When the gangrenous process attacks the vulva, the lesion is usually seen in a cachectic or weakly child, who has lately passed through an ex hausting illness. Severe measles occurring in a scrofulous subject is some times followed by this dangerous sequela. As in gangrene of other parts the earliest symptoms are usually loss of appetite, headache, and nausea. Then the child complains of severe burning pains in the genitals ; and a light red circumscribed patch is seen on one of the labia, often on its inter nal aspect. Around it the tissues are dense and swollen for some distance. The patient cries frequently with the pain, and seems to suffer great dis tress in passing her water. After a day or two ashy gray spots appear. These are circumscribed and limited by a light red ring. Soon their colour changes to a dark brown or black, and the gangrene spreads to the upper part of the vulva, the perinxum, and the anus. Often there is a purulent, offensive discharge from the diseased surface. The general symp toms also become more pronounced. The pulse is small and rapid ; the features are pinched, and the face is very pale. The child lies moaning in her bed, and complains of pains not only in the diseased parts, but also in the limbs and body. Sometimes a watery diarrhoea comes on, and in that case the child soon dies exhausted. If by energetic treatment the gan grenous process can be arrested before it is too late, the sloughs separate, the swelling and darkness subside, and a granulating surface is left which quickly heals.
The gangrenous patch is sometimes single and of limited extent. Often the case is first seen when the separation has partially occurred, and a sloughy-looking ulcer is found on one of the labia. Still, however mall the local lesion may be, the general symptoms are severe, and on account of the exhausted state of the patient the danger is very great. At the be ginning of the disease a slight febrile movement is sometimes noticed, and the temperature may reach 100° or 101'; but the pyrexia usually quickly subsides, and the temperature for the remainder of the illness is below the level of health. Death in cases of gangrene may occur from exhaus tion. Sometimes it is ushered in by a series of convulsive attacks. In Dr. Gee's case of gangrenous ulcer of the vulva an extensive embolism was found in the cerebral arteries.
Diagnosis.—The diagnosis of spontaneous gangrene in the child pre sents little difficulty. The only case in which a mistake is likely to be made is that in which the disease attacks the extremities of the fingers or toes. In that case the pricking pain, combined with the livid hue of the skin, is suggestive of chilblains ; and, indeed, according to Raynaud, cases of this variety of gangrene have been often confounded at the begin ning with this common and insignificant disease. In most cases of gan grene, however, the pains are far more severe, the occurrence of the local symptoms is more abrupt, and several fingers and toes are attacked simul taneously. Moreover, the gangrenous lesion is often found at a season when the common chilblain is not usually suffered from.
Prognosis.—In every case of gangrene, whatever part of the surface be attacked, the prognosis is most unfavourable. The patient, indeed, does not always die, but instances of recovery are rare. If the patient be a new born infant, or a child of weakly constitution, he may be considered to have still fewer chances of passing safely through so formidable an illness.
The most favourable cases are those in which the gangrene is of the dry variety and remains limited to a finger or toe. If the gangrenous process appears successively in several parts of the body, little hope of recovery can be entertained.
Treatment.—In all cases where a cachectic child is attacked with gan grene, every effort should be made to support the strength of the patient, and improve the state of his nutrition. He should be supplied with as much nourishing food as be can digest. Meat—pounded if necessary, and strained through a fine sieve—eggs, milk, well cooked vegetables, and a judicious quantity of farinaceous matter must form his diet. Stimulants are always required, and the child may take half an ounce of port wine, or the St. Raphael tannin wine, diluted with an equal proportion of water, after each quantity of food.
If the patient be an infant at the breast, we should inquire if the sup ply of milk is adequate to his necessities. If the breast milk is poor and insufficient, additional food must be given as directed elsewhere (see page 603). White wine whey is very suitable in these cases. Tonics are always required. Quinine can be given in full doses (two grains for a child of three years old, three times a day), or the ammonia and bark mixture can be ordered, Mr. Cripps speaks highly of opium given frequently in small doses.
In cases of disseminated moist gangrene the heat of the part should be maintained by hot applications ; and directly a slough is noticed on the surface its further extension should be prevented by the free application of a powerful escharotic. Strong nitric acid should be applied once thor oughly, and the part must be then kept covered with hot poultices. When the slough separates, the resulting sore or sores can be dressed with a carbolic-acid lotion (five drops to the ounce of water), or a solution of bo racic acid (twenty grains to the ounce). In all cases of gangrene of the vulva this method of treatment is useful ; and the local measures employed in the treatment of gangrenous stomatitis are equally serviceable when the vulva is the part affected. Parrot advocates the use of powder of iodoform, especially in cases of gangrene of the vulva. The ulcers must be first carefully cleaned. Then they must be completely filled with the powder, no part of the raw surface being left uncovered. If the ulcer is very moist, it ought to be dressed twice a day. This method of treatment is painless, and is said to arrest the progress of the ulcer in three or four days. At the same time the surrounding oedema rapidly diminishes.
When the gangrene is limited to the extremities, the affected part should be wrapped in cotton wool, and gentle frictions with a piece of flannel moistened with eau-de-Cologne are recommended by Raynaud. This author disapproves of the use of energetic local stimulants, and states that he has seen very disastrous results follow quickly upon undue local irritation. Directly a line of demarcation forms, hot dry applications, such as bags of heated bran or sand, should be kept applied to the seat of the lesion, so as to preserve the dryness of the tissues and hasten the separation of the sphacelated part. In extensive gangrene amputation has been sometimes performed, but without saving the life of the patient. In deed MM. Rilliet and Barthez are of opinion that the removal of the dis eased member only hastens the fatal termination.