THE INTRINSIC BLOOD-VESSELS OF THE KIDNEY 
AND THEIR SIGNIFICANCE IN'NEPHROTOMY. 
Max - 
[PRELIMINARY COMMUNICATION.1] 
In view of the enormous number of investigations of the 
different structures of the kidney recorded in the literature 
it seems strange that only scanty information exists on the 
actual course of the larger blood-vessels and their relation to 
the pelvis of the kidney. The normal and abnormal arrange- 
ment of the vessels at the hilum are well known and the 
microscopical pictures of the vessels in the cortex and 
pyramids are likewise thoroughly familiar to every student. 
But as to the actual form of the pelvis and the course and 
distribution of the larger vessels around its walls very vague 
ideas still prevail. It is evident that exact knowledge of 
the anatomy of this region would prove of the utmost im- 
portance to the surgeon in enabling him to Open the pelvis 
of the kidney without running the risk of cutting large 
branches of the renal artery. 
In order to study this region I made a large number (40) 
of celloidin injections of human kidneys. The injected 
1 Since this article was sent to press, I learned that Dr. William 
Keiller, of Galveston, Texas, has been following a similar line of 
research. His findings were embodied in a report to the Texas State 
Med. Soc., in whose Transactions for 1900 they appear. I have just 
received through the kindness of Dr. Keiller some of his specimens 
which substantiate many of the points brought forth in this paper, 
although the methods he employed differed essentially from mine. 
This being merely a preliminary communication precludes the possi- 
bility of discussing in detail Dn. KeillerVe*eeHßnf work, 252 
specimens were then digested2 and the casts thus obtained, 
examined. Nearly thirty additional injected kidneys were 
not digested, but were cut into sections in various planes 
in order to control the results obtained by the method of 
digestion. Some of these sections were rendered translucent 
by the usual methods. 
I made separate injections of the arteries, of the venous 
system and of the pelvis, combinations of any two out of 
three and finally triple injections. The great majority were 
of the last class. At first I confined my injections to kidneys 
which seemed normal so far as regarded form and size; later, 
after I had, in this way, determined the law according to 
which the vessels were grouped, I concentrated my attention 
upon abnormally shaped kidneys. The present paper will 
contain a short abstract of the main results of these studies. 
I shall confine myself to the description of the normal form 
and mention briefly only a few variations. A more elaborate 
communication will appear later. 
The Pelvis of the Kidney.—From a surgical standpoint all 
forms of pelves may he classified under two main groups. 
(1) True pelves with major and minor calices. 
(2) Divided pelves, where there is no free communication 
possible between all of the calices inside of the kidney. 
(1) True Pelves.—Fig. 1 shows the ideal form of a true 
pelvis. There are eight calices; the uppermost (1) and 
lowest (8) of which many have double papillae. The remain- 
21 employed Schieferdecker’s corrosion-method, slightly modified by 
Mixter arid Mall. The procedure was as follows : The vessels and pelvis 
of the kidney were thoroughly washed out and then dehydrated with 
alcohol and ether. The arteries, veins and pelvis were then injected 
with cinnabar, Prussian blue and arsenic preparations of an alcohol and 
ether solution of celloidin, respectively. The kidney was then placed 
in a digesting fluid consisting of varying amounts of 1:3000 pepsin 
(Sharp & Dohme) dissolved in 0.3 per cent to 0.5 per cent of HCI. The 
process of digestion was completed in from three to four days to two 
weeks. When the substantia propria and the connective tissue of the 
kidney were completely dissolved, they were washed out with a gentle 
stream of water, leaving only the casts of the injected vessels and 
pelvis. The casts were preserved in glycerin to which a few drops of 
carbolic acid were added. mg six ealices stand upon the pelvis in a double row; an 
anterior, irregularly arranged (3, 4, 6) and a posterior, more 
regular, row (3, 5, 7). 
The horizontal axis of the pelvis (Fig. 1 D, a, a') runs from 
the posterior surface of the kidney obliquely through the 
organ to the outer third of its anterior surface and the two 
rows of calices leave this axis at almost equal angles. The 
posterior calices, therefore, point to a line just a little pos- 
terior to the lateral convex border of the kidney (5), while 
the anterior calices are directed straight forward into the 
convex anterior region of the organ (c). This form of the 
pelvis is, next to the -distended pelvis, the most favorable for 
a surgical incision. 
The great majority of pelves have well defined major 
calices, with a very narrow lumen, and owing to this condi- 
tion it is often impossible to gain access to the minor calices 
and remote pockets through a surgical incision into the 
pelvis at the site of the hilum. Furthermore, this incision 
must he short, as there is a constant branch of the renal 
artery running downward over the posterior surface of the 
pelvis at the hilum. 
The varieties of the ideal form are very numerous and 
will he described in detail in the fuller communication above 
referred to. All kidneys with a true pelvis have a smooth 
surface or moderate degree of lobulation, regular outline 
and, as a rule, a normal blood-supply. 
(3) Divided Pelves.—Fig. 3 shows the typical form of a 
divided pelvis. Comparing it with Fig. 1 one finds that 
between calices 8, 3 and 4, 5 there is a zone of cortical 
substance (a), which extends to the hilum. It divides the 
upper part of the pelvis from the lower, and in the majority 
of cases the lower portion receives the greater number of 
calices. Although the number of calices in divided pelves 
may he eight, they are generally more numerous. In other 
respects the topography of these pelves is similar to that of 
the true pelves. A kidney with a divided pelvis, as a rule, 
preserves its foetal lobulations and has an abnormal arterial 
circulation; the division between the individual sections of 
the pelvis is generally marked on the surface by an especially 254 
deep groove, thus causing the appearance as though there 
were two separate kidneys, one on top of the other. Fre- 
quently they are indeed separate organs as far as their secre- 
tory function and their arterial circulation are concerned. 
The veins, however, collect, as a rule, in one single trunk. 
These conditions are readily understood hy one who is 
familiar with the different stages of the development of the 
kidney, with its .origin, its ascent from the pelvis to the 
lumbar region and finally the wandering in of the vessels. 
The Renal Artery.—The renal artery divides at the hilum, 
as a rule, into four to five branches, the distribution of which, 
in relation to the pelvis, is such that three-fourths of the 
blood-supply is carried anteriorly, while one-fourth runs 
posteriorly. The relative size of the two systems may occa- 
sionally be i : | : -j, but rarely :4- The arteries are 
end-arteries in the strictest sense of the word and the 
branches of the anterior division never cross over to the 
posterior side, or vice versa. They do not anastomose with 
each other.3 The plane of division between the two arterial 
trees is indicated by the axes of the posterior row of calices 
(see Fig. ID b and Fig. 3 B arrow). 
Fig. 3 B demonstrates this in a schematic way. The sec- 
tion is imagined as passing transversely through the middle 
of the kidney, as in the lower diagram in Fig. 1. The artery 
(a) sends a large branch (a') anteriorly and a small branch 
(■a") posteriorly. Both branches are seen running close to 
the pelvis and the calices up to the region of the papillae, 
whence they send off fan-like branches (h) around the pyra- 
mids. The anterior branch (a') supplies the whole of the 
anterior pyramid (P) and the anterior portion of the pos- 
3 To Hyrtl apparently is due the credit of having first mentioned the 
“natiirliche Theilbarkeit der Niere,” hy which he means that in a 
corrosion specimen the two arterial systems are completely separated 
by the pelvis. He also affirms that this arrangement of the renal arteries 
is found “without exception in all mammalia from the whale to man.” 
[Hyrtl, Topographische Anatomic. Wien, 1882. Bd. I, pg. 884.] 
Hyrtl’s statement has unfortunately been overlooked and up to this date 
the text-books on anatomy and surgery make no mention of this anato- 
mical fact, so important to the surgeon. terior pyramid (P'), while the posterior branch (a") supplies 
only the remaining portion of the posterior pyramid (P'). 
The arrow indicates the division between the two vascular 
trees, c represents a section of the long lateral column of 
cortical substance, which is situated between the anterior 
and posterior rows of pyramids P and P'. 
The greater part of the arterial circulation of the kidney 
follows this system. The entire region from calices 2to 7 
has this arrangement. Around the uppermost (1) and lowest 
(8) calyx, however, the arteries have a somewhat different 
arrangement (Pig. 4). They are derived from the anterior 
group of vessels and run either as a single trunk, having a 
diameter of 2-3 mm., to the base of the major calyx, or 
divide before they reach the calyx into three branches, I, 11, 
111. Branch I and branch 111 run courses similar to those 
of branches a' and a" in Pig. 3 B, i. e. anteriorly and poste- 
riorly to the calyx. It is obvious that their arrangement must 
prolong the arterial division, existing in the central portion 
of the kidney, upward and downward. Branch II may he 
short, as in Fig 3 A (upper pole), and vessels coming from 
branches I and 111 partially may take its place. Or it may 
he of considerable length, as in Pig. 5, where it makes a long 
sweep around the inner border of the pole. Branch II is the 
one that generally plays the role of the supernumerary 
artery; it may arise from the renal artery near its aortic 
origin (Fig. 5 a and h) or even from the aorta (Fig. 5 c); in 
the latter case it must be considered a supernumerary artery. 
Although separate arteries are found in kidneys with 
smooth surfaces, they are much more frequently met with in 
those that have preserved their foetal lobulation. This ab- 
normal arrangement of the arteries is, perhaps, the cause of 
the persistence of the lohulated form. When he meets with 
a kidney having a distinctly lohulated form, the operator 
may expect to find a long hilum with separate arteries and 
an abnormal renal pelvis. 
The further course of the arteries, the irregularities that 
may occur and to what extent they affect the above described 
schema, will he dealt with in a fuller communication. 
The Renal Vein.—Concerning the veins, I shall here record 256 
only a few notes dealing with their more important char- 
acteristics. 
While there is a complete arterial division in the plane 
connecting the posterior calices and terminating in the lat- 
eral half of the ripper and lower calices, the veins follow 
quite a different arrangement. Around the bases of the 
pyramids they anastomose and form the familiar venous 
arches. They unite in large branches that run between the 
sides of the pyramids and the columns of Bertini to the 
necks of the calices, where they lie between the pyramid and 
the arterial branches. The thickness of these collecting 
veins accounts for the peculiar lobulated appearance of the 
base and sides of the pyramids (Fig. 6 B). Around the necks 
of the calices, both anteriorly and posteriorly, these veins 
form a second system of anastomoses (Fig. 6 B h) much 
shorter and thicker than that at the base of the pyramids (a). 
This appears as a number of thick loops or rings which fit 
like a collar around the necks of the calices. Nearly all the 
collected blood of the posterior region is carried anteriorly 
through these short thick stems, to join that of the anterior 
portion at the point indicated by c. 
In comparing Figs. 3 and 6 one finds that an incision 
through the posterior row of calices would avoid all the 
arteries but would sever six of these collecting veins. As 
there remain, however, sufficient anastomoses at the upper 
and lower pole of the kidney, no serious consequence should 
follow an injury to these veins. The large veins at the 
hilum are generally described as being in front of the artery. 
This is, however, only the case in the neighborhood of the 
vena cava, Avhile at the hilum and throughout the entire 
kidney the veins are usually situated between the arteries 
and the pelvis. 
The Surface of the Kidney and its Relation to the Under- 
lying Structures.—If one is thoroughly familiar with the 
kidney’s surface it is a comparatively easy matter to deter- 
mine the arrangement of the undenting structures; one can 
map out fairly accurately the position of the pyramids, of the 
columns of Bertini and of the calices; and as a consequence 257 
the position of the plane of arterial division can also be 
determined. Let us consider briefly the principal landmarks. 
The anterior surface (Tig. 7 B) of a normally shaped 
kidney is convex and has its greatest prominence at the lower 
portion at the point indicated by a. The posterior surface 
(A) is somewhat flattened. A lateral view of the organ (C) 
shows this very clearly; there is also rendered visible a 
depression (5 h'), which indicates the position of the lateral 
column above referred to, or the line of division between the 
anterior and posterior rows of pyramids. This depression, 
however, by no means indicates the division between the 
arterial systems, as below it is situated the greatest number 
of large vessels contained in the kidney. This line (5 V) is 
therefore a most important landmark and in every neph- 
rotomy should be thoroughly mapped out. The other depres- 
sions on the surface indicate the positions of the margins 
of the individual pyramids or subdivisions of such. 
Tig. 8 shows the same kidney as Fig. 7, with its pyramids 
and calices schematically drawn. The posterior pyramids 
(A 3, 5, 7) are long and slender, while the anterior ones 
(B 2, 4, 6) are more rounded at their base, thicker and do 
not extend so far laterally as the posterior pyramids. Con- 
sequently, the line of division (D h and V) between the pyra- 
mids leans more towards the anterior surface of the kidney, 
so that the anterior surface of the organ bulges, while the 
posterior is flat. 
Between the pyramids are the columns of Bertini which 
carry the larger vessels. Fig. 8 C shows that these columns 
join in a longitudinal column (b V), in which all of the 
largest vessels of the kidney (three-fourths of the arteries 
and all of the veins) are found (see also Figs. 3 and 6). 
As was said before, in lobulated kidneys this column is 
indicated as a distinct depression on the surface. The cap- 
sule seems thickened along this line and frequently forms 
a whitish hand, to which the perirenal fat appears to be 
more intimately attached than elsewhere. 
Lobulation of varying degrees of distinctness is found in 
the great majority of cases. The trained eye can detect this 
lobnlation in kidneys which a novice would pronounce per- 258 
fectly smooth. Should, however, the kidney present not the 
slightest depression or lobulation, the arrangement of the 
large stellate veins of the capsule will still serve to suffi- 
ciently locate the limits of the pyramids and the position of 
the important lateral longitudinal column (b V, Figs. 7 and 
8). These veins are found to he more conspicuous and are 
arranged in rows along the lines where the foetal lobulation 
has been. (See Fig. 7.) 
The Incision and Subsequent Suture.—The above described 
landmarks should suffice to guide the surgeon in making his 
incision so that the kidney can be readily opened between 
its anterior and posterior arterial branches. 
Fig. 9 A shows the lateral view of the kidney; a a' repre- 
sents a line showing the lateral convex border; b V indicates 
the position of the lateral longitudinal column bearing the 
large vessels; c d is the line along which an incision should 
be made. Diagram B shows the direction in which the 
knife should pass. An incision through the middle of the 
kidney (cl e), would be inadvisable, inasmuch as it would cut 
through large vessels in region f and would fail to open 
the posterior calices. The proper direction is indicated by 
c x, the knife remaining in the posterior half of the kidney. 
The cut should be made anteriorly to the posterior papillae 
(p) in order to avoid severing the collecting tubules of the 
posterior pyramids. It is advisable to palpate if possible 
the vessels and the pelvis at the hilum before making the 
incision, and if their arrangement is found to be normal, i. e. 
the pelvis at the posterior region of the hilum and the great 
majority of vessels anterior to the pelvis, then the above 
described procedure is applicable. 
I wish to add a few suggestions as to the incision itself 
and also as to the subsequent suture. 
A short incision is made into the lowermost posterior 
calyx if possible by means of blunt dissection (Fig. 1 A 7), 
and through this incision the pelvis is explored. In a col- 
lapsed state of the renal pelvis it may be difficult to enter 
one calyx. In such cases a moderate distention of the pelvis 
with sterile water or boric solution will facilitate the pro- 
cedure considerably. If this short incision does not prove 259 
satisfactory, the three ealices (3, 5, 7) should he carefully 
opened hy means of an incision from within to the surface 
(Fig. 10). A curved knife will best answer this purpose. 
A glance at Fig. 3 A shows that short transverse incisions 
through the anterior or posterior parenchyma may produce 
little hemorrhage, provided they do not come too near the 
hilum. However, such incisions never open the pelvis satis- 
factorily. 
The arrangement of the vessels in the kidney suggests 
the mattress suture as best adapted for approximating 
the two cnt surfaces. Simple interrupted sutures almost 
always tear the tissues and produce an insufficient union. 
The mattress sutures are placed at right angles, or nearly 
so, to the large vessels and thus effectively prevent any 
tearing of the kidney substance. If the bight of the suture 
he to 2 cm., no strangulation of kidney substance should 
result. The sutures should be applied in the manner repre- 
sented in Fig. 11. 
I. The pelvis is approximated with fine catgut sutures (a). 
These ought to be placed between the calices and take in 
only the fat, the outer fibrous coat and the muscular layers. 
The mucous membrane should not be included. 
11. The second system of sutures should also he of catgut 
and should unite the region of the papillse. They should be 
mattress sutures (Fig. 11 b) and are best placed hy means 
of a long straight three-cornered needle with a blunt point, 
so that no injury to the large vessels results. A possible 
oozing would only serve to tighten the grip of these sutures 
and thus render them more effective. 
HI. The third system of catgut sutures should also he 
mattress sutures and he placed parallel to the second through 
the cortex near the bases of the pyramids (Fig. 11 c). Occa- 
sionally the third system of sutures is superfluous. 
IV. The capsule is then closed in the usual manner (Fig. 
11 d). 
Dr. Holmes asked if Mr. Brodel had met with the anoma- 
lous distributions of renal blood-supply in which the vessels 
go to the poles of the kidney directly from the aorta, in ad- 260 
dition to those to the hilum; and whether both sets 
anastomose. It may be considered a law that arteries which 
usually come from a common stem may spring directly from 
the parent trunk. Thus the three diverging branches of the 
external circumflex are often formed directly from the pro- 
funda or common femoral; or the inferior thyroid and 
transversalis colli from the subclavian; or gastric and hepatic 
from the aorta, the coeliac axis being absent. Conversely 
arteries closely associated may at times spring from a com- 
mon trunk, as the superior and inferior profunda in the 
arm, or the facial and lingual in the neck. In the kidney the 
four or five branches which usually arise from the renal 
artery may come separately from the aorta and may he dis- 
tributed to the poles as well as the hilum. This is of great 
importance to the surgeon, Ist because the amount of hem- 
orrhage depends not only upon the size of the artery cut, hut 
upon the size of the trunk from which it springs, and 2nd, 
because after ligating the mass at the hilum, he is apt to 
cut ruthlessly, ignorant of the possibility of large branches 
running to the extremities. Doubtless some of the profuse 
hemorrhages after nephrectomies are due to this. PLATE XXVII. 
Fig. I.—Left kidney drawn as though transparent, showing 
form and divisions of a true pelvis. The major calices are not 
very marked, the minor calices being situated directly upon the 
pelvis. 
A. Posterior view. 
B. Anterior view. 
C. Lateral view. 
D. Transverse section through 
B viewed from above. PLATE XXVIII. 
pIG 2. Left kidney with typical form of a divided pelvis. The two 
divisions of the pelvis are separated by an area of corticle substance (a) 
extending almost to the hilum. As a rule the upper division is narrow 
and has fewer calices than the lower. The division between the two 
branches of the pelvis is generally marked on the surface of the kidney 
by a deep depression. PLATE XXIX. 
Fig. B.—The renal artery 
and the distribution of its 
branches in relation to the 
pelvis. 
A. Anterior view of a left 
kidney. There are 6 main 
branches seen entering the 
kidney substance. Only one 
of these (the third) passes 
posterior to the pelvis at the 
hilum, also small arteries 
coming from the upper and 
lower main branches are seen 
to pass posterior to the upper 
and lower calices. All the 
rest of the arteries pass an- 
terior to the pelvis and its 
calices. The small branches 
to the cortex of the anterior 
portion of the kidney have 
not been drawn in order that 
the large branches and the 
pelvis might appear more 
distinctly. 
B. Transverse section 
through the middle of the 
, same kidney seen from above. 
The anterior branch of the 
artery supplies about % of 
the kidney substance while 
the posterior branch supplies 
only The dotted line and 
arrow indicate the plane of 
arterial division. PLATE XXX. 
Fig. 4.—Arrangement of the arteries at the upper and lower pole. 
They come as single trunks from the main artery and run at an angle of 
45° or more upward and downward to the "vicinity of the major calices, 
where they divide into three branches. 
I. Anterior branch. 
11. Median branch. 
111. Posterior branch. 
The anterior and posterior branches are as a rule much larger than 
the median. PLATE XXXI. 
Fig. 5.—Variation of the median branch. This branch may be larger 
than usual and arise separately from the main artery at points a and &, 
or from aorta direct (c). It may be as large as the renal artery itself, in 
which case it gives off branches I and 111 or more. Such an arrange- 
ment of the arteries is as a rule associated with an abnormal form and 
position of the renal pelvis. PLATE XXXII. 
Fig. 6 The renal vein and 
the relation of its branches to 
the pelvis of the kidney. 
A. Anterior view of the left 
kidney. For the sake of clear- 
ness the small veins of the 
cortex of the anterior portion 
of the kidney have been omitted. 
B. Transverse section seen 
from above. There is no col- 
lecting vein posterior to the 
pelvis; all the veins of the 
posterior region cross over to 
the anterior portion between 
the nechs of the minor calices 
(6) to join the veins of the 
anterior region at a point indi- 
cated by c. PLATE XXXIII. PLATE XXXiV. 
Fig. B.—Same kidney as seen in Fig. 7 with a semi-schematic repre- 
sentation of the pyramids. The converging lines indicate the direction 
of the uriniferous tubules. 
A. Posterior region. 
B. Anterior region. 
C. Lateral view. 
D. Transverse section through B 
seen from above. PLATE XXXV. 
Fig. 9.—A. Lateral view of left 
kidney, showing the location of the 
most advantageous incision through 
the parenchyma in kidneys which 
have a normal arterial arrangement. 
aa' Lateral convex border of kid- 
ney. 
by Position of lateral column of 
cortical substance containing the 
vessels. 
cc' Best incision. 
B. de Incorrect direction of in 
cision 
cx Correct direction of in 
cision. PLATE XXXVI. 
Fig. 10.—Posterior view of left kidney, showing method of exploring 
and opening the pelvis. The lower diagram indicates the direction of the 
incision in relation to the papillae of the posterior pyramids. PLATE XXXVII. 
Fig. 11.—-Imaginary transverse section through a kidney similar to 
Fig. 9 B, showing manner of placing the mattress sutures.