Symptoms and signs of chronic fatigue syndrome, 1991, Komaroff

Abstract
This review summarizes the symptoms and signs seen in patients with chronic fatigue syndrome (CFS). It is based on the authors' experience with two cohorts of approximately 510 patients with chronic debilitating fatigue and on the reported experience of other investigators with similar patients. The most characteristic symptoms of CFS are the sudden onset of an infectious-type illness, the subsequent chronic and debilitating fatigue, and postexertional malaise; many patients also have recurrent fevers, pharyngitis, adenopathy, myalgias, sleep disorders, and cognitive impairment.

https://pubmed.ncbi.nlm.nih.gov/2020806/

https://sci-hub.zidianzhan.net/10.1093/clinids/13.Supplement_1.S8#

this is the earliest paper of any kind I can find, so far, with postexertional malaise. I only did some general searching on google, only on the term 'postexertional malaise' also hyphenated and spaced spelling.

(apparently there are several PEM, eg protein-energy malnutrition, and anyway I think the abbreviation has only been used relatively recently)

 

Great that you did that @Sly Saint.

It's very interesting to re-visit the archives.

However, it's also a frustrating and maddening reminder that the biomedical evidence of the day was not given credence.

 

Great detective work @Sly Saint.

Google Books has a feature called the "Ngram Viewer" which allows you to check the frequency of usage of words and phrases (in books and in other printed material).

It may be spurious, and Google Books won't reveal the source, but the first reference to "post - exertional malaise" that the Ngram Viewer cites is from 1988. I don't know where that reference might come from, but 1988 is the year that the CDC convened the conference which (unfortunately) came up with the term "Chronic Fatigue Syndrome."

It would not surprise me if Dr. Komaroff (who was at the conference) is the one who came up with term "Post - Exertional Malaise."

At a much later talk, he sort of defined PEM as a patient saying, "The strangest thing has been happening to me, Doctor. Whenever I do anything, any physical exertion, the next day I feel completely beat up." Dr. Komaroff then went on to say, "I've never heard that - from any patient with any illness other than people with chronic fatigue syndrome."

I think it's a very good description of the onset of PEM.

 

In the interests of pedantry it should be noted that the meeting was in 1987, I think March but would have to check that. The report was published in 1988.

 

Confirming your Google search I ran the same search (post-exertional malaise) OR (postexertional malaise) OR (post exertional malaise) on PubMed and got the identical result of Komaroff 1991 for first publication.

 

The term may have been an innovation, but the concept was not. Ramsay had something broadly similar in his definition. Perhaps, as the US researchers rejected his work, something new had to be concocted.

 

Good catch. I'm pretty sure that 1988 CDC report doesn't actually contain the term "post-exertional malaise," so it seems like it may have been used in some other publication of the time, possibly one written in the wake of the CDC paper.

 

"[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."
https://me-pedia.org/wiki/Ramsay_definition


My point in doing this was try and confirm that the term 'post exertional malaise' was created to specifically describe a defining feature of ME/CFS and is not just a particular symptom that was/is recognised in other illnesses like fatigue.

I think this needs to be pointed out to all those who have since started using it.

 

I must admit to having thought that the first identified use of PEM was by Komaroff in the CIBA conference paper. The symposium was held in May 1992 and the book published in 1993. The paper was Clinical presentation of CFS. In that he says that in our experience 80% of patients with CFS have an exceptional post-exertional malaise.

He does cite the Komaroff, Buchwald paper1991 Symptoms and signs of chronic syndrome, but not specifically in relation to this point.

The ensuing discussion was very revealing. Kleinman jumped in immediately with his "story-telling" meme.

The conclusion of the discussion was depressing.

Kleinman: Another point, which social psychologists have demonstrated repeatedly, is that the social context of experiencing symptoms can strongly influence their interpretation and expression (McHugh and Vallis 1986). Does Tony Komaroff want a final word?

Komaroff: I could sum up by saying that I tried to enter a note in favour of the conventional biomedical model, only to then reject that model.

I had not previously noted this reference to McHugh and Vallis, which some of you will know has been a favourite topic of mine.

 

Holmes et al. 1988 mention as one of the 11 symptom criteria:

"Prolonged (24 hours or greater) generalized fatigue after levels of exercise that would have been easily tolerated in the patient's premorbid state"
​

But without using the term post-exertional malaise.

 

As I feared, it seems as though Ngram Viewer's 1988 citation for "post-exertional malaise" may have been spurious.

I did some further checking and found that Dr. Melvin Ramsay's 1988 book "Myalgic Encephalomyelitis and Postviral Fatigue States: The Saga of Royal Free Disease" contains both the words "post-exertional" and "malaise," but not "post-exertional malaise."

The Ngram Viewer indicated that it was searching for [post - exertional malaise], which I assumed was the equivalent of putting the term in quotes. Apparently not.