994 THE URINARY ORGANS. 



the tissues by which it is surrounded, either moving in its capsule or else moving with the capsule 

 in the perinephric tissues. This condition is known as movable kidney, and is more common 

 in the female than the male. Other malformations are the persistence of the foetal lobulation ; 

 the presence of two pelves or two ureters to the one kidney. In some rare instances a third 

 kidney may be present. 



The kidney is imbedded in a large quantity of loose fatty tissue, and is but partially covered 

 by peritoneum ; hence rupture of this organ is not nearly so serious an accident as rupture of 

 the liver or spleen, since the extravasation of blood and urine which follows is, in the majority 

 of cases, outside the peritoneal cavity. Occasionally the kidney may be bruised by blows in the 

 loin or by being compressed between the lower ribs and the ilium when the body is violently 

 bent forward. This is followed by a little transient haematuria, which, however, speedily passes 

 off. Occasionally, when rupture involves the pelvis of the kidney or the commencement of the 

 ureter, this duct may become blocked, and hydronephrosis follow. 



The loose cellular tissue around the kidney may be the seat of suppuration, constituting 

 pennephritic abscess. This may be due to injury, to disease of the kidney itself, or to extension 

 of inflammation from neighboring parts. The abscess may burst into the pleura, constituting 

 empyema ; into the colon or bladder ; or may point externally in the groin or loin. Tumors of the 

 kidney, of which, perhaps, sarcoma in children is the most common, may be recognized by their 

 position and fixity ; by the resonant colon lying in front of it ; by their not moving with respira- 

 tion ; and by their rounded outline, not presenting a notched anterior margin like the spleen, with 

 which they are most likely to be confounded. The examination of the kidney should be biman- 

 ual ; that is to say, one hand should be placed in the flank and firm pressure made forward, while 

 the other hand is buried in the abdominal wall, over the situation of the organ. Manipulation 

 of the kidney frequently produces a peculiar sickening sensation, with sometimes faintness. 



The kidney is mainly held in position by the mass of fatty matter in which it is embedded. 

 If this fatty matter is loose or lax or is absorbed, the kidney may become movable and may give 

 rise to great pain. This condition occurs, therefore, in badly nourished people or in those who 

 have become emaciated from any cause, and is more common in women than in men. It must 

 not be confounded with the floating kidney : this is a congenital condition due to the develop- 

 ment of a mesonephron, which permits the organ to move more or less freely. The two con- 

 ditions cannot, however, be distinguished until the abdomen is opened or the kidney explored 

 from the loin. 



The kidney has, of late years, been frequently the seat of surgical interference. It may be 

 exposed for exploration or the evacuation of pus (nephrotomy) ; it may be incised for the 

 removal of stone (nephro-lithotomy) ; it may be sutured when movable or floating (nephror- 

 raphy) ; or it may be removed (nephrectomy). 



The kidney may be exposed either by a lumbar or abdominal incision. The operation is 

 best performed by a lumbar incision, except in cases of very large tumors or of wandering 

 kidneys with a loose mesonephron, on account of the advantages which it possesses of not 

 opening the peritoneum and of affording admirable drainage. It may be performed either by 

 an oblique, a vertical, or a transverse incision. Perhaps the preferable, as affording the best 

 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 spinse. 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 lumbar fascia, 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 kidney is then reached 

 from the outer side of the colon, ascending or descending, as the case may be, and the vessels 

 of the colon are not interfered with. If the incision is made in the linea alba, the kidney is 

 reached from the inner side of the colon, and the vessels running to supply it must necessarily 

 be interfered with. The incision is made of varying length according to the size of the kidney, 

 commencing just below the costal arch. The abdominal cavity is opened. The intestines are 

 held aside, and the outer layer of the mesocolon incised, 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 the 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 



