History of Medicine

EINSTEIN TO DEBAKEY:

EVOLUTION OF ANEURYSM SURGERY

     Albert Einstein had a pain in his belly, not a new one, but worsening. Admitted to Brooklyn Jewish Hospital in December of 1948, his white hair defying gravity, he underwent surgery and was found to have a grapefruit-sized aneurysm of the aorta (an expanding section of the body’s major artery) that threatened to rupture. The surgeon, Rudolph Nissen, wrapped a piece of

Albert Einstein (Wikipedia)

polyethene cellophane around the visible part of the aneurysm, considering it too dangerous to raise the vessel for a full wraparound. Polyethene had irritant properties that caused a fibrous thickening of the aneurysm wall, hopefully strengthening it enough to prevent a rupture. Einstein recovered uneventfully and returned to work in Princeton, N.J.

     Though he had intermittent pains he did well until April, 1955, when he was readmitted with severe abdominal pain. Now a huge mass extending from the left lower rib cage to the pelvic brim pulsated visibly. It was his aneurysm, greatly enlarged and again in imminent danger of rupturing. Surgery was offered, this time to resect the aneurysm and replace it with a section of aorta from a cadaver. Einstein refused, saying it was time to go and “I will do it elegantly”. He expired five days later, and at autopsy a ruptured aneurysm was the reason. Did the cellophane wrapping prolong Einstein’s life? Based on statistics at the time, probably yes.   

    Fifty-one years after Einstein’s death, on New Year’s Eve of 2006, another celebrity of the scientific world had a similar problem. Dr. Michael DeBakey, age 97, suffering a fierce chest pain, diagnosed the pain as a dissecting aortic aneurysm. He

Michael DeBakey (Wikipedia)

would know, as he had operated on hundreds, maybe thousands, of aneurysms over the years. Dr. DeBakey refused hospitalization but consented to a CT scan, which confirmed a dissecting aneurysm of the ascending aorta (saccular enlargement due to a tear of the inner lining of the aorta, just above the heart, in danger of rupture and internal bleeding). He declined hospital admission and, pale and unsteady, gave a lecture three days later, followed by a luncheon. He grew weaker, ate little, and was finally admitted to Methodist Hospital, Houston, on Jan 23, where another scan showed “dangerous” enlargement of the aneurysm. His physicians advised surgery in spite of his age, but, like Einstein, DeBakey said no. By Feb. 9, with the aneurysm still expanding, DeBakey had lost consciousness. His surgeons, though, still felt he had a chance with surgery.

     As related by the noted physician-journalist Lawrence Altman, who knew DeBakey well, the family gave permission to operate, but the anesthesiologists of the hospital refused to anesthetize him, feeling they would be looked upon as aiding his death. Another anesthesiologist, an old colleague, was brought in. Heated discussions that included doctors, lawyers, and hospital

Methodist Hospital, Houston (Wikipedia)

administrators dragged into the evening. Complicating the issue were a note saying that he did not want surgery and a signed “do not resuscitate” order, both in DeBakey’s chart. But Mrs. DeBakey and the doctors, all long-time colleagues, felt that the situation had changed enough to make these wishes inapplicable. The ethics committee of the hospital was summoned to an emergency meeting at about 10PM. After an hour of inconclusive deliberation Mrs. DeBakey, waiting outside, burst into the room shouting that her husband would die if nothing were done soon. The ethics committee agreed to the surgery at 11 PM. No minutes were taken of the meeting.

     The operation lasted seven hours, with DeBakey placed on a bypass pump and his body temperature lowered. The aortic tear was resected and replaced with a Dacron graft, an operation DeBakey had pioneered himself years earlier. After a prolonged and “stormy” course, including dialysis, he recovered enough to resume work. One year after surgery he could walk unassisted but preferred a motorized scooter, on which he raced up and down hospital corridors. His mind remained clear. He said later that he was happy that his wish to avoid surgery was ignored. He passed away in July of 2008, cause not mentioned. The cost of his care was estimated at over $1 million. 

Aorta showing two aneurysms, a large one in
the thoracic portion and another, sectioned in two,
in the lower aorta (from Clinical Lectures on the Principles
and Practice of Medicine, by John H Bennett, 1860)

     Michael DeBakey was born in Louisiana of Lebanese immigrant parents and attended the Tulane School of Medicine. In WWII he helped develop Auxiliary Surgical Groups that provided surgical care close to the front lines, a predecessor of the MASH units of the Korean and Vietnam wars. He subsequently built the small Baylor College of Medicine department of surgery into a large, advanced, surgical training center and helped pioneer many innovative procedures, especially in cardiovascular surgery. He was also instrumental in forming the National Library of Medicine.

     In 1952 DeBakey did his first aortic aneurysm resection, replacing the aortic segment with cadaver aorta, the same operation offered to Einstein in 1955. Cadaver aortas were in short supply, however, and a synthetic material was sought. Nylon and related materials were tried but did not work well. One day DeBakey, looking for nylon in a store, was offered a new material, Dacron. Trying it in dogs, he found it performed well, and Dacron soon became the standard for aorta surgery. The gap between the surgeries of Einstein and DeBakey covers this period of major progress in aortic surgery.

     The debates around DeBakey’s surgery at age 97 clearly reflect today’s struggles over defining what is reasonable treatment for patients in advanced age, a problem all too common as our population grows older.

SOURCES:

Cohen, J R and Graver, M. “The Ruptured Abdominal Aortic Aneurysm of Albert Einstein.” 1990; Surg, Gyn, Obst 170 (5): 455-8.

L Altman. “The Man on the Table was 97 but He Devised the Surgery”. New York Times Dec 25, 2006.

L Altman. “Michael DeBakey, 99, Rebuilder of Hearts, Dies”. New York Times July 13, 2008.

Chunn, C F. “Treatment of Aneurysms by Polyyethene Wrapping”. Ann Surg 1954; 139:  751-9.

DeBakey, M E. “The National Library of Medicine: Evolution of a Premier Information Center”. JAMA 1991; 266: 1252-8.

Morris, Thomas. The Matter of the Heart: A History of the Heart in Eleven Operations. 2017; St. Martin’s Press. Chap. 3.

“The Michael E. DeBakey Papers”. Profiles in Science, National Library of Medicine. Online at: https://profiles.nlm.nih.gov/ps/retrieve/Narrative/FJ/p-nid/322