On the heels of our case discussion in the prior Princess Diana episode, we’d like to discuss another famous medical case having received lots of good feedback on that episode. So let’s talk about another case–one that involves a personal hero of mine, Erich Weisz. You may know him as the one and only Harry Houdini.
I’m curious, without prompting, do either of you know how Houdini died?
Many people know Houdini as a magician and escape artist. He was very much those things. But Houdini was also a world renowned debunker. With his vast knowledge of designing and performing illusions, Houdini was especially adept at confronting and exposing psychics and spiritualists who, popular as they were at the time, would take money in exchange for pretending to contact a person’s family members or other loved ones. He was on a personal crusade against this practice as he saw it as fraudulent and predatory.
A full re-telling of Houdini’s life is beyond the scope of this medical history show, but I’ll do a brief summary here to set the scene.
He was born Erich Weisz in Budapest, Hungary in 1874. His father was a Rabbi and the family moved to the U.S. on July 3rd, 1878 and landed in, of all places, Appleton, Wisconsin! He later moved with his family to good ol’ Milwaukee. As a child, a young Erik Weiss saw a magician named “The Bloodless Vivisectionist” at the “Dime Museum”, described as a “lurid theater” on Wisconsin Avenue. This place sounds absolutely fascinating by the way. The magician used knives to appear to dismember a volunteer from the audience in front of a live crowd before using a flourish to end the show and replace his victims' apparently amputated appendages. A young Houdini was hooked on magic as his future career. I only wish my own career origin story was half that interesting.
Erich is pursuing his dream of professional magicianship (totally a word) and starts calling himself “Harry Houdini'' after reading the biography of Jean-Eugene Robert-Houdin in 1890. I’m going to gloss over a lot of his life but it’s good to appreciate that Houdini was far from successful when he started. He was apparently okay at sleight-of-hand stuff but not exceptionally gifted. He could, however, escape from a pair of handcuffs and his break came in 1899 when he impressed a manager named Martin Beck in St. Paul, Minnesota by doing so. As he focused on creating and performing more and more dangerous escape acts, his popularity skyrocketed him to eventual international fame.
His escapes were truly incredible. Some of the more notable ones included the water torture cell where he would be suspended by locked manacles head down into a sealed water chamber, having to escape out. He did an escape from a nailed and rope tied packing crate after it was tossed into NYC’s east river. He had handcuffs and leg-irons on for that one and the thing was weighed down with 200lbs of lead. Took him 57 seconds to get out, apparently leaving the crate intact with the manacles inside. And, of course, there were his buried alive stunts where he would be, well, buried alive and have to escape in front of the crowd. In Santa Ana, California in 1915, on his first attempt at this trick, he almost died. He panicked and was trying to dig his way to the surface, collapsing just as he broke his hand through and had to be pulled from his grave by assistants. To be clear, these were acts, but they were very dangerous and more than a few magicians have died trying to reproduce Houdini’s escapes.
The other fascinating part of his career was as an incredible debunker of mystics. Houdini, though he could make people believe in the impossibility of his spectacles, was an ardent skeptic and in his later career would go on to make spectacles of exposing so-called psychics and mediums. There is so much more to this part of the story that I’ll leave alone, lest I be distracted away from the medical history of this story, but I would encourage everyone to do their own deep dive on Houdini.
With that all being said, let’s get to the medical case.
Among all of his death defying escape acts and professional psychic busting, Houdini had a bit he would do where he would challenge people to punch him in the stomach. If you’ve ever seen pictures of Houdini you’d appreciate that he was, medically speaking, jacked. Especially for the time, Houdini had a strong physique and this included a set of abs able to withstand punches–if he was prepared.
In Montreal, Canada, on Oct 22nd, 1926, Houdini was backstage prior to his performance that night, kicking back on a couch. He was in the company of three local medical students from McGill University, which has been mentioned more than once on this show. He’s lying on the couch because he had apparently broken his ankle in a prior recent performance. The topic of his ability to withstand punches to the abdomen comes up and one of the medical students named Gordon Whitehead asks if it’s true that Houdini can’t be hurt by gut punches. Houdini says it’s true and either invites Whitehead to try or Whitehead just assumes he can give it a go. While Houdini reclined on the couch with a broken ankle, Whitehead delivered “some very hammer-like blows below the belt” well before Houdini’s abs could be tightened. Below the belt means lower abdomen in this context, FYI. Belts were just higher back then.
Houdini is described as appearing to be in significant pain after this, has Whitehead stop and manages to carry on with his performance. He spends two days in constant pain but travels from Montreal to Detroit, Michigan on Oct 24th, 1926 for his next scheduled show. As his abdominal pain is not improving and severe, he goes to a doctor before that performance and is apparently told he needs immediate surgery on his abdomen. He has a fever of 102 degrees at that time. He politely declines and goes to the Garrick Theater in Detroit to carry on with his performance. By the time he takes the stage, his fever is up to 104 degrees but even this does not stop him. He is described as ill-appearing and making uncharacteristic mistakes during the performance. One account even has him passing out and being revived prior to ending the show. He makes it through the show and returns to seek medical attention at Detroit’s Grace Hospital.
He is admitted to the hospital with fever and abdominal pain and, for reasons not entirely clear to me, days go by until he undergoes an operation. Upon opening his abdomen they find he has diffuse peritonitis (describe) from what appears to be acute perforated appendicitis. The surgeon does a wash out and Houdini survives for the time being. He apparently is still spiking fevers so days later he returns to the operating room for a second washout of his abdomen. Unfortunately this does not help and on Oct 31st, Halloween, 1926, Houdini dies from sepsis and overwhelming infection at age 52. It wasn’t a magic trick gone wrong. It was a common diagnosis that ended his life. But while appendicitis is common enough, I think you guys will agree that this is a really unusual story for this, correct? Let’s talk about the way appendicitis should work to highlight why this is strange and see if we can explain this.
I think it’s fair to say most listening to this show have heard of appendicitis. I’ll go ahead and guarantee that more than a few of our listeners have experienced this diagnosis and are living perfectly normal lives without their appendix at this very moment.
The appendix is a noodly appendage of sorts that hangs off of the first part of your large intestine, called the cecum, in the right lower part of your abdomen. It’s typically about the size of an average pinky finger and is a meaty hollow tube with a closed end and an open end where it attaches to the large intestine.
Appendicitis happens when material (read poo) plugs up the opening to the appendix causing it to close off and become inflamed with bacteria. It swells up, becomes painful and, if left unchecked, will expand with infection to the point it falls apart or “ruptures” causing bacteria and pus to spill into the inside of your abdomen, causing rampant inflammation of the lining of the abdomen which is called peritonitis. The pus and bacteria, if still left unchecked, will work their way into the bloodstream and overwhelming infection and its ill effects on the human body–something we call sepsis–ensue until death. Today we perform surgery promptly to try and remove the swollen/infected appendix before it ruptures as we know people can live without it.
But there is a reasonable question to ask before you remove a part of the body–what does it do? Good question. This is an area of some debate. We are not the only creature to have an appendix suggesting there is or may have been some useful function served. While there is a camp that believes the appendix is a purely vestigial organ–one that is no longer used thanks to the tides of evolution–there is an emerging camp of research that suggests the appendix may be a healthy bacteria storage unit for the large intestine, keeping and harboring bacteria helpful to the functions of the large intestine. There is a third camp of cynics that proposed that the appendix exists only to provide college funding for the children of surgeons. As neat as all that may be, it does stand that people can live perfectly normal lives without this colonic danger noodle.
A neat offshoot of researching this case was finding out a bit about the history of the appendix and diagnosis and treatment of appendicitis. Let’s talk about that for a bit and we’ll return to Houdini’s death.
Appendicitis has been around–like many things–for ever. As long as there have been appendixes there have been appendicitiseses. One article I’d reviewed recalled the example of an Egyptian mummy that was opened to discover scar tissue and evidence of peritonitis in the right lower abdomen suggestive of appendicitis.
But it took awhile to coin the name of this diagnosis. Surely there were many cases of people likely dying from this intra-abdominal infection over the past thousands of years, but it took some time not only to identify the appendix as the cause, but also just to identify the appendix as a structure at all. You might say that much like Houdini, the appendix escaped the attention of anatomists and surgeons for hundreds of years.
It certainly escaped Galen’s attention. You might remember him as the famous Greek physician that couldn’t perform dissections due to cultural norms of the time and therefore made up a bunch of nonsense about medicine that was followed as gospel for over a thousand years. He did mention a condition causing right lower quadrant pain and subsequent illness but never mentioned the appendix as a structure of note–though he did do dissections of gorillas and whatnot.
In ancient times, medical texts would describe cases of what we now know to be advanced appendicitis wherein the abscess (think boil) that formed inside the person’s abdomen could, at times, grow to poke through the abdominal wall, draining to the outside. I can only imagine how astonishing it would have been for people to just start expelling pus from their abdomen which was now open to the outside world in this case. People did, sometimes, survive when that happened because the infection essentially escaped, but much of the time, as one surgical history article put it, they would “die a peaceful death” from sepsis. I feel like “peaceful” is doing a lot of lifting in that sentence.
By the Renaissance period, at least the appendix was being named as its own structure. First descriptions of appendix appear in the late 15th, early 16th centuries. Before he was swinging around katanas and eating pizza, Leonardo Da Vinci drew an appendix among his anatomy drawings in 1492 though it was not published until the 18th century and Da Vinci did not give it a distinct name. Berengario Da Carpi, a professor of surgery at Pavia and Bologna, Italy in 1522 was the first to give the appendix some sort of name.
Andreas Vesalius, who has been mentioned before in a few episodes, in 1543 illustrated the appendix in his work “De Humani Corporis Fabrica”, but called it “the cecum” and helped confuse terminology for a while to come. In other words, though he illustrated it, he felt it was just a part of the large intestine and not its own sovereign anatomical structure. I’ve included a picture here in the notes for my co-hosts and will include it on our website with show notes.
Moving ahead to the Age of Enlightenment, we have the appendix not only verified as a thing, but physicians and surgeons start to question its function. They still haven’t, at that time, realized that the appendix is a source for the abdominal infections they’d see from time to time. In 1735, a surgeon by the name of Claudius Amyand is credited with performing the first appendectomy–albeit the story is strange and it’s not as if he did the surgery trying to remove the appendix. He performed a surgery on an 11 year old who had developed a painful inguinal hernia. This is where a portion of the intestines escapes the abdominal wall and, as is often the case in males, slithers down the groin to get stuck in the scrotum. It just so happens that the hernia here involved the cecum and attached, inflamed appendix which Amyand removed successfully. A hernia containing the appendix is still called an Amyand’s hernia if you’ve ever heard the term. Basically, he cured a case of appendicitis by doing surgery for another reason. We call this failing correctly.
By the late 18th century, famous surgeons like John Hunter of England were describing case after case of right lower quadrant intra-abdominal abscess and even abscess surrounding the appendix, but they still were not connecting the fact that the appendix itself was the cause of these infections.
In the 19th century we start connecting the dots. Here come some big-time name drops–at least for medical history nerds.
In the early 19th century, Dr. Baron Guillaume Dupuytren–a leading surgeon at the Hotel Dieu’ in Paris–associated right lower quadrant inflammation/abscess with “cecal pathology”, meaning he realized it was starting at that part of the large intestine where one finds the appendix. This was echoed in a graduation thesis published in 1830 by Dr. Goldbeck called “Inflammation in the Right Iliac Fossa” which described all the signs of appendicitis but attributed it to arising from the large intestine, not the little wormy-looking appendix. So close.
In 1848, a surgeon named Dr. Hancock performed abdominal surgery with the then new-fangled chloroform anesthetic, draining an abscess that had formed around the appendix, but before it had grown large enough to poke through the abdominal wall and drain to the outside. Almost 20 years after that, in 1867, Dr. Willard Parker writes about four cases of peri-appendiceal abscess drainage–purposefully waiting a few days for symptoms to develop, but trying to do surgery before the abscess inside the abdomen had grown large. This starts the thinking that treatment for appendicitis may be earlier and earlier surgical intervention which definitely did improve the mortality of this illness.
Finally, in 1886, a Harvard pathologist named Dr. Reginald Herber Fitz presented a paper to the American Association of Physicians called “Perforating Inflammation of the Veriform Appendix” and he said plainly that the cause of most right lower quadrant inflammatory abdominal disease is perforated appendicitis. He also recommended the appendix be removed prior to becoming an abscess when the diagnosis is suspected and this is still the standard of care today.
The year after, in 1887, Dr. Thomas Morton performs the first successful operation deliberately to treat the now titled diagnosis of “appendicitis”. He had been treating a 26 year old male patient who he ultimately took to the operating room after a week of calomel, soda water, stimulants, quinine, warm compresses, and good ol’ fashioned medical leeches failed to treat the appendicitis. He opens the abdomen, finds an abscess around the appendix, cleaned out the pus and removed the appendix as well. He irrigates (washes) out the abdomen and the patient recovers well. Regarding this operation, a contemporary of his named Dr. Chapman wrote about the case and gave his thoughts on the manner of whether or not this little organ should be removed: “A true veriform appendix is found only in six animals: man, gorilla, chimpanzee, orangutan, gibbon and wombat. There can be no doubt, therefore, that the cecal appendix is one of the parts of the human body having no particular function of significance, being of use only in animals… In the human being it ought to be removed with no bad effect whatsoever, so that I thoroughly agree with Dr. Morton in what he has to say regarding the opening of the abdomen and taking out the appendix. It seems to me that the human being is better off without the appendix than with it, for it is nothing but a trap to catch cherry stones and other foreign bodies.”
I feel compelled to mention that Dr. Morton’s brother and his son both died of appendicitis prior to this.
The last name drop prior to returning to Houdini’s case is that of the surgeon, Dr. Charles McBurney, a US surgeon who, in 1889, described the classic case of appendicitis we all learn as physicians. Pain starts typically around the umbilicus which intensifies and moves to the right lower quadrant as the appendix becomes more inflamed and touches the abdominal wall, accompanied by nausea, vomiting, unwillingness to eat and fever. Though this is how the textbook teaches the diagnosis, I think I’ve seen this exact presentation 2-3 times in the probably 100+ times I’ve diagnosed appendicitis over the last 10 years. Is this your experience as well, gentlemen?
So with that classic but uncommon story for appendicitis in mind, let’s return to Houdini. It’s 1926 and he shows up to the hospital in Detroit with a fever and a concerning lower abdominal exam. I don’t think any of us would hesitate to make this diagnosis given those findings. You see that patient, get some bloodwork, and you call the surgeon with your classic exam. Your surgeon invariably agrees with your suspicion and asks for a CT scan anyway. The scan confirms appendicitis and can tell us whether or not the appendix has ruptured. We put the patient on IV antibiotics and they go to an operating room urgently to have the appendix removed. If it is ruptured, the pus is cleaned out and antibiotics are continued to quell any worsening of the infection. In Houdini’s time, antibiotics had yet to be discovered so that wasn’t an option. In uncomplicated cases, patients may be discharged the next day. While they used to do a large incision in the right lower quadrant for this, nowadays a tiny pair of incisions is made and laparoscopic tools are used to remove the appendix and minimize wounds to the abdomen, allowing a really speedy recovery when all goes well. It’s good to be in the modern age.
I think the interesting question in Houdini’s death is what about the punches to the abdomen? Did they have anything to do with this final diagnosis? What do you guys think?
There appears to be two main schools of thought on this matter. One is that Houdini, being the consummate showman and performer, may have developed the early signs of appendicitis but minimized the symptoms, rendering the punching of the abdomen as a red herring that had nothing to do with it. He carried on with his performance until his symptoms advanced to the stage that he presented with ruptured appendicitis. Whether this is the case, it should be noted that his final performance in Detroit was likely done with a ruptured appendix. That is some pain tolerance.
I can’t know for sure, but after researching this episode, I actually think there is plausibility that the punches to the abdomen did have something to do with this. Looking through multiple sources for medical case reports I discovered numerous reports of trauma associated appendicitis. In reading these, it seems that direct trauma to the lower abdomen, if able to strike and compress the appendix or adjacent large intestine, can cause perforation, thus allowing the colon bacteria to escape and start inflaming the appendix. This progresses to appendicitis but appears to start because of the trauma.
One systematic review of the literature found 28 cases of trauma induced appendicitis from 1991 - 2009 (various causes of trauma–falls, MVC, strike to abdomen). One of the most fun case reports I found of this was a case of traumatic appendicitis thanks to a well-delivered camel kick. I cite this as my favorite evidence to support the claim that Houdini had trauma induced appendicitis. I will link this in the show notes, of course.
Well, that’s the story of the unfortunate end of Houdini and the history of appendicitis. Were you guys not entertained?
-https://pubmed.ncbi.nlm.nih.gov/28673696/ (Appendicitis due to MVC)
-https://www.hindawi.com/journals/cris/2021/6667873/ (Appendicitis due to camel kick)
-https://pubmed.ncbi.nlm.nih.gov/20513274/ (Systemic review of traumatic appendicitis cases)