Sir W. Hale White has some pregnant observations on this point. Many patients, he says, “with chronic arthritis are quite wrongly said to have gout; usually they have osteoarthritis. The presence of bony outgrowths is strongly against gout, though it is not conclusive, for such may occur in true gout either more or less all round the joint or in the form of little nodules, but they never attain the considerable size common in arthritis,” and he adds: “If no urate of soda is visible anywhere the diagnosis may be very difficult.” To proceed, the general and local phenomena of chronic articular gout are such as scarcely lend themselves to succinct definition, and for their description we would refer the reader to the chapter dealing with its clinical aspects. As that careful observer Sir Alfred Garrod states: “Chronic gout is at times confined to one or two joints, but sometimes numerous articulations are involved.” In other words, chronic articular gout may be mono-, oligo-, or poly-articular in distribution; and naturally the process of differentiation is modified accordingly. This being so, I purpose dealing in the first instance with chronic monarticular gout, and in succession with the types of oligo- and poly-articular location. CHRONIC MONARTICULAR GOUT Occasionally gout in its recurrences clings obstinately to the great _toe_ and _tarsal_ joints. But since the advent of _radiography_ there should be little or no difficulty in differentiating a chronic gouty arthritis of the great toe from the only other arthritic lesion with which it is likely at this stage to be confounded, viz., _osteoarthritis_. But at the same time we would refer the reader back to the chapter dealing with the differential diagnosis of the localised variety of acute gout, as therein we dealt fully with other possible sources of fallacy, _i.e._, _static deformities_, etc. We shall therefore now proceed to discuss those exceptional cases in which chronic gout is located not in one of the small, but in one of the _larger_, articulations. MONARTICULAR GOUT IN LARGE ARTICULATION A RARITY Given a chronic arthritis of one of the larger joints, say the ankle, knee, or elbow, we should be careful not to jump too readily to the conclusion that it is of “gouty” nature. The more obscure it appears the more need for caution. Needless to say, if the objective changes be but minimal and the condition be, so to speak, practically a mere arthralgia, there rests upon us the paramount necessity of careful discrimination before labelling it as “gouty” in kind. Thus, if it be the knee, it may be a referred pain due to hip disorder, _e.g._, _osteoarthritis_ or _tuberculous_ disease, or it may be symptomatic of an inflammatory process, or, having regard to the usually mature or advanced age of the subject, it may be a _neoplasm_ in the bones.