There is relevant history behind the issue of trauma and the risk of attacks, or the onset, of MS. The great Dr. Douglas McAlpine achieved international recognition for his specialization in MS at the Middlesex Hospital in London. Among his many original observations, he was the first to recognize that physical trauma increased the risk of MS exacerbations.

After moving to Montreal from Boston in 1971, I had the good fortune to work with my esteemed colleague, J. Bertrand R. (Bert) Cosgrove, at the Montreal Neurological Institute (the "MNI"), at McGill University. He had been trained in neurology at the National Hospital at Queen Square in London (England) and with Dr. McAlpine. At that time, I was introduced to the reality of the clinical problem of MS.

We saw large numbers of MS patients, and Dr. Cos-grove introduced me to a myriad of less commonly recognized issues that patients with this disease confront. Dr. Cosgrove was especially interested and introduced me to the issue of factors that increase the risk of exacerbations of MS. He pointed out that these factors included pregnancy, infection, burns, electric shock, stress, and surgical or accidental trauma.

Dr. Cosgrove emphasized that trauma, whatever the cause, was inevitably associated with emotional stress. With Dr. Lucien Gratton, a French psychopharmacol-ogist, we prospectively studied stress and found a strong association between stress and new attacks of MS. Dr. Cosgrove attributed the first recognition of these aggravating factors to Dr. McAlpine.

Despite the observations of McAlpine and Cosgrove, the relationship between trauma and onset or worsening of MS is considered to be unproven by some. Physicians of limited experience particularly echo this. However, critics are correct when they point out that this has not been studied scientifically. In the original observations, McAlpine did review his detailed clinical records retrospectively and did report a doubling of the risk of an attack of MS in association with surgery or other trauma. He pointed out that this appeared to be true even for dental extraction. In fairness, McAlpine's records were recorded and collected prospectively and in a more modern sense were a database recorded on paper.

Dr. Cosgrove, however, observed that certain traumas were associated with greater risk than others. Importantly, accidents and surgical trauma similarly are associated with psychologic stress. It is difficult, in most situations, therefore, to separate the physical from the psychologic component in accidents and their individual contributions in this regard. If this is true, how can it be explained? Tissue trauma necessarily activates the immune system, which might reasonably lead to an increased risk of an attack of autoimmune disease in genetically predisposed individuals. It is likely that this reaction might serve to make a minor attack more clinically apparent.

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