On the other hand, suppose the subject come complaining not much of pain in his joint, but more troubled because of its _enlargements_. If now on examination we find also that there is little or no tenderness, but simply a condition of _peri-articular thickening_ or _intra-articular effusion_, what shall be our method of procedure? Certainly not to leap forthwith to the conclusion that it is gouty. No, not even if he exhibit _tophi_ in his ears. Now, as to pain and tenderness, it is a blessed feature of gouty arthritis that, generally speaking, in the chronic forms pain becomes much attenuated. But let us at the same time recollect that _syphilitic_ arthritis, both secondary and tertiary, is relatively _painless_. But it is the much rarer _tertiary_ form, be it remembered, which is usually _monarticular_. By the bye, too, we should never forget that a _Charcot’s joint_ is also painless. Coming now to the _objective_ phenomena, is the case predominantly one of peri-articular infiltration or intra-articular effusion? As to the former, while you never know, still _tuberculous_ joint disease is exceptionally rare at the age at which we usually meet gout. On the other hand, _gummatous synovitis_, with or without osteoperiostitis, is occasionally met with. It is just such a case as this that may be confounded with gout, the irregular lumpy thickening of the sub-synovial tissues with effusion being wrongly attributed to a gouty process with uratic deposits. Do not be misled if a history of injury be forthcoming in such cases, for it is not uncommon and may be given in good faith. Now what if synovial effusion of chronic or recurring form be the striking objective feature of the case under review? In this event always recollect that of all the causes of _monarticular_ disorder _injury_ is far and away the most frequent. Not a few cases of monarticular joint disease come annually to the Royal Mineral Water Hospital, Bath, under the diagnosis of “gout” and “rheumatism.” But in all too many the symptoms are referable in truth to ligamentary strain, displaced cartilage, or foreign bodies, lesions always to be sought for and excluded in monarticular joint affection. Duckworth has it that _hydrarthrosis_ is met with in chronic articular gout, in his deforming variety. He states that “hydrarthrosis is less commonly due to gout than to rheumatism,” but, we would remark, apart from traumatic lesions, more commonly due to _gonorrhœa_ or _syphilis_ than to either of them.