Karl May's Final Illness And Cause Of Death

In the year 1910 Karl May started to complain of severe bodily pain, insomnia, and loss of appetite. The pain was strong enough to cause depression:

"Moreover brutal bodily pain prevents me from writing as I would like to...my body, looking before so unbeatable, has finally given in. It will break down. « for about a year I am deprived of natural sleep. If I want to rest sometimes for a few hours, I have to use artificial means, the sleeping pills, which only make me drowsy, however are not without side effects. I also can not eat. Only a few bites during the day, which my poor, good wife forces me to take. And for that pain, without end, terrible nerve pain, which drags the whole night and during the day knocks out the pen from my hand a hundred time! I feel as shouting all the time, crying for help. I cannot lie, cannot sit, cannot walk and cannot stand, and yet I have to do all of these. » The best would be to die «die, die», and yet I do not want it and am not allowed to do so, because I am not yet at the end of my life. I have to fulfill my task."^[1]

In December 1910 Karl May became ill with lung inflammation. The healing was slow and the inflammatory process was still present in February 1911. Dr.med. Johannes Leopold Curt Mickel (1858 - 1939) issued a medical certificate, presumably around the middle of 1911:

"The writer Karl May at Radebeul had suffered between X-mass [1910] and almost till the end of February [1911] from a serious catarrhal lung inflammation, after which cure I have advised him very urgently to take a trip to recover in the south. Unfortunately it did not take place at that time, because the above named was fully occupied with his lawsuit and found no time to do so. How fully justified at that time my recommendation has been, shows at present the fact that Karl May, who did not yet recuperate from his previous illness, as the result of accumulation of court hearing terms and with this connected tension, developed a nervous complain, and because of that he became incapable of attending [the court]. It is quite impossible - confirmed also by another doctor, a specialist for nerve disorders in Dresden, whom I asked for an opinion to be sure, - that, in view of the coming proceedings, his strength would be sufficient to last for the expected business dealings and the prolonged attendance at them. Furthermore it is fully out of the question, that he could undertake such a demanding life, connected with the travel and other hardship, without doing first something, which would contribute not only to maintaining, but also to improvement of the present ailment. Therefore I advise urgently - for how long is impossible to say right now - to undergo an earnest cure for a few weeks, if he does not want to deteriorate rapidly."^[2]

"In the summer of 1911 I have seen the writer for the last time and spoken with him ... Karl May became under the indescribable pressure of the past years very old and his previously enormously strong body seemed not to be able to withstand the never ending battles: however his spirit was lively and stayed bright and his eyes were shining with pride and fire."^[3] Karl May spent five weeks - from the 8. May 1911 until the 17. June 1911 in Jachymov spa, where the treatment alleviated the severe pain. Before leaving for the spa he wrote in a letter:

"Again gravely ill, I write to you today only shortly. I have overestimated my strength, the lung inflammation and physical excitement at the witness hearing exhausted me totally...I have to go to a spa; I am leaving already on Thursday..."^[4]

At Jachymov spa the doctor who was looking after him, Dr. Gottlieb, wrote towards the end of May, 1911, the following official medical certificate:

"The undersigned certifies herewith, that the writer Karl May is present here for the purpose of spa treatment, because of a nervous and neuralgic ailment. At present there is as the result of the effects of radioactive baths a reaction [to the treatment], which makes it impossible for the patient to travel. Also at the present state of the treatment an interruption is out of the question, because of that the whole result of it would become illusionary. The patient can not appear at the court in June for the scheduled hearing, and because the cure affects heavily the organism, the patient requires after finishing the treatment complete rest and care and a cure to follow for at least of 8 weeks duration in a fresh-air resort."^[5]

In March 1912 Karl May traveled to Vienna, where he held on the 22. March 1912 a two and a half-hour lasting lecture. During it he apologized stating that he was ill, and had been observed to take a pill.^[6]

Karl May died at his home in Radebeul on the 30. March 1912. His wife, Klara May, was the only person present at his deathbed. She described the last moments of Karl May's life in these words:

"He developed during the lecture in Vienna a slight cold and had after arriving home to be indoors, without staying in bed. On Saturday, the 30. March [1912] he was feeling a little stronger and asked me to reserve a room for the coming week in the Silesian spa Salzbrunn. Being worried I spent the whole day close to him, even if I did not anticipate any fatal outcome of his disease. I was the only one who was present at the time of his last hour at his side. Because that day was the anniversary of our wedding, he spoke with me about happenings from our past and also about the future. He was bright and occupied himself with new plans: he wanted to write a drama, which would resemble his own life and only long after his departure should become public. Only then his work would be understood and what all he aimed for.
In the afternoon he fell into kind of lucid dreams and talked to himself, as he often used to do, a lot with the many personalities of his imagination.
Around seven o'clock in the afternoon he went to sleep, however continued the talking with himself in an unintelligible murmur on. Towards eight o'clock he suddenly set himself straight up in bed, looked up with shining eyes, which seemed to see nothing from its surroundings, into the distance and said with a clear voice: 'Victory, a great victory! I see everything rose-red!'
Then he fell back with a lasting friendly, clear expression; his breathing became weaker, until after a few minutes it ceased - "^[7]

"I became a cigarette maker...I liked the job as well. I found it very interesting. I learnt to recognize all sorts of tobacco and to manufacture all kinds of cigars, from the cheapest to the most expensive ones." ^[8]

"I enjoy smoking very much, and never in my life have I come across a cigar which would have been too strong for me. I have even smoked the famous 'Three-men-tobacco', which got the name from its dreadful taste; whoever smokes it, if he does not want to keel over, has to be supported by three men."^[9]

Cigarette smoking is responsible for most cases of bronchial carcinoma, and the increased risk is directly proportional to the amount smoked and to the tar content of the cigarettes. It occurs most frequently between the ages of 50 and 75. The death rate from bronchial carcinoma in heavy cigarette smokers is 40 times that in non-smokers.

The onset is usually insidious. Cough is the most common early symptom, dyspnoea (shortness of breath) may occur, as repeated slight haemoptysis (coughing up blood). Pulmonary infection gives rise to a febrile illness accompanied by the clinical features of pneumonia. The illness is unusually slow to respond to treatment, fails to resolve satisfactorily and recovery is not complete. Pain in the chest wall or in one or both upper limbs with a nerve root distribution may be present if the tumor involves intercostal nerves or the brachial plexus. Lassitude, anorexia and loss of weight are late symptoms, usually indicative of extensive metastatic spread. The average period of survival after the diagnosis is made is less than one year.^[10]

The diagnosis Dr.med. J. Mickel made on Karl May in 1911 was "serious catarrhal lung inflammation" ("eine schwere katarrhalische Lungenentzundung"). Dr.Mickel also stated in his certificate that the patient "did not yet recuperate from his previous illness."

What diagnostic tools were available to Dr.Mickel in 1911 except percussion and auscultation of the patient? Even if the X-ray was known at that time (Wilhelm Conrad Roentgen (1845-1923) described the principles in 1895), it was applied mainly to the examination of bones. One of the standard medical textbooks of medicine described the clinical signs in 1897 as follows:

"The symptoms of lung carcinoma are various. Quite often we do not recognize the disease, mainly because it does not cause any significant symptoms. In particular small tumors, located deep in the pulmonary lobe and not accessible to physical examination, escape the physician's attention. Otherwise the symptoms are similar to any other lung disease: cough, chest pain, mainly on the affected side and reaching various distant places, sometimes a little of short breath, catarrhal expectoration, rarely haemoptoe [coughing up blood] ... The patients during the illness allegedly are not as cachectic as with other localization of cancers. The disease is of long duration as a rule, many months...It is clear from all this, that to recognize lung cancer is often an impossible task...hard to diagnose."^[11]

There are photographs of Karl May from 1911. These photos are very important in our quest for the diagnosis, because they reveal one symptom, connected with an advanced lung cancer. It is the Horner's syndrome, also called Syndrome Claude Bernard-Horner.

Horner's syndrome is pupillary constriction, enophthalmos [retraction of the eyeball] and ptosis [a drooping of the upper eyelid from paralysis]. When we look at Karl May's photo from 1911 we can recognize two components: the deep sunk eyeballs in the sockets, and the half-closed eyes because the upper eyelids are down, almost closing the eyes. Karl May's face is visibly emaciated.

The Horner's syndrome comes as a result of paralysis of the cervical sympathetic fibres. It is caused by pressure on the sympathetic chain at the level of C7-Th1 vertebrae [seventh cervical and first thoracic bodies of the vertebrae]. Bronchial carcinoma originating at the apex of the lung is one of the common causes of this syndrome. The tumor extends early along pre-existing apical adhesions to invade the brachial plexus, sympathetic chain, upper ribs and adjacent vertebrae. The lesion is particularly distressing owing to the early production of intractable pain, which is difficult to relieve, combined with a relatively slow growth.^[12]

Horner's syndrome could appear only on one side, or it could be bilateral. The pressure of the tumor on intercostal nerves or the brachial plexus is causing steady pain in the chest wall and shooting pain down the arms, so called brachial neuralgia. This condition (brachial neuritis) is comparable to sciatica in the leg.^[13]

Karl May complained already in 1910 of persistent "brutal bodily pain" which "knocks out the pen from my hand a hundred time!" This is consistent with the above-mentioned involvement of the brachial plexus. Karl May had been seen by three doctors who all confirmed involvement of peripheral nerves in his illness, not just some "nervous" condition. Dr.Mickel sent May to a nerve specialist. Dr.Gottlieb at the Jachymov spa confirmed a "nervous and neuralgic ailment".

The lung inflammation from X-mass of 1910 never cleared up. By the summer of 1911 Karl May has lost a lot of weight, as we can see from the photos. In June 1911 he wrote, "again gravely ill ... the lung inflammation and physical excitement ... exhausted me totally." The symptoms of advanced cancer - fatigue and loss of weight, started to intrude. Karl May knew he had a serious illness - and looked for a cure in the latest spa - Jachymov.

Parisian physicist's Antoine Henri Becquerel's curiosity about Roentgen's new rays, lead him to discovery in 1896 of natural radiation emanating from uranium salts. Marie and Pierre Curie isolated the elements emitting Becquerel's natural radioactivity. During 1898 they announced their discovery of two such elements, polonium and radium. They extracted minute amounts of radium from tons of ore, which was a byproduct of silver mining at Jachymov, and was called 'Pitchblende'.^[14]

In 1864 there sprung in one of the silver mines at Jachymov a well, which water nearly took over several levels. Local people soon discovered that bathing in this water had stimulating effects. After the isolation of the first gram of radium by the Curies in 1904 it was believed that radiation in small doses was beneficial for health. Such believe was probably linked to the presence of small amounts of radium and radon in the waters of Jachymov. At the beginning of the 20th century, the world's first radioactive spa was built around Jachymov's springs.

After 1904 medical applications of radium had been discovered and attracted considerable publicity. 'Curie therapy' became, together with surgery, the only means of treating deep-seated cancers. Fine needles containing radium or its daughter product radon were most often used for this purpose.

Friedrich Ernst Dorn discovered radon in 1900. Radon emits alfa particles. The main hazard is from inhalation of the element and its radiodecay products which collect on dust in the air. Radon is present in some spring waters. Radon is measured in picocuries per liter of air (pCi/L), and the level below 4 pCi/L is considered safe. There are many places, which are considered to have dangerously high concentration of radon. An Indian reservation in Wisconsin, USA, for example, shows the indoor air concentration of radon 5.8 pCi/l, and the ground water has even higher content of radon.^[15]

Ionizing radiation passes through the body, and interacts with the tissues transferring energy to cellular and other constituents by ionizing of their atoms. This phenomenon has been extensively studied. At low doses, cell death can be accommodated by the normal mechanism that regulates cellular regeneration. However, at high doses repair and regeneration may be inadequate, so that a large number of cells may be destroyed leading to impaired organ function.

What was the dose of ionizing radiation and the radon level when Karel May was in Jachymov from 22 May to 17 June 1911, we do not know. Karl May dictated a letter to his wife during the stay:

"We find ourselves here, in the strongest Radium spa of the world, to take a cure. The reaction from bathing is so strong, that I cannot hold the pen and also cannot write. My present doctor, the Imperial Councilor and district physician, will not let me go before June, to say nothing about the treatment afterward."^[16]

Klara May also bought a "Radium-pack" and reported that it had done wonders for Karl May neuralgia.^[17] What Klara bought was most probably just the "Pitchblende", unprocessed ore similar to what Madam Curie originally received. Only uranium milling, which has not been carried out in 1911 at Jachymov, extracts uranium from the ore. Such uranium concentrate is today commonly referred to as "yellowcake", and generally contains more than 60% uranium. Radiation exposure to low doses and dose rates do not produce acute early effects. Acute Radiation Syndrome (producing acute radiation sickness) requires radiation exposure of 6 to 16 Gy, an extreme known nowadays from Nagasaki, Hiroshima and Chernobyl.

Karl May's extreme fatigue during his stay at Jachymov spa, was most probably a combination of the effects of travelling, daily bathing procedure, perhaps an exposure to the unknown radon dose. Certainly not because of applications of the "Radium-pack". The weakness was mainly caused by his condition: the metastatic spread of the lung cancer.

What other treatment - apart from the spas - was available to Karl May between 1910 and 1912? Karl May stood at the threshold of modern medical inventions. Even though X-ray did exist, it was not yet used to diagnose chest conditions. Radium therapy was at its experimental stages. Surgical procedure to remove tumours from the chest cavity was at its beginning also."^[18]

Fatigue and pain were the main symptoms facing the practicing physician. To improve the general condition was behind the suggestion to Karl May to undergo the spa treatment. For pain there were available three main medicine:

Heroine was used chiefly to control severe pain and cough. It was indicated in Karl May's condition. It is of interest to note what Dr.E.Schmid wrote in the summer of 1911, when he met with Karl May. He noted that in spite of May's deterioration in health "his spirit was lively and stayed bright and his eyes shined proudly and fiery." It is hard to imagine Karl May in his condition to give a two and a half-hour public lecture in Vienna in March 1912, without any medication. He was indeed observed to take a pill. What it was we can only surmise from what was available in those days and from the description of Karl May's behavior during the lecture and in his last interview.^[22]

"Slim, fleshless, but unbelievably tough", was the description of Karl May by one of the Austrian journalists, "with sharp profile and lightning, young eyes." "Haggard old man ... who is recovering from weeks lasting struggle with death" was the impression of another journalist present at Karl May's lecture.^[23]

Another observation: "Karl May looks in spite of his seventy years active ... pale face ... but his voice has a surprising strength, governing the wide hall ... (for) more then two hours ... feeling no tiredness."^[24]

However a different impression by another journalist "an old, tired man with harsh facial features."^[25]

"Karl May not long ago has recovered from a serious illness and was overcome approximately in the middle of his lecture by a weakness, which however luckily disappeared as quickly as it came."^[26]

"A momentary intermission. Karl May asks to be excused, he feels sick. He takes a pill and then carries on talking."^[27]

"Karl May is a septuagenarian, who for his age and despite a just overcome illness is extraordinarily active and speaks very well ... he appeared on the platform deadly white..."^[28]

During his last interview the reporters noted that Karl May "stood up and paced lively up and down in the room."

We have the photo of Karl May from the day of his lecture in Vienna on the 22 March 1912, eight days before his death. He looks very emaciated and tired indeed. Taking a heroin tablet would have been quite consistent with the description of his liveliness, the expression in his eyes, and the ability to carry on a lecture for over two hours.

When a bronchitic and emphysematous patient develops a chest infection pyrexia and anoxia may quickly make him cyanosed, drowsy and disoriented. Arterial blood analysis would show that he has CO2 retention, acidaemia and anoxaemia - the characteristic triad of respiratory failure. Such a patient may die suddenly and unexpectedly.^[29]

This is also quite compatible with the description of the writer's last hours as narrated by his wife. The drowsiness, disorientation and slow lapsing into a coma with final respiratory failure.

Was Karl May citing his own short poem when he uttered the last words "Victory! Great Victory! I see everything rose-red!"?

The immediate cause of death (Mode of dying):	Respiratory Failure
Disease or condition Directly leading to death:	Bronchial Carcinoma
Morbid condition:	Metastasis to the lungs (Carcinoma apicis pulmonum) Cachexia
Other significant conditions Contributing to the death:	Chronic obstructive airways disease (Chronic bronchitis and emphysema) Tobacco smoker

[1] Karl May: "Ich." Karl-May-Verlag, Bamberg, 1968, pp.266-267. Written in 1910. The passages between « » have been left out in the "Ich." Radebeul bei Dresden edition from 1916, p.493, edited by Dr.E.Schmid.

[2] Hecker, Manfred: "Karl May Kuraufenthalt 1911." Mitteilungen der Karl-May-Gesellschaft, #44, June 1980, pp.7-15.

[4] Griese, Volker: "Karl May Stationen eines Lebens Eine Chronologie seiner Reisen" Sonderheft der Karl-May-Gesellschaft Nr.104/1955, entry for 8 May 1911.

[9] Karl May: "Winnetou." Karl-May-Verlag Radebeul bei Dresden, Band 7. (336. Bis 360 Tausend); No date, p.184. This passage has been translated into English for the US edition (Karl May: "Winnetou." Translated by Michael Shaw; The Seabury Press 1977, New York, USA, p.121): "I enjoy smoking very much, have never found a cigar too strong for my taste, and have no reason to believe that this Indian peace pipe would bowl me over."

[10] Davidson, S.: "The Principles and Practice of Medicine." E&S. Livingstone Ltd., London 1969, pp. 375; 377-8.
Davidson's Principle & Practice of Medicine. 15th Edition, Churchill Livingstone, London 1987, pp. 252-253.

[11] Thomayer, Josef, Professor at Czech University in Prague: "Pathologie a Therapie Nemoci Vnitrnich." [Pathology and Therapy of Internal Diseases.] Bursik & Kohout Publ., Prague 1897, p.477.

[12] "Bailey & Love's Short Practice of Surgery." 14th Edition, London 1968, p.665.

[13] Clain, A.: "Hamilton Bailey's Demonstration of Physical Signs." John Wright & Sons Ltd., Bristol 1967, p.207.

[14] Pitchblende or Pechblende (in Czech 'smolinec' from the word "smula" = bad luck; the German word "Pech" means either pitch or colloquially hard luck), got its name from the fact, that where it appeared, the silver - the miners were after - disappeared.

[15] John F. DeWild - James T. Krohelski: "Radon-222 Concentration in Ground Water and Soil Gas on Indian Reservations in Wisconsin." US Environmental Protection Agency, Washington 1988.

[16] Griese, Volker: "Karl May - Stationes eines Lebens Eine Chronologie seiner Reisen." Sonderheft der Karl-May-Gesellschaft Nr. 104/1955, entry for 24-25 May 1911.

[17] "Klara kauf fur 90 Kronen ein Paket Radium, welches bei Karls Nervenschmerzen Wunder gewirkt habe." In: Hecker, Manfred: Karl Mays Kuraufenthalt 1911." See under (2).

[18] Dr.Ferdinand Sauerbruch (1875 - 1951), found in 1904 a method for undertaking surgical operations in the thoracic cavity of man. With this Sauerbruch put an end to a centuries old medical doctrine that diseases within the thoracic cavity could not be treated surgically. This permitted operations on the lungs, heart and oesophagus. From that date started great advances in the treatment of tuberculosis and cancers.

[19] Laurence, D.R.: "Clinical Pharmacology." Third Edition. J. & A. Churchill Ltd., London 1966, p.238.

[20] Squires Companion to the British Pharmacopoeia. 17th Edition 1899,J. & A. Churchill, London, pp. 428 and 432.

[21] Lyons, A. & Petrucelli, R.: "Medicine - An Illustrated History." New York 1979, p.587.

[22] Gerber, A. & Nhil, W. & Wilhelm P.: "Karl May in Wien - Letzte Interviews (1912)." JbKMG 1970.

[29] Birch, C.A.: "Emergencies in Medical Practice." 5th Edition, E. &S. Livingstone Ltd., London 1956, p.141.

[30] Griese, Volker: "Karl May - Stationes eines Lebens Eine Chronologie seiner Reisen." Sonderheft der Karl-May-Gesellschaft Nr. 104/1955, entry for 1 July 1897: "Das Leben is ein Kampf, Der Tod is der Sieg; Ich lebe, um zu kampfen, Und ich sterbe. Um zu siegen."