140 TOPOGRAPHIC AND APPLIED ANATOMY. 



FIG. 65. The left kidney seen from in front. 



FIG. 66. The right kidney seen from in front. 



FIG. 67. Anterior view of the relations of the right kidney. 



FIG. 68. Anterior view of the relations of the left kidney. 



responsible for the neuralgic pains which accompany renal swellings and tumors and which 

 may radiate into the thigh and into the external genitalia. 



The right kidney is easily found by elevating the liver, the right lobe of which bears upon 

 its inferior surface the impressio renalis (see page 131 and Fig. 63). To the inner side of 

 the right kidney (Fig. 67) are the inferior vena cava, which may be compressed by renal 

 tumors, and the descending portion of the duodenum. Renal abscesses may rupture into these 

 structures and into the hepatic flexure of the colon which is in relation with the inferior pole of the 

 kidney. A tumor of the right kidney may push this hepatic flexure forward so that the tumor 

 will apparently give a tympanitic note, which will disappear when the intestine has been thor- 

 oughly emptied. The colon holds a similar relation to the left kidney. 



The left kidney is more concealed than the right one and is not so easily located by the tyro. 

 If the hand is pushed around the spleen until it reaches the facies renalis (see page 133), the left 

 kidney may be palpated, and if the spleen is displaced upward the inferior pole of the kidney 

 may be made to appear more distinctly in the angle of the splenic flexure of the colon (Fig. 68). 

 The remaining portion of the kidney is in relation anteriorly with the tail of the pancreas and 

 with the posterior surface of the stomach (in the region of the lesser peritoneal cavity). Below 

 the pancreas, the kidney is covered by the splenic flexure and by the commencement of the 

 descending colon (Fig. 68). The spleen rests upon the external renal margin (Plates 12 and 

 15 and Fig. 61). 



More distant organs may also be involved by large renal tumors. If the right kidney be- 

 comes greatly enlarged, it may push the liver upward and anteriorly and interfere with the ex- 

 pansion of the right lung. A large left-sided renal tumor, in addition to its effect upon the 

 stomach and the spleen, may directly compress the left lung and the heart. Owing to the firm 

 foundation of the kidney, which is composed of strong muscles and bones, it follows that en- 

 largements in the posterior direction are not so frequently observed as those extending forward, 

 upward, and downward. Diseases of neighboring structures, such as hepatic abscesses, psoas 

 abscesses, and caries of the vertebras, may extend to the kidney. 



The surgeon naturally prefers to attack the kidney from behind, since not only the kidney 

 but also the renal pelvis is retroperitoneal. At the hilus the pelvis is the most posterior struc- 

 ture, then comes the artery, and anteriorly is the renal vein (Fig. 65), although variations 

 are sometimes observed. This relation only holds for the main trunks, the terminal divisions 

 of which are subject to manifold variations, so that large arterial branches are often observed 

 to enter the kidney at some distance from the hilus. In all cases, however, the position of the 

 renal pelvis, situated as it is behind the great vessels, is favorable for the removal of renal 

 calculi from behind, as the large vessels generally escape injury. Hemorrhage from the renal 

 vessels is retroperitoneal, as a rule ; an intraperitoneal hemorrhage must be preceded by a lacer- 

 ation of the peritoneum. If the pelvis of the kidney becomes perforated, the urine no longer 

 flows along its normal channel in the ureter, but forms a retroperitoneal urinary abscess upon 



