KierkegaardStudies

Edited on behalf of the

Søren Kierkegaard Research Centre

by Niels Jørgen Cappelørn and Hermann Deuser

Walter de Gruyter · Berlin · NewYork

Yearbook2007

Edited by

Niels Jørgen Cappelørn, Hermann Deuserand K. Brian Söderquist

Walter de Gruyter · Berlin · NewYork

Kierkegaard Studies

Edited on behalf of the Søren Kierkegaard Research Centreby Niels Jørgen Cappelørn and Hermann Deuser

Yearbook 2007Edited by Niels Jørgen Cappelørn, Hermann Deuser

and K. Brian Söderquist

The Søren Kierkegaard Research Centre at Copenhagen Universityis funded by The Danish National Research Foundation.

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What Does the Doctor Really Know?

Kierkegaard’s Admission to Frederik’s Hospital and His Death There in 1855

By Ib Søgaard

Translated by Bruce H. Kirmmse

On Tuesday, October 2, 1855 Søren Kierkegaard was admitted to Royal Frederik’s Hospital (see fig. 1). As neither of the hospital’s two medi-cal officers1 was present when he arrived, Kierkegaard was received by the intern who was on duty. When Kierkegaard’s paperwork had been completed and he had been shown to his hospital room, a single room on Mynster’s Corridor, a medical record2 was to be begun.

One has the sense that the person who wrote in the medical record was a bit self-conscious with respect to his famous patient, and after a couple of introductory notes regarding the patient’s ordinary child-hood diseases and his minor difficulties with bowel movements, Kierkegaard himself took over:

He cannot cite any particular cause of his present illness. He does, however, connect it with imbibing some cold seltzer water in the summer, with a dark dwelling, as well as with strenuous intellectual work that he believes [has been] too much for his frail phy-sique. He considers his illness to be fatal. His death is necessary for the cause upon the furtherance of which he has expended all his intellectual energies, for which alone he has labored, and for which alone he believes he has been intended – hence the strenu-ous thinking in conjunction with the frail physique. Were he to go on living, he would

1 In 1855 Herman Emun Silfverberg (1815-85) and Adolph Hannover (1814-94) were the two medical officers at Frederik’s Hospital, serving alternating shifts. They not-ed their names on the first pages of medical records. If both medical officers were absent, the intern on duty carried out the initial examination. Kierkegaard’s record had no notation from a medical officer.

2 Søren Kierkegaard’s medical record in “Medicinske Journaler, Triers Afdeling, November 1855” [Medical Records, Trier’s Department, November 1855], in the National Archives.

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have to continue his religious battle, but then people would tire of it. Through his death, on the other hand, his struggle will retain its strength, and, as he believes, its victory.

After this scarcely scientific portion of the record, the intern probably remembered his instructions for keeping a record, namely, that the case history (the anamnesis) was certainly supposed to be the patient’s own description of the illness, but filtered by the physician, and that interpretations would come at a later point. Perhaps the medical grad-uate also reflected a moment upon the thought that the chief physi-cian would read the medical record aloud when he made his rounds the next morning. In any event, the remaining portion of the patient’s medical record is strictly medical.

This means, then, that Kierkegaard only replied to questions that were put to him. Thus the record says nothing about whether or not Kierkegaard had had a childhood spinal injury resulting from a fall from a tree.3 This fall could have caused a fracture in his spinal col-umn. In that case there would be a possible explanation of the patient’s frequent back pains, and perhaps also accounting for his slightly skewed back and his uneven, erratic gait. The medical record informs us that Kierkegaard had had the symptoms of a respiratory infection for some time, with coughing and phlegm which had been creamlike at first, but had gradually become clear and thin, with yellow blobs.

Two weeks before his admission to the hospital he had slid off a sofa because he had leaned over too far and had difficulties in getting to his feet again. That was the first time he had noticed a weakening of his legs. This repeated itself many times in the days that followed. At no point had there been dizziness, headache, or loss of consciousness. Because this was accompanied by occasional difficulties in urination, and especially because he had begun to experience pins and needles and the feeling of being “asleep” in both legs, he had consulted his physician and was admitted to the hospital.

This is in fact the end of the basic medical record. There are no objective examinations, and in particular there was no stethoscopy of the heart or lungs. Many previous researchers have been surprised that this investigation was not undertaken, particularly in Department A, where the chief physician was named S. M. Trier.4 Trier had written the

3 Henriette Lund Erindringer fra Hjemmet [Memories from Home], Copenhagen, 1909, p. 52.

4 Seligmann Meyer Trier (1800-63), Chief Consultant at the Medical Department at Frederik’s Hospital, 1842-63; during the period 1852-63 his area of responsibility included Department A, where Kierkegaard was a patient in the autumn of 1855. As Chief he made the daily rounds, accompanied by the intern who had responsibility

What Does the Doctor Really Know? 383

Fig. 1: The cover page of Søren Kierkegaard’s medical record from the day of his admission to Frederik’s Hospital, October 2, 1855

384 Ib Søgaard

first textbook of stethoscopy, Anvisning til at kjende Lunge- og Hjer-tesygdomme [Indications for the Recognition of Diseases of the Lungs and Heart], in 1830.5 In other contemporaneous medical records from that department it is clear that careful stethoscopy was undertaken, particularly when there were any signs of respiratory infection.

My claim that the basic medical record ends without having been completed has no immediate visual basis in the handwritten record. The continuation of the record, however, repeats the details that have already been mentioned and goes on to include a couple of pieces of information not mentioned in the basic record, for example, that the arms were in every respect unaffected. This part of the record con-cludes with a partial stethoscopy, with only the front of the chest having been listened to. This is specified more explicitly: “Dorsal auscultation not performed. There is no tenderness along the spine or at any single point, and in general nothing abnormal. Paresis.” This last portion of the main record may be a summary by a more experienced physician who did not repeat the investigations that had already been performed, but merely supplemented them. It could very well have been Trier him-self who dictated this to the intern the next day, October 3, 1855.

The record is written in uniform handwriting, and in the first part of the record there are no corrections. There is no date indication for October 3, and the date indication of October 4, 1855 is placed unnecessarily high on the sheet entitled “Continuation 1” (see fig. 2). On the following days, record entries were made daily, with the date indication at the beginning of the sentence each time.

The first portion of the extant record must be a fair copy made by the intern who was permanently assigned to the patients in private rooms, and a page with the draft of the investigation and relevant stethoscopy undertaken by the original record keeper may be missing.

for the patients in private rooms. See Oluf L. Bang Det kongelige Frederiks Hospital 1757-1857 [Royal Frederik’s Hospital, 1757-1857].

5 Trier’s textbook on stethoscopy had been inspired by Oluf Lundt Bang (1788-1877), his predecessor as Chief at Frederik’s Hospital, who had visited Laennec in Par-is in 1823, bringing back to Denmark a stethoscope, which he then proceeded to use. Bang also wrote the first Danish article on stethoscopy, “Nogle Bemærknin-ger om Percussionen og den umiddelbare Auscultation i Lungesygdomme” [Some Remarks on Percussion and Immediate Auscultation in Lung Diseases] in Bibliotek for Læger, 1824, no. 4, pp. 6-15. Bang also wrote the foreword to Trier’s book. The obituary of Trier (in Bibliotek for Læger, 1864, no. 8, pp. 217-26) was therefore in error when it stated that it had been I. D. Herholdt, who served as private physician to the Trier family, who had inspired Trier to work with stethoscopy.

What Does the Doctor Really Know? 385

Who Wrote the Record?

As a general rule, in our day all notations in a patient’s record would be signed with a name, or in any case with initials. As an historian of medicine, one could wish that this might always have been the case. That this is the practice nowadays is most likely attributable to the increasing number of complaint cases, and it probably has some con-nection, as well, to the right of patients, under the Right-to-Know Law of 1987, to see their own medical records. The only physicians’ names appearing in the records kept at Frederik’s Hospital during the period Kierkegaard was a patient there are those of the two medical officers, and they did not write in records. Over the years a number of physi-cians have been proposed as the ones responsible for having written in Kierkegaard’s medical record.

Fig. 2: Pages 3 and 4 of the medical record. Note the placement of the date “4/10-55.” All the other dates in the notes are given at the beginning of a line

386 Ib Søgaard

In an earlier article, “Sørens sid-ste sygdom” [Søren’s Final Illness], I asserted that the record must have been written by Harald Krab-be6 (see fig. 3). There were eight interns employed at Frederik’s Hospital in October 1855.7 Medical graduates were appointed for two-year terms, with one year’s service in the medical department and one year’s service in the surgical department. Kierkegaard’s record is bound together with those of 69 other patients, and the records are organized so that all medical records in the bound volume con-cerned patients who left the hos-pital in November 1855. Among these patient records, however, there is one concerning a patient who was admitted to the hospital on February 28, 1855. This medical record was written by the same hand that wrote Kierkegaard’s record. This reduces to four the number of those who could possibly have writ-ten in Kierkegaard’s record. After obtaining handwriting samples from these four candidates I concluded that the medical record must have been written by Harald Krabbe.

Recently, in Kierkegaard Studies: Yearbook 2006, Niels Jørgen Cappelørn published a letter from Peter Christian Zahle. The letter,

6 Harald Krabbe (1831-1917). Received his medical (cand.med.) degree from Copen-hagen University in January 1855; served as an intern at Frederik’s Hospital from November 1854 to February 1857; received doctoral (dr.med.) degree in March 1857 with a dissertation “Om Fosforsyremængden i Urinen og om de fosforsyre Jordarters Udfældning deraf ved Kogning” [On the Amount of Phosphoric Acid in Urine and on the Precipitation of Phosphoric Acid Earths by Means of Boiling]; assistant in teach-ing anatomy at the Veterinary and Agricultural College in Copenhagen, 1858; subse-quently private instructor at the same institution; apppointed professor of anatomy at the Veterinary and Agricultural College in 1892. “My father was originally a physi-cian, but he never practiced,” wrote his son, the neurologist Knud Krabbe (1885-1961) in his memoirs, Livserindringer [Memoirs], Copenhagen, Munksgaard, 1956.

7 See Fr. Gredsted Det kongelige Frederiks Hospital 1757-1907 [Royal Frederik’s Hospital, 1757-1907], Copenhagen, 1907, op. cit., pp. 177 and 213.

Fig. 3: Harald Krabbe, who made a fair copy of the medical record and followed Kierkegaard’s case during

his entire period in the hospital

What Does the Doctor Really Know? 387

addressed to John Aschlund, mentions yet another possible name of the person who may have written Kierkegaard’s medical record:

Now a couple of little details about his illness and burial. As he was always deferential to authority, he also believed in the authority of the Chief Physician at the hospital. After having been seen on the street for a number of days in a condition approaching collapse, he was found one morning to be paralyzed in his lower body, and he had his physician, Nutzhorn, bring him to Frederik’s Royal Hospital. The intern on duty at the time (Kiær) then came to him to write up the record. Here S. K. communicated everything he thought might explain the illness.8

The letter gives no indication of the source of Zahle’s information. It cannot have been from Kierke-gaard himself because there are no accounts of a visit by Zahle to Kierkegaard’s sickbed. Who was intern Kiær? His full name was Jørgen Johan Kiær9 (see fig. 4). He and Harald Krabbe knew one another very well. They had sat for their medical examinations at the same time, in the winter of 1855, and they had become medi-cal graduates on the same day, January 22, 1855. Harald Krabbe, however, had already begun his internship at Frederik’s Hospital in November 1854. At that time it was possible for medical students to obtain permission to function as physicians [jus. Practicandi] before they had taken their final examinations, provided they had been recommended by a member

8 N. J. Cappelørn “Brev fra Peter Christian Zahle om Kierkegaards sygeleje, død og begravelse” [Letter from Peter Christian Zahle concerning Kierkegaard’s Illness, Death, and Funeral], Kierkegaard Studies: Yearbook 2006, pp. 271-315, p. 278.

9 Jørgen Johan Kiær (1829-1911). Received his medical (cand.med) degree from Copenhagen University in January 1855; served as an intern at Frederik’s Hospi-tal from June 1855, ended the appointment (normally a two-year appointment) in 1856 to establish himself as a practicing physician in Ribe, Jutland, where he later became public health officer (county physician) and an honorary citizen of Ribe.

Fig. 4: Jørgen Johan Kiær, who according to the most recent research was the intern who examined Kierke-gaard upon admission and wrote up the basic information in draft form

388 Ib Søgaard

of the then-extant Sundhedskollegium [Health Department]; see the note in Trier’s obituary).10 J. J. Kiær, on the other hand, did not begin his internship until June 1, 1855. Since, as previously mentioned, there is a medical record from the end of February 1855 containing hand-writing of the same type as that in Kierkegaard’s record, it cannot have been Kiær who wrote in the record. Of course, he may have been the person who examined Kierkegaard and wrote up the basic medi-cal record, which may have been done in the form of a draft.

The Course of the Hospitalization

Kierkegaard’s medical record has been published a number of times. The first time was in 1895 by P. A. Heiberg, in a slightly abridged version, on pp. 41-48 of Bidrag til et psykologisk Billede af Søren Kierkegaard i Barndom og Ungdom [Contribution to a Psychologi-cal Portrait of Søren Kierkegaard in His Childhood and Youth]. In introducing his reasons for publishing Kierkegaard’s hospital record, Heiberg writes: “What I actually learn from the medical record with respect to a medical diagnosis is little more than NOTHING, but for the sake of completeness and caution I nonetheless want to put for-ward everything which can be said to concern the diagnosis, so that the ‘nothing’ of reality does not give birth to a ‘nothing’ of fantasy.” All the same, Heiberg concludes:

Thus, with the help of the evidence at hand, a medical diagnosis can scarcely go further than a surmise concerning an insidious, chronic disease of the spinal cord, of traumatic etiology – (perhaps spondy-lomyelitis, that is, infection of the spinal cord stemming from a spi-nal infection; some have straightforwardly labeled S. K. as “hunch-backed”); in view of the reputedly early onset of the disease, it could perhaps be placed in a causal connection with S. K.’s thin, weak lower extremities and his generally slight build. On the other hand, when speaking of S. K.’s bodily weakness it must not be forgotten that he was never whimpering, bedridden, or sickly.

10 Anonymous obituary, Bibliotek for Læger, 1864, op. cit., p. 219: ”Even before he [Trier] took his final medical examinations he had served as a jus practicandi under the supervision of Herholdt, a privilege which, those days, all members of the Health Department could bestow upon a medical student, and the supervision was of course of merely nominal significance.” Harald Krabbe had had a similar arrangement.

What Does the Doctor Really Know? 389

The first physician who wrote about Kierkegaard’s medical record was the otologist Kristen Iversen Nørregaard (1861-1935), who read the record when he was an intern at Frederik’s Hospital (1889-1890) and later made a copy of it. In 1913 he published an almost complete edition of it in Ugeskrift for Læger [Danish Medical Journal], but did not himself comment on it, remarking instead, “There was no autop-sy, and I will not go further into the diagnosis, but it might well be the case that a present-day neurologist could make something more of the description of the illness than could other physicians.”11

The psychiatrist Hjalmar Helweg (1886-1960) discusses the record in his book from 1933, Søren Kierkegaard – et psykiatrisk-psykologisk Studie [Søren Kierkegaard: A Psychiatric and Psychological Study], and ascertains that Kierkegaard had had spinal cord pathology with paralysis of his lower extremities and difficulties in urination. And Helweg continues:

Whether it was a compression of the spinal cord as the result of pathology in the spinal column or an actual infection of the spinal cord (myelitis) cannot be determined on the basis of the medical notes. Those at the hospital seem to have inclined toward the former view and were apparently thinking of tuberculosis of the bone (spondylitis tuberculos)…but it is not possible to come to certainty on this point.

In Breve og Aktstykker vedrørende Søren Kierkegaard [Letters and Documents Concerning Søren Kierkegaard], published in 1953, Niels Thulstrup published Kierkegaard’s medical record almost in its entirety, citing – in apparent agreement – Helweg’s explanation of the cause of the illness.

In the issue of Dagens Nyheder [Daily News] for November 13, 1955, physician Johannes Ove Jakobsen published an article on the occasion of the one hundredth anniversary of Kierkegaard’s death. Jakobsen’s article was entitled “Søren Kierkegaard’s sidste svære Dage” [Søren Kierkegaard’s Final, Difficult Days] and dealt with Kierkegaard’s illness and death at Frederik’s Hospital, viewed through the lens of Kierkegaard’s medical record. The first portion of the record, up to October 6, is reproduced word for word, and the remainder of the record is reproduced with a number of omissions. At the end of the article Dr. Jakobsen asks:

What did he die of? Most likely a myelitis – an infection of the spinal cord. The symp-toms are indicative of this illness: paralysis of the legs, difficulty in walking, difficul-

11 K. Nørregaard “Feuilleton. Søren Kierkegaards Journal” [Special Pamphlet: Søren Kierkegaard’s Medical Record] in Ugeskrift for Læger [Danish Medical Journal], 1913, no. 41, pp. 1673-78 and 1712.

390 Ib Søgaard

ties in urination, disruption of tactile sensation, as well as the course of the illness, which began in his youth. Spinal tuberculosis can be ruled out.

In a chapter entitled “Final Phase” in volume five of his biography of Kierkegaard, the neurologist Carl A. V. Jørgensen (1888-1977) discuss-es the illness, directing a great deal of attention to Kierkegaard’s cough and the expectorate associated with it, in particular the fact that this expectorate was creamlike. Jørgensen concludes that it must be a case of a boil in the lung, a so-called lung abscess. Carl Jørgensen mentions the rather scanty stethoscopic investigation recorded in the notes:

One could find this account scanty; the prolonged exhaling is not of much significance. But when we bear in mind that we are in Trier’s department and that Trier was in fact one of the leading people in stethoscopy, we can permit ourselves to draw the conclu-sion, based on the information indicated, that it is scarcely likely that this involved an active case of tuberculosis of the lung. The negative stethoscopic findings do not weaken the diagnosis of a lung abscess; it is quite common for a lung abscess to pro-duce little or no audible evidence.

Oddly, neurologist Jørgensen seems to have strikingly little interest in the actual neurological evidence:

It is typical of the period’s dawning interest in neurology that the record demonstrates repeated interest, in particular, in the question of whether the patient might be suf-fering from an infection of the spinal cord, a myelitis; of whether the patient’s bouts of weakness, which could not be explained, might perhaps have been a symptom of paralysis of the legs? A faradization [i. e., electrical stimulus] apparatus was used, pro-ducing a weak reaction one day and a strong reaction another day. In addition, in the record entry for October 4 it is noted: There is no tenderness along the spine or at any single point.

This pretty well rules out myelitis. And in any case, one does not die of myelitis; one can become an invalid from myelitis, but one does not die of it. It is not true that the absence of tenderness along spinal column rules out myelitis.

The orthopedic surgeon Ole Helmig (born 1928) includes Kierke-gaard’s medical record in chapter five of his dissertation Spondylitis Tuberulosa, published in 1971, entitling the chapter “Clinical Illustra-tion, Elucidated by Means of a Medical Record.” In the introduction to the chapter Helmig writes:

An excellent description is provided of the ferocious course of a columna tuberculosis, with accompanying paresis. In the anamnesis there is brilliant description of the first symptoms of spastic paresis and subsequently of tubercular meningitis. The precise diagnosis was never made, but the picture is virtually indistinguishable from that of fulminant tubercular columna osteomyelitis with paresis, and the picture we have of the patient permits us to conjecture that he may well have had a gibbus [spinal hump].

What Does the Doctor Really Know? 391

In his article from 1979, “Kierkegaard’s Final Illness and Death,”12 Fre-derick L. Holder concurs with the diagnosis of tubercular spondylitis after having consulted a medical acquaintance, Dr. William S. Smith.

In his article “Spørgsmålstegnet ved dødsårsagen i Søren Kierke-gaards sygejournal” [The Question Mark Relating to the Cause of Death in Søren Kierkegaard’s Medical Record], the philosopher Jens Staubrand declares his concurrence with Helmig:

The cause of Kierkegaard’s death must realistically be assumed to have been tuber-culosis of the lungs which spread to the spinal canal. In other words, this was a case of tubercular spondylitis, a tubercular infection of a lumbar vertebra, its collapse, and consequent compression of the spinal cord. On the other hand, Staubrand does not accept Helmig’s hypothesis that Kierkegaard’s death was owing to tubercular menin-gitis: Based on a close reading the patient’s medical record, we must also dismiss this hypothesis, inasmuch as Kierkegaard had no headache, nausea, vomiting, of stiffness of the neck.13

In my article from 1991 “Sørens sidste sygdom” [Søren’s Final Ill-ness],14 I myself have maintained that I do not believe he had tubercular spondylitis with compression of the spinal cord, caused by a destroyed vertebra. The paralysis of the legs and the intermittent problems with urination mentioned in the record could well be explained by com-pression of the spinal cord. But there was no total compression, for in that case there would have been no tactile sensation at all. In the record it is specifically noted that tactile sensation was normal. A compression of the spinal cord that was caused by direct compression from a destroyed vertebra would also have led to stationary paralysis, and in my reading of the record I find signs of progressive paralysis:

When the patient was admitted it was thus established that there was a partial paraly-sis of both legs, with sensation intact, but also that the paralysis included a portion of the back musculature on his left side, at least part way up, because the patient slumped over to his left side when sitting. Furthermore, his mind was absolutely clear, and there was no fever.

During the days which followed, the pareses increased, but there must still have been pain, even if it is not mentioned in the record, because

12 F. L. Holder “Kierkegaard’s Final Illness and Death” in Anglican Theological Review, 1979. no. 61/4, pp. 508-514.

13 J. Staubrand “Spørgsmålstegnet ved dødsårsagen i Søren Kierkegaards sygejour-nal” [The Question Mark as to the Cause of Death in Søren Kierkegaard’s Medical Record] in Dansk Medicinskhistoriske Årbog, 1989-90 [Danish Yearbook of Medi-cal History, 1989-90], pp. 142-66.

14 I. Søgaard “Sørens Sidste Sygdom” in Dansk Medicinskhistoriske Årbog, 1991, pp. 9-34.

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turpentine massages were prescribed. He had disturbances of his sphincter muscles, with involuntary urination and constipation. On October 12, his left leg was entirely paralyzed, and several days later he complained of joint pains in his left hip and knee. The entry in the medical record for October 15 states: “He has no strength whatever to support himself with his arms because he cannot contract his back muscles; he moves the arms themselves freely.”

Pastor Emil Boesen (1812-1881) visited Kierkegaard many times from the 14th to the 27th of October.15 On October 18th he reported: “He [Kierkegaard] was very weak. His head hung down on his chest and his hands trembled.” This must mean that the muscles of the upper back, which hold the head erect, had also been affected at that point. The trembling of his hands indicate the beginnings of loss of function in the arms.

After his visit of October 20th Boesen wrote: “Two women attend-ants carried him from the one chair to the other. He was entirely with-out strength. His head hung down on his chest, and he quickly dozed off. He said that his entire illness was now a death struggle. He asked me to hold his head, and for a while I stood and held his head up.”

On October 27th Boesen saw Kierkegaard for the last time: “The last time I saw him he was lying down and was nearly incapable of speaking.” But his mind was absolutely clear and he was aware of his surroundings.

In an entry from October 29th, the medical record states: “The patient appears to be steadily losing his strength. He sits up during the day, but is very slumped over. At times he is very much bothered by a cough. His mental powers are still unimpaired.”

In the entry of November 6th: “His strength decreases more and more, and he cannot bring up the expectorate. But his appetite is quite good.”

November 9th: “In recent days the patient’s strength has visibly decreased; he lies quietly dozing (stuporous), does not speak, eats and drinks nothing. There appears to be some distortion in his face, as the left corner of the mouth appears to be pulled slightly upward. The day before yesterday his pulse was about 100, steady, weak . Urine is still passed involuntarily, is rather clear; excrement is also passed involun-tarily. Pulse today is 130, less steady, weak.”

15 Bruce H. Kirmmse Encounters with Kierkgaard: A Life as Seen by His Contempo-raries, Princeton: Princeton University Press 1996, pp. 121-26.

What Does the Doctor Really Know? 393

November 10th: “The patient remains in the same stuporous condi-tion. Pulse 130, still somewhat strong, though less so than yesterday, irregular. If one lifts his arms, they fall back down heavily. They are rather stiff at the elbows. He can lift both eyelids, and the distortion of his face is not clear and pronounced. His bodily appearance is very collapsed. He breathes rapidly, soundlessly.”

November 11th: “The patient lies in the same condition. The pulse is weaker. Breathing heavy, short.”

November 12th: “He remained in the same condition. Died yester-day evening at 9:00.”

The pulled-up corner of Kierkegaard’s mouth prompted P. A. Hei-berg to suggest that Kierkegaard had had a stroke. This idea was not, however, embraced by others. The pulled-up corner of the mouth is seen as a symptom for a contralateral, unilateral facial paralysis, a facialis paresis. On the following day, the corner of the mouth was no longer pulled up, and this indicates a bilateral facialis paresis, which was related to Kierkegaard’s inability to speak or to swallow. There are indications of the progress of a disease, which had now reached the brain stem, with paralysis of both arms and total loss of muscle tone. In a letter written to Emil Boesen on the day of Kierkegaard’s death,16 Kierkegaard’s nephew, the physician Henrik Sigvard Lund (1825-1889) wrote:

He [Kierkegaard] therefore became weaker and weaker, and subsequently became less and less aware of things going on around him. He recognized no one, made no replies, and fell at last into a comatose state, in which sad condition he remained the last three days, without regaining consciousness.

Kierkegaard was not unconscious, he was locked-in, a quite dreadful condition in which a totally paralyzed patient is alert and can hear everything that is taking place around him without being able to react to it.17 Kierkegaard tried to communicate with the only means he had,

16 Ibid., p. 129.17 See, e. g., J. R. Patterson and M. Grabois “Locked-In Syndrome: A Review of 19

Cases” in Stroke, 1986, no. 17/4, pp. 758-86, where it is stated in the introduction: “In 1966 Plum and Posner introduced the term ‘locked-in syndrom’ to refer to a neurological condition associated with infarction of the ventral pons. The syndrome is manifested by quadriplegia, lower cranial nerve paralysis, and mutism with pres-ervation of only vertical gaze and upper eyelid movement. Consciousness remains intact and the patient is able to communicate intellligibly using eye blinking. The ‘locked-in’ patient is literally locked inside his body, aware of his environment but with a severely limited ability to interact with it.” A patient, who had experienced and survived such a condition, describes it in an article by N. Chisholm, G. Gillett “The Patient’s Journey: Living with Locked-In Syndrome” in British Medical Jour-

394 Ib Søgaard

namely, opening and closing his eyelids. In the end, the process of the disease reached the respiration center in his brain, and Kierkegaard’s breathing stopped.

The Diagnosis

An attempt at a diagnosis can be seen on the first page of Kierke-gaard’s medical record, where it has been crossed out. What was writ-ten there is “Hemiplegia,” which means paralysis on one side, thus paralysis of one arm and one leg. As a final diagnosis was written “Paralysis! (Tubercul..?).” Paralysis means the total inability to move. It is a description of a symptom and not an etiological diagnosis. In my opinion, the addendum “Tubercul.?” does not mean that it was a case of tuberculosis – indeed, quite the contrary. I interpret it as meaning that they were here confronted with an illness which at a number of points might certainly call to mind tuberculosis, but which, despite this, was not.

People knew quite a lot about tuberculosis, which in those days was far more prevalent in the country than it is today. A total of 1,134 patients were admitted to Medical Department A in 1855, and of these 28 were given a diagnosis of tuberculosis, half of whom died.18 It can be seen from medical records that tuberculosis patients were stethoscoped many times during their hospitalization. The depart-ment’s resident physician Andreas Brünniche (1823-1908) was espe-cially interested in tubercolsis and in 1857 had written a dissertation “On den akutte Tuberkulose” [On Acute Tuberculosis].19

nal, 2006, no. 331, pp. 94-97, as follows: “I felt like I was in a really bad nightmare constantly for about the first 3 months. I could only just hear ( I couldn’t even open my eyes or breathe by myself); without them even knowing that I still could hear; the doctors and specialists in front of me said to my mum that I would die. They even asked my mum if she wanted them to turn the life support machine off after a few days.”

18 See “Aarsberetninger fra det kong. Fred. Hospital for Aaret 1855- Medicinsk Afde-ling A. Prof. Trier” in Bibliotek for Læger, 1856, no. 4/9, pp. 117-24. The article also states that seven patients were described as paralyzed, of whom two died.

19 A. Brünniche “Om den acutte Tuberculose,” Copenhagen, 1857, dissertation. Dur-ing his time as a patient, Kierkegaard was treated with electricity in an attempt to reduce the paralysis. Brünniche also knew something about this subject. In 1854 he had written a long survey article on the subject, “Om Elektricitetens Anvendelse i Lægevidenskabelige Øiemed” [On the Use of Electricity for Medical Purposes] in Bibliotek for Læger, 1854, no. 4/4, pp. 372-411.

What Does the Doctor Really Know? 395

In 1869 the neurologist and neuropathologist Carl Lange (1834-1900) published an article in Hospitalstidende [Hospital Times] enti-tled “Om opadstigende spinal Paralyse” [On Ascending Spinal Paral-ysis].20 The patient was a 61-year-old man who had been admitted to Frederik’s Hospital in February 1866. For several months before his hospitalization he had sensed weakness in his legs, especially when he went up or down stairs. In the beginning he ascribed this weakness to his increasing age, but he soon noticed that it was increasing unusually rapidly, so that as early as late February he collapsed from exhaustion on the street and before long he was unable to walk any more. At first the weakness was most pronounced in the right leg, but the difference between the two legs soon evened out. At the time of his transferral to Almindeligt Hospital on March 26, he was still capable of walking a little, with support, but shortly thereafter even this became impos-sible. When he had been admitted to Frederik’s Hospital in February, there had been no paralysis of his arms. Only ca. one month later did he begin to notice weakness in the upper extremities. As noted, after a month’s hospitalization the patient was transferred to an ordinary hos-pital (Almindeligt Hospital) for care. There was now paralysis of both arms and legs. There was difficulty in speaking, and the patient had difficulty in coughing up mucus, rather large quantities of which had collected in his throat. His intellect was completely normal, as were the higher senses. No headache. His tactile sense was still completely unimpaired. His breathing, specifically exhaling, became increasingly difficult, so that great quantities of mucus collected in his bronchia. The patient died of suffocation (strangulation) on May 30. This case history resembles Kierkegaard’s in important ways. It had merely last-ed a bit longer. In addition to his own case, Lange had twelve similar cases in the literature, of which the first had been described by Landry in 1859, with a diagnosis of Paralysie Ascendante Aigue.21 An autopsy had been performed on one of the twelve patients, but no decisive cause of the illness had been found, and in particular no changes had been found in the spinal cord or in the so-called peripheral nerves extending from the spinal cord. But as will be noted subsequently, there is a good explanation for this. As can be seen from the first page

20 C. Lange “Om opadstigende spinal Paralyse” in Hospitalstidende, 1869, no. 12, pp. 21-22, 25-27, 33-35, 37-39.

21 O. Landry “Note sur la paralysie ascendante aigù” [Note on Acute Ascendant Paralysis] in Gazette hebdomadaire de médicine et chirurgie [Weekly Gazette of Medicine and Surgery], 1859, no. 6, pp 472-74, 486-88.

396 Ib Søgaard

of his medical record, no autopsy was performed on Kierkegaard, either. His family had opposed it.22

In 1916 the French neurologists Guillain, Barré, and Strohl described two soldiers from the First World War with this same case history, albeit a more harmless one, inasmuch as both patients survived, and the illness, ascending spinal paralysis, was henceforth given the name Landry, Guillain, Barré’s Disease, or simply Guillain-Barré’s Dis-ease. The most important contribution to the diagnosis of the disease made by the French neurologists was that they could demonstrate an elevated protein level in the spinal fluid and a normal or very slightly elevated number of cells in this same fluid. This clearly differentiates the illness from meningitis. Since that time, it has been electrophysi-ologically demonstrated that the nerve impulse speed in the periph-eral nerves is slower, and with the electron microscope it has been shown that the reduced nerve impulse speed is due to the destruc-tion of the insulation (the myelin sheaths) around the individual nerve fibers. Had an autopsy been performed on Kierkegaard, it would not have been possible to find the nerve lesions with the light microscopes then in use.

The illness most often arises after an acute infectious disease, either viral or bacterial, a respiratory infection, or an infection of the alimentary tract. Today the most frequent cause is said to be a campy-lobacter infection.23 The illness is a so-called autoimmune pathology, in which the organism, after antibody reaction to an antigen, begins to break down its own tissue – in this case, attacking the insulating sheath around the nerve fibers. In the most serious cases the nerves themselves are destroyed. In a number of cases where the nerve fib-

22 See Frederik Benedikt Møller, in Kirmmse op. cit., p. 132: “Several days later I was with some medical students who were indignant because an autopsy has not been performed on Kierkegaard, and his brain had not been examined. They thought that the hospital had the right and even the obligation to do so on behalf of science, but that the hospital had yielded to the wishes of the family. I thought it was decent of the hospital, but those who were enthusiasts for science did not think that sort of thing should be taken into consideration.”

23 B. M. Allos “Association Between Campylobacter Infection and Guillain-Barré Syndrome” in Journal of Infectious Diseases, 1997, no. 176 (Suppl. 2), pp. 125-28: “Guillain-Barré Syndrome, a neurological disease that produces ascending paraly-sis, affects people all over the world. Acute infectious illness precedes 50 %-75 % of GBS cases. Although many infectious agents have been associated with GBS, the strongest documented association is with Campylobacter infection”. Neurological symptoms are more severe and more likely to be irreversible when GBS is preceded by Campylobacter Jejuni infection. One of every 1058 Campylobacter infections results in GBS and 1 of 158 Campylobacter type O:19 infections results in GBS.”

What Does the Doctor Really Know? 397

ers themselves are intact, the disease progresses to a certain higher level after which the condition of the patient gradually improves as the myelin sheaths are repaired. Even in cases in which the disease has progressed so far that breathing has been compromised, it is still possible in many cases to save patients by placing them in a respirator, either for a relatively brief period or for an extended time. There is still no medicinal treatment of the cause of the disease. Thus it is pos-sible, though not certain, that Kierkegaard could have survived the disease if he had been given respirator treatment.

What does the doctor really know?24

According to Pastor Boesen, the first time he visited Kierkegaard in the hospital, the latter said: “The doctors do not understand my ill-ness. It is psychical, and now they want to treat it in the usual medical fashion. It’s bad. Pray for me that it will soon be over.”25

Preserve Medical Records!

It has only been possible to arrive at the many interpretations of Søren Kierkegaard’s medical record because the notes has been pre-served. The increasing number of patients admitted to and treated at the nation’s hospitals – and thus the increasing number of medical records – has gradually led to major problems related to archiving these materials. In 1884, after being bound into book format, a year’s worth of medical records from a large, centrally located hospital in the provinces took up eight centimeters. The entire year’s records from Odense Hospital in 1913 took up 15 centimeters, and 1992 a year’s worth of medical records from Odense Hospital occupied archive space equivalent to 425 meters of shelving.26

About 15 years ago a group of hospital administrators applied to the National Archives for help in the archival storage of their patient

24 “And when you get right down to it, in the medium of actuality and becoming, what does the physiologist know and what does the doctor really know?” SKS 20, 66, NB:73. The passage is cited here in order to illustrate the difference between the philosopher’s and the physician’s view of natural science in Kierkegaard’s time, but it is certainly applicable in our times as well, and it ought to give pause to all the doctors who have taken an interest in Kierkegaard, including the author of the present article.

25 In Kirmmse op. cit., p. 124.26 I. Søgaard “Ought Medical Records to be Preserved?” in Bibliotek for Læger, 1993,

no. 1, pp. 80-90.

398 Ib Søgaard

notes. Since the Provincial Archives, which had previously been help-ful in taking responsibility for the storage of a number of years’ worth of medical records, were now also beginning to report space problems, another solution had to be found. In 1996, after long deliberations by a commission appointed to study the problem, a new archive law was passed, permitting very comprehensive destruction of archives. This law has subsequently been extended in almost unaltered form, merely with a name change: it is no longer a law about “discarding,” but about “preserving.” From the law it is implicit that everything that does not have to be preserved may be discarded.

Appendix 6 to regulation no. 575, dated June 16, 2003, concern-ing the preservation and destruction of archives held by county (now regional) governments, contains a resolution requiring the preserva-tion of the following materials:1. All medical records terminated before December 31, 1949;2. All medical records terminated after January 1, 1950, concerning

persons born on the first of a month;3. All discharge summaries from medical records terminated during

the period 1950-1976, concerning persons born from the second day through the last day of the month;

4. From 1976, only records and discharge summaries concerning per-sons born on the first of the month.

This means, in fact, that it is now possible for various hospital admin-istrators to permit the destruction of 97 % of all medical records begun after 1950. So of course it is a good thing that in a few years we will have a national system consisting of electronic medical records (EMR), after which the great majority of problems associated with archival storage ought to be solved. This does not help at all, however, because in the remarks accompanying the Archive Law it is stated that “Electronic medical records do not have to be preserved.”

The reason given for this is that the necessary information is already available in data bases, specifically in LPR (Landspatientregistret) [National Patient Registry], to which all hospitals have been obligated to provide data since 1977. The Registry makes it possible, on the one hand, to view the work performed, over time, in a specific hospital, and, on the other hand, to calculate total hospital usage by regions and towns. The regulations governing the reporting of data to LPR are issued by the Coordination Group for Individual-Based Patient Registration. The reporting regulations are set forth in the common contents for the fundamental registration of hospital patients, which is issued once a year.

What Does the Doctor Really Know? 399

In 2002, the Register contained the following items, arranged sys-tematically:

• hospitalnumber• departmentnumber/sectionnumber• typeofpatient• thenationalhealthnumberoftheindividual• startingdateandhourofadmission• hourandminuteofarrivalatemergencyroom• townnumber• referraldateandmethod• conditionsofadmission• terminaldateandhourofdischarge• methodofdischargeortermination• dischargedorterminatedtootherhospitalordepartment• contactcausecode• accidentcode• dateofpreliminaryexamination• dateoffinaltreatment• diagnosistype• diagnosiscodenumber• proceduretype• proceduredate,hourandminute• mainnumberfordepartmentperformingtheprocedure• dateofvisit• passivewaitingtimeandcause• passivewaitingtimewithstartdate• passivewaitingtimewithenddate

Reporting of Hospital Admissions to LPR

A report of data from Søren Kierkegaard’s medical record would only provide scanty information:

• Royal Frederik’sHospital inCopenhagen,MedicalDepart-ment A

• male,050513-xxx• admitted02101855,___o’clock• acuteadmission• enddate111118559:00PM(dead)• diagnosis:paralysis• treatment:intermittentbedrest,sedatives,laxatives

400 Ib Søgaard

The National Patient Registry is an economic and statistical data base which is well-suited for comparing the productivity of various hospi-tals. It is absolutely unsuited for evaluations relating to cultural his-tory. What is interesting in medical records from the point of view of cultural history is not the diagnosis and the treatment as such, but all the other material in the notes: both the physician’s interpretations and evaluations in the case history itself, and the subsequent interpre-tations of laboratory results and various mechanized investigations. There are some bright spots on the horizon, however. The provisions of the present Archive Law, which permit the destruction of 97 % of all post-1950 medical records, are justified exclusively on the problem of archival storage space with respect to paper archives. These space problems do not exist with respect to electronic medical records. Mod-ern servers can preserve colossal quantities of data and their capacity is being increased all the time. Naturally, it is a real problem to get all the paper records from the post-1950 period scanned in, and we may hope that it will be possible to obtain the funding necessary to do so.

Patterns of disease and hospital admissions are important pieces to consider in viewing the lives of individuals, and future researchers in the field of cultural history should of course have the same possibili-ties to investigate these matters as past and present researchers have had through the preservation of Søren Kierkegaard’s medical record.