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A peri-articular abscess may spread in several directions, sometimes invading tendon sheaths or bursæ, and finally reaching the skin surface by tortuous sinuses. Reactive changes in the vicinity of tuberculous joints are of common occurrence, and play a considerable part in the production of what is clinically known as white swelling.
On the other hand, the disease may show itself clinically as a tumour of bone, which may attain a considerable size, and may be mistaken for a sarcoma, unless the existence of the primary cancer is discovered.
Although the cancer cells constantly attack the walls of the adjacent veins and spread into their interior at a comparatively early period, secondary growths due to dissemination by the blood-stream rarely show themselves clinically until late in the course of the disease.
It will be noticed by the foregoing classification that the terms "mild" and "malignant" endocarditis are used. The purpose is to convey the fact that there may be no etiologic distinction between the two forms, and it is impossible to decide clinically in the beginning of an endocardial inflammation which form is present.
The differences in inflammation in the two cases is really one of degree, and the classification is made to coincide with this probable fact. it is, of course, clinically recognized that endocarditis following certain diseases, especially rheumatism, is of the simple or mild type, while that termed ulcerative endocarditis may occur apparently as a primary or general infection, and the causative bacteria, as a rule, are readily discovered in the blood.
We may confidently expect that a more pronounced mastery over diseases of the mind will come when physicians in general are taught psychiatry clinically, so that the beginnings of mental alienation may be intelligently met by the family practitioner. The supreme achievement of the medicine of the Nineteenth Century undoubtedly has been the development of its preventive feature.
In advanced cases it may be impossible to differentiate between a periosteal and a central tumour, either clinically or after the specimen has been laid open. Pathological fracture is more common in central tumours, and sometimes is the first sign that calls attention to the condition.
Clinically, the condition resembles tuberculous disease of the synovial membrane, for which it is probably frequently mistaken, but in the syphilitic affection the swelling is nodular and uneven, and the subjective symptoms are slight, mobility is little impaired, and yet the deformity is considerable.
Clinically, the osteoma forms a hard, indolent tumour attached to a bone. The symptoms to which it gives rise depend on its situation. In the vicinity of a joint, it may interfere with movement; on the medial side of the knee it may incapacitate the patient from riding. It incapacitates the patient from wearing a boot. When it presses on a nerve-trunk it causes pains and cramps.
In our opinion it is probably better to regard these as clinically impure types. Great difficulties are also met with in the manic-depressive group proper. So often a stupor begins with the same indefinite kind of upset as does another psychosis that the development may furnish no clew.
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