For it may be of specific infective origin, _gonococcal_, syphilitic, pneumococcal, etc. _Quâ_ a concomitant arthritis, then, the diagnostic significance of tophi, at any rate when of _ab-articular_ site, must not be overrated. It is at once a beacon and a warning. In other words, the diagnosis of a co-existent arthritis as “gouty” should not be entertained pending the exclusion of all other forms of arthritis. _Conversely, in the absence of tophi, the diagnosis of an arthritis as “gouty” is not absolute, but presumptive._ For in the lack of these objective stigmata how can the authenticity of our diagnosis be established? Is it not when achieved a _nosological_ rather than a diagnostic feat? Put otherwise, is not our diagnosis, especially in _initial_ attacks, largely _topographical_? Not that we would for one moment decry the advantage of realising the predilection of certain organisms for this or that particular joint: of the gonococcus for the sterno-clavicular, of typhoid for the hip, post-scarlatinal rheumatism for the phalangeal joints, etc. But we would drive home the fact that our diagnosis in _initial_ attacks of “gout” is very largely _topographical_. Let but inflammatory trouble ensue in the _big toe_, and forthwith we assume it gout, as if, forsooth, this particular joint were immune from all other forms of disease, this, too, while in the same breath we comment on its extreme liability to injury. So, indeed, we maintain, is the marked predilection of gout for the toe joint explained. Is not this a little crude? Does not the same circumstance increase its liability to _infection_ and, we may add, not less important, its proneness to _static deformities_? But to this we shall recur when discussing _differential_ diagnosis. To return, how often, apart from the above pitfalls, is the diagnosis “gout” arrived at without any search for tophi wherewith to support the assumption. Our contention is that even in primary attacks of gout our search for _tophi_ should be exhaustive. If undiscoverable, why not be honest with ourselves and recognise that our diagnosis is _presumptive_ pending their development? Sir William Roberts on this point observes: “As a rule, diagnosis of acute articular gout is easy, but exceptional cases of difficulty occur. The _gouty_ character of the inflammation is _affirmed by the discovery of uratic concretions_ in the rim of the ear or elsewhere.” Again, Sir William Osier, discussing the diagnosis of acute gouty polyarthritis, remarks: “We have had of late years several cases admitted for the third or fourth time with involvement of three or four of the larger joints. The _presence of tophi_ has settled the nature of a trouble which in previous attacks has been regarded as ‘rheumatic.’”