A Perfect Parable - Just Not About Patient Compliance

Primary Source: 2 Kings 5: 1-19 (New Living Translation)

Patient Compliance and The Story Of Naaman

While the story of the healing of Naaman, at least the way I learned it in Sunday School, seems directly on point regarding compliance, it is, instead, only a metaphor, based on the cliched notion of compliance as obedience to authority, to explicate acquiescence to God’s will. Still, its use in this ancient parable indicates that even in Old Testament times, patient compliance was a concern.

Second Kings: Chapter 5: 1-19

The Healing of Naaman
1 The king of Aram had great admiration for Naaman, the commander of his army, because through him the Lord had given Aram great victories. But though Naaman was a mighty warrior, he suffered from leprosy.¹
2 At this time Aramean raiders had invaded the land of Israel, and among their captives was a young girl who had been given to Naaman’s wife as a maid. 3 One day the girl said to her mistress, “I wish my master would go to see the prophet in Samaria. He would heal him of his leprosy.”

4 So Naaman told the king what the young girl from Israel had said. 5 “Go and visit the prophet,” the king of Aram told him. “I will send a letter of introduction for you to take to the king of Israel.” So Naaman started out, carrying as gifts 750 pounds of silver, 150 pounds of gold,² and ten sets of clothing. 6 The letter to the king of Israel said: “With this letter I present my servant Naaman. I want you to heal him of his leprosy.”

7 When the king of Israel read the letter, he tore his clothes in dismay and said, “This man sends me a leper to heal! Am I God, that I can give life and take it away? I can see that he’s just trying to pick a fight with me.”

8 But when Elisha, the man of God, heard that the king of Israel had torn his clothes in dismay, he sent this message to him: “Why are you so upset? Send Naaman to me, and he will learn that there is a true prophet here in Israel.”

9 So Naaman went with his horses and chariots and waited at the door of Elisha’s house. 10 But Elisha sent a messenger out to him with this message: “Go and wash yourself seven times in the Jordan River. Then your skin will be restored, and you will be healed of your leprosy.”

11 But Naaman became angry and stalked away. “I thought he would certainly come out to meet me!” he said. “I expected him to wave his hand over the leprosy and call on the name of the Lord his God and heal me! 12 Aren’t the rivers of Damascus, the Abana and the Pharpar, better than any of the rivers of Israel? Why shouldn’t I wash in them and be healed?” So Naaman turned and went away in a rage.

13 But his officers tried to reason with him and said, “Sir,³ if the prophet had told you to do something very difficult, wouldn’t you have done it? So you should certainly obey him when he says simply, ‘Go and wash and be cured!’” 14 So Naaman went down to the Jordan River and dipped himself seven times, as the man of God had instructed him. And his skin became as healthy as the skin of a young child’s, and he was healed!

15 Then Naaman and his entire party went back to find the man of God. They stood before him, and Naaman said, “Now I know that there is no God in all the world except in Israel. So please accept a gift from your servant.”

16 But Elisha replied, “As surely as the Lord lives, whom I serve, I will not accept any gifts.” And though Naaman urged him to take the gift, Elisha refused.

17 Then Naaman said, “All right, but please allow me to load two of my mules with earth from this place, and I will take it back home with me. From now on I will never again offer burnt offerings or sacrifices to any other god except the Lord. 18 However, may the Lord pardon me in this one thing: When my master the king goes into the temple of the god Rimmon to worship there and leans on my arm, may the Lord pardon me when I bow, too.”

19 “Go in peace,” Elisha said. So Naaman started home again.

Footnotes

1. 2 Kings 5:1 Or from a contagious skin disease. The Hebrew word used here and throughout this passage can describe various skin diseases. [back]
2. 2 Kings 5:5 Hebrew: 10 talents [340 kilograms] of silver, 6,000 shekels [68 kilograms] of gold. [back]
3. 2 Kings 5:13 Hebrew: My father. [back]

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G.L. Brindley: Show & Tell

Personal Commitment In Medical Research

While medical research has a tradition of impressive and even spectacular self-experimentation, sometimes putting the scientist’s life at risk,¹ research presentations rarely evoke that level of drama or involve that level of personal participation.

One medical meeting presentation, however, proved the exception.

Not Your Usual PowerPoint Presentation

The setting is the 1983 Las Vegas meeting of the American Urological Association.

Word of Dr. Giles Brindley’s urological research has prompted an invitation for him to present his findings. In addition, one American doubter has suggested that proof would require something “beyond charts, tables and graphs.”²

It is uncertain what that challenger had in mind, but, in any case, Brindley was equal to the task.

Brindley, a British physiologist, was an old hand at such meetings, having presented numerous papers at scientific conferences. He had, in fact, a reputation in Europe for original research, especially in bioengineering. In 1964, for example, he had devised the world’s first visual prosthesis and had implanted three pairs of electronic eyes in humans before terminating the work when the costs did not justify the results. effectiveness. Once, to explore the effects of centrifugal force on a rabbit’s ability to land on its feet, Brindley dropped a rabbit from the roof to the floor of a car (driven, one assumes, by someone else) making a sharp turn – while the car was going eighty miles an hour.

Accounts of the details of Professor Brindley’s presentation vary, but they all agree on certain points:

1. Dr. Brindley’s research focused on what is now commonly called erectile dysfunction and included injecting his own penis with 33 drugs³ prior to making the original discovery that phenoxybenzamine, an alpha-blocking smooth muscle relaxant that works as a non-specific vasodilator, would result in an erection.⁴
2. Prior to his presentation, Dr. Brindley privately injected his own penis with phenoxybenzamine.
3. During his presentation, entitled something along the lines of ‘Vaso-active therapy for erectile dysfunction”⁵ Dr. Brindley revealed (A) the fact that he had injected himself with phenoxybenzamine and (B) the results of that action – his fully erect penis.




“[Brindley] dropped his pants before the audience
… a very respectable erection”
Prof Alvaro Morales, Queen’s University, Kingston, Ontario⁶




4. The audience - consisting primarily of physicians who spent much of their professional lives performing examinations of the sort that tend to jade ones response to male genitalia – gasped.




“I had been wondering why Brindley was wearing sweatpants,” says Dr. Arnold Melman, chief of urology at New York’s Albert Einstein College of Medicine, who was there. “Suddenly I knew.”⁷ “It was a big penis, and he just walked around the stage, showing it off.”⁸




5. Brindley, a former athlete, then proved he was not using a silicone prosthesis, by descending from the stage to the audience, inviting them to inspect his erect penis.




As Dr. Irwin Goldstein, a Boston University urologist who was present for Dr. Brindley’s presentation, describes it, “He walked down the aisle and let us touch it. People couldn’t believe it wasn’t an implant.”⁹

Fortune magazine observed that Brindley’s presentation put the erection “back in the spotlight.”¹⁰

Resolving Conflicts

Accounts of some aspects of Dr. Bindley’s presentation do conflict.

There are, for example, incompatible reports about the precise methodology used for Brindley’s unveiling. While some sources are cautiously silent on this point, others indicate an unzipping, and still others specify a lowering of the pants. One account insists that Brindley gave his entire talk clad only in underwear which he removed for the presentation.

While such details may appear frivolous or silly, I submit that they are part and parcel of Professor Brindley’s approach, which does seem significant.

The consensus of reports implies that Brindley was little more than a blatant self-promoter if not a brazen exhibitionist. His presentation is frequently labeled a “stunt.” One report, however, has the ring of truth and has convinced me that many of the other accounts have been contaminated with sensationalism.

The Klotz Account

How (not) to communicate new scientific information: a memoir of the famous Brindley lecture by Laurence Klotz¹¹ is not only an eye-witness account but has three important advantages compared with most other reports: (1) it was written in first person while most other stories in the press are written by journalists who, at best, interviewed those in attendance at the presentation, (2) it was published as a memoir in a professional journal where there would seem to be less pressure to exaggerate or focus on lurid material to gain public attention as there might be in the popular press, and (3) Dr. Klotz fortuitously saw Professor Brindley prior to the lecture and thus was privy to information not available to others.¹²

I recommend reading Dr. Klotz’s two page report, which is, happily, available online cost-free at How (not) to communicate new scientific information: a memoir of the famous Brindley lecture; its style and content will, I believe, prove convincing.

Pertinent points from Dr. Klotz’s article follow with my annotations in italics:

• “It [Brindley's lecture] was relatively poorly attended, perhaps 80 people in all.” Most accounts that mention the audience size describe a “roomful” or “thousands” of members of the American Urological Association in attendance, almost certainly confusing the total attendance at the annual meeting with attendance at this presentation.
• “Most attendees came with their partners, clearly on the way to the reception. I was sitting in the third row, and in front of me were about seven middle-aged male urologists, and their partners in ‘full evening regalia’. ” None of the other reports I reviewed noted the presence of physicians’ spouses or that some members of the audience were dressed for a reception scheduled for later that evening.
• Dr. Klotz, who serendipitously shared an elevator with Professor Brindley 15 minutes prior to the lecture, noted that “He [Brindley] appeared quite nervous, and shuffled back and forth.” The notion that Professor Brindley was anxious is absent from other accounts.
• The lecture itself seems reminiscent of many, many such presentations at medical meetings. Dr. Klotz notes that Professor Brindley “began his lecture without aplomb” and proceeded to show and narrate slides demonstrating his success inducing erections by “injecting vasoactive agents into the corporal bodies of the penis.” One significant point not mentioned elsewhere is Professor Brindley’s explanation that “Lacking ready access to an appropriate animal model, and cognisant of the long medical tradition of using oneself as a research subject, he began a series of experiments on self-injection of his penis with various vasoactive agents, including papaverine, phentolamine, and several others.” Further, Professor Brindley acknowledged that “one could not exclude the possibility that erotic stimulation had played a role in acquiring these erections.”
• Also missing from other accounts is Professor’s Brindley’s preface immediately prior to the most dramatic portion of the presentation: “He [Brindley] indicated that, in his view, no normal person would find the experience of giving a lecture to a large audience to be erotically stimulating or erection-inducing. He had, he said, therefore injected himself with papaverine in his hotel room before coming to give the lecture, and deliberately wore loose clothes (hence the track-suit) to make it possible to exhibit the results.”
• Only when it became apparent that the tightening the loose fitting pants around his genitalia didn’t, in Professor Brindley’s words, “display the results clearly enough” did he drop his pants to reveal “a long, thin, clearly erect penis.”
• When Professor Brindley then approached the audience (which required him to waddle down the stairs from the stage to the floor of the meeting room with his trousers at his knees) to, again in Professor Brindley’s words, “confirm the degree of tumescence,” four or five of the women in attendance screamed, Professor Brindley pulled up his pants, and, returning to the stage, concluded the lecture. This response from the audience and Professor Brindley’s reaction are unmentioned in other accounts I’ve found.

The Denouement

Professor Brindley’s seminal article from this research was published a few months later, ¹³ and a new era of advancement in the field of erectile dysfunction commenced.

Dr. Klotz, while he spares no details, does not describe a grandiose, thoughtless performance but, instead, a presentation by one who “belongs in the pantheon of famous British eccentrics who have made spectacular contributions to science.”

I should note that I ventured to ask Professor Brindley, via a rather elaborately (over)written e-mail, about his motivation for the presentation. His reply, in full, follows

One can argue about Dr. Brindley’s appropriateness or his taste but his intent and motivation certainly appear to have more to do with scientific research than personal narcissism or showboating.

And, that seems fitting for the instance in which the penile erection was transformed from a mysterious, psychoanalytic phenomenon into a composition of flesh, arteries and veins, smooth muscle, neurons, and neurotransmitters accessible to bioengineers, chemists, and physicians.

Supplemental Material

Professor Brindley was a prodigious scholar who, while working primarily at the London Hospital and the University of London, published over 100 physiological research papers, especially in the areas of visual, genitourinary, sexual, and perceptual functions.

He also appears to have been a beloved mentor. Several memoirs by physicians and researchers note, with evident pride and respect, that it was Professor Brindley who gave them their first job, encouraged their work, arranged for funding of their research, or provided them with vital instruction and direction.

And, there is more.

Get The Picture?

In one of those throwaway ironies that the gods toss off to keep themselves amused, only two photos could be initially found on the internet of Giles Brindley, a man who had not only amassed a prestigious reputation in research, many awards, multiple publications, and various honors from professional and academic societies, but is appropriately credited for the most memorable presentation ever given at a meeting of professionals.¹⁴

There were, indeed, only those two photos. Coincidentally, as the (perhaps apocryphal) story has it, there were, in the early 1900s, only two cars in the entire state of Kansas, one in Kansas City, and one in Wichita.

Those two cars collided.

These two photos labeled “Giles Brindley” seemed equally destined to collide.

The individual pictured on the right is identified by the Urological Sciences Research Foundation web site and the web site of Zafar Khan, M.D., a urologist, as the “Giles Brindley” who is the subject of this post.

The Southwark Consorts of Winds Programme also identifies the person in the photo on the left, who looks like the same fellow to me, as “Giles Brindley,” the composer of “Variations on a Theme by Schoenberg, (op. 26).”

After reviewing numerous internet sites, I found plenty of references to Giles Brindley - the physiology researcher and a fair number pertaining to Giles Brindley - the musician who composed and who developed the logical bassoon “which aimed to improve intonation and evenness of tone through use of electrically-activated key combinations that were too complex for the human hand to manage.”¹⁵ I did not, however, find a single source that confirmed that both sets of accomplishments accrued to the same individual.

Multiple emails ensued. By the end of the day, ten or so physicians and musicians from the U.S., Canada, and Britain had interrupted their workday to assist in my quixotic quest to solve the Giles identification conundrum.

The consensus was that there was but one Giles Brindley who was responsible for the music and the research, but no one was certain. Raymond Rosen, MD, a professor of psychiatry at the University of Medicine and Dentistry of New Jersey, was able to certify that the photo on the Urological Sciences Research Foundation web site was definitely Giles Brindley, the physiologist.¹⁶

Finally

The definitive response arrived by e-mail later that same evening,

As it turns out, Professor Brindley has published numerous musicological papers as well as performing and composing music.

Thank Goodness For Esoteric Dissertations

In sifting the net for Brindley information, I found his name mentioned in Enclosing the Field: from ‘Mechanisation of Thought Processes’ to ‘Autonomics’, a dissertation submitted by David Clark “in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Computer Science.” A photo was mentioned in but was not part of the online dissertation, which was formatted as a text file. A bit of digging, however, ferreted out a photograph, archived at Wellcome Library, London, of “The Ratio Club” at Cambridge. Fortuitously, the single photo was taken at a Ratio Club meeting held May 2-3, 1952 that was attended by a guest, “Giles Brindley (London Hospital).” Giles is the gent marked by the yellow circle. (Also in this group are two pioneers in computer science that are so significant that their names are immediately recognizable: that’s Donald MacKay marked in red and Alan Turing in green. Nice club, eh?)¹⁷

This is Giles Brindley cropped from the others.

Professor Brindley confirmed that he is, indeed, the fellow in the picture.

One Final Point

Dr. Brindley was 57 at the time of his Las Vegas performance, an auspicious age that I reached during the preparation of this post. Upon reflection, I feel inspired and perhaps even stirred.

Photo Credit
Las Vegas, 1983 was taken by Monika Betley.

Footnotes

1. Consider these two examples (of many, many possible examples) of self-experimentation:
   A. To support his theory that Helicobacter pylori caused peptic ulcers, gastroenterologist Barry Marshall drank a broth containing the bacteria, causing nausea, vomiting, and biopsy-proven gastritis.
   B. In 1929, Werner Forssmann, a German surgeon, catheterized his own heart by inserting a 65 cm cannula through a vein in his arm, then climbed a flight of stairs to the X-ray department to produce a radiograph demonstrating that the catheter was, indeed, lying in his heart.

   Both examples are from How far would you go to advance medical research?, Manjulika Das. BMJ Career Focus 2004;329:142-143. [back]

2. The secret history of Mr. Happy Salon.com [back]
3. Not tonight, dear… The Age, 25 Oct 2003) [back]
4. The physiological mechanics by which a smooth muscle relaxant leads to an erection is nicely explained in the
   How Stuff Works article, How Viagra Works and is straightforwardly illustrated by a definitively non-lurid Quick Time clip at The Urological Sciences Research Foundation [back]
5. Klotz, Laurence (2005) How (not) to communicate new scientific information: a memoir of the famous Brindley lecture. BJU International 96 (7), 956-957. [back]
6. http://www.bbc.co.uk/science/horizon/2003/sexchem.shtml [back]
7. Excerpt from A Mind of Its Own by David Friedman, 2001 http://www.powells.com/biblio?show=0684853205&page=excerpt [back]
8. The Rise of Viagra: How the Little Blue Pill Changed Sex in America Meika Loe. New York University Press, 2004 [back]
9. Consultants Try the Hard Sell Jill Rosenfeld. Fast Company February 2001 [back]
10. The Rise of Viagra: How the Little Blue Pill Changed Sex in America Meika Loe. New York University Press, 2004 [back]
11. Klotz, Laurence (2005) How (not) to communicate new scientific information: a memoir of the famous Brindley lecture. BJU International 96 (7), 956-957. [back]
12. My attempts to contact Dr. Klotz have been thus far unrequited. [back]
13. Brindley GS. Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Br J Psychiatry 1983; 143: 332–7 [back]
14. Were mobile phones with cameras as ubiquitous then as they are now, one can only speculate about the resultant news stories. [back]
15. Wikipedia: Bassoon; Brindley’s original article is The Logical Bassoon, Giles Brindley, Galpin Society Journal, Vol. 21, Mar., 1968 (Mar., 1968), pp. 152-161 doi:10.2307/841438 [back]
16. Other responses included one individual’s conviction that the pictures were of different people altogether, one correspondent who thought Giles Brindley might be dead, and another who was certain of that. My favorite response, however, was that of Leonard Marks, MD, the Medical Director Of Urological Sciences at UCLA, who told me he had found the picture of Brindley now on the Urological Sciences Research Foundation web site in a brochure and couldn’t confirm the identity. In a P.S. to this email message, he wrote, ” Please let me know the upshot of this inquiry, as you are the first to raise this question.” [back]
17. The photo’s complete roster follows: “From left to right; standing: Giles Brindley, Harold Shipton, Tom McClardy, John Bates, Ross Ashby, Edmund Hick, Thomas Gold, John Pringle, Donald Sholl, Albert Uttley, John Westcott, Donald MacKay; sitting: Alan Turing, Gurney Sutton, William Rushton, George Dawson, Horace Barlow.” [back]

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I had indicated to some folks that today’s AlignMap blog post would be a tad aberrant in that it would have no direct connection with AlignMap.com’s customary subject of adherence to prescribed treatment but would instead deal with Professor G.S. Brindley, an extraordinarily interesting individual, and his unusual contribution to medicine.

And, that was indeed the plan until 1 AM this morning when I serendipitously discovered a new source of pertinent information. To expand and incorporate that material, some of which contradicts data I had gleaned elsewhere, I am deferring the Brindley post, which I now anticipate publishing Monday, 6 Nov 2006.

I apologize for the last minute change.

Standing in for Professor Brindley today is another extraordinarily interesting individual who also made an unusual contribution to medicine: Professor Freud.

These anecdotes about Freud were told to me by one of his last analysands, Roy Grinker, MD, who was the Director of Psychiatry at Michael Reese Medical Center, where I served my residency and, as far as I know, are not available elsewhere on the internet except in protected databases. They are posted at Heck Of A Guy, my personal blog, which is not oriented specifically to healthcare professionals and which values entertainment as much as enlightenment.¹ I believe you will find these vignettes are both enlightening and entertaining.

The Roy Grinker Stories about Freud can be found at these links:

Footnotes

1. This is my subtle way of alerting readers that the writing style and attitude in the Heck Of A Guy posts may not be identical with the style and attitude I use at AlignMap [back]

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“The Role of the Hospital in the Development of Modern Medicine: A Sociological Analysis”
Ivan Waddington Sociology, Vol. 7, No. 2, 211-224 (1973)
as quoted in The Limits of Medicine Edward S. Golub. Crown; 1st edition (November 1, 1994)
______________________________

The practice of medicine hospitals shifted after the French Revolution. Especially notable was the ascension of the doctor to the dominant role in the clinician-patient relationship, a dramatic contrast to the same relationship in the early eighteenth century in which the patient was dominant. Within that context, this quotation, dealing with adherence, is poignant.

According to an English observer of the Parisian hospitals in 1843, the patients were “always required to conduct themselves in an orderly and respectful manner; they are aware on entering the hospital that they must comply, unhesitatingly, with [the doctors'} advice, and abide by the directions of the medical officers; if the slightest difficulty occurs they are immediately discharged. " [Italics mine]

Commentary

Patient compliance and the doctor-patient relationship ain’t what they used to be — unless one picks the historical period carefully.

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Leviticus 13:1-45
_____________________

Leviticus 13:1-45 provides instructions for the diagnosis and management of leprosy and subsumed diseases.¹

Even the most cursory of readings reveals the language of this passage to be precise, the content detailed, the tone imperative, and the manner certain.

Commentary

Obviously, medical compliance is not at issue until there is a treatment recommendation with which to comply. Further, healthcare recommendations can range in mood from the completely optional to absolute demands. Old Testament prescriptions, such as those found in Leviticus 13:1-45 would, one assumes, anchor the more draconian pole of that spectrum.

Western civilization and, in turn, western concepts of medicine are, of course, intertwined with and derivative of Judeo-Christian beliefs and philosophy. It is not difficult to trace the long-standing image of the authoritative physician to even more authoritative stance of the ancient Jewish priests and the deity who is, philosophically, the primal source of authority itself.

Footnotes

1. ”Leprosy,” as used in Leviticus, includes not only the disease now known as leprosy, but also tuberculosis leprosy and a number of diseases known today as herpes, ringworm, eczema, and psoriasis. G. A. F. Knight, Leviticus (Edinburgh: Saint Andrew Press, 1981), p. 72. [back]

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