The Diagnosis and Treatment of Food Allergy

The identification of foods responsible for the production of allergic manifestations may occasionally be made by the sufferer himself. Whenever hives, headache, asthma or allergic rhinitis occur promptly following the ingestion of a food infrequently eaten, cause and effect are easily recognized. Urticaria from eating strawberries or sea food is often experienced in childhood by allergic individuals and the offenders then avoided. However, when allergenic foods are consumed frequently or every day, diagnosis becomes much more difficult.

This is especially true since partial tolerance prevents an explosive reaction. In addition, a wide range of symptoms, not ordinarily thought of as allergic in origin, may result from the daily ingestion of such foods. The ingredients of vitamin preparations, drugs and other chemicals may also be responsible. Inhalation of animal emanations and house dust may induce similar complaints. The subject, therefore, can be quite complex.

Although much work has been done on the biochemical mechanisms involved in sensitization, our ignorance is still abysmal. A discussion of current concepts would be time-consuming. However, I would call to your attention the studies of F. M. Pottenger, Jr.¹ demonstrating that cats fed a diet limited to cooked foods, rapidly degenerated emotionally and physically so that reproduction beyond the third generation was, in most cases, impossible. In addition to manifesting practically all the diseases of civilized man, these cats developed a markedly increased incidence of allergy from less than five per cent in healthy animals on raw food, to more than 90 per cent in the third generation on cooked food. Interestingly enough it took three generations on raw food to restore a few survivors to normal health. This suggests that poor nutrition may be a most important factor in the development of the allergic constitution.

This indirect evidence is substantiated by the observations of Sir Robert McCarrison.² He fed animals typical English and American diets containing a preponderance of cooked food and a high proportion of white bread, polished rice and refined sugar. His experimental animals also developed infections and degenerative diseases common to mankind. Pathological examination revealed adrenal hypertrophy, atrophy of the other endocrine glands, liver damage and elongation, distension and atrophy of the intestinal tract.

It is logical to assume that endocrine damage should decrease resistance to stress of all kinds, including noxious agents. It is also logical to believe that reduction of digestive enzymes and atrophy of the intestinal tract should increase the absorption of undigested or incompletely digested food–thus increasing the incidence of food allergy.

With such disturbances in metabolism, one might expect damage to, and alteration of, the nucleoproteins concerned with inheritance.

Food allergy may be divided into two categories, namely atopic and nonreaginic. It is interesting that the late Dr. Arthur F. Coca, together with Dr. Grove³ first demonstrated in 1925 the presence of allergic antibodies in cases of hayfever, bronchial asthma, serum sickness and atopic dermatitis. In 1938 Dr. Coca developed the concept of nonreaginic allergy and expanded this thesis into a scientific monograph⁴ which has gone through three editions. For reasons which will be discussed later on, this pioneering work has not met with the enthusiastic acceptance which it deserves.

Diagnosis

The methods available for the diagnosis of food allergy may be listed as (1) a good history and physical examination; (2) elimination diets; (3) skin tests; (4) leucopenic index studies; (5) the Black Cytotoxic Test and (6) the pulse-dietary technique.

The importance of a good history and physical examination is well known. Laboratory studies are naturally included.

Diagnosis by the exclusion of foods may be simple or complicated: and the results are variable. a) One or more suspected foods may be eliminated from the diet for one week and then reintroduced. If allergic manifestations improve and then return in an exaggerated form and repetition of the procedure reproduces the picture, one of the suspected foods is probably the culprit and can be identified. Exaggerated symptoms after a short avoidance are due to decreased tolerance. This approach is sometimes effective if food sensitivities are few in number.

More complicated and stringent elimination diets have been advocated and used with success by Albert H. Rowe. He and his son are convinced that food allergy is more widespread and important than most physicians believe and they include evidence that ulcerative colitis is primarily an allergic manifestation. It is probable that they are dealing with cases of nonreaginic allergy. They might find Coca’s pulse diagnostic method more reliable and a study of their cases from this angle would be most interesting, since they report skin tests to be of little help in these cases. Others have found it difficult to persuade patients to follow these strict diets.

Skin testing is notoriously unreliable in the case of foods. Large positive reactions are suggestive only and must be confirmed or ruled out by feeding experiments. No patient should be told he is allergic to any food solely on the basis of positive skin reactions. Since there may be no clinical confirmation whatsoever, such advice tends to discredit the practice of allergy in the minds of both patient and physician.

The leucopenic index as introduced by H. Rinkel, L. P. Gay and others is time-consuming and expensive. It has been discarded by most allergists. Dr. Gay is now enthusiastic in his use of the pulse-dietary technique.⁶

The Black cytotoxic test is being used by Robert T. Pottenger and others. It has much promise, but as yet awaits improvement and standardization.

Coca’s method of diagnosis by observation of the pulse rate following contact with allergens either ingested or inhaled is relatively new–the first edition of his monograph having been published in 1943. In view of the scientific accuracy of this diagnostic procedure, acceptance has been surprisingly slow. It seems worthwhile to examine the reasons therefore and to include a brief account of what led to his discovery.

In 1938 Coca observed in a member of his immediate family a very serious reaction to the administration of a sedative given for angina pectoris. Vascular collapse was accompanied by a pulse rate of 180. Although recovery ensued, it was for some time in doubt. Later he noticed milder but severe reactions to foods, again accompanied by tachycardia. Because he was curious and a good observer, Coca began recording this patient’s pulse rate during waking hours. This led to recognition and elimination of pulse-accelerating foods, some of which induced the anginal pains of which she originally complained. Only after a number of the incriminated foods had been omitted from her regime, did she realize and admit that other symptoms of many years duration, such as colitis, inordinate fatigue and dizzy spells, had disappeared.

Dr. Coca was naturally quite excited at these findings and proceeded to apply this technique not only to other patients, but to himself, since he had long suffered from fatigue, headaches, hypertension and other allergic manifestations. When, by means of the pulse technique, he discovered that beef was the only food he could consume without tachycardia, he underwent a simple lumbar sympathectomy with the hope this might improve his condition. Following this surgery he could tolerate 14 foods. A similar sympathectomy on the other side failed to enlarge this list of compatible foods by even one. At a later date Dr. Coca discovered that house dust, to which he was atopically allergic, produced a tachycardia. The usual precautions against house dust, including an air filter were helpful, but complete relief of his hypertension due to such dust was not obtained until a preparation called Dust Seal (R)* was used to treat fabrics, rugs and furniture throughout the house.

As a result of his clinical observations, the concept of familial nonreaginic allergy was completely developed and made available to the medical profession.³ Dr. Coca called this fifth category of allergy Idioblapsis, meaning “life spoiler”. In spite of his scholarly and scientific work, the application of this new knowledge has met with marked resistance on the part of physicians and scientists. Let us explore some of the reasons for this slow acceptance.

• The concept is entirely new. Since no reagins or antibodies have so far been demonstrated, some authorities feel this phenomenon should not be classified as a true allergy. Nevertheless, the marked specificity leaves no other explanation for those who have taken the trouble to use the pulse-dietary method.
• The fact that idioblapsis in at least a minor way, afflicts up to 90 per cent of the population stretches the credulity of many.
• Idioblapsis is responsible for many symptoms that have heretofore not been classified as allergic in origin. Coca,³ Gay,⁷Milo G. Meyer,⁸ and others^{9, 10,11} have recorded the following complaints as the result of pulse allergy: acne, allergic rhinitis, purpura, asthma, “cold sores”, marked fatigue, neuritis, arthritis, spasm of the trapezius muscles, aches and pains, headache, corneal ulcer, migraine, epilepsy, vertigo, neurodermatitis, dysmenorrhea, urticaria, hypertension, cardiac arrhythmia, renal colic and hematuria, gall bladder colic, indigestion, colitis, peptic ulcer, constipation, hemorrhoids, and even cases of encephalopathy, emotional depression and multiple sclerosis. Such a variety of complaints relieved by elimination of offending allergens naturally engenders doubt.
• Application of the pulse method of diagnosis presents numerous difficulties. In typical cases–which are all too few–tachycardia occurs within five minutes of contact with inhalants and within one hour after the ingestion of allergenic foods or chemicals and subsides fairly rapidly. This is a scientific fact and can not be missed. However, prolonged reactions occur, which complicate the picture. Some patients may consume a food allergen and show an elevated pulse rate for several days. This casts suspicion on foods consumed during the reaction period and discourages those who are not familiar with the pitfalls described in Coca’s monograph. Delayed clinical reactions to foods add to the confusion.
  
  Once the primary allergens have been isolated and removed from a patient’s environment, the pulse rate settles down to a very narrow range and is extremely stable. However, even after a period of weeks, minor allergens–previously suppressed by major ones–may then become manifest by tachycardia and renewed symptoms. Both patient and physician at this point may become discouraged and…
  
  The frequent pulse readings necessary for diagnosis (eleven per day) are time consuming: so is the interpretation. While most individuals can be taught pulse counting accurately, a few are unable to learn. All patients must be checked in the office to be sure their results tally with those of the physician. Some will never cooperate.
• Multiple sensitivities may render detection extremely difficult. In such instances patients must be limited to a few foods or in unusual cases a fast of several days may be indicated to get rid of residual pulse-accelerating foods and bring the pulse rate to a low level which permits testing. Under these circumstances, a stellate ganglion block with novocaine, may obliterate many food sensitivities and lead to isolation of those remaining. The procedure also indicates the results to be expected from sympathectomy.
• Other causes of tachycardia, such as hyperthyroidism, hypoglycemia, infections and tension states may confuse the picture.
• Many physicians believe that allergic manifestations rest primarily on a psychosomatic basis. I do not agree with this thesis. I am sure that tension can induce attacks, but they are superimposed on an allergic constitution. In most cases discovery and removal of food allergens, or hyposensitization by injections of house dust and pollens prevents the attacks. I do believe that in a few cases, prolonged emotional tension may produce endocrine fatigue and thereby induce the allergic state.

Whereas the reasons just enumerated may help to explain the lack of acceptance accorded Coca’s concept of idioblapsis, they do not excuse the failure of intelligent students of allergy to at least explore the value of the pulse-dietary method in actual practice. It is almost axiomatic that success in the diagnosis and treatment of allergic states is directly proportional to the knowledge and industry applied toward the solution of such problems. To neglect any new method of diagnosis based on scientific observations suggests either slothful indifference or smug satisfaction with the status quo. Intelligent patients these days are loath to accept either interpretation as an excuse.

Discussion and Summary

Before the discovery of the fifth category of allergic disease (idioblapsis), diagnosis of food allergy was difficult and often the result of guesswork, confirmed by clinical trial. It still is beset with many difficulties.

Skin tests are unreliable and must be confirmed by clinical testing by ingestion of suspected foods. Elimination diets are useful but complicated. The leucopenic index has been all but discarded. The Black cytotoxic technique holds promise but is cumbersome and expensive.

Pulse-dietary studies hold the best promise from the scientific standpoint, even though numerous difficulties beset the user of this method. Because of the high incidence (90-95 per cent) of idioblapsis in the white population, recognition of this problem is of vast importance to the prevention as well as curative aspects of medical practice.

Early use of simple lumbar sympathectomy should be encouraged in severe cases allergic to most staple foods. Surgery should not be considered until the most important foods in the average diet have been tested following a novocain, stellate ganglion block. This gives a rough indication of the increased number of foods which may be tolerated following sympathectomy.

Why idioblapsis affects the sympathetic nervous system is not known. Nor is it understandable why severing the sympathetic chain in one area should abolish some food sensitivities, while not affecting others, and without influencing the effect of inhalant allergens.

It is earnestly to be hoped that a biochemical etiology and method of treatment for idioblapsis will eventually be discovered. In the meantime relief of symptoms due to this “life-spoiler” depends upon the recognition and avoidance of allergens, with lumbar sympathectomy reserved for the more severe cases.

The scholarly and scientific observations of Dr. Coca deserve study and trial by all conscientious allergists and physicians.

 

References Cited:

1. Pottenger, F. M., Jr.: “The effect of heat-processed foods and metabolized Vitamin D Milk on the dentofacial structures of experimental animals.” Am. J. Orthodontics and Oral Surg., 32:8 (Aug.) 1946.
2. McCarrison, Sir Robert: Studies in Deficiency Disease, London, Frowde, Hoddor and Stoughton, 1921. (Reproduced by Lee Foundation for Nutritional Research, Milwaukee, U.S.A., 1945.)
3. Coca, A. F. and E. P. Grove: J. Immunol., 10:445, 1925.
4. Coca, A. P.: Familial Nonreaginic Food Allergy. 3rd Ed., Charles C. Thomas, Springfield, Mass., U.S.A., 1953.
5. Rowe, A. H. 
6. Gay, L. P.: “Nonreaginic Allergy in the Management of Essential Hypertension.” J. Applied Nutrition, 12:71, 1959.
7. Gay, L. P.: “Dermatological problems solved by the pulse dietary technique.” J. Applied Nutrition 11:196, 1958.
8. Meyer, M. G.: Ann. Allergy, 6:417, 1948.
9. Knight, G. F.: “Nonreaginic allergy in theory and practice.” J. Applied Nutrition, 8:311-316, (Dec.) 1954.
10. Locke, A. P.: “Familial nonreaginic food-allergy as a predisposing cause of common cold.” Ann. N. Y. Acad. Sc., 50: 796, 1949.
11. Price A. Sumner: “The role of food-allergy in hypertension.” Rev. Gastroenterol., 10:233, 1943.