Clinical Nutrition (2003) Supplement 2: S7–S8r 2003 ESPEN. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S0261-5614(03)00145-6

The birth of ESPEN

E.VINNARS

Krolinska Institute, Stockholm, Sweden

Complete parenteral or intravenous nutrition is atherapeutic method that has been available for 50 years.The successful development of this mode of therapy, in amodern sense, was initiated in the late 1930s. However,the history of this field dates back more than 350 years.

In the beginning of the 20th century it was known thatdietary proteins were hydrolysed in the intestinal tract.It was than logical to investigate the effect of IVadministration of amino acids and hydrolysates. Thetwo Danes, V. Henriques and A. C. Anderson, whoinfused a beef hydrolysate into a goat and achieved apositive nitrogen balance, reported the first successfulstudy in this field in 1913.

However, in the early days, most intravenous infu-sions of electrolytes and glucose were followed by febrilereactions, which sometimes were quite alarming. Thesereactions were believed by many to be unavoidablewhen infusions were given intravenously, but it was laterrealized that the reactions originated from contamina-tion with certain organic substances, termed pyrogens.These pyrogens had been discovered and described byFrancis Siebert in 1923. Later, it was shown thatpyrogens consist of endotoxins from bacteria. Withoutthe knowledge of pyrogens, it would have beenimpossible to develop and produce infusion solutionsnot associated with febrile reactions.

Robert Elman published in 1937 the first successfulstudies on intravenous infusion of amino acids in theform of a fibrinogen hydrolysate in man, which was anindisputable landmark in the development of intrave-nous nutrition. Undoubtedly, Elman deserves to becalled the ‘father of intravenous nutrition’.

In Europe the first protein hydrolysate on the marketwas developed by A. Wretlind and was introduced 1944in Sweden. In contrast to Elman’s preparation whichwas hydrolysed by strong acids, Wretlind hydrolysedcasein enzymatically and then dialysed the product totake away large polypeptides. The protein hydrolysateshad the disadvantage that the amino acid pattern couldnot be changed. On the other side, they contained allamino acids necessary for protein synthesis. Afterwardsit has been shown that many of the small polypeptideswhich were included in the products contained a lot ofglutamine, and therefore the effect on the nitrogenbalance was very effective, and it took a long time before

crystalline amino acid solutions could be produced withsimilar biological effects.

The first to develop a nontoxic fat emulsion was theSwedish scientist A. Wretlind, who in 1961 introducedIntralipid together with O. Schuberth. After many yearsof trials and errors Wretlind found that an emulsionprepared from soybean oil and as emulsifier, egg yolkphospholipids, could be used as a safe emulsion.Afterwards other companies copied Intralipid.

In 1962 Arwid Wretlind presented a full programmefor TPN, including glucose, fat and amino acids, traceelements and vitamins. Also the use of a central venouscatheter was discussed. The symposium where theprogramme was presented was held in Kungalv andthe whole symposium was published in 1964 in ActaChirurgica Scandinavica.

Local symposia had been organized by differentcompanies to catch the interest among doctors. On amore regular base the International Union of NutritionSciences, had begun to organize one symposium onparenteral nutrition. At the 1966 International Congressof Nutrition in Hamburg however, a group of cliniciansdecided to form the International Society of ParenteralNutrition (ISPN) for discussion of the scientific workarising from the rapid development in Europe. Espe-cially in the beginning, the congresses were supported bythe companies Pfrimmer with Werner Fekl fromGermany and Vitrum with Arvid Wretlind fromSweden, two companies that do not exist today.Initially, ISPN was composed of Europeans only, butas interest in parenteral nutrition developed in the USAduring the late 1960s, the number of American membersincreased substantially. The ISPN held meetings duringthe ICN Congresses in Prague (1969), in Mexico City(1972), in Kyoto (1975) and finally in Rio de Janeiro(1978).

The foundation of the American Society of Parenteraland Enteral Nutrition (ASPEN) in 1977 changed theinternational scene. ASPEN quickly established a muchwider appeal for the many American clinical andparaclinical professions associated with the growingclinical interest in nutritional support, thereby providinga national focal point for the association and training ofmedical and non-medical personnel. This meant that theinterest and support from the USA and Canada for

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ISPN dropped dramatically. At the beginning twoGermans, Professor Berg and Professor Heller had beenthe presidents with Ray Meng as Secretary and myself asTreasurer from the Prague Congress. At the KyotoCongress it was suggested that the next president-electshould be an American. The choice was between J.Fisher and S. Dudrick and at the voting, Dudrick wasthe winner. After Rio de Janeiro meeting S. Dudrick wasthe official president and I was the next president-elect.We had to plan for the next meeting of ISPN in SanDiego, but ISPN from the American side was no longerviable and the meeting had to be cancelled. Conse-quently, we had to continue by ourselves from theEuropean side, but after some consideration came to theconclusion that without an active American support,ISPN could not survive. Further we found the aims ofISPN too narrowly defined and no longer sufficient forthe needs of those involved in clinical nutrition inEurope, and thereby ISPN was more or less dead.

A group of Scandinavians, including Oscar Schu-berth, Arvid Wretlind and myself from Sweden andHans Christian Boerresen from Norway attended thesecond ASPEN meeting in Houston in 1978 and we wereimpressed by its success. With ISPN no longer existing,there was a good case for creating an organization toprovide common ground for European scientists frommany disciplines involved in clinical nutrition withspecial regard for parenteral nutritional support. Boer-resen suggested that we should call the new organizationESPEN. A number of small annual meetings onnutritional support had already been held in Scandina-via, which provided a model on which to found aEuropean society. Shortly after the Swedish groupreturned from Houston, a British group including RonClark, Alan Shenkin, Simon Allison and Harry Leevisited Stockholm for an informal nutrition meeting.While travelling together in a bus to Linkoping, theBritish and Swedish groups discussed and supported aproposal for a new Society which would have a strongscientific base, differing somewhat from the style ofASPEN where, at that time, the educational programappeared to dominate. It could be said, therefore thatESPEN started in a Swedish bus.

Later that year, in Luxembourg, I discussed a newsociety with colleagues from West Germany and theNetherlands, including Professor Ahnefeldt and Wes-dorp, and they were equally enthusiastic.

It was therefore decided to organize an informalinternational meeting in Stockholm in September 1979.Letters of invitation were sent to as many keyindividuals as possible in every European country wherethere was an established interest in parenteral andenteral nutrition. Oscar Schuberth was asked to bepresident for the meeting. Schuberth was professor in

surgery in Stockholm and was the most experiencedclinician interested in clinical nutrition in Sweden, andthe one who worked very closely with Arvid Wretlind tointroduce Intralipid in the clinic. John Wahren, profes-sor in clinical physiology at Karolinska Institute, wasasked to be Treasurer. Wahren had a great experience inthe European Society of Diabetes, which was known tohave a very high scientific level and he was thereforeexpected to help us to keep the scientific standard in ournew society. I myself was working as OrganizingSecretary.

A group of Europeans from a number of countriesmet informally at the third Aspen Congress in Boston in1979 where we discussed the programme for theStockholm meeting later that year. Two eponymouslectures were established to honour the Europeancontributions to the field made by Sir David Cuthbert-son and Arvid Wretlind. Four industrial firms based inthe United Kingdom gave money for the first Cuthbert-son Lecture (given by John M. Kinney) and one Swedishfirm funded the first Wretlind Lecture (given by StanleyJ. Dudrick). Financial support was obtained from theCity Council of Stockholm and the Swedish Govern-ment. A number of large European industrial organiza-tions also provided money and, importantly, financialguarantees.

Although the 1979 Stockholm meeting, which wasformally opened by the King of Sweden, will alwaysbe regarded as the first ESPEN Congress, the Societywas not formally established until 1 year later. TheStockholm meeting, lasting 3 days, with one foreducation, attracted 700 participants from all overEurope and was judged a success in scientific andfinancial terms. At an informal General Assembly itwas agreed to set up the European Society of Parenteraland Enteral Nutrition for the study of metabolicproblems associated with acute disease and theirnutritional implication and management. The multi-disciplinary nature of the subjects was emphasized andwould be reflected in its membership. It was alsoproposed that there should be an official publicationor journal of the Society.

Doubt was expressed at the Stockholm meetingwhether there was sufficient need for yearly meetings,but the majority view was inclined to follow the ASPENexample with an annual congress. Ivan Johnston offeredto organize the next meeting in Newcastle as Presidentwith Peter Wright as Secretary. A group of three, ErikVinnars, Ron Clark and Ad Grunert was commissionedto write a constitution for the Society to be presented tothe Newcastle meeting after which the Society would bean official Scientific Society.

The rest is history, which has been published by RonClark and myself in Clinical Nutrition, 1994.

ARTICLE IN PRESSS8 THE BIRTH OF ESPEN