The Clinical Features of Myalgic Encephalomyelitis
Melvin Ramsay, M.D., 1986
In the textbook, Ramsay began with the symptoms of the disease at its onset, then followed with the symptoms of chronic M.E. However, since most patients are unaware of the disease at onset, I have begun with the chronic symptoms. The symptoms of the onset of the disease follow - in case the reader is interested in how it begins, or in case the reader suspects there is a new cluster outbreak. There used to be cluster outbreaks; there is no reason (except for ignorance of the disease) why cluster outbreaks aren't recognized today.
[Disease in chronic state]
Once the syndrome is fully established the patient presents a multiplicity of symptoms which can most conveniently be described in three groups.
- Muscle phenomena
- [Fatiguability]: Muscle fatigability, whereby, even after a minor degree of physical effort, three, four or five days, or longer, elapse before full muscle power is restored and constitutes the sheet anchor of diagnosis. Without it I would be unwilling to diagnose a patient as suffering from ME, but it is most important to stress the fact that cases of ME or mild or even moderate severity may have normal muscle power in a remission. In such cases, tests for muscle power should be repeated after exercise.
- [Pain:] In severe cases of ME, muscle spasms and twitchings are a prominent feature and give rise to swollen bands of tissue which are acutely tender. In less severe cases, muscle tenderness may not be so readily elicited but careful palpation of the trapezii and gastrocnemii (the muscle groups most commonly involved) with the tip of the forefinger should enable the examiner to detect minute foci or exquisite tenderness .
- [Clumsiness:] In the aftermath of the disease patients frequently fumble with relatively simple manoevres such as turning a key in a lock or taking the cork of a bottle.
Circulatory impairment. Most cases of ME complain of
- Cold extremities and
- Hypersensitivity to climactic change . . .
- Ashen-grey facial pallor, some twenty or thirty minutes before the Patient complains of feeling ill
- The cardinal features:
- Impairment of memory
- Impairment of powers of concentration and
- Emotional lability
- [Other] common deviations from normal cerebral function:[Accompanying] features [that] can only be attributed to involvement of the
- Failure to recall recent or past events,
- Difficulty in completing a line of thought . . .
- Becoming tongue-tied in the middle of a sentence, and a
- Strong inclination to use wrong words, saying door when they mean table or hot when they mean cold . . .
- Complete inability to comprehend a paragraph even after re-reading it
- Bouts of uncontrollable weeping . . .
- Alterations of sleep rhythm or vivid dreams, or both . . .
Autonomic nervous system:
- Frequency of micturition (urination)
- Hyperacusis (hypersensitivity to noise)
- Episodic sweating
- Orthostatic tachycardia . . .
Variability and fluctuation of both symptoms and physical findings in the course of a day is a constant feature in the clinical picture of myalgic encephalomyelitis.
An alarming tendency to become chronic. [Added in the 2nd edition, 1988]
The onset of the disease is similar to those described in the various recorded outbreaks. Thus it may be sudden and without apparent cause, as in cases where the first intimation of illness is an alarming attack of acute vertigo, but usually there is a history of infection of the upper respiratory tract or, occasionally, the gastrointestinal tract with nausea and/or vomiting.
Instead of an uneventful recovery the patient is dogged by:
- Persistent and profound fatigue accompanied by a medley of symptoms such as
- Muscle pain, cramps, or twitchings
- Muscle tenderness and weakness
- Paraesthesiae [numbness or tingling in the extremeties]
- Frequency of micturition [urination]
- Blurred vision and/or diplopia [double vision]
- Hyperacusis [sensitivity to noise sometimes alternating with deafness or normal hearing]
- Tinnitus [constant sound in the ears], and a
- General sense of feeling awful.
Some patients report the occurrence of fainting attacks relieved by a small meal or just eating a biscuit; these attacks were the result of hypoglycaemia
All cases run a low-grade pyrexia (fever), seldom exceeding 100°F (c. 38°C) and usually subsiding within a week.
A very thorough examination of the central nervous system should be made and this should be accompanied by a careful estimation of muscle power, especially in the limbs and neck. A search for enlarged lymph nodes should never be omitted. If muscle power is found to be satisfactory, a re-examination should be made after exercise; a walk of half a mile is sufficient, as very few ME cases can make more.
[A. Melvin Ramsay, M.A., M.D. Myalgic Encephalomyelitis and Postviral Fatigue States: The saga of Royal Free disease (London, 1st ed. 1986, 2nd ed. 1988). Ramsay died in 1990. Thanks to Connie Nelson of the UK for making this available to me.]
Go to the CFIDS/M.E. Information Page