In my last entry, I mentioned I had read an article in the June issue of the JACI "The Allergy Archives--Pioneers and Milestones" entitled "Food Allergens:  Landmarks along a historic trail" by Sheldon Cohen, MD".  It's a good article,  and I recommend  reading it.  But, while reading it I kept coming to an image:  the image of a man vainly searching in the dark, looking at the ground, in a parking lot.  He would look under one parking light, and then the next.  When a stranger came up and approached him and asked what he was doing, he said "I'm looking for my car keys...I dropped them".  The stranger asked why he was only looking under the lights.  "Because that's where I can see the best", he said. 

We all like to "look under the lights" when we are searching for something valuable.  But sometimes remembering that valuable things aren't just what can be seen easily under the lights is worthwhile too. 

As I had said last time, there were two great men highlighted in the article by Cohen.  One was Walter Vaughan, and the other was Oscar  M . Schloss, M.D.   As I've said before, to get your picture published in the JACI you generally (1) have to be dead and (2) have made a VERY valuable contribution to the allergy field.  I talked about Vaughan in my last entry, so let's talk about Schloss...

Cohen points out in his article that Schloss held the positions of professor and chairman in the Departments of Pediatrics at Cornell Medical College and at Harvard.  As noted by Cohen: 

"In 1912, the controlled, in depth study of Oscar Schloss established the practicability of scratch tests for clinical hypersensitivity". 

Pretty impressive.  But did Schloss do anything else equally impressive?  In the interim since my last blog, I was curious enough about Vaughan's works to order a rare first edition of his work, "Strange Malady, the Story of Allergy", published 67 years ago, in 1941.  In a moment of rare inspiration, I checked the index to find whether his contemporary, Dr. Schloss, was mentioned. 

                                           Indeed, he was....

Here's what Warren Vaughan says about Dr. Schloss (missing from the JACI article):

A child was brought to Dr. Oscar Schloss, a New York pediatrist.  There was a most unusual story of idiosyncrasy.  The lad had had diarrhea when ten days old and was treated with barley water and raw egg white.  This relieved the complaint and caused no unpleasant symptoms.  He received no more egg until he was fourteen months old.  Almost immediately after eating part of a soft-boiled egg he cried out, clawed at his mouth, and his tongue and mouth swelled until they were many times normal size.  Hives soon appeared around the mouth...When the boy was two years old his mother noticed that if he were to play with empty eggshells he would break out with hives on his hands and arms.  Schloss suggested that the boy's experience might be due to this new condition, recently receiving so much attention, called allergy....He injected the boys blood into a guinea pig.  Later he injected egg white.  The animal had typical shock...

 ...He mixed the white of a raw egg with water and diluted it so many times that you would scarcely have thought there was any egg left.  He fed this to the boy with a medicine dropper.  Nothing happened.  He kept on giving this curious medicine every day, increasing the number of drops each time and gradually increasing the strength of the solution...He finally increased the tolerance to such an extent that the lad could eat eggs in moderation with no consequent discomfort....Here again was something well worth telling to the world  Schloss published his report in 1912.

...Two methods of desensitization were now available--hypodermic and oral.  We use both today..." 
    

So, in 4 years, we'll be celebrating the 100th anniversary of successfully documented sublingual food desensitization.  Schloss published his findings, entitled "A Case of Allergy to Common Foods", in Am J Dis Child 3:341, 1912. 
Sounds like a landmark to me.  And hidden away in a forgotten allergy textbook by Warren Vaughan for decades..But was Schloss the first one?  According to Lisa Lundy, in her superb review paper entitled  "Historical background of food allergy", she writes that

A physician in England, Dr. Alfred Schofield, wrote in 1908 about successfully treating a boy who suffered from angioedema and asthma because of an allergy to eggs.  (Schofield, Alfred:  A Case of Egg Poisoning, Lancet, p. 716, 1908).  This egg desensitization was confirmed by Drs. Keston, Walters, and Hopkins (Keston, B, Walters, I, Gardner, J:  Oral Desensitization to common foods.  J Allergy 6:431, 1935). 

.So SLIT for foods was documented by multiple doctors  at the turn of the 20th century, nearly 100 years ago. But Schloss deserves a major credit nonetheless.   Can we learn something from the classical literature?  You bet.  Schloss used a serial dilution technique for successful desensitization in a patient highly allergic to eggs...Seems to me that's important....We can also learn that we all have a bit of arrogance in "modern allergy" in "copping an attitude" that everything worth knowing in the field has been published within the last 10 years (or mentioned in the latest CME exercise we did...)   

...Open-mindedness and an obsessive sense of curiosity is  a hallmark of the Renaissance Allergist.  As Renaissance Allergists, we're interested in looking not just "under the lights" of our accepted (and preconceived) notions that SLIT for foods is a "new" idea and "new" treatment, never tried before. We look everywhere...whether it's under a light or not.  An interest in classical allergy literature pays many dividends for the Renaissance Allergist.  Here's one more.    

Later, Dude. 

As I sat in my office, perusing the latest June issue of the Journal of Allergy and Clinical Immunology, I was intrigued by the article by Sheldon G. Cohen, in "The Allergy Archives--Pioneers and Milestones" discusing "Food Allergens:  Landmarks along a historic trail.  As noted in the article, Dr. Warren T. Vaughan was the author of Practice of Allergy, 1939, and editor of the Journal of Laboratory and Clinical Medicine.  In his article, Dr. Cohen notes:

"In 1930, Vaughan, in collaboration with Frances Wilson, an academic botanist, initiated studies of shared characters of plant-derived foods as the first stage in the development of a classification intended to serve as a rational and workable basis for selecting test allergens representative of members of a group.  ...Of special interest is a 75-year-retrospective review of Vaughan's contribution, noting that with few exceptions his compilation was valid and met the test of time"  

 As a Renaissance Allergist, I have an interest in classical (medical) literature, and an overwhelming sense of curiosity--basically, what else did Vaughan write--and what might it tell us in addition to Cohen's article? 

Here's some things not pointed out in the article by Cohen:  

First, Vaughan wrote on a wide range of topics he felt were related to the allergy field:  check these out:

1.  Vaughan, WT.  Allergic Migraine.  JAMA 88:1383, 1927.

2.  Vaughan WT.  Role of specific and nonspecific factors in allergy and allergic equilibrium.  J Lab & Clin Med 13:633, 1928.  

3.  Vaughan WT.  Allergic factor in mucous colitis.  South M J 21:894, 1928.

4.  Vaughan WT.  Atypical and borderline allergic manifestations as important factors in general medicine.  South Med & Surg 95:15, 1933.  

5.  Vaughan WT.  Food allergy as a common problem.  J Lab & Clin Med 19:53, 1933.

6.  Vaughan WT.  Food idiosyncrasy as a factor of importance in gastroenterology and in allergy.  Rev Gastroenterol 5:1, 1938.  

7.  Vaughan WT.  Palindromic rheumatism among allergic persons.  J Allergy 14:256, 1943.

Secondly, we know Vaughan was a brilliant physician.  ( For anybody to get their picture in the JACI, you've got to be brilliant).  Even his son was a brilliant doctor--John Heath Vaughan, was an internationally recognized authority on allergy and autoimmune diseases and a former member of the University of Rochester School of Medicine and Dentistry, who recently passed away at the age of 85 on Nov 11, 2007.  So why was  a brilliant physician like Vaughan writing about palindromic rheumatism and it's relation to allergy?  What does his "classical" writing tell us?  Are you curious? I was. 

In his article, Vaughan described 27 cases with recurrent or chronic joint symptoms among a large group of allergic patients, in whom the arthritic symptoms were attributed to food sensitivity.  He called this syndrome "palindromic rheumatism", a term used by Hench and Rosenberg 2 years earlier to imply recurring joint disease without articular residue.  Vaughan would note that about half of his patients seemed to have abnormal joint changes at the time of exam.  His original discription of this group of patients is repeated here for its remarkable accuracy:

"The second consideration was a small group of allergic persons with intermittent attacks resembling subacute rheumatoid arthritis in whom we have demonstrated specific food incitants.   The evolution of the attacks resembled those of intermittent hydroarthrosis, but multiple small joints were involved; often just one hand or foot was affected.  Sometimes the reaction occurred in more than one extremity, and at times one or two large joints became inflammed either simultaneously or independelty.  The local picture was of swelling, redness, paind, and tenderness.  The attacks would last from several days to a week, rarely longer.  In some, the joints were objectively normal between attacks.  In others, there were low grade arthritic changes..."

Now--be honest--how many allergists take rheumatic histories on our patients?  I do.  For example, I can remember the patient with a strong dust sensitivity who suffered an acute attack of palindromic rheumatism after sweeping out her basement.  In truth, being curious and delving into the older "classical" allergic literature---which was devoid of the built-in constraints of IgE-mediation, may offer us new insights.  Remember what I wrote last month about the mast cells and the synovium?  

Warren T. Vaughan was a Renaissance Allergist.  A brilliant clinician.  And he believed that palindromic rheumatism could be triggered by food incitants.  Renaissance Allergists in today's world need to follow-up on his meticulous & compelling observations. ...

Later, Dude.  

 

 

 

 

 

In my last post I mentioned that I took a 3 month "blog sabbatical" to try to redefine what I felt we needed in the allergy field, and express it as succinctly as possible--in a positive manner.  I considered many ideas, but in the end, only one concept--one word-- made the final cut:  

                          Renaissance

The word "renaissance" is of French derivation--for rebirth.  What characterized the Renaissance?--a "rediscovery" of classical literature/art, curiosity and objectivity, and an emphasis on individualism (among other things.)  The true "Renaissance Man" embodies these ideals in a multi-talented fashion.   In my (humble?) opinion, the allergy field needs more "Renaissance Allergists", and alot less "asthma docs".  We made a fundamental mistake as allergists when we anatomically delimited our field--because the field is basically not one to anatomically demarcate.  In that respect, it's alot like our "brother specialty"--infectious disease.  Imagine if the IDSA  (Infectious Diseases Society of America) changed their name, for example, to emphasize "bronchitis", and became the Infectious Diseases Society of America and Bronchitis?  What if you went to infectious disease meetings, and all they talked about was the respiratory infections they cared about?  How interesting would that be?  We've done that with our own societies--tagged "asthma" along with the official titles, as if to say that's "who we are". Asthma docs. 

And that's what the Renaissance Allergist is not.   What is he?  Easy.  He's a multi-talented physician first, an allergist second, and an asthmalogist (a distant) third.  He/she is interested in all immunological aberrations (both non IgE and IgE mediated) over all mucosal surfaces, as well as the skin and joints.  And come to speak of it, he's even interested in the human synovium, and how his allergic patients might respond there.  Remember--mast cells have long been known to be present in the human synovium, and mast cell numbers also increase 1-10 fold with diverse disorders, including juvenile and adult rheumatoid arthritis.  (See "Mast Cells and arthritis"  by Malone & Metcalfe, Ann Allergy 61:  27-30, 1988 if you're interested).  Yes, a spirit of curiosity, individualism, and love of classical literature are characteristics of the Renaissance--and of the Renaissance Allergist. 

Which brings me to the latest Allergy Archives, and Warren T. Vaughn.  But that's for another time, and another post.

Later, Dude