Re: for Le Teshia (M.E. description)

[Guest guest]

Hi Le Teshia,

Here is an old (and long) description of M.E. written by a UK expert, the late

Dr Ramsay. It can be difficult to find medical professionals who know about the

illness and some confuse M.E. with other conditions.

Kindest regards,

Annette

(in London)

MYALGIC ENCEPHALOMYELITIS : A Baffling Syndrome

With a Tragic Aftermath. By A. Melvin Ramsay M.D., Hon

Consultant Physician, Infectious Diseases Dept, Royal

Free Hospital.

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 aresult of acute hypoglycaemia. There is usually a low-grade

pyrexia 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

pan encephalitis 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 encephalomyelitis since any

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 encephalomyelitis 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

comprehending 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 personality, 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 righthanded 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.

THE END

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