4 i 4 APPLIED ANATOMY. 



2. The inferior ileoc&cal fold passes from the termination of the ileum to the 

 front of the meso-appendix ; it contains a small recurrent branch of the appendicular 

 artery. Beneath it and between it and the meso-appendix is the inferior ilcoccecal 

 fossa, which may sometimes contain the appendix. 



3. The retrocolic fold is not constant and may be multiple. It passes from the 

 lower and outer surface of the caecum to the peritoneum beneath. It binds down the 

 end of the caecum and not infrequently must be divided before the caecum and 

 appendix can be raised; the fossae on each side of it are called the retrocolic fos see. 



Lymphatics of the Caecum and Appendix. The lymphatics of the caecum 

 and appendix drain into a group located in the mesentery of the ileocaecal angle, 

 accompanying the ileocolic artery. According to Poirier and Cuneo there are three 

 sets : an anterior caecal, a posterior caecal, and an appendicular. 



The anterior cczcal lymphatics drain the anterior surface of the caecum and, after 

 traversing one or two small nodes, pass in the ileocaecal fold up to the main ileo- 

 caecal group. 



The posterior cczcal lymphatics drain the posterior portion of the caecum and, 

 after traversing three to six small nodes, empty likewise into the ileocaecal group. 



The appendicular lymphatics form four or five trunks which accompany the 

 artery between the layers of the meso-appendix. They then pass across the posterior 

 surface of the ileum to empty into the ileocaecal group. 



Poirier and Cuneo state that these lymph-trunks from the appendix pass through 

 one to three nodes placed in the retro-ileal portion of the meso-appendix, but Kelly 

 and Hurdon state that in the majority of cases these trunks empty into one or two 

 nodes some distance above the ileum in the ileocaecal angle, forming a part of the 

 ileocaecal chain. These latter authors state that there are three sets of lymph- 

 capillaries in the appendix : a superficial or subperitoneal set, another between the 

 submucous and muscular layers, and a deep set in the mucosa around the glands of 

 Lieberkuhn. 



The three great lymph-streams, anterior caecal, posterior caecal, and appendicu- 

 lar, are quite distinct from each other and from the surrounding lymphatics of the 

 pelvis and colon; when these latter are involved it is not by a lateral extension 

 from these three streams but by direct infection from the regions which they them- 

 selves drain. From the ileocaecal nodes the lymphatics follow the arteries to the 

 nodes at the root of the mesentery and empty into the receptaculum chyli. They 

 do not follow the veins to the liver, hence infection of the liver is not caused through 

 the lymph-channels in appendicitis. 



Appendicitis. Diagnosis. The most fixed part of the appendix is its root. 

 This corresponds to a point on the linea semilunaris opposite to the anterior superior 

 spine of the ilium. The painful tip of the appendix may be anywhere in a circle 

 around this point 10 cm. (4 in.) in radius. It may be lying posterior and simulate 

 calculus or other kidney trouble; it may be up toward the liver or gall-bladder; it 

 may be toward the left, even beyond the midline; it may be in Douglas's cul-de-sac 

 and be confounded with disease of the uterus, tubes, and bladder. It overlies the 

 ureter and may be mistaken for calculus therein. An enlarged gall-bladder can 

 have its painful apex at McBurney's point. Typhoid ulcers occur close to and, as 

 we have observed, may involve the appendix. All these relations must be remem- 

 bered. McBurney placed the most tender point 4 to 5 cm. ( i ^ to 2 in. ) from the 

 anterior superior spine in a direction toward the umbilicus. Personally we would 

 place it near the root of the appendix at least 2.5 cm. (i in.) lower down and 

 a little farther in. 



Operation. An incision for appendicitis often used is a longitudinal one over the 

 edge of the rectus muscle, either going directly through it or drawing it to one side 

 (Fig. 425). In McBurney's operation the external oblique is split in the direction 

 of its fibres and the internal oblique and transversalis are parted upward and inward 

 in the direction of their fibres, thus making a square hole through which the appendix 

 is removed. The writer (Annals of Surgery, Jan. 1906. p. 106) uses a transverse 

 incision with its centre over the linea semilunaris opposite to or 2.5 cm. (i in.) 

 above the anterior superior spine. The sheath of the rectus is divided transversely 

 and the muscle displaced toward the median line. The outer portion of the incision 



