An Address ON THE DIAGNOSIS AND TREATMENT OF ACUTE INFLAMMATIONS OF THE UPPER ABDOMEN: Delivered before the Norfolk and Norwich Medico-Chirurgical Society, October 12th, 1909
Authors: A. W. M. Robson
Journal: BMJ (1910)

upward displaced appendix, kidneys, or inflamed lymphatic glands, and may be due to ulcer, perforation, abscess, con- cretions, hydatids, cancer, internal hernia, or other pathological conditions.The acute seizure may occur after well-marked sym- ptoms of disease extending over long periods, or may come on suddenly without premonitory symptoms to indi- cate the cause; in the former, the diagnosis is, as a rule, more simple, but lh the latter it may be most difficult, and may sometimes be even impossible without exploration.In nearly every case pain is the prominent symptom, and it is usually associated with rigidity of one or both recti and with local and general tenderness.In other cases profound collapse may be the first sign, and the site of the trouble may only be indicated by rig_ of the muscles, by tenderness, and at times, in caeft perforation of a hollow viscus, by absence of liver dullnem and a bhri obtained on delicate palpation.In the sulier stages the temperature is no guide, though it may afford valuable information.Pinched features, an anxious expression of countenance, and general distress are usually seen in the acute cases, but are less marked in conditions coming on gradually.Shallow breathing, immobility of the lower ribs and of the abdominal muscles are characteristic of peritonitis in the upper abdomen from whatever cause.High Appendiiiti8.I think it is not sufficiently recognized that acute appendicitis nearly always commences by sudden pain above the umbilicus, and only after some hours does the pain settle in the caecal region, though from the first rigidity of the lower part of the right rectus and tender.ness at some point between the umbilicus and right anterior superior spine of the ilium will usually indicate the true nature of the disease.If, however, the caecum be displaced upwards, or the appendix be unusually long and extend upwards, appendi.citis may lead to confusion in diagnosis, as in the following case:A gentleman aged 27, seen in June, 1907, had had several attacks within the yearof pain starting just below and to the right of the ensiform cartilage, associated with rigidity upper part of the right rectus, and tenderness at a point between the ninth costal cartilage and the umbilicus, but nearer to the former.Each attack was associated with vomiting and some general abdominal distension, and was followed by sallowness, but without definite jaundice.After a severe seizure abdomen was opened by a vertical incision below the right costal margin, when an inflamed appendix, nearly seven inches in length, was found containing pus, the tip being adherent the liver, though the caecum was in its uisual place.The bile passages and the duodenum were involved in adhesions, otherwise healthy, and the removal of the appendix complete recovery.In another case a displaced appendix had been slightly inflamed on a number of occasions during several antecedent to the attack in question, and the inflammation presented the ordinary signs of catarrhal appendicitis.seen by me in consultation in February, 1906, the patient had had rigors for three days.His breath was foul, he looked extremely ill, and was evidently ing from septicaemia.In this case all the tenderness was above the umbilicus under the right costal and the caecal region couqld be pressed on without pain.Although there was no general abdominal distension, signs free fluid could be elicited by flicking with the finger-nail.From the previous history of definite appendix attacks, and from symptoms and signs then present, a diagnosis of appendicitis associated with acute cholecystitis was made.On opening 4