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One of the many areas of clinical practice in which GPs are accused of failing to keep up with modern methods is in the management of allergies. It seems that every couple of years some elite medical body documents the woeful state of standards in primary care and insists on the urgent need for more training for GPs as well as demanding the provision of more specialist services.
So when patients ask for a referral for skin tests or other forms of expert investigation and treatment, I duly oblige. It is always something of an anticlimax when they return with a recommendation for a prescription for some combination of an antihistamine, a steroid cream, inhaler or nasal spray, and sodium cromoglycate eye drops. I used to think — ‘I could have done that’ — in fact, I already had. But now, I'm just grateful that by the time they have discovered the uselessness of patch testing and the limitations of all these medications, their symptoms have usually passed (at least until next time).
It is reassuring to discover, from Mark Jackson's excellent Allergy: the history of a modern malady, that doctors and patients have been engaged in a frustrating waltz around the problem of allergy for more than a century, indeed since 1906 when the Austrian paediatrician Clemens von Pirquet coined the term. Like most such neologisms, this one was not well received by his peers and it took a while to catch on.
Yet in time it proved a potent and enduring metaphor for the ‘pathologies of progress’ in the 20th century, its associated conditions expressing a ‘symbolic aversion to the diverse horrors of modern life’.1 Jackson notes the pioneering allergists' difficulties in establishing a firm scientific foundation for their emergent clinical speciality.
Nor could science resolve the long-running turf war between mainstream allergists who insisted on a strict definition of allergic conditions in terms of hypersensitivity reactions and clinical ecologists who sought to include a wide range of disorders attributed to diverse environmental factors and associated with a vast range of non-specific symptoms.
This battle was once characterised by the paediatric immunologist John Soothill as a conflict between ‘the blimps’, predominantly respectable physicians, and ‘the nuts’, sometimes renegade doctors or psychiatrists, joined by a range of alternative therapists and nutritionists. For the blimps, allergy meant simply hay fever, asthma, urticaria, and eczema, for the nuts, however, allergy signified the full diversity of human responses to the toxic hazards of modern life.
Over the past two decades a growing environmentalist consciousness has provided a ready resonance for the notion of an epidemic of allergic disorders resulting from atmospheric pollution and from chemicals in the workplace, in the home, and in foods and drugs. The blimps have baulked at nutty notions such as ‘multiple chemical sensitivity’, and have rejected many nutty (though lucrative) tests. However, they have pragmatically relabelled ‘food allergy’ as ‘food intolerance’ and have entered the flourishing market in elimination diets and nutritional supplements.
While the blimps have always been quick to accuse the nuts of quackery and profiteering, ever since Big Pharma (in the shape of Parke Davis & Co) financed Sir Almoth Wright's pioneering Department of Therapeutic Inoculation at St Mary's in the 1920s, the boundaries in allergy between science and pseudoscience, and between evidence-based practice and commercially-driven practice, have always been blurred.
It is heartening to see that, 20 years after GPs were effectively banned from giving courses of desensitising injections for hay fever after a series of anaphylactic fatalities, immunotherapy is now making a comeback (at least in hospital outpatient departments). A century on, allergy has come full circle. As Jackson observes, ‘perhaps more than any other condition, allergy embodies the biological, political, and spiritual challenges faced by inhabitants of the post-modern world’.1