It’s all in your head

In Gray Matters Theodore H. Schwartz offers a lively and compelling “biography” of brain surgery. He charts the development of the speciality, interwoven with an account of his training, personal, and professional life. He begins with the “founding father” of neurosurgery, Harvey Cushing (1869–1939), and ends with the futuristic promise of the “brain-computer interface”, which, via tiny implants, could help the visually impaired “see”, or restore movement to a paralyzed limb. Along the way he sidesteps into popular culture – discussing everything from H. G. Wells’s The Island of Doctor Moreau to the primetime television behemoth Grey’s Anatomy. He tells moving stories from his life, for example sharing details of his mother’s successful carotid endarterectomy, a procedure intended to prevent future strokes.

Schwartz explains painstakingly the science of brain surgery. Clear and comprehensive, even for those without medical training, he discusses gunshot wounds to the head, chronic traumatic encephalopathy (a progressive neurological illness often associated with repeated head injuries such as those experienced during contact sports), malignant brain tumours, aneurysms and epilepsy. Each is illustrated with diagrams, cases from Schwartz’s professional experience and celebrity stories such as those of John F. Kennedy, Muhammad Ali and Joe Biden. The book is long and detailed, but remarkably entertaining and easy to understand.

The author also detours into the history of medicine, offering snapshots of famous surgeons and their cases and inventions. Here he’s on slightly shakier ground. He devotes a chapter to psychosurgery – of which the lobotomy is the most famous example. He describes and condemns this “misguided and ill-conceived operation” as a “large-scale tragedy”. The performance of lobotomies on mentally ill patients unable or uninvited to consent was indeed a “dark stain” on the field, but it was also an operation made possible by the culture and context of the medical and surgical profession in the early twentieth century. Schwartz is rightly cautious about the distorting gaze of hindsight. He’s no supporter of early lobotomies, but nevertheless is unwilling to condemn past practitioners with reference to twenty-first-century standards.

Yet his analysis remains unsatisfying. At first he denounces the neurologist and pioneer of American psychosurgery Walter Freeman as an “egomaniacal man who abused his medical degree and the trust of his patients”; as someone “obsessed with power” and akin to Hannibal Lecter. Later he backtracks slightly, insisting that “Freeman was not really an evil man”; instead, he “truly believed that he was helping his patients”. Slight contradictions aside, the moral values of an individual seem less important than understanding the context that enables that individual to act; Schwartz says little of the power structures, social norms and professional standards that aid and abet harm and acts of cruelty. Later he absolves the profession of neurosurgery from the sins of lobotomy almost entirely; “the rise and popularity of psychosurgery” was driven “by the public, hyped up by the media … as well as psychiatrists”. While he might have been aided by a neurosurgeon, James Watts, Freeman was, after all, a neurologist.

The central premiss of Gray Matters is that brain surgeons have two main attendant stereotypes – “brilliant but egotistical renaissance men” or “sociopathic mad scientists” – and that in reality the brain surgeon is neither. The book is dedicated to unpacking the detail of brain surgery and, in the process, complicating and blending these two reductive ideas of the surgeon. But at the end the reader is left wondering where the stereotypes emerged from and how they’ve been maintained. Understanding the answers to these questions might help to illuminate the emergence of operations such as lobotomies. The culture of brain surgery – indeed, surgery more broadly – involves a set of professional norms that include dispassion, paternalism, decisiveness, authority and precision. These aren’t necessarily negative characteristics, but they are things that render surgery hierarchical, male-dominated and a profession that has all too often drowned out the patient voice.

If, then, the metaphor of “biography” were to be extended, then Theodore H. Schwartz’s book offers a detailed and energetic account of brain surgery’s main events – its birth, marriages, divorces, dramas and deaths. It tells those stories well and imparts a huge amount of knowledge. But it has less to say about the social, cultural and political context in which brain surgery has lived and thrived, or about its motivations and desires, and tells only a partial story about its personality, either past or present.

Agnes Arnold-Forster is a Chancellor’s Fellow at the University of Edinburgh. Her books include Cold, hard steel: The myth of the modern surgeon, 2023

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