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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“I felt so frantic I couldn’t see my screen”: why aren’t we taking mental health sick days?

Some employees with mental health problems fake reasons for taking days off, or struggle in regardless. What should companies be doing differently?

“I would go to the loo and just cry my eyes out. And sometimes colleagues could hear me. Then I would just go back to my desk as if nothing had happened. And, of course, no one would say anything because I would hide it as well as I could.”

How many times have you heard sobbing through a work toilet door – or been the person in the cubicle?

Jaabir Ramlugon is a 31-year-old living in north London. He worked in IT for four years, and began having to take time off for depressive episodes after starting at his company in 2012. He was eventually diagnosed with borderline personality disorder last January.

At first, he would not tell his employers or colleagues why he was taking time off.

“I was at the point where I was in tears going to work on the train, and in tears coming back,” he recalls. “Some days, I just felt such a feeling of dread about going into work that I just physically couldn’t get up ... I wouldn’t mention my mental health; I would just say that my asthma was flaring up initially.”

It wasn’t until Ramlugon was signed off for a couple of months after a suicide attempt that he told his company what he was going through. Before that, a “culture of presenteeism” at his work – and his feeling that he was “bunking off” because there was “nothing physically wrong” – made him reluctant to tell the truth about his condition.

“I already felt pretty low in my self-esteem; the way they treated me amplified that”

Eventually, he was dismissed by his company via a letter describing him as a “huge burden” and accusing him of “affecting” its business. He was given a dismissal package, but feels an alternative role or working hours – a plan for a gradual return to work – would have been more supportive.

“I already felt pretty low in my self-esteem. The way they treated me definitely amplified that, especially with the language that they used. The letter was quite nasty because it talked about me being a huge burden to the company.”

Ramlugon is not alone. Over three in ten employees say they have experienced mental health problems while in employment, according to the Chartered Institute of Personnel and Development. Under half (43 per cent) disclose their problem to their employer, and under half (46 per cent) say their organisation supports staff with mental health problems well.

I’ve spoken to a number of employees in different workplaces who have had varying experiences of suffering from mental ill health at work.

***

Taking mental health days off sick hit the headlines after an encouraging message from a CEO to his employee went viral. Madalyn Parker, a web developer, informed her colleagues in an out-of-office message that she would be taking “today and tomorrow to focus on my mental health – hopefully I’ll be back next week refreshed and back to 100 per cent”.

Her boss Ben Congleton’s reply, which was shared tens of thousands of times, personally thanked her – saying it’s “an example to us all” to “cut through the stigma so we can bring our whole selves to work”.

“Thank you for sending emails like this,” he wrote. “Every time you do, I use it as a reminder of the importance of using sick days for mental health – I can’t believe this is not standard practice at all organisations.”


Congleton went on to to write an article entitled “It’s 2017 and Mental Health is still an issue in the workplace”, arguing that organisations need to catch up:

“It’s 2017. We are in a knowledge economy. Our jobs require us to execute at peak mental performance. When an athlete is injured they sit on the bench and recover. Let’s get rid of the idea that somehow the brain is different.”

But not all companies are as understanding.

In an investigation published last week, Channel 5 News found that the number of police officers taking sick days for poor mental health has doubled in six years. “When I did disclose that I was unwell, I had some dreadful experiences,” one retired detective constable said in the report. “On one occasion, I was told, ‘When you’re feeling down, just think of your daughters’. My colleagues were brilliant; the force was not.”

“One day I felt so frantic I couldn’t see my screen”

One twenty-something who works at a newspaper echoes this frustration at the lack of support from the top. “There is absolutely no mental health provision here,” they tell me. “HR are worse than useless. It all depends on your personal relationships with colleagues.”

“I was friends with my boss so I felt I could tell him,” they add. “I took a day off because of anxiety and explained what it was to my boss afterwards. But that wouldn’t be my blanket approach to it – I don’t think I’d tell my new boss [at the same company], for instance. I have definitely been to work feeling awful because if I didn’t, it wouldn’t get done.”

Presenteeism is a rising problem in the UK. Last year, British workers took an average of 4.3 days off work due to illness – the lowest number since records began. I hear from many interviewees that they feel guilty taking a day off for a physical illness, which makes it much harder to take a mental health day off.

“I felt a definite pressure to be always keen as a young high-flyer and there were a lot of big personalities and a lot of bitchiness about colleagues,” one woman in her twenties who works in media tells me. “We were only a small team and my colleague was always being reprimanded for being workshy and late, so I didn’t want to drag the side down.”

Diagnosed with borderline personality disorder, which was then changed to anxiety and depression, she didn’t tell her work about her illness. “Sometimes I struggled to go to work when I was really sick. And my performance was fine. I remember constantly sitting there sort of eyeballing everyone in mild amusement that I was hiding in plain sight. This was, at the time, vaguely funny for me. Not much else was.

“One day I just felt so frantic I couldn’t see my screen so I locked myself in the bathroom for a bit then went home, telling everyone I had a stomach bug so had to miss half the day,” she tells me. “I didn’t go in the next day either and concocted some elaborate story when I came back.”

Although she has had treatment and moved jobs successfully since, she has never told her work the real reason for her time off.

“In a small company you don’t have a confidential person to turn to; everyone knows everyone.”

“We want employers to treat physical and mental health problems as equally valid reasons for time off sick,” says Emma Mamo, head of workplace wellbeing at the mental health charity Mind. “Staff who need to take time off work because of stress and depression should be treated the same as those who take days off for physical health problems, such as back or neck pain.”

She says that categorising a day off as a “mental health sick day” is unhelpful, because it could “undermine the severity and impact a mental health problem can have on someone’s day-to-day activities, and creates an artificial separation between mental and physical health.”

Instead, employers should take advice from charities like Mind on how to make the mental health of their employees an organisational priority. They can offer workplace initiatives like Employee Assistance Programmes (which help staff with personal and work-related problems affecting their wellbeing), flexible working hours, and clear and supportive line management.

“I returned to work gradually, under the guidance of my head of department, doctors and HR,” one journalist from Hertfordshire, who had to take three months off for her second anorexia inpatient admission, tells me. “I was immensely lucky in that my line manager, head of department and HR department were extremely understanding and told me to take as much time as I needed.”

“They didnt make me feel embarrassed or ashamed – such feelings came from myself”

“They knew that mental health – along with my anorexia I had severe depression – was the real reason I was off work ... I felt that my workplace handled my case in an exemplary manner. It was organised and professional and I wasn’t made to feel embarrassed or ashamed from them – such feelings came from myself.”

But she still at times felt “flaky”, “pathetic” and “inefficient”, despite her organisation’s good attitude. Indeed, many I speak to say general attitudes have to change in order for people to feel comfortable about disclosing conditions to even the closest friends and family, let alone a boss.

“There are levels of pride,” says one man in his thirties who hid his addiction while at work. “You know you’re a mess, but society dictates you should be functioning.” He says this makes it hard to have “the mental courage” to broach this with your employer. “Especially in a small company – you don’t have a confidential person to turn to. Everyone knows everyone.”

“But you can’t expect companies to deal with it properly when it’s dealt with so poorly in society as it is,” he adds. “It’s massively stigmatised, so of course it’s going to be within companies as well. I think there has to be a lot more done generally to make it not seem like it’s such a big personal failing to become mentally ill. Companies need direction; it’s not an easy thing to deal with.”

Until we live in a society where it feels as natural taking a day off for feeling mentally unwell as it does for the flu, companies will have to step up. It is, after all, in their interest to have their staff performing well. When around one in four people in Britain experience mental ill health each year, it’s not a problem they can afford to ignore.

If your manager doesn’t create the space for you to be able to talk about wellbeing, it can be more difficult to start this dialogue. It depends on the relationship you have with your manager, but if you have a good relationship and trust them, then you could meet them one-to-one to discuss what’s going on.

Having someone from HR present will make the meeting more formal, and normally wouldn’t be necessary in the first instance. But if you didn’t get anywhere with the first meeting then it might be a sensible next step.

If you still feel as though you’re not getting the support you need, contact Acas or Mind's legal line on 0300 466 6463.

Anoosh Chakelian is senior writer at the New Statesman.

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