The English patient: Britten in 1968. Photograph: Cecil Beaton Studio Archive, Courtesy of National Portrait Gallery.
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Notes from a cardiologist: Unravelling the mystery of Benjamin Britten’s heart

Cardiologist Hywel Davies describes the origins of the syphilis claim from Paul Kildea's biography of Benjamin Britten, which began as an "ordinary conversation" in a colleague's house in the late 1980s.

In 1892, William Osler published the first edition of The Principles and Practice of Medicine, in which he stated that tertiary syphilis of the nervous system, known then as general paralysis of the insane, was due to stress. Not many years later, a bacterium, called the spirochaete, was identified as the cause of syphilis and Osler was obliged to modify his textbook for the next edition. I thought of Osler’s dilemma in the context of Paul Kildea’s recent biography Benjamin Britten: a Life in the 20th Century, which claims that Britten had syphilis. The very public denials of this, some of them by people who could not possibly know one way or the other, along with the calls for revisions in the second edition, brought Osler to mind.

In assessing this, I can only gather what seems to be reasonable evidence on either side. For me, this begins with the testimony of my friend and colleague Donald Ross, the surgeon who operated on Britten’s heart on 7 May 1973 at the National Heart Hospital in London. During this procedure, he and his assistant surgeon would have inspected the heart thoroughly, at close range and from all available angles, using feel as well as vision, inside and out. Ross cut out the native aortic valve and replaced it with a homograft, which is made of tissue from a human source. This has the practical advantage of not requiring the use of anticoagulants to prevent clots forming later on the valve, as would have been the case with a mechanical prosthesis.

Ross recorded his impressions in his operative report written immediately after the surgery. This has recently been lodged at the Britten-Pears library, together with a selection of other records from Britten’s medical history, which I have been able to examine. Apart from his account of the procedure, Ross expresses clearly that when he was in theatre he was not able to tell, with any degree of assurance, exactly which disease process he was looking at, writing: “The aetiology of this valve lesion is not clear to me and certainly not characteristic of bacterial endocarditis, nor was the valve of bicuspid structure which would suggest a congenital valve.” The significance of these words is that Britten in 1968 had been treated with heavy and prolonged doses of penicillin for bacterial endocarditis, which means infection on the heart valve. There was none of the expected evidence “whatsoever” on the valve of previous infection from bacterial endocarditis. Nor were there signs of a congenitally deformed valve, since those are usually bicuspid (have only two cusps). This speaks against heart disease in infancy and childhood.

Ross adds that, on closure of the aortotomy (the initial incision in the aorta), the heart “came off bypass without difficulty”, yet: “The external appearances were those of an enlarged, bulky and flabby myocardium with a poorly contracting left ventricle.” In other words, none of the explanations given up to that point for the weakness of Britten’s heart, many of them involving assumptions that Britten had carried since childhood, appeared to be borne out. Ross proceeded to take biopsies from several parts of the heart that, together with the excised valve, were sent to the pathologists for their opinions about what the abnormal appearances might represent. He underlined the word “biopsy” each time he used it, as if to emphasise how critical the information would be to his conclusion.

In recent months, some commentators have asserted that Ross would have announced his thoughts and reservations at once in the operating theatre. On the contrary, it is extremely unlikely that he would have done this, for both intellectual and social reasons. Unclear about causes, he would never have speculated openly about such matters to what was a semi-public audience. He did, at the same time, make clear in his notes that he had been looking at something that was in his wide experience most unusual. It would have taken some weeks for the specimens to be studied and reported on before being reviewed by him. It would not – nor should it – have been a quick and hurried process. Unfortunately, if the reports of the biopsies, together with those of the relevant blood tests, were ever included in Britten’s other medical reports, they are no longer with them, but Ross would have insisted that he see them and they would have been an essential element when he came to draw his conclusions.

Over years of working with and discussing such things with Ross, I came to appreciate how keen and incisive his judgement always was in cardiac and other matters. He probably had as great an experience of assessing beating hearts as anyone before or since and a marked interest in anatomy and structure that he pursued in academic quarters. Between 1964 and 1973, 850 patients, many of them Ross’s, underwent aortic valve replacement at the National Heart Hospital and he worked elsewhere, too. As a cardiologist at Guy’s in the 1960s, I worked closely with him on the launching of his new technique of homograft valve replacement; the world’s first case, naturally in his hands, was my patient. I cared for and studied many of his homograft patients after that.         

Thus, when, during an ordinary conversation in his house in the late 1980s, Ross chose to tell me that Britten’s heart was syphilitic, I took him at his word, knowing that his opinion was that of a seasoned professional at the peak of his power in his field of expertise. I asked no further questions, except one to his assistant surgeon, present on the same occasion, as to whether he concurred with Ross’s conclusion, which he did. Beyond that, I had no particular interest in the story and did not speak to anyone about it.

Except one person. When I lived and worked in Colorado in the 1960s and again in the 1980s, one of my friends was a senior medical scientist named Basil Reeve, an Englishman who had grown up in Lowestoft with Britten, had known him well and had played the piano with him. A qualified doctor, Basil was also friendly in the Second World War with the philosopher Ludwig Wittgenstein, then working at Guy’s Hospital as a porter during the Blitz. One day in the early 1990s when I was visiting Denver again, Basil and I were having lunch in a local restaurant. He talked about these friends and, knowing his interest in Britten, I saw no reason not to mention to him what Ross had told me freely and without pledging me to silence.   

I was surprised, however, that Basil’s reaction was swift and pointed. He said: “The world should know it and we should make the information public.” I had no wish to do this and I declined to go along with his request. He repeated it a few times on the telephone during the following years and, although I realised how strongly he felt about it, I still chose to say no. Shortly after his last request, I sold my home in Switzerland and moved elsewhere. A couple of years later, I happened to call at Basil’s house during another visit to Denver. When he opened the front door, his face paled and he said, “Good God, I thought you were dead.” He explained that in the interim he had phoned again to Switzerland to repeat his request, to be told by the operator that the line had been discontinued and I could not be contacted. He drew the perhaps understandable conclusion that I was no more and accordingly felt able to speak about what I had told him. In 1999, he told the story to Kildea, the young head of music at the Aldeburgh Festival. Kildea was sceptical but, when he came to write his biography in 2008, he tracked me down to check Basil’s information. I initially told him that I was not willing to comment but over time came to realise that he was a serious scholar, interested in getting to the bottom of a puzzling case, and I decided to help him with some of the medical aspects of his book.

Based on what Ross and others wrote at the time and what Ross told me later, we may question further what this most experienced surgeon observed in the operating theatre with such puzzlement. First, Britten’s heart was much enlarged, the bulk of this consisting of a very thick left ventricle. The reason for this was ostensibly a long-standing aortic valve insufficiency – leakage backwards from the aorta into the ventricle after the aortic valve closes. The immediate reason for the enlargement and thickening (hypertrophy) of cardiac muscles is usually excessive work, as occurs in other muscles of the body. Leakage in the aortic valve results in an increase in the amount of blood the heart has to pump.

There are two conflicting descriptions of the condition and function of Britten’s ventricle that appear in the clinical notes. The first is the report on the pre-operative angiogram, which states that the left ventricle “contracts vigorously”. The second is the operation note in which Ross describes the enlarged, bulky and flabby muscle and poorly contracting left ventricle. The use of the word “flabby” speaks for itself and Ross inserted special sutures in an attempt to secure the new valve in the friable, weakened tissue. A month after the operation, Britten’s cardiologist Graham Hayward wrote to Ian Tait, Britten’s GP in Aldeburgh: “He presented us with many problems, as you know, during and after surgery as his heart was much larger and worse than one anticipated.”

The reasons for these “many problems” might not have been evident to the surgeons. They would have gone through the main possibilities, including those that the consultant physician John Paulley of Ipswich spelled out in 1960 after seeing Britten. He was the first, it appears, to make the diag nosis of aortic valve insufficiency and, in a letter to Tait, he asked the latter to arrange a WR and Kahn blood test, the standard for syphilis. He could have ordered one himself but he preferred that Tait did it. (“Reasons will probably be obvious to you?”) We must assume that the test was carried out. Paulley’s request is proof, if any were necessary, that syphilis was and still is a major diagnostic possibility in a patient with aortic valve insufficiency. Ross would have known as well as Osler that syphilis is a great mimic of other diseases and a negative blood test does not rule out the disease, especially in patients who had been treated heavily with penicillin, as Britten had.

I have taken a position in this matter largely because I find that the strongest evidence we have is that of the surgeons and I do not believe their conclusions should be cast aside lightly. (In the 1970s, the assistant surgeon passed on Ross’s conclusions to a senior colleague who repeated them to Kildea, so I was not the only route by which they reached him.) On the basis of Ross’s surgical report and his unequivocal opinion, it seems that Kildea is substantially right in what he says, though some amendments to wording, to reflect what we now know from the report, could be made before the next edition of his book. This is a sentiment with which Osler, if he were here, might well approve.

In a long career as a consultant cardiologist, Hywel Davies held posts in leading London and US hospitals before being invited by Sir Terence English to be the cardiologist to the cardiac transplant team at Papworth Hospital

This article first appeared in the 10 June 2013 issue of the New Statesman, G0

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The secret anti-capitalist history of McDonald’s

As a new film focuses on the real founder of McDonald’s, his grandson reveals the unlikely story behind his family’s long-lost restaurant.

One afternoon in about the year 1988, an 11-year-old boy was eating at McDonald’s with his family in the city of Manchester, New Hampshire. During the meal, he noticed a plaque on the wall bearing a man’s face and declaring him the founder of McDonald’s. These plaques were prevalent in McDonald’s restaurants across the US at the time. The face – gleaming with pride – belonged to Ray Kroc, a businessman and former travelling salesman long hailed as the creator of the fast food franchise.

Flickr/Phillip Pessar

But this wasn’t the man the young boy munching on fries expected to see. That man was in the restaurant alongside him. “I looked at my grandfather and said, ‘But I thought you were the founder?’” he recalls. “And that’s when, in the late Eighties, early Nineties, my grandfather went back on the [McDonald’s] Corporation to set the history straight.”

Jason McDonald French, now a 40-year-old registered nurse with four children, is the grandson of Dick McDonald – the real founder of McDonald’s. When he turned to his grandfather as a confused child all those years ago, he spurred him on to correct decades of misinformation about the mysterious McDonald’s history. A story now being brought to mainstream attention by a new film, The Founder.


Jason McDonald French

“They [McDonald’s Corporation] seemed to forget where the name actually did come from,” says McDonald French, speaking on the phone from his home just outside Springfield, Massachusetts.

His grandfather Dick was one half of the McDonald brothers, an entrepreneurial duo of restaurateurs who started out with a standard drive-in hotdog stand in California, 1937.

Dick's father, an Irish immigrant, worked in a shoe factory in New Hampshire. He and his brother made their success from scratch. They founded a unique burger restaurant in San Bernardino, around 50 miles east of where they had been flogging hotdogs. It would become the first McDonald’s restaurant.

Most takeout restaurants back then were drive-ins, where you would park, order food from your car, and wait for a “carhop” server to bring you your meal on a plate, with cutlery. The McDonald brothers noticed that this was a slow, disorganised process with pointless costly overheads.

So they invented fast food.

***

In 1948, they built what came to be known as the “speedy system” for a fast food kitchen from scratch. Dick was the inventor out of the two brothers - as well as the bespoke kitchen design, he came up with both the iconic giant yellow “M” and its nickname, the “Golden Arches”.

“My grandfather was an innovator, a man ahead of his time,” McDonald French tells me. “For someone who was [only] high school-educated to come up with the ideas and have the foresight to see where the food service business was going, is pretty remarkable.”


The McDonald brothers with a milkshake machine.

McDonald French is still amazed at his grandfather’s contraptions. “He was inventing machines to do this automated system, just off-the-cuff,” he recalls. “They were using heat lamps to keep food warm beforehand, before anyone had ever thought of such a thing. They customised their grills to whip the grease away to cook the burgers more efficiently. It was six-feet-long, which was just unheard of.”

Dick even custom-made ketchup and mustard dispensers – like metal fireplace bellows – to speed up the process of garnishing each burger. The brothers’ system, which also cut out waiting staff and the cost of buying and washing crockery and cutlery, brought customers hamburgers from grill to counter in 30 seconds.


The McDonald brothers as depicted in The Founder. Photo: The Founder

McDonald French recounts a story of the McDonald brothers working late into the night, drafting and redrafting a blueprint for the perfect speedy kitchen in chalk on their tennis court for hours. By 3am, when they finally had it all mapped out, they went to bed – deciding to put it all to paper the next day. The dry, desert climate of San Bernardino meant it hadn’t rained in months.

 “And, of course, it rained that night in San Bernardino – washed it all away. And they had to redo it all over again,” chuckles McDonald French.

In another hiccup when starting out, a swarm of flies attracted by the light descended on an evening event they put on to drum up interest in their restaurant, driving customers away.


An original McDonald's restaurant, as depicted in The Founder. Photo: The Founder

***

These turned out to be the least of their setbacks. As depicted in painful detail in John Lee Hancock’s film, Ray Kroc – then a milkshake machine salesman – took interest in their restaurant after they purchased six of his “multi-mixers”. It was then that the three men drew up a fateful contract. This signed Kroc as the franchising agent for McDonald’s, who was tasked with rolling out other McDonald’s restaurants (the McDonalds already had a handful of restaurants in their franchise). 

Kroc soon became frustrated at having little influence. He was bound by the McDonalds’ inflexibility and stubborn standards (they wouldn’t allow him to cut costs by purchasing powdered milkshake, for example). The film also suggests he was fed up with the lack of money he was making from the deal. In the end, he wriggled his way around the contract by setting up the property company “McDonald’s Corporation” and buying up the land on which the franchises were built.


Ray Kroc, as depicted in The Founder. Photo: The Founder

Kroc ended up buying McDonald’s in 1961, for $2.7m. He gave the brothers $1m each and agreeing to an annual royalty of half a per cent, which the McDonald family says they never received.

“My father told us about the handshake deal [for a stake in the company] and how Kroc had gone back on his word. That was very upsetting to my grandfather, and he never publicly spoke about it,” McDonald French says. “It’s probably billions of dollars. But if my grandfather was never upset about it enough to go after the Corporation, why would we?”

They lost the rights to their own name, and had to rebrand their original restaurant “The Big M”. It was soon put out of business by a McDonald’s that sprang up close by.


An original McDonald restaurant in Arizona. Photo: Flickr/George

Soon after that meal when the 11-year-old Jason saw Kroc smiling down from the plaque for the first time, he learned the true story of what had happened to his grandfather. “It’s upsetting to hear that your family member was kind of duped,” he says. “But my grandfather always had a great respect for the McDonald’s Corporation as a whole. He never badmouthed the Corporation publicly, because he just wasn’t that type of man.”

Today, McDonalds' corporate website acknowledges the McDonalds brothers as the founders of the original restaurant, and credits Kroc with expanding the franchise. The McDonald’s Corporation was not involved with the making of The Founder, which outlines this story. I have contacted it for a response to this story, but it does not wish to comment.

***

Dick McDonald’s principles jar with the modern connotations of McDonald’s – now a garish symbol of global capitalism. The film shows Dick’s attention to the quality of the food, and commitment to ethics. In one scene, he refuses a lucrative deal to advertise Coca Cola in stores. “It’s a concept that goes beyond our core beliefs,” he rants. “It’s distasteful . . . crass commercialism.”

Kroc, enraged, curses going into business with “a beatnik”.


Photo: The Founder

Dick’s grandson agrees that McDonald’s has strayed from his family’s values. He talks of his grandfather’s generosity and desire to share his wealth – the McDonald brothers gave their restaurant to its employees, and when Dick returned to New Hampshire after the sale, he used some of the money to buy new Cadillacs with air conditioning for his old friends back home.

“[McDonald’s] is definitely a symbol of capitalism, and it definitely sometimes has a negative connotation in society,” McDonald French says. “If it was still under what my grandfather had started, I imagine it would be more like In'N'Out Burger [a fast food chain in the US known for its ethical standards] is now, where they pay their employees very well, where they stick to the simple menu and the quality.”

He adds: “I don’t think it would’ve ever blossomed into this, doing salads and everything else. It would’ve stayed simple, had quality products that were great all the time.

“I believe that he [my grandfather] wasn’t too unhappy that he wasn’t involved with it anymore.”


The McDonald’s Museum, Ray Kroc’s first franchised restaurant in the chain. Photo: Wikimedia Commons

Despite his history, Dick still took his children and grandchildren to eat at McDonald’s together – “all the time” – as does Jason McDonald French with his own children now. He’s a cheeseburger enthusiast, while his seven-year-old youngest child loves the chicken nuggets. But there was always a supersize elephant in the room.

“My grandfather never really spoke of Ray Kroc,” he says. “That was always kind of a touchy subject. It wasn’t until years later that my father told us about how Kroc was not a very nice man. And it was the only one time I ever remember my grandfather talking about Kroc, when he said: ‘Boy, that guy really got me.’”

The Founder is in UK cinemas from today.

Anoosh Chakelian is senior writer at the New Statesman.