Characterization of the nature and skeletal distribution of gout was accomplished in a Chamoru (Chamorros) population with predilection to the disease. Uniform excavation by the gouty diathesis produces a punched-out appearance to these predominantly monarticular lesions. The lesion is distinct from that seen in rheumatoid arthritis, spondyloarthropathy, or infection. Reactive new bone formation in some gouty lesions also has an apparently unique, ivory-like discoloration (contrasted with the adjacent bone), which facilitates diagnosis. © 1995 Wiley-Liss, Inc.