization technique it is intimately attached to the portraiture of the pathological and thus deeply bound to the history of the clinician’s gaze. This gaze is not identical with the perspective of a biologist or a chemist and must be treated within deliberation of the normal and the pathological instead of wrestling objects of nature from systems of culture.Footnote ⁸⁸ Clinical photography was neither fully committed to eye-witnessing natural phenomena, nor did it work as a pure visualization of nosological knowledge, tables and categories or diseases.

Just months after the invention of the daguerreotype, the earliest form of photography in 1835, the first medical images were taken. In 1852 Berend published photographs that focused on orthopedic diseases, Squire colored photographs in 1864 to show dermatological textures and in 1893 the first comprehensive handbook for medical photography, La photographie medicale was published in France. That year the first issue of the new journal Internationale Medizinisch-Photographische Monatsschrift was published, which taught doctors and photographers alike how to take medical photographs. Photography had become a successor to earlier “visual concepts of pathology” and provided a radical new “medium of seeing” disease.Footnote ⁸⁹ By the middle of the twentieth century, photography had become the most important medium for the increasingly visual basis of medical diagnostics.

However, this was not a smooth progression to prominence unhindered by resistance, critique and protest. The physician William Keiller expostulated his concern about the craze for medical photography in the 1894 issue of the New York Medical Journal that the “excellence and cheapness of the recent methods of reproducing photographs by photo-engravings has driven the majority of medical illustrators photo-mad.” He continued, “How many text-books and articles are spoiled by beautiful photo-engravings which teach absolutely nothing, where simple diagrams would have been most instructive!”Footnote ⁹⁰ Similar concerns were raised in the British Medical Journal, where authors complained about the overall lack of detail in photographic visualization.Footnote ⁹¹ These outspoken photography protests were not representative of the majority of the medical profession. But many doctors, editors and publishers remained skeptic about the instructive faculty of photography. What was it about a photograph that provoked these concerns, and what ways were found to overcome the epistemic obstacles that forged clinical photography into a genre that could – as in the case of AIDS – express both the stability of medical knowledge and the appearance of a new, poorly understood and mysterious disease?

Moritz Kaposi, who identified and subsequently named the skin cancer that would become an index marker for AIDS, refused to use the new medium. As one of the best-known dermatologists of his time, Kaposi represented the dermatology school of Vienna. Between 1898 and 1900, Kaposi published the Handatlas der Hautkrankheiten für Studierende und Ärzte, which relied exclusively on watercolor illustrations, using wax moulages as templates.Footnote ⁹² In his preface, Kaposi claimed that the atlas not only collected all significant clinical pictures for dermatology, but visualized the different appearances of the most significant diseases, such as syphilis. He did not give explicit reason for ignoring the half-century history of medical photography, which had already been used in other dermatological atlases.Footnote ⁹³ Instead, he expressed his admiration for the “superior art” of illustration. The atlas consists of hundreds of beautifully painted aquarelles, which depict the then-known dermatological diseases, affixed with short captions.Footnote ⁹⁴ Beyond the brief preface, no textual commentary is found in the atlas. The authorial medical voice had disappeared from the text or rather taken up residence in the drawings that were fully trusted by Kaposi to transmit knowledge and his clinical perspective in the intended form.

Historically, photographs were mistrusted by physicians because they showed too much. It was not always easy to find particularly poignant cases, photograph them in the right way and crop the resulting picture in a manner that the disease can take center stage. While medical metaphors traveled to conventional portrait photography in the nineteenth century, to lend authority and professionalism to the urban studio photographer, the medical photographer was concerned that his practice would bear too much resemblance to classic portraiture.Footnote ⁹⁵ The overarching presence of a person, rather than the symptom, was particularly difficult to contain when diseases appeared in the face.

When KS occurred in patients with AIDS, one of the unusual aspects was its manifestation throughout the patient’s body. Classically, in the cancer’s appearance before the time of AIDS, KS lesions were usually to be found along the lower limbs. But the AIDS related appearance of lesions in patient’s faces provided new problems for the atlas editors and photographers. As could already be seen in the first example of this chapter (Fig. 1.1), photographing lesions on and close to the face challenged not only the anonymity that was guaranteed to the volunteering patients, but in regard to the visualization of a disease, it made it significantly more difficult to make the person behind the KS lesion unseen. But KS in persons with AIDS often appeared in the face, and it was partly for that reason that it was the most visible and immediately recognizable sign of AIDS at the time. This prominence exceeded the doctor’s vision, as the facial KS lesion became a spectacle, working as AIDS’s index sign in popular culture, film and television.Footnote ⁹⁶ But it was still important to draw attention to the unusual facial location, so doctors knew exactly where to look. Ethical considerations and the heated political conflicts around AIDS compelled the editors to maximize anonymity. Their answer in the 1986 atlas was to crop as much of the surrounding visage as possible, to reveal just enough to enable clinical recognition of the signs; to this end the editors were prepared to manipulate pictures extensively.

But securing a photograph’s message to be concerned with disease and not a personal portrait was far more challenging, if the disease did not present through characteristic lesions. In the photograph discussed at the beginning of this chapter (Fig. 1.1), we not only see lesions of KS at the edge of the man’s beard but also another striking feature: The facial hair around the chin has become gray.Footnote ⁹⁷ Graying hair might have been indicative of another process, which was vague in its definition and even more problematic to visualize: the acceleration of appearing old. At the end of the atlas’s section on clinical presentations, the editors drew reader’s attention to AIDS-related signs of “rapid aging.” Two photographs, taken on two separate occasions with an interval of two years, demonstrate the progress of “premature greying, frontal recession and thinning of hair, loss of facial fat with hollowing of contour.”Footnote ⁹⁸

The photographs look like standard portrait photographs or passport pictures, but two black lines, forming a T-shape, were intended to ensure patient anonymity while enabling the usability of the photograph (Fig. 1.6). Many facets of these pictures are puzzling. The AIDS manifestation described here as “rapid aging” is difficult to define in detail. The overall impression of aging is hard to condense into a comprehensive list of indicators. Where does aging become medical? What excess of aging is too much, and how is this measured? This overall impression is captured in the familiar arrangement of a before-and-after depiction of the person’s face. The premature graying, also present in the KS photograph in the preceding text (Fig. 1.1), the thinning of hair and absence of facial hair is captured in the second shot, but so are other features. The unusual blue background on the left picture suggests it to be perhaps an older prepathological, personal photograph, while a changing haircut hints at the movement of fashion, styles and taste and a sense of the facial expression – in both pictures serious and performing an emphatic neutrality – makes these photographs, despite the editorial gesture of anonymity, particularly vulnerable to be seen as a portrait of a person.

Fig. 1.6 Two photographs selected to demonstrate the process of rapid aging as a symptom of AIDS in the 1986 atlas by Farthing. The black lines guarantee anonymity but also turn the portrait photographs into functional representations, supposed to reveal recognizable signs of aging without compromising the privacy of this person with AIDS.

Source: Charles F. Farthing, Simon E. Brown, Richard C. D. Staughton, Jeffrey J. Cream, and Mark Mühlemann, eds., A Colour Atlas of AIDS: Acquired Immunodeficiency Syndrome (London: Wolfe Medical Publications, 1986), p. 58. Permission granted by Elsevier.

Despite the black lines’ questionable success in keeping the identity of the patient protected, they made these photographs a clinical picture. Among the practices that photographers, editors and designers applied throughout the atlas, this might be one of the most intrusive and obstructive to the readers’ gaze, hindering a recognition of the person and guiding to an analytical observation of the signs of aging listed in the caption. The black lines practice an abstraction through which the photographs were intended to become readable as a vessel of clinical information. Such practices of taming the photographs’ content have a long tradition. Draping, covering and hiding unnecessary aspects to guide the reader’s gaze to substantial features contributed to the very act of turning a photograph into a medical photograph, by establishing it as an analytical perspective.

Clinical photography adopted these practices from illustration. But it also owes much of its conventions to the wax moulage. In reverse, at the end of the nineteenth century the art of moulage became increasingly dependent on photography. The fragile wax models were photographed for distribution far beyond the hospitals that stored them for teaching purposes. The Atlas der Hautkrankheiten. Mit Einschluß der wichtigsten venerischen Erkrankungen für praktische Ärzte und Studierende, published in 1903 by Eduard Jacobi, used photography exclusively as reproduction of wax moulages, rather than as a technique to capture cases in vivo.Footnote ⁹⁹ The editor of this dermatological atlas, reissued until the 1920s, gave some hints about why he chose photographed moulages. His reasons were partly based on technical problems. But he also emphasized the advantage of photographed moulages, as they maintained the idealized perspective of the doctors and artists, produced in such perfection, to exactly resemble the disease in the living patient.Footnote ¹⁰⁰ Jacobi emphasized that he relied on photographs of moulages as representations of typical diseases, and he expressed no interest in the contemporary trend of bringing monstrous or “interesting” cases to the fore.Footnote ¹⁰¹ That his atlas illustrated typical clinical pictures, he saw the utmost value in guided visual representations so that the practicing physician or the student of dermatology would profit most from reading the atlas.Footnote ¹⁰²

Syphilis was at that time the central topic of dermatology and venereology. Many publications used visual sources to establish a canon of referential images, and Jacobi dedicated a long chapter of his atlas to the pressing problem of a widely distributed syphilis epidemic. He recalled the history of isolating the syphilis infectious agent, the spirochaeta pallida, and listed the visible and invisible clinical signs of its presence in a patient’s body. Detailed and vivid descriptions of lesions, their characteristic appearance and their usual places on a body were briefly referenced by Jacobi in the text but were also visualized through illustrations of so-called Schleimhautpappeln (papulosa).

Two photographic reproductions of moulages (Fig. 1.7) showed the face, or rather a portion of the face. The moulage had been modeled in detail to create a lifelike appearance, emphasized by details like the fingers that pull down the lip to make the lesions visible. As with photography, lifelike impression was the key element that led many doctors to trust the moulage as a teaching instrument. As the moulages’ immobility and fragility were impractical for dissemination and expensive to reproduce and to store, their circulation through photography was of immense value. The act of cropping and draping stands in for the clinician’s analytical perspective, guiding the gaze to the significant details. Cropped into diagnostic certainty, the moulage offered standardized clinical pictures, ready to be widely distributed through photography.

Fig. 1.7 Two photographed moulages in a chapter on Syphilis in Jacobi’s dermatological atlas from 1903. While the moulages were too fragile to be widely circulated, photographic reproduction made these three-dimensional and lifelike illustrations of diseases widely accessible.

Source: Eduard Jacobi, Atlas der Hautkrankheiten. Mit Einschluß der wichtigsten venerischen Erkrankungen für praktische Aerzte und Studierende (Berlin and Wien: Urban & Schwarzenberg, 1903), plate 112. Courtesy of the Wellcome Collection.

Returning to the AIDS atlas, a resemblance between the aesthetic of Jacobi’s photographed wax moulages and the persons with AIDS in, for example, the pictures of aging (Fig. 1.4) is uncanny. In both cases, we see lifelike representations of the symptoms on patient’s bodies, body parts moved to reveal the symptom in its entirety and a series of pictures of bodies juxtaposed to render the individuality of patients, the arbitrary appearance of symptoms in single cases unseen. Cropping and captioning the photograph was a practice modeled on the historical example of illustration and moulage to process diagnostic certainty, so that photographed patient bodies in the AIDS atlas would seem no more than wax models. The point of focus was artfully crafted through a doctor’s speaking eyes, the established medical authority that in turn allowed the pictures to be trusted as instruments of comparison and teaching to recognize actual cases. Drawing on the diagrammatic faculty of the illustration, photographs needed to be tamed, pictures needed to be turned into structured representations of lesions to show a disease.

It is a commonplace that a photographs’ content becomes visible through their material arrangements. “[H]ow they are printed and viewed, as albums, lantern slides, or mounted prints, is integral to their phenomenological engagement, structuring visual knowledge.”Footnote ¹⁰³ But as Edwards has argued further, while arrangement makes the photograph a readable entity and structures our reading of its content, the photograph’s picture can never fully be disclosed, its meaning is never quite secure and its vision never firmly anchored: The “photograph awakens a desire to know that which it cannot show.”Footnote ¹⁰⁴ Showing a lesion, to visualize a rash as it manifests on a person’s body, might be achieved through the material arrangement and manipulation of a photograph in an atlas. But for the photograph to work as a visualization of AIDS, it must do more. It is here where the unseen surplus of the photograph becomes important, where precisely that which illustration cannot show acquires importance and where the relationship of signs of a disease and the person depicted moves to the center.

Here, a second historical genealogy of clinical photography is apparent. Distinct from the diagrammatic capacities of illustrations and wax moulages, photography could bring something new to disease visualization: It showed disease in the contingent individual and singular shape that resisted formal account and abstraction. Skeptical to the idea of solid disease entities, classes and tableaus, the photograph contributed in the late nineteenth century to a new appreciation of disease as an excessive state of life. Precisely because photography was able to integrate the individual picture of disease into the crafting of formalized accounts, it enfolded attraction as a visual representation of pathology as both an abstract entity and a lived reality.

Photographing AIDS as a Disease

Clinical photography transformed the perception of the epidemic through its first decade, but the genre struggled to arrive at abstract representations of the syndrome. Initially a medium prone to conflate identity and morphology to make AIDS visible, it only hesitantly became a technique tasked with separating the notion of the abstract entity of AIDS from the portraits of persons who contracted it. Increasingly, in the late 1980s, photography was supposed to make their entanglement unseen to perceive the one as a disease and the other as a generic, interchangeable body hosting a virus. But was it ever possible to capture the disease as an abstract entity on a photograph? Or is a photograph of a disease inescapably a medium of semantic transgression?

Sander Gilman considered the visualization of AIDS through photographs as a continuous encounter with uncertainty and an “indeterminable universe” of illness that required control, boundaries and the construction of a stable difference between health and disease.Footnote ¹¹¹ The photograph of the patient created difference, as it served as a vehicle to achieve an initial understanding about the assumed social nature of the disease.Footnote ¹¹² To many physicians in the early 1980s, homosexuality prompted suspicion and susceptibility for AIDS.Footnote ¹¹³ The notion of AIDS as a homosexual disease, or as a disease implicated in homosexual lifestyles, disallowed its characterization as a viral disease divorced from social prevalence, and foregrounded an image of transmission through sexual practices at the cost of seeing other routes of spread. Clinical photography, one could argue therefore, foregrounded the perception of AIDS as a disease of homosexual lifestyle and identity, simply because it failed to present AIDS as an abstract entity.

A visual precedent of this perception, Gilman argues, can be identified in the history of syphilis. Here, a sexually transmitted disease was bound to a long-standing history of visualizing sexual transgression. The appearance and spectacle of the disease was part of an iconography of punishment.Footnote ¹¹⁴ Seeing the photograph of the diseased body reassured the healthy viewer’s impression that this illness was deserved and fit to unseen moral failures of the person. The carrier of the disease and the photograph represented the boundaries of the epidemic, isolating the threat to particular persons and identities, while bolstering the image of immunity and safety for everyone else.

On an aesthetic level, photography of people with AIDS – within and beyond the medical AIDS atlas – was, of course, occupied by traces of decay, symbolism of doom and icons of bodily crisis. The disintegration of the body, the destruction of political subjectivities and the annihilation of sexual identities structured the visual language of AIDS photography throughout the epidemic’s first decade. Following Gilman’s arguments, Watney directs attention to the fact that it was fairly surprising to use photography at all, given that AIDS was understood as a diagnostic category of several different and not always visible opportunistic infections. Choosing to frame the appearance of AIDS as a “discrete illness rather than a conceptual diagnostic category” attracted significant success to craft an image of the AIDS carrier as a person who is understood to be qualitatively different from the majority of the population.Footnote ¹¹⁵ The victim was perceived as threat to public health and safety and is ostracized through the frame of difference. Furthermore, as Grover notes, almost everyone pictured in circulating photographs of AIDS in the early 1980s was destined to die and had most probably died, leaving us with images of their “visible lesions.”Footnote ¹¹⁶

Call it stigmatization, isolation or the framing of difference, photographs of illness continued to distinguish the subject from what was assumed to be healthy, normal and morally correct. Sontag took up the perception of the Other’s suffering to argue at length about the effects of identification with depicted pain that guarantees spectatorship immune from what they were witnessing.Footnote ¹¹⁷ Judith Butler has also worked extensively on the frames of war, in which an economy of grief is visually organized, demarcating deserving lives from those less deserving of our empathy.Footnote ¹¹⁸ Both arguments resonate with ACT UP’s calls for action, the activist’s struggle for visibility and particularly the “Ashes Actions,” when activists and relatives of people who died of AIDS threw their ashes on the lawn of the White House, demanding their recognition with ultimate means.Footnote ¹¹⁹ Both Sontag and Butler point to the uncontrollable resonances of visual representations of a body in crisis, and that visualizations of suffering bodies do not necessarily encourage a humane response or provoke emphatic identification. If we consider these effects to inevitably accompany a photographic representation of AIDS, how could – if at all – photography be used to encourage a sober and abstract representation of AIDS that is safely removed from perception of lifestyle and sexual identity?

Monstrous Photography?

This characteristic quality of AIDS photography to carry vague signs of identity into representations of diseases attaches these images to another tradition of medical photography from the later nineteenth century. A close look onto this history illuminates the attraction medical photography had in the early years of AIDS but will also explain how the genre lost most of its appeal after the epidemic’s first decade.

In the late nineteenth century, many medical photographs were collected in private or public collections, traveled with “freak shows” and presented as trophies of nature’s experimentations to a morbidly fascinated public. These images earned a reputation for visualizing a quality in its awe-inspiring distance from health, normality and society. This visual regime of extreme pathological signs and exceptional anomalies must be regarded as a second quality of clinical photography, which bears no direct relation to the tradition of pathological illustration, but is deeply embedded in late-nineteenth-century fascination for the idea of the monster.

As already discussed, photography was swiftly praised for overcoming the weaknesses of illustration and for providing representations based on empirical observation. Medical photography was often contrasted with the subjective and imprecise genre of drawing as it moved away from ideal representations in favor of exemplary and characteristic cases. Grounded in the “real” by the end of the nineteenth century, medical photography sometimes left the realm of classifying diseases and became the focus of efforts to collect, expose and curate archives of biologically grotesque appearances, abnormal tumors and spectacular deformations. Long series of photographs showed disfigured fetuses, collections of inoperable tumors and unthinkable deformations. Public appreciation for the extreme forms and shapes made medical photography a recording practice for the unpresentable, never-before-seen and unthinkable aspects of human life and death.Footnote ¹²⁰ While the taste for the grotesque and monstrous surely had a longer history than photography, medical photography took part in making the aesthetic of the ugly and abject widely available.Footnote ¹²¹

Photographs of spectacular appearances reflect shifts in European medical thinking that rejected understanding diseases as species that were bound to their own ontologies. The most influential interventions came from Rudolf Virchow, a German proponent of cell theory and social medicine, who argued in 1847 that diseases could not be thought of as autonomous organisms or parasites that entered and attacked the human body. Rather, diseases were more akin to various forms of life. So rather than being different in kind, they could be understood as excessive forms of physiology. The French physician Claude Bernard, famous for his work on experimental medicine, also argued that “physiology and pathology are intermingled and are essentially one and the same thing.”Footnote ¹²² Canguilhem followed Bernard’s and Comte’s reasoning about the identity of disease and human life, arguing for a late-nineteenth-century medicine, which considered diseases to be a mere quantitative excess of human life, rather than its opponents.

“The existence of monsters,” Canguilhem wrote, “throws doubt on life’s ability to teach us order.”Footnote ¹²³ The notion of the monstrous, which emerged in the late nineteenth century, was both intimately bound to the idea of organic organization as much as it posed a substantial challenge to understanding the norms that governed organic life forms. Proponents of this approach rejected ontologist theories that considered diseases as natural entities. Instead, the focus rested on lumps, tumors, swellings and spectacular disfigurements. A medical photography of the spectacular, monstrous and excessive physiological form presents an opportunity for Canguilhem’s thoughts to be extended into visual history. Photography offered a visual instrument with which the pathological was interrogated as nature’s experiments, a form in which the radical identity of disease and human life was constantly performed.Footnote ¹²⁴

To use photography as an instrument to frame life’s excess contributed to its rejection by those physicians who disliked the idea of disease as a continuum of pathological and physiological states. Doctors and atlas editors who were more interested in visualizing characteristic and archetypical states of pathology, as in the cases of Jacobi and Kaposi, refused outright the usefulness of spectacular or interesting cases to be presented to the atlas’s audience.Footnote ¹²⁵ Photography of “monsters” stirred common understandings about health and disease and prompted questions about the validity of disease categories. The practice contributed to an ongoing and contingent documentation, an archive of the unclassifiable. The genre did not present clinical signs as a discrete aspect of a nosological entity, a class or abstract table of a disease, but visualized disease as an erratic and poorly differentiated situation along the spectrum of life. This mode of photographic visualization was more akin to the appearance of enormous tumors as excess to the body’s own tissue than to the idea of an infection by a foreign microorganism. Due to this association with excess rather than difference, photography was distrusted as a productive instrument for stabilizing classes of disease but assumed prevalence as a portraiture of spectacular cases that pointed to the limits of classification and the borderlines of medical knowledge.

The KS photography in Friedman-Kien’s atlas confronts us with a combination of representational modes of the person with AIDS and the diseases indicative of AIDS. Rows and rows of pictures neither fully engaged with the discrete entity of an opportunistic infection and its symptoms, nor did they commit clearly to the social profile of the infection or the epidemiology of the immunodeficiency syndrome. The atlas uses photography of single cases, grouped together to reveal different social settings of KS, to deliver an argument of how AIDS-related KS was separated from African KS and Classic KS. Photographs in this atlas worked as portraits of individual cases rather than indeterminate visualizations of a syndrome. They illustrated the appearance of a disease in a group defined through sexual practice. Both the patients as well as the disease appeared in Friedman-Kien’s atlas as discrete entities, begging the question of how their relationship has defined the short history of AIDS. The photographs seem almost to “illustrate” the history of how AIDS came into view, rather than contributing to the task of solving problems and open questions.

Beyond its instructive and demonstrative faculty, clinical photography was always also bound to such an illustrative capacity, adding the unique value of individual cases to the definition of diseases. Where this capacity of photography made pictures of monstrous appearances and spectacular cases to desirable objects for collection and exhibition it also added a new level to what Fox and Lawrence describe as photography’s “visual concepts of pathology.”Footnote ¹²⁶ Photography could contribute a visible representation of disease based on “people who suffered afflictions.”Footnote ¹²⁷ The ways in which these visualizations came to be convincing instruments in textbooks and atlases are complicated, as “photography did not replace drawing to depict morbid anatomy until new conventions were created to represent tissues and tissue change.”Footnote ¹²⁸ Partly based on the diagrammatic tradition of drawings and moulage, photography also introduced a radically new element to the textbook, atlases and instructive publications of medicine: The appearance of individual and exemplary patients was no longer dependent on narratives, case descriptions and personal remarks, but could be represented through photographic reproductions of the patient’s bodily appearance.

An exemplary account of the gradual introduction of unmasked portrait photographs of cases is given by yet another dermatologist, a contemporary of Jacobi called Edmund Lesser.Footnote ¹²⁹ He published his Lehrbuch der Haut- und Geschlechtskrankheiten für Studierende und Ärzte between 1886 and 1887 at F. C. W. Vogel in Leipzig; it was a well-known dermatologist’s handbook and was distributed widely with 14 new editions before 1927. It was used both as an atlas and as a textbook, in which diseases were described through detailed texts as well as visualized in photography.Footnote ¹³⁰ The familiar tone of a textbook dominated Lesser’s teaching instrument and photographs remained subsidiary; predominantly used to “illustrate” the detailed written accounts of diseases and dermatological abnormalities.

Take, for example, the chapter on Herpes tonsurans. Accompanying the dense descriptions are four pictures: a magnified picture of the fungus Trichophyton tonsurans at 300:1, a visualization of Herpes tonsurans in the skin, a visualization of a herpes infection on the side of a bearded face and a microscopically enhanced picture of a fungus infection within hair structures.Footnote ¹³¹ The text in Lesser’s atlas stayed vague about the conditions of the pictures, and none is contextualized in detail but used as a secondary illustration, anchored in the text through markings and reference numbers but not integral to the image that the book conveyed. Photographs were added as complementary add-ons to emphasize details explained in the narrative of the written description. They stabilized and made evident what is known and described about herpes tonsurans through repetition in a subsidiary visual means. This demoted inclusion of photographs in the atlas represents a fundamentally different way of using visual media compared to the earlier atlas of Cruveilhier, or to the “silent” illustrations used by Kaposi.

This pattern was repeated in a remarkable photograph of a male patient that visualized a “papulo-ulceroeses Syphilid” (Fig. 1.9). The photograph appears near the end of Lesser’s book in an addendum of photographic plates. The picture has been taken in accordance with aesthetic norms of portrait photography of the time, in its visual arrangement intent on guiding the viewer’s gaze to the syphilitic symptoms on the forehead, biceps and forearm of the patient. In contrast to Cruveilhier’s more abstract depiction of the patient’s body, or to the draped sections of patients’ bodies presented in moulages, this photograph gave a full upper-body view of the patient and his face. The posture, the facial expression and the disease-stricken body became part of the visualization of the clinical picture. The disease was not revealed through visual isolation of its signs or analytical close-ups; instead its signs were shown as part of a larger composition of the suffering patient. The medically significant part, the syphilitic rash on the arm and the face, was emphasized using captions and by anchoring the photograph to the chapter on syphilis.

Fig. 1.9 Portrait of a patient with syphilis in Lesser’s dermatological handbook from 1890. Instead of guiding the readers gaze directly to clinical signs, this photograph emphasized the embodied nature of the disease, illustrating the abstract definition of the disease with a singular case.

Source: Edmund Lesser, Lehrbuch der Haut- und Geschlechtskrankheiten für Studierende und Ärzte (Leipzig: Vogel, 1886), Appendix, Plate III. Courtesy of the Wellcome Collection.

Photographs such as this do not display a picture of disease in the way Kaposi’s atlas or Jacobi’s moulages did, nor do they seek to isolate a disease entity from the patient’s body. A characteristic picture is not revealed – nor is it the photograph’s purpose – but the picture illustrates agreed-upon knowledge with visual references to patients and their suffering. Photographs like this one ground the abstract disease category of syphilis in a particular case, which demonstrates to a medical audience the impact and crisis that comes with the development of the disease. The photographed disease is illustrated through the single case, neither bound to an analytical gaze (there is no draping, cropping or covering), but relies on an emphatic and affective impression of a person enduring the affliction. Such pictures visualize specific disease in its entanglement with the person affected, and they require a more complex and extensive anchoring in descriptive and analytical text, as their contribution lies in the translation of knowledge into visibility instead of vice versa.

This example suggests that photography cannot be understood as the simple successor to, or improved version of, medical illustration. Yet it would also be a mistake to understand the sidelining of visual practices in Lesser’s atlas as a rehabilitation of written clinical pictures at the end of the nineteenth century. Photography presented a classic epistemological obstacle, as Bachelard put it, when set to the task of establishing a visual clinical picture.Footnote ¹³² Photography pointed to the limits of delivering characteristic pictures based on the single case, as well as to potential for delivering a new way of seeing the pathological. Photography’s novelty allowed the pathological to be appreciated as a structured appearance that maintained an arbitrary, contingent and irreducibly undefined element.

Photographic Illustration of Cases

The work of Edinburgh-based clinician Byrom Bramwell and his Atlas of Clinical Medicine, published in three volumes between 1892 and 1896, is further illuminating to understand the clinical integration of exemplary photographic case portraits. Lacking both preface and introduction, the work shows unusual as well as typical cases in the voluminous atlas, which covered a broad range of medical specialties. It is remarkable that most of the pictures were visualized through both photography and watercolor illustrations side by side. Both strategies of visualization were further complemented by detailed descriptions and structured case histories. The clinical presentation of a case, along with two pictures, was described in the following way: “The case which is depicted in Plates XII and XIII presented all the symptoms characteristic of chronic progressive bulbar paralysis, in its advanced stage.”Footnote ¹³³ The patient, a 50-year-old peasant, died by the time the atlas was published. The “characteristic” photograph (Fig. 1.10) is an aesthetic portrait of an aged man sticking out his tongue. The accompanying description emphasized the great pain that sitting for this photograph would have caused the patient, as well as noting how the disease developed rapidly and how many of the crucial features of this clinical picture could not possibly be communicated through a photograph.

Fig. 1.10 Photographic plate from Bramwell’s clinical atlas from 1892. In combination with the watercolor detail of the tongue, this photograph contributes to the appearance of an embodied and personalized case; a characteristic example for a well-defined disease, supported by the aesthetic appearance of a “carte visite.”

Source: Byrom Bramwell, Atlas of Clinical Medicine (Edinburgh: Constable, 1892), vol. I, p. 118. Courtesy of the Wellcome Collection.

On the next page, the photograph is contrasted with a colored illustration that magnified one part of the photograph, the tongue, to reveal its “uneven, wrinkled, ‘hob-nailed’ condition.”Footnote ¹³⁴ The author explained that:

The photograph served a different function to the illustration, as in the author’s reflection it seemed to hide, rather than reveal the diseases key features. The photograph fits easily in the conventions of nonmedical portrait photography, deviating only in its facial expression. Bramwell perhaps attempted to show the disease in its larger environment to demonstrate its occurrence in ordinary people, whereas the illustration maintains its abstract and analytical function, especially in its coloring, which was supposedly drawn directly from the original case. At the end of the nineteenth century, a clinical atlas problematized the authenticity of photographs as media too close to aesthetic norms, while the illustration is included to deliver a characteristic and exemplary visualization of disease.

Lesser’s choice to sideline photographs in his handbook, the absence of photography in Kaposi’s atlas and the combination with illustrations in Bramwell’s atlas all account for a belief that photography could not alone deliver what was required for atlases and handbooks. If used at all, photography’s function was to individualize, portray or illustrate the otherwise abstract notion of diseases, given by text or illustrations. In other words, photography introduced a way of seeing disease as an ever-embodied form in which the endeavor of separating the experience of disease from abstract classes of thinking and knowing diseases was questioned. Photography thus adopted a position in medical knowledge production that had previously been inhabited by case histories.Footnote ¹³⁶

Photography has since its inception posed a challenge to the idea that there can be a clear line between health and pathology. These simplistic categories of normalcy and disease fade, and in their place the liminal, unsolved and unusual appears. A photograph can document what is not, or not yet, known, classified and ordered whether as a monstrous extreme or an arbitrary individual case. In photography a disease cannot appear as an isolated clinical sign but as a poorly differentiated situation of life. In Canguilhem’s approach, photography could be seen as an instrument of observation and interrogation in which diseases are not isolated and defined in their own ontologies, but where disease is inescapably presented as an embodied entanglement with life. I propose to see the significance and the success of clinical photographs of AIDS therefore to be essential for setting up a kind of experimental system in which the process of separation, the strategies of isolation and the methods of visualization of a disease could be seen, rather than the disease.

It is crucial to understand that photographs always denied doctors the chance to exercise tight control over categories, classes and genres of diseases. This challenge to authority and definition suggests a rationale for photograph’s marginalized position, occasional absence or their extensive visual anchoring through illustrations in medical publications in the late nineteenth century. None of the atlas editors from this bygone century relied on photographs to speak for themselves or teach an audience in the way illustrations and moulages had been entrusted. Photographs carried a certain mistrust because of their excess of signification and because the visibility of personal element made the pictures liable to distract the less experienced observer. But photography’s contribution to medicine was also not exclusively bound to a visualization of unusual singularity.Footnote ¹³⁷ As I have shown previously, photography was also used to reproduce characteristic visions by distributing mechanical reproductions of illustrations and moulages. As a medical tool, photography could both be useful in showing new and previously unseen singularities, and by distributing subjective accounts of characteristic images more widely than ever before. By the 1980s, it had become the perfect genre equipped to visualize an impending crisis, as well as renewing a traditional medical authority in absence of clarity and reliable medical understandings.

The epistemic tension of photography between the patient’s illness and an abstract definition of disease that was set up in the late nineteenth century continued through the twentieth century. Peter Hansell, photographer at the Department for Medical Photography in London’s Westminster Hospital argued just after World War II for a timely transformation of medical photography. He hoped it could become a method of knowledge dissemination rather than mere recording.Footnote ¹³⁸ Despite an increase in professional education he demanded the installation of standardized archives and the inclusion of arrows, labels and scales within the pictures to regulate medical photography as a useful and exploratory tool of modern clinical practice.Footnote ¹³⁹ Similar ideas have been articulated by Brian Stanford, who argued for clinical photographs to “provide an absolute image to the mind of a doctor who has never seen the patient before; they must even provide an absolute image to a doctor who has never seen a similar complaint before.”Footnote ¹⁴⁰ He demanded standardization and broad institutionalization of clinical photography to “evoke a real image”Footnote ¹⁴¹ of the disease, and not just mere partial glimpses of illness, pain and affliction.

Mifflin has recently pointed out that this entanglement between photographic records and spectacular diseases could again today be of use in medical teaching to demonstrate illnesses, symptoms and full-blown disease pictures in their original, untreated stages that have never been seen by most medical students or doctors.Footnote ¹⁴² The photographs of people with AIDS work similarly today compared to the 1980s, as pictures of full-blown AIDS that is rarely seen in contemporary clinics or even publications. The emerging epidemic was photographed in its early years, when its complicated, confusing and sensitive appearance was best captured by the historically developed practice of a clinical photography: It provided a way of seeing, that remained on the surface, both individually and regarding the epidemic’s unresolved etiology. The spectacle of newness, unusualness and rarity could be captured to illustrate what was known about the threatening epidemic, while teaching how it was to be seen so to reestablish medical authority in face of an epistemic crisis.