by Hilton Als
On the second try, the G-tube was properly installed. I fed it every four hours, a total of four times a day, with formula—think baby formula—and an equal volume of water. After trial and error with brands and caloric distributions, I settled on Fibersource HN, 300 calories and 13.5 grams of protein, a product of Nestlé, the same company that gives the world Gerber baby food, Häagen-Dazs, Kit Kat bars, and Purina Dog Chow. On the package, offset within an attention-grabbing oval graphic, was the word “unflavored,” which made me wonder: Are there flavored enteral feeding formulas? Other than on our tongues, we have taste receptors in the palate, larynx, and upper esophagus—but in our stomachs?
G-tube meals meant no muss, no fuss. No food prep. No risk of aspirating or choking. No smoothie stare-downs. No marital discord over what or how much was consumed. One feeding to the next, it was the same comforting routine: fill beaker with water; spread towel on lap; crush pills, add water, stir; shake and unseal two containers of Fibersource; pour formula into a second, empty beaker; clamp G-tube to prevent stomach contents from escaping when opening valve; open valve; unwrap fresh syringe, dip nozzle in formula, withdraw sixty centiliters; insert nozzle securely into valve; gently push plunger. The syringe empties slowly, and the formula gently pools in your stomach. If you “plunge” harder, the formula surges, the jet pelts your pink insides, and you feel the stomach lining flinch. That’s all the sensation there is. Pleasure, satisfaction, beauty never crossed my mind.
I devoted myself to the G-tube. Feedings were inviolable. The dietician prescribed eight eight-ounce containers daily. Eight is an auspicious number in Chinese culture.
After ten weeks of daily infusions at 2,400 calories and 108 grams of protein, I cracked 120 pounds. At the rate of two pounds per week I could hit my target, 150, in four and a half months.
From my journal, March 29, 2012: “Woke, fed tube, went to acupuncture, came home, fed tube, napped, fed tube, emailed, fed tube.” In the locution of the cancer ward: Your only job is to get better.
I am astonished, now, at how many of my first memories of places are related to food: goose in Hong Kong, lardo in Florence, cherrystones in Boston, pizza in New York. And milestones, too: my fortieth at ABC Seafood, my son’s graduation at Lupa, my mother-in-law’s seventieth at Providence, my daughter’s haircut party at Hop Li. I fondly remember the ham-and-Swiss sandwich at Bay Cities, the crispy-skin cubes of pork belly at Empress Pavilion, the roast-duck noodles at Big Wing Wong, the grilled prime rib at Campanile, those perfect bites of charred, almond-and-olive-wood smoky, tapenade-smeared meat dabbed in flageolet beans and braised bitter greens.
With the G-tube, I did not eat—I fed the tube. My mind did not equate the formula with food, as other patients do—how could I confuse the two? Goose in Hong Kong is a meal, not a feeding; the table is laid with utensils, not a syringe; one dines, not feeds.
I’d been feeding the tube for three months when a PET scan showed, in the words of Dr. L, “hypermetabolic activity that is asymmetric.” That meant trouble. A PET scan measures bodily functions, such as glucose metabolism, using a radioactive tracer; cancer cells, which require lots of sugar, light up the scan. That night, feeding the tube seemed futile. Why bother if all that five hundred containers of formula yielded was more disease?
I was referred to another ENT, who strode into the examination room and, without introduction, threaded a light and camera up one nostril and down my throat. On the color monitor my throat showed up gray instead of carnation pink.
In the world of abnormal healing, he said, my case was abnormal. He doubted my ability to heal.
I can’t say if he was seated or standing, I just remember him towering over me, and me wondering why he wouldn’t stop talking.
The day would come, he went on, when I would have to choose between speaking and swallowing. He didn’t elaborate and I didn’t ask. I just wanted to leave before he said any more.
Later, I turned to my wife for answers. Since when were talking and swallowing optional? And how did one go about choosing? A pros-and-cons list?
In the end, a surgeon made the choice for me. Radiation and chemo had failed me, the cancer was back, and the only option left was a total laryngectomy, in which the entire larynx is removed and the airway is separated from the mouth, nose, and esophagus. In the operating room, the surgeon reattached mouth to esophagus rather than mouth to trachea and reconstructed the upper esophagus as a funnel of flesh with skin from my thigh.
If it had been up to me, I would have chosen the same. Swallowing, every time. I imagined the first thing I would eat—hot ramen noodles searing my throat on their way down.
From an early age I had learned the price of things, a consequence of growing up in an immigrant household. “How mucha cent?” was one of my mother’s signature English phrases. She wanted to know the cost of things to take your measure: Had you been duped? How big a fool were you? Her brain worked like The Price Is Right, all goods were pegged to a number, and if your purchase went over, she would click her tongue; if it was under, she would say, “Waaaa!” and you would feel golden. Of the oncological deal she would have said, “Waaaa!” Anything in exchange for the rest of your life is a good value.
You take that deal every time.
The cost has been steep, though. I breathe through a hole in my neck; my nose and mouth serve no respiratory function; I can’t talk; I can’t whistle, moan, sigh; I can’t scream (once, while cooking for my wife and daughter, I cut myself badly and jumped away from the cutting board shaking my hand, silently spraying blood); I can’t smell anything, not bacon, not diesel fumes, nothing; mine is a vestigial nose, on my face solely for looks. And I can’t eat, either.
Now that I’m at some remove from the surgery, I wouldn’t mind being replumbed, having my windpipe hooked up to my mouth. At least then I could sing again, blow out candles, laugh at my daughter’s jokes. This eating thing has been a bust. I’m a hundred percent Fibersource via the G-tube. When someone texts me a photo of their lunch, if I happen to be feeding the tube and feeling bitter, I text back a photo of a beaker of ecru formula with the empty container posed close by: “Here’s mine.”
“Do you miss it?” my wife asked me recently. She meant eating at restaurants, dinner parties with friends. She had just polished off takeout sushi from a new restaurant that we would have already visited, back in my eater days. Her postmeal rundown was enthusiastic at first—the rice was the perfect temperature, as if the chef had factored in the time it took her to transport the food home. But then she seemed to lose heart and the review sputtered, her voice taking on an apologetic tone.
Four years ago, after living crisis to crisis for so long after the surgery, it finally seemed safe to exhale and dig out of the chaos. It was time to reclaim a measure of normalcy. I was going to surprise my wife with a dinner out with our daughter. We were celebrating our wedding anniversary, after letting the past few slip by virtually without notice. I made a reservation at Connie and Ted’s, a New England seafood shack in West Hollywood. The menu was right up my culinary alley—raw bar, steamers, chowder—but I would go as a bystander.
It hadn’t occurred to me that people would stare until I walked into the restaurant. I hadn’t been out in public except for doctor’s appointments and walks in the neighborhood. While I was getting dressed, my wife had asked if I planned to wear a scarf to hide the tracheostomy tube that poked from my throat. As we were seated, I wondered if she had asked for my comfort or hers.
At the table, though, we were back to the old normal, studying the menu in forensic detail. “They have Fanny Bays,” my wife said, reading off the oyster list. “And Malpeques. Or is it Malaspinas that you like?” Our dinner out came crashing down around me. What did it matter which bivalve I preferred? I was here only to window-shop.
My wife was undeterred. She ordered enough food for three adult eaters. Nothing says festive like a crowded table, and she was determined that I not withdraw to the fringes of the party. She wo
uld eat the oysters, and I would sip the liquor from the shells. For my entrée she ordered Rhode Island clam chowder. It was undeniably briny and clammy, easily the most delicious thing I’d tasted since I stopped eating. But I didn’t take a second spoonful. We were out in public now. I couldn’t take in liquid without dribbling on my shirt. I wouldn’t embarrass us here.
My wife couldn’t maintain her good cheer. By the time the entrées arrived, she was overwhelmed by the accumulation of food—lobster roll for her, squid for the kid—joining the We’re still working dishes that remained on the table.
In the photos of that night my daughter looks wretched. She was nine, and had entered the stage in which smiles for the camera are self-conscious, betraying little of what is going on inside. Even with a just-delivered plate of fried clams and french fries in front of her, her eyes mirrored how the rest of the table felt: We wished we were far away.
We faked it, played at dining out. We pretended that cancer was behind us, throwing a scarf over it. Whenever we remember that dinner, my wife says, “Never again,” and I flash the thumbs-up: I’ll drink to that.
People dine. We eat consciously, looking, tasting, smelling, gauging texture and temperature. We share. We talk. My wife and I seemed to talk differently when there was food between us. We loved restaurants, loved to go out and indulge in the rituals of a shared meal: settling in at our table, scanning the room, dissecting the menu, faking our knowledge of wine. After our orders arrived, we dug in, tasted each other’s dishes, critiqued the kitchen’s hits and misses. For hours we sipped and chewed.
Do I miss it?
I can tell you that eating nice food and drinking good wine with my wife was the best thing ever. In my memories of dinner together we are enveloped in gilded light that seems to emanate from the table’s 720 square inches and the plates of food and glasses of red wine between us. “Communion,” “spiritual,” “intimacy,” come to mind as words to describe these moments.
I can also tell you that chewing was glorious. Swallowing was king. I can remember specific dishes and name the ingredients, but I can no longer tell you what it felt like with a platter of Dungeness crab on the table, what the sight of the orange carapace, the aroma of garlic, ginger, scallion, aroused in me. I can’t relate to the old, eater version of me. I don’t remember how it feels to be in the presence of food and crave it, want to own it, or how it feels to know its pleasure and anticipate having that pleasure again. I can’t relate to that kind of beauty anymore.
I am told that cancer has not changed the essential me. “You’re still David,” my wife says, tactfully omitting the rest of the sentence: despite physical damage and eroded quality of life. As much as I love her for saying that she sees me past the wreckage, I think she’s lying, at least a little, because from in here things have changed. Five years without a morsel of food passing between my lips has made me a stranger. Seeing food now doesn’t make me hungry; neither does reading about it or thinking about it. Drop a steak in front of me and what am I going to do? Will my mouth water or my blood pressure rise, my pleasure centers spark in my brain? None of this happens, because it can’t. A plate of rib eye might as well be behind the glass of a Hall of Mammals diorama.
At home, in my kitchen, I watch the dog eat. She puts her head down and doesn’t come up for air until she’s emptied the bowl. All day she wants food, and as soon as food arrives, it’s gone. She has all that mouth, all those teeth, all that jaw, and she doesn’t chew, just mindlessly inhales the premium kibble. It’s textbook carnivore behavior, I know, brutal at its core, tear and swallow, take in the largest hunks that won’t choke you. All the dog does is ingest a substance for the sole purpose of loading up the gastrointestinal tract: the same joyless thing that I do. Breathe, I would tell her, if I could. Sniff. Relish the chicken-and-liver recipe. Chew.
Amit Majmudar
Five Famous Asian War Photographs
from Chicago Quarterly Review
That Nameless Afghan Girl on the Cover of National Geographic
Her eyes are green because they had to be green for the photograph to mean anything to us.
Her eyes’ intensity, and their hunted look, depend on their greenness (and, admittedly, a slightly disproportionate size relative to the rest of her face). Recessive eye colors are associated by people of European origin with people of European origin, and hence with a fully developed personality. Her face loses the one-sidedness so often read into the Asian both by SEAL teams and college admissions committees: the default Asian, depending again on the eyes, “looks like” either a religious fanatic or an uncreative overachiever. But not an Asian with green eyes; such an Asian is set apart. Green eyes add mystery and a sense of recognition simultaneously. Green eyes, in the setting of this otherwise standard refugee-face, create instant empathy, forcing us to imagine, in this most unexpected place, Someone Like You or Me.
Of course, her green eyes are themselves a recessive trait. They penetrated that far east of Europe, or south of Russia, in the forced injections of genetic material brought about by the British Army’s invasion in the 1800s or the Red Army’s in the 1900s. Or the Macedonian Army’s in the 300s bc, or the United States Army’s a couple of millennia later. The girl is nameless; she does not exist, she represents. So there is a possibility our empathy for the Afghan female in wartime is being aroused, when we look at this photograph, by the genetic trace of the ancient rape of an Afghan female in wartime.
That Guy in Saigon Who Is About to Get His Brains Blown Out
This is a photograph that has a clear precedent in painting: Goya’s The Third of May 1808, in which a row of Napoleonic soldiers have lined up firing-squad-style in front of a group of Spanish resisters. The center of the group is that unforgettable man in the white shirt with his arms up. The left sleeve (the right is obstructed by the head of a fellow Spaniard) is the second brightest spot in the painting, slightly brighter than its own light source, the small box that the soldiers have set down to illuminate their targets. The brightest white in the painting belongs to the tiny sliver of the white in his eyes. His eyes are open, and his head is tilted, as if he were pleading, or about to plead. This is a man who might be shot in the next instant—but then again, he might simply be arrested.
The guy in Saigon who is about to have his brains blown out has no arms at all; the twisted front of his shirt would suggest they are bound behind him, but in the photograph, his shoulders taper abruptly into nothingness. He cannot throw his arms up in surrender, and he cannot throw his arms across his face in futile defense against the blast. He is, literally, an unarmed man getting shot.
This is only one way in which the photograph improves on Goya. The second aspect is the intimacy. Firing squads had to be five to eight strong: military men knew that a few of the soldiers always shot wide on purpose, and that the close-quarters executions were psychologically sustainable only if the soldiers could offload the guilt onto their neighbors in the squad: his bullet made the actual kill, not mine. Even this pseudo-anonymity takes a toll on soldiers; hard as it may be to believe, the nervous breakdowns of SS men in Polish forests prompted Himmler’s shift from conventional, bullet-based massacres to the gas chambers. The Saigon picture is much more intimate, with two men foregrounded.
Goya does not show us the executioners’ faces; the Saigon photograph shows us the shooter in profile, and his chin is unexpectedly weak. His weak chin has a clear relationship to the smallness of his pistol. The guy about to get shot is unarmed, but the guy shooting him is unmanned. These details articulate visually a very basic, widely held truth about a soldier who kills a civilian: it is an act of weakness; it marks an inadequate man, who did not deserve to be granted the strength and dominance of the soldier. His weapon has shrunk in his hand, just as he is about to shoot. He is, in a sense, impotent.
The photograph also benefits from the surreal fast-forward effect of the civilian’s face. Parts of his face are a few seconds in advance of the rest of the photograph. The
re seems to be blood about his mouth, and his right eye, closest to the pistol, has already shut.
Douglas MacArthur Wades Ashore in the Philippines
Several photographs were taken of this apparently staged procession from various angles, showing various water levels along the pants and boots, which must have been terribly soggy afterwards. The one that is most widely circulated, however, shows the general and several cronies from the right, facing away from the camera. They are still close enough to the boats for the boats to be seen in the background, and the water is roughly knee level. Most importantly, however, the shore is not included in the frame. MacArthur is actually wading the Pacific itself, with the mighty tread of an aroused giant. He is walking from left to right, which on a map would be from east to west—from the Philippines, toward Japan.
The brim of his hat parallels the upward angle of the prow immediately behind him. He is at once the white American avenger and the flagship of the Pacific fleet, the instrument of American vengeance. (The atomic bomb, that supreme Vergeltungswaffen, hasn’t been built yet.)
To these Americans, treading the ocean floor, the Japanese home islands will be less than sandbars. In the photograph, MacArthur’s pants seem dark to the hips, but later photographs of him on the sand prove that he was never more than knee-deep. He was set down very close to this quiet Leyte beach, on an island secured much earlier—by Marines who waded through water at navel level or higher, their rifles over their heads, taking fire.
That Buddhist Monk Who Has Set Himself on Fire