A careful study must be made of each individual patient in every way possible to ascertain to what substance or substances he is sensitive. These substances vary from common foods, pollens, bacteria, drugs, hairs, and feathers, to such unexpected materials as the colored ink used in printing the rotogravure section of a newspaper. Findings which can be explained on the basis of smooth muscle spasm or increased permeability of blood vessels should be noted. A careful history, including the family history, will often establish at least the probability of an allergic state as an hereditary trait. Skin tests are valuable only if they are positive, for other parts of the body may be sensitive when the skin reaction is entirely negative. The intradermal and patch tests are much more reliable than the scratch method. Simplified diets may be used to test for food hypersensitiveness. When a selection is found which frees the patient from symptoms entirely, foods causing reactions may be isolated by adding one to the list at a time. Frequently by laboratory test, changes in the relative numbers of certain types of circulating white blood cells are noted in allergic individuals.
TREATMENT OF ALLERGIC PATIENTS
Elimination. If the offending substance is a food it should be eliminated from the diet if possible. If the patient is sensitive to eggs, wheat, or milk (the most common food offenders), these should be eliminated from the diet temporarily. But if the problem is more complex, elimination diets may be tried, such as those advocated in this country by Rowe, in which small groups of foods are used in the beginning to which, statistically, patients are least likely to become sensitized. After such a diet has been used if the patient is entirely free from allergic symptoms, then one food may be added at a time at intervals of several days, watching for any reactions. The elimination plan would be entirely successful if it were not for the fact that all these patients have an inherent tendency which permits them to become sensitized to new contacts.
If the tonsils, teeth, or nasal sinuses are teeming with pathological germs to which smooth muscle or blood vessels are sensitive, these foci of infection should be re-moved. Patients with hay fever usually improve when they can move to a location free from the offending pollen, or if they can make use of air conditioned rooms. It may be necessary to give away the dog or pony if the patient is sensitive to the hair or skin emanations of these animals. It may be necessary to sleep on a fiber pillow if there is sensitiveness to feathers, or the feather pillow may be covered with an impervious cover.
Hypersensitivity to any one food or substance is not a fixed state. A patient who is sensitive to wheat may eventually become sensitive to rye or rice. One who is sensitive to ragweed pollen may eventually become sensitive to sage pollen in moving, for example, from Illinois to California. Total separation from an object or food causing reactions may in a short time free one from the sensitiveness that existed. Partial elimination of of-fending substances seems to be sufficient in some cases. A patient who is sensitive to milk may be able to tolerate the small amount of milk found in butter. A patient might not be able to take a mixed diet containing 3,000 calories, but he might be able to take a similar mixed diet if it contained only 1,000 calories.
Immunization. Tolerance to any offending substance can be built up by taking increasing doses of the material beginning with very small amounts. This type of treatment given hypodermically is most successfully used in the treatment of hay fever with pollen extracts, and bacterial asthma with vaccines made from the offending organism. Small amounts of an offending food may be used with no symptoms, and increasing amounts given as the patient’s immunity increases. Children sensitive to milk have been fed in this way. Beginning with one drop per day by mouth, each succeeding day one drop is added to the amount used, until several glasses of milk can be taken in the day’s three meals without discomfort.
Calcium. For some unexplained reason, patients with allergy often seem to improve when calcium medication is given. The indigestion theory would explain why some of these patients do not absorb calcium well. Diets low in milk, which is often an offending article of food, de-crease the calcium intake. Calcium has been shown to decrease nerve irritability, and so would act in line with the sympathetic nervous system, which is intimately related to the function of smooth muscle tissue.
Digestive Aids. The general suggestions made in the treatment of indigestion are in place here. Special attention should be paid to the digestive functions. When pepsin is missing from the gastric juice it may be given by mouth. When hydrochloric acid is missing or low, acid fruits and fruit juices may be used. If a patient is sensitive to lemon or grapefruit, then chemically pure citric acid may be used. When bile is missing, bile or bile salts may be given. When pancreatic ferments are low, they may be supplied in the form of coated pancreatin. In giving digestive help one must plan always on giving, according to the theory mentioned above, not only enough to combine with all of the foods eaten, but an excess which can be absorbed into the blood stream.
Insulin may be given hypodermically, always testing the patient at first to ascertain whether or not he is sensitive to the proteins in it. A patient who is sensitive to insulin made from pork may not be sensitive to insulin made from beef. The method of giving insulin three times per day hypodermically, should be ideal in preventing sensitization to this substance, and should increase immunity to the foreign proteins in it.
Vitamin B, because it increases the flow of digestive juices and stimulates the appetite and intestinal motility, should always be provided in adequate amounts.
It is obvious from the above discussion that no one line of treatment for allergic states can be successful in all cases. A combination, however, of the general principles of eliminating the suspected contacts, immunization where possible, adequate amounts of the mineral food calcium, and especial attention to aiding digestive functions does bring about fairly satisfactory results. Patients must be taught the nature of the handicap so that they may assist in their care by noting any unusual symptoms.