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by A. Melvin Ramsay M.D., Hon Consultant Physician
Infectious Diseases Dept., Royal Free Hospital
(Pub. 1986)
The syndrome
which is currently known as Myalgic Encephalomyelitis in the UK
and Epidemic Neuromyasthenia in the USA leaves a chronic aftermath
of debility in a large number of cases. The degree of physical
incapacity varies greatly, but the dominant clinical feature of
profound fatigue is directly related to the length of time the
patient persists in physical effort after its onset; put in
another way, those patients who are given a period of enforced
rest from the onset have the best prognosis.
Although the
onset of the disease may be sudden and without apparent cause, as
in those whose first intimation of illness is an alarming attack
of acute vertigo, there is practically always a history of recent
virus infection associated with upper respiratory tract symptoms
though occasionally there is gastro-intestinal upset with nausea
and vomiting. Instead of making a normal recovery, the patient is
dogged by persistent profound fatigue accompanied by a medley of
symptoms such as headache, attacks of giddiness, neck pain, muscle
weakness, parasthesiae, frequency of micturition or retention,
blurred vision and/or diplopia and a general sense of 'feeling
awful'. Many patients report the occurence of fainting attacks
which abate after a small meal or even a biscuit, and in an
outbreak in Finchley, London, in 1964 three patients were admitted
to hospital in an unconscious state presumably as a result of
acute hypoglycaemia. There is usually a low-grade pyrexia [fever]
which quickly subsides. Respiratory symptoms such as sore throat
tend to persist or recur at intervals. Routine physical
examination and the ordinary run of laboratory investigations
usually prove negative and the patient is then often referred for
psychiatric opinion. In my experience this seldom proves helpful
is often harmful; it is a fact that a few psychiatrists have
referred the patient back with a note saying 'this patient's
problem does not come within my field'. Nevertheless, by this time
the unfortunate patient has acquired the label of 'neurosis' or
'personality disorder' and may be regarded by both doctor and
relatives as a chronic nuisance. We have records of three patients
in whom the disbelief of their doctors and relatives led to
suicide; one of these was a young man of 22 years of age.
The too
facile assumption that such an entity - despite a long series of
cases extending over several decades - can be attributed to
psychological stress is simply untenable. Although the
aetiological factor or factors have yet to be established, there
are good grounds for postulating that persistent virus infection
could be responsible. It is fully accepted that viruses such as
herpes simplex and varicella-zoster remain in the tissues from the
time of the initial invasion and can be isolated from nerve
ganglia post-mortem; to these may be added measles virus, the
persistence of which is responsible for subacute sclerosing
panencephalitis that may appear several years after the attack and
there is a considerable body of circumstantial evidence
associating the virus with multiple sclerosis. There should surely
be no difficulty in considering the possibility that other viruses
may also persist in the tissues. In recent years routine antibody
tests on patients suffering from myalgic encephalomyelitis have
shown raised titres to Cocksackie B Group viruses. It is fully
established that these viruses are the aetiological agents of
'Epidemic Myalgia' or 'Bornholm's Disease' and that, together with
ECHO viruses, they comprise the commonest known virus invaders of
the central nervous system. This must not be taken to imply that
Cocksackie viruses are the sole agents of myalgic encephalo-
myelitis since eny generalised virus infection may be followed by
a period of post-viral debility. Indeed, the particular invading
microbial agent is probably not the most important factor. Recent
work suggests that the key to the problem is likely to be found in
the abnormal immunological response of the patient to the
organism.
A second
group of clinical features found in patients suffering from
myalgic encephalomyelitis would seem to indicate circulatory
disorder. Practically without exception they complain of coldness
in the extremities and many are found to have abnormally low
temperatures of 94 or 95 degrees F. In a few, these are
accompanied by bouts of severe sweating even to the extent of
waking during the night lying in a pool of water. A ghostly facial
pallor is a well known phenomenom and this has often been detected
by relatives some 30 minutes before the patient complains of being
ill.
The third
component of the diagnostic triad of myalgic encephalo- myelitis
relates to cerebral activity. Impairment of memory and inability
to concentrate are features in every case. Many report difficulty
in saying the right word and are conscious of the fact that they
continue to say the wrong one, for example 'cold' when they mean
'hot'. Others find that they start a sentence but cannot complete
it, while some others have difficulty compre- hending the written
or spoken word. A complaint of acute hyperacusis is not
infrequent; this can be quite intolerable but alternates with
periods of normal hearing or actual deafness. Vivid dreams
generally in colour are reported by persons with no previous
experience of such a phenomenom. Emotional lability is often a
feature in a person of previous stable person- ality, while sudden
bouts of uncontrollable weeping may occur. Impairment of judgement
and insight in severe cases completes the 'encephalitic' component
of the syndrome.
I would like
to suggest that in all patients suffering from chronic debility
for which a satisfactory explanation is not forthcoming a renewed
and much closer appraisal of their symptoms should be made. This
applies particularly to the dominant clinical feature of profound
fatigue. While it is true that there is considerable variation in
degree from one day to the next or from one time of the day to
another, nevertheless in those patients whose dynamic or
conscientious temperaments urge them to continue effort despite
profound malaise or in those who, on the false assumption of
'neurosis', have been exhorted to 'snap out of it' and 'take
plenty of excercise' the condition finally results in a state of
constant exhaustion. This has been amply borne out by a series of
painstaking and meticulous studies carried out by a consultant in
physical medicine, himself an ME sufferer for 25 years. These show
clearly that recovery of muscle power after exertion is unduly
prolonged. After moderate excercise, from which a normal person
would recover with nothing more than a good night's rest, an ME
patient will require at least 2 to 3 days while after more
strenuous excercise the period can be prolonged to 2 or 3 weeks or
more. Moreover, if during this recovery phase, there is a further
expenditure of energy the effect is cumulative and this is
responsible for the unrelieved sense of exhaustion and depression
which characterises the chronic case. The greatest degree of
muscle weakness is likely to be found in those muscles which are
most in use; thus in right- handed persons the muscles of the left
hand and arm are found to be stronger than those on the right.
Muscle weakness is almost certainly responsible for the delay in
accommodation which gives rise to blurred vision and for the
characteristic feature of all chronic cases, namely a proneness to
drop articles altogether with clumsiness in performing quite
simple manoeuvres; the constant dribbling of saliva which is also
a feature of chronic cases is due to weakness of the masseter
muscles. In some cases, the myalgic element is obvious but in
others a careful palpitation of all muscles will often reveal
unsuspected minute foci of acute tenderness; these are to be found
particularly in the trapezii, gastrocnemii and abdominal rectii
muscles.
The clinical
picture of myalgic encephalomyelitis has much in common with that
of multiple sclerosis but, unlike the latter, the disease is not
progressive and the prognosis should therefore be relatively good.
However, this is largely dependent on the management of the
patient in the early stages of the illness. Those who are given
complete rest from the onset do well and this was illustrated by
the aforementioned three patients admitted to hospital in an
unconscious state; all three recovered completely. Those whose
circumstances make adequate rest periods impossible are at a
distinct disadvantage, but no effort should be spared to give them
the all-essential basis for successful treatment. Since the
limitations which the disease imposes vary considerably from case
to case, the responsibility for determining these rests upon the
patient. Once these are ascertained the patient is advised to
fashion a pattern of living that comes well within them. Any
excessive physical or mental stress is likely to precipitate a
relapse.
It can be
said that a long-term research project into the cause of this
disease has been launched and there are good grounds for believing
that this will demonstrate beyond doubt that this condition is
organically determined.
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In 1956, M.E.
pioneer Dr. A. Melvin Ramsay formally coined Sir Donald Acheson's
selected name for the disease myalgic
encephalomyelitis in a paper describing the 1955
