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Switzerland
  1. H P Mattle
  1. Deputy Chairman, Department of Neurology, Inselspital, 3010 Bern, Switzerland; heinrich.mattle{at}insel.ch

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The Editor sent me an email: “Heine, we have never had a letter from Switzerland. Would you like to do one? You can write on anything which is Swiss and vaguely neurological, from children’s stories celebrating your love of the mountains to keeping a gun under your bed to not being part of the European Union, or about the punctual Swiss railways!”

How shall I start? As a boy, when I first went to Zurich, I was impressed by the huge hall of the train station. Stepping out towards the Bahnhofstrasse, a memorial of Alfred Escher, 1819–82, caught my interest, and I remember my father telling me that he was an important statesman and entrepreneur. Only recently, however, did I read his biography and realise how profoundly he had influenced the economic liberalism, cultural and political life of Zurich and the development of Switzerland in the 19th century.1 For example, as a member of the cantonal government of Zurich, and later as a member and three-times President of the Swiss National Council, he endorsed the idea of building and running railway lines in Switzerland. That was around 1850, when there was already a dense network of railways in England, the USA and neighbouring countries of Switzerland such as France and Germany (the first railway for passengers had been opened in England connecting Stockton with Darlington as early as 1825). In Switzerland, the first railway was opened only in 1847 connecting Zurich with Baden, a distance of a mere 23 km. This train was later nicknamed “Spanischbrötlibahn” because Zurich aristocrats used to send their servants by train to Baden to buy fine, fresh pastries in a Spanish bakery. At this time the industrialisation of Switzerland was lagging way behind—indeed most Swiss were peasants surviving on small farms. But in those years Escher brought several landmark institutions into being, including the Gotthard Railway, the Nordostbahn Railway and Swiss Life and, to finance all these enterprises, Credit Suisse, always driven by his vision to promote industrial development. Alfred Escher was thus crucial for the industrial revolution in our country, although it occurred decades later than in other European countries.

Switzerland has not been at war since 1817. There was, however, a short civil war among Catholic cantons and most other Swiss cantons in 1847 with few casualties. This nevertheless had a major impact in the sense that it made the Swiss understand the need for unity and strength towards its European neighbours. Even today many Swiss are opposed to joining the European Union (EU), although our economic practices are largely in conformity with those of the EU and people can move freely between the EU and Switzerland. Although full EU membership is a long-term objective for some Swiss, there is considerable popular sentiment against this supported by the conservative Schweizerische Volkspartei (SVP, Swiss people’s party). The western French-speaking areas and the urban regions of the rest of the country tend to be more pro-EU.

Not having been at war, coupled with the character of the average Swiss being a hard worker, has greatly enhanced the economy of Switzerland in the 20th century. Today, banking, pharmaceutical, chemical and biological science industries, manufacture of precision instruments for engineering, watch-making and tourism contribute most to the gross national product, and also the many international organisations and companies based in Switzerland such as Nestlé, Novartis, Roche, Credit Suisse and Zurich Financial Services.

And yet our country is small and land-locked with 7.6 million people living on only 41 285 square kilometers. It is divided into 26 states called cantons which vary considerably in size and population. Bern is the capital (fig 1), while other cities such as Zurich, Geneva and Basle are larger and economically more important. The official foundation of Switzerland took place on 1 August 1291. The current Federal Constitution defining a direct democracy was adopted in 1848 and amended in 1874 and 1891. Civil rights include the right to submit a constitutional initiative or a referendum, which may overturn parliamentary decisions.

Figure 1 Aerial view of Bern, a medieval city founded in 1191 by the Dukes of Zähringen. The old centre is situated in the loop of the Aare river which provides excellent swimming in summer. The name Bern comes from the Celtic and means river loop.

Our society is multicultural and there are four official languages: German (63%) in the north, east and centre of the country; French (20%) to the west; Italian (6%) in the south and Romansh (0.5%), a Roman language spoken in parts of the canton of Graubünden. The spoken German is a group of dialects referred to as Swiss German. For written communication standard German as spoken in Germany is used, although younger people tend to use Swiss German for informal written communication more and more—for example, for text messaging with mobile phones.

Most people live in the Midlands between the Alps and the Jura mountains, running from southwest to northeast, the Alps in the south and the Jura in the north. Approximately 40 alpine summits are over 4000 m. Some, like the Matterhorn were climbed for the first time by British alpinists guided by Swiss “Bergführer” in the 19th century. Today, the Midlands tend to be overcrowded—almost one big city from Lake Geneva to the Bodensee (Lake Constance), so it is fortunate that the mountains give one the opportunity to withdraw from the crowds at weekends and for holidays (fig 2).

Figure 2 Tahluu is my 100% reliable companion on hikes in the Alps in any kind of weather, pictured here in front of Piz Terri in the canton of Graubünden, close to the village where I was born.

Travelling in Switzerland is easy. There is a good road system and excellent public transport. It takes less than an hour to get from Bern to Zurich by train—rather too brief to finish reading the newspaper. Speaking of travelling, we are back to the railways. You might wonder what the link is between them and neurology. Well, the Swiss Neurological Society (SNG) turns 100 this year; it was founded in the Bahnhofbuffet (the train station's restaurant) at Olten on 15 November 1908, at the junction of the Swiss railways.2, 3 There were just 10 founding members, Robert Bing (1878–1956) being the most prominent. He founded the first neurological clinic (Nervenambulatorium) in Basle in 1907. In 1909 he wrote a textbook of topical diagnosis in brain and spinal cord diseases and in 1913 a textbook of neurology (Nervenkrankheiten). His books, with many later editions, were widely used and also translated into other languages. In his 1913 textbook he described a headache type he called erythroprosopalgia (erythros  =  red, prosopon  =  face), later redescribed by Harris (1926) and Horton (1939), and today known as cluster headache or Bing-Horton syndrome.

However, neurology itself had started much earlier in Switzerland. In 1658 Johann Jakob Wepfer (1620–1695) from Schaffhausen described thrombosis and haemorrhage as causes of stroke in his book on apoplexy. André David Tissot (1728–1797), Professor in Lausanne, published a famous Traité de l’épilepsie in 1770, giving accurate descriptions of different types of seizures. Binswanger’s disease is named after Otto Ludwig Binswanger (1852–1929) from Münsterlingen, and Johann Friedrich Horner (1831–1886) from Zurich recognised the damage of sympathetic nerve fibres underlying the triad of ptosis, miosis and enophthalmos. Other pioneers include Constantin von Monakov (1853–1928) from Zurich, known for his accurate studies of brain anatomy and pathology and for having founded the first neurological clinic in Zurich (the first in Switzerland) in 1887. The hall of fame of Swiss neurology includes many others such as Walter R Hess (1881–1973), who won the Nobel prize for elucidating the mechanisms of sleep. And I would like to add just a few more who were influential on my early education and career: Felix Jerusalem, Günter Baumgartner, Volker Henn and Marco Mumenthaler who, now aged 83 years, is probably the most famous neurology teacher in German-speaking countries. I had the privilege to publish with him editions 10–12 of his neurology textbook and two editions of fundamentals of neurology.4, 5

Today there are neurology departments in all universities and many cantonal or community hospitals, and numerous neurologists in private offices. Neurology residency is six years (see http://www.fmh.ch). The trend is towards specialisation (as everywhere in the world) and the costs are soaring. Healthcare insurance companies are trying to cut costs and improve quality and effectiveness in medicine at the same time. As a result, we do more and more paperwork, but do not see any more patients. However, I still think the francs are well spent. Even today every Swiss has access to a good healthcare system and is free to select his or her physician. My hope is that the economists will not interfere too much in the medical care system of our country and leave us our freedom.

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