This newspaper ran a front-page story recently in which Professor Edward Shorter, a historian and the author of a book on the history of psychiatry, asserted confidently that a number of conditions, such as chronic fatigue, repetitive stress injury and hypoglycemia, are not real physical illnesses but hysteria. He argued that no underlying organic cause has been found, that the incidence of these conditions rises and falls, and that they are mere "media-spread illness attributions." He says, "And if you have basically hysteria and you can dignify it with something that makes it sound like you have a serious illness, then you get more respect from people." I know hysteria exists: I treat it. But to point out, as Shorter does, that a condition rises and falls at certain points in history or with media attention, or that it lacks a known organic cause, is no proof of hysteria. Once, AIDS didn't exist, then it did, and hopefully one day it won't. In the period when the syndrome was being clarified, but before the virus was discovered, many had their doubts that it was a single entity because many different organ systems were affected. Similarly, being unable to find an organic cause (as we couldn't for some time with AIDS) is also no proof of hysteria.

Hysteria is never a diagnosis one should make just because one can't figure out what is happening medically in a patient. The technical term for this practice is "diagnosis by exclusion." That means that one comes to a diagnosis ("It must be in the patient's head") only because one has excluded every other possibility one can imagine.

Doctors approaching patients that way simply assume that "if it doesn't show up on my lab test or physical exam, it doesn't exist." But lab tests and physical exams are only windows into known disease processes. Sometimes they provide an excellent view, sometimes not.

I raise these concerns because there may have been an important medical breakthrough in understanding one of the conditions that has often been stigmatized as being nothing but hysteria. That condition is fibromyalgia, and a new approach may in fact knit together the mystery of chronic fatigue, hypoglycemia and some forms of muscle and tendon problems.

Fibromyalgia is a misnomer. It means "muscle pain" and is used because many of these patients -- 85% of whom are women -- have bouts of muscle aches and tender spots in muscles and tendons. They are often sore and stiff. Most also can't get enough restorative sleep or have insomnia, fatigue easily and experience a mental fog. (These symptoms are a lot like those of chronic fatigue.)

But they are also prone to inflammatory bowel disease and -- as is less well known -- bladder or vulvar pain, pain during intercourse, chronic infections, brittle nails and excessive tartar on their teeth. A subset suffer from hypoglycemia and weight gain. As the problem progresses, they become increasingly immobilized and depressed; in later years, they often develop osteoarthritis.

With so many different symptoms, they do the rounds with different kinds of doctors, chiropractors and naturopaths and do poorly in treatment. Rheumatologists now say fibromyalgia is the most common disorder they see. Because anxiety and depression are prominent, these patients are often treated as having psychiatric problems. Symptomatic treatment with antidepressants and pain medications may help, but only a little. Many lives are ruined.

But Dr. R. Paul St. Amand, an internist and endocrinologist who has treated more than 5,000 fibromyalgics, has figured out a new way of helping, if not all fibromyalgics, at least a large subtype. In his model, chronic fatigue and hypoglycemia may be different aspects of the same condition. Originally, St. Amand was treating gout patients. One day, one of his patients showed him that he had a massive tartar buildup. St. Amand was intrigued, so he studied the composition of tartar and found it was made up of calcium and phosphate. Immersing himself in the study of gout, he found that when it was originally described, some gout patients also had chronic fatigue and muscle aches. Then he began to see a number of patients who just had the fatigue and muscle aches. He decided to give them gout medications, and, amazingly, they got better. When the term fibromyalgia was introduced, he realized this was the same group of patients.

Next, St. Amand came across a 1989 study in which the muscle and red blood cells of fibromyalgics were studied and were shown to be low in a chemical called adenosine triphosphate -- three phosphate molecules attached to adenosine. All our cells use adenosine triphosphate to produce energy. St. Amand's insight was to remember his patient who had excessive tartar (calcium and, more importantly, phosphate). He recognized that some fibromyalgics he treated also had heavy tartar. As well, some had brittle nails (nail minerals are predominantly calcium and phosphate, and when these are off-balance, crystals form and the nails get brittle).

According to St. Amand's theory, fibromyalgia is a genetic problem in which the sufferer has difficulty getting rid of phosphates. Over a lifetime, negatively charged phosphate builds up in the cells, interfering with the functioning of adenosine triphosphate. This makes it hard for cells, especially in the brain, muscles and immune system, to generate energy. As well, calcium, which is positively charged, moves into the cells to "buffer" -- or electrically neutralize -- the excess phosphate. Because calcium normally turns on cellular and muscular activities, the cells are put into overdrive, adding to the person's exhaustion. The fibromyalgic's tender spots are produced because certain muscles can't turn off and chronically contract. The drug he uses, guaifenesin, is available over the counter. It was discovered in 1543 and acts on the kidneys. When patients go on it, the phosphates empty out of their cells into the bloodstream. Patients on gaufenesin show a 65% increase in phosphate excretion into their urine. They also lose the excess calcium, and the tender spots go away. As the phosphate pours into the bloodstream, symptoms may get worse. But when it is excreted, they feel better, often for the first time in years. Patients cycle like this until their systems are consistently free of symptoms.

There are two catches, though. First, guaifenesin doesn't work in the presence of salicylates (which are in Aspirin, many cosmetics, aloe strips in shavers and many herbs and plants), so one must vigilantly restrict them; they block the site in the kidneys where guaifenesin acts. Second, a subset of patients must be on a low-carbohydrate diet, because they have carbohydrate intolerance and hypoglycemia. St. Amand shows how these are related to fibromyalgia.

Dr. St. Amand's book for the general reader, What Your Doctor May Not Tell You About Fibromyalgia, by Warner Books, is clear and interesting. The Web site is at www.fibromyalgiatreatment.com.

Norman Doidge, M.D., is a research psychiatrist and psychoanalyst.
His column appears in The National Post every other Wednesday.