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Spring 1998, Vol.5, No.1
Commentary on McBurney Article Kenneth A. Forde, M.D. It is hard to believe that acute appendicitis did not become established in the medical literature until the latter part of the ninteenth century. Although Reginald Fitz of Boston (a pathologist) is recognized as the first to describe and name the specific entity "acute appendicitis" (American Journal of Medical Sciences, October 1886)1 it was from New York and, especially from the College of Physicians and Surgeons of Columbia University, that many of the early reports appeared. William S. Halstead, P&S graduate, being among the few surgeons willing to operate early in the course of acute appendicitis in his day, describes being assisted by one Dr. Richard Hall on two such operations as the first appendectomies performed in New York. This would have been several years before the presentation by Dr. Fitz. In fact, in June 1886 Dr. Richard Hall, a P&S graduate and later apprentice of Sands and colleague of Halstead, published the paper: "Suppurative Peritonitis due to ulceration and suppuration of the vermiform appendix; laparotomy; resection of the vermiform appendix; toilet of the peritonaeum: drainage; recovery."2 It was certainly Henry B. Sands of P&S and McBurney, P&S 1889, who developed the early clinical experience in the management of acute appendicitis. McBurney's major contribution, it appears now, was stressing the importance of early diagnosis and early operative intervention in order to minimize the insult, and, hopefully, prevent the overwhelming morbidity that attended diffuse peritonitis from perforated or gangrenous appendicitis. Strange as it may now seem, Fitz's presentation was met with strong objections by members of the prestigious American Surgical Association for many years. Two major points in McBurney's contribution have special relevance to today's physicians and surgeons. First of all, McBurney, in arguing for early diagnosis, pointed out the single most important physical finding that should lead to operative intervention as evidence of localized peritonitis. He even went so far as describing a specific distance (1 1/2 to 2 inches) along the line from the anterior superior iliac spine to the umbilicus as the constant location of that point. That this point might vary depending on the size and the habitus of the patient apparently did not occur to him and it remained for subsequent generations to describe "McBurney's Point" as two thirds of the way along the line from the umbilicus to the anterior superior iliac spine. In today's practice style of employing an array of diagnostic tests and imaging techniques in order to make as precise a preoperative diagnosis as possible, we are beginning to observe some delays in the patient with early acute appendicitis arriving in the operating room. Fortunately, with the perioperative antibiotics now available an attack of acute appendicitis may often be muted. If the patient is left with an abscess, which is contained or which subsequently ruptures, the patient's need for complicated diagnostic and therapeutic measures certainly exceed the morbidity of an early uncomplicated appendectomy through a limited ( McBurney ) incision directly over the area from which the signs were elicited. This brings us to McBurney's second contribution. The concept of minimal access for removing or controlling the source of peritoneal contamination was really an extension of Celsus' old dictum: ubi pus, ibi evacua (where there is pus, there evacuate). In today's world of "minimal access surgery" removal of the appendix at "laparoscopy," feasible even with one trocar, is not only possible but widely practiced. That it is not universally accepted may be related to the nature of right lower quadrant peritonitis, as it may not be discovered by or resolved through limited (endoscopic or open) access to the peritoneal cavity in all cases. For the traditional abdominal surgeon this has meant extending the McBurney incision or making a second incision. For the minimal access (laparoscopic) surgeon it means "conversion" to a traditional open procedure. Despite the passage of time and a myriad of diagnostic tests the diagnosis of early acute appendicitis remains a challenge for the surgeon the world over with patients from cradle to grave. While the surgical management of early acute appendicitis and even appendicitis with perforation and local abscess formation has improved significantly with advances in anesthesia, perioperative metabolic care and the careful use of antibiotics, perforated appendicitis with diffuse peritonitis remains an entity fraught with high morbidity and mortality. McBurney's attention to the details of (1) recognizing on physical examination the signs of right lower quadrant peritonitis and (2) seeking operative access in as limited a fashion and as closely related to the pathology as possible still ring true over a century later. References 1. Perforating Inflammation of the Vermiform Appendix; with special reference to its early diagnosis and treatment. The American Journal of The Medical Sciences: PP 321-346. Oct. 1886 2. Higgins, G.A. Hall of the College of Santa Barbara: Chiron Books, 1989
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