For, far more often than is currently realised, their eruption _antedates_ the _articular_ outbreaks.[27] Moreover, they may not be solitary, but numerous, the _cutaneous gravel_ of older authors. In truth, these cases of tophi, _uncomplicated_ by _articular_ lesions, seem to merit some distinguishing term, representing as they do a purely _ab-articular_ form of gout.[28] They constitute what might be termed primitive elemental gout, of which the subsequent _articular_ outbreaks are but an extension, a further manifestation of the “gouty diathesis.” For it is just this same tendency to _uratosis_ or deposition of sodium biurate, and this alone, that to our mind constitutes _gout_, this “primordial vice of nutrition,” not the congeries of distempers that with the passing ages have clustered around the primitive gout, well-nigh submerging its identity. _Premonitory Symptoms of Tophus Formation._—While tophi may _antedate_ articular attacks, we do not always meet with them as _mature_ concretions easily recognisable as such. We must have regard therefore to the symptoms and signs indicative of their impending eruption. Consequently in a patient complaining of the various functional disturbances that so frequently anticipate gout we should never dismiss as trivial any complaints of _pricking_ or _tenderness_ in the _ears_. Sometimes the pain in the ears is _acute_, the tenderness such as forbids their pressure on a pillow. Graves, of Dublin, not only noted that the pain in some instances was agonising, lasting a few hours, but he himself suffered also from such attacks of auricular pain, which only disappeared when gout supervened in his _fingers_. I have myself frequently known the pain and soreness referred to chilblains, though later their tophaceous nature was disclosed.