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1955 Royal Free Hospital outbreak
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[[File:RoyalFreeOld.jpg|right|frame|The building that housed the Royal Free Hospital in 1955 when the outbreak occurred]] The '''Royal Free Hospital outbreak''' was a [[Epidemic myalgic encephalomyelitis|cluster outbreak]] of [[myalgic encephalomyelitis]] at the [[Royal Free Hospital]] in London. In 1955, between July and November, 292 members of the medical, nursing, auxiliary medical, ancillary, and administrative staff fell ill, of which 255 were admitted to the hospital.<ref name="RoyalFree1957">{{Cite journal | last = ((The Medical Staff Of The Royal Free Hospital))| first = | date = Oct 19, 1957 | title = An Outbreak of Encephalomyelitis in the Royal Free Hospital Group, London, in 1955 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1962472/ | journal = British Medical Journal | volume = 2 | pages = 895β904|via=}}</ref> The disease name [[myalgic encephalomyelitis]] was first coined to describe the illness in an editorial in the Lancet, in 1956.<ref name="MyalgicEncephalomyelitis-first-named">{{Cite journal | journal = Lancet | volume = 1 | issue = | pages = 789β790 | date = 1956 | title = A new clinical entity? | url = https://mecfsj.files.wordpress.com/2019/05/lancet_e383a9e383b3e382bbe38383e383881956_me.pdf}}</ref><ref name="Ramsay1965">{{Cite journal | last = Ramsay | first = A. Melvin | author-link = Melvin Ramsay | date = 1965-10-30 | title = Hysteria and βRoyal Free Disease.β | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847119/ | journal = British Medical Journal | volume = 2 | issue = 5469 | pages = 1062|doi=|issn=0007-1447|pmc=1847119|pmid=|access-date=|quote=|via=}}</ref> ==Location== The outbreak occurred at the [[Royal Free Hospital]], then situated at 256 Grays Inn Road, London, [[England]], which is now the Eastman Dental Hospital.<ref name="Ramsay56">{{Cite journal | last = Ramsay | first = A. Melvin | author-link = Melvin Ramsay | last2 = O'Sullivan | first2 = E | date = May 26, 1956 | title = Encephalomyelitis simulating poliomyelitis |url =https://www.sciencedirect.com/science/article/pii/S0033350657800225 | journal = The Lancet | volume = 270 | pages = 761-764|via=}}</ref> (The current Royal Free Hospital site is now in the Hampstead area of London.) == Onset == Onset involved symptoms of an [[upper respiratory infection]], [[sore throat]], [[Gastrointestinal system|gastrointestinal]] disturbances including [[nausea]] and [[vomiting]], or acute [[vertigo]].<ref name="Ramsay1978">{{Cite journal | last = Ramsay | first = A. Melvin | date = November 1978 | title = 'Epidemic neuromyasthenia' 1955-1978 | url = https://www.ncbi.nlm.nih.gov/pubmed/746017 | journal = Postgraduate Medical Journal | volume = 54 | pages = 718-721|via=}}</ref> == Symptoms == Symptoms included: <div style="column-count:2"> * Severe [[headache]] * [[Malaise]] * Lassitude * [[Vertigo]] * Pain in limbs * [[Nausea]] * [[Dizziness]] * [[Neck stiffness]], [[neck pain]] * [[lower back pain|Pain in back]] * [[Myalgia]], which in some patients caused them to cry out in [[pain]], [[muscle weakness]], [[muscle cramps|cramps]], [[muscle fasciculations|twitching]] * [[Depression]] * [[Abdominal pain]] * [[Vomiting]] * [[Double vision|Diplopia]] (double vision) * [[Tinnitus]] * [[Diarrhea]] * [[Swollen lymph nodes]] * [[Paraesthesia]]<ref name="Ramsay1978" /> </div> Usually by the second or third week of the disease, there was objective evidence of involvement of the [[central nervous system]] which appeared to be characteristic of the outbreak. == Signs == * [[Low-grade fever]] (tended to transiently occur with relapse of symptoms) * Swollen lymph nodes * Objective sensory impairment and muscle tenderness * Extensor plantar responses * [[Nystagmus]] * [[Double vision|Diplopia]] == Findings == * Inconsistent or normal [[cerebrospinal fluid]]<ref name="Ramsay56" /><ref name="Underhill2021" /> * [[Electromyogram]]s showed abnormalities of activity, but no evidence of lower [[motor neuron]] degeneration<ref name="Ramsay56" /> (12 of 25 abnormal).<ref name="Ramsay1978" /> * non-specific [[EEG]] abnormalities<ref name="Ramsay56" /> * [[Neutropenia]] and abnormal [[lymphocyte]]s,<ref name="Compston">{{Cite journal | last = Compston | first = N.D. | date = 1978 | title = An outbreak of encephalomyelitis in the Royal Free Hospital Group, London, in 1955 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2425309 | journal = Postgraduate Medical Journal | volume = 54 | pages = 722-724|via=}}</ref><ref name="Ramsay56" /><ref name="Underhill2021" /> consistent with a viral infection * normal or slightly elevated [[erythrocyte sedimentation rate]]<ref name="Ramsay1978" /> * negative virology<ref name="Ramsay56" /> * abnormally high [[lactic dehydrogenase]] and [[glutamic oxaloacetic transaminase]]<ref name="Ramsay1978" /> "Evidence of involvement of the sympathetic nervous system or actual [[Hypothalamus|hypothalamic]] damage was to be found in most cases. This often took the form of [[orthostatic tachycardia]]chilliness of the extremities with increased [[Body temperature|sensitivity to cold]], circulatory impairment and hypothermia."<ref name="Ramsay1978" /> ==Epidemiology== Between July 13, 1955 and November 24, 1955, 292 people, of whom the vast majority were hospital personnel, became ill. Personnel from the medical, nursing, auxiliary medical, ancillary, and administrative departments were affected. Of these two hundred fifty-five were admitted to the hospital.<ref name="Compston" /> Despite the hospital census being near capacity, only 12 patients were afflicted.<ref name="Ramsay1984">{{Cite book | last = Ramsay | first = A. Melvin | author-link = Melvin Ramsay | title = Post-viral fatigue: The saga of the Royal Free Disease | date = 1984| publisher = Gower|location=London|isbn=978-0906923962| title-link = Myalgic Encephalomyelitis and Postviral Fatigue States: The Saga of Royal Free Disease}}</ref> By October 5, 1955, the hospital had to close to new admissions to contain the outbreak and because of the shortage of unaffected staff.<ref name="Underhill2021" /> The first to report ill were a resident doctor and a ward sister.<ref name="Dawson1988">{{Cite journal | last = Dawson | first = J | date = Feb 7, 1987 | title = Royal Free disease: perplexity continues | journal = British Medical Journal (Clinical Research Ed.) | volume = 294|issue =6568 | pages = 327β328 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245346/pdf/bmjcred00006-0005.pdf | pmc=PMC1245346|doi= 10.1136/bmj.294.6568.327}}</ref> More females became ill than males, but at the time it was believed to be because of the staff's living quarters not gender, as more females than males resided at the facility.<ref name="Compston" /> Similar cases had occurred in the population of North West London before this outbreak and sporadic cases continued to occur after the outbreak.<ref name="Ramsay56" /> == Prognosis == For many patients, symptoms waxed and waned in intensity over a long period. A very large majority had complete recovery of neurological function. ==Long-term follow-up== A follow-up study 65 years later found that there was one group of patients that recovered completely or nearly completely, a second group that recovered but was subject to relapses, and a third that showed little or no recovery, these patients remaining incapacitated.<ref name="Ramsay1978" /> Another follow-up study in 2021 interviewed twenty-seven former hospital staff who were present during the outbreak (including a few who developed ME), and reported on their recollection of patient symptoms and circumstances at the time. The accounts of the former staff were found to be inconsistent with the McEvedy and Beard hypothesis that the illness was [[psychosomatic illness|psychosomatic]] in nature, caused by [[mass hysteria]] or psychoneurosis. Observable signs of physical illness reported by the former staff included enlarged posterior cervical glands, ptosis (drooping of the eyelids), hemiparesis (one-sided paralysis), some patients crying due to extreme [[muscle pain]], nausea, and vomiting. Patients typically delayed seeking medical treatment for the first few days, which is also inconsistent with patients overly anxious about the possibility of contracting an illness. Some patients had blood tests which found leukopenia, or lymphocytes typical of [[virus]]es. While some patients seemed to be neurotic and lacked physical signs, a large number of patients were seriously ill with significant physical signs, leading to most hospital staff at the time believing that the cause of illness was an [[infection|infectious disease]]. Some patients remained hospitalized for over six months.<ref name="Underhill2021" /> Five patients developed long-term [[paralysis]] in a part of their body.<ref name="Underhill2021" /> ==Notable studies and publications== *2021, [https://dx.doi.org/10.3390%2Fmedicina57010012 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Organic Disease or Psychosomatic Illness? A Re-Examination of the Royal Free Epidemic of 1955]<ref name="Underhill2021">{{Cite journal | last = Underhill | first = Rosemary | author-link = Rosemary Underhill | last2 = Baillod | first2 = Rosemarie | author-link2 = Rosemarie Baillod | date = Jan 2021 | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Organic Disease or Psychosomatic Illness? A Re-Examination of the Royal Free Epidemic of 1955 | url = https://www.mdpi.com/1648-9144/57/1/12 | journal = Medicina|language=en | volume = 57 | issue = 1 | pages = 12|doi=10.3390/medicina57010012|pmc=PMC7824095|pmid=33375343|access-date=|quote=|via=}}</ref> *2020, [https://www.tandfonline.com/doi/full/10.1080/21641846.2020.1793058 Myalgic Encephalomyelitis (ME) outbreaks can be modelled as an infectious disease: a mathematical reconsideration of the Royal Free Epidemic of 1955]<ref name="Waters2020">{{Cite journal | last = Waters | first = F.G. | last2 = McDonald | first2 = G.J. | last3 = Banks | first3 = S. | last4 = Waters | first4 = R.A. | date = 2020-04-02 | title = Myalgic Encephalomyelitis (ME) outbreaks can be modelled as an infectious disease: a mathematical reconsideration of the Royal Free Epidemic of 1955 | url = https://www.tandfonline.com/doi/full/10.1080/21641846.2020.1793058|journal = Fatigue: Biomedicine, Health & Behavior |language=en | volume = 8 | issue = 2 | pages = 70β83|doi=10.1080/21641846.2020.1793058|issn=2164-1846}}</ref> *2016, [http://www.theguardian.com/lifeandstyle/2016/apr/04/chronic-fatigue-syndrome-cfs-taken-seriously#comment-71789644 Is chronic fatigue syndrome finally being taken seriously?] *1987, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245346/?page=1 Royal Free disease: perplexity continues] *1984, [[Myalgic Encephalomyelitis and Postviral Fatigue States: The Saga of Royal Free Disease]], A. Melvin Ramsay, Gower Medical Publishing, London (book) *1978, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1604957/pdf/brmedj00128-0006b.pdf Epidemic myalgic encephalomyelitis] ([[The BMJ]]) *1978, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2425324/ Epidemic neuromyasthenia 1955-1978]([[Melvin Ramsay|A. Melvin Ramsay]], [[The BMJ]]) *1977, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1607215/?page=1 Icelandic disease (benign myalgic encephalomyelitis or Royal Free disease)]([[Melvin Ramsay|A. Melvin Ramsay]], [[Elizabeth Dowsett]], J V Dadswell, W H Lyle, and J G Parish, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699088/?page=1 Epidemic malaise] (Dr Betty Scott, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699022/?page=1 Epidemic malaise] (Dr Nigel Dean Compston, H. E. Dimsdale, [[Melvin Ramsay|A. Melvin Ramsay]], and A. T. Richardson, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1698971/?page=1 Epidemic malaise] (Dr E D Acheson, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699452/ Epidemic malaise] (Dr Paula Gosling, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699458/?page=1 Epidemic malaise] (Dr G J Burke, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699426/ Epidemic malaise] (Dr E J Hopkins, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1699416/?page=1 Epidemic malaise] (Dr J F Galpine, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700311/ Epidemic malaise] (Dr D C Poskanzer, [[The BMJ]]) *1970, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700986/ Epidemic malaise] (Dr J G Parish, [[The BMJ]]) *1978, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2425309/pdf/postmedj00263-0019.pdf An Outbreak of Encephalomyelitis in the Royal Free Hospital Group, London, in 1955], Dr Nigel Dean Compston *1965, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1846496/?page=1 Eclipse of hysteria] (Dr Betty Scott, [[Melvin Ramsay|A. Melvin Ramsay]], [[The BMJ]]) *1965, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847119/?page=1 Hysteria and 'Royal Free Disease'] ([[Melvin Ramsay|A. Melvin Ramsay]], [[The BMJ]]) *1957, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1962472/ An Outbreak of Encephalomyelitis in the Royal Free Hospital Group, London, in 1955], The Medical Staff Of The Royal Free Hospital ==See also== *[[Epidemic myalgic encephalomyelitis]] *[[List of myalgic encephalomyelitis and chronic fatigue syndrome outbreaks|List of outbreaks]] *[[Royal Free Hospital]] *[[Melvin Ramsay|A. Melvin Ramsay]] *[[Myalgic Encephalomyelitis]] *[[Royal Free Disease]] *[[1948-49 Akureyri outbreak]] (Iceland) ==Learn more== *[https://dx.doi.org/10.3390%2Fmedicina57010012 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Organic Disease or Psychosomatic Illness? A Re-Examination of the Royal Free Epidemic of 1955] ==References== {{Reflist}} [[Category:History]] [[Category:Outbreaks]] [[Category:Outbreaks in the 1950s]] [[Category:Outbreaks in the United Kingdom]]
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