American Scientist

GRAY MATTERS: A Biography of Brain Surgery. Theodore H. Schwartz. 512 pp. Dutton, 2024. $32.00.

What do Robert F. Kennedy, Eva Perón, Michael J. Fox, and Malala Yousafzai have in common? They have all had encounters with neurosurgery. In his recent book Gray Matters: A Biography of Brain Surgery, neurosurgeon Theodore H. Schwartz gives readers a fascinating window into a field of medicine that is a mystery to most people outside of the field, complete with compassion and even humor.

Schwartz covers the history of neurosurgery, but rather than organizing the book chronologically, he divides the book into topics. The first section, “Beginnings,” traces some of the origins of neurosurgery and debunks popular myths surrounding the specialty. Next, he explores “How do brain surgeons think?” with vivid examples of decisions that neurosurgeons face inside and outside the operating room. Finally, the book culminates in looking ahead to exciting developments on the horizon that almost sound like science fiction. Here, Schwartz writes about how developments in neurotechnology inform our understanding of philosophical questions about identity and free will.

Each section contains stories—of both famous cases that are public knowledge, as well as those of Schwartz’s patients—that help to illustrate how far we have come in understanding the structure and function of the human brain, and how to fix problems when things go awry. The chapter on penetrating head trauma compares the assassination cases of John F. Kennedy and Abraham Lincoln to demonstrate the effect of gunshot wounds to the head. The surgery for a severe penetrating head wound (such as that from a bullet) was developed back in 1896 and is called a craniectomy, or removal of part of the skull. When the brain swells following an injury such as a gunshot wound, the swelling tissue increases the pressure in the skull, which can cause further damage and be life-threatening. A craniectomy relieves this dangerous pressure by removing part of the skull, allowing the brain to swell and heal. Eventually, weeks to months later, the piece of bone (or a synthetic replica) is replaced once the brain has returned to its normal size and position. Although there have been advances in the tools involved, the principles of this surgery remain the same as those from more than 100 years ago.

Throughout the book, Schwartz frequently links the past with the present. He examines JFK and Lincoln’s cases and draws parallels to the shootings of Gabrielle Giffords (U.S. House of Representatives for Arizona) in 2011 and Malala Yousafzai (Pakistani education activist) in 2012, showing how past advances in neurosurgery are still relevant today.

The book covers more than traditional neurosurgery topics, though. Schwartz spends a chapter on the storied history of the National Football League (NFL) and discovery of a condition called chronic traumatic encephalopathy (CTE), a saga covered widely in the popular press. Perhaps less frequently known, however, is how involved neurosurgeons were in the discovery and exposé of CTE. Schwartz recounts the heated debates in the early 2000s that unfolded in the pages of one of the top scientific journals in the field (aptly named Neurosurgery). Early research surrounding the NFL and head injury was driven by Elliot Pellman—a rheumatologist who was sponsored by the NFL—who published what is now recognized as flawed research underreporting the effect of football impacts on neurologic functioning.

The neurosurgical community called out Pellman and the NFL as evidence mounted that the numerous hits football players took throughout their careers could contribute to brain damage that manifests later in life. This research, along with pressure from the public, helped drive the NFL to take their players’ brain health more seriously. Ultimately, the NFL elected two neurosurgeons (Richard Ellenbogen and Hunt Batjer) to lead their concussion committee and create new policies to improve the game’s safety. Since then, the rules surrounding head injury and football have vastly improved, and the NFL has publicly recognized the impact of CTE on their former players. Schwartz uses this example to demonstrate how neurosurgeons can not only have an effect on their individual patients, but also have wide-reaching impact in matters of public health.

Although the field has made incredible strides in saving lives, neurosurgery hasn’t had a perfect history, and Schwartz doesn’t shy away from recognizing this. He explores troubling aspects of neurosurgery’s history, perhaps most notably the media-spurred frenzy surrounding the procedure of frontal lobotomy popularized in the 1930s and 40s. The technique was first developed by the Portuguese neurologist Egas Moniz as a way to subdue mentally ill, violent, or agitated patients.

The procedure gained popularity in America, in part because of the work of Walter Jackson Freeman II, an American neurologist who “refined” the technique from Moniz. Freeman’s method involved sliding an ice pick just above the eyeball and swiping back and forth, effectively destroying the area of the brain just above the eye, the frontal lobe. This procedure would leave patients less violent, but apathetic and sometimes unrecognizable, personality-wise. Schwartz condemns the practice, but also situates it within the historical context to help readers understand how such a barbaric and devastating practice became widespread for a period of time.

Schwartz also describes what it takes to become a neurosurgeon. He includes his own tales from residency at The Neurological Institute of New York at Columbia-Presbyterian Medical Center, and his current career at Weill Cornell Medical Center at New York-Presbyterian Hospital, where he also serves as faculty. He survived the grueling work schedule of training, in which he frequently worked 36-hour shifts (as of 2003, residents are legally limited to 80-hour workweeks, but this was after Schwartz’s time). He tells stories of operating through the night, as well as instances where he could not save his patients, giving readers a flavor of the extraordinary range of highs and lows in neurosurgery.

Five chapters are devoted to exploring how brain surgeons think, providing examples of the decisions running through neurosurgeons’ heads as they review a scan of a new brain tumor, operate on an aneurysm, or delivers bad news to a patient’s family. Schwartz has had numerous meetings with patients and their loved ones who have just found out they have an aggressive and terminal brain cancer. Even with surgery, the median survival is just over a year for glioblastoma, or late-stage brain cancer. The challenge is “walk[ing] this tightrope between truth and hope,” as these meetings are “more psychoanalytic than surgical,” as Schwartz writes. The son of a Freudian psychoanalyst and the product of a liberal-arts education, Schwartz seems particularly attuned to the humanistic side of medicine; he majored in English literature and philosophy at Harvard, after a brief foray into astrophysics. His love of and attention to language and its meaning become apparent when he explains that he intentionally chooses words like “we” and “us.” He writes, “I want them to know they have a seasoned veteran as their ally.”

Schwartz not only shows readers how the field of neurosurgery evolved, but also how he became an accomplished neurosurgeon in New York City, a hypercompetitive environment for medicine. Neurological conditions have touched his personal life, and he writes about the experience of being at the bedside, not as a doctor, but as a worried family member or friend. He tells the heart-wrenching story of his father losing the ability to speak after a routine stomach surgery. Suspecting a stroke and frustrated by the slow pace of the hospital over a weekend, Schwartz wheels his father’s hospital bed to the computed tomography (CT) scanner himself to expedite his care, ignoring protests from hospital staff. The workup reveals that his father not only had a stroke in the language-center of the brain, but also has lung cancer, with only weeks to live. Schwartz grapples with this devastating news and reflects on the painful realization that he has limited time left with his father, leaving him with a greater empathy for what his own patients go through.

Although Gray Matters can, at times, read like a whirlwind tour through neurosurgery history, the current state of the field, and exciting, upcoming advancements, Schwartz also makes it feel personal and intimate through his own experiences and commentary. Indeed, the subtitle is “a biography of brain surgery,” not “a history of brain surgery,” and this choice is reflected in the content. The result is a greater understanding and respect for how history has shaped neurosurgery today, and how far brain surgery has come from its early days.