PRACTICAL CONSIDERATIONS: THE KIDNEYS 1893 



however, as cases of both polyuria and threatened suppression have followed the 

 gentle and partial insertion of the ureteral catheter (Tilden Brown). 



Tumors of the kidney have, as a class, the following distinctive anatomical 

 characters, which have been well summarized by Morris : 



(a) The large intestine is in front of the tumor. Normally the right kidney, 

 unless enlarged, lies a little way from the lateral wall of the abdomen, behind and to 

 the inner side of the ascending colon ; not in close contact with the abdominal wall, 

 and outside the ascending colon, as the hver does. When the kidney is enlarged, 

 the ascending colon is usually placed in front of and towards the inner side of the 

 tumor. On the left side the descending colon is in front of, and inclines towards the 

 outer side of, the kidney below ; in some cases coils of small intestine may overlie either 

 right or left tumor if the enlargement is not sufficient to bring the kidney into direct 

 contact with the front abdominal wall. When the colon is empty or non-resonant, 

 it can be felt as a roll on the front surface of the tumor. Bowel is not thus found in 

 front of splenic tumors and very rarely in front of a tumor of the liver. 



(yb') There is no line of resonance between the kidney dulness and the vertebral 

 spine, and no space between the kidney and the spinal groove into which the fingers 

 can be dipped with but little relative resistance, as there is between the spleen and 

 the spine. 



(<:) While a renal tumor fills up the "hollow of the back" somewhat, it does 

 not often protrude or project backward. Marked posterior projection usually indi- 

 cates perinephric swelling, as from an abscess or a urino-sanguineous effusion. 



{d) A kidney tumor can sometimes be recognized by its proneness to maintain 

 an outline resembling that of the normal kidney. 



(^) A kidney swelling, if inflammatory in origin, descends less in inspiration 

 than does a splenic, hepatic, or adrenal swelling; this symptom in a case of new 

 growth is not very valuable, as the renal tumor may have a considerable degree of 

 movement. 



(yf) As a rule, kidney tumors do not reach the mid-line, do not invade the 

 bony pelvis, and are separated from the hepatic dulness by a line of resonance. If 

 large enough, the tumor may reach the anterior abdominal parietes about the level 

 of the umbilicus, but external to it. 



(yg) In large renal tumors varicocele, from compression or distortion and dis- 

 tention of the spermatic vein, has been noticed in a number of instances. 



Operations upon the kidney for its fixation (nephrorrhaphy, nephropexy), for 

 drainage or relief of tension (nephrotomy), for the extraction of a calculus (nephro- 

 lithotomy), or for the establishment of collateral circulation (decortication), are almost 

 invariably done through the loin. 



The vertical incision — on a line about an inch posterior to the middle of the 

 crest of the ilium and running from that level to the twelfth rib — does not, as a rule, 

 give sufficient room, divides the last dorsal and the lumbar vessels and nerves, and 

 hence jeopardizes the subsequent integrity of the ilio- costal wall. 



The oblique incision begins about a half inch below the twelfth rib and at the 

 outer border of the erector spinae. It is well to count the ribs from above downward, 

 as when the twelfth rib is rudimentary it may not project beyond the edge of the 

 erector spinae and may be mistaken for the transverse process of the first lumbar 

 vertebra. In such circumstances the incision, having by error been made close to 

 the edge of the eleventh rib, has, in reported cases, opened the pleura. 



The oblique incision is extended forward for three or four ii|i:hes parallel with 

 the twelfth x\h,—i.e. ,_ with the vessels and nerves of the region. The skin and super- 

 ficial fascia, the latissimus dorsi, and the external and internal oblique muscles having 

 been divided and the lumbar aponeurosis and the transversalis fascia severed, a 

 layer of fat will^ then appear or will bulge into the incision (perirenal or transversalis 

 fat). As this is cut through or separated with fingers or forceps, a layer of con- 

 nective tissue may be recognized— the posterior layer of the perirenal fascia— and 

 then a second layer of fat (perinephric fat, capsula adiposa), which is sometimes finer 

 in texture and more distinctly yellowish fMorris), and which, if it is incised or torn 

 through and drawn into the wound, will present a funnel-shaped opening leading 

 down directly to the kidney (Gerota), which can then often be isolated by blunt 



