The London bus route 38 has been running since 1912. It passes Piccadilly Circus, the major museums and Buckingham Palace until it finally says “get off everyone” at the world-famous Victoria Station. Most of the spontaneous stops on the tour, which currently – depending on the time of day – last between three quarters and a good hour, are unpopular, after all, the metropolis is chronically plagued by traffic jams. But a more unusual unscheduled stop by a red double-decker can be traced back to a (forgivable) intention: a good four decades ago, its driver parked the bus directly in front of Shaftesbury Hospital, about a ten-minute walk south of the British Museum, and entered.
It wasn’t an emergency – on the contrary. The man had come because he had been made healthy here: he wanted to thank the doctors. A full eight days after he was freed from the torment of his kidney stone in Shaftesbury, the driver was back behind the wheel of his double-decker. This was due, among others, or rather above all, to John Wickham (1927–2017), a professor of urology and a great innovator with rebellious instincts, in whose memoirs the bus episode found its way.
Wickham is the man who gave the world one of those few medical terms that almost everyone understands: “minimally invasive.” He coined it in 1986, and in 1989 he coined the term “minimally invasive surgery”. Wickham also founded the first medical society specifically focused on this. He worked intensively with like-minded people in the USA, France and, last but not least, Germany. From there, Wickham soon imported the first British lithotripter to London – the shock wave machine from the manufacturer Dornier, which has its roots in aircraft construction, with which stones like the bus driver’s can be smashed from outside the body without any cuts. The principle of the stone crusher was derived in Bavaria, among other things, from wing studies on the Starfighter, supported with funds from the Federal Ministry of Defense: a clever technology transfer.
In that golden era of medical technological progress, this new therapy also entered medicine – like many others. In 1983, for example, the first commercial magnetic resonance imaging scanner went into operation in Missouri, USA, a Siemens Magnetom, whose prototype had already scanned 800 patients free of X-ray exposure at the Hanover Medical School. And the list could be extended further to include ultrasound and positron emission tomography, super-fast computer tomography (CT) for emergency rooms and much more.
One of the most groundbreaking turning points in the history of surgical medicine was the philosophy of minimally invasive surgery itself. However, Wickham and his international collaboration circle did not just make friends with it. Their new methods ultimately not only questioned the traditional, technically demanding surgical procedures, but also their primacy in everything that can be surgically healed in the human body. In England, the resulting conflict of interest was particularly noticeable – in British medicine, the deep division of the profession into “Physicians” (the doctors) and “Surgeons” (the surgeons, in earlier times also “surgeons”), which had long been forgotten in Germany, was particularly noticeable. called) remained untouched: surgeons and non-invasive doctors each maintained their own – of course elite – royal college in upscale London locations, each with their own sense of class and claim to interpretation.
For the eloquent polemicist Wickham, the surgeons of his day portrayed themselves as people who cut holes in people into which one could stick one’s head in order to be able to have a good look around while doing things (for example on the kidney). According to Wickham, this would then cause weeks of recovery time, trigger complications and block hospital beds.
Certainly: every significant innovation brings redistributions. And with every redistribution, some people have a lot to lose. That explains the sharp tone of those days – which is completely normal when there are upheavals in medicine. The surgeons had also achieved their own emancipation from the subordinate craft with the slight smell of field hospitals in the previous century thanks to groundbreaking innovations against all resistance: sterile surgery defeated the wound infections that had long been supposedly unavoidable and overcame the high mortality rate in many procedures. And the anesthesia made it bearable and thus freed patients from the stigma of being the drug of last choice.
Cycles of replacing the tried and tested with the new have repeated themselves throughout the history of medicine. Antibiotics and hygiene replaced the high-altitude clinics for lung sufferers, and the cardiac catheter replaced the majority of open procedures in the chest. And this was practically always associated with the rise of new pioneering disciplines in clinics and practices. One of the most recent such emancipation stories of medical disciplines was radiology, whose enormous rise also began in the Wickham era and continues to this day. It was often a rise in the truest sense of the word: in many hospitals in the industrialized world, the X-ray doctors actually worked in the deep catacombs of the time-honored buildings, in which the interior and surgical departments occupied the best corridors. The only partially joking cliché image of the examining specialist among colleagues is reflected in the typical doctor’s joke about the extent of the (supposedly complete) doctor-patient conversation during the appointment: “Take a deep breath. Hold your breath… and… breathe out.” The core competence of the subject was reduced to a kind of advanced photography including the ability to interpret images well. None of this has anything in common with the reality of our day.
And this changed reality is also the reason why you will find a new list of doctors in this issue: the subject of “Interventional Radiology” has been added. It has created a synthesis of minimally invasive surgery and state-of-the-art two- and three-dimensional imaging – its specialists are able to navigate tiny instruments throughout the entire body. They control their actions from outside, thanks, among other things, to computer tomography. Predecessors from related disciplines had to introduce sophisticated microcamera systems into the body.
Philipp Paprottka, professor at the Technical University of Munich, is one of the leading representatives of the subject. In the current election period he is also the head of its specialist society, the German Society for Interventional Radiology (DeGIR). Like many doctors, he says, he was struck by a surprising love for his final professional focus – Paprottka originally wanted to become a trauma surgeon. A subject that is as demanding as it is dramatic, requiring quick decisions, targeted action and a keen eye. However, he now knows that interventional radiology has the right tools in its arsenal, even for a variety of serious injuries. “Take the pelvic fracture, for example. Arterial bleeding there is often life-threatening, but the blood vessels are complicated and individually branched. They need good orientation in order to stop the bleeding. And it has to happen quickly.” Not just because of the rapid blood loss, which can be temporarily compensated for with transfusions. But every additional blood dose worsens the prognosis. In order to be able to visualize the arterial branches using contrast medium and to gain an overview of the entire field of a life-saving procedure, Paprottka and his team recently built a large-scale project at the University Hospital of the Technical University of Munich. They now have a hybrid room in which they combine the angiographic representation of the vessels and the three-dimensional imaging with the computer tomograph, supported by algorithms that make such an overall view possible. This can sometimes stop bleeding in record time: emergencies have long been an important area of work in interventional radiology.
But just one from a very wide range, says Philipp Paprottka: “Many people know, for example, that we are able to open closed vessels in a minimally invasive way.” On the leg, for example, they can be kept stably open with a stent, similar to what cardiologists have long been doing with catheters on coronary arteries. But it can also be done much more subtly, for example in the field of neuroradiology. Aneurysms, bulges in cerebral arteries, can be filled with tiny metal meshes called “coils” – the risk of a sudden cerebral hemorrhage due to rupture is averted. Treatment with a catheter guided from the groin is also an option for many acute strokes: interventional radiologists or neuroradiologists can specifically remove the clot that is robbing a region of the brain of blood flow.
One of the very general and common advantages of minimally invasive work under imaging control is that it generally does not require general anesthesia – this is particularly important for older patients because they are significantly more stressed by the anesthesia. “What is much less known, for example, is that interventional radiology has long been a further and essential pillar of tumor treatment,” says the professor. “We can now destroy a three-centimeter tumor through a three-millimeter-long incision, often in such a way that it cannot returns.” And at least gain lifespan in cases that are no longer considered treatable in some places. He hopes, says Paprottka, that knowledge about the possibilities of his field will spread quickly among patients. From the beginning of minimally invasive medicine, the well-informed among them have proven time and again to be important allies of the innovators: They specifically looked for gentler and – as Philipp Paprottka puts it – quite “elegant” methods.
Almost half a century after the courtesy visit of the cured London bus driver, many paths for progress are still open: Medical robotics is developing further – John Wickham, the great pioneer, had already co-developed an automated surgical machine, but the time was not yet ripe for this machine at the time . AI and telemedicine will certainly open up completely new perspectives for heavily computer-based disciplines such as interventional radiology to heal people outside of the metropolises of wealthy countries. And, as was the case then, at the end of the next leaps forward there should be a fruitful division of labor between the different “flavors” of medicine, as we already know today from the close integration of cardiac surgery and cardiology in the heart centers or from the interdisciplinary tumor conferences.
And finally, it’s not just a virtue of the bus drivers to say thank you: Our research institute Munich Inquire Media (MINQ) was able to cooperate closely with the specialist society DeGIR, led by Philipp Paprottka, for the research of the newly added “Interventional Radiology” list. As Minq editorial director Mirjam Bauer reports, this resulted in a very high response rate when answering the associated doctor survey in this subject (see the presentation of the methodology on the following pages). Many doctors were also personally available to our team as interview partners.
