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Historical Notes In Pelvic Surgery

Anecdotes on Appendicitis

Charles McBurney, MD (1845–1913)

Powell, John L. MD, FACOG, FACS

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The physician-anatomist, Berengario Da Carpi, first described the appendix in 1521. The appendix was clearly depicted in anatomic drawings by Leonardo da Vinci (1452–1519) in 1492, but was not published until the 18th century. It was well illustrated in the Andreas Vesalius (1514–1564) work, De Humani Corporis Fabrica, published in 1543, although it was not described in the text. Acute inflammation of the vermiform appendix is probably as old as humankind, and an Egyptian mummy of the Byzantine era exhibits adhesions in the right lower quadrant, suggestive of old appendicitis.

The first recorded removal of the appendix occurred in December 1735, when Claudius Amyand, a founder of St. George’s Hospital in London, operated on an 11-year-old boy with a long-standing scrotal hernia and fecal fistula. On opening the hernia, he found omentum surrounding an appendix perforated by a pin, giving rise to the fecal fistula. The appendix and omentum were amputated. The fistula closed and the lad recovered.

The French physician Mestivier in 1759 was the next to describe a diseased appendix. He performed an autopsy on a 45-year-old man who died shortly after having a large right lower abdominal abscess incised and drained. Mestivier found that the man also had in the appendix a large pin, which had become encrusted and had eroded through the wall and was probably the cause of the patient’s death.

In 1812 the first record of a proven acute inflammation of the appendix appeared in the Transactions of the Medico-Surgical Society of London by the surgeon John Parkinson. A 5-year-old boy had died 48 hours after the onset of acute abdominal pain and vomiting. At autopsy, an acutely inflamed appendix was found; it contained a fecalith. It is important that Parkinson quite clearly stated in his presentation that no disease was present in the cecum or proximal appendix, but in the appendiceal tip. There was much debate and confusion over the next 70 years as to the exact anatomic site of the inflammation noted in the right lower quadrant.

In 1830, Goldbeck, a student under the supervision of Professor Puchelt of Heidelberg, wrote his MD thesis on “Inflammation in the Right Iliac Fossa.” He collected 30 clinical cases and described accurately all the symptoms and signs of appendicitis with which we are so familiar today. Because he believed that “The essential nature of the condition consists in a preliminary inflammatory irritation of the mucosa of the caecum,” he named it “perityphlitis,” with Puchelt’s approval, thus adding confusion to the literature for the rest of the century.

In 1848, Henry Hancock, President of the Medical Society of London, first reported appendicitis complicating pregnancy. Ten days after a preterm delivery, an appendicial abscess was drained through a right lower quadrant incision and the patient recovered. An American surgeon, Willard Parker (1800–1884) of New York, published a paper in 1867 recounting his experiences, beginning in 1843, with drainage of appendiceal abscesses. He reported a total of four cases and advocated surgical drainage after the fifth day of illness, but without waiting for fluctuance. This surgical approach gained some acceptance and was later credited with reducing the mortality rate for appendicitis. The first known successful appendectomy for a diagnosis of “typhlitis” was performed in 1880 by renowned British gynecologist Robert Lawson Tait (1845–1899) from Birmingham, who was also the first to operate successfully for ruptured tubal pregnancy in 1883 by doing a salpingectomy.

Credit must go to the French physician Louyer-Villermay for being the first to prove that the appendix could be the site of inflammation. In 1824, Louyer-Villermay gave a presentation to the Royal Academy of Medicine in Paris entitled, “Observations of Use in the Inflammatory Conditions of the Cecal Appendix,” in which he described two examples of acute appendicitis leading to death in two young men. Francois Melier added six additional autopsy descriptions of appendicitis, one of which had been suspected before death. Melier clearly suggested the possibility of surgical removal of the appendix in 1827.

It is said that Melier’s paper was largely ignored because of the influence of Baron Guillaume Dupuytren (1777–1835), surgeon-in-chief of Hotel Dieu in Paris, who did not recognize the appendix as a cause for right lower quadrant inflammatory disease. He continued to feel that such processes began in or around the cecum. Dupuytren is infamous for his quote, “I have been mistaken, but I have been mistaken less than other surgeons.” The first textbook to give a description of the symptoms that accompanied inflammation and perforation of the appendix was published by Bright and Addison, the great physicians of Guy’s Hospital, in 1839 in Volume I of a book entitled, Elements of Practical Medicine.

In June 1886, Reginald Heber Fitz (1843–1913), Shattuck Professor of Pathological Anatomy at Harvard University, read a paper entitled, “Perforating Inflammation of the Vermiform Appendix; With Special Reference to It’s Early Diagnosis and Treatment” at the first meeting of the Association of American Physicians in Washington, DC. He gave a lucid and logical description of the clinical features and described in detail the pathological changes of the disease. He was also the first to use the term “appendicitis.” Fitz urged early surgical removal of the appendix. After Fitz, there was no serious challenge to the appendix as the cause of most right lower quadrant inflammatory disease, and the terms “typhlitis” and “perityphlitis” gradually became extinct.

In 1897, Harvey Cushing was surgical resident at The Johns Hopkins Hospital under William Halsted. From Fulton’s biography we learn that on Sunday, September 26, 1 week after a patient of his had died following operation for appendicitis, Cushing diagnosed appendicitis in himself. He then had to convince his senior colleagues to operate; both Halsted and Osler advised against it. Cushing, however, persuaded them otherwise such that 22 hours after the onset of his symptoms, Halsted took him to the operating room. By this time, Cushing had admitted himself to the hospital and performed the admission physical examination. All of this he documented, together with a diagram of his own abdominal signs. He then wrote his own pre- and postoperative orders. No doubt he would have assisted at the operation if it had been humanly possible!

In the history of medicine, Charles McBurney’s name will ever be associated with the vermiform appendix as the first surgeon to point out a ready means of detecting a diseased appendix by pressure on a particular spot. Charles McBurney (1845–1913) was professor of surgery at the College of Physicians and Surgeons and worked mainly at Roosevelt Hospital in New York. In 1889, he described the point of maximal abdominal tenderness (“McBurney’s point”) to be determined by the pressure of one finger placed one-third of the distance between the anterior iliac spine and the umbilicus. McBurney pioneered early diagnosis and early operative intervention and in 1894 he described the muscle-splitting incision that today bears his name. The incision in the skin is oblique and about 4-inches long. It crosses a line drawn from the anterior iliac spine and is situated such that its upper third lies above that line.

Charles McBurney was born in Roxbury, Massachusetts on February 17, 1845. He was the son of Charles and Rosine Horton McBurney. He was educated in private schools in and about Boston and entered Harvard University in 1862, receiving the degree of A.B. in 1866, and A.M. in 1869. He earned his M.D. at the College of Physicians and Surgeons in New York City in 1870, interned at Bellevue Hospital in 1871, and went abroad to continue his medical studies in Vienna, Paris, and London. He began his practice upon his return to New York City.

In 1872, McBurney was appointed assistant demonstrator of anatomy in the College of Physicians and Surgeons and filled this position until 1880, when he was elected instructor in operative surgery. From 1889 to 1892, he was professor of surgery; from 1892 to 1897, he was professor of clinical surgery, and later professor emeritus. He continued to attend to private and hospital practice until 1907 when he retired to Stockbridge, Massachusetts. He was visiting surgeon to St. Luke’s Hospital from 1875 to 1888, and was the only attending surgeon to Roosevelt Hospital from 1889 to 1901.

Through the gift of William J. Syms, in 1892 McBurney established the first model elaborate private operating pavilion, “The Syms Operating Pavilion.” This surgical facility, opened in 1892, achieved national and worldwide prominence for its surgical teaching and research. It was here that he introduced the practice of having the entire surgical team wear rubber gloves, shortly after Halsted had recommended this practice at Johns Hopkins.

He was also consulting surgeon to the New York, Presbyterian, St. Mary’s, and Orthopedic Hospitals, and to the Hospital for the Ruptured and Crippled. He was an honorary member of the Royal College of Surgeons, the College of Physicians and Surgeons in Philadelphia, the Surgical Society, and other medical organizations.

Among his contributions to surgery are The Indications for Early Laparotomy, The Treatment of Appendicitis, A Contribution to Cerebral Surgery, and Dislocation of the Humerus Complicated by Fracture. He was a contributor to Dennis’ System of Surgery and to The International TextBook of Surgery.

Charles McBurney married Margaret Willoughby Weston on October 8, 1874. They had two sons and a daughter. Mrs. McBurney died on June 1, 1909. Dr. McBurney died at his sister’s house in Brookline, Massachusetts on November 7, 1913 at age 68. His legacy to surgery of the biliary tract was not awarded the recognition that his contributions in appendicitis received, but his early advocacy of sphincterotomy for common duct stone is worthy of remembrance. He reported six successful cases of removal of biliary calculi from the common duct by the duodenal route in 1898. This novel approach anticipated by at least half a century the operation sphincterotomy for common duct stones, now a mainstay of endoscopy practice.

Additional Reading List

Amyand C. Of an inguinal rupture with a pin in the appendix caeci encrusted with stone: some observations on wounds in the guts. Philosoph Trans R Soc London 39: 329, 1736.
    Deaver JB. Appendicitis. 3rd edition. Philadelphia, P. Blakiston’s Son & Co., 1905.
      Fitz RH. Perforating inflammation of the vermiform appendix; with special reference to its early diagnosis and treatment. Trans Assoc Am Physicians 1: 107, 1886.
        Goldbeck G. Ueber eigenth umliche entzündliche Geschwülste inder rechten Hüftbeingegend. Worms, JA Kranzbulher, 1830.
          Hancock H. Disease of the appendix caeci cured by operation. Lancet 2: 380, 1848.
            Louyer-Villermay JB. Observations pour servir à l’histoire des inflammations de l’appendice du caecum. Arch Gen Med (Paris) 5: 246, 1824.
              McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 50: 676, 1889.
                McBurney C. Removal of biliary calculi from the common duct by the duodenal route. Ann Surg 28: 481, 1898.
                  McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 20: 38, 1894.
                    Melier F. Mémoires et observations sur quelques maladies de l’appendice cécale. J Med Chir Pharm (Paris) 100: 317, 1827.
                      Mestiver M. Observation sur une tumeur située proche de la region ombilicale, du côté droit, occasionnee par une grosse épingle trouvée dans l’appendice vermiculaire du caecum. J Med Chir Pharm (Paris) 10: 441, 1759.
                        Parker W. An operation for abscess of the appendix vermiformis caeci. Med Rec 2: 25, 1867.
                          Parkinson JWK. Case of diseased appendix vermiforms. Med Chir Trans 3: 57, 1812.
                            Shepard JA. Acute appendicitis: An historical survey. Lancet 2: 299, 1954.
                              Tait RL. Five cases of extra-uterine pregnancy operated upon at the time of rupture. Br Med J 1: 1250, 1884.
                                Tait RL. Surgical treatment of typhlitis. Birmingham Med Rev 27: 26, 1890.
                                  Williams GR. Presidential Address: A History of Appendicitis. Ann Surg 197: 495, 1983.
                                    © 2001 Lippincott Williams & Wilkins, Inc.