Famous Patients, Famous Operations, 2002 - Part 3: The Case of the Scientist with a Pulsating Mass
Albert B. Lowenfels, MD
 
Introduction

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, 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.

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."

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.

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. 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.

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. 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. The long-term results of this procedure need additional evaluation to assess the frequency of complications, such as leakage around the graft.

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.