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Eck-Pavlov shunt: The 120th anniversary of the first vascular anastomosis
Eck-Pavlov shunt: The 120th anniversary the first vascular anastomosis Igor E. Konstantinov, From the Linkiiping,
Department
MD, Link~+~g, of
of
Sweden
Cardiothoracic Surgery,
Linkiiping
Heart Center,
University
Hospital,
Sweden
On doit des Cgards aux vivants; on ne doit aux marts que la v&it& [We owe respect to the living; to the dead we owe nothing but truth.]-Voltaire; Lettres SW Oedipe, 1. THE HISTORY OF RECONSTRUCTIVE VASCULAR SURGERY begins in the Military Medical Academy in St. Petersburg, Russia, where Nikolai V. Eck performed the first vascular anastomosis in 1877. This anastomosis is known as Eck’s fistula. Eck’s fistula became known in the world thanks to the work of Nobel prize winner Ivan P. Pavlov. This was not only the first vascular anastomosis but also a model with which Pavlov made the greatest single contribution to the study of portal venous physiology. Alexis Carrel is referred to as the founder of reconstructive vascular surgery. Although it is undoubtedly a fair statement, it is regrettable that nothing is known about the personalities of those by whom the first vascular anastomosis was made. Hopefully, the material presented here will reveal historical events as yet unknown and describe contributions not adequately acknowledged.
ECK’S FISTULA-THE FIRST PRIMITIVE VASCULAR ANASTOMOSIS Nikolai V. Eck (1849-1908). Nikolai V. Eck (Fig. 1) was born on November 9,1849, in St. Petersburg, Russia. He was the only son of Vladimir E. Eck, a professor of medicine at the Military Medical Academy. Nikolai Eck entered the Military Medical Academy in 1865, and on graduation in 1871 he started postgraduate training in surgery. Because of his family background and excellent education, Eck experienced few hardships and was economically privileged. In 1877 as a 29-year-old surgeon Eck, working in the Military Medical Academy in St. Petersburg, published an article scarcely more than one page long’, *, that assured immortality for his name.‘, 3 In this article Eck Accepted
Jan.
Reprint Surgery,
requests: University
17, 1997.
Surgery
1997;121:640-5.
Copyright
D 1997
Igor E. Konstantinov, MD, Dept. Hospital, S581 85, Linkiiping,
0039-6060/97/$5.00
640
SURGERY
by Mosby-Year t 0
11/56/80637
Book,
Inc.
of Cardiothoracic Sweden.
Fig. 1. Nikolai V. Eck ( 1849-1908). Courtesy of professor V. 0. Samoilov.
described his experiments and technique for creating a portacaval shunt (Eck’s fistula) in eight dogs. This was not only the beginning of the surgical treatment of portal hypertention but also the first vascular anastomosis. Seven of the eight dogs died during or within the first week after the operation. The eighth dog survived and was observed for 2% months before it escaped from the kennel, never to be found. In this article Eck wrote, “I had to postpone further experiments because I was called up for active service.” He was sent to the Balkan
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Volume 121, Number 6
3. Eck’s fistula, surgical technique. From: Hahn M, Massen VN, Nenski M, Pavlov IP. Arch Biol SC (St. Petersburg) 1892;1:400.
Fig.
2. Ivan P. Pavlov (1849-1936). Courtesy of professor V. 0. Samoilov. Fig.
front to face the Turkish armed forces where he worked as a surgeon in field hospitals from June 20, 1877, to March 31, 1878. He left military service in 1880. Eck’s career was enigmatic and sparse. He published a total of 26 medical papers. In 1874 he reported the first successful abdominal hysterectomy in Russia; in 1877 he reported the first description of successful posterior interstitial myomectomy reported in the world’s literature. During 1881 and 1882 Eck attempted resection of the pyloric part of the stomach in three patients. On May 13, 1882, he presented a paper on his methods of gastric resection at the meeting of The Society of Russian Physicians in St. Petersburg.4 This was the first successful gastric resection in Russia. In the paper Eck proposed an operation that subsequently was described by Theodor Billroth and called Billroth II. Billroth implemented this idea on January 15, 1885. Because Eck reported the idea 3 years before the Billroth II operation was described in 1885, this operation was sometimes referred to in Russia as Eck-Billroth operation. For 13 years, from 1884 to 1897, Eck practiced surgery in many hospitals in St. Petersburg and served as the physician in the Ministry of Finance. In 1888 Eck was awarded a degree of Doctor of Medicine for his dissertation “An Experience of Analyzing Death-Rate Statistics in Russia.” From 1897 to 1908, the year of his death, he had a private practice in St. Petersburg, also became
involved in geology and mining engineering in southern Russia, and published several papers on the subject. 5, 6 Eck was a widely educated man of encyclopedic knowledge. His home library contained about 70,000 books. Because of his diversity and deep interest in various branches of science he was accused of being “ill-suited to his profession.” After a description of the fragments of Eck’s life Warren’ wrote, “This cursory examination of the sketchy details of his life certainly leaves the impression of a brilliant but erratic man who was seeking something which he probably never found.” Was that really so? It is difficult to say a century later. On his death on April 2, 1908, Eck was eulogized in St. Petersburg’s newspapers as “a very kind hearted man who was exceptionally good with patients and always gave patients hope.“’ In contrast to Warren’s assumption that during the 13 years while he served in the Ministry of Finance, Eck was completely divorced from medicine and surgery, Professor N. J. Chistovich,s who knew Eck very well personally, wrote in 1908: His main characteristic as a practitioner, making his death a specially aching void in my heart, was an extraordinary kindness, cordiality and ability to cheer up and to amuse the patient. Eck had a very special charisma of spiritual cheerfulness, and even in the most difficult cases, patients depressed by grief and anguish after his arrival cheered up, revived by hope and everyone felt easier. In spite of a fast growing med-
642 Konstantinov
~~%-~
June 1997
Fig. 4. I. P. Pavlov and associates in the Militaiy
Medical
Academy during
the civil war in 1920. Courtesy
of professor V. 0. Samoilov. ical practice, in spite of waning energy with years passing by, to his very last day Eck remained a physician equally open to everyone and utterly unselfish.
ECK’S FISTULA OR ECK-PAVLOV
SIIUNT?
Ivan P. Pavlov (1849-1936). In 1893 Pavlov (Fig. 2) and associates in the Military Medical Academy in St. Petersburg published a paper that is probably the greatest single contribution to the study of portal venous physiology.6 Of the 60 dogs in which Pavlov created Eck’s fistula, 20 lived and were subsequently studied.6, ’ The authors described and provided illustration (Fig. 3) of the primitive vascular anastomosis originally used by Eck. Although Pavlov later refined the technique, this operation remained a very difficult pr0cedure.l’ Pavlov wrote, “The whole operation lasts one to one and onehalf hours. Although it requires no extraordinary skill, it does demand the uninterrupted attention of the surgeon and is, therefore, rather exhausting.” Eck’s work provided an initial model with which Pavlov conducted his extensive studies in liver physiology. Pavlov gave the original description of “meat intoxication” in the dogwith Eck fistula and showed that this was not “a perfectly safe operation” as was stated by Eck. Pavlov received the Nobel prize in medicine and physiology in 1904 for his work on the physiology of digestion. Without the work of Pavlov, Eck’s fistula would probably have remained unknown outside Russia, as
Eck’s gastrectomy and myomectomy are today. Eck’s fistula was often referred to as Eck-Pavlov shunt in St. Petersburg.5 However, Pavlov was strongly against this, saying that the idea of this anastomosis belonged exclusively to Eck and thus this fistula must bear Eck’s name only. In 1897 Pavlov said: The essence of the operation is in idea. The operation has been introduced 20 years ago, when surgeons tried their best to avoid any injury of the vessels.And at that time Dr. Eck introduced an extraordinary witty and brave idea,-by his operation to switch blood flow from one part of living body into another. Thus, this operation has a full right to be named exclusively after Eck.‘l Ivan P. Pavlov was born on September 26, 1849, 2 months before Eck. Unlike Eck, he endured numerous hardships and difficulties of all kinds during his life.12, l3 Among his guiding principles were honesty, complete devotion to science, accuracy in observation and reporting, and careful analysis of logical and precisely designed experimental procedures.6, 12, l3 Pavlov graduated from the Military Medical Academy on December 29, 1879. On May 21, 1883, he presented his doctoral thesis “Afferent Nerves of the Heart” and was awarded a degree of Doctor of Medicine. When Russian surgical achievements of the beginning of the twentieth century are described, it is impor-
Surgey
Konstantinov 643
Volume 121, Number 6
Fig. 5. Ivan P. Pavlov (center) with Herbert Samoilov.
G. Wells (left) and his son (right). Courtesy of Professor V. 0.
tant to show not only what was done but also under which circumstances this was achieved. No scientific advance arises in a theoretical vacuum without free exchange of ideas by scientists from the entire world. Pavlov realized this very well. In 1918 in the journal Russian Doctor Pavlov published an article “Reflex of Freedom, ” in which he wrote “without freedom it is impossible to see anything truly new.” In December 1918 after the Russian revolution the situation in his laboratories became dramatic. Pavlov continued to work selflessly; it seemed that nothing could break his strong willpower and strength of mind. “If there was no heating, he put on a fur coat and a cap, if there was no light he operated under the light of a spill, which was held by his assistant above the operating area.“r3 Almost 1500 flagons of gastric juice were still sent annually from the Institute of Experimental Medicine to the drugstores of the city in 1918 and 1919. However, it was stopped in 1920 because all dogs at the “factory of gastric juice” died of starvation. During these years of civil war Pavlov continued not only his research but also to teach students at the Military Medical Academy (Fig. 4). In 1918 and 1919 Pavlov’s team managed to publish three articles annually; in 1920 they published only two articles. In June 1920 Pavlov wrote a petition to the Soviet government concerning the “freedom to leave Russia.” In the petition he wrote, “The whole of my life I preferred a straightforward, open way to action . . . the same way as I will act in this case.” He wrote that his main reason for leaving the country was the impossibility of continuing his research because of “insurmountable obstacles of all kinds” and “the absence of contacts with the world science”; the
second reason was his nonacceptance of the “social experiment” in Russia, which, in his opinion, “will bring nothing, but political and cultural death”; finally, the third reason was “heavy everyday life, inexorably leading to physical emaciation and exhaustion.” This petition was received by Vladimir I. Lenin, who ordered a reply to Pavlov asking him not to leave the country, “immediately provide Pavlov, his personal life, his lab oratories, his animals and his co-workers with everything he may need.” In September 1920 the famous English novelist and scientific romancer Herbert G. Wells visited Pavlov. In his book Russia in the Shadows Wells wrote: Our blockade has cut them off from all scientific literature outside Russia. They are without new instruments, they are short of paper, the work they do has to go on in unheated laboratories. It is amazing they do any work at all. Yet they are getting work done; Pavlov is carrying on research of astonishing scope and ingenuity upon the mentality of animals. The scientific spirit is a wonderful spirit. If Petersburg starves this winter, the House of Science will starve too, but these scientific men said very little to me about the possibility of sending them supplies. What they were all keen about was the possibility of getting scientific publications; they value knowledge more than bread. Pavlov still continues his marvellous researchesin an old coat and with his study piled up with the potatoes and carrots he grows in his spare time. . But many of the others are evidently stricken much harder. The mortality among the intellectually distinguished men of Russia has been terribly high.
Pavlov did not m’ention to Wells his intention to leave the country; toward the end of September 1920 he probably decided not to leave Russia. On January 1921
644
Konstantinov
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June 1997
the Soviet government accepted a resolution about the creation of special conditions for Pavlov for research work. On September 25, 1923, two days before his seventyfourth birthday, he stood before a class of medical students assembled in the auditorium of the Department of Physiology of the Military Medical Academy in Leningrad, to which he devoted 50 years of his life. He was about to address his first class of the new academic year. It was his custom to prepare the first lecture on a general theme. The subject of the lecture was “Communist Dogmatism and the Autonomy of Science in the Soviet Union in the Early 1920s.” In the lecture, noteworthy for the courage of the delivery under adverse circumstances, Pavlov reviewed the impressions he had gathered during his travels in Europe and the United States in the summer of 1923, criticized the prevailing ideology of Soviet communism, and discussed the role of science in a totalitarian system.14,‘5 By the end of 1923 Pavlov’s work was dramatically improved. He wrote to B. P. Babkin in America, “My work expands in a large scale, I have many co-workers and I am unable to accept everyone.“l’, l3 In May 1927 Pavlov underwent an operation for choledocholithiasis, which was first misdiagnosed as gastric cancer. Leading Russian surgeons S. P. Fedorov and I. I. Grekov were hesitant to operate on the 78-year-old Pavlov. Proposals were made to invite a surgeon from Germany. However, Pavlov refused any “foreign help.” His words “I do not believe that German surgeons are better than Russian” ended all discussions. At the conference held in his apartment by his good friends, famous surgeons themselves, Pavlov asked Aleksei V. Martinov to operate on him, “I personally find it highly unpleasant to operate on a familiar dog. . . I see you, professor Martinov, for the first time.” The operation went well. On the day of discharge Pavlov gave a lecture to patients about the difficult work of those who treat them. Pavlov continued to work hard, and by the beginning of the 1930s he had created one of the world’s finest centers of surgical research. In 1934 H. G. Wells visited Pavlov again together with his son, a biologist, for whom Pavlov became a real hero (Fig. 5). Wells was impressed by the new laboratories and the work done there; he wrote that Pavlov’s reputation contributed to the prestige of the Soviet Union, which provided him with everything he needed. Pavlov reminded Wells of their first meeting and asked, “What about your Russia in the Shadows?” The prophet of man’s future and the author of such science fiction books as The Time Machine, The Island ofDr. Moreau, and The Invisible Man did not know what to say. Later when recounting this, Pavlov laughed, “The man of the most powerful imagination ran out of fantasy!”
Pavlov continued an active investigative career, working from 10 to 17 hours daily, until February 27,1936, when he died at the age of 86, still working a heavy schedule in his laboratory. He was buried as a national hero, with thousands of people attending his funeral. It is nevertheless regrettable that his fame in other roles has largely eclipsed any memory of his unique contribution to vascular surgery. The early work on vascular anastomoses by Eck and Pavlov was to be continued by Carrel.
ECK’S FISTULA AND A PROPER VASCULAR TECHNIQUE Alexis Carrel (1873-1944)-the founder of vascular surgery. Alexis Carrel, a 21-year-old intern in Lyon, France, became interested in vascular surgery in 1894, when Sadi Carnot, president of France, died of a portal vein wound after an assassination. Even the leading surgeons of France were unable to repair the wound.r6 Apparently the only information available to Carrel in the world literature on vascular anastomoses were articles published by Eck and Pavlov. Carrel begun to work in vascular surgery in France in 1901, and in 1906 he moved to the Rockefeller Institute in New York to accept the position of director of the department of experimental surgery. In 1902 Carrel described his technique of “triangulation,” which enabled him to suture any blood vessel.” In 1906 Carrel published a paper on the improved simple technique of Eck’s fistula, in which he described a proper vascular technique.” After visiting Carrel’s laboratory in 1905, Harvey Cushing included Eck’s fistula in his student dog surgery course at Johns Hopkins. Thus the original Eck’s fistula was transformed by Carrel from an operation that severely tested the skills of even so fine an experimental surgeon as Pavlov into one that could be used to teach students6
EPILOGUE It is noteworthy that Eck’s fistula was performed by Eck and Pavlov during the last century with the equip ment of that century. For instance, Pavlov first became acquainted with the cutting and coagulating properties of electrical current in the 1920s during his visit to the United States. Harvey Gushing wrote that Pavlov became so excited watching the tumor excision by electrosurgical methods that he almost fell off the box on which he was standing to look over Gushing’s shoulder.lg Carrel was awarded the Nobel prize in medicine and physiology in 1912 for his work on the suturing of blood vessels and transplantation of organs. He was the first scientist working in an American laboratory to be awarded the Nobel prize for medicine.20 It is absolutely true that Carrel is a founder of reconstructive vascular
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Konstantinov
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surgery. However, the early work on vascular anastomoses by Eck and Pavlov should be remembered and never regarded as just a historical curiosity. I conclude with words of Harvey Cushing, “What has been accomplished does not die, but too often, alas, the personality of those who have handed the torch from one generation to another soon fades into oblivion.“21 REFERENCES 1. Eck NV.
o pereviazke
(Concerning
vorotnoi
ligation
veni:
of the vena
predvaritelnoye porta:
notification). Voen Med Zh 1877;130:1-2. 2. Child CG. Eck’s fistula. Surg Gynecol Obstet
cases of pyloric v St. Peterburge
5. Rocko JM, 1985;51:641-4. 6. Warren opment
Swan
KG.
WD. Presidential of portacaval
resection). Trudi 1882;26:257-61. The
Eck-Pavlov
preliminary
Obshestva
NJ. Sanktpeterburgskie
(Newspaper 8. Chistovich
published daily in St. Petersburg). NJ. To the memory of N. V. Eck.
1908;15:526. 9. Hahn M, Massen
Russkih Am
address: reflection on the early shunts. Ann Surg 1980;191:519-27.
7. Chistovich
zwischen
10. Pavlov IP. Own modification tal vein and the inferior 1893;2:580. Il.
Salaskin cussion].
Vedomosti,
der unteren
Nenski
M, Pavlov
Hohlvene
und
IP. Die
April
Surg devel-
5, 1908.
Russkiy
der Pfortader
Eck’ und
vena
Exp
Pathol
1949. 13. SamoilovVO,
Chicago:
Mazshuhin
Pharmakol
1893;
of the Eck fistula between the porcava. Arch Biol (St. Petersburg)
SS. A role of the liver in the nitrogen Trudi Obshestva Russkih vrachei
1897;65:192-5. 12. Babkin BP. Pavlov.
The
University
metabolism [disv St. Peterburge of Chicago
Lenizdat;
Pavlov on communist in the Soviet Union
1989. dogmatism and in the early 1920s:
the auton1923 (clas-
Vrach
sche ihre
Fistel Fol-
Ivan
Springfield (IL): Charles C Thomas; 1974. 17. Carrel A. La technique operatoire des anastomoses la transplantation 18. Carrel 1’Eck.
des viceres.
Lyon
Med
H. When
20. Brewer LA. Alexis wilderness of early
Pavlov
visited
Pav-
its consesurgeon.
vasculaires
a
1902;98:85964.
A, Guthrie CC. Methode simple pour Compt Rend Sot Biol Par 1906;60:1104.
19. Cushing 42:358-g.
Press;
AS. PavlovinPetersburg-Petrograd-
St. Petersburg:
lov’s suppressed defense of scientific freedom and quences. Integr Physiol Behav Sci 1993;28:137-42. 16. Edwards WS, Edwards PD. Alexis Carrel, visionary
Surg VN,
Arch
sical article). Integr Physiol Behav Sci 1992;27:267-78. 15. Horowitz IL. The politics of physiological psychology:
1953;96:375.
connection.
Organismus.
14. Pavlov IP. Ivan omy of science
3. Starzl TE, Porter KA, Francavilla A. The Eck fistula in animals and humans. Curr Probl Surg 1983;20:687-752. 4. Eck NV. Dva sluchaia chrevosechenia s cel’iu resectii privratnika (Two Vrachei
den
Leningrad.
K voprosu
soobschjenie
gen Fur 32161-210.
America.
etablie Surg
une Neurol
fistule 1994;
Carrel: a cardiovascular prophet crying in the twentieth century surgery. J Thorac Cardiovasc
1987;94:724-6.
21. Fulton JF. Harvey Cushing: the story of a great New York: Blackwell Scientific; 1946. p 609.
medical
pioneer.
Department
MD, Link~+~g, of
of
Sweden
Cardiothoracic Surgery,
Linkiiping
Heart Center,
University
Hospital,
Sweden
On doit des Cgards aux vivants; on ne doit aux marts que la v&it& [We owe respect to the living; to the dead we owe nothing but truth.]-Voltaire; Lettres SW Oedipe, 1. THE HISTORY OF RECONSTRUCTIVE VASCULAR SURGERY begins in the Military Medical Academy in St. Petersburg, Russia, where Nikolai V. Eck performed the first vascular anastomosis in 1877. This anastomosis is known as Eck’s fistula. Eck’s fistula became known in the world thanks to the work of Nobel prize winner Ivan P. Pavlov. This was not only the first vascular anastomosis but also a model with which Pavlov made the greatest single contribution to the study of portal venous physiology. Alexis Carrel is referred to as the founder of reconstructive vascular surgery. Although it is undoubtedly a fair statement, it is regrettable that nothing is known about the personalities of those by whom the first vascular anastomosis was made. Hopefully, the material presented here will reveal historical events as yet unknown and describe contributions not adequately acknowledged.
ECK’S FISTULA-THE FIRST PRIMITIVE VASCULAR ANASTOMOSIS Nikolai V. Eck (1849-1908). Nikolai V. Eck (Fig. 1) was born on November 9,1849, in St. Petersburg, Russia. He was the only son of Vladimir E. Eck, a professor of medicine at the Military Medical Academy. Nikolai Eck entered the Military Medical Academy in 1865, and on graduation in 1871 he started postgraduate training in surgery. Because of his family background and excellent education, Eck experienced few hardships and was economically privileged. In 1877 as a 29-year-old surgeon Eck, working in the Military Medical Academy in St. Petersburg, published an article scarcely more than one page long’, *, that assured immortality for his name.‘, 3 In this article Eck Accepted
Jan.
Reprint Surgery,
requests: University
17, 1997.
Surgery
1997;121:640-5.
Copyright
D 1997
Igor E. Konstantinov, MD, Dept. Hospital, S581 85, Linkiiping,
0039-6060/97/$5.00
640
SURGERY
by Mosby-Year t 0
11/56/80637
Book,
Inc.
of Cardiothoracic Sweden.
Fig. 1. Nikolai V. Eck ( 1849-1908). Courtesy of professor V. 0. Samoilov.
described his experiments and technique for creating a portacaval shunt (Eck’s fistula) in eight dogs. This was not only the beginning of the surgical treatment of portal hypertention but also the first vascular anastomosis. Seven of the eight dogs died during or within the first week after the operation. The eighth dog survived and was observed for 2% months before it escaped from the kennel, never to be found. In this article Eck wrote, “I had to postpone further experiments because I was called up for active service.” He was sent to the Balkan
Konstantinou
suv?Y
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Volume 121, Number 6
3. Eck’s fistula, surgical technique. From: Hahn M, Massen VN, Nenski M, Pavlov IP. Arch Biol SC (St. Petersburg) 1892;1:400.
Fig.
2. Ivan P. Pavlov (1849-1936). Courtesy of professor V. 0. Samoilov. Fig.
front to face the Turkish armed forces where he worked as a surgeon in field hospitals from June 20, 1877, to March 31, 1878. He left military service in 1880. Eck’s career was enigmatic and sparse. He published a total of 26 medical papers. In 1874 he reported the first successful abdominal hysterectomy in Russia; in 1877 he reported the first description of successful posterior interstitial myomectomy reported in the world’s literature. During 1881 and 1882 Eck attempted resection of the pyloric part of the stomach in three patients. On May 13, 1882, he presented a paper on his methods of gastric resection at the meeting of The Society of Russian Physicians in St. Petersburg.4 This was the first successful gastric resection in Russia. In the paper Eck proposed an operation that subsequently was described by Theodor Billroth and called Billroth II. Billroth implemented this idea on January 15, 1885. Because Eck reported the idea 3 years before the Billroth II operation was described in 1885, this operation was sometimes referred to in Russia as Eck-Billroth operation. For 13 years, from 1884 to 1897, Eck practiced surgery in many hospitals in St. Petersburg and served as the physician in the Ministry of Finance. In 1888 Eck was awarded a degree of Doctor of Medicine for his dissertation “An Experience of Analyzing Death-Rate Statistics in Russia.” From 1897 to 1908, the year of his death, he had a private practice in St. Petersburg, also became
involved in geology and mining engineering in southern Russia, and published several papers on the subject. 5, 6 Eck was a widely educated man of encyclopedic knowledge. His home library contained about 70,000 books. Because of his diversity and deep interest in various branches of science he was accused of being “ill-suited to his profession.” After a description of the fragments of Eck’s life Warren’ wrote, “This cursory examination of the sketchy details of his life certainly leaves the impression of a brilliant but erratic man who was seeking something which he probably never found.” Was that really so? It is difficult to say a century later. On his death on April 2, 1908, Eck was eulogized in St. Petersburg’s newspapers as “a very kind hearted man who was exceptionally good with patients and always gave patients hope.“’ In contrast to Warren’s assumption that during the 13 years while he served in the Ministry of Finance, Eck was completely divorced from medicine and surgery, Professor N. J. Chistovich,s who knew Eck very well personally, wrote in 1908: His main characteristic as a practitioner, making his death a specially aching void in my heart, was an extraordinary kindness, cordiality and ability to cheer up and to amuse the patient. Eck had a very special charisma of spiritual cheerfulness, and even in the most difficult cases, patients depressed by grief and anguish after his arrival cheered up, revived by hope and everyone felt easier. In spite of a fast growing med-
642 Konstantinov
~~%-~
June 1997
Fig. 4. I. P. Pavlov and associates in the Militaiy
Medical
Academy during
the civil war in 1920. Courtesy
of professor V. 0. Samoilov. ical practice, in spite of waning energy with years passing by, to his very last day Eck remained a physician equally open to everyone and utterly unselfish.
ECK’S FISTULA OR ECK-PAVLOV
SIIUNT?
Ivan P. Pavlov (1849-1936). In 1893 Pavlov (Fig. 2) and associates in the Military Medical Academy in St. Petersburg published a paper that is probably the greatest single contribution to the study of portal venous physiology.6 Of the 60 dogs in which Pavlov created Eck’s fistula, 20 lived and were subsequently studied.6, ’ The authors described and provided illustration (Fig. 3) of the primitive vascular anastomosis originally used by Eck. Although Pavlov later refined the technique, this operation remained a very difficult pr0cedure.l’ Pavlov wrote, “The whole operation lasts one to one and onehalf hours. Although it requires no extraordinary skill, it does demand the uninterrupted attention of the surgeon and is, therefore, rather exhausting.” Eck’s work provided an initial model with which Pavlov conducted his extensive studies in liver physiology. Pavlov gave the original description of “meat intoxication” in the dogwith Eck fistula and showed that this was not “a perfectly safe operation” as was stated by Eck. Pavlov received the Nobel prize in medicine and physiology in 1904 for his work on the physiology of digestion. Without the work of Pavlov, Eck’s fistula would probably have remained unknown outside Russia, as
Eck’s gastrectomy and myomectomy are today. Eck’s fistula was often referred to as Eck-Pavlov shunt in St. Petersburg.5 However, Pavlov was strongly against this, saying that the idea of this anastomosis belonged exclusively to Eck and thus this fistula must bear Eck’s name only. In 1897 Pavlov said: The essence of the operation is in idea. The operation has been introduced 20 years ago, when surgeons tried their best to avoid any injury of the vessels.And at that time Dr. Eck introduced an extraordinary witty and brave idea,-by his operation to switch blood flow from one part of living body into another. Thus, this operation has a full right to be named exclusively after Eck.‘l Ivan P. Pavlov was born on September 26, 1849, 2 months before Eck. Unlike Eck, he endured numerous hardships and difficulties of all kinds during his life.12, l3 Among his guiding principles were honesty, complete devotion to science, accuracy in observation and reporting, and careful analysis of logical and precisely designed experimental procedures.6, 12, l3 Pavlov graduated from the Military Medical Academy on December 29, 1879. On May 21, 1883, he presented his doctoral thesis “Afferent Nerves of the Heart” and was awarded a degree of Doctor of Medicine. When Russian surgical achievements of the beginning of the twentieth century are described, it is impor-
Surgey
Konstantinov 643
Volume 121, Number 6
Fig. 5. Ivan P. Pavlov (center) with Herbert Samoilov.
G. Wells (left) and his son (right). Courtesy of Professor V. 0.
tant to show not only what was done but also under which circumstances this was achieved. No scientific advance arises in a theoretical vacuum without free exchange of ideas by scientists from the entire world. Pavlov realized this very well. In 1918 in the journal Russian Doctor Pavlov published an article “Reflex of Freedom, ” in which he wrote “without freedom it is impossible to see anything truly new.” In December 1918 after the Russian revolution the situation in his laboratories became dramatic. Pavlov continued to work selflessly; it seemed that nothing could break his strong willpower and strength of mind. “If there was no heating, he put on a fur coat and a cap, if there was no light he operated under the light of a spill, which was held by his assistant above the operating area.“r3 Almost 1500 flagons of gastric juice were still sent annually from the Institute of Experimental Medicine to the drugstores of the city in 1918 and 1919. However, it was stopped in 1920 because all dogs at the “factory of gastric juice” died of starvation. During these years of civil war Pavlov continued not only his research but also to teach students at the Military Medical Academy (Fig. 4). In 1918 and 1919 Pavlov’s team managed to publish three articles annually; in 1920 they published only two articles. In June 1920 Pavlov wrote a petition to the Soviet government concerning the “freedom to leave Russia.” In the petition he wrote, “The whole of my life I preferred a straightforward, open way to action . . . the same way as I will act in this case.” He wrote that his main reason for leaving the country was the impossibility of continuing his research because of “insurmountable obstacles of all kinds” and “the absence of contacts with the world science”; the
second reason was his nonacceptance of the “social experiment” in Russia, which, in his opinion, “will bring nothing, but political and cultural death”; finally, the third reason was “heavy everyday life, inexorably leading to physical emaciation and exhaustion.” This petition was received by Vladimir I. Lenin, who ordered a reply to Pavlov asking him not to leave the country, “immediately provide Pavlov, his personal life, his lab oratories, his animals and his co-workers with everything he may need.” In September 1920 the famous English novelist and scientific romancer Herbert G. Wells visited Pavlov. In his book Russia in the Shadows Wells wrote: Our blockade has cut them off from all scientific literature outside Russia. They are without new instruments, they are short of paper, the work they do has to go on in unheated laboratories. It is amazing they do any work at all. Yet they are getting work done; Pavlov is carrying on research of astonishing scope and ingenuity upon the mentality of animals. The scientific spirit is a wonderful spirit. If Petersburg starves this winter, the House of Science will starve too, but these scientific men said very little to me about the possibility of sending them supplies. What they were all keen about was the possibility of getting scientific publications; they value knowledge more than bread. Pavlov still continues his marvellous researchesin an old coat and with his study piled up with the potatoes and carrots he grows in his spare time. . But many of the others are evidently stricken much harder. The mortality among the intellectually distinguished men of Russia has been terribly high.
Pavlov did not m’ention to Wells his intention to leave the country; toward the end of September 1920 he probably decided not to leave Russia. On January 1921
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the Soviet government accepted a resolution about the creation of special conditions for Pavlov for research work. On September 25, 1923, two days before his seventyfourth birthday, he stood before a class of medical students assembled in the auditorium of the Department of Physiology of the Military Medical Academy in Leningrad, to which he devoted 50 years of his life. He was about to address his first class of the new academic year. It was his custom to prepare the first lecture on a general theme. The subject of the lecture was “Communist Dogmatism and the Autonomy of Science in the Soviet Union in the Early 1920s.” In the lecture, noteworthy for the courage of the delivery under adverse circumstances, Pavlov reviewed the impressions he had gathered during his travels in Europe and the United States in the summer of 1923, criticized the prevailing ideology of Soviet communism, and discussed the role of science in a totalitarian system.14,‘5 By the end of 1923 Pavlov’s work was dramatically improved. He wrote to B. P. Babkin in America, “My work expands in a large scale, I have many co-workers and I am unable to accept everyone.“l’, l3 In May 1927 Pavlov underwent an operation for choledocholithiasis, which was first misdiagnosed as gastric cancer. Leading Russian surgeons S. P. Fedorov and I. I. Grekov were hesitant to operate on the 78-year-old Pavlov. Proposals were made to invite a surgeon from Germany. However, Pavlov refused any “foreign help.” His words “I do not believe that German surgeons are better than Russian” ended all discussions. At the conference held in his apartment by his good friends, famous surgeons themselves, Pavlov asked Aleksei V. Martinov to operate on him, “I personally find it highly unpleasant to operate on a familiar dog. . . I see you, professor Martinov, for the first time.” The operation went well. On the day of discharge Pavlov gave a lecture to patients about the difficult work of those who treat them. Pavlov continued to work hard, and by the beginning of the 1930s he had created one of the world’s finest centers of surgical research. In 1934 H. G. Wells visited Pavlov again together with his son, a biologist, for whom Pavlov became a real hero (Fig. 5). Wells was impressed by the new laboratories and the work done there; he wrote that Pavlov’s reputation contributed to the prestige of the Soviet Union, which provided him with everything he needed. Pavlov reminded Wells of their first meeting and asked, “What about your Russia in the Shadows?” The prophet of man’s future and the author of such science fiction books as The Time Machine, The Island ofDr. Moreau, and The Invisible Man did not know what to say. Later when recounting this, Pavlov laughed, “The man of the most powerful imagination ran out of fantasy!”
Pavlov continued an active investigative career, working from 10 to 17 hours daily, until February 27,1936, when he died at the age of 86, still working a heavy schedule in his laboratory. He was buried as a national hero, with thousands of people attending his funeral. It is nevertheless regrettable that his fame in other roles has largely eclipsed any memory of his unique contribution to vascular surgery. The early work on vascular anastomoses by Eck and Pavlov was to be continued by Carrel.
ECK’S FISTULA AND A PROPER VASCULAR TECHNIQUE Alexis Carrel (1873-1944)-the founder of vascular surgery. Alexis Carrel, a 21-year-old intern in Lyon, France, became interested in vascular surgery in 1894, when Sadi Carnot, president of France, died of a portal vein wound after an assassination. Even the leading surgeons of France were unable to repair the wound.r6 Apparently the only information available to Carrel in the world literature on vascular anastomoses were articles published by Eck and Pavlov. Carrel begun to work in vascular surgery in France in 1901, and in 1906 he moved to the Rockefeller Institute in New York to accept the position of director of the department of experimental surgery. In 1902 Carrel described his technique of “triangulation,” which enabled him to suture any blood vessel.” In 1906 Carrel published a paper on the improved simple technique of Eck’s fistula, in which he described a proper vascular technique.” After visiting Carrel’s laboratory in 1905, Harvey Cushing included Eck’s fistula in his student dog surgery course at Johns Hopkins. Thus the original Eck’s fistula was transformed by Carrel from an operation that severely tested the skills of even so fine an experimental surgeon as Pavlov into one that could be used to teach students6
EPILOGUE It is noteworthy that Eck’s fistula was performed by Eck and Pavlov during the last century with the equip ment of that century. For instance, Pavlov first became acquainted with the cutting and coagulating properties of electrical current in the 1920s during his visit to the United States. Harvey Gushing wrote that Pavlov became so excited watching the tumor excision by electrosurgical methods that he almost fell off the box on which he was standing to look over Gushing’s shoulder.lg Carrel was awarded the Nobel prize in medicine and physiology in 1912 for his work on the suturing of blood vessels and transplantation of organs. He was the first scientist working in an American laboratory to be awarded the Nobel prize for medicine.20 It is absolutely true that Carrel is a founder of reconstructive vascular
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surgery. However, the early work on vascular anastomoses by Eck and Pavlov should be remembered and never regarded as just a historical curiosity. I conclude with words of Harvey Cushing, “What has been accomplished does not die, but too often, alas, the personality of those who have handed the torch from one generation to another soon fades into oblivion.“21 REFERENCES 1. Eck NV.
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