Abstract
This article is in our series on Winston Churchill's illnesses
Introduction
The Churchills had been out to dinner with Lord and Lady Salisbury on the night of 15 November, returning to Hyde Park Gate at about midnight. 1
Before retiring, Churchill went into his wife's room to say goodnight, leaving Howells outside the bedroom door, who recalled more than a decade later: ‘I heard a thud and Lady Churchill called out: “Howells, come quickly!” I ran in and found Sir Winston lying near the wardrobe in Lady Churchill's dressing room which led off the bedroom’. 1 Apparently, having kissed his wife goodnight, Churchill had half-turned to tell her something as he was going out of the door, lost his balance and fell against the side of the wardrobe. 1 The corner caught him between the shoulder blades. 1 At that time, Churchill relied heavily on a walking stick 1 following the effects of a stroke in 1953,2,3 and he had a habit of pivoting on his left foot which meant that sometimes he was caught off balance. 1 Although Churchill was warned on many occasions that this was an unwise thing to do, ‘with usual Churchillian pugnacity he paid little attention to medical advice’. 1
With extensive use of the medical and nursing records, which have not been published previously, we review Churchill's fall in November 1960, his subsequent stroke and his recovery punctuated by possible drug-exacerbated confusion.
Methods
Information regarding Churchill's fall in November 1960 was available from various sources. Foremost were the medical records of Professor Herbert Seddon held by the Library of the Royal College of Surgeons 4 and the nursing records held by the Churchill Archives Centre, Churchill College, Cambridge. 5 Sir Russell Brain Bt recorded some relevant information in 1961. 6 Ronald (Roy) Howells (Churchill's personal nurse) added further details, 1 as did Sir Martin Gilbert (Churchill's main biographer). 7 Lord Moran, Churchill's personal physician, did not record the accident in the first edition of his book, 8 though it is mentioned in the second edition. 9
16 November 1960
Following the fall, Churchill lay on the carpet in great pain. Howells made him comfortable and wrote that he phoned Lord Moran (Figure 1), though Moran claimed he was contacted by Lady Churchill (see below).
9
While Moran was on his way, Howells checked to make sure no limb was broken, then fetched the policeman (Constable Clarke
10
) on duty outside the house to help roll Sir Winston on to a rug. Using this as an improvised stretcher, Howells and the policeman carried him to his bed. The policeman was called in because at that time there was no butler in the household and the only other person in the house was Lady Churchill's maid.
1
Lord Moran arriving with a present for Sir Winston Churchill's birthday © Alamy (E0W132).
Moran recorded that he had been telephoned by Lady Churchill ‘about Midnight’ on the 12 November 1960. 9 This is incorrect; it was the night of 15–16 November 1960. Lady Churchill explained that ‘Winston had come to her room to say Goodnight. He had kissed her, when stepping back he lost his footing and fell backwards; his head struck the wall, and then he fell heavily to the ground’. 9 Moran explained that when he got to the house: ‘Howells said that he found Sir Winston lying on the floor; he looked like marble; he had no pulse; he thought he was dead’. 9
According to Howells, Moran arrived and put Sir Winston under ‘light sedation’. 1 Churchill then spent ‘a fitful night’ with Moran sleeping in the room above. 1 Howells recalls that Churchill was in such pain that his physician could not carry out a proper examination until the next morning. 1 However, Moran noted that Churchill ‘seemed to understand what I said and there were no signs of shock. I decided to stay with him for the night’. 9
Moran invited the opinion of Professor Herbert Seddon (Figure 2), Clinical Director of the Royal National Orthopaedic Hospital.
9
Seddon arrived at Hyde Park Gate at 11.45 a.m. and found Churchill propped up in bed and very comfortable: There was a small swelling on the back of his head but nothing else. A little tenderness at the upper part of the thoracic spine but no other abnormality either there or elsewhere. I telephoned Campbell Golding who told me that x-rays of the upper thoracic spine taken with a portable machine would be useless. We would have to go to his consulting room. Trying to wrap up Sir Winston produced such violent pain in the upper thoracic spine that we had a bit of a game getting him down the stairs and into the ambulance.
4
Professor Herbert Seddon CMG ©NPG (185200). Dr Frederick Campbell Golding.
Seddon recorded I held Sir Winston's head firmly during the journey, but he still had a good deal of pain. Golding took x-rays of the thoracic spine and of the pelvis, and we found a crush fracture with no displacement of T5. I would have liked pictures of the cervical spine too, but Golding said that it would be necessary for him to sit on a stool; this was out of the question because it would have hurt him so much. Anyway there was nothing to suggest a fracture in the neck. Lord Moran and I agreed to nurse him at home with day and night nurses from St Marys Hospital.
4
The formal report by Golding stated: There is a wedge deformity of the body of thoracic V, and there is a minor deformity of the disc plates of thoracic VIII and IX. There is some osteoporosis of all the vertebrae. I have no sure way of telling whether these changes are recent or old. In the lateral film one can imagine that the condition has been present for some time, but in the antero-posterior film the deformity of thoracic V looks more recent. There is a little lipping of all the vertebral margins and some narrowing of the disc of thoracic XI – XII. The film of the pelvis shows some degenerative changes in the lower lumbar vertebrae, but none in the hip joints. There is no evidence of an injury. There are arterial changes in several regions.
4
… that we should probably make an earnest effort to get lateral films of his cervical spine, if there is any clinical indication injury in this region. One could hardly do this lying down since he has a short neck and high shoulders.
4
We must not talk about a fracture of the spine because this conjures up the idea of permanent paralysis in the lay mind. Sir Winston has a fracture (of the 5th thoracic vertebrae) but it is not a serious or disabling affair and there is no paralysis. If pressed we may honestly add, there is no cause for anxiety.
11
Moran wrote: When a man is in his eighty-seventh year and fractures his spine anything may happen, but in the bulletin we were content to record that Sir Winston had fallen and broken a small bone in his back. Seddon's sound judgement and good sense are a great comfort. I do like a man who knows his job.
9
He is in bed and must remain lying on his back for the present. Professor HJ Seddon…said last night: ‘He will be in bed a little while, but it is nothing serious’. …It was learnt last night that he [Churchill] is in some discomfort and the only easy position for him is on his back in bed. Lady Churchill was with him, and he was said to be ‘quite cheerful’. Sir Winston's secretary said that there was no cause for anxiety.
13
17 November 1960
The nursing records state that Churchill was ‘awake at 9.15 a.m. Very difficult’.
5
Seddon recorded that Churchill had been fairly comfortable sleeping on his back but Lord Moran told me that this position would almost certainly be fatal; his chronic bronchitis made his chest like a musical box. He must be sat well up. So I ordered a hospital bed that we could crank up. It was higher and narrower than his own bed and Churchill did not take kindly to it at all, grumbling incessantly about the discomfort it caused.
4
later in the day [3.00 p.m.] Philip Yeoman [Senior Registrar] and I – purposely avoiding saying to Sir Winston what we had in mind – lifted him smartly into the sitting position and moved him to the new bed. The patient expressed his views about this in the strongest possible terms, ending with a growl ‘Narrow bed – narrow minds’. We could not have avoided hurting him, but the pain soon subsided and we never had another cross word.
4
After seeing Churchill on 17 November, Moran told The Times ‘Things are going very well’. 14 A bulletin stated that ‘Sir Winston had a very good night and is resting in bed’. 15
Churchill received many telegrams and cables as soon as news of the accident became known. Her Majesty the Queen sent a telegram to Churchill: ‘I am so sorry to hear about your accident and send you my best wishes for a speedy recovery. Elizabeth R’ 16 Churchill replied by return: ‘I am most grateful to Your Majesty for your very kind message. Winston S. Churchill’
President Eisenhower cabled Churchill: Dear Winston All the people in America are distressed to learn of your accident none more so than I. I do trust that the whole business is not too painful and while I know you will not enjoy the enforced period in bed. I hope you will do exactly what the doctors say. Do take care of yourself. Mamie joins me in affectionate regard to Clemmie and yourself. As ever IKE
17
The nursing records state that a codeine compound tablet (codeine phosphate 8 mg, aspirin 260 mg, phenacetin 260 mg) and a Disprin™ tablet (soluble aspirin 300 mg) were given at 10 p.m. Churchill slept from 10.15 p.m. until 12.50 a.m.
18 November 1960
Churchill slept again from 1.00 a.m. to 5.15 a.m. when he awoke complaining of pain in his right shoulder radiating to the sternum. 5 ‘Sir Winston was extremely apprehensive-colour good with pulse volume quite good-perspired freely’. 5 A codeine compound tablet was given at 5.15 a.m. and repeated at 5.30 a.m. 5 Seddon was informed at 5.55 a.m. and told nursing staff: ‘Will visit later to examine and decide whether the pain is from fracture, right shoulder or chest infection’. 5
Churchill slept for short periods from 6.00 a.m. to 10.00 a.m. 5 Churchill was examined by Yeoman at 10.00 a.m. The day nursing records state that Churchill was still complaining of some pain in the left (not right) shoulder extending down the left arm. 5 Breathing exercises and leg massage were carried out by Miss Martin-Jones, the physiotherapist. 5 ‘Patient not unduly distressed during treatment but very drowsy after. Slept for three-quarters of an hour’. 5
When Moran saw Churchill, he recommended that the physiotherapist should concentrate on deep breathing exercises rather than leg massage. 5 The shoulder pain was still present at 6.00 p.m. when it was observed that Churchill was ‘slightly cyanosed around the lips. Breathless on slightest exertion’. 5 At 7.00 p.m., the nursing records state: ‘Pulse irregular at times. Volume varies’. 5
Seddon wrote A very busy day starting with a telephone call at 6 a.m. to the effect that Sir Winston had wakened with pain in the right shoulder radiating to the sternum. One or other of us made visits during the day, and the last one was by Lord Moran, John Richardson (Figure 4) and myself at 8.45 p.m.
4
Sir John Richardson© Sybil Richardson by kind permission of Anne Stafford and Clare Wales. Richardson did an ECG. Fortunately, he had one that had been made in June. He found no change at all and the physicians concluded there had been no serious cardiac episode during the night. However, the patient was still bothered by pain in the neck and in both shoulders. I knew he had dislocated the right one when he was young, and it would not abduct beyond 90°.
4
Lord Moran, John Richardson and I found ourselves standing in a row before Sir Winston, telling him what we had found. His little budgerigar was flitting about the room and settled on Lord Moran's shoulder, then he moved on to John Richardson and looked as though he was going to peck his ear. So I put out my finger, and the little bird hopped onto it. So I stood there with my index finger as a perch looking pretty silly. Winston chuckled so much that I don't think he paid any attention to what the physicians said.
4
Richardson also recalls another earlier consultation at Chartwell: Winston did not wish to see any doctor and did not say a word to me except in answer to direct questions during my whole detailed examination including of course his electrocardiogram. I packed up and walked to the door in silence. ‘Aren't you going to tell me what you think Sir John’. ‘No Sir, I'll tell Lord Moran’, 'Well, I'm very much obliged to you' was said with a wicked smile and I was across the room and on a stool at his feet in seconds, telling him. I saw him quite often after that, including one long night at Hyde Park Gate, and he was always grateful and courteous, but I was rather pleased at having experienced his wrath and to have survived.
19
Today's bulletin stated that Churchill ‘has had a rather disturbed night, but his spinal injury is progressing satisfactorily and is giving no anxiety’.
21
The Times reported that Churchill's daughter, Mary (Soames) had travelled from Scotland overnight. She spent nearly two hours with her father. ‘He is bored with being in bed, but he seems fine and in good spirits. There is no cause for worry…now he is quite well. He was able to eat his lunch’.
22
19 November 1960
Immenoctal (quinalbarbital; secobarbital) 100 mg was ordered and given at 1.45 a.m. 5 Churchill slept for short periods until 2.50 a.m. 5 Then he became ‘extremely restless and confused. Continuously trying to get out of bed. Restrained with some difficulty. Refused to have TPR taken and was altogether uncooperative. Eventually went to sleep at 4.30 a.m. Slept well since’. ‘Intake [presumably over the previous 24 hours]: Champagne 8 oz, coffee 3 oz, soup 9 oz, brandy 1 oz and sips of water’. 5
Churchill was seen and assessed by Moran and Seddon. Today's bulletin stated: ‘Sir Winston did not have a very good night but the pain of his injury is less’. 23
The nursing records state that Churchill's temperature was 98.0°F (36.7℃) at 1.00 p.m. and that at 2.45 p.m. he was sponged and his pressure areas received attention. 5 ‘Patient objected most violently to being moved and washed. Settled down eventually. Complaining of ? severe pain in left shoulder at 4.00 p.m.’. 5 Churchill was stated to be ‘rather quiet this evening though not complaining of any pain’. 5 A codeine compound tablet was given at 10.15 p.m. ‘Churchill slept from 10.30 p.m. until 1.45 a.m’. 5
20 November 1960
Churchill was awake from 1.45 a.m. to 4.20 a.m. 5 ‘Confused but quiet and resting well’. 5 ‘Sir Winston has a rash over right hip and upper right leg. The spots are small and red almost “pinhead” in type. Sir Winston denies they are irritating but has been seen to scratch them’. 5 Calamine lotion was applied, and Churchill was said to be very cooperative by his nurses.4,5 Churchill had his usual breakfast of coffee, fruit and orange juice at 9.30 a.m. 5 Yeoman reviewed Churchill at 10.15 a.m., and the patient ate a small lunch after sleeping from 12.00 mid-day until 1.00 p.m. after physiotherapy. 5
Today's bulletin stated: ‘Sir Winston had a better night and his condition continues to improve’. 24
Churchill was reviewed by Moran at 3.00 p.m. and recommended a codeine compound tablet as night sedation. 5 The nurses recorded that Churchill was able ‘to move around very well in bed. Able to turn his head without pain’. 5 Although Churchill was given a codeine compound tablet at 10.30 p.m., quinalbarbital 100 mg was also administered at 2.15 a.m. despite Moran's earlier stipulation.
21 November 1960
Churchill slept until 6.10 a.m. Nursing staff observed that Churchill was ‘mentally extremely confused at times. Extremely difficult’. Calamine lotion was applied to the rash, and cortisporin™ (neomycin, bacitracin, polymyxin B and hydrocortisone) ointment was applied for anal irritation. 5 At 9 a.m., Moran telephoned Seddon to say that Churchill had had a disturbed night with some mental confusion and had had angry words with Howells. 4
Howells later wrote, probably about this incident: On one occasion I remember we had a blazing row over the bed rest and I'm afraid we swore at each other. Afterwards we made it up. Sir Winston, his bottom lip jotting, said: ‘You were very rude to me, you know.’ I told him, ‘Yes but you were rude too.’ Then with just a hint of a smile, he looked up and said blandly, ‘Yes, but I am a great man.’ There was no answer to that. He knew, as I and the rest of the world knew, that he was right.
1
Moran also recorded the same incident (though he dated it 17 November 1960): Last night he shouted at Howells till at last the poor man's patience gave out and he answered back. This morning Winston told me that Howells was mad; he would have to leave. I asked Howells what Winston had said. ‘Oh, he just shouted abuse at me. You see, sir, even when Sir Winston is well he never says anything to me, unless, of course, he has to ask me for something.’
9
During the morning, Churchill announced to his nurses that ‘He would be getting up this afternoon!! Seems quite happy at the prospect’. 5
Seddon and Moran both visited Churchill today.
5
Seddon recorded: At 3:30 p.m. two nurses got Churchill into a chair without any difficulty, and he took three steps himself. He remained up for 12 minutes, perfectly comfortably, but his head slumped forward, and he seemed afraid to hold it straight. Pulse rate not increased.
4
The nurses recorded that Churchill was ‘very cooperative – able to get out of bed with very little assistance’. 5 Churchill subsequently complained of some pain in the left shoulder after being moved, but the pain did not appear to be very severe and soon subsided. 5 Churchill slept from 5.00 p.m. to 6.30 p.m., but was ‘rather cross on awaking’. 5
Moran told reporters, ‘There is not going to be a bulletin today. The position is the same as before – there is nothing to add. No news is good news’. 25
Churchill finished dinner at 9.00 p.m. and his son-in-law, Christopher Soames, visited until 10.30 p.m. 5
Quinalbarbital 100 mg was given at 10:45 p.m. and repeated at 2.50 a.m. Soluble aspirin 300 mg was given at 1.40 a.m. 5
22 November 1960
Churchill was observed to be very confused in the early hours of the morning. ‘His facial expression showed distress, cause not known. Pulse 100/min’. 5 At 2.50 a.m., Moran was informed of his patient's condition. 5 Quinalbarbital 100 mg was ordered at 3.00 a.m. and Churchill slept from 3.45 a.m. to 7.00 a.m. 5 He settled quickly again and was still sleeping at 2.00 p.m., so was awakened. 5 Moran telephoned at 8.00 a.m. and told the nurses he would review the question of night sedation later. 5
At 3.00 p.m., Churchill was observed by the nurses to be ‘very cooperative and cheerful. Sitting up in bed reading newspapers’. 5 Churchill was seen by Yeoman at 3.15 p.m., by Moran at 3.30 p.m. and by Seddon at 6.30 p.m. Moran decided that quinalbarbital 100 mg could be given on ‘settling’ and that the barbiturate could be repeated three hours later if necessary. Soluble aspirin 300 mg could also be given between the doses of quinalbarbital. 5
Churchill was helped out of bed and sat in the chair from 4.10 p.m. to 5.10 p.m. 5 ‘Not complaining unduly of any pain…Would not use the electric shaver himself’. 5 Churchill was able to walk the short distance from chair to bed. 5
Seddon examined Churchill at 6.30 p.m. He put Churchill's ‘neck through a full range of movements with no difficulty and no discomfort. Sir Winston was most cooperative’. 5
At 7.00 p.m. Churchill was visited by his dermatologist Dr RMB MacKenna (Consultant, St Bartholomew's Hospital, London) who recommended that Churchill's usual prescriptions (‘lotions and ointments’) for his skin diseases should be continued. 5 Following this assessment, Churchill ‘decided to have a wash and clean his teeth!’ 5 His ablutions were followed by a four-course dinner! 5
The Times reported that Churchill had got up for a time yesterday sitting in a chair…Earlier yesterday Mrs Duncan Sandys [Churchill's daughter, Diana], had said he was getting better all the time. He is sitting up in bed and keeping very cheerful…Lord Moran said 'The position is the same as before-there is nothing to add. No news is good news.
25
Later that night, Churchill had ‘complained of pain in the left shoulder and arms with numbness in the left thumb which was painful on movement’. 5 The pain had developed immediately after Churchill's position had been changed. 5 Churchill later said his thumb had been numb for some days. 5 Nursing staff thought there was some diminished use in his left hand. 5
Churchill was given soluble aspirin 300 mg at 10.15 p.m. and quinalbarbital 100 mg at 10.35 p.m. and though he ‘settled down’ he did not sleep. 5 A further tablet of quinalbarbital 100 mg was given at 2.15 a.m. 5
23 November 1960
Overnight, Churchill was ‘restless and confused at times’. 5 However, by 12.45 p.m., he was sitting up and reading newspapers and was most cooperative. 5 Moran assessed Churchill at 12.55 p.m. He recommended that one tablet of quinalbarbital (presumably 100 mg) should be given initially followed by a quarter tablet (presumably 25 mg), then a further quarter if required. Churchill then ‘ate a good lunch’.
At 1.45 p.m., Moran telephoned Seddon to say that Churchill had complained of a little loss of sensitivity over the left thumb and that he had found the left grip weak. This suggested to Moran a mild hemiplegia. 4 Churchill walked to the bathroom with assistance. Appeared to ‘drag’ his left foot more than usual…walked back to his chair and remained out of bed until 4.35 p.m. 4
Seddon reviewed Churchill himself at 3.45 p.m.
4
Patient sitting comfortably in his chair, holding his head well up, but apathetic and mis-communicative. Upper limbs: cannot raise left more than 90 ° (full active movement on 18 November 1960), grip about one-third of that on the right and the hand lay on his lap in the pen holding position.
The biceps jerks were brisk bilaterally, the triceps jerk was brisk on the left but absent on the right and the supinator jerk was brisk on the right but absent on the left. There was no spasticity and cutaneous sensation in the left forearm and hand was normal. ‘The nurses had noticed he had dragged his left foot. Some drooping of the left corner of mouth and sagging of the naso-labial fold but no demonstrable weakness of the facial muscles’. 4
Moran reviewed his patient again at 4.15 p.m. and encouraged frequent head and shoulder movements. 5 Although Churchill was tired in the evening, he ate a fairly good dinner. 5
At 10 p.m., it was recorded that Churchill's ‘left arm was still painful. Unable to apply very much pressure with left hand’. 5 Later in the night, the nursing notes stated: ‘Left arm painful, some loss of movement/poor grip. Quiet and cooperative, rather confused’. 5
Quinalbarbital 100 mg was administered at 10.30 p.m., but Churchill remained restless until 1.00 a.m. 5
The Times reported that Lord Moran had stated that Churchill is ‘going on all right’. 26
24 November 1960
Further sedation was declined by Churchill, but he slept from 1.00 a.m. to 4.00 a.m. 5 Thereafter, he slept intermittently until 9.00 a.m. ‘Rather cross and uncooperative during bed changing’, 5 the nursing staff stated. Seddon recorded during his assessment at 10.00 a.m. that Churchill had been incontinent at 4.00 a.m. and 9.00 a.m. On examination, Seddon found Churchill's ‘grip as yesterday. No spasticity. Upper limb reflexes unchanged except the biceps and triceps are less brisk. Lower limbs possibly a little diminution of power below the left knee. No spasticity. Reflexes unchanged’. 4
Moran assessed Churchill at 3.00 p.m. and recommended that the usual night sedation regimen (quinalbarbital 100 mg on retiring, followed by a 25 mg tablet, repeated if necessary) be continued. 5 Churchill ‘sat out in a chair from 3.30 p.m. until 5.00 p.m. with no ill effects’ and was alert when he had a visitor (both Lord Beaverbrook and Mr Onassis were listed on the engagement card for the early evening 27 ) for one hour at 5.45 p.m. 5 At 7.45 p.m., Churchill ‘had a wash and was very cooperative. Says he is very hungry. Ate a good four course dinner. Appears a little vague’. 5 Later that evening, Howells noted that Churchill was able to turn the pages of his book with his left hand, implying some improvement in the power in his left arm. 5 Quinalbarbital 100 mg was given at 10.55 p.m., and Churchill slept very well but was ‘confused at times’. 5
25 November 1960
Churchill ‘woke up at 8.45 a.m., rather vague but cooperative. Had a small amount of breakfast. Slept for 1.5 hours until 12.50 p.m. Visited by Lord Moran – no change in treatment ordered’. 5
Seddon also assessed Churchill and recorded: Left arm reported to be a little stronger but some pain in the shoulder. Evidence in favour of left hemiplegia is:
dragging of left foot said to have been present on 23rd November; Slight weakness of the left leg muscles that I found on 24th though I could not be certain of it. Against a hemiplegia: No change in lower limb reflexes at any time. If it is not a hemiplegia, it is a lower motor neurone lesion at the level of C5–C7. But on the 23rd the biceps and triceps were brisk, and the grip was weaker than it is today. Yet the pain and vague sensory disturbance in the hand suggests a radicular lesion.
4
26 November 1960
Awoke at 9.20 a.m. Seemed rather depressed. Had usual breakfast of coffee and fruit. Complaining of a lot of pain in the left arm when he was first raised up in the bed. The pain did not ease during the morning.
5
The Times reported that Churchill was ‘still going on nicely’. 28
27 November 1960
Churchill woke at 10.45 a.m., when he was observed to be ‘rational but drowsy’, and sat out between 3.00 p.m. and 4.30 p.m. 5 He also walked to the toilet with assistance. 5 Moran examined his patient at 4.45 p.m. 5 It was agreed that Moran and Seddon would discuss on 28 November whether it was appropriate for Churchill to sleep again in his own bed. 5 Nursing staff recorded that Churchill was cooperative but ‘rather low in spirits’ in the afternoon, but was moving his left arm more freely. 5 Churchill ate a ‘fairly good supper’ and was reading quietly at 9.15 p.m. 5 Quinalbarbital 100 mg was given at 10.30 p.m.
28 November 1960
Churchill slept until 02.00, passed urine and then slept ‘restlessly’ until 4.30 a.m. 5 He passed urine again and slept until 7.30 a.m. 5 He spent the morning reading newspapers, but got up for lunch from 1.00 p.m. to 2.30 p.m. 5 Churchill walked to the toilet twice. 5 ‘Right eye is discharging and both eyes look reddened...eye drops instilled’. 5
The Times reported that Churchill was sitting up in his chair and is still visited daily by Lord Moran. 29 Churchill was given quinalbarbital 100 mg at 10.15 p.m. after which he slept for long periods, though he was ‘confused at times’. 5
29 November 1960
The nursing report states that Churchill had a ‘quiet morning. Some confusion for short periods then quite rational’.
5
‘Very cooperative. Sat out of bed at 12.30 p.m. Walked to toilet…’
5
‘Requested to go back to bed at 1.10 p.m. Rather breathless…had lunch in bed’.
5
The nursing notes state: Very vague most of the afternoon. Appears to know what he wants to say but finds difficulty in completing a sentence. His inability to remember things tends to upset him more. Visited by Lord Moran at 2.15 p.m. Lord Moran saw Sir W[inston] in this confused state.
5
30 November 1960
On 30 November, Churchill celebrated his 86th birthday. The day began with him eating a ‘good breakfast. Very cheerful and rational. Read newspapers’. 5 He slept from 11.30 a.m. until 12.15 p.m. 5 Churchill was assessed by Moran and Seddon who agreed that Churchill's time out of bed should be directed by Churchill's own wishes. Churchill got up for lunch, and close relatives (daughters Mary and Sarah, son Randolph, grandson Winston) joined him for lunch. His daughter Diana came after lunch and Lord Montgomery at 4.00 p.m. Most importantly, as far as Churchill was concerned, was that he was allowed to transfer back to his own bed! 5 Although Churchill was stated to be ‘extremely tired’ after celebrating his birthday, he still ‘ate a fair supper’.
Moran reported ‘He is getting on very well’.
30
Churchill issued the following statement: I am very grateful to all those who have so kindly sent me messages of good wishes for my health and for my eighty-sixth birthday. There are so many I cannot acknowledge all of them personally, but I would like to express my warm thanks to the senders for the thought which has given me much pleasure.
30
Quinalbarbital was given as usual at 10.15 p.m., but Churchill ‘did not sleep for some time’. 5
1 December 1960
Howells recorded that Churchill had only slept for three hours the previous night. He woke up at 9.30 a.m. when he was observed to be ‘fairly cheerful’. After breakfast, Churchill had a ‘quiet morning’. 5 Moran attended at noon. 5 Churchill got up for lunch in Lady Churchill's room and retired to bed at 2.30 p.m., where he read. 5 Churchill semi-dressed for dinner. Moran saw Churchill again at 10.00 p.m. Quinalbarbital was given at 10.50 p.m., but Churchill ‘slept restlessly until 2.00 a.m.’. 5
2 December 1960
After passing urine at 2.00 a.m., Churchill slept until 8.00 a.m. 5 He then ate a good breakfast, slept for 30 min and then spent the rest of the morning reading quietly. 5 Churchill was semi-dressed for lunch and up for 1.5 hours. ‘No apparent tiredness afterwards’. 5 Churchill also semi-dressed for dinner and there was ‘no apparent tiredness afterwards’. 5 Seddon assessed Churchill again and observed Churchill walking. 5
Howells recorded in the nursing notes that Churchill demanded that the wedge be removed from his bed. It was explained to him that it was Lord Moran's wish that he should not sleep flat. Sir Winston was adamant, so the wedge was removed.
5
This was part of a long struggle between Churchill and his nurses over this issue. Howells later wrote in his book: After a day's battle it was agreed that he could have his own bed back as long as he had fracture boards under the mattress to support his back while he was lying flat on a wooden support at a 45 ° angle to prop him up during the day. He agreed to all this and it was generally thought to be a good compromise and that he would settle down to the business of getting well again. He had other ideas however. The next day he announced that he did not intend using the back support and that he was going to take a bath. From that time onwards, it was ‘open warfare’ between Sir Winston and the nursing team. Every morning there was a struggle to get the angle wooden support into his bed. He firmly resisted all attempts to do this but it was always installed after a rather exhausting struggle.
1
Churchill retired at 9.30 p.m. ‘Pressure areas treated. Ointment applied to groins and around anus’. 5 Quinalbarbital 100 mg and a vitamin B compound tablet were administered at 10.00 p.m. 5 ‘Churchill had a better night and slept flat on two pillows from 10.30 p.m. to 5.00 a.m’. 5
3 December 1960
Moran agreed after visiting Churchill at 1.00 p.m. that he may have the back rest (the wedge) removed at night but that he must be kept propped up as much as possible with pillows. 5 Churchill got up for lunch and played cards afterwards, a total of 2.5 hours out of bed. 5 Churchill dressed for dinner, but requested to go back to bed after one hour. 5 Quinalbarbital was administered at 10.45 p.m. Churchill slept from 11.00 p.m. until 2.10 a.m. when he requested and was given quinalbarbital 25 mg at 2.20 a.m. 5
4 December 1960
At 2.20 a.m., when Churchill awoke, Howells wrote: …was quite rational and alert but finding no one responded to his ‘cries of help’ proceeded to ‘bang on the wall’ with a urinal [bottle] although his bell was at hand and he had already turned on the light, used a bottle, replaced it selecting an empty one with which to strike the wall. This went on for about two minutes. Sir Winston was extremely abusive for about 15 minutes. I may say that Sir Winston when asked said he did not require anything and refused to say why he was cross. Abusive again at 9.00 a.m. Uncooperative !!!
5
Seddon saw Churchill at 1.45 p.m. Very comfortable and cheerful. During the night he had an unexplained outburst of rage and banged a urinal (empty) against the wall so hard that this dented the plaster. He was grumpy this morning and again for no apparent reason.
4
Seddon also recorded that there was: ‘A most disturbing development, a definite angular deformity at the cervico-thoracic junction which looked rather more than what one sees fairly often in old people. Had there been a second fracture? I telephoned Moran (in Stafford) and then Golding’. 4
Churchill dressed for dinner, and Seddon visited again at 7.45 p.m. 5 It was agreed again that while the bed was to remain elevated by the wedge during the day, at night two pillows could be substituted. 5 Quinalbarbital was given at 10.15 p.m., and Churchill slept until 1.45 a.m. when he requested more night sedation; quinalbarbital 25 mg was given. 5
5 December 1960
Seddon recorded: …we went by ambulance to Golding's rooms. Golding took superb pictures and they showed an old lesion of the 4th and 7th cervical vertebrae which were all fused. There was no change in the state of the 5th thoracic. I then recalled a serious accident the young Churchill had suffered on 10 January 1893 when he jumped from a bridge at [Branksome Dene, near] Bournemouth.
4
Seddon tells me that without this protective block it is probable that one of the cervical vertebrae would have been fractured in his fall, and then we should have been in real trouble. Winston, as I have said before, seems to have nine lives.
9
Sir Winston Churchill went from his home in Hyde Park Gate, London, by ambulance to Harley Street for an X-ray examination. Sir Winston was examined by Dr Frances Campbell Golding, a radiologist. He returned home after an hour and 40 minutes. It was his second x-ray examination since his accident. Lord Moran…said the x-ray ‘was very satisfactory. He is making good progress.’
31
6 December 1960
The Times reported that Moran had visited again and that Churchill ‘is still making progress’. 32
12 December 1960
Seddon recorded that Churchill was ‘very confused during the previous evening and in the night’. 4
19 December 1960
Moran recorded: A bad day. Winston knows what he wants to say but cannot say it; he cannot get the words he wants. To make matters worse, the Prime Minister chose to visit him today…I gather the meeting was rather a flop, and they are afraid the Prime Minister will talk. Winston asked: ‘How long have I to go on like this, waiting for death?’
9
21 December 1960
Seddon's notes indicate that Churchill was able to get out of bed without assistance and he walked up and down the room with fair confidence, holding his head much stronger. 4
22–31 December 1960
Churchill left Hyde Park Gate on 23 December to spend Christmas at Chartwell with his family. Just before Churchill set off, two men arrived with four green steel boxes. 1 They contained the first four reels of The Valiant Years, the 26-part film made by the American Broadcasting Company and based on Sir Winston's Second World War memoirs. The reels were especially tailored to fit the projector at Chartwell's basement cinema. It was a series which gave Churchill hours of pleasure. 1
The Churchills entertained the Prime Minister, Harold Macmillan, to dinner at Chartwell on 29 December. 33
Churchill and Seddon
Seddon wrote to Montague Browne on 31 January 1961: Lady Churchill was good enough to speak to Lord Moran and you to my secretary about my fee for attending Sir Winston. Sir Winston returned to the House of Commons last Thursday. That I was able to help towards this is a sufficient reward, and if he and Lady Churchill have no objection, I would prefer to leave it that way. May I take this opportunity of thanking you most warmly for many acts of kindness during what was, for a while, rather an anxious undertaking.
34
…I would just like to add, if I may, what a comfort it was to us all to know that you were in charge. I think that Sir Winston's present good health is a wonderful tribute to what you did.
35
Montague Browne has shown me your letter of 31 January. Please allow me to express to you my gratitude for all your skill and care during my illness, and my warm thanks for the graceful terms in which you phrase your letter. It was indeed fortunate for me that I should have been attended by you and I am well aware of the trouble you took. I hope you will accept a photograph and a copy of my biography of Marlborough which I have signed for you.
36
… Will you please read the enclosed letter. I have no means of knowing how Sir Winston would regard an expression of an opinion on the writing of history from someone who is no more than an enthusiastic dabbler. But he could not have sent me a more welcome gift and that is why I have written more than a simple letter of thanks … I was greatly touched by your personal note: I too hope that we may meet again though I trust on a sunnier occasion.
37
Seddon wrote to Churchill on 6 February 1961: I am grateful to you and Lady Churchill for your extremely kind letters. And may I say how delighted I am to have this excellent photograph and the signed volumes of your biography of Marlborough. May I dilate a little on the last. I have not yet read all your books ─ The River War was to be the next ─ but of those I know Marlborough is my favourite…I have not yet come across a picture of it that can compare with yours. And when the subject of a biography is a hero, and Marlborough was in all conscience, I applaud the writer who brings out the heroic lineaments; when this is done the faults, the human failings, are usually faithfully dealt with too…I shall not forget the great kindness of Lady Churchill and of yourself that so greatly lightened Lord Moran's and my task.
39
18 May 1961: review by Sir Russell Brain
On 18 May 1961, Churchill was reviewed by Sir Russell Brain (Figure 5): Some little time previously, Churchill had had a fall in his bedroom which had resulted in a crush fracture of one of his dorsal vertebrae. I was asked to see him again because he was complaining of painful numbness of the left index finger which seemed to have troubled him since his fall. I found some analgesia over the finger. There was no muscular weakness, but the left triceps jerk was diminished. It appeared to be a lesion of the 6th cervical root which I thought was due to cervical spondylosis, exacerbated by the fall. He had had his spine x-rayed and when I saw the x-rays, I found they showed gross changes: marked lordosis from the 1st to the 5th cervical vertebrae, while the 5th, 6th, and 7th were kyphotic; their bodies appeared fused together, C5 and C6 at an angle leading to the kyphosis, with wide separation of the tips of the spinous processes of these two vertebrae, apparently due to old trauma. This is the cause of the characteristic posture of his head on his shoulders.
6
Sir Russell Brain Bt © NPG (164682).
Churchill's principal doctors
Lord Brain (1895–1966)
Brain was a Consultant Physician at the (then) London Hospital and the Maida Vale Hospital for Nervous Diseases. Brain earned his living primarily from his private practice and as the author of Diseases of the nervous system, Clinical neurology, and other medical and non-medical books. 41 He was President of the Royal College of Physicians from 1950 to 1956, succeeding Lord Moran.42,43 Brain had assessed Churchill previously at Moran's request on 5 October 1949, 15 October 1949 and 8 December 1949 after Churchill's first stroke 44 and on multiple occasions in 1950–1952 for further episodes of cerebrovascular disease, 45 in June 1953 after Churchill's second stroke, 2 in June 1955 after a the cerebellar infarction again with an excellent recovery, 46 and a left hemisphere stroke in October 1956. 47
Brain was knighted in 1952, made a baronet on 29 June 1954, and on 26 January 1962 was created Baron Brain of Eynsham in the County of Oxford. In March 1964, he was elected as a Fellow of the Royal Society.
Dr Frederick Campbell Golding (1901–1984)
Golding was born and educated in Australia; his schooling was first in Sydney and then at Scots College in Melbourne.48–51 He went to St Andrew's College of the University of Sydney to study medicine and qualified in 1926. A few years after qualification, he came to England and obtained a post as registrar at the Royal Free Hospital. He then began to study diagnostic radiology after obtaining MRCP. After various appointments, including the directorship of the X-ray diagnostic department at the Royal Marsden Hospital, London, he came to the Middlesex Hospital, London in 1933 at the invitation of Sir Harold Graham-Hodgson to assist him in the development of the new X-ray diagnostic department. He was also Consultant Radiologist to the Royal National Orthopaedic Hospital, London.
His knowledge and teaching ability immediately made a great impression and he was largely responsible for the important reputation developed by this department. In 1956, he succeeded to the post of Director of Diagnostic Radiology and held this until his retirement in 1967. He became Civilian Consultant in Radiology to both the Royal Navy and the Royal Air Force. He was also radiologist to the Medical Research Council Decompression Sickness Panel.
Lord Moran MC (1882–1977)
Charles Wilson 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 and remained his personal physician until Churchill's death in 1965. 52 He treated Churchill for chest pain in December 1941 in Washington, 53 for pneumonia in London in February 1943, 54 for pneumonia and atrial fibrillation in Carthage in December 1943 55 and for pneumonia in London in August 1944. 54 Moran also treated Churchill in 1949 when he suffered his first stroke 44 and was primarily responsible for managing the further episodes of cerebrovascular disease in 1950–1952, 45 his second stroke in 19532 and Churchill's recovery from it, 3 the cerebellar infarction in June 1955 again with an excellent recovery 46 and a left hemisphere stroke in October 1956. 47 In 1958, he treated Churchill for pneumonia, atrial fibrillation and jaundice 56 and in 1962 cordinated treatment for Churchill's hip fracture. 38
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). 52
Lord Richardson LVO (1910–2004)
Richardson undertook his clinical training at St Thomas’ Hospital, London, where he won the Bristowe Medal and Hadden Prize, before qualifying in 1936 and being awarded a Perkins Fellowship. 57 His career was interrupted by being called up into the Royal Army Medical Corps in August 1939. 57 He saw service at Dunkirk and was later posted to North Africa as a lieutenant colonel medical specialist, where he looked after King George VI on a visit to the troops in 1942. 57 It was here that he met Harold Macmillan who was travelling with the royal party, which he described as ‘the greatest good fortune of my life’; he was to act as Macmillan's personal physician for over 40 years. After World War II, Richardson returned to Thomas’ and, apart from an initial year off with pulmonary tuberculosis, spent 28 years there as a consultant physician. 57 He was President of the Royal Society of Medicine (from 1969 to 1971), President of the British Medical Association (from 1970 to 1971) and recipient of its gold medal, and Master of the Society of Apothecaries (from 1971 to 1972) and President of the General Medical Council from 1973 to 1980. 57 He gave the Harveian Oration at the Royal College of Physicians in 1978 on Harvey's exhortation, in which he emphasised William Harvey's exhortation to Fellows to keep their house in order. As Richardson's unpublished autobiography states, Richardson provided expert advice to Moran on Churchill not only on this occasion but also on several others.
Richardson was made a Member (fourth class) of the Royal Victorian Order (MVO) in 1943, which was reclassified as Lieutenant (LVO) on 31 December 1984, for treating King George VI for sunburn. He was knighted in 1960, was made a baronet in Macmillan's resignation honours in 1963 and was created a life peer in 1979, taking the title Baron Richardson of Lee in the County of Devon. 57
Professor Sir Herbert Seddon CMG Kt (1903–1977)
Seddon graduated in 1928 from St Bartholomew's Hospital, London with honours and the University Gold Medal, passing his Final Fellowship Examination in the same year. 58 In 1930, he was appointed instructor in surgery to the University of Michigan at Ann Arbor. Seddon returned to the UK to take up appointment as resident surgeon at the Royal National Orthopaedic Hospital, Stanmore. There he spent eight pioneering years, but in 1939, he was appointed Nuffield Professor of Orthopaedic Surgery at Oxford. 58 There he undertook his work on peripheral nerve injuries which came to be accepted worldwide. The Institute of Orthopaedics in London had been created in 1946; two years later, Seddon became Director of Studies and subsequently the first Professor of Orthopaedics in the University of London. 58 He became a member of the Medical Research Council for four years and was a member of the Advisory Medical Council of the Colonial Office and President of the British Orthopaedic Association. Seddon was the leader of the surgical team responsible for treating Churchill's hip fracture in 1962, 38 and he also treated Churchill again in 1963 for a disorder of his lower limbs.
Seddon's role with the Colonial office led to extensive tours of Africa for which he was appointed CMG in 1951. 58 He received the accolade of Knight Bachelor in 1964.
Discussion
The clinical events and radiological evidence indicate that Churchill sustained a partial crush fracture of the T5 vertebra in the fall which occurred on 15 November 1960. This was initially very painful, but the pain had substantially improved within a week of the accident, as he was able to get out of bed, with the help of nurses, on 21 November, taking three steps. As to the cause of the fall, it seems likely this was due to Churchill's already unsteady gait, necessitating regular use of a walking stick, and probably acutely provoked by him turning, while walking, to speak to his wife.
Churchill complained of pain in the shoulder and left arm on several occasions over the next few days. Seven days following the fall, he reported numbness of the left thumb with pain on moving the thumb. The latter suggests a local musculoskeletal cause, while the cause of the former was not established with certainty. Subsequent X-rays of the cervical spine, which Seddon had been much concerned about obtaining, showed changes attributable to Churchill's neck trauma in earlier life, together with degenerative changes. It seems probable that the fall may have exacerbated the longstanding cervical spine disease, leading to pain in the shoulder and arm and possibly also the transient sensory impairment in the thumb.
It was not until eight days after the fall, on 23 November 1960, that Moran detected weakness of grip in the left hand, and on the same day, Seddon confirmed this and also found weakness of elevation of the left arm at the shoulder, together with a mild left facial droop, though without demonstrable weakness. On the same day, the nurses noted that Churchill was dragging his left foot. Seddon did not find any change in the left arm reflexes, nor any increase in muscle tone in the left arm. It is noteworthy that Seddon performed his neurological examination on this day and on the next day with Churchill sitting in a chair, not an ideal posture for detecting subtle signs of neurological deficit. On 24 November 1960, Seddon recorded that the left biceps and triceps tendon reflexes were less brisk, and there was possibly some weakness below the left knee. The plantar reflexes were ‘impossible to elicit because the soles of the feet are extremely ticklish’.
On 25 November 1960, Seddon recorded that the left arm was stronger, but with weakness of the left shoulder girdle; he did not find left leg weakness. Seddon weighed up the evidence in favour of, and against, a hemiplegia. It seems that he came down on the side of nerve root lesions as the major pathological basis of the physical signs found.
By 28 November 1960, Churchill was walking to the bathroom, with no obvious left-sided weakness. Seddon recorded that all reflexes were present, though there was puffiness and tenderness in the left anatomical snuffbox, raising the possibility of a scaphoid fracture in Seddon's mind. On 2 December 1960, Churchill's gait was shuffling, but ‘symmetrical’, according to Seddon.
Putting all this together, in retrospect, there seems little doubt that, eight days following his fall, Churchill sustained a mild left hemiparesis, which had substantially resolved within five days. Under the prevailing circumstances, clinical assessment was understandably difficult, and this new stroke occurred in the context of the acute crush fracture of the T5 vertebra and exacerbation of longstanding post-traumatic and degenerative cervical spine changes. This transient stroke would be consistent with a small subcortical, probably thalamocapsular stroke, due to small vessel disease, in keeping with the likely basis for Churchill's previous strokes.44–46
One might question why Moran did not involve Brain, the neurologist, in the acute stages of this episode, particularly as Brain had examined Churchill on many occasions previously. Brain was not asked by Moran to see Churchill until some six months later, in May 1961, on account of painful numbness of the left index finger. Brain's examination revealed no weakness, a reduced left triceps jerk and reduced pin-prick sensation in the left index finger, signs which Brain concluded were due to a lesion of the sixth cervical root due to cervical spondylosis exacerbated by the fall in November 1960. 35
We may conclude now that Churchill already had multiple medical problems and that, as events unfolded, and in the context of difficult conditions for detailed neurological assessment, it was not obvious either to Moran or Seddon that a small acute stroke had indeed occurred.
Features of Churchill's ill-health following the fall included periods of confusion, irritability and behavioural change, including an uncharacteristic outburst of aggressive behaviour, and several episodes of incontinence. Three factors are likely to have contributed to these symptoms. First, his age: Churchill was 86 on 30 November 1960. Second, small vessel cerebrovascular disease. Churchill had already had several symptomatic cerebrovascular episodes.2,45,46 In the modern era of CT and MR scanning, it is often the case that in people of Churchill's age and with similar history, imaging shows evidence of widespread small vessel disease, with multiple lesions, not all attributable to documented clinical episodes of neurological deficit.
And third, even though Moran regularly reviewed the regimen for quinalbarbital, Churchill was prescribed this hypnotic during his illness on a regular, probably nightly, basis, often with more than one dose per night. The medical 4 and nursing 5 notes both confirm that Immenoctal (better known in the UK as quinalbarbitone (now quinalbarbital) and in the US as secobarbital), a barbiturate hypnotic, was prescribed by Moran as night sedation. The British National Formulary (1957) 59 mentions only two quinalbarbital strengths, whether dispensed as a tablet or capsule: 50 mg and 100 mg. Lovell 60 described Moran's prescriptions and stated that Moran prescribed ‘reds’, which contained quinalbarbital 100 mg in tablet form, ‘baby capsules’ which contained quinalbarbital 15 mg and ‘midget capsules’ which contained quinalbarbital 7.5mg. However, the nursing notes 5 are explicit and state repeatedly that Churchill was administered either a whole tablet or a quarter tablet, presumably therefore 100 mg or 25 mg. Of course, barbiturates are now never used as hypnotics, but their use in Churchill reflected standard prescription practice at the time. Long-term use of barbiturates can cause confusion, dizziness, depression, and ataxia with an increased tendency to fall, especially in the elderly, who may suffer a fracture as a consequence. 61 Alcohol may exacerbate these adverse effects as may opioids such as codeine which Churchill was also prescribed for pain; Churchill continued to imbibe alcohol throughout his illness.
In support of our conclusion that quinalbarbital was an important contributory factor to Churchill's episodic confusion, behavioural disturbance and incontinence, is the relative preservation of his cognitive function and wit, evident during this illness. His reaction to Seddon and Yeoman moving him unexpectedly to a new bed (‘Narrow bed – narrow minds’), and his quip, in annoyance, to Howells on 21 November (‘Yes, but I am a great man’) both indicate that his intellect was remarkably well preserved, given his difficult circumstances. As Howells later recalled, ‘It was an extraordinary performance for a man of his age’. 1
On 27 January 1961, Seddon wrote, We have been disturbed by certain abnormalities of behaviour, sudden bursts of rage, periods of apathy and sulkiness, with intervals of cheerfulness. What bothered me was whether this injury had caused an acute ageing, as fractures sometimes do with old folk. But at the finish that is to say nine weeks after the injury, Sir Winston was in Lord Moran's view back to where he had been before.
4