The Source of All Things

by Reinhard Friedl

  Huyen pushed him aside. “Nutcase!”

  “And sometimes even beautiful women!” Yücksel laughed.

  Huyen took a deep breath. Were these two about to quarrel again? I had observed that a number of times already. No, this time Huyen only complained to the big chairman in the sky: “Lord, please give my colleague some brains.” And then we all concentrated on the operation during which the ductus was to be closed.

  Operation in the doll’s kitchen

  As the cut will be between the ribs on the left, Maria is placed on her right side. Yücksel is concentrating hard now and reacts attentively to my every cue. We have carried out this operation together a few times, and he knows how I like to work and how he can best help me—and he kindly adjusts to me. When I operate with him, I have four arms and four eyes. Four hands can operate on a patient of thirty centimeters only if their owners aren’t shy of bodily contact. We stand as close as possible. Otherwise it would not be possible to look into the tiny body I was about to open.

  “Knife.” Everything now follows a carefully rehearsed choreography. Operating room nurse Klaus places the knife in my open hand with slight pressure while my eyes are locked on the marked incision line between the ribs. I can’t see Klaus, as Yücksel is standing between us. It is quite an art to place a small knife in an open hand so the surgeon receives it safely and it does not fall to the ground. Klaus does it perfectly. Yücksel lightly touches my forearm and then looks me in the eyes intensely. In this way he signals that he is completely ready now.

  Surgeons can read eyes as if they were open books. They look into eyes every day for many hours, and I believe it is correct what abbess and naturalist Hildegard von Bingen observed 1,000 years ago: the eyes are the windows to the soul. We are otherwise fully covered in headgear, surgical mask, and sterile clothing. Surgeons wear magnifying glasses, and I am also equipped with a head light, like that of miners who work in the dark. But we look similar to them sometimes, and every now and then patients even say to us: my heart is sitting in my chest like a stone.

  * * *

  It is now very quiet in the operating room. Blood is streaming from the five-centimeter cut. I sever the fine respiratory muscles between the ribs and open the pleura, the membrane lining the inside of the chest wall. Tiny hooks in Yücksel’s hands, so small they could be from a doll’s kitchen, hold the wound open. I insert the rib spreader and slowly wind it open. The lung becomes visible; Yücksel gently pushes it to the side. It is in a dangerous position, as breathing now becomes even harder. But a window opens through which we can see the ductus arteriosus. There are numerous blood vessels and nerves running through the chest, and it is essential to identify them correctly. With the tweezers I indicate all the important ones: the aortic arch, the aorta descendens (descending aorta), the arteria subclavia (subclavian artery). Yücksel confirms this and points to the nervus vagus (vagus nerve) and the branch of it that is central to our operation, the nervus laryngeus recurrens (recurrent laryngeal nerve). Heart and brain exchange messages via the vagus nerve. The aforementioned branch does an extra lap around the ductus arteriosus, which is close to the heart, before ascending to the vocal cord, keeping it open. Without the recurrens, which means something like “the returning one,” we could only speak with trouble and produce only croaky sounds, as the glottis would half-close.

  After Yücksel and I have identified the anatomical landscape before our eyes, we set about the task of closing the ductus arteriosus. The blood vessel made from embryonic tissue is only half a centimeter long. Its walls are not elastic and flexible like those of other arteries, but extremely prone to tearing. It is not made for a whole life but meant to close and become a strand of connective tissue that is still present in adults and called ligamentum arteriosum. The operation consists of extracting the ductus arteriosus from the surrounding tissue, entwining it with two threads, and disabling it with two knots. Quite simple, really, if it weren’t for its tininess and tenderness.

  * * *

  The heat lamp is shining onto my head, which feels as if it were in a toaster. I am one of those people who remain at a steady temperature even in a sauna. Yücksel always sweats, so he wears a headband. While operating on the extremely fragile ductus arteriosus I feel as if I were part of a bomb squad kneeling over an explosive device. Extracting the detonator from the center isn’t usually a big deal. But it needs only a tiny tremor, the smallest false move—and an explosion will occur. In my case I would then see red, as in a split second the operation area would be flooded with blood. Even a tiny person has a rather big aorta and big lung arteries. I made tiny cuts with fine scissors around the ductus, the path connecting these vessels. Incise a little, spread a little with blunt scissors, but not too much. Drops of blood continue to seep from the surrounding connective tissue. Yücksel has the doll’s kitchen suction drain ready and at the same time touches my tweezers with an electronic cautery device which coagulates the injured blood vessel caught between its jaws. The anesthetist asks us again and again to let go of the lung as the oxygen supply drops too much. Then the whole area of operation vanishes beneath the inflating lungs and has to be readjusted. Finally we have uncovered the ductus. I pass a clamp under it, then gently open the clamp just enough to allow Yücksel to place a thread into it. It is a fluent, synchronous movement of two people with four hands. We work and breathe in sync. It is highly probable that our heartbeats have synchronized.

  Surgeons in the choir

  When two people master a difficult task such as working together in surgery, playing in an orchestra, or dancing together, a large amount of intellectual and physical choreography is required. Heart rate variability provides a parameter, for the first time, with which to determine how hearts beat in sync. I was quite surprised to find that the hearts of mother and child synchronize themselves and that the child’s hearing possibly plays a role in this. But what about two grown men in sync when they operate on a heart? So far we have only one report on the interlinking of chaotic oscillators such as heart and breathing. It was published by the renowned Royal Society in London.1 With a lot of lifeblood and physics, electronic engineers and doctors succeeded in proving that the synchronization of hearts in well-rehearsed teams will rise exactly when really tricky situations are being mastered. This phase-synchronization of hearts was also described for singers in a choir, which seems logical to me. When they sing a piece, they have to breathe nearly identically. Coordinated breathing is possibly a catalyst that synchronizes other oscillating systems such as the hearts of the fellow singers. The slower the breathing, the better the mechanism of this so-called resonance frequency breathing will work.2 Coherence between the hearts of adults occurs especially strongly during the singing of mantras and hymns—which may shed new light on the singing of soccer club songs before games. Could team members become one in this way to focus on the task ahead? Or are the individual players too nervous before the game? The origin of the lyrics, by the way, does not matter. Coherence occurs during “Holy God, We Praise Thy Name,” as well as during “Om Mani Padme Hun” or collective yoga breathing.3 Scientific studies show that during a collective activity we abandon our egocentric worldview in favor of a common perspective.4 Many of our inner and outer senses play along in this concert of coherence. The lung’s stretch receptors, the autonomic nervous system, receptors in the heart, our hearing, our hormone system, our muscles and movements, and of course our brain attune themselves to each other and dance together. Collective activity and experience leads to common perspectives and goals.5

  Happy end

  “Should I dab the sweat away?” Huyen’s question is intended for Yücksel, and he turns to her thankfully. Some more hearts seem to synchronize in this intensive care department. Yücksel and I continue to stitch. It is the knots that are critical. If they are too tight they can damage the vessel; if they are too loose the ductus may not be properly closed.

  “Saturation and pressure rising,” reports the pediatric anesthetis
t—so the blood’s oxygen content is going up together with the blood pressure. Then he vanishes with his ear trumpet behind the sterile drapes separating us from the anesthetic equipment. After two minutes he pops up again: “The machine noise can no longer be heard.”

  * * *

  Pfffffffft.

  * * *

  My tension releases itself in a concentrated exhalation. Pfffffffft is the sound made when maximum tension escapes from the lungs, like a locomotive. I have often heard it in the operating room. With some stitches and sutures, you only have one chance.

  * * *

  The rest of the operation is routine. Carefully we check that everything is “tight,” as we call it. As I am very meticulous in this regard, Yücksel jokes, not for the first time, that I’m counting red blood cells. He looks at Huyen for approval. She smiles. The strain and the worry for Maria have vanished from her face, have vanished from all our faces, or at least our eyes—which is all we have seen of each other for a while. Finally we put in a drain tube, made of flexible plastic, for fluids from the wound to flow through. Then we slowly retreat, stitching all levels of the wound carefully. Only a small scar will remain.

  I hope that Maria will soon be on her mother’s tummy and hear her heart. When that is not possible, recordings of the mother’s heart sounds are sometimes used to calm babies in intensive care.6 Close to the heart they feel at home. I take off my green clothes and look forward to the coffee Yücksel, Huyen, and I had planned to have together. After all, we haven’t sufficiently discussed the topic of hatchlings. But to my surprise I see the two of them setting off without me. And judging from how closely they are walking beside each other, I don’t think they will miss me. A few minutes to myself now would also do me good. I am still under considerable strain, even though the inner tension is gradually subsiding. And my heart supports me in this.

  WHAT THE HEART CAN FEEL

  The heart has a fine and sophisticated sensor system for the pressures in its ventricles and atria. It knows how much it is stretched and even has sensors for the chemical environment and the composition of the blood in its chambers.1 These data are passed on to the brain, and it depends on them how much blood and information is ejected with the next heartbeat. It becomes too much sometimes even for a robust type like our heart. If there is too much pressure and it is all too “full,” the heart may let off steam. It spills hormones called ANP (atrial natriuretic peptide) and BNP (brain natriuretic peptide). We have to take a break, go to the restroom and urinate, the amount of fluid in our body decreases, the blood vessels widen, and the excess pressure in the heart abates.2

  ANP reduces the amount of stress hormones circulating in the body and exercises a positive influence on our immune system and our behavior.3 The heart’s ability to perceive physical signals allows it to always return to an equilibrium, to a balance of exertion and relaxation. Some scientists say the heart acts intelligently.4

  Heart breakers

  Had Yücksel and Huyen already finished their coffee break? I couldn’t find them in the cafeteria. Only when I was looking for a seat with a cappuccino on my tray did I spot them. They had retreated into the furthest corner. To fight? No, not this time. They were enjoying an animated conversation. And it looked like much more than flirtation. I decided, grinning, not to disturb them but sat down not too far away. They did not even notice. I enjoyed my coffee and let my thoughts wander.

  * * *

  With couples in love, sometimes a look into each other’s eyes is enough for their heart and breathing frequencies to align.5 Yücksel and Huyen were now sitting so close to each other that my clinical glance immediately detected the cuddle hormone oxytocin. In the section “The all-purpose glue of love,” above, I discussed how the heart is able to produce oxytocin by itself. Thus it is not surprising, even though not widely known among heart specialists, that our heart is equipped with feelers for the love hormone. Those who believe that love originates in the brain alone may well ask why, if this is true, the heart also has such receptors? Our body is a highly complex, finely tuned masterpiece—every receptor and every pipe has its purpose, nothing is left to chance.

  * * *

  As you read earlier, the love hormone is the initiator of your first heartbeat. But it also has a lifelong protective function for your heart. Researchers say it is cardio-protective: it constrains the distribution of inflammatory mediators and thus the development of atherosclerosis. It has been shown in experiments that the amount of dead heart tissue—indicating the size of a heart attack—was reduced by two-thirds if the hearts had been flooded with oxytocin, as it reduces the heart’s oxygen requirement and widens its blood vessels. Blood pressure drops and the pulse becomes slower.6 In stem cell therapy involving the heart, researchers let new heart cells grow when the old ones have been destroyed during a stroke. Before the new ones are implanted in the heart, they are bathed in oxytocin, because it allows heart cells to grow especially well.7

  * * *

  Several studies have found that people in stable partnerships live longer.8 I am sure that has to do with love and its repercussions for the heart. And it might well be that Yücksel and Huyen were laying the foundation for a long happy life right at this moment.

  Yücksel kept interrupting his animated chat and touched Huyen’s upper arm or left hand as if by accident. As if he wanted to be sure she heard his words and opened her heart to him. What is vital for us as babies we also like as adults. A loving touch can synchronize romantic partners in an instant. Their skin resistance, breathing, and heart rates attune. Even the time the pulse wave needs to travel from the heart to the tip of a finger adjusts.9 Recently it has been proven that the skin possesses special nerve fibers, so called C-tactile afferents, which trigger the release of love hormones.10 My two colleagues looked as if it all came from the heart, with the signal paths via the brain playing only an inferior role.

  * * *

  With each one of Yücksel’s touches, Huyen blushed a little, and Yücksel’s cheeks were already glowing. Soon the lights in the cafeteria might be switched off. Possibly the two of them would not even notice; they had not once looked around the room, had not seen me, for example. Well, I had no part in their romance. What I saw with increasing amazement and great joy was a most beautiful spectacle—what people have thought-felt-known for thousands of years: the heart is the organ for love. It beats in our throats and races with excitement and joy. It flutters in the chest and becomes big and wide. And sometimes it is given away, as was happening five tables down from me. We blush and our blood pressure rises, the hands shake and sweat. The electric skin resistance is lowered, the skin becomes more sensitive, we become literally more touchable.11

  * * *

  A love potion made from adrenaline, noradrenaline, and the joy hormone dopamine is responsible for these unmistakable symptoms. Its ingredients are well-known: neurotransmitters in the brain and hormones from the adrenal gland. That they also come from the heart and are produced there by specialized cells—that is a fact so far completely neglected by love research.12 Instead, love has been more and more vehemently situated in the brain in recent years. That did not happen by chance. It is in the brain that noradrenaline causes sleepless nights and lack of appetite. Dopamine has inspired poets to write love poetry and musicians to write love songs.13 I believe that it is precisely the duet of heart and brain that achieves great works of art. And a few tables away I was able to observe lines from many well-known love songs in action.

  * * *

  I took a sip of coffee and thought of my little patient, Maria. In a minute I would go to the intensive care department and check on her. The biochemistry of love and the therapy to save gravely ill hearts in intensive care are basically identical. For the heart not only produces noradrenaline, adrenaline, and dopamine, it also has receptors for them.14 Heart surgeons know this, and after heart operations these substances are given intravenously for days and weeks to support the gravely ill heart. I doubt, however, i
f “gravely ill” would be the correct diagnosis for the hearts of Huyen and Yücksel, even though they had begun in the meantime to appear a little feverish—and also disoriented, as actually our break had come to an end.

  Hearts don’t lie

  In one study, the partners of thirty-two ethnically mixed couples in love were placed across from each other, and their breathing and heart rate variability were measured. Six percent were Asian, 75 percent light-skinned American, 2 percent of African descent, and 18 percent Latin American. First, they were asked to look deeply into each other’s eyes for three minutes. No touching, talking, or grimacing. Their hearts followed a shared trajectory of fast to slow, then becoming faster again nearly at the same time. Independent of the participants’ origin, Cupid’s love beat seems to pulsate in a universal language that is understood and is the same everywhere.15 In a second round, the participants were asked to try to imitate their partner’s breathing and heart rate. Concerning the breathing this worked quite well; it is visible after all. But with the hearts, the subjects lost their beat; the effect was partly even the opposite of the intended one. For example, the male hearts beat faster when the female hearts were slowing down. In other words, the participants were not able to deliberately establish this sort of touchless beating in sync. At the risk of sounding corny, I say: hearts don’t lie.