Hepatic and gastrointestinal

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 Arab Journal of Gastroenterology xxx (xxxx) xxx

Contents lists available at ScienceDirect

Arab Journal of Gastroenterology

journal homepage: www.elsevier.com/locate/ajg

Review article

Hepatic and gastrointestinal involvement in coronavirus disease 2019

(COVID-19): What do we know till now?
Sherief Musa
Endemic Hepatogastroenterology Department, Faculty of Medicine, Cairo University, Cairo, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Since December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative
Available online xxxx pathogen of coronavirus disease 2019 (COVID-19), has posed a serious threat to global health and is cur-
rently causing a major pandemic. While patients typically present with fever and a respiratory illness,
Keywords: mounting evidence indicates that patients might also report extra-pulmonary manifestations, including
SARS-Cov-2 those affecting the liver and gastrointestinal tract. This involvement may have important implications to
COVID-19 the disease management, transmission, and prognosis, especially in patients with pre-existing hepatic or
Liver
digestive co-morbidities.
Gastrointestinal tract
Endoscopy
In this review, the characteristics and possible explanations of hepatic and gastrointestinal involve-
ment caused by SARS-CoV-2 infection are summarized, adding to our knowledge of the spectrum of
COVID-19. In addition, preventive measures implemented in endoscopy departments to prevent further
dissemination of SARS-CoV-2 infection are proposed.
Ó 2020 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.

The end of 2019 was marked by emergence of an outbreak
caused by a novel coronavirus, severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), initially reported in Wuhan, China [1].
More than 200 000 laboratory confirmed cases and nearly 10 000
deaths in over 100 countries have been reported to date [2], lead-
ing the World Health Organization in March 11, 2020 to character-
ize the infection, subsequently named coronavirus disease 2019
(COVID-19), as a pandemic [3]. The spectrum of symptomatic
COVID-19 ranges from mild respiratory tract infection to severe
pneumonia that may progress to acute respiratory distress syn-
drome or multi-organ dysfunction [4]. It is well established that
fever along with respiratory symptoms such as cough and dysp-
noea represent the common symptoms of COVID-19 similar to
the diseases caused by the other two highly pathogenic coron-
aviruses: severe acute respiratory syndrome (SARS) in 2003 and
Middle East respiratory syndrome (MERS) in 2012 [5]. There is
uncertainty about extra-pulmonary manifestations of COVID-19,
including those affecting the liver and gastrointestinal tract. This
review aims to provide insight into characteristics, possible mech-
anisms and implications of hepatic and gastrointestinal involve-
ment caused by SARS-CoV-2 infection, adding to our knowledge
of the spectrum of COVID-19.
COVID-19 and the liver
Liver involvement has been reported in patients infected with
SARS-CoV [6] and MERS-CoV [7]. Likewise, published case studies
reporting clinical features of patients with COVID-19 have shown
that they may develop different degrees of liver dysfunction (sum-
marized in Table 1). In these studies, the incidence of liver injury
ranged from 14.8% to 78%, mainly presenting with abnormal levels
of alanine aminotransferase (ALT) and aspartate aminotransferase
(AST) accompanied by slightly elevated bilirubin levels [8–19]. A
deeper look at available data shows higher rates of abnormal levels
in severe COVID-19, as high as 78% in one study [18].
Currently, the underlying mechanisms for hepatic injury in
patients with COVID-19 are still unclear. Liver damage might be
directly caused by virus-induced cytopathic effects. SARS-CoV-2
binds to the angiotensin-converting enzyme 2 (ACE2) receptor to
enter its target cells [20]. Data from two independent cohorts
revealed significant enrichment of ACE2 expression in cholangio-
cytes (59.7% of cells) compared to hepatocytes (2.6% of cells) sug-
gesting that SARS-CoV-2 might directly bind to ACE2-positive
cholangiocytes to dysregulate liver function [21]. Although ACE2
is highly expressed in bile duct cells, recent works suggest that
gamma-glutamyl transferase (GGT) was elevated in 54% of
COVID-19 patients, whereas only 1.8% of patients (1/56) had ele-
vated alkaline phosphatase level [22]. Elsewhere, pathological

E-mail address: sheriefmusa@cu.edu.eg

https://doi.org/10.1016/j.ajg.2020.03.002
1687-1979/Ó 2020 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.

Please cite this article as: S. Musa, Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now?, Arab
Journal of Gastroenterology, https://doi.org/10.1016/j.ajg.2020.03.002
2 S. Musa / Arab Journal of Gastroenterology xxx (xxxx) xxx

Table 1
Characteristics of liver biochemical profile in published COVID-19 case studies.

Patients with Patients with abnormal biochemical liver profile Patients with pre-existing
COVID-19 liver co-morbidities
Guan et al. [8] 1099 Abnormal ALT, 158/741 (21.3%): 23 (2.1%)
- 19
8% in non-severe COVID-19
- 28
1% in severe COVID-19
Abnormal AST, 168/757 (22.2%):
- 18
2% in non-severe COVID-19
- 39
4% in severe COVID-19
Abnormal total bilirubin 76/722 (10.5%)
- 9.9% in non-severe COVID-19
- 13.3% in severe COVID-19
Cai et al. [9] 298 44 (14.8%) 8 (2.7%)
9.6% in non-severe COVID-19
36.2% in severe COVID-19
Fan et al. [10] 148 75 (50.7%)- Abnormal ALT (18.2%)- Abnormal AST 6 (8%)
(21.6%)- Abnormal total bilirubin (6.1%)
Wang et al [11] 138 Mild elevation of ALT and AST 4 (2
9%)
Chen et al [12] 99 43 (43%) NA
- Abnormal ALT 28%
- Abnormal AST 35%
- Abnormal total bilirubin 18%
- Abnormal albumin 98%
Lu et al. [13] 85 33 (38.8%) 6 (7%)
Shi et al. [14] 81 43 (53%) 7 (9%)
Xu et al. [15] 62 10 (16%) 7 (11%)
Yang et al. [16] 52 15 (29%) NA
Huang et al. [17] 41 15(31%) 1(2%)
Zhang et al. [18] 82, deaths 64 (78%) 2(2.4%)
- Abnormal ALT 30.6%
- Abnormal AST 61.1%
- Abnormal total bilirubin 30.6%
Huang et al. [19] 36, non-survivors - Abnormal ALT 13% NA
- Abnormal AST 58%
- Abnormal total bilirubin 12.9%

Abbreviations: SARS-Cov-2, severe acute respiratory syndrome coronavirus 2; ALT, alanine transaminase; AST, aspartate aminotransferase.

analysis of hepatic tissue from a patient who died from COVID-19
did not find viral inclusions in the liver [23].
In addition, immune-mediated inflammation might contribute
to liver injury in patients with COVID-19 who are critically ill
[22]. Previous studies have shown that inflammatory cytokine
storm is associated with adverse outcomes of SARS-CoV [24] or
MERS-CoV infection [25]. Inflammatory cytokine storm is an over-
active inflammatory response, which leads to persistent activation
of lymphocytes and macrophages that secrete huge amount of
inflammatory cytokines [26]. Lymphocytes are important for
inhibiting overactive innate immune responses during viral infec-
tion [27]. Thus, the typical lymphopenia during SARS-CoV-2 infec-
tion may result in increases in interleukin-6 (IL-6), IL-10, IL-2 and
IFN-c levels and aggravated inflammatory responses, leading not
only to pulmonary injury, but also the injury of non-pulmonary
organs including the liver [28]. A study of the risk factors involved
with hepatic injury in patients with COVID-19, found that lym-
phopenia and CRP level were independently associated with liver
injury, suggesting that inflammatory cytokine storm might be the
major mechanism [29].
Another possible contributing factor may be the high levels of
positive end expiratory pressure that can cause hepatic congestion
by increasing right atrial pressure and impeding venous return.
However, published data suggest that admitted patients with
COVID-19 have liver abnormalities without mechanical ventila-
tion. Furthermore, the distribution of aminotransferase levels
among patients with COVID-19 does not support hypoxic hepatitis
being common [30]. Importantly, drug-induced liver injury during
COVID-19 treatment should be carefully investigated. It might be
caused by antiviral medications (lopinavir/ritonavir), antipyretics
(acetaminophen), antibiotics (macrolides, quinolones) or steroids
[31]. In a paper describing the first 12 patients with COVID-19 in
the United States (U.S.), the three hospitalized patients, who
received remdesivir at the time of clinical worsening, reported ele-
vated liver enzymes [32].
COVID-19 and pre-existing liver disease
Given the high burden of chronic liver disease worldwide, inter-
actions between pre-existing liver disease and COVID-19 need to
be further investigated. Preliminary data indicate 2–11% of
patients with COVID-19 had liver comorbidities [22]. However,
the exact cause of pre-existing liver conditions has not been out-
lined in the published case studies (Table 1).
In a study of 1099 patients with laboratory confirmed COVID-
19, 23 (2.1%) patients had hepatitis B infection. Severe cases were
more likely to have hepatitis B infection (2.4% vs 0.6%) than non-
severe cases [8]. SARS patients with HBV/HCV infection were more
prone to develop severe hepatitis, probably due to enhanced viral
replication during SARS-CoV infection [33]. Individuals at high risk
for severe COVID-19 are typically of older age and/or present with
comorbid conditions such as diabetes, cardiovascular disease, and
hypertension, a similar profile to those at increased risk for nonal-
coholic fatty liver disease, making them more susceptible to liver
injury. In patients with COVID-19 with autoimmune hepatitis,
the effects of administration of glucocorticoids on disease progno-
sis is unclear. Given the expression of the ACE2 receptor in cholan-
giocytes, whether infection with SARS-CoV-2 aggravates
cholestasis in patients with primary biliary cholangitis, needs to
be studied [22].
Moreover, patients with liver cirrhosis might be more suscepti-
ble to infections because of their systemic immunocompromised
status [34], thus, preventing infection with SARS-CoV-2 is of
utmost importance. In a study of 111 patients with decompensated
cirrhosis in Wuhan, none of the participants had clinical symptoms
suggestive of SARS-CoV-2 infection, when certain precautionary

Please cite this article as: S. Musa, Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now?, Arab
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 S. Musa / Arab Journal of Gastroenterology xxx (xxxx) xxx
approach was maintained, in contrast to an incidence of 17% of
COVID-19 among a comparative group of 101 decompensated cir-
rhotics at other hospitals where these measures had not been
implemented [35]. Finally, liver transplantation might involve a
risk of transmission of viral infection from donor to recipient, as
shown in the previous SARS outbreak [36]. Michaels and colleagues
recently described possible risks associated with transplant in
COVID-19 positive recipients [37]. In Italy, where the COVID-19
outbreak is rapidly spreading, the Italian Transplant Authority rec-
ommended nasopharyngeal swab or bronchoalveolar lavage to
identify COVID-19 before donation, with consequent exclusion of
positive donors [38].
COVID-19 and the gastrointestinal tract
Since SARS-CoV-2 RNA was first detected in a stool specimen of
the first reported COVID-19 patient in the U.S., much attention has
been paid to gastrointestinal tract infection by SARS-CoV-2 [39].
Gastrointestinal involvement is well known in coronavirus infec-
tions of animals and humans [40]. Previous studies have revealed
that 10.6% of patients with SARS and up to 30% of patients with
MERS had diarrhea [41].
Similarly, data from early reports of the current pandemic sug-
gest that concurrent gastrointestinal symptoms are not uncommon
in patients with COVID-19 [42]. In one of these studies, nausea or
vomiting, or both, and diarrhoea were reported in 55 (5
6%) and 42
(3
8%) patients [8]. In another cross-sectional study, enrolling 204
patients with confirmed COVID-19 from 3 hospitals in Hubei pro-
vince, 99 patients (48.5%) presented with digestive symptoms as
the chief complaint, including 7 cases in which there were no res-
piratory symptoms [40]. This should alert gastroenterologists to
raise their index of suspicion when at-risk patients present with
digestive symptoms rather than waiting for respiratory symptoms
to emerge. This may help with earlier identification of COVID-19
with earlier treatment and isolation [42].
A recent study by Wei et al. attempted to delineate differences
between COVID-19 patients with diarrhoea (26/84) and those
without. Despite finding no difference in most of the laboratory
and radiologic findings, they noticed that COVID-19 patients with
diarrhoea suffered headache, myalgia or fatigue, cough, sputum
production, nausea, vomiting more frequently than those patients
without diarrhoea, but seldomly suffered abdominal pain, abdom-
inal distension and tenesmus [43].
Patients without digestive symptoms were more likely to be
cured and discharged than patients with digestive symptoms
(60% vs. 34.3%). This could be due to either viral replication in
the gastrointestinal tract causing more severe disease or that
patients who do not initially have typical respiratory symptoms
present with later stages of disease [42].
There are many hypotheses why COVID-19 appears to cause
digestive symptoms, but, the exact molecular mechanism needs to
be further investigated. Firstly, interaction between SARS-CoV-2
and ACE2 might result in diarrhoea. A recent bioinformatics analysis
revealed that ACE2 was not only highly expressed in alveolar type II
(AT2) cells in the lung, but also in the glandular cells of gastric and
duodenal epithelia [44]. Similar findings were found in the study
by Liang et al. [45], ACE2 was highly expressed in proximal and distal
enterocytes, directly exposed to food and foreign pathogens. The
ACE2-expressing enterocytes are invaded by SARS-CoV-2, leading
to malabsorption, unbalanced intestinal secretion and activated
enteric nervous system, resulting in diarrhoea finally [44]. Secondly,
SARS-CoV-2 indirectly damages the digestive system through a
chain of inflammatory responses [42]. Another possible factor caus-
ing diarrhoea in COVID-19 patients might be antibiotic associated
diarrhea [43]. Finally, changes in the composition and function of
Please cite this article as: S. Musa, Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now?, Arab
Journal of Gastroenterology, https://doi.org/10.1016/j.ajg.2020.03.002
3
digestive tract flora mutually affect the respiratory tract through
immune regulation, the so-called ‘‘gut-lung axis” [46].
Autopsy studies are needed to understand the digestive system
involvement of COVID-19; however, to date, there has been only
one autopsy report for an 85-year-old man with COVID-19, which
showed segmental dilatation and stenosis in the small intestine
[47]. Whether this finding is secondary to COVID-19 is unknown
[48].
All these findings and hypotheses could have a clear impact
regarding transmission precautions, especially in hospitalized
patients. Considering the evidence of faecal excretion for both
SARS-CoV and MERS-CoV [49], it is possible that the digestive sys-
tem may serve as an alternative route of SARS-CoV-2 infection. It
has been reported that the stool from confirmed cases tested pos-
itive by RT-PCR for SARS-CoV-2 [39]. In terms of the fact that most
of the patients in the initial outbreak reported a link to a wild ani-
mal market, this observation raises questions about whether this
virus was transmitted via contaminated food at the small intestine
[45]. Another issue of potential significance, is the extended dura-
tion of viral shedding in faeces. In one study, it was observed that
for over half of patients, faecal samples remained positive for SARS-
CoV-2 RNA for a mean of 11.2 days after viral clearance in respira-
tory tract samples [50]. According to current guidance, the decision
to discharge hospitalized COVID-19 patients is based on negative
results of RT-PCR testing for SARS-CoV-2 from at least two sequen-
tial respiratory tract specimens collected 24 h apart [51]. There-
fore, routine stool sample testing with RT-PCR could be added and
transmission-based precautions should be continued if faecal sam-
ples test positive [50].
COVID-19 and pre-existing digestive diseases
In general, presence of co-morbidities is associated with poorer
outcomes in patients with COVID-19. This may have implications
for the management of patients with pre-existing digestive dis-
eases [52]. Patients with cancer are more susceptible to infection,
however, whether patients with gastrointestinal cancers are more
likely to be infected with SARS-CoV-2 than healthy individuals
remains unknown [48]. In a nationwide analysis from China, 18
(1%) of 1590 COVID-19 cases had a history of cancer. Among these
18 cases, three had a history of colorectal cancer. Patients with
COVID-19 and cancer had a higher risk of severe events [53]. Like-
wise, patients with inflammatory bowel disease (IBD) using biolog-
ics and immunosuppressive agents are at increased risk for more
frequent and severe infections and could be more susceptible to
SARS-CoV-2 infection [48]. Fortunately, with early precautions
for COVID-19 prevention and control, not a single patient of the
318 patients (204 with ulcerative colitis and 114 with Crohn’s dis-
ease) in the IBD registry in Wuhan, has been reported to be
infected with SARS-CoV-2 [54]. These precautions included recom-
mendations on the use of immunosuppressive agents and biolog-
ics, diet, and intentional postponement of elective surgery and
endoscopy, as well as personal protection provisions [55]. In regard
to recurrent Clostridioides difficile infection, experts in faecal
microbiota transplantation believe that screening of stool donors
is needed, as the risk of transmitting SARS-CoV-2 might be higher
than that in other tissue transplants [56].
COVID-19 in the endoscopy unit
Worldwide, as millions of people are instructed to stay home to
minimize SARS-CoV-2 transmission, health-care workers are at
high risk from COVID-19. Figures from China’s National Health
Commission show that more than 3300 health-care workers have
been infected as of early March [57]. Despite being not directly
4 S. Musa / Arab Journal of Gastroenterology xxx (xxxx) xxx

Fig. 1. Suggested workflow in GI endoscopy units during SARS-CoV-2 outbreak.

involved in management of COVID-19 patients, personnel working
in endoscopy units are still at increased risk from inhalation of air-
borne droplets, conjunctival contact, and touch contamination
[58]. Human-to-human transmission occurs primarily via infected
droplets [59]. Airway suctioning, and other cough-inducing proce-
dures pose an increased risk of transmission of SARS-CoV-2 [58]. It
must be noted that the risk of exposure is not limited to upper
endoscopy considering the potential transmission through faecal
shedding [60].
All endoscopy facilities should develop standard operating mea-
sures for COVID-19 prevention and control in conjunction with
infection control team members, and share these widely among
staff members [61]. Based on prior experience from SARS and our
current understanding of epidemiological characteristics of
COVID-19, the following steps should be implimented in endo-
scopy units:
1. Reduction of non-essential exposure to SARS-CoV-2: It is rec-
ommended to limit endoscopy during the current outbreak to
emergency procedures to treat patients with conditions such
as acute gastrointestinal bleeding, foreign bodies in the gas-
trointestinal tract and acute cholangitis secondary to biliary
obstruction [62].
2. Risk assessment and stratification of patients prior to any
endoscopic procedure: A high index of suspicion to diagnose
SARS-CoV-2 infection, is crucial for prevention of transmission.
Screening of patients for COVID-19 should be based on case def-
initions established by WHO and local health authorities [63].

Please cite this article as: S. Musa, Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now?, Arab
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 S. Musa / Arab Journal of Gastroenterology xxx (xxxx) xxx
The assessment must include history of fever, respiratory symp-
toms, or diarrhea, history of contact with a suspected or con-
firmed case of COVID-19 and any recent travel to a high-risk
area [61].
3. Negative-pressure room: Whenever possible, endoscopy
should be performed in an isolated room with negative pres-
sure. If not available, endoscopy should be performed in a ded-
icated room with adequate ventilation [64].
4. Staff protection: The minimal composition of personal protec-
tive equipment (PPE) for personnel in endoscopy units should
include gloves, hairnet, protective eyewear (goggles or face
shield), waterproof gowns, and respiratory protective
equipment, modified on the basis of risk stratification [61].
The surgical facial mask is effective in blocking splashes and
large-particle droplets, whereas, filtering facepiece (FFP) respi-
rator class 2 or 3 (FFP2/FFP3) achieves efficient filtration of air-
borne particles (up to 0.3 mm) [65]. In addition to PPE, health
care workers must be educated the principles of contact and
airborne precautions for both suspect and probable COVID-19
patients [64].
5. Reprocessing of endoscopes and endoscopic accessories:
Enveloped viruses such as SARS-CoV-2 can be inactivated by
disinfectants having virucidal activity [67]. Whereas high-
level disinfection is recommended for endoscopes, and other
‘‘semi-critical’’ instruments, sterilization is recommended for
‘‘critical’’ instruments, including biopsy forceps, polypectomy
snares and papillotomes. Disposable accessories are an alterna-
tive to sterilization of reusable devices [68].
6. Decontamination of endoscopy rooms: This process should
include cleaning all surfaces in the procedure room to remove
all soil and biofilm, followed by proper disinfection [61].
Chlorine-containing detergents are recommended for floor
cleaning every day [67].
To prevent SARS-CoV-2 transmission in endoscopy units during
the current outbreak, a workflow is proposed (Fig. 1) in accordance
with recommendations of endoscopy societies [61–66].
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Another random document with
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 “You want to know how old Henry C. Terry is,” promptly said Reese.
Then plainly puzzled, he shook his head and went on to a question as to
what was the floor covering. The next question was: “Where did I do my
first newspaper work?”
He gave correctly the answer. The last slip Reese took in his hand, but
did not open it. He handed it back and directed the writer to hold it. Then
Reese said:
“Emma Drew was your mother’s maiden name.”
The answer to the first five questions had been given in a room adjoining
the court, but for the last Reese walked into the courtroom and gave his
answer in the presence of the judge and jury.
Judge Rosalsky wrote several questions, as follows:
“What was the ruling in the Shelly case?”
“How much money have I in the bank?” and
“What is the name of my favorite school-teacher?”
The demonstrator not only told what the questions were, but gave the
correct replies. Reese is seventy-four years old.
“I don’t know myself how I do it,” he said. “The answers just sort of
flash on my brain as a picture, just as ordinary objects are seen through the
eye.”

Kaiser’s Big Cannon Can’t Make Raindrops.

So many days during the last two months have been rainy or cloudy that
a great many people are led to believe that so much wet weather is owing to
the war in Europe. “Our heavy rainfall is probably caused by so much firing
over there,” is a remark frequently heard. Indeed, as long as man can
remember, it has been a theory accepted by many that constant or heavy
explosions in the air will produce rainfall. Tests of this kind have been made
in various parts of the country—more often in the west and southwest—and
sometimes with evident success, yet skeptics were quick to say: “Shucks, it
was time they had a shower, anyway.”
Now let us see how the ancients looked at this question. Almost since
the beginning of history there has been a theory—a silly one, says one
scientist—that battles caused rain. Battles, not explosives, observe, for in
the early centuries, A. D., there were no gunpowder or similar explosives.
“Banish the thought,” says Forecaster Pennywitt, of the United States
Weather Bureau, in discussing the question of explosives and rainfall.
“There never was a more absurd idea. Not in all the history of the world is it
recorded that human endeavor wrung rain from the skies, either
intentionally or unknowingly. Rain falls by the will of nature only, and the
influence of man over nature, in so far as producing rain is concerned, does
not exist.
“None of men’s activities on earth has the slightest effect on the rainfall.
If nature decrees it shall rain, then rain it will; no other power or force can
bring precipitation.
“Almost since the beginning of history there has been a silly theory that
battles caused rain. This was the case even before gunpowder came into
use. The Greek writer, Plutarch, as far back as the year 150 A. D., held the
belief that the glitter and clash of the sabers of the ancient Greek and
Roman warriors on the field of honor produced rain. He believed it because
it generally rained after every battle. As a matter of fact, it had to rain after
every battle, because they fought only on clear days in those times; and,
besides, it always rains once every three days in the year, according to
average.
“After gunpowder became an instrument of destruction, rains during
time of war were blamed on it. Even the United States government has
shared this belief that powder will produce rain, and it wasted thousands of
dollars trying to make it rain in Texas. Similar experiments were made in
Europe several years ago, and in France one scientist thought that by
employing the explosive he could transform hail into more harmless rain.
“Strange as it may seem to a good many people, there has been less than
a normal rainfall in western Pennsylvania and other eastern districts during
the last six months.”

Bees Settle in a Mail Box.

The wanderlust of summer got into the blood of a swarm of bees
belonging to Leo Nickoli, 448 Bellaire Avenue, Kansas City, Mo. They
circled in the air and flew away. Mr. Nickoli followed.
 The awning in front of the drug store of the Klee Drug Company first
attracted the bees. But finding no place to alight there, the bees transferred
their attentions to a mail box near by. In a moment the box was the center of
the swarm, who were preparing to settle down among the letters.
Mr. Nickoli, however, had different plans. With a hive baited with honey
comb, he began coaxing the bees into a new home. A crowd of two hundred
persons watched his operation, which lasted several hours.

Aged Preacher Finds His Long Lost Sister.

An only sister, whom he had not seen nor heard from for more than
forty-five years, and whom he believed to be dead, has been found by
Reverend W. H. H. Ruble, of Harrison, Ark., and immediately after the
locating of the long-lost sister, he has received news that sight has been
restored to the woman who has been blind for many years, as a result of
cataract.
Reverend Ruble’s sister is Mrs. E. J. Willis, of Knoxville, Tenn. She is
ninety-two years of age, and was last seen by her brother more than forty-
five years ago in Cleveland, a small town of Tennessee. As many people do,
the brother and sister kept in touch for a time, but gradually ceased writing,
until each had changed address and the old addresses were forgotten.
Receiving no word for years, each believed the other to be dead, until
last January, when the annual conference of the M. E. Church was held in
Harrison, Ark. At that time Reverend Ruble met Reverend Murphy, a
delegate, who told him of the whereabouts of Chaplain J. A. Ruble, of the
Old Settlers’ Home in Johnson City, to whom Reverend Ruble wrote,
believing that the chaplain might be his nephew. The belief was true, and
the letter from Harrison was forwarded to Mrs. Willis, who was overjoyed
when she wrote again to her brother, the first time in nearly half a century.

Arizona Girl Carries Mail on Horse.

Miss Matilda Sorey, of Higley, Ariz., may not be the only girl in the
United States who carries mail on a R. F. D. route, but she is probably the
only one who does so on horseback. When a new route was established out
of Higley, Miss Sorey, who is just twenty-one years old, was appointed
carrier. Her friends supposed she would use a horse and buggy, but, instead,
she covers the route six days a week on her handsome gray saddle horse.
She carries the mail in a sack swung over the pommel of her cowboy
saddle.

Didn’t Even Have a Barrel.

A short time ago C. J. Debes, who lives on a farm a few miles south of
Hagerman, N. M., arose early, as was his custom, and, after lighting his
gasoline stove and placing his kettle on, sauntered out through the
delightful morning air to feed his stock, without changing his night robe for
the more substantial clothing of the day.
Debes being a bachelor, and there being no near neighbors, everything
went well with him until he started to return to his house and found it
almost consumed by fire. His predicament seemed precarious, when the
neighbors, seeing the flames, rushed to the scene. Debes, however, took
refuge in the barn until a friendly neighbor brought in some heavier
raiment. The gasoline stove had exploded and enveloped the entire building
in flames, making quick work of its destruction.

No Government Reward for Passenger Pigeon.

Recent widespread newspaper accounts to the effect that the United
States Department of Agriculture is offering ten thousand dollars reward to
the person finding a passenger or “wood”-pigeon nest containing two eggs,
resulted in hundreds of letters being sent to the department.
The report is not based upon facts, as the department has offered no such
reward, and there is every reason to believe the passenger pigeon which
formerly roamed the country in flocks of millions is extinct. In 1910 about
one thousand dollars in rewards was offered by Clark University for the
first undisturbed nests of the passenger pigeon to be found in the United
States. This was a great stimulus to action. The hunt for this pigeon was
fruitless. The offer of rewards was renewed for several years, until it was
fully established that the pigeon was extinct.
The passenger pigeon up to 1885 ranged the American continent east of
the Rocky Mountains. The mourning dove has often been mistaken for the
passenger pigeon, which in a general way it resembles. However, this bird
is quite distinct from the passenger pigeon; it is shorter and has different
color markings.
The press reports stated that the now extinct passenger pigeon was
valued because of its usefulness in destroying the gipsy moth and other
moths and pests which are doing millions of dollars of damage. Although
the preservation of this pigeon is much to be desired, it would be of
absolutely no value in eliminating the gipsy moth, as the pigeons are almost
entirely vegetarian in their diet.

Wounded Dog Returns Home.

A dog belonging to Edward Dougherty, of Spring Grove, Pa., was shot
through the head twice with a thirty-eight-caliber revolver by Dougherty.
The dog lay on the same spot for seven days and seven nights, but on the
beginning of the eighth day he came back to his old home, hardly able to
drag himself along. After being fed and given water to drink, the dog
seemed to be all right.
The dog ate eggs from the nests in Dougherty’s henhouse before his
punishment and since his extraordinary experience he has not eaten one
egg. Mr. Dougherty is sure he put two bullets through the dog’s brain.

Muskrat and Trout Battle.

Lew McQuiston, a well-known angler of Bellefonte, Pa., witnessed a
unique battle a few days ago between a muskrat and a two-foot trout.
McQuiston went to Spring Creek shortly before dusk to try and land
some big trout. While whipping the stream, he saw something doing on the
other side of the creek, about sixty feet away from where he was standing.
In the quickly gathering shadows it was hard to tell at first what it was, but
after closer inspection he saw that it was a mammoth trout and a muskrat.
They were engaged in mortal combat, and they slashed around through
the water until it was churned into foam. Then the muskrat managed to get
out on the bank, pulling the trout along with it. But the big trout seemed to
be able to fight on land as well as in the water, flopping around and holding
on to the muskrat’s nose until they finally both fell back into the water.
 Then there was another lashing and foaming, and the noise died away. A
few ripples told that the struggle was ended.
McQuiston looked around in the water for evidence of who had won the
battle, but found neither the muskrat or the trout. He does not know whether
it was a fight to the finish or a draw.

Tongue Fenders Demanded.

Tongue fenders for salted-peanut vending machines. That’s the latest
slogan of Montclair, N. Y., which already has put a legal muffler on barking
dogs and crowing roosters. It was proposed by Health Commissioner James
McDonough after he saw a small boy thrust his tongue into a cup container
of a vending machine to get the “crumbs.”

Finds Pennies in Turtle.

Roy Bowsher, of Ashville, Ohio, went fishing last week and caught a
turtle, which he sold to C. R. Cook, proprietor of a saloon. When Cook
opened the turtle, preparatory to serving it on his lunch counter, he found
two hundred and thirty-four pennies in it.

The Nick Carter Stories

ISSUED EVERY SATURDAY BEAUTIFUL COLORED COVERS
When it comes to detective stories worth while, the Nick Carter Stories
contain the only ones that should be considered. They are not overdrawn
tales of bloodshed. They rather show the working of one of the finest minds
ever conceived by a writer. The name of Nick Carter is familiar all over the
world, for the stories of his adventures may be read in twenty languages. No
other stories have withstood the severe test of time so well as those
contained in the Nick Carter Stories. It proves conclusively that they are
the best. We give herewith a list of some of the back numbers in print. You
can have your news dealer order them, or they will be sent direct by the
publishers to any address upon receipt of the price in money or postage
stamps.
730—The Torn Card.
731—Under Desperation’s Spur.
732—The Connecting Link.
733—The Abduction Syndicate.
738—A Plot Within a Plot.
739—The Dead Accomplice.
746—The Secret Entrance.
747—The Cavern Mystery.
748—The Disappearing Fortune.
749—A Voice from the Past.
752—The Spider’s Web.
753—The Man With a Crutch.
754—The Rajah’s Regalia.
755—Saved from Death.
756—The Man Inside.
757—Out for Vengeance.
758—The Poisons of Exili.
759—The Antique Vial.
760—The House of Slumber.
761—A Double Identity.
762—“The Mocker’s” Stratagem.
763—The Man that Came Back.
764—The Tracks in the Snow.
765—The Babbington Case.
766—The Masters of Millions.
767—The Blue Stain.
768—The Lost Clew.
770—The Turn of a Card.
771—A Message in the Dust.
772—A Royal Flush.
774—The Great Buddha Beryl.
775—The Vanishing Heiress.
776—The Unfinished Letter.
777—A Difficult Trail.
782—A Woman’s Stratagem.
783—The Cliff Castle Affair.
784—A Prisoner of the Tomb.
785—A Resourceful Foe.
789—The Great Hotel Tragedies.
795—Zanoni, the Transfigured.
796—The Lure of Gold.
797—The Man With a Chest.
798—A Shadowed Life.
799—The Secret Agent.
800—A Plot for a Crown.
801—The Red Button.
802—Up Against It.
803—The Gold Certificate.
804—Jack Wise’s Hurry Call.
805—Nick Carter’s Ocean Chase.
807—Nick Carter’s Advertisement.
808—The Kregoff Necklace.
811—Nick Carter and the Nihilists.
812—Nick Carter and the Convict Gang.
813—Nick Carter and the Guilty Governor.
814—The Triangled Coin.
815—Ninety-nine—and One.
816—Coin Number 77.
NEW SERIES
NICK CARTER STORIES
1—The Man from Nowhere.
2—The Face at the Window.
3—A Fight for a Million.
4—Nick Carter’s Land Office.
5—Nick Carter and the Professor.
6—Nick Carter as a Mill Hand.
7—A Single Clew.
8—The Emerald Snake.
9—The Currie Outfit.
10—Nick Carter and the Kidnaped Heiress.
11—Nick Carter Strikes Oil.
12—Nick Carter’s Hunt for a Treasure.
13—A Mystery of the Highway.
14—The Silent Passenger.
15—Jack Dreen’s Secret.
16—Nick Carter’s Pipe Line Case.
17—Nick Carter and the Gold Thieves.
18—Nick Carter’s Auto Chase.
19—The Corrigan Inheritance.
20—The Keen Eye of Denton.
21—The Spider’s Parlor.
22—Nick Carter’s Quick Guess.
23—Nick Carter and the Murderess.
24—Nick Carter and the Pay Car.
25—The Stolen Antique.
26—The Crook League.
27—An English Cracksman.
28—Nick Carter’s Still Hunt.
29—Nick Carter’s Electric Shock.
30—Nick Carter and the Stolen Duchess.
31—The Purple Spot.
32—The Stolen Groom.
33—The Inverted Cross.
34—Nick Carter and Keno McCall.
35—Nick Carter’s Death Trap.
36—Nick Carter’s Siamese Puzzle.
37—The Man Outside.
38—The Death Chamber.
39—The Wind and the Wire.
40—Nick Carter’s Three Cornered Chase.
41—Dazaar, the Arch-Fiend.
42—The Queen of the Seven.
43—Crossed Wires.
44—A Crimson Clew.
45—The Third Man.
46—The Sign of the Dagger.
47—The Devil Worshipers.
48—The Cross of Daggers.
49—At Risk of Life.
50—The Deeper Game.
51—The Code Message.
52—The Last of the Seven.
53—Ten-Ichi, the Wonderful.
54—The Secret Order of Associated Crooks.
55—The Golden Hair Clew.
56—Back From the Dead.
57—Through Dark Ways.
58—When Aces Were Trumps.
59—The Gambler’s Last Hand.
60—The Murder at Linden Fells.
61—A Game for Millions.
62—Under Cover.
63—The Last Call.
64—Mercedes Danton’s Double.
65—The Millionaire’s Nemesis.
66—A Princess of the Underworld.
67—The Crook’s Blind.
68—The Fatal Hour.
69—Blood Money.
70—A Queen of Her Kind.
71—Isabel Benton’s Trump Card.
72—A Princess of Hades.
73—A Prince of Plotters.
74—The Crook’s Double.
75—For Life and Honor.
76—A Compact With Dazaar.
77—In the Shadow of Dazaar.
78—The Crime of a Money King.
79—Birds of Prey.
80—The Unknown Dead.
81—The Severed Hand.
82—The Terrible Game of Millions.
83—A Dead Man’s Power.
84—The Secrets of an Old House.
85—The Wolf Within.
86—The Yellow Coupon.
87—In the Toils.
88—The Stolen Radium.
89—A Crime in Paradise.
90—Behind Prison Bars.
91—The Blind Man’s Daughter.
92—On the Brink of Ruin.
93—Letter of Fire.
94—The $100,000 Kiss.
95—Outlaws of the Militia.
96—The Opium-Runners.
97—In Record Time.
98—The Wag-Nuk Clew.
99—The Middle Link.
100—The Crystal Maze.
101—A New Serpent in Eden.
102—The Auburn Sensation.
103—A Dying Chance.
104—The Gargoni Girdle.
105—Twice in Jeopardy.
106—The Ghost Launch.
107—Up in the Air.
108—The Girl Prisoner.
109—The Red Plague.
110—The Arson Trust.
111—The King of the Firebugs.
112—“Lifter’s” of the Lofts.
113—French Jimmie and His Forty Thieves.
114—The Death Plot.
115—The Evil Formula.
116—The Blue Button.
117—The Deadly Parallel.
118—The Vivisectionists.
119—The Stolen Brain.
120—An Uncanny Revenge.
121—The Call of Death.
122—The Suicide.
123—Half a Million Ransom.
124—The Girl Kidnapper.
125—The Pirate Yacht.
126—The Crime of the White Hand.
127—Found in the Jungle.
128—Six Men in a Loop.
129—The Jewels of Wat Chang.
130—The Crime in the Tower.
131—The Fatal Message.
132—Broken Bars.
133—Won by Magic.
134—The Secret of Shangore.
135—Straight to the Goal.
136—The Man They Held Back.
137—The Seal of Gijon.
138—The Traitors of the Tropics.
139—The Pressing Peril.
140—The Melting-Pot.
141—The Duplicate Night.
142—The Edge of a Crime.
143—The Sultan’s Pearls.
144—The Clew of the White Collar.
145—An Unsolved Mystery.
146—Paying the Price.
147—On Death’s Trail.
148—The Mark of Cain.
Dated July 17th, 1915.
149—A Network of Crime.
Dated July 24th, 1915.
150—The House of Fear.
Dated July 31st, 1915.
151—The Mystery of the Crossed Needles.
Dated August 7th, 1915.
152—The Forced Crime.
Dated August 14th, 1915.
153—The Doom of Sang Tu.
 Dated August 21st, 1915.
154—The Mask of Death.
Dated August 28th, 1915.
155—The Gordon Elopement.
Dated Sept. 4th, 1915.
156—Blood Will Tell.

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