I love movies...any movie.  But the movies I love the most are from what I call "The Golden Age of Movies"...You see, way back before the digital "light and sound shows" of today, there were...Actors.   When Bogie walked into Rick's Cafe with his white tux and cigarette, he didn't need any sissy digitized backdrop to jazz things up or to compensate for any lack of acting on his part.  The movie and the power behind the movie was:  himself. Pure and simple. No Pixar.  No computers. 

And it was magic.

And a long time ago, I contend we had a similar Golden Age:  Of Allergy.  Am I just being maudlin?  Think about it.  There was a time when allergists diagnostically didn't have serum IgE levels or other immunological parameters to measure and follow; to "fall back on" when seeing a patient.  They only had their 4 senses, and a skin test.  They would listen to their patient, observe, and draw their own conclusions, not preconceived by the "tyranny" of IgE (i.e, "it's not IgE mediated, so who cares?").  If a patient ached after eating a food, they recorded it.  If a patient had vaginitis symptoms after an exposure, they recorded it.  If a patient had headaches after  ingesting a food, they recorded it.  It was in this spirit of observation that Albert Rowe's textbook on food allergy was born.  Likewise Arthur F. Coca's textbook "Familial Nonreaginic Food Allergy".  And Rinkel, Randolph, and Zeller's work "Food Allergy".  The list goes on and on.  These are seminal examples of the Clinician At Work.  And just like we can learn alot about how to make great movies NOW, when we watch the Old Masters at work in classic flicks, so we as modern allergists can take a cue from the Old Masters when it comes to broadening our horizons in the present day allergy field.  As I've said before in prior entries, the discovery of IgE was the best thing--and the worst thing--for the field of allergy....for when we got IgE... we ceased being curious...

  In the Golden Age, the allergist also didn't have effective "asthma controller" medications for their patient population.  Perhaps this made immunotherapy much more attractive than it is today--it was, so to speak, "the only show in town".  We certainly had a number allergists actively trying to optimize immunotherapy treatment  at that time--Herbert Rinkel, French Hansel, and others were very active in this area....Our mantra at the time was not "Asthma Controller Medication" because we didn't have effective controller medication at the time--immunotherapy was the only performer on stage....

Now, am I suggesting that the "old days" of allergy were better than what the modern allergist has to offer?  No, of course not.  But I am suggesting that we can learn from early clinicians, who were unencumbered by the "knowledge" we now have about immunological mechanisms, and take away a valuable lesson:  focus on the patient and their reactions to the environment, even if it is non-IgE mediated.  ... Which brings me to the topic of my next miniseries, "The Late Show", which will begin shortly... 

"The Late Show" stars "The delayed skin test reaction", which, like Rodney Dangerfield, "just gets no respect" by the allergy community at large.  Yet, this is not a new phenomenon:   it was first described by Walker & Adkinson in 1917.  They described "hot, very red, slightly elevated reactions..resembling a mild infection, but sterile...(which) disappear over the next two days..."  And over the next 90 years, have we made any progress in this area?  Take a look at what a standard allergy textbook says about the matter...

"Late phase reactions are often not recorded because their exact significance is unknown..."

       --Allergy, Principles & Practice, 5th Edition

         Elliott Middleton, Ed
 

Here is an official statement by the ACAAI concerning delayed skin test reactions:

Delayed reactions can occur several hours after skin testing, sometimes causing swollen, reddened bumps at the spot where the testing was done. The delayed reaction usually disappears 24 to 48 hours later, but should be reported to the physician. However, when there has been no immediate reaction, delayed reactions do not signify the presence of allergy. (my emphasis)

As clinicians, we should follow the skin text to extinction.  Not become bored with it after ten minutes of observation.  Where is our sense of curiosity?  What an incredible cop-out to say it "doesn't signify the presence of allergy".    Well, what DOES it signify, Gaylord?  "Shouldn't we be listening to the patient, recording their delayed skin test reactions, and trying to make sense of this mystery without preconceived notions--in short, trying to emulate the Old Masters  in "The Golden Age" of allergy?  As the late Keith Eaton MD explained, in writing about the delayed skin test, he concluded:

"there must be a strong presumption that such reproducible and marked bodily reactions are not going to be without biological significance, which is probably associated with a disease state..."

"But you're not talking about an immediate skin test reaction", I can almost hear you say, "so it isn't a concern".  Well, you know how I feel about lack of interest? To quote another figure from the Golden Age of Movies,

Frankly, My Dear, I don't give a damn..." 

As I've mentioned before in a prior journal entry, one of the hallmarks of a superior allergist is simply being curious about what we can't easily explain.  And our sense of curiosity is unfortunately as empty as a cannister of albuterol in the hands of a status asthmaticus patient...but no more...for grab your popcorn, because we're going to "The Late Show"--and confront the mystery behind the delayed allergy reaction. Stay tuned...I promise this show is a good one...and in the meantime, as one of my favorite actors was fond of saying, "Here's looking at you, kid..."