Asleep: The Forgotten Epidemic That Remains One of Medicine's Greatest Mysteries (2 page)

She could not even tell them they were wrong.

CASE HISTORY ONE

Austria, 1916—17
NAME:
An unknown soldier
PHYSICIAN:
Dr. Constantin von Economo

CHAPTER 1

An Epidemic Begins

F
rom miles away, the Earth shook. Starbursts of white light exploded overhead. Rockets whistled, and exploding shells rumbled like thunder. An enormous mass offlint-colored smoke cloaked everything. As many as 100,000 shells fell like rain every hour, leaving pieces of metal all over the fields to shine like silverfish in the moonlight. Where the shells landed, geysers of mud flew, stones and splinters sprayed, and the trenches, in long lines, like scars in the landscape, would break, leaving men abandoned all over the field. Lying in the hollowed-out trenches, separated from the rest of the lines, looking to the sky, the French soldiers watched as German observation balloons flew overhead. A French carrier pigeon, their last one, flew through the cloud of smoke carrying dispatches: “We are still holding our position, but are being attacked by gases and smoke of very deadly character. We are in need of immediate relief.” A few days later, another message from a dispatcher read, “We are in desperate straits.” And, finally, a fragmented note that said only: “ . . . must go on.

The battle of Verdun, fought in 1916, is regarded by many historians as the longest and most devastating battle in world history. The plan was born on Christmas night, 1915, when German command decided to attack the ancient French fort town in a battle that would come to epitomize a war of attrition. It was meant only to bleed the French army white. No ground would be gained or lost or even sought. The battle would simply match life for life until the army with the fewest souls left surrendered. The pointless slaughter lasted ten months with over 700,000 casualties.

For men who had been raised believing war to be a venture in heroism, patriotism, and bravery, the sad truth became all too real during World War I. Young men who dug deep into muddy trenches, surrounded by barbed wire, were of little use against the machinery of an approaching enemy. What little hand-to-hand combat the men fought took place amid a spray of machine gun fire in a vast openness between the trenches called “no-man’s land.” To most soldiers, there seemed to be neither heroism nor cowardice in hunkering down in a trench waiting for a shell to fall and explode. Many wounded were left on the field to die because many more would have died retrieving them. Bodies that fell remained until the rats found them, and rather than exterminate the rats, the armies decided to let them do the cruel work of returning to the Earth what belonged to her.

Any photographs from World War I are, of course, in black-and-white. They appear in shades of gray more than anything else. The bodies are hard to discern from the mounds of dirt, decapitated tree trunks, and upended hedges, bare and spindly like beached coral. The faces of the living and those of the dead are also hard to separate. In every direction soldiers looked, green landscapes had turned sepia-toned, golden fields had grown ashen. For the soldiers, too, the world became colorless—even the blood, which ran so heavily it turned black.

It was a war of unnerving, even surreal contrasts, with bayonets and machine guns, carrier pigeons and aircraft, cavalry charges and tank warfare. Horses and men alike wore gas masks in chemical battles. This was not a war the world was prepared to understand, a conflict born out of the Progressive Era when technology changed everything, medicine had made tremendous advances, and humanity had become in every sense of the word more civilized. When that technology and science were used against people in the form of weaponry and chemical warfare, the human psyche was assaulted as well. That realization would come later—in the offices of neurologists and psychiatry clinics.

The men who entered the war, the soldiers who were capable during Christmastime of 1914 to come out of the trenches to meet the enemy on the field, sing “Silent Night,” and exchange cigarettes, would no longer exist by 1918. In those four years, violence, terrorism, genocide, attrition, and civilian casualties were seeded and grown in the twentieth century. World War I took every hope for humanity and shattered it. But the battle of Verdun would leave the world with another legacy not yet realized.

A
rmy ambulances, some still horse-drawn, flanked the edges of the battle, with medics and stretchers waiting for a clearing. Screaming voices could be heard even above the artillery and lisping sound of stray bullets. When the smoke cleared enough, the wounded soldiers who could be reached were carried from the chaos of the battle to make the short and rutted ride in an ambulance to the field hospital. There, in neat rows, contrary to everything on the battlefield, modes of injury and death were laid out in an organized grid with as much exactitude as the tombstones in a field.

At least one wounded patient made this journey from the trenches to the field hospital, where he waited for the medical train. In the beds all around him were injured or dying men. Some were dying of wounds inflicted by men—blinded by mustard and chlorine gas, whole faces missing, limbs lost to the constant shelling. Some bodies were broken open, peppered with shrapnel. Although field hospitals had no shortage of gruesome injuries inflicted by machines, the ones inflicted by microbes proved even more deadly. The victims of those enemies had none of the crude, gaping wounds of field injuries. The enemy that attacked these men killed from within. The epidemic diseases had their own wards, with beds separated by white curtains to help contain the spread of illness. After all, battlefields and war hospitals were aflame with typhus, cholera, influenza, pneumonia—especially as war rations had produced emaciated, malnourished soldiers. It’s a strange fact of war that a conflict between men becomes more than a contest with weaponry, but a conflict within nature as well. In the most practical sense, city men clash with country men, western men with eastern men, northern men with southern men. Thousands of people who would not normally encounter one another are brought from all corners of the world. Some were brought from the Far East to help build trenches. Some were brought from across the Atlantic to fight. Others were shipped from colonies in Africa or Southeast Asia. Unknowingly, they brought some native microbes as well. The war presented nature with its own unique opportunity, a microscopic holocaust.

This unknown soldier may have had a physical wound or an illness or even a mind that had been injured. Whatever the reason, he was evacuated from the hellish battlefield at Verdun for the field hospital and, finally, for Paris.

T
wo physicians on opposite sides of the war worked in neuropsychiatric hospitals—one clinic was in Paris, the other in Vienna. The psychiatric clinics filling with patients were testament to the brutality of this war and the inexperience of its participants. When the war began, soldiers still wore leather helmets, but they soon learned that modern warfare left its mark by the metal embedded in skulls, as well as the cuts inflicted on the psyche. By the end of the war, helmets were made of steel. Even with the stronger helmets, shrapnel could cause visible injuries to the brain and, inadvertently, gave neurologists a chance to map the brain, matching its parts to body functions, using physical damage as the guide marker. Likewise, the psychological damage was paving the way for modern psychiatry. In what would become one of the few positive points to come from World War I, brain study would advance at rates faster than ever before.

The French physician, a pathologist and pediatrician, working in the Paris clinic was named Jean René Cruchet. When Cruchet met with the unknown soldier from the front in Verdun, he was struck by an unusual set of symptoms. At first, he wondered if the symptoms could be the aftereffects of mustard gas or even a new chemical weapon. Other patients soon followed, and in all, Cruchet saw sixty-four similar cases with no standard diagnosis. What was striking about these patients was the unusual range of symptoms. Some had fever; others did not. Most complained of headache and nausea. Strangest of all was how much these soldiers slept.

It would have seemed almost serene at first—blank, expressionless faces, free of terror and pain, calmly asleep in row after row after row. What was frightening about these men was that they would not wake. It must have felt like being in a room full of the breathing dead. At first, their symptoms vaguely matched any number of diseases, but as they progressed, they did not follow the course of other diseases of the trenches. The soldiers were not comatose; they were simply asleep.

Cruchet spent several months studying the sick soldiers, and he prepared a paper on the unusual cases he found coming from the trenches in Verdun. He did not know, could not know, that on the other side of the war another physician was witnessing the same. That physician, in a clinic in Vienna, was preparing a similar paper on the same subject. Though the two men could not coordinate their efforts, nor even contact each other, they were witnessing the same disease. By definition, that made it an epidemic.

CHAPTER 2

Constantin von Economo

A
drowsy, confused patient wandered into a psychiatric clinic in Vienna in January 1917. He sat slumped over in his seat, nodding off to sleep, his neck falling forward or his head hanging limply to the side like the wing of a wounded bird. He could be roused, but not fully awakened, peering out from a sliver of open eye. Aside from his obvious sleepiness, the most unusual thing about this patient was that he was a civilian.

The Wagner-Jauregg Clinic had seen a large number of patients recently, but most of them were returning soldiers with wounds to the head. This sleepy, lethargic patient had nothing to do with the war. The physicians could not even identify what was broken—there was no physical trauma, no history of insanity, no single infection that caused symptoms like this. It was unlike anything the doctors had ever seen. To make matters worse, his case was soon followed by a dozen more.

In nearly all cases, the patient’s eyes changed. The eye muscles malfunctioned, causing dull, unresponsive eyes, or just the reverse: eyes that twitched or rolled back into the head. So many unusual symptoms appeared in these cases that in a timely analogy one doctor compared it to a burst of shrapnel in the nervous system.

The symptoms only became stranger.

An epidemic of hiccups erupted, and one of the clinic’s patients actually died of incessant hiccuping. Other patients exhibited bizarre tics—repeating the same word or phrase, blinking uncontrollably, twitching. There was also a sudden influx of schizophrenia patients, dementia patients, patients who salivated uncontrollably, or ones who froze still in a catatonic state. In all cases, an unusual sleepiness accompanied the symptoms.

It was a complete mystery to the physicians at the clinic. The only factor connecting these patients, the one thing they had in common, was no clear diagnosis. In medicine, and in brain study in particular, that created an unusual dilemma—this was a disease that could be diagnosed only by ruling out all other diseases.

In this clinic in Vienna a young, unknown neurologist named Constantin von Economo first took notice of these peculiar patients who seemed to have no connection to one another and found the link common to all. There was no known neurological disease that caused indefinite sleep. And, likewise, with no other disease would the patient suddenly and inexplicably awaken.

“We are dealing with a sleeping sickness,” he said, bewildered.

D
r. von Economo waited in the halls of the Vienna psychiatry clinic. They were white and stone. Clean. They reflected lamplight and smelled of antiseptic. Snow fell outside the windows. Indoors, however, the clinic was teeming with physicians and patients. Long metal tables were stacked with paperwork, charts, and graphs. It was orderly and efficient.

Von Economo could not have been better positioned. In Vienna, and throughout eastern Europe, groundbreaking work on brain study was taking place during the early decades of the twentieth century. Julius Wagner-Jauregg, the neurologist for whom the Vienna clinic was named, was experimenting with fevers to treat mental illness. He would win the Nobel Prize for his experiments using malaria as a treatment for neurosyphilis. In neighboring Germany, Emil Kraepelin was studying dementia praecox, the disease that would later be called schizophrenia, and Alois Alzheimer was publishing papers on the disease that would bear his name. And Europe was becoming the birthplace of psychoanalysis, thanks to Sigmund Freud and Carl Jung. According to Freud, exposure to so many taboo, immoral, violent actions was more than the human mind could take in many instances. The scores of patients with “war neurosis” seemed to support his theory as patients became catatonic, suffered nightmares, and saw recurring images of bayonets and mutilated bodies. They could not get the scent of the yellow clouds of mustard gas out of their nose, the feel of trench barbs out of their skin, or the staccato sound of continuous gunfire out of their ears.

V
on Economo himself was more of a clinical physician and had returned to Vienna only a few months before. Like most other Austrians, he had enlisted in the weeks after Austria’s archduke had been assassinated by a disgruntled patriot from Sarajevo. He enlisted first for the air corps, but when he was stationed in Vienna to organize the air force, he transferred to the automobile corps to get onto the Russian front faster. While the Central Powers had declared the war would be over by Christmas, von Economo rightly viewed that as a gross underestimation. “The war is a huge wave,” he told his wife, “that will not ebb for a long, long time.” Eventually, waiting out the long winters in small villages along the Eastern Front bored von Economo. He reapplied for a position in the air force in 1916 and was at last granted one. On the days when he was not flying, von Economo volunteered to do medical assistance.