Document kmxyQBvb4MRdNX1o2BBJL1bYV

-fl Vob 14, Nil. 17 licnlv Thyroid function may be depressed in a higher percentage of eases if.urclhanc 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 CHLORACNE--MEIGS 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-effects were minimal. It is con cluded that rectal administration of urethane is preferable to oral or intravenous administration. 2065 Adelbert Rd. (6) (Dr. Weisberger). CHLORACNE FROM AN UNUSUAL EXPOSURE TO AROCHLOR 1. Wisfer Mr/gs, M.D., lack Jonathan Alhom, M.D. and Bernard L. Kanin, M.D., New Haven, Conn. ' The first outbreak of acne like lesions due to high boiling chlorinated compounds in industry in this coun try was noted by Schwartz 1 in 1936. Subsequently, dur ing World War 11, various reports of acne-like lesions in workers exposed to certain chlorinated naphthalenes and diphenyls followed. Collier - reported 12 cases of chloracnc of the face in workers exposed to the fumes or dust of chlorinated naphthalene and one fatal case due to acute yellow atrophy of the liver. Fifty-five cases of acneform dermatitis were reported by Kelley a 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. Hie chlorinated naphthalene, which was im pregnated into the asbestos and wrapped around the wire as insulation. Baked off in the stripping process. In the eases described, two months elapsed before the appear ance of the chloracne of the face. There was no systemic involvement. Peck.* Cranch,1 and Greenburg 1 discuss the 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.* 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 worker exposed suffi ciently to these chlorinated compounds for a few months these lesions will develop. The exposure may be either to fumes from the hot material or to the solid material on continued contact. Repealed or continuous contact is essential. Lesions have not been reported after short or infrequent exposures. Vesiculocrythematous eruptions, as seen in acute eczematous conlact-lype dermatitis and simple erythematous eruptions with pruritus, have also been described.** This paper reports the development of lesions of chlor acne in seven workers 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 (Arochlor) 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 (h drr*,tn>cnt# of pubik health and Interna] medicine, Yale Unlvrtilty School of Medicine. . Auoclate Profcaaor of Occupational Medicine, Department of Publk Health (Or Mtlgt), Auitiant Clinical Professor of Dcrmatnlorv. Depart ment of Internal Medicine <Dr. Alhom). and Auitiant Clinical Professor of Medicine. Department of Interna} Medicine (Dr. Kama). Yale Uni versity School of Medicine. I. Schwartz. L.: Dermatitis From Synthetic Retina tod Wim, Am. J. Pub. Heallh 2j5S6 (June) 19)6. 3 Collier. E.: Poisoning by Chlorinated Naphthalene. Lancet 1172 Dan. !6l >90. 3. Kelley. E. F.: Acne From Synthetic Wax (Halowaa). Urol. A Cuian. Rev. 4 T i 2)1 (April 1) 1943. 4 Good, C. K., and Penalty, N.: Halowaa Acne ("Cable Rash"): Cutaneous Eruption in Marine Electrician! Due to certain Chlorinated Naphthalene! and Diphenyl*. Arch. Dermal. A Syph 4H:25l (Sept.) 194J. 5. Schwart*. L.: Outbreak of Jlalowa* Acne ("Cable Rath") Among Electrician!. ). A. M. A. 12`2: 13ft (May 15) )94J. 6. Peck. S. M.: Dermatitii from Culling Oils. Sohent*. and Dielectrics, including Chloracne. ). A. M. A. X25: 190 (May 20) 1944. 7. Cranch. A. G.: Chlorinated Compound*: Precautions Id Handling, Indus). Med. I3t 110 Dan.) 1944. fl. Greenburg, L.: Chlorinated Naphthalene* and Diphenyl*, tnduai. Med. X*i 520 (Aug.) 194). 9. (a) Mayer*, M. R , and Silvcrbcrg. M. O.: Skin Conditions Result, ing from Exposure to Certain Chlorinated Hydrocarbons. J. Induat. H)g dt Toakot. #Ot244 (March! 193*. (6) Sehwanz * (<) Greenbu/g DSW 030663 STLCOPCB4014625 UI CHLORACNE--ME1CS ET AL. 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 waj 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. ASST, OPERATOR I OPERATOR SUMP FOR CHLORINATED Dl PHENYLS Schtfnslic ds*irij of hct ayateto in -*hlch The chlo>lnt<6 diphenyl was weed od the point* at which workers were exposed to fume*. An operator making organic acid A ("operator,1' 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 checks end 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 J4, 1*54 counts and urinalysis were normal in all instances All had normal blood pressures with no other elinieal evi dence of any chlorinated diphenyl toxicity. After the recognition of these eases of chloiucnc. all but one of the gasketed joints in the heat exchange sys tem, including the cover of the sump, were welded to gether. A hand hole 6 in. (15 cm.) in diameter was tell with a gasketed cover so that the system could be drained or filled when necessary . After that time no vapors were visible, and the odor of chlorinated diphenyls was barely detectable in the immediate vicinity of the sump pump Continued careful observation of workers has revealed no new cases of chloracne. COMMENT The unusual feature of this outbreak of dermatitis was the long period of exposure before any eases were recog nized. The sudden recognition of seven cases after expm sure up to 19 months was due to the especially careful examination of the skin of all exposed employees after discovery of the first case. Of 14 nren exposed or poicntially exposed to the vapors of chlorinated diphenyls. 7 presented clinical evidence of chloracne There was not a very good correlation between the apparent degree of exposure and the development of signs of disease l or example, a foreman, an assistant foreman, and a plant superintendent whose duties would appear to have ex posed them only incidentally to the toxic agent had mild to moderate signs. The mean length of exposure of those in whom signs developed was 14.3 months and of those who did not show signs was 11.4 months, hut there was considerable overlap, with chloracne developing in one worker after only 5 months in contrast to another who showed nosigns even after 19 months' exposure to sapors Since the manifestations were exclusively on exposed areas of the skin, it appears that the vapors were de posited directly on exposed skin and did not go through 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 50% 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 diphcnct f Aiochlor). Leakage of these vapors from a heat exchange system occurred chiefly outdoors, hut chloracne was ol> served among men working inside the adjacent budding In all cases the condition cleared up alter treatment Control of vapors by welding all joints in the heat ex change system prcvcnied recurrences. 3)0 Cedar Si. (Dr Meigs). DSW 030664 STLCOPCB4014626