Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Sunday, August 26, 2012

On Tattoos

Two news stories, separated only briefly in time, recently caught my attention. In the first, a possibly deranged neuroscience graduate student named James Eagan Holmes walked into the midnight showing of the summer's blockbuster in Aurora, Colorado, and murdered a dozen innocent theatergoers, as well as injuring 58 others. This was widely reported. Less well known was a follow-up story: a tattooist in Roanoke, Virginia (at the wonderfully named Asylum Studio) donated his piercer’s commission to a victim's fund. Come in, get a tattoo, and we’ll send money to help the injured.


Two weeks after the Aurora killings, a Neo-Nazi skinhead named Wade Michael Page walked into a Sikh temple in Oak Creek, Wisconsin, murdered six worshippers, then exited and shot a policeman before turning a gun on himself. News reports after the shooting say that he had a 9/11 tattoo, as well as a "14" in Gothic lettering superimposed on a black cross. The "14" referred to the “14 words” apparently cherished by white supremacists: "We must secure the existence of our people and a future for white children."


Both stories feature assault rifles in the hands of the seriously deranged, slaughtering the innocent: terrorist activity, not in Iraq or Afghanistan, but on American soil. The message of terrorism is the same everywhere: you are not safe. The public space is no longer a safe place. Power comes out the barrel of a gun. According to a something called Security Director News, "the massacre could be a Virginia Tech for movie theaters, causing security to become a bigger part of the conversation and more stringent security procedures to be adopted at theaters across the country." The insecurity industry, as ever, looks for new ways to dominate our lives.


But it was the second part of both stories that caught my attention: the way in which tattoos colored both stories. In the first case, an altruistic response to a tragedy; in the second, a code for something dark and xenophobic, manifest in the inked skin of a dead man.


This got me thinking about tattoos, which I rarely think about, perhaps because I have none. I have never cared much for the irreversible, and tattoos are the essence of irreversibility. If, at one time, I grew my hair long, had a mustache my fiancé insisted I remove as a condition of marriage, and on occasion wore a polyester leisure suit (ugliness personified), well then all of those fashion statements were readily reversible. It is harder to remove a tattoo: laser bleaching is only moderately effective, and leaves your skin blotchy.


And -- the medical oncologist in me is ashamed to admit -- I just don't like needles. It isn't a phobia, just a dislike. I don't care much for coffee either. 


I’m also in the wrong age group. Tattoos are a generational marker. In my youth the only people who got tattoos were marines, sailors, and drunken college students. Today, if surveys are to be believed, somewhere over a third of those aged 18-29 have tattoos. One of my colleagues told me that her child had gone to a birthday party recently where temporary tattoos were handed out as party favors. I can only imagine my parents’ response had I come home with one when I was 10 years old.


Once a mark of individuality and rebellion, tattoos are well on their way to becoming a new form of social conformity. Tattoos are so ubiquitous that tattoo parlors now use mass-produced patterns, copyrighted designs sent to tattoo artists as "flash," a fascinating new form of industrial design. Can tattoo advertising be far behind? How long before the enterprising rent out a left arm to Coca Cola, and a right to Apple?


My own very square Midwestern town, or so Google tells me, is awash in tattoo parlors, with names like Metamorphosis, Artistic Skin Designs, and Monster-Ink. Do they sub-specialize, like medical oncologists? Do they attract differing clientele? I’m sure some sociologist has studied these things, but they are a mystery to me.


Tattooing is an ancient art.  The oldest tattoo found to date belongs to Otzi the Iceman, dating to 5300 years ago. Egyptian mummies have tattoos, as do mummies found in the Andes. The Roman Empire tattooed soldiers, slaves, and gladiators to prevent their desertion.


Modern tattooing was introduced (or re-introduced) to the West by sailors returning from the South Pacific. The word “tattoo” itself is an import, from the Samoan “tatau,” as first reported by members of Captain Cook’s expedition. For a long time tattoos were a rarity. Melville makes a point of describing Queequeg’s tattoos in Moby Dick as a sign of his otherness, his apparent savagery, to his 1850’s reading audience.


Tattoos have long had a religious component. The Maoris of New Zealand considered tattoos a storage container for one's "tapu," or spirit being, while awaiting our passage to the afterlife. Something sacred, in other words. In the Middle Ages Croatian Christian tattooed their children with crosses to prevent forced conversion to Islam (an early form of identity-theft prevention).


Modern religions differ on tattoos: Sunni Islam forbids, and Shia Islam allows, tattoos. Hinduism endorses tattoos, while Jews eschew them.


If tattoos are sometimes on the side of the angels, they clearly distinguish some of society’s less social members. Japanese Yakuza tattoo themselves, as do Russian mafia members and South LA gangbangers.


What all of these things have in common is the establishment of identity. We ink to define. Usually the defining is voluntary, but sometimes it is imposed. Nazi guards at Auschwitz wore SS tattoos with pride, even as they inflicted serial numbers on the forearms of their victims (with letter coding: A and B for Jews, Z for Gypsies, AU for Soviet prisoners of war). SS tattoos became a lethal liability in 1945, as Germany’s enemies closed in for the kill.


Tattoos may be a source for regret, as occurs today with aging gang members trying to escape a life of violence. Aging itself is a source of regret for the tattooed. We get fat, we sag, the colors fade over time, and the name of the beloved at age 19 is not always the same name as at age 50.


Tattoos have an interesting medical history. I was always taught, when evaluating someone with jaundice, to enquire as to their tattoo history: Hepatitis B is transferable with dirty needles, and tattooing has been implicated in HSV, tetanus, staph, TB, and HIV transmission at one time or another. Most recently, as reported in the New England Journal of Medicine, an outbreak of atypical mycobacterial skin infections was traced back to contaminated tattoo ink.


Doctors are occasional tattooists: my breast cancer patients frequently bear tattoos placed by radiation oncologists to define the radiation ports, and some gastroenterologists have recommended the use of tattoos to identify the area where rectal polyps were removed as an aid to subsequent cancer surgery.


Tattoo needles have also been used for vaccination; I saw an article suggesting their use in an intradermal technique for DNA plasmid inoculation, which was said to induce stronger humoral and cellular immunity.


The tattoos I bear, I suspect, are the mental ones, the experiences and beliefs inked onto my frontal cortex. Many have them: my mother died when I was six, I'm a cancer survivor, I lost my child, I was raped, I was fired after years of faithful service, I was subjected to the horrors of war. No laser can remove them. Mental tattoos, not mental jewelry or a mental hairstyle, mark us all, sooner or later: life happens.


Mark us, but do they define us, like the ones inked into ours skins? Are they truly irreversible? Perhaps. "I am a part of all I have met," said Tennyson's wandering Ulysses. But is all we have met part of us? The patients I see in clinic differ enormously in their response to potentially life-ending illness. Some come to define their existence in terms of their cancer diagnosis: BC and AC, before and after cancer.  For others, time’s healing properties, or their own inner constitution, rapidly remove cancer’s ink from the mind’s dermis.