What is innovation?

H ow do we avoid falling in the water or how do we climb out after having fallen in? Knowledge, or innovation, or both. Presumably medical journals provide knowledge, although that may be questioned in the broader context of “what is knowledge?” This supplement is meant to feature innovation, although, by intention, there is some “knowledge” (or perhaps, alternatively described as “previous innovation”) worth describing, lest it be forgotten. What is innovation? Is it the initial concept? Is it the proof of concept? Is it the implementation? Is it the proof that something “new” is effective? Is it always possible to discover the origins of a concept? Most often is there a single origin of a concept, or is there a development trail, or perhaps parallel developments? The cover of this supplement was chosen for several reasons. First, the art itself. Beyond that, it highlights some interesting points. Pieter Bruegel the Elder’s engraving was executed in the same year (1568) as his famous painting of the same name, “The Blind Leading the Blind,” that hangs in the Naples Museo Nazionale di Capodimonte. Which came first? Which was the innovation? Artists of the 16th and 17th centuries sometimes used etchings as studies for paintings; at times, the reverse was true. Furthermore, both were preceded by 9 years (1559) by his painting, “Flemish Proverbs,” now in the Gem€ alde Galerie in Berlin, in which the smallest of figures in the farthest distance appear to be one blind person leading two others. Bruegel depicted a series of proverbs, and traditionally their origins have been attributed to the New Testament. However, Sullivan cites Erasmus, who noted at least in the case of this proverb, that its origin can be traced, as well, to Horace, who wrote one to perhaps two centuries earlier than period of the writing of the New Testament. The issue is further entangled, in that the New Testament was written in the version of Greek that was common at that time. Thus, it is possible that there are two distinct lines of innovative heritage operating. Some of the proverbs can also be traced to Hebrew roots. Thus, what may appear to be an innovative concept sometimes is not. The origin may be obscure and difficult to find. Only four impressions are known of the engraving on the cover (N. Orenstein, Curator Department of Drawings and Prints, The Metropolitan Museum of Art New York, personal communication, 2012). Descriptions of the painting make no reference to the engraving and museums rarely offer public display of their prints. In medical writing modesty, the lack of prominence, author self-importance, or lack of appropriate citation, as occurs, at times, may leave the true innovator forgotten. Returning to art, for example, it is unclear if cubism was first developed by Braque or Picasso or whether they independently developed it nearly simultaneously or perhaps they developed it jointly, yet it is nearly universally attributed to the latter, likely owing to his greater renown. In answering the questions posed at the outset, I believe that innovation may encompass all the possibilities of concept, proof of concept, and implementation, as each step may be innovative, most often requiring many mini-innovative components. Concepts may be attributable to a single source or, perhaps, more frequently multiple sources, as appears to be the case for Bruegel’s painting and engraving. As in this case, often it is difficult to discern. His art and innovation is not lessened for having developed and implemented a concept that had originated at least 1500 years earlier, but depicted in a different and innovative manner. In this supplement of TRANSFUSION, we have examples of each: concept, development, implementation, and proof. In some cases, as happens in medical science not infrequently, observation or implementation precede our understanding of the underlying basis or mechanism, as is demonstrated in the papers by the groups led by Cap and by Pati exploring why platelets stored at 48C function better and for longer periods than do platelets stored at