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When the air hits your brain
  1. Tom Hughes,
  2. Katharine Harding
  1. Department of Neurology, University Hospital of Wales, Cardiff, UK
  1. Correspondence to Dr T Hughes, Department of Neurology, University Hospital of Wales, Cardiff CF14 4XN, UK; tom.hughes2{at}

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by Frank Vertosick Jr. 2008. Publisher: WW Norton: New York

Books written by neurosurgeons are popular. Frank Vertosick, an American neurosurgeon, originally published this book in 1996. He subsequently developed Parkinson's disease and stopped operating in 2002. The postscript particularly captures the times and goal of the book, if not the mood. He describes how many of the techniques he used have been superseded as a consequence of medical advances. However, When the Air Hits Your Brain (figure 1) is not really about technology, or the medicine, or the surgery, or our times, but about the human aspect of disease, “the human dimension of those who suffer from it, and the human dimension of those neophytes, like me, who learn to treat it”. After reading this book, it is difficult not to conclude that he knows as much as any of us about the nature of the patient-doctor compact.

Figure 1

When the Air Hits Your Brain.

This book is a rollercoaster ride for the reader. It is not for the faint-hearted, or for television fans who hide behind the sofa. In a single sitting the reader may experience entirely new and forceful bulbar functions, to the accompaniment of novel involuntary noises created by suction and plosion: cough-smiling; cough-cringing; lateralised teethy breathing; perseverative tutting; suppressed laughter; convulsive laughter; cough-wheezing laughter; bottom lip trembling; and possibly, if you are willing to risk chapter 10, a brief period of crying simultaneously through your eyes, nose and mouth until your ears are wet. A persisting jaw-dropped face of admiration may take a while to clear. It should be compulsory reading for all junior surgeons making specialty-related decisions, but is probably best left off the reading list for sixth-formers and physicians in training, and should be hidden from all paediatricians, particularly those with teddy bears on their stethoscopes.

Vertosick deftly combines a House of God type humour with hints of Oliver Sacks-type descriptions, but it is the coruscatingly clear and vivid account of the harrowing daily (and nightly) grind of a trainee neurosurgeon's life that draws the reader in and which makes this book unputdownable. It is sometimes difficult to put up with the raw alpha male buoyancy, but just around every corner there is clever, insightful and empathic ballast. He thinks neurosurgeons are arrogant, he knows it attracts a certain personality type, and he is aware of how their personalities can slip away as a surgical psychosis takes hold. At the same time, in a seemingly parallel furrow of awareness, he manages to preserve a steely sense of his own agency and a gritty, no-nonsense empathy for his patients and his colleagues, perhaps as a result of his appreciation of patients’ stories and his Damasio-type awareness that without recognised feelings it is difficult to think clearly. These footholds see him through the horror of his first failure with aneurysm surgery—“you become a neurosurgeon when an aneurysm blows up in your face”—and maintain him as he witnesses the demise of patients with cancer (“where the cells relive the heyday of their fetal youth”).

His descriptions along the way are memorable: a single vertebral artery as ‘one vert to the gourd’, biological decay as an essential part of a business dealing in renewable goods, and a primitive neuroectodermal tumour as being composed of Peter Pan cells. His on-call room had a hard bed and a loud phone, and he describes the brain as having venous moorings, and two parts (the left hemisphere, and not the left hemisphere). With four pages to go, he finally describes himself as “one of them”, a trained neurosurgeon. To paraphrase Philip Larkin, he had let himself by specious steps be haled, half willing, half abandoning the will, across the wide circumference of his scorn (The Dance, Collected Poems, 1988) but his basic enthusiasm for life prevails to the end, captured in his description of his sense of privilege as a patient recovers after meningioma surgery.

Medicine involves a complex social interaction informed by the humanities and the sciences, leading to interventions that can heal or harm. The torment of the neurosurgeon is a microcosm of the torment of the medical profession. It is books like this that help us see the wood for the forest plot. We are forwarding our book club copies to the Cochrane Collaboration.

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  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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