Document 5kBXjQOBzDBOBmRN6Y8roemgz

It 105 AN* ACXEFORM DER-MATEKGOS1S JACK W. JONES. MJX AXB HERBERT S. ALDEN. M.D. ATLAXTA, m. It t* only within conqaratiwly recent time* that the ifertnaiMkigttt has htternml himself in dermatoses associated with or ranted by the daily work. With the advent of a mure clearly defined ajijiraisal of the words eczema and dermatitis and the ruurd jgnwrnl use of the patch tert. der matologists have necessarily inquired more aftd nture lcvply into the htnumeralile chemical contacts that occur in the <bv In* ilav lives <>i tlteir patients. As well as being conversant with dermatology. the dcrmatobfist must have a working knowledge of the ntamifactnrc and content of the many new and old cimqiuundx that are handled and applied by large numbers of persons. Hence, more ami more derma tologists are becoming industrially minded, and it is ilawning on them that the solution oi some oi their industrial ditncuhies may aid them in a clearer conception oi the dermatoses that are encountered in their every-day practice. Dri-matergoses of the acneform type occurring in persons working with chemicals have been repeatedly reported in Europe and discussed as industrial "chlor-acne.*' ` This term "hlor-*cn" was first usel by Herxheimer8 in 1S99 to describe an eruption composed oi comedones and small setaceous pustules that occurred on the arms and faces of workers manufacturing chlorine gn* cJectnJyiieally. using carl ion electrodes. It was natural to assume that the chlorine was the causative agent. Bettiitan*1 had observed in March 1S97 two patients whose skins were diffusely pigmented, dark, rough and dry, m whom were observed small tenacious comedones associated with numerous small follicular abscesses. Subsequently he reported twenty-one additional eases with similar symptoms in workmen who were engaged in cleaning out an acid tower used in the manufacture oi hydrochloric acid. At no time did these men come in contact with free chlorine, but numerous loose Scad at the Piity-Eichth Annas] Meeting oi the American Dermatologica) Assaciauen. lac. Wliht Sulphur Springs. W. Ya_ Mar i IMS. L WMit Prosser: The Dermatergnee*. cd. i New York. Paul B. Mother. Ine. 1934. i Heraheimcr: Monehen. wed. tVehnsehr. 1899. 1 Bttunaa: Demsehc toed. Wchnsehr. 27:437,1901. iterivnm chlorine Krun have let vrrnr of chlorine, cundhiia lx chkwi l*trne tetra-nhi Cldurina >>f aenci krauthei by Tekl of eaxs naphtha) _ mass an the worl and tetv yellow j chlorine cent, ant content to Kcrai prnlispo Sonn due to ' Hallopec niann. I 4. O. Welfare, brochure: 5. \V *Cy and I lion. 193: 6. X to the 5l 7. T. (Jan. 391 t Be Oeeepatic fare. Imc 2*5. 9. I. and Heal national LEXOLDMONOOI791 JOXES-ALDEX--ACXEFOKH VEXVATERG0S1S 1023 derivative* of coal tar were present. Herxheimer later absolved the chlorine Imt considered the truulde to te due to various chlorhenicncs. From time to time other rqions of the occurrence of "chlur-acne" have Item made in the Ettrujiean journal*, each author continuing the error of Herxheimer in atstmtini' that the cause of the condition was chlorine. Some of these repons have been indefinite a* to the chemical condition* under which the men worked, except that they were ex]tsed to chlorine gas. However, some authors have sus|iecte<l various chkrIsmzrne derivative*, sttch a* hexa-chbirbrnavne. hexa-chlrcthylene. para-nitrobciuene. jtcTchlomaphtledcne t"]terna*'.l and protaltly other*.4 Chlorinated naphthalene was first buKncd,liy Waiter s in 1V1S as a muse jt ante form minions of the skin, the condition being called Peruokruntheit. His observatiun* were confinned hv Knelsch* anti recently by Teleky.* The latter reported an exhaustive study of a large number of ca-es occurring in workers engaged in the manufacture of perchlornaphihalene. in which the wurker* were exposed to fumes of the molten nets* and also to the sublimated dusts. In approximately one-half of the workers exposed there developed comedones of a particularly heavy and tenneient* t,vpe with resultant sebaceous accesses, containing heavy yellow jnts and scrum. Considerable improvement resulted when the chlorine content of the mas* was decreased irum 30 per cent to $ per cent, and Teickv believed that the disease was due directly to the halogen content of the substance. He mentioned the similarity of the disease to teeraene (tar acne) but parried the analog no further. Individual predisposition appeared to alter receptivity. Some authors have leaned to the view that the acnetorm eruption is due to direct external comae: with the chemicals i notably Bettman. Hallopeau. Jacaitet. Fumcmze. Teleky and Koelsch *). Others (Leh mann. Herxheimer. Jacobi. Roth and Koben `) considered it to be a 4. Occupation and Health: Encyclopedia of Hygiene. Patholoey and Social Welfare. International Labour Office. Boston. World Peace Foundation. 1925. brcehurct 34 and 225. 3. Wauer. died in Occupation and Health; Encyclopedia of Hygiene. Pathol ogy and Social Weitire. International labour Office. Boston, World Peace Founda tion. 1925. brochure 34. d. KoelKh. F,, in VUmaim. K.; Oppenhdm. M. and Rille. 1. H.: Injuries to the Shut. Ldpxig. Leopold Vom. 1920. vol. 2. p- JQJ. 1. Teleky: Klin. Wcbnschr. 0:*43 (April 20); 7 (May 7) 1927; 7:214 (Jan. 29) 1921 l Bemoan: HaDopeau: Jacquet: Fumouae: Teleky. and KoelKh. died in Occupation and Heahh: Encyclopedia of Hygiene. Pathology and Social Wlfare. Imcmational Labour Office, Borton. World Peace Foundation. 1925, brochure 'Si 9. Lehmann; Herxheimer; Jacobi; Roth. and Kohert. cited in Occupation and Wealth: Encyclopedia ef Hygiene. Pathology and Social Welfare. Inter- national Labour Office. Borton. World Peace Foundation. 1925. brochure 225. SBRN001921 1024 .ARCHIVES OF UF.RUATOLOCY .4X1) SYPHILOLOC.Y dermatitis due to the absoqaion of chemical cumjminds by the lung* or ganro-intestinal tract, with elimination Ity way qf the setaceous glands. The majority of writers on the subject, particularly I'tosht White.1 have seemed to feel that chlorine as such has little to <lw with the formation oi the cuntetkmes and cysts. ami they hare rqvatedly referred to tar ami products of the distillation of tar as ihe prime causative factor*. Pntsscr White relmketl authors for using the term "chlor-acitc** at all ami cxj>re*Mt1 the Iwlief that the process i one of the ntanibild cutaneous reactions pnslucnJ by tar and its derivatives. Kccratly we have had the npjmjnunity to study, with the full cnopera* lion of tlte manufacturers. an nnlmrak of acnefurm eruption occturing in a group oi workers engaged in Ihe manufacture of chlorinated di-phenyl. This study has brought out some jartnu in the production of this tmtistKil dermatosis that we feel are important in * *lvir>g its exact cause. The following case is typically illustrative of the disease as it occttrred m the men working in this Jibuti. KF.I-nST or A CASS .Vinery.--O. D~ a S'tffe aged 26. began work m the distillation id chlorinated di-phenyl m April 1920 and worked regularly smil the latter pan oi the year 1921. About' May oi 1922. he noticed the appearance oi blackheads on his iset. neck, arm* and legs. Then areas itched slightly. In a short time blackheads began to appear on the chest, back and lower part at the Abdomen, around the navel and on the scrotum and penis, litany of these blackheads swelled and became aliened. discharging thick pus. The areas healed with difficulty and piten left scars. The condition seemed to be prorressive until November 1922. When seen in December 1922 the patient complained of lassnude, loss oi appetite and loti oi `.*rio and said, that his cutaneous condition scemcd to be improving. ' Phytutl Examination.--On examination he seemed in good general health. Kis complaint of lassitude was not borne out by anything mere than the usual tempera ment oi the Negro toward work. On the forehead, extending within the hair Kite, and on the cheeks, chin, nose and neck were irameruts small very Mack, tenacious comedones, their distributism best described as bring '`peppered** within the skin. Many oi the comedones stirmourned frm thotlikt cists, which in some areas cattained viscid yellow pus. The pustular elements were mere noticeable on the neck. Similar shotlike comedones ami cysts had appeared on the shoulders, midpenion oi the back and chest, with an occasional large eyes. A peculiar peppering of the skin with tenacious carhon-ctdorsd comedones was apparent around the umbilicus and tower portion of the abdomen. The scrotum and penis were involved in a similar process, the former being given more to the formation of cysts. The outer surfaces of the forearms and anterior thighs showed similar bat fewer comedones. The whole eruption su aentforw bat differed from acne particularly in the lack of a seborrheic appearance of the skin and in the peculiarly deep Mack nf the comedones as well as the general peppered distribution in areas not usually involved m acne vulgaris. A general physical exatninatton had revealed nothing of importance. ` 6BRN001922 Trrtlmt * hears Ssko mstS distilhd art of rm Mlcntat it* mm the hair I Atn lii tx :A 3* a# 4tr m -r at * St su is MP ; .< s tie v tert r lest is Kt ~ HP JO * Tfclf r denruetior follicles a: cavity. In (bowed tb exudate. * enlarged < Slight edr hot they LEXOLDMONOOI793  ~iifiXMin ~rr~"~ " IOXES-.UJJEX--.4CXEPOKM PEJt.U.n F.XCO.MS IU!5 TrfimrMt.--Ht m instructed lo scrub hit skin ibirnofhiT before and after Jim he* { work, to wear irerh clothing each ty during mrt and to use a kiiuii marl* up ai Mlwn: line sulfate 4 Cm. potassium sulfurata 4 Cm. ami distilled viler to make 125 ce. On rccrentmndation Ik later reported fur rvklv 4>ki i4 fiontgcn radiation according to th* usual manner of trratmg acne rulgarit. Mirnupfit Examiaatiam.--A portion of th* skin of the chert was removed fur microscopic study (Kg. 1). The ehief feature of the lection* trai noted in the hair follicle* and sebaceous gland*, m which there were cynic dilatation. Sammarr *f ike Semftomt and Treatment in Sixteen Catft #/ .4,-mejarm Eruption Cm* |t IK as s *ir Oi 4 a JQ 5* SB Ilr SC 7i< Si :;<3 a ; %* r:u Si ut :.*r ss *? so Bm* WMtf Twtl tw MtirrMr: ItrriMif mm Ttpil Krahtwu ir% trail VMlf Wbiia While WMla Whit* JicfTO N<aro Sffra ATtnit tfolMffllFIt tmait -tn Jtrtrvc* Mrrht>: prrvwtti ccM feberThrle ATrfUCt htltwRlwic ---- Thfliae mmuShw: If* #tm ' fHflttaf mnwiwn: larva mil ! tatfiubY IMm mu Sw; lire* Mill n,l iMtnu TWITum teaimkart: lr* trait mi lm Ml Mvh I*ittttt wwlon1; ihr|t |ltfTm Ml Mrk: tMWfytU Xrrthriuient lit!Sum rout*ton#*: !,* nnsli rrm f*a kfiUfTml rod> loatt; mtmkob! tftt tiilfvtt taiimionH: tyni: naall Whitt White TV*hilt Wurtt Nrrre While Avrrtft : Tny Mtorrhft* dMwavt * Atetmtt SetmrlwK $rattrr*U miMiail iImhi fstatTtrf laiRptaKi: Mtanoaal ilttni F** ckfhMf orrvfieatJ rrrt Omnul rom*letn Very ter ronwlMM Sourml mmtoM ypeto Seterrlww TWltusr renmlwim: Wmii lock an,l tatt Tlmrut J*lmman e wontIn dwmiila Mi^ial TmiNwat laHatwa: hblltff lhvra|i]r $ ThrUMVbMM drataiafv M NNWIM Xmw 4 ThfiwfMfHt Sod* M> mMitftf (Matas lanfieo: flfainavv Nut 1 mouths Sam ThrMchMi RorntVtMo ihmi*r Smooths yM Threurarat JtOtfltffUM IMihf 5 moBihi yea* Thnatliont Kern 1C umarM Near Tlirmifftont BatatvthM Baittv*vM thtracr * Thu rare u rrpertnl is lentil. dettniction of th* hair, marked thinning and atrophy of the epithelium of the follicles and a heavy plug of keratiniaed material which partly filled th* cystic cavity. In Mm* area* there was a superficial ping at th* surface opening: others showed the suriace open and th* plug deeply situated. There was no purulent exudate. There were a ton* of moderately dens* connective tissue surrounding the enlarged follicles, slight' edema and infiltration by lymphocytes but no leukocytes. Slight edematous changes were noted m the occasional sebaceous glands present, but they were strikingly few. Th* Mint gland* were normal. 6BRN001923 *5t=y IflA .m'HU'EM of tMK.V.rin/.tM.r .ix/i *YI'lill.nun.Y Of the dUphcnvl 1933. tt the face an mm |ire*cr trilmtkm u In many f timlarlv ai Fif. l^Sfftfcw of *km from ihc thw, ^hinriai Unvkicic chuyo in the t'oraaiiin of an acncform cnqitioa. GBRN001924 - Fig. 2.-- and the rt fcarrinf. developed t Until yt laboratory In the expt crude, and to fumes a In the earl LEXOLDMONOQ1795 LEXOLDMONOOI796 I KUS ARCHIVES OF DERMATOLOGY AXO SYVHILuLOGY quantities. the Ui-phenyl was mule In* heating benzene derived from crude coal tar. Whrn heated in a anitalde medium Jnzene i CH.) -becomes <li-phenyl This sulwtance is then chlorinated at various saturation point!, by exposing; it nmler suitable conditions to free chlorine pas. Distillation of the resulting chlorinated di-phmyl '* * results in a purified commercial jirodnct (fig. 3). -The xunmwrrial benzene always has a small quantity if htqmritics. Int some f the cruder conunercia) Iwnzenes contain relatively large <ptantities of these rig. Can iiltmrating tne prts$ o: nan-jiacturc oi chlorinated di-phenyl. cruder benzenes, the toluenes ami xyienes. " hen present in large qtinn- tities. may produce the chemical substance styrene, which has the formula C. Ha CH: CH.. Styrene when chlorinated fit being insepa rable from the di-phenyl) is an unstable compound dropping its chlorine atoms very readily. I: is prubahie that ether complex hydro carbons may be formed from these impurities, which on chlorination become quite as unstable as the styrene. - One of these compounds may be chlorethyl benzene (C. H, CH-G-CH.j. . 10. Chlorinated tli-phrntl eutiins oi a mixture oi di-phc-nyl chlorinated at various saturatien points: nona-chloro-di-phenyl (C HCL. -C. Oi) etc. In tb dt-jihrm chlurinai quantha heating designed the wnr mamtfac chkirinat examine tier] >enc un the f: sivcly engaged had a >1 .was give of 1932. conditior chased t panicula product i until Oc present a oi the sa The : of a poo: ship.' O offending Jt sec causative chlorinat However The prol sary to r The cannot t mild corn cm nttrner and the i lienzene. instance, area prod which pet LEXOLDMONOOI797 Jt)XES-.HLL)E.\'--.1(..\H)KM JTEKi(>.\/.f 1029 In the experimental *tage and in the early manufacture uf chlorinated di-phenyl. the nm working were c9E|>m<I for long leriwlt to thee chlorinated leudactt. A* the tlemand for the rini>hcd product increased, quantitative manufacture wa* jierdrd up rapidly. and sqm Mill* and heating turns were uf necessity used until Iletter ei|tii)anem could be designed ami made. Jw rinee no physical trouble hsnl developed in the workers previously there was no aftjiarem hazard cwmceicd with manufacture. On nr alemt March 1933 the electrical |irnpmies of the chlurittatcl di-phenyl produced in the plant the worknten of which were examined fell below the specification*, ami the color of the product -deepened. v\l*mt rate month later an acneform eruption was uiiservrd on the faces and arm* of several of the worker*, which Iweante progres sively worse, gradually liecoming apparent among all ilte workers engaged in the process at that time. Although one of the men had had a slight acneform ertiptirm on his face in January, little ihought was given to it until the eruption ap|x*areil in the others. In the summer oi 1932. six or eight months jjreviuns to ihe general outbreak of the condition, owing to a difference in price, the crude Iwnzene was pur chased from another smirce. and it was not until the purchase of this particular -henzcnc wa# liiscontinned. in October 1533. that the finished product came up to the standard. During the period from March 1933 until Oaober 1933. the eruption continued among the men. and it was present as already described when the men were examined in December oi the same year. The appearance ci the eruption coincidentally with the production of a poor grade of chlorinated di-phcnvl seemed to indicate a relation ship. On due chemical investigation styrene was assumed to be the offending substance causing the low grade oi the finished product. It seems that it may be readily assumed that our problem as to The causative agents oi the acneform eruption was connected with the chlorinated products of the impurities present in the crude benzene. However, with the exception oi styrene, these products are not known. The problem hence Incomes difficult of exact solution, and it is neces sary to resort to a reasonable deductive hypothesis.. The exact conditions under which the men contracted their eruption cannot be satisfactorily duplicated experimentally since prolonged mild contact seems to be a deciding factor. Repeated patch test* nude cm numerous persons with the finished product, chlorinated di-pheny). and the foreign substances styrene, styrene di-chloride and ehlorethylbenzene, have not resulted in an acneform eruption except in one instance. Repeated patch tests made with ehlurethylbenzene in the same area produced on the third attempt an erythematous follicular eruption, which persisted only a few ilavs last which was hv no mean* typical. BBRNOO1927 KUO ARCHIVES OF DERMATOLOGY ASD .\YPHILOLOGY We could not dujilieate this in xher imtanee*. Since nyrene. chlorinated styrene. chlorethvllienzene. .xylene, toluene and their prohalde products are fur the most ]irt lipid solvent*. they will produce death and denudation of the epithelium. and one kaw obtain* a chemical burn in response to a patch test made with the styrene and styrene di-chioride. Small <|uantitie* mixed lowrly with an inert powder or dissolved in ether produce a mild erytheniatott* reaction but no acneform eruption. Patch test* made with the rinished pnahict. chloriv nated di-phenyl, at no time produced any erythema <ir evidence "f irritation: hence the chlorinated di-]>hciiyl can l alw*dntely alnolved as an irritating agent. In looking over the cwixcmive history ot the development of the eruption! we found it a|i|>arent that the men were in sonte degree exposed to, the xhljirinated impurities in the Iwnzrne fur some time before the cru|*iun actually a|t|wared. and that to duplicate the condition* we should have to make repeatvil patch tests daily tor long jieriods in the same ]>erson. a jirocedure which is not feasible. As a group, the workers in the dost* ami vajir*. which were rresunuibly saturated with chlnrinated hydmcarlmn*. were not cleanly, nuking little effort to bathe after work, anil sweating and rubbing enhanced the liability to deposition of the substances on the skin. Theoretically, the chlorinated hydrocarbons, presumably styrene di-chloride and cklorethylbcnzene. deposited on the kin gather around the hair follicles and eebaceons glands and arc gradually rubbed in. Being lipid solvents, they dissolve sebum and in the reaction, which is modified by the heat of the body and the water present, give oft hydro chloric acid, which causes death or irritation of the cells. This in turn causes an excess of cell growth, innanintation. sebaceous plugging and an acneionn eruption (.rig. 4). This process repeated over a long period may resuit in severe sebaceous infection, sebaceous abscess and scarring. One would naturally expea this process to occur in the seborrheic areas as well as where clothing might rub the panicles into the skin. Also one would expea the process to enhance an already existing acne vulgaris. This occurred in cases 1 and 6 (table 1). the cases in which there was the worst involvement with sebaceous abscesses. In the beginning an attempt at prevention of the condition was made by being especially careful that all men engaged in the manufaoure oi chlorinated di-phenyl should have a thorough bath after working hours and that they should wear freshly laundered clothing before starting work. They were also instruned to apply night and morning veterinary white lotion to the affected pans. Some of the patients having the most numerous cysts and follicular infeaions were instructed to report for roentgen treatment administered in the manner usually employed in treating acne vulgaris. Following the - change distillir ini)inn gen r this fo course, hydruc tlte mt are gn an occa ******--' Fir which c Wb it is ah in most lipid so cases, chlorine chlorina close cc from ss to do GBRN001928 < LEXOLDMONOOI799 J0XES-.1LDEX-. ICXEFOkM DEHM.4TEHCOSIS IU1 change in the type of benzene uteri and the employment of enclosed distilling apparatus ami ventilation fans, there was noted a gnuhial improvement m the aenefurm entpekm. Those patients receiving roent gen radiation improved much more rapidly, hut it cannot he said that this form of treatment gave tmusual results. The final treatment, of course, was removal of the patient fnen the unending chlorinated hydrocarbons, and then cleanliness ami relief from any infection. All the men showing evidence of ctitamnm* liM-ae. mi far as is knuwn. are greatly improved, or the condition has entirely cleared cxcc]* for an occasional comedo and a few scars. Fig. 4--Froctss oi manutsemre ci chlorinated di-phenyl eomaining impurities which cause an acnet'erm eruption. When one recalls the cases reported by the European investigators, it is altogether plausible that the chemical process outlined here occurred in most instances. The slow liberation of chlorine in the presence of a lipid solvent (usually chlorinated hydrocarbons) was present in most cases. It is doubtful whether the disease is influenced by the quantity of chlorine present; it is apparently more due to the formation of unsable chlorinated hydrocarbons as well as to the liability of the workers to close contact without a thorough cleansing of the skin and a change from saturated clothing. It is also probable that the disease has little to do with nr itseli but more with the products formed by the 6BRND01929 1012 ARCHIVES OF DERMATOLOGY A.XD SYPHILOLOGY chlorination of tar. .Hence, the disease cannot be called "chlnr-acne" or "tar ante.** That h in nut earned by internal ahsorptiun is evident when one considers the following fans: First, acute intoxications liv chlorine tardy occur, since sutfieaikm and death by pulmonary edema ensue even in the presence of relatively small iptamities of chlorine gas in the air. Second, when ingested, chlorine and the chlorinated hydro* carbons are so ra|iidly oxidized and chlorine so readily cuntliines with sodium that opportunity for acne-like cnqnions. snch as occur in liromine intoxication. is not possilde. In retrospect, we are intrigued ltv the hyjaxhesi* that these theoreti cal considerations may have wane relation to acne vulgaris. The past quarter of a century ha* <n ai| enormous increase in the use of coal for heating honw* a* \vi-ll~a* in industry. The smoke stacks of the cities have lielched an ever increasing stream of coal smoke--smoke heavily laden with carbonaceous products containing numerous hydro-carlxms. It is well known that coal smoke contains hydrochloric acid. Is it not possible that at least some of the acne vulgaris may have a part of its origin in the constant contacts with the chlorinated hydro carbons of coal smoke? iVMMASY We 1Stave recorded herein observations concerning an industrial dermatosis of an acneform type. The type of eruption and the causative factors are-analogous to those in the previously reported cases spoken of in the European literature as instances of "chlor-acne." tar acne or Pcrnaknnkheit. Although exact duplication of the conditions under which the-workers acquired the dermatosis cannot be accomplished by experimental means, reasonable deductions as to the cause of the difficulty can lie made. The eruption occurred during the manufacture of chlorinated di-phenyl from benzene. The dermatosis occurred at a rime when the benzene nsed contained excessive quantities of toluene; xylene and paraffin as impurities. The heating and chlorination of these impurities probably resulted in the production of styrene di-chloride and chlorethvibenzenc, which, we lielieve. on contact with the skin produced the acneform eruption by the slow liberation of hydrochloric add and not by interna! absorption of any chemical. While many chlorinated hydroearbons. as brought out by Trosser White.* are lipid substances producing death or irritation of the cells by the liberation of chlorine, this is not true in all instances, since the finished produet, chlorinated di-phenvl. did not, either experimentally or actually, produce any cutaneous or sebaceous irritation. Irritation apparently depends on the ease with which chlorine atoms are released from the hydro carbon hast. We believe that these dermatoses should be labeled acne* torn dermatergoses resulting from certain -unstable chlorinated SBRN001930 hydroeari The sues may bctl Da. O three m ner it c I am r> problems. Altai d Dr. M This piic in those v site and d <m the -fat into the f patients p -with kcki Both deep acne, wen were prer and manv 18 to JO was tppa; by a cher this isnp ehlor-cr.h contact w. fssgiede diiltralty. formula, lesions til through a; with acne Da. X triboted a of seeing half ago. Pitch tar these com and also mentioned the age o: sexes. 1 belie between a vulgaris, estrogenic genie and tion of act LEXOLDMONOOI801 JOXES-JLUEX--.ICXEFOK.U JlEKU.lTEXCOstS 10U hydrocarbons and shuuld not lie *]token of a* "chlor-acne" or tar acne. The suggestion ha* liem made that tome of the acne vulgaris of the *kin may lie the result of the same type of irritatimt front *001 nr coal mute. ABSTRACT OF DISCUSSION* Da. Own S. Oantar. Chicafu: I shnnld like u> add an mcrinet t had three month* ago that i* of intrrnl in thi r<emeritiet. 1 think that Ur. Jim*' *a|nr extraordinarily interroma ami valuable. ami the small pia* caw* I am come to rr|irt may add w hit troubles rather than wdve any f the problem*. About three mumh* at" in Michigan. 1 u a patient. ihr>eti the courtesy of Dr. Milton G. Butler, who prrsented an extraordinary acneform eruption. Thit patient wat IS year* old and had Heen nbsmvd hy Dr. Butler. The cruptam in them variou* curt cumisicd of acm'iurm pustules'and fntmxkmes of varialde site and depth, with tear*, taut of which were keloidal. The eruption occurred on the face and neck, particularly over the posterior portion, and extended well tip into the toIp. The tnmk. arm*, thighs ami legs were alto involved. Two of the patients pretented an the back of the neck deep perifollicular pustular lesions, whh keloidal searv such a* are teen in Kaposi** ricraathit papillaris rapiltitii. Both deep and superficial atrophic scars, such as are teen in deep lesions leaving acne, were pretent in other portion! of the neck, face and trunk. The fmtedonc* were prominent in all areas, mcludiiig the lees. They were of variable rise, and many were large and deep. The age of the affected patten* varied from IS to 50 years, the younger ones being more severely affected. The condition wat apparently produced by contact with an ingredient in a fungicide produced ' by a chemical company for destroying iungi in junjber. The particular chemical in thit fungicide that apparently was responsible for the eruption wat sodium tttrachloT-anho-phcnylphcnatc. which is a yellow powder. Only those who eintc in contact with it had the eruption. Those who handled the other ingredients of the fungicide and did not come hi contact with this particular chemical had no difficulty. As there were apparently no chlorine, bromine or tar radical* in the iermula. h is difficult to determine the active factor in the production of the 'lesions and also whether the eruption was caused by local action by contact or through absorption and internal effects. The eruption was not concerned in any way with acne, and no patient in whom the eruption developed had had acne previously. Da. Mattox B. Snxacaeta. New York: I think that Dr. Jones hat con tributed a study that will be very interesting when continued. I had an opportunity of seeing a group of patients with acne oi external origin about a year and a half ago. The patients were all employed in a factory making radio condenser*. Fitch ur and a type of wax (halowax a chlorinated naphthalene) were used in these condensers. The acne which developed wat like that described by Dr. Jones and alto included comedones on the legs, as did that which Dr. Ormsby hat mentioned. I saw six patients from this one small factory. They were all in the age of puberty or the early twenties, and the group included persons of both sexes. I believe the most important point in this study is the possible connection between aenriorm dermatoses distinctly due to external irritants and true acne vulgaris. It is interesting that many derivative* of tar are closely allied to the estrogenic hormone, that certain components at tar arc both estrogenic and acnegenic and that the estrogenic hormone must perhapa he incriminated in the produc tion oi sent vulgaris. There can be no doubt that acne is often due to stimulation or GBRN001931 10M ARCHIVES OF DERMATOLOGY AXD SYFHILOLOGY irritation f thf pfloscfwctous apparatus and that hccmwtal a* well a* external iafhs- meet can produce due nunulatina. In.the patient suffering from acne, who hai. uf rourw. come in coman with the estsngenic hormune during imra-utcrinc life and then hat had no further contact with thit hormone for the dearly related testicular hormone) until he nr he begins to form his uc her n hornume*, me can readily conceive the paihngcnrsil of acne vulgaris aa bring hated an an excessive stimulation of the hair (ullielcf, a ohnulatiun produced hy the sodden new formation nf the hornHuies ai pufwny. It is aa though the hdlkies. after being Hnshited to the horwtone* during fetal roman ami then passing thenugh a period of freedom from ctmucl. react exeessively to the new and missive comacts with the products nf the grauult at puberty. 1 have ditcaascd ihia subject aa great deuil elsewhere. ' Da. H. C. lavtxc. Mhmcaiadis:..tj wish to cmtrnicm m vnt point and m complimem Dr. Jones on an cxrrllcm piece of work and his presentation of to. There was a difference between his situation and that'which Dr. Tunnacliff and I encountered fAarit. Dumjit. t Svrti. 33:30f> |Fch] 193d). h his cate the manufacturers called wt the medical profession to help ndve the pruMenu Our study was undertaken where lay people were in charge. It elmws clearly the need of medical advice in the prufociion nf various chemical preparations. Da. Jack W. Jews. Atlanta. Ca.: I am very grateful for the discussion. I did not have time to go into the various preventive measures attempted in eon* trolling the outbreak or the treatment. In most of the cases the condition has fbislly clrtrtd up. Srgardtng Dr. Sulzberger's discussion, we studied this outbreak and the literature rather carefully for a year and a half or two yrars. and wc are con vinced that the etiology in this particular group can be'ascribed to external irritation and not to any imrmal complications. Our idea is that the unstable chlorinated hvdrocarbcats give off chlorine very easily, whereas the chlorine that is fixed in the bcniene ring is comparatively stable. V.'hen these unstable chleritated hydrocarbons come into contact 'with the skin and enter the hair follicles. they art broken down slowly, giving chlorine to form hydrochloric add. Wc feel that this it the primary cause of the trouble. GBRN001932 Aseistar Assistsr n* profess times has bet tenda i A' <pe#rio anti hi SO per In 192 ieal kv the nre or the a vahv cubic c three ; decrea.* of car mainta constar Fro General 1. * tnta Dir 2.1 Skin: 3. J matosea. LEXOLDMONOOI803