42 8 APPLIED ANATOMY. 



the liver and gall-bladder, spleen, and ovaries. A longitudinal coil of resonant intes- 

 tine passing over the tumor is prima facie evidence of its being renal in character. 

 Renal growths appear as more or less spherical tumors which can in some cases be 

 palpated around their entire circumference. If one portion only can be felt, the 

 remainder leads towards the loin ; in gall-bladder tumors (cysts) the base of the 

 growth leads toward the liver and is in contact with the abdominal wall, overlying 

 the colon and small intestine. In splenic tumors a notch can sometimes be felt and 

 the growth makes its appearance from above, down under the left costal margin. 



Abscesses. The kidney is frequently involved in suppurative affections. 

 Calculi and tuberculous diseases are of that nature, and pyogenic infection may 

 creep up from the bladder, producing pyelonephritis, or siirgical kidney. The pus 

 may be extrarenal, involving the adipose capsule and perirenal fascia ; it commonly 

 points in the loin. As this fascia is open below and to the inner side the pus may 

 descend to the iliac fossa or follow inside the sheath of the psoas muscle beneath 

 Poupart's ligament. It may work its way up along the psoas under the ligamentum 



Diaphragm 



XII rib 



Colon 



Iliac fascia 



Iliacus 

 muscle 



FIG. 43(1. Diagrammatic longitudinal section, showing relations of supporting tissue to right kidney. (Gerota.) 



arcuatum internum and empty through the lung, or perforate the diaphragm at the 

 hiatus and so reach the lung (page 425). We have seen it work along the under 

 surface of the liver and point anteriorly at the costal margin. It may also rupture 

 into the duodenum or colon. Sometimes it goes posteriorly and perforates the 

 lumbar fascia to appear at the outer edge of the latissiffrus dorsi and erector spinae 

 muscles in the iliocostal space, or at the triangle of Petit (page 394). 



OPERATIONS ON THE KIDNEY. 



Access to the kidney is demanded for fixing it in place when movable, for the 

 removal of calculus, for the treatment of cystic conditions, abscesses, growths, and 

 even for the entire removal of the organ, which sometimes is greatly enlarged. 



Incision. Lumbar incisions have already been discussed (see page '395). 

 There are three things to be borne in mind, viz. : the direction of the muscular fibres 

 and position of the muscles, the position of the nerves, and, last, the pleura. 

 A longitudinal incision along the outer edge of the erector spinae muscle is large 

 enough to remove a normal-sized kidney, but large kidneys or growths require an 

 oblique incision. This latter begins 2 cm. ( ^ in. ) below the last rib, at the edge of 



