A Biography of Brain Surgery
Renowned neurosurgeon Schwartz unveils brain surgery's evolution from crude beginnings to Neuralink's future. Praised by Dr. Sanjay Gupta as "a must-read," this Economist Best Book of 2024 reframes JFK's assassination, NFL's CTE crisis, and our understanding of consciousness itself.
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In a world where the brain remains our final frontier, neurosurgery stands as both science and art-a delicate dance at the edge of human capability. Theodore Schwartz's "Gray Matter" pulls back the curtain on this mysterious profession, revealing not just the technical brilliance required to operate on our most precious organ, but the profound philosophical questions that arise when we literally touch the physical substrate of consciousness. Consistently ranked among Bill Gates' favorite medical reads and praised by neurologists and laypeople alike, this book offers a rare glimpse into a field where millimeters mean the difference between triumph and tragedy. As we explore the world of those who navigate the three-pound universe inside our skulls, we confront the ultimate question: what happens when humans attempt to heal the very organ that makes us human?
Brain surgery has become cultural shorthand for extreme difficulty-the gold standard against which all complex tasks are measured. This reputation wasn't earned lightly. In the early 1900s, neurosurgery carried a staggering 50% mortality rate until one man transformed it into a legitimate specialty: Harvey Cushing. Cushing's journey began with European travels to observe surgical pioneers, establishing a tradition that continues among neurosurgeons today. After studying under luminaries like Emil Kocher and Victor Horsley, he returned to Johns Hopkins where he convinced a reluctant William Halsted to let him focus exclusively on brain surgery. His 1905 publication "The Special Field of Neurological Surgery" became the field's unofficial birth certificate. What made Cushing remarkable wasn't just technical skill but his combination of ego, sangfroid, and determination. Operating without MRIs or CAT scans, relying solely on symptoms and physical examinations, he reduced mortality rates from 50% to under 10%. He meticulously documented operations with Leonardo da Vinci-like precision and preserved patients' brains after death to study his failures. This dedication came at tremendous personal cost. Working 14-16 hour days, six days weekly, Cushing was an absentee husband and father. When his 23-year-old son died in a car crash, he completed his scheduled surgery before claiming the body. His operations were legendary-exasperatingly slow, conducted in complete silence with hand signals for instruments, requiring absolute focus from assistants ("Eyes on the ball!"). Despite his brilliance, Cushing held the anti-Semitic prejudices of his time, yet paradoxically helped Jewish physicians escape Nazi persecution. His legacy includes identifying the Cushing reflex and Cushing's disease, founding the largest American neurosurgical society, and winning a Pulitzer Prize for his biography of William Osler. Today, any U.S.-trained neurosurgeon can trace their educational lineage back to Cushing within six degrees of separation. While Hollywood has created memorable fictional neurosurgeons-from brilliant but egotistical renaissance men like Dr. Strange to sociopathic mad scientists-the reality is more nuanced. The profession remains dominated by white men, with only 9% of U.S. neurosurgeons being women and 3.8% Black. Though women now represent nearly 20% of residents in training, Black trainees still constitute less than 5%. The first female neurosurgeon, Dorothy Klenke Nash, completed training in 1928 but remained the only one for 32 years, while Johns Hopkins didn't admit its first female Black resident until 2017.
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What drives someone to become a brain surgeon, knowing the grueling path ahead? Several distinct types emerge: intellectuals fascinated by the nervous system; socially adept, outgoing athletes who view technical challenges like competitions; musicians redirecting their dexterity from instruments to surgical tools; and conscientious achievers-the Boy and Girl Scouts who always did the right thing. The selection process, known as "the Match," resembles a Hunger Games-style competition. Candidates endure nerve-wracking interviews where they might be tested on surgical dexterity or challenged about their toughness. One interviewer questioned whether my Harvard education made me too soft for neurosurgery's blue-collar reality-a profession where surgeons get covered in blood and brain matter. Before 2003's regulations, resident hours were unrestricted. My schedule was punishing: alternating thirty-six-hour and twelve-hour shifts in an endless loop. My first year consisted mainly of menial tasks-drawing blood and replacing IVs rather than performing surgeries. Neurosurgical training follows a gradual progression of responsibility. Residents begin with "opening and closing"-managing skin, muscle and skull-while the attending handles the brain work. Only after years of constant supervision might residents perform brain procedures independently. This creates extraordinary stress during a surgeon's first post-residency years when the training wheels come off. Unlike sports or music where prodigies peak young, neurosurgery values experience and judgment over youthful dexterity. After years of practice-assisting in some 2,000 surgeries and tying approximately 100,000 knots during residency-surgeons eventually enter a "flow state" where operations require less conscious effort. Instruments become extensions of the body, and hours pass in a state of complete presence.
Head trauma forms the foundation of neurosurgery practice. The field's origins stem directly from managing head injuries, with early cranial surgery (trephination) performed almost exclusively for trauma across ancient civilizations. For neurosurgery residents, trauma cases provide their first hands-on surgical experience, allowing more participation than elective surgeries. The assassination of John F. Kennedy remains controversial regarding bullet trajectory and brain damage. Dr. Robert Grossman, a neurosurgeon present but never officially interviewed, published his account 40 years later confirming a clear entrance wound in the occipital region, supporting the single-shooter theory. He concluded that Dr. Clark must have mistaken macerated brain tissue for cerebellum, as bloody brain tissue from different regions looks similar-"like purple mush." Lincoln's assassination presents an interesting comparison. Despite receiving similar wounds to Kennedy's, Lincoln survived significantly longer because of vastly different bullet velocities. Booth's Philadelphia Deringer propelled its bullet at only 400 feet per second, while Kennedy's assassin used a Carcano rifle firing at 2,500 feet per second. Since bullet damage is calculated as mass multiplied by velocity squared, Kennedy's brain received approximately forty times more force than Lincoln's. The survival of James Brady, Gabby Giffords, and Malala Yousafzai versus the deaths of Kennedy and Lincoln came down to three factors: the force of the bullets, their trajectories, and most crucially, the speed and quality of neurosurgical intervention to control brain swelling. Unlike other body parts that can expand under elastic skin, the brain is confined in a rigid skull, causing pressure to rise rapidly when swelling occurs. The hemicraniectomy-removing half the skull-allows the swollen brain to safely expand outward, but must be performed within five hours of injury to be effective.
As a neurosurgeon in Scarsdale, I frequently field calls about concussions from worried parents. Though we can't medically shorten concussion recovery, we serve as the first line of defense. Concussions-occurring in less than one in ten thousand helmet impacts-no longer require loss of consciousness for diagnosis. The damage occurs microscopically, below imaging resolution, with symptoms ranging from headaches to amnesia. These mild traumatic brain injuries cause axonal damage, disrupt blood flow, create inflammation, and trigger scarring. Four tragic cases illustrate the devastation of second impact syndrome. Matthew Gfeller, 15, died after a helmet-to-helmet hit caused an acute subdural hematoma. Jaquan Waller, 16, suffered a concussion in practice, was cleared to play days later, then collapsed after another hit and was brain-dead upon hospital arrival. Nathan Stiles, 17, complained of headaches that resolved, received a normal CAT scan, and was cleared to play-only to collapse with a subdural hematoma and massive swelling after scoring his second touchdown. Thirteen-year-old Zackery Lystedt returned to play after rolling on the ground clutching his head, then collapsed after another hit, developing bilateral subdural hematomas. These cases prompted protective legislation nationwide, requiring concussed students to be removed from play until medically cleared. While concussion reporting increased 50% after these laws, fatalities have declined by nearly half. Football's violence and popularity create a perfect storm for brain injuries. The NFL's handling of mild traumatic brain injuries became contentious when their internal research was published in the journal Neurosurgery. What began as seemingly legitimate research quickly unraveled under scrutiny from neurosurgeon reviewers, who identified serious flaws in methodology and conclusions. The case of Mike Webster, the legendary Pittsburgh Steelers center nicknamed "Iron Mike," became a pivotal moment in understanding football's impact on the brain. After a Hall of Fame career spanning 245 games, Webster's post-retirement life spiraled into cognitive decline, aggression, homelessness, and ultimately death at age fifty. When pathologist Dr. Bennet Omalu examined Webster's brain, he discovered tau proteins and amyloid plaques consistent with chronic traumatic encephalopathy (CTE), similar to the "dementia pugilistica" previously documented in boxers.
Every brain tumor operation presents a critical decision point: how aggressive should the surgeon be? The ideal is complete tumor removal, but many tumors sit perilously close to brain regions controlling essential functions, or wrap around vital nerves and blood vessels. This moment of truth typically arrives between the third and fourth hour of surgery, just as fatigue begins to set in. Eugene O'Kelly, CEO of KPMG, faced a multifocal glioblastoma that had already spread across his brain. While one neurosurgeon recommended debulking surgery requiring six weeks of recovery, I suggested a safer biopsy that would preserve his faculties and allow quicker radiation treatment. O'Kelly chose the biopsy and then made another unusual choice-refusing chemotherapy to avoid its debilitating effects. He lived 100 more days, writing the bestseller "Chasing Daylight" about transforming his final days. Rather than pursuing aggressive treatment, he focused on presence, creating perfect moments with loved ones, and finding closure in relationships. The surgeon's dilemma after surgery involves balancing truth and hope-whether to share preliminary "frozen" biopsy results immediately or wait for definitive "permanent" results a week later. Unlike some who defer these difficult conversations, I believe in revealing truth at a deliberate pace while preserving what Jerome Groopman calls "true hope"-not false promises of beating the disease, but the possibility of being among the rare long-term survivors or finding beauty in remaining days. Patients diagnosed with brain tumors inevitably ask "Why me?" While most cancers arise from a combination of genetic predisposition and environmental triggers, the root cause of most brain tumors remains frustratingly unknown. I emphasize to patients they did nothing wrong-their condition results from random cellular events altering DNA or disrupting protein balance. The only definitively proven environmental cause of brain tumors is radiation exposure.
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Like Mount Everest or the Mariana Trench, certain regions of the brain are so inaccessible they seem forbidden to human exploration. As a skull base surgeon, I specialize in operating within these hidden chambers-Meckel's cave, Dorello's canal, the cavernous sinus, and the sanctum sanctorum: the third ventricle. This quarter-sized chamber at the brain's geometric center is so difficult to access that an entire 1,000-page textbook was published just to guide surgeons there safely. Each of these regions houses critical structures - cranial nerves controlling facial movement and sensation, blood vessels feeding the brain, and hormone-producing tissues that regulate essential body functions. Mrs. X, a world-renowned designer, experienced alarming weight gain despite her best efforts, gaining nearly forty pounds in six months. She also suffered from nightly bathroom trips, increasing irritability, and unexplained mood swings that began affecting her work relationships. When her vision began blurring, particularly in her peripheral field, an MRI revealed a craniopharyngioma-a rare tumor growing in her third ventricle that was pressing on both her optic nerves and hypothalamus. The tumor's location made it particularly challenging, as it sat adjacent to structures controlling vision, hormone production, and vital functions. After consulting multiple neurosurgeons who recommended either extensive craniotomy or partial treatment, she found me-a young assistant professor who'd developed a minimally invasive endoscopic technique perfect for her tumor type, requiring only a small nasal entry point. Neurosurgery demands complete focus and emotional detachment during operations, a state of mind that takes years to develop. Working deep in the brain requires eyes and hands working in perfect harmony, with the first move always being to survey the actual landscape and compare it with expectations from preoperative imaging. The surgeon manipulates delicate instruments through corridors barely wider than a pencil to separate nerves and tiny arteries from tumors, constantly adjusting to control bleeding without damaging critical structures. Every millimeter matters, as the difference between success and catastrophe can be thinner than a sheet of paper. Though patients nominally participate in decision-making, they retain only about one-fifth of information presented in consultations, a fact that becomes especially apparent during follow-up visits. This leaves the surgeon to ultimately weigh risks and benefits in the moment, making choices they would want for themselves or their family members. The responsibility is immense, as these split-second decisions can affect everything from motor function to personality and memory. Modern neurosurgery has evolved to include real-time imaging and navigation systems, but the fundamental challenge remains: accessing the brain's deepest regions while preserving the intricate network of vessels and nerves that make us who we are.
Every neurosurgery resident anticipates with equal parts dread and excitement the moment they truly become a neurosurgeon-clipping their first aneurysm. These dangerous balloonings of blood vessel walls can rupture without warning, flooding the brain with blood and causing instant death in 10% of cases, with another 40% eventually dying even with treatment. Two months into my first job as an attending, my rare Saturday date night was interrupted by my beeper. The resident described a 52-year-old hypertensive man who had collapsed at home with a ruptured aneurysm. This would be my first aneurysm case without supervision. When I called my senior partner for advice, his territorial response was blunt: "If you do this case, you are on your own," followed by a click. The surgery went well, as did my next five aneurysm cases. But my sixth case was catastrophic-the aneurysm didn't simply rupture but the blood vessel disintegrated. Despite stopping the bleeding with temporary clips, I couldn't safely secure the aneurysm or reconstruct the vessel, leading to the patient's death days later as her brain swelled uncontrollably. In 1988, Joe Biden experienced what he described as "lightning flashing inside my head" before passing out in his hotel room. A spinal tap revealed blood in his cerebrospinal fluid, and an angiogram showed two brain aneurysms. When he asked his neurosurgeon about his chances, the doctor bluntly replied, "Senator, for morbidity or mortality?" Biden clarified: "What are my chances of getting off this table and being completely normal?" The surgeon answered, "Your chances of surviving are much better." Perception is a two-way street, where seeing and knowing constantly inform each other. As my professor insisted, "You see what you look for, and you look for what you know." But before perception can occur, proper illumination and magnification are essential-tools the surgical microscope provides. The real barrier to adoption wasn't technical limitations but a failure of imagination-surgeons couldn't envision what they couldn't yet see.
Walter Freeman achieved his life's ambition by marketing the lobotomy, though his scientific reputation suffered greatly in subsequent decades. Despite vocal skepticism from medical luminaries like William Scoville and Karl Pribram, the procedure flourished without meaningful oversight-60,000 frontal lobotomies performed between 1935-1955, with Freeman personally conducting 4,000. The procedure became increasingly abused, with psychiatrists using it to control difficult patients often without informed consent or proper medical justification. Husbands authorized lobotomies for "disobedient" wives, and even children as young as four underwent the procedure for behavioral issues. In state hospitals, it became a tool of convenience to manage overcrowding and understaffing. Freeman wasn't inherently evil but genuinely believed he was helping patients during a time with few treatment options for mental illness. Before antipsychotic medications, mental institutions were overwhelmed with patients suffering from severe psychosis, depression, and mania. His ego and growing celebrity status gradually blinded him to the harm he caused, but he never intended to violate his Hippocratic oath. He meticulously documented his cases and truly believed he was advancing medicine. Contrary to popular belief, the neurosurgical community never fully embraced the lobotomy-it was the public and media who championed it as a miracle cure, fueled by sensationalized stories of dramatic recoveries. The psychosurgery debacle, despite severely damaging neurosurgery's reputation, ironically propelled the field into the modern era by motivating development of new technologies like stereotactic surgery and gamma knife radiosurgery. It led to the modern field of functional neurosurgery, where precisely placed electrodes rather than ice picks alter specific brain circuits. Deep brain stimulation (DBS) now effectively treats various behavioral disorders including treatment-resistant depression, anorexia nervosa, substance abuse disorders, and severe obsessive-compulsive disorder. The key difference is that DBS is reversible and precisely targeted, unlike the crude destruction of frontal lobe tissue in lobotomies. What's particularly remarkable is how minute electrical changes in specific brain regions can dramatically affect mood, sensation, and conscious experience. Patients report immediate feelings of joy, relief, or clarity when devices are turned on, which vanish just as quickly when current stops. This striking manipulability reveals how ephemeral our sense of self truly is-in one fascinating case, electrode activation triggered a sudden passionate appreciation for Johnny Cash's music that completely disappeared when the device was turned off. Similar cases show how stimulating different brain regions can instantly alter personality traits, emotional responses, and even moral decision-making, raising profound questions about consciousness and free will. These modern interventions demonstrate both how far we've come from the era of lobotomies and how much we still have to learn about the relationship between mind and brain.
Brain-computer interfaces (BCIs) represent the merging of human cognition with technology-a concept that has evolved from science fiction to scientific reality. These devices fall into two categories: output BCIs that extract signals from the brain to control external systems, and input BCIs that feed information into the brain. The fundamental challenge lies in translating between the brain's complex neural code and computers' binary language-a translation problem that machine learning algorithms are beginning to solve by simultaneously recording neural activity and physical movements to establish correlations. For the 80,000 Americans with locked-in syndrome, communication BCIs offer hope. Jean-Dominique Bauby wrote an entire book by blinking his eyelid to select letters, while Stephen Hawking used cheek muscles to select words at about 15 words per minute. Early BCIs used a point-and-click system that reached only 2 letters per minute, but implantable Utah arrays improved this to 40 letters per minute. The latest breakthrough from Stanford neurosurgeon Jaimie Henderson's team achieved 90 characters per minute-six times faster than Hawking's system and approaching normal texting speed. Chang's groundbreaking work with Pancho demonstrates the remarkable potential of brain-computer interfaces. Using a 128-contact electrode grid implanted over Pancho's speech motor cortex, Chang's team created a digital "Rosetta stone" that translates brain signals into text at 15 words per minute. This achievement marked a watershed moment for BCI communication-Pancho's first sentence, "My family is outside," echoing the historic significance of Bell's first telephone call. Within five years, fully implantable commercial devices will likely help paralyzed and locked-in patients navigate the world using only their thoughts. While telepathic BCIs remain science fiction for now, we stand at the precipice of the next great leap in human evolution-one where neurosurgeons will play a pivotal role in transforming our species.
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Modern neurosurgery owes its existence to brave pioneers who made the brain's hostile landscape more hospitable for future generations. These trailblazers faced significant resistance and skepticism from their peers. Walter Dandy's aggressive surgical approaches directly challenged Harvey Cushing's more conservative philosophy, creating a professional rift that would influence the field for decades. Similarly, Mahmut Gazi Yasargil, now considered the father of modern microneurosurgery, was initially forbidden from operating on aneurysms by his department chief, forcing him to develop his techniques in relative isolation. The field's history is marked by such conflicts between innovation and tradition. From Victor Horsley's earliest brain tumor removals in the 1880s to Lars Leksell's development of radiosurgery in the 1950s, each advancement faced initial resistance before becoming standard practice. These struggles highlight how progress in neurosurgery often requires not just technical brilliance but also tremendous persistence and moral courage. Contrary to popular belief, neurosurgeons aren't inherently smarter than others-a comprehensive 2021 study showed they scored no better on intelligence tests than the general population. What distinguishes successful neurosurgeons is a unique combination of attributes: laser-like focus during lengthy procedures, unwavering dedication to improvement, strict self-discipline, genuine humility in the face of the brain's complexity, exceptional manual dexterity, measured confidence under pressure, and willingness to sacrifice personal time for patient care. The psychological demands are as challenging as the technical ones. Neurosurgeons must maintain composure during critical moments, make split-second decisions with permanent consequences, and shoulder the emotional burden of outcomes that can dramatically alter patients' lives. They must also develop resilience to cope with inevitable complications and losses while maintaining empathy and professional objectivity. Like priests or soldiers, neurosurgeons dedicate themselves to a higher purpose, embodying the warrior-healer ethos: "I will always place the mission first. I will never accept defeat. I will never quit." This dedication extends beyond the operating room, requiring constant study, practice, and refinement of skills. Perhaps that's what truly makes it "brain surgery" - not just the technical complexity, but the profound responsibility of holding someone's identity, memory, and consciousness literally in your hands, while maintaining the emotional strength to bear that burden day after day. The field demands a rare combination of physical stamina, emotional resilience, and ethical fortitude. Successful neurosurgeons must navigate not only the intricate anatomy of the brain but also the complex landscape of medical politics, patient expectations, and their own limitations. This holistic challenge makes neurosurgery unique among medical specialties, requiring practitioners to be not just skilled technicians, but complete physicians in the fullest sense.
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