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

MARTIN O’NEILL
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The new young fogeys

Today’s teens and twentysomethings seem reluctant to get drunk, smoke cigarettes or have sex. Is abstinence the new form of youth rebellion?

In a University College London lecture theatre, all eyes are on an elaborate Dutch apple cake. Those at the back have stood up to get a better look. This, a chorus of oohs and aahs informs me, is a baked good at its most thrilling.

In case you were wondering, UCL hasn’t rented out a room to the Women’s Institute. All thirty or so cake enthusiasts here are undergraduates, aged between 18 and 21. At the third meeting this academic year of UCL’s baking society, the focus has shifted to a Tupperware container full of peanut butter cookies. One by one, the students are delivering a brief spiel about what they have baked and why.

Sarah, a 19-year-old human sciences undergraduate, and Georgina, aged 20, who is studying maths and physics, help run the baking society. They tell me that the group, which was set up in 2012, is more popular than ever. At the most recent freshers’ fair, more than 750 students signed up. To put the number in perspective: that is roughly 15 per cent of the entire first-year population. The society’s events range from Great British Bake Off-inspired challenges to “bring your own cake” gatherings, such as today’s. A “cake crawl”, I am told, is in the pipeline. You know, like a pub crawl . . . but with cake? Georgina says that this is the first year the students’ union has advertised specifically non-drinking events.

From the cupcake boom to the chart-topping eminence of the bow-tie-wearing, banjo-plucking bores Mumford & Sons, the past decade of youth culture has been permeated by wholesomeness. According to the Office for National Statistics (ONS), this movement is more than just aesthetic. Not only are teenage pregnancies at their lowest level since records began in the 1960s, but drug-taking, binge drinking and sexually transmitted infections among young people have also taken significant dives. Drug use among the under-25s has fallen by a quarter over the past ten years and heavy drinking – measured by how much a person drinks in an average week – is down by 15 per cent. Cigarettes are also losing their appeal, with under-25 smokers down by 10 per cent since 2001. Idealistic baby boomers had weed and acid. Disaffected and hedonistic Generation X-ers had Ecstasy and cocaine. Today’s youth (which straddles Generations Y and Z) have cake. So, what shaped this demographic that, fairly or otherwise, could be called “Generation Zzzz”?

“We’re a lot more cynical than other generations,” says Lucy, a 21-year-old pharmacy student who bakes a mean Welsh cake. “We were told that if we went to a good uni and got a good job, we’d be fine. But now we’re all so scared we’re going to be worse off than our parents that we’re thinking, ‘Is that how we should be spending our time?’”

“That” is binge drinking. Fittingly, Lucy’s dad – she tells me – was an anarchist with a Mohawk who, back home in the Welsh valleys, was known to the police. She talks with deserved pride about how he joined the Conservative Party just to make trouble and sip champagne courtesy of his enemies. Lucy, though decidedly Mohawk-free, is just as politically aware as her father. She is concerned that she will soon graduate into a “real world” that is particularly hard on women.

“Women used to be a lot more reliant on men,” she says, “but it’s all on our shoulders now. One wage isn’t enough to support a family any more. Even two wages struggle.”

***

It seems no coincidence that the downturn in drink and drugs has happened at the same time as the worst financial crisis since the Great Depression. Could growing anxiety about the future, combined with a dip in disposable income, be taming the under-25s?

“I don’t know many people who choose drugs and alcohol over work,” says Tristan, a second-year natural scientist. He is one of about three men at the meeting and it is clear that even though baking has transcended age it has yet to transcend gender to the same extent. He is softly spoken and it is hard to hear him above a room full of sugar-addled youths. “I’ve been out once, maybe, in the past month,” he says.

“I actually thought binge drinking was quite a big deal for our generation,” says Tegan, a 19-year-old first-year linguistics undergraduate, “but personally I’m not into that. I’ve only been here three weeks and I can barely keep up with the workload.”

Tegan may consider her drinking habits unusual for someone her age but statistically they aren’t. Over a quarter of the under-25s are teetotal. Neither Tegan nor Lucy is dull. They are smart, witty and engaging. They are also enthusiastic and seemingly quite focused on work. It is this “get involved” attitude, perhaps, that distinguishes their generation from others.

In Absolutely Fabulous, one of the most popular British sitcoms of the 1990s, a lot of the humour stems from the relationship between the shallow and fashion-obsessed PR agent Edina Monsoon and her shockingly straitlaced teenage daughter, Saffie. Although Saffie belongs to Generation X, she is its antithesis: she is hard-working, moral, politically engaged, anti-drugs and prudishly anti-sex. By the standards of the 1990s, she is a hilarious anomaly. Had Ab Fab been written in the past couple of years, her character perhaps would have been considered too normal. Even her nerdy round glasses and frumpy knitted sweaters would have been considered pretty fashionable by today’s geek-chic standards.

Back in the UCL lecture theatre, four young women are “geeking out”. Between mouthfuls of cake, they are discussing, with palpable excitement, a Harry Potter-themed summer camp in Italy. “They play Quidditch and everything – there’s even a Sorting Hat,” says the tall, blonde student who is leading the conversation.

“This is for children, right?” I butt in.

“No!” she says. “The minimum age is actually 15.”

A kids’ book about wizards isn’t the only unlikely source of entertainment for this group of undergraduates. The consensus among all the students I speak to is that baking has become so popular with their demographic because of The Great British Bake Off. Who knew that Mary Berry’s chintzy cardigans and Sue Perkins’s endless puns were so appealing to the young?

Are the social and economic strains on young people today driving them towards escapism at its most gentle? Animal onesies, adult ball pools (one opened in west London last year) and that much-derided cereal café in Shoreditch, in the East End, all seem to make up a gigantic soft-play area for a generation immobilised by anxiety.

Emma, a 24-year-old graduate with whom I chatted on email, agrees. “It feels like everyone is more stressed and nervous,” she says. “It seems a particularly telling sign of the times that adult colouring-in books and little, cutesy books on mindfulness are such a massive thing right now. There are rows upon rows of bookshelves dedicated solely to all that . . . stuff.” Emma would know – she works for Waterstones.

From adult colouring books to knitting (UCL also has a knitting society, as do Bristol, Durham, Manchester and many more universities), it is hard to tell whether the tsunami of tweeness that has engulfed middle-class youth culture in the past few years is a symptom or a cause of the shrinking interest in drugs, alcohol, smoking and other “risk-taking” behaviours.

***

Christine Griffin is Professor of Social Psychology at Bath University. For the past ten years, she has been involved in research projects on alcohol consumption among 18-to-25-year-olds. She cites the recession as a possible cause of alcohol’s declining appeal, but notes that it is only part of the story. “There seems to be some sort of polarisation going on,” Griffin says. “Some young people are actually drinking more, while others are drinking less or abstaining.

“There are several different things going on but it’s clear that the culture of 18-to-25-year-olds going out to get really drunk hasn’t gone away. That’s still a pervasive social norm, even if more young people are drinking less or abstaining.”

Griffin suggests that while frequent, sustained drinking among young people is in decline, binge drinking is still happening – in short bursts.

“There are still a lot of people going to music festivals, where a huge amount of drinking and drug use goes on in a fairly unregulated way,” she says. It is possible that music festivals and holidays abroad (of the kind depicted in Channel 4 programmes such as What Happens in Kavos, in which British teenagers leave Greek islands drenched in booze and other bodily fluids) are seen as opportunities to make a complete escape from everyday life. An entire year’s worth of drinking, drug-taking and sex can be condensed into a week, or even a weekend, before young people return to a life centred around hard work.

Richard De Visser, a reader in psychology at Sussex University, also lists the economy as a possible cause for the supposed tameness of the under-25s. Like Griffin, however, he believes that the development is too complex to be pinned purely on a lack of disposable income. Both Griffin and De Visser mention that, as Britain has become more ethnically diverse, people who do not drink for religious or cultural reasons – Muslims, for instance – have become more visible. This visibility, De Visser suggests, is breaking down taboos and allowing non-mainstream behaviours, such as not drinking, to become more socially accepted.

“There’s just more variety,” he says. “My eldest son, who’s about to turn 14, has conversations – about sexuality, for example – that I never would’ve had at his age. I think there’s more awareness of alcohol-related problems and addiction, too.”

De Visser also mentions the importance of self-image and reputation to many of the young non-drinkers to whom he has spoken. These factors, he argues, are likely to be more important to people than the long-term effects of heavy drinking. “One girl I interviewed said she wouldn’t want to meet the drunk version of herself.”

Jess, a self-described “granny”, is similarly wary of alcohol. The 20-year-old Liverpudlian, who works in marketing, makes a bold claim for someone her age. “I’ve never really been drunk,” she says. “I’ve just never really been bothered with alcohol or drugs.” Ironically, someone of her generation, according to ONS statistics, is far more likely to be teetotal than a real granny at any point in her life. Jess says she enjoys socialising but her nights out with close friends are rather tame – more likely to involve dinner and one quick drink than several tequila shots and a traffic cone.

It is possible, she suggests, that her lack of interest in binge drinking, or even getting a little tipsy, has something to do with her work ethic. “There’s a lot more competition now,” she says. “I don’t have a degree and I’m conscious of the need to be on top of my game to compete with people who do. There’s a shortage of jobs even for people who do have degrees.”

Furthermore, Jess says that many of her interactions with friends involve social media. One theory put forward to explain Generation Zzzz is that pubs are losing business to Facebook and Twitter as more and more socialising happens online. Why tell someone in person that you “like” their baby, or cat, or new job (probably over an expensive pint), when you can do so from your sofa, at the click of a button?

Hannah, aged 22, isn’t so sure. She recently started her own social media and communications business and believes that money, or the lack of it, is why her peers are staying in. “Going out is so expensive,” she says, “especially at university. You can’t spend out on alcohol, then expect to pay rent and fees.” Like Jess (and as you would probably expect of a 22-year-old who runs a business), Hannah has a strong work ethic. She also has no particular interest in getting wasted. “I’ve always wanted my own business, so for me everything else was just a distraction,” she says. “Our generation is aware it’s going to be a bit harder for us, and if you want to support yourself you have to work for it.” She also suggests that, these days, people around her age have more entrepreneurial role models.

I wonder if Hannah, as a young businesswoman, has been inspired by the nascent strand of free-market, “lean in” feminism. Although the women’s movement used to align itself more with socialism (and still does, from time to time), it is possible that a 21st-century wave of disciples of Sheryl Sandberg, Facebook’s chief operating officer, is forswearing booze, drugs and any remote risk of getting pregnant, in order to get ahead in business.

But more about sex. Do the apparently lower rates of sexually transmitted infections and teenage pregnancies suggest that young people are having less of it? In the age of Tinder, when hooking up with a stranger can be as easy as ordering a pizza, this seems unlikely. Joe Head is a youth worker who has been advising 12-to-21-year-olds in the Leighton Buzzard area of Bedfordshire on sexual health (among other things) for 15 years. Within this period, Head says, the government has put substantial resources into tackling drug use and teen pregnancy. Much of this is the result of the Blair government’s Every Child Matters (ECM) initiative of 2003, which was directed at improving the health and well-being of children and young adults.

“ECM gave social services a clearer framework to access funds for specific work around sexual health and safety,” he says. “It also became a lot easier to access immediate information on drugs, alcohol and sexual health via the internet.”

***

Head also mentions government-funded education services such as Frank – the cleverly branded “down with the kids” anti-drugs programme responsible for those “Talk to Frank” television adverts. (Remember the one showing bags of cocaine being removed from a dead dog and voiced by David Mitchell?)

But Head believes that the ways in which some statistics are gathered may account for the apparent drop in STIs. He refers to a particular campaign from about five years ago in which young people were asked to take a test for chlamydia, whether they were sexually active or not. “A lot of young people I worked with said they did multiple chlamydia tests throughout the month,” he says. The implication is that various agencies were competing for the best results in order to prove that their education programmes had been effective.

However, regardless of whether govern­ment agencies have been gaming the STI statistics, sex education has improved significantly over the past decade. Luke, a 22-year-old hospital worker (and self-described “boring bastard”), says that sex education at school played a “massive part” in his safety-conscious attitude. “My mother was always very open [about sex], as was my father,” he says. “I remember talking to my dad at 16 about my first serious girlfriend – I had already had sex with her by this point – and him giving me the advice, ‘Don’t get her pregnant. Just stick to fingering.’” I suspect that not all parents of millennials are as frank as Luke’s, but teenagers having sex is no longer taboo.

Luke’s attitude towards drugs encapsulates the Generation Zzzz ethos beautifully: although he has taken MDMA, he “researched” it beforehand. It is this lack of spontaneity that has shaped a generation of young fogeys. This cohort of grannies and boring bastards, of perpetual renters and jobseekers in an economy wrecked by less cautious generations, is one that has been tamed by anxiety and fear.

Eleanor Margolis is a freelance journalist, whose "Lez Miserable" column appears weekly on the New Statesman website.

This article first appeared in the 05 February 2015 issue of the New Statesman, Putin's war