Rachel Jenkins and James Mowbray; eds. 463 pages. New York: John Wiley & Sons; 1991. $137.50.

Chronic Fatigue Syndrome.

David M. Dawson and Thomas D. Sabin; eds. 218 pages. Boston: Little, Brown; 1993. $65.00.

In the past decade, the subject of chronic fatigue has aroused considerable interest and controversy. Although nearly everyone agrees that chronic fatigue is a common problem, little consensus exists about its cause, pathophysiology, precise diagnosis, and treatment. When one considers that chronic fatigue has been a concern of physicians for generations, it is perhaps surprising that only a few books on the subject have been published. Of these, most are targeted to the lay reader. I believe these two texts are the only currently available works that address the medical and scientific questions related to chronic fatigue.

One of the problems that confounds understanding of this condition is whether chronic fatigue is one or many conditions. Comparison of these two texts highlights this enigma. Post-viral Fatigue Syndrome views the condition from the British perspective, one that believes most cases result from a viral infection (most often Coxsackie virus or other enterovirus). The American position, that the chronic fatigue syndrome is a heterogeneous group of illnesses that may result from infectious, toxic, psychiatric, endocrine, or other causes is reflected in Chronic Fatigue Syndrome.

The British book, published in 1991, collates contributions from many disciplines. It emphasizes studies showing enteroviral nucleic acid in muscle biopsy specimens and a unique enteroviral antigen in serum of some patients (perhaps as many as 65%) with the postviral fatigue syndrome. Other British studies have shown, with molecular hybridization techniques, evidence of Epstein-Barr virus in a smaller group of patients (perhaps 20%). That some investigators have been able to document and measure definite muscle mitochondrial and chemical abnormalities, as well as electromyographic changes, further supports the notion that an "organic" basis underlies this syndrome. The book's focus then shifts successively to the perspectives of the general practitioner and multiple specialists—among others, the cardiologist, the neurologist, the psychiatrist, and the occupational health physician. Each offers his own particular slant (sometimes rather peripheral, as in the case of the cardiologist) on the approach to diagnosis and management of patients with chronic fatigue. Perhaps even more tangential are chapters relating nutrition and fatty acid metabolism to the syndrome. A serious but not very persuasive attempt is also made to associate Giardia and Candida with the chronic fatigue state.

Parenthetically, I found the British sense of humor occasionally evident in this book to be charming. For example: "ME was derived as a short form of myalgic encephalomyelitis (used interchangeably in the United Kingdom for the chronic fatigue syndrome), which was far too much of a mouthful for medicine, let alone the patient!"

The liberal sprinkling of "pseudoscience" over a credible foundation of clinical observation and laboratory research leaves me feeling ambivalent about this book. I need to cite only a few examples of "pseudoscience": "Triple doses of normal -globulin can benefit as many as half of patients" and "The usual cause of chest pain in these patients is chronic benign pericarditis." No supporting data are cited. Even more confusing are management tips, which include avoidance of alcohol for 1 year, exclusion diets, recommendations for and against antidepressant medication, and even relaxation classes.

Perhaps more solidly grounded on conservative footing is the newly published Chronic Fatigue Syndrome. Edited by two neurologists, this book capably begins with a well-researched chapter on the history of the illness. Clearly emphasized are some of the difficulties in making the diagnosis: differentiation from many metabolic, neurologic, and psychiatric diseases (as well as sleep disorders and fibromyalgia), lack of any readily available diagnostic and confirmatory tests, and the fact that the diagnosis remains one of exclusion. Since most contributors to this book are from North America, the Centers for Disease Control and Prevention case definition is stressed, and enteroviral causation is downplayed. Treatment options are balanced and reasoned. For example, the authors state that "intravenous immune globulin cannot be recommended because of its cost, and further studies are warranted" to clarify the conflicting studies on efficacy that are currently available. Antidepressant medication may have a role but is not a panacea.

Are there any deficiencies in Dawson and Sabin's work? I can mention only a few. Natural history and prognosis of this order are hardly mentioned beyond a brief paragraph. (Some follow-up studies have shown that a large percentage of afflicted patients improve, and many return to normal, productive lives.) I would also question the recommendation to obtain Epstein-Barr virus, cytomegalovirus, and toxoplasma serologic tests in most patients with chronic fatigue.

Chronic Fatigue Syndrome is a worthy effort that sheds light on a controversial subject that has polarized physicians and confused the public. I found it to be a whiff of fresh air in dispelling the fog that sometimes envelops us in dealing with the fatigued patient. We all hope research now under way will soon provide more answers to this vexing problem. In the meantime, clinicians will have this helpful source to turn to.