By Matthew Smith
The reaction begins not with a bang, but a whimper; a gentle tickle in the back of your throat. You cough politely. Then, everything changes. Your throat constricts, as if crushed by invisible, murderous hands. Out of the corner of your eye, you notice your cheeks puffing, then your ballooning upper lip. A wave of nausea washes over you and you struggle to stay upright. As you frantically search for your epi-pen, that life-saving shot of adrenaline, you see your fingers have turned an eerie shade of blue. Cyanosis is setting in. Is this the end? And all because of what? A peanut?
The fear of an allergic reaction, at its worst an anaphylactic shock, must have been uppermost in the mind of Mrs. Richet (pseudonym), when she wrote to the Edmonton Eskimos football club in 2006 and asked them to change their policy on peanuts. Peanuts were an institution at 60,000-seat Commonwealth Stadium, home of the Canadian Football League’s Eskimos. This snack was typically washed down with copious amounts of over-priced beer in plastic cups. Fans found that cracking open and eating peanuts was the perfect accompaniment to a tense encounter with the Saskatchewan Roughriders or the hated Calgary Stampeders.
Leaving the stadium was also a peanut-related ritual. Fans shuffled over millions of peanut shells, grinding them into a fine dust that rose to ankle height. For most fans, peanuts were integral to the Edmonton Eskimo experience. But for Mrs. Richet’s severely allergic son, the nuts, shells and smell transformed what should have been a fun day out into a risky encounter with his mortality. Much to Mrs. Richet’s surprise, her letter to the club made an impression. Within days she had a reply, informing her that peanuts would be banned outright, joining alcohol, drugs and weapons in the list of prohibited substances. There was little outcry at first. Canadian football fans are a considerate bunch, and given how terribly the Eskimos had been playing, most were more concerned about the lack of form on the field, rather than what was being consumed off it.
But that all changed in 2009 when veteran rockers AC/DC came to town. The fuss started when the Edmonton Journal published a document of banned items for fans attending the sold-out concert. Top of the list was the humble peanut. Now, one might ask: who the heck brings peanuts to an AC/DC concert? Given the subsequent uproar, that detail didn’t seem to matter.
The AC/DC fans, predictably, were split down the middle. On one side were fans who saw the ban as a grievous attack on their civil liberties: ‘Jeesuz,’ one complained, ‘I’m so sick and tired of situations where 60,000 people have to change… because one person can’t be bothered to look after themselves. Sorry you’re allergic but enough already. The world isn’t turning only for you.’ Another added, ‘It’s not just about no peanuts at AC/DC, it’s about peanut bans in schools and other public areas. Survival of the Fittest is being ruined by restrictions that coddle people with allergies – when nature was meant to take its course.’
On the other side of the debate were the allergic and those sympathetic to their cause. ‘What if I smell your peanuts and die? Huh? What if?’ asked one sufferer, who described going into anaphylaxis on a flight when she smelled someone’s peanut butter sandwich. Another claimed that those who opposed the ban were ‘selfish, ignorant, belligerent bullies. …. Not bringing peanuts is such a small, small sacrifice for you to make and yet it can make all the difference.’
Many of the comments were indicative of another chronic disease of civilization — Internet Comment Diarrhoea — and many writers were clearly attempting to be funny, we can probably assume that the gentleman who claimed: ‘If I can’t enjoy a good bag of peanuts while I listen to AC/DC then I might as well end it all’ was exaggerating his disappointment. But, hidden amidst the vitriol and black humor were many themes presented in more measured discussions.
Peanut allergy divides as much as it horrifies, placing the rights of certain individuals up against the freedoms of the community at large. For many, peanut allergy represents the very essence of political correctness or ‘health and safety gone mad’. It’s peanuts now, but what next? For the parents of an allergic child, however, peanut allergy is about life and death. That one peanut, smuggled into Commonwealth Stadium, could claim their child’s life. How could something as small as a peanut affect something as big as an AC/DC concert? For the parent of an allergic child, the question is: why should it?
Twenty-five years ago, Edmonton’s Great Peanut Debate would have been the stuff of science fiction. Up until the late 1980s, peanut allergy was extremely rare. Writing in 1982, one New York allergist couldn’t recall a single peanut allergy fatality. Today, peanut allergy is one of the most common causes of fatal anaphylaxis worldwide. Food allergies did exist, but the foods associated with allergy, and the nature of the reactions, were very different.
The term allergy was coined in 1906 by Austrian pediatrician, Clemens von Pirquet (1874-1929) in 1906 as ‘any form of altered biological reactivity’. This broad definition of allergy was to be embraced whole-heartedly by food allergists, who believed that food allergy was a widespread phenomenon characterized by a plethora of responses encompassing every system of the body. Von Pirquet, along with other clinicians attracted to the topic during this period, commonly cited food allergy as one of the most common and readily acknowledged types of allergy. But, instead of being typified by anaphylactic reactions to peanuts, food allergy at this time and for most of the twentieth century was identified by allergists who treated the condition with chronic, lingering and less dangerous reactions to countless foods. Clinicians did recognize anaphylactic reactions (the term anaphylaxis was coined by French physiologist Charles Richet in 1902 and was more commonly used than allergy until the 1920s, when anaphylaxis took on its modern meaning to denote severe, shock reactions to allergens), but they did not dominate discussion or debates. This was partly because they were thought to be less common than chronic conditions, but also because they were easier to identify.
As allergist Warren T. Vaughan asserted during the 1930s, most people with such ‘fortunate’, allergies did not need the help of an allergist because they knew what foods to avoid and because such foods were rarer and easier to avoid (for example, seafood or strawberries. Because such chronic or ‘unfortunate’ reactions were not as sudden or severe as those we see triggered by peanuts, it was difficult for allergists to determine the cause. Since scratch tests and desensitisation therapies invented during the 1910s and used to diagnose other allergies were unreliable for food allergy, causing too many false negatives and false positives, diagnosis depended on the use of elimination diets. By slowly reintroducing different foods into your diet after scaling back to just a few neutral items (pears are often used as barely anyone is allergic to them) you could perhaps identify the suspect, but this process relied heavily on patient testimony.
Despite, or perhaps because of these difficulties, food allergy became a popular explanation for otherwise unexplained chronic health problems. During the mid-twentieth century, food allergists claimed that everything from eczema and flatulence to asthma and mental health problems was triggered by food. Arthur Coca, a prominent food allergist and founder of the Journal of Immunology argued that multiple sclerosis, cancers and even baldness were common symptoms. A chapter in his book The Pulse Test for Allergy was entitled ‘You Don’t Catch Your Colds, You Eat Them’.
With increased food processing following the Second World War, substances such as corn, refined sugar and synthetic preservatives, colors and flavors, were added to a long list of possible food allergens. Subsequently, a host of ecological theories emerged to explain the apparent increase in allergies. Food allergy was seen by many ecologically-minded food allergists, such as Theron Randolph (1906-1995) as a prototypical disease of civilization, a modern malady that revealed how progress could be pathological. Those allergic to food were canaries in the coal mine; highly sensitive to substances that would inevitably be harmful to all.
For some, such as British psychiatrist Richard Mackarness, the solution was a return to a stone-age diet. This consisted of meat, fruit, vegetables and, ironically, nuts. For others, desperate to find foods they could eat, elaborate rotary diets were the answer. These diets provided patients with as varied diet as possible, including exotic meats such as kangaroo, elephant and even lion. Such diets represented extreme cultural responses to bodies locked in conflict with a toxic environment.
To orthodox allergists, such approaches were precisely why allergy was referred to as ‘witchcraft, a fad, or a racket’. Allergy remained on the lowest rungs of the medical ladder, an unscientific discipline that had more in common with quackery than it did with science. For orthodox allergists determined to legitimize their field, such broad definitions of food allergy were anathema. It was one thing if someone had an immediate anaphylactic reaction to seafood; such reactions were clearly allergic and represented ‘true food allergy’. But food allergy causing unexplained symptoms? Never. Allergists, such as Vaughan, Coca, Randolph or Mackarness, who believed that food allergy could cause asthma, migraine or mental illness were utterly irresponsible; their patients were thought to be deluded and better served by a psychiatrist. And the remission of symptoms following an elimination diet? Pure placebo.
This impasse deepened throughout the 1960s and 70s with the discovery of immunoglobulin E or IgE. This antibody appeared to serve as a marker for so-called ‘true’ allergic reactions; if it could be traced when a patient was exposed to a potential allergen, then the substance was thought to be allergenic. While orthodox allergists claimed that IgE ended the debates about food allergy for good, food allergists such as Theron Randolph denounced as ‘blockheads’ those who put their faith in IgE. Ultimately, Randolph and others abandoned the field of allergy altogether. By the 1980s, the last thing a respectable allergist would welcome was a patient complaining about food allergy, so much so that the orthodox chair of the American Academy of Allergy’s food allergy committee speculated about abolishing the committee altogether.
Enter the peanut. When stories about fatal peanut allergies suddenly appeared, allergists had to take note, catapulting food allergy back into the lap of allergy like a bad case of hives. Or was it so bad? One might think that conservative allergists would have done anything to downplay the peanut allergy epidemic. But viewed differently, peanut allergy was just what the doctor ordered: an alarming condition that forced the medical community to think twice about allergy and an opportunity for the clinical specialty of allergy to be taken seriously.
The case of the peanut also allowed conservative allergists, once and for all, to determine how food allergy might be understood. Instead of seeing it as a complicated, elusive condition, peanut allergy was simple, deadly simple; an IgE-mediated, anaphylactic allergy that left no one guessing. Allergists began lobbying for more informative food packaging for consumers and details of nut-containing dishes on menus to raise awareness about the pernicious peanut.
Surprisingly, the food industry listened. Or was it so surprising? By focusing on peanuts, food producers could ignore the charges that other substances, especially food additives, were also  It was much easier to rid one’s products of peanuts than it was to eliminate synthetic preservatives, flavors or colors. Plus, it was one thing if a middle-aged hypochondriac complained that food chemicals made them irritable; it was quite another if a child died after eating one of your peanut-contaminated chocolate bars.
Other institutions also listened. Schools, nurseries, and airplanes, places where peanuts were once common, soon became nut-free. One school in Florida even enlisted peanut-sniffing dogs. Libertarians protested, but in an era of health, safety and litigation, such measures were tolerated, AC/DC fans notwithstanding.
Somewhat lost in the debates about preventing accidental exposures, however, was a more fundamental question: what was the cause of the peanut allergy epidemic? Possibly because it harkens back to old, bitter debates about food allergy, allergists ignored this question, instead attempting to desensitize sufferers to peanuts, or designing hypo-allergenic peanuts.
That didn’t prevent explanations from emerging. Some researchers advocated the so-called ‘hygiene hypothesis,’ arguing that domestic environments had become too sterile through the use of household chemicals, which had resulted in immune systems unable to cope with potent foreign proteins. Similarly, some suspected that children historically had had more seasoned immune systems from fighting endemic infections. Others argued that the peanut oil thought to be found in some vaccines was responsible. Many alternative explanations were also put forward. None were satisfactory.
So what for the future? One authority to start with is the Nobel Prize-winning immunologist Frank McFarlane Burnet’s concept of self and non-self. This idea attempts to explain how the body distinguishes friend from foe. Whenever the body comes into contact with something foreign, the immune system has to determine whether it is self (friend) or non-self (foe). Most foods are considered self and, ultimately, become so literally after they have been consumed. No defense is launched. An influenza virus, in contrast, is correctly designated as non-self, and the immune system launches a robust defense to protect itself from attack.
The concept of self and non-self gets inverted, however, with food allergy. Allergies are what happen when the body – self – mistakenly identifies foreign proteins as dangerous – non-self – and launches an excessive, and possibly cataclysmic, defense. Self and non-self confusion also causes other immune system diseases. In autoimmune arthritis the body mistakes connective tissue for a threat and attacks it, resulting in crippling joint pain. Similar immune dysfunction causes Crohn’s Disease, multiple sclerosis, lupus and other autoimmune diseases.
The relationship between allergy and food allergy could be seen in a similar light. Until the recent peanut panic, orthodox allergists viewed food allergy, and food allergists, as a foreign threat to be expelled. In many other areas of medicine, ranging from cancer and heart disease to mental illness and obesity, self and non-self thinking also dominate. Perhaps such either/or, self/non-self responses make for good debates on CNN or 60 Minutes. But they make for bad medicine. They are as sadly misguided as the body’s destructive reaction to its own tissue, or, indeed, to peanuts.
History demonstrates that many of medicine’s most troubling questions have been answered not by being dogmatic, but by being open-minded. If allergists are ever to figure out what is behind the peanut panic, rather than forging ahead with a worldwide ban on peanuts, more pluralistic, creative thinking, that draws on both traditions, is necessary.
Matthew Smith is Senior Lecturer, Director of Research History and Deputy Head of the School of Humanities at the University of Strathclyde, where he is a member of the Centre for the Social History of Health and Healthcare. His books include ‘Hyperactive:The Controversial History of ADHD’ (2012) and ‘Another Person’s Poison: A History of Food Allergy’ (2015). He sits on the Executive Committee of the Society for the Social History of Medicine, is a book reviews editor for ‘History of Psychiatry’ and is a member of the Royal Society of Edinburgh’s Young Academy of Scotland. His current project, funded by the AHRC, is on the history of social psychiatry.
 “City Offers Tips,” Edmonton Journal, August 23, 2009.
 Joseph H. Fries, “Peanuts: Allergic and Other Untoward Reactions,” Annals of Allergy 48 (1982): 220–26.
 Allergy and Asthma Foundation of America, ‘Peanut Allergy’, http://www.aafa.org/display.cfm?id=9&sub=20&cont=517, accessed April 10, 2015.
 Clemens von Pirquet, “Allergie,” Münchener Medizinische Wochenschrift 30 (1906): 1457–58.
 Warren T. Vaughan, “Minor Allergy: Its Distribution, Clinical Aspects, and Significance,” Journal of Allergy 5 (1935): 184–96.
 Arthur F. Coca, The Pulse Test for Allergy (London: Parrish, 1959)
 Richard Mackarness, Not All in the Mind: How Unsuspected Food Allergy Can Affect Your Body AND Your Mind (London: Pan Books, 1976)
 Walter R. Kessler, “Food Allergy,” Pediatrics 21 (1958): 523–25.
 Theron G. Randolph, Environmental Medicine: Beginnings and Bibliographies of Clinical Ecology (Fort Collins, Colo.: Clinical Ecology, 1987), 289.
 See Matthew Smith, An Alternative History of Hyperactivity: Food Additives and the Feingold Diet (New Brunswick, NJ: Rutgers University Press, 2011).
 “Edgewater Elementary School Parents Want Student Home Schooled over Peanut Allergy,” Huffington Post, March 22, 2011, http://www.huffingtonpost.com/2011/03/22/peanut-allergy-edgewater-elementary-school_n_839091.html (accessed March 1, 2012).
 Aziz Shiekh, “Oral Immunotherapy for Peanut Allergy,” BMJ 341 (2010): 264; J. J. Riascos et al, ‘Hypoallergenic Legume Crops and Food Allergy: Factors Affecting Feasibility and Risk’, Journal of Agricultural and Food Chemistry 13 (2010): 20-27.
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