June 10, 2013

FINEST HOUR 134, SPRING 2007

BY JOHN V. BANTA M.D.

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On 2 October 1896, Lt. Winston S. Churchill arrived in India near the Sassoon Dock in Bombay. It was not an auspicious landing.

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“The identity of the designer of Bombay’s Sassoon Dock has not survived, luckily for his reputation,” wrote biographer William Manchester. “It is a triumph of incompetence, so ill-suited to disembarkation that impatient immigrants often chose to come ashore in skiffs, a risky procedure which could cripple a man before he set foot on Indian soil.”¹

This is precisely what happened to young Winston Churchill. As he described the accident in his autobiography, “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.”

Churchill had torn the capsular attachments of his shoulder joint. Although his shoulder did not “go out” at that time, he later noted its persistent instability, with dislocations at various times: when sleeping with his arm beneath a pillow, reaching for a book on a high shelf, or slipping on a staircase. From then on, he experienced repeated subluxations, causing him pain, instability and, by current medical accounts of similar injuries, the awareness that his shoulder would “go out.”

Churchill wrote that this injury was to last him all his life. It would “cripple me at polo…prevent me from ever playing tennis, and [prove] a grave embarrassment in moments of peril, violence and effort.”² In fact, as he noted in November 1897, he suffered a total dislocation as he “slipped on a stone stairs” prior to competing in the Inter-Regimental Polo Tournament in Meerut, India in 1899. Despite this handicap, his regimental team won the tournament, Churchill scoring two goals with his right elbow strapped to his torso with a leather harness!³

The next three paragraphs contain some fairly technical terms which some readers may wish to skim….

The shoulder joint is inherently less stable that the hip joint, because the latter is a ball and socket joint. In medical terms, the proximal end of the humerus has a semicircular articular head, which articulates with the lateral side of the scapula. The lateral portion of the scapula forms a circular enlargement called the glenoid, which has a small concave fossa forming the other side of the shoulder joint. The depth of the glenoid fossa is increased by a circular rim of cartilage: the glenoid labrum, to which is attached the capsule which together with the muscles and tendons, maintains the humeral head in close contact with the glenoid as the arm is moved throughout its great arc of motion.

The shoulder joint is somewhat analogous to a golf ball perched upon a tee whose diameter is approximately two-thirds that of the humeral articular head. When the arm is forcibly raised into a fully flexed overhead position, with the humerus externally rotated, the cartilaginous glenoid labrum is torn, resulting in the humeral head often being forced out of the joint—a frank dislocation.

In the past fifty years our knowledge of shoulder joint instability has been greatly enhanced by improvements in the care of athletic injuries. It is now recognized that many people sustaining the above-described labral and capsular tearing develop shoulder instability, with partial subluxation, the humerus partially riding out of the glenoid. When an affected individual attempts to move his arm into an overhead position or externally rotate the limb, he experiences sudden instability, pain and muscle spasm that disable the upper extremity from further voluntary movements. Athletes with such shoulder instability note sudden pain and loss of control when attempting to reach high overhead, or to the side with their affected arm externally rotated (such as when attempting to block a pass or tackle an opponent).

From a close reading both of Churchill’s descriptions and the accounts by Willam Manchester⁴ and Douglas Russell,’ it would appear that Churchill had sustained injury to the capsular attachments, rendering the shoulder prone to recurrent instability. Obviously, a cavalry officer with chronic instability of his dominant shoulder joint was precluded from effectively wielding his sword in combat.

The history of treatment of recurrent shoulder dislocation is first mentioned in the writings of Hippocrates (ca. 430 B.C.), who advocated creating a restrictive scarring of the front of the shoulder by applying a red hot cautery iron to the anterior axillary fold, and then dressing the resultant burn and binding the extremity across the chest for several weeks for the resultant scarring to limit any significant flexion or external rotation!⁶ By the end of the 19th century, various European surgeons recommended either shoulder fusion or resection of the humeral head to relieve symptoms.? In 1906, Perthes, a German surgeon, first described reattachment of the separated glenoid labrum to the bony rim with sutures.⁸

It was, however, the British surgeon A.S. Blundell Bankhart who, in 1923, perfected the surgical approach and the procedure which is now recognized by his name as the most appropriate repair for this deformity? Bankhart noted that a purely fibrous tear of the capsule would heal; however, there was no tendency for a detached capsule to heal to fibro cartilage at the edge of the bony glenoid unless it were reattached with sutures directly to the edge of the glenoid. As Bankhart’s biographer described, the surgeon was “determined to try it on the next suitable patient. Being a man of integrity, it did not concern him if the patient happened to be a duke or a dustman—it chanced to be one who had recently been his house-surgeon (and incidentally a very nervous type). The operation was a great success.”¹⁰ Bankhart’s procedure remains the standard operative repair for recurrent shoulder dislocation, today often performed by minimally invasive arthroscopic surgical repair.

The options open to Churchill in those days were indeed very limited. The field of elective reconstructivesurgery for the shoulder was not at all well understood at the close of the 19th century. The leading textbook, by the English surgeon William Johnson Walsham in 1903, recommended for chronic dislocations to “inject drops of chloride of zinc 10% into the joint”; should that fail, “an excision of the head of the bone holds the best prospect of relief.” Furthermore, infection was a horrible possibility in the pre-antibiotic era, when wound treatment to prevent septic inflammation consisted of “carbolic acid, perchlorate of mercury, boric acid, permanganate of potash and iodoform.”¹¹ Finally, military surgeons of the day were often required to treat fractures and penetrating wounds sustained during combat. Many of the modern advances in reconstructive orthopaedic surgery evolved with the experience gained by the allied surgeons during World War I.¹²

At the dawn of the 20th century, the accepted surgical techniques were undergoing rigorous reexamination. The world famous neurosurgeon Harvey Cushing, in his address to the International Medical Congress in London in 1913, said: “Observers no longer expect to be thrilled in an operating room; the spectacular public performances of the past, no longer condoned, are replaced by the quiet, rather tedious procedures the patient on the table, like the passenger in a car, runs greater risks if he have a loquacious driver or one who takes close corners, exceeds the speed limit, or rides to admiration.”¹³

After publication of his experiences in northern India, The Story of the Malakand Field Force, Churchill was most anxious to join Kitchner’s army in the Sudan campaign. He vigorously pursued his numerous contacts, both in the army and through family connectio ; in London, resulting in the following July 1898 wire from the War Office: “You have been attached as a supernumerary Lieutenant to the 21st Lancers it is understood that you will proceed at your own expense and that in the event of your being killed or wounded in the impending operations, or for any other reason, no charge of any kind will fall on British Army funds.”¹⁴

Cavalry officer equipment in those days included the Mark I Lee-Enfield carbine, revolvers, and the traditional sabre. Douglas Russell describes two models of the latter: the light and heavy cavalry swords. The latter weighed two pounds two ounces, was 35 1/4 inches long and l/8th inch wide. The standard pistol was an Webley-Wilkinson .455 calibre revolver. This weapon is a six-shot, double action revolver with a four-inch barrel, and a topbreaking, hinged frame, allowing the shooter to extract spent shells and reload.

Russell writes that Churchill purchased his Webley-Wilkinson from Wilkinson in London.¹⁵ Manchester states that Churchill forgot his “regular one, with its lucky silk lanyard, and had to buy a new Mauser pistol.” Churchill stated that he purchased “in London a Mauser automatic pistol, then the newest and latest design.”¹⁶

The Mauser C96—which Churchill admiringly dubbed a “ripper”—was the first efficient self-loading pistol. It was very reliable, since the frame was manufactured from a single solid forging with a ten-cartridge magazine of 7.63 mm ammunition, loaded from in front of the trigger guard. Upon discharge of its ten shells, one had only to reload by inserting a new clip.

On 2 September 1898, Kitchener’s forces were outside Omdurman and Churchill and the 21st Lancers were positioned along a nearby ridge. Ahead of them was a dry wash or khor, which later measured to be about twenty-five feet wide and four feet deep. As the Lancers slowly advanced on orders to “annoy them as far as possible on their flank and head them off if possible from Omdurman,”¹⁷ the regiment came upon what were thought to be a Dervish force of perhaps 150 warriors. Unbeknown to the Lancers, there were in reality nearly 2600 warriors concealed in the deep ravine. The British cavalry advanced at a walk, Churchill in command of the next-to-last troop. As he described the charge:

Before we wheeled and began to gallop the officers had been marching with drawn swords. On account of my shoulder I had always decided that if I were involved in hand-to-hand fighting I must use a pistol and not a sword I had practiced carefully with [the Mauser] during our march and journey up the river. This then was the weapon with which I determined to fight. I had first of all to return my sword into its scabbard, which is not the easiest thing to do at a gallop. I had then to draw my pistol from its wooden holster and bring it to full cock….

The scene appeared to be suddenly transformed. The blue-black men were still firing but behind them there now came into view a depression like a shallow, sunken road. This was crowded with men rising up from the ground where they had hidden. Bright flags appeared as if by magic and I saw arriving from nowhere Emirs on horseback among and around the mass of the enemy. The Dervishes appeared to be ten feet deep at the thickest, a great grey mass gleaming with steel, filling the dry watercourse.
Straight before me a man threw himself on the ground…. simultaneously I saw the gleaming of his sword as he drew back for a hamstringing cut. I had room and time enough to turn my pony out of his reach, and leaning over on the off side I fired two shots into him at about three yards. As I straightened myself in the saddle I saw before me another figure with uplifted sword. I raised my pistol and fired; so close were we that the pistol actually struck him….

Suddenly in the midst of the troop up sprung a Dervish. How he got there I do not know. He must have leaped out of some scrub or hole. All the troopers turned upon him thrusting with their lances: but he darted to and fro, causing for the moment a frantic commotion. Wounded several times, he staggered toward me, raising his spear. I shot him at less than a yard. He fell on the sand and lay there dead….I found I had fired the whole magazine of my Mauser pistol so I put in a new clip of cartridges before thinking of anything else.¹⁸

As Churchill wrote later to a friend: “It was I suppose the most dangerous 2 minutes I shall live to see. Out of 310 officers & men we lost 1 officer and 20 men killed—4 officers and 45 men wounded, and 119 horses of which 56 were bullet wounds. All this in 120 seconds.” In fact, Manchester noted, the casualties suffered by the 21st Lancers were over 22 percent, while the overall losses sustained by Kitchener were less than three percent of his total army.¹⁸

The Battle of Omdurman, Churchill, recalled in My Early Life, was full of “fascinating thrills. It was not like the Great War. Nobody expected to be killed. Here and there in every regiment or battalion, half dozen, a score, at the worst thirty or forty, would pay the forfeit but to the great mass of those who took part in the little wars of Britain in those vanished light-hearted days, this was only a sporting element in a splendid game.”

It is interesting to consider what good fortune Churchill experienced throughout these episodes. In combat he was obviously aware of his shoulder disability, and realized the need to use firearms instead of the usual sword. What is remarkable is his prescience in choosing the Mauser pistol. Did he, as Manchester wrote, “Forget his regular one”? Or was he blessed with the foresight to obtain the latest semi-automatic then available? Had he entered the charge with only his six-shot Webley-Wilkinson, it is entirely likely that he would not have had time to reload in the heat of that brief, intense conflict.

Lord Deedes summarized the historical impact of Omdurman when describing his own visit to the battlefield during a visit a few years ago, with the British ambassador in Khartoum. He described the battlefield memorial, “In memory of the officers, NCOs and the men of the 21st Lancers who fell here.” Then he added: “The first name is that of Lt. Robert Grenfell, one of nine sons, five of whom died in the country’s service, and the cousin of Julian and Billy, who were killed in the First World War. I have speculated since on how far our history might have turned out differently had Churchill’s name been on that memorial.”¹⁹

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ENDNOTES

1. Manchester, William, The Last Lion: Winston Spencer Churchill, vol. I, Visions of Glory 1874-1932. Boston: Little Brown, 1983, 237.
2. Churchill, Winston S., My Early Life: A Roving Commission. London: Thornton Butterworth, 1934.
3. Ibid.
4. Manchester, op. cit.
5. Russell, Douglas S., Winston Churchill, Soldier: The Military Life of a Gentleman at War. London: Brassey’s, 2005.
6. Mosley, H.F., Recurrent Dislocation of the Shoulder. Edinburgh and London: E & S Livingstone Ltd., 1961.
7. Rockwood, C.A. Jr. and Green D. P., Fractures, vol. 3. Philadelphia: Lippincott, 1966.
8. Ibid.
9. Bankhart, A. S. Blundell, Dislocations of the Shoulder Joint, in the Robert Jones Birthday volume, A Collection of Surgical Essays. Oxford Medical Publications, Humphrey Milford. London: Oxford University Press, 1928, 307.
10. Moseley, op. cit.
11. Walsham, William Johnson, Surgery: Its Theory and Practice, 8th edition. London: J & A Churchill, 1903, 576.
12. Jones, Sir Robert, A Collection of Thirteen Papers Concerning Aspects of Orthopaedics, 1899-1932. Address by Michael Phelps. Rare and Interesting Books on Medicine, Catalog 73.
13. Cushing, Harvey, British Medical Journal, London, 1913, 294.
14. Churchill, op. cit., 182.
15. Russell, op. cit., 94.
16. Churchill, op. cit., 204.
17. Ibid., 208.
18. Manchester, op. cit., 279.
19. Deedes, The Lord, “Let the Ghosts of Omdurman Sleep.” Finest Hour 99, Summer 1998, 33.