Lesions of the pancreas were not encountered. In a few cases the lymph glands about the head of the pancreas were slightly enlarged.
The spleen showed relatively little reaction and in only two cases was it enlarged. Fourteen times a diagnosis of acute splenitis was made on examination of the gross specimen. This diagnosis rested upon the finding of a swollen spleen with tense capsule and with a dark bulging pulp. The Malpighian bodies were usually in part or completely obliterated, though in a few instances these grayish nodules seemed even larger than normal. These spleens contained an excess of blood within the pulp. In one case several isolated areas appeared hemorrhagic as if a local rupture of the tissues had occurred. The microscopic examination of these specimens showed mainly a marked congestion of the sinusoids, a diminution in the size of the lymphoid corpuscles and some increase in the number of leucocytes within the blood spaces and reticulum. Only occasionally did we observe a proliferative reaction of the large mononuclear cells lying in the reticulum. This proliferation was not sufficiently marked nor uniformly present to be considered as characteristic. We did not find abnormal deposition of blood pigment indicating an unusual destruction of red blood cells within the spleen. It is interesting to note that 5 of the 32 cases showed obsolete miliary tubercles in the spleen.
Our analysis of the changes occurring in the kidney bore out the clinical findings observed in the wards. Like in so many acute infectious diseases urinary changes were commonly present. These are in part dependent upon systemic changes in the metabolism of tissues and not entirely the result of renal lesions. In acute epidemic influenza there was no common characteristic in the urinary output. The amount excreted in 24 hours was usually diminished to a small extent, the color was darker, the specific gravity slightly increased, as well as the total solids. There was no marked change in the total quantity of output of any one of the constituents as far as they were analyzed by us. Albumin was present in the urine in variable amounts and in the more severe cases casts were also present. There was only one case in which the quantitative output was much diminished and where some fear was entertained of development of acute uremic manifestations. This individual, however, died before these made their appearance and before there was any evidence that the retention of waste products was causing definite clinical symptoms.
In 30 cases coming to autopsy more or less cloudy swelling was to be observed in the kidney. This reaction varied from a very mild swelling and granular degeneration of the tubules of the cortex to a decided parenchymatous degeneration with loss of nuclear structure and erosion of some of the cells lining the tubules. The convoluted tubules were always most markedly involved. Occasionally this tubular degeneration was accompanied by a desquamation of the lining cells of the glomerular capsules. We were, however, unable to recognize an acute inflammatory reaction in the interstitial tissue or in the glomeruli in any of the cases, except the one which had developed a streptococcus bacteriæmia as a sequel to an otitis media. The kidney lesion reminded one very much of the toxic lesion which is observed in the kidney in typhoid fever. Differing, however, from the latter there was a variable congestion of the fine vessels associated with the cyanosis which was present in a certain percentage of these cases. At times the kidneys were quite wet with blood from the venous engorgement.
The lesions in the kidney were of a toxic type and did not resemble reactions following the presence of the bacteria in the stroma of the organ. In the majority of instances in other diseases where bacteria themselves locate in tissues we are able to recognize focal lesions of acute necrosis or inflammation. In epidemic influenza where a variety of micro-organisms within the lung are able to reach distant structures in a bacteriæmia, we would, because of their type, expect to find inflammatory reactions of a definite kind. The absence of such reactions is very suggestive that the bacteria do not commonly localize in the kidney, but that their toxins alone affect it during its elimination. We have also entirely missed the finding of any vascular lesions in the renal system. Neither degeneration nor inflammatory reactions of any of the coats of the blood vessels could be distinguished.
The partial incapacity on the part of the kidneys must, therefore, be viewed as a complication resulting from the effect of a diffusible toxin reaching them by the blood stream. The damage performed in this manner may be quite extensive upon the secreting tissues of the tubules leading to an increased or decreased output of the urinary constituents. Because of the nature of the lesion, it is probable that the kidney damage incurred during the acute epidemic influenza is only temporary and not permanent. Tubular degeneration is readily repaired, and in the absence of an inflammatory reaction in the interstitial tissue or the glomeruli avoids the development of a permanent mark or derangement in the system. This is as we find it in typhoid fever.
In two cases we observed very interesting lesions in the bladder. These two individuals during life had been excreting markedly blood-stained urine for some days preceding death. In the one case the hemorrhage was so marked that on standing, about one-tenth of the urine was composed of sedimented red blood cells. It was assumed that the hemorrhage was of kidney origin until the autopsy revealed a simple cloudy swelling of the kidney associated with a hemorrhagic state of the submucosa of the bladder. In both cases the posterior wall of the bladder was heavily infiltrated with blood so that the mucosa was raised from the surface and the prominent folds showed a superficial erosion with small points of greenish necrosis. This bladder hemorrhage was concomitant with hemorrhagic foci elsewhere in the body, pericardium, pleura, stomach and intestine. Alone in the bladder however, the hemorrhage formed a distinct mass and allowed a considerable escape from the lesions on the surface. These areas of hemorrhage were not infected and showed no local inflammatory reaction. They also appeared to be toxic in origin and resembled the hemorrhages occurring in the muscles of the abdomen.
Changes in the adrenal gland were noted in 14 instances. In all of these there was the picture of what is commonly known as cloudy swelling of the cortex and, in addition to this, in three cases small petechial hemorrhages were observed. The so-called cloudy swelling of the adrenal consists largely in a loss of the bright golden appearance of the cortical tissues accompanied by soft œdematous swelling. The tissues change color to a brown or clay color, and it is not uncommon to observe that the inner zone of pigmentation is more diffuse. There is no sharp demarcation between the layers of the cortex. With this alteration in the outer structure of the adrenal, the medulla not uncommonly appears smaller. This change is more apparent than real, and we have not been able to observe any definite lesion in the nervous portion. At times we believed that the inner tissue appeared more cellular, but it was not possible to determine any specific alteration in the cells.
The changes in the adrenal cortex are comparable to those observed in typhoid fever. The analyses of these tissues showed that the cells were almost devoid of cholesterin bodies and few doubly refractile globules could be demonstrated. This change in the adrenal is by no means specific for any acute disease, it being found in many of the severe infections. We regret that systematic analysis of the blood serum in these cases was not made to determine the cholesterin content. If the comparison bears out with typhoid fever, we would expect to find that the quantitative cholesterin of the blood is diminished. Some importance attaches itself to the study of the cholesterin metabolism, particularly in regard to the development of the peculiar fatty streaks which develop in the aorta and other arteries during these acute infections. It has been claimed that in the human these streaks bear an analogy to those produced in the experimental animals and that the arterial lesions are associated with an altered activity on the part of the adrenal cortex in handling the cholesterin compounds. In influenza there is evidence that the adrenal does not function in a normal fashion and that the storage of cholesterin-esters does not take place. From this, however, we cannot conclude that the blood content is increased, and, in fact, it is more than probable in comparing the other reactions of the disease that it follows the changes as seen in typhoid fever where the blood content of cholesterin is lowered. In this way comparison with the experimentally produced arterial lesions in animals is not clear, in as much as in the experimental work a true hypercholesterinemia was induced. Nevertheless it is possible that with the abnormal function on the part of the adrenal the cholesterin materials are made more available for absorption by other tissues and that a true hypercholesterinemia is not necessarily a constant factor, even with the abnormal accumulation of these substances in the intima. It may well be that the normal activity of the adrenal is related to the presence of toxins in the circulation and an attempt by mobilizing cholesterin to diminish the activity of these harmful substances.