LETTERS TO THE EDITOR
Vol. 216 * No. I
August 8, 1991
Dear Editor: The recent article by Hennington and co-workers' on the development of acute appendicitis after trauma brings to mind the most noted victim of this association. The famed magician Harry Houdini died in a Detroit hospital in 1966 of a ruptured appendix after a blow to the abdomen for which he was not prepared. Folklore has it that the blow itself caused the appendix to burst. Since hearing this anecdote repeated during my residency (in Detroit, coincidentally enough), I have asked fellow trauma surgeons if they have ever encountered such a case in their practice. Their answers have been uniformly negative. Alas, it appears that I should have directed my inquiries further south, to the state of North Carolina, where it appears that a virtual epidemic of this problem has now taken place. I must say, however, that I am not convinced that the trauma itself led to the development of appendicitis. Rather, I agree with the authors' alternative conclusion that the diagnosis of appendicitis may not be considered after blunt injury because the pain likely will be attributed to the abdominal trauma. I have now come to believe that that is what happened in Houdini's case, because the use of appendectomy was widely accepted at the time of his death.2 The difficulty in making the diagnosis is confirmed by the apparent need for four surgeons to care for the two appendicitis patients in this report. Appendicitis and trauma are two of the most common illnesses to occur in childhood and early maturity. They will occasionally coincide. Let us hope that Hennington and co-workers' article reminds surgeons of this fact and serves to prevent tragedies such as Harry Houdini's. References 1. Hennington MH, Tinsley EA, Proctor HJ, Baker CC. Acute appendicitis following blunt abdominal trauma: incidence or coincidence. Ann Surg 1991; 214:61-63. 2. Williams GR. Presidential address: a history of appendicitis. Ann Surg 1983; 197:495-506.
JEFFREY S. BENDER, M.D. Baltimore, Maryland
October 8, 1991 Dear Editor:
We read with interest the letter by Dr. Bender regarding our recent article on "Acute Appendicitis Following Blunt Abdom-
inal Trauma: Incidence of Coincidence?" As we had mentioned in a previous response, Harry Houdini was known to have died from a ruptured appendix after a blow to the abdomen. We agree that it is not possible to demonstrate causality in the case of Houdini, nor in the two patients that were the subject of our recent article. Primarily, we wish to raise the possibility that appendicitis can follow blunt abdominal trauma, either in a causal fashion or coincidentally. Certainly the hospital is a bad place to develop appendicitis, and we need to keep our index of suspicion at a high level with regard to this disease. One comment that needs to be addressed is Dr. Bender's comment that it took four surgeons to care for the two patients in our report. Certainly there were four authors for the article, but not four surgeons involved in caring for the two patients. A resident cared for each patient (Hennington for one patient and Dr. Tinsley for the
other) in concert with Dr. Proctor. After the death of Dr. Proctor, Dr. Baker assisted in compiling a manuscript and submitting it to the Annals of Surgery. We enjoyed Dr. Bender's letter and thank him for sharing his thoughts with us. Once again we thank the Annals of Surgery for publishing this paper, which has solicited more interesting correspondence than anything we have written in a number of years.
CHRISTOPHER C. BAKER, M.D. MARK HENNINGTON, M.D. ELLIS TINSLEY, M.D. Chapel Hill, North Carolina June 2, 1991 Dear Editor: In the February 1991 issue of the Annals of Surgery (Volume 213, Number 2) it was of marked interest to read the following articles: (1) "From the Editor," by Dr. David C. Sabiston, Jr., M.D.; (2) "Teachers of Surgery. Ravidin," by Dr. Leonard Miller, (3) Letters to the Editor. As a graduate of the University of Pennsylvania, I will never forget the sharpness and excellent teachings of Drs. Ravidin, Rhodes, Miller, and my classmate Brooke Roberts. The article by Dr. Miller should inspire us all to better things. In the "Letters to the Editor," the comments on 100 consecutive common duct explorations by Dr. Pappas and colleagues (Ann Surg 1990; 211:260-262) were very thought provoking. Before all of the articles in his bibliography, I had written a paper published in the Michigan State Medical Journal (1963; 62:752-753), which was the first pure study to my knowledge. The title was "Routine Choledochotomy With Cholecystectomy." I performed 150 consecutive cholecystectomies with choledochotomy, all patients with diagnosed cholelithiasis or nonfunction. Choledocholithiasis was found in 22% of patients, and a high percentage of inspissated bile was found but not considered a positive finding. The overall mortality rate was 1.5%. No common duct stenosis or ligation occurred, with the better visualization obtained by adequate exploration of the common duct. I am not advocating this approach now, with the advances made in diagnostic technology and endoscopy, but I believe this helps us to set standards as to what we can expect from therapeutic regimens as they develop and improve. J. W. MANNING III, M.D, F.A.C.S. Saginaw, Michigan
October 18, 1991
Dear Editor: I very much enjoyed reading Dr. Manning's review of his experience with "Routine Choledochotomy with Cholecystectomy."' I unfortunately had missed this reference in my previous review of the literature and was very interested to find a 22% incidence of common duct stones, which includes common duct "sludge." These are truly excellent results for 1963 and for 1991. Unfortunately, laparoscopic cholecystectomy has made most of these observations (and our own) obsolete. The incidence of common duct stones in a large series of laparoscopic cholecys-