Although in his fifties, he looked like an old man. His face was tanned and wrinkled, and his cheeks and lips were sunken because he had no teeth to fill them out. His gaunt temples emphasized his dark, sunken eyes. He had a full head of oily, unkempt black hair that was peppered with gray. On his hands and forearms were several crude tattoos in faded ballpoint pen. One spelled his ex-wife's name, and another represented the torso of a nude, headless woman. Various cellmates had etched these tattoos as they passed monotonous hours in the county jail for petty offenses: fighting, public drunkenness, driving under the influence of alcohol. The index and middle fingers of both his hands were stained brown, one of the stigmata of his years of smoking. His hands were calloused, and there were deep cracks in his skin around his knuckles. His left ring finger was missing above the first joint. His life had been rough, and his body bore the scars of the abuse that had been done to him by others and by himself.

He had gone to the physician because of pain in his tongue and an ache in his ear when he swallowed. Although he initially brushed it off, the pain became so bad when he swallowed that he had stopped eating; he had already lost 15 pounds. He had seen this physician for the first time 2 days earlier. The physician spent an eternity asking questions and examining him. After he finished, he told the man that he probably had a malignant tumor in his tongue, but he needed to do a biopsy to be sure.

A needle jabbed, and then he felt a deep, painful ache that faded into numbness as the anesthetic was injected. He gripped the armrests tightly, mouth open wide, eyes closed and tearing. Although the biopsy itself did not hurt, the feeling of tissue being torn from his tongue without pain was almost worse than the pain of the injection. After that, he was aware of the metallic taste of blood and, later, a dull ache as the anesthetic wore off.

"The results of your biopsy are back," said the physician.

The man waited for him to continue.

The physician hesitated. "I'm sorry, it doesn't look good. You have a malignant tumor in your tongue."

"How did it get there?" asked the man.

"Almost certainly from smoking. It's rare to see these tumors in people who don't smoke, and your drinking probably contributed as well."

"What are my chances?"

"That depends," said the physician. "There are two ways of treating this. The first way is to operate. We would have to take out most of your tongue, part of your jaw, and the lymph glands in your neck. It's a fairly big operation, and you'd probably be in the hospital for a couple of weeks, maybe even a month if you had problems healing. The other way would be to treat you with chemotherapy and radiation. With those, you'd probably have some nausea, you'd have a bad sore throat, and afterwards your mouth would be permanently dry. With either treatment, you've got about a 50-50 chance."

"No good choices, I guess. What if I do nothing?"

The physician paused before responding. "Well, the tumor would continue to grow."

"And how would it kill me?"

"Well, in this location, it would either grow big enough to choke off your airway or keep you from swallowing, or it would eat into a blood vessel and you'd bleed to death. Not very gentle ways to go. I really wouldn't recommend doing nothing. There's still a reasonable chance of curing this tumor." The two stared at one another for a moment before the physician continued. "Another thing ... it's really important for you to quit smoking. I know it's hard, but if you do, you'll tolerate the treatment better, and you'll be less likely to get another kind of cancer later."

The man sat staring at the wall, focusing on one of the spots of drywall showing through. He felt numb, just as he did whenever his foot fell asleep, a numbness that took his strength away. But this time it wasn't his foot: It was his mind and his soul that were numb. He shook his head to try to clear his thinking.

"How much time do I have to decide?"

"You really need to make a decision in the next few days," answered the physician. "Time isn't on your side, but this is an important decision, and you need to feel comfortable with your choice. Let's make an appointment for you to come in and talk right after lunch, the day after tomorrow."

The man nodded and sat in the chair for a few more moments. He put his hands on his knees and pushed himself upright. He walked out of the examination room and down the hall to the exit. As he pushed through the door, the sunlight was so bright that he had to squint. After a second, his eyes adjusted, and he could see the mountains in the background, behind the trees. A few feet away, next to the doorway, there was a bench.

The man sat down, looked again at the mountains, and took a deep breath. He swallowed, and there was the pain again, stabbing into his ear. He reached into his shirt pocket and took out his pack of cigarettes. Holding the pack between thumb and forefinger, he examined it. He closed his hand around the pack to crush it but then stopped. He removed a cigarette, put it in his mouth, and pulled a nearly empty book of matches from between the cardboard and the cellophane. Striking a match, he lit the cigarette, took it from his mouth, and held it to the stoma he had breathed through since he had lost his larynx to cancer. He inhaled deeply.