The Genito-Urinary System

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 4, 1 October 1927, Page 218

The Genito-Urinary System

Dr. Kendrick Christie

By

The genito-urinary system comprises two groups of organs, the Generative and the Urinary organs. The former group forms and liberates the products of the sex glands ; the latter group elaborates and excretes the urine. In the lowest verebrate animals these two groups of organs are inseparably united, so that the excretory duct of their primitive kidney may also transmit sex cells. In the higher vertebrates this union obtains only m the early embryo. In the adult the urinary and generative organs are quite independent apparatuses except at their terminal segment, where the uretha of higher animals may conduct either urine, or sex cells occasionally. In considering the diseases, treatment, and nursing of Genito urinary cases, we deal with the following organs : — 1. The Urinary Organs, i.e., the kidneys, ureters, bladder and urethra. 2. The Generative Organs, i.e., m the male : Generative glands (testes) the vas deferens, or generative duct, seminal vesicles, the external organs, the accessory glands, i.e., prostrate. In the female: Generative glands (ovaries), fallopian tubes, uterus or womb, vagina, external parts, accessory glands (glands of Cowper and Bartholin). Our main concern is to grasp the rational basis for treatment, and especially nursing treatment, m diseases of these organs. In order to have clear ideas of the why and wherefore, we must have definite working views of the anatomy and physiology of these systems. I propose to deal with each organ m turn, under the headings of Anatomy and Physiology, diseases, treatment and the essential points for the nurse. The importance of each point m the anatomy will be shown m its relation to disease and treatment, so that the origin of the disease will itself suggest the treatment of it. The Urinary System. Urine is a waste product of the body, and the essential waste substance it contains is urea. How does this arise m the first place?

Origin of Urea: Part comes from the protein of foods, and part from the breaking down of the tissues. Proteins are foodstuffs containing nitrogen. In digestion, ammo-acids are formed, and are absorbed to build the tissues. But some ammonia is also formed as a waste product, and this with waste ammonia from the tissues, is carried to the liver as carbonate of ammonia. The liver transforms the carbonate of ammonia into urea m the blood. The kidneys thus excrete urea, but do not manufacture it. The urinary organs get rid not only of urea, but also of other waste substances, and of poisons which enter the system. In order to carry out this function we must have an active filter, the kidney which separates the urine, a duct, the ureter, which conveys it to the bladder Avhere it is temporarily stored, and eventually passed out through the urethra and got rid of. These organs are m the pelvis, except the kidney, which is abdominal, and the ureters which are ab-domino-pelvic. 1. The Kidneys. Are two flattened bean-shaped organs, one on each side of the spine opposite the xiith dorsal and first two lumbar vertebrae. Each kidney has a supra-renal body placed like a cap on top of it. Each kidney is enclosed m a thin smooth fibrous capsule, and lies outside the peritoneum, surrounded by loose connective tissue containing fat. Most of the fat is placed around the lower and outer pole of the kidney (vide, m sheep). The kidney has a reddish brown colour, is 44 inches long, and weighs 44 ounces. It is so placed behind the peritoneum that its front surface is m contact with the viscera m the abdomen, and its back surface m contact with the muscles of the posterior abdominal wall. Hence, at operations the kidney may be reached either from m front or from behind. It is usually approached through the muscles from behind, m order to avoid opening the peritoneum. Many of the operations performed on the kidneys are for septic conditions, such as stone, and by not opening the peritoneum the risk of peritonitis is avoided.

Position : As stated, opposite 12 Dorsal and first two lumbar vertebrae. Notice that the kidney is not vertical, the upper end of each being nearer the spine than the lower end. The upper poles are covered by the 12th rib. The lower poles project below the 12th rib, are further out from the spine, and reach usually to li inches from the crest of the Iliac bones. Hence m the operation of exposing the kidney from behind (Lumbar Nephrotomy) it is the lower pole that is exposed. When this is grasped the kidney can be drawn out of the wound m virtue of its loose connective tissue surroundings, and the elasticity of the renal artery and vein. We may regard the kidney as beingpacked into its place by the surrounding fat, and by the pressure of the abdominal viscera. The outer layers of the kidney fat are condensed into a definite fibrous layer which slings the kidney on to the diaphragm. Being attached to the diaphragm, the normal kidney moves down about an inch m full inspiration. This fact is important m connection with movable kidney, and also m connection with tumours of the kidney. In normal persons the kidney cannot be felt through the abdominal walls, even m inspiration. If it can be so felt, we have the condition of dropped kidney or "Movable Kidney." This occurs m thin women, where there is loss of the fat which should be packed around the kidney. They have also loss of tone m the abdominal walls, and hence lack of support to the kidney. Again, m growths, if these have caused the kidney to be fixed they are certain to be malignant. The kidney is X-rayed m expiration, and again m inspiration, and the degree of movement thus noted. That surface of the kidney which looks towards the spine is indented, to receive the renal artery from the aorta and sympathetic nerves, and to give exit to the Renal Vein passing to the Inferior Vena Cava, and the ureter passing down to the bladder. The Renal Artery is derived directly from the Aorta, so that a large amount of blood reached the kidney. This amount is equal to its own weight every minute. Hence the secretion of urine is free, and wounds of the kidney bleed very freely. Before the artery enters the kidney it breaks up into branches.

The large number of Sympathetic Nerves entering the kidney account for the terrible pain of renal colic, which may be the worst of all pains. Many other diseases of the kidney are associated with severe pains also. The ureter commences m this indented part of the kidney, as an expanded portion about an inch long, called the renall pelvis, which tapers to form the ureter. Between the arteries, veins, nerves, and renal pelvis there is packed fatty connective tissue. Relations of the Kidneys to other Organs. The upper end of each kidney lies on the diaphragm, which separates it from the pleural cavity. This explains why sometimes an abcess of the kidney bursts into the pleural cavity. Suprarenal body is placed on top of each kidney. The kidneys lie one on each Psoas Muscle, which explains why pain or colic m the kidney causes the thigh to be drawn up. On the right side of the liver comes down over the front of the upper part of the kidney. For this reason, the right kidney lies a little lower than the left, and a " Movable Kidney " is nearly always the right one. In each case the Colon is m close relation to the kidney ; on the right side it is the ascending colon (Hepatic Flexure); on the left side it is the descending colon (Splenic Flexure). The colon is passing up or down just outside the kidney, and has to be avoided at operations. Sometimes it is wounded, and a faecal fistula results. These usually heal by granulation without a further operation. In place of the liver, we have on the left side the spleen m front of the upper pole of the left kindney. The duodenum is m front of that part of the right kidney where the vessels enter. In operations on the right kidney from m front, the duodenum has to be pulled inwards, and the liver upwards. In the same way the stomach and pancreas are related to the left kidney and m both cases, coils of small intestine are also m front of the kidneys. Hence it can be seen that the easiest way to expose the kidney is from behind. The chief dangers m the operation from behind are of wounding the peritoneum, the colon, or the pleura.

Internal Structures of the Kidneys: (Studied on a Sheep's Kidney). When split lengthwise the kidney is seen to contain the upper expanded end of the ureter. This is the renal pelvis. (Pelvis, a basin.) The kidney substance projects into this renal pelvis as a number of little projections or papillae. Each papilla is made up of from two to four little pyramids of kidney tissue. They appear radially striated, since they contain numerous minute tubules all running towards the apex of the papilla, with blood-vessels sandwiched between them. Urine is thus discharged from the apex of each pyramid into the renal pelvis. In order to collect it the renal pelvis sends out a number of short finger-like tubes, each of which embraces one papilla by means of an expanded cupshaped end known as a Calyx (calyx, a cup). Each Calyx embraces from two to four pyramids which together form one papilla. Between these calyces are passing m and out, as the case may be, the arteries, nerves, and veins. The structure of the kidney is much simplified if we remember that m the unborn child it consists of a number of separate lobules. Each is a gland with its papilla and calyx, and hence the bloodvessels and nerves must run between them. Later, these lobules become compressed together into one kidney, so that the blood-vessels are still found running between the calyces, or their papillae. The whole is covered with a smooth capsule, and m the adult but little trace of the lobulation remains. Diagram 2. The section of the kidney shows two zones, which together form the main substances of the organ. 1. The Cortex, or outer zone. 2. The Medulla, or inner zone. In the brown cortex are minute red dots, the Glomeruli. In the Medulla are the pyramids, consisting of excretory tubules. Between cortex and Medulla the blood-vessels break up into smaller arteries, forming loops from which the final branches run

out to end m the cortex. These do not anastomose with any other arteries, and are known as " end-arteries ". Their importance as such will be referred to later. The kidney, like other compound glands, is composed of a vast number of minute glands. Each of these small elements requires three essential parts: 1. To extract the fluid, urea, and salts from the blood, we have a "Glomerulus" (tuft), or twisted capillary, derived directly from the Aorta. 2. A tubule lined with secretory epithelium, which can re-absorb some of the water. 3. A duct, or drain, to convey away the now concentrated residue of urine. Diagram 3. The Glomeruli and the Tubules are m the Cortex. The ducts are m the pyramids of the medulla, and they join to open as one duct on the apex of the papilla, discharging into the calyx. These ducts with the small blood-vessels between them, give the radial striation to the pyramids. The whole of these structures are supported m connective tissue. Practical Application of these Facts. (a) The Arteries: From the arterial loops between cortex and medulla run out the end arteries which do not anastomose. Hence, if a small clot or other embolus. such as a mass of bacteria (germs) gets into and blocks one of these end-arteries the whole segment of kidney cortex supplied loses its blood supply and dies. This gives rise to a depressed scar on the kidney surface. If the embolus is a septic one (bacteria) an abcess is formed m the cortex. Again, where the blood-vessels break up (between cortex and medulla) into their smaller branches, it follows that there must be a slowing down of the rate of flow. This affords an opportunity for tubercle bacilli, which may be travelling m the blood stream from tonsils or tuberculous glands, to effect a lodgment; and we find that this zone between cortex and medulla is the usual startingplace for tuberculous infection m the kidney. With further reference to the arteries, we find m Bright's Disease

(chronic interstitial nephritis), that the inflamed connective tissue m the kidney becomes excessive m amount, and blots out many of the arteries, and tubules, by its pressure. It follows that less urine can be formed and these patients may die ultimately of Uraemia (retention of urea m the blood). (b) The Tubules and Ducts. In acute Nephritis, the kidney cortex is inflamed, and the tubules may be blocked either by blood getting into them or by their own epithelium being shed ofF into them. The blockage is aggravated by the general swelling of the kidney. Again, the itrine is diminished and the patient becomes urzemic. Some of the tubules may get rid of their contents, however, and then microscopic examination of the urine shows casts retaining the shape of the tubules. These, when seen, are proof positive of nephritis. Moreover, the damaged tubules now allow serum-albumen from the blood to pass through, and we have albuminuria. The casts prove that it is derived from the kidney, not the bladder. The albumen is m solution, and cannot be seen on looking at the urine. It is tested for by two tests : (1) The heat test. A white cloud on heating with a few drops of asetic acid. (2) The cold test. A white ring on adding commercial strong nitric acid. In the healthy kidney, the tubule is being continually flushed out by the fluid urine secreted by the glomerulus. The amount of urine depends upon the amount of blood passing through glomerulus, the amount of fluid this blood can spare, and the amount of foreign substance to be got rid of.

Thus more urine is secreted during excitement, due to the more rapid circulation, more m cold weather, due to diminished loss of fluid perspiration, and more after certain drugs called di-uretics.

In heart disease the circulation is slow, and the system gets water-logged (dropsy). Heart tonics are given )digitalis and mercury, etc.), the circulation

goes faster, and all the dropsical fluid is passed out as urine and disappears. Hence the practical importance of measuring and recording a 24 hours' specimen of urine. The kidney structure explains certain other diseases and medical tests, e.g.: Tests for Renal Efficiency: The glomerulus excretes not only urea, but also certain other substances as well, and poisons from the system. In testing the kidney, the " Urea test " consists m giving a Aveighed amount of urea, and finding what proportion of this is excreted m the urine m a given time. "Colour tests" consist m injecting into a vein a known quantity of an aniline dye (methylene blue or indigo-carmine), passing the cystoscope, and noting how long it takes each kidney to excrete the dye through the ureter. De Witt's pills contain Methylene blue, and this is excreted into the urine. We all know that blue and yellow mixed make green. The blue m the pill mixed with the yellow of the urine forms green, a colour most impressive to the patient. In Jaundice, bile is excreted by the kidney. The tests for bile m the urine are : 1. Test for Bile Pigments: Addition of commercial nitric acid to the urine, producing a play of colours, especially green at the point of junction of urine and acid.

2. Test for Bile Salts: Flowers of sulphur will sink m urine containing bile, because the latter diminishes the surface tension.

In Diabetes Mellitus, the kidney excretes glucose. The blood should contain 1% only of glucose. The excess due to the failure of the tissues to burn it, is excreted by the kidney. The test for sugar m urine is Fehling's. A red precipitate got on heating to boiling point a mixture of urine and Fehling's solution.

In this disease also, the kidney excretes di-acetic acid, the test for which is to add to the urine a crystal of soda nitroprusside, and a few drops of caustic potash, when a red colour is got, which remains on boiling. Acetone, which is also excreted m diabetes, is tested by adding a few drops of tincture ferri perchlor,

filtering off the precipitate, and adding a few more drops, when a red colour is got. In diabetes insipidus, too much urine escapes through the kidney, and the patient, whilst having great thirst, passes large amounts of urine. This disease is either hereditary, or m some cases due to disease of the pituitary gland. Nephritis. In acute nephritis, nurses are often puzzled because different physicians order different treatment. This refers especially to the question of giving fluids. Two schools of opinion have existed m regard to this. 1. Those who have regard to the kidney. 2. Those having regard to the renal oedema, or dropsy. It is obvious from the structure of the kidney as considered m the previous lecture, that fluids will flush out the tubules, thus helping them to get rid of their unusual contents (casts). On the other hand, the second school contends that fluids will increase the dropsy. This also cannot be denied. The most logical attitude to adopt seems to be to give fluids freely, m order to get the kidney tubules cleared as soon as possible. The restored kidney will then deal with any temporary increase m the dropsy. Diet m Acute and Chronic Nephritis. The milk is gradually thickened with arrowroot, and later gruel, so that light diet is reached as the temperature becomes normal and oedema disappears. Light diet may include eggs, rabbit, or chicken, fish. Red meat is not added for 14 days, and then cautiously. Avoid: Meat extracts, which stimulate the kidney too much. Alcohol, which irritates it, and salt, which attracts water into the tissues and makes excretion more difficult. This treatment is combined with hot packs, hot air baths to help elimination of urea by the skin, and with purgation by means of jalap or magnesium sulphate to get rid of fluid. Mercury is said to be harmful, since is excreted by the kidney.

Chronic Stage: Diet as m later stages of acute attack. Diet, etc., m Bright's Disease. We have adopted the view that the damage to the kidney here results from a disease with overgrowth of the connective tissue m the organ. The excreting parts of the kidney suffer as a result. Early and suspicious symptoms are: Headache and giddiness, dyspepsia and palpitation, general weakness, getting up at _ night to pass large quantities of pale urine with low specific gravity (1005--1010). Defective sight from retina being affected. Treatment: We can relieve, but not cure. Treatment conies under three Headings : 1. General: Regular action of the bowels every morning by giving fruit salts. Avoid chills; warm climate preferred. Avoid worry. Moderate exercise. Baths, fluids (hot water every morning), no alcohol. 2. Diet: Give a light, mixed, plain diet. Plenty of fluids. Red meats are to be reduced m amount. 3. Symptoms: Treatment may be required for high blood pressure, dyspepsia, or urasmic symptoms. Surgical Conditions of the Kidney. These can be reviewed briefly as follows : — 1. Congenital Conditions: Abnormalities of shape, size, number, and position. When one kidney is absent or very small, it is not permissible to remove the other.' In a recorded case where this was done* the patient lived 13 days, the first symptom being nausea and vomiting, and the cause of death being uraemic coma. More usually death would take place m about seven days. Sometimes the kidneys are fused at their lower ends into a horse-shoe shape. Naturally such a kidney could not be removed. .Malpositions usually occur m fused kidneys, and the kidney has been found m the hollow of the sacrum. A misplaced kidney might give rise to mistake m diagnosing an abdominal swelling.

2. Moveable Kidney has been referred to. 80% of the cases occur m women, and usually it is the right kidney that is unduly mobile. It may cause pain, vomiting and neurasthenia by dragging on the sympahetic nerves ; it may cause indigestion by pulling on the duodenum, congestion of the kidney by stretching its own vessels, or a hydronephrosis by kinking of the ureter. 3. Injuries: A blow may cause bruising or tearing of the kidney, and the kidney punch was barred from amateur boxing. There ma}' be signs of internal haemorrhage, and blood may appear m the urine. After abdominal injuries this is one of the things that the nurse watches for. A penetrating wound gives rise to bleeding, and if pelvis of the kidney has been punctured, to the discharge of urine. Infection is liable to follow since the fatty tissue round the kidney has poor resistance to infection. The result is an abscess, and sinus. Injuries of the kidney occasionally give rise to reflex suppression of the urine. 4. Blockage of the ureter, if sudden and complete, causes pain and atrophy of the kidney. If gradual and incomplete, it gives rise to hydronephrosis, a condition of distension of the renal pelvis by the accumulated urine. This will gradually destroy the kidney, or m some cases it becomes infected and turns to a pyonephrosis where the renal pelvis is full of pus. A hydronephrosis is diagnosed by forming a swelling which is fluid, and by a pyelogram, which shows it under the X-rays. An opaque solution is injected through a fine tube passed up the ureter, and an X-ray taken then shows the outline of the renal pelvis. It is treated by an operation to restore the continuity of the pelvis and ureters— a plastic operation. A pyonephrosis requires nephrectomy (removal of the kidney). 5. Inflammation of the Kidney. May be acute or chronic. Acute nephritis is a medical disease; but m chronic nephritis, with dropsy, which will not clear up, an operation to

strip the capsule from the kidney is sometimes done. Acute pyelitis, or inflammation of the renal pelvis, may recover, or pass into the chronic form. When the disease spreads to the kidney substance also, it is called pyelo-nephritis. This is indicated by rigors, and the general condition getting much worse. Pyelitis may have its origin from the 1)1 ood stream. B. coli travelling to the kidney via the blood from the bowel. Sometimes it is an ascending tuberculous infection, forming small ulcers on the apices of the pyramids. Another form is known as " surgical kidney " and occurs during " catheter life." where the patient is passing his own catheter with insufficient aseptic precautions. Cystitis first arises, and the B. coli ascend from the infected bladder to the renal pelvis. In the acute form, only one kidney is usually affected. The onset is always sudden, with fever, sweats, and rigors. The temperature is important, as if it becomes swinging, pyelo-nephritis has occurred. The acute form may subside or become chronic, or may as noted become pyelo-nephritis, with abcesses m the kidney, requiring operation at once. If the ureter gets blocked, it may become a case of pyo-nephrosis, or pus m the renal pelvis, requiring operation. Chronic Pyelitis may be seen m persons leading "Catheter life," and they have pus m the urine, irregular attacks of fever, and septic symptoms, such as loss of weight, anaemia, and irritability. The kidney region m the loin is usually tender. In pregnancy it is important to relieve constipation, which is a cause of ovelitis m such cases. The chronic form is treated by vaccines and drugs, and sometimes by washing out the renal pelvis through a catheter passed up the ureter. It may also occur m children, particularly girls, and is a cause of screaming m children. Chronic: Includes chronic pyelitis, syphilis, and tuberculosis. Chronic pyelitis has been considered. Syphilis is treated medically with mercury, iodies and arsenic.

Tuberculosis commonly becomes a surgfical disease, since if tuberculin fails to cure, an operation has to be performed.

T.B. of the kidney usually occurs m young men, and often m red-headed persons. Nearly all the cases are infected through the blood stream, as noted. A few may get an ascending infection along the ureter from tuberculosis m bladder or epididymis of testis. Generally, only one kidney is infected, and the other remains healthy m most of the cases. Infection via the blood stream lodges between cortex and medulla. Infection coming up the lymphatics of the ureter causes small ulcers on the apices of the pyramids. The result is an illness, with pain, frequency and pyuria, and often haematuria. Healing may take place ; but more often the disease progresses, and the bladder is infected, and occasionally the other kidney. One sequel of a tubercular infection, m the kidney is a similar infection of the ureter with blockage, and pyonephrosis. (Pus m the renal pelvis.) The treatment is first to test the other kidney, and then to remove the tuberculous one. (Nephrectomy.) Then feed the patient. Pus m the urine is tested for by adding liquor potassse (caustic potash). The urine becomes gelatinous, and can be poured from one vessel into another with an audible "plop." Tumours of the Kidney. A congenital condition is the pressure of cysts m the kidney, which gradually grow and form a large tumour, known as a congenital cystic kidney. The disease affects both kidneys, and neither must be removed. In children, sarcoma is the malignant growth. In adults, carcinoma (cancer), or a papilloma (benign growth). These tumours cause bleeding, pain and swelling. The treatment is early nephrectomy. This must be done before the kidney has become fixed. Growths m the kidney have a tendency to form secondary deposits m bones. In children a secondary deposit occurs m the orbit. In adults with carcinoma

(called hypernephroma) a secondary deposit may form m the long bones, e.g., the Tibia. Stone m the Kidney. Symptoms are due to the pain of the stone, and to infection setting m. Thus we get shooting pains, colic from clots passing, frequency, and pus m the urine. X-rays show the stone. These stones are due to insoluble substances m the urine, substances which are soluble m blood serum but not m the watery urine. They crystallise out. Stones are formed of urates of ammonia and soda, due to uric acid, and oxalates and to salts of lime. The treatment is to remove a small stone by nephrotomy, either through the kidney substance or through the renal pelvis. A large stone may necessitate removal of the kidney (nephrectomy). The stone may be m the renal pelvis, or m the calyces, or m the cortex. Sometimes a stone m the right kidney is mistaken for appendicitis. When a stone becomes stuck at the entrance of the ureter, an attack of renal colic results. Hence the small stones are those which produce colic. Those which are too large to move produce dragging pains and pus m the urine. The Treatment of a Case of Acute Renal Colic. The nurse might be confronted with such a case m a country place. There is agonising pain, which shoots down into the loin, along the course of the ureter. There is cold sweat, and subnormal temperature. After the attack, there will be a little hsematuria. Between attacks there is variable pain m the kidney region. Treatment during the attack must aim at reducing the pain. Hot poultices and bottles are applied over the kidney. Rest m bed, and hot drinks are prescribed. Morphia and atropin will be required. When attack is over, patient to watch for any stone that may be passed. Between the attacks: Medicinal treatment can be given. It must be remembered that no drug will dissolve a calculus. The bowels must be attended to regularly. Give

sodium bicarbonate three times a day. Test the urine with litmus until it is alkaline, and keep it so. Diet: Avoid red meats, which might produce uric acid. Avoid acid vegetables such as rhubarb, spinach, strawberries, tomatoes, because these produce oxalates contained m calculi. Give plenty of other vegetables, which are alkaline. Whey is good to promote excretion, and fluids are indicated. Apart from these measures, give an ordinary simple diet. A stone m the kidney, of course, should be removed surgically at the first favourable opportunity, unless it passes naturally. Haemorrhage from the Kidney. Occurs m acute nephritis, m T. 8., m stones, m growths, and m a condition called "essential haematuria," which is due to small patches of nephritis. Emergency Operations on the Kidney. 1. Calculus Anuria. One kidney is absent or not functional. The other becomes blocked by a stone. No urine can be passed, and the operation must be done at once. Either the stone is removed or a temporary urinary fistula is made from the renal pelvis to the surface. 2. Injuries: A blow over the kidney, with signs of internal haemorrhage, or a penetrating wound of the kidney. Kidney is either stitched up, or removed, according to its condition. 3. Abscesses (Pyelo-nephritis). Must be opened and drained. Female urethra — Length 1^ inches. Operations on the Kidney: General. Exploration : Exposing and examining the kidney. Nephropexy : Fixing up a movable kidney. Nephrotomy : Exposing and opening the renal pelvis. Nephrectomy : Removal of the kidney. Before operating on the kidney we require to know the nature and situation of the diseases, and whether one or both kidneys is affected ; also the efficiency of the other kidney. For example, a stone m the kidney has been mistaken for appendicitis. When the diagnosis has been

made, the efficiency tests are carried out on the other kidney, and the operation proceeded with. Preparation of the Patient for a Kidney Operation. (a) The Bowels. Must be well emptied, since a common complication is distension of the colon. Hence give a purge 36 hours before operation. It should be castor oil or a vegetable pill. Avoid salts, which are uncertain and produce flatulence. A small enema is given on the morning of the operation. b. Diet. Give moderate diet for the last 36 hours. Avoid starchy food, potatoes or bread, which form gas. Give toast instead of bread. Avoid green vegetables and salads* which leave too much residue. It is an advantage to give liquid paraffin regularly where possible for some weeks before operation. (c) Urinary antiseptics are always given before operations on the kidney or bladder. Position on the Operating Table. For lumbar nephrectomy, use the "kidney position." Lying on the sound side, with an air cushion or sandbag under the sound loin to open out the space between the last rib and the crest of the ilium. The upper arm is supported on an arm rest out of the way. This allows freedom to the chest m breathing. Lower arm drawn forward out of the way of the sandbag. Upper leg is straight. Lower limb is fully flexed at knee and hip, and this with the use of a sandbag m front of the upper knee, and behind the lower buttock, prevents the patient rolling out of position. The Operation. A curved incision is made starting from between the last rib and the erector spime muscle, and extending down towards the anterior superior spine of the ilium. The thick muscles are partly cut and partly retracted. Free haemorrhage is stopped with artery forceps or pack. The kidney is behind the peritoneum, and this must not be opened accidentally.

Other dangers to avoid are the colon, to outer side, and the pleura and diaphragm above. The kidney is brought outside and dealt with. Drainage is not done except after nephrotomy to allow any escaping urine to get aAvay, or after opening an abscess. In the former case, the tube is left m for from two to four days, the lesser time if no urine escapes. It is best covered with a gauze eusol pack to prevent entry of infection to the poorly resisting perirenal fat. After opening an abscess, drain until there is no more pus. After the Operation. Nurse the patient on the bad side if there is a drain m place. He should remain m bed for three weeks to get a firm scar, and avoid any tendency to hernia through it. The immediate dangers of the operation are : — Shock : Treated m the usual fashion. Haemorrhage : Which may be internal or external. Infection : Requiring wet dressings, or evacuation of pus. Flatulence : Treated by turpentine enema, and eserine or pituitrin. Give a dose of castor oil daily : on the second day. Uraemia is a rare complication with modern methods of preliminary testing of the sound kidney. It requires hot packs and purgation, etc. Retention of Urine: Hot pack to bladder. Catheter if other means fail. The Ureters or Renal Ducts. Originally the kidney arose m two parts : 1. The cortex or essential part was developed m situ. 2. The renal duct grew upwards from the bladder into the cortex or secreting part. This renal duct formed the ureter, renal pelvis, calyces, and the excretory duct m the pyramids of the kidney. The renal pelvis has two main parts, upper and lower, each of which gives out its group of 4 to 6 calyces, making a total of 8 to 12 calyces.

The renal pelvis and ureter are placed behind the blood-vessels to the kidney. Hence, at operations, the kidney is turned forwards, and the renal pelvis opened from behind. This avoids danger to the renal vessels. In contact with it on the right side is the duodenum, and on the left side the pancreas. Before it has reached the lower pole of the kidney, the renal pelvis has narrowed down to form the ureter. The ureter, from kidney to bladder is 10 inches long. It lies outside or behind the peritoneum, surrounded by fat. Its average diameter is 5 millimeters (l/sth inch). ft has three narrow parts: 1. Where it joins the renal pelvis. 2. Where it crosses the pelvic brim. 3. Where it enters the bladder. A stone passing down tends to be arrested at one or other of these three points. Structure of the Ureter. 1. Mucous membrane lines it, and is thrown into folds to allow 7 of expansion. It has no glands, because the urine keeps it wet, and it thus requires none. 2. Muscular coat, of three layers, two longitudinal with a strong circular layer between. The muscle coat is present also m the renal pelvis. 3. Fibrous coat, which m the last inch above the bladder contains strong longitudinal muscle bundles. The Blood Supply. 1. The upper part is supplied by branches from the renal artery. 2. Middle part by branches from the ovarian (female), or spermatic (male). 3. Lower part by ureteric artery from internal iliac ; and 4. By branches from the middle haemorroidal (rectal) or inferior vesical (bladder) arteries. These arteries anastomose, forming a network around the ureter. It follows that the ureter can be extensively stripped up from its bed and still preserve enough blood supply to keep it alive. The veins run into the spermatic or ovarian veins, and into the internal iliac.

The lymphatics drain into the glands along- the aorta. The Nerves: Supplied by sympathetic nerves. Minute ganglia lie within the fibrous coat of the ureter. This explains the automatic contractions of the ureter m expelling urine, and also the fact that violent contractions m renal colic cause great pain. Abnormal UretersOne or both ureters may be double m part or the whole of its length. The upper end. or renal pelvis, may have various shapes and subdivisions which are important to recognise m pyelograms. Occasionally one ureter may open into the prostatic urethra or into the vagina. In the first case this causes blockage of the ureter and hydronephrosis. In the second (vaginal opening) it causes leakage of urine. Stones m the Ureter. These occur m cases with acid urine. The commonest is composed of a mixture of oxalate and phosphate of lime, and throws a shadow m X-rays. A stone composed of uric acid only sometimes occurs, and does not throw a shadow m X-rays. A stone must be small to enter the ureter at all. Its diameter is only l/sth of an inch. When one enters, it becomes stuck at one of the three narrow places mentioned. In 75% of cases this impaction is only temporary, and the stone will pass on to the bladder after a time. It may have to be helped by passing instruments, or the injection of novocain. Some stick at the lower end projecting into the bladder, and can be removed by passing special scissors through the cystocope and splitting the opening. The remainder will require an operation for removal. The nurses' treatment of a case of ureteric calculus would be the same as that given under renal calculus. A stone m the ureter causes colic, slight ruematuria, and irritability with frequency of the bladder. X-rays will usually show it. The lower part of the ureter can be palpated by the linger

through the vagina m the female. It cannot be reached per rectum m males unless a stone is lodged m it, and not always then. In each case there would be tenderness on feeling the lower end if a stone were present. The ureter is deeply placed and well protected, especially m the pelvis. Hence it is not often injured. Occasionally it is accidentally cut at an operation for growths m the pelvis, especially m complete hysterectomy. The ureter is running forwards and inwards to the bladder, and one lies on each side of the cervix uteri. Tf a ureter is so cut, it may be repaired, or implanted into the bladder higher up, or simply tied. Usually it will be simply tied, because the patient has already had a big operation and may not stand the extra time required to repair it. The effect on the kidney would be to cause atrophy. Operations on the Ureter. These may be part of an operation on the kidney, as for hydronephrosis or part of another operation as for injury during hysterectomy. The ureter itself may be operated upon for an injury or stricture or for tuberculosis. Growths are very rare m the ureter, but it may suffer from growths of other organs pressing upon it, as m carcinomas m the pelvis, or m the kidney, or colon. Before operating, there are several methods of diagnosis for the ureter. Much information may be gained by cystoscopy, or catheterising or sounding the ureters, and by X-rays, pyelograms, or ureterograms. These procedures require much practice to be of any value. The diagnosis must be accurate before any operation is undertaken. The ureter may be reached either through the abdomen (trans-peritoneal route), or by the extra-peritoneal route, or occasionally the lower end through the bladder itself.

As a rule the trans-peritoneal route is avoided, as, though it is rapid and easy, the disadvantages are that the peritoneum may be infected, and that drainage is not possible. In this method the ureter is found at the brim of the pelvis and

traced up or down. On the right side the colon overlaps it, and on the left, the sigmoid. The method is chiefly used for repair after injuries during uterine operations. The trendelenberg position is used. The usual causes for removing a ureter are either m kidney growths, m tuberculosis, or pyo-utereritis (distension of the ureter with pus). The extra-peritoneal operation is done from m front also ; but the peritoneum is stripped inwards instead of being opened. Ureters may be transplanted, for various reasons. Temporary transplants are done into the vagina. Permanent transplants are done into the bladder or the other ureter. If transplanted into the colon, there is too great a risk of infection (colon bacillus), and of stenosis.

Plastic operations are done on the ureter m cases of hydro-nephrosis. Sometimes this is caused by an additional artery which runs to the lower pole of the kidney, and over which the ureter has become kinked. Such an artery has to be tied and cut. It is thus evident that a good many operations are done on the ureters. Those for stone, or where the ureter is opened, require drainage tubes, m case of escape of urine from the spot opened. Such tubes are* usually left m for from two to four days. In all operations on the kidney, bladder or ureter, catgut only should be used for ligatures, because sutures, which are not absorbed, are likely to form the nucleus of latter calculi, lime salts being deposited around the ligature. (To be Continued.)