A tattoo on the brain

In his brilliant 1993 satire “Et Tu, Babe,” Mark Leyner proposed a new concept in body art, which is the specialty of “visceral tattoos.”   The narrator travels to Mexico where his chest is opened and the insignia of a “guy surfing a wave of lava, wearing polka-dotted trunks,” is tattooed directly on his heart.  The dye used shows up on CT scans and apparently women, especially x-ray technicians, love it.   Superficially, a jest at those who indelibly paint their skin, Leynor’s parody is an allegory to the brutal invasiveness of healthcare.  Going even further, we must understand that medicine often causes deep injury beyond that of the flesh.  That injury is a tattoo of the mind.

When someone is treated for disease, their body is invaded.  We open someone’s chest and replumb the vessels of the heart, remove and rebuild a breast, reconstruct a larynx, open the skull to remove a cancer, resect and reconnect inflamed bowel or simply use a scope to repair a knee.  With these procedures, a person is healed, fixed and often cured.  They are whole and pure again.  Perhaps … but what about the mind?

Any invasion of the body that scars bone, muscle, and vessel, also scars the mind.  An imprint on the spirit if you will, changing us at the deepest level.  The psychological damage may be slight, just a little irritation, to be tucked away and never again considered.  Sometimes the cut is so deep, so profound, that the person becomes forever a patient transformed, always wounded.  The emotional ghost of the invasive act is a complex visceral picture stamped on conscious and unconscious mind, like the residual image of a brilliant flash bulb to the eye.

How can we predict how deep a wound may become, and how much it may transform? Is it the person or the act?  It was just a minor procedure, a one day stay in the hospital, not really much pain, rapid recovery, she was back to work in two weeks, but somehow the wound buries deep into the core of a mind changed forever, a deep pain that never heals.  Stage 1 melanoma … take out the ovaries …  a near lethal aneurism … no big deal … really?

Such transformative wounds humiliate and confuse.  How do you tell those that you love that though you are cured you are still in pain?  How does one say, “I am different.” Should you not just be happy to be alive, and healthy?  It is time to enjoy life and get back to the day-to-day!  The world knows that you are well.  Why does it not feel that way?

I have a patient who is born again healthy.  His diverticulitis was treated with two surgeries, heart disease bypassed, prostate cancer in remission, hip replaced, cataracts removed, laryngeal polyps gone, hypertension controlled, hearing aids fitted and ulcers healed.  He is perfect and has a fine prognosis.  Nonetheless, he is a shell of the man who raised children, built a career, reveled in sunsets and deeply loved his wife.  A posttraumatic skeleton.  Empty, depressed, nervous … the surgeon’s brand burned into his mind.

The critical lesson for doctors is the deep psychic affects of even successful therapy.  Physicians must be aware that we invade not just the body, but also the psyche, leaving behind transformative images of pain, humiliation, and fear.  This means choosing therapies carefully, educating well and giving care gently.  It requires engaging with each patient after it is “over” to help him or her reconnect and heal.  It means being aware that very long after the procedure, the invasion, wisps of suffering remain deep inside.

As family and friends of patients, we must also remember that healed and Healed are not the same thing.  Just because the body is better, does not mean that the mind has followed.  We need empathetic support and understanding long after the crisis has past.  New trauma or stress can release demons, and we must all be aware and sensitive, for yesterday’s surgery is tomorrow’s pain.

Finally, as patients we must understand we have been changed.  There is something brutal about invasive medical care, which may affect us deeply. We must be gentle with ourselves and realize healing is more than tissue deep.  Healing is of the mind, and may in part take a lifetime.  A wound hard to expect, a sore slow to mend.  If we are not cautious, it can change our soul.  A tattoo on the brain.



  • Cindy Cedrone
    Thank you Dr Salwitz for confirming to me what I already knew to be true.You hear what we say as your patients and you completely understand.
  • Liz
    Bravo! A wholistic look at conventionally treated people. Love reading your weekly rounds.
    • James Salwitz, MD
      Thanks. I guess no matter how someone is treated they are "whole" people, until we change them. jcs
      • I overheard a conversation where a doctor initialed a woman's uterus..or cervix after surgery..truth or fiction?
        • James Salwitz, MD
          Seems pretty unlikely ... pathology departments get upset about those kind of things. jcs
  • Eileen Burns McNally, RN
    You stated what I know in my heart to be true after many health issues. I'm not the same person though I look fine. I do think it's a form of post-traumatic stress. Now I get anxious even if I'm only going to have blood drawn. I never before could understand that but I can now... Thank you for voicing this...
  • aw
    Your article is brilliant ! My mother, sister, cousin and I had breast cancer. I developed, what I coined.."post traumatic breast cancer disorder" Every bald women, compression sleeve, pink ribbon(s), month of October and my 6 month follow up care evoked a flooooood of emotion. I am now 2 months out from elective bilateral mastectomy and feel peace and freedom for the first time in 6 years.. My oncologist, anesthesiologist and surgeon were the holy trinity.
    • James Salwitz, MD
      PTBCD ... not an easy way to live. I am very happy to hear you have found freedom and are able to get beyond that plague. Keep up the walk toward wellness. jcs
    • Supposedly many sexual cancers can initiate problems PTSD similar to rape..I believe Dr. Susan Love made that observation...
  • For successful recovery, doctors should treat physically as well as psychologically. They have to earn patient's trust.
    • James Salwitz, MD
      Very true. Real trust does indeed need to be earned which takes patience and listening. jcs
    • Even more than that. Serious study of cause and affect of various psych. disorders could help prevent many negative problems.
  • stacey vespoli
    Dr. Salwitz, you put into words what I have been feeling. Thank you. I always feel better after my office visits with you. Thank you for being such a warm and caring doctor. sv
    • James Salwitz, MD
      I too am honored. jcs
  • I too have a tattoo on my brain. In January I suffered a heart attack and now am the owner of a stent. Having lived with an over- stimulated, hyper-aroused nervous system(fibromyalgia) this new condition of heart disease my brain is forever altered. Although I have been studying and writing about neuroplasticity and the ways in which I can change my brain it isn't happening yet. Post traumatic stress, hyper-vigilance, generalized anxiety plague me daily. You have captured it all in this blog. I am eternally grateful.
    • James Salwitz, MD
      Thanks for your comment, although I am distressed to learn of your experience. Sudden heart problems frequently cause complex emotional change, which can be very hard to "get your head around." It does get better, but can be tough. Hang in there, jcs
  • A very good post! Before my breast cancer diagnosis I had a call from my older sister..her husband was in the ER...blacked out at the wheel driving he had to pull over. She called the doctor and kind of tricked him into going there. She herself has many physical and spiritual scars from numerous surgeries, tests, treatments. I left work after overtime everyday to see and check on him. He needed bypass surgery..not even 50 but any competent doctor would have been able to guess that by looking at him. He had been in the hospital a year earlier for kidney stones..had tests etc. No heart issues. He sat in a room for a week while arrangements were being made..appointment with a cardiologist..getting anxious..feeling fine basically . Decided he would like to go home. My sister called frantic..asked me to try and stop them from releasing him. I showed up early Saturday morning..he was still sleeping,,just watched and looked at him. So handsome, over 6'3", a former paratrooper in the 82nd..married at 20 ..He woke up. He smiled that stupid grin he always gave me. I asked him why he did not just stay put. He said he felt fine and before he had surgery he had to go to work and clean out his locker, move an old and get a new refrigerator...etc. His, or one of his primary care doctors came in and spoke to him while I sat there..and was releasing him. I went nuts. I ran after the doctor in the hall and asked him if he even talked to him or listened to what he was saying? He patronized me and assured me he was a big boy and good make his own decisions. I was in shock at his glib comment etc. My Dad showed up to drive him home...I was exhausted. Started some early bleeding..menstrual I though from the stress...three days later I had a miscarriage. I was out of the hospital and back home, made some cole slaw for Rich, my husband took it over. Friday night. The next call I received was from my nephews Mother in Law. He and my sister were at the police station..they were trying to resuscitate him. He was in the car with her driving, and, well, from there I went to the hospital and saw my younger brother outside in tears, we held each other. He was DOA. I went into the hospital..three doctors standing with my intimidated traumatized sister, the partners, one I fought with, cardiologist, "well do .want an autopsy!!".. I punched the metal file next to me. During a scan from having the miscarriage the resident oncologist saw something on my liver that was brought to his attention and I was to report to him for follow up. A hemangioma but I asked for full work up and mammogram. My cancer was found during the mammogram..same day as the wake. I will never recover. I know that!
    • Holy Cow! I thought I'd been through a lot. I hope you are able to rest. Maybe a part of getting it back together is to talk about what you've been through to whomever will listen. One day your brain will absorb what has happened. I look at things a little differently maybe than most because I would be proud of that brain tattoo. Sure you're forever different but that doesn't have to be a bad thing. Honor yourself for getting through all you've been through. That tattoo is like a badge of honor.
  • Liz
    After the surgery for cancer #1 (breast cancer) my mom said, "The doctor said they got it all so you can put this behind you and get on with your life". Now that it is 10 years later, most likely this is correct (although I have now had it on the other side along with several other cancers) but at the time I hadn't even really begun to adjust to the fact I had been hit with cancer, let alone be able to put it behind me. I was still in the psychiatric emergency stage of the diagnosis. The thing my mom didn't understand is that cancer can be (and for me was and still is due to getting so many of them since then) an emotional earthquake. While cancer is not who I am (and I think this is why I hate the BC pink ribbon, define yourself by having had BC expectation, I am so thankful my other cancers don't do that), it is what I had and have, and it has left its mark. I think it took me about 4 years not to think about it every single day the first time around. Of course when I look in the mirror and see the scars - that serves as a reminder as well... Besides the immediate damage from the emotional earthquake, the emotional earthquake aftershocks can hit unexpectedly at times... one day running the math to figure out how much I can put in a Roth RIA and realizing that the fact that I have not saved enough for retirement isn't going to matter (one of my cancers has no cure), realizing, at a relative's 90th birthday party, that I will never know if I would have hit 99 or 104 like some of my relatives had not cancer hit, wondering if I will outlive my cats or if my cats will outlive me knowing my kid will not keep them (too painful to think about her so I think about my cats)... often these snippets hit without warning and sometimes tears flow once again. But of course this emotional earthquake process also functions like grief - the moments of pain become shorter and shorter and further and further apart, although any given episode of pain is not necessarily any less painful. Putting it all behind me and getting on with my life as if this had never happened would be lovely. I think that ending is only in story books though and someone forgot to write me into that story LOL. Instead there is the tattoo on the brain and sometimes a dagger in one's heart.

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