Sometimes it happens that elderly patients exhibit a persistent oedema involving the extremity that has been the seat of gouty in flammation. This complication causes considerable disability and pain, and is often very refractory under treatment. It is due to a paretic condition of the local vasomotor nervous apparatus, and re quires the employment of the various topical applications that have been already specified. If the oedema be not occasioned by renal or cardiac disease, these measures will often prove successful. But if they fail it may be well to apply a flannel bandage, or an elastic stocking, for the support of the vessels. The application of flying blisters and the actual cautery may be reserved for extreme cases.
The fact that in many instances the uratic deposits very nearly approach the cutaneous surface, has raised the question of surgical interference for their removal. In the majority of cases, however, this will be either unnecessary or positively injurious. Superficial de posits, such as are often visible upon the ears and in the skin, some times excite ulceration of the overlying cuticle, and thus evacuate themselves. Occasionally a subcutaneous bursa spontaneously dis charges its contents and must be treated like any other abscess. If such fistulous openings cannot be freely incised and cleansed, recourse must be had to compresses wet with alkaline solutions and covered with oiled silk or a rubber bandage. Such lotions should consist of po
tassiuin bicarbonate, or potassium iodide, or lithium carbonate, to the amount of sixty or eighty grains in a pint of water, which may be agreeably perfumed if the patient be of sufficiently exalted rank and wealth. When large concretions have formed in and around certain joints, ulceration sometimes occurs, and the tophi are spontaneously extruded. This process is sometimes witnessed at the knuckles and phalangeal joints. Various surgeons have attempted to anticipate or to assist this effort by making free incisions and endeavoring to turn out the mineral masses that interfere with articular movement. Care ful scraping of the bone3 and curetting of the cavities of the joints, followed by antiseptic dressings, may sometimes be accomplished with some degree of benefit to the patient. But in the majority of cases it is better to abstain from all surgical measures, and to reek relief by the methods that have been already described. The same opinion must be entertained regarding the employment of electricity. If it does no harm it is very doubtful whether it can effect anything more than temporary alleviation of pain in a few cases of acute gout.