CFAD v. Anacor, IPR2015-01776
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`Borie Acid Poisoning
`
`t-"‘.t‘e’
`A Report of Fetal /lrtlith.‘ Case fro-in Cato-Itco-i..'.s‘
`.~l Cr-it-Ecol
`.E‘U04l'££flit03l- of the Use of
`Th-5.5‘ Drug in Darn-:.o-t‘r;log-is Prod-ice
`
`JAMES W. JORDON. M.D., and JOHN T. CRISSEY, Nl.D.,. Buffalo
`
`Boric acid, in one preparation or another,
`has been used in medical practice since Lord
`Listerl
`first described its effects in 1875.
`
`Solutions of it have been used extensivel_v
`for irrigating wounds and empyema cavi-
`ties, and for bladder,
`rectal, and vaginal
`irrigations, etc. Because of its nonirritating
`properties, its lack of staining, its buffering
`qualities, and mild antiseptic values,
`this
`Clrtig is one of the commonest List-.(l
`in der-
`niatologic practice.’
`It is used in powders,
`lotions, wet dressings, ointinents, and pastes.
`Most physicians,
`including dermatologists,
`regard boric acid as
`:1 substance of
`low
`toxicity and relatively harmless, and there-
`fore use it indiscriniinately.
`In our opinion,
`insufficient warning is given in standard
`dcrmatologic texts of the possibility of seri-
`ous poisoning or death from the indiscrimi-
`nate use of boric acid preparations on the
`skin.
`
`to
`this presentation is
`The purpose of
`report a fatal case of boric acid poisoning
`from the indiscriminate use of this drug in
`the trea.trner1t of a skin condition, to discuss
`the toxicity of boric acid,
`to study the ab-
`sorption of
`the drug from the skin when
`it
`is used in the treatment of various skin
`
`conditions,
`
`to consider
`
`the possibility of
`
`poisoning from such use, and to discuss the
`value of the drug in the treatment of skin
`Conditions.
`
`Received for publication Aug. 22, 1956.
`From the Departnient
`of
`De1‘1TI21l.0lL)g_\‘
`Btiflalo School
`Syphilology, University of
`Medicine.
`
`and
`of
`
`the
`Read before the 76th Annual Meeting of
`American. Dermatological Associitlion,
`l:1(:., Santa
`Barbara. Calif., June 18. 1956.
`720
`
`Report of Case
`
`A woman aged 35 was admittetl to the DEF111it-
`tologic Service of
`the Buftalo General Hospital
`at 11 a. m. on May 8, 1954. The following lIiSl0r_\'
`was obtained from relatives.
`The patient had had varicose veins [or 21 num-
`ber of years. A rash developed on the left l1I'Il{lC
`about."
`the middle of March, 1954,
`for which her
`fa.mil_v pliysician prescribed a proprietary oint-
`ment containing ethyl aiminohenzoate fbenzocaiiie).
`Shortly alter
`this ointment was used,
`the rash
`spread and about April 15, 1956,
`it became gen-
`eralized. For
`this, continuous wet
`(lressings of
`saturated solution of boric acid were ])rescril'ned
`on or about April 23. These were continued and
`used for a total of about 14 clays.
`lixttept for the
`discomfort of the skin eruption,
`the patient was
`otherwise well and able to be up and about until
`Ma).-' 4, 1954, when she became lethargic, chose
`to remain ll'l bed, and, 24 hours hel"ore zulniission
`to the hospital, hecaine comatose.
`Plimirof E.-rt:m-im':..*frm.~T|ie 1'JatienI was in tleep
`coma. On the entire skin surface there was a
`generalized El’_\-'I.'l'l€l113. with some scaling. There
`was a cyanotic Hush to the face;
`the extremities
`exhibited pallor, cyanosis, and were cold to H143
`touch. The pupils failed to 1'E:lt‘.l.'
`to light and
`accornrnodation;
`the tongue was dry and coated;
`the heart exliihited no rnur-n11n's;
`the blood pres-
`sure was unohtainable; the pulse was l2U; res1Jil'c'
`tions were 40; the chest was clear; the extremities
`spastic. To patient was obviously l1'10l'il31.|1It'l. The
`following are the results of the laboratory e:«:a111I-
`nation done at the time of admission: Spinal Huicl
`exa.n1inatiol1—-—fluit‘l clear; pressLn'e—l20—140: Ffllnftl
`tluid protein—-0.029 gm. per 100 cc.: spinal H-uld
`Wasserinanii and colloidal gold tests—lI€.!P:«'ltl"‘3’
`Blood glucose—170 mg. per 100 cu; blood urea
`nitrogen-26 mg. Blood W’asserrnann l'CE1<.'ll0I1:"'
`negative;
`red blood cell
`c0unt~—-1-,l00,[l'D0: “hire
`blood cell connt—34,00[l; m_velocytes—l;
`J_“"°l“'lC
`for-n1s——2; band forIns—38; hasophils—l: 5'95"‘?
`phils—l;
`ly111pl1ocytes—l, Death
`occ11r1'ed
`14
`hours alter admission to the hospital, on 1‘:l21)’ 9!
`1954.
`_
`lifting!
`Postmorteni examination (done h_v Dr.
`Terplan)
`showed the following positive I'inrl:ng'5-
`
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`}3(J1€1C ACID POISONING
`
`The liver and lungs were l'I)’[J6l'cl‘I‘llC; Imicroscopic
`exznnination of the kidneys showed the glomerular
`lgnps
`to be dilated and filled with blood. The
`tubules showed degeneration and nec1'osis. The
`bone marrow was l1}’])6l'[)l‘dSlZiC, with predominance
`of
`the eosinophilic series. Analysis of various
`nrg'.‘1n§ and Huids [or boric acid showed the fol-
`lgwillg‘ per
`10C! gm.:
`livcr—79 n1g.; brain—69
`n1g_; urine——52S mg.; spinal
`fluid——95 nig_; blood
`._.35() mg.
`
`Review of the Literature
`
`Numerous cases of serious poisoning or
`death from boric acid have been reported
`in the literature. Most of these have been
`
`ingestion of boric
`accidental
`from the
`acid."-" Among this group, regrettably, were
`sc\'e1‘al hospitalized babies who died as a
`
`result of boric acid solution accidentally
`mixed in their formulas.5'7 Severe poison-
`ing or death has been reported from the
`use of boric acid as gastric lavages, rectal
`enemas,3""3 bladder irrigations,“ subcutane-
`ous
`clyses,1” vaginal packs,“
`intravenous
`ad1ninistrations,11
`irrigation of
`empyema
`cavities 3; from inhalation of boron hydrides
`Ltscd
`in industry 19;
`the use
`in surgical
`\-\-'ountls,“" burns,” ulcers,15 and skin erup-
`tiiJ11s.4’3"“'”‘
`Pfeiffer,
`I-Iallnian,
`and
`[-.itZI'Sl‘l 1" found that the minimal lethal oral
`
`dose for dogs was 2 gm. per kilogram and
`the subcutaneous minimal lethal dose was 1
`
`gm. per kilogram. They found boric acid
`lzoxie for all laboratory animals wliieh they
`studied. McNally and Rust 7 reported that
`six infants (average weight 7 1b.), fed 3 to
`6 gm. of boric acid, died. McIntyre and
`lfiurke 11 reported that one patient given 15
`gni. as a subcutaneous clysis developed only
`slight symptoms of poisoning, and Peyton
`and Green 1°
`reported that 18 gm. given
`subcutaneously produced severe poisoning
`with recovery. From the literature, Pfeiffer,
`I-tallman, and Gersh 1” believe that the fatal
`dose in human adults is 15 to 20 gm.,
`in-
`fants 5 to 6 gm. These authors also state
`that single large doses, as reported by Me-
`lntyre
`and Burke 11
`and Peyton
`and
`-Green,’‘'’ are not so dangerous as repeated
`smaller doses. From the foregoing it
`is
`
`Jrr.?'1'tf0fl-—CJ't-.i'I€fil
`
`that boric acid is a potent poison
`evident
`when Sl.Ifi'iClel"ll.' amounts of it are absorbed
`into the blood stream by one means or
`another.
`
`Po-i.roi-i.in.g from C-utaneoiis A;b,bilica.t-ioii.—-
`Rothinang‘-' and others 21 have outlined the
`principles of percutaneous absorption.
`In
`general, water-soluble,
`lipoid—soluble non-
`electrolytes penetrate the unbroken skin
`best. Since boric is both water-soluble and
`lipoid-soluble and is not an electrolyte,
`it
`falls into the group of substances that theo-
`retically are best absorbed.
`Kalilenberg,”2 in 1924, was able to den1on-
`strate that boric acid, but not its salts, could
`pass through the normal skin and appear
`in the urine in limited quantity.
`I-‘feifiier
`and -his co-workers 1” anrl Goldbloom and
`Gl‘JlClblDDI11J' were unable to demonstrate
`that boric acid passed through the normal
`skin under the experimental conditions set
`up by them. Vignec and Ellis 23 were un-
`able to demonstratclany amount of boric
`acid in the urine of infants who had had
`5% boric acid powder used in the diaper
`area. No serious cases of poisoning have
`been reported,
`to our knowledge, from the
`use of boric acid preparations on normal
`skin.
`
`It has been pointed out that the epidermis
`is a principal barrier
`to the passage of
`chemicals through the skin. W’hen the con-
`tinuity of this structure is broken by trauma
`or disease,
`substances which may have
`passed through the unbroken skin only in
`limited quantities, may be readily absorbed
`and pass into the bloodstream with case.
`We, as dermatologists, are principally in-
`terested in the possibility of poisoning from
`the use of boric acid preparations on the
`skin which has been altered by disease or
`trauma.
`In considering this, it is important
`to point out the work of Pfeiffer and l1is co-
`workers,“’ who in laboratory experiments,
`found repeated nonlethal subcutaneous in-
`jections of boric acid produced cumulative
`effects.
`In their animals it took 14 days for
`a mean plateau to appear in the urine. This
`finding ‘is of importance in the considera-
`"31
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`tion of the use of this drug in the treatment
`-of skin conditions, since repeated applica-
`tions are commonly used, and thus the pos-
`cumulative
`sibility
`of
`effects must
`be
`considered.
`reports in the
`There are a number of
`literature of
`serious poisoning or death
`from the use of boric acid preparations on
`wounds, ulcers, burns, and miscellaneous
`skin conditions whicl1 are of interest to us
`
`as dermatologists.
`The First case of serious poisoning was
`that reported by Brose 15
`in 1883, who re-
`corded the death of a 31-year-old man from
`the use of boric acid powder for five days
`on a chronic leg ulcer. This was followed
`by a report from Best 1"
`in l9(}3 of a pa-
`tient who died from the use of 6 oz.
`(180
`gm.) of boric acid powder used in a surgi-
`cal wound.
`In 1905, Dopfer“ attributed
`the death of a child to the use of a 1092,-
`boric acid ointment on a 3 by 12 cm. skin
`burn. The preparation was iised over a
`period of four days. Savariaud'3“ reported
`the death of an 8-year-old child from the
`use of boric acid powder
`on
`a burn.
`Maguire 2“ reported t-he death of a 23-year-
`old woman from the use of boric acid fo-
`mentation
`on
`a
`traumatic
`leg wound.
`Gissel14 recorded the death of a —'l—year—old
`child from the use of 30 gm. of boric acid
`powder on a burn. Abramson“‘ recorded
`the death of an infant
`from the use of
`boric acid powder and ointment on an ex-
`coriated eruption in the diaper area. Brooke
`and Boggs 3 likewise reported the death of
`an infant from the sprinkling of boric acid
`powder on a diaper dermatitis. Ducey and
`Williaiiis 13 reported poisoning in three in-
`fants, one from borated talc used on a
`diaper rash for seven days, one from the
`use of boric acid solution and crystals on a
`diaper rash. This resulted in death. The
`third infant
`suffered poisoning without
`death from a similar application.
`VVatson 17 reported a case which he be-
`lieved developed boric acid poisoning from
`the use of boric acid ointment and the
`saturated solution of
`the drug on severe
`
`722
`
`.4. M. /l. ARC}-Hl’-'ES OF D.L’Rll«f/ITOLOGY
`
`infantile eczema.
`
`The child died. Post-
`
`mortem examination showed the iminediate
`cause of death was pneumonia and purulent
`meningitis. Goldblooni and Goldbloom‘ re-
`ported four alleged cases of boric acid
`intoxication from tl1e use of borated talc in
`the diaper area. One of
`the imthors later
`retracted this and stated the criteria used
`were cr1'o11eous.27
`Since the Goldbloom and Goldblooin * re-
`port, Vignec and Ellis 23 have done careful
`investigations on the possibility of poison-
`ing from the prolonged use of 5% boric
`acid powder in talc on buttocks of normal
`infants and infants with diaper dermatitis.
`They found no significant boric acid absorp-
`tion.
`
`Fisher‘, Freiinuth, and O'Connor” did a
`similar. carefully controlled, study and like-
`wise
`found no significant absorption of
`boron from the use of borated powder.
`These authors offered the statemen-t that of
`alkaline talc combined with the boric acid
`to form an inabsorbable salt.
`
`Experimental Studies
`
`No adequate _studies have been done on
`the absorption of boric acid from its der-
`inatologic use in various skin conditions.
`Cope '39 considered the absorption of 10%
`boric acid ointment and saturated solution
`of boric acid as an irrigant on skin burns.
`He found that up to 2 gm. of boric acid
`appeared in the urine in 24 hours after the
`application of 10% boric acid ointment, and
`when saturated solution of boric acid was
`used as an irrigant up to 2.5 gm. appeared
`per day. He stated that the prompt excre-
`lion of
`the drug prevented toxic blood
`levels.
`To study the possibility of boron ]}oiSDl'1‘
`ing from the
`absorption of boric acid
`preparations used in various Clf3l'lI‘l£!IOl0gic
`conditions, a group of 22 hospitalized P3’
`tients were employed. Boric acid was 115*’-d
`in the form of 5% ointment
`in While
`petrolatum, as a saturated solution of lJ01’}°
`acid, and in the form of pure boric afild
`I/at
`975, Mass 1957
`
`I
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`
`BORIC A CID POl'.S'Or\-"r'r\-"G
`
`ll
`
`Sir-ii!-:Jro—J'_v of Snrrljr of TtUcm‘_I.'—Ttt‘o Po¢‘icn.l.r for Borir xieirl Ab.ror[2l':'on-
`
`]‘:1tIent
`1
`
`Age
`Yr.
`[33
`
`_
`Diagnosis
`Sex
`(dermatitis vcnerzatul
`M Exfo1Ial.lve dermatltls
`
`% Body
`b'uI'l'aee
`99+
`
`‘
`Irorin oi
`:\pplIc-atlon
`5% in petreliitum
`
`Blood Boron
`Level
`Du1'nI.1m1 of
`Application Mg. per 100 cc.
`3 weeks
`'l‘1':|c[- (2nd wk.)
`
`2
`3
`-1
`5
`I3
`?
`8
`9
`10
`11
`12
`13
`1-}
`15
`it‘:
`17
`18
`19
`20
`21
`22
`
`7.’:
`51
`til
`27
`I39
`13
`E?
`til}
`GE
`G?
`-1-1
`31
`-16
`(‘-1
`5115
`T1
`52
`(iii
`50
`iii]
`«IS
`
`1-‘ Derumtitis \'enen'.1t:1
`(tlr.'rrn:1l.ltis liypostaticrl)
`M Derrn:It.iI.I3 velienuta
`11‘
`Pernphigus \'tl1tt«"Iris
`F
`Der1nnLiI.is venenat:L
`M Denuimtitis verienata
`M Dermatitis veneliata
`M Dermatitis venenata
`I‘ Dermatitis venenuta
`(psoriasis)
`M Dermatitis veilenato
`tdennutiris Iiynost:n.ieu‘i
`M Dermatitis venenata
`M Dermatitis venenata
`F Dermatitis venenam
`F Dermatitis venenata
`F Dermatitis veneuata
`(dermatitis liypostntiea)
`M Dermatltis \'euenuta
`M Mycosis Eungolrles
`(l‘ung':LI.lng)
`M Ecthyma tperlieulosis
`corporisl
`M Stasis ulcers
`M Stasls ulcers‘
`1*‘
`stasis ulcers
`F Delmatitis veneoata
`
`13
`2?
`15
`Ii
`25'
`12
`S
`‘£2
`15
`53
`40
`1?
`20
`40
`33
`99 plus
`11
`1
`2
`1
`{iii
`
`5% in ])I2I.ml:1I.nn1
`I
`.‘i:l.I'l}1".llI:t'l soliltion
`5% 1n pelnoI:1:.unI
`I:
`in peLI'ol.:itum
`5 .-, ln petrol-a1.nm
`.1
`1|] patrolutiun
`5 9 in petrolntnm
`sutiirnied solution
`5% ln petrolatnnn
`5% 1n peLI':)1:1tum
`5% in petrolatum
`1
`5
`in |JetroInI.urn
`5 g in petrolnI.nn1
`sutulalerl solution
`5% 111 lletrolalmm
`s:1t-u:'nLe<l solution
`5% III 11etro1n1.nm
`5% in netrolumni
`saturated solution
`5 0 in pelrointum
`5 9 in petinlaituni
`5% In ])I:I.I'0l:1l.lllll
`5% in petrolatum
`Crystals
`Crystals
`5% in petrolnttliii
`
`3 weeks
`2 weeks
`R weeks
`1 week
`In (luvs
`I week
`2 weeks
`-1 weeks
`4 weeks
`2 weeks
`3 weeks
`2 weeks
`-I weeks
`:5 weeks
`3 weeks
`3 weeks
`2 weeks
`-l weel-is
`3 weeks
`2 weeks
`2 weeks
`
`(11.5
`Traee t2n:l wk]
`-(0.5
`4.15
`‘P1-ace (10 days)
`41,5
`({]_5
`<05
`-(0.5
`<05
`0.5
`(second)
`-(0.5
`-50.5
`‘Trace (21111 wk.)
`'<IJ.5
`-<05
`<U.5
`(0.5
`<.l).."r
`41.5
`<l).."s
`
`It was applied to such conditions
`crystals.
`as exfoliative dermatitis, dermatitis vene-
`nata,
`leg ulcers, mycosis
`fungoides, and
`extensive ecthyma. The areas of the body
`over which the applications were applied
`varied from 1% of the total body skin sur-
`iace to 99% of the total skin surface. Blood
`boric acid levels were determined at at least
`
`weekly intervals. The volumetric method
`
`In
`outlined by Kolmer3° was employed.
`no instance was there a rise in blood boric
`
`acid levels that could be considered signifi-
`cant.
`
`The accompanying table gives the perti-
`nent data on the 22 patients studied.
`In
`interpreting our results,
`it must be remem-
`bered that small amounts of boron (0.04
`to 1 mg. per 100cc.) of blood may be a
`normal level and that fatal levels are usually
`100 mg. or more per 100cc. In view of our
`inability to produce significant boric acid
`levels in the bloodstreams of our patients
`from the topical application of boric acid
`preparations,
`it
`is difficult
`to explain some
`of
`the severe poisonings and deaths
`re-
`ported in the literature,
`including our own
`
`J'ordon—Cn':se_~,r
`
`case from the application of this drug to
`the skin. Some of the cases reported may
`not have been authentic instances of boric
`acid poisoning and others may have resulted
`from the accidental, unknown ingestion of
`the drug.
`It was noted among our patients
`in most instances that rapid healing of the
`skin took place under
`treatment with the
`drug. Such healing would tend to prevent
`further absorption.
`In the fatal case re-
`ported the skin condition,
`instead of im-
`proving, grcw continuously worse. This
`would enhance the absorption of boric acid.
`Other factors may be involved. It is possi-
`ble in some individuals more storage takes
`place than in others.
`In these patients
`elimination of the drug may be slower than
`normal. Since the drug is principally elimi-
`nated by thc kidney,
`impaired renal func-
`tion may account for the high blood levels
`observed in some patients. There was no
`evidence of
`renal disease in our patients.
`Our findings agree with those of Cope,”
`who believed that among his burn cases,
`rapid excretion prevented toxic cumulative
`levels.
`
`723
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`
`A. M. A. ARCHIVES OF DERM,£lTOLOGi"
`
`Evaluation of Boric Acid
`
`Summary
`
`The widespread use of boric acid on the
`skin for topical
`therapy appears to be a
`habit acquired from our predecessors. When
`the drug was originally introduced it was
`found to be less irritating and thought to
`be less toxic than most other antiseptics
`then in vogue.
`It has certain physical and
`chemical properties that probably explain
`its widespread use.
`It is a keratoplastic, a
`butler against alkali,
`it
`is relatively non-
`irritating,
`colorless,
`and may be
`incor-
`porated in a number of vehicles. The drug,
`however, at best
`is a weak antiseptic;
`a
`2.5% solution inhibits the growth of most
`bacteria, but does 11ot destroy them.31
`It
`also checks the growth o£ harmless yeasts.
`While some of
`the above outlined prop-
`erties are desirable for topical
`therapy of
`skin conditions, none of
`them make the
`drug indispensable. There are better and
`safer antiseptics available;
`there are many
`keratoplastic agents, safe buffering agents,
`anti numerous substances which may be em-
`ployed to soothe the inflamed skin. Some
`authors believe that boric acid has no place
`in modern therapy.1'”‘“
`\*Ve believe from the studies on our 22
`patients treated with boric acid preparations,
`such preparations may be safely used if they
`are not used indiscriminately.
`It
`is our
`opinion that the pure boric acid powder or
`crystals should not be employed. Likewise,
`we feel that boric acid preparations should
`not be used on extensive areas for periods
`of more than a week, particularly if
`the
`skin condition shows no sign of resolution,
`because some patients seem to exhibit an
`unusual susceptibility to boric acid poison-
`ing, the reasons for which are yet obscure.
`Physicians who employ the drug should be
`familiar with the symptoms of boric acid
`poisoning and be cognizant of the possibil-
`ity of poisoning from the transepidermal
`absorption of
`the drug. The diagnosis of
`boric acid poisoning should not be made
`merely from the presence of boric acid in
`the urine. It is necessary in such instances
`to demonstrate toxic blood or tissue levels.
`
`724
`
`A fatal case from transepidermal absorp-
`tion of boric acid is presented. A study of
`22 patients with various
`skin conditions
`treated with boric acid preparations failed
`to show a significant rise in blood boric acid
`levels. Boric acid may be used in treating
`skin conditions, but should not be employed
`over
`large body surfaces, and treatment
`with the drug should not be prolonged.
`University of Buffalo.
`
`ABSTRACT OF DISCUSSION
`
`the
`to
`
`D11. Enwaao F. Coksoiv, Philadelphia: Some
`years ago,
`I
`read with surprise one of
`those
`rather scarey pediatric articles, pointing out
`the
`dangers of boric acid when used topically.
`I have
`been a heavy user of it for many years and have
`never noted any ill effects.
`I put it in powders,
`lotions, salvcs and it has grown to he :1 sort of
`office habit, like doodling.
`I feel rather sure that without my support,
`twenty-mule tealn outfits could have been cut
`eighteen.
`that approach those
`I never saw any eltects
`which were mentioned in the articles,
`some of
`which Dr. Jordon has shown on the screen. The
`only patient
`I ever saw who almost undoubtedly
`had boric acid poisoning was in a urologie ward,
`a boy awaiting operation for exstrophy of
`the
`bladder. He was being given boric acid in cap-
`sules by mouth, and his bladder was
`irrigated
`several times a day with boric acid solution. When
`he began to show signs of irritation, the abdoirillal
`skin being inflamed,
`the urologist, to be consistent;
`applied boric acid ointment, with ill effect. T11?“
`patient seemed definitely to have a case of
`this
`nature. However‘, he recovered. As a result Of
`the
`fright
`induced by these various articles,
`I
`have persisted in my old habits.
`‘
`I
`DR. R1-alas B, R1~;1:s, San Francisco:
`think It
`should be pointed out
`that at
`least one ol
`ll“?
`commercial preparations which we used for
`‘E115
`obtaining of aluminum acetate solution contaliifi
`boric acid, which is used for buFfering |m1'P95"-5‘
`It should be pointed out that perhaps the 531110
`situation exists with ammonialed mercury, which
`is another ver_v popular
`remedy with dermatol-
`ogists, because one can not only get :1lJsorp:i:'n1 Oi
`mercury, but there is the theoretical possibility OE
`ztcrodynia developing in a younger child.
`DR. Ctansncia S. Llvmcoon, Detroit: In 1'€C°“l
`months Dr. James Hildebrand and l have had 5111
`opportunity to de-monstrate experimentally this cllf‘
`Eerence in absorption from denuded infiamzmatofi’
`skin as compared with an intact cutaneous .sI!1‘l"-35°
`Vol’. 75, Mir)‘:
`-1957
`
`it
`
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`
`BORIC ACID POISONING
`
`In one of our experiments involving the application
`of C“ hydroeortisone lotion to the skin of the fore-
`31‘-I11. of a volunteer subject we applied the lotion-
`to an area of skin which had been abraded and
`in-itatecl by the application of 1% mercury bichlo-
`ridc solution and coiupared this result
`in a late1'
`experiment with the same subject,
`in which case
`the lotion \'as applied to intact skill.
`In the first
`instance,
`approxiimately 14% of
`the radioactive
`material was excreted in the u1'ine during a four-
`clay period following the application, whereas less
`than 1.5% of
`the raCl.ioactive material was re-
`covered in the urine when the lotion was applied
`to intact skin.
`DR. S'l‘E[-‘HEN ROTHM.-\N, Chicago: The problem
`that Dr. Jordon has dealt with has great clinical
`significance.
`In his case,
`the high boron values
`found at autopsy in blood, urine, and internal
`oi-gaiis leave little doubt that death was caused by
`boron poisoning. Thus, he supplied further data
`showing that boric acid can be absoi'bed through
`broken skin in such amounts that poisoning and
`death may ensue.
`is
`it
`llointed out,
`But, as Dr. Jordon himself
`rather difficult
`to explain the rarity of such tragic
`occurrences in view of the fantastically widespread
`topical use of boric acid on broken skin.
`it is
`also hard to explain that
`if one starts to experi-
`ment with boric acid, applying it
`to broken skin,
`3-: Dr. Jordon did, and as was done also by Vignec
`and Ellis, one cannot
`rep1'ocluce this massive ab-
`sorption to any degree.
`Another queer
`feature of boron poisoning is
`that single large doses, given internally, a1'e rel-
`atively harmless, while
`1'epeated
`smaller doses
`caiise accumulation and poisoning, a very unusual
`toxicological phenomenon.
`It
`seems
`that
`there
`must he a quite special
`situation in which the
`application of boric acid to broken skin Surfaces
`hecoines dangerous, and we just don’t know what
`factors
`lead to this
`i'ai'e|y occurring’
`situation.
`l.)nce_\' and \\"illia,nis,
`for
`instance,
`report on a
`pair of infant twins, sister and brother, who were
`lrealed [oI' similar diaper rashes with boric acid
`giowtlers in a very similar fashion by the mother.
`The bal.1_\' girl died from boric acid poisoning.
`while the boy did not get even obviously sick.
`the
`ln any case,
`the lite1‘ature indicates
`that
`danger is particularly great in infants. and it also
`seems that,
`in adults,
`the danger is pi'esent when
`boric acid wet packs are applied to large surfaces
`continuously for a week or longer.
`I
`should like to confess
`that
`l myself have
`been a sinner in having used plenty of boric acid
`topical applications in my long practice.
`I never
`had any trouble, although.
`in 3? years of practice,
`I prescribed many kilograms and maybe tons of
`bo|'ic acid.
`It is true, I have been unable to order
`boric acid wet dressings to our hospitalized babies
`because the use of boric acid is strictly forbidden
`
`.l' oi-don—Crr'.r.s‘e_'y
`
`.
`
`in our children’s hospital and in our lying-in hog-
`Dita]. But our soft pastes, our routine soft pastes
`“nth 3% b91'i‘3 add: C10 Slip through even there.
`I had heard, of course, and read about sporadic
`cases of poisoning in the newborn, but I always
`thought
`that such catastrophes occurred by acci-
`dental
`ingestion, due to some fatal error in the
`nursery.
`
`the alleged virtues of
`Dr. Jordon wonders if
`boric
`acid,
`its extreniely weak antiseptic and
`keratoplastic potencies, and, we may add, its weak
`acidity and astringeney,
`justify its use.
`I would
`go a step further and state that nobody ever has
`shown by controlled experimentation that
`l)orie
`acid wet packs are any better than saline solutions,
`or that
`the addition of 3% or 5% boric acid to
`ointments or pastes makes any difference.
`I fully
`agree that
`the use of boric acid is “:1 habit ac
`quired from our predecessors,” as Dr. Jordon ex-
`pressed it.
`the concept of
`Finally, one more word about
`l)roken skin.
`‘\Ve know today that the chief barrier
`to percutancons absorption lies at the base of the
`horny layer, and it seems that
`this barrier meni-
`brane includes part of or the whole thickness of
`the granular layer. There can be little doubt that
`in parakeratolic contlitions of any kind in which
`the granular layer is not continuous,
`this barrier
`is damaged, and this is particularly true for cases
`of exfoliatire eryllirotlerma, to which Dr. _Tordon's
`case seems to belong. Any lesion in which the
`snbcorneal barrier is daiinagcd must be regarded
`as a.
`lesion with broken skin.
`It is absolutely not
`necessat'_\'
`to have grossly visible breakage, such
`as erosions, oozing, or ulcerations,
`to expect
`in-
`(liscrituinate and massive absorption.
`In practically
`all cases in which derinatologisls use boric acid.
`the skin is broken.
`indebted to Dr.
`should all be
`I believe we
`Jordon for having called our attention to this
`important subject.
`DR. Em-"IN EPSTEI.-\', Oakland, Calif;
`this paper very fascinating.
`in Oakland, we have a large veterans’ hospital
`with 712 beds. All patients with generalized der-
`matoses would be treated with boric acid ointment.
`boric acid wet dressings and starch and soda
`baths.
`.~\ month ago,
`in checking our statistics.
`it was
`found that we had treated about 4200
`patients by this method. Many of
`them had
`kidney disease; many of
`them had liver disease,
`and most of
`the.n'1 had severe generalized derma-
`toses.
`II1 that length of time, there were no cases
`of boric acid poisoning. VVI: could find no instance
`in which a dermatitis was made worse by the ap-
`plication of these measures.
`Furthermore,
`these three measures, plus hos-
`pitalization, were
`so suceessftll
`that,
`in many
`cases, it was not necessary to institute more specific
`treatment.
`
`found
`
`I
`
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`
`My interest in the problem was aroused because
`at Stanford University,
`they have forbidden the
`use of boric acid in any form, for any patient,
`for any condition.
`I
`think it
`is very important,
`when a substance in common use produces poison-
`ing, to report it. However, I think we should also
`stress that these remedies are very often valuable
`and safe in the form and manner prescribed in
`dennatologic practice.
`DR. FRANK C. COMBES, New York: Tl1e1'e is
`one advantage that boric acid possesses over most
`other salts; this is, in a saturated solution at room
`temperature,
`it
`is practically isotonic with body
`fluids.
`I
`think that
`is really its principal virtue,
`regardless of
`its antiseptic properties. Certainly,
`it has an advantage over plain tap water.
`think,
`I
`The furor over boric acid poisoning,
`was
`really instigated by the cases Dr. Jordon
`mentioned in whicll
`it was inistalcenly taken in-
`ternally instead of milk sugar. This error oc-
`curred in Norwich, N. Y.
`Inunediately after
`verdicts of, I think, $20,000 were awarded in each
`case t.he Department of Hospitals in the City of
`New York placed boric acid on the poison list.
`This means that
`it and anything containing it
`would be treated like habit—foi1ning drugs.
`It
`would be kept unde1'
`lock and key, a.nd patients
`could not
`themselves apply bo1'ic acid ointment
`or boric acid solution. This so co1nplicate(l therapy
`that, as a member of
`the Forrnularly Committee
`of Bellevue Hospital,
`I said we could dispense
`with boric acid altogether. This was over 10
`years ago, and we have got along pretty well,
`substituting saline,
`sodium sulfate solutions, and
`tap water.
`I think one thing should be stressed not only to
`dermatologists but
`to the general practitioner.
`Wlieii boric acid is used as a wet dressing it
`should be dissolved in water at room tetnperature
`a11d not
`in hot water. At 37C it
`is soluble to
`about 4%; as the temperature of
`the water
`in-
`creases it solubility increases rapidly. As the water
`co-ols
`it precipitates and is
`irritating. As Dr.
`Jordon has mentioned,
`tl1e use of boric
`acid
`powder and boric acid crystals should be avoided,
`as they are -potentially dangerous. Another point
`to he remembered in using boric acid compresses
`and poultices is that as the dressing dries, it should
`be moistened, not with more boric acid solution
`but with plain water. Qtherwise you a1'c going
`to get a supersaturated solution and precipitation
`of boric acid crystals in the dressing.
`I think this is a very good reason for dispensing
`with the routine use of boric acid wet dressings
`and substituting something else, even if it is plain
`tap water.
`
`DR. STEPHEN ROTHMAN, Chicago: Mr. Chair-
`man,
`it was a slip of
`the tongue in my saying
`that water is as good as boric acid solution. My
`726
`
`A. M. A. ARCH}!/.t*.'5 OF DERMATOLOGY
`
`is
`
`in
`
`manuscript reads “saline solution," so that
`reply to what Dr. Combes has said.
`' There is one more point which Dr. C01’11.bE5
`touched upon. Many nurses use the wrong tecl1-
`nique. Wlieii,
`the wet dressing dries and war-Ins
`up, they do not remove it and do not resoalc it in
`the solution but
`leave the cloth on the skin and
`add boric acid water from a syringe. Thereby
`they steadily increase the concentration of boric
`acid because water evaporates but boric acid does
`not. The same mistake is committed also with
`solutions
`of
`potassium permangante
`and of
`altunintun subacetate.
`Such practice should be
`energetically discouraged.
`D11. Am-Hons.-' C. CI1=0I.1..-mo, New York: I have
`always been interested i|1 boric acid poisoning,
`ever since the first reports came out of deaths
`following the ingestion of boric acid.
`I wonder
`whether we are 11ot driven somewhat by a fear
`complex, whetl1e1'
`the
`subsequent
`reports
`that
`came out
`following that
`first
`report were not
`based, perhaps, on inadequate observations.
`It
`is very clifficult
`for me
`to appreciate the
`fact
`that
`lit)’ applying wet dressings to one ex-
`tremity, boric acid solution for two weeks, enough
`boric acid could be absorbed by a11 adult healthy
`person to cause the death of
`that person, and 50
`several questions come to my mind.
`First, has the amount of boric acid which was
`consumed by this patient, by local application,
`been accurately determined or calculated to justify
`the large amounts that were found in the various
`organs?
`Second, was it possible that by some ntistaltrr,
`this patient
`ingested the boric acid rather
`than
`absorbing it from just one extremity?
`I cannot help but bring to your attention also
`the fact that one competing pharmaceutical house,
`immediately after the first reports of boric acid
`poisoning came out, promoted a remedy as a sub-
`stitute for boric acid, and used the most horrible
`pictures in the A. M. A. publications and in other
`journals
`to bring to our attention the terribly
`harmlul efiects of using boric acid on the su1'l'a-:1
`of the skin.
`
`Finally, only very recently, one of the govern-
`mental agencies——and I believe it was the l’-‘u1'e
`Food and Drug Administration—thoroughly BX’
`amined this whole question of boric acid poisoning
`from local absorption, and I
`think it was their
`finding that
`there was no danger in using boric
`acid solutions and boric acid ointment as we have
`been using them for
`the treatment of various
`derrnatologic contlitions.
`l3uPfalo: I knew when I
`DR. JAMES W’. JORIJON,
`presented this subject that there would be a great
`deal of controversy about
`it, since most derma-
`tologists use this drng on the skin and have 110*
`observed poisoning from its external use.
`
`Val. 75, May. 195?
`
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`BORIC .-I CID POISON