by Kaspar Kiepenheuer
This paper is devoted to the case and life history of an individual child, Adrian, who suffered from acute lymphatic leukaemia from the sixth to the ninth year of his life. During this period he made more than 300 drawings, of which only a small selection can be examined in the space of this paper. I gratefully acknowledge the insights I gained into the inner experience of this very reserved child as a result of studying and evaluating some of the somatic and psychological contents of these pictures with Susan Bach. This offered me a strong supportive basis for communicating with him. And, finally, this form of communication helped to lead his parents and brothers out of their isolation and mute bewilderment.
Adrian, born on April 1, 1965. The diagnosis of leukaemia was made when he was six years old. After an initial hospitalisation of six weeks, he had regular check-ups in our out-patient department. Meningeal involvement was found in March 1973. There was a bone marrow relapse and brain infiltration in October 1973. Meningeal involvement started again in February 1974, and bone marrow relapse in March 1974. In the intervals that were free from relapses and complications the child was in satisfactory general condition and was able to go to school. On June 26, 1974, a bone marrow transplant was performed after preparation of the patient with high doses of antileukaemic medication and whole-body radiation while he was being cared for in a sterile unit. On July 12, 1974, the child died of a serious pulmonary infection.
All the titles of these pictures were given by the author.
Figure 2.1: Through this picture we are introduced to the family: to the left we see Adrian himself, with folded arms, head slightly inclined and his mouth strangely rectangular and stiff. However concerned and preoccupied we are with the fate of the patient, we do not want to forget that, in the background, there is a family affected and suffering in its own way. Thus, it is all the more helpful to have our attention drawn to the family situation by means of a picture like this. Children and parents are drawn in two separated frames. The two younger brothers are clearly removed from Adrian, the older one; they seem to be in the background; C. stands with raised arms and laughing; W., the smallest, is characterized as a cry-baby by his wide-open mouth with lines coming off from either side. Strangely, both parents have no arms! In connection with their facial expressions, that gives me the impression of helplessness and perplexity.
In a talk with the mother, we learned that little W. draws attention to himself not only by his crying, but also by continual bed-wetting, while his big brother - and perhaps rival - has, through his illness, become the centre of his parents' interest. C., on the other hand, was more and more often given the difficult task of standing in at home not only for the bigger brother, but even for the parents when they had to accompany Adrian to the hospital. Finally, he too had to see a doctor on account of his troubled sleep and stomach aches.
Figure 2.2: Only rarely do we get the drawn representation of a dream from a child. Adrian pictures himself with a highly raised head. Above it there is a large expanse painted white like a carrier or frame of the dream contents. An unrecognizable figure in a muffled disguise enters, running. It is followed by a shape which the boy referred to as a ghost (additionally, it looks like a moving white blood cell with a black nucleus). Close by we see a symbol representing death, well-known to the boy. One cannot help wondering how Adrian will manage to face all these things and take them into himself, especially when one compares these three threatening symbols on the large white expanse with the small white head of the child himself. However, here in the picture he was able to convey these inner experiences impressively and colourfully.
From the case history, we learn that a leukaemic infiltration of the meninges had already started. Only a few months later the first bone marrow relapse occurred.
Figure 2.3: Under its large, red wavy roof, this house is remarkably low, as if cut off or sinking. Exactly above it is a pale red little figure: half-man half-bird, his arms (or wings) raised towards the threatening red weather in the West. The crown of the poorly rooted tree seems to be aflame, and a small black figure (perhaps a bird) is just about to raise his wings and take off.
Adrian has been in the hospital for four days on account of a bone marrow relapse and a leukaemic brain infiltration with a focal epileptic fit: this, a double acute process which may be reflected pictorially in the roof of the house and the crown of the tree. As a result of this, both house and tree seem to have become equally uninhabitable. Still, the anti-leukaemic and anti-epileptic therapy proved sufficiently effective, and in the picture "he" gets solid brown earth under his feet again. Less acute, but no less numinous is the impression created by the four black clouds and the four black birds. Exactly four months later, we were bewildered to discover there was a further relapse.
Figure 2.4: The title of the picture corresponds to that of the fairy tale from 1001 Nights in which Ali Baba (the same initials as our patient!) gains secret admission to the cave of the robbers by the magic formula, "Open Sesame". Ali Baba skillfully evades the robbers' pursuit, and the tale ends with the outwitting and killing of all 40 robbers by Ali Baba and his cunning servant.
Let us concentrate first on the description of the picture: it is divided into two halves. To the left, halfway up, and "floating" like a mirage, the child draws the treasure cave. At a conspicuous distance from this, five figures take up the right half of the picture. In their midst is a kind of skeleton man, consisting of twelve white parts - a traditional way of presenting death. In his raised hand, he holds a saw (Ali Baba is a woodcutter, after all). Through his wide open left eye, he looks straight into the eye of the beholder and - the drawing child! This observation I owe to Susan Bach. Indeed, it proves helpful to relate the position of the drawing patient to each of the figurative representations. We take note of this "White Death" (leukaemia, leukos = white), and all the more so as he does not appear in the fairy tale. Three of the figures, presumably robbers, seem to be pointing grim looks and shiny weapons at him. Their attitudes are strangely ambivalent: for instance, the hand of one of them is timidly reaching backwards. The fourth manikin at the bottom of the picture goes his own way; his brisk pace, his weapon and his open look all point left, in the direction of the cave, and make him a great contrast to the others with their ambivalent attitudes. This fourth manikin is drawn in more vivid colours too. He passes just beneath the skeleton man's saw: his clothes are curiously "sawed" at the edges.
In evaluating the picture, we try to grasp the child's whole personality, i.e. to understand the picture as a representation of his physical and psychic condition. As a physical image, this picture may reflect the desperate struggle with the "white illness". The "burning" red light on one of the heads reminds us of the meningeal infiltration which was once more occurring at that time. The three black flashes of lightning on the other head look like a pictorial representation of the head radiation. It follows that the sharp weapons might be a compliment to our (passingly successful) therapy. And it is perhaps thanks to this that the manikin at the bottom of the picture "made it" once more; with renewed vigour and colour, yet marked by the saw of death, he can turn towards another goal - the cave with its promising treasures.
If the picture is evaluated psychologically, the two sides appear separated from each other by a long distance, a yawning void: on the one hand, there is a vigorous rebellion against illness and dying; on the other, something remote, promising, static and restful. This hiatus between the two realms could be understood as a call to accompany the child on his way and to help him build a bridge from one side to the other.
A short time later the child had a second bone marrow relapse which was again overcome by radical therapeutic measures. Adrian's decisive cooperation at that time impressed us.
Figure 2.5: On waves splashing high, the big-bellied ship sails from left to right. On deck there are ten Vikings of various sizes and colours, and with an assortment of weapons. All the weapons are raised: swords, lances, clubs, sabres and daggers. Strikingly, there are only nine shields at the disposal of ten Vikings! Six blood-red stripes cover a part of the bulging sail. On the white space after the sixth stripe would be room for about three more stripes. Above, in the masthead, is an eleventh Viking. He looks through his telescope in the direction they travel, to the right. In the usual style of this gifted child, the seven strokes above this Viking's head probably denote that something has suddenly caught his attention. The existence of this far-seeing man offered me a welcome opportunity to start a conversation with Adrian. It struck me again and again how important it was for this reserved child that I should take note of the contents of his drawing. He asked me to describe the picture down to the last detail. After I had duly admired it, its many colours, the weapons, etc., I asked: "And who is that up there?" Since there was no reply, I went on to ask: "What does he see in his telescope?"
He said: "Another ship."
Some weeks later I asked him again who was up there. He replied: "That's you!"
Once again, Adrian expressed himself by means of a far distant epoch, even one steeped in legends, the medieval Vikings, bold seafarers of the North. Alerted by Susan Bach, my attention was drawn to the significance of numbers in this picture, especially in relation to some biographical data: if the six blood-red stripes correspond to six healthy years of life, we can estimate how much room remains for the following "white" (leukaemic) years. If the ten Vikings have only nine protective shields, what happens to the tenth in the case of attack? Or, again in terms of the same time unit, what will happen in the tenth year after nine protected ones? The course of the illness provides a deeply moving answer.
Yet, from another level, so to speak, something new is in sight so significant that it is worth seven little strokes to the boy artist. That he links the doctor who takes care of him with this far- and fore-sighted figure may perhaps be taken as a confirmation that he felt inwardly understood in our kind of dialogue. That encouraged me to continue on the same level, pursuing at the same time, however, the haematological procedures.
Figure 2.6: In the lower half of a big sheet, Adrian drew "Three wild animals hunting something unknown", as he explained to his nurse. When studying this picture with Susan Bach, we were puzzled by the word "hunt" as we looked at the expressions of these animals. They seem to be bracing themselves against the direction in which the "unknown" is supposed to be. Their coats and even the ground they walk on are bristling. They bare their teeth, show their orange-pink tongues, and their stiff tails and ears express a mood of alarm. Adrian meant to rub out the small animal to the right with its faint pencil outlines. Instead, "by mistake" he took the yellow crayon: a yellow line cuts through the head and one paw of the animal.
In conversation with the child, the "unknown" did not become more evident. But the previous as well as the actual course of the illness provide sufficient cause for the gravest misgiving. Because of a renewed focal epileptic fit, Adrian is undergoing heavy anticonvulsive treatment. Further relapses and complications are certain to occur. Only a bone marrow transplant might still provide a chance of recovery, however slim.
In order to experience this child's view of his own physical and psychic state through this drawing, I tried to put myself into the situation of these animals, to slip into their skin as it were: the ground is shaking and trembling beneath one's feet; the feeling of fright and terror in the face of something gruesome is piercing. One would like to scream. The child's inner fears - so vividly illustrated in this picture - were perhaps all the stronger as they were not expressed verbally. From then onwards our medical team encouraged his parents to talk frankly to him. His father told him about the nature of his illness, about the serious prognosis, the importance of medication, etc. Thus, considering the chances and dangers of the planned bone-marrow transplantation, we could talk very openly with him.
With admirable courage, Adrian entered a sterile unit in preparation for this serious operation. What he felt during this phase, the following drawing may illustrate:
Figure 2.7: The picture was a present for the chief nurse of the department, whom he called "Sheriff" in jocular consideration of her rank. In the left corner of the picture, we see twelve pirates, as the child called them himself. Some are only half visible. They carry many kinds of weapons and appear in full attack. Some lack a leg, an arm or an eye. The fat, athletic pirate in the foreground is particularly conspicuous. He has three weapons: a dagger, a sabre with a strange (skull-like!) handle as well as a big pistol whose shot - in the middle of the picture - is aimed at the shadowy form on the right. According to the child, it is a ship belonging to the pirates. Its outline is barely recognisable. Of the two portholes, the one on the left seems to look like a proper eye; the other is empty (blind?), and a ladder with rungs leads inside. The twelve pirates are separated from their ship by a grey, rising kind of threshold.
With the external, physical interpretation, one could be tempted to see among the pirates not only our "Sheriff" chief nurse, but also all the other members of our team who fight against Adrian's leukaemia; or, the child himself in his physical fight and his co-operation with our antileukaemic measures. The weapons (our therapy?) are impressive. But are they effective? The child's pictorial language indicates a lack of co-operation and integration in this fight. Susan Bach, as she looked at this picture, was reminded of the disintegrated, pathological growth of leukaemic cells. The Sheriff's pistol dominates the picture. That very day an important and incisive injection had to be carried out after it had been explained to Adrian. The picture tells us how this "shot" may have dominated his feelings and thoughts! The whole body radiation, planned for a few days later and also discussed with the child, may be announcing itself and its "burning out" effect in this burnt-out ship.
Let us now look at the drawing as a representation of the child's inner experiences. Again, two opposed worlds are facing each other. To the left, colourful life, the daily courageous grappling with reality, but also unrest, confusion, contradictions. To the right, colourless, stiff, motionless and quiet: a death ship? As the picture tells us, the child seems to "know" that, however radical the operation, such a burnt-out shadowy structure cannot be saved anymore. On the contrary, it is already steering towards new horizons. Do the twelve rungs (for the twelve pirates?) not bear a gruesome resemblance to the ribs of the "death" in Figure 4 (twelve there, too)? Here they give access to the realm of the shadows. The visit to Hades was the twelfth and last of the labours of Herakles in Greek mythology, and surprisingly, Charon's boat that carried people across the river Acheron is depicted on Greek vases with an eye at the bow!
The threshold to this new horizon is low, the anchor is ready for weighing. Thus, the fight is still on.
Figure 2.8: Before he did this drawing, Adrian talked with his mother. Together, they thought of all the people who were praying for him. He drew with pencil on a green sheet of paper that he had chosen for himself. At the top is God with a halo, surrounded by clouds, fourteen stars and the crescent of the waning moon. Below are the names of his nearest and dearest who pray for him: Daddy and Mummy (in Spanish, his mother tongue); C. and W., his brothers. The enclosed room below represents his sterile unit. He is lying stretched out on his bed. Above his head there "floats" what is presumably the content of his prayer: "healthy", plus an upright little figure with strong raised arms (cf. the bird-man in Figure 3), and next to it, a hand that seems to be pushing away four syringes. To the right, at a great distance from the child, there sits his mother, who had in real life - in sterile clothing - been able to participate to a considerable degree in the care of her child. She is also praying. Between them there is a table with a set of sterile instruments. Last, the child draws the seven beams between heaven and the sterile unit (see Bach, 1974/75).
This is the very last picture Adrian ever drew. How different it is from all the previous ones! There is no suggestion of fighting now. Peace has been made with the "other side", which is no longer unreachably distant (Figure 2.4). It is not something unknown and frightening outside the picture either (Figure 2.6), nor is it stiff and inanimate (Figure 2.7). No, in this picture the other realm proves to be the Kingdom of Heaven, peaceful and almost serene. In the context of the whole picture, I understand the word "Healthy [gesund]" in the child's prayer to mean redeemed, saved, hale (salvatus). After all, the small (soul) man with his raised arms points in the direction of God. The syringes that have been pushed aside suggest: Enough injections have been given; they are no longer necessary now. In contrast to previous pictures, here the void between the two facing sides is bridged by seven beams, although they do not actually reach the child's unit. Are they showing him the way? Having learnt to take seriously the significance of numbers in the drawings of our children, we ask ourselves what the number seven means for this child. Or, in the particular context of this picture and the child's situation: In what way do seven units separate this child from - or lead it to - Heaven?
To what extent this picture was right, only the further course of the illness showed. After the co-operative child had, at first, overcome the major operations, the medical record tells of the first feared side-effects. An obscure fever worried us more and more. We could not influence it with our medication. After seven days, on the night between the 11th and 12th of July, 1974, Adrian died of a serious lung infection. His parents were present, and told us that Adrian had remained fully conscious almost to the end and had died peacefully.
This picture is now kept by the parents as a legacy. Weeks after his death, we looked at it again together. In tears, Adrian's mother confessed to me: "Adrian has given us so much more than we could give him." Indeed, I too, had been deeply impressed by the inner composure and strength of this dying child. More and more his parents had become able, so to speak, to rely on his guidance. How much strength can be derived from deep religious convictions is shown not only by this last drawing, but also by a remark he made to his parents: "Jesus has given me so much strength that I shall get over anything that is coming now."
On my regular visits to the family after Adrian's death, I wished to comfort the parents and to show them my sympathy. During these long evenings we faced many memories that emerged from the parents and Adrian's own drawings. We learned to see this child's short life as a life picture, a meaningful unity that had come full circle. [[Compare this feeling with Bach's chapter 1, Small Circles - Closed Early [Editor]. ]] In spite of all their grief, the parents expressed a feeling of great happiness about this. On the other hand, one has to be aware not to gild the memory of a child so much that he becomes an idol. Such a deviation from reality would again have condemned the two brothers to a forgotten, marginal existence. Their behaviour alarmed me already: the smaller, W., had stopped wetting his bed from one day to the next after Adrian's death, but promptly began again when I paid a visit to the family! C., on the other hand, was remarkably quiet and did not manage to utter one word concerning his dead brother. But when I turned to him and told him how pleased I would be to have a picture from him, he drew the following:
Figure 2.9: Onto a black sheet he drew, incomplete, the memory of a trip they had taken together to the Black Forest. When asked about the white fisherman, he said: "That is somebody." Urged further, he replied, very carefully: "That is Adrian." From then on, he was again able to pronounce the name of his brother.
W. expressed his relationship with his dead brother some weeks after Adrian's death as follows: "It is wonderful that Adrian is in Heaven with God. But now I want him to come back." His drawing shows us how alive the presence of his brother has remained for him.
Figure 2.10: According to the child's commentary, Adrian is above in Heaven near God waving down happily smiling. From below, he (W.), waves back, his look turned upwards. To the left, just on the edge as if looking round the corner, there are the parents and C. This is W.'s version, in continuation of Adrian's last picture, where all members of the family were also involved. It may be taken as his relationship between his world and the Beyond. W.'s fascination (or envy?) for his brother in Heaven became so overwhelming that he expressed his wish to die and join Adrian in Heaven, much to the parents' great terror. At their request, I then saw the child for psychotherapy.
The circle is complete when we turn back to the family picture (Figure 2.1), which had even then drawn our attention to some emotional needs of the individual members of the family. The tension and perplexity, which showed itself there, seems to have been resolved in Adrian's last drawing and C. and W.'s pictures.
All of us dealing with this dying child were not only deeply moved, but also fortified by the inner strength that he conveyed by his drawn communications. This helped us in our attitude toward his parents and brothers, and it also made us more sensitive in the psychological care we give to other dying children and their families. Above all, he helped us to see his fate (and in the end, our own!) - which was, after all, so bitter - in a new light. And this also allowed us to accept what happened instead of rebelling against it.
In our care of leukaemic patients and their families through illness and dying, our attention is drawn time and again to the urgent need that more be done. Clearly we see the need to bridge the gaps that exist in the care available for these children. I wish to stress the importance of such a bridging by a new term: "perithanatal" care (Thanatos, Greek = death).
Based on Adrian's drawings, I have tried to describe this task. In his case, it was possible for a bridge to be built from the child to the doctor and the nursing staff, from the child to his family, also from the physical to the psychological aspects of his illness, from the active struggle with the reality of illness to presentiments of the hereafter. And finally, our attention was bridged or drawn from the dying and dead child to those still living who were left behind.
The case history of a leukaemic boy (6 to 9 years old) is presented and illustrated by a selection of his spontaneous drawings. These were an invaluable help in the care of this child, i.e.:
After the boy's death intense attention was given to his two brothers, their feelings also being represented by their spontaneous drawings.
Bach, S.R. (1974/75), Spontaneous Pictures of Leukaemic Children as an Expression of the Total Personality, Mind and Body, Acta Paedopsychiatrica, 4, 1, p. 100.