The Magic Mountain - A Time - Canadian Bulletin of Medical History

The Magic Mountain -A Time
Capsule of Tuberculosis Treatment
in the Early Twentieth Century
PETER HUMPHREYS
Abstract. The Magic Mountain (Der Zauberberg), a novel originally published
in 1924, was instrumental in gaining its author, Thomas Mann, the Nobel Prize
for literature in 1929. Ostensibly a parody of life in a pre-World War I tuberculosis sanitarium, the novel gives an accurate portrayal of European society in
the early twentieth century, and reveals the conflict of philosophies and
political ideals which led inexorably to war. At the same time, Mann's book
precisely documents the methods of diagnosis and treatment of tuberculosis
available prior to the anti-tuberculous-drug era. Using The Magic Mountain as a
vehicle, this paper reviews the impact of tuberculosis on Western society at the
turn of the century, discusses the diagnostic techniques then in use, and
considers the evolution of such treatment modalities as the sanitarium, artificial pneumothorax, and immunotherapy.
I
R6sum6. La Montagne magique (Der Zauberberg), un roman publie pour la
premiere fois en 1924, a permis A son auteur d'obtenir le prix Nobel de
litterature en 1929. Le roman, qui est une parodie manifeste de la vie dans un
sanatorium d'avant la 1"Guerre mondiale, offre un tableau exact de la societe
europeenne au debut du 20e siecle et met A jour les conflits de philosophie et
d'ideaux politiques qui menerent inexorablement A la Guerre. En m6me
temps, le livre de Thomas Mann offre une documentation precise sur les
methodes de diagnostique et de traitement de la tuberculose qui etaient disponibles avant l'ere de la pharmacologie anti-tuberculeuse. Cet article, en
utilisant La Montagne magique comme ressource, presente un aperw global de
l'impact de la tuberculose sur la societe occidentale au tournant du sikle;
l'article discute aussi des techniques diagnostiques utilisees alors et il examine
l'6volution de modalites de traitement comme la sanatorium, le pneumothorax
artificiel et l'immunoth6rapie.
The Magic Mountain,' originally published a little over 60 years ago, is
by all odds one of the most important and influential novels of the
Peter Humphreys, Neurology Service, Children's Hospital of Eastern Ontario, 401
Smyth Road, Ottawa, Ontario K1H 8L1.
Received 20 January 1989; revised manuscript accepted 25 April 1989.
CBMHIBCHM l Volume 6: 1989 l p. 147-63
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PETER HUMPHREYS
century. Ostensibly a parody of life in a tuberculosis sanitarium, it is at
the same time a vast intellectual treatise revealing the conflict of philosophies and political ideals which ended in the "thunderclap" of the
First World War. For many readers around the world, the story of The
Magic Mountain was a summing-up of a bygone era destroyed in the
trenches of Flanders and Galicia; as such it was influential in bringing
its author, Thomas Mann, the Nobel Prize for literature in 1929. For the
physician reader, the novel is an astonishingly precise documentary of
the treatment of tuberculosis in the first decade of this century. This
paper reviews the principles of early twentieth-century management
of tuberculosis, as outlined by Thomas Mann, in the context of the
advances made in the treatment of the disease just before and during
the author's lifetime.
LIFE OF THOMAS MANN
The author of The Magic Mountain was born in the Baltic seaport town
of Lubeck in 1875. His father, also Thomas, was a prosperous grain
merchant, the last of a long line of successfulbusinessmen; his mother,
Julia da Silva, was of Creole ancestry. Mann later claimed that he
inherited his artistic temperament from his mother; from his solid,
practical father he inherited the ability to apply a systematic, wellresearched method to his literary works, an almost scientificcast that is
particularly evident in The Magic Mountain.
Although young Thomas revealed considerable talent in creative
writing, he seemed destined to follow his father into a business career.
Upon the somewhat premature death of Thomas Sr., however, the
family business was sold. Thomas moved with his mother to Munich
where he eventually went to work for an insurance company, continuing his writing activities in his spare time. The publication of a short
story brought him to the attention of the literary establishment.
Increasing success as an author enabled him to leave the insurance
business and to attend the University of Munich where he studied
history, political economy, literature, and art. Thereafter he devoted
himself entirely to his life's work as a writer.
His first major work, appearing in 1901, was Buddenbrooks, a novel
depicting the decline and dissolution of a family of business magnates,
obviously modelled to some extent on the experience of his own
family. Like many authors, Mann did not hesitate to draw upon his
own life experiences in the creation of his literary works; the turmoils
of his own courtship and engagement are amusingly described in the
later novel, Royal Highness. It would be a mistake, however, to look
upon any of Mann's works as autobiographical. While one can see
reflections of the personality of Thomas Mann in many of his major
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characters-Hanno Buddenbrooks, Tonio Kroger, Gustave Aschenbach, Hans Castorp, Joseph, and Adrian Leverkuhn-these literary
creations are unique personalities, each very different from the other
and fundamentally different from the author. Mann's art does not
attempt to recreate life; life experiences are used only as a departure
point in the creation of a series of literary universes.
In 1905, Mann married Katia Pringsheim, the daughter of a professor
of mathematics at the University of Munich. As a student of mathematics and physics (she studied with Rijntgen), Katia brought another
injection of the scientific method to the creative work of Thomas Mann.
Although Katia never pursued a career in science, devoting herself
to the nurturing of a family, she was an important source of advice and
criticism for her husband, sharing in the gestation of his subsequent
major works. The marriage produced six children, of whom the oldest
three (Erika, Klaus, and Golo) all became internationally known
authors in their own right.
The success of Buddenbrooks made its author a national literary figure
almost overnight. There followed the series of masterworks that made
Mann one of the giants of twentieth-century literature: Tonio Kroger,
Death in Venice, The Magic Mountain, Mario and The Magician, the
tetralogy Joseph and His Brothers, and Dr. Faustus. International recognition followed swiftly. An English translation of Royal Highness was
published in the United States in the midst of the First World War
(1916), a remarkable comment on the universal appeal of Mann's work
considering the political turmoil of the times and the fact that Germany
and the United States were shortly to be on opposing sides. The Magic
Mountain was published in November 1924; the English translation
followed in 1927 and made a particularly profound impression in
North America.
The culmination of Mann's rise to international repute came two
years later with the awarding of the Nobel Prize.
In his early years Mann's political leanings, if any, were rather
conservative and nationalistic. His political orientation gradually
shifted during and following the First World War, as Germany suffered
a catastrophic financial collapse and its society became increasingly
polarized between right and left. The publication of The Magic Mountain signalled Mann's arrival at a position of tolerance, and equilibrium, with a world view of civilization that permeated his writings for
the rest of his life. Even though Mann moved away from his early
conservatism, he never espoused left-wing causes except insofar as
they supported his world view. He abhorred extremism of any stripe,
he was as critical of the position of Senator Joe McCarthy as he had
earlier been of Hitler and Stalin. A phrase from a 1934 letter to Karl
Kerenyi, an Austrian philologist, best summarizes Mann's attitude: "I
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PETER HUMPHREYS
am a man of balance. I instinctively lean to the left when the boat
threatens to capsize on the right, and vice versa. . . ."2
Considering this political posture it is hardly surprising that Mann
early came into conflict with the National Socialist movement in Germany. As the Storm Troopers and their adversaries began to attack
each other in the streets of German cities, Mann published letters and
articles vigorously expounding the cause of humanitarianism and
social democracy. He was increasingly vilified in the Nazi press.
Shortly after Hitler became Chancellor of Germany in 1933, Mann
went into exile, initially in Switzerland, then in the United States.
Mann accepted a position at Princeton University as lecturer in the
humanities and moved there with Katia in 1938. As the war clouds
gathered in Europe and finally burst forth in torrents, Thomas' brother
Heinrich (also a distinguished author), and all of the Mann children
eventually made their way to the United States. Thomas, Heinrich,
Erika, Klaus, and Go10 all actively pursued their literary careers, each
continuing to produce masterworks in what must surely be the closest
thing the world of literature has to offer to counter the astounding
output of the Bach family in music.
Although Mann was as happy as circumstances permitted, living in
New Jersey, making considerable progress toward the completion of
his Joseph tetralogy, he and Katia found the climatic extremes difficult.
Consequently 1941saw them move again, this time to the Los Angeles
area, where Mann remained for the remainder of the decade, working
steadily, finishing the Joseph series and producing his last major work,
Dr. Faustus, a parable of the seduction and destruction of his native
land. During the McCarthy era following the end of the war the
American vessel began to list dangerously to the right; Mann, perhaps
experiencing feelings of dCjh vu, began to lean in the opposite direction. He became increasingly concerned about the new, and for him
unexpected, spirit of intolerance in his adopted country. Finally,
Thomas and Katia elected to return substantially closer to their roots,
moving back to Switzerland in 1952. There, three years later, Mann
died shortly after his eightieth birthday.
THE STORY OF THE MAGIC MOUNTAIN
In 1912, Katia Mann developed some pulmonary symptomatology
which refused to clear spontaneously. Although her complaints were
almost certainly not due to tuberculosis (in retrospect), she was
advised by her physician to spend six months resting at a high altitude.
The place chosen for this sojourn was a sanitarium in Davos, Switzerland. While Katia lay on her balcony taking the cure, Thomas remained
in Munich to look after the children. In May 1912, Thomas spent three
weeks visiting his wife, living in the sanitarium and following some
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151
components of the regimen prescribed for the patients. After a week or
so of this spartan routine, Mann developed an upper respiratory tract
infection with a persistent cough which brought him to the attention of
the sanitarium physician. There followed a physical examination by
the head doctor, amusingly (and probably accurately) recreated in The
Magic Mountain, during which a "moist spot" in one lung was discovered. The reluctant patient was advised to remain at the sanitarium for
a "cure," preferably for six months. He demurred (and shortly got
better on his own); then, in Mann's own words, "I wrote The Magic
Mountain instead."
Prompted by the peculiarities of his sanitarium experience, and
intrigued by the concept of a small artificial universe devoted to sickness and death, Mann was determined to write a humorous short story
as a companion piece to Death in Venice. As the project began to take
form, Mann soon realized that "this subject matter tended to spread
itself out and lose itself in shoreless realms of t h ~ u g h t . "Work
~
on the
novel ceased entirely for a five-year span with the outbreak of World
War One; Mann found that the wartime atmosphere made his original
conception of the novel somehow irrelevant. Indeed, had he pressed
on to finish his project the end result would have been a charming
intermezzo in comparison to the complex titanic symphony that eventually evolved. In the same way that Ravel's "La Valse" was altered
fundamentally by the composer's war experiences, so did The Magic
Mountain become a requiem for a society destroyed by its own inconsistencies, with but a glimmer of hope for a more humane future civilization.
Reinforced by a prodigious amount of research, Mann restarted his
novel in 1919 and laboured for another five years before his tale was
completely spun out.
He was convinced that his brainchild was too long and far too
complex to be of any interest to the general reading public, particularly
outside Germany. In this respect Mann was quite wrong. Primed by a
decade of cataclysmic changes, readers around the world identified
closely with the novel's principal character, understood the influences
that played upon him, and sympathized with his somewhat naive but
determined efforts to find meaningful life in the midst of death and
destruction. The book quickly became a best-seller.
The story of Hans Castorp can be told briefly. In August 1907, Hans
takes time from his job as a naval engineer in Hamburg to visit his
cousin Joachim Ziemssen, recently admitted to a tuberculosis sanitarium in Davos (of course). Like his creator, Hans intends to remain in
the Swiss Alps for three weeks; while there, he follows the Berghof
routine, eating prodigiously and lying for hours outside on his balcony, covered with blankets. Shortly after his arrival he contracts a
respiratory ailment and pays a visit to the examining rooms of the
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hospital's two doctors, Behrens and Krokowski. Dr. Behrens discovers
a moist spot in one lung and advises Hans to remain in Davos for a few
months.
Unlike Thomas Mann, Hans Castorp agrees to stay, to monitor his
temperature, and to submit to the treatment regimes prescribed. His
motivation for staying in the mountains is not entirely a matter of
concern for his own health: he finds his job as a designer of ships rather
boring and is strongly attracted to the lifestyle of the sanitarium.
Besides, he has developed a discreet but consuming passion for a
fellow patient, Clavdia Chauchat. The respiratory problem clears up
fairly quickly; eventually even the good Dr. Behrens has to agree that
there is nothing wrong with Hans. After a few months, the largely
repressed worship of Frau Chauchat abruptly comes to the boil in a
singlenight of passion, followingwhich Clavdia leaves the sanitarium.
Joachim, an officer cadet in the German army, is anxious to rejoin his
regiment; he decides to sign himself out against medical advice and
leaves for the flatland. Hans stays on. Joachim's health quickly collapses and he returns, soon to die of laryngeal tuberculosis. Hans stays
on, unable to escape from the timeless enchantment of the magic
mountain, even though all conceivable reasons for remaining have
evaporated.
Although he cannot free himself from the tenacious bonds of sanitarium life, Hans does not remain in suspended animation as a naive,
somewhat stodgy engineer. His discovery of sexual love prompts an
extensive reading program in the Berghof library, investigating the
current state of information about various biological functions. This
exploration of the mechanics of living processes leads inexorably to a
fascination with the processes of organic dissolution and death. At the
same time, Hands understanding of the social, intellectual, and economic conflicts threatening to destroy his society undergoes a profound evolution. This quest for knowledge is fostered by contact with a
series of unforgettable characters, all tuberculosis patients at the sanitarium. Among the most important of these are:
Ludovico Settembrini: An impoverished down-at-heels Italian
academic, a linguist, devoted to the rational evolution of social democracy, to the idea of progressive improvement in human society; in
short, using modern terms, an articulate, somewhat ineffectual, leftleaning liberal intellectual.
Leo Naphta: A Galician Jew converted to Roman Catholicism, a Jesuit
priest with a brilliant mind and radical-conservative outlook, devoted
to the irrational and the violent; committed to the ideal of an authoritarian, theistic, essentially medieval society and quite prepared to use
force to bring his ideal into reality; in short, a highly corrosive personality who, a decade later, would have been called a fascist.
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153
Pieter Peeperkom; A well-to-do retired Dutch coffee-planter also enamored of Clavdia Chauchat; a large, imposing charismatic man whose
physical presence and attractive manner of speech are enormously
influential; a man of opinions, exciting in form but devoid of meaning,
all appearance and no substance; in short, a very appealing character
with all the earmarks of the successful politician.
Hans Castorp has to endure the constant crossfire of conflicting
opinions emanating from these individuals, particularly Settembrini
and Naphta. His predicament typified the position of the unsophisticated middle-class citizen of Europe as the world war approached,
stimulated by a vague notion of an ideal society while trembling before
an impending avalanche of violence and death.
The pinnacle of the novel may be found in Hans's experience of a
snowstorm while skiing in the mountains, a wild convulsion of indifferent, hostile nature. Trapped in a swirling maelstrom of falling snow,
face-to-face with death, Hans has a dream in which he has a glimpse of
a future (or past?) world in which humanistic principles hold sway,
where loving kindness and mutual respect prevail in human relationships in spite of, or because of, the ever-present reality that the human
condition ends in death.
From this tantalizing vision, Hans is snatched away. After a stay of
seven years in the mountains, his idyll ends with the intrusion of the
outbreak of war. Suddenly "coming to his senses," Hans rushes off to
enlist in the army and is last seen as a bit of cannon-fodder, charging
with the rest of his infantry brigade into a swirling maelstrom of
exploding shells.
It is not the intent of this paper to dwell on the literary attributes of
this famous novel; a few general comments must suffice. On the
surface, The Magic Mountain is a realistic and often humorous account
of life in a sanitarium. Certainly it is also an accurate depiction of early
twentieth-century society. Like many good works of art, however, it
can be appreciated on many levels.
As with Camus' La Peste and Mann's own Dr. Faustus a generation
later, The Magic Mountain portrays a diseased society, oblivious of the
fact that it is terminally ill, preoccupied with the pursuit of pleasure,
fascinated with the idea of death. Hans's obsession with sex and death
at another level typifies much of the artistic expression of the era; an
obsession seen in the paintings of Munch, the drawings of Beardsley,
in Wagner's Tristan, or in Rakhmaninov's Isle of the Dead. The work is a
novel of personal education and growth (Bildungsroman) in the tradition of Goethe's Wilhelm Meister. An even older tradition, that of the
tale of the quest for the Holy Grail (Galahad, Parsifal, etc.), is
suggested by Hans Castorp's search for meaning in the midst of death.
At yet another level, Mann's novel is an immediate successor to the
symbolist literature of Mallarme and Verlaine. Rather than simply
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PETER HUMPHREYS
treating people and places as symbols of inner spiritual realities (The
Magic Mountain does at least this), symbols are incorporated into the
very structure of the novel. The Berghof Sanitarium is a symbol of
timelessness, of eternity, yet its occupants, while seemingly impervious to the passage of time as reckoned by the outer world, are all
obsessed with schedules, days broken into a multitude of precisely
timed activities.
Time is one of the major recurring themes in the book, as is a
preoccupation with the related phenomenon of numbers. In his commentary on the works of Thomas Mann, Feuerlicht emphasizes the
magical quality or symbolism of certain numbers, particularly the
number 7. Hans Castorp stays at the Berghof for 7 years. Clavdia's
room number is 7, Castorp's 34 (3+4=7). One leaves a thermometer in
one's mouth for 7 minutes. There are 7 tables in the sanitarium dining
room. There is an abundance of names having 7 letters: Castorp,
Clavdia, Behrens, Berghof, etc.4
The elasticity of time is symbolized in the construction of the novel.
In the initial sections, corresponding to Hans's arrival and his first
three weeks stay at the sanitarium, time seems to pass by very slowly
(much as it seems to us to do in novel situations). Pages and pages are
devoted to the events of a few minutes or hours. Then, with the
passage of time, individual chapters concern themselves with increasingly long periods of time as measured in the work-a-day world.
Eventually, years pass by in a few sentences. Time is rushing by the
inmate so quickly it appears to stand still. For the first three and one
half years of Hans's sojourn in Davos, we are more or less aware of
dates and seasons. After 1910, until the thunderclap of 1914, the reader
is no longer aware of time passing at the sanitarium; chronology has
become irrelevant. We have achieved a kind of artificial eternity.
Finally, mention must be made of the musical attributes of the book.
Mann's style of writing is strongly influenced by musical principles. As
has already been noted, time becomes a sort of Wagnerian leit-motif in
The Magic Mountain, a theme restated in varying ways near the beginning of each chapter. Furthermore, one can perceive the phenomena of
thematic exposition and recapitulation in the novel as a whole, similar
to what one might see, for example, in the opening movement of a
Beethoven symphony.
TUBERCULOSIS IN THE EARLY TWENTIETH CENTURY
As was pointed out in the introduction to this paper, Mann's attention
to detail in his exposition of tuberculosis and its treatment is quite
astonishing. We are given an overview of the nature of the disease and
society's perception of the factors involved in its pathogenesis. We
encounter patients with many of the various manifestations of the
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155
disease; we see the diagnostic techniques used, with all their imperfections. The available forms of treatment are presented, sometimes at
length, with some accounts of the complications of these treatment
methods. In addition, we are given information of a more general sort,
pertaining to biology in broad perspective, particularly in the section
entitled "Re~earch,"~in which Hans lies for hours on his balcony
reading medical and biological textbooks. There is a discussion of the
early twentieth-century conception of the biophysics of life processes,
followed by presentations on human embryology and anatomy, as
well as the basic pathophysiology of tuberculosis.
After reading this material one is tempted to surmise that Mann
must have had some sort of medical training, or at least a physician in
the family. Neither is true. Mann was simply a first-class researcher of
written information. Just as he became a temporary medical expert in
order to write The Magic Mountain, so later did he become a Biblical
scholar in order to write the Joseph tetralogy, and an expert in theories
of musical composition for Doctor Faustus. Mann had no pretensions of
being an expert in any of these fields; he forgot the details almost as
quickly as he learned them. He explained the reasons for his apparent
erudition in a letter written late in his life:
Let me say a word about my reputation of being a "second Leonardo" and my
dazzling pseudo universality, which in reality is everywhere only skindeep. . . . Nowadays real universality is not possible, of course, and in my case
what actually exists is a kind of brilliant ignorance. Perhaps I am too good at
display, the "show window," at the manipulation of esotericmaterial. Perhaps
I have always acquired knowledge solely for a purpose, for the moment, and in
order to play with it. And yet I should not like to see the-sit venia verboFaustian expansiveness, which distinguishes my books from other contemporary works, represented entirely as mere swindle. At least I try to give it
authenticity, and my "dabbling" with various branches of knowledge has
always had a peculiar intensity of empathy which has allowed me to achieve a
creative familiarity with new fields that astonished the specialist^.^
8
From the viewpoint of the astonished specialist it nevertheless
remains true that Mann's account of pre-World War I tuberculosis
treatment is everywhere consistent with what we know from many
other sources to have been in place.
In order to become a temporary medical expert, Mann read extensively in current medical literature. A sense of perspective in this
reading stemmed from lifelong correspondence with a number of
physician acquaintances. Unfortunately, much of the earlier correspondence was lost when Mann fled Germany. There are a number of
letters extant from his correspondence in exile which illuminate
Mann's medical sources. A particularly important medical resource
was Dr. Frederick Rosenthal, a German internist who emigrated to the
United States at about the same time as Mann, practicing medicine in
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PETER HUMPHREYS
Beverly Hills, California. Dr. Rosenthal was the principal source of the
extraordinary description of bacterial meningitis appearing in Doctor
Fau~tus,~
as well as the elaboration of the symptoms of uterine cancer
that form the central structure of The Black Swan.8
THE DISEASE
I
It is difficult, from our vantage point 40 years into the antituberculous-drug era, to appreciate the significance of tuberculosis in
society at the turn of the century. The nineteenth century had witnessed a marked rise in the incidence of the disease, largely as a result
of urban crowding after the Industrial Revolution. Although the incidence had begun to decline by the time of Hands voyage to Davos, 17
to 30 percent of all deaths in urban centres of population were due to
tubercul~sis.~The
annual mortality rate from tuberculosis varied from
100 to 500 per 100,000 population in both western Europe and North
America.loThus it is hardly surprising that tuberculosis and its devastating effects permeated the culture of the era.
Admittedly, some of the mystery surrounding the disease began to
disappear with Koch's identification of the tubercle bacillus in 1882.
The concept that tuberculosis might be caused by an infectious agent
spread through the air was a very old one, dating back to the Hippocratic School. Many influential nineteenth-century physicians, before
1882, were opposed to the germ theory of tuberculosis, being of the
opinion that the disease was the result of an hereditary weakness of the
lungs. Others were convinced that tuberculosis resulted from a dissolute lifestyle, from crowded living conditions, or from sublimated passions. There was an element of truth in many of these suppositions. In
any event, belief in these alternative etiologies for the disease carried
through into the twentieth century, Koch notwithstanding, and feature prominently in The Magic Mountain.
For many educated persons at the turn of the century, tuberculosis
was an "interesting," refined, edifymg disease. Many of the period's
best artists died of it, usually at a young age. Consumption appeared to
be a necessary consequence of the creative process, the price of fame;
one was literally "consumed" by the ardor of creative expression.
Byron, Keats, Chopin, the Bronte sisters, and many more, had all
succumbed to the creative flame; their consuming fevers and progressive wasting were symptoms of that flame. In like manner, Settembrini
and Naphta are both paying the required penalty for their intellectual
abilities and creative energies. Even Hans Castorp undergoes progressive refinement as a result of disease, or if not the disease, the resulting
environment.
The afflictionof many of the century's most attractive and successful
people, as well as similar characters in operatic and theatrical produc-
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157
tions (the Mimis and Violettas) necessarily altered society's perception
of beauty and desirability. Emaciated pallor was considered to be the
epitome of both feminine and masculine beauty. One has only to
consider the stylized undernourished women portrayed by Aubrey
Beardsley (himself a victim of consumption) and other members of the
Art Nouveau group of artists to appreciate the truth of this assertion.
Many of the most "attractive" female patients at the Berghof were thin
and pale-Mannfs descriptions of Frau Chauchat are reminiscent of
Beardsley portraits.
In some ways, current tastes in feminine beauty are reminiscent of
the "consumptive" era. Susan Sontag, in her book Illness as Metaphor,
asserts that the current cult of thin-ness in women's fashions is a direct
projection of the metaphors associated with the romanticizing of
tuberculosis a century ago. Then we had consumption: now we have
anorexia nervosa.l1
Tuberculosis patients did not always "suffer" from their disease; at
times they felt euphoric, ate excessively, and had increased sexual
desire. The latter phenomenon is a recurring theme throughout The
Magic Mountain. On Hans Castorp's first day in the sanitarium, he
overhears a Russian couple in the room next door engaged in loud
uninhibited sexual activity. His own preoccupation with sexual fantasies follows in short order. Sexual disinhibition is expected in the
Berghof; it is part of the disease. In Castorp's view, the product of
extensive research, sexual union is one of the most powerful expressions of the life force, but carries within itself the seeds of death. Or,
more simply put, sex tuberculosis-, death. Dr. Krokowski, a sort of
protopsychoanalyst, on the other hand, feels that disinhibited love,
whether sexual or otherwise, is a potential cure for consumption.
During one of his biweekly lectures to the denizens of the sanitarium
he asserts that suppressed love does incalculable damage to the integrity of the biological organism. "Symptoms of disease are nothing but a
disguised manifestation of the power of love; and all disease is only
love transformed." In this, Dr. Krokowski only echoed what was then
a prevailing medical opinion. In our own era, the same kind of sentiments have been expressed about the genesis of cancer.
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DIAGNOSIS
The basic tools available to the physicians at the Berghof for detecting
tuberculosis are essentially the same as those employed today.12 The
principles of physical diagnosis developed by Laennec, Corvisart,
Stokes, and others were, of course, employed by the Hofrat and his
assistant. As is still sometimes the case, there was a tendency to
over-interpret the information yielded by inspection, palpation, percussion, and auscultation of the chest. It is doubtful that either Castorp
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PETER HUMPHREYS
or Mann ever had the slightest trace of mycobacterial infection. Probably the patients who responded most gratifyingly to the sanitarium
regime never had the disease in the first place! We have already
referred to the examination scene when Hans is discovered to have his
"moist spot." What is particularly striking to a physician about this
droll scene is the evolution of the doctor-patient relationship. Castorp
is transformed in a trice from a curious visitor to a name on a file;
Behrens from a hail-fellow-well-met to the dispassionate harbinger of
bad news.
The radiologic diagnosis of pulmonary tuberculosis was made possible by the discovery of x-rays by Wilhelm Rontgen (Katia's teacher) in
1895. Roentgenographic machines of a primitive and, by today's
standards, probably dangerous nature were widely available in European and North American hospitals within a decade. The Berghof was
no exception; all the patients had to have their chests radiographed.
Unlike the modern hospital, however, the sanitarium had no film
library. The patients all kept their chest films in their rooms, or even on
their persons! When Clavdia Chauchat leaves the sanitarium she
makes Hans a present of her chest x-ray, a sort of memento of their
shared intimacy. The chest film was a constant reminder to the patients
of the biological reality of their disease. There is a striking vignette
during Hans's initial radiological examination. After seeing, under the
fluoroscope, the skeletal outline of his hand and the beating heart of
Joachim, he comes for the first time face-to-face with his own mortality.
Bacteriological confirmation of the presence of pulmonary tuberculosis was routinely carried out at the Berghof. The technique used
was an acid-fast stain of a sputum smear. All patients with productive
coughs were expected to provide sputum samples to the sanitarium
laboratory once a week; they carried smallbottles around with them for
this purpose. The number of acid-fact bacilli noted on smear was
quantitated according to the so-called "Gaffky scale." Each patient
knew his-or-her weekly Gaffky number and could gauge the progress
of the disease accordingly. Prescribed lengths of stay in the Berghof
were, in part, determined by the Gaffky number. Gaffky Two implied
good progress and a further stay of perhaps six months; Gaffky Ten
meant a "life sentence." The bald fact was that the 5-year survival rate
for a patient with positive sputum was 50 percent. Mann does not
mention whether culture facilities were available at the sanitarium.
E. L. Trudeau had demonstrated the possibility of growing Mycobacterium tuberculosis within three years of its initial identification by Koch.
Major sanitaria such as the Saranac Lake and Brompton institutions all
had guinea pig innoculation facilities by 1907;13it is likely that Davos
was no exception.
Tuberculosis on The Magic Mountain
159
These various diagnostic methods certainly helped in the management of the disease, but were by no means free of error. Healthy
appearing patients who had a small cavity on chest x-ray might have a
Gaffky Ten sputum. On the other hand, a moribund patient with
extensive pulmonary cavitation might have no identifiable bacilli
whatever on sputum smear. Nevertheless, the beginnings of rational
management of tuberculosis were in place when Hans made his fateful
trip.
TREATMENT
The S~nitariurn~~
I
The first reference to the idea of providing tuberculosis patients with a
regime of a special diet, exercise, and fresh air in a rural setting came
from George Bodington, an English physician, in 1836. His ideas were
never realized due to a lack of support from the medical community. It
remained for Dr. Hermann Brehmer to open the first sanitarium for the
treatment of tuberculosis in Gorbersdorf, Silesia, in 1859. At first,
vigorous exercise was considered beneficial, but this practice gradually
died out as it became clear that some patients tolerated exercise programs poorly. The concept of the "rest-cure" seems to have originated
with Peter Dettweiler, a military surgeon who, for a while, was a
patient in Brehmer's Gorbersdorf institution. Dettweiler opened his
own sanitarium in Falkenstein in 1876, and instituted a regime similar
to the one Hans encountered in Davos: extensive bed rest, particularly
while febrile, both in and out of doors, special breathing exercises, and
frequent high-calorie feedings. Once the infectious nature of tuberculosis was confirmed the following decade, the rationale for sanitaria
was even more cogent, as the rural location of these centers resulted in
the effective isolation of the patients. In North America the first sanitarium was opened in Saranac Lake, New York, by E. L. Trudeau, a
tuberculous physician who cured himself serendipitously by going to
the Adirondack Mountains, ostensibly to die peacefully. Trudeau subsequently read about the work of Brehmer and Dettweiler and opened
his establishment, in emulation of the European centres, in 1885.
The Berghof sanitarium was located well above the town of Davos,
in a mountain meadow, surrounded by fields and gardens. It was
constructed, from Mann's description, much like a hotel, with several
stories of individual patient rooms, accessed from a central corridor
connected to the ground floor by both a stairwell and an elevator.
There were no nursing stations on the floors; when the physicians and
nurses made rounds on their patients, they simply went from room to
room. The most striking architectural peculiarity of the Berghof was
that each room opened out to a large balcony where the patients
160
l
PETER HUMPHREYS
reclined in the open air for two hours, morning and afternoon, regardless of the weather. The individual balconies were connected to each
other on the outside of the building. Thus the physicians were able to
visit their patients during the rest periods simply by going from one
balcony to the next. This "private" connection between rooms also
fostered the frequent sexual liaisons between patients, as has already
been mentioned. Not all sanitaria had this balcony arrangement ,for
rest periods. Others had separate pavilions or liegehallen, roof-covered
but with one side completely open to the elements.15
All patients who were well enough were expected to eat in the
common dining room. Meals were frequent and hearty. There were
two separate breakfasts, in the early and late morning, lunch, tea, and
dinner. After the evening meal, the patients often congregated in a
group of salons, or games rooms, where they played cards, sang,
played the piano, or gossiped. Those who were still hungry could
order food in the salons before retiring to bed, usually early. And so the
days passed: eating, resting, walking, gossiping, eating, resting, eating. Little wonder that, after a while, time appeared to stand still.
The doctors' offices, examining rooms, operating room, radiology
suite, and the laboratory were located in the basement. As the sanitarium was constructed on a sloping field, one side of the basement level
opened to the outdoors. Those patients who died were efficiently
whisked from their rooms to the basement, and thence down to the
graveyard in Davos where whole sections were reserved for the unfortunate denizens of the sanitarium. In the winter, the corpses had to be
transported down the hill by bobsled, a fact that very much appealed to
Hans's evolving sensibilities.
Where specific treatment methods lethal to the tubercle bacillus
were lacking, rigid attention to rules and schedules must suffice. As
already noted, the patients' days were strictly regimented, with
lengthy rest periods, regular meals, etc. The sick person's clinical
status was monitored with twice daily physicians' rounds, onceweekly sputum examinations, and regular temperature measurements. Patients were expected to monitor and record their temperatures four times daily, using their own thermometers: under the
tongue, lips closed, seven minutes precisely.
The possibility that collapsing a lung affected by tuberculosis might
assist the healing process had been considered in the seventeenth
century. DeBligny in 1679 and Baglivi in 1696 both observed a cure of
tuberculosis following a sword wound to the chest creating an open
pneumothorax. That one might deliberately create a pneumothorax to
treat consumption was first mentioned by Edmond Bouru in 1771.The
Tuberculosis on The Magic Mountain
I
161
first attempt in a tubercular patient was made in 1822 by a Liverpool
physician, JamesCarson. Like any scientist he had tested his technique
first by demonstrating that rabbits could easily tolerate having one
lung collapsed via an incision in the chest wall. Unfortunately, his
patient trial was not nearly as successful; the two patients incised
already had so many pleural adhesions that their lungs refused to
collapse. During the next 50 years, a number of physicians tried similar
techniques in individual patients with varying degrees of success, but
the procedure was never widely accepted. The person deserving credit
for the development of a safe, reliable technique of artificial
pneumothorax is a Milanese physician, Carlo Forlanini. In a series of
reports published between 1882and 1912, Forlanini described a closed
method of administering nitrogen into the pleural cavity through a
hypodermic needle. His apparatus consisted of two titrated glass bottles containing water and attached in series. Elevation of one bottle
drove a precisely measured amount of nitrogen from the second bottle
into the patient's chest. In a relatively large series of patients for the times
(25), Forlanini demonstrated sigruficant improvement after lung collapse in most instances; his technique was, after some initial resistance, widely used in Europe and North America. Forlanini's method of
controlled pneumothorax was probably the single most important
advance in the treatment of tuberculosisbefore the antitubercular drug
era.
Many of the Berghof patients who had advanced unilateral pulmonary tuberculosis were being treated with artificial pneumothorax in
1907. Hans encounters his first pneumothorax patient the day after his
arrival. While out for a walk he meets a young woman whose chest
whistles at him as she passes by. At first offended by this affront, he is
mollified by Joachimwho explains that Fraulein Kleefeld belongs to the
Half-Lung Club, that she has an open fistula in her chest and cannot
help whistling when she breathes. Apparently, having a pneumothorax was a sort of status symbol at the sanitarium; those so treated
formed a separate clique among the patients.
Artificialpneumothorax was certainly not devoid of risk. The nitrogen introduced into the pleural cavity was absorbed gradually; more
gas had to be introduced about every two weeks. At one point, Hans
encounters a certain Frau Zimmerman, a pneumothorax patient who
has been "overfilled." She has been given her original pneumothorax
by Hofrat Behrens and has done very well. After a while, she makes a
trip from Davos to Zurich; while there, she foolishly visits an inexperienced physician, "a nice, amusing young man" who, in attempting to
top off her pneumothorax, puts in far too much gas. She develops a
pronounced mediastinal shift, returns to Davos in extreme respiratory
distress, and expires shortly thereafter. Another patient, Herr Ferge,
has an unfortunate tendency to develop profound hypotensive
162
PETER HUMPHREYS
episodes, presumably syncopal in nature, whenever the needle penetrates his pleural membrane.
More permanent methods of inducing and sustaining pulmonary
collapse were developed during the closing years of the nineteenth
century. Thoracoplasty was an accepted procedure by 1907 and,
according to Mann, Hofrat Behrens was particularly adept at the technique.
l
After he discovered the tubercle bacillus, Koch developed a glycerine
extract of dead mycobacteria which he called tuberculin, a compound
he hoped would be useful in treating the disease. By giving a series of
injections of tuberculin in gradually increasing doses, it was
anticipated that progressive immunity to the disease would be
achieved. The results of this treatment were often catastrophic;
nevertheless a number of physicians were using tuberculin as a therapeutic method by 1907. Mann makes no mention of any of the Berghof
patients receiving tuberculin. Perhaps Dr. Behrens had already
decided that the risk outweighed the benefits.
Behrens is not averse, however, to trying experimental techniques if
he thinks they are reasonably safe. After Hans has stayed at the
sanitarium for about three years, Behrens comes to the conclusion that
his patient had not only a small dose of consumption, but also a chronic
streptococcal infection. The latter problem was adduced to explain
Hans's depression following the suicide of Mynheer Peeperkorn and
the consequent final departure of Frau Chauchat. The Hofrat decides
to treat the cocci by using a kind of antistreptococcal vaccine prepared
using Castorp's own blood. Hans is not deceived by this change of
tack; he already knows from his own research and observations that he
does not have tuberculosis, but he is powerless to break his bonds and
leave. He submits to a course of several weeks of "Strepto-vaccine"
which, fortunately, does neither good nor harm.
CONCLUSION
Whatever the Berghof sanitarium and its fascinating occupants came to
mean for postwar Europe, or for generations of afficionados of literature, the novel was clearly a work of personal education and growth, a
bildungsroman for Thomas Mann. Like his hero, Hans Castorp, "life's
delicate child," Mann grew, in the creation of The Magic Mountain,
from a skilled writer of limited horizons and provincial outlook into a
world-class author with a wry, patient, tolerant view of human civilization that continues to stimulate and to endear him to succeeding
generations of readers. Because of his careful, exhaustive, scientific
Tuberculosis on The Magic Mountain
163
method of researching his background material, Mann has recreated
for us, in a way that no medical textbook or history of medicine could, a
vibrant, living survey of tuberculosis and its treatment in a world that
for us is otherwise a fuzzy faded photograph from a dog-eared album
in our grandparents' attic.
ACKNOWLEDGMENTS
I wish to thank Professor Toby Gelfand for his helpful suggestions. Joyce McKay, Dianne
Joanis and Joanne Lee assisted in the preparation of the manuscript.
NOTES
I
1 Thomas Mann, The Magic Mountain (New York: Alfred A. Knopf, 1967), p. 1-7l6.
2 Thomas Mann, Letters, selected and translated by R. and C. Winston (New York:
Alfred A. Knopf, 19711, v . 214.
the Magic Mountain (New York: Alfred A. Knopf, 1967),
3 Thomas ~ a n n The~aki&of
;
p. 7l9-29.
4 ignace Feuerlicht, Thomas Mann (Boston: Twayne, 1968), p. 29-30.
5 Mann, The Magic Mountain, p. 267-86.
6 Mann, Letters, p. 641-42.
7 Mann, Letters, p. 511-12.
8 Mann, Letters, p. 644-45.
9 American Lung Association Bulletin 68 (2) (1982): 2-3; Rene Dubos, "The Romance of
Death," American Lung Association Bulletin 68 (2) (1982): 5-6.
10 Dubos, "The Romance of Death," 5-6; Milton B. Rosenblatt, "Pulmonary Tuberculosis: Evolution of Modern Therapy," Bulletin New York Academy of Medicine 49
(1973): 89-91.
11 Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 1978),
p. 29.
12 Rosenblatt, "Pulmonary Tuberculosis," 89-91.
13 J. R. Bignall, "Treating Tuberculosis in 1905: The First Patients at the Brompton
Hospital Sanitarium" Tubercle 58 (1977): 43-52.
14 Rosenblatt, "Pulmonary Tuberculosis," 89-91; Bignall, "Treating Tuberculosis in
1905," 43-52; J. R. Bignall, "A Century of Treating Tuberculosis," Tubercle 63 (1982):
19-22.
15 Bignall, "Treating Tuberculosis in 1905," 43-52.
16 Rosenblatt, "Pulmonary Tuberculosis," 89-91; Bignall, "A Century of Treating
Tuberculosis," 19-22; Alex Sakula, "Carlo Forlanini, Inventor of Artificial
Pneumothorax for Treatment of Pulmonary Tuberculosis," Thorax 38 (1983): 326-32.
17 Rosenblatt, "Pulmonary Tuberculosis," 89-91; Bignall, "Treating Tuberculosis in
1905," 43-52.