Nedarim 41b ~ Fever

נדרים  מא, א–ב

אמר רבא האי אישתא אי לאו דפרוונקא דמלאכא דמותא מעלי כחיזרא לדיקלי חד לתלתין יומין

Rava said about a fever: "Were it not for the fact that it is an agent of the Angel of Death, it would be beneficial for a person as a prickly foliage is for palm trees, if it is experienced once every thirty days...(Nedarim 41a-b).

When I worked as an emergency physician I treated hundreds and hundreds of patients who came to the ER with a fever.  In fact, fever is the third most common reason in the US for which people visit the ER - accounting for over 5 million visits each year. At virtually every visit they'd be given a medicine to reduce their fever, as if by doing so we were achieving something medically important. But in this page of Talmud, we read that according to Rava, fever is actually beneficial to a person (at least when it does not kill...).  How does this claim made by Rava, a Babylonian sage who died around the year 352 CE, stand up to today's medical science? Remarkably well, it turns out. Here's why.

Fever 101

Here are some basic things to know about fever. First, it is usually defined as a core temperature in humans above 38.3 C, or 101 F.  Second, there are lots of reasons why people get a fever, of which bacterial and viral infections are the most common, but not the only causes.  Third, and this is really important, not all fevers mean the same thing in terms of their seriousness.  Fever in a baby less than a month old requires an urgent and extensive evaluation. The same fever in a healthy toddler does not.  Fever in a healthy teenager is not the same as fever in an elderly patient on chemotherapy.  Finally, fever is not caused by the infection, at least not in the way you might think. It is the body's response to that infection that produces a fever.  Here's how.

The Biochemical Pathway to Fever

When bacteria infect the body, their foreign structure is recognized by white cells in the blood called macrophages. These macrophages then release a prostaglandin E2, interleukin-1, interleukin-6, and tumor necrosis factor. These act on a region deep in the brain called the hypothalamus, which acts as a thermostat for the body. Under the influence of interleukin-1 the hypothalamus releases a hormone called cyclooxygenase 2 (COX-2) which resets the body's thermostat, causing the temperature of the body to rise by a few degrees.  

How a fever is caused by a bacterial infection. From Evans, Repasky and Fisher. Fever and the thermal regulation of immunity: the immune system feels the heat. Nature Reviews Immunology June 2015: 15: 337.

It's not just people who get fevers. Dogs and cats do too, as do mice (and all mammals), reptiles, and even goldfish. Why would so many animals respond to an infection by developing a fever?

The Benefits of Fever

The reason is simple. The immune system fights infections better when the body is hotter. The way it does this is now well-understood but very complicated; here are just the highlights. 

Under what immunologists call "thermal stress" (and the rest of us call "a fever,") neutrophils, the white cells that are needed to fight infection, are released in greater numbers from the bone marrow.  These neutrophils also do a better job of fighting bacteria at the site of the infection when the body is warmer.  Fever also improves the killing ability of another group of blood cells called natural killer cells, and it increases the ability of the macrophages to ingest and destroy the invading bacteria. In an excellent review of fever and the thermal regulation of immunity in Nature Reviews, the authors concluded that "[t]he picture that emerges is one in which febrile temperatures serve as a systemic alert system that broadly promotes immune surveillance during challenge by invading pathogens."  

So your body does a better job of fighting bacteria when it is hotter.  Why then, do doctors give medicines that reduce a fever?  Good question. The truth is, they really shouldn't.

Don't Reach for That Tylenol/Paracetomol/AcAmol 

If you are the parent of a child with a fever, you are likely to give your sick offspring a medicine that interferes with the immune system, like Tylenol if you are in the US, Paracetamol if you are in the UK or South Africa, or Acamol in Israel (though they are different words for the same medicine).  But if, as we have seen, the body does a better job of fighting infection when it is a few degrees hotter, might reducing the fever lead to a worse outcome for the child?

This question was recently examined by a group from McMaster University in Canada. They looked at the side effects of reducing a fever in those who are sick from a population level . What happens in a large group of people when some of them - infected with, say, influenza - take medicines to reduce their fever? The answer is that more of them transmit the virus and so more of them fall ill.  On a population level the effect is rather drastic:

Putting together our estimates of the treatment probability p and the individual transmission enhancement factor fi ...we conclude that the current practice of frequently treating fevers with antipyretic medication has the population-level effect of enhancing the transmission of influenza by at least 1% (95% CI: 0.04–3%)...This estimate does not take into account the known effect that the infectious period of influenza is also increased by antipyresis, nor does it take into account the potentially large effect of increasing the rate of contact among infectious and susceptible individuals because antipyresis makes infectious individuals feel better...To put our lower bound...into perspective, consider that approximately 41,400 ...deaths per year are attributed to seasonal influenza epidemics in the United States (and an order of magnitude more worldwide). Taken at face value, our results indicate, for example, that...at least 700 deaths per year ... could be prevented in the US alone by avoiding antipyretic medication for the treatment of influenza...

“In the absence of meaningful evidence for the beneficial effects of fever reduction, the commonplace reduction of fever in critically ill patients must be called into question.”

— Ryan and Levy. Clinical Review: Fever in intensive care patients. Critical Care 2003, 7:224.

The Canadian investigators concluded that "...the use of antipyretics can have subtle and potentially important negative effects at the population level. Any medical intervention that aims to relieve the symptoms of an infectious disease in an individual should also be evaluated in light of potentially harmful effects at the population level..." And it's not just populations that can suffer: individual patients are at risk too. In a 2011 paper looking at the treatment of fever in very ill patients with sepsis in the ICU,  a French team looked at the beneficial and detrimental effects of fever, and concluded that "...the widespread use of antipyretic methods in ICU patients is not supported by clinical data and fever control may be harmful, particularly when an infectious disease is progressing..."

From Lainey Y. et al. Clinical review: Fever in septic ICU patients - friend or foe? Critical Care 2011:15:222

The Death of Rav Assi - from Fever

So Rava's teaching in tomorrow's daf, Nedarim 41b appears to be spot on.  Fever is indeed beneficial for the body, though it is a sign that something bad is going on.  Elsewhere in the Talmud (Niddah 36b, which we will learn on Shabbat, May 1, 2027, הבא עלינו לטובה) we read that another Babylonian Amora, Rav Assi, died from a fever accompanied with chills - the classic description of sepsis (and a lot else besides, too). It is interesting to note that Rav Assi's attendants tried to reduce his fever.  Perhaps they were not aware of the tradition that Rava - who was born two generations later - would later teach.

R. Assi fell ill and they had to put him in hot [blankets] to relieve him from chills, and in cold [compresses] to relieve him from heat,[but] his soul departed to its eternal rest. (Niddah 36b.)

Fever may be beneficial, but the underlying infection of which it is a sign never is.  Which is why, in the next daf  (Nedarim 42), Rava's teaching was not accepted by Rav Nachman bar Yitzchak who retorted: לא היא ולא תירייקה:  "Give me neither fever, nor its antidote!"

Nedarim 39b ~ Visiting the Sick

This post is for the page of Talmud to be studied tomorrow, Shabbat.

Print it up now and enjoy.

נדרים לט, ב - מ, א

תניא ביקור חולים אין לה שיעור ... אמר אביי: אפי' גדול אצל קטן רבא אמר אפי' מאה פעמים ביום אמר רבי אחא בר חנינא כל המבקר חולה נוטל אחד מששים בצערו

יצא ר' עקיבא ודרש: כל מי שאין מבקר חולים כאילו שופך דמים. כי אתא רב דימי אמר: כל המבקר את החולה גורם לו שיחיה וכל שאינו מבקר את החולה גורם לו שימות

Visiting the sick is a mitzvah that has no limit... Abaye said that even an important person must visit a lesser person who is ill...Rava said: [you must visit a sick person] even one hundred times a day...Rabbi Acha bar China said: "Whoever visits a sick person takes away one-sixtieth of his suffering...

Rabbi Akiva expounded and said: "Whoever does not visit the sick, it is as if he sheds blood." When Rav Dimi came [from Israel to Babylon] he said: "Whoever visits the sick causes the person to live, and whoever does not visit the sick, causes the person to die." (Nedarim 39b-40a)

In 2015 I visited the famous Grady Memorial Hospital in Atlanta, and was privileged to be given a tour of their new Neurocritical Care Unit, part of the Marcus Stroke and Neuroscience Center (and thank you, Bernie "Home Depot" Marcus).   While the unit has all the fancy equipment you'd expect, what impressed me the most was a feature I had not seen in any other intensive care unit (ICU): every patient room has an adjoining suite where a family member can eat, sleep, shower and wait (and there is a lot of waiting in ICUs). There are no visiting hours; the family member literally lives in the ICU with their loved one.  My tour guide explained that the unit sees the presence of  visitors as a way of offering the best care to the patient. It is a wonderful approach to the care of the sick - but it wasn't always like that.

A History of Visiting the Sick - in Hospitals

Visiting times in hospitals still vary greatly, and many have an open door policy. But not too long ago, you might only be able to visit a patient in a hospital for a couple of hours each week. In the 1870s, Doncaster Royal Infirmary in Britain limited visiting to three afternoons a week - which was a more generous policy than that of the Royal Berkshire Hospital, which allowed only one 15 minute visits twice a week. In a survey of over 400 British hospitals conducted in 1988, over a quarter of those which replied allowed visiting for no more than two hours a day. Perhaps these restrictive policies were in response to some visitors who abused the generosity of Britain's glorious National Health Service:

“[A more open visiting policy] proved to be a disaster, primarily because of abuse of the system by visitors. Many would arrive promptly at 8 am and stay all day. They would bring sandwiches and flasks . . . and camp out by their relative’s bed . . . Others would eat patients’ food, [and] ask for extra cups of tea...there was even a threat of violence from a visitor asked to leave temporarily...”

— Alderman B. Hospital visiting hours. BMJ 1988;296:1798-9.

Help Patients Get Well Sooner - By Visiting Them

In 2006 an Italian group reported the results of a study on the effects of hospital visitors on patient outcomes in its small intensive care unit.  The ICU changed its visiting policy from a restricted one (one visitor twice a day for thirty minutes) to an unrestricted one every two months.  After two years of this alternating policy, the authors compared the outcomes of their 226 patients. Despite significantly higher environmental microbial contamination during the unrestricted visiting periods, septic complications were similar. But the risk of cardiocirculatory complications was twice as high in the restricted visiting periods, which were also associated with a (non-significantly) higher mortality rate. The unrestricted group was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. The authors concluded that "liberalizing the visiting hours seems to be more protective because it is associated with a reduction in severe cardiovascular complications."

Incidence, with Odds Ratio and 95% Confidence Intervals, of septic and major cardiovascular complications in patients enrolled during the restricted (RVP) and unrestricted visiting periods (UVP) adjusted for age, gender, and time of enrollment. RR indicates relative risk; UT, urinary tract; pul., pulmonary; and CV compl., cardiovascular complication. From Fumagalli et al. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial. Circulation. 2006;113:946-952.

Writing in The Journal of the American Medical Association in 2004, Donald Berwick and Meeta Kotogal called for a change in the policy of restricted visiting hours in intensive care units.  They noted three areas which are often of concern to ICU staff when considering the question of visiting hours.  They also noted that although these concerns seem reasonable, the scientific literature tells "quite a different story."

Physiologic Stress for the Patient: "The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress." 

Barriers to the Provision of Care: "The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians." 

Exhaustion of Family and Friends: "The third concern is that constant visiting with the patient may prove exhausting for family and friends who fail to recognize the need to pace themselves. While that does sometimes happen, it is also true that open visiting hours help alleviate the anxiety of family and friends, allowing them to spend time with the patient when they want and to feel more secure and relaxed during the time they are not with the patient. One study found that open visitation had a beneficial effect on 88% of families and decreased anxiety in 65% of families."

A review of visitation policies in ICUs produced by the American College of Critical Care Medicine Task Force went one step further and found "no evidence that pets that are clean and properly immunized should be restricted from the ICU environment." So don't forget to bring the dog next time you visit a family member or friend in the ICU (or anywhere else for that matter). 

“ ...the preponderance of the literature supports greater flexibility in ICU visitation policies. Descriptive studies of the physiologic effects of visiting on mental status, intracranial pressure, heart rate, and ectopy demonstrated no physiologic rationale for restricting visiting. In fact, in seven of 24 patients with neurologic injuries, family visits produced a significant positive effect, measured by decrease in intracranial pressure. ”

— Davidson et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Critical Care Medicine 2007; 35 (2): 612.

How To Visit A Friend Who's Sick - Then, and Now

Most of the evidence about the benefits of visiting the sick that we've been discussing have centered on the ICU- because that's where most of the research has been done. But for most of the time, an ill friend will not be in the ICU, or even in the hospital. Instead they will be at home, so that is where the visit will occur.  Sadly, the ability to be a friend to a friend who is sick does not come easy to all of us.  Here's what Letty Pogrebin noted, in her recent book How to be a Friend to a Friend Who's Sick:

It's not uncommon for people to freeze or panic in the company of misery, botch gestures that were meant to ease, attempt to problem-solve when we have no idea what we're talking about, say the wrong thing, talk too much, fidget in the sick room, sit too close to the patient or stand too far away. Some of us don't visit our sick friends at all...

The Talmud sensed that visitors need some guidelines as to how to behave, and so in the daf that we will learn on Sunday, Rav Shisha suggested the following rule: "One should not visit a sick person in the first three hours of the day or in the last three hours of the day." In addition, the Talmud notes that "one who goes to visit the sick should not sit on the bed nor on a bench or a chair, but instead should wrap himself up in his cloak and sit on the ground, because the divine presence rests above the bed of a sick person." While we may no-longer follow this advice, the suggestion that we take our visits to the sick seriously is one that we should heed. Let's close with some more advice, updated for the modern era, from Pogrebin's 2013 handbook (p86-86):

1. Ask the patient to be honest with you and all their friends.

2. Be honest with yourself about your attitude toward the visit.

3. Think through your role in the visit.

4. Don't visit if you can't abide silence.

5. Be prepared to respond without flinching to whatever scene or circumstances greet you during your visit.

6. Be sensitive to your friend's losses.

7. Talk honestly with your children about the demands illness makes on friendship and how important it is to visit people who want company.

“What is the reward given for visiting the sick in this world? “God will guard him and restore him to life and he will be fortunate on earth, and You will not give him over to the desire of his foes.” [Ps 41:3.]:
”God will guard him” - from the evil inclination.
”And restore him to life” - from his suffering.
”And he will be fortunate on earth”- in that everyone will take pride in him.
”And You will not give him over to the desire of his foes”- for he will have good friends...

”

— TB. Nedarim 40a

Nedarim 31b ~ Great is Milah

In today’s daf we learn of the religious virtues of male circumcision:

נדרים לא, ב

רבי ישמעאל אומר: גדולה מילה שנכרתו עליה שלש עשרה בריתות. רבי יוסי אומר: גדולה מילה שדוחה את השבת חמורה. רבי יהושע בן קרחה אומר: גדולה מילה שלא נתלה לו למשה הצדיק עליה מלא שעה. רבי נחמיה אומר: גדולה מילה שדוחה את הנגעים. רבי אומר: גדולה מילה שכל המצות שעשה אברהם אבינו לא נקרא שלם עד שמל שנאמר "התהלך לפני והיה תמים" דבר אחר גדולה מילה שאלמלא היא לא ברא הקב"ה את עולמו שנאמר כה אמר ה' אם לא בריתי יומם ולילה חקות שמים וארץ לא שמתי

R. Ishmael said, great is [the precept] of Milah (circumcision), Since thirteen covenants were made concerning it.  R. Jose said, circumcision is a great precept, for it overrides the strict laws of  Shabbat. R. Joshua b. Karha said: great is [the precept of] circumcision. For [neglecting] which Moses did not have [his punishment] suspended even for a single hour. R. Nehemiah said, great is [the precept of] circumcision, since it supersedes the laws of Nega'im. Rabbi said, great is circumcision, for in spite of all the commands that Abraham fulfilled, he was not called complete until he circumcised himself, as it is written, “walk before me, and be complete.” Another explanation: great is circumcision, since but for that, the Holy One, Blessed be he, would not have created the universe, as it is written, “but for my covenant (בריתי) by day and night, the laws of Heaven and Earth I would not have established." (Nedarim 31b).

Non-Religiously Motivated Circumcision

Medical circumcision is widely practiced in the US where the rate of male newborn circumcision is about 55%, down from a high of about 62% in 1999, although precise numbers are hard to come by. (This change may be due to an increase in the Hispanic population, which is traditionally non-circumcising.) In Europe the rate varies greatly by country. In Britain about 16% of male babies are circumcised; in Denmark, the figure is less than 2%. Worldwide, about one-third of all male boys are circumcised by the age of fifteen.

In 2012 the Task Force on Circumcision of American Academy of Pediatrics reviewed the scientific literature about the health benefits of male circumcision.  The Task Force concluded that “the preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.”  However, these health benefits were not enough for them to recommend circumcision as a routine procedure for all male newborns - and this position is also held by Britain's National Health Service.  What then, are the health benefits of male circumcision?

Global prevalence of male circumcision. From Male circumcision: global trends and determinants of prevalence, safety and acceptability. World Health Organizations and the Joint United Nations Program on HIV/AIDS, 2007. 

“In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.”

— Technical Report: Male Circumcision. American Academy of Pediatrics. Pediatrics 2012; 130 (3): e756-785.

Sexually Transmitted Diseases – including HIV

In 2005 the first study on the role of circumcision in protecting against HIV infection was published. The study was run in South Africa, where over 3,200 men were randomized to circumcision or no-circumcision. The study was stopped early when an interim analysis showed that HIV infection was 60% lower in the circumcision group. Male circumcision prevented six out of ten potential HIV infections. This was a remarkable finding.  In fact the study team commented that male circumcision provided an equivalent degree of protection against acquiring HIV infection “to what a vaccine of high efficacy would have achieved.”

And male circumcision is not just protective against HIV. It decreases the transmission rates for human papilloma virus (HPV) and herpes simplex virus 2 (HSV-2) in female partners, and the balance of evidence suggests that it also protective against syphilis. (But it doesn’t seem to protect against the two most common sexually transmitted diseases in the US – chlamydia and gonorrhea.) A team from John Hopkins University School of Public Health predicted that if neonatal circumcision rates in the US would fall to European levels of about 10%, the result would be an additional $500 million in healthcare costs. Over a ten year period, there would be more than 4,000 new HIV infections in men and more than 125,000 new herpes simplex infections.

“With an estimated cost per infection averted in the range of $150 to $900 over a 10-year period (depending on the local incidence of HIV infection), male circumcision appears to be one of the most cost-effective preventive approaches, requiring only a one-time intervention.”

— Piot and Quinn. Response to the AIDS Pandemic - A Global Health Model.New England Journal of Medicine 2013. 368;23. 2210-2218

Urinary Tract Infections and Phimosis

Male circumcision also protects against urinary tract infections – but according to the Task Force you’d have to circumcise about 100 babies to prevent one such infection. Phimosis (an inability to retract the foreskin) and other inflammatory problems of the penis are either absent or much reduced in circumcised boys:  “From ages 1 through 8 years, the rates were 6.5 penile problems per 100 circumcised boys over the study period, compared with 17.2 penile problems per 100 uncircumcised boys.”

Penile and Cervical Cancer

Penile cancer is rare, but cervical cancer is not.  Male circumcision reduces the risk of penile cancer by about 50%, and it seems that it also reduces the odds of cervical cancer in the man’s partner (especially if he has had six or more lifetime sexual partners.)

The Risks from Male Circumcision

There are of course risks associated with the procedure of male circumcision itself, but these are rare.  A recent study reviewed 1.4 million male circumcisions and found only 16 cases in which an adverse event occurred, although ten of these were serious.  Overall, the procedure is very safe when properly performed in the first year of life, but complications rise up to twenty-fold if the procedure is performed after infancy. (It goes without saying that the dangerous practice of metzizah  be-peh should never be performed.)

What about life after a safely performed circumcision? Does that change? One recent Belgium study of more than 1,000 men,  “circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis).” A Danish study found a similar result: “circumcised men …were more likely to report frequent orgasm difficulties…and women with circumcised spouses more often reported incomplete sexual needs fulfillment.” These were however, individual studies, and in 2013, the Journal of Sexual Medicine published an exhaustive meta-analysis of 36 publications describing the effects of male circumcision on aspects of male sexual function. It found no evidence overall "for any significant difference in components of sexual function, sensitivity, sexual sensation, or sexual pleasure in men who are circumcised and men who are not." Furthermore, it examined several studies of men circumcised in adulthood, which are of particular research interest since these men serve as their own control.  In this group too, the meta-analysis failed to find any adverse effect of circumcision on the parameters examined. 

The Costly Investment of Brit Milah

The medical benefits of male circumcision are well documented, and its risks are small. But none of these benefits were known to those who first introduced the ritual, and anthropologists wonder why circumcision, and other painful and irrevocable rites of passage, should be so common across cultures.  One possible answer comes from the theory of costly investment.

This is based on the finding that religious, ethnic and tribal groups that demand more from their members do better in the long run than those that demand less. These groups have to ensure that all members contribute equally, and that there are no “free-riders” – those who are taking from the group but not giving back. One way to weed out the free-riders is to demand a costly and irrevocable investment in order to join the group – and that investment might be circumcision, tattooing or scarification, all of which are used as a means to induct new members. Once the costly investment is made, a person will be less likely to leave the group. Joseph Henrich, from the departments of Psychology and Economics at the University of British Columbia, has a term for these investments: credibility enhancing displays (CREDs):

Participation in rituals involving costly acts will elevate people's degree of belief commitment. If the professed beliefs involve group commitment, cooperation toward fellow in- group members, or the hatred of out-groups, then ritual attendees will trust, identify and cooperate with in-group members more than non attendees.

...In learning how to behave and what to believe, learners give weight to both prestige and CREDs, among other things. Thus, successful cultural forms, especially those involving deep commitment to counterintuitive beliefs, will tend to begin with and be sustained by prestigious individuals performing CREDs. Cues of prestige influence who people pay attention to for learning, while CREDs convince them that the prestigious model really believes (is committed to) his or her professed beliefs. The “virtuousness” arises from these prestigious individuals' role as models. CGS [Cultural Group Selection] will favor, over long swaths of historical time, religions with role models who effectively transmit beliefs and practices that strengthen in-group cooperation, promote intra-group harmony and increase competitiveness against out-groups. 

From Henrich, J. The evolution of costly displays, cooperation and religion: credibility enhancing displays and their implications for cultural evolution. Evolution and Human Behavior 2009; 30: 244-260.

Nelson Mandela's Ritual Circumcision

Whether or not Brit Milah is just another credibility enhancing display, it is a very widely practiced ritual- and extends far beyond the Jewish and Muslim communities.  The late great Nelson Mandela recalled his own circumcision (at the age of 16!) in his autobiography: 

When I was sixteen, the regent decided that it was time I became a man. In Xhosa tradition this is achieved through one means only: circumcision.  In my tradition, an uncircumcised male cannot be heir to his father's wealth, cannot marry or officiate at tribal rituals. An uncircumcised Xhosa man is a contradiction in terms, for he is not considered a man at all, but a boy...

The night before the circumcision there was a ceremony near our huts with singing and dancing. Women came from the nearby villages, and we danced to their singing and clapping...At dawn, when the stars  were still in the sky...we were escorted to the river to bath in its cold waters, a ritual that signified our purification before the ceremony...We were clad only in our blankets, and as the  ceremony began, with drums pounding, we were ordered to sit on a blanket n the ground with our legs spread out in front of us...I could see a thin elderly man emerged from a tent and knee in front of the first boy...The old man was a famous ingcibi, ad circumcision expert...

Suddenly, I heard the first boy cry out: "Ndyindoda!"   (I am a man!), which we were trained to say at the moment of circumcision...before I new it, the old man was kneeling in from of me...without a word he took my foreskin, pulled it forward, and then, in a single motion, brought down his assegai...I felt fire shooting through my veins; the pain was so intense that I buried my chin into my chest. Many seconds seemed to pass before I remembered the cry, and then I recovered and called out, "Ndiyindoda"...A boy may cry; a man conceals his pain...I was given my circumcision name, Dalibunga, meaning "Founder of the Bunga,"...

Jewish Criticism of Milah

Among the most vocal critics of the practice today are those who are born Jewish. But circumcision has been criticized for as long as it has been practiced, and these self-criticisms are not new.  In the 1780s, a British Jew (who wrote anonymously) published a pamphlet called A Peep into the Synagogue, in which he was critical of many Jewish practices.  And his most scathing words were those he penned about circumcision:

In the extravagant Catalogue of Jewish absurdities, there is not one more shameful than that of Circumsition [sic], it is a barbarous violation of the principles of Nature,  For what can be more unhuman, than to punish an Infant by a cruel operation on a part of its body, done by a bungling Butcher of a Priest! Or what can be more insulting to all-wise Creator, than for a stupid Fool of a Fellow, to presume to correct His workmanship, by finding one superfluous part, and taking that away to reduce the subject to perfection. (Anonymous. A Peep into the Synagogue, or A Letter to the Jews. London, undated.) 

The Joy of Milah

Although it is under attack in Europe and is less popular than it has been US, circumcision remains a time for joy for the many faith communities in which it is practiced. The ritual is often accompanied by feasting and gift-giving, whether it is performed in Muslim or Jewish communities, or by members of African tribes.  The Talmud explains why, for Jews, the ritual is one that is associated with so much joy. It is an explanation that is as simple as it is profound:

שבת קל, א

 תניא רשב"ג אומר כל מצוה שקיבלו עליהם בשמחה כגון מילה דכתיב "שש אנכי על אמרתך כמוצא שלל רב" עדיין עושין אותה בשמחה

It was taught in a Baraisa: Rabban Shimon ben Gamliel says: Any commandment that the Jewish people accepted with joy - like circumcision, as it it written: "I rejoice over your word like one who finds great spoils" [Ps. 119:162]  - they still perform with joy...(Shabbat 130b.)

Nedarim 20b ~ Blushing and Shame

נדרים כ, א

תניא "בעבור תהיה יראתו על פניכם" זו בושה "לבלתי תחטאו" מלמד שהבושה מביאה לידי יראת חטא מיכן אמרו סימן יפה באדם שהוא ביישן. אחרים אומרים כל אדם המתבייש לא במהרה הוא חוטא, ומי שאין לו בושת פנים בידוע שלא עמדו אבותיו על הר סיני

It was taught in a Baraisa: "So that the awe of Him will be on your faces" (Ex. 20:17). This refers to the characteristic of being susceptible to shame [since bushing is that which is noted "on your faces". The verse continues] "So that you will not sin". This teaches that shame leads to the fear of sin.  From this [teaching] they said it is a good sign for a person to be [easily] embarrassed. Others said that any person who feels embarrassed will not quickly sin. And if a person is not [the kind of person who is] embarrassed - it is known that his ancestors did not stand and Mount Sinai. 

Detail from A Girl with a Black Mask by Pietro Antonio Rotari

Charles Darwin called blushing "the most peculiar and the most human of all expressions." It occurs when the face, ears, neck and upper chest redden on darken in response to perceived social scrutiny or evaluation. It is this feature of blushing - that it is seen on a person's face, that leads the Baraisa on this daf to understand the verse "So that the awe of Him will be on your faces"as referring to blushing. And as the commentary of the Ran explains, it is because blushing is so easily seen by others, that is serves to prevent a person from sinning:

מלמד שהבושה מביאה לידי יראת חטא, דעל פניכם משמע בושת פנים,  וכתיב בתריה לבלתי תחטאו 

WHEN DO WE BLUSH?

There appear to be four social triggers that result in blushing: a) a threat to public identity; 2) praise or public attention 3) scrutiny, and oddly enough, 4) accusations of blushing. This last trigger is especially fascinating: just telling a person that they are blushing - even when they are not - can trigger a blush. 

Blushing is not only triggered by certain social situations; it also triggers other responses in those who blush. The most commonly associated behaviors are averting the gaze and smiling. Although gaze aversion is a universal feature of embarrassment, its frequency differs across cultures: in the United kingdom 41% report averting their eyes when they are embarrassed, whereas only 8% of Italians report doing so. Smiling is also a common response. Up to a third of those who are embarrassed display a "nervous" or "silly grin." 

“The blush is ubiquitous yet scarcely understood. In the past it has attracted little scientific attention and it is only in recent years that it has begun to attract systematic scientific attention.”

— Crozier and de Jong. The study of the blush. In Crozier and de Jong (eds.) The Psychological Significance of the Blush. Cambridge University Press 2013.

WHY DO WE BLUSH?

It is unclear why humans blush. Of course, we blush when we are embarrassed, but why should this physiological response occur? The blood vessels in the face (and the other areas that blush) seem to differ structurally from other vessels, and so respond in a unique way. But just how they do so, and why, remains a physiological mystery.  Here's the surgeon Atul Gawande's explanation, from the pages of The New Yorker.

Why we have such a reflex is perplexing. One theory is that the blush exists to show embarrassment, just as the smile exists to show happiness. This would explain why the reaction appears only in the visible regions of the body (the face, the neck, and the upper chest). But then why do dark-skinned people blush? Surveys find that nearly everyone blushes, regardless of skin color, despite the fact that in many people it is nearly invisible. And you don’t need to turn red in order for people to recognize that you’re embarrassed. Studies show that people detect embarrassment before you blush. Apparently, blushing takes between fifteen and twenty seconds to reach its peak, yet most people need less than five seconds to recognize that someone is embarrassed—they pick it up from the almost immediate shift in gaze, usually down and to the left, or from the sheepish, self-conscious grin that follows a half second to a second later. So there’s reason to doubt that the purpose of blushing is entirely expressive.

There is, however, an alternative view held by a growing number of scientists. The effect of intensifying embarrassment may not be incidental; perhaps that is what blushing is for. The notion isn’t as absurd as it sounds. People may hate being embarrassed and strive not to show it when they are, but embarrassment serves an important good. For, unlike sadness or anger or even love, it is fundamentally a moral emotion. Arising from sensitivity to what others think, embarrassment provides painful notice that one has crossed certain bounds while at the same time providing others with a kind of apology. It keeps us in good standing in the world. And if blushing serves to heighten such sensitivity this may be to one’s ultimate advantage.

BLUSHING AND CROSSING BOUNDARIES

So blushing may confer an advantage. It keeps us in good social standing, insuring that we do not step outside of the bounds of accepted behavior. This notion is supported by some recent work (published more than a decade after Gawande's 2001 article) that supports this notion of blushing having a social utility.  Those who blush frequently showed a positive association between blushing and shame. These frequent blushers generally behaved less dominantly and more submissively. Writing in the journal Emotion in 2011 (yes, that really is the name of this academic journal), three Dutch psychologists demonstrated that blushing after a social transgression serves a remedial function. In their (highly experimental lab) work on human volunteers, blushers were judged more positively and were perceived as more trustworthy than their non-blushing counterparts.  

But Not All Shame is Useful

While there are useful features of shame, it also has negative effects.  Perhaps the best documented of these is shame as a cause for delay in many types of medically recommended examinations that involve the parts of the body usually kept private.  Interestingly, other types of shame that are an impediment to timely medical testing is the shame that the symptom might turn out to be from a "trivial cause" (though in my many years serving in the emergency department, I recall no patients exhibiting this kind of embarrassment).  

Negative consequences of fear of embarrassment on health. From Harris. Embarrassment: A Form of Social Pain. American Scientist 2006. 94; 524-533.

Do Monkeys Feel Shame?

In a 2006 paper, a group of researchers demonstrated that primate color vision has been selected to discriminate changes in skin color - those changes (like blushing) that give useful information about the emotional state of another.  But does this mean that non-human primates feel shame? That's a harder question. 

“The primate face and rump undergo colour modulations (such as blushing or blanching on the human face, or socio-sexual signalling on the chimpanzee rump), some of which may be selected for signalling and some which may be an inevitable consequence of underlying physiological modulations.”

— Changizi, Zhang and Shimojo. Bare skin, blood and the evolution of primate colour vision. Biology Letters 2006. (2) 217.

Frans De Waal directs the Living Links Center at the Yerkes National Primate Research Center at Emory University in Atlanta. In his wonderful book The Bonobo and the Atheist (guess which of these he is), De Waal discusses emotional control among primates - and in particular, the role of shame. When a human feels shame after a transgression, "we lower our face, avoid the gaze of others, slump our shoulders, bend our knees, and generally look diminished in stature...We feel ashamed and hide our face behind our hands or "want to sink into the ground." This is rather like the submissive displays made by other primates: "Chimpanzees crawl in the dust for their leader, lower their body so as to look up at him or turn their rump towards tim to appear unthreatening...shame reflects awareness that one has upset others, who need to be appeased."

Only humans blush, De Waal writes, and he doesn't know of "any instant face reddening in other primates."

Blushing is an evolutionary mystery... The only advantage of blushing that I can imagine is that it tells others that you are aware of how your actions affect them.  This fosters trust.  We prefer people whose emotions we can read from their faces over those who never show the slightest hint of shame or guilt. That we evolved an honest signal to communicate unease about rule violations says something profound about our species. (The Bonobo and the Atheist, 155.)

And then De Wall makes a remarkable observation, one which seems to have first been observed in the Baraisa with which we opened:

Blushing is part of the same evolutionary package that gave us morality.

So it turns out that evolutionary biologists, psychologists, and social scientists, while they may disagree on some details, agree on one feature of the emotion of shame. It is a vital emotion for any ethically sound society. Which is precisely what we learned in this daf:

 ומי שאין לו בושת פנים בידוע שלא עמדו אבותיו על הר סיני

And if a person is not [the kind of person who is] embarrassed - it is known that his ancestors did not stand and Mount Sinai. 

[See also Talmudology on Ketuvot 67b, from where some, but not all, of this post is taken.]