Multiple Sclerosis: Clinical Challenges and Controversies

This excellent book provides a fresh approach to multiple sclerosis, detailing the newest developments in a lively style. Particular emphasis is placed on areas of controversy and uncertainty The information conveyed is accessible to all practitioners in the field of multiple sclerosis.

The incidence of multiple sclerosis is about 5 to 6 per 100,000 population, and despite the benefit of national support groups, patients are often devastated when the diagnosis is made. Equally, physicians caring for them feel helpless in the face of an illness for which there is no known cure or cause. Only in the past few years have definitive suppressant agents become available, but even these reduce the incidence of clinical relapses in remitting and relapsing multiple sclerosis by only about 30 percent, and their effect can be proved only in large controlled series. These agents are not without side effects, the development of antibodies to the medications may reduce their beneficial effect, and it is difficult to detect a response in any particular patient. Thus, despite major advances in the field, management of multiple sclerosis remains an art rather than a science and largely involves a good deal of symptomatic treatment and support.

This multiauthored book has the aim of "covering topics relevant to the disease process, its treatment and management, in which there have been developments but which remain unclear." In large measure, the editors have achieved their goal.

As with any book with several authors, there are some repetitions, but these are not tedious and do round out the various chapters. The subjects covered include epidemiology, the presentations of clinical variants, the use of magnetic resonance imaging in diagnosis, and current immunotherapy. Patients' questions often revolve around practical issues such as the effect of pregnancy, immunization against winter influenza, and how to manage bladder, bowel, and sexual dysfunction. All of these are dealt with in a common-sense way and with scientific support for the advice offered. For the social scientists there are chapters on quality-of-life issues, the benefit of inpatient therapy, and the various models of care for what often turns out to be a progressive and disabling disease affecting young people.

The chapter on the role of T cells and cytokines in the pathogenesis of multiple sclerosis is, for the non-immunologist, largely "word salad," but it does review the subject from a very specialized viewpoint and for a very specialized audience.

The chapter on the role of trauma in the pathogenesis of relapses is unconvincing, because the arguments both for and against are not particularly supported by the data given. On the basis of the available evidence, neurologists rarely concede a role for trauma in multiple sclerosis, and this position may well be true, but confirmation awaits further epidemiologic studies with analysis of magnetic resonance data as they accumulate.

Overall, the book presents a good overview of the state of the art in the diagnosis and treatment of patients with multiple sclerosis and deserves a place on the bookshelves of all those actively engaged in the management of this disease.

Reviewed by Michael Ronthal, M.B., B.Ch.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.