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Slave system
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The folk, empiric medicine had considerably developed in that epoch. The so-called temple medicine appeared. “Medical schools” were created for teaching the art of medicine at temples. Such schools were in Egypt, Babylon, India, and Greece. Temple medicine was closely connected with religion explaining the origin of illnesses by “anger of gods. ” Hence the main feature of medical treatment was confession and a priest was a mediator between the deity and man.
Medical knowledge primarily was acquired in the family and consisted mainly in memorizing the symptoms of illness and ability to make medications. The knowledge was handed down, thus the first domestic medical schools were created.
On a background of common development of human society, development of medicine and other sciences, obstetrics developed as well. As a rule, help during labor to women giving birth was rendered by experienced women.
It should be marked that in Egypt doctors knew some female illnesses, such as wrong menstruations, prolapsed walls of vagina, falling of uterus. In India obstetric knowledge was extensive. Indian doctors were the first in the world who tried to study obstetrics as a science and offered some rational methods of help in childbirth.
So, Shushruta (one of the compilers of “Ayurveda”) was the first to mention about wrong positions of the fetus, he recommended to produce a version, bringing down the head or the leg into the pelvic inlet. He was also the first to suggest the destructive operations on the fetus.
In ancient Greece temple medicine was not so developed and influential, as in the slave-owning states of Ancient East. Medical schools of Greece were aimed at extending the sphere of their activity, they were not family schools. Famous Hippocrates was a follower of such school on the island of Kos. The Greek doctors already knew some surgical methods of delivery, in particular they were aware of caesarian section which was performed only on a dying woman.
Those were women who rendered help at birth in ancient Greece, they were called “cutters of umbilical cords” (omphalotomoi). At difficult birth the male doctors were called for help. In ancient Greece they were able to terminate pregnancy at early terms; this operation was also made by women (omphalotomoi). The first grounded knowledge appeared that time. Thus, for example, Greek omphalotomoi determined the presence of pregnancy by absence of menses, change of appetite, salivation, vomiting, nausea, appearance of dark patches on face.
The doctors of Greece also performed such operations as embryotomy, scraping out (curettage) the cervix uteri, sounding the uterus.
In ancient Rome help at labor to a woman giving birth was also provided by women, a doctor was invited in pathological cases. Especially famous in Ancient Rome were Filumen and Celsus.
Filumen was the first to state that the reason of female infertility could be overgrowing of vagina and uterus. He tried to remove this reason by an operative way, using vaginal specula at that. Filumen was the first to make dissection of abscess of Bartholin’s glands, removal of mammary gland in case of its cancer. He suggested cauterization of bleeding tissues with burning hot iron on order to stop bleeding. Filumen was the first who tried to turn the fetal presentation from cephalic to breech in difficult cases of birth at head presentations, with subsequent extraction of the fetus by the leg.
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Aulus Cornelius Celsus offered the methods of extraction of the dead fetus from the uterine cavity; he described the manual selection of afterbirth.
Soran Efessky, Greek by birth, lived in Rome in the I century A. D. He was engaged in anatomy, surgery and especially obstetrics. Soran studied the anatomy of female reproductive organs; he was the first to determine the position of uterus — between the bladder and rectum. He described the anatomic structure of uterus, ovaries and uterine tubes.
Soran was the first to give a correct description of the intrauterine nutrition of fetus; he determined the presence of fetal (amniotic) membranes and placenta, which he described in detail.
The Feudal System
In the epoch of feudalism under the influence of church and scholasticism, medicine, especially obstetrics, developed poorly. However, in spite of hindering influence of religion, the study of nature and medicine proceeded. Thus, the Armenian doctor Anany Shirakatsi was the first to suggest auscultation of the fetal heart sounds.
Salerno town had one of the famous medical schools of a secular character. Defence of perineum in delivery, symphysiotomy at a narrow pelvis and some other difficulties in childbirth were known to doctors of that school.
Period of Capitalism
The period of capitalism origin (the epoch of Renaissance) was characterized by a rapid development of sciences, including medicine. The anatomic researches by G. Fallopio, A. Vesalius (Fig1), B. Eustachio, L. Botallo refer to this period. The French surgeon and accoucheur Ambroise Pare contributed much to the development of obstetrics of this period. A. Pare introduced into practice the forgotten method of version of fetus on a leg and improved it. He was the first to found a midwife school at Parisian hospital, from which a lot of famous obstetricians graduated.
Fig 1. The female pelvic anatomy. From Vesalius's De Corporis Humani Fabrica, 1543.
The XVII — XVIII centuries were characterized by further development of medical science and practice. The Fransua Moriso’s works are known, who published a treatise about illnesses of expectant mothers, refuted the opinion about considerable separation of symphysis pubis in delivery, about greater viability of 7- than 8-month children. He assumed the possibility of spontaneous delivery of fetus in breech presentation and offered the method of extraction of subsequent head.
The invention of the first obstetric forceps refers to the same period of time (Chemberlen, Palfin). The fundamental works by Deventer in anatomy of female pelvis appeared in the XVIII century in which he in detail described pelvis justo minor and flat pelvis, frequent forms of contracted pelvis. Jan-Joan Lewie Bodelok, French obstetrician, offered measuring the external size of pelvis which is used up to now.
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The opening of maternity hospitals in a number of cities (Strasbourg, Berlin, Petersburg, and Paris) was of great significance. However, gathering of certain number of pregnant women and parturients on the same territory resulted in so-called “maternity fever”. A high death rate from “maternity fever” compelled to study the nature of inflammatory diseases in a postpartum period, to search methods of its prophylaxis and treatment. An idea of asepsis, antisepsis, microbiology appeared that promoted the occurrence of scientifically grounded concepts of inflammation nature, puerperal septic diseases, sepsis, their prophylaxis. The development of these questions was instrumental in the improvement of operative technique, improved the results of abdominal obstetric operations (the cesarean section); contributed to decrease of maternal and perinatal morbidity and death rate.
One of the most famous practitioners of the 18th century was Nestor Maksimovich-Ambodik (1744-1812). Doctor Maksimovich-Ambodik was a widely educated encyclopedist scientist, the author of the first major original Russian work on obstetrics (in 6 parts). He taught the pupils not only theoretically and on a phantom, but also in the clinic, for the first time in St. Petersburg. He was the first in Russia, who applied obstetrical forceps on the ferus head in labor.
A major contribution to the development of Russian obstetrics in the XIX century was made by A. Ya. Klassovsky. I. P. Lazarevich, N. N. Phenomenov. Great contribution to the development of obstetrics in the XIX century was made by professor of Kharkov University Ivan Pavlovich Lazarevich. The researches on the nervous adjusting of the uterus, anaesthetizing births belong to him. Lazarevich suggested a new modification of obstetric forceps, which made his name well-known in Europe. I. P. Lazarevich founded the midwife institute in Kharkov, in which many midwives were trained.
N. N. Phenomenov (1855-1918) – a professor at the Kazan University. He was one of the first in Russia to introduce an aseptic method of surgery, suggested several original surgical operations (kleidotomy, pelvioplasty), invented and perfected a number of obstetric instruments (obstetrical forceps of Simpson-Phenomenov, perforator and scissors for embryotomy). NN Phenomenon wrote a well-known textbook " Operative Obstetrics. "
AP Gubarev, NI Pobedinskiy, M. S. Malinovsky, KN Zhmakin made a significant contribution to the development of obstetrics in our country.
Deontology in Obstetrics
The life and work of physician present one of the widest and deepest forms of human activity. A. P. Chekhov wrote, “Profession of a doctor is an exploit. It requires self-affirmation, purity of soul and purity of thoughts. One should be mentally clear, morally clean and physically neat”.
А doctor should be able to establish the relationship with patients in such a way as to bring them the maximal use. Attention and care of the doctor should be aimed at maximal elimination of harmful consequences of illness both of a somatic and psychical aspect.
It is common knowledge that doctor’s word has a great effect not only on mentality of patient, but on his psychical state as well. This feature should be taken into account by obstetrician-gynecologist from the first moment of his communication with a woman addressed him anywhere: in a maternity welfare clinic, at home treatment, in the hospital, especially during obstetrical examination.
Neat clothes and appearance of a doctor, strict following the rules of personal hygiene, the observance of cleanness of premises are the necessary conditions of a successful work of a doctor.
A doctor should be respectful, quiet, and confident in relations with patients. Uncertainty in diagnostics and expedience of the administered treatment are perceived negatively by patients.
It decreases efficiency of medical and prophylactic measures. In such cases the doctor should inform the patient about hypothetical diagnosis and explain the necessity of additional examinations and consultations with other specialists for the final decision about the character of disease. One should be careful in announcing the hypothetical diagnoses of severe diseases which treatment requires radical operations. Sometimes it can result in development of psychical trauma, which may lead to further dysfunctions in a female organism.
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The doctor should be able to make contact with any patient, to reveal individual characteristics of patient and her disease. Good knowledge, constantly refreshed and improved, the ability to clinical thinking, heartiness, love to people, aspiration to close contact with patients are the distinguishing features providing faith of the patient in her doctor and success of the administered treatment.
An obstetrician-gynaecologist should pay great attention to the features of anamnesis, which touch upon the secret sides of a woman’s private life. The specificity of obstetric examination which is often made in presence of several medical workers should be taken into consideration. It should also be remembered about the deontologic rules of informing the spouse about the state of sexual system of his wife or announcing the prognosis in regard to a menstrual or genital function in one or another disease and its consequences.
Childbirth is always an urgent situation, which is fraught with unexpected complications, threat to health and life of mother and fetus. Apart from necessary knowledge and practical skills, the doctor giving help at birth should be self-controlled, cool, be able to soberly estimate an obstetric situation and quickly carry out all the measures, including the operations directed at saving life and health of mother and child. The doubts at choice of manual procedures and surgical interventions should be unknown to the patient until the final decision is taken. The decision should be stated to her as an insistent recommendation; in an accessible form it is necessary to account for need and expedience of planned measures to her and child’s benefit.
Great attention, timely and correct carrying out the administered medical and prophylactic measures provide a parturient with confidence in a favourable outcome of birth, operation, and generally in a favourable course of puerperal period.
CHAPTER 1. THE FACTS FROM THE HISTORY OF IVF
In 2010, the Nobel Prize in Physiology or Medicine received a British scientist, embryologist Robert Edwards as the author of technology of in vitro fertilization (IVF)
(Photo № 6).
Photo № 6. Robert Edwards (1925-2010).
In 1968, he developed a method of obtaining oocytes from follicles during the laparoscopy, jointly with gynecologist Patrick Steptoe. He also improved media and conditions for gametes and embryos cultivation. 14th Feb 1969 R. Edwards with P. Steptoe announced of IVF technology at Cambridge University.
In 1978 an eight-cell embryo (day 3 embryo), obtained through in vitro fertilization, was implanted in Mrs. Brown’s body resulting in birth of Louise Brown, the first " test tube baby" on 25th July, 1978.
Since then, the era of fertility treatment by the method of assisted reproductive technologies began.
Robert Edwards was awarded the Albert Lasker Clinical Medical Research " for the development of in vitro fertilization, a technological advance that has revolutionized the treatment of human infertility" in 2001. He has established the European Society of Human Reproduction and Embryology (ESHRE).
On 4 October 2010, it was announced that R. Edwards had been awarded the Nobel Prize in Physiology and Medicine for the development of in-vitro fertilization (IVF). Patrick Steptoe was not awarded because of his death of cancer in 1988 (Nobel Prize, as is known, not be awarded posthumously).
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In the 1970s and 1980s in USSR four groups of scientists, independently of each other, conducted research on the fertilization of human eggs in vitro at the clinic.
B. V. Leonov, E. A. Kalinina - All-Union Research Centre for Maternal and Infant Health Care. 1975-1986 yrs. The first " test-tube baby" was born in the USSR.
V. I. Grishchenko, F. V. Dakhno - Institute for Problems of Cryobiology and Cryomedicine, Kharkov. 1982-1991 yrs. The first " test-tube baby" was born in Ukraine.
A. I. Nikitin, E. M. Kitaev – Institute of Midwifery and Gynecology n. a. D. O. Ott, St. Petersburg, 1971 – 1986 yrs. They conducted research on in-vitro fertilization and the second " test-tube baby" was born in the USSR.
V. M. Zdanovskiy, M. B. Anshina - The Second Moscow Lenin Order State Medical Institute n. a. N. I. Pirogov, Moscow, 1981-1989 yrs. The third " test-tube baby" was born in the USSR.
The experimental researches of the human ovum fertilization were started in the world in the 1940s:
1944 – Hamilton (USA) was experimenting on the human oocytes fertilization in vitro and given data on formation and the exiting of the polar bodies in pericellular space only.
1944 - Rock, Minkin (USA) - after a number of failed attempts (posted 800 experiments) they observed the development of human eggs outside the body to the stage of two blastomeres in three cases (the study was terminated due to the multiple failures).
This is how Prof. E. M. Kitaev (the first obstetrician-gynecologist in the USSR, who began to work on the practical application of IVF in the 70-ies in St. Petersburg) described the studies of the Americans in his memories: “The history of the development of the IVF program in Russia” in the journal “Problems of reproduction” in 2002: “…In the early 1940s gynecologists from Harvard Rock and Minkin were working in the USA for the fertilization of ova outside of the human body for four years. They even published the results of their research, but without being sure that got a true fertilization, they refused to continue useless, as they considered effort. The Americans returned to work in this field only in 1978”. (The American scientists continued their research only after the first IVF baby-girl; Louise Brown was born in England).
1951 – Chang (USA) started a development of the medias and conditions for gametes and embryos cultivation in vitro.
1953-1955 – Shettles (USA) observed the separation of the polar bodies after 10-20 hours of incubation. The later stages of fertilization and crushing of ova had not been obtained.
1966 – Edwards (UK) found that the maturation of female ova in vitro occurs within 36-37 hours after the LH peak.
Therefore, nobody in the world has been working on the fertilization of the ova outside the body (in vitro) from 1953 to 1966 yrs.
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