David Erlik (1909–1995)
A Founder of Surgery in Modern Israel
Moshe Hashmonai
Faculty of Medicine, Technion – Israel Institute of Technology, Haifa , Israel
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David Erlik ( fi g. 1 ) was born in Pinsk in 1909, at the
time a Russian town within the 'Jewish Sector' or 'Pale
of Settlement', namely that part of tsarist Russia in which
Jews were allowed to live, as ordered by Tsar Alexander
III. Due to World War I which was followed by the Bolshevik
Revolution, he was merely a 6-year-old child,
when he started a long tribulation over Russia to end in
1922 in the newly established Independent Poland. Two
years later, stimulated by Zionism, he landed in Palestine.
His family established itself in Haifa and, during the coming
4 years, young David succeeded to graduate from the
'Reali' Hebrew High School (one of the two foremost high
schools in the country). These were the only years of regular,
uninterrupted studies he had. To achieve his childhood
dream and become a physician, he had to return to
Europe. He chose to study medicine in Montpellier, France, but on his way met friends who convinced him
to enroll in Strasbourg's School of Medicine, France,
where he studied during 1928–1935. He earned his living
by working in a sanatorium for tuberculous patients. It
was probably this work that led him to choose his MD
thesis, 'Les résultats de l'aurothérapie de la tuberculose
pulmonaire, dans le cadre de la cure sanatoriale' [The results
of the aurotherapy for pulmonary tuberculosis, in
For many centuries and until less than 100 years ago,
the Promised Land was merely a province of the Ottoman
Empire. At the turn of the 19th century, the religious interest
of European powers in the region initiated the development
of Jerusalem. At the same time, scattered Jewish
intellectuals in Europe established a movement, called
Zionism, aiming to revive the Jewish Nation and rebuild
its historical homeland. Jews began to immigrate. The
thousands year-old Hebrew language was reintroduced in
daily use. In 1918, at the end of World War I, Britain received
the mandate over the province, renamed 'Palestine'.
This event enhanced the introduction of modern
concepts of life and western culture. Schools and hospitals
were built. In 1924, the Hebrew Technical Institute (later
renamed 'Technion – Israel Institute of Technology') was
founded in Haifa, to become the fi rst academic institution
in the country. It was shortly followed by the establishment
of the Hebrew University in Jerusalem. However,
there was no Medical Faculty in either institution.
To become a physician, a youngster had to return to Europe.
During this period, the medical staff of the small
number of hospitals in the country comprised a few specialists,
who got their training abroad. Some arrived because
of Zionism, others were world famous physicians
who managed to escape on time from Nazi Germany. In
the newly created Hadassah Hospital in Jerusalem, surgery
was undertaken by Dr. E.G. Joseph, a Mayo-trained
New Zealander, who immigrated into his historical homeland.
In 1937, the young Dr. David Erlik became the fi rst
resident of surgery in the country, under the tutorship of
Dr. Joseph. At that time, there was no training program
the frame of sanatorium treatment]. In 1935, he received
his MD diploma from the University of Strasbourg and
returned to his homeland, not before he observed on the
eastern side of the Rhine River, the gathering storm which
was to sweep over and destroy Europe a few years later.
The working opportunities for a freshly graduated physician
in the British Mandate of Palestine were scant at
the time. There were no residencies in the recently created
few existing hospitals. Dr. Erlik was, therefore, fortunate
to be appointed as general practitioner in a small newly
established agricultural settlement, in the Lower Galilee.
He came there in contact with the Jewish pioneers, who
worked the land and fought for their survival. For 2 years,
he practiced medicine in conditions unimaginable today.
Yet, as he mentioned later, these were days in which medicine
was far from being scientifi c but was humane. He
was loved and respected by the community he served and
was elated to be part of the rebirth of the Jewish settlement
in the country. However, his dream to become a surgeon
was not abated. In 1936, the Hadassah Hospital in Jerusalem
established a few residencies. Residents were called
at the time 'house physicians' because they lived in the
hospital. Dr. Erlik applied, was accepted out of 40 applicants,
and moved to Jerusalem. Until his position was
opened, he worked as a volunteer and spent a year in the
department of radiotherapy. The treatment of cancer patients
in the late 1930s was rather restricted, consisting in
many cases of analgesics in addition to 'tender love and
care'. Yet, this year crystallized the humane attitude Dr.
Erlik gave his patients during his entire career.
In the period 1938–1948, Dr. Erlik acquired his surgical
training. In those years, Surgery was 'General' indeed.
Orthopedics had begun to branch off, but chest and urological
operations were part of the general surgical repertoire.
Vascular surgery was undreamed of. Thus, his training
was general and he remained an outstanding general
surgeon to the end of his career. His teacher was Dr. Edward
G. Josef, a surgical trainee of the Mayo Clinic, one
of the foremost medical institutions in the world. Despite
the precarious facilities in the fi rst years, young Dr. Erlik
was exposed to the most advanced techniques of those
days. In the mid-1940s, the Jewish-Arab confl ict escalated,
culminating in the Israeli War of Independence. The
Campus of the Hebrew University and the Hadassah Hospital
complex on Mount Scopus in Jerusalem were under
siege. Dr. Erlik was left as Head of a restricted medical
staff. The modern operating rooms of the hospital could
not be used, being under fi re. It was, therefore, in a small
room without windows, next to the kitchen, that the operations
of the wounded defendants were performed.
In 1948, Dr. Erlik was appointed as Chief of Surgery
in the Rambam Hospital, Haifa, to become the major
medical center in northern Israel. He was aged 39 and
fulfi lled this task for almost 30 years. It is during this period
of time that Urology, Cardiothoracic and Vascular
Surgery became separate specialties. The hospital expanded
its facilities and almost tripled the number of its
beds. Finally a Medical School, which became the Faculty
of Medicine of the Technion, was established and
opened its gates in the autumn of 1969, located in a modest
old monastery building next to the Rambam Hospital
( fi g. 2 ). Dr. Erlik functioned as its fi rst Dean for 10 years.
The Rappaport Family Building for Medical Sciences, in
which the Faculty is now located ( fi g. 3 ), was built next to
the Rambam Hospital Complex. Dr. Erlik was the driving
force for all these achievements, not only as instigator,
but also as the one who managed to gather the enormous
amounts of required donations.
Many objected in the early 1970s to the connection of
the new medical school with a technical institution, although
the very high academic standard and international
reputation of the Technion were indisputable. Indeed
all over the world, there were and still are very few such
examples of medical faculties in the frame of technical
institutions. I clearly remember Dr. Erlik's statement in
reply: In future, medicine will be intimately and inevitably
intricated with advanced technologies . This was said when
the medical application of ultrasonography and computed
tomography, fl exible endoscopy and endoscopic surgery
were undreamed off. Yet, within the next 15 years,
Fig. 1. Professor David Erlik.
David Erlik (1909–1995) Dig Surg 2004;21:447–451 449
the concomitant existence of a large medical clinical teaching
center, and a foremost technical academic institution,
triggered the establishment of the fl ourishing biomedical
industry in Haifa. Dr. Erlik's vision became reality.
The major achievements of Dr. Erlik were, however,
much more important. He established the foremost surgical
center in northern Israel. Despite the modest fi nancial
means, he maintained the highest and most modern standard
of surgery. He used to travel regularly, and met the
foremost surgeons of his time: Garlock, Cattell, Swenson,
Smithwick, Dragstedt, Wangensteen, Lillehei, Varco,
Bailey, Holman, Longmire, Belt, Potts, Hunt, Maingot,
Banzet, Nesbit, Gil-Vernet, DeBakey, Cooley and many
others. From each trip, he brought back new techniques,
which he introduced and applied in the Rambam Medical
Center. Thus, he performed the fi rst aortic aneurysmectomy
in Israel, using dry-freeze human grafts. In 1966
he carried out the fi rst kidney transplant in Israel and,
during his days, Rambam became the leading transplant
center in the country. Sub-specialties, like urology, vascular,
chest, and cardiac surgery, and intensive care were
stimulated by him and strived for. Most important, he
created a surgical standard of excellence, which he imbedded
in the next two generations of surgeons. The last paper
Dr. Erlik ever wrote was a history of the Rambam
Fig. 2. The old monastery building in which
the newly created medical school was located
in 1969. Haifa, Israel.
Fig. 3. The Rappaport Family Building for the Medical Sciences
in which is presently located the Faculty of Medicine of the Technion.
Haifa, Israel.
Hashmonai
Dig 450 Surg 2004;21:447–451
Hospital and its contributions to medicine in the northern
part of Israel [1] .
In 1977, a new Dean replaced Dr. Erlik at the head of
the Faculty of Medicine he had created. Two years later,
he fi nally retired from all medical activities in the Rambam
Medical Center. However, due to his merits, he was
called by the Ministry of Health to supervise surgery in
the Poryah Hospital in Tiberias, a task he fulfi lled for
more than 1 year. When he left in early 1983, he fi nally
parted from all medical activities. In his retirement Dr.
Erlik wrote two books. The fi rst, 'Between Me and Medicine
– On Dreams and Realty' (1986), was his autobiography.
The second, 'Break-Through in Medicine' (1990),
dwelt on key events in the history of medicine. Unfortunately,
both books were never translated from their original
Hebrew, thus being inaccessible to the international
readership. The last event in this long, remarkable, and
honorable carrier was his being nominated Laureate of
the Prize of Israel for Medicine in 1992, the highest award
of the State of Israel.
Toward the end of his life, Dr. Erlik developed an anaplastic
change in his long-standing recurrence of thyroid
carcinoma, resulting in severe dysphagia. The old surgeon
decided against any further surgical intervention or artifi
cial methods of nutrition; he died peacefully on October
28, 1995.
The Surgeon
Dr. Erlik possessed an outstanding surgical technique.
He never made brisk, fast movements. Yet, his operations
were always very short, because he never made unnecessary
movements. When a problem arose during an operation,
his decisions were taken immediately and no
time was procrastinated on thinking what to do, or how
to do it. No need to tell that his decisions, as a rule, turned
to be correct.
He would always censure a surgeon for mistakes, but
would always do so in the most benevolent and paternal
manner. Yet he admitted mistakes. He claimed that there
is no surgeon to whom mishaps do not occur, but that a
good surgeon knows to deal with them.
His humane bearing was even more evident in his attitude
towards the wounded patients. During the wars
(Six Days, Yom Kippur), when the Rambam Hospital
became the major referral center for the wounded, and in
between, he admitted and treated both Israeli soldiers
and Arab wounded prisoners of war with the same impartiality.
The patient was no more than a wounded human
being and all equally benefi ted from his excellent
abilities.
In the last decade of his life, Dr. Erlik quitted all medical
practice, and openly declared so. When laparoscopic
surgery was introduced in the early 1990s, he refused even
to observe the new operations claiming that he detached
himself from medicine. How many surgeons know to put
a limit to their practice and admit that their time is
passed?
Contributions to Surgery
Dr. Erlik's original contributions to surgery were mainly
in the fi eld of portal hypertension. They were due to
his ability to fi nd solutions to the most complicated and
unexpected problems. Shortly after Blakemore described
in the early 1950s techniques for porto-caval shunting,
Dr. Erlik introduced the operation in the Rambam Hospital.
One of the causes of portal hypertension is the
Budd-Chiari syndrome. In this disease, contrary to the
case in liver cirrhosis, the rapid progress of portal hypertension
does not allow the development of collateral variceal
circulation, nor of substantially enlarged vessels in
the portal system. Thus, failure to perform a porto-caval
shunting was due either to the use of too small vessels or
to its being performed at a too advanced stage of the disease.
At such advanced stage, the liver is so enlarged and
congested, that the cava is compressed, and a porto-caval
shunt does not effectively reduce the portal pressure.
When a patient presented in the acute phase of Budd-
Chiari syndrome, Dr. Erlik successfully performed an immediate
side-to-side porto-caval shunt. The patient survived
and recovered. The publication of this case [2] was
the fi rst description of a successful surgical treatment of
the Budd-Chiari syndrome.
In another operation performed for portal hypertension
which required a side-to-side shunting, the two veins
could not be approximated. Dr. Erlik's solution to the
problem was to transect the left renal vein, ligate its distal
end, proximal to the confl uence of the adrenal and gonadal
veins, and anastomose the proximal stump to the
portal vein, bridging the caval and portal systems. Thus
he conceived the proximal (central) porto-renal shunt [3] .
He subsequently examined the left renal function and
found it unhampered by the renal vein ligation [4] . Ligation
of the left renal vein was subsequently used not only
in porto-systemic surgery, but also in surgery for juxtarenal
artery aortic aneurysm repairs.
David Erlik (1909–1995) Dig Surg 2004;21:447–451 451
Another example of Dr. Erlik's resourcefulness in solving
unexpected problems was the use of a vascularized
rectal wall fl ap for reconstruction of the posterior urethra
[5] . The use of vascularized bowel to bridge missing segments
of visceral organs later culminated in the ileal
pouch used to replace the urinary bladder and the rectum.
The Future
During Dr. Erlik's long and exceptional carrier, medicine
underwent a dramatic change. At the beginning of
his carrier, medicine was humane though far from being
scientifi c. In the last years of his activity, he often bitterly
complained that the patient had become 'a number',
that a disease is been treated, not a sick person. In one of
his last publications, Dr. Erlik also mused on the confl ict
between the scientifi c truth and the charitable approach
to the sick human being [6] . It was his hope that medical
schools will fi nd the necessary time in the overloaded curriculum
to teach future physicians the required humane
approach to patients, and more important, fi nd the teachers
capable of imparting such education. He wished that
the pendulum of medicine come back to a middle path
and returns to be humane and not only scientifi c.
Dr. Erlik's substantially contributed to the understanding
and surgical treatment of portal hypertension.
In addition, he was a precursor in the use of bowel segments
for the reconstruction of other organs. His place in
surgical history is that of an innovator, an outstanding
surgeon, and an exceptional personality. His legacy is the
example he set to all those that knew him: excellence, humanity
and humility.
References
1 Erlik D: History of Rambam Hospital and its
contributions. Harefuah 1989; 117: 165–167.
2 Erlik D, Schramek A, Brandstaetter S, Basan
H: Surgical cure of primary hepatic vein occlusion
syndrome by side-to-side portocaval
shunt. Surg Gynecol Obstet 1962; 114: 368–
374.
3 Erlik D, Barzilai A, Schramek A: Porto-renal
shunt: A new technic for porto-systemic anastomosis
in portal hypertension. Ann Surg
1964; 159: 72–78.
4 Erlik D, Barzilai A, Schramek A: Renal function
after left renal vein ligation. J Urol 1965;
93: 540–544.
5 Erlik D: Use of rectal wall fl ap for reconstruction
of posterior urethra. J Urol 1958; 80: 40–
42.
6 Erlik D: A charitable approach to medicine.
Harefuah 1984; 107: 98–99.
Editorial Comment
Moshe Schein
Koekuk, Iowa, USA
In this issue of the 'historical section' of Digestive Surgery,
Prof. Moshe Hashmonai of Haifa, Israel, describes
the eventful life of one of the founders of modern surgery
in what was Palestine and today is Israel.
Prof. Hashmonai is a graduate of the Hadassah-Hebrew
University Medical School in Jerusalem. He is an
emeritus Director of Surgery at the Rambam University
Medical Center in Haifa and a Professor of Surgery at the
Faculty of Medicine, Technion – Israel Institute of Technology,
Haifa.
In 2000, Digestive Surgery launched this historical section
with the aim of letting colleagues introduce us to
'modern surgical giants'. In an opening statement [Dig
Surg 2000;17(3):315] we wrote:
Defi ning and selecting a 'surgical giant' defi es any scientifi c
criteria
and is controversial. The person who for some represents a 'giant'
may signify a 'monster' to others. Should a surgeon's stature
be judged based on his remarkable scientifi c contributions, his
legendary
operative virtuosity, or the number of times his name appeared
on books, covers, chapters, and international meeting programs?
Another dilemma we were confronted with is whether to
concentrate on the 'professional side' of the 'giant' or – instead
– on
the human factor which hides within or behind the 'giant'. We decided
to combine it all and bring into the fore past colleagues who
rose above their peers in reputation, accomplishment, character,
and knowledge. Those who served as a role model that others 'look
up to'. But mainly those who remain remembered long after leaving
this world.
Hitherto, this section dealt with Drs. Sony Du Plessis,
Theodore Kocher, Oven Wangensteen, Ivor Lewis, Jan
Mikulicz-Radecki, Allan Whipple, Aladár Petz, George
L. Jordan and Edward Delos Churchill.
We invite raeders to submit their contribution to this
section.from this modest beginning, Dr. Erlik lived to become. one of
the pillars of surgery in modern Israel. The Biography. David Erlik