1136 THE URINARY ORGANS. 



means for exploring the whole surface of the kidney, is an incision from the tip of the last rib 

 backward to the edge of the Erector spinae. This incision must not be quite parallel to the rib, 

 but its posterior end must be at least three-quarters of an inch below it, lest the pleura be 

 wounded. This cut is quite sufficient for an exploration of the organ. Should it require removal, 

 a vertical incision can be made downward to the crest of the ilium, along the outer border of the 

 Quadratus lumborum. The structures divided are the skin, the superficial fascia with the 

 cutaneous nerves, the deep fascia, the posterior border of the External oblique muscle of the 

 abdomen, and the outer border of the Latissimus dorsi ; the Internal oblique and the posterior 

 aponeurosis of the Transversalis muscle ; the outer border of the Quadratus lumborum, and the 

 deep layer of the transversalis aponeurosis, and the transversalis fascia. The fatty tissue 

 around the kidney is now exposed to view, and must be separated by the fingers or a director in 

 order to reach the kidney. 



The abdominal operation is best performed by an incision in the linea semilunaris on the 

 side of the kidney to be removed, as recommended by Langenbuch. The incision is made of 

 varying length according to the size of the kidney ; its mid-point should be on a level with the 

 umbilicus. The abdominal cavity is opened. The intestines are then held aside and the outer 

 layer of the meso-colon opened, so that the fingers can be introduced behind the peritoneum and 

 the renal vessels sought for. These are then to be ligatured ; if tied separately, care must be 

 taken to ligature the artery first. The kidney must now be enucleated, and the vessels and 

 ureter divided, and the latter tied or, if thought necessary, stitched to the edge of the wound. 



THE URETERS. 



The Ureters are the two tubes which conduct the urine from the kidneys into 

 the bladder. They commence within the sinus of the kidney by a number of 

 short truncated branches, the calices or infundibula, which unite either directly 

 or indirectly to form a dilated pouch, the pelvis, from which the ureter, after 

 passing through the hilum of the kidney, descends to the bladder. The calices are 

 cup-like tubes encircling the apices of the Malpighian pyramids ; but inasmuch as 

 one calyx may include two or even more papillae, their number is generally less 

 than the pyramids themselves, the former being from seven to thirteen, whilst the 

 latter vary from eight to eighteen. These calices converge into two or three 

 tubular divisions which by their junction form the pelvis or dilated portion of the 

 ureter. The portion last mentioned, where the pelvis merges into the ureter 

 proper, is found opposite the spinous process of the first lumbar vertebra, in which 

 situation it is accessible behind the peritoneum. 



The ureter proper is a cylindrical membranous tube, about sixteen inches in 

 length and of the diameter of a goosequill, extending from the pelvis of the 

 kidney to the bladder. Its course is obliquely downward and inward through 

 the lumbar region into the cavity of the pelvis, where it passes downward, 

 forward, and inward across that cavity to the base of the bladder, into which it 

 then opens by a constricted orifice, after having passed obliquely for nearly an inch 

 between its muscular and mucous coats. 



Relations. In its course it rests upon the Psoas muscle, being covered by 

 the peritoneum, and crossed obliquely, from within outward, by the spermatic 

 vessels ; the right ureter lying close to the outer side of the inferior vena cava. 

 Opposite the first piece of the sacrum it crosses either the common or external 

 iliac artery, lying behind the ileum on the right side and the sigmoid flexure 

 of the colon on the left. In the pelvis it enters the posterior false ligament of the 

 bladder below the obliterated hypogastric artery, the vas deferens in the male 

 passing between it and the bladder. In the female the ureter passes along the 

 side of the cervix of the uterus and upper part of the vagina. At the level of the 

 external os it is three-fifths of an inch external to the cervix, and is crossed by 

 the uterine artery, a venous plexus intervening (Holl). At the base of the bladder 

 it is situated about two inches from its fellow, lying, in the male, about an inch and 

 a half behind the prostate. 



Structure. The ureter has three coats a fibrous, muscular, and mucous. 



The fibrous coat is the same throughout the entire length of the duct, being 

 continuous at one end with the capsule of the kidney at the floor of the sinus, 

 whilst at the other it is lost in the fibrous structure of the bladder. 



In the pelvis of the kidney the muscular coat consists of two layers, longitudinal 

 and circular : the longitudinal fibres become lost upon the sides of the papillre at 



