Neurosurgeon, Theodore H. Schwartz, M.D.

Hi, it's Doctor Robert Siker with episode #21 of the Doctor Podcast Show. Thanks for tuning in. Today we have a great guest, Doctor Theodore Schwartz, who is a Professor of Neurosurgery at the Wild Cornell Medical Center. Dr. Schwartz specializes in minimally invasive neurosurgery, especially neurosurgery for patients who have brain tumors of various types. He is very innovative in finding new techniques and technologies to operate on these patients and helped save their lives and he's been of great tremendous benefit to these patients.

Thanks for coming today to speak with us. Thank you for having me. Yeah, you're a very busy guy, so we really appreciate the time. So looking at your credentials, I reviewed them. I noticed that you graduated Magna cum laude from Harvard University, and usually people who do that wind up being rocket scientists. But instead you decided to go to Harvard Medical School and then become a neurosurgeon. Why'd you do that? Yeah, you know, I couldn't make it in rocket science. It's just too difficult, too challenging.

I was kind of the black sheep of my family, so they didn't talk about me much, but I ended up as a brain surgeon. I see. So why did you decide to do neurosurgery as opposed to other specialties in medicine? You know, I thought about neurology. I thought about infectious diseases. There were a lot of things that interested me. But the first time I went into an operating room and I saw the human brain exposed, and I saw, you know, a surgeon literally just sitting there like this, barely moving with these magnifying glasses on their eyes, looking at the human brain, manipulating it, and then going under a microscope and sort of zooming in on the brain.

I was smitten and I had no choice, honestly, at that point, Once you once I saw neurosurgery, there was nothing else I wanted to. Do right The training for neurosurgery is is very grueling and demanding and rigorous. I remember when I was a medical student, they told me what it's like. I said I don't know if I if I could do that. Tell us about how many years of training it takes to become a skilled neurosurgeon after medical school. So I had the same trepidation. I wasn't sure that I could handle the training, honestly.

And I had a lot of other interests before I went into medical school. I was really interested in music. I love playing the bass guitar and you know, reading books and doing things. And I sort of felt like if I went into neurosurgery I was going to give up my entire life all my interests and and to some extent that is true. It is a period of time where you really have to give up almost everything else and devote yourself to it. There's a one year internship and then there's a six year residency and that's after four years of Med school.

So when I finished everything I was about 33 years old. So my 20s are a blur. Like I really don't remember them. I was living in the hospital, but you make a life for yourself doing that. And I think at some point you give yourself to it. You know, when you first start out, you fight against that. You try to pretend you can still lead a normal life and be a neurosurgery resident, and then at some point you realize you can't. But then there's sort of this stage of acceptance. It's like the 12 stages of becoming a neurosurgery resident, where you finally accepted.

Like, this is your lot in life. You're going to live in the hospital for a little while, and once you do that, you realize all the amazing things that you're doing and you're learning and what an incredible field it is. So it was challenging. It's a very difficult period of time. I can't tell you it was fun the whole time. It really wasn't. There was some miserable points to it. But in the end that, you know, the training you get is remarkable and you have this skill that you learn that very few people know how to do.

And there's a wonderful feeling to that. Yeah, I I read. I got a advance copy of your book called Gray Matters biography of brain surgery, which is coming out in August I believe, right. Yeah. And it's actually available on Amazon now if you want to pre buy it. And I read the section of where you trained and what the on call was like. Can you tell us what that was like being on call and how often? You were on sure. So when I trained, we were on call every 3rd to every fourth night. It varied. And So what that meant was you work all day.

You do all your work and then everyone would leave the hospital except for you, you know, and you would carry this beeper. And anytime anything happened in the hospital related to any neurosurgery patient, someone came into the emergency room, anything. Your people would go off. So you might try to go to sleep and you'd catch an hour or two and your people will go off and you'd have to run down to the emergency room, see a patient, you'd have to go put an IV in. Whatever you have to do, you have to do and then you know maybe you get an hour or two of sleep.

The next thing you know it's 7:00 in the morning and you don't get to go home and go sleep for the day. You actually, that's when the work day starts. So you just kind of start again. We used to joke that a shower was worth about two hours of sleep. So it it would be worth it to wake up, you know 1/2 an hour before round started just to get a shower because that was like an extra 2 hours of sleep because it would give you just that little extra bit of of energy. But it it was tough. There was a lot of my Co residents who, you know, got very frustrated and would, you know, throw things and you know, there's some stories about, you know, chart racks being thrown and telephones being broken and things like that 'cause you just get, you know, you get when you're so sleep deprived, you can't control your emotions to some extent.

And so you know, you look back, you sort of forgive them for it and it's tough. It's tough to give up your life or work that hard for such a long period of time when you're in the prime of your of your youth, you know. But it does allow you to develop certain skills and ability to concentrate under extreme situations, like when you're operating on someone's brain. Is that right? And we'll. Operate for hours, you know, at a time. And you know, some people say like, how do you, how do you do that?

Like you can't go to the bathroom, you can't eat anything. But you kind of get in this state of focus where you know, you're concentrating only on this one task at hand. And I, you know, I I kind of liken it to if you were a kid and you would like build, you know, model ships, you know, and you'd follow the directions and you'd be there building your ship and next thing you knew like 4 hours had passed and you were working on whatever The thing is that you work on. It could be practicing an instrument if you're, you know take to music and and and piano playing or whatever it is.

So time just passes and you get in this zone, this flow state where you're just focused on kind of fighting against the anatomy of the patient and their brain and the tumor you're trying to take out and figuring out what the normal anatomy is and the abnormal anatomy. And you try one thing and it it doesn't work and you try something else. And then you find a pathway that works and you sort of keep going in that direction. And so that whole process is almost like this Zen, like, meditative state.

And time just passes. You don't even realize that. You don't realize you have to go to the bathroom until the case is over, you know? And then you kind of stand up and you're like, oh, my God, my shoulder is killing me, you know, my back because I didn't eat anything. But for that period of time, you're so engrossed and meshed in what you're doing, the outside world does not exist. It's gone. Right. You mentioned that you operated today. You did a very long case. Can you tell us about that this was some kind of a tumor that you specialize?

Yeah. So this, you know, you're an ophthalmologist. And so as you know, there are a lot of tumors that push on the optic nerves. And I see a lot of patients, that's one of my specialties, patients who are losing vision because they have something pushing on their optic nerves. And it's not an easy place to get to necessarily right because the brain's on top of it and the eyes are in front of it, the nose is below it. And so there are 1,000,000 different approaches to to get us there. The traditional approach is we just make a big incision here.

We come in around the brain and we would move the brain out of the way and kind of find our way around and the optic nerves would be there sort of sitting in your way and you take a tumor out. And about 25 years ago, people started to think about other ways to to do that. And one of those ways is to go up through the nose because you can go in through the nostrils and put an endoscope, which is a long thin telescope up through the nose, not make any incisions at all. And you can actually get to the optic nerves on both sides from below.

But if you have a tumor pushing on the outside coming from below is not going to help. So we developed another way to do that in conjunction with oculoplastic surgeons, not, you know, I started doing it, but there are other surgeons around the world who do it where you can make little incisions just in the eyelids, which is like cosmetic surgery. Right above the eyeball. Right above the eyeball in the eyelid. So you don't see the incision at all afterwards because when you open your eyes the the skin crease covers it and you can actually get to the optic nerves from the outside by going through the eyelid.

So and again we use endoscopes to do this. We make very small incisions. The endoscope is like the diameter of a pencil, it's like the scope like a laparoscope or if you have your gallbladder removed and we can see through that and we can access all these places in the skull base now without making any incisions or making very, very small incisions in the eyebrow, the eyelid or just go right up the nose. So that was the case that we did today. Right. How long did that take you? You know, I work with other surgeons in a lot of these cases, so the whole operation took 6-7 hours.

But honestly, I was in there for 45 minutes through the nose part and I was probably in there for another, you know, hour through the eye part because the other surgeons were doing what they needed to do to get me there. And that's also the beauty of doing these minimally invasive approaches is that when we come in from here, you know, you start from the beginning and it takes you an hour and a half just to get to the optic nerves, you know, when you start the operation. But here I have another surgeon who does the approach for me through the nose and then I come in and I just do the critical part.

You know, I'm just drilling out the bone over the optic nerve and taking the tumor out. And that can often be done fairly quickly if you you know if you're good at it, you've been doing it for a while. Because it's the approaches it's getting there that really is a lot of the work of neurosurgery right now. You specialize in minimally invasive surgery, specifically of of brain tumors. Right. So these incisions are much smaller. The recovery is therefore quicker. Right. Patients get out of the hospital faster, the recovery is faster and we don't compromise anything, but that was the initial thought.

When you're going through the nose or through the eyelid, can you really take the tumor out? The truth is it, it gets us a trajectory that you can only get through that approach. So we actually can often take out more of the tumor and do a better job than we can coming in from the more traditional approaches where we go out on the side of the head. It's pretty amazing. Optic nerves are very delicate, so you have to have incredibly steady hands, and you're doing this all under high magnification and being extremely careful not to touch or annoy the optic nerve because if it's damaged, it doesn't recover.

So this is very critical because you want to get rid of this brain tumor but also preserve the vision. The what are some of the more other common conditions that you do? What kind of brain tumors and? Other Yeah. So the two most common brain tumors we see are either one called a glioblastoma, which is a malignant brain tumor that a lot of people are familiar with. People like Ted Kennedy died of a glioblastoma. McCain died of a glioblastoma. Beau Biden, Joe Biden's son, died of a glioblastoma. A lot of people, you know, have faced this disease.

I read that in your book you have a section about different politicians and celebrities who've had brain. Tumors and glioblastomas, yeah, yeah. And you know, it's a, it's a horrible disease because it is surgically operable. We can take it out, But they're microscopic cells that are usually left behind at the end of the operation. And we can treat those with chemotherapy and radiation. But often the tumors grow back, you know, And so it's one that we have a hard time curing. So we can, we extend life, we can maintain quality of life for a period of time.

We do have some long term survivors that are these miracle cases that no one really knows why they survived so long. They didn't have anything special, no special clinical trial. So there's the glioblastoma on the one hand and then there's a meningioma which is a benign tumor, which is the other most common. Those are the two most common tumors we take out. And meningiomas are benign in that, you know, they they push on things like the optic nerves, you can lose your vision, but if you take the whole thing out, you can actually cure someone.

And even if you can't take the whole thing out, you can radiate what's left behind to prevent it from growing back. So if it doesn't grow back for the rest of their lives, they're essentially cured, even though there's a little tumor left behind. So those are the most common ones. And then the other more common very common tumor I take out is called the pituitary adenoma. Which is a specialize in pituitary surgery and that sits also between the two. Optic nerves? Yeah, so often. Extremely. Delicate area patients come in, they're losing vision.

In fact, you'll appreciate this. I wrote a paper on a lot of my patients come in and they're like, you know, Doc, I'm losing my vision. I went to see an ophthalmologist and he said I had a cataract. So I had cataract surgery. I didn't really get any better. So then I saw someone else and they were like, well, maybe you should get an MRI scan. You know, I'm sure enough they have a big tumor pushing on their optic hair. So we go in and those are another case you can take out through the nose. You don't make any incisions.

You can take the whole thing out. You can cure them and you can restore their vision dramatically, which is really an incredible feeling and I'm sure you get that as well as an ophthalmologist, you know, vision is, is the most important sense that we have. A third of the brain is dedicated to processing vision. And when you're losing your vision, you know, it's a, it's a disaster. You can't watch TV. You can't read, You can't get around. And when a patient comes in and they're losing their vision and you can do a surgery and they wake up in the recovery room and they're like, Oh my God, I can see, you know, it's an incredible feeling.

It's so rewarding as a as a physician to be able to restore vision to someone who's losing them. Right. One of the other fascinating things I read in your book is, is you mentioned that one of your biggest rewards is when you get a hug from a patient and patient's family after spending a whole day in the operating room. That hug is is. Everything, right. I mean that's the payment, right. That's that's the what we get back for doing this. It's why we do it, you know and it's the best because it it's incredible how often it happens.

You know you sort of and and often you don't know these. You don't know the patients families that well. You've met them once in the office for half an hour. You met them for 10 minutes before the operation. You know where you mark them and talk say this is what we're doing, got to sign consent and obviously this brain surgery is one of the biggest days of their lives and their families lives and their families are terrified. You know, they don't know. They don't realize that that that their loved one is going to come out of the operation and be the same person they were before.

Because we think about brain tumors and brain surgery as, you know, that's who you are. And if there's a problem, you know, you could wake up as a different person and not be able to talk, not be able to move, not recognize, you know. So when you come out of the OR and you say, hey, everything went right, they're going to be fine. There's this, You can just sense it. It's palpable. The relief that the family members have and they literally are just like, can I give you a hug? I'll just ask you, you know, And it's this beautiful moment where I'm like, absolutely, you know, and they just this like relative stranger, just like reaches out and starts hugging you.

It's great. It's. Beautiful. There's nothing like it. Very rewarding. One of the other things that was fascinating in the book is you mentioned that in many types of surgery that you do, the patient is actually awake and you need them awake, yet they're operating on the brain. You explain how you can operate in somebody's brain while they're awake and they don't feel anything, and what the advantages of having the patient wake while you're operating on their brain. So the the times when you need someone awake or when you're operating on a tumor and often the glioblastoma or sometimes on some of these epilepsy patients where the tumors are near parts of the brain that are important for language.

And and what's interesting about brain organization is they're very specific parts of the brain that we know are important for language. And I I write about in the book like we discovered them and now we know about that and the different neurosurgeons who figured it out and it turns out that language is actually in a slightly different place than everybody. It's not in exactly the same place. So there's some things like the part that moves my left arm is more or less always in the same spot and we can figure that out.

But the language in the temporal lobe could be almost anywhere. You know, it's within an an area that's about four or five centimeters, but we don't know exactly where. So if you're taking out a tumor near those areas, you need to have the patient awake so you can map that out so you can know exactly where it is. And the way we do that is, first of all, we give them a lot of local anesthesia, right. So the scalp is totally numb. We give them IV drugs so they kind of fall asleep when we're doing our opening and the drilling and all that.

Everyone's asleep for that. But then at some point we wake them up, you know, and the and the brain has no pain fibers. So it turns out you can, they can touch the brain that doesn't have sense fibers either. And you wouldn't even know that I was touching your brain if I actually touched your brain because it doesn't have those receptors there. So it doesn't know. That's amazing. It controls the pain sensation everywhere else in the body, but it doesn't actually have its own pain sensors. Doesn't have the sensors, right?

And so you have them awake at that point and then there's a conversation, right? That's a whole process of, like, slowly waking them up because they don't really know where they are. You know, they're lying on a on a bed. Their head is fixed in clamps. We put these clamps that literally have, like spikes on them, three spikes to fix their head so they can't really move their head. And sometimes they wake up and they're a little like, where am I? And they start moving their arms. You really have to kind of calm them down and say we're in the operating room, remember?

But once they calm down and they realize it and they wake up more than you can have a conversation with them, like, you know, it's a, you know, what did you, what did you do last night? You know, did you go to the movies last night? And and you kind of want to do that. But then when you start, you want to make them comfortable. When you start mapping the brain, the way it works is you'll have a, a neuropsychologist or someone showing them pictures. There's a lot of ways to do it, but the most common way, they show them a picture of an object, you say and they name it and they say this is a car, this is a dog, this is a ladder.

And while they're naming these objects, you take a electrode that either has one contact or two contacts, and you basically stimulate the brain and you March around the brain. When you get to the part of the brain that's really important for speech, the patient will say this is, and they just, they can't get the name out. And it's a phenomenon we've all had because we've all forgotten the names of objects, right. So they don't realize why they can't access that name. Because often you'll be at a dinner party and like someone will walk in and you'll be like, who's that again?

Like, I forgot the name or, you know. So it's that same feeling we call like the tip of the tongue. You can't quite get it, but you know that that's an important area. So you you put a little marker on the brain or you can actually cut out a little number, like a number. So we can mark. We can mark the brain, and then you March around. You map out the whole thing. You figure out where the language areas are, You figure out where the tumor is you want to take out. You can't get too close to those, and then you don't.

You know and you resect what you can. So it's it's basically marking the areas of the brain so you know exactly where you are. So it's like Google Maps. Correct. During surgery, yeah, they're landmines. You have to figure out where the landmines are to avoid them. And so same thing with motor. If you stimulate the part of the brain that moves the arm, you know you said the arm moves you and you can map out, you know, the fingers, the hand, the face, all of that can be mapped out sensation. You can map out a part of the brain where the hand feels or the foot feels.

If you want to make a very detailed map to save all of that so that when you take out your tumor you don't affect any of those functions. Occasionally tumors invade those areas, though, and then then it's a problem. Then patients have some deficits. Often the tumor will cause a deficit and then you don't want to make that worse. So those are those situations where we leave somewhere behind, right? Because we may not be able to cure them anyway, right? If it's a glioblastoma, if we take out, try to push that limit.

So there's no reason to leave them with a neurologic. Deficit It's pretty amazing. There are a lot of new technologies that are coming out in neurosurgery and in medicine in general. What what new things are are you working with? Because I know you're. The, the Vice Chairman of Clinical Research, yeah, Surgery there as well. So yeah, what's happening? Couple of things. So you know robots and lasers are always a fun exciting thing to talk about. So we don't do that much robotic surgery in neurosurgery, but we do now have robotic arms that help us put electrodes in.

So for epilepsy, for example, when you want to figure out where seizures are coming from. And So what a seizure is, is basically a part of the brain that the neurons start to fire out of control. And often there's some disease tissue there, There's a scar, There's a problem there. Sometimes you don't know exactly where it is because you can't see it on an MRI scan, but you have to find it because if you can remove that area, you can cure them of their epilepsy. So we do a surgery where we want to put electrodes all around the brain and we can basically on a computer map out where we want those electrodes to start and stop, put that information into a computer.

And then the computer will basically take a a laser image of the face, know where everything is in the head. And then a robotic arm you push, you step on a a pedal actually, and a robotic arm will move right to that area. And then you drill a hole in the skull, put the electrode in and then you you tell it go to the next one and it'll it'll tell you you put the electrode in there. So we do have robotic arms that we use, which is kind of fun in the operating room and you have to trust it. That's the other thing, right?

You're trusting the robot's saying put it here. And so I'm drilling a hole in the skull and I'm putting an electrode there and hoping the robot knows what it's doing. And it does get it right all the time. But there is this element of trust, you know, And then lasers is another thing. So we can now when you find in a part of the brain that causes epilepsy deep in the brain or a small tumor, we can use that same robot and advance a laser probe deep in the brain and basically burn that tumor from the inside out.

And we can do that in an MRI scan or some patients in the MRI scan and we can burn the tumor and then we can image it on the MRI scan. So we can actually see, we do what's called Mr. thermography. We can make a heat map of the heat from the laser burning the tumor and we can see how far it's going. And then when it gets to the point where we want to stop, we just stop the laser and we're done. Pull it out, we move on. It's pretty amazing. You mentioned that there's not that much actual robotic surgery going on the brain.

Is that because the it's very tiny and even the robots aren't really? So the da Vinci robot, which is the main robot we use for prostates, we use it for heart. You can use it, you know in the in the ovaries and things like that. You know the the way it's designed, it's designed by a company for that. And the arms are pretty far apart and the scope is a pretty big endoscope that they put in there to see. And because of the trajectory of the arms, the trajectory we need for neurosurgery is like this.

It's very, very small. And so those arms just don't work on the brain. They didn't build it. They could, one could build a robot to be used in the brain. But you know, it's a classic sort of business strategy. You'd spend all this money to build a robot. Neurosurgery is a very small market. So they probably wouldn't make their money back in the in the short run. And so we just don't have one yet, but it it, it will happen when the cost of building it. It's the same with ophthalmology, actually. There's still no robotic surgery that can operate inside the eyeball because the structures are too delicate and our hands are still better than the robots.

But I think that's probably going to change in the next five years or so. That's pretty amazing technology. You work with other doctors. You mentioned you work with an oculoplastic specialist with ENT doctors. So it's a team effort basically when you're doing these surgeries, yeah. And you know in in in surgical specialties and I know you appreciate this, we're very siloed. So I trained in neurosurgery. So I learned from neurosurgeons how to do neurosurgery. But there's a lot of stuff that our colleagues are doing in other fields that we don't learn about.

You know, you do an internship in IT. You you rotate there for a month or two, you don't really learn anything. And so I found it incredibly eye opening upon, intended to work with other surgeons and see what they were doing right. And and they have different equipment and different instruments. And for them, you know, making an incision in the eyelid and going around the eyeball, it's trivial. Like it's like every day they do that. And when I would open up the head and get near the eye, I'd get nervous like, Oh, my God, we're near the eye, you know?

And when they operate through the eye, they get near the brain. They don't want to see the brain because brain's a problem. And I'm like, what the brain, actually, you see the brain every day. What's the big deal? Same thing through the nose. You know, if we get near the sinuses, we get nervous, oh, my God, we're going to get infections. It's going to get the brain. Sinus surgeons, they don't want to see the brain. So I learned an incredible amount from these other surgeons. And I would watch them operate and I would see what they were doing and and see how comfortable they were and how much you can retract on this.

And because of that collaboration and breaking on the walls of those silos, you realize how much you can accomplish that you didn't realize you could because we're so, so specialized. Right. It's pretty interesting. I once was doing a corneal transplant case and there were special scissors for doing corneal transplant and the nurse says, oh, they're not in ER And I go, well, where are they said, I think gynecology borrowed them. I go what? What are they doing? Well, the curvature of the corneal scissor turned out to be perfect for doing fallopian tube surgery, and some gynecologist figured that out, probably from a colleague.

So collaboration is important in sharing technologies. You also are involved in research and and clinical trials. Tell us about the importance of that. So my I run a lab basic science lab and it's an epilepsy lab. So I work in in mice. I have a mouse model, mice models of of epilepsy where we can create little folk eye of abnormality in in the mouse and then we do a lot of imaging. So we have ways now of imaging where we can genetically manipulate these mice so that every time a neuron fires there, it fluoresces a particular color, green, red, whatever, whatever you want.

And we can now create these mice so that, you know, excitatory cells will fluoresce one color, inhibitory cells will fluoresce another color. So we can take a camera suspended over the brain and basically map out this individual cells firing as a seizure starts and spreads through the brain, which you know, we never knew exactly what was happening because we just put electrodes on the brain. You kind of get a sense of the fields, the general stuff that's going on, but not neuron by neuron. And that technology is constantly improving, getting faster, higher resolution, more sensitive.

So that helps us figure out how do seizures spread in the brain, how, where, what cells do they start in? And then you could say, all right, well, how do we interrupt that? You know, how do we, how do we ZAP that with the laser or how do we give a particular drug or optogenetically, which means how do we shine light so that a channel opens on that one cell so it doesn't fire. You know, we can bring all these new techniques in once we really understand how seizures spread through the brain. So that's a basic science thing that I do separately from all the surgeries that I do.

So you're working 24/7 or? Maybe 20 need more hours in the day? Yeah, 25, eight I. Think exactly what you need. How similar is a mouse brain to a human brain? Obviously it's much smaller, but are are there certain parts that are? There are. You know, they we have a hippocampus and they have a hippocampus. We have a thalamus, they have a thalamus. You know, they have a layered brain neocortex, which is what I work in the neocortex and they have lobes, you know, parietal frontal lobe and and a lot of the the connections are the same as well, which I'm interested in because a lot of the times what seizures will do is they'll sort of hijack the normal connections of the brain.

So you could kind of figure out what parts of the brain are connected to other parts of the brain and how seizures use that. So there are a fair amount of similarities. It's not identical, but pretty good enough. Pretty amazing. What I'd like to discuss now is something that's really fascinated me for years and you're an expert, is brain Computer Interfaces. I have this vision that in maybe 10 years we won't need schools anymore because you'll go to sleep and download an encyclopedia into your brain overnight and be an expert in Greek or Roman history.

Right. That would be nice. That would be. Neurosurgery or. Neurosurgery, whatever it is you want, you could download it. I think we're getting kind of close to that. I know you work with a company Precision Neurosciences as a consultant and tell tell me some more about Brain Computer Interface. So, you know, that's something we see on science fiction movies all the time. And there's tons of movies where someone plugs into the, you know, computer and suddenly they're integrated with it and you know, can do all of these things.

And one of the things I try to talk about, and it's in the very end of the book where I'm sort of talking because it's sort of the future of neurosurgery. There's a big difference between taking information out of the brain and putting information into the brain. They're they're not the same. And right now, we're much better at taking information out of the brain than we are putting information into the brain. So, for example, we can put an electrode over the part of the brain that moves your hand and we can record either from individual neurons or from sort of groups of neurons.

And every time you move your hand in similar way, those neurons will fire in a similar pattern, right. Because the neurons are making the move, the hand move. And if we do it enough times, you can use something called machine learning. So a computer can actually figure out what's the pattern of electrical activity in the brain that I'm recording that makes the hand do this versus this versus this this thing or this finger, this finger reach here, reach here, reach here. You do that activity again and again and again, the neurons firing the same way.

A computer will figure that out. Oh, this is the pattern. So once you have the electrodes implanted on the brain and the machine figures out how to translate from brain neuronal firing to the activity, it can make a robotic arm do exactly the same thing, right? It can make that translation and that's an output brain computer interface to control a robotic arm. And we can do that now, right? We can have someone just think about moving their arm and they can move an arm and you can imagine. And with legs as well, you can make your legs move, and that's getting information out of the brain.

Putting information into the brain is much more difficult because the information that comes into the brain comes through very specific neurons that interface on very specific parts of the brain and make literally millions of neurons fire in a particular pattern, right. We don't have the ability to make a million different neurons fire in a particular pattern, which is how you would put information into the brain. We don't know how to do that. We can't do that. The only thing we can try, we're starting to do is envision there's a little bit of work in it and I can talk about that sensation.

You could do some of that and then you might think about, well, you know, we have these, there is this thing called a retinal implant and there's a cochlear implant. But those implants, retinal and cochlear implants don't actually implant to the brain, right. They implant to the retina. So the optic nerve brings the information in and if you implant into the cochlea, the cochlear nerve brings the information in. So you haven't actually, you're not actually inserting the information into the brain, you're inserting it into a peripheral sensory organ.

So for vision, it turns out years ago, these neurosurgeons like Oster and and sorry, Firster and Otford Firster, I'm forgetting the other one's name, actually. But anyway, these two neurosurgeons in Germany figured out that if you stimulate the brain and, yeah, in the visual cortex, the patient will see little flashes of light. So if I stimulate the brain in one little area in your visual cortex, you'll see a little light bulb go off here. And so they figured that out. And another nurse surgeon in Wilder Penfield did more work stimulating the brain, different areas, and saw that you could see these flashes of light in different areas.

So people started to think, well, if I can put an electrode on the surface of the visual cortex and I can stimulate the brain in a patterned way, maybe I can create little flashes of light and recreate vision. And you can actually do that. And that was done in the 1970s. There was a guy named William Dobell who built a company around this. This whole story behind that where you create a device where you basically wear a pair of glasses with a camera on it and that records the the visual information in the world and you put into a computer and the computer then goes into the brain and stimulates the the visual cortex to create flashes of light.

But the resolution is very poor because you're not actually activating the visual cortex the way it was meant to be activated. You're not activating the individual neurons. You're basically just blasting, you know, a bunch of neurons, and they all kind of fire in some disorganized way in one particular place. So you see a flash of light. So what you could see with that type of vision is sort of the outline of of what's going on around you in flashes of light, almost like like a Jumbotron from the 1970s.

Or you know, a pixelated, old pixelated graphic where it was just, you know, a couple of flash bulbs or even like if you imagine in the 4th of July when the fireworks go off and they and they create sort of a figure that you can see not the drone fancy ones, but just like a firework. So you can kind of imagine that with a couple of pixels you get some sort of vision, but it's really not serviceable, useful vision that we're used to. So getting information out of the brain, not so hard. Putting information in very, very hard.

And for getting it out, that doesn't just mean, first of all, it's not only can you move an arm, but for example, if you wanted to fly a plane with your brain, we could do that, right? That's doable. If you wanted to drive a car with an implant, that's doable because it's a motor output, So every time you think about turning the wheel, you know you're moving your hands in a particular way. I can interpret those signals and figure that out. So that's doable. Language is also doable. We have a way to take a language out of the brain because every time I speak, I move my the muscles of my tongue and my mouth in a particular way.

So if I say a particular vowel or consonant, all those things, I'm moving my mouth in a particular way. And if I'm recording from the brain, I can say figure out what the pattern of my neurons firing in those areas are. So you can take language out of the brain. You can do the same thing with handwriting. Every time I write an AI, do the same thing. Every time I write, ABI do the same thing. So you can figure out the handwriting, take the information out. And so someone can literally just be sitting there and thinking about writing in script and on a computer screen, the words would come out, the words would appear.

We can do that. What we can't do is take your thoughts out of your brain. We can't do that. Yet we don't know how that happens. We have no idea where that comes from exactly and how that happens. So we can't figure that out. So what's nice about that is people worry about privacy. You have a brain computer interface, like, are they reading your mind? Like, how do you keep thoughts private? And the truth is, right now, all those brain computer interfaces, if they're going to take any communication out of the brain, you have to willfully articulate it.

You can't just think that thought and it'll come out of the brain. You have to articulate that thought through speech or through writing for it to get out of your brain so you still can maintain your privacy. Right. And I'm sure you know about Neuralink, Elon Musk's company, They just got FDA approval to do clinical trials for a chip that they would implant. And it would allow people who are paralyzed to to actually do things through a robot. And then he's got this optimist robot that is with Tesla.

So potentially somebody who's totally paralyzed could have a robot to make breakfast for them. Or you know. Take out the car so that technology already exists, right? So that is not an innovation of of Elon Musk's. He's sort of using what can already be done. So we can already put an array of electrodes. The most common one used is called the Utah array which was invented years ago. And it's basically 100 electrodes on a little chip that's about this big and you can implant it in the brain and take that information out to to move a robotic arm.

What neural Link is doing and and it's an incredible technology, is they actually have a machine that essentially sews in or or almost like hair plugs. You know what you imagine, like hair plugs go in. So they'll plug in like 1000 electrodes in a tiny area of the brain, which is a great idea to try to get very, very high resolution information out of the brain. And so just like the Utah array which does the same thing in a smaller area, takes information out of the brain, the neural link device could also do that.

And again taking information out motor controlling the robot, we know how to do that. That's not so innovative at the moment as opposed to putting information into the into the brain. The precision Neuroscience, the other company that I work with has a different philosophy which is to instead of putting electrodes directly into the brain, they've developed a a bigger chip. It's about this big that sits like a postage stamp. It sits on the surface of the brain and it records has 1000 electrodes and the size of a postage stamp.

And they've developed a way to put it in in a very minimally invasive way, which I, you know, very thoughtful way to do that because the head of the company is a neurosurgeon to put it in and basically take out information in the same way that neural link would. It's it's a very similar device, but it uses a different strategy. How did Neural Link get its FDA approval for clinical trials? You know, I don't know the answer to that. I'm sure they put in an application and you know, given that there are clinical trials going on already at major universities using brain computer interfaces to control robotic arms, it's already happening, right?

There's already papers showing that it's published, it's doable. So they they may not have needed so much approval because it's already being done I. See, Ross talks about a vision chip in a few years. I guess what you said it's it's much harder to put in the vision and to take out how many years do you think it will take for us to yeah. I mean, I think it'll be decades, honestly, because it it may be because you need to get the information into the optic nerves in a way. You need to get them into the into the white matter.

You know, we when you put something right on the Gray matter of the brain, it's not, it's not how the brain is meant to get information into it. It's meant to come in through incoming neurons for the axons, that synapse in the right way. And if you bypass that, you're not going to get the brain to function in the way it's supposed to function. Now, is it possible that if you did an implant like that in an infant or a baby, and the brain is still plastic and it's still learning how to process information, could that be more functional?

And the answer is probably it could, because, you know, there's this, this plasticity period of a couple of years where the brain is very plastic and it's basically forming all of its connections, which basically means it's figuring out how to interpret the incoming information and make sense of the external world. There's a period of time where the brain does that, after which it doesn't really do that very well anymore. So in an adult, if you don't use the programmed inputs, which is the the white matter as we call it, that it's coming in.

You try to just put something on the surface of the brain. The brain's not really going to know how to interpret it, which is why you just see these flashes of light. You don't see objects. So I'm not sure what Musk's strategy is. You know, I I don't know. So I think, you know, the other option would be maybe if you could put some drugs on the brain, some chemicals that would increase the plasticity of that area of the brain. So that it would sort of rewire itself so that the incoming information could be interpreted in a different way.

That might be possible. Or if you could implant a chip in the white matter so that it comes in through the normal inputs. You mentioned white matter and Gray matter. Can you tell us what difference is? And by the way, your book is titled Gray Matter. Matters. Right. So what's the difference between white matter and Gray matter? So Gray matter are the neurons. It's the surface of the brain. There's some deep, but mostly on the surface, which are the the bodies of the neurons themselves which do all the calculating.

Neurons are the nerve. Cells. Those are the nerve cells, correct? And then those neurons talk to other neurons by basically sending wires, right? It's like a communication wire. And those wires are the white matter. So basically most of the brain is made-up of the communication, the wiring pattern from cell to cell. And the reason why it's white is that it's covered with this fatty substance called myelin. So it looks whiter, but it's really the white matter is all the communication from cell to cell.

It's like fiber optic, you know? Cables. So how does a 3 1/2 LB brain have computing ability? That's far superior to tons and tons of computers and wires that we have today. And do you think we'll ever match it with artificial intelligence? Yeah. You know, evolution is a very powerful a few billion years. Took. A few billion years, right. But it works and we know that, you know, so I think that because I do believe that the brain is just a very sophisticated computer that eventually we'll get there when we have complex enough computers that also can change the strength of their connections, which they, you know, they do sort of use artificial intelligence.

But the complexity, you know, is enormous. It just has to become so much more complex to reach the the complexity of the human brain. I want to discuss a few things I read in your book, which to me are are fascinating. You you discuss a little bit about football, injuries to the head and concussions. That's a big news item. In the last few years, there's been a lot of football players who get premature dementia and other problems. So what? What's the story with injuries to the head? Should kids be playing football?

Yeah, so should. Kids be playing soccer and heading soccer. Yes. It's pretty clear now that

multiple blows to the head over a prolonged period of time leads to a disease called chronic traumatic encephalopse CTE, right. And it's a degeneration of the brain cells and deposition of proteins in the brain. And it can occur from a lot of different things, right? So we think of it from football and we get a lot of hits to the head. And it's not just a concussion, right. It's what we call sub concussive injuries, which are these minor, minor traumatic brain injuries. Like every time a football player hits another football player, there's a minor brain injury there.

And that can occur not only from football, it can occur from boxing. There's now reports out, you know, a lot of these in the military where they're shooting these shoulder mounted rockets. Every time they shoot a rocket, there's a blow to the head. It's not just a blow to the head, there's a pressure wave through the head. And they've realized that a lot of these people are getting something like CTE. They have scarring in their brain and then over time, if they do it enough times repetitively, you know, you can become depressed and anxious and confused, and it leads to psychological issues.

So what we don't understand is who? Why do some people get it and other people don't? Right? That's the mystery, right? Because there are a lot of football players who played their whole careers and they seem cognitively fine. So there's got to be some sort of genetic predisposition that leads some people to have it and other people don't. I mean people get hit all the time, you know, and have a cardiomyopathy and you can die on a basketball court. It's because you've got a problem. You know, there's there's an issue going on.

So there's probably some genetic predisposition that leads to that. So it's got to be a lot of hits over a a period of time. So you know, should children not play football, There are now reports of, you know, 20 year old, 30 year old, younger people who are having this problem. I think what it's going to come down to is eventually we're going to have a test that's going to tell you you are predisposed to CTE. You should not play football. You can play football here, not previously. You don't have a genetic.

We'll have a test that we can do. Blood tests and you check for certain genes and then you figure it. Out or we'll do it and we'll do, you know you'll get hit and they'll do an eye movement you know analysis and we'll just make sure that you're doing OK We'll have better sideline testing. Actually eye movements is very much more sensitive to concussion than anything else we think about pupils. But really eye movements is probably the most sensitive test we have now one of the most sensitive. So the other thing is that we obviously benefit a lot by playing sports.

You know, my kids played hockey. And I would definitely get where there were a couple times my my kids would come off and they would get hit in the head and they were like, you know, 10 years old, 12 years and they'd be like, dad, my head really hurts. I'd be thinking, Oh my God, what am I doing to my is this worth it? But what they got out of it, sort of the camaraderie and learning how to play on a team, You know, there's so much we benefit from sports that I'm not willing to say that we should just hang up all, you know, high school sports.

But I think if you're going to play college football and professional football, you need to be aware of the risks, and the risks are great, but that's why they get paid so much money. What about soccer? Young kids playing soccer and heading the ball? Yeah, my kids used to make fun of me because when they played baseball, I used to make them wear the plastic helmets before it was popular and they thought I was nuts, But I was always afraid they would get hit in the head, right? So the question is, how many hits do you need?

How many of these small hits do you need until you cause damage? I don't know the answer to that. We don't really know. But I think if you're just playing through high school, you're probably pretty safe. Although, and I write about in the book there, there you can, you can die playing high school football. I mean there are high school football players who have gotten hit and have something called Second Impact syndrome where they basically their brain starts to swell. Now it's incredibly rare. How?

Soon after the injury. Very, pretty soon after they call it Second Impact syndrome. But a lot of the times it's a first hit. They sort of think, well, if you get one concussion, you get another concussion soon afterwards, you're at higher risk. That's why it's called Second Impact syndrome. But a lot of the times, it's the first hit that causes the problem. And sometimes it's not the second hit, but it's the fifth hit that causes the problem. So again, there's probably a genetic predisposition. There's probably some kind of hit that they get that's bad enough.

And the young child's brain is very big. There's not a lot of room. As you get older, your brain starts to shrink. We're losing, like 50 million neurons a day. It's very sad to think about, but it's true. So our brains are kind of atrophying over time. But when you're young, you've got all the neurons you're going to have, and so there's not a lot of room in there. And so if you get the right kind of hit, what happens is that your blood vessels in the brain will dilate and the pressure goes up and that can cause a serious injury to, you know, and even death.

If they don't go in, neurosurgeon can go in quickly and like remove half the skull to let the pressure out. Otherwise it can be deadly. It's very rare, but it can happen. What's damage? Is it the Gray matter, white matter, or both? All of it. All of it is damaged wiring and the cells, Yeah. One other thing you discussed in your book, which was really awesome reading, great reading, is cell phone radiation. Now, in 1995, I actually got AUS patent for a device that blocks cell phone radiation. Because I heard of a couple of cases of this, I actually got a patent.

I contacted the cell phone company to see if they were interested. They denied that there's any association, yet there are a few people who worked on the original cell phones who died from brain tumors. What? What do you think is going? On. So look, the story is compelling, right? You, if you think of it like cigarette smoking, you've got a big business cell phones. They want to make money. They want you to buy their phone. If you say that it's dangerous, they're gonna be like, of course it's not dangerous.

You know, we funded a study showing it's not dangerous, but, you know, you can't believe the study they funded. So the story makes us worried, you know, because we lived through the whole cigarette crisis. But the truth is, if you look at all the studies that have been done, these are studies not done by cell phone companies as well. And you put them all together and what they do is they'll, they'll have, you know, whatever 100,000 people who used a cell phone, you know, on the right or on the left, the right-handed left side.

And they and a certain percentage of them will get brain tumors. And you sort of ask them, you know, how often did you use your cell phone? And they're having to remember what hand they used and how often they used it. And there's a lot of errors in those studies. But when you put all the information together, there's a couple of studies that show maybe a little bit of an increase. And then there's just as many studies that actually show that you have fewer brain tumors, right. But you don't hear about the studies that show the cell phone users had fewer brain tumors.

The the press only picks up on the ones that show more. So when you put them all together, you do like a meta analysis or systematic review. It really doesn't wash out that cell phones 'cause any brain tumors. And then you look at the science like, so what's the mechanism? How would that happen? Like, we understand how cigarettes smoke. There's carcinogens in there that can cause lung cancer. You think about radiation sounds bad. Radiation sounds bad. But not all radiation is the same. In fact, visible light is a form of radiation.

There's an electromagnetic spectrum. You've got ultraviolet, you've got infrared, you've got gamma rays and X-rays on one side. That's dangerous, right? You want to stay away from gamma rays and X-rays. Then you go to the other side, you get microwaves, you get cell phones. Those don't break DNA bonds, right? They don't alter the DNA. And right now in order to for something to be a carcinogen, it has to alter your DNA, right? It has to alter your you have to mutate your DNA so that the cell, the cell starts dividing, it can't stop dividing or it has to alter whatever protects those cells from from their division.

So right now we don't, we don't know a mechanism. The only thing a cell phone does is it heats up whatever it's next to, just a little, little tiny bit, gets a little bit warmer, but like a trivial amount, like .1°, you know, nothing that we think causes damage. So we don't have a mechanism whereby cell phones cause brain tumors. We don't have any epidemiologic evidence. In other words, a big study showing that, yeah, if you use your cell phone or you get a brain tumor, you don't have any of that.

So there really is not a great mechanism to show, even in children, that cell phones cause brain tumors. So at this point I use a phone, my kids use a phone and I'm not worried about it. I use my speakerphone whenever I can, so that phone is as far away from my brain. Yeah, if you're if you're more comfortable, more power to you. The bigger risk of cell phones, honestly, is texting and driving, right? There's a ton of accidents that more people die from that than anything else. So if you're worried about cell phones causing deaths, you probably should stop texting while you drive and not worry so much about brain change.

Right. I see that every day in the streets here in Manhattan, people driving and texting. One other thing that I saw in the book, which I wasn't aware of, is that President Biden apparently had a brain bleed many, many years ago. Yeah. Is that right? Well, he. Yeah. He had a brain bleed, and he had what's called an aneurysm. An aneurysm is a little ballooning of a blood vessel. It's a weakness of, like, if you, if your tire hits the curb, you know you get a little bump when it gets weak. As that grows bigger and bigger and bigger, it can eventually rupture.

So Biden had a aneurysm that ruptured many years ago, and he had to go in for emergency surgery to have it fixed. And it's a great story because his surgeon was he had two surgeons, Eugene George, a neurosurgeon, and and Neal Cassell. Neal Cassell is actually only has one eye and never graduated from high school. Really. Yeah. So the story. Yeah, exactly. So I tell the story like, how did the president of the United States life get saved by a neurosurgeon who only has one eye and never graduated from high school?

So the story. So neurosurgery can't be that hard. Exactly. It's not that hard. It's all a mess. The sell story is great. And I actually, I interviewed him because I wanted to make sure I got it right, because I was going to write about it and I read stuff online and I was like, this can't be true. Like, there's no way he didn't graduate from high school. How is that possible? So the story is that he was go to high school and he wasn't, He wasn't really paying that much attention. He wasn't doing that well.

And his family basically said, you know, he didn't graduate from college. I think it was. I think he graduated from high school and he did graduate from college. OK, I think that was it. I gotta, I'll, I'll look back. I know I just wrote about it and I'm already forgetting. But so the story was that he, he worked over the summers. He got a summer job working for a guy named Thomas Langfitt. Thomas Langfitt was the head of nurse surgery at the University of Pennsylvania. And it was a time when there weren't that many neurosurgery residents around.

So Cassell was so into neurosurgery and working in in Langfitt's lab that he published all these papers. And then when surgeries would come up, Langfitt would be like, hey, why don't you come help me. So he started assisting him and he got into he, he started doing, he got into the University of Pennsylvania, and he was working with Langfitt the whole time. He was writing papers with him. He was assisting him in the operating room. You know, he was as good as a lot of the residents who were training there.

And Linefit went to the head of the medical school and said if you let this guy into the Med school, I'm going to give him a spot in my residency program. And I think at that point he wasn't doing very well in college because he was spending so much time working in Linefit's lab, publishing papers and assisting him in the operating room. He wasn't focusing on college. I'll have to check that. Sorry Neil, I'm forgetting the details, but so he basically said they they let him graduate from college even without all his credits and he they basically pushed him into Med school.

He finished Med school and he got, he trained there and became a very talented neurosurgeon at the University of Virginia. And he was born with something called micropthalmia. You can explain what that is. Yeah. It's basically a tiny. Eye that doesn't function doesn't have all the proper anatomical structures. Right. So he only had one eye. And I, so I said to him, I'm like, what is that like? He goes, I can ski, I can, you know, ride a bike. He says he can do everything he wants with one eye. He's figured it out.

And if you think about brain plasticity, the brain adapts. Right, but there's one thing the brain can adapt to. We have something called stereo vision where the two eyes together allow us to judge death. So if, like you mentioned, clipping an aneurysm is scary the first time you do it as as a resident. How do you clip an aneurysm if you don't have depth, depth of field? So it's the same in eye surgery. I'm working in a two or three. Millimeter space, right. So you'll appreciate this. We talked a lot about endoscopic surgery.

And as you know, a lot of surgeons do surgery with endoscopes and I do very fine brain surgery around the optic nerves with an endoscope. So an endoscope only has one lens and one light source and IT projects it on a screen and it's a 2D screen. So every time we do endoscopic surgery, we're operating in two dimensions. We're not. We have no 3D depth of field. And the question is how do we do it? And So what happens is, as you're operating when you move an instrument in and out, you get this knowledge of depth of field by the movement.

There's this also what's called parallax. You get a sense of where things are based on other objects that are moving around near them. And you can recreate the depth of field by having instruments moving around. And your brain has a way to do that. So you're passing different anatomical structures and since you know the anatomy so well, you know. And you. But you also see the instruments you're moving in and how it changes the size, right? If I move something deeper and closer, and I move another instrument deeper and closer, it's going to change its size as it moves, as it triangulates in.

All that information gets integrated in your brain, and you can operate very, very carefully in two dimensions. So I was skeptical like you were. And then I realized that I've been operating in two dimensions all this time. And then I also got very involved in a company called Vision Sense at the time that made a 3D endoscope for neurosurgery. It's another great story. This guy, Avi Aron, is his name. He actually had brains. He had a colloid Cyst removed, and he had it done open without the scope.

And the surgeon told him, well, the endoscope's only two-dimensional. I can't really operate in two dimensions. So he took it upon himself. He's an engineer. He invented a three-dimensional endoscope for neurosurgery and I worked with him to sort of make it smaller and make it work in in in neurosurgery. And we have other companies that Storks makes a 3D endoscope. There are other small narrow endoscopes and I've used them and honestly I'm now more comfortable operating in two dimensions, particularly in high definition.

You know in 4K that the 3D endoscopes look funny to me. They just they don't look natural, which is so this is bizarre phenomenon where now we're more comfortable. Your your brain does have some plasticity because I have patients who lose an eye during adulthood and initially they feel off balance and are uncertain. They have trouble driving cars, but eventually as they go along, they get used to it, and the brain figures out other ways to to figure out depth perception. So plasticity doesn't. And completely, there's still some.

There's. Plastis and there's also calculating like taking in new information and figuring out how to integrate it. Right. There was an interesting section in in your book you called it Psychosurgery versus. Psychosurgeon, psychosurgery or psychosurgeon? Right, exactly. Tell us about that. That goes back a while, but it's important. Yeah, yeah. So, you know, one of the things I wanted to do this book was sort of look at, had some of the stereotypes and the myths of brain surgeons. You know, one is, is sort of the Harvey Cushing myth that like we're all these sort of brilliant Renaissance person who is Vaseline, can do everything and neurosurgery's so hard.

And that's sort of the Harvey Cushing mouth. And the other one is sort of the mad scientist, like the person who takes advantage of the fact that they're in your brain, that they're going to control you or that you're going to, they're going to screw you up or you're going to wake up different than when you went to sleep. So that whole myth really comes from this era of psychosurgery, which when I trained in neurosurgery, nobody ever talked about. It was like this secret. And a lot of people don't know about it.

You sort of do a little bit and, you know, you know, there was something called a frontal lobotomy. What was the frontal loboty? People make jokes. I'd rather have a bottle in front of me than a frontal lobotomy. What was that about? Never heard that one. I haven't heard that one. Yeah. So the frontal lobotomy was a surgery that was invented by a guy named Egos Moniz, who's a Port Portuguese neurologist. He wasn't a neurosurgeon. He was a neurologist. And how he thought of it is actually remarkable because it was.

This was back in the 1950s, and he went to a conference and someone presented data on 2 chimpanzees too, who had had their frontal lobes removed. And in one of those chimpanzees they they they had done some tasks that made them anxious, and after that was done they were less anxious. Now they now it turns out they couldn't. Even the tasks that they were able to do very fastly before they were no longer able to do very well. But one of them was a little less anxious and frustrated by another test that that they could do.

So he took this data from one chimpanzee who got a little less anxious, ignored the fact that they could no longer do this complex banana getting task, whatever, and decided to try it on patients who were schizophrenic. I went back to Peru and got another neurosurgeon named Lima to help him and they would basically make holes on either side of the skull here and they would take a little loop called the leukotone. They would go in and they would just basically sweep it back and forth and disconnect the frontal lobes.

And they found that some patients actually got better. Seem to get better. They seem to be less, you know, anxious. They seem to be less sort of crazy and schizophrenic. Whatever metric they were using, it was a very crude metric that they were using. So Fast forward, There's a neurologist living in the US named Walter Freeman, and he's at Georgetown and he gets a job at a psychiatric hospital. And in those days, there's no treatment for mental illness. So if you had severe depression or you had schizophrenia, they had nothing to give you.

So you would basically get admitted to a hospital where you would sit in a corner by yourself for the rest of your life. That was it. And they would try these crazy things like they would, you know, put you in very hot water or very cold water. They'd give you insulin and lower your glucose because they didn't know. They had no idea what they were basically torturing you, and you would get mistreated by the staff there. That's the whole one flow of the Cuckoo's Nest model of treatment of mental illness.

So to be fair to him, there was no alternative. So he reads this article about Moniz and he goes, oh, some of the people got better, You know, maybe we'll try it. So he starts doing this operation and he gets a neurosurgeon to help him do it. And again, making under general anesthesia, they made little holes in the top of the skull and they would put this instrument down and sweep it back and forth and disconnect the frontal lobes. And sure enough, some patients got better, many patients got much worse, and many patients were completely incapacitated, one of which was Joe Kennedy's daughter JF KS sister RF KS sister named Rosemary.

She had a front lobotomy by Walter Freeman and she was devastated by this and never recovered from it. But Walter Freeman, who was a showman and had a big ego and wanted to make his mark on the world and wanted to impress everyone, he was actually related to another famous nerve, first person to take out a nerve, a brain tumor in the US His, like, grandfather was a famous neurosurgeon, so he wanted to be a famous doctor as well. So he started doing lobotomies and doing more and more. And he started to get frustrated by the fact that he had to let his neurosurgeon do the lobotomies.

And he, he was a neurologist, psychiatrist. He wanted to do it on his own. And so he read an article written by an Italian fiumberte. It's Italian's name who figured out that you could actually do the same operation. Remember we talked about transorbital surgery, right? If you pick up the eyelid and you put basically an ice pick below the eyelid above the eyeball, and you jam it through the roof of the frontal bone there, it's incredibly thin. The bone above the orbit, it's very thin. You jam it up there, you can go right into the brain and you can sweep it back and forth from below.

So you do it one on this side and one on this side and you sweep them back and forth. And he realized that he could do this without a nurse surgery. He could do it on his own. The problem was anesthesia, right. How do you anesthetize the patients? Because I need an anesthesiologist. So he figured out, well, I'm allowed to do ECT, which is electroconvulsive therapy, where you basically put electrodes on on a depressed patient's head and you give them a seizure. And after someone has a seizure, they're very sort of out of it.

They're lethargic and confused after your seizure. So he would basically, in order to become independent, he would give them ECT that they didn't need. He would then they would be lethargic. He would then unsterily jam this ice pick above their eyelid into their brain and sweep it back and forth. All right, it sounds crazy. He would do. He could do it in about 15 minutes and he would do 25 in a day. He would go from Psychiatric Institute to Psychiatric Institute doing. And there were maybe 60,000 frontal lobotomies done in America, like from 1950 to 1970 in that period of time, roughly.

So it was this big trip. And then everyone realized that it, it was hurting more people than it was helping. And then a drug called Thorazine came around to treat schizophrenia. So we didn't need to be doing frontal lobotomies anymore. But he was a fanatic and he would go around doing case after case after case. And, you know, he would publish pictures of his before and after pictures of these patients as if he was selling a diet drug. You know what I mean, Just trying to promote it. So it was, it was really interesting for me to look back at what happened.

Most of the there were lobotomies being done by neurosurgeons, but the guy who really promoted it more than anyone was not a neurosurgeon. He was actually a neurologist. And the neurosurgeons who did it, some of them did some very careful studies where they would work with psychiatrists and they would do a sterile operation where they would remove a little part of the brain and and then have a psychiatrist blinded, in other words, not knowing sort of who had the surgery, who didn't and then check again and see if they got any better.

And it turns out there there are a, there were a percentage of patients, maybe 20%, who actually got better from this surgery who went back to work. And we don't quite understand. You know, we we have operations we can do now that are much more sophisticated, but more so many people were hurt by the operation that it was abandoned, you know, and not many neurosurgeons ended up doing it. And and I talk a lot about the neurosurgeons that did. There's some great stories about, you know, Eva Peron, who Evita, you know, was married to Juan Peron in in Argentina.

She had a frontal lobotomy done near the end of her life. And one and a neurosurgeon from America actually flew down and did it on her. And. And a lot of people think she never knew that she was having it done. It was kind of forced on her. There's a whole story behind that because it was very hidden that she had that surgery done. Wow. That's that's really incredible. Speaking of the Kennedys, you brought up the Kennedys recently. There is news coming out about JFK President Kennedy that he was shot from multiple directions by different people.

You have a section on Kennedy. I do. You know, there's a documentary that that was done, that just came out on Paramount. I couldn't get on. I wanted to watch it because it was on Paramount. I couldn't log in for some reason, but yeah, So what I did was I I wanted to use the Kennedy assassination as a way to teach just sort of basic neuro anatomy. Right. I wanted to find a way to introduce people to what's the difference between the frontal lobe, the parietal lobe, the occipital lobe and the cerebellum, which are the basic, you know, the brain has four lobes, frontal, parietal, occipital, temporal and the cerebellum is this like little sub brain in the back.

And so I use the Kennedy assassination because there was a controversy. You know, he was shot in the back of the head and he was exam examined by a neurosurgeon called Kemp, Clark, Walter Kemp, Clark and Kemp as he sort of he had a nickname named Kemp, examined him from behind. And in his original report, he didn't find an entrance wound. He says there was no entrance wound in back all he said he's thought that the bullet had grazed the side of the of Kennedy's head and it turns out and and that was very controversial because if he was shot from behind you know how is in our entrance room.

And then he also said that he saw cerebellum leaking through the the the the wound, which doesn't make sense based on where. Where it was Cerebellum's all the way back and. Back back here. And so it turns out there was another neurosurgeon in the hospital where Kemp was doing his examination who was six months out of his residency and no one took his testimony. Nobody spoke to him. His name is Bob Grossman. He became the chair in at Texas Methodist Hospital, and he eventually published an article 40 years later.

And he said, this is what I remember from Kennedy's assassination. And so he remembers very clearly that there was an entrance wound here and it was in it was in the occipital lobe. And it turns out the occipital bone covers the cerebellum and the occipital lobe and the and the right, sorry, the occipital lobe and the cerebellum, they're right next to each other. So there was some brain oozing out. You know, Kemp Clark couldn't really tell the difference. Bob Grossman said. There was clearly an entrance wound.

I don't know why Kemp didn't write about it, but there's no question that we felt an entrance wound back here, and there was an exit. The exit wound was here, which is kind of where everything kind of shattered out. So I used that whole story to sort of introduce people to the four lobes of the brain and the bones, because then I go on and talk about them more and I kind of want to get them interested in it. And it was sort of this interesting fact that I found. And neurosurgeons know this. Like, we've all read this article that was published in the Journal of Neurosurgery about Bob Grossman, who was there, who basically said I don't know why Clark didn't see the entrance wound, but it was clearly recognizable.

Maybe they were on call too much and retired. Who knows? Yeah, but now I just saw the other day Rob Reiner, who's in showbiz. Apparently it has some new film that shows that there were three or four people who shot Kennedy. It's kind of bizarre. I'm not sure. I'm not sure if we're we'll ever figure that out. What one other person you discuss in your book, which is fascinating, is Muhammad Ali, the boxer and what? What happened to him? So we all know that Ali developed Parkinson's disease, right?

He was very open about it and he couldn't really hide it, right? So he had to be open about it. He never got in Autopsy, so whether boxing contributed to his Parkinson's disease was always a question. But I did speak to his neurologist. He's actually Parkinson's neurologist. And you know, after reading a lot about it, it, it was clear to me that boxing definitely contributed. And there's something called dementia pugilistica, which is an old malady that was described in 1973, something like that.

And basically, these neurologist doctors realized that boxers would get punch drunk. There's something called being punch drunk. We all heard about that. You get hit in the head enough. You're not quite right. You know, you're not quite the same. And So what Punch drunk is and dementia Pujolistica is the, the official Latin name is basically these boxers near the end of the life would get something like chronic traumatic encephalopathy, like what the football players would get. And there's a a broad range of what repetitive head injury can do to the brain.

And some people have more cognitive issues. So we hear about these football players or hockey players who commit suicide, and, you know, they become very angry. They have more Gray matter damage. But there's another group that gets movement disorders like Parkinson's disease. We know that repetitive head trauma can cause Parkinson's disease. And actually, there's studies showing that even football players, there's a higher risk of Parkinson's disease from their repetitive head trauma. So there's this sort of spectrum by which head trauma causes injuries to the brain, and some of the symptoms can be movement disorder, Parkinson's syndromes.

And so that's what Muhammad Ali had. I also write about Michael J. Fox, obviously another famous person who had Parkinson's disease. Now, Michael J. Fox had mostly tremor, and he had a surgery to try to slow down his tremor. And Muhammad Ali never had surgery. And one of the reasons was that tremor really wasn't his big problem. He was having more cognitive slowing issues, actually. And the Parkinson's surgery that we do, deep brain stimulation, doesn't really work for that. It works better for the tremor, which is why Michael J. Fox had surgery and Muhammad Ali didn't, although Muhammad Ali got a consult from a Mexican neurosurgeon.

Madraso was his name who was had a clinical trial where he was doing transplants of adrenal cells because the problem with Parkinson's disease you don't have enough dopamine in part of the brain and so the adrenal cells make dopamine or norepinephrine similar drug and and he would transplant the the adrenal cells into the brain to try to stop Parkinson's disease. And there are all these trials that have gone on over the years of transplanting different cells or doing gene therapy or things like that anyway, to increase dopamine in that part of the brain to try to treat Parkinson's disease.

So Ali actually went down to consult with him, but never went through. How does the deep brain stimulation for Parkinson's work? What? What are you actually doing there? So what you do is you're actually turning off certain cells. The electrode goes into an area to turn down cells that project somewhere else in the brain to help with the tremor. So you're sort of shutting off because with the electrical stimulation at just the right frequency, you can basically shut down a bunch of cells. So you put it in just the right place.

The projections of those neurons will help reduce the tremor. Your book is amazing because it has all these stories in it that were really fascinating. How how long did it take you to do that? You know, it took me about a year. I wrote it, yeah. In 2021 I spent the whole year writing the book. And then I I had written this entire. Book this is like between 2:00 and 4:00 in the morning. Saturday and Sunday mornings, you know, in the winters when I couldn't play golf, I would, I would write. So you got to do something with your free time.

So it took about a year. And then, you know, but I had this 550 page book, which was too long, and I didn't know what to do with it. So I started. I spoke to some friends of mine who were writers and they're like, you know, you can't really sell the entire book. That's not the way the publishing industry works. First you need to get an agent, and then the agent sells it to a publisher. I was like, all right, so I have to send an agent. So I sent out the book. They recommended a bunch of different agents and I got rejected by a lot of agents.

But I someone said yes. Yeah, you know, you never know people. It's not what they're interested in. Maybe they didn't read. It's, it's long, you know. And I'm sure they thought, you know, who's going to read a 550 page book about nursery now? It's much shorter. I'm just saying it's much shorter. We edited it down significantly, but. So it's great and I I think the public will enjoy it because it's not technically complicated. It's it's language you can understand, but it really opens your mind. No, no pun in.

Yeah, yeah. No, it's meant to be for anybody interested in learning about the brain surgery. It's not a technical book and I just try to tell stories, you know, try to tell the story of neurosurgery. So, but the next step after you get a agent is you have to, she has to sell it. He or she has to sell it to a publisher and they want a 100 page writing sample and like a four page summary and then an outline of where all the chapters are going to show. And so I basically had to then work to get this long thing into something that I could sell to a publisher, which I realized, you know, that's the way it's supposed to be done.

But then it was easier for me because normally you just sell a writing sample and an idea which says, yeah, I like that, then you have to write the book. I'd already written the book. So what I have to do is edit it down to a digestible form, you know, so it wasn't sort of too long. So did you write the book just for yourself, your own self satisfaction, and then later decide maybe I can actually sell this? Well, I mean, I I can't say I wrote it not hoping that someday it would get published, right?

So obviously I thought, wow, maybe this will be published, but I just wrote it because I I enjoy writing. I was a philosophy and English major in college. I really like writing. I like reading, you know, So I like thinking about ideas and expressing them and talking about them. So well. I think it's going to be a best seller. And as I mentioned earlier, it's already available on Amazon. You can pre-order it and it's it's called Gray Matter. It's a biography of Brain Science and it's really fascinating.

I spent the whole day yesterday reading it. I thought I was just going to look at it for a few minutes, but it was so good that I spent a lot of time on it. I appreciate that. So thank you very much for coming today for taking the time to come here. I know your pleasure. Very busy schedule. I think the watchers and listeners out there will enjoy this tremendously. Thank you for having me. I appreciate it. Great to meet you, Robert. Yep, it was a pleasure. Thank you all.

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