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K. Patrick Ober, MD



"Man is the Only Animal that Blushes. Or needs to."

 [Mark Twain, Following the Equator]


I. The Blush of a New Discovery

Despite the efficiencies of the electronic age, it is still hard to beat a personal trip to the library as a means of discovery. I confess that I enjoy hanging out in libraries. Not too long ago, in response to a tip, I wandered into the Z. Smith Reynolds Library on the main campus of Wake Forest University, and headed for the Special Collections & Archives.

I had a mission. I wanted to confirm that the library housed a special book by the famous naturalist Charles Darwin. I was not seeking The Descent of Man. I was not hunting for On the Origin of Species. I was looking for [and found] a less famous book. This book. 

Click to view larger image.

There is a good reason why this particular volume is housed within the Special Collections of the library. It is special. It is a rare book. Indeed, it is a unique book, due to the identity of the book’s original owner, who signed his name on the second flyleaf.

 Samuel L. Clemens
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 Yep. The book was once part of the personal library of Samuel L. Clemens [Mark Twain]. It eventually came into the possession of Nancy Susan Reynolds [the daughter of R. J. Reynolds of tobacco fame, and the sister of the Z. Smith Reynolds Library’s namesake]. She gave it to the WFU library in 1970.

If you could hold the book and take a closer look, you might discover that Twain wrote more in the book than his signature.

Twain had a habit of writing in the margins of his books to identify passages of particular interest to him. He used a simple old-fashioned pencil. You may personally prefer to mark your own books with a highlighter that leaves a trail of brightly fluorescent yellow [or blushingly bold pink?] to identify passages that seem important. As remarkable as it may seem, though, your favorite marker had not been invented when Mark Twain was marking his marks, and so he marked with what he had at hand. A pencil.

You may not be surprised to learn that Mark Twain was intrigued by a number of Darwin’s observations.

If you looked through the book’s pages, you would find a vertical line in the margin of page 139. It is a pencil mark, but it is not just any pencil mark. It is a pencil mark made by Twain, drawn to identify two sentences that were of particular interest to him. Now, as you look at the page more than a century later, your attention is first drawn to Mark Twain’s pencil line [a notable line, because Mark Twain made it]; eventually, though, you will feel compelled to shift your attention to Darwin’s text. What it was that earned Twain’s mark of interest? [In your anticipation, you may even be inclined to magnify the magnitude of Darwin’s words, even before you read them, simply knowing that Mark Twain found them to be important.]

What did Darwin write that so intrigued Twain?

Click picture to view larger image.

It seems such a simple observation: both monkeys and humans get red in the face when they are angry. But it is not so simple, really, and Mark Twain knew he needed to return to it to contemplate it further, if Darwin did not have anything else to say about it.

Darwin did have more to say about it, though.

It is true, Darwin declared on page 310, that both men and monkeys get red in the face when they are enraged, as he considered the observation on page 139.

But…Charles Darwin noticed something inherently unusual about all of this. Mark Twain also recognized the oddness as soon as he read Darwin’s words. It might now seem to be a strange thing to you, too, if you pause to think about it.

What was the thing that caught Darwin’s [and then Twain’s] attention?

It is this.
Both men and monkeys can get red in the face when they are mad.

Somehow, though, the type of getting-red-in-the-face known as blushing is an entirely different business from getting-red-in-the-face caused by anger.

Blushing, Charles Darwin concluded, is not even a monkey thing at all.

It is a uniquely and strangely human activity:

BLUSHING is the most peculiar and the most human of all expressions. Monkeys redden from passion, but it would require an overwhelming amount of evidence to make us believe that any animal could blush.

It is easy to picture Twain, with Darwin’s text in hand, pondering Darwin’s comments. There is a convoluted complexity here. Flushing and blushing seem to be essentially the same thing, biologically. How could it be, then [Twain may have asked himself], that both humans and monkeys are able to get reddened in the face when they are impassioned – they both can flush – but only humans can blush? What exactly was it about a blush that made it, as Darwin proclaimed it to be, “the most human…of all expressions”?

Mark Twain approached the enigma by paraphrasing Darwin’s comments to state the facts of the case. "Man,” Twain wrote to summarize Darwin’s observation, “is the Only Animal that Blushes.”

Then he found the solution to Darwin's unstated puzzle.

Twain brought the answer to light [and his famous aphorism to completion] by considering his own observations of the human race. Then he tacked on three additional words. “Or needs to.”

The difference between flushing and blushing, as Charles Darwin and Mark Twain figured out, is subtle.
The difference isn’t so much in the reaction itself.

It’s in the trigger of the reaction.

A flush is a physiological response. It can be brought on by exertion. Or hot temperatures. Or anger.

A blush is triggered by emotional factors.

A blush requires self-awareness. A blush requires a highly developed propensity for feeling shame or embarrassment. Only Man among the animals has perfected those prerequisites for blushing. As a consequence, Man is the Only Animal that Blushes. In fact, Mark Twain suggests, a blush should not be a rare event. Man so routinely and predictably demonstrates behaviors that should cause shame and embarrassment that Mark Twain could reach but one conclusion: Man is the Only Animal that Needs to Blush, the only Animal that Should Blush, the only Animal that Ought to Blush.

And even though he didn’t say so, Twain had one important lesson for us to take away from all of this.

A blush may be interesting, and a blush may be colorful, but the blush itself is never the most important thing.

It is the reason for the blush that deserves our rapt attention.


II. A Blush of Another Complexion

A blush is always involuntary, with one exception. The word “blush” can also refer to a red or rosy color applied for cosmetic purposes. This painted-on “blush” is used [it would seem] to create an appearance of blushing by the deceiver who applies it. The motivation of the pseudo-blushers seems unclear. Who are they, really? And what are their goals? Are they compensating for an inability to generate a natural blush of their own?  [Are they without shame?] Or are they at the other extreme – overly sensitive and embarrassed by the frequency of their own spontaneous and unpredictable blushes, hoping to disguise their propensity to blush with the application of an artificial blush, trying to create uncertainty by blurring the real with the fake?

“Blush” [the noun], as it is known in the United States, is called “blusher” in Britain and rouge in France. It is a red-colored powder that is brushed on the cheeks to create a picture of rosy health. The creation of an appearance of plethora may be one of the underlying purposes of the use of blush.

The application of blush could even be envisioned as an action of Darwinian significance – a pale and anemic woman may be at a disadvantage when it comes to natural selection and survival of the species. What could be better than a ruddy complexion to demonstrate good nutrition and a healthy circulation? If Man is the Only Animal that Needs to Blush, Woman is the Only Gender that Applies Blush, in her effort to present herself as the very picture of vigorous and rosy-cheeked health.

The cosmetic blush does not cleanly parallel a natural blush. The cosmetic blush is not intended to suggest a state of constant embarrassment. It is not a mimic of a natural blush. It is meant to be something just a little bit different.

A woman’s blush is an outward reflection of her inner beauty and a sign of her glowingly good health.

It doesn’t seem like there should be anything embarrassing about that.


III. A Story of a Blush

At the beginning, she appeared to have a fairly straightforward problem. At least that is how it seemed, at first blush.

I was the attending physician for the month, and my internal medicine team had admitted a number of complex patients overnight. All of the patients had multisystem medical problems, except for her. All of them were destined to be around for a while, except for her. Compared to all of the others, she was going to be the easiest to manage. At least that is how it seemed…at the beginning…at first blush…

She was a young woman. She had always been the very model of good health, until now. In recent days, though, she had noticed some pain, tenderness, and redness of her left breast. The symptoms gradually worsened. Embarrassment delayed her from seeking medical attention at first, but the pain finally won out and she came in to the emergency room. Her physical examination was normal except for the fiery redness and exquisite tenderness to even the lightest palpation over the affected breast. She was sick. She had a fever of 101 degrees. Her white blood cell count was twice normal, with a predominance of neutrophils and band forms, the classic “shift to the left” pattern of bacterial infection.

She was treated with intravenous antibiotics, and she improved quickly and impressively. The recovery was gratifying for everyone involved. She never had much to say when we visited her on rounds. She never talked much when individual team members checked in on her throughout the day. She seemed shy, mostly. She seemed grateful for the attention she was receiving. Her pain improved. Her temperature came down. Her white blood count normalized. She was comfortable. The pain and redness of the breast disappeared, and her mastitis/cellulitis had remitted. She was one of those patients you never come to know well, due to some unexplainable distance or unidentifiable barrier between the two of you…or maybe because there is not enough time in the day. But she was getting better, and that was the important thing. She would be able to go home the next day, where she would be able to finish out the course of treatment with a few additional days of an oral antibiotic.

But she didn’t go home the next day.

On the day of planned discharge, it was obvious that something was different about her from the moment we walked into the room. Distress showed on her face. Everything is back, she told us, with tears in her eyes. She pulled her bed sheet over a few inches to reveal the edge of the breast while maintaining her modesty, showing us the return of raging inflammation. Palpation over the area, even at the periphery, was almost impossible. At the lightest touch, she winced, she withdrew, she pulled away from us in tears. She was distraught and miserable. We were miserable, in her misery. [We were miserable, in our failure.]

We second-guessed ourselves. Why the setback? What had we missed? Our guesses were both anatomic and pharmacologic. Was there an obstructed duct with a nidus of infection lodged behind? A cancer? Had she developed an abscess? Was our discontinuation of IV antibiotics premature?

We switched her back to IV antibiotics.

She was no better the next day. She had more tears of pain. Her face showed anguish, and something more, now. Accusation. We were inept, and she knew it. [We knew it.] The degree of inflammation looked horrendous. We still had no explanation for her relapse. The gentlest effort to palpate, to gain more understanding of what had gone awry, was more than she could tolerate. She cried. She withdrew. [We withdrew.] An imaging procedure was considered and rejected – a mammogram or an ultrasound would be an intolerable test for her if the lightest touch could not be tolerated.

Perhaps it was time for a consultation. The breast surgeon was called in, not because we suspected cancer, we told her [although we were worried about the possibility, a little bit], but mainly because the breast surgeon would bring more experience, in case there was a small pocket of infection that needed drainage before the antibiotics could work their best to overcome the infection.

The breast surgeon came to see our patient that afternoon. She was in the room for a while. She finally walked out of the patient’s room with a smile on her face. Well, I think we have solved that one!, she announced to our team, seated at the nursing station. We all awaited her pronouncement. The grin told us there was no cancer. The grin didn’t seem to fit for an abscess, either. The grin didn’t fit at all with anything in our differential diagnosis. [The grin fit with the possibility we were inept.] Then she explained it all by holding a white washcloth up to us.

It wasn’t perfectly white.

The white washcloth was streaked in red.

The hue was not exactly what you would call a blood red.

It was more of a…well…more of a chemical red…a powdery red…a cosmetic red...

At first, the surgeon had been as puzzled as the rest of us by the patient’s relapse, but she managed to do something our all-male team could not bring itself to do. She overlooked the tears, ignored the wincing and withdrawal, and proceeded to perform a thorough palpation of the breast. In the terminology used by prior generations of doctors from earlier centuries to denote the indicators of inflammation, her exam confirmed the presence of rubor [redness] and some questionable dolor [pain], but found no evidence of the expected calor [heat], and no sign of tumor [swelling].

At the end of her exam, the surgeon noticed something else. Her own examining fingertips had turned red…the same shade of red as the patient’s breast. And the patient’s breast was correspondingly less red than it had been a few minutes earlier, and was now marked by streaks of white where the surgeon had palpated most vigorously.

The surgeon then grabbed a washcloth, and wiped all of the “inflammation” off the breast with a few vigorous scrubs. Now the breast was normal. Cured. No more redness; or, if you will, no more rubor…no more rouge.

The patient made her confession. She showed the surgeon the collection of cosmetics she kept hidden in the bedside table, including the “blush” she had started to paint on her breast every day after the infection started to clear, the “blush” that extended her hospital stay, the “blush” that made all of us go a little crazy.

I went to the patient’s room in my need to talk with her a bit. What was her motivation? Was something else going in her life that made the hospital a safe refuge? Did she have any thoughts about what her “end-game” would look like after she ran out of rouge, or when her rouge and her ruse would inevitably be discovered?

She was gone. She had fled the hospital immediately after the surgeon’s visit. No surprise. My questions go unanswered.

Years later, I still replay the whole scenario in my head. Should we have been more aggressive in our examination, more willing to inflict additional pain upon a woman already in pain, when the diagnosis already seemed so apparent? Should we have abandoned our sensitivity to her situation, and ignored her unwillingness to be examined? Should we have distrusted her, even as we expected her to trust in us? It still comes out the same way, no matter how often I replay it.

If you have compassion and trust for everyone you meet, you will be doing the right thing, always.

You will pay a price for that trust, sometimes. You will be tricked a few times as a result of your compassion. There will times in your career when you will be embarrassed when you discover you have been treating a healthy rouge-painted breast with an IV antibiotic, when a brisk scrub with a washcloth was really all that was required.

Even years later, the memory will cause you to blush.

But there are few things better for nurturing our humanity [and our humility] than our remembrances of past errors…and the blushes that sear those memories into our souls.

After all, we are the only animal that blushes.

Of course, we are the only animal that needs to.


[ACKNOWLEGMENTS: I am grateful to my friend and colleague, Alan Gribben, Professor of English at Auburn University at Montgomery  – author of Mark Twain’s Library: A Reconstruction  – for telling me that Mark Twain’s “Darwin texts” are housed in the Special Collections & Archives in the Z. Smith Reynolds Library of Wake Forest University. I am also greatly appreciative of the exceedingly gracious assistance provided by Megan Mulder of the ZSR Library for navigating me through the Twain collection and allowing me the surreal pleasure of holding Mark Twain’s personal copy of The Expression of the Emotions in Man and Animals in my own hands, knowing that I was seeing the very same words – the same paper, the same ink – that motivated Mark Twain to create one of his most famous aphorisms. I am also profoundly grateful to my baffling patient for giving me one more lesson in humility.]

  July 24, 2014

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