Again, despite Duckworth’s assertion that “the gouty throat is like no other,” I am convinced that it presents no specific appearances. Nor have I been able to satisfy myself that striated and fluted nails of, it is usually affirmed, exceptionally brittle nature, are distinctive of gout any more than the premature whitening of the hair so frequently accredited to the subjects of this diathesis. One point, however, I would emphasise is, the frequency with which potentially gouty persons suffer from local _syncopes_ and _asphyxias_ of the hands. They are precisely similar to those met with in _rheumatoid_ or _atrophic arthritis_, certain cases of which, as we shall see later, have another affinity with gout, viz., _retardation in the output of exogenous purin_. _Locality, Race, Climate, etc._—As to the geographical distribution of gout, the salient fact would appear to be the almost complete restriction of the disorder to the _temperate_ zone. Among the natives of Africa gout, according to Livingstone, is unknown. Neither apparently is it to be met with in Turkey, China, Japan, Peru, and the Brazils. The indigenous peoples of India, and the East Indian Archipelago, also seem exempt, though the immunity does not extend to Europeans resident in these tropical climes. It is significant that Duckworth, inquiring of practitioners from foreign parts as to their experience of gout, found that little or none was forthcoming “save where Europeans have formed part of the community.” This statement, to my mind, does but add cogency to my contention that gout is always _hereditary_. If we restrict our purview to the British Isles and the Continent, we find that as a nation we have achieved the unenviable distinction of being _facile princeps_ in point of the liability to and incidence of gout. The bulk of examples, too, are met with in England, the disorder being much less frequent in Scotland and Ireland. Moreover, in the two latter countries, the disorder is practically restricted to the upper classes. By contrast, in England it has extended to the lower orders also, in respect of which peculiarity we stand unique as compared with all other countries. Reverting to the Continent, gout appears to be more common in France than in Germany, Austria, and Italy. Indeed, it is said to be endemic in Normandy, Burgundy, and the Rhone Valleys. In Holland, according to Duckworth, there is practically no gout, and the same is true of Russia, save in Petrograd and the Baltic Provinces. In Belgium, also, gout is not common, and in Greece it is much less prevalent than in France or England.