The Surgeon

Sixteen

In the heart of Mexico City, human blood once ran in rivers. Beneath the foundations of the modern metropolis lie the ruins of Templo Mayor, the great Aztec site which dominated ancient Tenochtitlán. Here, tens of thousands of unfortunate victims were sacrificed to the gods.

The day I walked those temple grounds, I felt some measure of amusement that nearby loomed a cathedral, where Catholics light candles and whisper prayers to a merciful God in heaven. They kneel near the very place where the stones were once slippery with blood. I visited on a Sunday, not knowing that on Sundays admission is free to the public, and the Museum of Templo Mayor was aswarm with children, their voices echoing brightly in the halls. I do not care for children, or for the disorder they stir; if ever I return, I will remember to avoid museums on Sundays.

But it was my last day in the city, so I put up with the irritating shards of noise. I wanted to see the excavation, and I wanted to tour Hall Two. The Hall of Ritual and Sacrifice.

The Aztecs believed that death is necessary for life. To maintain the sacred energy of the world, to ward off catastrophe and ensure that the sun continues to rise, the gods must be fed human hearts. I stood in the Hall of Ritual and saw, in the glass case, the sacrificial knife which had carved flesh. It had a name: Tecpatl Ixcuahua. The Knife with the Broad Forehead. The blade was made of flint, and the handle was in the shape of a kneeling man.

How, I wondered, does one go about cutting out a human heart when equipped with only a flint knife?

That question consumed me as I walked later that afternoon in the Alameda Central, ignoring the filthy urchins who trailed behind me, begging for coins. After a while they realized I could not be seduced by brown eyes or toothy smiles, and they left me alone. At last I was allowed some measure of peace — if such a thing is possible in the cacophony of Mexico City. I found a cafe, and sat at an outdoor table sipping strong coffee, the only patron who chose to be outside in the heat. I crave the heat; it soothes my cracking skin. I seek it the way a reptile seeks a warm rock. And so, on that sweltering day, I drank coffee and considered the human chest, puzzling over how best to approach the beating treasure within.

The Aztec sacrificial ritual has been described as swift, with a minimum of torture, and this presents a dilemma. I know it is hard work to crack through the sternum and separate the breastbone, which protects the heart like a shield. Cardiac surgeons make a vertical incision down the center of the chest, and split the sternum in two with a saw. They have assistants who help them separate the bony halves, and they use a variety of sophisticated instruments to widen the field, every tool fashioned of gleaming stainless steel.

An Aztec priest, with only a flint knife, would have problems using such an approach. He would need to pound on the breastbone with a chisel to split it down the center, and there would be a great deal of struggling. A great deal of screaming.

No, the heart must be taken through a different approach.

A horizontal cut running between two ribs, along the side? This, too, has its problems. The human skeleton is a sturdy structure, and to spread two ribs apart, wide enough to insert a hand, requires strength and specialized tools. Would an approach from below make more sense? One swift slice down the belly would open the abdomen, and all the priest would have to do is slice through the diaphragm and reach up to grasp the heart. Ah, but this is a messy option, with intestines spilling out upon the altar. Nowhere in the Aztec carvings are sacrificial victims depicted with loops of bowel protruding.

Books are wonderful things; they can tell you anything, everything, even how to cut out a heart using a flint knife, with a minimum of fuss. I found my answer in a textbook with the title Human Sacrifice and Warfare, written by an academic (my, universities are interesting places these days!), a man named Sherwood Clarke, whom I would very much like to meet someday.

I think we could teach each other many things.

The Aztecs, Mr. Clarke says, used a transverse thoracotomy to cut out the heart. The wound slices across the front of the chest, starting between the second and third rib, on one side of the sternum, cutting across the breastbone to the opposite side. The bone is broken transversely, probably with a sharp blow and a chisel. The result is a gaping hole. The lungs, exposed to outside air, instantly collapse. The victim quickly loses consciousness. And while the heart continues to beat, the priest reaches into the chest and severs the arteries and veins. He grasps the organ, still pulsating, from its bloody cradle and lifts it to the sky.

And so it was described in Bernardino de Sahagan’s Codex Florentio, The General History of New Spain:

An offering priest carried the eagle cane,

Set it standing on the captive’s breast, there where the heart had been, stained it with blood, indeed submerged it in the blood.

Then he also raised the blood in dedication to the sun.

It was said: ‘Thus he giveth the sun to drink.’

And the captor thereupon took the blood of his captive

In a green bowl with a feathered rim.

The sacrificing priests poured it in for him there.

In it went the hollow cane, also feathered,

And then the captor departed to nourish the demons.

Nourishment for the demons.

How powerful is the meaning of blood.

I think this as I watch a thread of it being sucked into a needle-thin pipette. All around me are racks of test tubes, and the air hums with the sound of machines. The ancients considered blood a sacred substance, sustainer of life, food for monsters, and I share their fascination with it, even though I understand it is merely a biological fluid, a suspension of cells in plasma. The stuff with which I work every day.

The average seventy-kilogram human body possesses only five liters of blood. Of that, 45 percent is cells and the rest is plasma, a chemical soup made up of 95 percent water, the rest proteins and electrolytes and nutrients. Some would say that reducing it to its biological building blocks peels away its divine nature, but I do not agree. It is by looking at the building blocks themselves that you recognize its miraculous properties.

The machine beeps, a signal that the analysis is complete, and a report rolls out of the printer. I tear off the sheet and study the results.

With just a glance, I know many things about Mrs. Susan Carmichael, whom I have never met. Her hematocrit is low — only 28, when it should be 40. She is anemic, lacking a normal supply of red blood cells, which are the carriers of oxygen. It is the protein hemoglobin, packed within these disk-shaped cells, that makes our blood red, that pinkens the nailbeds and brings a pretty flush to a young girl’s cheeks. Mrs. Carmichael’s nailbeds are sallow, and if one peeled back her eyelid, the conjunctiva would appear only the palest shell-pink. Because she is anemic, her heart must work all the faster to pump diluted blood through her arteries, and so she pauses at every flight of stairs to catch her breath, to calm her racing pulse. I picture her stooping forward, her hand to her throat, her chest heaving like a bellows. Anyone passing her on the stairs can see she is not well.

I can see it just by looking at this sheet of paper.

There is more. On the roof of her mouth are flecks of red — petechiae, where blood has broken through capillaries and lodged in the mucous membrane. Perhaps she’s unaware of these pinpoint bleeds. Perhaps she has noticed them elsewhere on her body, beneath her fingernails, or on her shins. Perhaps she finds bruises she cannot account for, startling islands of blue on her arms or her thighs, and she thinks hard about when she might have injured herself. Was it a bump against the car door? The child clinging to her leg with sturdy fists? She seeks external reasons, when the real cause lurks in her bloodstream.

Her platelet count is twenty thousand; it should be ten times higher. Without platelets, the tiny cells that help form clots, the slightest bump may leave a bruise.

There is yet more to be learned from this flimsy sheet of paper.

I look at her white blood cell differential, and I see the explanation for her woes. The machine has detected the presence of myeloblasts, primitive white blood cell precursors that do not belong in the bloodstream. Susan Carmichael has acute myeloblastic leukemia.

I picture her life as it will play out in the months to come. I see her lying prone on a treatment table, her eyes closed in pain as the bone marrow needle penetrates her hip.

I see her hair falling out in clumps, until she surrenders to the inevitable, and the electric shaver.

I see mornings with her crouched over the toilet bowl, and long days of staring at the ceiling, her universe shrunken to the four walls of her bedroom.

Blood is the giver of life, the magic fluid that sustains us. But Susan Carmichael’s blood has turned against her; it flows in her veins like poison.

All these intimate details I know about her, without ever having met her.

I transmit the STAT results by fax to her physician, place the lab report in the out basket for later delivery, and reach for the next specimen. Another patient, another tube of blood.

The connection between blood and life has been known since the dawn of man. The ancients did not know that blood is made in the marrow, or that most of it is merely water, but they did appreciate its power in ritual and sacrifice. The Aztecs used bone perforators and agave needles to pierce their own skin and draw blood. They poked holes through their lips or tongue or the flesh of their chest, and the blood that resulted was their personal offering to the gods. Today such self-mutilation would be called sick and grotesque, the hallmark of insanity.

I wonder what the Aztecs would think of us.

Here I sit, in my sterile surroundings, garbed in white, my hands gloved to protect them from an accidental splash. How far we have strayed from our essential natures. Just the sight of blood can make some men faint, and people scurry to hide such horrors from the public eye, hosing down sidewalks where blood has spilled, or covering children’s eyes when violence erupts on the television. Humans have lost touch with who, and what, they really are.

Some of us, however, have not.

We walk among the rest, normal in every respect; perhaps we are more normal than anyone else because we have not allowed ourselves to be wrapped and mummified in civilization’s sterile bandages. We see blood, and we do not turn away. We recognize its lustrous beauty; we feel its primitive pull.

Everyone who drives past an accident and cannot help but look for the blood understands this. Beneath the revulsion, the urge to turn away, throbs a greater force. Attraction.

We all want to look. But not all of us will admit it.

It is lonely, walking among the anesthetized. In the afternoon, I wander the city and breathe in air so thick I can almost see it. It warms my lungs like heated syrup. I search the faces of people on the street, and I wonder which among them is my dearest blood brother, as once you were. Is there anyone else who has not lost touch with the ancient force that flows through us all? I wonder if we would recognize each other if we met, and I fear we would not, because we have hidden ourselves so deeply beneath the cloak that passes for normality.

So I walk alone. And I think of you, the only one who ever understood.