The Source of All Things

by Reinhard Friedl

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  For Josef and Olivia

  REINHARD FRIEDL

  For Tex Poole (1926–2020),

  whose noble heart gave out aged ninety-three

  GERT REIFARTH

  “You always hear of people who lost their mind because of love. But there are also many who lost love because of their mind.”

  JEAN PAUL, novelist

  “I had explored the mysteries of the brain, and it was time to devote as much academic rigor and hard science to exploring the secrets of the heart.”

  JAMES R. DOTY, clinical professor of neurosurgery at Stanford, and the founder and director of the Center for Compassion and Altruism Research and Education

  REVEALING THE HEART

   Ba-Boom, Ba-Boom, Ba-Boom

  Most of the time you don’t hear it, but if your heartbeat were suddenly to stop, you’d stop too. You live from one beat to the next. In between, death resides. If after one heartbeat there isn’t another, the clock of life stands still. It might happen while we’re sleeping—or shopping. None of us knows the hour of our death.

  * * *

  Your heartbeat is my profession. Sixty to eighty times per minute, this sound creates life. Most hearts beat calmly and strongly, some in a constant rush. Even if the heart stumbles occasionally, it always tries to go on. I have seen many hearts laboring with their last ounce of strength. The heart knows no weekend, no holiday. On your seventy-fifth birthday, it will have beaten about three billion times. It started its work eight months before your birth, twenty-two days after procreation. The heart is the first organ to develop, long before the brain and the first breath. Nothing works without the heart. It throbs through the years and decades, unnoticed—until something ceases to function. Or until a high-tech scan, by accident, discovers a defect that has not yet been felt.

  Afflictions of the heart are always dramatic. A pain in the chest is completely different from a pain in the hip. We perceive everything to do with the heart as an attack on our lives, on our inviolability. Even if later it turns out not to be life-threatening, an aching heart is a cause for concern and often triggers a fear of dying. A headache can also be a harbinger of danger; it can eventually lead to death by stroke or brain hemorrhage. Yet a severe headache worries us less than a light pressure in the chest. Deep inside, human beings sense that the heart is the source of all life.

  * * *

  As a heart surgeon I have held thousands of hearts in my hands. I have operated on premature babies and repaired the heart valves of patients well advanced in years. I have implanted artificial hearts and stitched up knife wounds to the heart. As an organ, the heart has been investigated down to its smallest parts. We seem to know everything about it—and yet we know nothing. Every week there are hundreds of new scientific findings published about this organ that has not changed since Homo sapiens emerged 300,000 years ago.1 It seems that the French philosopher and mathematician Blaise Pascal is still correct: “The heart has its reasons of which reason knows nothing.”

  Independently, separated by time and space, without knowledge of each other and despite different languages, all human beings draw hearts to express love, both earthly and celestial. Does this point to an inner truth anchored deeply in every human being? Or merely to a desire that we all share unconsciously? All great cultures, from the Stone Age to the present, and all religions and spiritual movements perceived and continue to perceive the heart as a symbol, as the biological center for love, compassion, joy, courage, strength, truth, and wisdom. But in the age of heart transplants and data migration, the magic of the heart seems to have vanished—as if it could not withstand our mechanized world. But maybe those qualities are precisely what we need for a more humane future.

  In Saint-Exupéry’s The Little Prince, the fox says: “One sees clearly only with the heart.” Yet so far we have not found eyes on our biological heart, nor sensors for compassion and love, nor a pump discharging courage and strength. However, we all experience these heart qualities as an inner reality that guides our lives. How, then, are these related to our physical, pumping heart? What can science reveal about this “other” heart and its dimensions of consciousness? And how do these things influence illnesses and therapy?

  * * *

  Aristotle believed the heart rather than the brain was the source of all emotions. Modern neuroscience argues that love originates in the brain. Has it stolen the secrets of love away from the heart? And is our language only a memory—but of what? Or is it just trivial metaphors when we speak of someone becoming close to our heart, of closing off our heart to someone or inviting them into it, of losing or taking heart, of a weight felt on or being taken off our heart, of a broken heart or something that makes our heart stop, of stealing someone’s heart or giving ours away, of wearing our heart on our sleeve, which is better than something saddening it or making it sink? What is dear to the heart’s heart? Some of these symptoms are indeed taken to a cardiologist—for example when they manifest as cardiac arrhythmia or angina pectoris. Doctor, I feel as if there’s a stone weighing on my chest. In the past I took care of these people solely as a surgeon; today I am interested in the whole human being.

  * * *

  Heart surgeons can put hearts to sleep and make them beat—but they usually don’t speak with a lot of heart, rather in terms of mechanics: heart-lung machines, ECG, ultrasound, or even artificial hearts. And of course they speak with their colleagues—assistant doctors, anesthetists, cardio technicians, surgical nurses. A heart operation is not an intimate matter. The heart, hidden deeply in the chest and well protected by the ribs, is opened up to the glaring light of high-tech operating rooms under the concentrated gaze of many pairs of eyes. To the heart surgeon, it is first of all a pump they have to repair, the motor of life. In contrast to all other doctors, heart surgeons don’t only know this motor’s functions through video images and data generated with the help of ultrasound or computed tomography (CT) scans, intracardiac catheters, or magnetic resonance imaging (MRI). Even in this era of high-tech medicine, it makes a big difference to one’s understanding of this organ to see it with one’s own eyes and touch it with one’s own hands—rather than just observe it secondhand via monitors.

  As a heart surgeon, I reach deep into the chest and put hand to heart. A heart is not used to such contact. Hearts can react very sensitively to touch. Some get a fright and respond with arrhythmia. Yet even sick hearts are strong, so powerful that their inherent strength astonishes me time and time again. When they lie in my hand it feels as if they are the essence of life, the pure and absolute will to live. For me, every heart is its own being; every heart has its own appearance. I never know what is about to be revealed to me when I cut the skin with a scalpel and open the chest. Some hearts are very lively and muscular, others a little chubby with clearly visible fat. Some betray their long path through life and appear tired and spent. Yet th
ey all have one thing in common: they like nothing more than to beat.

  What is it, really, that I am holding in my hand? Merely a pump, or the origin of all human consciousness?

  Neuroscience has not yet been able to explain the mystery of how consciousness arises. The prevalent thinking suggests it emerges as a result of biochemical and electrophysiological processes in the central nervous system and the brain. Neuroscientists know the components, their functions and complicated circuitry, very well. However, how something intellectual emerges out of the organic matter of our bodies, how a thought or an emotion is formed—this remains largely unknown. According to famous neurosurgeon Eben Alexander and other brain researchers, the emergence of consciousness is a blank spot on the map of neuroscience.2 What if the heart could fill in at least part of this unknown territory?

  Shut down

  I remember when I saw a heart for the first time as a young doctor. It reminded me of a tender, freshly peeled fruit. I looked at the orange-sized organ with awe. Pumping muscles, partly covered by a thin layer of fat, nothing more. Or so it seemed to me at first. I had to hold the suction drain to take away leaking blood and was glad to have something in my hand to hold onto—the sensations were so overwhelming. The heart continued to beat unflinchingly while my colleagues prepared for the heart-lung machine to be connected to it and placed numerous sutures on the heart and the aorta.

  Most heart operations can only be carried out after shutting down the heart; this is done by interrupting the supply of blood and therefore oxygen. To achieve a protected shutdown of the heart, a specific mix of liquids, mainly blood and potassium, is infused into the arteries. In this way, the heart’s electrical activity is shut down—it stops beating. Its energy consumption is thus reduced and its cells need less oxygen. Sometimes it is also cooled. The heart can then survive for a certain time without major damage, until it is supplied with blood again. In order for this artificially created cardiac arrest not to lead to death, the heart is connected to a heart-lung machine before being shut down. This machine now transports the blood (instead of the heart, which takes a break during the operation) and also supplies the heart with oxygen.

  * * *

  Often someone needs to hold the heart in a certain position during an operation, for the surgeon to have access to the heart chambers while operating on the valves and to be able to fix a bypass to the posterior wall. This task usually falls to the youngest assistant doctor. So suddenly a heart was placed in my hand. I did not know what was happening and stood stock-still. Let me not damage anything, let me not make a mistake. I held the heart as I would a premature baby. It seemed so delicate, so fragile, even though simultaneously I could feel its strong muscles, even in its shut-down state. I did not yet have any sense of its consistency and texture, its essence. I think it was a man’s heart, but it could have been a woman’s—they look nearly the same, are the same size and strength and both weigh about 300 grams.

  * * *

  As the months and years passed, my tasks as a prospective heart surgeon in the operating room became more demanding. I was allowed to open the chest, to take over the connection to the heart-lung machine, eventually to suture my first bypass. My teachers supervised my every move with watchful eyes, occasionally even led my hand. I was so nervous that I sometimes nearly dropped the needle clamp, and my own heart nearly stopped whenever the smallest drop of blood leaked through. Was I too deep or still okay? My experienced colleague did not say anything, so I continued. I learned to control my emotions, or better still not have any. Millimeter by millimeter the needle crept through the parchment-thin walls of the arteries whose inner diameter is only a millimeter or two. If the aorta, life’s great stream, were to tear, the blood could squirt up to the operating light … this thought makes the hands of every beginner shake. A clear mind and utterly precise mechanics make an operation safe. I internalized this truth and became more confident, while outside the operating room, this need to function without emotion left a mark on my heart—and in my unconditional drive to become a good surgeon, I did not even notice that.

  Eight years later, now a heart surgeon myself, I sutured the skin after a long operation without thinking much about it. I was in awe of technology and its fascinating possibilities. I had learned how to conduct a certain kind of bypass operation routinely, even on a beating heart. But during most operations the heart is shut down, as described above, then repaired and started again. Both the complex repairs of valves and the enormous responsibility of my profession excited me. The heart does not easily forgive mistakes, and the time pressure is enormous, as the shutdown of the heart should not normally last more than sixty to ninety minutes. The shorter the better. It is a bit like a tire change in Formula One; the pit stop can’t be too long or the patient will be out of the race. I had a wonderful teacher who put it like this: “The patient must not skid off the road during an operation, and this requires a motor that has been repaired in a technically excellent fashion.”

  * * *

  As a doctor, naturally my first desire was to help my patients. But I won’t deny that the outward glory, the admiration that is often bestowed on heart surgeons, also appealed to me. Their renown and the responsibility they shoulder are similar to that of a jet pilot. But compared to the heart, a plane is a rather straightforward machine, one that always reacts in a similar way due to predictable technical laws. However, as a heart surgeon I cannot rely on any definite causality such as “When I press this button, the valve will shake.” The mechanics of the heart are much more subtle and uncontrollable—it is not unusual for hearts to behave differently from how one expects them to. Surgeons have to anticipate anything at all, have to stay in control, remain calm, and must never allow themselves to be led by emotion. All of which I perfected.

  Restarted

  Day in, day out, I worked with hearts. My life existed in the sterile reality of the operating room. My encounters with hearts were restricted to standing in front of opened-up chests every day. With my team I brought half-dead patients back to life and repaired pumps to restore their owners’ quality of life. I rarely thought beyond the operating table. Heart operations take place at the well of life, which afterward starts to gush again for most people. But some die. You have to put that aside. You must not feel too much, compassion least of all, otherwise you will cease to function. One day I realized that I was no longer able to hear the voice of my own heart properly. More and more I asked questions that had nothing to do with surgery. Is the heart more than a pump? Can we sense things consciously with the heart? Maybe even act from the heart? Is there a connection between the voice of the heart and illnesses, between a fulfilling life and one full of suffering? I wanted answers to all these questions. You hold in your hands the result of my journey into the secrets of the heart.

  * * *

  Where to begin? As a scientist I researched the work of colleagues from my own field and then went beyond my discipline. Mathematicians, engineers, and heart specialists increasingly approach the heart with technology and virtual reality—which is extraordinarily fascinating. I developed cardiovascular navigation systems myself. But unfortunately I did not find what I was looking for. One day a bright red heart beamed at me in a train station’s bookshop. “Heart Ache” read the headline of the Bild newspaper, followed by the question: “How do I know if my heart is sick?” That was something I wouldn’t mind knowing myself, so I read more closely and found the article contained only well-known facts about heart attacks and related matters. A magazine next to it promised “Everything you need to know about high blood pressure, cholesterol, heart attacks, vascular constriction, heart failure, arrhythmia, angina and organ replacement.” As a scientist, you shouldn’t sit in an ivory tower, so I invested eight euros and ninety cents—and learned nothing new.

  * * *

  A friend sent me an article: “Neurology: How the gut rules the head.” In it, I read interesting things about the gut’s nervous system and its communic
ation with the “head brain,” as it was called—and I learned that anger affects the stomach and that certain types of consciousness originate in the intestines. “The brain in the gut is highly intelligent,” declares American neuroscientist Michael D. Gershon, chair of the Department of Pathology and Cell Biology at Columbia University. If there was “intelligence” in the gut, hitherto known only for digestion and producing feces, there could well also be something to discover higher up, in the heart. But reading on, I received quite a blow: “The heart, in contrast, is a primitive pump,” explained Gershon.3 For a moment, my heart was knocked down. But it refused to be out for the count; it beat in my throat, up to my brain. I felt outraged. Primitive? My heart? Never!

  I used to be a boxer and had learned to anticipate my opponent’s punches. This one, though, caught me flat-footed. Somewhere deep inside I knew it wasn’t true. But how could I prove that? I held the heart’s biology, its sounds, and its mechanics in high esteem—like a violin maker who loves his Stradivarius: a violin is not merely a wooden box with four strings. A universe of music and emotion emerges when someone knows how to play it.

  If the heart was only a primitive pump, how had nobody managed to manufacture a replica that worked even nearly as perfectly? Why could one not simply replace the heart? Why did so many people die waiting for a transplant?

  My warrior heart awoke. In a sense I went back to square one and left behind the safe ground I had acquired as a heart surgeon. I started to ask questions that reached beyond the operating table. I looked anew at this “primitive pump,” from unconventional perspectives, in order to reconcile it with my experiences in thousands of heart operations. In the operating room my eyes became more watchful. I did not want to miss the slightest movement of the heart.