Dr. Friedman : I have not had experience with acute pernicious
anemia, but I have observed some patients for from eight to ten
years. Everyone knows that in pernicious anemia there occur
blood crises, especially in the initial stages. On one examination
you will find a typical picture, and one month later the picture is
questionable, for instance megaloblasts will not be found. Improve-
ments in the blood picture do occur even without treatment. I
don't know why the blood picture does not remain constant. It
never impressed me that splenectomy could benefit the patient
because the enlargement of the spleen is certainly a secondary con-
dition in pernicious anemia. In hemolytic jaundice, which is due to
Hypersplenism, this really is of service. I have a patient who is well
now two years after splenectomy for hemolytic jaundice. The
two conditions are different. In pernicious anemia enlargement of
the spleen is not so pronounced as in other conditions. The spleen
below the umbilicus is rare. The primary condition is not in the
spleen or in the bone marrow. As to the infectious nature of the
disease, I think Dr. Smithies has produced good experimental evi-
dence in his cases. We are accustomed lately to attribute all latent
infection to the tonsils, but we should also consider gastric ulcer,
duodenal ulcer, appendicitis, poliomyelitis. We shall soon be look-
96 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
ing for the primary site of all these infections, which used to be
considered the tonsil. If these cases of pernicious anemia can be
attributed to infection the discovery is of great importance to pre-
ventive medicine. In regard to achylia gastrica, I have never seen
pernicious anemia without this symptom. If there is no achylia,
diagnosis should be made with great reserve. Some years ago I
had a case with typical picture of pernicious anemia â€” with normo-
blasts, megaloblasts, enlarged spleen. The man was seen also at
the Roosevelt hospital, and they refused to make a diagnosis of
pernicious anemia there, because achylia gastrica was not present.
It seems to me this symptom is necessary to complete the diagnosis.
Dr. Baar: If I had had nothing else to repay my trip here, I
should have been abundantly compensated by listening to this paper,
from which I have learned very much. I have gotten the same re-
sults, but in addition I have always observed a constant indicanuria,
as well as the achylia gastrica. This has always given me the clue.
If I don't find that, the case falls into the other category mentioned
by Dr. Smithies. In one case, a boy of nineteen, with enlarged spleen
and liver and tender gelatinous swelling of the glands I tried sal-
varsan injections. The hemoglobin improved from thirty to seventy-
five per cent, and all swellings subsided except the parotid
swellings. Later the patient had erysipelas from which a
streptococcus was recovered. Then he had a focus of infec-
tion in the sphenoid. He took a vaccine treatment. Then
a purulent iritis broke out. He had the same coccus in the blood,
the parotid and the naso-pharynx. He had a pronounced indi-
canuria. As this disappeared, the man's hemoglobin's came up.
In another case of supposed pernicious anemia, in a woman, I found
perforation of the nasal septum. Salvarsan cleared up the condi-
tion, which was congenital syphilis. The immense value of the
"cocci" statement must be appreciated. I don't think it is a case
of looking for bugs in the tonsils. They are there undoubtedly in
many cases. Some of the anemias are also frequently syphilitic.
Dr. W. H. Mercur: I am interested as to the statement by Dr.
Smithies as to the performance of fifty-one laparotomies in this
condition. There is a general impression that splenectomy is the
cure for this condition. Splenectomy is only a cure when the spleen
is the focus of infection; in other words, if the appendix or the
gall bladder is the point of bacterial infection, taking the spleen
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 97
out won't cure the disease. I remember Dr. Osier, some years ago,
in a case of pernicious anemia, said "look at tbe mouth;" the man
had decayed teeth. We learned to look for trouble with the teeth.
In regard to transfusion in these cases, one point advocated by
Percy if of value. One may take all precautions to prevent hemo-
lysis and still it may occur and cause serious trouble. Percy takes
a small quantity, one half c.c. of blood and introduces that. If it
causes hemolysis the donor is unsuitable. This half c.c. will cause
trouble in ten seconds, if at all, and the introduction of 300 c.c. of
the same blood, if unsuitable, would cause much more trouble.
Personally I have never seen cases of pernicious anemia get well.
Dr. Smithies says he had twenty-six cases of pernicious anemia
get well and remain so from six to fifty-one months. I saw the
woman he refers to as the case of longest duration. She certainly
looked robust and in perfect health. It may be that if the source of
infection is removed that the cure is permanent. Dr. Barach spoke
of the use of 606-Arsenic as certainly an advantage but the anemia
in those cases is probably syphilitic. Bradley of Edinburgh proved
that these cases in which salvarsan was beneficial were luetic ane-
mias. An important point is that in a high degree of anemia the
Wassermann is negative. In a case where the Wassermann was
negative, autopsy showed lues from the brain down. Much per-
nicious anemia is luetic in origin. I would like to mention one case
in which we were going to transfuse a pernicious anemia patient
with blood from his brother. The patient had a negative Wasser-
mann and emphatically denied lues. The donor showed a four
plus Wassermann. When he was questioned he said, "Oh yes, I
got that trouble at the same time my brother did," which shows
that the Wassermann reaction is negative in these cases.
Dr. Friedman : I would like to ask why do these patients have
remissions in pernicious anemia. If these cases originate with
infections, do they have reinfections? One point made I don't
think was well taken. It was stated that if the infected tonsil were
removed the case would get well. This does not necessarily follow,
because the damage has been done, but that does not prove that in-
fection did not produce the disease.
Dr. Haythorn: The question that Dr. Mercur raised about the
use of salvarsan in pernicious anemia should be considered. Dr.
Smithies does not need my support, that is evident, but I would
98 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
say that in the last three autopsies we have had, we have recovered,
either from the bone marrow, hearts' blood or spleen a virulent pyo-
genes and an unrecognized spirillum. Salvarsan in the blood stream
is a bactericidal agent and some workers have cleared up streptococci
in the blood stream by this means. Experimental animals have been
saved by this means. I don't think it is necessary for persons to
have syphilis to be benefited by salvarsan. The bone marrow must
be reached by the injection. I would like to see salvarsan used
experimentally in cases where there was no syphilis.
Dr. Ives : We had an extremely interesting case at the Mercy
hospital clinic this morning â€” an endocarditis due to streptococcus
viridans in the blood. In this case the injection of salvarsan cleared
the blood stream of streptococci. A second injection for the same
reason raised the temperature, which came down in the course of a
week. The third injection cleared up the case, which ran a normal
temperature two or three days later. This would seem to indicate
that the temperature was caused by bacteria in the blood, which
were cleared up by 606. It would seem then that salvarsan has
bactericidal action. In the case of streptococcus viridans invasion
of the tonsil, disappearance of the germs can be caused by the appli-
cation of arsenated mercurio-inesol.
Dr. Frank Smithies: I wish to thank the members for their
interesting discussion. In my fragmentary presentation, many
points necessarily were left uncovered. In this disease we have
definite evidence of the infective process in the mouth as in pellagra,
kala-azar, sprue, etc. The first treatment is by chlorate of potasli
mouth wash, or one-half per cent, formalin wash, before anything
else is done. Many of these cases are non-lnetic by laboratory tests
and it is concluded that the action of salvarsan is bacteriolytic. I
am glad to hear reports from Dr. Baar of intermittently active in-
fections in pernicious poisoning. The type is a low-grade septicemia,
by protein end-products poisoning. Salvarsan reactions upon the
temperature and anemia and one could class this disease with low
grade intermittent infection, much as kala-azar. We have not em-
ployed salvarsan in every case. Two had had salvarsan before they
came to us. Any chronic anemia, such as anemia in cancer, may
be called pernicious. The anemia is a lytic anemia, whether it is
caused by bacterial or metabolic products. In the study of immense
material, Cabot states that ninety-nine per cent, have died within
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 99
three and one-half years. The report of blood tests showed that
our patients had had all the remissions they were going to have
before they came to us. Forty per cent, were brought in on stretch-
ers ; some in extremis. We don't know about spontaneous cures,
but we do know that spontaneous cures have not been hindered by
anything that we have done. Recurrences are not uncommon after
splenectomy. The hemo-lymph nodes in the spine may take on the
function of destroying the red blood corpuscles. Patients may
come back with recurrence. We have definite alterations in the
hemo-lymph nodes which have taken up the functions of the spleen.
Dr. Friedman spoke of focal infection. It is not sufficient to say
infection about the teeth or tonsils, but it is important to say what
type of infection. W r e may have vigorous growth of harmless
organisms or very slow growth of very pathogenic organisms.
These can produce serious damage. Removal of the tonsil does not
cure this. There may also be mutations of organism which are
harmless into those which produce serious lesions. Rosenow has
shown this. In regard to achylia gastrica â€” I agree that this is a
constant finding in pernicious anemia, also pancreatic achylia. This
is, however, the end result, where the damage has been done. We
ought now to study the living pathology instead of centering our
attention on dead-house pathology. If the surgeon has done nothing
else, he has contributed a certain amount of pathology while the
patient is still living. Posterity will laugh at us for talking of
achylia gastrica and gastric atrophy. It is a symptom, not a cause.
Diminished hydrochloric acid or pancreatic secretion is an end result.
So it is with the spleen. It has suffered from a chronic, low grade
inflammatory irritation, and there is no intense reaction as in typhoid
fever. In ten of these spleens we may not find any organisms. In
the next ten cases there may be organisms in the tissues of every
one. The bone marrow cultures will tell us what organisms we are
dealing with in some cases. I think Dr. Baar's observations about
indicanuria bring out the point of the chronic intermittent type of
infection in these cases. It does not matter whether it is in the
gall bladder, the alimentary tract, or the appendix, so long as it is
active, it will produce indicanuria. I wish to further emphasize
that all we can do in analyzing these cases is to present certain facts
and let men interpret them for themselves. The prophet has never
been very successful, as far as history goes. The point I wish to
leave with you is this, in the treatment of pernicious anemia, we
don't treat the disease by splenectomy, we treat it on the basis of
100 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
any clinical, pathological, bacterial focus. That teaches us to re-
duce any infective foci, whether external, abdominal or elsewhere;
and to counteract infection by transfusion. In addition treatment
may include laparotomy to search for focal infection, and to remove
the spleen if the organ requires removal.
Dr. R. W. Wilcox : It may seem strange that we have had to
deal with so many instances of measles and mumps, but the country
boy does not have the chance to acquire immunity against these dis-
eases. The gutter-snipe, on the other hand, is generally immune to
any and every infection. The measles problem is not difficult.
Plenty of fresh air and sunlight soon stop the epidemic. Cerebro-
spinal meningitis patients get on well with the use of serum. In
regard to typhoid and paratyphoid we have done splendidly. Some-
times, however, the reaction to paratyphoid inoculation is consid-
erable. If the camp water supply were absolutely safe, there
would be little or no typhoid. Dr. Park has presented extremly
comprehensive and accurate statements in a very interesting paper.
Dr. R. W. Wilcox : I desire to record the appreciation and
thanks of the congress for the hospitality shown by Drs. Jones,
Lichty and Mercur in entertaining us. I wish this statement to be
incorporated in the remarks of the president so that our apprecia-
tion of the efforts of the local committee on our behalf may be
duly noted in the Proceedings of the Congress.
The American Congress on Internal Medicine feels a loss, irre-
trievable, in the death of our late Secretary General, Dr. Heinrich
Stern. For a year or more prior to his death, Dr. Stern was
seriously ill but with that never- failing perseverance and unselfish-
ness which he manifested all through his life he forgot his own
suffering in the interest of our organization. Prior to the meet-
ings of the congress in 1916 and 1917, a wonderful supply of tem-
porary energy was his, which enabled him to be in attendance in
order that we might benefit by his views, that he might guide us
with his unfailing judgment. Although he expressed the greatest
pleasure after the Pittsburgh meeting, the trip certainly taxed his
strength, and this together with the extreme cold which occurred
at that time, hastened his death which took place on Jan. 30, 1918.
Upon unanimous resolution of the Council of the Congress, the
following Obituary was ordered printed in the Transactions of the
THE AMERICAN CONGRESS OX INTERNAL MEDICINE 101
was born near Frankfort, Germany, fifty years ago.
Soon after arriving in this country he began the study
of medicine. He received his first Medical Degree
twenty- four years ago and a few years later he took
a second degree. After some years in general practice
he began to devote himself to a study of diseases of
metabolism. The prize offered by the New York
County Medical Society for the best essay on diabetes
was won by him and this brought him to the notice of
the profession. From that time on his work was con-
sistently in the field of internal medicine.
He was connected either as founder or member of
the following organizations : The Institute for Medi-
cal Diagnosis, Philantropen Hospital, Visiting and
later Consulting Physician, St. Mark's Hospital. Con-
sulting Physician, Central Islip and Seney Hospitals.
Sometime Professor of Clinical Medicine at the Ger-
man West Side Post Graduate Medical School. Lec-
turer on Medicine, Boston University. Founder and
Editor of the Archives of Diagnosis. Founder of
the Manhattan Medical Society, of the American
Congress on Internal Medicine, and of the American
College of Physicians, which was the fulfilment of a
In addition he was a member of many other medi-
cal societies. He was the author of upward three
hundred medical articles and of a half-dozen text-
102 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
books on medicine, most of which were devoted to
treatment of disease in its various phases.
About fifteen years ago, Dr. Stern conceived the
idea of a congress of internists, that should not be
limited to those in prominent teaching positions but
that should be open to all of the profession who were
particularly interested in internal medicine â€” and
among those, who by meritorious work, study and
investigation had done something for the good of
humanity and the profession, a certificate, causa hon-
oris, in the American College of Physicians, should
be given. These dreams and ideals he repeated
time and again to his friends until finally he
interested some of his professional brethren who saw
the truth and possibilities of his concept. After much
labor and deliberation, stimulated and abetted by his
enthusiasm, the American Congress on Internal Medi-
cine and its exemplar â€” The American College of
Physicians â€” were formed. When these were fully
organized and had justified his prophecy, it was denied
him, as it was to Moses of olden time, that he should
see the promised land in the progress and brilliant
success of these organizations which will be perma-
nent memorials of their founder and the ideals of
the internists and consultant which have become
Reynold Webb Wilcox, Chairman.
Thomas F. Reilly.
Joseph H. Byrne.
This organization shall be known as The American Congress on
The objects of the congress shall be: To promote the advance-
ment of the science and practice of medicine, to further the study
of biological medicine among its members, to elevate the standard of
preliminary education of physicians and the standing of medical
education, and to secure enactment of just medical laws by the State
and Federal Governments and of a Federal Law providing for a
national medical license, to obtain the establishment of a National
Board of Health, to promote friendly intercourse among physicians,
to enlighten and direct public opinion in regard to the great prob-
lems of health and medicine, and to unite those working in the
domain of internal medicine, to secure recognition for the term
internist as the proper designation for such workers and to obtain
proper scientific and material recognition of their work.
The congress shall meet annually at such time and place as the
council may determine. Twenty-five members shall constitute a
Section i. The officers of the congress shall consist of a presi-
dent, a vice-president, a secretary-general, a treasurer, and twenty-
five councilors, who with the officers shall constitute the council,
all to be elected from the active membership by ballot at an annual
meeting, a majority of whom shall reside in the city of New York
or its vicinity, excepting that the secretary-general shall be elected
for a term of ten years.
104 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
Sec. 2. The council may be convened at any time by the presi-
dent at the request of any five of its members. Its decisions shall
be equivalent to acts of the congress, and shall be reported to it at
its next regular meeting. The council shall constitute the nom-
inating committe of the congress.
Sec. 3. A vacancy occurring in any office may be filled by the
Section i. Any qualified physician engaged in the general or
special practice of internal medicine or in laboratory research per-
taining to it, may be proposed for fellowship.
Sec. 2. Applications for fellowship in the congress should be
made in writing to the council. Five negative ballots shall reject an
Sec. 3. Applications for fellowship shall be accompanied by the
annual dues of five dollars.
Sec. 4. Resignation of fellows shall not be accepted until all
dues have been paid.
All proposed changes in the constitution must be offered in writing
at a regular meeting of the congress. They are to be considered
only at the next annual meeting when a two-thirds vote of the mem-
bers present shall be necessary for their adoption.
The President shall preside at the annual meeting of the Con-
gress and deliver an address, and shall be the chairman of the
Council. In the absence of the President, the Vice-President shall
The secretary-general shall keep a record of the transactions of
the congress, and the council, and committees, conduct all corre-
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 105
spondence of the congress, and mail to each fellow a program of
the meeting at least two weeks in advance of the date thereof.
The records, publications and seal of the congress shall be in his
The treasurer shall collect all moneys due the congress, disburse
the same as directed by the council, keep a proper account of all his
transactions, and render an annual statement to the congress. He
shall have charge of all property belonging to the congress not
otherwise provided for. He shall give bonds for the faithful per-
formance of his duty, in such sum as shall be determined by the
The council shall constitute a standing committee to consider all
matters of interest to the congress. It shall appoint all committees
and conduct all business affairs of the congress. It may, in its
discretion, organize special scientific and local sections of the
Five members of the council shall be elected annually by the con-
gress, each to serve for a term of five years.
Charges against any fellow must be made in writing. They
shall be referred to the council for investigation and action.
The annual dues shall be five dollars, payable before the annual
The order of business shall be as follows:
(1) Reading of the minutes of preceding meeting.
(2) Reports of officers, of the council and committees.
(3) Presentation of communications.
(4) Miscellaneous business.
(5) Election of officers for the ensuing year.
FELLOWS OF THE AMERICAN CONGRESS ON
INTERNAL MEDICINE, 1917-1918.
Aaron, Charles O., Detroit, Mich.
Acuff, S. D., Knoxville, Tenn.
Alexander, J. Hope, Pittsburgh, Pa.
Also]), Thos., Atlantic City, N. J.
Amster, J. Lewis, New York City.
Altshul, H., Hartford, Conn.
Anders, James M., Philadelphia, Pa.
Arneill, James Rae, Denver, Colo.
Aten, William H., Brooklyn, N. Y.
Baar, Gustav, Portland, Ore.
Babcock, Robert H., Chicago, 111.
Bacon, Theo. T., Springfield, Mass.
Baketel, H. S., New York City.
Bangs, Charles H., Boston, Mass.
Barach, Jos. H., Pittsburgh, Pa.
Barnes, James, Cicero, 111.
Barnes, Noble P., Washington, D. C.
Bartley, E. H., Brooklyn, N. Y.
Bate, R. Alex., Louisville, Ky.
Bathurst, Wm. R., Ark.
Beck. Harvey G., Baltimore, Md.
Beling, C. C, Newark, N. J.
Bell, Tohn M., St. Joseph, Mo.
Benedict, A. L., Buffalo, N. Y.
Berg, G F., Pittsburgh, Pa.
Berger, Samuel S., Cleveland, O.
Bettman, Henry W., Cincinnati, O.
Betts, Lester, Schenectady, N. Y.
Biddle. Andrew P., Detroit, Mich.
Bieber, Joseph, New York City.
Billings. Fredk. T., Pittsburgh, Pa.
Bishop, Ernest S., New York City.
Bishop, James, New York City.
Bishop, L. F., New York City, N. Y.
Blackwood, A. L., Chicago, 111.
Bloch, Leon, Chicago, 111.
Blackwood, A. L., Chicago, 111.
Bohan, P. T., Kansas City, Mo.
Bonney, Sherman G., Denver, Colo.
Bosworth, Robinson, St. Paul, Minn.
Bowen, William, Knoxville, Tenn.
Briggs, L. Vernon, Boston, Mass.
Brockway, Robt. O., Brooklyn, N. Y.
Brooks, Harlow, New York City.
Brown, Alex. G., Richmond, Va.
Brown, Samuel S., Brooklyn, N. Y.
Buesser, Fredk. G., Detroit, Mich.
Bumsted, C. R., Newark, N. J.
Bunker, Henry A., Brooklyn, N. H.
Burns, G. H., Central Islip, X. Y.
Burrage. Thomas J., Portland, Me.
Butler, Glent. R., Brooklyn. N. Y.
Byrne, Joseph, New York City.
Byrne, Jos. Henry, New York City.
Caille, August, New York City, N. Y.
Calvert, W. J., Dallas, Tex.
Carman, Albro R., New York City.
Cassidy, John M., Jersey City, N. J.
Chapin, Edward, Brooklyn, N. Y.
Christie. Arthur C, Corry, Pa.
Churchill, Jas. F.. San Diego, Cal.
Clark, Ramond, Brooklyn, N. Y.
Cohen, Bernard. Buffalo, N. Y.
Collins, Danl. W., Wilkes-Barre, Pa.
Conklin, C. B., Washington, D. C.
Connolly, Richard N., Newark, N. J.
Connor, Guy L., Detroit, Mich.
Conway, F. C. Albany, X. Y.
Cooper, W. G., Ogdensburg, N. Y.
Corbus, B. R., Grand Rapids, Mich.
Cornwall, E. E., Brooklyn, N. Y.
Coughlin, Robert E., Brooklyn, N. Y.
Coulter, F. E., Omaha, Neb.
Crafts, Leo M., Minneapolis, Minn.
Cramp, Arthur J., Chicago, 111.
Crofton, Alfred C, Chicago, 111.
Cruikshank, Wm. J., Brooklyn. N. Y.
Cullings, Jesse J.. Memphis, Tenn.
Cummings, Rol., Los Angeles, Cal.