The Pátzcuaro Incision

Come closer to the table, so you can see. Ah, you can’t, can you. Our backs make a wall, plus you’re not even here. You’re floating above us, looking down. As a student I never had such a view. The little eye suspended above, with magnification and light, recording everything, seeing what I’m seeing with my headlight and loupes. I’m going to continue the curvilinear incision here, at the hairline, in the pterional region, that’s Greek, claw of the eagle, just to the side of left eye, and her nose over here under the drapes. She’s lying on her right side, rotated toward me so her shoulder doesn’t interfere. I started before breakfast but got hungry and had to go eat something. You can do that because she’s under endotracheal anesthesia. You can’t see it, but I can assure you her pupils are dilated like a cat’s at night. A little clotting over here, the scalp sort of bloody, but I can control it by pressure with my other hand until I get the scalp clips on. I just wipe the blood away, and then we continue the incisions. The scalp is like an elastic onion. It takes forever to do it right, but at the same time the clock hands seem to fly. Now, when we’re ready, a burr hole at the pterion. That’s it. Now a double-action Leksell Rongeur to make the burr hole a little bigger, biting away the bone. Use a little muscle when you do this, but gently, gently, so we can go on to the next step. We use a number three Penfield dissector to separate the dura mater from the inner table of the skull. The dura, as you’ve studied, is the tough leathery lining inside the skull. Look at the blade on this saw, so sharp and clean before you begin. Maybe it’s the clean part that reminds me of a woman like this one, a cellist with long dark hair, in Mexico, with smooth beautiful toes and a passion for Mozart. A summer off from college. Be prepared. The saw is going to screech. The little turbine is driven by compressed Nitrogen, from that tank over there. Now, spattering a little blood and bone dust, flying all over. Swimming in the lake, with the blue wild volcanic mountains in the background where you weren’t supposed to go. Turn the frontal bone flap. Droplets of water on her breasts. Now we place the tenting sutures to hold the opened dura in place and prevent bleeding in the epidural area. Oh so gently, elevate the left frontal lobe on a self-retaining Leyla. Named after a little Iranian girl by the way. Her necklace inspired the retractor’s design. You know how hard it is to forget unfinished loves. That’s it, that’s good. And Beethoven, the magnificent Late String Quartets, my Alicia and her friends in the advanced stages of die Große Fugue, in B-flat Major, Opus 133. The gentle, searching, plaintive lifting to God in the Third Movement, the music drifting through the stone house on the side of the lake, the polished tile floors, the terrace where the surrealists sat, or so the legend has it. With their friends André Breton, Remedios Varo, Leonora Carrington, and Gordon Onslow-Ford. Ah, and the view of the lake! Cattle standing up to their knees, grazing on islands of green. The painters María Izquierda, Manuel Gonzalez Serrano, and long-browed Frida, who declared she was herself, not a surrealist discovered by André Breton. And the house where Breton argued with Trotsky, where Diego Rivera, who hadn’t written a word of it, signed the manifesto on the independence – if not the separation – of art from politics. Follow the olfactory tract down to the carotid artery. The mountains, the moon, the mist over the distant lights of Pátzcuaro. Walking with Alicia, where Trotsky, along with his body guards years before, two in front, two behind, in single file, strolled beside the listening lake and the grebes. And we see the optic nerve is displaced by the dome of a beautiful pulsing turgid aneurysm. At first, she was so disappointed in the women she played music with, from Morelia, Mexico City, Zirahuén, and Uruapan. They talked about soap operas, affairs their husbands had, affairs they themselves were afraid to initiate, with men below their class. Women who watched satellite television from Miami and tried to make themselves look younger. Shit! Excuse me. As you can see, the aneurysm has just ruptured. I must have pushed too hard. This is a crisis. The trick is to keep on breathing. There’s blood everywhere. It’s opaque. I can’t see a thing, and it would be easy to put the clip on other blood vessel, with – catastrophic consequences. Quickly now, both suctions to clear the mess. They wanted to look tight-skinned and youthful for their absent husbands, but kept on eating pork and sugar. Now we put a temporary clip across the parent artery, which is down here somewhere, take my word for it. That will stop the bleeding from the rupture. Don’t worry, her brain can get along for a few moments without blood. So much hidden disappointment. Now a Sugita clip across the neck of the aneurysm. With luck it’s not blocking any other vessels behind the aneurysm – the ones I couldn’t see because of the rupture. My god I love this! It’s my third case since nine o’clock last night. The clip is titanium and will stay on the artery permanently. We’ll put a little glue here to hold the clip in place. There! Now blood – look how it glistens – can’t enter the aneurysm. And this, of course, is where we should play something more like Satie, rather than Beethoven, so the blood vessels – because of the clip – don’t want to spasm and choke off blood to the brain. Which can be fatal. And then there’s the chance of swelling. Sometimes the brain won’t fit back in the skull, and some has to be removed. The quartet became a women’s group. By the way, you have to make sure the clip is MRI-compatible. They drank Chilean Merlot – Toro y Concha – and talked about how people died in the villages, the black-lipped corpses with exploding arteries, waiting for this or that moon phase, this or that sign, before putting the body under. The eyes of the dead, they swore, followed them around the room, when they and their Purépecha Indian friends were just girls. In the gagging candlelight. We’ve stopped the bleeding. We’ll begin closing up. This is going well. Old men whose penises swelled over night and stayed erect while their eyes sank inward. Grandmothers burning rags soaked in car oil to mask the smell. Now we suture the dura, putting her back together. Babies bloated until it was impossible to see the hollow of their eyes. The waiting periods above ground that were too long. Open sores that became black stinking holes, in the stomach. And oh my god the black swollen feet! That’s the way they talked. I hope you don’t mind me telling you all this. Lets bring the bone flap down, close the layers of the scalp. She was astounded. She wanted to go beyond superficialities, but this was too far, too dark, too much death. I can’t do this when I’m depressed, which is really more than half the time. Lets suction. This is going beautifully. I can’t believe how fast I’m working. She was different after these meetings. They practiced more. Always Beethoven. Always Die Große Fugue, in B-flat Major, Opus 133. More stories. Trusting dogs lifted up and hanged from trees with a wire around the neck. An out-of-wedlock baby, half way out, the neighbor waving a rooster over them, then wringing its neck, while the mother struggled to breathe, and then gave up. The complicated wake because of the awkward shape, which they refused to change. The father of the dead teenage mother chased her teenage lover and hacked him down in a stream, with a machete, turning the black polluted water red. Then they let the boy lie in the creek until the neighboring village complained about the snarling rot-eating dogs that came home stinking. We stayed together for several months more. I called her hysterical. She called me remote. Then she disappeared. Some say she drowned in the lake, swimming alone, borne under by the stories. That she was stuck in a morbidity she couldn’t understand. That it was the inexorable counterpoint to the televised crap from the North. They searched for a week. Some carried alfalfa, on advice from curanderos, healers from Hidalgo, to distract the Goat, if he was blocking her path and she couldn’t come back from the lake. I went on my own, looking for her along the shore, expecting to see her long flowing hair, a hand moving with the waves, her lovely toes. Some say she took a bus back to Los Angeles to visit her sister. I called the sister, but she refused to talk to me. After a while there’ll be no trace of what’s happened here. It is a good feeling sewing a life back together. Lets keep her warm. She’s a lovely woman, the dark hair, the olive skin. She could be from Pátzcuaro. Perhaps she’s a musician. A cellist. I think I’ll stop now. Thank you for your attention. I hope you learned something. Hope to see you again, soon.

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