In 1986, Dr Melvin Ramsay, a British physician renowned for his research and advocacy on myalgic encephalomyelitis (ME), published Myalgic Encephalomyelitis and Postviral Fatigue States: The Saga of Royal Free Disease (originally titled Postviral Fatigue Syndrome: The Saga of Royal Free Disease). The book documents cases of ME following various confirmed or suspected infectious outbreaks, including the notable 1955 Royal Free Hospital outbreak, during which Dr Ramsay served as a consultant. Drawing on his clinical experience and broader observations, Dr Ramsay described the core features he believed defined ME – an account that later became known as the Ramsay definition. Although not formal diagnostic criteria and never widely adopted in clinical practice, his narrative framework played a foundational role in shaping early understanding of the disease. Dr Ramsay’s contributions remain deeply influential in relation to awareness and recognition of ME.
Note on disease nomenclature
Dr Ramsay criticised the use of geographically based names like “Iceland disease” or “Akureyri disease,” arguing that such labels misleadingly suggest the disease is limited to specific locations when it can be found worldwide. He also objected to the term “benign myalgic encephalomyelitis,” finding the “benign” aspect inappropriate given the serious, and often long-term effects of the disease.
Instead, Dr Ramsay supported the term “epidemic myalgic encephalomyelitis” as a more suitable alternative, and colloquially referred to the disease as ME. Nevertheless, he acknowledged “post-viral fatigue syndrome” as another term that had gained acceptance internationally and had avoided “the confusion which arises from different names for the same disease.” Ultimately, he chose to use “ME” in the aforementioned book, as it was a term “which we have all been familiar for so many years past.”
Summary of the Ramsay definition
ME is an endemic disease (presents within a geographic region) which is subject to periodic epidemic outbreaks (rapid spread among a community at the same time).
Onset and initial presentation
- Onset may be sudden and without apparent cause, as in cases with acute vertigo (dizziness) at the outset
- Usually there is a history of upper respiratory tract infection or gastrointestinal tract infection (with nausea and/or vomiting)
- There is subsequent, persistent and profound fatigue accompanied by a medley of symptoms, such as: headache, giddiness, muscle pain, cramps/twitching, muscle tenderness and weakness, paraesthesia (pins and needles), frequent urination, hyperacusis (increased sensitivity to sound) sometimes alternating with deafness or normal hearing, tinnitus, general sense of “feeling awful”
- All cases have low grade fever, usually subsiding within a week
- Some patients report fainting attacks as a result of hypoglycaemia (low blood glucose)
Once the syndrome is fully established, symptoms can most conveniently be described in three groups –
- Muscle-related
- Muscle fatigability: Dominant and most persistent feature… “diagnosis should not be made without it”. Restoration of muscle power can take three to five days, or longer.
- Muscle tenderness
- Circulatory impairment
- Cold extremities
- Hypersensitivity to climatic change
- Facial pallor (ashen-grey in colour)
- Cerebral (brain) involvement
- Impairment of memory
- Inability to concentrate
- Emotional lability (rapidly and dramatically shifting between emotional states)
- In the most severe cases – “‘crises’ of acute sweating with hypothermia”
Disease course
- “Relapses resulting from excessive physical and/or mental stress or after a further virus infection are an accepted feature of the disease.”
- “In most cases there is fluctuation in symptoms from one day to another or from one part of the day to another.”
Prognosis
- “Absolute rest in the early stages of the disease can prove a very strong determining factor in the outcome.”
- “Some never recover fully and become chronic sufferers, with permanent muscular weakness and restriction of movement due to joint involvement.”
- “A small group of patients recover completely but are subject to relapses even after a period of several years.”
Considerations
Although Ramsay’s definition has not been widely used in clinical or research settings, and some may consider the emphasis on muscle findings limiting, its influence is evident in subsequent case definitions.
A review noted that “following the release of Ramsay’s monographs, a number of researchers and physicians developed the London criteria for ME,” including Dr Charles Shepherd of the ME Association (MEA). Dr Ramsay was not involved in the production of this criteria. A modified version of the London criteria was later used in the oft-criticised PACE trial, prompting a formal response from the MEA. Dr Shepherd clarified that the MEA was not involved in the decision to use the modified criteria and was also critical of the PACE trial.
While ME continues to be under-recognised decades later, Ramsay’s early work laid essential groundwork for ongoing research and advocacy.
Reference:
Ramsay, A.M. (1986) Postviral Fatigue syndrome: The saga of royal free disease. London: Gower.
