More information is badly needed as to the relationship of their formation to acute attacks of gout. Garrod on this point remarks: “The deposits are probably formed during an attack of gout, but occasionally they appear shortly afterwards. In one case, of which I have notes, the ears were carefully examined without result when the patient left the hospital, but within ten days, on re-examination, a deposit was found. Perhaps some fluid was effused during the fit, but being at first transparent, could not be easily distinguished.” Sir Dyce Duckworth, too, observes: “After acute attacks of gout have passed off there may follow renewed pain in the neighbourhood of the joint, and later there is discovered a nodular or soft swelling. In the latter case there may be fluctuation, indicating a liquid collection of urates. This should never be opened. In a few weeks this tumour tends to indurate, grow more compact, and a so-called ‘chalky’ concretion is established.” Reflection upon the foregoing considerations leads me to the conclusion that not only was Garrod right in his affirmation that “_gouty inflammation is invariably attended with the deposition of urate of soda_,” but more that _examples of true uratic arthritis which lack tophi are exceptional_, and that _in their absence their diagnosis as such cannot be with certitude established_. We have now, we trust, sufficiently defined our attitude towards the tophus, the salient objective stigma of a “gouty diathesis,” and the indispensable _rôle_ it plays in enabling us to establish the diagnosis of articular gout. CHAPTER XX CLINICAL DIAGNOSIS (_continued_) ACUTE ARTICULAR GOUT—LOCALISED VARIETY The nonchalance with which not a few writers dismiss the diagnosis of _acute gout_ when located in the _great toe_ or elsewhere in the foot is, to say the least of it, somewhat remarkable. “It is a very easy matter,” say they, and as an earnest of their good faith are silent as to the many pitfalls that await the unwary. Should they deign to _differential_ diagnosis, they are at pains to discriminate between it and _acute articular rheumatism_, which _re_ classical outbreaks in the _toe_ seems a little superfluous! But not a word of _traumatic_ lesions, _infective_ processes and _static_ deformities, all infinitely more likely stumbling-blocks. Did all cases conform to the classic type, _acute sthenic gout_, it might be held relatively easy. But such are not, to say the least of it, common nowadays. More often than not our examples are, as Garrod terms them, of acute _asthenic_ character. As he observes: “There may be indeed pain and tenderness in the toe, and some amount of swelling, but accompanied with little heat or redness, and all febrile disturbance may be absent; still œdema is generally observed and itching and desquamation follow.”