We do not know what might have happened if E. Saling had not done his revolutionary research in the beginning of the sixties. He taught us to look into the black box womb and to surrender ideological walls. The fetus and the newborn were drawn out of the fatalistic dark of the past; diagnostic and therapeutic measures came into reach, and E. Saling was the programmatic obstetrician for all of us, especially with his book, The Child in Obstetrics.
K Vetter, 1998, p.3.1
This quotation is taken from the first chapter of the Textbook of Perinatal Medicine,2 which was dedicated to Erich Saling (Figure 1) – the father of perinatal medicine. The following questions should be asked:
Why has this huge two-volume textbook, elaborated by so many worldwide outstanding perinatologists, been dedicated to Erich Saling?
Why has the 10th World Congress of Perinatal Medicine (held in November 2011 in Uruguay) been dedicated in honour to Erich Saling, Professor Kazuo Maeda and Professor Roberto Caldeyro-Barcia?
Why has the World Association of Perinatal Medicine named the perinatal prize after Erich Saling?
To answer these questions, the history of perinatal medicine has to be considered, which is inseparably interwoven with the lifework of Erich Saling. The obstetric views and opinions of the time when Erich Saling and other pioneers of perinatal medicine began their work are today, for the younger generation of physicians, hardly to be comprehended – to look after the welfare of the infant was only possible after birth. Many methods that we use today in routine pregnancy care, such as sonography, had not yet been developed. Apart from auscultation of the fetal heart tones, there was no method that would have allowed us to deduce the state of the infant before and during birth. (The first pioneering works for the registration of the fetal heart sound had already been made with a sphygmograph in 1890 by Pestalozzi3 and, in 1906, Cremer4 recorded the first fetal electrocardiogram. In the 1950s, Edward Hon5 and Roberto Caldeyro-Barcia6 started to work in this field, but cardiotocography was not available for routine clinical use until the end of the 1960s.) Inspection of the amniotic fluid via the cervix (amnioscopy) was not known. The puncture of the amnion sac (amniocentesis) was performed only as an emergency measure in cases of extreme hydramnios and, from the 1950s onwards, for diagnosing Rh fetal erythroblastosis.7 In 1948, amniocentesis for the measurement of intrauterine pressure was published by H Alvarez and R Caldeyro-Barcia;8 however, this was fundamental research. Direct manipulation of the unborn infant was, in most countries, completely unthinkable and would even have been considered taboo.
Nevertheless, in 1960 (first published in 1961) Erich Saling, as a young assistant, performed the first fetal blood analysis.9–12 With this method, a tiny incision was made in the scalp of the unborn child in order to sample fetal blood. The first examinations were made, in cases of fetal erythroblastosis, for serological and haematological examination. Shortly afterwards, Erich Saling started examining fetal acid–base balance and blood gas analysis, and these examinations fundamentally changed the character of the supervision of the fetus, for example, the consequences for termination of labour under the aspect of fetal indication. This method represented the first direct approach to the human fetus that could be already used for routine clinical practice; this can be regarded as the moment of the birth of prenatal/perinatal medicine. In 1961 (first published in 1962) Erich Saling performed the first amnioscopy.13 The significance of these two new methods to gain access to the unborn infant for applied medicine for the first time was appreciated in 1966 by the British pediatricians, R H Dobbs and D Gairdner (p. 453) as follows: ‘With the advent of the techniques of amnioscopy and foetal blood sampling by Saling, and of amniocentesis and foetal transfusion due to Bevis and Liley, we witness the end of the long period of foetal inaccessibility and, we hopefully believe, the start of the science of foetal medicine’.14
During his career as physician and scientist, Erich Saling made several other important contributions, most of them aiming to reduce the infant mortality and morbidity rates and the number of preterm births. However, this was only part of his life work. In addition, he also played an important role in the development of perinatal medicine (see below); indeed, the term ‘perinatal medicine’ was introduced by Erich Saling in 196715 and has become widespread all over the world. He can, rightly, be regarded as a living legend of perinatal medicine (as Frank Chervenak, President of the World Association of Perinatal Medicine, recently called him). But who is this living legend?
Prof. Dr. med. Dr. h.c. mult. Erich Saling, obstetrician and perinatologist, was born in Stanislau (now the Ukraine) on 21 July 1925. The following information was extracted from the website of the Institute of Perinatal Medicine.16
He studied medicine from 1946 to 1952 at the University of Jena (Germany) and at the Free University of Berlin; from 1954 to 1958 he completed his training in obstetrics and gynecology at the Women's Hospital in Berlin-Neukölln. He qualified as a University Lecturer in 1963 and was offered a Professorship at the Free University of Berlin in 1968. In 1976 he became the Director of the Institute of Perinatal Medicine of the Free University Berlin and the Head of the Department of Obstetrics in the Women's Hospital Berlin-Neukölln. In addition to his clinical practice he has been engaged in research in the field of obstetrics and perinatal medicine since 1958.
In 1963 Saling started one-week introductory courses for physicians in modern obstetrics and perinatal medicine.
Erich Saling founded, from 1967 onwards, the first national and international societies of perinatal medicine and organized the first national and international congresses in this field (see below).
Since January 1991 he is ‘Professor Emeritus’ at the Charité, University of Medicine Berlin. In continuation of research activities in 1993 he founded the Institute of Perinatal Medicine under private law at his old department in Berlin-Neukölln and is its director.
In May 2005 Prof. Saling was elected as President of the newly founded International Academy of Perinatal Medicine, and in October 2010 he was re-elected for a further 5 years.
Erich Saling as a scientist
Erich Saling has been a practising obstetrician as well as a scientist. He has done fundamental research now and then, but in research, his main focus was on the practical side, i.e. on issues that could be directly applied to routine care. Erich Saling was, and is, unbelievably creative in his ideas to improve the care of mother and child. To date, more than 600 of his publications have been on the subject of obstetrics and perinatal medicine (plus many ideas and even some methods that have been used but have never been published because of the lack of time).
His most important studies are compiled on www.saling-institute.org in a list of his special scientific achievements and new developments.17 For the purpose of this review, we have asked Erich Saling to choose, from his point of view, the 10 most outstanding achievements and new developments, and these are detailed below.
The progress was for blood infusion via the umbilical vein system. For the exfusion the umbilical artery and aorta could be used simultaneously. This technique is much more gentle than the conventional technique of using only one catheter in the umbilical vein system with an alternating in- and exfusion.
First blood gas analysis from central circulation to determine the effectiveness of resuscitation methods in the newborn20
After catheterization of the aorta descendens via umbilical vessels, blood samples were taken and analysed. This made it possible to examine which methods were the most effective during the resuscitation process.
Development of amnioscopy – a method for examining amniotic fluid with the membranes still intact11–13
Amnioscopy is a method to find out which fetuses, in late pregnancy, are for the next 48 hours at low risk (clear amniotic fluid) and which are at higher risk (meconium-stained amniotic fluid). The latter need more intensive supervision.
Development of the concept of the so-called oxygen-conserving adaptation of the fetal circulation (by other authors later erroneously so-called ‘brain-sparing effect’)11,12,21,22
Describes a useful reaction of the fetal circulation in situations of decreased respiratory supply of the fetus from its mother.
Introduction of modern monitoring of the fetus during labour by the combined use of cardiotocogram and fetal blood analysis22
Explained enough by the title.
Introduction of a new method of external cephalic version in cases of breech presentation by relaxing the uterus with tocolytic substances (together with W Müller-Holve)23,24
In a considerable number of cases of breech presentation, external version facilitates the turning of the fetus into a cephalic position and, consequently, it often leads to a vaginal delivery. Thus, unnecessary operative interventions such as caesarean sections can be avoided.
The programme aims to detect risk factors of infections ascending from the genital tract, which are a main risk for premature birth. In addition to routine prenatal care and risk assessment, routine vaginal pH measurements were introduced, which allows detection of the precursors of vaginal infection.
Development of a project of a prenatal care–self-examination by the pregnant patient for the prevention of prematurity30,31
By inclusion of the pregnant patient into the Prematurity Prevention Programme in the form of self-measurement of the pregnant patient's vaginal pH, the vaginal milieu can be measured at short intervals (2–3 times a week). In this way, disturbances of the vaginal milieu can be detected very early – this was never possible before.
Erich Saling and the fetus as a new patient in literature
Up to the beginning of the 1960s, the mother had been the main focus for obstetricians, as the fetus was not accessible. However, with the development of the new perinatal medicine methods, developed by the pioneers of perinatal medicine, in addition to the established care of the mother, the fetus for the first time received significant attention and became a real patient. This can be proven by studying textbooks on obstetrics published up to the beginning of the 1960s, where there were only single pages of information published about the fetus.
But in 1966, Erich Saling published the first real book concentrating on the infant before and during labour:
Das Kind im Bereich der Geburtshilfe11 (translated title being The Infant Within the Field of Obstetrics). In 1968, the book was translated into English; unfortunately under the not quite correct title Foetal and Neonatal Hypoxia in Relation to Clinical Obstetric Practice.12 The significance of this book, for all now working in the field of perinatal medicine, has already been illustrated by the quotation of Klaus Vetter at the very start of this article.
In 1973, Erich Saling founded, in Berlin, the very first journal entitled Journal of Perinatal Medicine. Roberto Caldeyro-Barcia, Edward Hon and Stanley James (as a neonatologist) joined him as editors of the journal.32
Erich Saling and perinatal medicine as a new branch of medicine
Erich Saling has been a key driver in the development of perinatal medicine as a new branch of medicine. The very first national scientific society in co-operation with other disciplines – mainly neonatology – was founded by Erich Saling on 6 February 1967 and it was the German Society of Perinatal Medicine. This point in time can be considered as the official public birth of perinatal medicine.
In November of the same year, the first national congress was held in Berlin, Germany. One year later, in 1968, the first international congress took place in Berlin (First European Congress of Perinatal Medicine), both organized by Erich Saling and coworkers. Erich Saling was also involved in the organization of many scientific meetings later.
In 1968, the first international society, the European Association of Perinatal Medicine, was founded and Erich Saling was the founder president of this association. This step was the beginning of the official international public corporation of perinatal medicine.
Erich Saling and new clinical structures
Erich Saling was also a pioneer with regard to recommending reforms of clinical structures; with the shift of care for only the pregnant woman to care for mother and unborn child, the time for reforms of clinical structures was also overdue. In order to facilitate the concentration on mother and fetus, in 1967 for the first time Saling recommended establishing special units within women's departments.15 But his initiative was not accepted and was blocked by the conservative, older generation of colleagues in Germany, his own country. Five years later, in 1972, the first maternal–fetal units were established in the USA and many other countries followed.
Did Erich Saling ‘retire’?
Since January 1991, Erich Saling has been an emeritus professor, and on 21 July 2012 he celebrated his 87th birthday, but until now he has never ‘retired’. In a continuation of his research activities, in 1993, he founded the Institute of Perinatal Medicine under private law at his old department in Berlin-Neukölln and is the institute's director. While working in this institute, he developed the Self-Care Programme for pregnant women to prevent premature birth. (He regards this as one of his best achievements. So far its validity has only been tested by observational studies and time will tell if he is right – as he is so often.) Besides the scientific and public education activities, the institute's main current emphasis is the Supraregional Counselling Center for the Prevention of Prematurity, thus benefiting many expectant mothers. Let us also mention in this context that the non-profit institute relies mainly on funds and donations – and that Erich Saling himself is one of the most important financial supporters.
Even today he is still working on scientific research in perinatal medicine and is passing on his knowledge, for example at scientific congresses. One of the themes that was and still is the focus of his activities is the prevention of preterm birth. Another area of his work is the history of perinatal medicine. This is why, at the 10th World Congress of Perinatal Medicine (November 2011 in Uruguay), he was asked to give a keynote lecture on the history of perinatal medicine – who can better teach the younger generation about history than the father?