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I saw Mr John Turner first on June 25th last year. He came to me on the recommendation of a general practitioner at Watford: I have the letter before me.

Dear Mr Hughes,

I should be grateful if you would make an appointment to see a patient of mine, Mr John Turner. Mr Turner has been suffering from attacks of vertigo and fainting: I have been attending him consequent on a fall which he suffered in the Strand Palace Hotel, when he was unconscious for some minutes. I have found some apraxia, and the sight of his left eye appears to have become subnormal in recent months. In view of a severe head injury which he incurred in the year 1943 I feel that an intracranial lesion may be at the root of his trouble, and it is upon this diagnosis that I would like you to see him.

Mr Turner is married, but has no children. He is in some branch of the food business, and lives in a style corresponding with an income of £800-£1000 per annum.

Yours very sincerely,

V. C. Worth, mb, bs

Mr Turner came to see me by appointment that afternoon; the first thing that I noticed when my receptionist showed him in was the scar. It stretched as a deep indentation from a point about an inch above the left eyebrow up in to the hair on the crown of the head, over four inches long. It was a deep cleft in his forehead, red and angry looking.

The rest of Mr Turner was not very prepossessing. He was about forty years old with a fresh complexion and sandy hair, going a little bald. He had a jaunty air of cheerfulness and bonhomie which did not fit in well with my consulting-room; he was the sort of man who would be the life and soul of the party in the saloon bar of a good class pub, or at the races. He was wearing rather a bright brown suit with a very bright tie, and he carried a bowler hat.

I got up from my desk as he came in. “Good afternoon, Mr Turner,” I said.

He said: “Cheerio, doctor. How’s tricks?”

I smiled. “I’m all right,” I said. I motioned him to the chair before my desk. “Sit down, Mr Turner, and tell me what you are complaining of.”

He sat down with his bowler on his knee, and grinned at me with nervous cheerfulness. “I’m all right,” he said. “You won’t find much wrong with me, doctor. May want a bit of a tonic. You know,” he said confidentially, “this wound on my napper frightens people. I tell you, straight, it does. Every doctor that I go to gets the wind up and says I ought to see a specialist. They’ll none of them touch me. If I want my corns cutting, they say I ought to see a specialist.” He laughed heartily. “I’m not kidding you. They get the wind up.”

I smiled at him; one has to create confidence. “Does the wound give you any trouble?” I asked.

He shook his head. “None at all. Throbs a bit, now and then. The only trouble I get is at the hairdressers’ when they come to cut my hair—it don’t half fox them.” He laughed again. “Not that I’ve much to cut, now.”

I pulled my pad towards me. “Let me get down the preliminaries first,” I said. He gave me his age, address, and occupation; it seemed that he was a flour salesman. “Cereal Products Ltd.,” he said, “I went to them in 1935, and then went back to them again after the war.”

I picked up the letter on my desk and glanced it over. “I see that you told Dr Worth about attacks of giddiness,” I said. “Do those come very frequently?”

He said: “Oh no. Might be two or three in the last month. They don’t last long—just a few seconds, or maybe half a minute.” He laughed nervously. “Sort of make you feel you want to hold on to something. I think I want a tonic, doctor. I told Dr Worth.”

“Yes,” I said, writing on my pad. “How long since you had the first of those, Mr Turner?”

“I dunno. Couple of months, maybe.”

I glanced again at the letter. “Dr Worth says that you had a fall in the Strand Palace Hotel,” I said. “How did that happen?”

“Well,” he said, “it was like this. We have to do a bit of entertaining in my line—it all goes on the firm, you know. Well, to cut a long story short I was in the American Bar last Thursday with Izzy Guildas and another Portuguese—Jew-boys, you know, but good types all the same—and I suddenly passed out cold. Fact, I’m telling you. I passed out cold, and fell down off the little stool on the floor, clean out. When I came to I was in the lavatory lying on my back on the floor with somebody splashing water on my face, and my collar all undone. I wasn’t half in a mess, I tell you.”

I said: “How long were you unconscious, Mr Turner?”

“I dunno. Maybe three or four minutes.”

I made a note upon my pad. “When you came to, did you feel any pain?”

“I had the hell of a headache. I was sick, too.”

“What time of day was this?”

“About eight o’clock in the evening. We were just going to have dinner. I was looking forward to that dinner.” He laughed.

“What did you do? Did you see a doctor in the hotel?”

He shook his head. “I sat about in the lavatory for half an hour or so till I felt better, and then I went home by Underground and went to bed. The wife made me stay in bed in the morning and see Dr Worth.”

“I see,” I said. I made another note. “Had you been drinking heavily, Mr Turner?” I asked. “Forgive me for such a question, but I have to have the facts.”

He laughed again. “I been tight often enough not to mind talking about it, doctor. You ask anyone who knew Jackie Turner in the war. But, matter of fact, I hadn’t had a lot. I had a couple of pints at lunch, and then nothing till we went to the American Bar that evening. I had one dry Martini, and Izzy was just ordering the second round when I passed out.”

“That’s quite moderate,” I said.

He took me up. “I wish you’d tell that to the wife. She don’t half carry on about the beer I drink. But I think beer’s best. I started to lay off spirits the thick end of a year ago. I got a sort of throbbing, so I stick to beer, mostly.”

I made a note. “You get this throbbing with whisky, say, but not with beer?”

“That’s right.”

“Where is this throbbing, when you get it? Under the wound?”

“No—sort of right inside.”

I made another note. Then I passed him the silver box of cigarettes; he took one. I lit my own, and absentmindedly slipped the lighter back in my pocket as I glanced over my pad. “Were you very tired that night?” I asked.

He looked up at me quickly. “Funny you should ask that,” he said. “I was just about all in. I dunno when I felt so tired.”

“You’d had a very heavy day?”

He shook his head. “I’d not been doing much. I think I want a tonic. A good, stiff tonic, doctor—that’s what I need. I told Dr Worth, ‘That all that’s wrong with me,’ I said.”

“Do you get this feeling of exhaustion very often, Mr Turner?”

He did not answer; he was fumbling with his lighter. The cigarette was held between his lips. He had taken the lighter from his jacket pocket with his right hand and held it for a moment as if to strike it with his right thumb, but his thumb did not move. The little finger waggled to and fro instead. Then he took it in his left hand and with some difficulty rotated the knurled knob, and made a flame, and lit his cigarette. “I’m sorry,” he said. “What was that you said?”

“I asked if you felt tired very often.”

“I do sometimes. I didn’t used to. I’m a bit run down.”

“Are you left-handed, Mr Turner?”

He stared at me. “No.”

I said: “I saw you had some trouble with your lighter. Let me see you light it again.”

He pulled it out of his pocket. “You mean, light it with my right hand, doctor?” He was flushing a little.

“Yes. Can you do it with your right hand?”

He said awkwardly: “Well, I always used to, but it doesn’t seem to go, now.” He was fumbling with it. “I don’t seem able to put my thumb on to the knob.”

“How long have you had this trouble with it?”

“I dunno. Couple of months, perhaps.”

I did not want to frighten him. I said: “All right, never mind that now.”

He stared at me uneasily. “Rheumatism, that’s what it is. I knew a chap once lost the use of every finger on his hand, every bloody finger, doctor, all through rheumatism. He got it right by taking Kruschen salts. Every morning he took salts, much as would go on a sixpence. He never had no trouble since.”

He paused, and then he said: “I got some salts last week, and I been taking them.” He glanced at his thumb. “It’s much better than it was. It’s only the lighter I can’t seem to manage.”

“I’ll make a physical examination of you in a minute,” I said. “First of all, though, tell me about that wound. You got that in the war?”

“That’s right,” he said.

“Mortar?”

He shook his head. “It happened in one of them aeroplanes. Twenty millimetre. It burst right in front of me, right inside the cabin.”

I made a note. “You were in the Royal Air Force in the war?”

He shook his head. “I was in the Royal Army Service Corps. I was on my way home from Algiers,” he explained, “by air. In 1943, that was. We come by Gib and then straight from Gib to the UK, four of us, in a Hudson with a crew of three. A Jerry jumped us over the sea somewhere around Ushant, a Ju 88. He had four goes at us, but he couldn’t get us down. Over and over again he come at us, and his shells bursting on the wings and in the cabin every time. I got put out on his second run, so I didn’t see the end of it. They said some Spitfires came and drove him off.”

In the quiet peace of my consulting-room I made my note. “You got back to England all right, then?”

“In a manner of speaking,” Mr Turner said. “The second pilot made a belly landing in a field by Penzance. There was him and me and another chap all in hospital together when I come to. That’s all that there was left, out of seven of us.”

I wrote again upon the pad. “What was the hospital?”

“Penzance General Hospital.”

“That is the normal civilian hospital, is it? Not a service hospital?”

“That’s right. They took us to the nearest one there was.”

I made another note. “Who operated on you?”

There was silence. I glanced at him; he was troubled, evidently distressed that he could not remember. I tried to help him. “Was it a civilian surgeon?”

He looked up. “It was an Army doctor, a major. I know his name quite well. I had it on the tip of my tongue to tell you, case you wanted to know. But I can’t say it now.”

“Try and think,” I said. “It’s rather important to get all the records of your case together.”

There was a long pause.

“Never mind,” I said at last. “Do you remember what he looked like?”

“Oh aye. He was a young chap with sandy hair like me, rather thin. He knew his onions all right. The sister and the matron said he made a rattling fine job of me. Well, he did, now, didn’t he?”

I smiled. “I should say so. Do you remember the date when this happened?”

“End of September 1943,” he said. “I dunno the day.”

I made another note. “That’s good enough. I can find out all I want to from the hospital.” I glanced over the notes that I had made upon my pad, and then got up. “Now will you please take off your shirt, Mr Turner, and let me have a look at you.”

He got up and took off his coat. When it came to unbuttoning his waistcoat the same functional disability of the right hand became apparent; he had to use the left. I stopped him, gave him a pencil, and told him to sign his name upon my blotting-pad, but he could do that all right. The disability seemed to be confined to certain familiar actions, such as unbuttoning his clothes or lighting the lighter. For these familiar actions he had no control over his fingers.

Apart from that, I did not find much physically wrong with him. Reflexes were normal. Blood pressure was rather higher than it should have been, but that might have been due to anything. Heart, lungs, stomach seemed to be quite all right. When I came to examine his eyes with the ophthalmoscope, however, I found the disc of the left eye to be blurred and pinkish. That was the only physical sign of real trouble that I found. On giving him an eye test I found the vision of that eye subnormal in all ways.

I let him put on his clothes, and we sat down again.

“Well, I think you’ll have to come into hospital for a few days, for examination, Mr Turner,” I said. “I want to take some X-ray pictures of your head, and we can do a lumbar puncture for pathological examination at the same time. That’s quite a simple matter.”

He said: “I’m all right, though, doctor?”

“That’s what I’m trying to find out,” I replied. I leaned towards him. “Look, Mr Turner—you know as well as I do that you aren’t quite right at present. So far the symptoms are not serious. There is the slight functional disability of your right hand, lighting the lighter and buttoning your clothes. We’ve just found that your left eye isn’t doing much to help you see; of course, you didn’t notice that. Added to that there is the giddiness and fainting, and the exhausted feeling that you get. There’s some reason for all this, you know. It may be that something under that wound of yours requires a little attention. You’ll have to come in to hospital for a week for observation.”

There was a long pause. “Okeydoke,” he said at last. “If that’s what’s got to happen, well that’s that. When would it be, doctor?”

“I’ll have to see when I can get a bed,” I said. “You’d like a private ward?”

“How much is that?”

“Six guineas.”

“I suppose so,” he said. “Be nicer if the wife comes to see me.”

I nodded. “I’ll fix it up as soon as I can,” I said. “Probably in about a fortnight. I’ll write to Dr Worth and tell him what I can arrange.”

“I’ll tell him what you said.” He stared down at his hat for a minute, and then looked up. “You’d be able to see splinters and that in the X-ray?” he said.

“Were there any splinters left in the wound?” I asked.

He said: “I think there was. I don’t think they got ’em all out. They was too deep in.”

“I see,” I said thoughtfully. “Oh yes, they’ll show all right. If any of them are giving trouble, that may show, too.”

“They wouldn’t, after all this time, would they?” he asked.

I got up and pressed the bell upon my desk. “I hope not, Mr Turner,” I said. “But that’s what we’ve got to find out.”

He went away, and in the evening I wrote to the War Office about surgeons in the Penzance neighbourhood in September 1943 who might have operated on him after that crash. In a few days they sent me an answer. At that distance of time they could not identify the surgeon, but they gave me a list of five names of RAMC officers stationed in the district at that time who were of sufficient seniority to tackle such an operation, any one of whom might have done it.

One of them, Major P. C. Hodder, struck a chord of memory. Percy Hodder had been a medical student in the London Hospital under me in 1934. I remembered him particularly because of his great interest in the brain. He had been a thin, sandy-haired young man. I turned to the Medical Directory and looked him up; he had got his FRCS in 1938. Percy Hodder was probably my man. He was now practising in Leeds.

I sat down and wrote to him.

Three days later I received an answer.

Dear Mr Hughes,

I remember the case of Captain Turner very well; I did the operation at Penzance about the time you mention. I doubt if we could locate the X-ray photographs now, and my own case records were destroyed by enemy action in London at the time of the V bombs.

So far as I can remember, I had to leave several splinters in the brain matter as the immediate operative danger to the patient in their removal seemed greater than the risk that they would create trouble later on. I am not, therefore, greatly surprised if trouble has developed.

I shall be in London on Tuesday next, and could look in to see you at your rooms in Harley Street at about five o’clock if that would be convenient for you.

Yours sincerely,

P. C. Hodder

When we met in my consulting-room he said at once: “If it’s the Captain Turner I remember, he’s had some years of useful life. I never thought he’d live to make old bones.”

I described the man to him, and his apparent injury.

“That’s him all right,” said Hodder. He thought for a minute. “So far as I remember,” he said slowly, “there were seven or eight metallic splinters or fragments in the cerebrum. I know I left three of them in, as being altogether too deep seated to be tackled. As it was, the patient very nearly died of shock; we had a great deal of trouble in saving him after the operation. I didn’t think he’d live. After that, I didn’t think he’d recover all his faculties. But he did. I saw him some months later, and he seemed to be completely normal.”

He went on to tell me in some detail where he thought the other splinters were. The more I heard of it the less I liked it. The man was older now, and less able to resist operative shock.

“Not a very good prognosis,” I said at last.

He shook his head. “I wouldn’t like to try to get those out, myself,” he said. “Would you operate, sir, in a case like that?”

I said slowly: “I doubt it. That is, assuming that the present X-ray supports your memory of where the pieces are.”

“I think you’ll find that fairly accurate,” he said. “I remember this case particularly, because of all the circumstances.”

“You mean, the crash?” I said.

He hesitated. “Well, yes, there was that. But they were prisoners awaiting court martial, in a detention ward. Did the patient tell you that?”

I said dryly: “No, he didn’t.”

He said: “Well, that’s what they were. There was an armed guard on the door of the ward.”

“He told me that he was on his way home from Algiers,” I said. It is not helpful when the patient tells you a pack of lies. It just wastes time.

“Well, that was true enough,” said Hodder. “They were sent back from Algiers. There was a load of four or five of them. This man Turner and two others were wanted for some black market racket in London, selling Army stores, I think. They were found out when they got drafted to the Med. Turner was the only one of that lot who came through the crash alive. Then there was a paratrooper up for murder in a London pub. The DAJAG sent them all back for trial in England in this Hudson, the one that got shot up and crashed.”

“Nice party,” I said. “How many of them survived the crash?”

He wrinkled his forehead in thought. “Three or four, I think, but they weren’t all my patients. They weren’t all prisoners, either. One couldn’t have been a prisoner—the second pilot, the one who crash-landed the machine. He had a broken thigh; an RAF doctor was treating him. I think he was taken in with the rest of them, and not moved when they put the guard on. I think there were four altogether. There was the pilot, and Turner, and the paratrooper, and the Negro. That’s right. Four.”

“A Negro?” I said.

He nodded. “There was an American Negro soldier in the ward, who’d cut his throat. He wasn’t one of the party from Algiers. The hospital put him in with them, in the same ward, because he had to be under guard and he was too bad to be moved.”

“What did he want to cut his throat for?”

“I forget—some civil offence or other. The American military police were chasing him. He went into an air-raid shelter and cut his throat. But he didn’t know anatomy.”

I returned to the subject in hand. “I’m taking Mr Turner into hospital for examination,” I said. We stood together for a few minutes longer, discussing what I meant to do with him and talking generally about the case. “I’ll drop you a line later on to let you know what happens,” I said finally. “But I doubt if it will be very satisfactory, from what you tell me.”

“I wouldn’t lose much sleep over that,” said Hodder. “I’ve not got a lot of use for people like Mr John Turner, myself.”

“No,” I said thoughtfully. “They make a lot of trouble and they don’t pay much dividend.”

I did not see Turner again till just before the X-ray, and then only for a few moments. I got the photographs and the reports from the pathologist and house surgeon that afternoon, and after my consultations were over for the day I sat down with the photographs at the stereoscope. As Hodder had said, there were three metallic fragments. Two were sizeable pieces not far below the dura. It might be possible to get at those if necessary, though there was the gravest danger to the patient in such an operation. The third was very small and much deeper in the cerebrum; it was surrounded by a darker infusion of the negative in the immediate vicinity. It was quite inoperable.

I sat for half an hour studying this thing and trying to think out ways and means of dealing with it. I did not want to be beaten, even in the case of Mr Turner. But presently I put the negatives and the reports back into their envelopes and said quietly to myself: “Well, that’s that.” I stubbed my cigarette out, put on my hat and coat, and went home.

I slept very badly that night. At the age of fifty-eight one does not normally lose sleep over a patient, but I lost sleep over Mr Turner. I wanted to do something for him, wanted to very badly. I had a queer inverted feeling that because this little black market racketeer was a man of no account, the case called for the very utmost limit of my skill. I put that down with diffidence because it looks absurd on paper, but that’s what kept me awake. I could not sleep for running over in my mind the possible combinations of operative and anaesthetic technique, of palliative operations and of neurological treatment. I got out of bed once and went down to my study to look up some recent German work on intracranial fibrosis; I read German rather slowly, and stayed down there for an hour. Then I went back to bed, and slept a little before dawn.

I saw Turner next morning in his ward at the hospital. I took the X-ray photographs along with me. The sister showed me in to his room; after a perfunctory examination I sent her away and sat down in the chair beside his bed.

“Well, you’ve got three metal fragments in your head still, Mr Turner,” I said. I pulled out the negatives and showed them to him; they were quite clear without the stereoscope.

“Gosh,” he said. “Is that me? I don’t half look a guy.”

“The prettiest girl doesn’t look any better, taken in this way,” I said. I picked out one of the pictures. “This one is the side view—this shows it best. These white things are the metal pieces. These two high up, there, and that one farther in.”

He was interested. “Where would they be on me, doctor?” He put his hand up to his head. “Somewhere here?”

I laid two fingers on his head. “The first two, here and here. The third one about two inches down, under here.”

I showed him the other views. He looked at them carefully and quite intelligently. “Is this third bit the same stuff as the others, doctor?” he said presently. “I mean, those two are sort of clear cut, but this one looks all fuzzy.”

I nodded. “That’s the one that’s giving you your trouble. I should say that that is fibrous matter forming round the piece of steel.”

He glanced at me quickly. “Something that oughtn’t to be there?”

“Yes,” I said. “That is my own interpretation of these photographs. To some extent it is supported by the pathological report.”

He said weakly: “Well, that’s bloody good fun.”

There was a short silence. “Would that be what makes me feel tired, doctor?” he said at last.

“I think so,” I replied. “It would account for that and for the disability of your right hand. It would account for the fits of giddiness and fainting, and for your eye trouble. In fact, it fits in with most of the symptoms that you’ve got.”

He said: “I suppose this means I’ve got to have another operation?”

I was silent for a moment. “I’m a surgeon, Mr Turner,” I said at last. “I’ve been operating all my life, and mostly on the head. What I have to tell you now is that there are limits to the things that operative technique can achieve. If you have your leg cut off in some accident, the surgeon cannot operate and give you a new, wholesome leg. In the case of the cranium there are similar limits. There are some operations that one does not usually attempt.” I paused, and looked him in the eyes. “I’ve got to tell you, Mr Turner, that I think this is one of them.”

The slight grey on his rather florid face showed that he understood me. “You mean that if you tried to get that bit out, I’d die?” he said.

I said evenly: “I’ve given this a lot of thought, Mr Turner. I have to tell you that I could not undertake such an operation with any expectation of success.” I paused. “At the same time, you must understand that that’s only my personal opinion, the personal opinion of one man. If you feel you would like to have another surgeon to examine you and study these photographs, I should be very pleased to arrange it for you, or to co-operate with anyone you choose. Because one man admits defeat, it doesn’t mean that everybody else does, you know.”

He said: “You’re the best in England on this sort of thing, aren’t you, doctor? That’s what Dr Worth told me.”

“Oh no, I’m not,” I replied. “There are other people here in London just as experienced as I am. You could see Mostyn Collis, for example.”

He said: “Well, what’s going to happen if you leave it alone, the way it is? Will it get any worse?”

I said: “It doesn’t have to get worse, but it may. I can give you certain palliative treatment that may arrest the lesion. That means it may heal up of itself and give you no further trouble.”

“Does that often happen?”

I shook my head. “Not very often, in my experience. I have known it occur, though.”

He asked: “How often?”

I thought for a moment, and then I said: “Perhaps one case in ten improves under the sort of palliative treatment that we can apply. Not more, I am afraid.”

“The other nine get worse?”

I nodded.

He whispered again: “Bloody good fun.”

There was a long silence in the little ward. A fly buzzed on the window-pane, the knob at the end of the blind cord tapped on the window, the bright sun streamed in; from below came up the noise of London traffic. I sat by his bedside waiting for him. It’s best to give the patient plenty of time, in a case like this. It’s all that one can give.

At last he said: “If it goes on getting worse, doctor, what’s it going to mean? What’s it going to be like?”

I knew that was coming, of course. I, too, had had time to think. “You say you first noticed this about six months ago,” I said. “The disability, so far, is not very great. I can’t estimate the actual rate at which it will progress, you know.”

He said impatiently: “Yes, but what do you think, doctor? I mean, I’ve had it, haven’t I?”

I said: “I should say that there might be a progressive loss of faculties, Mr Turner. You might be able to carry on your normal life for another six or eight months, but these attacks of fainting will grow more frequent. You ought not to drive a car again. Generally speaking, I think you must expect all the symptoms to increase as time goes on.”

He said quietly: “After that, I’ll die.”

“We’ve all got to do that, Mr Turner,” I replied.