One may, we think, gather from these two statements the inference that both these distinguished authorities hold _tophi_ to be the _only infallible criterion_ upon which to base a diagnosis of _gouty arthritis_. In my own practice I must affirm that I never feel justified in christening any arthritis as _gouty_ unless I have discovered _tophi_, and then only when to the best of my ability _all other known causes of arthritis_ have been excluded. FREQUENCY OF TOPHI IN TRUE GOUTY ARTHRITIS UNDERESTIMATED In reviewing the statistics of authors as to the frequency of the incidence of tophi in their cases of assumed gouty arthritis I am inclined to think their relative infrequency is apparent rather than real, in other words that many of their cases of alleged “gouty” arthritis which _lack tophi_ would, if investigated by modern methods, have been shown to be due to other causes of arthritis, this especially as regards their assumed cases of _chronic_ gout. For who can doubt that prior to the discovery of X-rays many cases of _osteoarthritis_, etc., were thus erroneously labelled? Nor indeed, as we hope to show later, is it improbable that similar fallacies obtained even in regard to _acute_ types of gout, particularly when of _polyarticular_ distribution. It will be noted that we confine our criticisms to those examples of “gouty” arthritis _unassociated with tophi_. But if, as we maintain, our scepticism be justifiable, then it follows that it _diminishes_ to an unknown extent the _percentage of cases of genuine “gouty” or uratic arthritis which lack tophi_. DIFFICULTY OF DETECTING TOPHI Apart from the probability of such erroneous relegation to the “gouty” category of _non-gouty_ arthritides, there remains this further consideration, the ease with which tophi, even when superficial, may be overlooked. We look for pearly white concretions, and if none are seen we straightway assume that _tophi_ are _absent_. This, I am sure, is a very common pitfall. At their inception tophi are neither white nor hard. They are largely fluid and soft to touch. The skin over them may be unchanged in colour or reddened. Only when mature, and the overlying skin is thin, do they assume the ordinary aspects of a tophus. These observations apply not only to tophi in the ears, but to those in the vicinity of the small joints of the hands and feet or elsewhere. I would urge that in the case of all soft localised swellings of dubious nature in the neighbourhood of the phalangeal joints aspiration with a hypodermic syringe will often prove very helpful. If fluid can be withdrawn and the same microscopically examined, it will more often than is supposed reveal the presence of biurate crystals.