Document NEv9m9VKVGXdMNMx0EqgaGoyD

/ ' J^Uvff^uA Vol. If4, .No. 17 AvM.A, J tients. Thyroid function may he depressed in a higher percentage of cases if urethane therapy is maintained for a longer period. This possibility is currently being in vestigated. SUMMARY Twenty patients were treated with rectal suppositories of urethane. The therapeutic effectiveness of rectally ad 6*?z~H\ CHLORACNi:--MK1GS ET AL. 1417 ministered urethane is equivalent to that of orally admin istered urethane. Urethane administered rectally is as effective as 'Fowler's solution in spacing irradiation ther apy. Undesirable side-elTects were minimal, ft is con cluded that rectal administration of urethane is preferable to oral or intravenous administration. 2065 Adelberl Rd. (6) (Dr. Weisberger). CHLORACNE FROM AN UNUSUAL EXPOSURE TO J. Wisier Meigs, M.D., Jack Jonathan Albom, M.D. and Bernard L. Kartin, M.D., New Haven, Conn. lAROCHLOR | r-D.E_EPJXPHJI.IBI!IT?N The first outbreak of acne-like lesions due fo high boiling chlorinated compounds in industry in this coun try was noted by Schwartz 1 in 1936. Subsequently, dur ing World War II, various reports of acne-like lesions in workers exposed to certain chlorinated naphthalenes and diphenyls followed. Collier - reported 12 cases of chloracne of the face in workers exposed to the fumes or dust of chlorinated naphthalene and one fatal case due lo acute yellow atrophy of the liver. Fifty-five cases of acneform dermatitis w'ere reported by Kelley :: in 200 persons exposed to chlorinated naphthalene (Halowax). Good and Pensky * described 52 cases in electricians, who handled the cold-finished product for the most part. In none of their cases was systemic involvement found. Schwartz's report concerned the involvement of elec tricians. who installed and stripped wires in ships during the war. The chlorinated naphthalene, which was im pregnated into the asbestos and wrapped around the wire as insulation, flaked off in the stripping process. In the cases described, two months elapsed before the appear ance of the chloracne of the face. There was no systemic involvement. Peck.,; Crunch,1 and Greenburg ' discuss (he chlorinated naphthalenes and chlorinated diphenyls, the appearance of the dermatological lesions, their value in industry, and precautions in handling these chemicals. The value of the chlorinated naphthalenes and di phenyls in industry is due primarily to their resistance to water and alkali, high insulating value (high dielectric constant), thermoplasticity, chemical stability, and flame resistance, as described by various writers.!l The characteristic lesions of chloracne are pinhead to pea-sized pale straw-colored cysts formed by the plug ging of the orifices of the sebaceous glands, resulting in retention of the secretion and in the keratinization of the lining membrane. Comedones are present but are not a striking feature. In nearly every w'orker exposed suffi ciently to these chlorinated compounds for a few months these lesions will develop, The exposure may be either fo fumes from the hot material or to the solid material on continued contact. Repeated or continuous contact is essential. Lesions have not been reported after short or infrequent exposures. Vesiculoerythematous eruptions, as seen in acute eczematous contact-type dermatitis and simple ery thematous eruptions with pruritus, have also been described, This paper reports the development of lesions of chlor acne in sevenworkers employed in a chemical plant con cerned with organic chemical production. HISTORY OF EXPOSURE A chemical company had for some months been using molten salt at 350 F as a medium for supplying accu rately controlled quantities of heat to a large jacketed reaction chamber. Because of the dangers of solidifica tion of the salt in the return line, as well as the corrosion problem, it was decided to use a chlorinated diphenyl (ArochIor),, as the heat exchange material. The same apparatus was used. This included an oil-fired furnace containing the heating coils, a steel pipe supply line to the reaction chamber, a return line to a large sump pump, and an outflow line from the sump to the furnace (see figure). The reservoir for the sump pump had a capacity of about 400 gal. (about 1,680 liters). The chemical product, designated as organic acid A, was manufactured with the use of molten salt for heat exchange from January to December, 1949. At that time, chlorinated diphenyl was substituted as a heat exchange material. It was soon apparent that under certain condi tions there was slight leakage of vapors from a number of places, particularly around the cover of the sump, and also from all gasketed connections in the system. Because of the known toxicity of these substances, the assistance From the departments of public health and internal medicine, Yale University School of Medicine. Associate Professor of Occupational Medicine, Department of Public Health (Dr. Meiys), Assistant Clinical Professor of Dermalolopy, Depart ment of Internal Medicine (Dr. Albom), and Assistant Clinical Professor of Medicint, Department of Internal Medicine (Dr. Kartin), Yale Uni versity School of Medicine. 1. Schwartz, L.: Dermatitis From Synthetic Resins and Waxes, Am. J. Pub. Health 26: 586 (June) 1936. 2. Collier, E.: Poisoning by Chlorinated Naphthalene, Lancet 1:72 (Jan. 16) 1943. 3. Kelley. E. F.: Acne From Synthetic Wax (Halowax), Urol. & Cutan. Rev. 47:238 (April 1) 1943. 4. Good. C. K., and Pensky. N,: Halowax Acne ("Cable Rash"): Cutaneous Eruption in Marine Electricians Due lo Certain Chlorinated Naphthalenes and Diphenyls, Arch. Dermal. & Syph. 48:251 (Sept-) 1943. 5. Schw; rtz, L.: Outbreak of Halowax Acne ("Cable Rash") Among Electricians, J. A. M. A. 122: 158 (May 15) 1943. 6. Peck, S. M.: Dermatitis from Cutting Oils, Solvents, and Dielectrics. Including .Chloracne, J. A. M. A. 1123: 190 (May 20) 1944. 7. Cranch, A. G.: Chlorinated Compounds: Precautions in Handling, Indust. Med. 13:110 (Jan.) 1944. 8. Greenburp, L.: Chlorinated Naphthalenes and Diphenyls, Indust. Med. 12 : 520 (Aup.) 1943. ` 9. (n) Mayers, M. R., and Silverberp, M. G.: Skin Conditions Result ing from Exposure to Cert,tin Chlorinated H\drocarbons, J. Indust. H\y. & Toxicol. 20; 244 (March) 1938. (/>) Schwartz.5 (c) Greenburg ' WATER PCB-SD0000039073 1418 CHLOKACNE--MEIGS ET / L. of the Bureau of Industrial Hygiene, Connecticut State Department of Health, was sought and received. A field study under conditions of obvious vapor leakage was said to have shown negligible air concentrations of the chlori nated diphenyls in the actual breathing zones of the workers. In this study, which was four months prior to the dermatological findings reported here, the air con centration of chlorinated diphenyls was reported by the bureau to be 0.1 mg. per cubic meter of air. The rec ommended maximum allowable concentration is 1.0 mg. per cubic meter. The figure shows that most of the leakage was at points outside the building but under a roof. No one worked regularly at the points of leakage, Neverthe less, repeated attempts were made to control vapor leak age, without complete success. This operation continued for 19 months without incident or recognition of skin or other manifestations of exposure to chlorinated diphen yls, Each employee had a complete physical examination by an internist prior to working in this environment. SUMP FOR CHLORINATED DIPHENYLS Schematic drawing of the heat exchange system (in which the chlorinated diphenyl was used and the points at which workers were exposed to fumes. An operator making organic acid A ("operator," fig ure) was sent to one of us because of acute contact der matitis of the face. In addition to the contact-type of dermatitis, there were noted pinhead-sized straw-colored cysts and comedones on both cheeks and the forehead, A diagnosis of chloracne was made, and the source of exposure was determined. Examination of other workers in this working environment uncovered six additional cases. In all the face was involved especially the cheeks circumorbitally, the forehead, ears, and in one case the mastoid region. All employees were examined carefully by an internist. The seven employees in whom chloracne had developed had liver function tests performed. Tests included direct and total bilirubin determinations and 24 and 48 hour cephalin flocculation, thymol turbidity, and alkaline phosphatase determinations. Six of the subjects had completely normal test results. One employee had borderline cephalin flocculation and thymol turbidity. Thirteen months later repeated liver function tests showed an unchanged cephalin flocculation and im proved thymol turbidity. Results of complete blood cell J.A.M.A., April 24, 1.' counts and urinalysis were normal in all instances. . had normal blood pressures with no other clinical c dence of any chlorinated diphenyl toxicity. After the recognition of these cases of chloracne, but one of the gasketed joints in the heat exchange s\ tern, including the cover of the sump, were welded : gether. A hand hole 6 in. (15 cm.) in diameter was 1. with a gasketed cover so that the system could be drain or filled when necessary. After that time no vapors \n visible, and the odor of chlorinated diphenyls was baa detectable in the immediate vicinity of the sump pum Continued careful observation of workers has reveak no new cases of chloracne. COMMENT The unusual feature of this outbreak of dermatitis w. the long period of exposure before any cases were reco. nized. The sudden recognition of seven cases after exp; sure up to 19 months was due to the especially caret examination of the skin of all exposed employees alu discovery of the first case. Of 14 men exposed or potei tially exposed to the vapors of chlorinated diphenyls, presented clinical evidence of chloracne. There was m a very good correlation between the apparent degree r exposure and the development of signs of disease. Fc example, a foreman, an assistant foreman, and a plar superintendent whose duties would appear to have e.\ posed them only incidentally to the toxic agent had mil. to moderate signs. The mean length of exposure of tho.v in whom signs developed was 14.3 months and of thos. who did not show signs was 11.4 months, but there wn considerable overlap, with chloracne developing in on. worker after only 5 months in contrast to another win showed nosigns even after 19 months' exposure to vapor> Since the manifestations were exclusively on exposci areas of the skin, it appears that the vapors were de posited directly on exposed skin and did not go througl the clothing. The nature of each factor determining the appearance or nonappearance of lesions is not clear. Skin pigmentation may be a factor. Three of the workers were Negroes, and none of them had chloracne. No correlation with perspiration could be made, but all cases were dis covered toward the end of the summer. Prevention consisted of controlling the leakage of vapors. The fact that tests of the air, even in the presence of vapors, showed only negligible amounts of chlorinated hydrocarbons indicates that this type of intermittent but fairly long continued "mild" exposure is not innocuous. The low concentration of the chlorinated diphenyl in the air might account for the fact that lesions developed in only 509o of those involved. SUMMARY Seven cases of mild to moderate chloracne of the face and head occurred among 14 chemical operators ex posed from 5 to 19 months intermittently to small con centrations of the vapors of a chlorinated diphenyl (Arochlor). Leakage of these vapors from a heat exchange system occurred chiefly outdoors, but chloracne was ob served among men working inside the adjacent building. In all cases the condition cleared up after treatment. Control of vapors by welding all joints in the heat ex change system prevented recurrences. 310 Cedar St. (Dr. Meigs). WATER PCB-SD0000039074