Book Review: A Neurosurgeon’s Inside Look At The Brain
Many years ago, I read a book about neurosurgery by a journalist who had undergone an operation for a brain hemorrhage. One anecdote is still vivid in my memory: a story about a neurosurgical resident who was slowly drilling a burr hole in a patient’s skull when the drill suddenly jammed and then broke through, plunging the equipment into the brain and killing the patient.
No such misadventure is included in “Gray Matters: A Biography of Brain Surgery,” although the author, Theodore H. Schwartz, cautions that neurosurgeons wielding power drills must develop enough skill “to know exactly when to stop” to avoid just such disastrous accidents from occurring.
But there are other medical mishaps and misjudgments described in this sprawling book, examples that Schwartz, a neurosurgeon at Weill Cornell Medicine in New York, uses to underscore both the risks of mucking around in the brain and the scientific and medical advances that have emerged from doing so.
In an early chapter, Schwartz, who specializes in brain tumors and epilepsy and is known for his expertise in minimally invasive neurosurgery, describes making a serious mistake himself: As a first-year resident, he accidentally grabbed a vial of potassium chloride instead of sodium chloride, and handed it over to be injected into a patient’s IV, triggering a cardiac arrest. He quickly admitted his error to the senior resident, he writes — “Don’t tell anyone what you just told me,” he reports that she said — allowing her to save the patient’s life.
“Gray Matters” is not quite a memoir, not quite a history, not quite a medical thriller, not quite an anatomy text, but at different points it seems to aspire to each of these things.
Virtually everything that can harm the human brain is contained in the book’s more than 500 pages, from tumors and gunshot wounds to sports injuries, shaken baby syndrome, aneurysms, and psychosurgery.
In the prologue, Schwartz ushers his readers into the operating room, where he is about to operate on a patient who has a tumor just behind the left eye. He intends to take out the malignancy not in the traditional manner — with a craniotomy, removing a slab of bone from the side of the patient’s skull — but by accessing the brain through the eye socket.
A few days before, he had met with the man to discuss the surgery. “My goal is to project calmness and confidence,” he writes, “like an airline pilot letting the passengers know they are headed into a bit of turbulence but that everything will be fine.”
In fact, Schwartz had never performed this novel procedure before. His patient had consulted several other specialists, “all of whom recommended — no, more like insisted,” that a craniotomy was the only way to go, he writes. But if the surgery is successful, it will allow the patient a faster recovery, and minimize any of the potential damage a craniotomy might do to the brain.
Drilling through bone and cutting a small hole in the covering of the brain, he removes the tumor “with just a few scoops of the curette,” a process that takes only 10 or 15 minutes. “Dare I say it was … easy?” he asks readers.
Indeed, if there is an overarching goal of “Gray Matters,” it may be to deconstruct the common saying “It’s not brain surgery,” an aphorism Schwartz returns to more than once in the book, sometimes to refute it, sometimes to show how it applies.
Moving from chapter to chapter, he details the rigorous and lengthy training that neurosurgeons undergo. He cites the relatively recent arrival to the field of women, minorities, and people with disabilities and reviews the portrayals of neurosurgeons in movies and television shows.
Readers are introduced to a roster of the field’s most noted practitioners, including Harvey Cushing, who practiced in the early 1900s and is known as “the undisputed founding father” of neurosurgery; Walter Dandy, a student of Cushing’s at Johns Hopkins and later Cushing’s rival; and Wilder Penfield, who pioneered a neurosurgical treatment for epilepsy, mapping of the brains of patients while they were awake. And after an extended look at brain-computer interfaces, he ends the book with a philosophical discussion of free will, personality, and the concept of self.
Sprinkled through “Gray Matters” are case histories — historical and contemporary — many of which involve people who made headlines for problems that are of interest to neurosurgeons. In a section on penetrating head trauma, for example, Schwartz analyzes the bullet wounds that killed Presidents John F. Kennedy and Abraham Lincoln, and those that allowed James Brady and Gabby Giffords to live.
He recounts the fatal 2009 skiing accident of the actress Natasha Richardson, who felt fine for about an hour after she fell and hit her head, a period of time that neurosurgeons refer to as “the lucid interval” — before dying from a brain hemorrhage. And in a section on so-called second impact syndrome, or SIS, he writes about four teenage football players who died or had severe brain damage after receiving blows to the head during games spanning from 2006 to 2010, cases that led to the passage of laws requiring that students with suspected concussions be examined and then cleared by a doctor before being allowed back on the field.
Schwartz uses the football example, as he does with other cases throughout the book, to underline a broader point: The controversy over the deaths of the football players — originally thought to occur after a prior concussion — led to a better understanding of the causes of such fatal injuries.
The term SIS and the focus on prior concussions, Schwartz notes, turned out to be misleading. “Trying to create a disease by lumping together a hodgepodge of symptoms and imaging findings can sometimes do more harm than good,” he writes. “Although the intent is to protect patients and make the doctors’ jobs easier, until the real cause of the problem is understood, it may be best to just describe the findings and treat them individually rather than concern ourselves with whether a case is manifestation of a syndrome such as SIS.”
And throughout the book, he is not shy about giving voice to unpopular opinions. In a section on psychosurgery, the field’s “dark chapter,” as he calls it, he argues that not every frontal lobotomy performed in the mid-1900s to treat mental illness was disastrous for the patient. Although the lobotomy, developed as a treatment in the 1930s by Antonio Egas Moniz, caused damage not just to patients but to the reputation of the field, he writes, many people “were indeed better off after the procedure,” and it led to the development of the more precise and sophisticated psychosurgeries used today.
As a writer, Schwartz is no Oliver Sacks, and he is prone to periodic dips into clunkiness: “People ask me all the time, ‘What’s it really like to be a brain surgeon?’ and I never have a good answer. I mean how much time have you got?” he writes at one point. But neither does he succumb to the cookbook “reader-friendly” prose found in many aspirational books by doctors. His tone is conversational, and his narratives easy to read, if not paragons of writerly style.
Yet who the audience is for this book remains a question. In some parts, Schwartz seems to be speaking to colleagues, in others to students, in others to a more general readership. Those with a strong interest in medicine or the workings of the brain will find “Gray Matters” engaging, despite its length and overambitious list of topics. Others may not.
In the end, though, Schwartz makes a persuasive case for the field’s remarkable technological advances. “We are standing on the precipice of the next great leap in human evolution, and if my hunch is correct, neurosurgeons will play a pivotal role in the forthcoming transformation of our species.”
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