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Clinical Review ABC of adolescence

Fatigue and somatic symptoms

BMJ 2005; 330 doi: (Published 28 April 2005) Cite this as: BMJ 2005;330:1012

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In "Fatigue and Somatic Symptoms", an article which will impact on
sick children and their families, Viner and Christie state that "the
definition of chronic fatigue syndrome (CFS) in adults has been much
debated. The syndrome, often known by patients as myalgic
encephalomyelitis or postviral fatigue syndrome, was first commonly
described in the 1980s.."

Here is one description of ME :-
a) Fever characterised by daily
fluctuations in temperature from 97°F to 99°F (36.0-37.2°C) .
(b) Pain
which was described as rheumatoid or influenzal in character, an ache in
the muscles or bones, but often of sufficient intensity to awaken the
patient from sleep, and, in most instances, it was aggravated by exercise.
It was not confined to any particular part of the body, and
characteristically varied from day to day in its distribution. However,
common sites were the muscles at the back of the neck, between the
shoulders, and in the lumbar region of the back. Pain in the muscles of
the limbs was also common. Abdominal cramps, associated with tender and
painful abdominal muscles, were not infrequent.
(c) Headaches.
(d) Muscle
tenderness .
(e) Muscle twitching, which consisted of fibrillar twitching
of muscle fibres, individual muscles or whole groups; tremors
(f) Nausea,
and, occasionally, vomiting.
(g) Irritability and drowsiness.
Stiff neck and back.
(i) Vertigo.
(j) Photophobia accompanied by severe
ocular pain.
(k) Sore throat, coryza, or cough and chills and diarrhoea
were usual pro­dromal symptoms.
(1) Sensory symptoms included skin
hyperaesthesia, paraesthesia, and anaesthesia, and varied from day to day.

(m) Easy fatiguability.
(n) Menstrual disturbances (increase or decrease
in flow, or change in cycle).
(o) Emotional upsets, including irritability
and crying spells.
(p) Memory difficulty, difficulty in concentration.
Transient personality changes of varying degree of severity.
(r) Urinary
difficulties giving a clinical picture of cystitis.
(s) Insomnia.
Localised muscle weakness, obtained from records of the hospital
physiotherapists, orthopaedic surgeons and personal interview of the

And here is another:-
1. Fatigue: The patient must have a significant
degree of new onset,unexplained, persistent, or recurrent physical and
mental fatigue that substantially reduces activity level.
2. Post-
Exertional Malaise and/or Fatigue: There is an inappropriate loss of
physical and mental stamina, rapid muscular and cognitive fatigability,
post exertional malaise and/or fatigue and/or pain and a tendency for
other associated symptoms within the patient's cluster of symptoms to
worsen. There is a pathologically slow recovery period–usually 24 hours or
3. Sleep Dysfunction: There is unrefreshed sleep or sleep
quantity or rhythm disturbances such as reversed or chaotic diurnal sleep
4. Pain: There is a significant degree of myalgia. Pain can be
experienced in the muscles and/or joints, and is often widespread and
migratory in nature. Often there are significant headaches of new type,
pattern or severity.
5. Neurological/Cognitive Manifestations: Two or more
of the following: Concentration and short-term memory consolidation,
disorientation, difficulty with information processing, categorizing and
word retrieval, and perceptual and sensory disturbances–e.g., spatial
instability and disorientation and inability to focus vision. Ataxia,
muscle weakness and fasciculations are common. There may be overload
phenomena: cognitive, sensory–e.g., photophobia and hypersensitivity to
noise–and/or emotional overload, which may lead to “crash” periods and/or
6. At Least One Symptom from Two of the Following Categories: a.
Autonomic Manifestations: orthostatic intolerance–neurally mediated
hypotenstion (NMH), postural orthostatic tachycardia syndrome (POTS),
delayed postural hypotension; light-headedness; extreme pallor; nausea and
irritable bowel syndrome; urinary frequency and bladder dysfunction;
palpitations with or without cardiac arrhythmias; exertional dyspnea. b.
Neuroendocrine Manifestations: loss of thermostatic stability– subnormal
body temperature and marked diurnal fluctuation, sweating episodes,
recurrent feelings of feverishness and cold extremities; intolerance of
extremes of heat and cold; marked weight change–anorexia or abnormal
appetite; loss of adaptability and worsening of symptoms with stress. c.
Immune Manifestations: tender lymph nodes, recurrent sore throat,
recurrent flu-like symptoms, general malaise, new sensitivities to food,
medications and/or chemicals

The first of course is Gilliam in 1934, and the second Carruthers et
al. in 2003, and I believe they are worth careful comparison. Both of
these descriptions apparently came about through the meticulous collation
of data from patients. However, with respect to the "much debated"
research definitions Viner and Christie mention, Professor Leonard Jason
and others have recently appraised the CDC definition, that Viner and
Christie recommend in their article, thus : “The Fukuda et al (1994)
criteria do not exclude people who have purely psychosocial or psychiatric
reasons for their fatigue (and) this broadening of the CFS definition
raises questions regarding the extent to which patients with purely
psychiatric explanations are erroneously included within the CFS
rubric...the erroneous inclusion of people with primary psychiatric
conditions in CFS samples will have detrimental consequences for the
interpretation of both epidemiologic and treatment efficacy findings”. In
view of this it is of course unsurprising and perfectly rational that
"many young people and their families are resistant to a psychological
explanation for the symptoms and feel that such explanations mean they are
not being believed ". It must surely be one of the most appalling and
damaging experiences for any child and their family to experience.

Viner and Christie also state that ME "was first commonly described
in the 1980s". However, thanks to Dr Gordon Parish who has taken the
trouble to organise pre-80`s data, and to MERGE where this data can be
easily accessed on their website, Viner and Christie might be interested
in some details of the sequence of events before the 1980`s, when ME "was
first commonly described".

[The American term “epidemic neuromyasthenia” refers to a condition
similar to “ME”.Icelandic Disease is the original name for the illness]

EPIDEMIC 1 1934 Los Angeles City and California State, USA Gilliam
AG Epidemiological study of an epidemic diagnosed as poliomyelitis
occurring among the personnel of the Los Angeles County General Hospital
during the summer of 1934. Public Health Bulletin No. 240, April 1938.
[11 related papers]

EPIDEMIC 2 1936 Fond-du-Lac, Wisconsin, USA Armstong G Report to the
Surgeon General, US Public Health Service of the investigation of an
outbreak of “Encephalitis” in the St. Agnes Convent, Fond-du-Lac,
Wisconsin, 1936.

EPIDEMIC 3 1937 Erstfield, Switzerland Stahel H Die Poliomyelitis —
Epidemic bei Stab Geb. IR 37 and Geb Sch Bat II, Erstfeld, 18–30 July,
1937. Die Abortiv — Poliomyelitis. Schweiz Med Wochenschr 1938; 68: 86–91.
[one related paper]

EPIDEMIC 4 1937 Frohburg Hospital, St. Gallen, Switzerland Gsell O
Abortive Poliomyelitis. Verlag Thieme, Leipzig
1938; 13–18. (The three Swiss epidemics 3, 4 and 6 are summarised in
review articles by Gsell O (1958) and Parish JG (1978).

EPIDEMIC 5 Degersheim, St. Gallen, Switzerland Gsell O Abortive
Poliomyelitis. Helv Medica Acta 1949; 16: 170-2

EPIDEMIC 6 1946–47 Iceland Sigurjonsson J Poliomyelitis and Akureyri
Disease. Mixed epidemics of poliomyelitis and a disease resembling
poliomyelitis with the character of the Akureyri Disease. Nord Med 1959;
61: 174–82.

EPIDEMIC 7 1948–49 North Coast Towns, Iceland, Akureyri Nov/Dec 1948,
Saudakrokur Dec 1948/Feb 1949, Isafordur Jan/April 1949 Sigurdsson B et
al. A disease epidemic in Iceland simulating Poliomyelitis. Am J Hyg 1950;
52: 222–38.
[two related papers]

EPIDEMIC 8 1949-51 Adelaide, South Australia Pellew RAAA clinical
description of a disease resembling poliomyelitis seen in Adelaide, 1949-
51 Med J Aust 1951; 1: 944-6.
[3 related papers]

EPIDEMIC 9 1950 St. Joseph Infirmary, Louisville, Kentucky, USA
Steigman AJ An outbreak of an unidentified illness in the Nurses Training
School of St. Joseph Infirmary, Louisville, in Kentucky in October 1950.
Report to the National Foundation of Infantile Paralysis, 1951. (Data
summarised by Henderson DA, Shelokov A, see Review article 2, 1959). [one
related paper]

EPIDEMIC 10 1950 New York State White DN, Burtch RB Iceland Disease —
a new infection simulating Acute Anterior Poliomyelitis. Neurology 1954;
4: 506–16.
[one related paper]

EPIDEMIC 11 1952 Middlesex Hospital Nurses Home, London, England
Acheson ED Encephalomyelitis associated with Poliomyelitis Virus. Lancet
1954; 2: 1044–8. Acheson ED Outbreak at the Royal Free. Lancet 1955; 2:

EPIDEMIC 12 1953 Copenhagen, Denmark Fog AT Neuritis Vegitiva
(Epidemica?). Ugeskr Laeger 1953; 115: 1244–51.[two related papers]

EPIDEMIC 13 Lakeland, Florida, U.S.A. Henderson DA, Shelokov A
Epidemic neuromyasthenia-clinical syndrome? N EngI J Med 1959; 260: 757-

EPIDEMIC 14 1953 Whitley Hospital, Coventry And Coventry District,
England Macrae AD, Galpine JF An illness resembling Poliomyelitis observed
in nurses. Lancet 1954; 2: 350–2.

EPIDEMIC 15 1953 Chestnut Lodge Hospital, Rockville, Maryland, USA
Shelokov A, Habel K, Verder E, Welsh W Epidemic neuromyasthenia. An
outbreak of poliomyelitis-like illness in Student Nurses. N Engl J Med
1957; 257: 345–55. Hardtke EF Iceland disease in Indiana. J Indiana State
Med Assoc 1955; 48: 245–50. {Case also described by Acheson ED, see Review
article 1, 1959).

EPIDEMIC 16 1953 Jutland, Denmark Pedersen EP Epidemic encephalitis
in Jutland. A clinical survey for the years 1952–54. Dan Med Bull 1956; 3:

EPIDEMIC 17 1954 Tallahassee, Florida, USA Bond JO A new clinical
entity? Lancet 1956; 2: 256.

EPIDEMIC 18 1954 Seward, Alaska Deisher JB Benign myalgic
encephalomyelitis (Iceland Disease) in Alaska. Northwest Med 1957; 56:

EPIDEMIC 19 1954 British Army, Berlin, Germany Sumner DN Further
outbreak of a disease resembling poliomyelitis. Lancet 1956; 1: 764–6.[one
related paper]

EPIDEMIC 20 1954 Liverpool, England Comparative epidemiology: see
Official Public Health report for Epidemic 24 (1955).

EPIDEMIC 21 1955 Dalston, Cumbria, England Wallis AL An unusual
epidemic. Lancet 1955; 2: 290. (Further details in Letters, Lancet 1955;
2: 1091 and Lancet 1956; 2: 146)..
[two related papers]

EPIDEMIC 22 1955 Royal Free Hospital, London, England Anon Infectious
mononucleosis. Br Med J 1955; 2: 309–10.
[14 related papers]

EPIDEMIC 23 1955 Perth, Western Australia Steen AS Virus epidemic in
recurrent waves. BMJ 1956; 1: 235.

EPIDEMIC 24 1955 Gilfach, Geoh, Wales Jones TD Virus epidemic in
recurrent waves. BMJ 1956; 1: 348.
[two sproradic case papers London&Boscombe]]

EPIDEMIC 25 1955 Addington Hospital, Durban and Durban City, South
Africa Hill RCJ Memorandum on the outbreak amongst the nurses at Addington
Hospital, Durban. S Afr Med J 1955; 29: 344–5.
[three related papers,one sporadic]

EPIDEMIC 26 1955–56 Segbwema, Sierra Leone, Oct 1955 – Oct 1956 Rose
JR A new clinical entity? Lancet 1956; 2: 197.
Rose JR An outbreak of encephalomyelitis in Sierra Leone. Lancet 1957; 2:

EPIDEMIC 27 1955–56 Patreksfordur and Thorshofn, Iceland, Oct 1955 –
April 1956 Sigurdsson B, Gudnadottir M, Petursson G Response to
poliomyelitis vaccination. Lancet 1958; 1: 370–1.

EPIDEMIC 28 April 1955 – Sept 1957 NW London, England Ramsay AM,
O’Sullivan E Encephalomyelitis simulating poliomyelitis. Lancet 1956; 1:
[two related papers]

EPIDEMIC 29 Ridgefield, Connecticut, USA Henderson DA, Shelokov A,
Heller JH, Stafford T Unpublished data, quoted by Henderson DA, Shelokov
A. Epidemic neuromyasthenia N EngI J Med 1959; 260: 757–64.

EPIDEMIC 30 1956 30Punta Gorda, Florida, USA Poskanzer DC, Henderson
DA, Kunkle BS, Kalter SS, Clement WB, Bond JO Epidemic neuromyasthenia. An
outbreak in Punta Gorda, Florida. N EngI J Med 1957; 257: 356–64.

EPIDEMIC 31 1956 Newton-le-Willows, Lancashire, England Lyle WH
Lymphocytic meningo-encephalitis with myalgia and rash. Lancet 1956; 2:
[two related papers]

EPIDEMIC 32 1956 Pittsfield, Williamstown, Massachusetts, USA
Deutaman W, Davis RK (Unpublished - Data included in survey in Henderson
and Shelokov. N Eng J Med 1959; 260: 757–64 and 814–18).

EPIDEMIC 33 Coventry, England Galpine JF, Brady C Benign myalgic
encephalomyelitis. Lancet 1957; 1: 757–8 and Br Med J 1957; 2: 645.
[two related papers]

EPIDEMIC 34 1957 Brighton, South Australia Hicks DA A new clinical
entity. Lancet 1957; 1: 686.
[four unrelated papers]

EPIDEMIC 35 1958 Athens, Greece Daikos G, Paleologue A, Garzonis S,
Bousvaros GA, Papadoyannakis N Arch Med Sci, Athens 1958; 14: 617.
[one related two unrelated papers]

EPIDEMIC 36 1959 Newcastle upon Tyne, England Pool JH, Walton JN,
Brewis EG, Uldall PR, Wright AE, Gardner PS Benign myalgic
encephalomyelitis in Newcastle-upon-Tyne. Lancet 1961; 1: 733–7.
[five other papers mainly on sporadic]

EPIDEMIC 37 1961–62 New York State Albrecht RM, Oliver VL, Poskanzer
EC Epidemic neuromyasthenia. Outbreak in a convent in New York State. JAMA
1964; 187: 904–7.

EPIDEMIC 38 1964–66 NW London Scott BD Epidemic malaise. Br Med J
1970; 1: 170. Ramsay AM
[five other papers]

EPIDEMIC 39 Franklin, Kentucky, USA Miller G, Chamberlin R,
McCormack WM An outbreak of neuromyasthenia in a Kentucky Factory — the
possible role of a brief exposure to organic mercury. Am J Epidemiol 1967;
86: 756–64.
[one other paper]

EPIDEMIC 40 1965–66 Galveston County, Texas Johnson JM, Micks DW
Epidemic neuromyasthenia Variant? Texas Reports on Biology and Medicine
1967; 25: 484.
[two other papers]

EPIDEMIC 41 1968 Fraidek, Lebanon Mourad S, Chidiac J Benign myalgic
encephalomyelitis in Lebanon. Leb Med J 1969; 22: 735–40.

EPIDEMIC 42 1969 Medical Centre, State University of New York, USA
Damadian R Unidentified symptom complex. N Engl J Med 1969; 280: 1131.
Correspondence: Trimble G. Epidemic Neuromyasthenia. N Engl J Med 1969;
281: 105. Fisher CM. On Damidian’s Ache, 281: 106. Epidemic
Neuromyasthenia, 281 : 797–8. Steigman AJ, Hart RH, Adamson JR

EPIDEMIC 43 1970 Lackland Air Force Base, Texas, USA Graybill JR,
Silva J, O’Brian MS, Reinarz JA Epidemic neuromyasthenia. A Syndrome or
disease? JAMA 1972; 219: 1440–3.

EPIDEMIC 44 1970–71 Hospital for Sick Children, Great Ormond Street,
London, England Dillon MJ, Marshall WC, Dudgeon JA, Steigman AJ Epidemic
neuromyasthenia: outbreak among nurses at a children’s hospital. Br Med J
1974; 1: 301–5. Correspondence: Br Med J 1974; 1: 574–5, Wallis GG, Perry
FS. 2: 276, Parish JG. 559, Dillon MJ.
[one related paper, one other]

EPIDEMIC 45 1976 Southwest Ireland Corridan JP Myalgic
encephalomyelitis. J Irish Med Ass 1976; 69: 414.
[two related papers, one other]

EPIDEMIC 46 1977 Dallas Fort Worth, Texas, USA Shelokov A, Currie DM,
Nelson M. “Epidemic neuromyasthenia’ Texas 1977. Postgrad Med J 1978; 54:
741 (Abstract).
[twenty-two other papers and letters]

EPIDEMIC 47 1979 Southampton, England May PGR, Donnan SPB, Ashton
JR, Ogilvie MM, Rolles CJ Personality and medical perception in benign
myalgic encephalomyelitis. Lancet 1980; 2: 1122–4. Correspondence:
[six other papers]

It seems to me that if other clinicians were to rely on diagnostic
equipment that is as faulty and unreliable as the CDC and Oxford "CFS"
criteria, not a few of them would be seeking alternative employment by
this point, or at least suing the manufacturers.

Douglas Fraser

Dr J. Gordon Parish (Epidemics)

Gilliam AG (1938) Epidemiological study of an epidemic, diagnosed as
poliomyelitis, occurring among the personnel of the Los Angeles County
General Hospital during the Summer of 1934. Public Health Bulletin, US
Treasury Department, No 240, pp 1-90, Washington DC, United States
Government Printing Office.

Postviral Fatigue Syndrome (Myalgic Encephalomyelitis), Edited by
Rachel Jenkins & James Mowbray, John Wiley & Sons, Chichester 1991
ISBN 0 471 92846

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working
Case Definition, Diagnostic and Treatment Protocol Carruthers et al.
Journal of Chronic Fatigue Syndrome 2003;11:7-115

The Clinical Syndrome Variously Called Benign Myalgic
Encephalomyelitis, Iceland Disease and Epidemic Neuromyasthenia E.D.
Acheson, D.M., M.R.C.P. American Journal of Medicine, Vol. 26, Issue 4,
Pages 569–595.

U.S. Case Definition of Chronic Fatigue Syndrome: Diagnostic and
Theoretical Issues Leonard A. Jason Caroline P. King Judith A. Richman
Renee R. Taylor Susan R. Torres Sharon Song
Journal of Chronic Fatigue Syndrome (The Haworth Medical Press, an imprint
of The Haworth Press, Inc.) Vol. 5, No. 3/4, 1999, pp. 3-33.

Variability in diagnostic criteria for chronic fatigue syndrome may
result in substantial differences in patterns of symptoms and
disability.Journal: Eval Health Prof 2003 Mar;26(1):3-22 Authors: Jason
LA, Helgerson J, Torres-Harding SR, Carrico AW, Taylor RR.

The specificity of the CDC-1994 criteria for chronic fatigue
syndrome: comparison of health status in three groups of patients who
fulfil the criteria. Kennedy G, Abbot NC, Spence V, Underwood C and Belch

Chronic Fatigue Syndrome: The Need for Subtypes Authors: Jason,
Leonard 1; Corradi, Karina 2; Torres-Harding, Susan 2; Taylor, Renee 3;
King, Caroline 4 Source: Neuropsychology Review, March 2005, vol. 15, no.
1, pp. 29-58(30) Publisher: Kluwer Academic Publishers

Competing interests:
None declared

Competing interests: No competing interests

03 May 2005
Douglas T Fraser
London W6