Mary Cappello

by Swallow: Foreign Bodies

  A Catastrophe of Childhood: Gastric Lavage

  Endoscopy without anesthesia, general or local, depends largely on the personal equation of the endoscopist, the perfection of his teamwork, and the confidence the patient has in him and his team. A silent, darkened room helps.

  —CHEVALIER JACKSON, Diseases of the Air and Food Passages of Foreign-Body Origin

  You’re old enough to understand what I’m saying. Will you open it now by yourself or shall we have to open it for you?

  —WILLIAM CARLOS WILLIAMS, “The Use of Force”

  Without Chevalier Jackson, I probably would never have learned that the medical term for “stomach pumping” is “gastric lavage.” I never realized that the evacuating of the contents of a stomach by the pump is afterward followed by the doctor’s sending a substance—a saline solution—back into the stomach through the hose to, in effect, “clean the stomach out.” I certainly couldn’t have remembered this detail from my own experience of having my stomach pumped at age four, because all that I can bring back from the episode, bring forth but never up, is a mutated sense of scale.

  At the scene of the tube introduced into my mouth, I became infinitesimally small until finally I disappeared (this happened at the point at which the tube touched down into the stomach, then pulled). Meanwhile, a pair of hands became large as the room itself—fat man hands—and the rubber insert, no doubt slender as a drinking straw, morphed to the size of a vacuum cleaner hose, enormous, thick as an elephant’s trunk, and black, much too large for my child mouth, wide as the moon but practically no greater than the circumference of a dime. Not black—probably the tube was amber, the color of garden snails my father drowned in amber-colored beer; black was the color of the hose attached to the basement sink that my mother used to wash my hair, a hose attached to the faucet and to the fear of being sucked down the drain.

  I remember taking a swig of bubble bath, and I remember that I was sitting on the toilet as I drank. Such a delightful feeling to be in that room of aqueous bubbles and play, to feel something coming in and going down at the same time that something else went out. The bubble bath was called Soaky, but I always called it Sody, as in soda pop. It was my brothers’ bubble bath, the bottle the shape of a fat-bellied sailor whose hat screwed off to access the soap. Such a friendly sailor. I loved his rosy face and knew that it was him I wished to eat. I was thirsty. I uncapped the bottle and drank.

  My mother tells me that I’d eaten an enormous lunch of soup and sandwich and more that day—I was ravenous. She’d never seen me so hungry. (There must have been a lot of stuff to pump.) When I came down from the bathroom, bubbles emerged from my mouth. The Poison Control Center was no help because the rotund sailorman bottle with his edible-seeming buttons and his grin, loopy and wide as his girth, bore no words: no ingredients could be found.

  And then the day resolved itself into a yellow teacup. My mother gave me milk in it to drink as she carried me, running to the hospital. And it was delightful to my mind, this bobbing yellow teacup, but she was worried and was running with me in her arms.

  Objects offer a resolution or a sense of coalescence to a self in disarray. Something collects inside an object, is filled, fulfilled, and held. If a child cannot find himself in the distracted response of a caretaker, he might look instead into the button eye of a doll. When the black irises of a stuffed toy elephant faded entirely to white, I implored my father to paint the black back on. Objects are more sentient to children than they are to adults, as though for those to whom life is more raw, less lived, everything is alive. Objects help children to imagine and then experience the real; they play a part in their own feeling real.

  Objects hold us and hold our attention. What do you wish this object to do for you? The “transitional object”—for example, the blanket that must accompany the child everywhere—holds a special place in the ego’s developing lexicon of self and things, the me and the not-me. “It comes,” Winnicott writes, “from without—from our point of view—but not so from the point of view of the baby. Neither does it come from within; it is not an hallucination.” This strange thing, held in suspension, holds a baby in a place of becoming, between time. A human subject can concede something to an object, according to Winnicott, and when a baby attempts to bite the head off her doll, she is testing the extent to which the world can withstand her.

  In an X-ray of a baby’s throat, a jackstone marks the torso’s spot like an X in a pirate’s map of buried treasure. In a girl’s throat, the toy dog detached from a charm bracelet faces the right direction and so seems animated—it’s motivated to romp down her throat (see figure 17). The dog that the three-year-old girl had swallowed in case #689 is not really a dog, but Chevalier Jackson is keen to identify the place and position of the object’s anatomy: “metal dog, four buried prongs, tail and three legs deeply anchored in esophageal wall; point of seizure, hind leg, tail being covered by tube-mouth during withdrawal” (DAFP, 169).

  Now I just don’t know how one set of humans—adults—forces or coaxes the mouths of another order of humans—children—to open. Doctor-poet William Carlos Williams took on the problem in a story called “The Use of Force” with such a sense of surreal domestic violence—the tortured tourniquet of familial love—you’d think you were reading Kafka. The story uncannily echoes the details from another contemporary modernist’s tale, the Russian doctor-writer Mikhail Bulgakov’s “The Steel Windpipe.” Both stories feature a type of girl-child, idealized (blond ringlets and all), who reminds their narrators of a mass-produced photogravure of femininity, the girl’s perfectly round, rosy-cheeked face an advertisement for a chocolate bar or a brand of cocoa (see figure 18). But she only appears this way at first because, in one case, she has a high fever, and in the other case, she’s struggling to breathe: in both cases, she’s entirely unwell—these girls have contracted diphtheria.

  Fig. 17. Fbdy 689, the case of Annie Z., age three, toy dog in esophagus, February 28, 1919. Radiographer, Dr. Willis F. Manges (1876-1936). Collection of the Mütter Museum, The College of Physicians of Philadelphia.

  Fig. 18. How do you get a child to open her mouth? Chevalier Jackson Papers, 1890- 1964, MS C 292, Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, Maryland.

  In Williams’s story, the doctor needs to see the child’s throat in order to confirm his diagnosis, and the narrative, unsentimental as an abstract painting, coolly rehearses the struggle between the child-patient as a withholding runt (in the story’s words, a “savage brat”) and the exasperated doctor. The child’s combination of vulnerability and intractability—to say nothing of her parents’ role in figuring the doctor/healer as the enemy—drives the doctor’s need to triumph in this battle of knowledge and of wills.

  How to get the child to unclench? Longing for her “muscular release,” determined to “take a look,” he works himself into a blind fury. The girl devours him with her stare; he grinds his teeth. She knocks off his glasses with a catlike swipe—she’s as strong as a heifer. At the doctor’s command, the father holds the girl’s wrists, but no sooner has the doctor slipped the tongue depressor in than she’s reduced the stick to splinters. “Burning with the pleasure of attacking the child,” determined now to protect the world from her and her family’s idiocy, “in a final unceasing assault,” the doctor “overpowered the child’s neck and jaws,” she gags, and he’s in.

  Reciprocity is out of the question in this visceral contretemps: the doctor wins not only the physical battle but also the child’s “secret.” She gives it up to him, the telltale “membrane” that reveals her illness—and it’s hard not to read it as a substitute hymen (the fact that both Bulgakov’s and Williams’s girl patients are unusually attractive makes the doctor’s conquest all the more suspect; it helps figure doctoring as a form of violation and defilement).

  The doctor will make a mess of the girl—that’s the sense one has in Bulgakov’s gruesome and even raucously comi
c tale of a bungling, unskilled, unpracticed young country doctor who knows the only way to save his wheezing girl is by cutting into her throat and inserting a steel tube. “You did the operation brilliantly, Doctor!” one of his assistants insists, even though he nearly killed the child. He knows nothing, really, and his medical practice is a sham, but the benighted country folk believe he possesses the knowledge of a wizard (they think he saved his patient by replacing her real throat with a throat made of steel), and his nearly botched tracheotomy earns him a booming practice.

  In both stories, the relation of doctor to patient is a strictly adversarial one—no compassion or ethics of care are to be had, and the only difference is that the doctor in Williams’s tale seems to hate the child as much as he despises her complicitly stupid parents, whereas Bulgakov’s physician appears to loathe the family more.

  The girls in these stories of forced entry, of prying in the name of care, lose something to their male doctors, but it’s also the case that the girls know something about the doctors that no one else does. “But Lidka [the girl patient] had no wish to speak with me,” Bulgakov’s story closes, while others sing his praises. She bears the wound, this wound of his that was “quite unlike any [medical] illustration.”

  Jackson’s contemporary doctor-writers figure pediatrics as an arena of ferocity, resistance, marked by a tug of war over ownership of the body, and the question of whether a child can retain bodily integrity and be cured at the same time. Maybe what makes the outcome of these stories as impossible as getting a child to open her mouth is that, while each girl is treated and cured, she also remains fundamentally betrayed.

  I still don’t know—and I want to know because I seem to need to remember what was done to me—how adults force or coax the mouths of children to open. A friend answers not with words but with a gesture: with her thumb and forefinger she closes her nose, and as she does this, her mouth, of course, opens. I have no memory of how the fat man hands got me to give them entry to my mouth, or even if they did it in a “here comes the train” sort of way. Of course no child is fooled by the train trick but agrees to make his tongue a trestle because he likes the idea of it and would prefer a miniaturized train inside his mouth to a forkful of peas.

  Jackson takes a different course:

  Inducing a Child to Open His Mouth: The wounding of the child’s mouth, gums, lips, in the often inefficacious methods with gags, hemostats, raspatories, etc., is entirely unnecessary. The mouth of any child not unconscious can be opened quickly and without the slightest harm by passing the mouth opener . . . between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx. This will cause the child to gag, when his mouth invariably opens. (DAFP, 191)

  What I don’t understand is how he gets the lips to part.

  This is what my brother, who was seven at the time, remembers from the hospital: “You screamed bloody murder.” This is what my mother remembers: that in the emergency room, the nurses and the doctors told her she couldn’t come into the room with me. She heard me crying, and afterward, when they put me in her arms, I was a mass of sweat and matted curls. When I collapsed into her arms, crying, she cried too.

  I remember—but can’t be sure it’s true—the command to swallow.

  “Swallow.”

  “Swallow.”

  “Swallow.”

  Someone said it more than once and with different intensities each time, different lilts, until my eyes went gooey and the room filled up with birds.

  So much afterward would need to be sorted: the forcing of an instrument into the throat is one kind of swallow, and the benighted, greedy, absentminded swallowing of food into an empty gullet or a hollowed-out gorge is another kind of swallow.

  Jackson explains that a person about to be entered through the mouth clenches his fists and contracts his forearms, both of which effect a tensing of the neck that makes the mouth hard to open, to say nothing of the throat. The tongue, he reminds us, is a “powerful muscular organ” (DAFP, 186), “most persons don’t know how to relax,” and muscular rigidity can hamper ease of access or a skillful endoscopist’s “knack” (DAFP, 189). With children, however, “their rigidity does not interfere seriously with the work of the operator who has acquired the essential knack” (DAFP, 191).

  The “knack” is a complicated, multipart skill. Here he describes it for entry into the mouth and the back of the throat in inspecting the larynx:

  The larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. Failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. The spatula should glide slowly along the posterior third of the tongue until it reaches the glosso-epiglottic fossa, while at the same time the tongue is lifted; when this is done the epiglottis will stand out in strong relief. The beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx. The elusiveness of the epiglottis and its tendency to retreat downward are readily mastered. The passage of air makes bubbles that assist in finding the glottis; but the patient must be warned; otherwise fear of asphyxia will increase his muscular tension and resistance. Overextension of the patient’s head is a frequent cause of difficulty. If the head is held high enough extension is not necessary, and the less the extension the less muscular tension there is in the anterior cervical muscles. Only one arytenoid eminence may be seen. The right and the left look different. Practice will facilitate identification, so that the endoscopist will at once know whether to move the lip of the laryngoscope to the right or the left to expose the interior of the larynx. Excessively wide gagging may increase muscular rigidity and crowd downward the mandible and hyoid tissues onto the laryngeal orifice. Of the difficulties that pertain to the operator himself the greatest is lack of practice. He must learn to recognize the landmarks even though a high degree of muscular contraction be present. The epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind’s eye, for it is only on deep, relaxed inspiration that anything like a typical picture of the larynx will be seen. (DAFP, 190)

  Most patients can’t do what is necessary to enable an instrument to pass into the throat because this would require “relaxing to limpness” (DAFP, 184). Most people can’t get into a rag-doll state prior to or during a procedure, but what remains of them following forced entry into the mouth is a state more closely resembling a doll’s than anything else. Endoscopy brings on “severe fatigue” in a child, “resulting in a deep sleep” (DAFP, 200).

  Following the pumping of what probably amounted to a teaspoon of mild soap as accompaniment to a heaping lunch, I was undone, spent, finished, beaten, exquisitely fallen, draped. I was self-forgotten, gone, taken, sent. I was leftover—because I know that day I left my body. I was left with obvious aftereffects—an inordinate difficulty throwing my head back for the dentist, for example—and less obvious bodily imprints: to this day, I do not throw up. Not because I don’t want to if I need to. I simply don’t and can’t. It’s as though the evacuation of my stomach by force when I was small forever after made me unwilling to give up the contents of my stomach. Or maybe I fear that to “throw up” would be to revisit that feeling of ceasing to exist, of being taken away.

  Chevalier Jackson pried into private cavities for minutes that must have felt like years to his subjects. Did they remember him? His face, his hands? Or did they erase him? What is remembered on the other side of entry?

  Talking to my brother at a distance of forty years after my stomach pumping episode, I realize that neither of us knows what he was doing home that day, why he wasn’t in school. My brother surprises me with a remembered detail that is lost to me but defining for him: he says that he saw me drink the bubble bath and “told on me,” and has felt guilty about it ever since. As though my getting my stomach pumped were all his fault.

  What I remember isn’t so much a fact of the matter or an indisputabl
e truth as an atmosphere of deeply pleasurable make-believe. I remember having my own set of wooden table and chairs stenciled with hearts that imitated flowers. In the small basement where my mother washes clothes, I sit at my table coloring, and the room seems to have nothing in it but my table and one toy that lights the room like a skidding sun: a wheeled plastic orange ladybug the size of a small cat with a toggle that I pull it by. I recall a favorite time of day, just after noon, when my brothers, who came home from school for lunch, would come down to the basement, after eating the food that our mother prepared for them, to enjoy another sumptuous meal prepared by me. They knew and I knew that my food was fake and couldn’t really be ingested, but I never felt so full as on those days when my brothers agreed to join me in “playing lunch.”

  The genres of my fake food were mixed—eggs sunny-side up and peas intermingled, pizza made of Play Doh hardened on a plate—and the plastic set of dishware featured items much grander than what we actually used upstairs: a fluted soup tureen and ladle, a serving dish with more than one compartment. My brothers were convincing in their enjoyment of the meal—one wiped his mouth wholeheartedly, while the other exaggerated his munching as though he were chewing gum. All of us were good at pantomiming the act of washing our food down with nonexistent drink.

  In those days, around my pretend lunch table, one brother was chubby. Now he’s rail thin. My other brother had been twig-like, hands perched on his bottle-thin hips, but now he moves slowly, as if dragging with him a water-balloon body. I had been nimble and neat as a child. Now I habitually spill food on my clothes and have to work against a burgeoning waddle. One brother used to eat to excess and now is obsessed with the latest healthful diet—the most recent requires the vigilance of eating seven small meals throughout the day. The other boy had been picky about his food, and hid parts of his meals inside seat cushions or behind the refrigerator rather than admit that he didn’t like the food before him. Now he subsists on 7-Eleven sandwiches and oversize iced teas. I was known for eating flowers and rug fuzz and, one day, bubble bath alongside regular meals. Today, I count myself among the finest cooks I know, and enjoy a widely brimming palate even though, if tense, I fear I won’t be able to swallow and might vomit into the dinner party or choke to death out of my body’s failure to follow my simple command: Swallow. (Flutter.) Swallow. (Retch.) Swallow. (Eat.)