A Clinical Lecture ON GRANULAR KIDNEY AND ITS SURPRISES: Being an Address delivered before the East Sussex Medico-Chirurgical Society.
Authors: S. West
Journal: BMJ (1911)

THE signs of granular kidney are usually obvious enough, yet there is no disease that is more often overlooked, even at the present time.The diagnosis, is missed chiefly because the condition is not thought of.For this there are two special reasons: 1.That granalar kidney is for a long time compatible with apparent health-that is, is associated with no striking loss of energy or strengtb.2. That the symptoms when present may be most misleading, and polnt almost anywhere else rather than to the kidney.Yet the pulse usually gives the indication if properly examined-not the pulse beats, for they may be unaltered; nor the pulse wave, for it may not be characteristic; nor the arterial tension, for this is not at all times high-but the artery itself, which is almost always markedly thickened.Arterial thickening in early middle life is almost always due to granular kidney, and in the elderly to atheroma or to both conditions combined.There is still another form of arterial thickening met with in young athletes.This is a physiological hyper.trophy accompanying the hypertrophy which takes place in the heart, but, with this exception, arterial thickening in persons below 50 should always raise the suspicion of granular kidney, and the suspicion once raised is con- firmed on farther examination by the discovery of the characteristic chbanges in the urine, in the heart, and it may be in the eye.If granular kidney, then, be so often overlooked, the diagnosis of it frequently comes as a shock and surprise to patient and doctor alike.There are enormous reserves in the kidney as in every other important organ in the body.It has been shown that as much as two-thirds of each kidney may be removed in animals before life becomes impossible.So in granular kidney the wasting may go on to a very considerable degree before grave symptoms arise, but all this time, as the wasting of the kidney progresses, its reserves become less and less, until at last on some very slight extra demand, or even without any apparent cause at all, the limit may be reached, and the symptoms of renal inadequacy manifest themselves in more or less serious form.So it happens that no suspicion whatever may have been aroused until some grave condition arises which makes the diagnosis only too obvious.It is with these surprises or unexpected first symptoms that I purpose to deal in this paper.The morbid lesions of granular kidney are found in the kidney, blood vessels, heart and eye, and it is in connexion with these organs that the first group of surprises come.The second group is probably toxic, and is composed of conditions which are often described under the heading of acute or chronic uraemia, or, as it would be better styled, acute or chronic renal toxaemia-for example, general cachexia, skin erapticns, violent vomiting or diarrhoea, cramp, gout, headache, epilepsy, and uraemia.This is a long list, but there is something of interest as well as of importance to be said about each item of it.1. Acuqte nephritis may be the first serious condition to arise in what has obviously been granular kidney of long