Faithful but unfortunate: Churchill and his shoulder

Abstract

The centenary of the end of the First World War allows an opportunity to reflect on the lessons learned from dissent, not only in political life but also in shoulder surgery. It is not commonly known that the young Winston Churchill had an unstable shoulder that was to affect him from his younger days into his later career. Although he chose to treat his shoulder problem conservatively, one of his contemporaries, ASB Bankart proposed a surgical approach that has come to be the ‘gold standard' of management of the unstable shoulder. This paper reviews the historical record of Churchill's shoulder instability and the lessons he learned from his experience.

The occasion of the 100th anniversary of the end of the First World War gives an opportunity to reflect on the great sacrifice given by many in the cause of the defence of liberty on the battlefields of Europe. This period is also inevitably associated with the emerging career of Sir Winston Churchill, subsequently Prime Minister of Great Britain during the Second World War. His impassioned speeches and broadcasts to the nation galvanised a spirit of resistance to the German onslaught.

His solemn words ‘… never in the field of human conflict was so much owed by so many to so few …’¹ have been captured in the popular imagination with the enduring image of him holding index and middle finger extended aloft in the famous ‘V for Victory’ sign as a symbol of motivation to troops in battle and the public at large.

However, closer examination of the historical and photographic record reveals that events in his younger days may have had a significant impact on the generation of this iconic image, and by wider implication, affected his subsequent behaviour and decision making in the war.

Youth and adventure

Born in 1874 at Blenheim Palace, the ancestral seat of the Dukes of Marlborough in Oxfordshire, Churchill was initially taught by a governess before attending Harrow School. School days were not a particularly happy time for him and eager for action and adventure, at the conclusion of his secondary education he commenced officer training at the Royal Military Academy, Sandhurst. He graduated in 1895 and joined the 4th Queen’s Own Hussars, a cavalry regiment. He had shown exemplary skills as a horseman and was keen to see action at the frontline in the service of the Empire.

At that time, the regiment was serving in India and he duly sailed for Bombay in 1895 at the age of 21. Arriving in the harbour he boarded a small boat to take him and his colleagues ashore. Full of energy and enthusiasm on arrival in this dominion of the Crown, he attempted to set foot on land, when the boat suddenly shifted in the opposite direction and he sustained an injury to his right shoulder.

We came alongside of a great stone wall with dripping steps and iron rings for hand-holds. The boat rose and fell four or five feet with the surges. I put out my hand and grasped at a ring: but before I could get my feet on the steps the boat swung away, giving my right shoulder a sharp and peculiar wrench. I scrambled up all right, made a few remarks of a general character, mostly beginning with the earlier letters of the alphabet, hugged my shoulder and soon thought no more about it. ²

Although in his memoir ‘My Early Life’ he does not describe any further treatment of this initial injury, he goes on to say how his shoulder problem was to plague him for the rest of his days, showing remarkable insight into the pathology of anterior instability:

Let me counsel my younger readers to beware of dislocated shoulders. In this, as in so many other things, it is the first step that counts. Quite an exceptional strain is required to tear the capsule which holds the shoulder joint together; but once the deed is done, a terrible liability remains. Although my shoulder did not actually go out, I had sustained an injury which was to last me my life, which was to cripple me at polo, to prevent me from ever playing tennis, and to be a grave embarrassment in moments of peril, violence and effort. ²

His history is typical of the progression of post-traumatic instability, with recurrent episodes occurring on increasingly trivial provocation:

Since then at irregular intervals my shoulder has dislocated on the most unexpected pretexts; sleeping with my arm under the pillow, taking a book from the library shelves, slipping on a staircase, swimming, etc. Once it very nearly went out through too expansive a gesture in the House of Commons, and I thought how astonished the members would have been to see the speaker to whom they were listening, suddenly for no reason throw himself upon the floor in an instinctive effort to take the strain and leverage off the displaced arm bone. ²

Following his arrival in India, the regiment was posted to Bangalore in southern India. There was no military action in the area at that time, so the young officers spent much of their time playing polo, maintaining their competitiveness and horsemanship. At the height of the Raj, evenings were spent in the clubs established for the expatriate community, and to this day there remains an unpaid bill that Churchill owed to the Bangalore Club.

Unfortunately for Churchill he had injured his dominant shoulder and was therefore at considerable risk of subluxing the joint while swinging the polo stick, as the rules required that it be swung through a full rotation when attempting to strike the ball. In a letter to his mother, Lady Randolph Churchill, in 1898 he writes: ‘You must excuse my handwriting as I have dislocated my shoulder at polo and am all strapped up. So painful it was – and I fear may ultimately end my polo career for it may slip out again’.³

Nonetheless, such was his passion for the game that he recovered by February 1899 and wrote again: ‘My shoulder is better and though still weak I shall play in the tournament. I think we may win’.³

However, by September 1899, in preparation for the Inter-Regimental Polo Tournament, which had never previously been won by a regiment based in southern India, he wrote to his brother, following a fall downstairs in which he injured both his ankle and re-dislocated his shoulder:

I am going to struggle across to the polo ground this afternoon – but I fear I shall not be able to play in the tournament as my arm is weak and stiff and may come out again at any moment. It is one of the most unfortunate things … I try to be philosophic, but it is very hard. Of course it is better to have bad luck in the minor pleasures of life than in one ‘s bigger undertakings. But I am very low and unhappy about it. Nor is it any consolation that next year I shall have forgotten all about it. ³

On his return to England, he did seek treatment. Churchill had devised a special brace with a waist strap and armband linked by a swivel (Figure 1). He wore this device for many years when playing polo and when necessary renewed it by special appointment from surgical suppliers in London. The concept of this brace was to prevent the arm being rotated and elevated to the position of subluxation, whilst still allowing enough movement to effectively swing the stick and connect with the ball (Figure 2).

Figure 1.

Churchill dressed and mounted for polo competition. The waistband and strap restraining elevation of the right arm can be clearly seen (Reproduced with permission of Curtis Brown, London on behalf of the Broadwater Collection © Broadwater Collection).

Figure 2.

Churchill in action playing polo around 1925, about to strike the ball while wearing his brace (with permission Getty Images).

Other than the brace, he wrote in a further letter to his mother in April 1905: ‘I have begun electrical treatment to tighten up my dislocated shoulder. It is rather pleasant’.³

Although he continued to wear the brace when playing polo (until his last match in 1925), there are certainly images of him swimming, shooting, playing golf and fishing without the brace, so it seems he had some measure of dynamic control over the instability episodes.⁴ He also became an accomplished bricklayer at Chartwell, his country retreat in Kent, and in his later years also developed his talent as a landscape painter.

He also continued his adventurous military life, serving with the Malakand Field Force in the northwest frontier of colonial India (now modern-day Pakistan). He commanded a troop of the 21st Lancers in the last great cavalry charge of the British Army against an army of 3000 Dervishes at the battle of Omdurman in Sudan in 1898. Shortly after his return to London, and in need of funds, he was made a war correspondent in the Boer War in South Africa. During this time, he was captured and made a prisoner of war, only to escape the prison camp and travel overland to Durban, arriving to much acclaim in December 1899.

Origins of the V-sign

The first recorded photograph of him displaying the famous ‘V for Victory’ sign dates from 1941, the year following the Battle of Britain (Figure 3). In this image, he holds his fingers in the V formation with elbow fully flexed and his shoulder in a few degrees of flexion. The success of this gesture was immediately apparent and he went on to make it his trademark, displaying it to civilian and military audiences wherever he travelled. However, it is rare to find images of him with his shoulder elevated in full flexion and external rotation: the so-called ‘apprehension’ position might have put him at risk of subluxation, so it seems he was careful to avoid it. In countless photographs throughout his career, he is seen with his arm elevated purely in flexion, anterior to the coronal plane and in the ‘safe zone’. However, there is at least one image where he was able to achieve a position of nearly full abduction and external rotation, but only when the arm was supported on the railing of an open-topped car.

Figure 3.

The first recorded photograph of Churchill demonstrating the ‘V for Victory’ sign, standing outside the Ministry of Information at the University of London, August 1941 (with permission Associated Press).

Nonetheless, it is also clear from other photographs of him holding his left (non-injured) arm aloft, that he was able to achieve the normal range of at least 90 degrees of abduction and 90 degrees external rotation. It is therefore reasonable to conclude that there was no anatomical restriction of motion in the injured shoulder and it was indeed a cautionary posture that he adopted to avoid the risk of recurrent instability.

Contemporary progress in shoulder surgery

One of the most famous surgeons in the history of shoulder surgery was Arthur Sydney Blundell Bankart, born in 1879, five years after Churchill. Bankart was a gifted student, attending Cambridge before completing his medical studies at Guys Hospital in London. He was one of the first registrars appointed to the newly established Royal National Orthopaedic Hospital, and joined the staff at the Middlesex Hospital as its first dedicated consultant orthopaedic surgeon. However, he continued to practise neurosurgery and paediatric surgery at other hospitals in London and was elected as President of the British Orthopaedic Association in 1933.⁵

As we have seen in Churchill’s case, at that time, the most common treatment for recurrent instability of the shoulder was overwhelmingly conservative, although operative treatment was performed on some occasions. A plethora of surgical procedures were advocated by various proponents, normally an indication that no single, simple, sure-fire solution existed. Bankart argued passionately that most operations failed to address the underlying pathology of recurrent instability and were therefore subject to a high risk of failure. Rather than deliberately shortening the subscapularis tendon and/or imbricating the capsule to reduce external rotation range to tighten the joint (the basis for the procedure described by Sir Harry Platt in Manchester), it was his assertion that ‘the only rational treatment was to surgically reattach the glenoid ligament to the bone from which it had been torn’. He first published his observations on a series of four cases in the British Medical Journal in 1923,⁶ but it did not attract much attention. He later published a second article in the British Journal of Surgery in 1938,⁷ describing his experience of a further 27 cases, including detailed illustrations of the surgical technique which has come to be known as the ‘Bankart repair’ and concludes:

Recurrent dislocation is due to a wide detachment of the glenoid ligament from the anterior margin of the glenoid cavity. This anatomical defect is quite constant, and can be demonstrated in every typical case of recurrent dislocation of the shoulder. An operation is described for the repair of this defect. This operation practically restores the shoulder joint to its normal anatomical state, and it invariably prevents recurrence of the dislocation.

So unequivocal was Bankart in his promotion of this idea, that his operation has subsequently become the gold standard by which all other methods of surgical shoulder stabilisation, both open and more recently arthroscopic, are judged. Although the procedure has been modified over the years, treatment of the labral detachment (the so-called ‘essential lesion’) remains its cornerstone. At the time though, he may have been regarded as a radical for proposing surgery as the treatment of choice.

Bankart died suddenly in 1951 aged 71 after finishing an operating list. In his obituary in the Journal of Bone and Joint Surgery, his colleague at the Middlesex, Philip Wiles, described him thus: ‘A man of strong convictions and supreme personal honesty, he could not be converted from the course he believed to be true. Tolerant of error, intolerant of fools, a giant amongst men’.⁵

Much the same observation could be made of Churchill. Whilst it is likely that the social and professional circles of leading politicians and medical practitioners in London at the time overlapped, it is not known whether the two men ever met and discussed Churchill’s shoulder condition. In a lecture given at the Cowlishaw Symposium of the Royal Australasian College of Surgeons in October 2006, the surgeon Wyn Beasley, from Wellington New Zealand, raised the same proposition.⁸ Could Churchill have opted for surgical intervention? Would it have changed the course of his life, or indeed the war? Was it a case of missed opportunity, or had he simply learned after 25 years to manage the problem as best he could? Churchill did, in fact, meet Sir Harry Platt, President of the Royal College of Surgeons of England, when he received his Honorary Fellowship of the College in 1956.

The published diaries of his personal physician, Lord Moran, reveal Churchill’s frequent defiance of the advice of the medical profession.⁹ He went on to survive a series of devastating strokes and recurrent depression (his ‘black dog’) amongst other medical conditions but nonetheless served a second term as Prime Minister (1951–1955). Despite his habit of smoking cigars and drinking copious quantities of Pol Roger champagne, claret, whisky, port and brandy, he lived until he was 90.

‘Fiel pero desdichado’, the motto of the Churchill family, derives from the Spanish ‘faithful but unfortunate’ and was adopted after Charles II knighted the first Duke of Marlborough’s father for his support of the royalist cause in the Civil War, but failed to compensate him for his wartime losses. But the sentiment also seems apt in relation to Winston’s shoulder injury. Such was the measure of the man, that even though it plagued him for the rest of his days, he commented:

This accident was a serious piece of bad luck. However, you never can tell whether bad luck may not after all turn out to be good luck. Perhaps if in the charge of Omdurman I had been able to use a sword, instead of having to adopt a modern weapon like a Mauser pistol, my story might not have got as far as the telling. One must never forget when misfortunes come that it is quite possible they are saving one from something much worse; or that when you make some great mistake, it may very easily serve you better than the best-advised decision. Life is a whole, and luck is a whole, and no part of them can be separated from the rest. ²

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.