Is it possible for people to have just a touch of MS, just as others have a touch of arthritis? Yes, indeed. Sometimes MS is so mild that it never announces itself at all. It just lies dormant, causing no trouble.

I was recently asked to see Helen, an 85-year-old woman who’d been suffering from headaches throughout her adult life. Her internist of many years had retired, and the new physician decided to obtain an MRI scan “just to make sure that everything was OK.” Well, the MRI showed that she had MS. And not a little bit of MS, lots of it, scars throughout her brain.

I love seeing older people, especially the spirited ones, like Helen. After a few minutes together, it became clear that her headaches were due to migraine, nothing more. I could prescribe a treatment to prevent attacks, in a very low dose given her age, and she’d be fine. Case closed. But what about the MRI? Had she ever experienced other neurologic symptoms?

“Oh, yes, young man,” she replied. “Often. I have multiple sclerosis, you see. It started with blurred vision when I was in college. I’ve had times with numbness, a little imbalance; sometimes I feel very tired. My bladder doesn’t work well, but many women my age have this problem. Most of my friends complain about the same thing. It might be due to my pregnancies or maybe it’s my MS. I’m really not sure. Anyway, I just live with it, and when my body starts growling at me, I just bark back. It’s really no big thing.”

Why is MS mild in some people and devastating in others? Bursts of inflammation in the MS brain vary from patient to patient. They are sometimes placid, often angry, occasionally catastrophic. Each is unique. Many are in “silent” areas of the brain, areas not being used, at least not consciously so, but over time these disrupt the thousand or so major cable wire systems that encode our experiences and regulate the behaviors, emotions, and desires that make us who we are. With each MS attack, the brain loses some of its reserve and becomes less flexible as it responds to injury. The battery drains.

We are born with 100 billion nerve cells in our brain, more or less. But beginning in our early twenties, we lose about a million each day. People with MS are also losing brain cells like the rest of us, but at a much faster rate: three million cells per day.

And they don’t grow back. It’s a sad fact of life. Fortunately, we really don’t need, or use, all of them. Women have smaller brains than men, and fewer numbers of cortical neurons—brain cells near the surface that do the really important things like thinking—but this is not necessarily a disadvantage. Size doesn’t matter. Elephants have huge brains, much larger than humans, but there are no elephants at Harvard, except for a few skeletons at the Agassiz Museum.  

What does matter is how effectively brain cells are used, and especially how well they connect with other cells, near and far. he ratio of brain weight to total body mass roughly correlates with intelligence, and here the average woman is better endowed than her typical male colleague. She has more brain per pound.

No matter where one’s brain begins, however, a daily loss of nerve cells sooner or later will take its toll over time, even though the age at which this becomes noticeable depends on what we ask our brains to do. Power hitters in baseball have difficulty turning on fastballs when they reach their mid-thirties. In tennis, the fall-off is even earlier, usually by the mid-twenties. For weekend warriors, age-related declines don’t become apparent until much later, unless you are going against your college-age kids in Jeopardy! or testing your hand-eye coordination against theirs on a video game. Still, in many academic, business, or social circles, elders often win due to combinations of experience, judgment, attention to detail, and, maybe, cunning.

When a person loses 1 percent or so of brain cells every year, sooner or later it becomes noticeable. Brain fog, fatigue, imbalance, and urinary urgency are near-universal complaints in people with MS, even in people who are otherwise doing well. But sometimes, even without treatment of any kind, MS causes little or no disability at all.

When I meet people like Helen—and I’ve met scores of them—people who’ve had MS for many decades, received little or no treatment, and are without any disability, they often have one thing in common. They’re tough. They have an arrogance toward the disease, more important things to do, no time to deal with the nuisance. They never give in. But when MS hits hard, as it more often does, a positive mindset alone is not nearly enough. MS is a cruel master that can checkmate the strongest will to win.

– From The Face Laughs While the Brain Cries: The Education of a Doctor by Stephen L. Hauser, M.D.. Copyright © 2023 by the author and reprinted by permission of St. Martin’s Publishing Group.

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