Given such auricular pain and tenderness, we should examine the _pinna for small red swellings_.[29] These, when definitely localised, should be punctured and the thick white fluid which exudes examined microscopically for _urate of soda_ crystals. In some instances the creamy-like exudate does not yield a crystalline deposit, and Dr. Munro and I are inclined to believe that there is a _pre-uratic_ stage in the evolution of tophi. We have observed this absence of crystalline deposits in apparently unmistakable tophi, as evidenced by the usual pearly white concretions in the rim of the ear. I recollect that the late Sir William Osler, when visiting our laboratory, was deeply interested in this possibility, as suggested by Dr. Munro, of a _pre-uratic_ stage. Needless to say, all local sources of fallacy—Woolner’s tip, fibroid nodules, sebaceous cysts—were excluded, while, in the lack of _crystalline_ proof, the evidence in favour of the associated _arthritis_ being gouty rested on its being at the classical site, the _great toe_. Moreover, as an alternative explanation we have the possibility of _reabsorption_. We may recall Duckworth’s well-known example where a man had two attacks of gout in the right great toe joint, yet autopsy revealed no speck of uratic deposit. We know, too, that, following an _acute_ attack, tophi may diminish in size or even disappear, while coincidently fresh tophi form at other sites. _Premonitory Articular Pains._—Again, when, in association with indigestion or other premonitory symptoms, twinges in the toe recur from time to time, especially after consuming wines or certain articles of food, these same are very suggestive of impending gout. Garrod is very definite on this point: “I have no doubt that many persons experience extremely slight attacks of gout before the development of the affection in an acute form, and several of my patients have assured me that for years before their first severe attack in the great toe they have felt slight periodic twinges. I am of opinion that when such twinges occur deposition has already taken place.” In conclusion, we would urge that, given _gastric_ or _hepatic_ disturbances, etc., in a subject predisposed by _heredity_ or _habits_ to gout, we should note the presence or absence of the following:— (1) Pain, pricking, or tenderness in the ears, with or without small red swellings. (2) Similar sensations at site of finger joints, with dorsal swellings over which the skin may be red or unchanged. (3) The existence or not of pearly white concretions, _i.e._ mature tophi (as tested microscopically), at the above sites or elsewhere. Further signs that may be sought for in cases of doubtful nature, _i.e._ _unevidenced by tophi_, would be:— (4) The presence of _uricæmia_. (5) A lowered or sub-normal output of uric acid in the urine. (6) Diminution or retardation of the output of exogenous purin.