cation or scurvy (Kraus).1 It is of comparatively frequent occurrence in acute leukemia, and is probably due to bacterial infection of the mucous membrane which has been deprived of its superficial epithelium by some mechanical trauma and, owing to its impaired nutrition, is unable to offer any resistance to the invasion of pathogenic germs.

Löri 2 and Hoffmann 3 have reported paralyses of the recurrent nerve from pressure or traction of the leukemic tumors on the vagus or recurrent.

The same alterations are found in pseudoleukemia as in leukemia, but the literature on the subject is very scanty. Stieda and Kümmel 5 observed diffuse infiltrations, which in the former's case led to a stenosis requiring tracheotomy for its relief, and in the latter's presented a peculiar marrow-like appearance and caused a thickening of the entire mucous membrane, as well as of the aryepiglottic folds and the posterior arc of the entrance to the larynx, and led to a laryngeal stenosis. In a case reported by Kraus 6 the mucous and muscular tissues of the pharyngeal vault and posterior nares were replaced by a hard, whitish mass, slightly raised above the level of the surrounding parts. Necrotic disintegration of the tonsils has occurred in pseudoleukemia, and hemorrhages from the nose, pharynx, and larynx are sometimes observed.

Contrasted with these diffuse pseudoleukemic infiltrations we meet with circumscribed lymphatic tumors on the epiglottis and on the base of the tongue, as observed by Beale and Eppinger 8 in general lymphomatosis.

With symptoms such as these, which in Eppinger's case led to a clinical diagnosis of multiple carcinomatosis, one may well hesitate whether to ascribe the neoplasms to pseudoleukemia or to consider them as idiopathic malignant

tumors.

There is another form of morbid growth, known as lymphosarcoma, to which it is even more difficult to assign a place among the pseudoleukemias. According to Kun

1 Kraus, Nothnagel's "Spec. Path. u. Ther.," XVI, 1.Th., 1. Abth., p. 291. 2" Die Veränderungen des Rachens," etc., p. 94.

3" Lebrb. der Constitutionskrankh."

4"Arch. f. Laryng.," IV, p. 46.

5 "Verhandl. der D. otol. Gesellsch.," 1896.

• Loc. cit., p. 393.

7 Quoted from Stieda, " Arch. f. Laryng.," vol. IV.

8 In Klebs' Handb. der path. Anat.," 7th ed., 1880, p. 209.

drat, 1 lymphosarcoma is more closely allied to lymphoma, especially of the pseudoleukemic variety, than it is to sarcoma, although it differs from the former by its atypical structure, its mode of growth, and its tendency to invade neighboring tissues." The close relation existing between pseudoleukemia and lymphosarcoma is shown by the tendency of pseudoleukemic lymphomata to change into lymphosarcomata. Kundrat describes them as originating in lymph glands (which consist of follicular and adenoid tissue) in certain regions, following the course of the lymph-channels in their subsequent growth. Lymphosarcomata often originate in the structures of the pharynx; and, according to Störk,2 the disease frequently begins as a hyperplasia of the pharyngeal tonsil, simulating the picture of adenoid vegetations. The general appearance of the patients, their pallor and cachexia, and the enlargement of the lymphatic elements in the mesentery and retroperitoneal space and of the lymphatic glands generally, which is found at the autopsy, point to leukemia, although the differential diagnosis is indicated by the absence of hepatic and splenic alterations. The tonsils and the follicles of the tongue and of the posterior pharyngeal wall may become enlarged, or an extensive infiltration distributes itself over the posterior and lateral walls of the pharynx, and appears in the larynx either primarily or as an extension from the pharynx. The infiltrated areas usually become the seat of tumors, which differ from similar growths in leukemia in their tendency to cicatrization. In the literature there is no record of hemorrhages.

THE MANIFESTATIONS OF LEUKEMIA IN THE EAR.

It has been known for some time that the ear sometimes becomes diseased in the course of leukemia. Vidal and Isambert found auditory disturbances in three out of thirteen and in four out of forty-one cases, respectively, but in the absence of reliable clinical observations and anatomic studies the nature of the aural disease and its connection with leukemia remained shrouded in mystery. In 1884 Politzer published a paper on the subject, and since then a

1" Wien. klin. Wochen.," 1893, Nos. 12 and 13.

2 Nothnagel's "Spec. Path. u. Ther.," XIII, 2. Th., 1. Abth.; vol. I, p. 204.

1

few other cases were reported. Finally, Schwabach 1 contributed a decided addition to our knowledge of leukemic disease of the ear by five observations of his own, with anatomic notes, and thereby brought the total number of cases reported up to fifteen.

It has been mentioned that, according to Vidal and Isambert, the proportion of aural complications in leukemia is 10%; Schwabach puts it at 33%, as his five cases of ear disease represent the proportion among fourteen cases of leukemia. F. A. Hoffmann 2 also considers disturbances of the hearing fairly common in leukemia.

The aural disease may appear at any time in the course of the general disease, but is most frequent in chronic cases during the last few weeks before death.

The auditory disturbance is usually profound and points to disease of the internal ear; as a rule, the onset is sudden, with vertigo, tinnitus aurium, and sometimes vomiting, and is immediately, or within a few days or hours, followed by marked reduction in the hearing or even by total deafness. In many cases, including the five out of the fifteen reported by Schwabach, the aural phenomena made their appearance suddenly, simulating the picture of Ménière's symptomcomplex.

It has not as yet been determined just how far one is justified in assuming a causal relation between leukemia and these attacks of deafness which do not present any definite clinical type. The assumption that there is a true leukemic form of ear disease is amply justified by the investigations of Schwabach, who found in fourteen of the fifteen cases examined so far anatomic alterations which were undoubtedly dependent on the leukemia.

These changes, which were also observed by F. A. Hoffmann, consist in hemorrhages and in lymphomata situated not only in the labyrinth, but also in the auditory nerve and its branches. Aggregations of leukocytes or lymphatic infiltrations with extravasations of blood were frequently found in the trunk of the auditory nerve, in the cochlea and vestibule, and in the semicircular canals; sometimes pigmentation was present-a consequence of former hemorrhages. The marrow-spaces in the spongy tissue of

1 "Zeitschr. f. Ohr.," XXXI, p. 103.

Lehrb. der Constitutionskrankh.," p. 79.

3 Alt und Pineles, "Wien. klin. Wochen.," 1896, No. 38.

the mastoid process may be filled to bursting with mononuclear leukocytes, interspersed with hemorrhagic extravasations. It would appear that these masses sometimes organize and are converted into connective or bony tissue.

A unique case is reported by Kast 1: The labyrinth and auditory nerve were intact, but in the medulla there was an area corresponding to the olivary nucleus, and to the nuclei of the hypoglossus, glossopharyngeal, vagus, auditory, and facial nerves, in which the medullated nervefibers were diminished. Yet here bulbar phenomena had not been observed, for the only clinical symptoms were impaired hearing and facial paralysis. Facial paralysis was also present in one of Schwabach's cases.

The complications of the middle ear are less pronounced and less frequent, and the external meatus and tympanic membrane scarcely ever present alterations referable to leukemia. If we disregard the deviations from the normal observed in the otoscopic image,-calcifications or opacities which had nothing to do with the leukemic process, we find few instances of hemorrhage or injection of the membrane and external auditory meatus. Occasional extravasations of blood, with a variable admixture of red and white blood-corpuscles, have been observed; more frequently the mucous membrane of the middle ear was thickened, but it was rarely the same extensive leukemic infiltration as that which occurs in the internal ear.

These findings are sufficiently characteristic to remove. any doubt that ear disease of leukemic origin is possible. But there is no reason for adopting the opinion of Gradenigo, 2 based on three cases, that an inflammatory process in the ear must be regarded as an essential predisposing factor of ear complications in leukemia.

Examination with the tuning-fork is of the greatest importance in the diagnosis of leukemic ear disease; there are, it is true, a few cases where the hearing was only slightly impaired, even for whispered sounds, but they are very exceptional compared to those which are characterized by great reduction in the hearing or even total deafness. Without the results of the functional test, which incidentally enables us to determine whether the soundconducting or the sound-perceiving apparatus is chiefly 1 "Zeitschr. f. klin. Med.," 1895. 2" Arch. f. Ohr.," XXIII, p. 261.

affected, the symptoms of tinnitus and vertigo are of no value in the diagnosis of leukemic disease of the organ of hearing, as both phenomena may be present in this as in other morbid states of the blood-producing organs, especially in anemia, quite independent of any organic lesion in the ear.

The prognosis is unfavorable, though there may be temporary improvement in the hearing.

Our knowledge of auditory disturbances in pseudoleukemia is very limited. Kümmel1 reports a case which he observed very carefully, and in which the tympanic membrane was dark blue, almost violet in color, the handle of the malleolus being very distinctly seen. At the autopsy an extravasation of blood, mixed with leukocytes, was found in the middle ear. In a case of Hodgkin's disease reported by Brauneck it is said that the hearing, which had always been bad, became worse toward the end, and the diagnosis of disease of the labyrinth or of the central organs was made by an ear specialist.

3. HEMORRHAGIC DIATHESES.

In the hemorrhagic diatheses-hemophilia, purpura, and scorbutus-the same processes are found in the mucous membranes as in the skin. Ecchymoses and hemorrhages may appear in the mucous membranes of the upper airpassages, just as they attack the external auditory meatus, the tympanic membrane, and the middle ear.

These complications are, however, rarely observed, and their diagnosis, when they appear in connection with the primary disease, presents no difficulties, so that nothing would be gained by giving a detailed description, and I shall content myself with presenting a few examples of the individual varieties, culled from the literature.

Epistaxis occupies the first place among spontaneous hemorrhages from mucous membranes in hemophilia; among 236 hemorrhages of various kinds 122, according to one authority, 3 were from the nose. In the same place

1. Verhandl. der D. otol. Gesellsch.," 1896.

2" Deutsches Arch. f. klin. Med.," vol. XLIV, p. 297.

$ Quoted from Hoffmann, "Lehrb. der Constitutionskrankh.," p. 121, No. 43