For myself, I am of opinion that each and every process of tophus formation is preceded by local inflammatory reaction of varying grades of severity. In a matter of this sort, positive is more valuable than negative evidence. We see that all the authorities quoted admit that _tophi_ are associated with _inflammation_ and some measure of _pain_, though they add the reservation that in many instances, if not the majority, these phenomena have apparently been absent. Apparently, we say advisedly, for conceding that the pain attending the formation of auricular tophi is but slight, how all too easy for the subject to have wholly forgotten it when he comes later under notice. By this time the tophi, from being latent, have become overt. The initial soft red swellings, their nature probably misinterpreted at their initiation, are now transmuted into pearly concretions of hard or semi-solid consistence. Small wonder, then, that attempts to elicit the history of slight pain and pricking or tenderness often prove barren; for, be it noted, tophi take months to mature, as Garrod long since pointed out. Moreover, we would emphasise the fact that _tophi_, more often than is thought, occasionally precede by some years the outbreak of _arthritic_ attacks. Both Duckworth and Garrod are quite definite on this, and we can confirm them. In such instances, then, even granted that our attention be drawn to them in their initial stages, how easy to misinterpret their true nature! Thus, we have known tophi in their early stages of formation confused with _chilblains_. In this connection we might remind the reader that, according to Duckworth, amongst the peculiarities of tissue in those goutily disposed is feebleness of the peripheral capillary circulation, “a condition leading to disorders of chilblain-type, the vessels filling slowly after being emptied.” We repeat that the cause or causes of tophi and, alike, of the arthritic phenomena of gout are, and must be, one and indivisible, for the process of tophus formation is but an attack in miniature of gout. Although he may never have had an arthritic outbreak, the individual who exhibits a tophus undeniably has gout. More certainly so than if he had had an inflammatory outbreak in his great toe; for this, at any rate, may be of _non-gouty_ origin, but the tophus, never! Reflecting on the foregoing considerations, we would submit— (1) That tophi are always preceded by local inflammatory reaction of varying grades of severity, and that the uratic deposits are sequels thereto; (2) That in their early stages their presence is betokened by soft red swellings associated often with sensations of pricking and tenderness; (3) That their transmutation into white pearly concretions is a process that takes months to mature; (4) That tophi and arthritic outbreaks have a common causal origin.