Document 1071KYbvGnzxrLRKyv0awKboa

*I*"*P SKIN CONDITIONS RESULTING FROM EXPOSURE TO CERTAIN CHLORINATED HYDROCARBONS* May R. Mayers Division of Industrial Hygiene, New York State Department of Labor AND Mabel G. Silveiiberg Cancer Unit, New York Post-Graduate Medical School and Hospital, Columbia University, New York City OR a number of years there has type of skin eruption. It was an!:. I Fbeen sporadic interest in the occurrence of a rather charac found that improvement in liygitc.: conditions in the factory immediatdi | teristic acneform eruption in workreerfslected itself in a reduction in t:.- \ handling the chlorinated naphtha incidence of this disease. Germane lenes! and diphenyls. Manufac perience along these lines was, Iks- turers of these substances recognized ever, interrupted when the "r | this condition among workers in came to a close. Since that tit" ? their factories years ago, and fount! however, there has been a gr-- f that the cas-es could be materially ing demand in industry for : reduced or even completely eliminated chlorinated naphthalenes and dips- ^ by the. introduction of adequate ven nyls wherever resistance to heat s- tilation and by the practice of good moisture are essential, as for exan.p E personal hygiene on the part of their in the insulation of wire or the rev. employees. facture of electrical condensers. T!.: r: During the World War when heat and moisture-resisting proper:; perchlornaphthalene suddenly began to be used in quantity in Germany under the name of ``Perna" as a substitute for resin and rubber, large numbers of workers contracted this together with the fact that they " ; non-inflammable, appear to givi-t"' : materials a unique place among : substances now available for purposes. . In New' York State a numb'1 . * Received for publication December 23, 1937. t The chlorinated naphthalenes are some times referred to as "Haiowax" by pur chasers and users. While the Haiowax t'orporation manufactures these sub stances, it also manufactures many others. The term "haiowax'' is merely a trade name for substances manufactured by this com pany and should not be used indis criminately. In all instances_ substances should be designated by their chemical names only. cases of skin eruptions occurnnworkers engaged in the ui!uwi;'rt of electrical condensers have time to time come to the attend^- the Department of Labor, sporadic reports or because the 'u'rJ applied for compensation. ' lowing up these cases it was 11 ` that while many of the erupt10"- ! : ; DSW 255003 STLCOPCB4060694 MS] dermatoses from chlorinated hydrocarbons 245 j-urod to be very mild, causing no work benches. In the case of each ^ability or serious discomfort, others factory careful instructions were given were very severe- in one such ease as to the safe handling of these cven involving the deeper layers of substances. thn skin and causing permanent facial Since all skin eruptions which were (ii'iipircincnt as a result of sear reported to the Department of Labor tPmu- formation. Superimposed in emanated from plants manufacturing i Action was also encountered as a electrical condensers, two of these I serious complication. The investiga- were selected for special study', at lion further revealed the fact, that tention being directed to an examina relatively few physicians appeared to tion of the lesions found among the be sufficiently, if at all, familiar with workers and the causative factors this disease entity, and as a conse involved. On the basis of this it was quence the condition was apparently hoped that an adequate program not always recognized when patients could be formulated for health main .pplied to their physicians for treat tenance in the industry. ment. Not oidy is treatment apt Because the skin condition found t be misdirected and inadequate among workers in this industry is not under these conditions, but patients sufficiently familiar to the medical permitted to go on working with profession, special pains were taken to these substances even when further describe it with care, and to point out exposure is definitely contraindicated elements in the picture that would because of hypersuseeptibility on their assist in making a differential diag part. nosis from other skin conditions pre It was for these reasons that the senting a similar clinical picture. present study was undertaken. Here The differential diagnosis from the was an occupational exposure believed acne of adolescence, known as acne to be potentially hazardous, concem- vulgaris, was particularly considered b'.g '' I ich relatively little was known because the two conditions resemble medically. Nevertheless there was one another in many ways. As a to believe that it might be background for this study the litera satisfactorily controlled by the in ture was reviewed and a bibliography troduction of proper hygienic compiled. measures. It was decided to make ffic use of these materials safe in the Review of Literature of New York. To this end a The literature was reviewed prin survey was made of the twenty-two cipally for information as to previous Pants employing these materials in * mir manufacturing processes. Three 0 these plants made insulated wire 411 the remainder made electrical wndensers. Their methods of opera_'un, and their ventilation were care^U1J appraised and the skin of all or 'crs inspected as they sat at their experience with the use of these materials in industry in relation to the skin eruptions which they pro duce. In 1934, in an article by Sulzberger, Rostenberg and Sher (1), three eases of severe acneform erup tions due to exposure to certain "waxes" were presented and discussed 246 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY M. w, HOJ in some detail. These waxes, it was learned by personal communication with the authors were chlorinated naphthalenes.* The fact that one of us (M.G.S.) had the opportunity to examine these cases at the time proved an added stimulus to the present investigation. Another illuminating contribution along these lines was a bulletin from the Pennsylvania Department of In dustry and Labor in 1936, in which Fulton and Matthews (2) presented the results of a study of 101 cases of dermatitis which occurred in a wire insulating plant in their State. In addition to describing the lesions as they found them, they showed that it is possible for a worker suffering from this type of dermatitis to transfer the skin disease to other members of his family through intimate contact with the clothing worn in the factory. Through the courtesy of Dr. Fulton, the authors had the opportunity to see one such worker, his wife and two children, one a young baby, xvho were all affected by contact with him and his clothes when he came home from work. As long ago as 1899 Herxheimer (3) accused the halogen, chlorine, of being the direct cause of acne, coining the word "chloracne." Considerable at tention wras thereafter concentrated on chlorinated substances as the cause of acne. Howrever, it gradually came to be felt that it was not the chlorine that was responsible but that a chlorinated hydrocarbon was to blame in most cases. Tar, mineral oil, vase line, paraffin and similar hydrocarbons have long been recognized as causative * Personal communication from Dr. M. Sulzberger. agents in follicular and acneforc ' eruptions. The use of a chlorinated naphthalene known in Germany as "Perna" h. already been mentioned. When tU 1 material came into use again afc the war, Teleky (4) described tfe many cases of skin eruptions that i> ; observed during the years 1926-7 I Improvement in hygienic conditio* \ in the factory appeared to be usk i in controlling this disease. It Teleky's final conclusion that tb i deciding factor as to the potency d ! any particular chlorinated wax i causing acneform dermatoses depend?. . not so much on its chlorine conte: as upon the amount of unbound .1 loosely bound chlorine that it tained. A method was subsequent; 1 introduced and patented for so treads the chlorinated naphthalene as : , remove all loosely bound chlorine, it was believed that the incidence? t acne in workers exposed to tb material was greatly reduced thereb ; Courtois-Suffit, Touraine f M6n6trel (5) in 1934 drew attend; , to this condition in France in i admirable paper in which they poisK out that the coal products that s \ most apt to give rise to lesions of;' pilo-sebaceous apparatus are tb . of the second distillation fractie These writers noted erythematous . vesiculo-edematous symptoms in & t workers as well as the acneforffl t? They believed that seborrhea ** predisposing factor and reported patch tests with the chloric waxes were negative in all cases In 1935, Jones and Alden P Atlanta, reported their obser^ ' concerning industrial skin erup r of an acneform type in work5 ' DSW 255005 STLCOPCB4060696 Jfr. I9S8] dermatosf;s from chlorinated hydrocarbons 247 ed in the manufacture of chlorin ated diphenyls. It was their belief that the eruptions were perhaps due to impurities rather than to the chemicals themselves. Schwartz (7) in a report on "Derma titis from Synthetic Resins and Waxes'' in 1936 confirmed the reports of other investigators that patch tests with these substances regularly give negative results. The literature with reference to possible systemic effects from exposure to these chemicals is not considered sufficiently pertinent to the present investigation to be discussed here. Chemistry and Toxicology Chlorinated naphthalene is a naph thalene in which one or more of the hydrogen atoms has been replaced by chlorine. Thus, there are many chlorinated naphthalenes beginning with the monochlornaphthalene and going up to the octochlor derivative. The chlorinated naphthalenes as used commercially, however, are usually mixtures, each of which contains more than one of the chlorine deriva tives. The so-called trichlomaphthalene, for example, which is most commonly used for the impregnation of condensers, in reality contains both the tri and tetra derivatives. Similarly the higher chlomaphthalenes he used in various combinations. tetra, penta, and hexachloroophihalenes are sometimes used combination with chlorinated mphenyls. Generally speaking the higher the formation, the higher is the melting j "d of the wax and the more water11..., ^ becomes. Since resistance to 1 moisture are the outstanding characteristics of these materials, the higher ehlorinations are in groat de mand commercially. Unfortunately, however, the higher the chlorination of the naphthalene, the more toxic docs it become. That is the dilemma which manufacturers of these products are working hard to solve. Diphenyls arc manufactured by passing benzene through molten lead so that CfiH is converted into C^Hio. Chlorine is then bubbled through, dis placing one or more of the hydrogen atoms and forming substitution prod ucts ranging from the monochlor diphenyl to the docachlor diphenyl, all of the hydrogen atoms having finally been displaced (C12CI10). The Process of Manufacture The manufacture of electrical con densers is not carried out in exactly the same way in all factories, but it usually follows the same general lines, depending upon whether the con densers manufactured are of the socalled "Inductive" or "Non-inductive" types. Winding and soldering.--In making inductive condensers, long ribbons of paper alternating with tinfoil (three sheets of paper with two of tinfoil) are rolled on small spools by winding machines. When the winding is com pleted the paper is seen to extend out beyond the tinfoil. In this type of condenser ingoing and outgoing metal leads are introduced at right angles to the direction of the winding and the condenser is then impregnated. In finishing condensers of this type, a wire is soldered to each lead by means of a soldering iron. In winding non-inductive con densers, the tinfoil strips are wider DSW 255006 STLCOPCB4060697 248 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY [voUoinoS than the strips of paper, so that when the winding on the spool is completed, the tinfoil extends beyond the paper. Sometimes aluminum foil is used instead of tinfoil. No leads are in troduced after impregnation. The soldering of these condensers is done by passing the tin or aluminum foil portions over a hot plate, using a stick of solder to solder on the wires. This process gives off far more fumes than does the soldering of the inductive con densers above described. Impregnation--After the spools are wound they are placed in wrire baskets, several dozen to the basket, which are subsequently put into an enclosed oven in which they are impregnated with one of the chlorinated hydro carbons. The one most commonly used for this purpose is a combination of trichlor and tetrachlor-naphthalene, a wax-like material heated to a temperature of 248-258 F. After im pregnation, the oven is opened, the basket of condensers is removed and immersed in an open vat usually containing mineral oil. Finishing operation--The basket of condensers is then transferred to a so-called finishing department where workers, mostly young girls, sit at long tables and perform various finish ing operations, including what are known as sealing operations and the soldering of metal parts to the con densers. The sealing of condensers may be done either by dipping them into a small pot containing a molten sealing compound, or by pouring such a molten compound into them. In many plants, including the two which were selected for special study, a pitch preparation was poured into the condensers to seal them. This (];ri not contain any chlorinated iiap|! thalene. Since this latter material |. difficult to pour in the ordinary vv because of the case with which ; solidifies on cooling, it is more (,;.. tomary in using this wax to dip tj. condensers into a pot in which t!, chlorinated naphthalene is kept at proper temperature. When it is ,|... sired, however, to pour molten chlor:;ated naphthalene into condensers, r especially designed small closed tank is used, in which the chlorinate naphthalene is kept at a prow: temperature. When a key is press., the molten wax drops from the tans into the condenser. The high*-: chlorinated naphthalenes are used these operations. The soldering operations have al ready been mentioned. In handling the condensers in thfinishing rooms, there is constat' contact of the hands with the chlor:: ated naphthalene in its cold wavstate, usually somewhat moister.-. with mineral oil. All workers engaged in testin' finished condensers or employed any other processes carried on in ' "finishing room" arc apt to be in directly exposed to the vapors of chlorinated naphthalenes given li in the soldering and sealing operative'unless the ventilation of the rocou-- whole is adequate. Examination of Workers In the present investigation, ' plants in which a mixture of tn * tetra-chlornaphthalene was empb' in impregnating condensers wore - j ied, and 31 workers examined of these workers were employed|D ' DSW 255007 STLCOPCB4060698 Xar.MS\ DERMATOSES FROM CHLORINATED HYDROCARBONS 249 ^o-called "finishing departments" where exposure to the material re sulted from flaming the impregnated condensers or otherwise causing a volatilization oC the wax. Ages and duration of employment-- The ages of the workers and the length of time that they had been employed in the same plant at the same process are presented in the following tables: iVum6rr of uirrkerA 18-25 years.................... ... 26 26-30................................ . . . . 4 31-40................................ . . . 1 Over 40............................ . . . . 0 31 Duration of Employment: Less than 0 months........ . . . . 11 6-11 months ................ ... 4 1-4 years.......................... . .. 15 5 vears and over............. .... 1 31 History--In examining the workers the history' taken in each case in'iuded (1) age, (2) sex, (3) process at f'hich worker was engaged, (4) dura:ion of employment before rash ap peared, (5) duration of rash, (6) total fmployment, (7) family history of acne -mgaris, (8) personal history of acne mlgaris, (9) family history of derma titis venenata, and other allergic 'aamfestatior.s, (10) whether work "1th chlorinated naphthalene was resumed, continued without inter ruption or permanently discontinued a-ter the onset of the skin eruption. fVr/i tests--The skin of the workers Tla rarefully examined and finally ^t'h tests were applied with the 'lowing substances: (1) potassium 25% in anhydrous lanolin, (2) potassium bromide 25% in anhydrous lanolin, (3) sodium chloride 25% and 50% in anhy'drous lanolin, (4) naph thalene, and (5) mineral oil in use in the factories, with (6) anhydrous lanolin and (7) ammoniated mercury ointment 5%, as controls. Dermatological Observations From an analysis of the observa tions made, the skin conditions ap peared to fall into three main cate gories, as follows: 1. Acneform eruptions with pus tules, papules and large come dones. 2. Yesiculo-erythematous eruptions usually observed in dermatitis venenata. 3. Simple erythematous eruptions with pruritis. In addition, localized dry scaling patches of dermatitis were observed in cases presenting any of the three types of eruptions listed. These patches were never a prominent part of the picture, and were never seen in the absence of one or another type of eruption mentioned. They were less than 5 cm. in diameter, and oc curred on the face, neck or arms. Such scaling patches are often asso ciated in the lay mind with eczema, and arc frequently seen in all types of patients who complain of any of the longstanding itching dermatoses. They are sometimes at least secondary to friction applied for relief of the itching. I. Acneform Eruptions. To the uninitiated the acne which is seen among workers in this industry, and acne vulgaris look very much alike. Their clinical differentiation will be considered later. DSW 255008 STLCOPCB4060699 250 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY M. , The high incidence of skin eruptions in workers engaged in the manufacture of electrical condensers has not es caped the attention either of employers or of those engaged in the manufacture of the chemicals used in this industry. Consequently there. has for years been a concerted effort on the part of all concerned to remedy this situation, and to a large extent this has been accomplished by the introduction of better ventilation into the workrooms. In addition the practice has been fol lowed, particularly in the larger plants, of examining all applicants for em ployment for any abnormalities of the skin, including the acne of adolescence. Only those with clear skins are or dinarily employed.* It is not surprising, therefore, when walking casually through plants en gaged in the manufacture of electrical condensers, and observing the skin of young men and women sitting at their work benches as carefully as one can under those conditions, to note that the incidence of acne vulgaris ap peared to be definitely lower among these young people than what one ordinarily finds in an average un selected group of workers of the same age. Severe cases--Among the 31 workers whose skins were carefully examined in the present series, there were six (4 females and 2 males) with marked acneform eruptions, showing pustules, papules and large comedones. One had a coexistent dermatitis venenata and was suffering from paronychia, involving the index fingers especially. * Then is an unconfirmed belief among employees m this industry that blondes are more susceptible to skin irritation than brunettes, so that the latter are usually selected for employment whenever possible. In the case of one young girl exam ined,- the acneform eruption was so severe and had persisted for so long a time that the deep layers of the skin had become involved; and though she was receiving excellent treatment there was marked scarring of the face with resulting permanent facial disfigurement. An investigation in the case of one girl who contracted a severe acne form eruption in one of the plants studied, but who was not present when the plant examinations were made and so is not one of the series now being reported, revealed the fact that at the site of an itching acneform eruption on the cheek, a furunculosis of the inner aspect of the cheek had developed which, probably due to sec ondary infection from scratching, went on to septicemia and resulted in her death. The tendency for this type of acneform eruption to develop pustules and even go on to abscess formation has been recognized and reported in the literature. Mild, cases--In four cases the acne form eruption was discernible but was so slight that its presence was noted but not regarded as significant. Along with a few pinpoint papules or scat tered comedones on the face there were found a few pinpoint papules surrounding hair follicles around the elbows or on the extensor surfaces of the arms. In none of these cases was there any pruritus. In 90016 instances there was an apparent sggravation of a pre-existing very mil acne vulgaris. The eruption was mild in these cases that one hesita to m$ke a definite diagnosis. Te ' distribution of the lesions, j more than anything else, tended : DSW 255009 STLCOPCB4060700 Kdf. W#I DERMATOSES FROM CHLORINATED HYDROCARBONS 251 guggeat a differentiation of these akin findings from a true acne vulgaris. Distribution of the eruption--The eruption appeared principally on the face and neck and the extensor sur faces of the arms. Sometimes the elbows were also involved, and very occasionally the chest, back and extensor surfaces of the legs. The forehead, cheeks and chin were most often involved, the line along the mandible being a site of special pre dilection. The eruption appeared there more often than elsewhere, and showed a marked tendency to persist there after it had cleared up elsewhere. It was striking that the nose was al most always spared. The importance at the distribution of the eruption as a means of differentiating it from acne vulgaris will be subsequently discussed. Description of the lesions--Six of the 31 workers examined suffered from a very severe acneform erup tion. In these cases the lesions were mostly pinpoint to pea size, yellow*hite or slightly pinkish papules, often distinctly perifollicular and sur rounding large comedones. Some times an area of closely packed large wmedones could be seen without surrounding reaction. This gave skin a black spotty appearance. Although pustulation occurred, it was a prominent feature in these C48e8- Occasionally there were also *e small blotchy areas of erythema PTOsent or scaly itching patches, file workers themselves were espe- impressed with the comedones ^ihe itching, so that the rash was aptly characterized by them "blackhead itch"--a term which seem to have coined. The ^ character of the eruption was mentioned by Fulton, but has not been greatly stressed in the literature as a whole. Though not a constant finding it is an important diagnostic sign when present because acneform eruptions as a group are not usually associated with pruritus. Acne vul garis seldom itches. Four of the workers in this group complained of intense itching. In one very severe case, the acne form eruption was associated with a dermatitis venenata, and a paro nychia which persisted long after the eruption had disappeared. This case will be mentioned later. Period of exposure preceding erup tion--The period of employment before the acneform rash appeared varied from a few weeks to a little less than 1| years. On the whole cases tended to be more numerous in the summer. On removal from exposure the rash tended to disappear in 2 or 3 months, though in very severe cases it appar ently may persist for a much longer period of time. Family predisposition--Though the cases were few, it was noted with some interest that there appeared to be a family predisposition to exposure to the chlorinated naphthalenes which was not apparently based on a sus ceptibility to acne vulgaris. For ex ample, three of the workers who were suffering from severe acneform erup tions had sisters or brothers who had had to give up that type of work because of serious skin eruptions. Two of these workers, both girls from two different families, each had two brothers so affected. One of these families was using iodized salt at home because the mother was suffering from goitre. This may have supple- DSW 255010 Her w4jl DERMATOSES FROM CHLORINATED HYDROCARBONS 253 jhest, though in one case it could simple erythematous eruption, one gjso be seen on the extremities. There was no typical acneform eruption in these cases. In one of the cases the eruption ap peared twice--once 6 months and again 1 year after beginning employ ment-each time clearing up in 2 or 3 weeks. In the second case, the eruption made its appearance 3 months after beginning employment and had a duration of about 1 week. In both cases the erythema in refused to be patch tested, and the other was negative. Mechanism, of acne production-- Because of the resemblance between the acneform lesions found among these workers and acne vulgaris, the question arose as to whether the same mechanism might not be operative in both conditions. If this were so, one might expect the sporadic cases to break out in those individuals who had already suffered from attacks of volved the face, neck and extensor surfaces of the arms; and was asso ciated with a severe pruritus. Both * workers complained not only of itching at the time of the eruption, but also acne vulgaris or in whose families there was a predisposition to such a condition. A careful examination of the evidence in this series of cases did not, however, appear to support this of intermittent attacks of itching ' even after the eruption was no longer visible. conclusion although a more extensive series might throw additional light on the question. Patch tests--As was anticipated in The further question suggested it the acneform cases, all of the patch self as to whether or not a relationship teste performed with the chlorinated naphthalenes in this series gave es sentially negative results. This was h accord with the experience of previ might exist between hypersuscepti bility to the chlorinated naphthalenes and a general hypersensitivity to members of the halogen group gener ous workers including that of Dr. hiuis Schwartz of the United States Public Health Service, ally, such as, for example, the iodides, or the bromides. That these latter substances are frequent causes of k the case which was associated *ith a dermatitis venenata the patch tet with the tri and tetrachlomaph- acneform eruption is well known. The relation of chlorides to the other halogens in these conditions is not (to which the worker was ^Posed) was positive, as were also ^ patch tests with the 25% potas- entirely clear. It is of interest to note, in this connection, that the chlorides are at present being pre nt iodide, 25% potassium bromide scribed by ingestion and injection in the 5% ammoniated mercury. cases of iodide or bromide poisoning words, this worker when with a view to mobilizing the other apparently had a polyvalent halogens. *^Ivity. The substance with Sulzberger, Rostenberg and Sher, he had worked was thus only as well as other writers, have felt many substances to which she that acne vulgaris may occur as a *** hypersensitive. result of a hypersusceptibility of the the two workers who had a pilo-sebaceous system to stimuli ema- DSW 255011 STLCOPCB4060702 254 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY [voUo,m nating from specific circulating endo crine substances. A hypersuscepti bility to potassium iodide, if clearly demonstrated by patch tests, might indicate that such individuals had an especially labile pilo-sebaceous system, easily responsive to a number of common insults to the pilo-sebaceous apparatus. It might on the other hand indicate a specific response to insults from members of the halogen family. Because of these theoretical con siderations, all cases studied were patch-tested with an ointment of potassium iodide, and an ointment of potassium bromide. Though the patch tests seemed to indicate a slight increase in susceptibility to these substances among the workers with the acneform eruptions, un fortunately, none of the reactions were sufficiently strong to warrant any definite conclusions on this point. There is still a question whether the eruption here discussed is due to mechanical plugging of the sebaceous glands in the skin, or whether the sebaceous glands are overstimulated either when end products are circulat ing in the blood or are being excreted by the skin after absorption of the waxes by the body. That these sub stances are not excreted unchanged by the skin has recently been demon strated by feeding experiments con ducted by Dr. Cecil Drinker.* He found no increase in the chlorine content of the skin of rats who had been fed toxic amounts of the higher chlorinated naphthalenes. As a final point in relation to the skin lesions, it may be pointed out that no correla- Private communication. tion existed between these lesions and systemic effects of any sort. This failure to connect skin and possible liver lesions corroborates the experi ence of others. Prevention The process of impregnating elec trical condensers has always presented so obvious a health hazard that all effort in the past to protect workers in this industry from injurious ex posure to fumes and vapors of the chlorinated naphthalenes has been concentrated at this point. In the early days, condensers were impreg nated in the general workroom. Un covered pots were sometimes used for this purpose and everyone in the plant was more or less exposed to what vapors were given off. The incidence of skin eruptions was high. Now adays, the impregnating rooms in most ; plants are completely separated from ) all other workrooms; the oven3 used j are, with few exceptions, tightly constructed and well covered; and the incidence of skin eruptions has dropped so low that one rarely sees a case in this department. It is the very innocuous looking finishing departments which are re sponsible for most of the cases of skin eruptions one sees. In the dip ping, pouring and soldering operations, the chlorinated naphthalenes are xolatilized by heating or flaming- Be cause the fumes are given off relatively small amounts from a gr^1 many different points in the *j_ room, their importance as a be hazard is apt to escape the attention of the casual observer. Consequ0 no concerted effort is usually correct this situation. DSW 255012 STLCOPCB4060703 Vor. i9SS) DERMATOSES FROM CHLORINATED HYDROCARBONS 255 flliile each plant has its own special ventilating problems which require special study, the following general principles are applicable to all, and should be carefully adhered to. Impregnation of Condensers Ail impregnating ovens should be enclosed and tightly constructed so iliat no vapors may escape as a result o! leakage. Each oven should be provided with : hood and equipped with lateral eihaust ventilation so disposed that jrken the door is opened, the vapors My be immediately exhausted at ijjcir source. A velocity of 1000 :p.m. is recommended. This process should be conducted in s.-oom which is isolated from other portions of the plant. Dipping When the chlorinated naphthalenes se used for sealing condensers, all its or pots into which such conwisers are dipped should be equipped | nth lateral exhaust ventilation having ' ivelocity of 1000 f.p.m. The higher iiorinations are employed in these ling compounds, and these are more ';hc than are the tri and tetrachlor^phthalene used for impregnation, inood over the pot, together with ?nrd exhaust ventilation as fre^tly employed at the present is inadequate for the purpose, should instead be a duct com ply surrounding the upper part ^ the pot through which the vapors 'exhausted laterally. Pouring condensers are filled by ^ instead of dipping, various pitch preparations are used more frequently than are the chlorinated naphthalenes. However, when these latter materials are employed for this purpose, the molten wax may be kept in a small tightly enclosed storage tank on the table. The condenser is placed under a slot beneath the tank, and when the operator presses a key the wax drops from the storage tank into the condenser. Such a tank should be supplied with lateral ex haust ventilation. The storage tank is refilled by dropping in lumps of the solid wax. Soldering Workers doing soldering should be similarly protected. Work benches at which this is done should be sup plied with a series of small hoods, one for each worker, under which the soldering operations are carried out. Each hood should be equipped with lateral exhaust ventilation so disposed that the fumes given off are carried back and away from the workers' faces. An air velocity of 1000 f.p.m. is required. Where soldering of tinfoil condensers is carried out by rubbing the end of the condenser on a hot plate, the hazard is greater than where wires are soldered on to leads. All such hot plates should be equipped with a hood having a slot at the end of the plate and supplied with lateral ex haust ventilation. An air velocity of 1000 f.p.m. is required. General Ventilation In addition to the local exhaust ventilation above outlined, careful attention should be directed to ade quate ventilation of the room as a DSW 255013 262 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY \vol.tOtK> mented the occupational hazard in that family, but the fact remained that no member of the family had ever suffered from acne vulgaris, as far as could be determined, and that all three who began working in the condenser plant developed a very severe type of skin eruption--so severe in the case of two of them that they had to go into some other type of work. Both recovered satisfac torily after exposure ceased. In the other family there was no history of the ingestion of iodides or bromides and yet three members in turn were forced to discontinue work in the plant because of severe acneform eruptions. Here again, there was no history of acne vulgaris in the family. The family where iodized salt was being used appeared to have a very poor standard of personal cleanliness, but in the other family a high standard of personal cleanliness was observed. Differential diagnosis from acne vul garis--In the severe cases, there is usually little or no difficulty in differ entiating these conditions. In the milder ones, however, the diagnosis is apt to be more difficult. Certain points of differentiation are helpful, however. When present, the intense pruritus, for example, is of great importance, since this is seldom found in cases of true acne vulgaris. The prominence of comedones in workers exposed to the chlorinated naph thalenes, and the frequency with which these comedones may be seen crowded together, is so striking as to suggest definitely this type of acneform eruption rather than acne vulgaris. The distribution of the lesions tends to throw further light on the differ ential diagnosis. The distribution along the extensor surfaces of the arms, and particularly around the elbows; and its predilection for the area along the whole length of the mandible is not characteristic of acne vulgaris. Furthermore, the back which is an important site of pre dilection for acne vulgaris, was less often involved in the workers ex amined. Lesions may also be ob served on the legs and abdomen, along the belt line, or other areas where there is friction from clothing, sites not usually involved in acne vulgaris. II. Vesiculo-Erythematou8 Eruptions One worker, in addition to having a severe acneform eruption, suffered from a weeping vesiculo-erythematous eruption of the dermatitis venenata type. The eruption had a widespread distribution on the face, neck, arms and trunk. It began about 6 months after starting work with the chlorin ated naphthalenes and cleared up within a month after exposure was permanently discontinued. The girl returned to work in the same plant and was given a job in a department were she would not come into further contact with the substances to which she was sensitive. Nevertheless, she continued to complain of recurrent attacks of moderately severe itching. This case, among others, showed chronic paronychia involving both index fingers which was extremely persistent. III. Simple Erythematous Reaction* Two of the workers examined ffere fount! to be suffering from what *P" peared to be a simple erythematou* eruption with severe itching, appeared mainly on the face DSW 255014 < 4 STLCOPCB4060705 1 256 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY [volio,^ s whole wherever any worker is exposed has been recommended for this putdo*. directly or indirectly to fumes or is the following:* vapors of the chlorinated naphthalenes or diphenyls. Zinc oxide.......................} oz Calomine lotion............. $ oz Personal Hygiene Salicylic acid..................20 grama Adepa Lan. Hyd............. 4 fluid oz. This may be briefly summarized as follows: Medical Supervision 1. Employers should supply workers 1. All workers should be instructed with highly starched uniforms, under as to the hazardous nature of their wear, caps and gloves; these clothes work and the rules to be followed should be laundered every day. in order to keep well. They should 2. Two lockers should be provided, be encouraged to report promptly any one for street clothes and the other evidence of a skin eruption or of for uniforms. general ill health. 3. Employers should provide work 2. Young workers suffering from ers with sanitary eating facilities, re acne vulgaris should not be employed moved from their workroom. in this industry. 4. Wash periods should be sched 3. Because of the possibility of uled on company time, and washing severe scarring of the face following up before lunch and before leaving a severe acneform eruption, it would work at night should be done under seem particularly desirable not to factory supervision. employ young girls. 5. Cold cream, plenty of hot water, 4. Workers developing skin erup soap and individual towels, together tions of any severity should be with a protective lotion for the skin immediately removed from further should be supplied by the management. exposure to the chlorinated naph Since the chlorinated naphthalenes thalenes. In rare cases the skin are not soluble in water, the wax-like eruptions may be a forerunner of film which is deposited on the skin systemic poisoning, such as acute should first be removed with cold yellow atrophy of the liver. cream in which it dissolves. Workers 5. All workers developing skin erup should then wash thoroughly with tions, particularly of the itchy variety, plenty of warm water and a mild soap. should be carefully watched so as to This ritual should be carried out guard against infection. conscientiously before lunch, and again 6. Workers should be given periodic before leaving the factory in the physical examinations. evening. A shower before leaving work is desirable. Summary j All workers should apply a protec 1. Exposure to the chlorinate*! j tive lotion to all exposed parts of the naphthalenes in the manufacture j body before starting work in the electrical condensers may result $ 1 morning and before starting work again after lunch. A lotion which * Recommended Corporation. by the Halo**1 * DSW 255015 : STLCOPCB4060706 Var. 1^81 DERMATOSES FROM CHLORINATED HYDROCARBONS 257 jcneform eruptions, characterized by pustules, papules and comedones. The association of comedones in large numbers, with a severe pruritus (itching) has given it the name "blackhead itch" among the workers. 2. The 31 workers examined in two plants using a combination of tri and tetrachlornaphthalene in the manu facture of condensers were all em ployed in the finishing departments, doing soldering or testing of condensers which had already been impregnated. 3. The eruption observed fell into three main types, which have been discussed. 4. The eruption may or may not become disabling. 5. It usually occurs within the first few months of employment, though there are exceptions to this rule. 6. There appears to be great differ ence in the susceptibility of individuals to these substances. Some workers are never affected. 7. The incidence of the acneform eruption appears to be higher in the summer than in winter. 8. The acneform eruption differs from the acne commonly found among adolescents in the following important respects: a. Severe pruritus, which very sel dom accompanies vulgaris. b. Association of acne with a derma titis venenata or a paronychia of the fingers, especially of index fingers. c' Comedones are far more nu merous, more closely crowded together to form patches. d- Distribution along the exterior surfaces of the arms and es pecially around the elbows, an area almost never affected by acne vulgaris. The back, so often affected in acne vulgaris is not commonly affected here except in very .severe cases. The legs and abdomen may be affected. The line of the mandible is an area of pre dilection. e. The condition may be transferred to other members of the family by contact with the skin and clothing, when these have a coating of the chlomaphtha- lene on them. 10. The mechanism for these acne form skin eruptions is not clearly understood. . 11. The eruption may in severe cases involve the deeper layers of the skin, and result in permanent scarring. One case of permanent facial dis figurement in a young girl was ob served in the course of the present study. 12. In severe cases, there is a tendency to secondary infection, es pecially when there is a coexisting pruritus and the worker scratches the lesions. In the present investigation a furunculosis of the cheek super imposed on a severe acneform eruption resulted in death from septicemia. 13. There is every reason to believe that attention to adequate local and general ventilation, good personal hygiene on the part of the workers and adequate intelligent medical supervision will effectively eliminate the hazard. 14. Fumes and vapors should be exhausted laterally at their source, the velocity of air being maintained at 1000 f.p.m. DSW 255016 STLCOPCB4060707 258 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY [vol.lO,no.i 15. General ventilation for the room as a whole should be introduced when necessary. 16. Principles of personal hygiene and medical supervision have been briefly outlined. BIBLIOGRAPHY 1. Sulzberger, M. B., Rostenberg, A. Jr., and Sher, J. J.: Acneform eruptions. N. Y. State J. Med., S4, 899 (1934). 2. Fulton, W. B., and Matthews, J. L.: A preliminary report of the derma tological and systemic effects of ex posure to hexochloro-naphthalene and chloro-diphenyl. Penn. Dept. Tabor, Spec. Bull. no. 43 (1936). 3. Herxheimer, K.: Ueber Chlorakne. Mflnsch. med. Wchnschr., 46, 278 (1899). 4. Telekt,L.: DiePernakrankheit. Klin. Wchnschr., 6, 845, 897 (1927) and 7 214 (1928). ' 5. COURTOIS-SUFFIT, TOURAINE ' AND Mntrel: Etude sur 1'intoxication professionnelle par le trichloro-naph- thalene. Ann. de Mdd. legale, /(, 422 (1934). ' 6. Jones, J. W., and Alden, H. S.: Acne- form dermatergosis. Arch. Dermatol. Syphil., 55, 1022 (1936). 7. Schwartz, L.: Dermatitis from ayn- thetic resins and waxes. Am. J, Pub. Health. t6, 586 (1936). DSW 255017 STLCOPCB4060708