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Local application of cod-liver oil in skin ulcerations
LOCAL APPLICATION OF COD/LIVER OIL IN SKIN ULCERATIONS* ERVIN EPSTEIN, M.D. LOS ANGELES,
T
HE therapy of wounds, uIcers and burns by the IocaI application of preparations of high vitamin content has been deveIoped in Europe during the Iast few years. Most reports to date have eminated from Germany1 while a few have appeared in the French2 and EngIish3 Iiterature. Despite the fact that the resuIts obtained by these workers have been encouraging, IittIe has been written in the journaIs of this nation. For this reason, this series of 31 cases is being recorded. AIthough, a group as smaI1 as this is insuffrcient to estabIish a therapeutic agent, the resuIts were so unencouraging, that it was deemed inadvisabIe to continue this study. TECHNIQUE Al1 types of skin uIceration, with the exception of mahgnant and Iuetic Iesions, were accepted for treatment. Other measures were obviousIy indicated in these two exceptions aIthough cod-Iiver oi1 and anhydrous IanoIin dressings were occasionaIIy used in conjunction with the indicated injection or surgical therapy. In most instances the patient was hospitalized but a smaI1 number were treated whiIe ambuIatory. The onIy auxiliary therapy empIoyed in these patients was the use of Ace bandages in the ambuIatory patients having uIcers secondary to varicose veins and in the healed ones after their release from the hospital. Biopsies, cultures, radiography and other laboratory procedures were used in establishing the diagnoses. AI1 of the patients studied in this investigation were charity cases and in none was the diet optimal. On the other hand, demonstrabIe cIinica1 signs or symptoms of avitaminosis were not * From
the Department
of Dermatology
CALIP.
noted in either series. Those in the hospita1 received a genera1 diet and no extra vitamins were administered oraIIy. The cod-Iiver oiI was mixed with equa1 parts of anhydrous IanoIin and a generous amount of this mixture was appIied to the uIcer. These appIications were renewed every second day. Ordinary gauze bandages covered with oi1 silk were used over the medication. The patient was advised not to use the extremity under treatment any more than was absoIutely necessary. Those in the control series were treated in the same manner except that anhydrous IanoIin aIone was used as a IocaI dressing. PIain cod-Iiver oil was empIoyed in several patients suffering from eczema or pyodermia. The resuIts were disappointing in most instances aIthough marked improvement was occasionaIIy obtained in pyogenic infections. It is unfortunate that no accurate method of comparison has been devised for the study of uIcers of the skin. The prognosis varies greatIy with the size, duration and cause of the uIcer so that the Iength of time necessary to affect a cure is not an accurate measure of the healing power of any remedy. Therefore, it has been found necessary to offer a clinica impression of the results obtained rather than a dehnite system of grading aIthough the latter would be preferable if practicabIe. resuIts in this study indicates “Good” compIete healing of the uIcer within a “reasonabIe length of time,” dependent on the factors mentioned which in genera1 was three to six weeks. The fallacy of this method is clearly shown in the two series presented in this report. The resuIts with cod-liver oil were slightly superior to those obtained with the anhydrous IanoIin alone
and Syphilology,
472
Los Angeles County
Hospital,
Los Angeles,
CaIif.
Ntw
Se~r~s
VOL. XXXVI,
No. 2
Epstein-Cod-Iiver
but the percentage of “good” resu1t.s obtained in the two series does not demonstrate this difference.
OiI AppIications
A me&an
Journal of Surgery
4-3
DISCUSSION
Many attempts have been made to demonstrate the mode of action of cod-
RESULTS
In reviewing TabIe I which presents a comparison of the two series, one is impressed by the fact that simpIer cases were treated with anhydrous IanoIin aIone rather than with cod-Iiver oi1 and anhydrous lanolin together. There were 22 per cent more varicose ulcers in the control series and there were 22 per cent fewer uIcers of more than one year duration. The one uIcer that had persisted for thirty-five >Tears made the average duration greater m the second group. A fact not recorded in Table I is that epitheliahzation proceeded more rapidly with the high vitamin preparation ahhough hearthy granuIation tissue was formed equally we11 with anhydrous IanoIin. The basic probIem of correcting the underIying etioIogica1 agents was purposely avoided in this study. This was done in order to test the actua1 heaIing power of the preparations being studied without introducing other factors. As a resuIt, 6 of the patients treated with cod-Iiver oiI and 2 of the control cases have aIready suffered recurrences. The onIy complication noted during the use of anhydrous IanoIin was the appearance of a new lesion in the area being treated in a patient with a trophic uIcer due to a centra1 nervous system Iesion. The compIications with cod-Iiver oi1 included a dermatitis venanata that deveIoped after two weeks of treatment, and recurred with each subsequent appIication of the oil. This patient aIso had an associated stasis eczema. An infection with BaciIIi pyocyaneus occurred in another patient and did not cIear with further appIications of cod-Iiver oi1. In studying these cases, it was noted that an uIcer that recurs after being “ heaIed” with either of these preparations, does not respond as we11 when treated with the same preparation a second time.
A
TABLE I BETWEEN THE TWO
COMPARISON
-
Cod-liver Oil Anhydrous Lanolin
arod
SERIES
Anhydrous Lanolin
I-
ISt% Male. Female.
.....
71.4
28.6
Age
Youngest.
Oldest. Average. Diagnosis Varicose. Microaerophilic streptocoCc”s Arteriosclerosis. Decubitus.
35 54.8 38.1
60
6
hemolytic
...... .
9.5 9.5 9.5 4.8
TTaumB~c............... .
Size of uker Largest. .................
4.8 4.8 4.8 4.8 4.8 4.8
90
Smallest. ................ Average. .................
X 16omm.
20 x 15mm. 30r3 sq. mm.
................ ................ .................
150 X 28 mm 15 x 3 mm. 1291.5 sq. mm. 35 Years
1 WeeK
2
2.9 years
Cod-liver Oil and Anhydrous Lanolin
Duration More than I year..
weem
6 years
Anhydrous LanoIin
61.9
Results Good. Fair. Poor. Ambulatory..
60 40
7r
Trophic.. . Thromboangiitis obliterans Thrombophlebitis. ... Acrodermatitis chronica atrophxans. . . Sckroderma. . Coccidioides. Poorly healed fracture..
Duration Longest. Shortest. A verage.
-I-
6 4
.
Complications Recurrences.. B. pyocyaneus infection Dermatitis venanata. New uIcer developing under treatment.. . .. .
14 3 4
66.6
7 *
70 30
3
14.3
*
*cl
6 f
28.6 4.8 4.8
2
20
0
0
14.3 19. I
10
0
474
American
Journal
of Surgery
Epstein-Cod-Iiver
Iiver oi1 in the healing of ulcers. AI1 investigators to date beIieve the resu1t.s to be due to the action of the vitamins. WoIbach and Howe4 pointed out that epitheIia1 repair occurs with recovery from vitamin A deficiencies. Nordman, Bisceglie and Katzenstein (quoted by LoehP) demonstrated that vitamins stimuIated growth m tissue cuItures. Dietrich (aIso quoted by Loch+) injected vitamin D concentrates into the ears of rabbits and found that this produced epithelia1 cysts and proIiferation. It has long been heId that vitamins are necessary to maintain the integrity and to promote the repair of the epithelia1 structures of the body. Santi5 feeIs that peptic uIcers can be produced in rats by the use of a vitamin A-free diet. Loehrlh has noted that cod-Iiver oil is steriIe and that when streptococci, staphylococci and BaciIIi coli are introduced into it they are soon destroyed. CuItures taken from uIcers under IocaI vitamin treatment continue to show the presence of these organisms for some time. Loehr, however, postuIated that they have Iost their toxicity. This is an important concept as uIcers kept at rest and free from infection tend to hea1. In this series, microaerophiIic hemoIytic streptococci were neither destroyed nor rendered non-toxic. in 193 I reported a cure in a Macintyre”” chronic uIcer by the use of “artificial sunlight.” Horn and Sandor” and ZoItan” have reported encouraging results in wounds treated with IocaI appIications of vitamin A. Loehr lgphhas been using codliver oil and Vaseline dressings in wounds for more than three and one-haIf years and is very enthusiastic about the resuIts obtained. Schmier6 secured good results with metuvit in uIcers of the skin. Metuvit is an ointment consisting of zinc oxide, Iithium and certain anima1 fats subjected to quartz Iamp irradiation. There are certain advantages to be gained by empIoying cod-Iiver oil in the treatment of ulcers. Its outstanding characteristic is found in its prompt relief of pain. The wounds are kept free from most
OiI Apphcations
MAY,1937
pyogenic organisms. The necrotic tissue rapidIy sIoughs away from the Iiving tissue Ieaving a cIean granulating surface. EpitheIiaIization proceeds at a fairly rapid rate. In this inadequate series, the uIcers were at Ieast temporarily heaIed in the majority of instances. On the other hand, a number of disadvantages are aIso apparent. The odor is very unpIeasant aIthough the patient eventuaIIy becomes accustomed to it. The treatment is expensive as Iarge amounts of the mixture are necessary to keep the Iesions saturated. It is very diffrcuIt to remove the odor from the bed cIothes and if washed with other clothes, the odor permeates the Iatter. GranuIation tissue forms more rapidIy than the epitheIia1 tissue so that it becomes necessary to cauterize the granulations at intervaIs. Recurrences are apt to occur if IocaI therapy aIone is employed. The oi1 may increase the toxicity of anaerobic organisms by its effect on the environment and it does not destroy BaciIIus pyoA contact dermatitis may aIso cyaneus. occur in susceptibIe patients. It does not cure the surrounding stasis eczema nor does it reIieve associated pruritus. Its superiority over anhydrous IanoIin is questionabIe and the disadvantages probabIy outweigh the advantages. The main objection is that “good” resuIts were obtained in onIy two-thirds of the cases in this smaI1 series. Fair resuIts or faiIures occurred in microaerophiIic hem0Iytic streptococcus infections (2 cases,) varicose uIcers (2 cases), arterioscIerosis (I case), coccidiodes (I case) and acrodermatitis chronica atrophicans (I case). Three of these cases were of Iess than one and onequarter years duration. Recurrences have aIready occurred in nearIy 30 per cent of the patients incIuding 5 who were listed as “good” resuIts. The resuIts obtained with anhydrous IanoIin aIone were aImost equa1 to those that foIIowed the use of equal parts of cod-Iiver oiI and anhydrous IanoIin. In a genera1 way, the advantages and disad-
NEW Smut-s
VOL.
XXXVI,
No. z
Epstein-Cod-liver
vantages of the treatment of ulcerations of the skin with cod-Iiver oiI appIy to the use of anhydrous Ianohn. In this series, cod-liver oil applied IocaIIy did not prove itself to be a satisfactory method of treating skin uIcers. However, the prompt relief of pain that usually follows the apphcation of this preparation suggests that it may prove to be a vaIuabIe addition to the other means of treating uIcers that are now being empIoyed. It is certain that it shouId not suppIant therapy aimed at correcting basic etioIogica1 factors. SUMMARY I. EquaI parts of cod-Iiver oiI and anhydrous IanoIin appIied IocaIIy heated uIcerations of the skin in two-thirds of the patients in this series. 2. Anhydrous IanoIin alone gave comparabIe results. 3. It is possibIe that the vitamin content of the oil enhances its heaIing powers by stimulating epitheIiaIization. 4. Cod-liver oil aIone does not constitute sufficient treatment as it does not offer permanent resuIts in the majority of ulcerations of the skin. REFERENCES 1:~ BCCHNER, 0. Cod-liver oil in the treatment of wounds. Deutscb. med. Wcbnscbr., 61: 2067 (Dec. 20) 1935. b. BUCKHEISTER, H. Honey and cod-liver oi1 in the treatment of wounds. Miincben. med. Wcbnscbr., 82: 1612 (Oct. 4) 1935. c. DRIGALSKI, W. Local action of vitamins in cod-liver oil bandages. Ztscbr. ,/. Vitamin,forscb., 3: 260
(Oct.) rgs‘&.
OiI Applications
Amcric:,~ Joornnl <,fSur,wv
1-5
d. HORN, Z. and SANDOR, I. LocaI application of vitamin A in therapy of wounds. Deutscb. med. Wcbnscbr., 60: 1018 (July 6) 1934. e. LANG. Cod-liver oil in the treatment of wounds. Scbweiz. med. Wcbnscbr., 65: 1248 (Dec. 28) ‘935. f. LAUBER, kI. J. and ROCHOLL, H. Experimental studies on action of vitamin ointments on healing. Klin. Wcbnscbr., 14: 1143 (Aug. IO) 1935. g. LOEHR. W. Cod-Iiver oil theraov of extensive burns of Iirst, second and third degrees. Cbirurg., 6: 263 (April) 1934; Cod-liver oil and plaster of Paris casts in poorly healing ulcerated stumps with large tissue defects due to charring, freezing or amputation. Zentrulhl. ,f. Cbir., 61 : 1815(Aug. 4) ‘934.
h. Idem. The treatment of fresh injuries, burns and phlegmonous inflammations with cod-liver oil salve with and without plaster. Tag. d. deutscb Ges. ,f. Cbir., 58, 1934. i. LUCKE, II. Honey and cod-liver oil in the treatment of wounds. Deutscb. med. Wcbnscbr., 61: 1638 (Oct. II) 1935. j. MEMMESHEIMER, A. hl. Effect of massaging skin and with ointments containing choIestero1 vitamins. Deutscb. med. Wcbnscbr., 60: 935 (June 22) 1934. k. TUMANSKIY, V. K. and YATSEVICH, I. A. Cod-liver oil in the treatment of infected wounds. Klin. Med., 13: 1528 (Oct.) 1935. I. ZOLTAN, L. Vitamins in the treatment of wounds. Zentralbl. f. Cbir., 62: 3031 (Dec. 21) 1935. 2. DEJUST, L. H. Local action of vitamins. Rep. de path. ccmparee, 34: 1771 (Dec.) 1934. 3a. MACINTYRE, E. J. Long standing ulcer healed by “artificial sunIight,” case. Brit. Jour. Actinotherapy, 5: 263 (March) 1931. b. STEEL, J. P. Cod-Iiver oi1 in the treatment of burns. Lancer, 2: 290 (Aug. IO) 1935. 4. WOLBACH, S. B. and HOWE, P. R. EpitheIiaI repair in recovery from deficiency in vitamin A. Jour. Exper. Med., 57: 5 I I (YIarch) 1933. 5. SANTI, hl. Experiments on rats indicate that deficiency of vitamin A is cause of peptic ulcer. Med. ital., 12: 155 (Marchj 1931. 6. SCHMIER, A. A. Treatment of ulcers. Am. Jour. Surg., 23: 198 (Jan.) 1934.
T
HE therapy of wounds, uIcers and burns by the IocaI application of preparations of high vitamin content has been deveIoped in Europe during the Iast few years. Most reports to date have eminated from Germany1 while a few have appeared in the French2 and EngIish3 Iiterature. Despite the fact that the resuIts obtained by these workers have been encouraging, IittIe has been written in the journaIs of this nation. For this reason, this series of 31 cases is being recorded. AIthough, a group as smaI1 as this is insuffrcient to estabIish a therapeutic agent, the resuIts were so unencouraging, that it was deemed inadvisabIe to continue this study. TECHNIQUE Al1 types of skin uIceration, with the exception of mahgnant and Iuetic Iesions, were accepted for treatment. Other measures were obviousIy indicated in these two exceptions aIthough cod-Iiver oi1 and anhydrous IanoIin dressings were occasionaIIy used in conjunction with the indicated injection or surgical therapy. In most instances the patient was hospitalized but a smaI1 number were treated whiIe ambuIatory. The onIy auxiliary therapy empIoyed in these patients was the use of Ace bandages in the ambuIatory patients having uIcers secondary to varicose veins and in the healed ones after their release from the hospital. Biopsies, cultures, radiography and other laboratory procedures were used in establishing the diagnoses. AI1 of the patients studied in this investigation were charity cases and in none was the diet optimal. On the other hand, demonstrabIe cIinica1 signs or symptoms of avitaminosis were not * From
the Department
of Dermatology
CALIP.
noted in either series. Those in the hospita1 received a genera1 diet and no extra vitamins were administered oraIIy. The cod-Iiver oiI was mixed with equa1 parts of anhydrous IanoIin and a generous amount of this mixture was appIied to the uIcer. These appIications were renewed every second day. Ordinary gauze bandages covered with oi1 silk were used over the medication. The patient was advised not to use the extremity under treatment any more than was absoIutely necessary. Those in the control series were treated in the same manner except that anhydrous IanoIin aIone was used as a IocaI dressing. PIain cod-Iiver oil was empIoyed in several patients suffering from eczema or pyodermia. The resuIts were disappointing in most instances aIthough marked improvement was occasionaIIy obtained in pyogenic infections. It is unfortunate that no accurate method of comparison has been devised for the study of uIcers of the skin. The prognosis varies greatIy with the size, duration and cause of the uIcer so that the Iength of time necessary to affect a cure is not an accurate measure of the healing power of any remedy. Therefore, it has been found necessary to offer a clinica impression of the results obtained rather than a dehnite system of grading aIthough the latter would be preferable if practicabIe. resuIts in this study indicates “Good” compIete healing of the uIcer within a “reasonabIe length of time,” dependent on the factors mentioned which in genera1 was three to six weeks. The fallacy of this method is clearly shown in the two series presented in this report. The resuIts with cod-liver oil were slightly superior to those obtained with the anhydrous IanoIin alone
and Syphilology,
472
Los Angeles County
Hospital,
Los Angeles,
CaIif.
Ntw
Se~r~s
VOL. XXXVI,
No. 2
Epstein-Cod-Iiver
but the percentage of “good” resu1t.s obtained in the two series does not demonstrate this difference.
OiI AppIications
A me&an
Journal of Surgery
4-3
DISCUSSION
Many attempts have been made to demonstrate the mode of action of cod-
RESULTS
In reviewing TabIe I which presents a comparison of the two series, one is impressed by the fact that simpIer cases were treated with anhydrous IanoIin aIone rather than with cod-Iiver oi1 and anhydrous lanolin together. There were 22 per cent more varicose ulcers in the control series and there were 22 per cent fewer uIcers of more than one year duration. The one uIcer that had persisted for thirty-five >Tears made the average duration greater m the second group. A fact not recorded in Table I is that epitheliahzation proceeded more rapidly with the high vitamin preparation ahhough hearthy granuIation tissue was formed equally we11 with anhydrous IanoIin. The basic probIem of correcting the underIying etioIogica1 agents was purposely avoided in this study. This was done in order to test the actua1 heaIing power of the preparations being studied without introducing other factors. As a resuIt, 6 of the patients treated with cod-Iiver oiI and 2 of the control cases have aIready suffered recurrences. The onIy complication noted during the use of anhydrous IanoIin was the appearance of a new lesion in the area being treated in a patient with a trophic uIcer due to a centra1 nervous system Iesion. The compIications with cod-Iiver oi1 included a dermatitis venanata that deveIoped after two weeks of treatment, and recurred with each subsequent appIication of the oil. This patient aIso had an associated stasis eczema. An infection with BaciIIi pyocyaneus occurred in another patient and did not cIear with further appIications of cod-Iiver oi1. In studying these cases, it was noted that an uIcer that recurs after being “ heaIed” with either of these preparations, does not respond as we11 when treated with the same preparation a second time.
A
TABLE I BETWEEN THE TWO
COMPARISON
-
Cod-liver Oil Anhydrous Lanolin
arod
SERIES
Anhydrous Lanolin
I-
ISt% Male. Female.
.....
71.4
28.6
Age
Youngest.
Oldest. Average. Diagnosis Varicose. Microaerophilic streptocoCc”s Arteriosclerosis. Decubitus.
35 54.8 38.1
60
6
hemolytic
...... .
9.5 9.5 9.5 4.8
TTaumB~c............... .
Size of uker Largest. .................
4.8 4.8 4.8 4.8 4.8 4.8
90
Smallest. ................ Average. .................
X 16omm.
20 x 15mm. 30r3 sq. mm.
................ ................ .................
150 X 28 mm 15 x 3 mm. 1291.5 sq. mm. 35 Years
1 WeeK
2
2.9 years
Cod-liver Oil and Anhydrous Lanolin
Duration More than I year..
weem
6 years
Anhydrous LanoIin
61.9
Results Good. Fair. Poor. Ambulatory..
60 40
7r
Trophic.. . Thromboangiitis obliterans Thrombophlebitis. ... Acrodermatitis chronica atrophxans. . . Sckroderma. . Coccidioides. Poorly healed fracture..
Duration Longest. Shortest. A verage.
-I-
6 4
.
Complications Recurrences.. B. pyocyaneus infection Dermatitis venanata. New uIcer developing under treatment.. . .. .
14 3 4
66.6
7 *
70 30
3
14.3
*
*cl
6 f
28.6 4.8 4.8
2
20
0
0
14.3 19. I
10
0
474
American
Journal
of Surgery
Epstein-Cod-Iiver
Iiver oi1 in the healing of ulcers. AI1 investigators to date beIieve the resu1t.s to be due to the action of the vitamins. WoIbach and Howe4 pointed out that epitheIia1 repair occurs with recovery from vitamin A deficiencies. Nordman, Bisceglie and Katzenstein (quoted by LoehP) demonstrated that vitamins stimuIated growth m tissue cuItures. Dietrich (aIso quoted by Loch+) injected vitamin D concentrates into the ears of rabbits and found that this produced epithelia1 cysts and proIiferation. It has long been heId that vitamins are necessary to maintain the integrity and to promote the repair of the epithelia1 structures of the body. Santi5 feeIs that peptic uIcers can be produced in rats by the use of a vitamin A-free diet. Loehrlh has noted that cod-Iiver oil is steriIe and that when streptococci, staphylococci and BaciIIi coli are introduced into it they are soon destroyed. CuItures taken from uIcers under IocaI vitamin treatment continue to show the presence of these organisms for some time. Loehr, however, postuIated that they have Iost their toxicity. This is an important concept as uIcers kept at rest and free from infection tend to hea1. In this series, microaerophiIic hemoIytic streptococci were neither destroyed nor rendered non-toxic. in 193 I reported a cure in a Macintyre”” chronic uIcer by the use of “artificial sunlight.” Horn and Sandor” and ZoItan” have reported encouraging results in wounds treated with IocaI appIications of vitamin A. Loehr lgphhas been using codliver oil and Vaseline dressings in wounds for more than three and one-haIf years and is very enthusiastic about the resuIts obtained. Schmier6 secured good results with metuvit in uIcers of the skin. Metuvit is an ointment consisting of zinc oxide, Iithium and certain anima1 fats subjected to quartz Iamp irradiation. There are certain advantages to be gained by empIoying cod-Iiver oil in the treatment of ulcers. Its outstanding characteristic is found in its prompt relief of pain. The wounds are kept free from most
OiI Apphcations
MAY,1937
pyogenic organisms. The necrotic tissue rapidIy sIoughs away from the Iiving tissue Ieaving a cIean granulating surface. EpitheIiaIization proceeds at a fairly rapid rate. In this inadequate series, the uIcers were at Ieast temporarily heaIed in the majority of instances. On the other hand, a number of disadvantages are aIso apparent. The odor is very unpIeasant aIthough the patient eventuaIIy becomes accustomed to it. The treatment is expensive as Iarge amounts of the mixture are necessary to keep the Iesions saturated. It is very diffrcuIt to remove the odor from the bed cIothes and if washed with other clothes, the odor permeates the Iatter. GranuIation tissue forms more rapidIy than the epitheIia1 tissue so that it becomes necessary to cauterize the granulations at intervaIs. Recurrences are apt to occur if IocaI therapy aIone is employed. The oi1 may increase the toxicity of anaerobic organisms by its effect on the environment and it does not destroy BaciIIus pyoA contact dermatitis may aIso cyaneus. occur in susceptibIe patients. It does not cure the surrounding stasis eczema nor does it reIieve associated pruritus. Its superiority over anhydrous IanoIin is questionabIe and the disadvantages probabIy outweigh the advantages. The main objection is that “good” resuIts were obtained in onIy two-thirds of the cases in this smaI1 series. Fair resuIts or faiIures occurred in microaerophiIic hem0Iytic streptococcus infections (2 cases,) varicose uIcers (2 cases), arterioscIerosis (I case), coccidiodes (I case) and acrodermatitis chronica atrophicans (I case). Three of these cases were of Iess than one and onequarter years duration. Recurrences have aIready occurred in nearIy 30 per cent of the patients incIuding 5 who were listed as “good” resuIts. The resuIts obtained with anhydrous IanoIin aIone were aImost equa1 to those that foIIowed the use of equal parts of cod-Iiver oiI and anhydrous IanoIin. In a genera1 way, the advantages and disad-
NEW Smut-s
VOL.
XXXVI,
No. z
Epstein-Cod-liver
vantages of the treatment of ulcerations of the skin with cod-Iiver oiI appIy to the use of anhydrous Ianohn. In this series, cod-liver oil applied IocaIIy did not prove itself to be a satisfactory method of treating skin uIcers. However, the prompt relief of pain that usually follows the apphcation of this preparation suggests that it may prove to be a vaIuabIe addition to the other means of treating uIcers that are now being empIoyed. It is certain that it shouId not suppIant therapy aimed at correcting basic etioIogica1 factors. SUMMARY I. EquaI parts of cod-Iiver oiI and anhydrous IanoIin appIied IocaIIy heated uIcerations of the skin in two-thirds of the patients in this series. 2. Anhydrous IanoIin alone gave comparabIe results. 3. It is possibIe that the vitamin content of the oil enhances its heaIing powers by stimulating epitheIiaIization. 4. Cod-liver oil aIone does not constitute sufficient treatment as it does not offer permanent resuIts in the majority of ulcerations of the skin. REFERENCES 1:~ BCCHNER, 0. Cod-liver oil in the treatment of wounds. Deutscb. med. Wcbnscbr., 61: 2067 (Dec. 20) 1935. b. BUCKHEISTER, H. Honey and cod-liver oi1 in the treatment of wounds. Miincben. med. Wcbnscbr., 82: 1612 (Oct. 4) 1935. c. DRIGALSKI, W. Local action of vitamins in cod-liver oil bandages. Ztscbr. ,/. Vitamin,forscb., 3: 260
(Oct.) rgs‘&.
OiI Applications
Amcric:,~ Joornnl <,fSur,wv
1-5
d. HORN, Z. and SANDOR, I. LocaI application of vitamin A in therapy of wounds. Deutscb. med. Wcbnscbr., 60: 1018 (July 6) 1934. e. LANG. Cod-liver oil in the treatment of wounds. Scbweiz. med. Wcbnscbr., 65: 1248 (Dec. 28) ‘935. f. LAUBER, kI. J. and ROCHOLL, H. Experimental studies on action of vitamin ointments on healing. Klin. Wcbnscbr., 14: 1143 (Aug. IO) 1935. g. LOEHR. W. Cod-Iiver oil theraov of extensive burns of Iirst, second and third degrees. Cbirurg., 6: 263 (April) 1934; Cod-liver oil and plaster of Paris casts in poorly healing ulcerated stumps with large tissue defects due to charring, freezing or amputation. Zentrulhl. ,f. Cbir., 61 : 1815(Aug. 4) ‘934.
h. Idem. The treatment of fresh injuries, burns and phlegmonous inflammations with cod-liver oil salve with and without plaster. Tag. d. deutscb Ges. ,f. Cbir., 58, 1934. i. LUCKE, II. Honey and cod-liver oil in the treatment of wounds. Deutscb. med. Wcbnscbr., 61: 1638 (Oct. II) 1935. j. MEMMESHEIMER, A. hl. Effect of massaging skin and with ointments containing choIestero1 vitamins. Deutscb. med. Wcbnscbr., 60: 935 (June 22) 1934. k. TUMANSKIY, V. K. and YATSEVICH, I. A. Cod-liver oil in the treatment of infected wounds. Klin. Med., 13: 1528 (Oct.) 1935. I. ZOLTAN, L. Vitamins in the treatment of wounds. Zentralbl. f. Cbir., 62: 3031 (Dec. 21) 1935. 2. DEJUST, L. H. Local action of vitamins. Rep. de path. ccmparee, 34: 1771 (Dec.) 1934. 3a. MACINTYRE, E. J. Long standing ulcer healed by “artificial sunIight,” case. Brit. Jour. Actinotherapy, 5: 263 (March) 1931. b. STEEL, J. P. Cod-Iiver oi1 in the treatment of burns. Lancer, 2: 290 (Aug. IO) 1935. 4. WOLBACH, S. B. and HOWE, P. R. EpitheIiaI repair in recovery from deficiency in vitamin A. Jour. Exper. Med., 57: 5 I I (YIarch) 1933. 5. SANTI, hl. Experiments on rats indicate that deficiency of vitamin A is cause of peptic ulcer. Med. ital., 12: 155 (Marchj 1931. 6. SCHMIER, A. A. Treatment of ulcers. Am. Jour. Surg., 23: 198 (Jan.) 1934.