McBurney point

In 1889, American surgeon Charles Heber McBurney described a site of maximal tenderness elicited by pressure with one finger, approximately 1½–2 inches from the right anterior superior iliac spine towards the umbilicus. In 1890, Lewis Atterbury Stimson introduced the term McBurney’s point. By 1900, however, medical textbooks employed differing anatomical definitions, placing the point either midway or one-third of the distance along the ASIS–umbilicus line.

Although McBurney described a clinical point of maximal tenderness, subsequent authors increasingly interpreted it as a fixed anatomical landmark corresponding to the appendiceal base. This assumption was challenged by Otto Lanz in 1908 and later radiological studies demonstrated significant variability in appendiceal position. Localised tenderness remains clinically relevant, but the conventional point does not reliably identify the anatomical position of the appendix.

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History of McBurney point

1886 – American physician Reginald Heber Fitz (1843–1913) introduced the term appendicitis. He established inflammation of the vermiform (worm-like) appendix as a principal cause of right iliac fossa inflammation and abscess. His work helped establish the clinical and surgical framework within which McBurney subsequently described his diagnostic finding.

As a circumscribed peritonitis is simply one event, although usually the most important, in the history of inflammation of the appendix, it seems preferable to use the term appendicitis to express the primary condition.

Fitz 1886

1889 – On November 13, Charles Heber McBurney (1845–1913) presented Experience with early operative interference in cases of disease of the vermiform appendix before the New York Surgical Society. He described the site of greatest tenderness in appendicitis as lying 1½–2 inches from the right anterior superior iliac spine along a line towards the umbilicus.

I believe that an every case the seat of greatest pain, determined by the pressure of one finger has been very exactly between exactly an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus.

McBurney 1889

1890 – On October 8, Lewis Atterbury Stimson (1844–1917) presented A contribution to the study of appendicitis before the New York Surgical Society. In the published paper of October 25, Stimson introduced the term McBurney’s point to recognise the diagnostic importance of McBurney’s observation.

For the sake of brevity, and a proper recognition of the value of this symptom, I shall speak of this point as ‘McBurney’s point.’

In the subsequent discussion, published November 29, 1890, Lewis Stephen Pilcher (1858–1934) also referred to the localised tenderness as the McBurney symptom.

1890 – Robert Fulton Weir (1838–1927) published Remarks on intermediate laparotomy for appendicitis in its quiescent stage. He questioned the diagnostic specificity of localised tenderness in appendicitis, providing an early challenge to the interpretation of McBurney’s clinical finding.

1891 – In The Indications for Early Laparotomy in Appendicitis, McBurney revisited the clinical diagnosis of appendicitis and responded to contemporary criticism of focal tenderness as a diagnostic finding. He emphasised the importance of localised tenderness as part of the clinical assessment rather than as an isolated anatomical observation.

1891 – William Henry Carmalt (1836–1929), discussing a case of caecal carcinoma, described McBurney’s point as an area 1½–2 inches from the right anterior superior iliac spine towards the umbilicus, presumed to overlie the appendix. His account retained McBurney’s original measurement while extending its interpretation towards an anatomical surface landmark.

1892 – Xavier Oswald Werder (1857–1919) published a paper on Peritonitis. He reproduced McBurney’s description of localised tenderness elicited by pressure with one finger, but identified the point as indicating the base of the appendix at its junction with the caecum.

1894 – In July, McBurney published The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. He distinguished his new technique from his earlier oblique incision, which divided the deeper abdominal muscles transversely. The modified operation separated the external oblique, internal oblique and transversus abdominis fibres along their natural directions, preserving the crossed arrangement of the abdominal wall.

1894 – In November, McArthur published Choice of incisions of abdominal wall; especially for appendicitis. He acknowledged McBurney’s July publication while reporting his own earlier experience with a comparable muscle-separating approach.

1899 – Medical textbooks described McBurney’s point using differing surface measurements. James H. Musser and John B. Deaver defined the point as midway between the right anterior superior iliac spine and umbilicus whilst George Marvin Tuttle placed it one-third of the distance along the same line. These definitions differed from McBurney’s original fixed measurement.

1908 – Otto Lanz (1865–1935) published Der McBurney’sche Punkt, questioning the assumption that the clinical point of maximal tenderness corresponded to the anatomical position of the appendix. His anatomical observations demonstrated substantial variability in appendiceal position and challenged the diagnostic and surgical significance attributed to the fixed landmark.

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Evolution of the anatomical landmark

McBurney originally described a clinical point of maximal tenderness, but within a decade the eponymous term had acquired differing anatomical interpretations and surface measurements. Contemporary authors variously defined the point by a fixed distance, a proportion of the ASIS–umbilicus line, or its presumed relationship to the appendiceal base.

Year	Author	Description	Significance
1889	McBurney	1½–2 inches from right ASIS towards umbilicus	Original site of maximal tenderness
1891	Carmalt	1½–2 inches; area presumed to overlie appendix	Early anatomical interpretation
1892	Werder	Original measurement; identifies appendiceal base	Clinical point becomes anatomical marker
1899	Musser	Midway between ASIS and umbilicus	Alternative surface definition
1899	Tuttle	One-third of the distance from ASIS	Proportional definition
1899	Deaver	Midway between ASIS and umbilicus	Additional midpoint description
1908	Lanz	Point does not reliably indicate appendix position	Anatomical challenge

Anatomical evaluation of McBurney’s point

Subsequent radiological studies investigated the relationship between McBurney’s point and the anatomical position of the appendiceal base. Although differing in methodology and patient populations, these studies consistently demonstrated considerable variation in appendiceal position relative to the conventional surface landmark.

1990 – Karim, Boothroyd and Wyllie published McBurney’s point–fact or fiction? They reviewed 51 supine barium enema examinations, identifying the appendix or appendiceal stump in 27 patients (53%). Of these, 70% lay below the interspinous line connecting the anterior superior iliac spines, and 59% occupied the authors’ pelvic quadrant. Their findings challenged the traditional anatomical representation of the appendiceal base, although the study did not directly measure its distance from McBurney’s point.

1993 – Ramsden, Mannion, Simpkins and deDombal published Is the appendix where you think it is–and if not does it matter?. They investigated the position of the appendiceal base in 275 double-contrast barium enema examinations. The appendix and its base were clearly visualised in 125 examinations; interpretation was also limited by potential displacement of the caecum during barium insufflation. Only 35.2% of appendiceal bases lay within 5 cm of McBurney’s point, although 85.1% were within 10 cm. Their findings demonstrated considerable variation in the relationship between the appendix and its conventional surface landmark.

2002 – In McBurney’s point: are we missing it? Naraynsingh et al. prospectively examined 100 post-evacuation barium enema studies using a radiopaque skin marker at McBurney’s point. The appendiceal base corresponded with the landmark in only one patient (1%). It lay cephalad to the point in 67% and caudad in 32%, reinforcing the limitations of McBurney’s point as a fixed anatomical marker.

2005 – Lee et al. used ultrasonography to identify the appendiceal base in 303 patients with acute appendicitis. The base corresponded with McBurney’s point in 31%, lay within a further 2 cm in 20%, between 2 and 5 cm in 28%, and more than 5 cm away in 21%. Ultrasound-guided skin marking also showed good correlation with the chosen surgical incision in 95% of cases.

2006 – Oto et al published Localization of appendix with MDCT and influence of findings on choice of appendectomy incision. They used three-dimensional multidetector CT to compare the appendiceal base with McBurney’s point in 100 adults. Exact correspondence occurred in only 4%, with the base lying within 3 cm in 36%, between 3 and 5 cm in 28%, and more than 5 cm away in 36%. Review of the CT findings would have altered the surgeon’s proposed appendicectomy incision in 35% of patients.

Collectively, these investigations demonstrate substantial anatomical variation and confirm that McBurney’s point is an unreliable predictor of the precise location of the appendiceal base.

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Clinical significance and diagnostic accuracy

Although anatomical studies demonstrate considerable variation in the position of the appendix relative to McBurney’s point, this does not necessarily diminish the clinical significance of localised tenderness. Tenderness in appendicitis reflects the distribution of inflammation and peritoneal irritation rather than simply the position of the appendiceal base.

However, the diagnostic value of tenderness at the McBurney point remains poorly established. Most clinical studies evaluate regional right lower quadrant tenderness or broader signs of peritoneal irritation rather than tenderness at the original anatomical landmark.

1996 – Wagner, McKinney and Carpenter reviewed the diagnostic value of clinical findings in suspected appendicitis in Does this patient have appendicitis? They identified migratory pain, fever and signs of peritoneal irritation as useful components of clinical assessment. The absence of right lower quadrant pain, guarding or fever reduced the likelihood of appendicitis. Their review did not establish the diagnostic accuracy of tenderness at McBurney’s precisely defined point.

2001 – Soda et al. published Detection of pinpoint tenderness on the appendix under ultrasonography is useful to confirm acute appendicitis. Using ultrasonography to identify the appendix or associated inflammatory changes, they applied focal pressure directly over the visualised abnormality. Their combined ultrasound diagnostic criteria demonstrated a sensitivity of 86.7% and specificity of 89.7%. All 50 patients with pinpoint tenderness directly over the appendix had appendicitis. Unlike conventional McBurney-point tenderness, this technique localised tenderness directly over the sonographically identified appendix rather than relying on a fixed surface landmark.

2004 – Andersson published a Meta-analysis of the clinical and laboratory diagnosis of appendicitis including 24 studies evaluating 28 clinical and laboratory variables in suspected appendicitis. Inflammatory markers, migration of pain and signs of peritoneal irritation, including rebound tenderness, percussion tenderness and guarding, provided the greatest diagnostic discrimination. Individual findings were relatively weak predictors, but their diagnostic value improved when combined. The analysis did not establish independent diagnostic accuracy estimates for tenderness at McBurney’s point.

2007 – Bundy et al. systematically reviewed the diagnostic accuracy of clinical findings in children with suspected appendicitis in Does this child have appendicitis?. Right lower quadrant tenderness had a modest positive likelihood ratio (LR+ 1.3), while its absence reduced the likelihood of appendicitis (LR− 0.45). Rebound tenderness was more discriminating (LR+ 3.0; LR− 0.28). These estimates describe regional abdominal tenderness and peritoneal irritation, not tenderness at the precisely defined McBurney point.

Clinical interpretation

McBurney-point tenderness remains a traditional component of the examination for suspected appendicitis. However, published estimates of sensitivity, specificity and likelihood ratios for general right lower quadrant tenderness cannot be attributed to tenderness at McBurney’s precisely defined point.

Anatomical variability does not invalidate the clinical significance of localised tenderness, but tenderness at a fixed surface landmark neither reliably identifies the appendiceal base nor independently establishes or excludes appendicitis.

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Eponymythology

Original description versus modern definition. McBurney described maximal tenderness 1½–2 inches from the right anterior superior iliac spine towards the umbilicus, not the modern one-third definition. By 1900, competing midpoint and one-third descriptions were already in use.

Origin of the eponymous term. McBurney described the clinical finding in 1889 and Lewis Atterbury Stimson introduced the term McBurney’s point in 1890.

Clinical finding versus anatomical landmark. McBurney described a site of maximal tenderness, not a fixed position of the appendiceal base. The subsequent anatomical interpretation was challenged by Lanz in 1908 and later radiological studies. McBurney-point tenderness, regional right lower quadrant tenderness and the anatomical position of the appendix remain distinct observations and should not be treated as interchangeable diagnostic findings.

McBurney point versus McBurney incision – The diagnostic McBurney point (1889) and the operative McBurney incision (1894) are distinct eponymous terms. One is the diagnostic point of maximal tenderness and the other an operative incision crossing the spinoumbilical line. They should not be regarded as interchangeable landmarks.

I believe that an every case the seat of greatest pain, determined by the pressure of one finger has been very exactly between exactly an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus.

McBurney 1889

The incision in the skin is an oblique one about four inches long. It crosses a line drawn from the anterior iliac spine to the umbilicus nearly at right angles about one inch from the iliac spine, and is so situated that its upper third lies above that line.

McBurney 1894

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Associated Persons

• Charles Heber McBurney (1845–1913)
• Robert Fulton Weir (1838–1927)
• Lewis Atterbury Stimson (1844–1917)
• Otto Lanz (1865–1935)

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References

Historical references

• Fitz RH. Perforating inflammation of the vermiform appendix: with special reference to its early diagnosis and treatment. 1886
• McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. New York Medical Journal, 1889; 50: 676-684.
• Weir RF. Remarks on intermediate laparotomy for appendicitis in its quiescent stage. The medical news 1890; 56: 226-227
• Stimson LA. A contribution to the study of appendicitis. New York medical journal 1890; 52: 449-456 with commentary pp609-611
• Keen WW. Appendicitis; operation; recovery. International clinics. 1891; 196-200
• Carmalt WH. Cancer of caecum; excision; end-to-end union; recovery. International clinics 1891; 3: 113-119
• McBurney C. The Indications for Early Laparotomy in Appendicitis. Annals of Surgery. 1891; 13(4): 233–254.
• Werder XO. Peritonitis. The Medical and Surgical Reporter 1892; 66(5): 173-178
• McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Annals of Surgery 1894: 20: 38–43
• McArthur LL. Choice of incisions of abdominal wall; especially for appendicitis. Chicago medical recorder 1894; 7(1): 289-292.
• Edebohls GM. Diagnostic Palpation of the Vermiform Appendix. American Journal of the Medical Sciences 1894; 107: 487. 
• Edebohls GM. Palpation of the vermiform appendix. Post-Graduate 1894; 9: 154-158
• Edebohls GM. A review of the history and literature of appendicitis. Medical record 1899; 56(22): 773-784
• Musser JH. Appendicitis In: A practical treatise on medical diagnosis for students and physicians. 1899: 739
• Tuttle GM. Appendicitis In: Diseases of children. 1899: 117
• Deaver JB. Appendicitis In: Cyclopaedia of the diseases of children, medical and surgical
• Lanz O. Der McBurney’sche Punkt. Zentralblatt für Chirurgie 1908; 35(7): 185-190.

Evaluation of McBurney point and McBurney incision

• Karim OM, Boothroyd AE, Wyllie JH. McBurney’s point–fact or fiction? Ann R Coll Surg Engl. 1990 Sep;72(5):304-8.
• Ramsden WH, Mannion RA, Simpkins KC, deDombal FT. Is the appendix where you think it is–and if not does it matter? Clin Radiol. 1993 Feb;47(2):100-3.
• Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996 Nov 20;276(19):1589-94.
• Naraynsingh V, Ramdass MJ, Singh J, Singh-Rampaul R, Maharaj D. McBurney’s point: are we missing it? Surg Radiol Anat. 2003 Feb;24(6):363-5
• Lee K, Kim MJ, Ko EY, Hong MS, Jeon EY, Hwang HS, Lee IJ, Yang I, Lee ES, Lee BH. Evaluation of the Appendix Base Location in Acute Appendicitis Using Sonography and its Clinical Significance. J Korean Soc Ultrasound Med. 2005;24(4):185–190
• Oto A, Ernst RD, Mileski WJ, Nishino TK, Le O, Wolfe GC, Chaljub G. Localization of appendix with MDCT and influence of findings on choice of appendectomy incision. AJR Am J Roentgenol. 2006 Oct;187(4):987-90
• Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007 Jul 25;298(4):438-51.
• Naraynsingh V, Teelucksingh SS, Goli S, Islam S, Cawich S, Singh Y, Maharaj R. CT guided appendicectomy incision: A prospective case series. Int J Surg Case Rep. 2017;41:307-310.

Eponymous term review

• Charles McBurney (1845-1913), point, sign, and incision. JAMA. 1966 Sep 26;197(13):1098-9
• Morgenstern L. Charles McBurney (1845-1913). Afield from the appendix. Surg Endosc. 1996 Apr;10(4):385-6
• Soda K et al. Detection of pinpoint tenderness on the appendix under ultrasonography is useful to confirm acute appendicitis. Arch Surg. 2001; 136(10): 1136-1140.
• Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004; 91(1): 28-37
• Grover CA, Sternbach G. Charles McBurney: McBurney’s point. The Journal of emergency medicine. 2012; 42 (5): 578-81.
• Thiery, M. Charles McBurney (1845–1913) and McBurney’s point. Gynecological Surgery, 2009; 6(4): 411–413
• Cadogan M. Appendicitis eponymous signs. LITFL