Reprinted from the 
University Medical Magazine, 
November, 1889. 
THE TOXIC ACTION OF CHROMIC ACID USED AS A 
CAUTERANT. 
J. Wiujam White, M.D., 
Professor of Clinical Surgery, University of Pennsylvania ; Surgeon to the Uni- 
versity , Philadelphia, and German Hospitals. Reprinted from the 
University Medicae Magazine, 
November, 1889. 
THE TOXIC ACTION OF CHROMIC ACID USED AS A 
CAUTERANT. 
J. William White, M.D., 
Professor of Clinical Surgery, University of Pennsylvania ; Surgeon to the Uni- 
versity, Philadelphia, and German Hospitals. 
For many years I have been in the habit of employing chromic acid in 
preference to all other cauterants in obstinate cases of recurrent vegetations upon 
the genitals. These papillary outgrowths, although they have no truly spe- 
cific character, and are not of necessity connected with any form of venereal 
disease, are yet extremely persistent, and frequently return after having been 
cauterized, or after having been burned even with such powerful cauterants as 
nitric acid, or glacial acetic acid, or the acid nitrate of mercury. Although 
often associated with urethral discharges, or with the various forms of venereal 
ulcer, they are simply manifestations of accompanying local irritation, and have 
no true dependence upon the specific poisons of these diseases. They are often 
found in young persons in whom there has been no possible venereal infection, 
and are frequently met with during pregnancy when the physiological 
congestion of the female genitals favors their development. Anatomically, they 
are merely papillary outgrowths occurring upon a basis of connective-tissue 
elements, and covered by an extensive mucous layer, the horny layer of the 
skin being frequently absent; for this reason they are usually covered with a 
moist and readily decomposable secretion, which is apt to become extremely of- 
fensive. They take their origin so deeply in the tissue of the derm that ordi- 
nary cauterants do not reach and destroy them. For this reason chromic acid 
has been for years in these cases the favorite application in the hands of many 
venereal specialists. 
My attention was called during October last to the case of a young woman, 
an inmate of the venereal wards of the Philadelphia Hospital, who had a mass of 
vegetations of this character, covering the labia majora and the nymphae, extend- 
ing up towards the pubes and down towards the anus, and several inches in thick- 
ness. This had been variously treated and had constantly recurred. I had been 
interested in trying the simple treatment recommended by Dr. Peters, of Prague, 
consisting in the application of cold poultices, a method indorsed by Zeissl 
and by Bumstead, who mention cases in which very extensive vegetations dis- 
appeared under the simple use of water-dressings. The patient, an otherwise 2 
WHITE, TOXIC ACTION OF CHROMIC ACID. 
healthy girl, was placed upon this treatment, which was continued for about two 
weeks, at the end of which time my resident reported to me that there had been 
absolutely no improvement. I then ordered the usual application of chromic 
acid solution, of the strength of one hundred grains to the ounce of water, di- 
recting him to protect the neighboring parts and to avoid using an excess of the 
acid. The application was made on the afternoon of the same day. The acid 
solution was applied by means of a tuft of absorbent cotton, about a half-ounce 
of the liquid being used. The vagina and anus were carefully protected by 
tampons of cotton soaked in carbolized oil. Afier coming from under the an- 
aesthetic she complained of a burning pain referred to her vulva ; this contin- 
ued through the night, during which time she was restless, and frequently 
called for water. About 4 A.M. she rose to urinate, and fell; she was assisted 
to bed and slept until 7 A.M. She continued thirsty but not feverish, all the 
morning, complained of nausea, and refused her food. When next seen, at 3 
P.M., she was pale, with cold extremities, rapid pulse, complained of pain in 
the left hypochondriac region, and expressed fear of approaching death. Tem- 
perature in axilla 990. Although active treatment was instituted her condition 
did not improve, and she died at 6.30 P.M., 27 hours after the application of 
the acid. Intellection was preserved to the last. 
A careful autopsy was made with the following results : Body, that of a 
well-nourished, medium-sized girl ; marked post-mortem discoloration on the 
back of trunk and limbs. Small scar on left thigh. Mass of venereal warts at 
vaginal outlet, occupying both labia, and extending from anterior commissure 
to anus ; dark in color and covered with an offensive discharge. Thorax.- 
Both lungs crepitant throughout; some hypostatic congestion posteriorly. The 
left lung adherent to the chest wall posteriorly, and to the diaphragm. Right 
lung free. Pericardium contained about two drachms of clear straw-colored 
fluid. Heart.-Right auricle filled with currant-jelly clot. Small, chicken-fat 
clot in left ventricle. Auriculo-ventricular and semilunar valves perfectly nor- 
mal. Abdomen.-Stomach distended, mucous surface shows numerous fine 
ecchymoses, the result of vomiting. Section of duodenum shows biliary ducts 
patulous. Large intestine distended with gas, and containing fecal matter. 
Liver small, weight 40 oz. ; on section shows the nutmeg change. Gall bladder 
distended, with a very dark-colored secretion. Spleen, flabby, pale, weight 5 oz. 
Kidneys the seat of passive congestion, small, weight 9 oz. Capsules strip off 
easily. Vagina.-Section of vagina shows mucous membrane dark-red in 
color, covered wi-th a yellowish discharge, with no evidences of contact of acid. 
Brain. -Dura thin, non-adherent, longitudinal sinus contains post-mortem 
clot. Veins of pia mater swollen and congested. Puncta vasculosa large. 
Choroid plexus injected. 
Portions of the various viscera were submitted to Dr. John Marshall for 
analysis, who reported as follows 
' ' The kidney tissue and the liver tissue both contained chromium, most 
likely as sodium chromate-a substance poisonous in doses of from one to three 
grains. The tissue of the rectus muscle was free from chromium. The 
chromic acid was absorbed, and entered into combination with the sodium WHITE, TOXIC ACTION OF CHROMIC ACID 
3 
of the sodium carbonate of the blood to form sodium chromate. This is the 
most probable explanation of what occurred." 
As I was greatly surprised and annoyed at the sudden and fatal termina- 
tion of this case, I at once carefully looked up the literature of the subject. The 
ordinary text-books upon venereal disease without exception mentioned chromic 
acid as one of the most active and efficient cauterants in these cases, but accom- 
panied this statement with no word of caution other than as to its local effect. 
A similar remark may be made of the treatises upon therapeutics which men- 
tion its efficiency and its powerful local action, but record no cases of death from 
its use. 
Dr. Lange1 long ago warmly recommended the employment of this acid in 
these cases, and Dr. Busch2 recommended it in a large variety of conditions in 
both dilute and concentrated solutions, and in full strength in carcinoma, lupus, 
and other malignant affections. 
These authors quoted Mr. Marshall,3 of the University College Hospital, 
London, who still earlier had reported a series of cases of warts and other 
growths upon the genital organs treated by the application of chromic acid in 
the strength of one hundred grains to the ounce of water, and with the happiest 
results. In 1868, Mr. H. S. PurdoiB recorded his results upon a large variety 
of cases, including condylomata, using it in the strength of two drachms to the 
ounce of wateT He recommended it strongly to the profession, and did not 
allude to any unpleasant consequences. M. Keller, even in advance of Mr. 
Marshall, had also strongly recommended the acid as an escharotic in all new 
growths, and especially in condylomata of the genital organs. 
Fromer5 advises the employment of chromic acid on account of its continuous 
and thorough action, having used it both clinically and experimentally in a 
large number of cases. He quotes the experience of Keller who tried it in 
many cases as an escharotic in the wards and clinical service of Sigmund, but 
makes no mention of possible danger from its use. He does allude to the care 
which is requisite in employing the chromic acid on account of its great power 
of penetration, and says that for that reason the concentrated solution (saturated) 
is to be preferred. 
M. Gubler6 remarks that chromic acid is one of the most powerful of caus- 
tics. He adds : " This caustic, applied over an extensive surface, may therefore 
give rise to a deep slough. Further, the absorption of chromic acid is not free 
from danger, and patients have been poisoned by a too extensive application 
to the surface of their bodies." 
The United States Dispensatory says that, according to M. Gubler, patients 
have been poisoned through absorption by a too extensive application of the 
acid to the surface, but gives no details. In the " Archives fur experimentelle 
Pathologic und Pharmakologie," Vol. 6, 1877, Dr. F. Gergens relates a num- 
1 Deutsche Klinik, vol. xii. i860. 
2 Ibid. 1886, vol. xv. 
3 The Tancet, January 24, 1857. 
4 Journal of Cutaneous Medicine, vol. ii. p. 40. 
5 Wiener Medicinische Wochenschrift, 1851, No. 8, page 119. 
e Gazette Medicale de Paris, and Bulletin de Therapeutique Medicale et Chirurgicale, 15th August, 1871. 4 
WHITE, TOXIC ACTION OF CHROMIC ACID. 
ber of experimental observations upon rabbits, from which he concludes that 
chromic acid kills after absorption into the blood, which it enters in the form 
of a chromate, on account of a secondary decomposition in the kidneys. The 
chromic acid is set free by the contact of the salt with the acid urine, exerting 
its intensely irritative effects upon the renal epithelium, and producing the pa- 
renchymatous inflammation of that organ which Gergens invariably found. 
Dr. August Meyer1 confirms these experiments, finding, in addition to the neph- 
ritis, congestion, ecchymoses, and even ulceration of the gastro-intestinal mu- 
cous membrane and the mucous membrane of the bladder. He also found evi- 
dences of chromic oxide in the liver, heart, blood, and kidneys. A few other 
unimportant and merely incidental references include all that I have been able 
to find in relation to this subject. As I had been using the acid for years in 
the same strength and by the same method, and both in hospital and private 
practice, without the occurrence of a single alarming symptom, I have never 
given much thought to the possibility of constitutional effects, still less to the 
chance of a fatal termination. I therefore desire to place the case on record, 
and to ask if similar cases have occurred in the practice of any of my fellow- 
members.2 
1 Medicinische Jahrbiicher, 1877. 
geonr1heldaitiNCneortbh1VT1?nI'eTri1Wllich W-aS Seadat the Meetin& of the Association of Genito-Urinary Sur- 
mv attention m ' 1 have re,ceived a, courteous communication from Dr. Louis Tullien callinsr 
xvtiVoh bod f°llowlI1f< Paragraph contained in his "Traits pratique des Maladies Venerie'nnes n 
,',^hI-nmV^lemapediIny ?fltlce although I had looked over his book and carefully gone over the index - 
A-Cld em?loyed .by. Marshall in 1857, and later by Key, Berkeley Hill and others is cermiX 
theyn^nlaCsmUnrrKenVatery s°lutl°'1 of 5 :3°. We advise, however, that it be employed only in'cases where 
out danger presents a sraa11 surface> as the absorption of a certain quantity of this substance is not with- 
„ Poxi<7 symptoms such as obstinate vomiting, involuntary stools, fever, etc., have been observed Tn 
Dr Tnlene::;hnOr,TUS.m"S of vegetation had been treated with' this substanct a fatal resuirensued " 
ie dS vous felicker et tO n-le~ V°tre observation est un appui nouveau i mon opinion etd"re 
lui avoir donng au contrake la pluslrande ® CmeUt P°int PaSS6e S°US SilenCe' mais de