Prognosis in gouty heart, including the heart of the man with goutiness, glycosuria and other irregular forms of the disease, is a subject of considerable practical difficulty. In my last lecture I read to you a short account of the case of a friend of my own who had had occasional attacks of gouty angina for 40 years. And certainly a large proportion of the old ladies of 60 or 70, whom you all have had as patients for years on end with weak heart and systolic murmur in the aortic area, owe their disablement to gout, if my observations are correct. The lesion proper of the aorta and aortic valves in these cases is atheroma, but the damage is accompanied with repair in the form of sclerosis, which, by increasing the loudness of the bruit, adds unreasonably to our anxiety about the case. Equally certain it is that patients belonging to this class improve under treatment. Still, the condition of arrest cannot go on indefinitely. In addition to extrinsic dangers, particularly those of Bright's disease, cerebral thrombosis and hæmorrhage, and bronchitis, failure of the heart is liable to supervene and prove fatal from the gravest of all intrinsic causes, namely, coronary degeneration. As this increases, the myocardium is steadily more and more impoverished; its contractile vigour declines, and residual dilatation of the chambers sets in with mechanical congestion of the viscera. Complaints of "the heart" increase, the breathing becomes oppressed, the face assumes more and more the characteristic "cardiac" appearance, and dropsy creeps up the lower limbs. Even then the prognosis is not hopeless, for undoubtedly a certain proportion of cases of dropsy in old persons with degenerated heart and vessels are still amenable to rational treatment. But the case has occasionally a more dramatic termination. As I was able to illustrate after my second lecture by a specimen from the Museum of Charing Cross Hospital, a branch of one of the coronary arteries that has been narrowed by atheroma for an indefinite length of time, with consequent cardiac weakness and discomfort, may any moment become thrombosed rapidly, apparently in consequence of some passing depression or other unfavourable influence, just as in thrombosis of degenerated cerebral vessels. Fatal angina is the result. This is a point of great practical importance--that sudden death will occur in old gouty subjects not from the lesion of which a basic or an apical systolic murmur is the evidence and which causes us concern, but from associated coronary atheroma, which we probably never suspect; indeed, that it may occur in those subjects with no murmur whatsoever to attract our attention and excite our fears.