I was on the phone recently with a colleague whom I admire...we were discussing an allergy case at his request when he said..."You know, it does my heart good to see you've gotten over your anger issues and renamed your blog  "The Renaissance Allergist"...

Inwardly, I beamed...maybe getting in touch with my Inner Child was finally doing me some good...it was amazing...maybe, just maybe, all that hard work I had done in resolving my previously unresolved suppressed anger at my father for not taking me to a Chicago Bears game in 1955 was finally coming to fruition...

And I was in a truly mellow mood when I picked up the latest issue of  Current Allergy and Asthma Reports, Volume 8, Number 4, 2008.  In it, the lead article was entitled "Recent Advances in Immunotherapy of Allergic Rhinitis", by Lee & Mo.  Not surprisingly, their first topic of discussion was Sublingual Immunotherapy (SLIT).  They had this to say in their first sentence of their first paragraph:

SLIT was first introduced in the 1980s in Europe."

Say whaaat?  

Screw my Inner Child.  I'm mad.  

Hey, wait just ONE minute....it may be becoming fashionable to quote the newer European literature on SLIT, but it's important not to ignore the "pioneers" when it comes to this technique. How long has SLIT been around?  20 years?  30 years?  40 years?

How about 109 years...

In 1900 a New York physician H.H. Curtis relieved his patients' hayfever by placing pollen antigen drops in their mouths.  Yes, 1900.  Not 2000.  Written up in "The immunizing cure of Hay Fever"  Medical News, New York 1900; 77:16-19.  In 1905 German doctors used oral immunotherapy to desensitize infants allergic to cow's milk (Finkelsteim, H. Kulmilch als Ursache von Ernahrungsstorungen bei Sauglingen Mmonatsschr Kinderheilk.  1905; 4:65-72.)  Actually allergy injection immunotherapy (SCIT) was first used 11 years AFTER oral immunotherapy by English physicians John Freeman and Leonard Noon.  

In the 30s and 40s, doctors used oral immunotherapy, mostly reporting favorable results.  Black desensitized 150 patients to pollen using oral drops--40% of them got satisfactory symptom relief. (Black, J.  The oral administration of ragweed pollen.  Journal of Allergy and Clinical Immunology.  1939. 10:156.)  Leo Conway began using oral antigen drops to control seasonal allergies by 1934.  (Conway, L.  Pollen allergy.  South Med Surg. 1943; 4.).  Gutterdam in 1933 reported on 85 patients receiving oral antigen drops, finding good symptom relief in 75-85% of patients.  (Gutterdam, E.  Oral administration of pollen extracts.  Southwest Medicine.  1933:17:199.)  They took 3-15 drops of pollen extract twice each day.  In 1937 Hollister & Stier reported good results in 78% of hay fever patients and in those allergic to animal dander and foods.  (Stier, R. Hollister, G.  Desensitization by oral administration of pollen extracts.  Northwest Medicine.  1937; 36:166).  

Were there others?  Of course.  Schofield, Walker, Stuart, Farnham, Keston, Waters, Hopkins to name a few.  I have written a previous entry on Oscar Schloss   who had successfully desensitized a child with anaphylaxis from eggs with serial dilutions of oral egg drops administered orally....in 1912.  

But for my money, the three real pioneers in the field were:  French Hansel, Larry Dickey, and David Morris...

I have been extremely privileged in my life to have known all three.  

French Hansel can be called the modern "father of sublingual immunotherapy".  Hansel experimented with sublingual drops for dust mites while he was a Mayo Clinic Fellow in the 1920s and published his results in 1936.  (Hansel, F.  Allergy of the nose and paranasal sinuses.  CV Mosby.  1936).  He was the first physician to observe that actually placing antigen drops specifically under the tongue prompted faster, more effective desensitization than in any other part of the mouth. He had this to say:

It is not unreasonable to assume that this highly absorptive sublingual area has definite immunologic function.  Through this route practically all the injectables, many of which are not well tolerated, can be introduced without apparent injury to or reaction in the local tissues"  ((Hansel, F.  Clinical Allergy.  CV Mosby.  1953)

He later described in greater detail sublingual treatment in "Sublingual testing and therapy. Trans Soc. Opthalmol Otolaryngol Allergy, 11: 93, 1970. During my early training, I was fortunate to have lunch with Dr. Hansel, and to discuss his experience with SLIT in particular.  How fortunate!  Guy Pfeiffer, MD, a student of Hansels, developed sublingual drops for foods.  Like Hansel, he was an ENT physician, who presented his five years of experience with SLIT at a 1963 ENT conference.  

Lawrence Dickey, a Colorado surgeon and urologist by training, started offering shot immunotherapy to his urology patients who had allergies, and after hearing Pfeiffer, he stopped treating his patients with shots and started treating them with SLIT.  Dickey wrote about the use of SLIT in Trans Soc Ophthalmol Otolaryngol Allergy 5:37, 1964, in an article entitled "Sublingual therapy in Allergy", and he also wrote in JAMA in 1971, with an article entitled "Sublingual Antigens", JAMA 217: 214, 1971.  Once again, I had the enormous priviledge of knowing Dr. Dickey; he was exceedingly gracious and generous in sharing his knowledge in this area.  At a 1964 ASOOAS conference, Dickey had this to say about SLIT:  

'sublingual therapy is more acceptable to our patients sand more convenient for our office personnel.  There have been fewer drop-outs from sublingual therapy than we had with injection treatment".  

Finally, my own colleague, to whom I owe such a personal debt of gratitude, wrote truly groundbreaking articles on SLIT.  David Morris, MD was at the ASOOAS conference in 1966.  He heard Pfeiffer and Dickey presenting at the conference.  And he became interested in SLIT and subsequently published in the Annals of Allergy in 1969 on SLIT for foods and in 1970 on SLIT for molds.  His 1970 paper on SLIT for molds broke new ground--he was the first to report success using SLIT specifically for treating respiratory diseases caused by mold allergy.  

 I wish to thank Dr. Morris for his historical lectures on SLIT, which are the foundation for this lecture (diatribe??)  But this raises a bigger question...if SLIT has been around for over 100 years, why haven't we heard more about it until now, and why do we promulgate the misplaced notion that "the Europeans discovered it?"  What does this imply about our specialty? 

My next post will address that intriguing question.  Until then, I'm back to my anger management program....  Again.  

Later, Dude