REPAIR OF WOUNDS 135 



simple cleanliness, with due regard to the all-important 

 consideration of the patient's opsonic immunity and gen- 

 eral condition. 



Vaccine therapy and internal medication are chapters 

 by themselves. Our chief duty is to stand by fully armed 

 while nature does the work. 



In dry old varicose ulcers, carbuncles with little fluid 

 drainage, and indurated swellings of various kinds in 

 which incision is not productive of the usual benefit, 

 the engorgement and coagulation of lymph in the ves- 

 sels about the lesion is probably preventing free access 

 of fresh opsonins or antibodies to the site of infection. 



Wright and others report good results in such cases 

 from the use of citric acid internally in sixty-grain doses 

 every three hours until a freer exudation of serum is 

 obtained from the wound. The local use of citrate of 

 sodium and salt solution is also advised — one tenth of 

 one-per-cent citric acid and four-per-cent sodium chlorid 

 wet dressings. 



One case of Ludwig's angina, reported by Sir Alm- 

 roth Wright, seemed hopeless despite free vertical inci- 

 sions in the neck and a measured opsonic index of 1.8, 

 there being serious physical prostration and insufficient 

 exudation from the incisions to enable Wright to ''fill a 

 platinum loop" for culture. Yet two or three doses of 

 citric acid, as mentioned above, resulted in free oozing 

 from the incisions and immediate institution of convales- 

 cence. As Wright says, it was not the patient's lack of 

 resisting power, not his need of vaccine treatment (as 

 shown by the opsonic index), but merely the choking of 

 the lymph vessels about the induration which prevented 

 his ample supply of antibactericiclal bodies from reach- 

 ing the Streptococci in the wound or lesion, and bring- 

 ing about recovery. 



