It will be seen that this observer holds that tophus formation “is usually preceded and accompanied by inflammation.” Garrod, as we know, believed uric acid to be the _cause_, and not the consequence, of gouty inflammation. But he emphasises the fact that the phenomena attendant on the eruption of auricular tophi are “exactly the same as when a joint is affected, and constitute, in fact, a true gouty paroxysm, commencing with infiltration of the tissue and subsequent inflammation.” Still, though venturing to differ as to the sequence of events, we gladly invoke this authority’s observations in proof of the fact that the _inflammation_ even in the _ear_ is not always of negligible grade: “I have seen many cases in which the ear symptoms have proved very annoying, so that patients have been unable to rest their ears on the pillow.” _Subacute gout_ sometimes occurs in the ears, says Duckworth, who furthermore believed that the _indurations_ in the _cartilage_ observed by him in _gouty_ subjects were the outcome of such attacks. Laycock, too, long before noted that the ears of gouty subjects often appeared to be “soldered.” _Pain or discomfort in auricular tophi often presages an oncoming articular paroxysm._ “Those gouty persons,” said Scudamore, “who are affected with concretions (chalk-stones), experience for a short time before the fit pricking pains in the parts where they are situated. This is described even by those who have minute points of concretions in the lobes of the ears and in no other parts of the body.” Hence tophi have a _prognostic_ as well as diagnostic valency in that the incidence of pain at their site may foretell the oncoming of _articular_ outbreaks. While, as before emphasised, the eruption of tophi may _antedate_ the occurrence of _articular_ gout, on the other hand tophi may be present at the joints, but lacking in the ears and all other _ab-articular_ sites. Auricular tophi, extracted occasionally by patients, are sometimes shed _spontaneously_. According to Duckworth’s statistics, in one-third of all well-marked cases of gout the ears present tophi in the _helix_, the _anti-helix_ and its _fossa_ and the _lobule_, and in some cases they may be situated on the _posterior_ surface of the _pinna_. OTHER SITES OF TOPHI Apart from the external ears, tophi are apt to form in various localities. Most frequently they are situated in the vicinity of the _joints_ and _bursæ_, especially that over the _olecranon_. As attack follows attack at short intervals the tophaceous matter is heaped up around the joint, and in this way many articulations may be involved, even all of them, says Trousseau, “as happened to Gordius, who composed on himself the following jocular epitaph:— “‘Nomine reque duplex ut nodus Gordius essem.’”