Diagnostic and treatment issues are considered from the perspective of clinical ecology. Finally, some case histories are presented that illustrate diagnostic and treatment procedures.
 
 

The first principle is the fact that medical environmental technology lags far behind the development of technologies employed in the environment. Ignorance on the part of the public and medical profession regarding potential triggering agents in the environment often hides otherwise apparent cause-effect relationships and may well negate the effects of conventional treatment.

The second principle deals with the concept of total body load, the sum of all incitants, including pollutants, which the body has to handle in order to function. The importance of body load as so conceived lies in its ability to distort many bodily homeostatic mechanisms. The vast amount of environmental pollution, in the form of water systems overloaded with synthetic chemicals, contamination with pesticides and via food additives, and home environments corrupted with outgassing synthetics, has resulted in a tremendous increase in body load and a consequent distortion of the homeostatic mechanisms.

Finally, the concept of bipolarity suggests that an individual may have an immediate stimulatory reaction to a substance, which is followed, after a variable interval, by noxious withdrawal symptoms which appear to be a function of the breakdown of the body=s defense system. Examples of such phenomena are seen in narcotic, tobacco, and alcohol addiction.
 
 

It appears that triggering of such inflammatory diseases may occur through the homeostatic mechanism, via both the immune and the nonimmune systems, through immunoglobulins or by the amplification systems directly; for example, activation of the alternate pathway of complement or other mediators such as kinin or prostaglandin. The result is membrane irritability with increased permeability, the consequence of which is edema, the initial symptom observed in many environmentally sensitive individuals. Edema may be generalized or localized, and rupturing of vessels may result in bruising, purpura, and petechiae. Biopsy of such lesions shows the leukocytoclastic type with polymorphonuclear invasion, the lymphocytic infiltrative, or the perivascular type. With continued pathologic involvement, disease processes become more fixed and are recognized as clinical entities such as angiitis, arteritis, vasculitis, collagen disease, etc.
 
 

The rationale for the creation of the Brookhaven Environmental Unit in Dallas was the need to have an ambience in which these parameters might be more clearly defined, by reducing the patient=s total body load and by isolating environmental incitants. It should be noted that failure on the part of the physician investigating environmentally triggered disease to control the ambient air of his office may result in misdiagnosis and inappropriate treatment.

Certainly, air is the most difficult parameter to assess, given the small amount of technology devoted to analysis of indoor pollution. Air depollution devices include charcoal, aluminum oxide impregnated with potassium permanganate, steel mesh, and paper filters. All of them have their own set of problems for the environmentally sensitive individual. Nevertheless, attempts were made to control ambient air by prohibiting outgassing from rapidly disintegrating synthetic fabrics, and by installing depollution devices constructed of relatively inert materials. Rooms in the Unit were also constructed of such relative inert materials; the most readily available for this purpose include plasterboard, aluminum wallpaper, plaster, ceramic tile, and porcelain steel. Besides symptom clearance and laboratory test results, an additional means by which air content was assessed at the Unit was direct analysis by gas chromatography and mass spectometry.

In order to study food as a principal parameter, it was necessary to utilize chemically less contaminated foods, given the high levels of additives and pesticides contained in commercially available food products. To this end, a food cooperative was established which contracted with farmers for the production of food grown without herbicides, pesticides, or other contaminants; the food was then stored in containers of uncoated cellophane or glass in order to prevent contamination. Furthermore, all food used for testing was prepared in iron, steel, or glass cookware in order to prevent contamination at a later stage.

Recent studies indicate significant contamination of our urban water supplies, and it would appear that both the lay and the medical community are largely ignorant of the potentially harmful effects of such water pollution. After approximately two days in the Unit, a cause-effect relationship may be established between water contaminants and patient reaction. Double-blind studies reveal that approximately 90% of chemically sensitive patients are intolerant of tap water. Clinical experience reveals that certain spring waters are the optimal water for use in the study of environmentally triggered diseases.
 
 

Eosinophils. Total body eosinophil count is typically found to be in a depressed state in individuals with environmentally triggered disease. Of 300 patients in the Unit who entered with food and chemical sensitivities, 90% had eosinophil counts depressed below 35 mm³ or completely absent, while 10% had elevated counts. If the eosinophil count was depressed on admission, challenge produced a further depression. If it was elevated on admission, challenge evoked an elevation.

IgG. Peripheral IgG was depressed on admission in some 5% of the patients studied. The depression that occurs on challenge remains unexplained at present.

Complement. Total hemolytic serum complement Ch₅₀ and CH₁₀₀ as well as the C₃ and C₄ components have been measured in some 300 patients. In 25% of the patients seven complements were abnormal. Incitant challenge appears to depress the total complement in 75% of the abnormalities and elevate it in the other 25%. Complements returned to control levels following an avoidance program.

T and B lymphocytes. B lymphocytes were depressed in less than 5% of the same patients and elevated in another 5%. The majority of patients had an absolute T lymphocyte count below 1000/mm³ (E rosettes). It would appear that this parameter is a sensitive indicator in many patients, since T lymphocytes and their factors are frequently depressed upon challenge.

Blastogenesis. Lymphocyte transformation due to incitant stimulation has been found, in certain concentrations, to be important in the assessment of sensitivity. Twenty-five percent of the patients have T lymphocyte blastogenesis problems.

While tests for leukocyte inhibitory factor and cytotoxic food tests have demonstrated mixed results, the challenge test under controlled conditions remains the most reliable and reproducible index.
 
 

Withdrawal and challenge remain the optimal tool for the diagnosis of food sensitivity. Intradermal skin whealing appears to correlate very highly (70%-80%) with food challenge in the Unit. Both the rotary diet and the process of intradermal neutralization, following the serial dilution technique, serve diagnostic as well as treatment functions.

Perhaps the greatest problem in diagnosing and treating environmentally triggered diseases is represented by the growing number of synthetic and natural chemical incitants. While skin testing has proven unrewarding with this group of incitants, controlled testing, using a stainless steel booth in which inhalation challenge is carried out, represents a critical diagnostic tool which is amenable to a double-blind procedure.
 
 

An optimal treatment of pollen, dust, and mold sensitivities combines avoidance and injection therapy for hyposensitization with careful attention to the home enviornment, which must be purged of contaminants.

In cases of food susceptibility, the rotary diet in conjunction with food neutralization injection therapy appears to be of significant value in treatment. Nevertheless, chemical overload in food-sensitive patients may clearly attenuate the efficacy of injection therapy; thus, attention is directed to the need to decrease total chemical load in many food-sensitive patients.

Neutralization injection therapy for chemical sensitivity appears to be merely a stopgap measure; avoidance is clearly the treatment of choice, and for this reason treatment of such sensitivities is complex. Patients are advised to consume optimally tolerable water (usually spring water) filtered or distilled, and chemically less-contaminated foods. The need for environmentally safe home conditions is paramount and, to this end, patients are urged to remove gas appliances as well as plastic and synthetic objects and other outgassing substances.
 
 

Case 1: A 46-year-old white male surgeon entered the Unit with chief complaints of loss of fine function of the right hand, weakness of the right leg, numbness of the right hand, arthralgia, and poor function of the right foot. Pulmonary symptoms had accompanies his exposure to defoliating agents in Vietnam some years ago, but his present symptoms began one year prior to admission. He was unable to move the right arm, except for gross movements. Rotation of the right hand was impossible. The fingers were swollen and blue on this hand. A pinch motion of the right thumb and index finger was impossible. The right leg dragged in a manner similar to that resulting from past cerebral vascular accident. Physical examination revealed 2+ left superficial temporal pulse; left carotid pulse 2+ and tender, without bruit; butterfly rash on face, with petechiae. Arteriogram showed spasm of the left carotid system. Four days of fasting in a tile and aluminum unit brought symptom relief. Challenge with both foods and chemicals, including chlorine, formaldehyde, phenol, and natural gas reproduced his symptoms. This acute exacerbation of vasculitis and immune deficiency was treated with a rotation diet of chemically less contaminated food and a chemical detoxification of the home environment. All standard laboratory tests were negative. Immunological parameters were assessed, revealing T lymphocytes upon entering the Unit at 783 (1600-2000) and after fasting 1287; B lymphocytes 501 (400-800); total complement 150 (70-120%); total eosinophils 158 (40-200/mm³); IgE 51 (41); CRP negative; and IgG 1120 (800-1800 mg/dl).

Case 2: This 12-year-old white female presented with chief complaints of burning sensation during urination, bladder pain with enuresis, nausea, and stomach cramping. The physical examination was unremarkable. Cystoscopy revealed nonspecific inflammation of the bladder. After five days of fasting in a plaster room at the Environmental Control Unit, the patient experienced clearing of symptoms. It was found that several foods and chemicals, including natural gas, chorine, and phenol, reproduced the initial symptoms, including enuresis. The dysuria secondary to food and chemical sensitivities was treated by both injection and avoidance, using food, chemical, and inhalant antigens, in conjunction with a rotation diet of chemically less-contaminated foods. Standard laboratory tests were negative. Immunological data showed T lymphocytes 624 (1,600-2,000); B lymphocytes 528 (400-800); total complement 103 (70-120%); total eosinophils 53 (50-200/mm ³); IgE 18 (41); CRP negative; and IgG 1160 (800-1800 mg/dl).

Case 3: A 38-year-old female presented with complaints of joint stiffness, red splotches on chest and arms, and soreness and edema of the left side of the body. Initial investigation suggested evidence of angioedema and vaculitis. Biopsy of spontaneous bruising revealed lymphocytic perivasculitis. Subsequent investigation led to the discovery of a developmental abnormality of the pancreas, in the form of a pancreatic divisum. During her hospitalization at the Unit, several food and chemical sensitivities were discovered, and following pancreatic surgery these sensitivities showed considerable improvement. It would appear that the patient=s congenital abnormality aggravated the condition by preventing the proper digestion of her food, thus exposing her to intolerable food and chemical incitants. All standard laboratory tests were negative except for serum anylase 330. Immunological parameters were assessed as follows: T lymphocytes 1300 (1600-2000); B lymphocytes 1040 (400-800); total complement 87 (70-120%); total eosinophils 35 (50-200/mm³); CRP negative; an IgG 1040 (800-1800 mg/dl). T lymphocytes returned to the 1040 to 1400 range one week after surgery. During the previous six months they had been depressed.