Naturally, the implication of so many varied structures casts its impress on the clinical picture, inasmuch as the physical characters vary with the different textures involved, their capacity for inflammatory distension, etc. On the _dorsum_ of the _hand_ and _foot redness_ and _œdema_ will be prominent, and Scudamore noted that the flush might be widely diffused, simulating _erysipelas_, with here and there small _ecchymoses_. When structures more deeply placed, _i.e._, _tendon sheaths_ at ankle, knee, and wrist, are singled out for attack, swelling is less marked and redness of the skin more patchy in distribution. The _bursæ_ at the elbow or back of the knee may swell with extraordinary rapidity. The parts become exquisitely tender and painful, while the overlying skin takes on an angry blush. They may subside, but more often continue permanently enlarged, defiant of reduction. Involvement of the _olecranon bursa_ is very typical of gout. Pratt, of Boston (1916), tells of a case in which the subject had during twenty-seven years suffered from recurring attacks of _acute gouty polyarthritis_. The eight or ten physicians who had treated him had all regarded the disease as _rheumatic fever_. Pratt himself observes: “I did not feel sure of the diagnosis until I saw the swelling on his elbow, which presented the typical picture of a chronic _gouty olecranon bursitis_.”[34] Occasionally the bursæ when filled with uratic deposit undergo _suppuration_ following injuries. The bursa in connection with the great toe frequently becomes acutely inflamed, and Scudamore in a gouty hand saw an old ganglion take on the same inflammatory reaction. The tendon sheaths when involved lead to great disablement, as even the most tentative attempts at movement give rise to sudden and agonising cramp. The _tendo Achillis_ is a favourite site, or the tendons of the wrist, or the ligament of the patella. The same is true of the _aponeuroses_, the predilection being for the lumbar or gluteal fascia, in which instance it may extend to the sheath of the sciatic nerve. These extensions of gout to tendon and nerve sheaths frequently outlast the articular lesions, and may become the dominant element in the clinical picture. Naturally, when not only joints, but _bursæ_ and other structures, are involved and implicate both upper and lower limbs, the victim presents a pitiful spectacle, one of almost complete helplessness. Œdema and general venous turgescence may be very pronounced in one or more members, giving a subjective sensation of almost overwhelming weight in the limb. Reverting to the _constitutional_ symptoms, the outstanding feature is that, notwithstanding the widespread involvement of joints with manifest local inflammatory reaction, the _pyrexia_ is of _moderate_ grade, and so frequently, indeed, is it _afebrile_ that this peculiarity is of diagnostic significance.