Abstract: There are many methods now available to help the clinician to define changes in the body homeostatic mechanisms that occur upon exposure to offending agents. These include measurements of eosinophils, IgG level, serum complement, T and B lymphocytes, blastogenesis, C-reactive protein, IgE, IgA, IgM, and Ig D, and leukocyte inhibitory factor. Tests available include the cytotoxic food test and challenge test, skin tests, and inhalant testing. The best treatment in all allergies is avoidance, to as great a degree as possible, of offending agents.

All nine components have been assayed in 75 patients who presented with initial depression of their total complements. Frequently, C₂ was also depleted. Ten percent of the patients in this category had very low terminal components. Seventy-five percent of the depressed complements returned to control levels by the time patients attained an adequate, consistent avoidance program.

However, caution should be used when treating a patient with low IgE levels and negative RAST results. These patients may well be extremely sensitive to inhalant antigens, probably through an abnormality in another as yet undefined mechanism. Many patients in the Unit had severe rhinitis, sinusitis, vascular headaches, salivary gland swellings, and numerous other entities that were triggered by pollen, dust, and mold. They also had total IgE levels in the range of 0 to 50, and the selective IgE level was low when the Fadal-Nalebuff scoring system was used on the RAST. A prospective ongoing study under super-controlled conditions has revealed that over 50% of the patients we see are initially skin-test negative, but are extremely sensitive to inhalation challenge with pollen, dust, and mold (Table 7). It should be pointed out that 30% of our patients, although immediately skin test positive, are IgE negative, which suggests another mechanism.

However, as has been previously mentioned, over 50% of the patients who were tested in the Environmental Unit were sensitive to these inhalants even though they had no skin whealing. Actually, most of these patients were supersensitive. Serial dilution titration certainly adds to the preciseness of the tests and allows for more rapid achievement of the optimal tolerated dose of any one substance in the individual patient.

The latter two categories are rather difficult to assess in the physician=s office, particularly if his environment is contaminated and the patient is chemically sensitive. Certainly, there appears to be a 95% correlation of positive skin tests occur. One must be extremely careful, however, in saying that a person does not have food problems just because the skin test is negative. To be certain of that statement, negative oral challenge after at least four days of avoidance must be proven in these possibly sensitive individuals.

Unfortunately, skin testing is not too rewarding in defining the extent of the chemical problem. Usually only phenol and ethanol are available. Occasionally, formaldehyde can be assessed by the whealing or sublingual method. Testing should be done under controlled conditions, using a stainless steel booth. The patient is placed in the booth and allowed to clear. Then challenge is carried out, allowing time to breathe the odors at the ambient dose to which he is exposed daily. These substances may include chemical fumes, phenol, alcohol, formaldehyde, pesticide, cigarette smoke, perfumes, polyester, and fumes from natural gas and other synthetics. In this way the physician can more properly assess a person=s sensitivities. These tests can all be done in a double-blind manner.

Of 100 consecutive patients seen with advanced environmentally triggered disease in our Unit, 71 had ear, nose, and throat symptoms prior to onset of the other symptoms. The majority had been treated by otolaryngologists with little effect. According to various authors, no etiology can be found in many patients with recurrent sinusitis, laryngeal edema, or Meniere=s disease. These conclusions were based primarily on skin testing and Vivonex fasting. Etiology had to be determined on many of these individuals by placing them in the Environmental Unit. The patients have much more widespread sensitivities than those who can be treated in the office. The following case histories are illustrative:

Physical examination revealed parotid swelling, extremely dry mouth, and noticeably dry eyes. The skin of the extremities had many petechiae and bruises. There was mild periorbital and digital edema. The hands and feet were blue. Laboratory results are shown in Table 8A.

Other patients have been seen with malfunction of the salivary glands who presented similar courses of treatment (Table 9). It should be noted that one patient was a beautician and her main sensitivity was fumes from the hair dressings. This case illustrates the fact that chemical sensitivity should be ruled out before classifying the disease as nonallergic.

Laryngoscopy and bronchoscopy done after the patient was clear revealed normal cord, larynx, and trachea.

Biopsy of the petechia showed non-necrotizing lymphocytic infiltrate around the vessel wall with edema of associated tissue. Other laboratory findings are shown in Table 8B.

The author has now worked up 81 patients in the Unit with recurrent sinusitis. These patients usually had combinations of inhalant, food, and chemical sensitivity. They could not be cleared without detailed attention to the food and chemical sensitivity problem. All had previously been given standard medical therapy without help.

The patient was admitted to the Environmental Unit and her symptoms cleared after seven days of fasting on safe water. The patient was then challenged with chemically less contaminated food, and eight foods reproduced her symptoms as did five chemicals. The laboratory data are shown in Table 11.

Plastic mattresses and covers are also mentioned only to be condemned. Although they decrease the amount of dusts and molds in the environment, they increase the risk of the allergic patient to the development of chemical sensitivity because of the constant fuming of the plastic. It is much better to strip the bed to the springs and then build up the area with cotton blankets and cover with a close knit cotton made from surgical barrier cloth. In this way, dust, mold, and chemicals can be managed. The mattress can be taken apart at any time and washed thoroughly.

If cotton mattresses are already available, one can place the barrier cloth over the mattress, as a cover. One should be sure that the mattress is not fireproofed with a chemical retardant or mildew proofed.

HyposensitizationCUsually pollen, dust, and mold hyposensitization is used conjunctively with the aforementioned precautions. Serial dilution titration appears to be the best method for finding the initial optimum dose. It allows one to start at safer higher doses and more rapidly reach ultimate optimum doses. When the RAST is positive and specific IgE level is elevated, the use of the Fadal-Nalebuff scoring system appears to be a significant advance in the treatment of inhalant sensitivity. This may also be used to effect the maximum dose rapidly. The optimum dose is occasionally difficult to attain, and in some patients the Lee and Miller neutralization technique using specific doses of pollen, dust, and mold has been useful.

Sensitivity to phenol and glycerine appears to be an increasing problem. It has been the author=s experience that many patients who have been intolerant to phenol or glycerine can be treated if these substances are left out of the injections. Of course, the extracts are more precarious in that they have to be kept frozen except when in use.

NeutralizationCFood neutralization injection therapy as advocated by Lee and miller seems to be an excellent adjunct to the rotary diet. In our Unit there is a high correlation between challenge testing and skin whealing in moderately sensitive patients (Table 12). After neutralization approximately 75% of the foods could be included in the rotary diet at least once every seven days. Some foods could be eaten with impunity, but more often, repetition leads to loss of tolerance for that particular food.

Physicians have been using neutralization techniques for foods for a long enough time to realize that injection therapy may fail at any given time. This is because of myriad problems. Chemical overload in food-sensitive patients appears to be the prime reason for injection therapy failure. Patients tend to do only what they must in order to get by environmentally. As our environment steadily deteriorates, the problem of chemical sensitivity increases. We now have had the opportunity to see patients who have been on injection therapy for foods up to seven years. These patients were followed by competent physicians who noted that an individual would suddenly become intolerant to his injections. The endpoints would constantly shift and could not be maintained. These patients were ultimately found to be intolerant to the phenol and glycerine in their injections. However, simple removal of these components was not enough. They had to decrease their chemical load further by cleaning their houses, often removing the gas heat and carpeting, and stopping the use of extermination products. The patients then were given frozen saline extracts until tolerance was regained. We have now observed this phenomenon in over 60 patients who have come through our Unit.
 
 

Principles of chemical avoidance will be discussed only briefly here. Those who wish more details can consult Human Ecology Susceptibility to the Chemical Environment, by Theron Randolph, MD; Clinical Ecology, by Lawrence Dickey, MD; and The Management of Complex Allergies, by Natalie Golos. The latter is a manual that is a Amust@ for every physician and patient.

Patients must use safe water. Usually charcoal-filtered water is adequate if all devices are made of stainless steel. The filter will not remove fluoride, however. Frequently, one of the many spring waters is best. This must be kept in glass containers, however, or the sensitive patient will not tolerate it. There are some patients who tolerate distilled water but fewer than the aforementioned. Approximately, 1% of the chemically sensitive patients can tolerate no water. These individuals are extremely difficult to manage.

Chemically less contaminated food is extremely important for those with chemical susceptibility. There are now enough patients in all major United States cities with this problem to be able to band together to form cooperatives. We have found it necessary to contract with farmers to grow chemically less contaminated foods in order to have a constant and safe supply. Reliance upon health food stores is difficult, because many foods sold there are contaminated.

The home environment is the most important place to maintain. Guidelines for construction of an environmental unit are applicable to the home and should be followed as closely as possible. There should be no gas appliances in the house. If petroleum products or coal are used, they should be kept away from the house, using boilers for heating; then, the hot water can be pumped into the central system and heat blown throughout the house. Lower temperature electric heat appears to be one type tolerated by many.

The bedroom should be the maximum oasis. Bedding should be 100% cotton or linen, as previously described. Carpets should be removed and a tolerable flooring applied. Window coverings should be either 100% cotton or metal blinds. Closets and dressers should be stripped of all clothing, except that which the patient can tolerate. Articles remaining in the bedroom and/or attached bath should be kept at a minimum; all plastics, cosmetics, and cleaning agents should be removed.

Finally, no pesticides, herbicides, fertilizers, and the like should be used in or around the home.