Document YjNBkJG1z6kVLkGk7w5kQ3Oyk

It 105 AN* ACXEFORM DER-MATEKGOS1S JACK W. JONES. M.D. JtXB HERBERT S. ALDEN. M.D. ATLAXTA, M. It is only within comparatively recent time* that the dcrnvunlogt-4 has interested himself in ileTtmtoses associated with or cattsed by the daily work. With the advent of a mure dearly defined apipwaisal of the word* eczema and dermatitis and the word jgettcral we of the patch te*t. iter* matolop^ts have necessarily inquired more aftd nture tlceply into the mnumeralilc chemical contact* that occur in the lav In* ilav live* <>i their patient*. A* well a* lasing conversant with dermatology. the tier* matobfist limit have a working knowledge of the mamtiactnrc and content of the many new and old compuund* that are handled and applied by large numbers of pxrrsons. Hence, mure ami more dertnatoloppsts are becoming industrially minded, and it is >lawning on them that the solution oi some oi their hxlu*iria! ditncuhie* may aid them in a clearer conception oi the dermatoses that are encountered in their every-day practice. Dermatergoses of the acneiorm type occurring in persons working with chemicals have been repeatedly reported in Europse and discussed as industrial "ehlor-acne.*' ` This term `'ehlor-acn" was first used by Herxheimer8 in 1S99 to describe an eruption composed oi comedones and small sebaceous pustules that occurred on the arms and fare* oi workers manufacturing chlorine gas electrolyiically. using car!ion electrodes. It was natural to asmine that the chlorine was the causative agent. Henman1 had observed in March 1S97 two patients whose skins were diituselv pigmented, dark, rough and dry, in whom were observed small tenacious comedones associated with numerous small iollicular abscesses. Subsequently he reported twenty-one additional ease* with similar symptoms m workmen who were engaged in cleaning out an acid tower used in the manuiaemre oi hydrochloric acid. At no time did these men come in contact with free chlorine, but numerous loose Read at the FiityEighth Annual Meeting oi the American Dermatologies] Atsoriatien. Inc. White Sulphur Springs. W. Va. Mar A IMA L 'Whitt Proeser: The Dcrmatcrgmts. cd. i New York. Paul B. Mother. Ine, 1934. A Hersheinter: Monehen. tned. Wchnsrhr. 41:171. 1899. A Brttman: Demsrhe tned. Wchttschr. 27:437,1901. 6BRN001920 k-rivativ chlorine Krun have In* error of chlorine, conduit a t chlori l*n*c*ne petra-nhi Clilurina of aenci trauthn by Tekl of care* uapihthal . mat* an the wor) and tetv yellow p chlorine cent, ant content to fcrroi pirnlispo J?omi due to ' Hallope: niann. I Ta Welfare. brcchure: 5. \Y ogyand lion. 193: AK to the 5l 7. T. (Jan. 391 t Be Oecopatic (are. Imc 2*3. 9. I.* and Heal national TOWOLDMONOOQ1485 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-chltirbnuene. hexa-chlorcthylnte. para-nitvoljcruene. )Krchtanaphthalnc t"]terna*'.l and prulaltly other*.4 * * * * 9 Chlorinated naphthalene was first buKned,liy Waiter s in 1V1S as a muse jt ante form erttinions of the skin, the condition being called Peruif kruntheit. His observatiun* were confinned hv Knelsch* anti recently by Teleky.* The laner reported an exhaustive study of a large number of ca-es occurring in workers engaged in the manufacture of perchloruaphihalene. in which the wurker* were exposed to fumes of the molten nets* an'l also to the sublimated dusts. In approximately one-half of the workers exposed there tleveloped comedones of a particularly heavy and tenacious type with resultant sebaceous abscesses. containing heavy yellow juts and scrum. Considerable improvement resulted when the chlorine content of the mas* was decreased from 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 iurthcr. Individual predisposition appeared to alter receptivity. Some authors have leaned to the view that the acneform eruption is due to direct external comae: with the chemical* i notably Bettman. Hallopeau. Jacaitet. Fumcmze. Teleky and Koelsch *). Others (Leh mann. Herxheimer. Jacobi. Roth and Koben `) considered it to be a 4. Occupation end Health: Encyclopedia of Hygiene. Pathnloey and Social Welfare. International Labour Office. Boston. World Peace Foundation. 1925. breehuret 34 and 235. 3. Wauer. cited m Occupation and Health; Encyclopedia of Hygiene. Pathol ogy and Social Welfare, International labour Office. Boston, World Peace Founda tion. 19.15. brochure 34. d. Koelioh. F, in VUmarm. K.; Oppenhcim. M. and Rille. 1. H.: Injuries to the Skm. Leipzig. Leopold Voss. 1910. vol. 2. p- 303. 1. Teleky: Klin. Wcbnschr. S:*4i (April 30); Kf (May 7) 1927: 7:214 (Jan. 29) 1921 l Bennait: Hallopeau: Jacques: Fumotize: Teleky. and Kwlidi cited in Occupation and Heahh: Encyclopedia of Hygiene. Pathology and Social Wel fare. International Labour Office, Bofton, World Peace Foundation. 1925, brochure 2fil 9. Lehmann; Herxheimer; Jacobi; Rnth. and Kohert. cited in Occupition and Heahh: Encyclopedia of Hygiene. Pathology and Social Welfare. Inter national Labour Office. Boston. World Peace Foundation. I02J. brochure 235. SBRN001921 1024 .4BCHIVES OF HF.XM.4TOI.OCV .4X0 EYPHILOLOCY dermatitis due tu the ahroqttion of chemical cumjtounds lv the lungs or ganro-intvstinal tract, with elimination hr way of the setaceous glands. The majority of writers no the subject, particularly fruiter White.1 have teemed to feel that chlorine as ench hat little to k* with the formation oi the cumctkme* and ey*t. ami they hare rqmttetUy referred to tar ami product* of the dinillation of tar as ihe prime causative factor*. Purser White rrlmked author* for using the term "chlor-acnr** at all and rxj>re*<e*1 the Iwlief that the process i* *me of the manibild attanvous reaction* prusiucixi by tar and its derivative*. Rccrnilv we have had the np|wijnunity to stttdr. with the full ctwperalion of tlte manufacturers, an nnlmrak of acneform eruption occurring in a group oi worker* engaged in ihe mannfacture of chlorinated di-phenyl. This study has brought out route jsrfnt* in the production of this unusual dermatosis that we feel are important in solving its exact cause. The following case is typically illustrative of the disease as it occurred in the men working in this Jibuti. aEi'onT or a case .Vinery.--O. D.. a Xtfre aged 35. began work m the di*tillation .4 ehtormaud di-phenyl m April 1930 and worked regularly until the latitr part oi the year !9.U. About' May of 1923. he noticed the appearance of blackhead* oa hi* tct. neck, am* and leg*. Then area* itched slightly. In a short time blackhead* began to appear on the chest, back and lower part of the abtkenen. around the navel and on the scrotum and pnti*. Many of these blackhead* twelltd and became infected, discharging thick pus. The area* healed with difficulty and piten leit tear*. The condition teemed to be progressive until November 1933. When teen in December 1933 the patient complained of lassitude. lot* of appetite and let* oi iKrio and *aid. that hi* cutaneous condition teemedto be improving. Phrtiitl Examination.--On examination he teemed in good general health. Kit complaint of lassitude was not borne out by anything mere than the usual tempera ment of the Negro toward work. On the forehead, extending within the hair Kite, and on the cheek*, chin, note and neck were munerunt small, very Mack, tenacious comedones. their distribution best described a* bring '`peppered** within the tkin. Minv oi the comedones snrmuumed firm thotlike cysts, which in some arras remained viscid yellow put. The pustular elements were mere noticeable on the neck. Similar thotlike comedones ami ryn* had appeared on the shoulders, midponicn of the back and chest, with an occasional large cyst. A peculiar peppering of the skin with tenacious earhon-oJored comedones was apparent around the umbilicus and lower portion of the abdomen. The scrotum and penis were involved in similar process, the former being given more to the formation of cysts. The outer nrfacet of the forearms and anterior thighs showed similar but fewer comedones. The whole eruption was acneform but differed from sene ptrticalarly in the lack of a seborrheic appearance of the skin and in the peculiarly deep Mack of the comedones as well as the general peppered distribution in areas not usually involved m acne vulgaris. A general physical examination had revealed nothing at importance. ' Trratmt hi* hemes < htHu matt distilled wi at m 2/irmar it* imrro* (hr hair f .Vnaaarr , An lii Z -* vi 3t 4tC m -t at * s I ID* Si y< :iu s imuni Kt ~ s* r n ~ kp sc * Tht$ r dertrnaior iolliclet a: eavhy. ]n showed th exudate. * enlarged f Slight edr hot they BBRN001922 TOWOLDMONOOQ1487 IOXES-.UJJEX--.4CXEPOKM PEJt.U.n F.XCO.MS IU25 Trentment.--Ht u instructed lo scrub hit skin ihfhlT before and after hit hours of work, lo wear imk cfashing each day during mrt and lo use a h4iu<i marl* up ai fallows: line sulfate 4 Cm. potassium suifurata 4 Cm. ami distilled wiicr to make 125 ce. On rwnimndaiiow he laier reported lur weekly * <4 nwntgen radiation acceding to the nanal maimer v( treating acne rulgaria. Mteenjeefie Exnminatian.--A portion el the akin of the chest was removed inr microscopic study (fig. 1). The chief feature of the sections was noted in the hair follicles and sebaceous gland*, m which there were cystie dilatation. Mammary 0/ Ike Semftomt and Treatment ia Sixteen Caset 0/ .4,-mejnrm Eruption C*f .'It IK a y *ir ai a y SB :ir sc li< Si 1:6 a ; r* 1 :u s: uz ft :.*r ss pp WMtf VMlf Wbiia Twtl tw MdirrMr: Itrrimif acm AWilt tfolMffllFIt tVhilt .ttrrmee -ter WMla Whit* NrfTO Jtrtrvc* M<snhe>: prrvwui ccM fekOTThrle Nfiro ATrfUCt Srtra Mwtlitk - Whlu Avrrtft : White Tny TV* hilt vriorrane Wurtt Sms While A**ravt * Atttmtt Vrlorrhrlc St-CTO Seborrtoit Ttpil Knthtwu ir% rrvtl Thfliae twawStw: Ift fTMl * Hfliipv wiwwiwn: larva rriti ami Hvtiih ISSm mu Sw: larer rrtts ami iMnm THffuaa tann-kwa*: Irr rrm m tan Ml ml ftflmt wiMoih; ihr|t Ml imk: mweytu Kmhviaaiens *11f. Suss mmkiM: !,* nnsli rrm f*a whwhI rota* -103**: MtatKOai tftt WItuse mavlsm: rrnt: naall usmm VattrrtU tombit>a; naiMiail 5itatm**f laApitKi: entarioaaJ Mmi F** romokfhM:' acratiosal ej-ft Otvanmsl tsimlm Vtt l niwImm Sniwinl KinwItM THIlusr mumlnnst: |.V>T|I< iwk aa,l late Tlmrul Ibiwm mwMW SaauMilia *lw*al TmiMtat lartttna: Mnta|<r .N'anv ThruaavInsaM IliritMa: rfrabiaft M MMmitaa Simw 4 ThfiaicMfHt Soot 90 imaitfif (matat lari*too: orainavv Noas 1 mouths Nuas TlmmchMit RMRtrao h**ri*r SanaiM font Thrmwaosi AotfltftllM IMihr 5 moBihi Nose Thnatliont Si mastM Tltrmifhont Sim Nam RotatvtB* ftmitiv*** thtracr * This rase U repertnl ia leiail. destruction of the hair, marked thinning ami atrophy of the epithelium of the follicles and a heavy plug of keratiniaed material which partly filled the cystic cavity. In some areas there was a superficial ping at the surface opening: others showed the surface open and the plug deeply situated. There was no purulent exudate. There were a tone of moderately dens* connective tissue surrounding the enlarged follicles, slight' edema and infiltration by lymphocytes hot 00 leukocytes. Slight edematous changes were noted m the occasional sebaceous glands present, but they were strikingly few. The swrat gland* were mental. 6BRN001923 I in* archiie* of iHiKM.rrnijH.y .no >rrmi.oi.nt.r Of the di*phcny| 1933. twen the face an mm |ron trilmtion u In many f limlarlv ai Tif. 1j--Swtion of rich* from ihc ehtn. fhinrinf hiiv4o< dmtgt* ,h* ipnnaii> of an amcform craiaien. GBRN001924 Fie- 2.-- and the rt jearriny. developed < Until vt laboratory In the txpt crude, and to fumes a In the earl TOWOLDMONOOQ1489 TOWOLDMONOOQ1490 I KUS ARCHIVES OF DERMATOLOGY AXO SYVHILuLOGY quantities, the di-phenyl was made In* heating benxene derived from crude coal tar. Whm heated in a aoitalde medium Jaam-ne i CH.) -becomes di-phenyl (C,,H,.). This sulwtance is then chlorinated at various saturation points. In- exposing; it under suitable conditions to free chlorine pas. Distillation of the resulting chlorinated di-phenvl '* '-results in a purified commercial jtrodnet (fig. 3). -The runmwrrial 11 benxene always has a small quantity tf insanities. Int some f the cruder commercial lnzene contain relatively large iptantities of these rig. 3--Chart illustrating tne prts$ o: maiujiacturc oi ehionnaitd di-phenyl. cruder benzenes, the tolnenes ami xyienes. when present in large qtiantities. may produce the chemical substance styrene, which has the formula C H, CH: CH.. Styrene when chlorinated (it being insepa rable from the di-plier.yl) is an unstable compound dropping its chlorine atoms very readily. I: is prubahie that ether complex hydro carbons may be formed front these impurities, which on chlorination become quite as unstable as the styrene. One of these compounds may if be chlorethyl benxene (C. H, CH-G-CH.j. . 10. Chlorinated tli-phrml cuiiisi* oi a mixture oi ili-phmvl chlorinated at various saturaiien points: nona-chloro-di-phenyl (C HCL. -C. O.) etc. In *> di*jihrn> ehlorina1 quantha heating designed the wn* ntamtfac chlorinai examine tlee]tenet on the f: lively engaged had a a) .was give of 1932. conditior chased i particula product : until Oc present a oi the sa The : of a poo: ship. ' O offending It sec causative chlorinat However The prol sarv to r 'The . cannot t mild com on nttmer and the i lienzene. instance, area prod which pet TOWOLDMONOOQ1491 Jt)XES-.HLL)E.\'--.1(..\H)KM JTEKi(>.\/.f 1029 In the experimental *tage and in the early manufacture uf chlorinated K-|>henyl. the nm working were c9E|>m<I for long leriwlt to thee chlorinated leudactt. A* the ikrmand for the rini>hed product increased, quantitative manufacture wa* |wrdrd up rapidly, and ijm Mill* and beating turns were uf necessity used until Iletter etptifanem could be designed ami made. Jw since no physical trouble hsid developed in the workers previously there was no ajijurent hazard cuimccicd with manufacture. On nr alemt March )'.>33 the electrical (irnpcnies of the chluriitatcl di-phenyl produced in the plant the worknten of which were examined fell liekiw the specification*, ami the color of the product -deepened. -.Alwm rme month fatter an acneform eruption was 4>*crved on the faces and arm* of several of the worker*, whieh Iwcante progres sively worse, gradually Incoming apparent among all ilte workers engaged in the process at that time. Although one of the men had had a slight acnefornt eruption on his face in January, little ihoughi was given to it until the cnijxion ap|x*ared in the others. In the summer oi 1932. six or eight month* previous to the general outbreak of the condition, owing to a ditTcrence in price, the crude Iwnzene was pur chased from another smirce. and it was not until the purchase of this particular Ijenzcne was discontinued, in October 1533. that the finished product came up to the standard. During the period from March 1933 until October 1933. the eruption continued among the men. and it was present as already described when the men were examined in December of the same year. The appearance ct the eruption coincidentally with the production of a poor grade of chlorinated di-phcnyl seemed to indicate a relation ship. On due chemical investigation styrene was assumed to be the offending substance causing the low grade oi the linished product. It seems that it may be readily assumed that our problem as to the causative agents of the aeneform 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 faetor. Repeated patch test* nude on numerous persons with the finished product, chlorinated di-pheny). and the foreign substances styrene, styrene di-chloride and ehlorethylbenzene, hare not resulted in an acnefornt eruption except in one instance. Repeated patch tests made with ehlureihylbenzene in the same area produced on the third attempt an erythematous follicular eruption, which persisted only a few days but which was hv no mean* typical. BBRNOO1927 1090 ARCHIVES OF DERMATOLOGY ASD .\YPHILOLOGY We could not hi|)lieate this in xher instance.*. Since styrene, chlorinated styrene. chlorethvllienzene. .xylene, toluene and their prohalile products are fur the most jmrt lijncl solvents. they will produce death and denudation of the rjnihcliuni. and one always olxain* a chemical liurn in resjxmse to a patch test made with the styrene and styrene di-chloride. Small <|uantitie* mixed lowrly with an inert powder or dissolved in ether produce a mild erythematous reactiun but no aeneform eruption. Patch tests made with the finished product, chloriv nated di-phenyl, at no time produced any vrythema ir evkkmce of irritation: hence the chlorinated li-]ihenyl can lie aliwJutelv alisolved as an irritating agent. In looking over the consecutive history of the development of the eruption! we found it afqnrcnt that the men were in sonte degree exposed to. the xhlprinatal impurities in the Itenzrae fur some time before the criijition actually a|t|wared. and that to duplicate the conditions we should have to make repeated patch tests daily for long jxrriodj in the same jierson. a |irocedure which is not feasible. As a group, the workers in the dusts ami vajsirs. which were rresunuihly saturated with chlorinated hvdrocarlions. were not dcanlv. making 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, jtresumalily styrene di-chloride and chlorethylhcttzene. deposited on the *kin gather around the hair follicles and sebaceous glands and arc gradually rubbed in. Being lipid solvents, they dissolve sebum and in the reaction, which is modified by the heat oi 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, innamntation. sebaceous plugging and an acneionn eruption (fig. 4). This process repeated over a long period may result in severe sebaceous infection, sehaccous 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 ntanufaeture 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 instruaed 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 vesting acne vulgaris. Following the - change distillit ini)inn gen r this fd course, hydrnc tlte mt are gn an ncca SUCTl 91* irlt 1 par* Mtli "T ^.rr.iuui Fir which c \Xh it is ah in most lipid so cases, chlorine chlorina close cc from ts to do GBRN001928 4 uZ - TOWOLDMONOOQ1493 J0XEX-.1LDEX-. ICXEFOkU DEHM.4TEttCOSIS 1W1 change in the type of benzene used and the employment of enclosed distilling apparatus ami ventilation fans, there was noted a gradual improvement m the aeneform entptiun. Those patients receiving roent gen radiation improved much more rapidly, hut h cannot he said that this form of treatment gave unusual remits. The final treatment, of course, was removal of the patient fnan the offending chlorinated hydrocarbons, and then cleanliness ami relief from any infection. All the men showing evidence of ctitaneou* disease. m> far as is knmvn. are greatly improved. or the comlitiun Ins entirely cleared cxcc]* for an occasional comedo and a few scars. Fig. 4.--Process oi manutserurt of chlorinated di-phenyl eonuining impurities which cause in icneierm 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 m 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 dose 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 itself but more with the products formed by the 6BRND01929 10U ARCHIVES OF DERMATOLOGY ASD SYFHILOLOGY chlorination of tar. Hence, the disease cannot be called "chlor-acne" or "tar aene.** That h n earned by internal ahsorpcitm is evident when one considers the following fans: First, acute intoxication* In chlorine rarely occur, since suffiratkm and death hy pulmonary edema ensue even in the presence of relatively small tptantitie* of chlorine gas in the air. Second, when ingested, chlorine and the chlorinated hydro* carbons are so rajmlly oxidized and chlorine so readily runtimes with toditim that opportunity for acne-like cnqaittns. snch as occur in lirumine imoxieaiion. is not possilde. In retrospect, we are intrigued Itv the hypothesis that these theoraical considerations may have wane relation to acne vulgaris. The past quarter oi a century ha* *etm ai| cnnrmuui increase in the use of coal for heating home* a* wcU~as in industry. The smoke stacks of the cities have lielchcd an ever increasing stream of coal smoke--;*mcike heavily laden with carbonaceous products cimtaining nnmerons hydro carbon*. It is well known that on) 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 oi coal smoke? SVMM.\*Y We have recorded herein observations concerning an industrial dermatosis of an acneform type. The type of eruption and the causative factors arejutalogou* to those in the previously reported cases spoken of in the European literature as instances oi "chlor-acne." tar acne or Pcrnaknnkheit. Although exact duplication of the condition* under which the- workers acquired the dermatosis cannot be accomplished hy experimental means, reasonable deductions as to the cause of the difficulty can be made. The eruption occurred during the manufacture of chlorinated di-phenyl irom benzene. The dermatosis occurred at a time when the benzene used contained excessive quantities oi toluene;' xylene and paraffin as impurities. The heating and chlorination oi these impurities probably resulted in the production oi styrene di-chloride and chlorethylbetuenc, which, we lielieve. on contact with the skin produced the acneform eruption hy the slow liberation of hydrochloric add and not by internal absorption oi any chemical. While many chlorinated hydroearbon*. as brought out hy IVosser White.1 are lipid substances producing death or irritation of the cells liv the liberation of chlorine, this is not true in all instances, since the finished product, 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 base. We believe that these dermatoses should be labeled acne* form dermatergoses resulting irom certain mistable chlorinated BBRN001930 hydroearl The sues may hctl Dm. (A three M n*r It I am a> 1 pfuMnns. Aiken M Or. X This patie in these size and i m the -lac into the s patients |> -with kelo Both deep acne, wen were prw and man? 1C to .*0 was sprat by a titer this fongi ehlor-cr.h contact w. fangtride dnfiealty. I formula. . . lesions Oil through a; with acne Da. X triboted a of seeing half ago. Pitch tar these com and also mentioned the age e: sexes. 1 belie between a vulgaris, estrogenic genic and :ion of act TOWOLDMONOOQ1495 /OXES-.41VEX--.4CXEFOKM HEXM.4TEMC0S/S 10U hydrocarbons and shtnald not lie *jtoken of a* "cMomkiw* or tar acne. The suggestion ha* l*en made that some of the acne vulgaris of the skin may lie the result of the *ame t.vjie of irritatim from *001 or coal snuJic. ABSTRACT OF DISCUSSION* Da. Ouvn S. Oasitar. Chicago: I rhnnkt like m add an experience I had three month* ago that i* of intern) in thi riemcetion. 1 think that Hr. Jin' paper it extraordinarily mtcreMnie ami vtiluaM*. ami the wwall pia* on I am Flint to report may add t*i hit trouble* rather than wive any ui the pruMem*. Abunt three mumh* at" m Michigan. I u a patient, thriwnh the courtesy of Dr. Milton G. Butler, who presented an extraordinary acneform eruption. Thit patiem wat IS year* old and had hern observed hy Dr. Bailer. The craptawi in them various cate* cunristcd of aenriurm pustules'and camcrinnes of varialde liat and depth, with *car. tow of which were keloidal. The eruption orrarred on the face and neck, particularly over the posterior portion, and extended well tip into the teaIp. The tnmk. arm*, thigh* ami leg* were alto involved. Two of the paiicmt pretented an the back of the neck deep pcriiollicular pustular lesion*, with keloidal seirv such a* are *cen in Kaposi** dermniti* papillari* rapiltitii. Both deep and superficial atrophic Kir*, such at are teen in deep teriont haring acne, were pretest m other portion* of the neck, face and trank. The eomedones were prominent in all ares*, including the lest. They were of variable rise, and many were large and deep. The age of the affected patients varied from IS to 50 year*, the younger one* being more reverely affected. The comlhiwn wa* apparently produced by eomaet with an ingredient hi a fungicide produced by a chemical company for demoying iungi in lumber. The particular chemical in this fungicide that apparently teat responsible for the eruption waa sodium tetra* chloT'ortho-phtnylphcnatc. which i* a yellow powder. Only those who earn* in contact whh it had the eruption. Those who handled the other ingredient* ei the fungicide and did not come in contact with thi* particular chemical had no difficulty. At there were apparently no chlorine, bromine or tar radical* in the formula, it i* difficult to determine the active factor in the production of the ietion* and also whether the eruption wa* cawed by local action by contact or through absorption and internal effects. The eruption waa not concerned in any way with acne, and no patient in whom the eruption developed had had acne previously. Da. Mattox B. Sruacacta. New York: I think that Dr. Tone* hat eon* tributed a study that will be very interesting when continued. I had an opportunity of seeing a group of patients whh acne oi external origin about a year and a half ago. Tha patient* were all employed in a factory making radio condenser*. Fitch ur and a type of wax (halowax a chlorinated naphthalene) were used in these condenser*. The acne which developed was like that described by Dr. Jones and also included comadone* on tha legs, a* did that which Dr. Ormsby ha* mentioned. I taw six patients from thi* one small factory. They were all in the age of puberty or the early twenties, and the group included person* of both sexes. 1 believe the most important point in this study is the possible connection between acneiorm dermatoses distinctly due to external irritant* and true acne vulgaris. It i* interesting that many derivative* of tar are closely allied to the estrogenic hormone, that certain component* of tar arc both rstrogmie and ante* genic and that the estrogenic hormone must perhaps he incriminated m the prodoc* non of acne vulgaris. There can be no doubt that acne is often due to nknuiaticei or GBRN001931 10M ARCHIVES OF DERMATOLOGY AXD SYFHILOLOGY irsnation of the pilose!uctous apparent* and that hwawiil a* ctfl a* entermi htfio- men can produce this nunulatino. In the patient suffering from acne. whn ha*, ut course. coma in coman rhh the estrogenic hnrmune during mtra-mcrinc life and Own ha* had no funhrr contact with thii hormone for the dearly related testicular hormone) until ha nr ha begins to form his ur her own hMamn, one can readily conceive the pathnemcri* of aent vulgaris as being based an an excessive stimulation of the hair follicle*, a nimulatiun produced hy the sudden new formation f the horimeie* ai paheny. It is as thnagh the follicles. after being senrhited to the hnnttnnes during fetal cnmact ami then parsing through a period of freedom from ctetuet. react cneesrively to the new and massive contacts with the products of the gtuuuls at puberty. 1 have discussed tbit subject is great detail elsewhere. ' Da. H. G. lavtxc. Mhmc-.ii>>litj wish to creitmcrH i vnt poim and to comptimem Dr. Jones nn an exrrilcm piece of work and hi* presentation of to. There tu a difference between hit situation and that which Dr. Tunnacliif and I encounterrd (Awn. Dmmjit. k Svrtt. 33:jOfi (Feb) 193d). la hi* rase the manufacturer* culled set the medical profession to help solve the pcublcnk Oar study wat undertaken where lay peu|dc were in charge. It rhnws clearly the need of medical advice in the preriuninn nt various chemical preparation*. Da. Jack \V. Jww. Atlanta. Ca.: I am very grateful for the discussion. I did net have time to go into the various preventive measures attempted in con* trolling the outbreak or the treatment. In most of the cases the condition has finally cleared up. Segardhtg Dr. Sulxbcrgtr's discussion, we studied this outbreak and the literature rather carefully for a year and a half or two years. and we 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 mutable chlorinated hydrocarbons give off chlorine very easily, whereas the chlorine that is fixed in the bcniene ring is comparatively stable. When these unstable chlcrinattd hydrocarbons come into contact 'wit h the skin and enter the hair follielet. they art broken down slowly, giving oE chlorine to form hydrochloric acid. We feel that this it the primary cause oi the trouble. 6BRN001932 Atristar Assistar - Th, profess tlrates has het tend* i A' <ptrio ami hi 50 per In 192 ieal stv the nre or the a vaht cubic c three ; <lecrea.> of car trainta constat Fro General 1. out Dir Z1 Skin: 3. J mitoses. TOWOLDMONOOQ1497