Abstract
Introduction
The Conservative Party had increasingly regretted its four-year political impotence within a Coalition led by David Lloyd George (Liberal and Prime Minister) and decided to try to bring the Coalition to an end. 1 On the morning of 19 October 1922, an independent Conservative had beaten the Coalition candidate at a by-election in Newport. 1 That same morning, 273 of the 335 Conservative MPs met at the Carlton Club in London to discuss whether or not to remain in the Coalition. 2 Austen Chamberlain (Conservative and Lord Privy Seal and Leader of the House of Commons) urged them to remain, but another Conservative member of Lloyd George's Cabinet, Stanley Baldwin, the President of the Board of Trade, pressed for an end to the association with Lloyd George. He was supported by Bonar Law, the former Conservative leader; only 88 MPs wished to remain in the Coalition. 2
Churchill, a Liberal MP at that time and Secretary of State for the Dominions and Colonies in the Coalition Government, had tried a week earlier to persuade Baldwin not to turn against the Coalition. 1 He had also planned to speak at Bristol on 17 October to put the case for a Coalition election, and to defend its policies, 1 but on the morning of 16 October he felt unwell and was not able to speak at the meeting in Bristol. 3 On 18 October, Churchill underwent an appendicectomy and could take no further direct part in the developing political crisis, though he continued to issue political material. Parliament was dissolved by Royal Proclamation on 26 October 1922 and elections were fixed for 15 November 19224; Churchill announced he would stand again to retain his seat in Dundee.
We publish the first detailed account of the operation on Churchill for acute appendicitis.
Methods
The clinical notes of Sir Crisp English regarding Winston Churchill's appendicectomy are held at the Churchill Archives Centre, Churchill College, Cambridge (WCHL 6/64). Churchill's own account of events provided further details,5,6 as did those of his daughter, Mary (Lady Soames) 7 ; Sir Martin Gilbert1,2,4,8–10 and Lord Jenkins, 11 Churchill's biographers, and Sir Maurice Hankey (Secretary of the Cabinet) 12 added additional details.
16–18 October 1922: history of the illness
On the morning of 16 October, Churchill felt unwell and complained to Edward Marsh, his Private Secretary, about pains in his side. 1 That evening it was announced from the Colonial Office that Churchill was suffering from acute gastroenteritis and was strictly confined to bed. 3 In fact, he had developed acute appendicitis. Sir Crisp English also recorded a history of indigestion for ‘some time'.
Gilbert states that it was on 17 October that Churchill's doctors decided it was necessary to operate for appendicitis; 1 we consider this unlikely, as a surgical opinion was not sought on that day. In addition, Beasley (medical historian) has stated that Lord Dawson, English and Dr Hartigan had a consultation on 16 October. 13 Although these clinical records have not survived, it is far more probable that Churchill was first assessed by Hartigan, his long-standing London general practitioner, on 16 October, who kept a ‘watching brief’ and did not seek a surgical opinion until late on 18 October, and the operation did not take place until 9.45 pm on that day.
This opinion is based on the practice adopted by English of operating urgently for appendicitis. Specifically, he wrote that operation should be undertaken ‘at the very earliest moment’ in the first 24 h of diagnosis. 14 ‘Immediate operation’ should be undertaken if the diagnosis had been made 24–48 h before. 14 On the third and fourth day after the diagnosis was made, English stated the outlook was critical and that it was ‘usually safest to operate at once, but each case calls for most careful consideration’. 14
This opinion is also supported by the contents of a letter Churchill dictated on 18 October to James Allison, the acting Chairman of the Dundee Liberal Association, explaining that I cannot tell whether I shall have to be operated on or not. If I am I shall be out of the fight altogether, but will send an election address as soon as I have sufficiently recovered…I will send a fuller message when I know what the verdict of the doctors is.
1
Furthermore, in all probability, Dawson did not review Churchill until 2 November. If Dawson had been involved from the 16 October, he would have been aware of the clinical details and would not have required these to be set out in an extensive letter. Most probably this was a new referral by English who requested a second opinion from a very senior and ennobled physician because of his concern that Churchill, a well-established political figure, might not be fit enough to travel to Scotland and campaign.
At some time between 16 October and 18 October Churchill was moved from his sick bed in Sussex Square, London W2 to a nursing home in Dorset Square, London NW1, one mile away.
18 October 1922: Operation
The operation took place at the nursing home at 4 Dorset Square, Marylebone, London on 18 October 1922 at 9.45 pm. 15 English was the surgeon and he was assisted by Dr Thomas Hartigan. Dr Chaldecot (probably Dr JH Chaldecott) was the anaesthetist and he used ether administered by the open drop method. 15
A 5-inch long oblique incision was made in the skin and the muscles were split. A black gangrenous perforated appendix was identified; 15 the appendix was necrotic from its tip to the caecum. The mesentery was oedematous. 15 ‘The appendix was removed with difficulty’. 15 The wound was sewn up using 10-day Van Horn chromic catgut No. 2 with through and through sutures, and a ‘fairly large drainage tube was sown in’. 15
The Times announced on 19 October that Churchill had been operated on successfully for appendicitis the previous evening and was doing very well. 16
On 21 October, Sir Maurice Hankey (Secretary of the Cabinet) recorded in his diary, Masterton Smith [Sir James Masterton Smith, Permanent Under-Secretary of State for the Colonies], told us a characteristic story of Winston Churchill, who had been stricken down quite suddenly with appendicitis and had been operated on two days ago. On coming to from his anaesthetic he immediately cried ‘Who has got in for Newport? Give me a newspaper’. The doctor told him he could not have it and must keep quiet. Shortly after, the doctor returned and found Winston unconscious again with four or five newspapers lying on the bed. Masterson Smith was to see Winston that afternoon, and the patient insisted on seeing Lord Birkenhead [Lord High Chancellor] and others, though less than two days have elapsed since the operation.
12
Post-operative course
Two samples were sent for bacteriology on 22 October and were examined by Dr William Broughton-Alcock (practising from 20 Grosvenor Street, London and Director, Central Laboratory, Ministry of Pensions). The first sample was a serous exudate coming through the wound. A moderate number of leucocytes were present on direct microscopic examination, and only a few gram-negative cocco-bacilli and a gram-positive diplococcus (probably staphylococcus) were present. The second sample was obtained by English from the deep part of the wound using a pipette. Direct microscopic examination showed equal numbers of leucocytes and red cells. A few gram-negative cocco-bacilli and short bacilli were seen after a careful search of the film. 15 These samples confirmed that no clinically significant infection was present at the wound site.
Lord Stamfordham (Private Secretary to King Georg V) wrote to Churchill on 25 October, The King desires me to say, firstly that he trusts you are making steady progress and that you must not impede it by your natural eagerness to join the Political Fray! – and further to express his great regret that you were unable to be present here this morning to hand over your seal of office and take leave of His Majesty. The King will look forward to seeing you when you are convalescent–he will be back in London on the 2nd November.
8
Churchill, although physically weak, was not mentally inactive during his forced absence. 11 From the West End of London, he bombarded Dundee with a stream of manifestos and political essays. One was a long document of 2000 words addressed to his new chairman, Mr Robinson, which The Times published in full.11,17 The other four, of almost equal length, were entitled Winston S. Churchill: Notes for his constituents. 9
2 November 1922: review by Lord Dawson
English invited Dawson to review Churchill on the morning of 2 November.
15
In preparation for this consultation, English wrote to Dawson on 1 December as follows:
15
Tomorrow will be the sixteenth day from the date of operation. The stitches are all out; the wound is soundly healed except where the drainage tube was inserted. This too looks as if it would heal quickly but of course it may be some days before it finally closes. He was moved to Sussex Square yesterday on a stretcher by ambulance and gets into a chair for the first time today. Temperature has been subnormal for more than a week and he has had daily massage to keep his muscles fit. He is very anxious if possible to go to Dundee on Friday the 10th and from a carrying chair to address a meeting on the 11th. He does not propose to do walking of any kind and I think fully realises the importance of being careful. As soon as the election is over he would come south and by December 6 would be ready to take a long holiday. The main point of the consultation is whether or not this is practicable. I have told him that we have let him go 50% faster than the average case, mainly because he has really made a very good and quick recovery. I said that the two things we want to guard him against are, a weak scar and from getting over-tired after a serious illness, in other words, the consultation is to decide how much we may let him do without running any risks or putting too much strain on him. As a matter of fact, he has shown surprising powers of recuperation.
15
Mr Churchill's medical advisers, Lord Dawson, Sir Crisp English and Dr Hartigan, have consented to his fixing provisionally Saturday, November 11th, as the date when he can address a public meeting in Dundee. Whether in fact Mr Churchill will be able to fulfil this engagement must depend upon the progress made in the next four or five days, when a further consultation will be held.
9
On 2 November, a press statement was issued which stated that:
Mrs Churchill had gone to Dundee on 6 November to represent her husband and had taken seven-week-old daughter, Mary, with her. As Mary (Soames) later pointed out, it was hardly a cheering omen that the house where she and her mother stayed was in Dudhope Terrace. 7
Churchill also wrote to his wife on 6 November from the nursing home. Hartigan had examined their daughter, Sarah, that morning and said she had a little cold behind the nose which would naturally cause a certain irritation of the ear, and that there was no connection whatever between this and the glands [Sarah suffered from tubercular glands in her neck about this time]. Her temperature is normal and she is quite all right. We are, however, keeping her indoors for a day or two as a precautionary measure… I do hope you were not too tired by your long journey. I thought it was a great effort for you to cart yourself and your kitten [daughter, Mary] all that way last night. Jack Wodehouse [Lord Wodehouse, one of Churchill's personal private secretaries] telephoned this morning that you are all right and were addressing a meeting this evening. Do take it easy. The mere fact of your presence will I am sure be highly beneficial… The doctors were quite content this morning with my progress and seem to think there is no doubt that I shall be able to keep my engagement at Dundee.
7
11–16 November 1922: Dundee
Churchill arrived in Dundee on 11 November. He was still very weak. Churchill has described the events in Dundee. On the 21st day after my operation I addressed two great assemblies. The first, a ticket meeting, was orderly and I was able to deliver my whole argument. The evening meeting in the Drill Hall was a seething mass of eight or nine thousand people, among whom opponents greatly predominated. I was unable to stand, my wound was still open. I had to be carried in an invalid chair onto the platform and from place to place (Figure 1). There is no doubt a major operation is a shock to the system. I felt desperately weak and ill. As I was carried through the yelling crowd of Socialists at the Drill Hall to the platform, I was struck by looks of passionate hatred on the faces of some of the younger men and women. Indeed but for my helpless condition I am sure they would have attacked me…
6
Churchill campaigning in Dundee and speaking seated; Mrs Churchill is sitting next to him. © Alamy (HRAC8P).
Churchill was out of parliament for the first time in 22 years. As Churchill left Dundee by the night train, he was seen off by a crowd of friendly students. Asked to say a few words from his sleeping compartment window he told the students that ‘he had always been a Democrat, and had always believed in the right of the people to make their own institutions. He bowed to that now, even though he thought that it was misguided’. Churchill quit Dundee and was ‘carried back to a long convalescence in London and the south of France’. 4
Recovery from loss of seat and Office
On 18 November, TE Lawrence (Lawrence of Arabia) wrote to Churchill: Dear Mr Churchill This is a difficult letter to write – because it follows on many unwritten ones. First I wanted to say how sorry I was when you fell ill, and again when you had to have an operation. Then I should have written to say I was sorry when the Government resigned. I meant to write & congratulate you on getting better: but before I could do that you were in Dundee and making speeches. Lastly I should write to say that I'm sorry the poll went against you – but I want to wash out all these lost opportunities, & give you instead my hope that you will rest a little: six months perhaps. There is that book of memoirs to be made not merely worth £30,000 [approximately £1,620,000 in 2018] but of permanent value. Your life of Lord Randolph shows what you could do with memoirs. Then there is the painting to work at, but I feel you are sure to do that anyhow: but the first essential seems to me a holiday for you…
9
…It is sometimes an advantage to a statesman that he should be temporarily excluded from the House of Commons: He is missed then, as I suppose Mr Bonar Law has been missed, and I do not doubt your star will rise again and will shine even more brightly than before.
9
Churchill wrote from Cannes to English on 9 March 1923: My dear Sir Crisp English, You will be glad to hear that I am getting on very well and have experienced so far no ill effects from the wound. The indigestion has been very tiresome, but has been getting steadily better out here through strict attention to eating dry at lunch – a horrible infliction. I have been playing polo since the middle of February and derive great benefit from it. But on Thursday of last week I was forced to exert myself unduly in a match, with the result that I have had a very unpleasant recurrence of indigestion and was a good deal exhausted. It is difficult in a match to avoid sometimes being forced to make exceptional exertions. However, I am much better now and hope to be able to compete satisfactorily. Enclosed please find a cheque for your skilful services and my very best thanks are once again repeated for all the trouble and care you took in my case. Everyone seems very much astonished that I should be playing so soon after a serious operation. It is exactly 20 years this evening since I had the honour of doing the operation upon you for acute appendicitis. The notes of your case remind me of the great severity of the attack which you had and the splendid way which you defeated it. I still operate on a great many of these cases, but honestly do not meet any with the great determination which you showed. With all gratitude and good wishes.
15
It is now just 25 years ago since I operated upon you for appendicitis at 4 Dorset Square and since then I have followed up all your splendid activities with much pleasure, and send you all the best of good wishes and good luck for many more years to come. Personally, I am still ‘carrying on’ at this same address. Yours very sincerely, Crisp English PS Yesterday was 22 years since I operated upon Miss Churchill: All good wishes to her.
19
My dear Crisp English How nice of you to write to me. I have never had the slightest trouble all these twenty-five years. Of course we went over the old ground again the other day [11 June 1947] when I had my operation for hernia. The cuts are pretty well merged into one, so it looks much bigger. Thank you so much for all you say in your letter and for your kind thoughts. I do not know whether you can find the time to look through this little book of Secret Session Speeches, which I send you. They differ from ordinary speeches as they give the vitals of the story. Yours very sincerely WSC20
Churchill's doctors
Viscount Dawson of Penn (1864-1945) PC GCVO KCB KCMG
Dawson (Figure 2) qualified in medicine at the London Hospital in 1890 and was elected to its honorary staff as assistant physician in 1896; he became full physician in 1906.21 He became Physician-Extraordinary to Edward VII in 1907 and attended the King on his deathbed. George V confirmed him in his office and three years later made him a Physician-in-Ordinary. Henceforward, he was treated by the Royal Family not only as its medical adviser but as a trusted friend. He bore a heavy load of responsibility during the King's illness in 1928 (septicaemia), and in January 1936, he wrote the celebrated bulletin announcing that ‘the King's life is drawing peacefully to its close’, aided it is now known by Dawson administering morphine and cocaine. He remained at the head of the medical households of Edward VIII, George VI and of Queen Mary.
Baron Dawson of Penn. © NPG x167038.
On the outbreak of war in 1914, Dawson went out to France as consulting physician to the British Armies, with the rank of Major-General. Subsequently, he emerged as a leader of the profession. He was President of the Royal Society of Medicine (1928–1930), a member of the Medical Research Council (1931–1935), President of the British Medical Association (1932 and again in 1943) and Senior Censor and then President of the Royal College of Physicians (1931–1938).
‘Dawson understood his countrymen because he treated all men, whether dukes or dustmen, with the same sympathy and the same respect. His unselfishness and his humility are exemplified in a hundred stories of his dealings with patients of every social class’. And with his qualities of humanity, he matched, in the words of The Lancet, ‘a greatness of general ability rather than some particular excellence: in many ways, he was a shade better than the average first-class man’.
He was created CB in 1916, GCVO in 1918, KCMG in 1919, he was raised to the peerage in 1920, was awarded KCB in 1926, made a Privy Councillor in 1929 and a Viscount in 1936.
Sir Crisp English KCMG (1878–1949)
English (Figure 3) qualified from St George's Hospital, London where he was William Brown scholar.22–24 He won the Murchison scholarship of the Royal College of Physicians in 1900, the year that he qualified, and the Jacksonian prize of the Royal College of Surgeons in 1902 for his essay on ‘Fracture of the skull, its consequences immediate and remote, including pathology and treatment’. He took the FRCS in 1903 and was a Hunterian Professor in 1904, giving three lectures on ‘The after effects of head injuries’. English was elected an assistant surgeon in 1904 and surgeon at St George's in 1912.
Sir Crisp English. © Valerie Herbert.
Initially, the First World War stalled his career intentions. He served with the Royal Army Medical Corps, first as an operating surgeon in France, Italy and finally with the Salonika force in the Balkans as a consulting surgeon with the rank of Colonel. His insistence on a regimen of operating early and asepsis is credited with saving many lives. He was four times mentioned in despatches, was created CMG in 1917, and advanced to KCMG the next year for his distinguished services there.
English ‘was an extremely dexterous, careful, and conscientious surgeon. There must be thousands who can testify to his skill and kindness and his unremitting care’. 24 ‘He was a sound surgeon of wide interests, and being of handsome appearance and social and intellectual distinction he soon established himself in a very successful practice’ 22 at 82 Brook Street, London. In 1933 he led the team operating on Princess Mary, the Princess Royal, only daughter of George V, sister of George VI and aunt of Queen Elizabeth II. He operated on two other princesses that year. English was never a prolific writer, but he made several useful contributions to surgical literature and published Patients and appendicitis in 1946 25 and Diseases of the breast in 1948. 26
Dr Thomas Hartigan (1871–1941)
Hartigan studied medicine in Dublin and Newcastle and graduated from Durham University in 1893, proceeding MD in 1907. He practised in London for many years, at Gloucester Terrace. The Obituary in the British Medical Journal stated:27 With his quiet reserve, he was not an easy man to get to know, but behind this lay a fund of endearing qualities, not the least of which was his dry and never-failing sense of humour. He was the epitome of what a doctor ought to be: the kind physician with a power of imparting confidence and a sense of trust, given only to those possessed of real ability and a great human understanding. Neither rash nor too conservative in outlook in his dealings with patients, he held to the single objective of what was the very best which could be done for each one; added to this was a real kindness of heart, such as is rarely met.
Discussion
Churchill presented with pain in his side (presumably the right side) and ‘gastroenteritis’, which suggests vomiting and possibly diarrhoea. It is not surprising that Hartigan was uncertain of the diagnosis when Churchill first presented and this probably explains the delay in English being invited to operate. Once English had examined Churchill, the operation was scheduled for that night. English used a McBurney incision, which involves splitting of the three muscle layers of the abdomen rather than cutting through them vertically. The operation report has right rectus sheath crossed out, suggesting that English did consider a vertical incision until the last moment. English was frank enough to state the appendix was removed with difficulty. Ether anaesthesia does not provide good muscle relaxation, and the greater the dose administered, the greater the post-operative nausea and vomiting, though this was not a severe problem in Churchill's case.
It was customary in 1922 to keep patients in bed for several weeks after an appendicectomy, though English advocated getting patients out of bed as soon as possible. 28 Specifically, in cases without drainage, he recommended the patient be got out of bed the day after operation. 28
The wound infection rate after an open operation for a perforated appendix was very high in the pre-antibiotic era. It is a tribute to the operative technique of English that Churchill did not develop a wound infection, despite late operation and the presence of necrosis. English placed a fairly large drainage tube into the peritoneal cavity and when the wound started to ‘weep’ he did not hesitate to use a pipette to extract fluid which might have been the early stages of an abscess. However, the microbiological examination of fluid samples showed only a few organisms of a species which rarely causes infection after an appendicectomy. Moreover, the absence of a wound infection is confirmed by the letter English wrote to Dawson, which stated that the wound had healed by the 15th day, except where the drainage tube was inserted.
Churchill himself later wrote of this experience: At the crucial moment I was prostrated by a severe operation for appendicitis, and in the morning when I recovered consciousness I learned that the Lloyd George Government had resigned, that I had lost not only my appendix but my office as Secretary of State for the Dominions and Colonies, in which I conceived myself to have had some Parliamentary and administrative success.
5