Abstract
This is an article in our series on Winston Churchill's illnesses
Introduction
In the summer of 1949, Winston Churchill and his wife Clementine spent their summer holiday on the shores of Lake Garda, where they had stayed before, shortly after Churchill’s defeat in the 1945 General Election. The Churchills flew to Bergamo in a Dakota on 25 July 1949 and first stayed with their entourage in an apartment with 12 rooms, on the third floor of the new wing of Grand Hotel Gardone Riviera, Lombardy, Italy. Despite being on vacation, Churchill remained in continuous contact with London via a special phone line managed by two secretaries, Miss Marston and Miss Gemme. In addition to political work, Churchill combined ‘hours of painting with hours of writing’ his war memoirs. 1 However, as the Churchills found the temperature and humidity in Gardone unbearable, they continued their holiday at the Grand Hotel Carezza, Nova Levante, in the Dolomites which was much cooler than Gardone and had ‘more paintable scenery’. 2
On 10 August, the Churchills went to Strasbourg where Churchill was to attend the Inaugural Session of the Consultative Assembly of the Council of Europe. 1 Churchill led the Opposition section and Herbert Morrison (Deputy Prime Minister) the Government section of the British delegation at Strasbourg. The first meeting was held on 12 August 1949 and on 15 August, applauded by large crowds, Churchill received the Freedom of the City. 3 Churchill was under the impression that the public holiday was in his honour; he had not realised it was for the Feast of the Annunciation! 3
On 17 August, Churchill gave a speech (Figure 1) which Harold Macmillan
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(Minister Resident in the Mediterranean [1942–1945] and future Prime Minister) ‘ranked in its effect with those in Fulton and at Zurich’. While Mrs Churchill flew home, Churchill left Strasbourg by air the next day for Monte Carlo to continue his holiday and left Macmillan in command of the Opposition group.
Churchill speaking at the Council of Europe on 17 August 1949. © Council of Europe.
Methods
Information regarding Churchill’s illness in 1949 was available from various sources. Foremost were those of Churchill’s personal physician, Lord Moran 4 and the eminent neurologist whom Moran consulted, Dr Russell Brain. 5 By courtesy of the present Lord Moran and the Wellcome Library, we have also had access to his grandfather’s original papers regarding this illness, though permission to include information not previously in the public domain was not granted. However, the present Lord Brain (Michael Brain DM FRCP) has kindly allowed us to cite clinical details from his father’s clinical records held by the Royal College of Physicians. Gilbert, 2 Churchill’s main biographer, added further details as did Churchill’s daughter, Mary. 1 Churchill’s colleagues, including Harold Macmillan, 3 and associates such as Brig Michael Wardell, 6 also added important information.
La Capponcina at Cap d’Ail, August 1949
The Churchill party were staying at a villa owned by Lord Beaverbrook (Lord Privy Seal 1943–1945 and newspaper proprietor), La Capponcina at Cap d’Ail, across the bay from Monte Carlo. For almost a week Churchill painted, worked on revising volume 4 of his war memoirs and swam, turning somersaults in the sea to amuse Merle Oberon (actress) who was a house guest. 2
On the evening of 23 August, Churchill played cards (gin rummy) with Beaverbrook, Wardell (vice-chairman of the Beaverbrook organisation) and others. Wardell has recorded: ‘At one o’clock in the morning we stopped for soup and cigars. Presently we resumed playing.’ 6 Churchill began to lose and he moved his father’s multi-band signet ring from his right hand to his left. ‘It’s never been off my finger. I’ll change my luck.’ 6 At about two o’clock Churchill complained of cramp in his right hand, the hand from which he had removed the ring. Nonetheless, he went on playing, giving his attention to the game. 6
At the end of the game, Churchill said he had a most peculiar sensation and must go to bed. He added up the score and wrote in a clear hand an ‘I.O.U.’. Churchill and Wardell walked up the stairs and Wardell carried Churchill’s cigars. As Churchill slowly mounted the steps he paused, turned to Wardell
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and said: The dagger is pointing at me. I pray it may not strike. I want so much to be spared, at least to fight the election. I must lead the Conservatives back to victory. I know I am worth a million votes to them … Perhaps two million.
Churchill then asked Denis Kelly (a barrister who joined Churchill’s literary team, first as an archivist, then as a literary assistant) to sit with him while he took a bath. Kelly recalled to Gilbert 2 that this was the only time in 10 years he had been asked to sit with Churchill while he had a bath.
When Churchill awoke at about seven o’clock on the morning of 24 August, the cramp was still present. 2 A little later, Churchill found he could not write as well as usual. Beaverbrook summoned Dr Gibson, a local practitioner, and telephoned his son (Max Aitken) in London who arranged for Lord Moran to come out immediately.2,6
Gibson telephoned Moran (Gilbert 2 wrote that Moran was contacted by Dr Roberts but this is probably incorrect as Churchill told Brain 5 he had been seen by the local doctor ‘a Scotsman’, whereas Roberts was a Welshman 7 ). ‘I think Mr. Churchill has had a stroke. I would like you to see him as soon as you can.’ 4 Moran arrived at Nice with his golf clubs (to suggest nothing was amiss with Churchill 2 ) and was met by Beaverbrook, also Moran’s patient, and informed of the previous night’s events.
On entering his bedroom, Churchill said to Moran 4 : ‘I am glad you’ve come; I’m worried.’ Moran 4 recorded that, ‘I could find no loss of power when I examined him; his grip was strong. Later, when he squeezed paints out of their tubes, he could not do it as well as usual.’ Churchill himself was certain that his speech was not affected and Moran 4 could detect no abnormality. Moran 4 asked Churchill about his writing. Reaching for his pen, and steadying a bit of paper against a book, Churchill wrote very slowly and carefully: I am trying to do my best to make it legible. It is better than it was this morning. W. Churchill. 4 Churchill was particularly concerned about his signature. Miss Gilliatt (Personal Private Secretary) later recalled, ‘He kept on practising it, asking one again and again, is it all right?’ 2
‘What has gone wrong, Charles? Have I had a stroke?’
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Moran explained that when people speak of a stroke, they mean that an artery has burst and there has been a haemorrhage into the brain. ‘You’ve not had that. A very small clot has blocked a very small artery.’
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Churchill responded, Will I have another? There may be an election soon. An election in November is now more a probability than a possibility. I might have to take over again. It feels like being balanced between the Treasury Bench and death. But I don’t worry. Fate must take its course.
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Although Mrs Churchill was kept fully informed about her husband’s condition, she remained at home. Although anxious about his illness, she concluded that her sudden arrival would certainly have aroused suspicions that Churchill was suffering from something more than a chill, 1 which was the diagnosis announced in the press on 26 August. Even his daughter Sarah was not informed of the correct diagnosis. She wrote from New York, ‘My darling Papa, I was so terribly relieved to hear that it was only a cold and that you are alright again.’ 2
Macmillan
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recorded that on 25 August he had received the shattering news of Churchill’s illness. We got the most exaggerated stories - he had pneumonia, he had had a stroke, he was gravely ill. However, Duncan Sandys [former Member of Parliament and Churchill’s son-in-law] came in to me early in the morning, to say that he had talked with him on the phone and he seemed in good form. It seems that he has certainly got a chill, and since Moran is with him, it is probable that he will not be allowed to return here [Strasbourg] - at least for some days. Naturally the rumours spread throughout the day, and were not altogether dispelled by a reassuring bulletin.
Macmillan
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wrote, In fact, as I was afterwards to learn, Churchill had suffered from one of those minor attacks which were to threaten him for the rest of his life. This one, happily, proved slight, and by careful control of the news was effectively concealed. This indomitable old man was still destined to fight two General Elections and form another Government which was to last nearly four years. As soon as he began to recover, the telephone began to ring with increasing urgency. We sat at a balcony table overlooking the street. A French lady in full evening dress passed by, stopped, gasped and curtsied. She could not believe her eyes. Churchill bowed from his chair … I realised he intended to show the world he was fit and well and had deliberately chosen this most public yet normal way of proving it.
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Return to London, 31 August 1949
Churchill returned home on 31 August and landed at Biggin Hill. When Churchill saw all the photographers with their cameras, he was certain they would notice that something was wrong with his gait, and ‘he waved them away with an angry gesture’. 4
On 3 September, Churchill felt well enough to go to Epsom to see his racehorse Colonist II run. 2 Churchill went to 11 Downing Street on 18 September to be told by Sir Stafford Cripps of the imminent devaluation. 2 Later, Churchill told Moran 4 at Chartwell: ‘I’m not the man I was before this happened. I had to see Cripps at No. 11 about devaluation. It was an act of courtesy on his part. He was cool and debonair, but I was in a twitter.’
As a gesture of thanks to Lord Moran, Churchill now executed a second seven-year Deed of Covenant in favour of Moran’s wife, Dorothy, for £500 a year, free of tax. Churchill wrote to Moran, ‘I hope you will not forbid me to do this and I have taken the necessary steps with the Bank.’ 2
Assessment by Dr Russell Brain on 5 October 1949
Brain 5 saw Churchill at Chartwell for the first time as a patient on 5 October, though this encounter is not recorded by Moran in his published record. Moran had informed Brain 5 that some years previously while Churchill was in the United States, he had had an attack of vertigo and unsteadiness, the latter taking some weeks to settle down, and which was attributed at the time to a labyrinthine lesion. In addition, Moran described the episode of chest pain which Churchill suffered while staying in the White House in December 1941. Moran feared Churchill had suffered a coronary thrombosis, but owing to the circumstances could not get an electrocardiogram done and Churchill carried on as usual, though complaining of dyspnoea. 5 On his return to London, Churchill was assessed by Dr John Parkinson who did an electrocardiogram, ‘and refused to commit himself’ 5 (in fact, Parkinson did commit himself and did not support the diagnosis of coronary thrombosis 8 ). In the summer of 1949, before Churchill went abroad, he asked Moran to feel his pulse after bathing and Moran thought it poor volume. 5 Moran said Churchill smoked 13 cigars a day and took a fair amount of alcohol – three brandies after dinner – but was never the worse for it. 5
When Moran and Brain 5 went into the room, Churchill handed his partially smoked cigar to his valet. Brain 5 recorded that Churchill was in his bed, which carried a shelf full of proofs, which he was correcting. On his left was a double-decker locker on which, among other things, stood a whisky and soda, while on the floor nearby was a white enamel bucket into which he shook his cigar ash. 5 Churchill was wearing a dark red and gold bed jacket and a night shirt which reached just below his waist and had a division down the middle behind because, as he explained to Brain, he wrote a good deal in bed.
Churchill began by saying: ‘You reconnoitre first, and then we’ll have the history of the campaign’, by which he meant that he wanted Brain to examine him before he gave his history. However, as this was bad medicine, Brain explained to Churchill that he must have the history first. Churchill reported that on 28 August (in fact it was 23/24 August), he had been bathing and painting during the day and was sitting up at 2 a.m. playing gin rummy. Suddenly, he felt his right leg go numb to above the hip, and also in the region of the shoulder, and when he tried to write down the score, he could not write properly. The next morning Churchill’s leg was still numb and he sent for the local doctor, a Scotsman (Dr Gibson). Moran arrived at 11 a.m. Churchill explained that it was thought his speech was a little affected, but Churchill claimed it was very slight, ‘as if I was between asleep and awake’. (At the time, Churchill himself was certain that his speech was not affected and Moran 4 could detect no abnormality.)
Churchill said there was a sensation like lumps in the upper part of the right thigh, but nothing to be seen. Churchill’s writing difficulty (which Brain recorded as being motor in origin) lasted three days and he had slight difficulty in walking. He was still unsteady on reaching England, but not now. He still got an occasional tight feeling in the right leg, right shoulder and the right side of the back near the spine. ‘Occasionally I get the twitters - a momentary feeling of giddiness.’
Brain’s examination revealed that speech and articulation were normal. The optic discs were normal, but there was some retinal arteriosclerosis. Pupils and ocular movements were normal and the visual fields were full. The remaining cranial nerves were normal. There was no weakness or ataxia of the limbs; the tendon reflexes were present and equal but the ankle jerks were a bit sluggish. The right plantar reflex was recorded as ‘? extensor’ in Brain’s original note, the left was flexor. To demonstrate something, Churchill made Brain sit on his bed while he pressed on Brain’s back. ‘It was like the hug of a bear!’ The abdominal reflexes were absent. There was no cutaneous anaesthesia. Pin prick was felt slightly less acutely on the right forearm than on the left. There was no postural loss. Vibration felt less acute on the right shin than on the left. Romberg’s sign was negative and the gait normal. There were frequent extrasystoles and the blood pressure was 160/90. 5 Brain 5 recorded that Churchill looked little more than 60 at 74.
Brain explained to Churchill that his symptoms were due to a temporary impairment of the circulation through a part of his brain. Churchill’s response, ‘I may be worth a million votes to the party. I must warn you that whatever advice you give me, I mean to go on. I am not afraid to die.’ 5 Churchill then began to wander around in his little bed jacket and night shirt, bare from the middle thighs downwards. 5 ‘You must see me walk’. 5 Churchill then did a kind of goose step and stood still with his eyes closed to show how steady he was. Churchill insisted on Moran and Brain 5 having a drink. ‘I diagnose that you would like some sherry!’ Moran, however, was anxious to get away as the Duke and Duchess of Westminster were coming to dinner and it was essential for political reasons that no one should know that Brain had seen Churchill. Moran and Brain 5 drank a hasty glass of sherry and left Churchill splashing in his bath.
Churchill was well enough by the middle of October to make two substantial speeches in London. The first to the Conservative Trades Union Congress was on 13 October, the second on the 14 October was to the Conservative Annual Conference.
Assessment by Brain on 15 October 1949
Brain 5 assessed Churchill again ‘… and there was no substantial change in his condition’. When Brain 5 told Churchill that the postponement of the election would give him four months respite, Churchill responded: ‘Yes, but in four months’ time, I shall be four months older. That I think is incontestable.’
On 20 October, Churchill gave the Chancellor’s address at the University of Bristol’s annual honorary degree-giving ceremony and on the following day spoke to several thousand veterans at the fourth Alamein Reunion (‘Up till Alamein we survived. After Alamein we conquered’). 2
Assessment by Brain on 8 December 1949
Brain
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assessed Churchill again at Hyde Park Gate. Churchill was in bed with his cigar and whisky and soda. He described his symptoms as follows: It is a quiet and agreeable, warm, india-rubbery, velvet feeling in the right groin and a stiffness around the shoulder. The first sensation was a lump which did not exist. There is no pain and no disability. It is like a sheet of warm material one-sixteenth of an inch thick and one inch from the surface, spread out over it.
5
On 29 December 1949, Churchill flew to Madeira for a working holiday with his wife, daughter Diana, literary assistant Bill Deakin, and personal secretaries Miss Sturdee and Miss Gilliatt. 9 The party stayed at Reid’s Hotel and were surrounded by Churchill’s war memoir materials. Churchill had intended to stay in Madeira for several weeks but, while he was away, Clement Attlee (Prime Minister) announced that a General Election would be held on 23 February 1950. Churchill flew back to London on 12 January 1950 to commence electioneering. 9
Churchill’s doctors
Lord Moran (1882–1977)
Charles Wilson (Figure 2) was appointed Dean of St Mary’s Medical School in 1920, a post he held until 1945. He became Churchill’s doctor on 24 May 1940 (two weeks into Churchill’s first term as Prime Minister) and remained his personal physician until Churchill’s death in 1965.
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He accompanied Churchill on a number of overseas trips. For example, he treated Churchill for chest pain in December 1941 in Washington,
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for pneumonia in London in February 1943 (after Churchill had returned from a trip to Casablanca),
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for pneumonia and atrial fibrillation in Carthage in December 1943,
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and for pneumonia in London in August 1944 (following a visit to Italy).
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Lord Moran. © Yousuf Karsh, Camera Press, London.
Wilson was knighted in 1938, created Baron Moran of Manton in the County of Wiltshire in 1943, and was appointed Treasurer (1938–1941) then President of the Royal College of Physicians of London (1941–1950). 10
Dr Russell Brain (1895–1966)
Russell Brain (Figure 3) was a consultant physician at the (then) London Hospital and the Maida Vale Hospital for Nervous Diseases. Brain
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earned his living primarily from his private practice in Harley Street as a consultant neurologist, and, latterly and more significantly, as the author of Diseases of the Nervous System, Clinical Neurology, and other medical and non-medical books. He was the editor of the neurological journal, Brain, from 1954 until his death in December 1966.
Dr Russell Brain. © NPG 164681.
Brain was President of the Royal College of Physicians from 1950 to 1957, succeeding Moran on 3 April 1950.13,14 As his successor Sir Robert Platt (later Lord Platt) wrote, To some of us Russell Brain before 1950 was the writer of a textbook (a very good one), we had not seen him as a leader of the profession; but fortunately for the College there was a substantial body of Fellows who knew better … so he was elected to the presidency without serious opposition. To those who had previously been ignorant, he at once showed his true qualities. Amongst these I would put very high his amazing (intuitive it almost seemed) grasp of a situation and of the possible consequences of action, and his calm and outwardly unruffled self-confidence which carried such conviction without any show of omnipotence, that you were persuaded that he knew best...
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Dr Herbert Robert Burnett Gibson (1885–1967)
Dr Gibson joined the Indian Medical Service as a Lieutenant in 1909 aged 24 years. 7 His subsequent hospital ship experience gained him MD (Honours) from Edinburgh University for his thesis Military Hospital Ships. 7 He retired from military service with the rank of Lt Col in 1926 and initially divided his time between the Winter Palace, Monaco (winter) and 18 Harley Street, London (summer), before devoting his whole time to his Winter Palace practice. 7 At the outbreak of WWII, he rejoined the military (aged 55 years) as commanding officer of HMHS Tairea. Gibson received five medals for his service and retired to Monaco once more to resume his practice at the Winter Palace among a predominantly elderly population. 7 He submitted letters to the British Medical Journal until 1965. 7
Discussion
There is no doubt that Churchill suffered a stroke in August 1949, at the age of 74. Brain found a mild neurological deficit when he first examined Churchill in October that year, some seven weeks after the onset of symptoms. The abnormal signs were subtle and almost exclusively sensory, comprising disturbance of some primary modalities of sensation on the right side. However, the right plantar reflex was equivocal, the only sign of pyramidal tract involvement. There is no good evidence of speech involvement, and the contemporaneous remarks concerning Churchill’s speech, quoting his exact words, indicate no impairment of his extraordinary linguistic ability and his characteristically pithy and witty powers of expression.
From the descriptions recorded by witnesses to the event and by Churchill himself, he experienced transient mild impairment of his ability to write. This seems to have been a problem of legibility, rather than a specific dysphasic–dysgraphic deficit. Brain did not record any deficits of cortical sensory function, but by that time, seven weeks after the onset of the stroke, Churchill’s sensory symptoms were minimal and intermittent.
Churchill’s transient writing difficulty was interpreted by Brain as being of motor origin, and Brain’s original note, verbatim, states that ‘Writing difficulty which was “motor” lasted three days only’. He probably reached this conclusion because of the finding of an equivocal right plantar response, indicating involvement of the corticospinal tract. However, Churchill’s prominent sensory symptoms clearly indicate thalamic involvement, and it is most likely that the lesion affected the ventral posterior sensory nucleus of the thalamus and the adjacent posterior limb of the internal capsule (a thalamocapsular infarct).
The onset and progression of the symptoms over several hours is now considered to be typical of small vessel occlusion, possible mechanisms including haemodynamic factors, propagation of thrombosis, excitotoxicity, inflammation or conduction block. A small haemorrhagic stroke cannot be entirely excluded, and a small deep haemorrhage may exactly mimic a lacunar infarct due to vessel occlusion. Could hypertension have been a factor? Sir John Parkinson recorded Churchill’s blood pressure on four occasions prior to this stroke: 160/85 mmHg (6 February 1942), 140/80 mmHg (3 June 1947), 150/90 mmHg (20 October 1947), 145/90 mmHg (26 May 1949). The blood pressure of 160/90 mmHg, recorded seven weeks after the onset of the stroke by Brain, would have been regarded at the time as borderline normal for a man aged 74 years, though now would be considered to be high. This and Churchill’s steady alcohol intake were risk factors for either occlusion or haemorrhage. He was in sinus rhythm, with frequent extrasystoles, but crucially, the cardiac rhythm was not atrial fibrillation (though Churchill had suffered two episodes of atrial fibrillation in December 1943 when being treated for pneumonia 12 ), so a cardiac embolus is unlikely. Finally, it is worth reflecting that the early days of computed tomography were still some 20 years ahead, and even then, in the early days of computed tomography scanning, resolution would quite possibly have missed a small capsular lesion.
One might wonder why Brain was invited by Moran to see Churchill only at such a long interval following the onset of the stroke (about seven weeks). However, when viewed in the context of the limited approach to investigation of stroke possible at the time, and the largely expectant management, taken together with the rapid improvement of Churchill’s mild symptoms, this is explicable.
In the light of later neurological events, it is relevant to consider whether there might have been any abnormal emotional or behavioural change at the time of this apparently first stroke, which might indicate the presence of more widespread cerebrovascular disease already at that time. It is clear from the descriptions of Brain and the non-medical witnesses to the event that Churchill’s command of language, his unconventional dress and his long-standing habits were unchanged. His colourful description of his symptoms matched his characteristic linguistic command and expressive succinctness. His request of Brain to ‘… reconnoitre first, and then we’ll have the history of the campaign’ supports this and also reveals that he wished to remain in complete control even at a time of serious personal vulnerability.
The visits of Brain to Churchill on 5 and 15 October and 8 December 1949 are not mentioned by Moran
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in his book Winston Churchill, the Struggle for Survival, which records Brain’s first consultation as taking place on 25 May 1950. Brain
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received a pre-publication copy of Moran’s book which was inscribed ‘Russell from Charles, April 29 1966’. Brain
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was upset that he had been quoted without his knowledge and permission, and was offended by the two comments made about his seeming failure to communicate adequately with Churchill. Brain is not good at patter. He did not seem to discern that the P.M. was seeking reassurance.
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Russell listened attentively to Winston’s story, but offered no comment. Winston waited impatiently for suggestions, but they did not come. He had told Brain the whole story that he might get his help. He wanted to be told that his mind was not giving way. He wanted to do something. “No,” Brain said shortly, “there is nothing I can add to the treatment.” Brain is an honest man, he has no patter.
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On 9 May 1966, Brain
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wrote a letter to The Times which was published the following day. After acknowledging that Moran had sent him a copy of the book, he went on to say: Since Lord Moran has already alluded to me in one of the published extracts, I must point out that these confidential matters have been published without my knowledge. To put matters in perspective, my notes show that I was first asked by Lord Moran to see Sir Winston in October, 1949, and that I saw him on 20 occasions, the last being during his final illness. Sometimes for various reasons I saw him alone, once, at least, at his request. During these 15 years I came to know him well, and I cannot accept the accuracy of all that Lord Moran says about the consultations which he reports … I hope that this unhappy controversy will not be allowed to obscure Lord Moran’s great services to Sir Winston. Over the years I saw his devotion at first hand, and I know that it was given at great personal sacrifice …