The Sick Child: Edvard, empathy and expertise

Can physicians discover empathy and derive clinical expertise from art? Let’s try with The Sick Child by Edvard Munch.

Learning objectives

1. Utilise The Sick Child to try and discover empathy

2. Reflect on the meaning of clinical expertise

3. Consider how experiences of illness can be expressed through art


Edvard Munch (1863-1944) is perhaps best known for his work The Scream depicting a moment of anxiety and existential dread that many feel resonates with our age. There’s even an emoji 😱 for our spectacular society.


A number of detailed interpretations of The Scream are already available online. In this post I wanted readers, specifically those from a health care background, to explore and reflect using the various versions of one of Munch’s other works titled The Sick Child (Det syke barn). Originally exhibited under the title Study, Munch returned to it time and again between 1885 and 1926. He painted it 6 times as well as creating many other pieces using lithography, drypoint and etching over a 40 year period.


“In the sick child I opened for myself a new path – it was a breakthrough in my art. Most of what I have done since had its birth in this picture.”

The Sick Child (1886)
The first in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:Munch_Det_Syke_Barn_1885-86.jpg

Questions

But, I’m a doctor/nurse/student/someone else, why should I be wasting my time looking at art and suchlike?


With a title like The Sick Child, unsurprisingly the work has a particular resonance with issues relating to child health. But the impact of good or bad health extends further than the individual or patient. It is important to have an insight into the experiences of those close to the child. Bertman points out that physicians need:

“…to go beyond our analysis of paediatric palliative care, to be mindful that we are dealing not just with symptoms or diseases but with young human beings and their families. Patients cannot always articulate their experiences clearly. Simply communicating the presence of physical pain can be problematic enough, but describing aspects of anguish that arise from emotional or spiritual distress is even more difficult. Many patients can benefit from the insights, perceptions, and acuity of artists and poets, deriving relief and understanding from their words or images.”

Chapter 5: Through the creative lens of the artist: society’s perceptions of death in children, Oxford Textbook of Palliative Care for Children

The usefulness of art in healthcare isn’t only confined to the patient experience and/or their family/friends. It is relevant to the practitioner in understanding themselves and developing the much sought after trait of acumen or expertise, beyond that of guideline recital or technical ability.

Image from Castro, E.M., Van Regenmortel, T., Sermeus, W. et al. Patients’ experiential knowledge and expertise in health care: A hybrid concept analysis. Soc Theory Health 17, 307–330 (2019). https://doi.org/10.1057/s41285-018-0081-6

Questions

What is clinical expertise?


Clinical expertise could be defined as a hybrid of practical and theoretical knowledge with an intuitive ability to efficiently make critical clinical decisions while grasping the whole nature of a situation.

But how can a clinician learn to apprehend the bigger picture? A Sweedish study by Wikström used The Sick Child to encourage student nurses to discover and explore their existing knowledge of empathy. The observation, open interpretation and reflection about the work stimulated discussion about ambiguity not only in The Sick Child but also modern day clinical care.

Aesthetics can act as a source of knowledge, as a means for individuals to understand the experiences of others through art. In the case of The Sick Child, we can try to understand Munch’s art (or as he describes, his self-confession) from his perspective which in turn can help us empathise with others.

I hope this post will allow the reader an opportunity to reflect on their own interpretation, develop expertise and perhaps even discover something new about themselves.


The angels of fear, sorrow, and death stood by my side since the day I was born.”

The Sick Child (1896)
The second in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:Munch_Det_Syke_Barn_1896.jpg

Questions

What are your immediate feelings about the image?


Edvard Munch had a complex relationship with illness that is expressed in his art. His experience with confronting death and grief started at a young age, his mother Laura dying aged 31 with tuberculosis in 1868 when he was aged 5. Another work called The Child and Death shows his dead mother but instead Edvard places the focus on the distress of his 6 year old sister, Sophie. It could be considered a precursor to The Scream except the terrified Sophie is silent, her torment internalised only to be communicated later through Edvard’s art.

Edvard’s father, Christian, was a physician in a low paid military role. Economically struggling, Christian did attempt to develop a private practice but it failed partly due to a charitable attitude toward patients unable to pay. Christian was subject to depressive episodes and combined with his deeply religious views had visions of his children’s damnation in hell.

After Laura dies, Edvard’s aunt Karen helps raise the children. She is described as warm, intelligent and artistic. She treats the children as her own, declining an offer of marriage from Christian and sleeps with the girls in their bedroom. She introduces Edvard to the world of art and later appears in a number of his works.


“I felt always that I was treated unjustly, without a mother, sick and with threatened punishment in Hell hanging over my head.”

The Sick Child (1907)
The third in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:Edvard_Munch_The_Sick_Child_Thielska_289.tif

Questions

How is empathy expressed in the image?


The infection passes through the family. Edvard suffers with significant health issues including a number of childhood respiratory illnesses. Aged 13, he recounts his own symptoms in Christmas 1876:

‘Papa the stuff I am spitting is so dark.’

‘Is it, my boy?’

He brought the candle, I saw him hiding something. Next time I spat on the sheet to see what it was.

‘It is blood Papa.’

He stroked my hair – ‘Don’t be afraid, my boy.’

So I had tuberculosis. There was so much talk about it. When you spat blood you had tuberculosis. My heart started to beat so loudly in my chest. I crept into father’s side for comfort.

‘Don’t be frightened boy,’ father said again.

But I was very frightened. I could feel the blood rolling inside of my chest with each breath that I took. It felt as if the whole inside of my chest had come loose and was floating around, as if all the blood had broken free and wanted to rush out of my mouth. Father tented his hands; to pray.

‘Jesus Kristus, Jesus Kristus.’

‘Papa, I’m dying – I can’t – I don’t dare, I’m frightened of dying – Jesus Kristus.’ Outside the church bells were ringing to celebrate Christmas.

I looked at my brothers and sisters, and I envied them. Why should I be chosen for this sickness, this punishment? Was I, then, more wicked than they? – That was a thought sent by the devil – I folded my hands and begged God’s forgiveness.

Edvard Munch: Behind the Scream, Sue Prideaux, Edvard Munch (2005)

“The illness followed me all through my childhood and youth,–the germ of consumption placed its blood-red banner victoriously on the white handkerchief.”

The Sick Child (1907)
The fourth in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:Edvard_Munch_-The_sick_child(1907)_-_Tate_Modern.jpg

Questions

What is being communicated in the image?


Christian saw the “bouts of severe, life-threatening bronchitis and tuberculosis suffered by Edvard as God’s ‘punishing illnesses’ to which the sole response could be penitential prayer and remorseful submission.” Edvard survives the episode.

A year later in 1877, Sophie is now also ill. The Sick Child records the moment preceding the death of his favourite sister from tuberculosis aged 15. Edvard was 14 years old at the time and writes:

Her eyes became red – it was certain then, that death was coming, unfathomable death. She lay looking straight ahead of her… I went over to the window and put my head behind the curtain. I couldn’t stop the tears. Evening came and Sophie lay burning up on her bed. Her eyes were bloodshot and restless; they never stopped roaming the room. She was hallucinating.

Edvard Munch: Behind the Scream, Sue Prideaux, Edvard Munch (2005)

Sophie is propped up by a large white pillow due to her breathing difficulties. The pillow was somewhat iconic of the era as Edvard reports: “As for the sick child, it was the period I think of as the Age of the Pillow. A great many painters did pictures of sick children on their pillows.” Edvard may have drawn some inspiration from Krohg’s Sick Girl (1881) and completed The Sick Child around the same time Fildes completed The Doctor (1891).

Edvard used Betzy Nilsen as the model for Sophie. They met when Edvard accompanied his father to treat the Betzy’s brother who had a broken leg. The thread of health and illness runs through his work as it did his life.

The woman next to Sophie is assumed to be Karen. Looking down, she appears more distressed than Sophie. In the centre of the whole piece, we see hands joined, clenched together. Patricia Donahue observes: “It is almost as though the child, knowing that nothing more can be done, is comforting a person who has reached the end of her endurance.”


“My home was the home of illness and death. I have never gotten over the calamity there.

The Sick Child (1925)
The fifth in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:MunchDaskrankeMaedchen.JPG

Questions

How do the details relate to the bigger picture in medicine?


The dark curtain toward which Sophie is gazing is often considered a symbol of death, adding a claustrophobic feel to the work. The use of green and yellow represent sickness, the red brush strokes invoking the haemoptysis of late tuberculosis. Even the child’s hair appears to be bleeding.

The brushstrokes are harsh and over time, the colours become more vivid, contrasting with the pale and almost transparent face of the child and the bright light of the pillow that is illuminating the room. The details become less clear and a more fluid style emerges. The memory is concrete, Edvard is looking through teary eyes.

Dying, Sophie asked to be lifted out of bed and placed in a chair where she died. Another of his works, Death in the Sickroom, shows the immediate aftermath of her death on the family with Sophie dead in her chair, now facing away from the viewer. Edvard kept that chair until his own death.


“I reworked the picture countless times in the course of a year—scratched it out—allowed it to infuse the paint medium—struggling again and again to recapture the first impression—its translucency—the pale skin towards the canvas, the trembling lips, the trembling hands.”

The Sick Child (1927)
The sixth in the series of paintings

Image from: https://en.wikipedia.org/wiki/The_Sick_Child_(Munch)#/media/File:MEp1631m001_2008.jpg

Questions

Are there challenging moments in your career that you have often revisited?


The scores in The Sick Child are harsh as if Edvard is trying to erase Sophie’s death. The repeated variations of image as further attempts to convey all the different aspects of his recollection of her death.

Munch’s father dies suddenly of a stroke in 1889. Reportedly, Edvard “came to believe that nothing ceased to exist. Rather, life was intertwined within Nature such that things and people were reborn from previous matter. Life was an endless cycle, rather than marked by birth and death.”


“I am convinced that there is hardly a painter among them who drained his subject to the very last bitter drop as I did in The Sick Child. It was not only I myself sitting there – it was all my loved ones…”

The Sick Child (1894)
Drypoint. Photo © Munchmuseet

Questions

As physicians, how do we emotionally reconcile the repeated exposure of life in one moment and death in the next?


In the 1894 drypoint, Munch included a landscape in the lower part of the piece unseen in other versions with a tree underneath Sophie. The British Museum suggests perhaps “he intended to contrast the blooming life of nature with the dying of humanity” or perhaps this is what Sophie is hallucinating or seeing behind the curtain.

In another post, I explored the relationship of nature in art with health outcomes.


“What I wanted to bring out―is that which cannot be measured―I wanted to bring out the tired movement in the eyelids―the lips must look as though they are whispering―she must look as though she is breathing―I want life―what is alive.”


Questions

Can health care professionals experience and understand the same event differently?


In a number of the variants, there is an emphasis on Sophie’s face. The face is now anything but that of the one in The Scream, it is resigned rather than anguished.

Tragedy continues to strike the family. Edvard’s brother, (Peter) Andreas, was a physician like his father and died of pneumonia in 1895 aged 30 years a few months after getting married. Edvard creates a number of variations of The Sick Child a year later.

Edvard’s younger sister, Laura experiences mental health issues for which she was often hospitalised and dies of cancer in 1926 aged 59. A year later Edvard completes what is believed to be his final painted version of The Sick Child.

Although The Sick Child is based on a personal memory, it expresses the universal feeling of grief.


Sickness, insanity and death were the angels that surrounded my cradle and they have followed me throughout my life.”


Questions

How do physicians express themselves and their experiences?


Edvard himself nearly dies of influenza during the 1918-1919 pandemic. Edvard develops visual problems (such as floaters, ocular haemorrhage and a scotoma) during his life which may have influenced his style particularly later in life. He creates a series of pieces in 1930 that show what he can now see during this period of convalescence. Interestingly, the ophthalmologist Max Linde was an important patron of Munch.

Karen dies a year later in 1931.


“Without fear and illness, my life would have been a boat without a rudder.”

The Sick Child (1896 uncertain)
Pastel. Photo © Munchmuseet

Questions

Do health care workers have a different understanding of the meaning of death because of their experiences?


Pedersen argues that The Sick Child can be interpreted beyond the usual historical-biographical perspective. It is not just Sophie that is portrayed, nor just a pictorial representation of tuberculosis or sickness in general. The images open up the world of death. It supremely concerns how the understanding of death is revealed and the reality of dying. It discloses what it means to cease to be.

Has art made you think about your own approach to certain clinical situations? Please consider sharing in the comments section below.


Summary

Art can be useful tool in helping clinicians learn empathy and discover expertise. Interpretation of The Sick Child with contextual reference to Munch’s life provides one opportunity for health care professionals to better understand their own experiences of illness and death and those of their patients.


“Nothing but illness and death in our family. We were simply born to it.”


Further resources

Det Syke Barn (The Sick Child)
https://www.bmj.com/content/338/bmj.b1439

Edvard Munch and The Scream: A Cry for Help
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259715/

Edvard Munch’s renditions of illness and dying: their message to contemporary physicians
https://pubmed.ncbi.nlm.nih.gov/16750772/

From My Rotting Body, Flowers Shall Grow, and I Am in Them, and That Is Eternity
https://wwwnc.cdc.gov/eid/article/17/3/ac-1703_article

Keeping It in the Family: the Childhood Burden of Tuberculosis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5382755/

Munch’s visions from within the eye
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876155/

On the Pictorial Thinking of Death: A Study in Martin Heidegger’s Unthought Art History of Being Regarding Edvard Munch’s The Sick Child and Metabolism
https://www.duo.uio.no/handle/10852/59044

Spring
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/482404

The Sick Child, Munch Museum
https://munch.emuseum.com/objects/8190/det-syke-barn?ctx=641b53c7-7dfb-4c5a-97c3-17089364e162&idx=0

The Sick Girl
https://www.virtualempathymuseum.com.au/wp-content/uploads/2018/11/The-sick-girl.pdf

Work of art dialogues: An educational technique by which students discover personal knowledge of empathy
https://pubmed.ncbi.nlm.nih.gov/11811344/

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