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Historical
Perspectives in Surgery

Famous Patients, Famous Operations, 2002 - Part 3:
The Case of the Scientist with a Pulsating Mass

from Medscape
Surgery
Posted 06/14/2002

Albert B. Lowenfels, MD

A 69-year-old white male scientist consulted his
physician because of pain in the upper abdomen. For a number of
years he had suffered from attacks of upper abdominal pain, which
usually lasted for 2-3 days and were often accompanied by vomiting.
These attacks usually occurred about every 3 or 4 months. The
patient was a pipe smoker and slightly overweight. The rest of his
history was noncontributory. On physical examination, his physician
noted a pulsating mass deep in the center of the abdomen.

Who is this mystery patient?
The patient is Albert
Einstein (Figure), considered to be the most influential person of
the 20th century and ranked as one of the top scientists of all
time. Albert Einstein, who was born in 1879 in Ulm, Germany, died in
Princeton, New Jersey, in 1955 at the age of 76. The immediate cause
of death was a ruptured abdominal aneurysm. In December 1948, Dr.
Rudolph Nissen, famous for developing a widely used operation to
prevent esophageal reflux, performed an exploratory laparotomy on
Einstein at the Brooklyn Jewish Hospital. At that time, a
"grapefruit-sized" aortic aneurysm was discovered to be the cause of
Einstein's abdominal pain.

Figure 1. (click image to zoom)
Albert Einstein.

During that era, ligation of the abdominal aorta had already
proved to be ineffective, and replacing the aorta with a graft was
still a decade away. The only available treatment was to attempt to
reinforce the aortic wall and delay the inevitable rupture.

Polyethene cellophane is a tissue irritant, producing marked
fibrosis. Dr. Nissen wrapped the visible anterior portion of the
aneurysm with this type of cellophane, in the hopes of stimulating
an intense fibrous tissue reaction that would strengthen the bulging
aortic wall. Einstein recovered from the operation, and after a
3-week hospital stay, returned to his home in Princeton, New Jersey.

Following this palliative operation, Einstein lived for 5 more
productive years with only minor symptoms. In 1952, he was offered
and declined the presidency of Israel. He published his last
scientific paper in 1954, in the Annals of Mathematics.
During this period he had occasional back pain and pain in his right
upper quadrant, labeled as "chronic cholecystitis."

On Tuesday, April 12, 1955, Einstein developed abdominal pain,
which became more severe on the following day. Although Einstein
must have realized that the aneurysm had finally burst, he initially
refused hospitalization. He finally agreed to be admitted to the
Princeton Hospital, only because he felt he was becoming too much of
a burden at home. He was seen by Frank Glenn, MD, then Chief of
Surgery at New York Hospital, who diagnosed cholecystitis and a
leaking abdominal aneurysm. Glenn recommended resection of the
aneurysm, even though the operation was new. At that time, Dr. Glenn
had only done a few such operations, using cadaver grafts to replace
the aorta. Einstein refused surgery, saying: "I want to go when I
want. It is tasteless to prolong life artificially. I have done my
share, it is time to go. I will do it elegantly."[1]

Five years after surgery, the patient collapsed at home and was
rehospitalized. Although he had intermittent bouts of generalized
abdominal pain requiring morphine for relief, he had pain-free
intervals when he appeared to be quite comfortable. The pain became
localized to the right upper quadrant, where a palpable mass was
noted. Five days after admission, he developed labored breathing and
expired at 1:15 AM on April 18, 1955.

An autopsy, performed by Thomas Harvey, MD, revealed a normal
gallbladder and a huge abdominal aneurysm. Harvey reported that
compression of the gallbladder from hemorrhage had simulated an
attack of cholecystitis.[2]

Was wrapping Einstein's aneurysm with cellophane useful, or
just a sham operation?
A recent review of life expectancy in
persons turned down for elective aneurysm surgery showed a median
survival of only 9 months in patients with aneurysms larger than 7
cm.[3] Einstein lived for over 5 years; perhaps wrapping
the aorta did prolong his life.

What would have been the anticipated outcome if Einstein had
been operated on?
In 1955, although resection of aortic
aneurysms had been practiced since 1951, resection of a ruptured
aneurysm, especially after a previous aortic wrapping procedure,
would have had a prohibitively high mortality rate.

How would Einstein's aneurysm be diagnosed
today?
There are now many ways to visualize the abdominal
aorta and to determine the relation of the diseased aorta to the
renal and iliac vessels. Formerly, arteriography was commonly used
to detect and evaluate aneurysms, but this procedure has been
replaced by computerized tomographic angiography or by magnetic
resonance angiography. These newer procedures are rapid, accurate,
and provide crucial information about the relationship of the
aneurysm to the renal and iliac vessels.[4]

Today, any patient without a serious medical contraindication who
has an aortic aneurysm greater than 5 cm is a candidate for surgery.
Einstein would have certainly been referred for surgery at the time
of his initial symptoms because his "grapefruit-sized" aneurysm was
at least 12 cm in diameter. When performed as an elective procedure,
the operative mortality rate is about 5%, increasing dramatically to
about 50% if the aneurysm has ruptured. Operating on aneurysms
smaller than 5 cm does not seem to improve long-term survival.

Until a few years ago, the operation of choice would have been
resection of the aneurysmal mass, followed by replacement with a
prosthetic graft.[5] But recently, endovascular grafts
have been developed that are inserted via the femoral artery,
positioned within the aneurysm, and secured with self-expanding
stents or hooks. This procedure is becoming increasingly popular
because it is less stressful for the patient and reduces the length
of hospitalization.[6] The long-term results of this
procedure need additional evaluation to assess the frequency of
complications, such as leakage around the graft.[7]

What happened to the world's most famous brain?
It
disappeared rather mysteriously after the autopsy, and was
discovered to have been secretly hidden by Thomas Harvey, the
pathologist who performed the 1955 autopsy! Forty years later, at
age 86, Harvey, along with a journalist, drove Einstein's brain
across the United States to be given to Einstein's granddaughter.
Michael Paterniti, the driver, describes the brain's discovery and
final trip in Driving Mr. Albert: A Trip Across America With
Albert Einstein's Brain.[8]

Albert B. Lowenfels, MD, Professor of
Surgery, New York Medical College, Valhalla, New York

Medscape Surgery 4(1), 2002. © 2002
Medscape

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