As Deep As Life Itself: The Birthmark Revisited

Dr. Robert A. Norman

In Nathaniel Hawthorne’s short story “The Birthmark” the mad scientist Alymer uses an elixir to remove a miniscule birthmark from the face of his beautiful wife Georgiana. In his attempt, he kills her.

"Aylmer," resumed Georgiana, solemnly, "I know not what may be the cost to both of us to rid me of this fatal birthmark. Perhaps its removal may cause cureless deformity; or it may be the stain goes as deep as life itself. Again: do we know that there is a possibility, on any terms, of unclasping the firm grip of this little hand which was laid upon me before I came into the world?"

"Dearest Georgiana, I have spent much thought upon the subject," hastily interrupted Aylmer. "I am convinced of the perfect practicability of its removal."

In his obsessive insecurity, Aylmer projects a need for perfect order in everything, including his wife’s face.
He is the ultimate in seeking control and thus the ultimate loser. The world Aylmer inhabits is a small world within worlds in which he senses the absence of blemishes represents beauty. If only Aylmer had been free of his obstinate pathology and felt a real, triumphant love, such as the love of Georgiana for Aylmer, a love that conquers all of her self-interest and devotes itself exclusively to the happiness of her husband. In the end Aylmer can find no redemption for his own guilt, and finds himself paradoxically looking into a forever flawed image.

Hawthorne noted Aylmer’s love for his wife to be “intertwined with his love of science." (Hawthorne, 203) Hawthorne described a young scientist who killed his own wife by pursuing "perfect future" (Hawthorne, 220). Perhaps Aylmer loved science even more than his own wife and to sacrifice her life for a perfect look on her face, for “perfect science,” was a justifiable step. I believe Hawthorne was not against science; he was against "perfect science," and against people like Aylmer who could not separate himself from his science.

Hawthorne paints the idea that Nature is equal for everyone, because there is no perfection in nature. He writes, "Nature, in one shape or another, stamps ineffaceably on all her productions." (Hawthorne, 205) Georgiana was a beautiful woman, and the birthmark on her face is what kept her in a perpetual balance with Nature. Hawthorne proves that any attempt to remove it should and would result in disaster. It is the ultimate cautionary tale. Nature, in all its randomness, can only be changed or altered at a price.

What price should be paid to even attempt perfection, and who should determine it? Primum non nocere. First, do no harm. In the case of the 29-year-old Iranian conjoined twins Ladan and Laleh Banji, what do we say about their iatrogenic deaths under the guidance of 12 surgeons, four radiologists, and 100 medical support staff? Did they have the full right to decide? Did Georgianna decide? She only agreed she wanted to please her husband.

Hawthorne’s insight into dreaming is, in fact, a wake-up call. "Truth often finds its way to the mind close muffled in robes of sleep, and then speaks with uncompromising directness of matters in regard to which we practice an unconscious self-deception during our waking moments." (Hawthorne, 207) Hawthorne foresaw (perhaps in a dream) what technological advances and how important science was becoming in our lives. He also understood how a false trust in science could evolve. Aylmer thought he was competent to remove the birthmark, "I feel myself fully competent to render this dear cheek as faultless as its fellow; and the, most beloved, what will be my triumph when I shall have corrected what Nature left imperfect in her fairest work!" (Hawthorne, 207) Also, "Aylmer appeared to believe that, by the plainest scientific logic, it was altogether within the limits of possibility to discover this long-sought medium." (Hawthorne, 211)

However, science can never solve all the problems, nor can humans develop such a science. Even Aylmer himself, in his experiments, admitted, "Much as he had accomplished, she could not but observe that his most splendid successes were almost invariably failures, if compared with the ideal at which he aimed. His brightest diamonds were the merest pebbles, and felt to be so by himself, in comparison with the inestimable gems which lay hidden beyond his reach." Aylmer had realized this himself, that’s a reason why he "can scarcely glance over and keep [his] senses." (Hawthorne, 214) All the great scientific discoveries are originated from great failures, but often people can only see the successes, not the failures. Perhaps more fundamentally, Hawthorne was revealing an essential truth, that a person can be a good scientist but an abysmal failure as a human.

Science will advance, step by step, but will never reach a "perfect science." The pursuit of "perfect science" can often lead to disasters because people live "once for all in eternity; to find the perfect future in the present." (Hawthorne, 220)

Nathaniel Hawthorne saw in his era’s fascination with scientific methods, apparatus, and experiments an arrogant temptation, not to learn more about the world and to improve it, but to play God. Aylmer is very much a product of this age of invention, with nothing too complicated or too profound for him to understand.

Aylmer’s mindset looks at nature and sees not beauty or symmetry, but imperfections that must be corrected. From a human perspective nature can seem very imperfect, with blight on our plants, or birth defects in our children. We abhor the ravages of disease or the devastating effects of natural disasters. Our first impulse is to do something about them, if the ability to do so lies within our power. Aylmer’s wife Georgiana has a birthmark that he believes he can surgically remove, and consequently he becomes obsessed with doing it. Although we would look at Georgiana’s birthmark as being something quite benign and harmless, to Aylmer it is an imperfection, and imperfections need to be eradicated or fixed.

Hawthorne assures us, on the other hand, that Georgiana’s birthmark is no flaw, but the clear evidence of the loving touch of the hand of God. As Hawthorne says, "Georgiana’s lovers were wont to say that some fairy at her birth hour had laid her tiny hand upon the infant’s cheek, and left this impress there in token of the magic endowments that were to give her such sway over all hearts." It is only Georgiana’s birthmark, actually, that proves she is not really a sort of divinity, not an angel encased in flesh, but thoroughly and wholly human.

But Aylmer does not want to see her humanity; humanity is inherently flawed, and he wants perfection. Aylmer is used to seeing the world, not as a miracle or wonder, but as a code waiting to be cracked, and he cannot see Georgiana’s birthmark in any positive way. It mocks him because he is a scientist and she is his wife; he should be able to make her absolutely flawless. And perhaps if she were flawless -- if he could fix her birthmark today, her wrinkles tomorrow, her osteoporosis forty years from now -- technically, she need never die.

Aylmer sees, after trying a few less-drastic measures, that the birthmark is not going to fade easily, and yet he continues with ever more invasive measures even though he knows -- or must know -- how dangerous the final procedure could be. It is hard to understand why he persists in his attempts, and he withholds from her the information of the operation's risks. And finally, Georgiana is lost. “The crimson hand, which at first had been strongly visible upon the marble paleness of Georgiana's cheek, now grew more faintly outlined. She remained not less pale than ever; but the birthmark with every breath that came and went, lost somewhat of its former distinctness. Its presence had been awful; its departure was more awful still. Watch the stain of the rainbow fading out the sky, and you will know how that mysterious symbol passed away.”

But all becomes clear when we see that it is Georgiana herself that is the imperfection. As human beings we are flawed; it is as much a part of our nature as beauty is. Certainly Aylmer does not consciously recognize that the inevitable cost of eradicating the imperfection would be to eradicate Georgiana, but nonetheless that birthmark symbolizes her very human life. As Hawthorne puts it, "It was the fatal flaw of humanity which Nature, in one shape or another, stamps ineffaceably on all her productions, either to imply that they are temporary and finite, or that their perfection must be wrought by toil and pain." Hawthorne’s story illustrates the sin of overextending our reach from the realm of the natural into that of the divine.

Aylmer is the forever seeking, forever-blind man of science attempting to learn Nature, and to taste the apple of perfect knowledge. Unfortunately, he is doomed to be blind forever and to lead others to their demise. Men like Aylmer will continue to be born, will continue to seek, and will continue to be punished and punish others.

And the modern media continues the portrayal of this never-ending pursuit. The show “Nip/Tuck” perhaps represents the current perfection-seeking story, a cautionary tale populated by two unscrupulous Miami plastic surgeons and boatloads of neurotic patients who are searching desperately for surgical cures for their insatiable unhappiness. Other television shows have fed the national obsession for eternal youth, including the reality show, “Extreme Makeover” which dished out liposuction and nose jobs to ordinary people. But Nip/Tuck has fed the powerful delusion of the baby-boomer generation in the most graphic way ever, with breast augmentations and buttocks implants and hot sex scenes performed to the tune of pounding rock music.

In each episode of this dark satire the consultations begin with the plastic surgeon requesting, “Tell me what you don’t like about yourself.” One of the patients, an aspiring model, states, “I don’t want to be pretty. I want to be better. I want to be perfect.” The showcased talented surgeons rarely improve lives with their nips, tucks, and more aggressive procedures, let alone save them.

In similar fashion, what is the purpose of our biomedical research? Can we ever find a silver bullet? A "silver bullet" is the perfect drug--one that zeroes in on a specific disease and eliminates it 100% of the time, with zero per cent side effects. And in the modern age, hopefully it’s cheap to produce and is put on all the HMO and hospital formularies.

Paul Ehrlich first used the term to describe his anti-syphilis drug Salvarsan. Penicillin came close to being the only real silver bullet in medical history in the days before antibiotic resistance. The more recent attempts at "silver bullets," including monoclonal antibodies, are plagued by tremendous expense, side effects and lack of efficacy. A silver bullet against all diseases, particularly cancer, is a monstrous undertaking. We must “shoot to kill” while swimming genetically upstream on a therapeutic boat. The roaring current, beating us down with the years of diseases that have persevered, may be insurmountable. Yet we will never give up.

One cannot help but be humbled when probing the mischievous creatures and maladies that have populated our history with their sordid triumphs. Bacteria such as syphilis have been married to human history. Not just the corkscrew shaped bacteria responsible for the infection that we call syphilis, but the tuberculosis that is the major killer in the world today. Should we not put our efforts into having a modicum of health for everyone? Or should we put our energy into the ephemeral yearnings of life for those who can afford all the beauty that the needle and laser can provide us? It is a personal decision perhaps more so than ethical, but I think it is one that each of us must consider.

I have often daydreamed while in front of the keyboard about my own profession’s existence. I wonder about the not too distant future dermatologist’s office, devoid of any trace of life as we have known it. Advanced technological devices are hooked up into every electrical orifice. Patients come and go, often in less time than it takes a laser beam to penetrate a tattoo.

Our pharmaceutical reps are still out to help us, right? Behind the scenes, they are spending the money that we generate for them on personal agendas, such as lobbying the makers of M and M’s to make the new M and M color titanium dioxide and yellow to match the 40 mg isotretinoin acne tablets. Therefore the transition between eating the candy to swallowing the acne medicine will be a smooth one.

While the dermatologists of the future are basking in the light of their computer screens, teledermatology having taken over much of direct patient care. (The new slogan— “If you were a dermatologist, you could be home by now” Or “Why not live like a radiologist? Never leave the comforts of your own home.” ) The pharmacists and mid-level practitioners will be providing vaccine injections for skin cancers and most dermatological diseases.

When dermatologists can no longer differentiate a Malphigian from a melanocyte, their differential diagnosis skills atrophied, fading into distant reservoirs in their cerebral cortexs that slowly dry up under the cosmetic sun, when they all have become an advanced esthetician with limited academic foundation to serve as a springboard for intellectual endeavors, when the creeping knowledge that their fundamental skills have evaporated like yesterday’s cryotherapy spray, after their brains are too scrambled with the selling points of their lotions and creams and snake oils, when they can’t tolerate being on the ephemeral see-saw of what is cosmetically fashionable, when the fact that their upcoming laser machine bills are coming due gains purchase in their mind, perhaps they will awaken to the fact that their inner Aylmer has taken over. When what we think of now as exotic becomes mediocre, it may be too late to turn back.

In a little known Dermatobiblical passage, it is written, “wrinkles are filled, knowledge fades.” Remember all your years spent examining and studying the human body, weaving intricate tapestries of shave-sharp therapeutic acumen and piecing together patterns of signs and symptoms? What about all the years our predecessors spent with direct patient care and wrote down their findings? And we are the jockeys of researchers, who have diligently struggled so that we can jot down remedies on prescription pads and get free CD’s at the medical meetings. The respect and honor for our profession and those that have provided for us may fade under the crunch of technology’s tires.

I have often turned away potential patients because of image issues. Red flags often rise high while I talk with those that are requesting procedures to please someone other than themselves, have ideals of social perfectionism, the morbid dissatisfaction of body dysmorphic syndrome or other deep emotional scars, or have general unrealistic expectations. Botox and chemical peels may improve your sense of self-esteem but rarely saves a floundering marriage.

What about the patients who don’t want cosmetic procedures and have the common sense to not always look for medical cures for their unhappiness? Often they have real concerns--skin cancers, horrible acne, or miserable psoriasis—and there are those that care for those needy souls.

I am not a cosmetic Luddite. I’ve Toxed a few rhytides and made leg telangiectasias disappear. But everything in moderation, my friend. Our medical knowledge separates and elevates us from those scurrying around in every Fountain of Youth Clinique of Cosmetics in the country. We are all trying to make a buck, and cosmetic payment is as primitive an exchange as you can have—here’s what I do for you and here’s how you pay me. Very little government and insurance interference. The HMO’s and National Health plans and lawyers are about as subtle dealing with medical care as someone going after a mosquito with an ax. But we always have problems, no matter what era; it’s the nature of the physician-patient political beast.

Technology, as anyone of you who has spent considerable time on the computer knows, can be both a wonderful asset and a stubborn master. Choose wisely.

“Alas! it was too true! The fatal hand had grappled with the mystery of life, and was the bond by which an angelic spirit kept itself in union with a mortal frame. As the last crimson tint of the birthmark--that sole token of human imperfection--faded from her cheek, the parting breath of the now perfect woman passed into the atmosphere, and her soul, lingering a moment near her husband, took its heavenward flight. Then a hoarse, chuckling laugh was heard again! Thus ever does the gross fatality of earth exult in its invariable triumph over the immortal essence that, in this dim sphere of half development, demands the completeness of a higher state. Yet, had Alymer reached a profounder wisdom, he need not thus have flung away the happiness which would have woven his mortal life of the selfsame texture with the celestial. The momentary circumstance was too strong for him; he failed to look beyond the shadowy scope of time, and, living once for all in eternity, to find the perfect future in the present.”

What have our great teachers written on the subject? In Section VII, number 87, the last aphorism of Hippocrates, he writes, “Those diseases which medicines do not cure, iron (the knife?) cures; those which iron cannot cure, fire cures; and those which fire cannot cure, are to be reckoned wholly incurable.” Some things are better off left alone. Hippocrates also wrote, “Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult.” No one ever said it was going to be easy, and certainly attempts at perfection are frivolous.

What would Sir William Osler say? He has got to be palpating himself in his grave, wondering what has happened to diagnostic and clinical skills. Rejoice in the truth there will always be a treponema or a birthmark. How boring life would be otherwise! What is it that draws your eyes to the screen while gazing at a nature show? The alligator while it rests silently in the sun? No. The chase! The struggle to survive! The survival of the fittest! The imperfections!

In the book Nature’s Chaos, written by James Gleick with photographs by the physician/photographer Eliot Porter, Gleick writes,” The essence of the earth’s beauty lies in disorder, a peculiarly patterned disorder, from the fierce tumult of rushing water to the filigrees of unbridled vegetation.” Gleick, in his fervor for fractals and chaos theory, states the “motivating contention of the new science of chaos theory is that such seeming irregularities can be contemplated, sorted, measured, and understood. Traditionally scientists looked for a more conventional order in nature and treated the erratic as a side issue, an unpredictable and therefore unimportant kind of marginalia. Now scientists are more willing to look directly at the irregularity. In similar fashion, when we try to tame any perceived human disorder (including birthmarks) we must have some inherent sense of orderliness in our vision and perception of nature. However, I submit that the essence of human beauty lies in its unpredictability, a pathology that draws our divine attention, an irreverent, captivating punch line almost imperceptibly delivered.

“We’re so busy finding out if we could that we never stopped to find out if we should,” Dr. Ian Malcom (Jeff Goldblum) states in the movie Jurassic Park. I find this statement a great summary of how we have plowed ahead, trying to discover a remedy for every one of life’s built-in deformities, and rarely pause to question the price in both economic and life quality terms.

Without the sickness we cannot appreciate our golden health. I doubt there is a reader that has not rejoiced at his or her own revival after a bout of sickness or trauma. I am happy there will always be a birthmark. I cherish the little imperfections of life, the physical and mental foibles that make us humble, make us laugh, and make us the most fully human and wishing to tell our stories.