Document xzKXLoXMwQGZ3wE3rgOw6p42y

i -*"'" ssbss ss-s-a, ***'*" AN ACN'KFOKM DJiRMATICKGOSIS JACK W. JONT.S, MI). HKUIJKRT S. AI.DK.M. M.l). U is only within comparatively recent limes that the dermatologist has interested himself in dermatoses associated will* or caused hy the daily work. With the advent of a more dearly delined appraisal of the words vvr.ema and dermatitis and the move .general use of the patch lest, der matologists have necessarily inquired more and more deeplv into the imiumerahle chemical contacts that occur in the day hy dav lives of their patients. As well as being conversant with dermatology, the dvr - matolngisl must have a working knowledge of the manufacture and content of the many new and old <;om|>ounds that are handled and applied by large mntilaTs of persons. Hence, more and more derma tologists are becoming industrially minded, and it is dawning on them (lull the solution of some of their industrial difficulties may aid them in a clearer conception of the dermatoses that are encountered in their every-day practice. . Dermalergoses of the acncform type occurring in persons working with chemicals have been rqx'ntedly rc|>nrted in Kttrope and discussed as industrial "chlor-netie.*' 1 This term "chlor-acne'* was first used hv llerxhcimer* in 1899 to descril*e an eruption composed of comedones and small sebaceous pustules that occurred on the arms and faces of workers ui^fiu factoring chlorine gas clectrnlyiicallv. using carl Km ' electrodes. It was natural to assume (hat the chlorine was the causative ic oi. Heilman had observed in March 18^7 two ]witients whose skins were diffusely pigmented, dark, rough and dry. iii whom were observed small tenacious comedones associated with numerous small follicular abscesses. Subsequently he re|*orted twenty-one additional cases with similar symptoms in workmen who were engaged in cleaning out an acid tower used in the manufacture nf hydrochloric acid. At no time did these men come in contact with free chlorine, hut numerous loose Rend at the l;ift.v-lr.iRhlh Annual Meeting of tlr American DermatnlnKtcaf Aiw*iaiinn, Inc.. White Sulphur Springs, W, Va., May 2. IV35. 1. While. I'nuwcr: The DcrmaleriMM*. ed 4. NVw Y-irk. Paid H. Inc.. 1934. 2. I lerxlu-iim-r: Miim-lim. mod. Welmsehr. 4:,,>7X. IHW. .1. lU'tlmnn: Deutsche med. Welmsehr 27:4.17, IWI. MOUS 096630 JOA'llS-AUMiV--ACiVtiHiKU MiKM.lTI-M.OSIS mi derivatives nf coal tar were present. Herxheimer later absolved (he chhiriiic'hut considered the trouble to l>e due to various chlorbenzenes. From time to time other ret>orts of the occurrence of "chlnr-acnc" have l>cen made in the Kuro|>efm journals, each author continuing the emir of Ilerxheimer in nssuminj' that the cause of the condition was chlorine. Some of these reports have been indefinite as to the chemical conditions under which,the men worked, except that they were exposed to chlorine tfas. However, some authors have suspected various chlorIwm.ene derivatives, such as hexa chlorbenzene, hexa-cliiorethvlene. para-nitrobenzene. |>erchlonjaphthnIcm: ("jierna"} and probahlv others.* Chlorinated naphthalene was first indicted hy VVauer ' in 1918 as a cause of acne form eruptions of the skin, the condition heint; called Pcnmkrankheif. 11 is observations were confirmed hy Koclsch " and recently by Tricky.' The latter rejmrted an exhaustive study of a Iarj*e number of cases occurrinjj in workers cnj'itKed in the manufacture of iterchlnruupUthuleuc, in which the workers were excised to fumes of the molten mass and also to the sublimated dusts. In approximately one-half of the workers exposed there developed comedones of a particularly heavy and tenacious ty|>e with resultant sebaceous abscesses, containing heavy yellow pus and serum. Considerable improvement resulted when the chlorine eontont of the mass was decreased from 30 per cent to 8- |>cr cent, and Teleky believed that the disease was due directly to the halogen content of. the substance. He mentioned the similarity of the disease to U't'racwc (tar acne) Init carried the analogy no further. Individual predisposition apjienred to alter receptivity. Some authors have leaned to the view that the acne form eruption is due to direct external contact with the chemicals (notably licttninn, Knllnpcnu, Jacqoct, Fummuc, Teleky and Koclsch*). Others (Leh mann. Uerxheimer. Jacobi, Rotli and Robert") considered it to lie a 4. Oreufintion amt Health: Kucyclnptsha of Hygiene. Pathology ami Social Welfare, Interwit innal (.ahotir Office, DmUmi, World Ponce Foundation. 1925, brochures 34 ami 285. 5. Wauer. riled in Occupation and Health: l*ocytli>|K,dia of Hygiene. Pathol ogy ami Social Welfare, International labour Office. Boston, World Peace Founda tion, 1925. brochure 34. ft. Kochch, F.. in UlInMUin, K.I Oppcnhcim. M. and Kille, J. H.: Injuries to the Skin, I.cipzig, ?.cnpniil Voa. 1926. vol. 2. p. 303. 7. Teleky: Klin. Wchnachr. t84S (April 30); try; (May 7) 1927: 7:214 (Jan. 29) 1928. * A. Rettmait: lialh>|aii; Jac<pirt; Fninonzc: Teleky. ami KoHvb. cited in Orrupatiwi ami Health ?. Kncyclopcdia of Hygiene. Pathology and Social Wei-* fare, Intcrnulinmd Labour Office, Boston. World Pcner F.... . 1925, brochure 285. 9. I .vlmumn: Uvrxhvmier: Javi'hi: Both. and Kohvrt. cited in Occupation and Health: Kmyelnpcdin nf Hygiene. I'allmlogy and Swial Welfare. Inter- nalioMHl I.alsmr Office. Boston. World Peace Foundation. 1925. brochure 285- MONo 096631 1024 AHCUniiS op OP.HMA i'PLOdV ,1X1) SYPH t LOLOt.Y dermatitis due to the alivirption of chemical ctim|Muinds by tin* turn's or j'nstro-intcMinal tract, with elimination by wav of the sebaceous L'laiuls. The innjority of writers on the subject, particularly Prosser White.' have scented to feel that chlorine as such has little, to do with the formation of the comedones and cysts, and thev have repeatedly referred to tar and products of the distillation of tar as the prime causative factors. I'rosscr White rebuked authors for using the term "chlor-acne" at all ami expressed the belief that the process is one of the manifold cutaneous reactions produced by tar and its derivatives. Kccently we have had the op|H>rttinity to study, with the full conjura tion of the manufacturers, nil outbreak of acne form eruption occurring itt a group of workers engaged in the manufacture of chlorinated di-phenyl. This study has brought out some points in the production of this unusual dermatosis that wc 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 plant. MKI'OMT OK A CASE History --O. D., a Negro aged 26. began work in the distillation of chlorinated di-phenyl .in April 1930 and worked regularly until the latter part of the year 1933. Alioiit May of 1933. he noticed the apitcarancc of blackheads on his face, neck, arms and legs. These areas itched slightly. In a short time blackheads began to appear on the chest, hack and lower part "I the alidomvM, around (he navel am) on the scrotum and penis. Many of these blackheads swelled and became infected, discharging thick pus. The areas healed with difficulty ami often left scars. The condition scented to he progressive until November 1933. When seen in December 1933 the patient complained of lassitude, loss ni apatite and loss of libido and said that his cutaneous condition seemed to l>c improving, Physical Examination.--On examination lie seemed in good general health. His complaint of lassitude was not borne out by anything more than the usual tempera ment of the Negro toward work. On the forehead, extending within tiie hair line, and on the cheeks, chin, nose and neck were numerous small, very black, tenacious comedones, their distribution best described as bring "peppered" within the skin. Many of the comedones surmounted firm shotlike cysts, which in some areas contained viscid yeUmv pus. The pustular elements were more noticeable on the neck. Similar shotlike comedones and cysts had appeared on the shoulders. mid|Nirtion of the hack and chest, with an occasional large cyst. A peculiar peppering of the skin with tenacious carlmn-colorcd comedones was apparent around the umbilicus and lower portion of the ahdmwcn. The scrotum and penis were involved itt a similar process, the former being given more to the formation of cysts. The outer surfaces of lire forearms and anterior thighs showed similar lint fewer comedones. The whole eruption was acncfnrui hut differed from acne particularly in the lack of a sclmrrheic appearance of the sfrlii ami in the (M'culiarly deep black of the comedones as well as the general peppered distribution in areas not usually involved in acne vulgaris. A general physical examination had revealed nothing of importance. MOMS 096632 JO.WfiS-. //,,/'/: A'--, OHM DUNMAI HHHOSIS t iviifnn-wf.-- ||v was instructed tt> 1 uli his skin thoroughly before atul after his hours of work, to wear fresh dHl'ing each day during work and to use a lotion up as follows: einc sulfate 4 fim., |H>tassium sulfurnta 4 (ini. and di'tilled water to make liS ec. On KCuimneudalion lie later rcjiorH'd for weekly <1oscs of roentgen radiation according to the usual manner of treating acne vulgaris. Mtt rn.u itfir llxmuiiuilion.--A portion <*t the skin of the chest was removed (or microscopic study (fig. 1). The chief feature of the sections was noted in the hair follicles and sebaceum glands, in which there were cystic dilatation, ....Snmmwv of the Synififnms oiut Trcahttml in .Si.vhva Cnsr.t of . Inicfornt l\rf`ly.m T) |M* of Sin-elnt fuse Ait- Mare Knipllnti Kspuinire 'l`rrtwrnt ttt White KcluirrlM'lr: f>l (Tiwr romrdmiro; 0 mouth* . Hidslmi; lirrvlou* who tew cysts riM'Kignio- ihrntpy Whim i lie I'MTusr crnm-iloiii'f, .'c nurnttis None lew cysts .IN unite .NelwvrrhHr MilTiw roiili'iltiiH'k; Tlirtuiulmut im'lwlott', Kiriterysts mxl ilrnliiHe JIIIMl tllt'N t\V White Avcnifr Pry inpnsromiirilniifs: iOiimihIIis None irg cysts and :.K at White <iH 'K* \\ hlfe : n ?t x<tru Ml to N>fro tin* W Negro At-crage SctfOrliHr; picrlnu* urn* NetKmhrtc Averaae Kchorritrle ' PI It I isc rniin'alfuM* lew rysts oil tnee mill n* rk PltTusr rmiuxtours; .lrc|i nlH*r*>rrs on iin-k; sever* eysl* I'.rytlM-mutows UK Ins* roiiirdimrs; Itw siiuftl eyrt* Krw senllerril mmI-Iours: OCCSStUMMl vyst PHTtis* roiiiriloiii's; T<>ronulio>it 10 months h mouths Tlirtslon: drains** Non* month* Nnn* Thrnimhmit lt>H.ll|!<IIO. ihvrtnw too l Ml UP tail it ItU i:l i-.p n ini* ifi Whit* Whit* White Witlin Nrifit White Nrjro Avrrnae Dry RrlKirrhele Averne* Averaa* firltorrlHtfe .VliurrliHn IIO'loUlllUll llllWH'SH Sml trrril roinnlniirs; wnishinn) nheeosa t*>w loiiirtlrmrs: arrsstOHiU cyst orrnsinnnl roinninn* Vitt Iri* rnuo'itfiiirs Henltrrrd roiliethiitra IlUfiisr romrilmir*; f. n cysts htirk mill fur* l> IMOlilh* Noun Throughout Itnriitgrrn* turnip? 2 immlha Non* I'tiroiijihoiit I:' iiimith* 1'iirinifthniit f Non* Non* ttonitirriiotlirrHoy HurrilijrnO' UtetHtW * This rssfi Is rrportril In ilrlalk destruction of the hair, marked thinning and atrophy of the epithelium of the follicle* and a henvy plug of keratiomd material which partly filled the cystic cavity. In some area* there wa* a wpvrhvkd plug at the surface opening; oilier* sftmved the surface open ami the plug ileeply situated. There was no purtilrut exudate. There were a *mic of moderately dense eonneetive tissue'surromidinit the enlarged follicle*, slight vdvma ami mfdtralimt hy fymphorytvs hut no leukocytes. Slight edematous changes were noted in the occasional sehnecous glands present, hut they were strikingly few. The sweat glands were normal. MOWS 096633 lojr. arcuh'hs oi- tninxtAioi.o<;y ash wnm.ot.oay P*<f* !.--Section of skin frrm the chest, showing histologic chances in the formation of an acncform enniion. MGNS 096634 JONfiS-.U.D/iX--. /C\V7:/m >KM DtiRMJlURUOStS lflj7 Of the twenty*four men workim/ in tin: manufacture of chlorinated di-plumyl within the period from the late summer of P.M2 to Uctolier. twenty-three were re|x>rted to have had an acneform entption on the face and body. ()f the twenty-three, sixteen were examined. These men presented eruptions of acneform character similar in type and dis tribution to that in the case referred to hut varying in severity {table). In many patients numerous small sebaceous abscesses developed, par ticularly around flu? cnllora line, which exuded heave, tenacious pus. lug. 2.--Characteristic appearance ami location of an acncfurm eruption. mid the remaining ulcers were indolent, leaving in their wake much scarring. In two of the cases particularly, many large abscesses develop'd on the neck and hack. , Until very recent times di-plienyl and chlorinated di-phenvl were only laboratory curiosities, and their cniiiuimial manufacture was unknown. In tint cx|K!iimcntal stage of manufacture the apparatus was necessarily crude, uul experimenters ami workers were exjiosed for long periods to fumes ami dusts containing much chlorine. Imth free and combined. In the early exjicriments. as well as in the early manufacture in large MGNS 096635 ml'm .i/aiur/is o/: diucmatouh.v axd svrun.ot.ouY <|umUities. flic di-phenyl was marie liv heating benzene derived fr-.m crude cunl <;r. When lican-d in a .suitable mediuin benzene (C'Jl,,) becomes di-phenyl This substance is then chlorinated At various saturation points, by excising it under suitable, conditions to free chlorine gas. Distillation of the resulting chlorinated di-phcm'l results in a purified commercial prodvtct (fig. .t). The commercial benzene always has a small <|u;mtity of impurities, but some oi the cruder commercial benzenes contain relatively large (piantitios of these impurities. such as xylene, toluene and paraffin. On the heating of the hiK- .1.--Chart illustrating the process <>{ manufacture of chlurjnatcd di-phcnyl. cruder benzenes. the toluenes and xylenes, when present in large (|uanlities. may produce the chemical substance styrene, which has the formula L',, H, CH : CH,. Styrene when chlorinated (it being insepa rable from the di-phenyl) is an unstable compound dropping its chlorine atoms wrv rcatfilv. It is probable that other complex hydro* carbons may l>c formed from these impurities, which on chlorination become quite as unstable ns the styrine. One of these eom\xnm<ls may lie chlorctltyl Iwtuene (C* CN-O-CII,). Mb Chlorinated di-phcnyl amsists of a mixture f di-phrm I chlorinated at various saturation point*: nmm-chl<*ri-<li-pbenyl IICl.i -O* CIO etc. MONS 096636 joxhs-.u.nnx--.icxniouM nnKM.-nnKcosis iojj In (Ik* exper inlentii! stage and in (In.1 early manufacture ol chlorinated di-phenyl, the men working were exposed for long periods to those chlorinated products. As the demand for the finished product increased, quantitative manufacture was speeded up rapidly, and open stills and heating units were of necessity used until heller equipment could he designed and made. Hut since no physical trouble had developed m (he workers previously there svas no apparent hazard connected with manufacture. On or about March 193.1 the electrical properties of the chlorinated di-pheml produced in the plant the workmen of which were examined fell helow the specifications, and the color of the product deepened. About one month later an acncform eruption was observed on the faces and arms of several of the* workers, which became progres sively worse, gradually becoming apparent among all the workers engaged in the process at that time. Although one of (he men had had a slight acncform eruption on his face in January, little thought svas given to it until the eruption appeared in the others. In the summer of 19,12, six nr eight months previous to the genera! outbreak of the condition, owing to a difference in price, the crude Ixmzene was pur chased from another source, and it was not until the purchase of this particular henzone was discontinued, in October 1933, that the finished product came up to the standard. During the period from March 1933 until OcIoIht 1931, the eruption continued among the men. and it was present as already dcserilnid when the men were examined in December of the same year. The apiKNinmce of the eruption coincidentally with the production of a i>nor grade of chlorinated di-phcnyl seemed to indicate a relation ship. On due chemical investigation styrene was assumed to he the offending substance causing the low grade of the linished product. It scents that it may be readily assumed that our problem as to the causative agents nf the acncform eruption svas connected with the chlorinated products of the impurities present in the crude benzene. However, with the exception of styrene, these products are not known. The problem hence Incomes difficult nf 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 he satisfactorily duplicated experimentally since prolonged mild control seems to he a deciding factor. Ucpesttvd patch tests made on numerous |>ersons with the finished product, chlorinated di-phenyl, and the foreign substances styrene, styrene di-chloride and ehlnrethylhenxene. have not resulted in an acncform eruption except in one instance. Kcpcaled |atch tests made with chlorethylhcnzene in the same area produced on the third attempt an erythematous follicular eruption, which persisted only a few days Iml which was by no means ty pical. MQNS 096637 Huo AHCiui r.s or nnu.M. 11 uux. v . iay; syi'iulolocy We could not duplicate this in other instances. Since '-tyrene. chlorinated styrene, ehlorethylhen/ene. xylene, toluene and their probable products are for the most part lipid solvents, they will produce death and denudation of the epithelium, and one alwavs obtains a chemical burn in rcs|x<nsc to a patch test made with the stvrcne and styrene di-chloride. Small quantities mixed loosely with an inert powder nr dissolved in ether produce a mild erythematous reaction hot no acnefonn eruption. Patch tests made with the finished product, chlori nated di-pheuyl, at no time produced any erythema m evidence of irritation: hence the chlorinated di-phcnyl can be absolutely absolved as an irritating agent. In looking over the consecutive historv of the development of the eruption, we found it apparent that the men were in some degree exposed to the chlorinated impurities in the benzene for some time before the eruption actually apjKarcd. and that to duplicate the conditions we should have to make repented patch tests dailv for long |>eriods in the same person, a procedure which is not feasible. As a group, the workers in the dusts and vapors, which were pre sumably saturated with chlorinated hydrocarbons, were not cleanly, making little effort to bathe after work, and sweating and rubbing enhanced the liability to deposition of the substances on the skin. Theoretically, the chlorinated hydrocarbons, presumably styrene di-ehloridc and chlnrethylhenzcnc, deposited on the skin gather around tlie hair follicles ami sebaceous glands ami are gradually rubbed iu. Kcing lipitl solvents, they dissnlve sebum and iu the reaction, winch is mnditied by the bent of the IhmIv and the water present, give olT hydro chloric acid, which causes death or irritation of the cells. 'This in turn causes an excess of cell growth, intlammatmn. sebaceous plugging and an acnelorm eruption (fig. 4f. This process re|>ented over a long period may result in severe sebaceous infection, sebaceous abscess and scarring. One would naturally ex|*-ct this process to occur iu the scltorrheic areas as well as where clothing might rub the particles into the skin. Also one would expect the process to enhance an already existing acne vulgar**. This occurred in cases 1 and f> f table 1 ). the cases in which there was the worst involvement with sebaceous abscesses. In the. Iicgiimiug an attempt at prevention of the condition was made by luring especially careful that all men engaged in the manu facture of chlorinated di-phcnyl should have a thorough bath after working hours ami that they dumlfl wear freshly laundered clothing before starting work. They were also instructed to apply night and morning veterinary white lotion to the allected parts. Some of the patients having the most numerous cysts and follicular infections were instructed to report for roentgen treatment administered in the manner usually employed in treating actie vulgaris. Following the MQN5 09663d JOiV/iS-.lUiliX--.ICM-.I Oh-M DtiK.U. \ TtiRCOSIS 10JI change ill (lie fype of ben/ene used ;md the cmplm incut of enclosed distilling apparatus and ventilation fans. (here was noted a gradual improvement in the aeneform eruption. Tlm.se patients receiving roent gen radiation improved much more rapidly, hut it cannot he said that this form of treatment gave unusual results. The final treatment, of course, was removal of the patient from the offending chlorinated hydmcarlHJiis. and then cleanliness and relief I'mm anv infection. All the men showing evidence of cutaneous disease, so far as is known, arc greatly improved, or the. condition has entirely cleaved except for an occasional comedo and a few scars. ]-'jgt 4.--ProccM of manufacture of chlorinated di-pltcnyI containing impurities which cause an acncfonn eruption. When one recalls the cases re] meted by the F.urnjxian investigators, it is altogether plausible that the chemical process outlined here occurred in most instances. The slow lilKwation 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 unstable chlorinated hydrocarl>nns as well n> to the liability of the workers to close contact without a ihorough cleansing of the skin and a change from saturated clothing. It is also probable that the disease has little to do with, tar itself hut more with the products formed by the MONS 096639 io.M .wain /;.s <)/ nnKMjroUH.Y .i.vn syr/nu>uu;y chloriualiuu of tar. I h nee. the disease cannot he called "ehlor-aenc" hi* "tar ncm*." That it is mil caused by internal absorption is evident when one considers the following facts: First, acute intoxications by chlorine rarely occur, since suffocation and death hv pu1nionniv edema ensue even in the presence of relatively small quantities of chlorine gas in tlii- air. Second, when invested, chlorine ami the chlorinated hvdroearbons are so rapid))- oxidized and chlorine so reatlilv cniuhines with sodium that opportunity for acne-like eruptions. such as occur in bromine intoxication, is not possible. In retros|>evt. we are intrigued by the hypothesis .Hint those theoreti cal considerations may have some relation to acne vulgaris. The past quarter of a century has seen an enormous increase in the use of coal for healing homes as well as in industry. The smoke stacks of the cities have hclehcd an ever increasing stream of coal smoke--smoke heavily laden witli carbonaceous products containing numerous hydro carbons, 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? SUMMARY We have recorded herein observations concerning an industrial dermatosis of an neneforni type. The* tv)c of eruption and the causative factors are analogous to those in the previously reported cases spoken of in the Hnropean literature ns instances of "chlor-aene." tar acne or I'i'ntakrankhcit. Although exact duplication of the conditions under which the workers acquired the dermatosis cannot be accomplished hv experimental means, reasonable deductions as to the cause of the difficulty can be made. The eruption occurred during the manufacture of chlorinated di-phenyl front benzene. The dermatosis occurred at a time when the benzene used contained excessive quantities of toluene, xylene mid paraffin as impurities. The heating and chlorination of these impurities probably resulted in the production of styrene di-chloride and chlorethyllienzene, which, we believe, on contact with the skin produced the acneform eruption by the slow lilierntinu of hvdrochloric acid and not by internal absorption of any chemical. While many chlorinated hydroearlmns. as brought out by I'rosser W hite.'- are lipid Mthstanccs producing tleaiji or irritation of the cells by the liberation of chlorine, this is not true in all iuslauccs. since the finished product, chlorinated di-plumyl. did not. either experimentally or actually, produce any cutaneous or sebaceous irritation. Irritation apparently depends on the case with which chlorine atoms arc released from the hydro carbon hast*, Wc believe that these dermatoses should be Iriliclcd acneform dermntergoses resulting from certain unstable chlorinated MONS 096640 JONFiS-ALDF.S--. It'/V/:/'()A',1/ l)lit<\Ui KRGOSIS IO.U hydrocarbons ami should in it he spoken of as "chlor-acne" or tar acne. The suggestion has liven made that some of the note vulgaris of the skin may he' the result of the same type of irritation from soot ov coal smoke. AH.STKACT Ok' DISCUSSION' Dr. Oi.ivkr S. Ohmsiiv, (. hii;>u<> I should like to add an experience ( had three mouths age* that is of intvmt in this rniniccMnit. I Ihitik that l)r. Jones' paper is extraordinarily interesting ami valuable. .-tin] the small group n( cam.-., I am going to report may add to his troubles rather than soke any of (lie problems. About three months ago in Michigan. I saw a patient, through the emirtese of Dr. Milton (. Rnfler. wlm presented an extraordinary nenefurm eruption. This patient was 18 years old and had been observed by Dr. Hutler. The eruption in these various cases consisted >( acne form pustules and comedones ot variable site anti depth, with sears, some of which were keloidal. The cni|itn.n occurred on the face and neck, particularly over the t*oslcnnr portion, and extended well tip into the scalp. The trunk, arms, thighs ami legs were also involved. Two of the patients presented on the back of the neck deep perifollicular pustular Ivsimts. with keloidal scars, such as are wen in Kaiwsi's dermatitis papillaris capilbtii. Roth deep ami superficial atrophic scars, such as are seen in deep lesions leavinu acnc, were present in other portions of the neck, face ami trunk. The comedones were prominent in all areas, including the legs. They were of variable sire, and many were large ami deep. The age of the affected patients varied from 18 to SO years, the younger ones being more severely affected. The condition was apparently produced by contact with an ingredient in a fungicide produced tty a chemical company for destroying fungi in lumber. The particular cht'imral in this fungicide- that apparently was rcs|xiusihic for the eruption was sodium tetrachlnr-urthn'plu'nylphcuMU', which is a yellow powder. Only those who came in contact with it had the eruption. Those who handled the other ingredients .-of die fungicide and did not come in contact with this particular chemical had no difficulty. As there were apparently no chlorine, bromine or tar radicals in the formula, it is difHctilt to determine the active factor in the production of the lesions and also whether the eruption was caused by local action by contact <>r 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. Du. Marion H. .Si'i.znr.ur.r.u, New York: 1 think that I)r. Jones has con tributed a study that will 1* very interesting when continued. I had an op|x>rtumty of seeing a group of patients with acne of external origin about a year and a half ago. The patients were all employed in a factory making radio condensers. Pitch tar anti a type of wax fhnlowax. a chlorinated naphthalene) were list'd in these cnmknacr*. The acne winch developed was like that described by Dr. Jones and also included coitterlmtrs on the legs, as did that winch Dr. Ormsby has mentioned. I saw six patients from this one -.mall factory. They were all in the age of puberty or the early twenties, ami ihc*group included persons of Ixuh sexes. . I believe the most imixirtant point in this study is the possible cmincctinu Ik'Iwccm nciH'form dermatoses distinctly due to external irritaids and true acne -vulgari*. It is interesting that many derivatives of tar are closely allied In the estrogenic iMirntone, that certain rnmpniirnl.* of tar arc Imth estrogenic ami avuv- genie ami that (he estrogenic hormone must perhaps tie incriminated in die produe- tinn of acnc vulgaris. There can l>c no doubt that acne is often due to .stimulation or MONS 096641 10,14 .IRClltl'!' < or- niiKU.l t OI.OCY .f.V/J SYl'IIILOLOGY irritation of the pih sebaceous apparatus ami that hormonal as well as external iud'icuccs can produce '>iis slttnnlnfim>. In ihc patient suffering from nine, who has, of course, come m contact with the estrogenic Imrmonv during intra-utcrine hie and llien tins lu.d no further contact with this hormone (or the eloel> related testicular hormone! until lie or sin- begins to Iorm his or her mu* hormones one can readily conceive the pathogenesis of acne vulgaris as being based on an excessive stimulation o( the hair follicles, a stimulation produced hv the sudden new formation of the hormones at puberty. It is as though the follicles, after being; sensitized to the Imrnmnvs during fetal contact and then passing through a period of freedom from contact, react excessively to the new and mawvc contact* with the pvoducls of the gonads at puberty, t have discussed this subject in great detail elsewhere. Dr. H. f>. Ikvink, Minneapolis: I wish to comment mi om- point and (n compliment Or. Jones on an excellent piece of work and his presentation m it. There ivas a difference between his situation and that which Dr. TunnaclitT ami I encountered (Awn, Dkruat. & Sunt, 33:.lt)h [|*eh| lOJn), In his ease the mamiftieturers called on the medical profession to help solve the prohU-ni. Oor study was tinderlaken where biy people were in charge. It shows clearly the need of medical advice in (he production of various chemical preparations. Dr. Jack \V. Junks, Atlanta, Gi.: l am very grateful for the discussion, t lid not have time to go into the various preventive measures attempted m con trolling the outbreak or the treatment. In most of the cases the conlm-o I... finally cleared up. ' Regarding Dr. Sulzberger's discussion, we studied this outbreak ami the literature rather carefully for a year and a hall or two years, ami we arc rn. vinccd that the etiology in this particular group can he ascribe*! u* external irritation and not to any internal complications. Our idea is that the unstable chlorinated hydrocarlwms give off chlorine very easily, whereas the chlorine that is fixed in the hcnmio ring is comparatively stable. When these unstable chlorinated hydrorarlxvus come into contact with the skin ami enter the haw follicles, they arc broken down slowly, giving off chlorine to form hydrochloric acid. We feel that this is the primary cause of the trouble. MONS 096642