Søren Kierkegaard Newsletter — Number 49: August 2005

Søren Kierkegaard Newsletter — Number 49: August 2005

The Health Matter Briefly Revisited

Epilepsy, “Hunchback,” and that tiny word (tubercl?)

Joseph Brown III, MD

Professor Emeritus, Pediatrics, Texas Tech University

MA Candidate, Columbia Theological Seminary, Decatur, Georgia

Testimonies to Kierkegaard’s physically and psychically tortured existence abound in the literature surrounding his life and works. Bruce Kirmmse’s landmark annotated compendium “Encounters with Kierkegaard” offers the most recent and most compact English resource to find observations by his contemporaries.[1] Joakim Garff, using his unparalleled access to primary source material, explores many of these physical and mental health issues in his monumental biography, recently released in an English edition, translated by Kirmmse. [2] In addition, over many years there has been a small but steady flow of books and articles that address Kierkegaard’s health issues, most are accompanied by conjecture over what effect a particular illness could have had on his literary work. Robert Widenmann and Henning Fenger discuss many of these speculative theories in their separate reviews.[3]

Epilepsy, pathological kyphosis (“hunchback”) and tuberculosis are addressed in all of the above commentaries. Importantly, these three singly or together could account for every physical and most psychological observations reported. Avoiding medical jargon and with the Kierkegaard scholar in mind, I will present pertinent medical insights into these three disorders. My hope is that the scholar will be better able to assess any conjecture when he or she encounters it.

Cup your hands over your ears (fingers pointing backward) and you have fairly well outlined the left and right temporal lobes of your brain. Specific regions in these two amazing interconnected structures organize and control many higher functions unique to our human species: language recognition and formation, sentence structure, long term memory, our emotions--ranging from psychotic ideations to flight-fright responses. Epileptic symptoms originating in these lobes range from a mere blank stare, to head twisting, blinking and tongue thrusting, with or without loss of consciousness They can include frightening psychic phenomena such as shrinking and tilting of visual images, depersonalization and derealization--to the point of autoscopy, the sense of seeing ones own body from the outside. As Garff points out, patients sometimes regard these episodes as “a feeling of sublime bliss.” Individuals with temporal lobe epilepsy may or may not remember the seizure episode, and indeed may be able to carry out some conscious activity in the midst of the seizure.

In 1975 S. G. Waxman and Norman Geschwind noted an inter-ictal (between seizure) symptom complex of approximately fifteen behaviors, “a personality profile” in some of their patients suffering from temporal lobe epilepsy. [4] The behavior complex has become known as the Geschwind syndrome, in honor of the late Harvard neurologist. Among the fifteen are such notable behaviors as “hypergraphia” (in some a 10 fold increase in words used to answer standard short essay questions when compared to normals), hyper-religiosity and altered sexuality, often accompanied by mood disorders, including overt depression. As one reads this litany, one could conclude it could be called the “Kierkegaard” syndrome or “Adler” syndrome: it also could be called the Dostoevsky or Van Gogh syndrome, or be named after any one of hundreds of geniuses or schizoid personalities whose lives have been compared to the profile since the symptom association was first noted.

In 1988, Heidi and Lief Bork Hansen first compared the features of the Geschwind syndrome with Kierkegaard’s well-documented behavior characteristics. [5] Lief Bork’s subsequent 1994-literary/medical review (with extensive Danish and English bibliography) explores his thesis that epilepsy lay at the center of Kierkegaard’s tortured life. [6] Hansen further postulates that his fascination with Adler may well be because of Adler’s “temporal lobe” characteristic hypergraphia and, most telling, the out of body ecstatic dissociative events (autoscopy) which both experienced. (Adler December 1842, Kierkegaard Easter 1848). “Through Adler Kierkegaard is confronted with himself.” Hansen also builds his case that the cause for Kierkegaard’s forgoing of marriage and ministry was in the name of secular and canon law. King Christian V’s 1683 law linked “falling sickness” as equivalent to leprosy and syphilis; if undisclosed prior to marriage they were grounds for annulment. Furthermore, epilepsy was viewed as a familial moral failing. Hansen links Kierkegaard’s intense study of Canon law to this concern. If not the entire thorn, Hansen believes that epilepsy certainly was the point.

Except for modest metabolic-anatomical insights provided by MRI and PET technologies, as of this writing there are no new medically transformational insights into the Geschwind syndrome—if it exists--since Hansen’s review of 1994. Finally, the very pertinent present day discoveries in psychopharmacology are beyond the scope of this essay.

I confess to being put off when the “diagnosis”--“hunchback”--is listed among Kierkegaard’s major maladies. For me “hunchback” somehow conflates into Hugo’s Quasimodo, an image that carries with it conscious and unconscious revulsion and/or pity over his horrid deformity. I believe this psychological content helps fuel biases—e.g., a hidden explanation for the actions of this “isolated, asocial” individual. Although we have only one idealized portrait and several caricatures to go by, I am confident that Kierkegaard was no Quasimodo. The medical term for forward bending of the spine is called kyphosis; present normally to a mild degree in all of us in our upper back. Certain disease processes will accentuate this bend, causing a “hump.” Linguistically sterile the word kyphosis may be, but blessed by absence of the psychological or sociological content Hugo gave it. Clearly Kierkegaard exhibited a significant, probably abnormal kyphosis. Several disorders could well have been its cause.

X-ray films of pathological kyphosis will show collapse of the front side of one or more vertebral bodies, the 24 mobile hockey-puck shaped bones which make up the weight bearing anatomy of the spine. The affected body will be wedged shaped, the apex to the front, producing a forward thrust of the column above it and the noticeable “hump” over the site on the individual’s back. Sometimes, in order to bring one’s weight back over his or her hips, an individual will develop an increase of the normal low back (sway-back) lordosis below the affected area, an observation seemingly caught by Klaestrup.

Kyphosis can be associated with rare severe inherited metabolic disorders resulting in structural weakness in the building blocks of skin, bone, cartilage, tendons, and related tissues. Invariably these illnesses exhibit striking features, such as those captured by Hugo (and Chaney). Most often these individuals also have a lateral twisting of the spine called scoliosis, the combination called kypho-scoliosis, a finding not apparent in our images of Kierkegaard.

More commonly, one or two vertebrae, particularly those in the thoracic region can collapse in a wedge seemingly spontaneously—an occurrence in an otherwise normal person. The condition occurs frequently enough to bear the name Scheuermann’s disease. Believed to be a disorder of the growth process, Scheuermann’s often will first appear at the onset of puberty. If not corrected, the condition is permanent. Most often it remains stable, the individual affected only by the appearance of the hump. However it can be severe enough to compress the nerves that comprise the spinal cord and cause varying symptoms of neuronal damage below the defect, ranging from abdominal pain, to sphincter problems to lower leg paralysis. When one considers that no mention ever was made of the hump until Kierkegaard’s adulthood, Scheuermann’s could well explain the notorious hump and its consequences.

Trauma and infection also can cause a sudden or gradual collapse of a vertebral body, (remember that memorable fall from a tree). One notorious infection, Pott’s disease, tuberculosis of the spine, seems so clearly relevant to Kierkegaard’s case that its discussion occupies the remainder of this essay. The medical history leading to the mid 19^th century highly sophisticated understanding of tuberculosis I believe will be instructive to non-physician readers. The story also centers on the prominent role French physicians played in this understanding and their influence on Kierkegaard’s doctors.

Fueled by the atrocious working and living environments that accompanied the industrial revolution, massive migration into cities, incessant wars and a high density of susceptible individuals, tuberculosis, the “White Plague” was devouring all major cities of Europe and the United states during the 18^th and 19^th century. According to Rene and Jean Dubos, during these centuries, “all dwellers in large cities of Europe became infected at an early age.” [7] Even after its infectious nature was understood (early 1880’s) and social and medical efforts had reduced the death rate in half (early 1900) “tuberculosis remained the greatest killer of the human race.” [8] Ironically, as opposed to dramatic lightening quick outbreaks of smallpox and cholera which caused public panic and demanded official attention, tuberculosis was so ubiquitous and indolent that scant attention was paid to its occurrence; death due to “phthisis” a matter of course, the will of God.

Although only an emerging “market town” of around 120,000 citizens, social and environmental conditions in 19^th century Copenhagen met all the requirements needed for explosive epidemics. I doubt it was spared its more populous neighbors’ tuberculous fate. Most likely everyone residing in Kierkegaard’s Copenhagen was infected. (Accurate data gathering was not fully implemented until after the infectious nature of the disease was understood late in the 19^th century. Citing various sources the Dubos extrapolate early 20^th century data to 1875, estimating that the annual tuberculosis death rate in Denmark was an astounding 300/100,000. [9] Remember that much less than 1% of those infected die from the disease). Speculative statistics aside, given the pervasive presence of the disease throughout Europe, it seems unlikely Kierkegaard was spared infection.

In spite of glaring examples to the contrary (Ole Bang’s folksy manual), Kierkegaard’s physicians were no back-woods practitioners of “voodoo” medicine. In addition to the peripatetic raconteur poet, medical manual publishing, Kierkegaard family physician, Oluf (Ole) Lundt Bang, other prominent contemporary Copenhagen physicians included S.M. Trier, C. E. Fenger, C.J.H. Kayser, A. Ahrensen, and A.H. Salmenson. Along with Bang, all were intimately associated with Fredericks and Almindeligt hospitals. Younger physicians active in practice at Royal Frederick’s included Kierkegaard’s nephews, Henrik (Sigvard) Lund and Michael (Frederick Christian) Lund, and the now, newly famous (thanks to Garff), naïve record keeping, recent medical graduate Harald Krabbe (Widenmann citing Dr. K. Norregaard gives credit to Emun Silfverberg for this medically dubious but historically important record). [10]

The older physicians were stalwarts in the royally chartered “Medical Society of Copenhagen,” an always social, sometimes scientific, highly elitist organization. Because of its Royal charter, its committee’s often wrote policies and participated in carrying out government health regulations. In addition to Bang’s 1823 plea for collection of “exact information about certain diseases by list of symptoms” (surely “consumption”), minutes of The Society substantiate sophisticated cutting edge scientific interests. [11] Smallpox vaccination of soldiers and control of outbreaks by vaccination occupied a number of meetings in the 1830’s and 40’s: S.M. Trier spoke of efforts to control the Soro epidemic of 1836. Considerable attention was paid to cholera epidemics of 1830, 1831, and 1847 and to the sudden and fulminate epidemic of 1853 that claimed several society members. At one undated meeting, Ole Bang discussed the need for a separate “special services” department for the treatment of syphilis at Almindeligt hospital.

In their student days, Bang and Trier had made the traditional medical grand tour to Paris, (the “studierejse,” part of the curriculum of any promising student from hospitals around the globe). [12] Apparently both attended lectures by the famous Rene Laennec, the inventor of the stethoscope and father of the lexicon of chest sounds in health and disease. However, of even greater importance, under the tutelage of his teacher Gaspard Bayle, Laennec was the first to describe the pathologic anatomy of tuberculosis. The young Danes surely also attended lectures by other contemporary French medical titans (including Claude Barnard and Pierre Louis). It was these latter physicians who developed and refined “bedside” teaching and the idea of “differential diagnosis,” the method of calculating the most probable diagnoses based on history, symptoms and findings of the patient. Trier carried the Laennec scientific traditions into Danish Medicine, lecturing in Copenhagen and writing about the use of the stethoscope. In addition to Paris, Kayser and Fenger together also visited and studied at the Prussian Medical capitals of Berlin, Heidelberg, and Halle as well as at the important scientific medical centers located in Vienna and finally to Zurich where they studied with the famous Professor J. L. Schoenlein.

In 1803 Laennec announced that “tubercles” (small round nodules) could be found in all organs of the body, (muscle and bone included), in patients dieing of “phthisis” (consumptive tuberculosis). Laennec traced pulmonary phthisis through all its manifestations, from the tiniest tubercle sitting like a gray pearl in the infected lung, which grew to the masses of cheesy material (caseous tuberculosis) to the cavities formed when this material was coughed out. As meticulously described by Laennec, tuberculosis will invade any organ of the body; most notoriously the lymph glands, (scrofula), bones (including spine) (Pott’s disease), brain (tuberculoma) and kidneys. In 1839 Professor Schoenlein suggested that the word “tuberculosis” be used as a generic name for all the manifestations of phthisis, “since the tubercle was the fundamental anatomical basis of the disease.” [13]

Although the infectious nature of tuberculosis was long suspected, it was not until 1882 that Robert Koch identified the tiny tubercle bacillus under the microscope, and proved that it was the causative agent of the disease. Usually the route of infection is through the air, the bacillus settling first in the lungs. Most people (95%) contain the infection there, dieing never knowing they were infected. In others less fortunate, for a variety of reasons (exhaustion, other diseases, pollution, poor nutrition, civil unrest, constitutional predisposition, etc.), the disease will progress in the lungs, sometimes rapidly, sometimes slowly, often times waxing and waning over years. In some individuals, the tubercle bacilli escape into the blood, seed themselves in other organs and take up residence there. The disease in these extra-pulmonary locations also can wax and wane over months or years, suddenly to explode into fulminating activity, causing rapid decline into death of the patient.

And so it is with Pott’s disease of the spine. The infection can be indolently active, off and on compressing spinal nerves (causing abdominal pain, constipation, possibly impotence, leg pain and in-coordination), suddenly to explode into lower body paralysis. If the infected vertebra is high enough on the back, there can be complete loss of sphincter control. In the meantime, yet another colony is busy destroying the kidneys causing bloody urine.

As is evident from the above, and in agreement with Garff, I believe it safe to say that Kierkegaard’s physicians knew their tuberculosis very well. However, unlike Garff, when the word “tubercul?” appears in his chart, I do not take it as a sign of befuddlement. To this day question marks in a record do not necessarily imply ignorance, but rather a “possible” diagnosis among several others, the question mark removed at the time of laboratory confirmation, or in Kierkegaard’s time, after autopsy. This was the French method. Although certainly they would have been much more precise and meticulous than our woe-be-gone house officer Krabbe, Louis’ and Bernard’s hands are seen in Kierkegaard’s care.

The above medical intuitions, coupled with the astute opinion of Kierkegaard contemporary Hansine Andrae, “paralysis of the legs as a consequence of tuberculosis of the spine marrow,” [14] and the report of his non-physician nephew Carl Lund in a letter to Peter “his chest is also under attack by consumption, which is at work in his lungs, spine, and other places,” [15] I along with other writers believe the case for tuberculosis is compelling. [16]

Scheuermann’s, Geschwind or Potts disease complicating pulmonary tuberculosis? We shall never know. However, had I answered any differently than the above to questions raised by my Professor of Internal Medicine on rounds at Atlanta’s Grady Hospital back in 1960, there is a fair chance I might have been available to pursue a career in philosophy rather than medicine. Until, of course, some Professor of Philosophy might have asked me to define Kierkegaard’s understanding of dialectic as expressed in the “Concept of Irony.”