Those Magnificent Men in Their Flying Machines

The smooth American played by the great Stuart Whitman, the deliciously evil English upper-class Sir Percy Ware-Armitage played by Terry Thomas (inspiring Hanna-Barbera’s character Dick Dastardly, from Wacky Races), and Gert Frobe, Auric Goldfinger in the 007 movie, absolutely magnificent. If you have not seen it, search your streaming provider and enjoy! The film opens with documentary footage of the early days of flying when most aircraft, well, didn’t, and a sweet cameo by Red Skelton.

Mankind’s desire to fly was grand, but initially ill-conceived or poorly executed; what would those early engineers and pilots make of modern aircraft? I recently watched the film yet again and it inspired me to think about medical innovations, the good, the bad, and the ugly, with strains of Ennio Morricone playing in the background.

Why do medics seek to invent? Simply put, belief that they have a great idea and aspiring to improve patient care. We know from Edison the journey from mind to marketplace is not straightforward; when asked about his failure to create an incandescent lightbulb he famously responded, “I have not failed. I’ve just found 10,000 ways that won’t work.” Nelson Mandela contributed a useful perspective: “I never lose, I either win or I learn.” Well, medical progress is peppered by developments that have lasted the course, others that have matured with time, and some that have thankfully been consigned to the scrap heap! Perhaps knowing about this might inform your choice of medical treatment just as it might guide your choice of aerial technology—GPS or NDB?

It is important to distinguish invention from innovation. The former is the first iteration of a new product or service; the latter, implementation, deployment, or improvement of current solutions. For instance, invention was the first airplane, the first jet, the first radar—most of what we see is innovation, building upon what has gone before. While invention is the basis for paradigm shifts in medicine, innovation dominates in sheer numbers of new drugs, devices, or techniques. In the pharmaceutical world invention would be a new class of drug, never seen before, while innovation might be enteric coated aspirin, for instance, taking an established drug and adding a coating to limit unpleasant gastrointestinal side effects.

My first meeting with a very talented chap, Paul Fearis, schooled me in how innovation best occurs in an era where bringing medical inventions or innovations to market is fraught with barriers and costs a fortune: 

“The process begins with Voice of Customer; i.e., ‘What do people actually NEED?’ This is followed by invention (to meet those needs) and then execution; confident in the knowledge that the underlying demand is real. This approach moves all of the risk to the front end and all of the costs to the back end, a far more prudent approach when budgets are limited and the cost to execute is at an all-time high due to numerous factors ranging from the cost of resources to regulatory burden. It also enables a team to iterate between invention and VoC as necessary in order to build confidence in an execution strategy and investment.”

So, what are some of the medical developments that did make it, those that failed and those that are thankfully forgotten? 

The Good

1. Surgery is art and science, removing errant body bits, and only errant bits, and reconstructing the remainder to preserve function. Getting inside the body to achieve this is the painful part. So why not find ways to make the holes tiny? Laparoscopy, or “keyhole surgery,” achieved that, leading to many new ways to treat multiple diseases. 
2. The word robot was coined by Czech playwright Karel Čapek in his play Rossum’s Universal Robots, describing a Utopian world where machines did mundane work. I was fortunate to assist a brilliant engineer, Dr. Yulun Wang, develop the first operating room robot, a technology initially designed to target terrestrial missiles from an orbiting platform. Surgical robots add precision that even the most skilled surgeon cannot achieve. 
3. Drs. Barry Marshall and Robin Warren believed that stomach inflammation and ulcers were not caused by stress, but by bacteria, Helicobacter pylori. Proving this included Dr. Marshall infecting himself and developing the disease, fundamentally changing ulcer treatment from surgery to medical therapy, winning the Nobel Prize in medicine in 2005. 
4. Dr. William Halsted was a genius whose contributions at Johns Hopkins shaped surgery. One innovation used cocaine for local anesthesia, based on the work of Sigmund Freud and others. To refine injection techniques for painless dental extraction, and like the aforementioned Dr. Marhsall, Halsted practiced on himself, becoming an addict in the process. Not so painless! Gerald Imber’s brilliant book, Genius on the Edge, about the good doctor is a fascinating read. 
5. As our understanding of the human body grows, so does our ability to develop clever medicines. A new class of drugs, the GLP 1 agonists (glucagon-like peptides), has revolutionized the treatment of diabetes and obesity and may have other positive health benefits.

The Bad

These are sound ideas, but did not achieve their stated goals or had unpleasant side effects, and I have chosen three to treat the global obesity epidemic.

1. Given that a sense of fullness suppresses hunger, doctors suggested inserting expandable balloons into the stomach, creating satiety. The long-term results are disappointing. Nice idea though!
2. The obesity epidemic is driven by high-fat, high-sugar fast foods. So why not prescribe drugs that impede fat absorption? Good thinking, apart from the bloating, perpetual flatus, and steatorrhea, a fancy way of telling patients they will produce foul-smelling, sticky, oily stool that floats and belligerently refuses to be flushed!
3. Fen-phen (Fenfluramin-Phentermine) was two drugs combined, one to suppress appetite, another a stimulant. It was wildly popular, and successful…until it was not! Reports arose of deaths due to heart valve or lung circulation problems; the medication was withdrawn and a $13 billion lawsuit followed. Many people lost excess weight though.

The Ugly

These not only provide no benefit, but are positively harmful, begging the question, “What are we doing now that future generations will sneer at us for?”

1. Patients used to be confined to bed for extended periods after heart attacks, illness or surgery. This effectively killed many from blood clots in their legs that traveled to the lungs, infected bed sores, and caused pneumonia. Nowadays we kick people out of bed within hours of operations, and out of the hospital as soon as possible.

2.Bleeding was a panacea, using leeches or incising veins; sadly, few benefited as blood loss is bad, and leech bites became infected or spread disease, and leeches are used sparingly today (e.g., for tissue grafts). After he suffered a seizure, King Charles II’s doctors applied tortures including repeatedly bleeding him, inserting enemas, burning him then lancing the resultant blisters, shoving irritants up his nose to induce sneezing to expel the “poison,” and feeding him crushed human skull and goat gallstones! In History of the World Part 1, Mel Brooks said, “It’s good to be the King!” Maybe not!

3. To address morbid obesity, doctors used to bypass the small bowel (not the same as modern gastric bypass). The operation achieved its goal, but sometimes people lost all their weight by inconveniently dying from complex malnutrition syndromes.

4.In 1937, Elixir Sulfanilamide, an antibiotic mixture, was sold in America; it contained diethylene glycol (DEG). This chemical is used, among other things, in brake fluid, and although an associated compound, ethylene glycol (antifreeze!) is used to clean the bowel prior to colonoscopy, in its elixir form, it killed more than one hundred patients being treated for infections like gonorrhea or strep throat. This scandal gave powers to control medications to FDA, and the chemist responsible, Howard Watkins, died by suicide while awaiting trial.

5. The concept of putting an ice pick or kitchen knife up someone’s nose and twisting it into the brain sounds horrific, but it was utilized to treat various “mental disorders,” and in fact, the inventor, Dr. António Egas Moniz, won the Nobel Prize for developing lobotomy. 

Dr. Samuel Coult (plain old Samuel Colt to you and me) made a fortune promoting laughing gas (nitrous oxide). Then a mere entertainment, it became an important anesthetic and analgesic. Colt later invented the revolver inspired by a ship’s wheel; one might say what goes around comes around!

Fly well!

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