Forgotten by history – On the trail of the sleep epidemic
Forgotten by history : on the trail of the sleep epidemic
What put hundreds of thousands of people into a twilight sleep in the 1920s?? Felix Stern, a physician, became the greatest authority on the disease. But then came the Nazi persecution of the Jews.
"26-year-old girl: Brought to the psychiatric clinic by the police. Confused for two days, falling asleep where she walks and stands. At the clinic, patient walks around the room with her eyes closed like a sleepwalker, vividly delirious and talking all sorts of colorful stuff. In the evening suddenly pulmonary edema and exitus."
In short portraits like this one, the Viennese psychiatrist Constantin von Economo described in the "Wiener klinische Wochenschrift" of 10. May 1917 a mysterious disease. In the weeks before, patients had repeatedly been admitted to the Vienna Psychiatric Clinic with similar symptoms: paralyzed eyes or limbs, fantasies, a strong tendency to sleep. Von Economo, a resident at the clinic, suggested in his article that it was "a kind of sleeping sickness," "the first symptoms of which begin with headache and nausea; then a state of somnolence, often coupled with vivid delirium, sets in". He called the disease "encephalitis lethargica".
This article is included in Spectrum – The Week, 05/2019
Because so many patients were affected in such a short time, von Economo speculated that it might be "a small epidemic". He was right. Small but the epidemic was not. After 1916, encephalitis lethargica first became rampant in Europe, and from the mid-1920s worldwide. At least 500,000 people fell ill, some estimates put the number of cases at over one million worldwide. About one third of those affected died within a few days or weeks. Of the survivors, the majority developed a chronic form with symptoms that resembled Parkinson's disease. The disease left many of these people in lifelong, almost absolute immobility.
Its gruesome consequences have made encephalitis lethargica one of the best-known neurological curiosities in the world. About her trigger and the reason that she disappeared by herself with time, is still puzzled and speculated today. Almost always the name of their discoverer von Economo is mentioned. But probably the greatest expert on the disease was another: a Jewish doctor named Felix Stern.
Like the disease to which Stern devoted his life, his biography today defies easy description. Few words by and about the neurologist have survived, scattered in archives in Germany and Britain. Taken together, they paint a picture of a researcher who was on the trail of "epidemic encephalitis" like no other.
One thing is clear: In the 1920s, Felix Stern was in charge of setting up Germany's first special ward for patients with encephalitis lethargica at Gottingen University Hospital. There he researched and treated hundreds of patients in all stages of the disease. His findings made him famous beyond the borders of Germany and resulted in his book "The Epidemic Encephalitis" of 1922 and 1928, which quickly became the standard work for all who dealt with the disease.
Stern treated his first cases in Kiel
When exactly the on 5. It is difficult to reconstruct how the physician, who was born on April 1884 in Grob-Glogau in Lower Silesia, today's Głogow, developed his fascination with encephalitis lethargica. It can be regarded as quite certain that he was already dealing with patients as an assistant physician in Kiel. In any case, he published his first article on the disease in the "Archiv fur Psychiatrie und Nervenkrankheiten" at the end of his work there in March 1920.
Like von Economo, Stern described several deaths from the mysterious inflammation of the brain in his 1920 article. In the anatomical and microscopic description of her brain tie, Stern's way of working shines through even in this early text: the attempt to find a pattern in the diversity of his observations.
"It seemed important to me to investigate whether, in contrast to the very rich and colorful clinical picture, the pathological histology showed simpler pictures which allowed identification with Economo's pictures."(Felix Stern, "Archives of Psychiatry and Nervous Diseases", 1920)
When he performed an autopsy on the brains of the deceased, however, he found hardly any consistent features. Brain edema, as von Economo had described in all his patients, was absent. The cerebral membranes appeared inconspicuous. It is true that the increased fluid prere of the inflammation had caused some cranial nerves to flatten – but not the same ones in all patients. Bleeding due to the inflammation also occurred with extremely variable severity and in different brain regions. In one case they were even missing completely. It was this "slightness or lack of macroscopic foci" that Stern was the first to clearly describe in his article, "The slight macroscopic finding is a striking one."
Besides his keen powers of observation, a second trait of Felix Stern's character shines through in the sources about him: During treatment, he was apparently extremely attentive and friendly with his patients. This can be seen, among other things, in a letter of recommendation that Alfred Siemerling, whose assistant Stern was in Kiel, later gave him:
"His skilful and understanding way of empathizing with the sick made it easier for him to deal with them and assisted him considerably in his healing successes. He enjoyed extraordinary popularity among the patients because of his friendly and always helpful nature." (CARA Archive, Bodleian Library, Oxford)
In 1920, with Siemerling's support, Stern moved to the Nervenklinik of the University Hospital in Gottingen as a senior physician. From 1922, the 38-year-old also became associate professor of neurology at the University of Gottingen.
The in-depth study of patients that his new position allowed him led him to notice patterns in the course of the disease after all – patterns that had escaped many of his colleagues in the following years. In 1928, he wrote in the second edition of his Epidemic Encephalitis:
"Anyone who has seen a number of cases of encephalitis is at first surprised at the variety of manifestations as well as the possibilities of development and the course of the disease. […] But on closer inspection one recognizes that even in this diversity there is no chaos. […] In the great majority of all cases of chronic encephalitis, as will be shown statistically later, the development of chronic encephalitis after an acute phase and out of the acute stage can be clearly traced. […] The regularities in the directional tendency of the overall course of encephalitis can, of course, only be recognized after the disease has progressed for a long time." (Felix Stern, "The Epidemic Encephalitis," 1928)
What the cases have in common?
What was peculiar and confusing about encephalitis lethargica, Stern says, was that it was initially characterized by both neurological and psychiatric symptoms. In children, it could even manifest as a kind of extreme attention deficit syndrome. It was only after puberty that the typical symptoms of the so-called postencephalitic parkinsonism appeared.
"Felix Stern was the real expert on encephalitis lethargica," says Australian historian of science Paul Foley. While researching his book "Encephalitis lethargica – the mind and brain virus" Foley discovered Stern's scientific legacy. "He understood that, for all the diversity of initial symptoms, the disease follows a pattern in the long run: an onset with drowsiness or insomnia, followed by disturbances of ocular motor function, followed by a phase of recovery, followed by Parkinson's-like symptoms. If this pattern was present, you could be sure: It's encephalitis lethargica," says Foley.
The majority of patients who overcame the acute phase of the disease sometimes developed the chronic end form with postencephalitic parkinsonism years later. It was these patients that neurologist Oliver Sacks treated with the newly developed drug levodopa (a precursor molecule of the neurotransmitter dopamine) in the 1960s and 1970s, giving them, after decades of immobility, a few months in which they could walk and talk again. Sacks and his patients became famous worldwide through his book "Time of Awakening" from 1973. In 1991, the book was made into a film, starring Robert de Niro and Robin Williams. Since then, the misconception has spread that Oliver Sacks treated patients with Parkinson's disease. All of his patients suffered from the late form of encephalitis lethargica.
"If, however, one is to comment on the causative agent of encephalitis itself, one enters an exceedingly obscure area which opens the door to controversy" (Felix Stern)
That's partly because the mysterious disease died out on its own after the 1940s for unknown reasons. "With the exception of unconfirmed outbreaks in Siberia in the 1960s, we haven't seen any cases since the 1950s," says Paul Foley. "There were reports of accumulations of similar symptoms."However, there are a number of pathogens that attack similar brain regions as encephalitis lethargica and Parkinson's disease (including the so-called basal ganglia) and thus produce comparable symptoms for a certain time. The last confirmed survivor of the epidemic, a man named Philip Leather, died in 2002 at the age of 82 at Yardley Wood Hospital in Birmingham, England – after spending 70 years in adult psychiatric institutions.
The cause of encephalitis lethargica, on the other hand, remains unclear. Its epidemic character and course, with a recovery period followed by chronic illness, had fueled speculation even in Stern's time that it must be an infectious disease. French researchers suspected the herpes virus as the trigger, but could not explain why some people got blisters on their lips while others developed severe neurological deficits. After the 1930s, there is hardly any mention of the herpes theory in the neurological literature. Later, the scarlet fever bacterium came into focus as a potential culprit, mainly because encephalitis lethargica in England coincided with the appearance of scarlet fever. But such a pattern had never occurred in mainland Europe. Instead, the Spanish flu was rampant here between 1918 and 1920. But again, there were no reliable similarities in the spread of the two diseases, only in Italy did influenza and encephalitis lethargica coincide. On top of that, 20 of the 40 million deaths claimed by the Spanish flu had occurred in India. But there, encephalitis lethargica was virtually unknown.
"An exceedingly dark area"
That no clear conclusions could be drawn from such data had been clear to Felix Stern early on:
"If, however, one is to comment on the causative agent of encephalitis itself, in contrast to the clear and straightforward results of clinical and anatomical research, one finds oneself in an exceedingly obscure area which opens the door to controversy and in which a firm decision is for the time being completely impossible." (Felix Stern, "The Epidemic Encephalitis," 1928)
Nevertheless, Stern followed the working hypothesis that it could be a polio-like virus. From this he tried to prevent the chronic cases of encephalitis lethargica by injecting his patients in the acute stage with so-called convalescent serum – i.e. the blood serum of other people who had survived the acute stage. The protective effect of antibodies was already known in his time, even if it was not understood exactly what antibodies actually were. With this approach, Stern had at least some success. "According to the notes so far, not one of those treated with serum early enough became chronically myastic," Stern wrote in "The Epidemic Encephalitis". So not a single one of these patients had developed the characteristic late-stage movement disorders.
Despite such initial successes and despite his sharp mind, sensitive nature and prominence, Stern was unable to continue the work of a lifetime. First he lost a malpractice suit against a cigar manufacturer to whom Stern had recommended sclerotherapy for a nervous condition – which was not uncommon at the time. Because of the great financial prere due to the compensation payments, Stern had to give up research in Gottingen and in January 1929 he took over the management of the nervous department of the Versorgungsarztliche Untersuchungsstelle in Kassel, but continued to teach as an associate professor at the University of Gottingen.
The National Socialists ban Stern from practicing medicine
Then came the next blow: in 1933, Stern, who was of Jewish descent, also had his teaching license revoked under the National Socialist "Law for the Restoration of the Professional Civil Service," and was forced into early retirement. In the same year he moved to Berlin. There he opened a private neurological practice at Kurfurstendamm 177, a house that still stands today. Then, in 1936, he was finally banned from practicing.
© International Tracing Service (ITS), Index of the Reich Association of Jews in Germany (detail)
But just as the disease did to its patients, Stern's fascination with encephalitis lethargica did not leave him even in those dark days. In 1936 he published one last article on encephalitis lethargica in the large "Handbuch fur Neurologie" by Oswald Bumke and Otfrid Foerster. Further publications were probably also forbidden to him after he was banned from his profession. In any case, the trail of his research life ends in Berlin.
From 1935 at the latest, Stern lived here at Kustriner Strasse 20, only a few hundred meters away from his practice, which was soon closed down. Many of his relatives had already emigrated or fled to the USA by this time. How Stern spent his remaining years in Berlin is largely unclear. Only the fact that he took in his brother Josef and other relatives can be seen in documents from the Berlin State Archives and the Berlin Restitution Office.
In the decision of the Berlin Regional Court of 10. October 1960 on the application for reparations filed by his cousin and sole heir, Elise Leppmann, stands:
"When he [Felix Stern] received word in August 1942 that he was to accompany a transport to the East as a doctor, d.h. was to be deported, he attempted to take his own life by ingesting poison. He was taken to the Jewish hospital, where he died after a few days on 30. August 1942 he died." (WGA 314606, Archive of the Compensation Authority, Berlin State Office for Civil and Regulatory Affairs)
© Gottingen State and University Library, Voit Collection: F. Stern, no. 1 (excerpt)
"I miss the regular scientific employment the most" | … writes Stern in 1933 on a questionnaire of the SPSL, a British organization that placed scholars in jobs abroad. None was found for Stern. (CARA Archive, Bodleian Library, Oxford University)
According to Elise Leppmann, after Stern's death his apartment was sealed and cleared out by the SS. Stern's body was cremated in Berlin-Treptow, his ashes were brought to Raudten in Silesia, today's Rudna in Poland, the place where the only survivor of his family, Elise Leppmann, had spent her childhood, only 20 kilometers away from Stern's birthplace. Stern's brother Josef was murdered soon after, in the spring of 1943, in Auschwitz. His uncle and cousin, with whom Stern shared his apartment, were killed by the Nazis in 1942 and 1943, according to entries in the Holocaust memorial Yad Vashem.
Whether even one leaf of Stern's intellectual legacy survived, a diary, scientific notes or letters, is unclear. In any case, the search for this seems as hopeless as the search for the cause of encephalitis lethargica. Since 1933, Stern had repeatedly applied in vain to the British Society for the Protection of Science and Learning (SPSL) for a position as a researcher abroad. The last words from Felix Stern's pen that survive today are from one of these letters to the SPSL dated 9. January 1939, which is housed in the Oxford Cara Archive under inventory number MS.SPSL.555, fols. 248-381 can be found. There he speaks of "a hitherto unpublished pathology on Dostoevsky and the epileptic character". In the commemorative book of the Kassenarztliche Vereinigung Berlin. A handful of historical articles Stern has since been mentioned. Never, however, devoted more than a few lines to it. Presumably because of his suicide, there is no record of Stern in the archives of the Yad Vashem memorial or in the memorial book of the Federal Archives. Not even Oliver Sacks seemed to have known about Stern. He does not quote him in any of his works.