Apart from arterial degeneration, we have to recollect the tendency to _phlebitis_ of _recurrent_ type. This when present always carries with it the risk of _embolism_ and sudden death. Cases therefore displaying this proclivity to phlebitis must be judged accordingly. The gouty _glycosuric_, too, is always subject to the risk that the condition may develop into one of true diabetes. The absence of response to dietetic restrictions, viz., persistent sugar in the urine, the onset of thirst, polyuria, or other concomitants of diabetes, will darken the prognosis. Also I myself believe that the presence of local foci of infection gravely prejudices the course of gout, accentuates any tendency to recurrence of the attacks, and incidentally reinforces any latent proclivity to vascular and visceral degenerations. Last, but not least, what of the subject’s habits? The “internal environment” of the tissue cells of the gouty is presumably of itself none too good; but if to this be added the poison of _alcohol_, lead, or the toxic products of gluttony, it is incalculably worse. The painter or the plumber, if he can, would be wise to change his calling. If the alcoholic be deaf to remonstrance or the glutton continue to gorge, their chances of life dwindle proportionately, and if given to both vices, still more so. In conclusion, the prospects of long life in gout depend in the main on the presence or absence of associated morbid states. If there be no complications such as I have indicated, the disease, in my experience, is not likely to shorten life materially, always provided that the victim is amenable to what should be the watchword of the gouty,— “The rule of not too much, by temperance taught In what thou eat’st and drink’st, seeking from thence Due nourishment, not gluttonous delight.” _Milton._ CHAPTER XIX ETIOLOGICAL AND CLINICAL DIAGNOSIS ARTICULAR GOUT The intimate cause of gout is unknown—a humiliating reflection, albeit salutary, if it but engender a more catholic attitude on our part when seeking to unravel the nature of this obscure joint affection. For, to secure ideal ends, diagnosis must be, not only clinical, but _etiological_. This is the more likely to be attained if we shed all preconceived ideas and prejudices. ETIOLOGICAL DIAGNOSIS Confronted, then, with a suspected case of gout, whether acute or chronic, what shall be our way of approach? Not the easy and hazardous path of lightning diagnosis affected by those who plume themselves on their so-called clinical “instinct,” but the slow, laborious route of clinical “observation,” that leads more surely to the vantage ground of truth, this assuredly in all diseases, but in none more so than in _joint_ disorders, whose outward resemblances so oft hark back to inward disparities.