(EDEMA AND GANGRENE OF THE VULVA.
During pregnancy edema is ordinarily only an effect of mechanical congestion, and in the puerperium it is an early sign of local infection. As a result of mechanical interference with the circulation both labia, as a rule, enlarge, since the obstacle to the circulation lies above. In the puerperium it most frequently occurs to one side, and in the vestibule or in the vagina we find slight abrasions of the mucous membrane covered with an unhealthy deposit. Such an edema is therefore an accompani ment of wound infection, and only appears after infection is an estab lished fact. This is why the swelling rarely appears before the third to the fourth day. I am inclined to lay great stress on this edema of the labia majors and minora, or as au indication of local infection calling for energetic local treatment. Further, when there exists an abscess in the vagina or its surroundings, swelling of the external genital organs is pres ent.
As an index of ulceration, swelling of the labia minors in pregnancy is of value.
Aside from general dropsy, edema occurs, independently of the puer perium, as a consequence of furuncles, erosions, ulcerations from gonor rhea and cancer. Generally dropsy is caused by Hydrernia, disease of the kidney, lung and heart affections, etc.
Since the above affections are of long duration, we may speak of chronic general and local edema. The diseases accompanied by general dropsy eventuate in great swelling of the genitals; they hang like large sacs interfering with local examination and catheterization. The women are unable to approximate the thighs, and as a result of interference with the circulation gangrene may set in, which may lead to pyemia, and end fatally.
Whenever the edematous skin breaks, the serum flows out, and the patients are relieved, but at the same time are liable to erysipelas, which frequently occurs after spontaneous or artificial opening of the edematous labia.
Gangrene of the external genitals ordinarily follows on the trauma tism of labor. The compressed parts, deprived of proper circulation, are readily infected, and mortification speedily may follow. Puerperal fever, in a more or less outspoken form, frequently is accompanied by such gan grene. Ritzen witnessed a case of puerperal fever where gangrene of the labia nympine and clitoris was present. I myself saw in Strasburg a case where the labia sloughed, and cicatricial contraction of the introitus vagina; resulted.
Aside from the puerperal state, gangrene, not the result of accidental causes, follows on the acute infectious diseases: typhus, measles, scarlet fever, small- pox.
In scrofulous, anemic children, spontaneous gangrene of the exter nal genitals occurs, which is analogous to noma of the face. The acute infectious diseases have apparently here as well great weight in etiology, and gangrene of this type is often epidemic. It begins as a broad-based sero-purulent infiltration and erythematous redness of the genitals, result ing in mortification of the tissues, and the formation of blebs, on the bursting of which there remains a phagedenic ulcer.
Wood has reported an epidemic which he witnessed, and he shows how grave the prognosis is. Of twelve observed cases, ten died. Billard com pares this noma with that of the mouth. Occasionally the initial symp toms are itching of the genitals and burning micturition. Again the symptoms are more intense, and general blood-poisoning and death follow rapidly on invasion of the genitals.
Heine has reported an instance where gangrene of the vulva led to the supposition of rape, although measles was present. The child was nine years old, but so apathetic that no information could be obtained. At the coroner's inquest the facts in the case were sifted and rape disap proved.
Phagedenic ulcers, the result of syphilis, spread widely on the surface but not in depth.
In the treatment of gangrene prophylaxis leads everything. Epidemic spreading from one child to another, during the course of an infectious disease, can certainly be prevented by recourse to antiseptic measures. The transmission of gangrene is only explainable on the assumption that poorly nourished children are directly affected through dirt or transfer ence of septic matter to an abraded surface. Cleanliness, disinfection, such are the measures to be resorted to for the prevention of spreading.
Yellow and black wash, camphor, etc., are to be applied on com presses. A clear indication is to tone up the system.
The treatment of edema is merged in that of the diseases which cause it. In case of general dropsy the aim is to prevent the occurrence of gangrene and of erysipelas. Edema during pregnancy may best be treated by posture, and in case of pendulous abdomen by the wearing of an abdominal binder. We should beware of puncture by lancet or needle, since erysipelas quickly develops. Where blebs have formed it is good practice, however, to give exit to the serum. Possibly puncture under antiseptic precautions, and under the use of iodoform, etc., are not so likely to be followed by erysipelas.