The Journal of the American Medical Association. Along with the interest shown for the national body, you should also help support its organ, The Journal of the American Medical Association. It can now boast of being the leading medical journal in the United States, and equal to any published in Europe. Under the able management of its present editor it has increased in circulation until it now has gone beyond ten thousand actual subscribers. If you are not a member of the National Association, you should at least keep in touch with it by becoming a reader of the columns of its official organ.

A Suggestion for Reorganization. It has been a noticeable fact for a number of years that neither the membership nor attendance at our State Society has been what it should be. Kentucky stands second to no State in the ability of her doctors, in the splendid standing of her medical schools, and especially in the medical laws governing the practice of medicine. It can not be gainsaid that as many, if not more, names of illustrious medical men adorn the pages of her history than that of any other State. It would be a shame if her State Medical Society was not kept up commensurate with these claims. May I offer what I believe to be the reason for this apparent lethargy or loss of interest in our annual meeting? To the careful observer it will have been noticed that county, district, and other societies have been made to take the place of the State organization. They are many in number, and the meetings are frequent. The busy doctor feels that that his duty, and perhaps

after having attended one or more of these his pleasure, has been sufficiently indulged. It may be that the physician living in the country feels that in his "home" society he is more to the "manor born," or that in the State meeting he is counted out by the city brother, the specialist, etc. These are not valid reasons surely. It must be conceded that it is the busy doctor who attends medical societies, and the wider the scope the more knowledge gained. Again, it can not be assumed that because one happens to live in a larger place that he is more learned in the science and art of medicine than his brother who lives in a smaller place. It is not the number of inhabitants that makes a good doctor, but rather the application to study and observation.

In this day of post-graduate instruction the dividing line of opportunity is broken down and the city and country doctor stand on equal footing. It is only necessary to remind you that Ephraim McDowell and Brashear lived in small country towns. Be this as it may, the inter

est manifested in your State Society is not what it should be. What is the remedy? I will try and suggest it. In the State of Indiana there are between 3,000 and 3,500 regular physicians. From this number 1,500 belong to and attend their State Society. You naturally ask how do they accomplish so much? With your permission and indulgence I will explain by reading from their Constitution and By-laws. Section I reads: "Any incorporated county medical society whose constitution embraces the objects of this Constitution and the Code of Ethics of the American Medical Association shall, upon application, become auxiliary to the State Society, and shall be entitled to one delegate for every five members, and one for every additional fraction of more than half this number."

“Section 5. Every county society shall, at least thirty days before the annual meeting of the State Society, make a full and correct catalogue of its members in good standing at the time, and transmit the same at once to the Secretary of the State Society, . . . and no one not a member iu good standing in his county society can be a member of the State Society."

A portion of Section 10 reads: "Regarding the appointments of delegates to the American Medical Association, the several county societies shall be required, at the time of appointing their delegates to this society, to nominate and forward to the Secretary the names of the delegates to the American Medical Association, the number of such nominations to be governed by the rules of said Association, and all the nominations shall be confirmed by the State Society."

It will be at once observed that by such organization encouragement is given to the formation of county societies; these form the basis of the State Society, as it is necessary to belong to the county society before they can belong to the State organization or the American Medical Association.

I would respectfully suggest that a remodeling of our Constitution and By-laws be effected, so as to include this splendid arrangement tested and found to be perfect by our neighbor State. The whole idea is to develop local societies and keep them in close touch with the State organization. Only one society should be formed in each county as part of the State Society, and this should be known by the name of the county. All papers read at the State Society should be first read before the county society, and then be referred to the State Society by the Secretary. Nothing in my opinion would do more to harmonize

the medical profession in the State than this. Nothing, also, would enable the State Board of Health to help enforce the medical law so much, because by such a procedure we would have a united profession. I trust that this body, looking to the upbuilding of this society, will give these suggestions careful thought and help the President to carry them into execution or formation during this meeting. I am aware of the fact that several years ago a resolution was offered in this society and carried, looking to a very similar arrangement, but so far it has proven to be only a dead letter. Let us begin where we left off and complete a perfect organization, one that will be an honor not only to the profession but to the State.

A Plea for Harmony. But while we are discussing the dissension between the people and the doctor, let us turn an eye, or an X-ray, upon ourselves. We can never command the respect of the people as a great profession should until we respect one another. No dissensions. should enter our ranks. We are working to accomplish the same end, all of us-the unification of the profession; in upbuilding a noble profession whose object is to protect the people against the ravages of disease. Your calling may at times seem to be a thankless and unprofitable one, but this should not deter you from a firm purpose and vigorous action. Let us then pull together and not listen to envious tongues, or be detracted from our course by slanderous tales. We are brethren indeed, and as such should battle for the right as an army, undaunted by evil tales. May your meeting this year be characterized by dignity and decorum, by love for each other, as becomes Kentuckians. May your future lives be full of peace and happiness, and may we all, by the grace of God, meet together again next year without the dropping out of a single one by the final summons, is the prayer and wish of your President.

KIDNEY FAILURE IN PREGNANCY.*

BY EWING MARSHALL, M. D.

Physician to Home for Friendless Women; Physician in charge P. E. Orphan Asylum.

In my opinion the subject of kidney pathology has to be entirely rewritten. Its present condition is one of chaotic gathering of wellfounded facts arranged in such a way as to be in keeping with the present erroneous conception of the kidney's part in these conditions.

*Read at the May meeting of the Kentucky Medical Society.

There is undoubtedly a mistake made by accepting the complex symptoms and signs of Bright's disease as due primarily to a kidney lesion. We have seen diabetes classed as a kidney trouble, then as a liver trouble, and by Claude Bernard's brilliant work shown that it was independent of either, and that sugar in the urine could be produced by central irritation.

I am not prepared to say it is so, though I believe the initial step is a failure of assimilation, and that the changes in the kidneys are secondary and resultant. The different morbid conditions classed under the head of Bright's disease are simply different stages in the same process.

Frerichs was the first to announce this opinion, and I agree with him so far as the pathological changes are concerned, but for clinical work I think Sir William Roberts' simple division into acute and chronic is all that is necessary.

When you have the earliest symptoms commonly credited to Bright's disease with or without albuminuria in pregnant or nonpregnant it is an index announcing this period, which I term the preorganic period, as it precedes kidney degeneration, but like the aura in epilepsy is a sign-board pointing toward danger that should be at once heeded, for then, if ever, is our time to prevent kidney disorganization.

I do not believe pregnancy per se can act as the cause of kidney failure.

Were it so, through what means would it produce it?

By pressure on kidneys or ureters?

Then would you not count on it in cases of twin-pregnancy? Would you not always expect it in hydramnios?

By distension of the uterus?

The objections to the above apply equally to this.

By increased excretory work placed upon the kidney?

If such were the case, would it not be the rule rather than the exception.

Bouchard, in his masterly utterances on Pathogenesis of Uremia, declares, "Now it is certain that the kidney can in a normal state eliminate an infinitely more toxic material than it generally does." Therefore, to have symptoms of Bright's disease develop during pregnancy, you must have some latent trouble and an already laboring kidney.

The symptomatology is well understood, but so rarely do we have serious interference from kidney failure in pregnancy that the most of us are too lax in our advice to our patients. In a general way we advise them to let us know of any symptoms; but unless specifically warned their families, their friends, and even their doctor will constantly remind them that most of their discomforts are either visionary or necessary concomitants of their condition. Simon claims that two thirds of the cases of Bright's disease run a latent or undiscovered course, yet Edward S. Gooddy says, even in a special report on Albuminaria in Pregnancy, in reporting one of his cases, "Her general symptoms were of no particular interest, consisting of neuralgia, headache, nausea, vomiting and general malaise." A very strong grouping of symptoms, I would say, pointing to failure of elimination somewhere.

Much stress is laid upon urine examination, and some of the most conscientious physicians think, if they examine the urine once during a pregnancy, they have used every precaution, and yet how often in Bright's disease in the non-pregnant do we find a comparatively healthy urine without albumin; and such also is the case in a certain proportion of cases occurring in pregnancy.

Samuel West, in the London Lancet (March 5, 1898): "Granular kidney is very often overlooked because there is little in the symptoms to call attention to the kidneys. The symptoms of granular kidney become pronounced, as a rule, in the middle period of life, but the disease has existed long before."

Edema is another symptom greatly depended upon. This again is misleading, for we have most serious complications arising in cases. where there has been little or no edema.

Eye symptoms are difficult to handle, and yet very valuable if we obtain them unprejudiced. Ask the average pregnant woman if her eyes trouble her and she will answer, yes. However, if she announces, unasked, that her eyes are not right, that she does not see so well, can not use them long, has a veil-like feeling pass over them, sees double, flashes of light, etc.; then frequent and persistent examination of the urine is very apt to disclose kidney failure.

Nausea and vomiting are commonly present early in pregnancy, disappearing to come on again in the late period; alone they are not of much use, but when persistent, and especially in the mid-period, the kidney should receive serious interrogation.