Should We Know About our Leaders’ Health?
Three Prime Ministers in the 20th century had historically important illnesses before they assumed office — Winston Churchill, Clement Attlee and Anthony Eden. To what extent did their ill health affect their policy decisions?
National leaders are usually middle-aged or older and at risk of disabling diseases. They may deny their illnesses and persuade their staff and doctors to lie to the public. There is a considerable literature on this topic, including the former Foreign Secretary David Owen’s In Sickness and in Power: Illness in Heads of Government During the Last 100 Years (Methuen, 2008). Lord Owen, himself a doctor, listed 26 leaders including Hitler, Yeltsin and Blair whose health problems were concealed from the public.
In the 20th century, Britain had 19 Prime Ministers, nine of whom had their terms of office curtailed by illness.
Three PMs from 1940 to 1957 — Winston Churchill, Clement Attlee and Anthony Eden — were looked after either at St Mary’s Hospital, London, or by my predecessors there as senior physicians-gastroenterologists such as Sir Charles Wilson (later Lord Moran) and Dr Thomas Hunt. Each of the three premiers had historically important illnesses before they assumed office.
Winston Churchill had chronic minor and non-disabling indigestion at least from 1912 when he had stomach pains that woke him with the acid regurgitation of heartburn. He was treated conventionally with ulcer-type
diets and carbonates of sodium, magnesium and bismuth. In 1950, he recalled that he had been “tortured” by his indigestion, but had been cured by massage.
In 1922, he saw Lord Dawson. In 1936, he saw Hunt. Educated at St Paul’s, Magdalen, St Mary’s and Vienna, Hunt was an orator and a linguist. He had stature, authority, courtesy, enthusiasm and curiosity and was the diplomat of British and world gastroenterology. He joined the staff of St Mary’s in 1930 and his advice was sought by many writers, whose vivid accounts of their illnesses are excellent. Churchill wrote: “The indigestion comes on during the night but disappears after the exercises in the morning. Painting always tries me highly…It is the mental concentration which seems to affect the stomach. I always paint standing up, as otherwise the indigestion would be very severe.” Churchill told Hunt: “The thing that gave most indigestion was the effort of trying to get just the right colour for a sunset on a canvas and not the strain of political and national affairs.”
X-rays of his stomach, duodenum and gall bladder revealed that everything was normal. Hunt concluded that the indigestion was of the nervous hyperacidity type, telling Churchill that his nervous tension caused painful contractions of the stomach. Hunt taught, “All creative artists are a group especially subject to dyspepsias of doubt and anxiety…My experience of generals and admirals makes me believe that their training for action relieves them of most doubts, except from that concerning their future promotion.”
A few years later, Churchill stopped seeing Hunt, having taken offence that when he wanted an appointment at 4.30pm the doctor would not cancel an already-booked appointment. Instead, Churchill became a patient of Sir Charles Wilson, who had trained at St Mary’s and had a good First World War, during which he was awarded a Military Cross and wrote his perceptive Anatomy of Courage. Wilson, a fine diagnostician, was appointed a physician at St Mary’s, and from 1920 to 1945 was the powerful Dean of its medical school. He was the doctor of Churchill’s close friends Brendan Bracken and Lord Beaverbrook, a generous patron of St Mary’s hospital and school. I assume, therefore, that Beaverbrook recommended Wilson to Churchill.
Wilson got the earlier X-rays, did no further tests and we hear little more of Churchill’s stomach. When Churchill became Prime Minister in May 1940, the Cabinet ordered that a personal physician accompany him worldwide. Bracken and Beaverbrook recommended the worldly Wilson, by now treasurer of the Royal College of Physicians (and its president from 1941-1950), a supreme wheeler-dealer of medical politics. He commissioned Annigoni for his official portrait, an excellent likeness of “Corkscrew Charlie”, as he was nicknamed.
Churchill’s first major illness was on 26 December 1941 in Washington, soon after Pearl Harbour, when he pushed open a jammed window and had severe pain in his chest and left arm with breathlessness. This was obviously a coronary episode. Churchill self-diagnosed muscle-strain. Wilson did not tell him the truth, saying merely that his “circulation was sluggish”, because he made the rapid decision that neither Churchill nor the British and Americans should know at this most critical time of the war that Churchill was an invalid needing six weeks’ bedrest. Wilson told no one. When he prevented Churchill from lifting a heavy box, he was told he was being “heart-minded”, so Wilson replied, “You’re all right. Forget your damned heart.” During the war, Churchill had various episodes of pneumonia, all well managed, including one in London when “two beautiful nurses from St Mary’s appeared as if by magic”.
Churchill’s other dangerous problem was his cerebral circulation. His first stroke was in 1949 and he was told truthfully that it was a temporary impairment of the blood supply to the brain. Wilson, now ennobled as Baron Moran of Manton, and the eminent neurologist Russell Brain, accepted Churchill’s insistence on concealment of the truth (except from Beaverbrook). Churchill was determined not to retire, but to continue as leader of the Opposition Conservative Party, and to fight the 1950 election. Yet Churchill had another stroke in January 1950, just before the election in February, which he lost, and a third in May 1950.
Churchill did win the 1951 election, but by now his intimates found him “past his prime”, forgetful and lacking tenacity. After a fourth stroke in 1952, Moran decided to discuss the prognosis with Churchill’s Personal Private Secretary, Jock Colville, Lord Salisbury and the Palace. They all agreed that Churchill would refuse the obvious solution to retire to the House of Lords. Churchill recovered but, by March, he had sufficient insight to admit to “a decline in mental and physical vigour”. Both Colville and Churchill’s wife did not think he would last long as Premier. Yet this insight was countered by self-deceptive wishful thinking that it would be a bad thing for the country if he retired now. Indeed, he told the 1922 Committee of Conservative MPs, “I would not stay if I found I was fading physically or mentally.” In April 1953, his heir-apparent, Anthony Eden, had his first operation and Churchill seemed more than happy that he could act as Foreign Secretary, too.
In June 1953, Churchill had his fifth and most severe stroke, which caused him to stagger and speak with a slur. But the Cabinet noticed nothing amiss. His left side became paralysed and he was driven to Chartwell. He ordered Colville to tell no one. Moran warned that Churchill might die that weekend, so Colville sent for the Chancellor of the Exchequer Rab Butler and Salisbury and told the Palace.
Moran: Churchill’s personal physician
Ordinarily, Churchill should have resigned, as his wife wished, and the Queen sent for Eden. However, that day Eden was being operated on in Boston. It was held to be unfair to Eden if Butler was appointed PM. Butler could have asserted himself, but as on two later occasions when he might have claimed the post, he loyally held back. There was no way a peer, such as Lord Salisbury, could have been made a caretaker
premier, so a conspiracy was hatched.
The first problem was the bulletin. Moran had prepared, and he and Brain signed, a tactful but honest bulletin: “For a long time, the Prime Minister has had no respite from his arduous duties and a disturbance of the cerebral circulation has developed, resulting in attacks of giddiness. We have therefore advised him to abandon his journey to Bermuda and to take at least a month’s rest.”
Butler and Salisbury vetoed this because medical correspondents would correctly tell the public that their PM had suffered a stroke. When King George VI had his chest operation, a bulletin talked loosely about “structural changes in the lung”, and while doctors assumed correctly that this meant cancer, this was not widely discussed in the press.
One of the few truthful royal bulletins, and certainly the most eloquent, was Lord Dawson of Penn’s on George V, stating: “The King’s life is moving peacefully towards its close.”
This sentence, written on a Sandringham menu card, was much appreciated throughout the Commonwealth. In Edward VIII’s sole Birthday Honours, Dawson was elevated to a Viscount. Dawson’s words were also truthful because 150 minutes after he wrote them, he killed the King with an injection of heroin.
Butler and Salisbury therefore prepared their own bulletin, which the two physicians agreed to sign: “The Prime Minister has had no respite for a long time from his very arduous duties and is in need of a complete rest. We have therefore advised him to abandon his journey to Bermuda and to lighten his duties for at least a month.”
Colville sent for the three press lords, Beaverbrook, Bracken and Camrose, who agreed to a total gag. Butler took the Cabinet and told them of Churchill’s stroke, although this was not minuted, while the business of the state was conducted by Colville and Churchill’s son-in-law, Christopher Soames.
However, surprisingly, Churchill made a remarkable recovery, chaired the Cabinet, again refused his family’s advice to resign and, helped by Moran’s stimulant tablets, made successful speeches to the House of Commons and the party conference: “If I stay on for the time being, bearing the burden at my age, it is not because of love for power or office.”
For the next two years, he repeatedly promised Eden, his ministers and his family that he would resign soon, but always retracted. He gave up on 5 April 1955. Moran could have forced him to leave office but didn’t. “I was, I think, alone in urging him to hang on, although I knew that he was hardly up to his job for at least a year before he resigned office. His family and his friends pressed him to retire; they feared he might do something that would injure his reputation. I held this was none of my business. I knew that he would feel that life was over when he resigned, and that he would be unhappy when there was no purpose in his existence. It was my job as his doctor to postpone that day as long as I could.”
Churchill lived for another ten years, and had further strokes. In 1958, Moran summoned Hunt to Chartwell because Churchill was semi-comatose, febrile with abdominal pain, jaundice, dark urine and pale stools. They agreed this obstructive jaundice was probably due to passage of biliary stones into the common bile duct.
Pragmatically, Hunt and Moran did no tests or X-rays. They treated Churchill with antibiotics and he made a complete recovery. Hunt was again consulted in 1960 after a similar episode that was also resolved
Fifteen months after Churchill died, Moran published his Winston Churchill — The Struggle for Survival. It was acclaimed by historians, but bitterly criticised by Churchill’s family and friends and by the medical profession for breach of confidentiality.
Clement Attlee had two illnesses that, although not life-threatening, did influence our nation.
On 1 September 1939, Germany invaded Poland, whose sovereignty had been guaranteed by Britain and France. Parliament met the next day and the Prime Minister, Neville Chamberlain, spoke. Many MPs thought he wavered, and feared that instead of declaring war immediately he might be considering further concessions by Poland to Hitler. The Tory Chief Whip despaired. It was the turn of the Labour Leader of the Opposition to reply, but Attlee was sick, convalescing after an unsuccessful prostate operation. When his deputy, Arthur Greenwood, rose to speak, the Conservative MP Leopold Amery shouted out, “Speak for England!” Greenwood made the speech of his career, probably more effective than any Attlee would have given, ending: “I wonder how long we are prepared to vacillate at a time when Britain and all that Britain stands for, and human civilisation, are in peril. We must march with the French.”
Attlee’s 1945 Labour government was re-elected in 1950, but with a smaller majority. In the financial crisis of 1951, when cuts were needed, the National Health Service, as was to become usual for all governments, was the target. Naturally, Aneurin Bevan, by then the Minister of Labour, fought to protect what he always considered his Health Service from a £10 million cut. At the Cabinet meeting on 22 March, Bevan reluctantly accepted a one-shilling charge for the until-then free prescriptions, but
refused to allow a payment for spectacles and false teeth. The Chancellor, Hugh Gaitskell, demanded all the cuts.
Meanwhile, Attlee had a recurrence of a chronic duodenal ulcer, for which he had been in hospital in 1948, and on 21 March 1951 he was admitted to a single room of the Lindo private wing of St Mary’s for five weeks of what should have been complete bed rest. On 9 April, Herbert Morrison, the Foreign Secretary, chaired the Cabinet and instead of achieving a compromise, allowed a vote that approved all Gaitskell’s NHS cuts. That day, Attlee was visited by Morrison, who wanted him to insist on Bevan
accepting the Cabinet’s decision. Next came Bevan and the President of the Board of Trade Harold Wilson to press their point of view. Attlee urged them not to resign on this issue, because he knew it would split the party and lose Labour the next election. Finally that evening, Gaitskell came in, refused to compromise and threatened to resign if Attlee backed Bevan.
The next day, the Budget was presented in the Commons and Gaitskell announced his cuts. Bevan and Wilson were joined by the Parliamentary Secretary John Freeman and again threatened to resign while Morrison, Gaitskell and others insisted that the PM force Bevan to resign unless he accepted not only the NHS cuts but also a rearmament programme for the Korean War. On 23 April, Bevan and Wilson resigned, to be joined by Freeman the next day. Attlee left hospital on 27 April, Labour split, lost the election on 25 October and the Conservatives held office for the next 13 years, the second-longest single party reign in 20th-century Britain.
Attlee always maintained that if he had not been in hospital and had chaired the Cabinet instead of Morrison, he could have effected a compromise, especially because the defence budget estimate was never fully spent, making the NHS cuts unnecessary. Wilson’s judgment was similar but others are convinced that the Gaitskell vs. Bevan conflict was incurable. However, I do not consider that Attlee’s ministers or his historians appreciated that in 1951, the object of admitting a patient with a peptic ulcer to hospital was complete bed rest. Attlee, normally master of his government’s prima donnas, confined to a tiny room, probably without en suite facilities, given a tasteless ulcer diet, prevented from smoking and conventionally sedated with barbiturates, was no match for the endless importuning visitors. Nevertheless, at least my predecessors at St Mary’s cured Attlee’s ulcer.
Anthony Eden had a charmed early life as the younger son of a country baronet. He was tall, handsome and immaculately dressed and had high self-esteem. He went to Eton, had a gallant war with a Military Cross, took a First at Christ Church in Arabic and Persian, won a safe Conservative seat and saw rapid promotion in the Foreign Office. Yet it has been said that Eden “was ill-served by his doctors”.
In March 1935, Eden had an exhausting trip with Viscount Cranborne (the future Lord Salisbury) to Paris, Berlin, Moscow, Warsaw and Prague. On his flight home, his plane was caught in a severe snowstorm, and had to land in Cologne. Eden had been so shaken and airsick, with a pulse rate of only 40 per minute, that he was immediately seen by a doctor who pronounced his heart “sehr schlecht” — very bad — and put him to bed in a hotel. The next morning, a specialist was equally gloomy about Eden’s heart and vetoed his plans to fly home. He returned to London by train and boat. King George V telephoned and ordered him seen by Sir Maurice Cassidy, the royal heart specialist. The electrocardiogram was said to show heart strain, and he was sent to a nursing home for four weeks, followed by two weeks at home. Naturally, there was a bulletin: “Mr Anthony Eden is suffering from heart strain resulting from his recent rough air journey. There is no cause for anxiety, but complete rest is essential for from four to six weeks.” This was followed by a dozen almost daily bulletins in The Times until the last on 9 May: “He has now recovered from the overstrain and will resume his work at the Foreign Office next month.”
In retrospect, I consider that on his flight, Eden had an episode of vasovagal syncope (fainting), and not a myocardial infarct (heart attack), and his six weeks’ rest was unnecessary. Nevertheless, as a
result Eden missed the Anglo-Franco-Italian conference at Stresa on 11-14 April. Before they travelled to Stresa, the Prime Minister (the demented Ramsay MacDonald) and his Foreign Secretary (John Simon) visited Eden, who has stated that he implored them to ensure that the conference faced up to German rearmament, agreed to prevent the Nazis from annexing Austria and stopped Italy invading Abyssinia. The British ministers, even when prodded by Robert Vansittart (the Foreign Office permanent under-secretary), failed totally. A French paper detailing the German army’s activities in the Rhineland was not presented, nor was the integrity of Austria and Abyssinia guaranteed. MacDonald by now was mentally almost incoherent and Simon unassertive. Eden later implied that if he had been there “Stresa might have influenced history” as a last chance to prevent the Second World War. His speculation is most unlikely because by then the appeasement of Germany was irreversible and war inevitable.
Eden was troubled from the 1920s by ulcer pain. He was periodically tired, exhausted and unwell during the war, with a recurrence of his duodenal ulcer in 1945. In March 1953, Marshal Tito commented on Eden’s colour. Eden was indeed jaundiced and X-rays in April showed gallstones. Sir Horace Evans advised an immediate operation by one of three biliary surgeons he recommended, but Eden insisted on choosing the general surgeon who had removed his appendix in 1948. On 9 April, the gall bladder was removed but other structures were damaged. A second three-hour operation saved his life, and he was advised to have a third operation by Richard Cattell in Boston. This eight-hour operation in May stabilised his condition, but Cattell warned that there would probably be further episodes of cholangitis (inflammation of the biliary ducts). Cattell was proved right in his prognosis.
Eden returned to London to find Churchill back at work. For the next two years, Churchill frequently promised to resign only to recant. Eden was left ever more frustrated and embittered. However, like Lord Rosebery, Foreign Secretary in Gladstone’s last premiership, Eden was too loyal to plot against his leader. Horace Evans had agreed that Eden’s health could allow him to succeed Churchill. Eden was left with the Suez problem that ended his career.
Eden: Forced to resign through ill-health
On 21 August 1956, Eden woke with severe pain, needing pethidine, and in October had a febrile episode of 106° Fahrenheit and spent three nights in University College Hospital. His periodic fevers continued with increasing exhaustion. Meanwhile, Eden continued his plans to attack Egypt. Fighting began on 31 October. On 19 November, Evans ordered complete rest in a warm climate. Eden flew to Jamaica on 23 November. He returned on 14 December, only to have recurrent fevers at Christmas. On New Year’s Day 1957, Evans told Eden and his wife that his illness would disable him from continuing as Prime Minister. On 7 January, Evans brought in Sir Gordon Gordon-Taylor (who had taught me surgery at the Middlesex) and Dr Thomas Hunt, both of whom firmly confirmed Evans’s advice. They all signed the inevitable bulletin: “The Prime Minister’s health gives cause for anxiety. In spite of the improvement which followed his rest before Christmas, there has been a recurrence of abdominal symptoms. This gives us much concern because of the serious operations in 1953 and some subsequent attacks of fever. In our opinion, his health will no longer enable him to sustain the heavy burdens inseparable from the office of Prime Minister.”
Eden resigned the next day. Ennobled as Earl of Avon, he lived for another 20 years, in variable ill-health with periodic fevers, and needed a further major operation in Boston in 1970.
There has been considerable debate over how much of Eden’s Suez disaster could be attributed to his illnesses and his prescribed medication, especially barbiturates, as well as hypnotics and stimulants for his depression. Amphetamines had been used in this way from the 1930s, and in the 1950s were still the only available antidepressant. Many of those who knew him well, including his doctors, doubt this hypothesis. Tommy Hunt’s considered opinion was that Eden would not have acted very differently in the Suez crisis if he had been in robust health.
I am not a political historian, I am a physician, but in both London and New York I have been involved in teaching bioethics. I pose eight questions, bearing in mind that I knew or met all the British doctors I named.
(1) Churchill replaced Hunt by Wilson as his medical adviser because Hunt refused to cancel another patient’s appointment to fit in Churchill.
Should a doctor allow a VIP to dislodge an ordinary citizen? And if Hunt had been Churchill’s physician, would he have acted differently?
(2) Moran took it on his own head to lie to Churchill about his heart attack in Washington because this diagnosis would have crippled Churchill and wrecked American esteem of Britain as an ally.
Did this reason of state justify a physician concealing the truth from his patient and the public?
(3) Moran never used the words dementia or senility. Moran and Brain knew of Churchill’s strokes before he fought and won the 1951 election, let alone those in the following four years.
Should they have tried to prevent his return to office?
(4) Moran and Brain’s truthful bulletin about Churchill was banned by Salisbury and Butler, who wrote instead an untrue one for them to sign.
Should doctors sign a bulletin that conceals the truth from the public?
(5) Moran’s book is a major contribution to the Churchill saga, but it broke confidentiality. In France, François Mitterrand’s doctor was struck off for revealing the President’s prostate cancer eight days after his death. Currently, the French Justice Minister’s obstetrician faces censure for boasting that he got her back to work in record time after her Caesarian section.
How long should a doctor wait to publish before breaking confidential personal clinical details?
(6) Attlee’s doctors ordered him to take five weeks’ bed rest in St Mary’s that cured his duodenal ulcer, but led to the Labour Party being out of power for 13 years.
Would banning visitors have made any difference?
(7) Sir Horace Evans combined the clinical acumen of Lord Horder with the great charm of Lord Dawson. He considered that a gall bladder operation should be done by a biliary surgeon, and gave three names to Eden, who insisted on a general surgeon.
Should Evans have frightened Eden by listing all the mishaps that could, and indeed did, happen after a cholecystectomy?
(8) Horace Evans allowed Eden his lifetime ambition by succeeding Churchill in April 1955, and then had to send him off to Jamaica on 19 November 1956.
Could he or should he have intervened earlier, perhaps avoiding the Suez debacle?
The many doctors who have written about the major illnesses of world leaders concur that the public are entitled to full disclosure of candidates’ medical data. I agree.