In the office, we use what are called provocative tests to detect food allergies. This is an excellent technique, although not quite as reliable or convincing as the food ingestion tests employed in the hospital. These provocative tests provide reactions in miniature, as it were, between four and thirty minutes after their application.
The tests are called provocative, since they seek to provoke a response in the patient to a suspected food. Clinical ecologists maintain a large number of extracts of various substances. If, in his history, the patient indicates exposures to any food once every three days or more frequently, or if he himself suspects a particular one, he will be tested with a drop of an extract of it placed under his tongue. Generally, the patient can complete two such tests on each visit, until he has tested all of the foods which he most commonly encounters. If a reaction is severe, however, only one test will be given.
As with a number of other innovations in this field, the provocative test was discovered by a doctor who himself had allergies he wished to control. Dr. Carleton Lee, of St. Joseph, Missouri, was highly susceptible to coffee. In the early 1960s, Lee found that he was able to create his characteristic coffee “hangover” with a minute intradermal (skin-deep) injection of coffee extract. In other words, he “provoked” the symptoms with a small dose. Even more intriguing was the fact that a still smaller dose would relieve the same symptoms and keep them in check for hours or days, even when he then drank coffee freely. He called this latter injection the “neutralizing” dose.
Intradermal injections for food allergies had been tried before but with little consistent success. For inhaled allergy-causing substances, such as pollen and dust, they had worked well, but for foods and chemicals they had never been very valuable. Lee presented his findings to food-allergy pioneer Herbert Rinkel, and together they published the first paper on the provocative/neutralizing technique in January, 1962.1
Dr. Guy Pfeiffer and Dr. Lawrence D. Dickey soon refined Lee’s intradermal test by making it a sublingual (under-the-tongue) procedure. The veins under the tongue are close to the surface and readily absorb traces of foods, beverages, and drugs. (It is for this reason that nitroglycerine and some other drugs are placed under the tongue for immediate absorption.) Sublingual extracts worked approximately as well as intradermal injections and avoided the unpleasantness of the injections. Both techniques are currently employed by clinical ecologists, although I myself prefer, and actually use, the sublingual provocative test in my office procedures.
Why the provocative/neutralizing technique works, we do not yet know. That it does work has been demonstrated in hundreds of physicians’ offices, although some orthodox allergists committed to the immunological theory remain skeptical. The provocative/neutralizing technique is a truly empirical procedure, used because it has been found to be effective. If we were to wait until the mechanism of every medical procedure were known before being used, few drugs, new or old, could be employed in medicine. Even the mechanism by which aspirin works is still something of a mystery, and the action of electroshock and tricyclic drugs for depression still must be accounted for. The provocative/neutralizing technique can be used in the same spirit, while research is performed on its mechanism of action.
After performing a provocative test with an extract of a commonly eaten food, we are likely to provoke a positive reaction. In about nine out of ten cases, the patient will respond with the same symptoms which the food is secretly responsible for in real life. If wheat, for example, is the hidden cause of respiratory symptoms, the patient might respond by suddenly coughing or wheezing. Sometimes, however, the symptoms provoked are one notch worse than the real-life symptoms. Thus, a patient who gets headaches (minus-two symptom) from cane sugar under normal conditions might become depressed (minus-three) or brain-fagged (minus-three) after a provocative test with cane.
Once a troublesome reaction has been provoked in this manner, we then attempt to find a neutralizing dose of the same substance. The purpose of this, in our office, is to spare the patient from having to go home with aggravated symptoms. This is the only use to which I generally put the neutralizing technique. Some doctors use the neutralizing dose as a regular treatment for food and chemical susceptibilities, however, providing the patient with a vial of extract to take on a daily or interim basis.
I generally do not do this, since the majority of my patients come to me from out of town. The dose frequently needs readjusting, as, for example, during hay-fever season, at times of virus infection, or for other reasons. It does little good for a patient to call me and say, “Doctor, my dose is no longer working,” when he lives five hundred or a thousand miles from Chicago. I generally help such patients to find a doctor nearer home who will provide such treatments: a list of such clinical ecologists can be obtained from the Society for Clinical Ecology, whose address is listed in Appendix C.
Clinical ecologists, it should be noted, do not generally use the familiar scratch or skin tests employed by most conventional allergists, since they do not give definitive results. According to Albert Rowe, M.D., “It is generally agreed that clinical allergy may exist in the absence of positive skin reactions, especially those to the scratch test. This is true primarily in food allergy and to a lesser extent in inhalant allergy.”2 In a statistical study of intradermal skin tests, Rinkel found such tests to be only forty percent accurate, and often less so.