All Of It with Alison Stewart

Episode: A Comprehensive History of Brain Surgery

Date: September 16, 2024
Host: Alison Stewart (WNYC)
Guest: Dr. Theodore Schwartz, neurosurgeon, author of Gray Matters: A Biography of Brain Surgery

Main Theme

This episode offers a fascinating and accessible history of brain surgery as told by Dr. Theodore Schwartz, a pioneering neurosurgeon. Using anecdotes, listener calls, and moments from his book, Schwartz explores the evolution of neurosurgical practice, the field’s trailblazers, the emotional and psychological burden of the work, and the advances that have transformed patient outcomes and understanding of the brain.

Key Discussion Points and Insights

1. Why Write a History of Brain Surgery?

• Dr. Schwartz wanted to demystify neurosurgery for the public, sharing what the field really entails and who it touches.
• He emphasized the emotional and ethical complexities involved: “I wanted to talk about what the training is like, what it's like to be a brain surgeon, how we see the world...and how our field has really impacted the world around us.” [01:44]

2. Ethical Reckoning: The Case of Frontal Lobotomies

• Schwartz was surprised by what he uncovered about the mid-20th-century practice of lobotomies—a “skeleton in the closet of [his] field”.
• He discovered that neurosurgeons often approached lobotomies more cautiously and scientifically than popularly believed, sometimes even abandoning the practice as unethical.
• Quote:

  “I felt like I was putting neurosurgery on the couch a little bit and putting on my dad's hat…and trying to look back and say, hey, were we complicit with this operation?” [03:06]

• Surprisingly, some patients did improve temporarily, but the harm overwhelmingly outweighed the benefit, leading to the abandonment of the procedure.
• Innovations devised during the lobotomy era later improved treatment for other brain illnesses, like Parkinson’s or epilepsy.

3. Founders of Brain Surgery

• Before Harvey Cushing (early 20th century), brain surgery had a 50% mortality rate and was a desperate, last-choice operation.
• Cushing’s main innovation was meticulousness and methodical speed—taking advantage of new anesthesia and antisepsis rather than prioritizing speed over safety.
• Drastic improvement: “By the end of his career...he had reduced the mortality of brain surgery from 50% to around 8%.” [05:32]
• Walter Dandy, Cushing's protégé, pushed for greater efficacy—aiming not just for survival, but full tumor removal.

4. Diversity & Representation in Neurosurgery

• The field is still overwhelmingly white and male.
• Women in neurosurgery have increased to 10%; projected at 30% by 2030. Minority representation remains stagnant at around 4%.
• Schwartz participates in outreach to underserved communities, inviting students to shadow and consider the field.
• Quote:

  “Neurosurgery is not for the faint at heart. And it is an enormous sacrifice. It takes an enormous amount of dedication.” [11:32]

5. Advances in Patient Care & Safety

• Elective brain surgery today has a mortality rate “far less than 1%...almost unheard of for someone to die on the operating room table...” [17:09]
• Modern imaging (MRI, CAT scans) has nearly eliminated exploratory surgery.
• Focus is now always balancing maximum tumor removal with preservation of function.

6. The Psychological Toll of Brain Surgery

• The emotional burden on neurosurgeons is heavy. “We bear an enormous psychological burden because a patient comes to us and looks to us as an expert and basically hands over to us their most prized possession, which is their brain.” [48:24]
• Schwartz shares the devastating story of diagnosing his father’s stroke, juxtaposed with a later case where new minimally invasive techniques saved a friend’s mother. [18:17–22:17]

7. Innovations in Minimally Invasive Surgery

• Patients and former patients called in to testify to the shifting landscape—surgeries through the nose, the eyebrow, or even using focused ultrasound.
• Example:
  • “We can now take out tumors without making any incisions going through your nostrils or a very small incision in your eyebrow or eyelid.” [27:30]
• Minimally invasive approaches reduce physical and psychological trauma, but patient expectations still have to be managed.

8. Balancing Aggression and Caution in Surgery

• Leaving some tumor behind is sometimes the best option to avoid devastating complications.
• Quote:

  “Sometimes doing that will hurt the patient because that last bit of tumor you take out...could damage the nerve and it may never recover. ...The hardest part is knowing when to stop.” [27:30]

9. Concussions and Sports

• A single concussion is usually recoverable, but cumulative smaller impacts form the bigger risk, i.e., chronic traumatic encephalopathy (CTE).
• Quote:

  “What's more concerning...is that we now know that it's not just the big concussions, but it's all the little hits...every player on that field is at risk.” [30:10]

• Explains we currently have no way to diagnose CTE in living people but future genetic and molecular tests may change that.

10. Patient Experience: Awake Brain Surgery

• The brain itself lacks pain receptors (“the brain does not have any pain receptors or touch receptors” [24:27]), allowing for awake surgeries that minimize risk to language and movement.
• Symptoms like headaches are caused by structures around but not inside the brain.

11. Techniques on the Horizon

• Focused ultrasound is offering new hope for treating Alzheimer’s by opening the blood-brain barrier.
• Deep Brain Stimulation (DBS) is in use for Parkinson’s tremor, OCD, and epilepsy, with ongoing studies for depression.

12. Brain and Mind: No Dividing Line

• Schwartz takes a materialist stance:

  “There may not be such a thing as mind. We have a word for mind. Our language has something called mind. But just because we have a word for it doesn't mean that it exists.” [43:09]

• Neurosurgery demonstrates that personality, preferences, and even memories can be directly altered by physical intervention in the brain.

13. Age and Risk in Surgery

• No strict age cutoff for brain surgery, but risks and life expectancy are major factors.
• “You look at the life expectancy of the patient and the growth rate of the tumor.” [46:37]

Timestamps & Notable Quotes

| Timestamp | Quote / Segment | Speaker | |------------|----------------------------------------|--------------------| | 01:44 | “I had a story to tell. I wanted to talk about what the training is like, what it's like to be a brain surgeon, how we see the world...” | Dr. Schwartz | | 03:06 | “I looked at [frontal lobotomy] as a bit of a skeleton in our closet of the history of my field that I had never learned anything about.” | Dr. Schwartz | | 05:32 | “Before Cushing, there really was no such thing as a brain surgeon. ... the mortality of brain surgery ... was about 50%.” | Dr. Schwartz | | 11:32 | “Neurosurgery is not for the faint at heart. ... It takes an enormous amount of dedication.” | Dr. Schwartz | | 17:09 | “It's almost unheard of for someone to die on the operating room table having brain surgery...if you're having an elective surgery, literally almost unheard of, it's like the plane going down. These things really don't happen anymore.” | Dr. Schwartz | | 18:17–22:17| Schwartz shares the emotional story of his father's stroke and the experience of being both family and physician. | Dr. Schwartz | | 27:30 | “We can now take out tumors without making any incisions going through your nostrils, or a very small incision in your eyebrow or eyelid.” | Dr. Schwartz | | 30:10 | “What's more concerning...is that we now know that it's not just the big concussions, but it's all the little hits...every player on that field is at risk.” | Dr. Schwartz | | 43:09 | “There may not be such a thing as mind...just because we have a word for it doesn't mean that it exists.” | Dr. Schwartz | | 48:24 | “We bear an enormous psychological burden because a patient comes to us and ...hands over ...their most prized possession, which is their brain.” | Dr. Schwartz |

Listener Interaction & Patient Stories

• Two former patients called to praise Dr. Schwartz’s surgical skill and empathetic approach, both describing surprising ease with minimally invasive procedures and the life-altering results (23:00–25:35).
• One caller described temporary sensory loss after surgery, which Schwartz explained as a calculated trade-off to preserve critical functions (25:35–29:59).

Memorable Moments

• Schwartz commandeering a hospital wheelchair to rush his father to a brain scan in an unfamiliar hospital, blending clinical urgency with family emotion (18:17–22:17).
• A caller describes their fears of brain surgery—only to experience a minimally invasive, through-the-nose approach with a much happier outcome than anticipated (25:35).

Conclusion

Dr. Schwartz’s conversation illuminates the dramatic progress in the once-scary field of brain surgery, balancing science with emotional candor and patient stories. Whether discussing surgical risks, the advances that have reduced mortality to a fraction, or the humbling limits of the field, Schwartz brings the professional—and personal—side of neurosurgery to life.

For anyone contemplating brain surgery or simply fascinated by the brain, this episode provides vital history, real-life perspective, and a respectful sense of hope and humility.