Knives, gunfights, pituitaries

The idiom “Don’t bring a knife to a gunfight” is meant to convey the importance of not entering a challenging situation without the proper equipment at hand. The expression has been used in some 20 movies and is also a favorite of some politicians. The concept that one must come properly prepared and equipped to any important task or confrontation is well-appreciated by ophthalmic surgeons, but this particular expression is rarely used by ophthalmologists teaching eye surgery to residents.

Only a philistine would not enjoy a good movie in which the protagonist, like Sean Connery in “The Untouchables,” uses this idiomatic expression to mock his opponent. I mean a philistine in the sense of its common usage of “a person who is hostile or indifferent to culture and the arts.” Of course, this word’s earlier meaning is that of a native or inhabitant of ancient Philistia. The Philistines were a powerful tribe that ranged from Lebanon to Crete to Egypt until they were conquered by the Romans.

Didn’t get the memo

The most famous Philistine (actually, the only one whose name I know) was Goliath the Gittite. Unfortunately for Goliath (the biblical giant whose name has become synonymous with losing in an upset), he did not get the memo about proper preparation.

Heavily armored and with sword in hand, he faced off against a young shepherd armed with a slingshot, the gun equivalent of his day. Apparently these slingshots, with practice, were so accurate that they could be used to shoot down birds in flight. His is a textbook case of bringing the proverbial knife to the proverbial gunfight. Goliath stood there while David loaded his slingshot and fired his rock, then lay unconscious while David sliced off his head.

Rather than causing me to think of David as a hero, this encounter has always made me think that Goliath was an idiot. Why didn’t Goliath hide behind his shield when he saw David about to shoot the rock at him or at least duck or otherwise protect his head? Why didn’t he run up close to David and just stab him?

Controversy

There is some controversy about this, but a number of people who ponder this type of question have an explanation for Goliath’s failure, and it is not that he was stupid. Rather, they believe that his pituitary was at fault.¹

Not only do they suspect he had acromegaly, but that he probably had a familial (autosomal dominant) form of the disease.² Familial isolated pituitary adenoma (FIPA) is an autosomal dominant condition with incomplete penetrance caused by germline mutations of the aryl-hydrocarbon receptor-interacting protein gene 4. Goliath’s brother and three sons were giants and one of his sons had six fingers on each hand and six toes on each foot. It must have been quite a treat to receive a year-end postcard of that family!

Anyway, the arguments supporting acromegaly in Goliath include:

• His height was “six cubits and a span”-apparently about 6’ 9” (pretty big for those days).

• He presumably had poor vision, as evidenced by his having a shield bearer lead him down to the field of battle to face David, his statement that David was carrying sticks when he had only a single shepherd’s staff, and his failure to duck or hide behind the shield as David prepared to launch his rock and his failure to dodge the missile that beaned him.

My conclusion? If the Philistines had neuro-ophthalmologists in their army, the battle would have turned out very differently.

References

1. Berginer VM. Neurological aspects of the David-Goliath battle: Restriction in the giant’s visual field. Isr Med Assoc J. 2000;2:725-727.

2. Donnelly DE, Morrison PJ. Hereditary gigantism-the biblical Goliath and his brothers. Ulster Med J. 2014;83:86-88.