B (2:54)

We're going to get into the research of this, the deep research in this, about brain surgery. But when you think about all that, you know, about brain surgery, what surprised you?

A (3:06)

What I really enjoyed researching the most, believe it or not, was the history of the frontal lobotomy. You know, we all sort of vaguely know that there was this period of time when there was a treatment for mental illness called a frontal lobotomy. And it was some sort of a gruesome, horrible operation that doctors gave to their patients without really knowing that they were hurting them more than helping them. I looked at it as a bit of a skeleton in our closet of the history of my field that I had never learned anything about. It was never talked about during surgery. And my father, as I discuss in the book, was a psychoanalyst. And I felt like I was putting neurosurgery on the couch a little bit and putting on my dad's hat and sitting in his chair and smoking his pipe, wearing Freud's mustache and beard, and trying to look back and say, hey, were we complicit with this operation? Is it something the neurosurgeons were eager to do? Were we reluctant to do it? What was the evidence behind it? And I really took a deep dive into that, and I think that was the most fun for me to explore. And what I uncovered was that most of the lobotomies were being pushed by neurologists and psychiatrists and by the public. And certainly there were neurosurgeons who were doing this operation, but most of them did it carefully and scientifically and actually studied it and studied how their patients did before and after and came to it with a skeptical perspective. Many abandoned it. Many realized, actually, that some were helped. That was another surprise. There were many people actually helped by the frontal lobotomy, but it clearly was hurting more people than it helped and needed to be abandoned, and was abandoned. But I also learned that many of the technical innovations of brain surgery that we still do today were invented back in the 50s and 60s in order to improve on the frontal lobotomy, Because a lot of neurosurgeons saw this operation as sort of a grotesque way to approach the brain and try to figure out more careful and delicate ways to do the same operation. They realized what they had invented wasn't good for lobotomies, but it was much better for Parkinson's disease or for epilepsy or for tumors.

B (5:09)

My guest is Dr. Theodore Schwartz. He is attending neurosurgeon at Weill Cornell Medicine Medical, and he's the author of the new book Gray Matters, a biography of brain Surgery. Let's go back to the very beginning. Harvey Cushing. You write about him as sort of the founding father of brain surgery. First of all, what was it like before Cushing?

A (5:32)

So before Cushing, there really was no such thing as a brain surgeon. Didn't exist. There were general surgeons who would do some brain surgery occasionally when they had to do it, they certainly didn't want to do it, because the mortality of brain surgery around the turn of the century was about 50%. And it's crazy to think of that, that half the patients who got on a neurosurgery operating room table and had someone open their skulls would literally die during surgery or soon after. And Harvey Cushing took on the task of saying, I want to take on the responsibility of this highly morbid operation and make it safe. And he did. And by the end of his career, which is about 30 years later, he had reduced the mortality of brain surgery from 50% to around 8%. And now, of course, it's far below 1% now. But that change in and of itself was dramatic because it allowed us to realize that you could do these operations safely. And before Harvey Cushing, we really couldn't.

B (6:27)

What did he do to make brain surgery safer?

A (6:30)

Well, he benefited a bit from his time, as we all do. Antisepsis was invented at the time, and anesthesia was invented at the time, so people were learning how to make surgery safer. In general, he was incredibly meticulous. He was very slow. He was very, very focused, very, very dedicated. He essentially gave his life to the pursuit of neurosurgery and realized that if, you know, if I did it very slowly and carefully, because back in the old days when anesthesia didn't really exist, the best surgeon was the fast surgeon, right? You think of the barber surgeon who could amputate your leg very quickly because there was no anesthesia. And Harvey Cushing benefited from anesthesia and said, hey, I can take my time now. Let's see how safe I can make it if I do this carefully. And what can I learn about how to make Surgery safe. And that's what he did.

B (7:16)

And so that's how he made it more effective, by being slower, by being meticulous.

A (7:20)

Well, I talk about efficacy. He had a protege named Walter Dandy who came after him, who was an upstart, a younger neurosurgeon who kind of wanted to show off to Cushing how great he was. And Cushing was constantly keeping him down. And their rivalry is one of the great stories in the history of medicine. Dandy really made it more effective because he stood on Cushing's shoulders and said, yeah, sure, we can do it safe, but let's see how fast we can do it. You know, let's not just try to get the patient out of the operating room alive. Let's see if we can actually take the entire tumor out. And that was something contributed by a different one of our forebears.

B (7:54)

We got a text from one of our listeners. Question is, considering the demographics of many victims of lobotomies, do we actually think most doctors thought it was not harmful?

A (8:06)

Well, at the time, you have to keep in mind that there was no other treatment for mental illness. So patients who had severe schizophrenia and depression would be institutionalized, and they would basically live in these institutions for their entire lives. And the competing therapies were things like giving them enormous amounts of insulin to lower their glucose or throwing them in ice baths to lower their temperature. These sort of shock therapies. So compared to what was the existing standard of care and best treatment at the time, the lobotomy was actually a progress and a step forward. And there were people who did get better. There's no question. For example, I give the example of Wilder Penfield, who's another one of our very famous forebears. And one of the goals of the book was kind of to tell the public, hey, there are certain neurosurgeons out there that were incredibly instrumental in our field and have changed the world. And I kind of want to introduce them. Penfield did, I think, seven lobotomies and abandoned it because he realized it was just too dangerous. So there were many neurosurgeons who felt that the lobotomy was an awful operation and should not be performed. But the public and many psychiatrists were demanding it.

B (9:14)

You mentioned the number of people who pass away during brain surgery. 8%, as you said, or no. Less than 1%, you said.

A (9:23)

Yes, far less than 1%.

B (9:25)

It's very sad. Why is that now the case?

A (9:28)

Well, because we know what we're doing, right? So we know the anatomy of the brain. We know how to get in and out of the skull very safely. We make our procedures much, much less invasive. You know, knowledge has progressed dramatically from, you know, the turn of the century. Back then, we didn't have MRI scans or CAT scans. So a lot of the surgeries were exploratory. Patient would come in with a problem, you would examine them, and you'd have to guess where the tumor was, and then you'd have to open up the head and go looking for it. Now we do an MRI scan. We know exactly where we're going, and we've sort of codified all of the approaches that we do to get in and out safely. And we're trained as to how to do them safely by our mentors in training programs.

B (10:11)

And you note in the book that the field of neurosurgery is still overwhelmingly male and overwhelmingly white. What would have to change? What needs to change?

A (10:23)

Well, it is changing. To be honest. We're doing a better job with women right now. About 10% of neurosurgeons are women. That number is projected to go up to about 30% in the year 2030, and that's really a reasonable number in a way. About 50% of. A little more than 50% of medical students are women. And you can't imagine that 50% of neurosurgeons will be women because it is a very, very demanding field. And a lot of women who just may say, look, you know, if I can't have children or if I have to put that on the. On the back burner, you know, it might not be the right field for me. 30% is reasonable, and it may go up from there. There's so many more role models who are women. Now, with respect to minorities, that number is still pretty low. It's about 4%, and it's not really moving. But neurosurgery has gone out of its way to try to promote, identify people. I myself go into high schools, you know, in underserved, underprivileged areas, and try to give lectures and have people shadow and make my operating room open to a diverse community of students who may want to go into neurosurgery but never be exposed to it.

B (11:29)

What do students want to know from you?

A (11:32)

First? They just want to see it. I think students initially, they just want to go in and see the human brain. It's sort of the shock value. They've seen it on tv. They feel like it's going to be like a horror movie. But eventually, then they want to know that it's possible to live a reasonable, balanced life and be a brain surgeon. And there's no question that it is. But I also do emphasize to any student that neurosurgery is not for the faint at heart. And it is an enormous sacrifice. It takes an enormous amount of dedication. I try to convey that in the book that we talk about Gen Z and Gen X, people ask me, are students becoming more lazy, they don't want to work as hard. The truth is the ones who choose neurosurgery as their specialty, they know they're going to be working really hard. They're incredibly dedicated. And that's one of the beautiful things of being in a field like this because you're surrounded by people who are just totally dedicated and focused to the well being of their patients and you know, their personal lives are important to them. But we all know that often our personal lives, you know, have to be second or third on the list when patient care comes at the forefront.

B (12:40)

We're talking to Dr. Theodore Schwartz. He's the author of Gray Matters, a biography of brain surgery. After the break, we'll take your calls and we'll learn a little more about what brain surgery is like.

A (12:50)

Today.

B (13:00)

You're listening to all of it on WNYC. I'm Alison Stewart. We're spending this hour talking to Dr. Theodore Schwartz, an attending neurosurgeon at Weill Cornell Medicine and author of the new book Gray Matters, a Biography of Brain Surgery. Listeners. We want to invite you into the conversation. What's a question you've always wanted to ask about brain surgery? Maybe you've had brain surgery. What was your experience like? Give us a call. 2124-3396-9221-2433. WNYC. You can call that number or you can text to us. Our social media is available at all of it. WNYC. Dr. Schwartz, let's talk about brain tumors. When you go in to remove a tumor, what are you most worried?

A (13:45)

The most worrisome thing is really making sure that the patient leaves the operating room fully functional, that I've been able to take out as much of the tumor as I can safely take out without hurting that person because often these tumors are ensconced in the brain very close to critical parts of the brain that are important for language or moving your arms and your legs or vision. We spend an enormous amount of time thinking before we cut about how are we going to get in and out safely? What approach are we going to use? How are we going to traverse the least amount of brain to get there, or hopefully no brain whatsoever. So my biggest fear, obviously, is hurting someone, because neurosurgery is all about that careful balance between doing good and doing harm. And we are walking on that thin tightrope with every operation we do. And the majority of operations are incredibly successful. And I want to emphasize that to the audience. But every once in a while, things happen and patients can wake up harmed. And of course, it's devastating for the patients, but it's also a huge psychological burden on the surgeon. Right. I mean, all we want to do is help people. That's why we went into this field. We're very sensitive people, and God forbid someone wakes up worse than they started out. It's devastating to us, and it's something that we carry with us at all times.

B (15:07)

How often do you go into brain surgery? Not really sure what you might find?

A (15:14)

Very rarely these days in terms of completely not knowing. MRI scans show an enormous amount of information. But that said, there are many things that the MRI scan don't show. I can know where a tumor is going to be, and I can see some of the blood vessels and nerves that are wrapped around the tumor and have a sense of where they're going to be. But when I get there, what I don't know is how firm is that tumor going to be? How stuck is that blood vessel going to be? Is there a small blood vessel that I didn't see on the MRI scan because it was smaller than the resolution of the MRI scan? Into every surgery with a plan of attack, for sure. But when we get there, often that plan changes, and we have to think on our feet, and we have to be facile and nimble with our thinking and not be too dogmatic and say, this is the way I'm going to do it, and I'm just going to do it this way, because there can be surprises, and often, you know, blood vessels will be very stuck. And so you instead of going, you know, on the left part, we have to try to go on the right part, or maybe we have to debulk more of the tumor more. So it's decision after decision after decision that we're making. And again, just to remind you, often we're working under a microscope with instruments that are very, very tiny, and we live in the realm of the millimeters and microns. Most people live in a world of feet and inches, and neurosurgeons don't live in that world. We have to train ourselves to essentially going down into the quantum realm and live in a very tiny area. Working our entire day in an area the size of a postage stamp to do what we want to do.

B (16:44)

Take a call. This is Mary calling from East Islip. Mary, thank you so much for calling wnyc.

C (16:51)

Oh, my pleasure. Thank you for having this guest. It's fascinating stuff and I'm just interested in the 1% that you mentioned that it's very survivable to have brain surgery. So is that if we're scheduled or does that include accidents as well?

A (17:09)

So the 1% was far less than 1%. Just to be clear, it's much less than that. So it's almost unheard of for someone to die on the operating room table having brain surgery. Unless, as you said, if you come in with a severe accident, let's say you have a gunshot wound to the head and we're trying to save your life. In that situation, we may be able to save 90%, but there's still going to be 10% where the injury was just so devastating that there's nothing that can be done or a huge hemorrhage in the brain that's just so devastating to the patient and so much of the brain has been damaged that nothing can be done. But 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.

B (17:56)

So my brain issue happened around areas 44 and 45, my language centers near the Broca Center. I know you wrote about this about your dad and your dad was struck with aphasia as well. First of all, what was that like for you, having your father, you know.

A (18:17)

Just to preface it, you know, one of the things I, one of the challenges of writing a book about brain surgery is, you know, how do you get the general public interested and how do you make it emotional and meaningful and not too technical? And one of the techniques I tried to use was to talk about patients I took care of and family members that I had to take care of. So I was a, I think a sixth year resident and my dad went in for a surgery for a benign tumor is duodenum nowhere near his brain. And it was Saturday morning and I was at home and my phone rang and I picked up the phone and I heard a voice on the other end of the line and it sounded like my dad, but it didn't sound like my dad and that he really wasn't able to get the words out. And he was struggling. And of course, six years of neurosurgery training is a lot. And I had heard that type of speech before of someone who has something called a Broca's aphasia. And you mentioned 44, 45. These are these Broadman areas of the brain, which are histological ways. We divide the brain up. But there's an area of the brain that's very important for producing speech, which is different than comprehension of speech. So he could understand everything, but he could not talk. And I threw my clothes on, ran into the hospital. Turns out it was not the hospital where I was a resident at the time, so I had no privileges there. And I went into his room, and sure enough, he couldn't talk. And I ran out to the nurses, and I'm like, my dad has a Broca's aphasia. He needs a neurology consultant. He's a CAT scan right away. And they called a neurology consult. I spoke to the neurologist. We got the CAT scan ordered. And I said to the nurses, so, where's CAT scan? And they said, fifth floor. I'm like, okay, let's go. And they said, well, we have to wait for transportation. And that's how hospitals work. And I was very well aware of it. But in neurosurgery, when we have neurosurgical emergencies, we are trained to get it done. Like, we don't wait for transport. We don't wait for blood draw. Like, we just did it ourselves. So I ran back into my dad's room, and I threw all the IVs on his bed, and I packed him up, which I knew how to do. And I literally wheeled him by the nurse's station. I remember hearing the nurses saying to me, you can't do that. And by the time they were done, I was in the elevator on the fifth floor, went to the scanner. You know, saw the tech there. And I said to the tech, you know, I'm Dr. Schwartz. This is my patient. He needs a CAT scan. And I didn't mention that I wasn't a doctor at this particular hospital. Put him on the CAT scanner, and we did the scan. And. And really, the most poignant part for me was sitting in the control room. And those who have been in hospitals know this. You sort of sit there with the tech, and the images come up one at a time. You know, they take them up in a series of slices. And so I was there sitting and looking at my dad's brain, which I'd never seen before in that particular way. I knew my dad's brain in other Ways, but not as an object. And as each slice came up, I was anticipating what I was going to see when Broca's area appeared. And sure enough, there was a big black circle there which indicated a stroke. So I essentially made the diagnosis on my own, saw my dad's stroke, and knew at that moment in time how devastating it was, because there was no way to reverse it. We don't have a way. We did not have a way to reverse stroke at that period of time. And my dad passed away a few weeks later. I tell that story, and I contrast it with Another story about 10 years later, a happier story, where one of my good friend's moms had a stroke in the emergency room at Cornell where I work. And I was able to call one of my partners, and a new technology had developed where we could put a catheter in and suck the strokes out of the blood vessels. I made sure to get that procedure done on her as quickly as possible. And it was a Sunday on the weekend, and we got it done, and she was cured of her stroke and made a complete and full recovery and is still around today. I just saw her last week, so it was a nice example of how progress has moved forward in neurosurgery health. We could do it through literally, a needle stick in her groin, you know, is a minimally invasive procedure, and was able to save her life.

B (22:17)

Let's talk to Mimi from Manhattan. Hi, Mimi. Thanks for calling, all of it. Hi, Mimi.

C (22:24)

Hi. Thank you for taking my call. Hello, can you hear me?

B (22:28)

Yes, we hear you.

C (22:30)

Hello, can you hear me? Yeah. Okay, great. Thank you for taking my call. I was calling in because I actually had a brain meningioma, and Dr. Schultz operated on me in 2015, and I'm doing really well, and I am so grateful that I found him. And what was exceptional about him is how he spoke to me. He was actually the third neurosurgeon I went to, and I was kind of out of that at that time, as you can imagine. And the other neurosurgeons were very, I don't know, maybe dismissive or patronizing. They felt like, oh, just listen to me, and you don't need to understand anything. And Dr. Schwartz was really kind and also had all these wonderful new techniques because, like, the old school person I went to said, oh, we're just going to peel your face back. And I was like, oh, my God. And Dr. Schwartz would think, well, we put these sensors on your skull, and it'll be like the gps. And I'm Going to a tiny thing in your eyebrow and drive around.

B (23:43)

Yeah, I'm going to cut you off there. Thank you so much for calling, Mimi. That was interesting. That one of your.

A (23:49)

So beautiful. Yeah, Mimi. So thank you for calling. That's really meaningful to me. You know, we don't often hear back. Often we do, and often we don't. But it's just so nice to hear a grateful patient. It's like food for our soul, right? I mean, that's why we do what we do. We hear these people whose lives we get to change. And that's what I'm trying to convey in the book also. Not just when things go bad, but what is it like when things go well? What is it like when you change someone's life for the better? It's just a beautiful experience that we get to participate in as brain surgeons.

B (24:17)

Here's a question. Somebody texted this to us. Is it true that the brain doesn't feel pain? If so, what pain causes the common headache?

A (24:27)

Well, Allison can comment on that as well. But it is true. The brain does not have any pain receptors or touch receptors. So the way we feel things is that there's a receptor designed for touch or pain or temperature on certain parts of our body, and that gets sent to the brain and the brain experiences it. But the brain itself doesn't have those receptors. So we don't know what's happening. Our brain just like we don't know what's happening in our liver or spleen. And so you can touch the brain and no one would know. So what causes a headache? Well, the blood vessels around the brain have some sensory fibers, and the periosteum, which is the covering of the bone and also the covering of the brain, which is the dura, is exquisitely sensitive. So there are a number of different things around the brain and near the brain that do have pain fibers in them and that do give us headaches. For example, we do awake surgery on a patient. We make sure we numb all of those things very, very carefully. But we can do an entire surgery on the brain without the patient knowing that we're touching the brain or doing anything to their body.

B (25:29)

Let's talk to Leti. Hi, Leti, thank you so much for calling in. She's calling in from Stockbridge, Massachusetts.

C (25:35)

Hi there. I'm a patient also of Dr. Schwartz's and, in fact, an old friend. So though I wasn't family, I was somebody he knew when he was in high school or college. And I am one of the ones who brings food to his soul, because I am so grateful. I had a pituitary adenoma. It wasn't cancerous, but it was a tumor, and it was threatening certain nerves in my skull. And I could have potentially lost facial nerves. I could have potentially lost a vision in one eye, as far as I understand it. What I wanted to bring up were two things. One, I immediately. When I was diagnosed, I immediately envisioned that my skull would be cracked open, that my hair would be shaved off, that, you know, I would lose part of the use of my mind, which is very important to me. I'm a writer. And what happened, in truth, was Dr. Schwartz went in through my nose with Dr. Vijay, I believe is his name, went through my nose, took the tumor out little by little and left some in. The second thing I want to raise is because I think I was told, but I was not prepared. I lost three of my senses. At the end of it, when I was recovering, I saw double. I couldn't smell anything. I mean, I couldn't smell my perfume. I couldn't smell onions, you know, sauteing in a pan. And my taste was off completely. And that came back. But until it came back, I think I was probably more upset about that than I was anticipating the surgery.

B (27:20)

Aw, thank you so much for calling. Yeah, that is interesting. After brain surgery, the things that you lose and you wonder, how long is this loss for.

A (27:30)

Yeah, no, it raises a bunch of interesting points, and thank you, Letty, for calling in. It means a great deal to me. The first thing has to do with the fact that neurosurgery is becoming less and less invasive. And I do emphasize, and I tell that story in the book in many, many different ways. So we can now take out tumors without making any incisions going through your nostrils or a very small incision in your eyebrow or eyelid. We can do some surgeries without even opening up the head using techniques like focused ultrasound and radiosurgery. And I describe all of. But the other point that Leti raises, which is a tremendously important point, is that she woke up and she was not perfect. Right. She couldn't smell. She had some double vision. And so this is what neurosurgery is about, in that you have to break a few eggs to make an omelet sometimes. This patient in particular, leti, needed surgery 100%. She did not have an alternative. There was no other option. Had we not done surgery, the tumor would have taken all of those functions and then some, and it might have taken her life. And the point is that we have to make a trade off when we do brain surgery and we have to decide, and she made this point, I left some tumor behind. Very often when you're doing a surgery and there's a chapter I write called the hardest part is knowing when to stop. And it's very true, because as surgeons, we want to kind of go in and take everything out. We want to make the MRI scan look perfect. We want to be able to tell the patient at the end of the operation, we got it all. But sometimes doing that will hurt the patient because that last bit of tumor you take out where you're peeling it off, a nerve could damage the nerve and it may never recover. And that patient doesn't care if you didn't take it all out. If they're never going to need another surgery again, they're going to care because that nerve doesn't work. So we made a decision during Leti's surgery to leave a little tumor behind. And all of the symptoms she had got better. So in the long run, she did great. To us, it's a great outcome. Now, obviously for her, she had those symptoms and maybe if she knew she was going to have all those symptoms and we'd gone through them like you're going to have this, this and this, she would have been terrified to show up the day of surgery. And she might not have had it, but she needed it. And her long term outcome is much better because she had the surgery and if she hadn't had it. And so as a neurosurgeon, you very much have to be careful with how you give information because you want that patient to show up the day of surgery. You know that is the best thing for them in the long run. And then you have to make the decisions during surgery to make sure it actually is the best thing for them in the long run. And sometimes that means leaving tumor behind.

B (29:59)

My guest, Dr. Theodore Schwartz, the name of his book is Gray Matters, a biography of brain surgery. I want to talk about concussions. First of all, what happens when you have a concussion.

A (30:10)

So a concussion is really the result of a pressure wave that is passing through the brain when your brain is moving in one direction and then abruptly stops. And a concussion can cause damage to neurons, it can cause damage to axons, which are the wires that connect the neurons to each other. And usually the results of that are temporary or self limited. So most people recover from a concussion. There are some people who can have long lasting symptoms of a concussion, but a single concussion is usually something that you make a full Recovery from. What's obviously more worrisome are these diseases like chronic traumatic encephalopathy that we're dealing with. And just this weekend, we saw Tua Tagovailoa, the quarterback for the Miami Dolphins, who had a horrible third concussion. And everyone is saying he should retire. He should retire. Retire. He wants to keep playing. And it's clear that all football players want to keep playing football. They love the game of football. They do not want to stop playing, and they're very well aware of those risks. But what's more concerning, in a way, than to his concussion, which was extremely concerning, was the fact that we now know that it's not just the big concussions, but it's all the little hits. It's the cumulative damage done by every hit. So every player on that field is at risk of chronic traumatic encephalopathy. We just worry about Tua, but we don't know that Tua's couple big concussions put him at more risk than every other player in the NFL. They're all at risk now. That being said, they know they're at risk, and they're getting paid very well to take that risk. And from my opinion, that's okay. There are a lot of jobs where we take risk. You're a window washer. You're an airline pilot. There's risk. And as long as you know what those risks are and there's full disclosure, and we do everything we can to try to make the game as safe as possible, which is being done, I think that's. That's reasonable. I get a lot of questions about high school kids and concussion. I just want to quickly say something about that. You know, there are some people, and there have been studies showing that even young people under age 30 who have symptoms and have played contact sports can have chronic traumatic encephalopathy that can cause, you know, mental illness and irritability and anxiety and depression. But I do think that a couple years of high school football is probably safe because you don't get that many hits in high school football. And as long as you don't start when you're, you know, in second grade, third grade, and play for, you know, years and years, I think the very young brain is at risk. And I think college football, if you don't have a high chance of playing in the pros, you should seriously be considering Whether playing Division 3 college football is worth it.

B (32:48)

If you could get your hands on the brain of a former player, football player, what would you look for?

A (32:56)

Well, you know, there's a great group in Boston led by Anne McKee and Rob Cantu that does autopsies on patients and looks for the signs of chronic traumatic encephalopathy. The biggest one of these tau proteins. But there are other changes you see in the brain. But what we really don't know, what's missing here is a way to make the diagnosis while someone's still alive. That's what we can't do. We can't tell you you are going to develop cte. We don't also understand why some players get it and some don't, right? You look at a guy like Peyton Manning, you know, who is obviously very smart and his brother. They're very intelligent. They took a lot of hits, right? And then you look at other players who maybe didn't get through it as well. So clearly there's something genetic that is a predisposition to developing cte. So we can't predict who's going to get it. We don't know who is getting it at the time. We can't see the early changes of CTE in the brain. We don't have that technology. But it is coming. And you can imagine a day where you do a genetic blood test and you say to someone, hey, you're at risk of cte. You probably shouldn't play football. You got to choose another sport. And we test patients maybe with a blood test or some imaging test at the end of the year, and they say, hey, we're starting to see CTE in you. Maybe you should quit football. But we just can't do that yet.

B (34:12)

We're spending the hour talking to Dr. Ted Schwartz, an attending neurosurgeon at Weill Cornell Medicine, about his new book, Gray A Biography of Brain Surgery. We'll have more of your calls after a quick break. This is all of it. This is all of it on WNYC. I'm Alison Stewart. My guest is Dr. Ted Schwartz, an attending neurosurgeon at Weill Cornell Medicine and author of the new book Gray A Biography of Brain Surgery Listeners. If you'd like to be a part of this conversation, what's a question you've always wanted to ask about brain surgery? 2124-3396-9221-2433 wnyc. We got a text here, Dr. Schwartz, that says, what are the considerations about anesthesia for brain surgery?

A (35:05)

I have the pleasure of working with a group of dedicated neuroanesthesiologists, and there actually is a subspecialty of anesthesia that just does neuro anesthesia, because you want to put patients to sleep in a very specific way to make sure their brain is relaxed during the operation. And there are special drugs that do that. You also have to know how to wake patients up during surgery and how to keep them comfortable while they're awake. So there are some special considerations that anesthesiologists need to know, and they go through extra training and fellowships to do that.

B (35:40)

Let's talk to Ann. Hi, Ann. Thank you so much for calling from the Bronx.

C (35:45)

You're welcome. I would like to know if brain surgery can be used to remove any of the plaque that accumulates in the brain that causes Alzheimer's.

A (35:58)

That's a great question. There are ongoing studies right now using a technique. It's not exactly brain surgery, but brain surgeons do the. The treatment. It's called focused ultrasound. We have a way of delivering ultrasound waves through the scalp and skull without opening the skull. There's a device that sends 1,000 separate ultrasound beams and can focus it in the brain. The idea is, one of the things that can be done with this is to open up something called the blood brain barrier, which is a moat, essentially, that the brain erects around itself so that things in the blood don't always get into the brain, because you can imagine toxic chemicals that are going through the blood. The brain wants to protect itself from those. So we can open up the blood brain barrier, and the hope is that if we do that in certain areas of the brain, it'll allow the brain's white blood cells and their devices that fight diseases to get into the brain a little more readily and clear some of those plaques out of the brain. So those studies are ongoing. The early results are pretty good. I think we're all hopeful that there will be a treatment for Alzheimer's disease forthcoming that's not just taking a drug, but also if there is a drug that could clear those plaques, we might be able to use focused ultrasound to help the drug get into the brain, because we could then break down that blood brain barrier and that would push the drug from the bloodstream into the brain, and maybe that will help patients with Alzheimer's disease. So there's a lot coming on the horizon.

B (37:27)

Let's talk to Happy, calling in from Manhattan. Hi, Happy. Thank you so much for calling, all of it.

C (37:34)

Thank you for putting me on. I'm curious. I know about deep brain stimulation for Parkinson's patients. Are there any other procedures, first of.

A (37:44)

All, for Parkinson's or other diseases treated by deep brain stimulants or Parkinson's?

B (37:50)

Well, first of all, would you explain to the most of the audience what deep brain stimulation is?

A (37:55)

And then deep. Yeah, of course. Deep brain stimulation involves placing an electrode into a very specific part of the brain and stimulating that electrode. So deep brain stimulation, we use it to treat mainly the tremor of Parkinson's disease. We also use it to treat obsessive compulsive disorder and epilepsy, and there are ongoing trials using it to treat depression, because it turns out that you can stimulate the brain and trigger not just movements, but also emotions, essentially any emotion that the brain feels. Envy, fear, brain fog can be triggered with electrodes in the brain. Parkinson's disease has many different symptoms and etiologies to it, but the one that neurosurgeons treat the most is the tremor. And in addition to using deep brain stimulation for tremor, we can also use that technique I described, which is focused ultrasound, to focus those ultrasound waves in a part of the brain that is involved in movement and alleviate someone's tremor just by focusing the ultrasound and ablating a small area of the brain. But with respect to all the other changes in Parkinson's disease, we don't have a neurosurgical treatment to comprehensively do all of that. There are some people who have tried gene therapy to put genes in the brain that will make dopamine, which is missing from certain parts of the brain. And those therapies are ongoing. We've tried a transplantation of cells that make dopamine because one of the problems in Parkinson's disease is there's a part of the brain that's missing dopamine. The problem with those therapies, even if they work, is that there are changes in the rest of the brain that also occur in Parkinson's, and that one little change will help a lot of the movement problems, but won't take care of the entire disease.

B (39:50)

Let's talk to George from Washington Heights. Hi, George. Thank you so much for calling.

C (39:55)

Hi. Thank you. I appreciate it. Doctor, given what we know about the prefrontal cortex as regards executive functions, especially decision making, and in light of the fact that people under 21 are prohibited from buying alcohol and tobacco products, et cetera, not to mention handguns, do you think people ought to be able to be drafted or enlist in the military and be deployed to combat under those circumstances?

B (40:27)

That was a little different than what he thought he was going to add. But the question was, how is that related to young people today?

A (40:33)

The prefrontal cornet, it's actually an interesting Question. I was asked a similar question by Ben Carson on his podcast about whether young people whose brains aren't fully developed should be able to make decisions about their gender, for example, which is a very controversial question, and I'm not going to answer that directly. But I will say that the brain's ability to make decisions changes over our lifetime. And the brain itself changes every day. Our brain is fluctuating constantly. We are never the same person yesterday as we are tomorrow. We lose different neurons, we make different connections. We have different experiences that change our brain. And as we get older and older and we lose so many neurons, and we can develop dementia, and we can lose the ability to make sound decisions. Not just because our brains aren't developed, because our brains are degenerating. So the question is, should we have a, for example, a president of the United States? What if they really develop dementia while they're the president? Can they continue? And who's going to make that decision? And how are we going to determine that? And I do think that we should allow our understanding of neuroscience and psychology and brain development and deterioration affect public policy to some extent. And what that will take will be a certain type of testing. So you could imagine, in the example of someone being enrolled in the military, that you give them a test and you say, are you competent to make enough decisions that you can make this decision about yourself? Here's a test we're going to give you, and if it seems like you pass the test, then, yes, you can enlist in the military. Same thing for a president. Could be different for the president. You have to take a test once every month, make sure that you're competent to make decisions. You pass the test, great. You can be president. If you're not, you can't. You can make the same argument about neurosurgeons. Should I be given a test every morning before I operate on someone else's brain and take that responsibility? In an ideal world, sure, yes, my airline pilot should do that as well. But the question is, really, who's going to design the test? How rigorous is it going to be? Do I have to take the test? Can I opt out of the test? Do I have the ability to say no? There's so many political, social questions that are very difficult for us to answer. So the question is a good question, and it's a bigger question than just that. But right now, we kind of assume that our brains work to a large degree all the time, and we allow people to make very important decisions without doing the type of testing we might need to do beforehand to make sure that those decisions are valid.

B (43:02)

A lot of us make a distinction between our brain and our mind. First of all, is there a distinction for you?

A (43:09)

For me, there is not. This is an age old philosophical question about the brain and the mind. And the whole concept that there might be something different called the mind than the brain is something called dualist philosophy, which dates back thousands of years and has been restated time and time again, most famously by Rene Descartes. But the problem with that is that we don't know what mind is. We don't know there's a substance that is mind. All we know of scientifically and can prove exists is brain. And I do write in the book a bit about how my experience as a brain surgeon has led me to realize that 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. We have words for lots of things, like unicorns. It doesn't mean that they exist. There's no question we experience something in our brain being active and we don't really understand why we have the experiences we have it, why it's something it's like to be a brain making the decisions that it makes. No one knows why that happens, but it's very clear from neurosurgery that you can manipulate the brain and you can then subsequently manipulate the mind. And then if you put electrodes in the brain when people are making decisions, you can see that there are neurons in the brain and modules in the brain that are making those decisions before we've even realized that we're about to make a decision and that the brain may really be controlling everything for us. And we're just sort of thinking about it after the fact and creating stories after the fact about why we did what we did, when really it's happening for reasons that we can't control.

B (44:45)

How can the. How can a brain injury affect someone's personality?

A (44:51)

Well, if you imagine that all your personality is, is the sum total of your brain and how it works, if you injure that mechanism, then it's going to change your personality. Just like a computer that gets damaged will change. It'll make the computer glitchy. You know, your brain can be glitchy and your personality can be glitchy. There's a great example of a case that was described in the literature where they put a deep brain stimulating electrode in someone's brain and when they turned it on, they suddenly liked the music of Johnny Cash, which they never liked before. And when they turned the electrode off, they no longer like the music of Johnny Cash. So if you imagine we can change someone's preference for a particular music type, and there's the famous Oliver Sacks book, of course, the man who Mistook His Wife for His Hat. Imagine if you can change your brain and suddenly you don't recognize your children or your wife. We can stimulate the brain in a bilingual patient and eliminate their ability to speak one of their languages, and they can still speak the other language. So all there really is is brain. And if you manipulate the brain in the proper way, you can create dramatic alterations to someone's personality and someone's experience of reality.

B (45:59)

Let's talk to Barbara from Queens. Hi, Barbara. Thanks for calling, all of it.

C (46:03)

Thank you for taking my call. I was wondering, is there an age limit on any kind of brain surgery that may be helpful if a person has things such as an aneurysm, one of those small tumors, and a small stroke, all those things that I understand brain surgery can correct or fix or help, but they would not do anything like that for someone who's older.

B (46:33)

A limit on age for people having brain surgery.

A (46:37)

So there is no minimum age, but we do take age into account in two ways. So, for example, if you have a small, benign brain tumor, and let's say you're 80 years old, and we look at that tumor and say, hey, the tumor is growing very slowly. If you live to be 110, that tumor is still not going to get big enough that it's going to need to be removed. So we're not going to do surgery on you. It makes no sense to take it out because you're never going to need to have it removed. So you look at the life expectancy of the patient and the growth rate of the tumor. The second thing has to do with the health of the patient. So you may have a disease and say, hey, you know, you really probably should have this surgery done, but maybe you have diabetes and high blood pressure, and we're worried if you go under general anesthesia, you know, you'll have a stroke because you had a stroke in the past, or maybe you're on anticoagulation. It's not safe for us to do neurosurgery, so we would send you to your internist and see if you could be medically cleared for surgery. But sometimes patients just have too many other illnesses, and we don't think it's worth it to operate on them, on the other hand, if what they have is so life threatening that they may die in the next month or two, then suddenly you're willing to take more risk. And we say, hey, this is a very risky surgery for you because of your age and your other diseases. But if we don't do surgery, the natural history and progression of what you have, this aneurysm could rupture in the next day or two. You have to take the risk. And that's really what brain surgery is about. It's again, the risk of doing something and the risk of not doing something, the risk of being too aggressive and not being aggressive enough, the risk of helping someone and the risk of hurting someone. And we're constantly balancing those risks in our mind when we make our decisions.

B (48:10)

And it also seems like a certain part of your job is psychological. There's a medical we've been talking about for an hour. But you have to have some sort of responsibility when it comes to the emotions and the fears of your patient.

A (48:24)

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. It's everything to them. And they give it to us. And they say, I'm going to give you this most precious thing to me for a couple hours. Please hand it back to me whole, I want it back the way I gave it to you. And it's an enormous responsibility. And they're relying on you. Their family is relying on you. Their children are relying on you to do your job perfectly, really. And that's our goal, is to be as perfect as we can. But we are not perfect, and no human being is perfect. And often the diseases we deal with are very dire, and the surgeries we do can often be very complicated. So even if you're technically very skilled and experienced, not every surgery is going to go perfectly. And then you have to deal with things when they don't go well. And that the psychological burden of knowing that you may have hurt someone. And every you, you look back at every decision you made. Because I spoke about, you know, before those sort of thousand decisions you make during a neurosurgical operation. And each one of those, you can second guess afterwards. But you should second guess. You have to second guess, second guess, and you have to be humble. As much as neurosurgeons often are very confident in what we do, and we have to be confident because, you know, you have to know that you can do a good job to take on that responsibility, you have to convey that to your patient. But God forbid something goes wrong, you have to be humble enough to realize why it went wrong so it never happens again. So you look at yourself and say, hey, at least I learned from that and I will never do that again. Because, you know, we all get better and better in everything we do forever. The public likes to think that we sort of emerge as a fully trained, perfect neurosurgeon the day we walk out of our residency. But that is far from the case. And I am still getting better. I'm still, I'm a better neurosurgeon today than I was even 10 years ago after practicing for 20 years. So one last thing to mention about psychological yeah, we have about 35. That it takes about 35 seconds is that we have to erect a certain amount of emotional armor to do what we do in the operating room, to sort of take ourselves out of what we're doing and be very sort of robotic and mechanical. And then we have to be emotionally flexible to be human beings for our patients at the same time.

B (50:43)

Got in right under the gun. Dr. Theodore Schwartz. The name of the book is Gray Matters, A Biography of Brain Surgery. Thank you so much for your time and for the hour.

A (50:53)

Thank you, Alison.

B (50:54)

And that's all of it. I'll meet you back here tomorrow.

A (51:01)

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B (51:31)

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