Holz saw two children who, on the second day of influenza, were attacked by a "cholera like enteritis with convulsions and unconsciousness." After a coma of twenty four hours they awoke and recovered without interruption. Simon points out that influenzal gastro enteritis occasionally sets in with very alarming symptoms of acute collapse, but, nevertheless, ends in remarkably rapid recovery. Such cases, which resemble cholera or an acute alimentary toxemia, are mentioned by Warfvinge, and particularly in the official reports from Bavaria, Baden, Hessen, etc. Harder and Behier called attention already in 1830 in Paris to the similarity of intestinal forms of influenza to cholera.

The gastric and other digestive disturbances continue occasionally long into convalescence, and thereby give rise to severe nutritive disturbances and frequently to marked loss of weight.

Besides a case of hyveremesis incoercibilis as a sequel of influenza, in a man nineteen years of age, who was anything but hysteric,** we observed many cases in which complete anorexia and other gastric disturbances continued for weeks after convalescence from influenza. _ The affected patients became markedly emaciated. In older individuals this produced a chronic "influenza cachexia" which often suggested a more serious gastric affection (carcinoma) until this apprehension was removed by recovery, often much delayed.

An exceedingly robust and stout brewer, forty years of age, during the seven weeks following influenza, by reason of complete anorexia, decreased in weight from 105 to 72 kilos. His appearance was so altered that his friends did not recognize him.***

Elste (German marine report) found loss of body weight in all cases. It was occasionally very marked, even up to 11 kilos, in cases of but five days' duration; the average was 5 kilos. The health report from the Grand Duchy of Oldenburg contains the following: "Some persons showed, within fourteen days, a decrease of body weight up to 7.5 kilos." Pribram, who weighed daily the patients in his own family, found, even in the first few days, marked loss in weight. Brakenridge (Edinburgh) and Umpfenbach report the same fact.

* Our influenza lectures, p. 36.

**Ibid., p. 33. An analogous case mentioned by Revilliod. ***Ibid., p. 33.

Liver

As regards influenzal hepatic disease, the reports are mainly pathologic. Hyperemic conditions, parenchymatous degeneration, cloudy swelling, small celled infiltration, microscopic tissue necrosis, and formation of thrombus (Kuskow) are mentioned.

The conditions for the formation of abscess of the liver, of which Krannhals and Cimbali have observed a case, are present in the severe forms of hemorrhagic ulcerative enteritis. The statements concerning acute yellow atrophy of the liver after influenza are to be received with extreme skepticism. Reynal describes a case of " icterus gravis" after influenza.

Experiences concerning the frequency of icterus in influenza are very varied. It is mentioned by Lancisi (1709) and by Huxham (1737) as an occasional occurrence,-"some fell into jaundice,"-as well as by many later authors (Stoll, 1775, and others).

Peacock, in his description of the epidemic of 1847-1848, remarked that " a frequent symptom was a feeling of heaviness and pain in the right hypochonclrium, which was generally combined with a certain amount of icteric discoloration of the conjunctivae or the skin in general." Baumler observed, in the last pandemic, "icterus, or at least icteric discoloration, of the sclera," in 88.5 per cent, in males and in 76.8 per cent, in females-that is, practically always. He considers, therefore, that jaundice is an " important diagnostic symptom" and "an important prognostic sign." Bile pigment was not, but urobilin was, found in the urine. He thinks the jaundice probably hematogenous, caused by the destruction of red blood cells.

In our 439 cases in the pandemic of 1889-1890 we recognized the presence of jaundice only twice during convalescence from influenza, but we must admit that we did not look for traces of icterus in the conjunctivae. We did so with great care in the following epidemic, but with absolutely negative results. But it is possible that our standard of "weakly icteroid," "subicteroid," color of the sclerotic differs from that of other observers. The hospital statistics of Hamburg, Leipsic, Munich, Wiirzburg, and the English authors and statisticians (Preston, Bristowe, Parsons) do not mention jaundice at all.

In the German collective investigations only 2 per cent, of the reporters mention jaundice, and in the collective investigation of Breslau, of 234 physicians who sent returns, only four of them reported cases of jaundice. Gutmann (Nuremberg) and Senator mention that they observed jaundice twice. Comby saw icterus but once among 218 children, while Weiss (Neumarkt a. R.) observed it four times in 110 cases. On the other hand, Rota (Bamberg) and Bergmann (Pottenstein) saw "numerous cases of icteroid discoloration of the conjunctiva? and skin, as well as marked catarrhal jaundice," and the medical officer for the district of Merseburg reports, as the result of information supplied by the physicians of his district, that "in all the febrile cases, whatever the form of the disease, there was slight jaundice of the skin and eyes, as well as bile pigment in the urine."

There can be no doubt that jaundice occurs but very rarely in influenza, provided we do not count as such every suspicious yellowish discoloration of the posterior fatty layer of the scleral conjunctiva. But since all, even the rarest, complications of influenza occasionally accumulate in particular localities, this may have been the case with the concomitant jaundice in Freiburg, Bamberg, Pottenstein, and Merseburg. These exceptions are very remarkable; possibly in these cases there is a mixed infection with the, still hypothetic, etiologic cause of the so called "catarrhal icterus." But it is impossible to consider jaundice in influenza as of "general pathognomonic diagnos tic significance."

Spleen

In influenza, as a rule, the spleen is but rarely so much increased in size that a distinct enlargement can be demonstrated at the bedside. This applies particularly to the immense majority of mild cases. But in several cases (about 15 to 20 per cent.) influenza, simple as well as complicated, gives rise to definite splenic enlargement, which can be determined with certainty during life, and whose existence is frequently confirmed at the postmortem examination.