Book review |
MULTIPLE SCLEROSIS: The history of a disease
By T. Jock Murray
2005. New York: Demos.
Price £29.95
ISBN 1-888799-80-3 ‘Once on this familiar spot of ground’
What means, and to what end does one study history?
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). Two hundred years after the death of this great poet, playwright and philosopher—sometimes called the inventor of German idealism—he is still commemorated and mourned throughout the German-speaking world. In this lecture, Schiller differentiates he who is merely the professional scholar (‘Brotgelehrter’) from the true philosophical mind. Whilst the insights of the former are valuable, these are solely as a means of getting rich; gaining attention from the newspapers; securing office, rank, esteem and reputation; and coaxing favours from the nobility. The professional scholar lives from science, not for it. He or she lacks dedication. For that person, the development of mental and spiritual attributes and scholarship are the means to an end and not aims in themselves. To Schiller, this type of scholar is immersed in a fortress school system and indifferent to the genuine evolution of knowledge. Constrained from making real progress, understandings offered by the professional scholar soon stagnate, only to become fossilized in dogmatism. Competition evokes fear in the professional scholar, as his sterile fiefdom is vigorously defended. Johann Gottlieb Fichte in 1794 and Friedrich Wilhelm Joseph von Schelling in 1799 each drew heavily on Schiller's ideas when themselves referring to the petty individual, the mercenary creature (‘Krämerseelen’) who misses the practical usefulness and daily applicability of universal history (Schiller, 1989; Safranski, 2005). Does one sense that, perhaps, Schiller did not hold the professional scholar altogether in high regard?
Having thus parcelled and reduced the professional scholar, Schiller elevates, and unambiguously admires, the philosophical mind. Here, there is a love of truth more than systems; and the confidence and preparedness to test ideas and be examined are much in evidence. Now, the passions are the questions, not the proofed and soothed answers. The philosophical mind is open to novelty, longing to search the wider horizons; and moved by questions such as: ‘whence are we coming from, where are we going to, and what purpose does all this serve?’ Enthusiastically, Friedrich Schiller ends his lecture: ‘we have come very far already, and therefore we will be able to go on much farther still.’ From this positive and clear understanding of history, Schiller offers his own contribution to the rich legacy of truths, morals and freedoms that makes up the imperishable strand fastening our transient participation in the human endeavour. But this clear and bright understanding of history in general is contradicted by Schiller himself in a much less well-known piece, written at about the same time. In Der Geisterseher (‘The ghost seer’) (Schiller, 1989) he adopts a much darker, more sceptical and desperate note; only the present exists, and the philosophy of history dazzles with the vision of a permanence that can never be sustained:
we are gliding over the ocean of history and forget that we are only a furrow or wrinkle which winds have blown into the surface of the sea. An historical entirety as an experienced reality does not exist, but only as a mental construct. We live on the narrow edge of a real presence between the two enormous realities of past and future ... hanging as dark, impenetrable covers at each end of one's life ... A deep silence reigns behind these covers and no one who ever gets behind them will ever give an answer, the only thing you can hear is a hollow echo of the question as if one had been calling into a vault ... it is the experience of senselessness. The cover makes a fool of man who is looking for a secret behind and he can hardly avoid the suspicion that behind it there liesnothing ...
This is hardly a cheerful attitude, but it might reasonably reflect the perspective of the individual with multiple sclerosis, at least intermittently during the course of the illness. The evidence is in several personal accounts of suffering, most notably The Journal of a Disappointed Man by B. F. Cummings, written under the pseudonym W. N. P. Barbellion and quoted in chapter nine of Professor Murray's account. More generally, in seeking a position on the necessity for understanding the role of history in medicine, and expressing uncomplicated enthusiasm for what is known about multiple sclerosis, Jock Murray provides an excellent guide to how eminent physicians, scientists and patients have viewed multiple sclerosis down the years, both as an interesting disease and a personal affliction.
Although several single cases of paraplegia with waxing and waning symptoms are described from earlier times (notably, St Lidwina from Schiedham or the lady from Göttingen described by Karl Marx—not the philosopher—in his 1832 monograph), in which the diagnosis of multiple sclerosis has been presumed in retrospect, it appears to be a historical fact that cases likely nowadays to be diagnosed as examples of multiple sclerosis begin to appear in the medical literature only during the first third of the nineteenth century. If this can be taken to indicate that the disease did in fact come into existence coinciding with the changing life-styles brought about by the industrial revolution, a search for the cause might concentrate either on environmental factors and social conditions, or a genetic mutation emerging at about that time (or both). But before the aetiologists get to work, we should remind ourselves that these early cases do not resolve the issue of whether there was confusion with disorders that make up the differential diagnosis of multiple sclerosis: take, for example, Heinrich Heine, who assumed that his disorder was ‘one of those illnesses which Germans suffer who privatize abroad’—neurosyphilis, the great imitator of many neurological diseases. The discussion of whether Jean Cruveilhier or Robert Carswell first depicted the pathological basis of multiple sclerosis relies heavily on Tracy Putnam and (with due acknowledgement) Alastair Compston. The contributions of Jean-Martin Charcot and his collaborators are dealt with in great detail, providing insight into many peculiarities of French academic life in those days—but not so different from what might be observed—mutatis mutandis—in modern academic circles. One is always a little bit astonished to realize that Charcot, after whom the disease was named for a long time in various countries, should only have seen 34 cases of multiple sclerosis during his lifetime. In reiterating this point, one cannot help noting the striking similarity—albeit embellished and fleshed out in superb detail—of Murray's history and the structure and material selected by Alastair Compston in his unsurpassed account in McAlpine's Multiple Sclerosis (1998), the new edition of which is eagerly awaited later this year by everyone interested in the story of multiple sclerosis—past, present and future. A century later, Murray can draw on the experience of dozens of physicians, reporting thousands of cases, many described in this book in great detail and providing an overview of all possible manifestations of this ‘remarkable lesion of the spinal cord’. Histological specimens (illustrated in different tones of grey) and concepts about the understanding of disease mechanisms and therapeutic concepts are much elaborated upon. In the earlier chapters, Murray rehearses the views of many prominent clinicians and scientists working in diverse medical cultures, and abundantly illustrates his text with their portraits gazing down from the mists of antiquity: histological details, electrophysiological and radiological findings, and, with exemplary attention to scholarship, elusive references are provided (and reinforced by multiple citation) that invite yet more detailed exploration of the history of multiple sclerosis. In an historical work with many hundreds of quotations taken from earlier times and in different languages, it is difficult to avoid the intrusion of many (although only minor) misspellings, especially where the French and German languages are concerned. The reader will eagerly scrutinize the many illustrations assembled here, several from obscure sources (and some, unfortunately, not matching modern publishing standards). The portraits are accompanied by small but significant quotations from the work of these investigators, giving testimony to the admirable accuracy of Jock Murray's research. In parts—take, for example, Chapter 11, on ‘searching for a cause’ of multiple sclerosis (itself 90 pages long)—the views and speculations of various researchers on the possible causes of multiple sclerosis gathered over a period of 170 years and dealing with infection, transmissibility, epidemiology, genetics, the vascular theory, immunology and environmental factors—inter alia—are assembled in meticulous detail. This well-organized collation of different views by eminent researchers over time, on all possible aspects of the still unknown aetiology of multiple sclerosis, is likely to contain kernels of truth that are still worth pursuing from the modern perspective. Chapter 15, ‘Searching for therapy’, is the longest because it has to cover so many stories of dashed hopes, false claims and unforgivable deceptions, repeatedly displacing Sir William Osler's legendary therapeutic nihilism. Here, the descriptive lineage of successes in the individual case or small series towards an evidence-based rationale becomes evident. Alastair Compston's sceptical summary is quoted (on page 488): ‘multiple sclerosis soon acquired a regrettable reputation for maverick medicine based on shameless exploitation of its capricious natural history favouring the uncritical and those devoted to extrapolation from anecdotal experience’. Treatment recommendations derived from carefully designed and rigorously conducted double-blind, placebo-controlled randomized clinical trials do not, however, spare the clinician the need to interpret statistical analyses of therapeutic effects, and translating these in a way that is understandable for the individual patient.
When the adage in neurology is still (as quoted on page 168 of this book) ‘If you believe you have discovered something new, first look it up in Gowers’, then certainly, if we consider ourselves to have unearthed something new regarding historical aspects of multiple sclerosis or have questions related to these details, we will do well to look it up in Murray: or, as Confucius said: ‘he who puts in front of his eyes the old again in order to understand the new—he may be a teacher to others’. Jock Murray, with this monumental book, has proved himself to be a teacher of the history of multiple sclerosis that sets a new standard and is unlikely to be surpassed, on this scale, for some time. Even in his darker moods, Friedrich Schiller would undoubtedly not have contemplated ascribing the misdemeanours of the professional scholar to Jock Murray: rather he would surely have elevated his work to the upper house of the true philosophical mind—where the passions are the questions, even if the soothing answers to the difficult problem of multiple sclerosis remain stubbornly enigmatic.
Valens, Switzerland
References
Schiller F. Was heisst und zu welchem Ende studiert man Universalgeschichte? Eine akademische Antrittsrede. In: Friedrich Schiller: Sämtliche Werke. Vierter Band. Historische Schriften. Darmstadt: Wissenschaftliche Buchgesellschaft Darmstadt; 1989. p. 749–67.
Safranski R. Friedrich Schiller oder die Erfindung des Deutschen Idealismus. Darmstadt; Wissenschaftliche Buchgesellschaft; 2005. p. 312.
Schiller F. Der Geisterseher. Aus den Memoiren des Grafen von O**. In: Friedrich Schiller: Sämtliche Werke. Fünfter Band. Erzählungen/Theoretische Schriften. Darmstadt; Wissenschaftliche Buchgesellschaft; 1989. p. 48–182.
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