Eck-Pavlov shunt: The 120th anniversary of the first vascular anastomosis Igor E. Konstantinov, MD, Link~+~g, Sweden

From the Department of Cardiothoracic Surgery, Linkiiping Heart Center, University Hospital,

Linkiiping, 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 noth- ing but truth.]-Voltaire; Lettres SW Oedipe, 1.

THE HISTORY OF RECONSTRUCTIVE VASCULAR SURGERY be- gins in the Military Medical Academy in St. Petersburg, Russia, where Nikolai V. Eck performed the first vascu- lar 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 recon- structive 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 vascu- lar anastomosis was made. Hopefully, the material pre- sented here will reveal historical events as yet unknown and describe contributions not adequately acknowl- edged.

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, Rus- sia. 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 excel- lent 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 as- sured immortality for his name.‘, 3 In this article Eck

Accepted Jan. 17, 1997.

Reprint requests: Igor E. Konstantinov, MD, Dept. of Cardiothoracic Surgery, University Hospital, S581 85, Linkiiping, Sweden.

Surgery 1997;121:640-5.

Copyright D 1997 by Mosby-Year Book, Inc.

0039-6060/97/$5.00 t 0 11/56/80637

640 SURGERY

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 por- tal 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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Fig. 2. Ivan P. Pavlov (1849-1936). Courtesy of professor V. 0. Samoilov.

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 in- terstitial myomectomy reported in the world’s litera- ture. 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 Rus- sian Physicians in St. Petersburg.4 This was the first suc- cessful gastric resection in Russia. In the paper Eck pro- posed an operation that subsequently was described by Theodor Billroth and called Billroth II. Billroth imple- mented this idea on January 15, 1885. Because Eck re- ported the idea 3 years before the Billroth II operation was described in 1885, this operation was sometimes re- ferred 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 disser- tation “An Experience of Analyzing Death-Rate Statis- tics in Russia.” From 1897 to 1908, the year of his death, he had a private practice in St. Petersburg, also became

Fig. 3. Eck’s fistula, surgical technique. From: Hahn M, Mas- sen VN, Nenski M, Pavlov IP. Arch Biol SC (St. Petersburg) 1892;1:400.

involved in geology and mining engineering in south- ern Russia, and published several papers on the sub- ject. 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 var- ious 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. Pe- tersburg’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 kind- ness, cordiality and ability to cheer up and to amuse the patient. Eck had a very special charisma of spiritual cheerful- ness, 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 great- est 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 one- half hours. Although it requires no extraordinary skill, it does demand the uninterrupted attention of the sur- geon and is, therefore, rather exhausting.”

Eck’s work provided an initial model with which Pav- lov conducted his extensive studies in liver physiology. Pavlov gave the original description of “meat intoxica- tion” 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 phys- iology in 1904 for his work on the physiology of diges- tion. 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 exclu- sively 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 in- troduced an extraordinary witty and brave idea,-by his oper- ation to switch blood flow from one part of living body into another. Thus, this operation has a full right to be named ex- clusively 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 report- ing, and careful analysis of logical and precisely de- signed experimental procedures.6, 12, l3 Pavlov gradu- ated 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 begin- ning of the twentieth century are described, it is impor-

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Fig. 5. Ivan P. Pavlov (center) with Herbert G. Wells (left) and his son (right). Courtesy of Professor V. 0. Samoilov.

tant to show not only what was done but also under which circumstances this was achieved. No scientific ad- vance 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 Med- icine 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 re- search but also to teach students at the Military Medical Academy (Fig. 4). In 1918 and 1919 Pavlov’s team man- aged 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 ex- periment” in Russia, which, in his opinion, “will bring nothing, but political and cultural death”; finally, the third reason was “heavy everyday life, inexorably lead- ing to physical emaciation and exhaustion.” This peti- tion 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 lab- oratories. It is amazing they do any work at all. Yet they are getting work done; Pavlov is carrying on research of astonish-

ing 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 researches- in 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 SUVFY 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 seventy- fourth birthday, he stood before a class of medical stu- dents assembled in the auditorium of the Department of Physiology of the Military Medical Academy in Len- ingrad, 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 gen- eral 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 circum- stances, Pavlov reviewed the impressions he had gath- ered during his travels in Europe and the United States in the summer of 1923, criticized the prevailing ideol- ogy of Soviet communism, and discussed the role of sci- ence 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 cho- ledocholithiasis, 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 con- ference 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 repu- tation 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, work- ing 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 contri- bution 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 sur- geons of France were unable to repair the wound.r6 Ap- parently 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 de- partment of experimental surgery. In 1902 Carrel described his technique of “triangulation,” which en- abled 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 fis- tula in his student dog surgery course at Johns Hopkins. Thus the original Eck’s fistula was transformed by Car- rel 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 be- came so excited watching the tumor excision by elec- trosurgical methods that he almost fell off the box on which he was standing to look over Gushing’s shoul- der.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 anasto- moses 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 obliv- ion.“21

REFERENCES

1. Eck NV. K voprosu o pereviazke vorotnoi veni: predvaritelnoye

soobschjenie (Concerning ligation of the vena porta: preliminary

notification). Voen Med Zh 1877;130:1-2. 2. Child CG. Eck’s fistula. Surg Gynecol Obstet 1953;96:375.

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 cases of pyloric resection). Trudi Obshestva Russkih Vrachei v St. Peterburge 1882;26:257-61.

5. Rocko JM, Swan KG. The Eck-Pavlov connection. Am Surg 1985;51:641-4.

6. Warren WD. Presidential address: reflection on the early devel- opment of portacaval shunts. Ann Surg 1980;191:519-27.

7. Chistovich NJ. Sanktpeterburgskie Vedomosti, April 5, 1908.

(Newspaper published daily in St. Petersburg). 8. Chistovich NJ. To the memory of N. V. Eck. Russkiy Vrach

1908;15:526. 9. Hahn M, Massen VN, Nenski M, Pavlov IP. Die Eck’ sche Fistel

zwischen der unteren Hohlvene und der Pfortader und ihre Fol-

Konstantinov

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10. Pavlov IP. Own modification of the Eck fistula between the por- tal vein and the inferior vena cava. Arch Biol (St. Petersburg) 1893;2:580.

Il. Salaskin SS. A role of the liver in the nitrogen metabolism [dis- cussion]. Trudi Obshestva Russkih vrachei v St. Peterburge

1897;65:192-5. 12. Babkin BP. Pavlov. Chicago: The University of Chicago Press;

1949. 13. SamoilovVO, Mazshuhin AS. PavlovinPetersburg-Petrograd-

Leningrad. St. Petersburg: Lenizdat; 1989.

14. Pavlov IP. Ivan Pavlov on communist dogmatism and the auton- omy of science in the Soviet Union in the early 1920s: 1923 (clas-

sical article). Integr Physiol Behav Sci 1992;27:267-78. 15. Horowitz IL. The politics of physiological psychology: Ivan Pav-

lov’s suppressed defense of scientific freedom and its conse- quences. Integr Physiol Behav Sci 1993;28:137-42.

16. Edwards WS, Edwards PD. Alexis Carrel, visionary surgeon.

Springfield (IL): Charles C Thomas; 1974. 17. Carrel A. La technique operatoire des anastomoses vasculaires a

la transplantation des viceres. Lyon Med 1902;98:85964.

18. Carrel A, Guthrie CC. Methode simple pour etablie une fistule 1’Eck. Compt Rend Sot Biol Par 1906;60:1104.

19. Cushing H. When Pavlov visited America. Surg Neurol 1994; 42:358-g.

20. Brewer LA. Alexis Carrel: a cardiovascular prophet crying in the wilderness of early twentieth century surgery. J Thorac Cardiovasc

Surg 1987;94:724-6.

21. Fulton JF. Harvey Cushing: the story of a great medical pioneer. New York: Blackwell Scientific; 1946. p 609.