Nevertheless, be it noted _tophi_ do but bespeak the “gouty diathesis,” not necessarily the “_gouty_” nature of an associated arthritis. For clearly tophi, of _ab-articular_ location, may coexist with an arthritis of _gonococcal_ or other origin. But given uratic deposits, either in the joint proper or its related structures, all reasonable doubts as to the true “gouty” nature of the arthritis are disposed of. On the other hand, in _the absence of tophi_, the diagnosis of an arthritis as “gouty” is _presumptive_, not absolute. This even in acute classical outbreaks in the _big toe_, viz., pending the finding or subsequent eruption of _tophi_. In saying this, I do not for one moment depreciate the diagnostic value of the clue afforded by location of the initial outbreak of the disorder, in the vast majority of instances, in the _big toe_. It is an invaluable, but not an _infallible_ clue; for, unfortunately, acute arthritic diseases other than gout may elect to announce themselves in the great toe. Moreover, there is nothing _specific_ in the external characters of acute “gouty” inflammation, nothing in the objective changes which would stamp them on sight as “gouty,” save only their _location in the great toe_; nothing distinctive about the angry blush, œdema, and engorged veins, all of which may be met with in _infective_ arthritis. There may be, as Garrod with good reason affirms, a local _intra-articular_ deposit of urate of soda, but this lies beyond our ken, presumptive but undemonstrable. Let but the _initial_ outbreak of gout occur elsewhere than at the _big toe_, say, _e.g._, in the _wrist_, _hand_, _ankle_, or _knee_, and we are at once, diagnostically speaking, _en l’air_. In this _impasse_ how impotent are we, and how painfully we realise that our diagnosis of acute gout is largely _topographical_, not _etiological_! Not, strictly speaking, etiologically diagnosable pending the eruption and detection of _tophi_. In short, location _per se_ in the big toe is strongly suggestive but not _diagnostic_ of “gout.” (_Vide_ Chapters on Diagnosis.) If this be done in the green, what then shall be done in the dry? In other words, if so precarious our diagnostic foothold in _acute_, how much more so in _chronic_ articular gout! for in the latter even _topography_ may wholly fail us, what then our diagnostic criterion?—_tophi_ and _tophi_ alone—aye, and demonstrable at that.