PRACTICAL CONSIDERATIONS : THE KIDNEYS. 1891 



free anastomosis between the lower intercostal and upper lumbar arteries, supplying 

 the parietes of the loin, and some terminal branches of the renal artery. This a 

 part of the " subperitoneal arterial plexus" (Turner) is accompanied, of course, 

 by a similar venous anastomosis. Thus the application of cups or hot fomentations 

 or counter-irritants to the loin may act, at least temporarily, by enlarging superficial 

 vessels and withdrawing blood from a congested or inflamed kidney. 



In somewhat the same line of thought, as to congestion, attention may be called 

 to the facts that the capsule and pelvis of the kidney are the sensitive portions ; that 

 renal pain, not dependent on infection, or on the irritation of a calculus, or on dis- 

 placement, usually means increased tension ; that great relief of both pain and con- 

 gestion is therefore often experienced after nephrotomies that are merely exploratory, 

 although, if the tension is due to accumulation of fluid within the renal pelvis, grave 

 renal congestion may follow its evacuation and the accompanying sudden relief from 

 habitual pressure just as it follows some cases of catheterization of habitually distended 

 bladders (Belfield) ; and that occasional cures of various forms of acute or subacute 

 nephritis, or of " albuminuria associated with kidney tension" (Harrison), have been 

 obtained merely by splitting the kidney capsule with or without puncture of the 

 kidney itself. The more recent attempt (Israel) to apply the method to chronic 

 nephritis with severe or dangerous symptoms (especially colic and haematuria), and 

 the still more recent introduction (Edebohls) of bilateral " decortication" decapsula- 

 tion in chronic nephritis without such symptoms, have not at this time demonstrated 

 their value. They are of much interest, however, in relation to the important sub- 

 ject of tension of the kidney and of the effects of modification of its vascular supply. 

 The beneficial results of relief of tension in swellings of the testicle (acute orchids) 

 or of the eye (acute glaucoma) are pointed out as illustrations of the manner in 

 which splitting the capsule benefits some forms of nephritis (Harrison, Israel). De- 

 cortication is supposed to act by removing a barrier the fibrous capsule to the 

 establishment of collateral circulation, promoting a free supply of blood to the kidney 

 previously impoverished by reason of the inadequacy of its vessels, and favoring the 

 absorption of excessive interstitial connective tissue, the regeneration of renal epi- 

 thelium, and the removal of injurious pressure upon the uriniferous tubules (Edebohls). 

 The problems presented have so distinct an anatomical bearing that their mention 

 here does not seem inappropriate. 



The rich blood-supply of the kidney, an amount of blood equal in weight to 

 that of the organ itself flowing through it each minute during full functional activity 

 (Tilden Brown), while it favors congestive conditions, makes total embolic necrosis 

 such as occurs in other glands confined within dense capsules, as in the submaxillary 

 salivary gland as a secondary result in angina Ludwigii (page 553) and in the testi- 

 cle in some cases of torsion with complete venous and partial arterial obstruction 

 (Gerster) very rare, only one case (Friedlander) having been reported. 



Subparietal injuries to the kidney are common, constituting 39 per cent, of 

 visceral lesions resulting from contusions of the abdomen or loin. Rupture of the 

 kidney by abdominal or lumbar contusion has been experimentally shown (Kiister) 

 to depend upon the effect of a force (hydraulic) acting through the full vessels and 

 the pelvis and causing the kidney to burst, usually along the lines radiating from the 

 hilum in the direction of the tubules, i.e. , transverse to the long axis of the kid- 

 ney, towards the point of maximum impact of the lower ribs, the opposing resistance 

 being supplied by the spine (Morris). There is reason to believe that the direc- 

 tion of ruptures radiating from the hilum to the periphery is influenced by the 

 lines of least resistance indicating the original absence of vascular loops and of their 

 accompanying connective tissue between the adjoining lobules of which the fcetal 

 kidney is composed. 



As the ribs in immediate relation to the kidney are the eleventh and twelfth, 

 which are rarely fractured, laceration by direct impact of broken ribs is relatively 

 uncommon, although it does occur. 



Ruptures may much more rarely be produced by muscular action alone, but in 

 such cases the violent muscular effort that usually adducts the ribs and forces them 

 against the kidney and towards the spine is almost always associated with forward 

 or lateral bending of the vertebral column. Forcible anterior flexion of the spine, as 



