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

Laura Hynd for New Statesman
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Having the last laugh

How Diane Abbott – overlooked, mocked and marginalised by her own party for three decades – ended up as the closest ally of a Labour leader

“I don’t think you’re up to it.” It is 1970, and Diane Julie Abbott, aged 17, is keen to apply to Cambridge University, but her history teacher has other ideas.

“I was an omnivorous reader,” she says now, sitting in her parliamentary office, in a prime spot overlooking the Thames, “and in all these books, particularly these novels between the wars, if you went to university, you went to Oxford or Cambridge.”

The teachers at Harrow County School for Girls, where Abbott was the only black girl in her class, were not supportive. Her memories are less happy than those of her contemporary Michael Portillo, who attended the affiliated boys’ grammar school, and who played Macduff to her Lady Macduff in a school play.

Even when Abbott succeeded, she was regarded with suspicion. She remembers getting an A-minus in an English class – a mark that disappointed her – and being asked to stay behind by the teacher. “She picked up my essay between her thumb and her forefinger and said: ‘Where did you copy this from?’ I was genuinely shocked.”

The story suggests that she acquired her ability to shrug off criticism early. It is also a reminder of how often she is underestimated. The Times journalist Matt Chorley once described a successful day for Labour as one in which “Diane Abbott was on TV a bit less”. Julie Burchill described her in the Spectator as a “preposterous creature” who “blotted the landscape of English politics, speaking power to truth in order to advance her career”. In the Guardian, Michael White dubbed her a “useful idiot”.

She has been endlessly dismissed as stupid, untalented and bad at politics – an obvious “diversity hire”. These criticisms are immune to evidence: her time at Cambridge, the only black British student from a state school in the entire university; her 12 years on the sofa with Portillo on BBC1’s This Week; her time in the shadow cabinet under Ed Miliband; her reliable ability to hold the line in television interviews; and now her status as Jeremy Corbyn’s closest political ally. She is largely ignored by lobby journalists, even as they lament their failure to secure a line into the Labour leader’s thinking. In 2017, Diane Abbott celebrates her 30th year in parliament. Should we take her seriously?

 

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Abbott’s mother, a nurse, and her father, a welder, were born in the same village in Jamaica, but met and married in London and lived in Notting Hill “before it was a fashionable place to live”. Abbott was born there in 1953, 12 years before the phrase “race relations” first made its way on to the statute books. “My father was very aspirational,” she recalls, “and so every weekend, he and my mother would drive round houses in Pinner, and every Monday they’d ring the estate agent, and the estate agent would say the house had gone. But, of course, the house wasn’t gone.”

Eventually, they did buy a house, not in Pinner but in Edgware, north London. “My brother – his best friend was Jewish,” she tells me, “and he’d attend the Jewish youth club with his friend, and one day his friend said in a really embarrassed way: ‘I’m really sorry, I’m afraid you can’t continue to attend the club, because they’re afraid it will encourage the girls to marry out.’

“The thing was,” she continues, “my brother was upset about this. We were all upset on his behalf but it was just part of life.” And in 1970, a black straight-A student being told that she wasn’t good enough to go to Cambridge was, again, part of life. It was her response that was out of the ordinary: “Well, I do think I’m up to it. And that’s what matters, isn’t it?”

At university, Abbott didn’t get involved in politics, and she found the Cambridge Union off-putting. Her hall tutor advised her to go into the civil service, and so she arrived at the Home Office in 1976, the lone black graduate trainee on what she now describes as “a quixotic quest to do good”.

In turn, that took her to the National Council for Civil Liberties, now Liberty. Believing it to be a hotbed of communist sympathisers, MI5 tapped the office phones, an action that was ruled unlawful in 1990. “One of the things that Diane still talks about,” a friend tells me, “is her experience not only of the Home Office, but of being the subject of official surveillance. She has a cynicism about the state that hasn’t gone away.”

Abbott also joined local campaigns on some of the issues that have defined her career, such as the abolition of the “sus laws”, the informal provision that allowed the police to stop and search anyone under the ­Vagrancy Act, which activists claim was used to target ethnic minorities in Britain. After joining the Labour Party, she became a councillor in Westminster in 1982.

In the 1970s and 1980s, as today, Labour took the lion’s share of the ethnic minority vote. But no one from an ethnic minority had ever sat as a Labour MP. In the 1983 election, just one person from a minority was selected as a parliamentary candidate, and in an ultra-safe Conservative seat. In response, Labour’s minority activists formed the Black Sections, a campaign to secure ethnic minority representation.

It was through these that Abbott met Linda Bellos, who was the leader of Lambeth Council, where Abbott worked as a press officer – her last job before entering parliament. “I was born here in 1950, one of 50,000 black people [living in the UK],” Bellos tells me. “We might have talked about going home but home for me was bleeding London, wasn’t it? Hence the need to make sure we were involved in all of the parts of the state. Someone like Diane had been to Cambridge, she’d been a councillor, she knew the democratic process, she was friends with a number of MPs, she knew the score. If someone like her couldn’t be selected, what was the point of any of us being here?”

The Black Sections wanted affiliated status, similar to that of the Fabians. But there were concerns that black candidates would not appeal to Labour’s presumed core white working-class vote. Some on the left saw “identity politics” as a distraction from the class struggle; and some on the right thought the Black Sections were too radical. At the 1984 conference, their plan was thrown out by a margin of ten to one.

Despite this setback, the fight had an important legacy. In the 1987 elections, four ethnic minority MPs entered the Commons for Labour: Paul Boateng in Brent South, Keith Vaz in Leicester East, Bernie Grant in Tottenham – and, in Hackney North and Stoke Newington, there was the 33-year-old Diane Abbott.

 

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She was the first black woman to be selected for a safe parliamentary seat. The Times marked the occasion with a leader denouncing her “rhetoric of class struggle and skin-colour consciousness”.

A few months later, the Sun profiled the “ten looniest Labour candidates” in Britain. “We were all there,” Abbott recalls. “Jeremy [Corbyn], the rest of us, and I was number eight.”

The local party in Stoke Newington was delighted with this firebrand reputation. “They said: ‘Stick with us, and we’ll take you right to the top!’”

The voters of north London were less welcoming. A brick was thrown through the office window of her local party. With Abbott as the candidate, some traditional Labour voters switched to the SDP-Liberal Alliance, taking the Labour vote below 50 per cent for the first time in the seat’s history (the second occasion was in 2005, just after the invasion of Iraq).

In parliament, the intake of ethnic minority MPs was regarded with caution. Abbott recalls that the then speaker of the House of Commons, Bernard Weatherill, was “very anxious”. She adds: “He thought we’d be like the Fenians and disrupt and collapse parliamentary process. So he invited Bernie [Grant], who was regarded as our leader, for port. And Bernie came for port and the speaker was very nice to him. And I imagine the speaker thought this was what stopped us being like the Fenians.”

Those Labour MPs who were disruptive – such as Corbyn the serial rebel – were in low spirits for other reasons. The marginalisation of Abbott and her allies during the late 1980s and 1990s explains why they have so little sympathy for the party’s beleaguered centrists in the current power struggle.

At the Labour conference in Liverpool this year – where she spoke as shadow health secretary – Abbott told me: “I came to party conference every year for 20 years, and we would lose and lose and lose. These people have lost twice and they’re complaining!”

Her thick skin was toughened during the New Labour years – and it reaffirmed her close friendship with Corbyn. (The two had a short sexual relationship in the early 1980s, which ended amicably. Abbott was married for two years to a Ghanaian architect from 1991 to 1993; her son, James, was born in 1992.) “She’s always had an odd hold on Jeremy,” one Labour MP tells me. “You would see them having lunch together and her bossing him about. I think people underestimate how influential she
is on his thinking.”

When David Lammy, her neighbouring MP in Tottenham, entered parliament in 2000 following the death of Bernie Grant, he found her “vilified, ostracised and exiled by the Blairites”. There were several attempts to remove her as an MP – another reason why the Corbyn camp is unconcerned by complaints from MPs such as Stella Creasy and Peter Kyle about their local parties threatening to deselect them.

Abbott retains a network of friends from her time before politics, including from her stint as a television producer. They urged her to quit in the Blair years – or to end her association with the left-wing Socialist Campaign Group. “I never thought I was willing to trade what I thought was right for some position in the party,” she says.

Some allies see it differently. “I don’t think Diane is someone who can quit [politics],” a friend told me. “I see her tweeting at all hours. She has interests, books and so forth, but she couldn’t walk away.”

Abbott says that Keith Vaz convinced her to stay, telling her, “You have forgotten what it took for us to get here.” (Some of Corbyn’s allies believe that this is what made the leader so supportive of Vaz during his latest scandal.) This sense of solidarity with other ethnic minority MPs has led to the long-standing rumour that Abbott would have nominated Chuka Umunna had Corbyn not stood for the Labour leadership.

“Diane is absolutely loyal to Jeremy,” one MP who knows them both well tells me. “She’s loyal to the project, yes, but she’s also loyal to him, in a way I don’t think you could honestly say about John McDonnell or Clive Lewis.” During the coup attempt against Corbyn last summer, Abbott spoke forcefully in favour of Corbyn remaining in place, rather than striking a deal to put Lewis or McDonnell on the ballot. “Her position,” one insider recalls, “was that we’d got a candidate we knew could win, and that candidate was Jeremy.”

Not that they always agree. Abbott advocated a less conciliatory approach after Corbyn’s first victory in 2015. “The thing that can be infuriating about Jeremy is that he likes to think the best of everyone,” she says. “I’m always perfectly straight with him as to what I think, and even if he doesn’t believe me at the time, he always does come round to my point of view.”

Abbott is one of the few people in the Parliamentary Labour Party whom Corbyn trusts completely. In their relationship, it’s hard to see who is the senior partner.

In the late 1990s and early 2000s, Corbyn and Abbott settled into a pattern of dissent, followed by defeat. Corbyn spent the time attending to foreign and human rights campaigns and signing thousands of early day motions. Abbott carved out a niche as a reliable critic of the Labour government under Tony Blair, with a month-long slot at the launch of the BBC’s This Week in 2003 blossoming into a regular gig alongside Michael Portillo. But away from Westminster, Abbott was making a decision that she knew could destroy her political career.

 

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The London borough of Hackney is today a national leader in schooling, but in 2002, just a third of students received five or more A*-C grades. That prompted Abbott to send her ten-year-old son, James, to City of London, a leading private school.

“I knew I could lose the seat over it,” she told me. “I was a single parent, and time after time, I had not been there for things at school, or I was too tired to take him out somewhere . . . I just thought, just this once, I should be prepared to make a sacrifice for him. If I lost the seat, then I lost the seat.”

She kept the seat. “Other things do annoy Diane – reporters saying things about her that aren’t true, people talking down to her,” one friend tells me. “But with [the schooling] I think she was very happy with that deal and to take that blow.”

Then, in 2010, Abbott’s career began a surprising second act: a bid for the party leadership. Activists and commentators felt uninspired by the choice in front of them – Ed Miliband, David Miliband, Andy Burnham and Ed Balls, four former special advisers from the New Labour era. Abbott called them “geeky men in suits”. Harriet Harman, in particular, was keen that the contest should not be an all-male field. Her support swayed Abbott. “If you had to pick one person, it was her,” she says, “because she was more mainstream.”

David Lammy set up a meeting between Abbott and David Miliband. The front-runner told her that, if she were a vote short in the nominations from MPs, he would vote for her. “But because it was David Miliband, I didn’t believe him.”

The elder Miliband had his own reasons for backing her. He believed that having her on the ballot would deprive his brother, Ed, of valuable support from the left. This was also the calculation that allies of Yvette Cooper made about Corbyn in 2015. “David’s legacy,” the Wakefield MP, Mary Creagh, wrote five years later, “made it normal – Blairite, even – to put a left-winger on the ballot to ‘have a broad debate’.’’

Of Corbyn’s campaign, Abbott says now: “I knew he’d do well, because what people missed is that had it been one person, one vote [in 2010], I’d have come third.”

Had the unions and the MPs not had a disproportionate influence on the result, she says, “I’d have beaten Andy Burnham, I’d have beaten Ed Balls. I’d been to 53 hustings – most Labour people are where Jeremy and I were. I knew there was much more left-wing sentiment in the Labour Party than the lobby thought.”

As a result of Corbyn’s victory in 2015, she is shadowing one of the great offices of state in what once looked like her final term in parliament. Her policy priorities as shadow home secretary are broad but include her favoured subjects of police reform and anti-racism. “I want to help shape the debate on migration,” she tells me. “I think we’ve had a very vacuous debate.”

That has put her at odds with the shadow chancellor, John McDonnell. Though both are long-time friends of Corbyn, their relationship is not warm. Allies believe that the division stretches back to the late 1980s, when McDonnell – then outside parliament – gloried in not going “soft” in the manner of Neil Kinnock. Abbott attracted suspicion, in part because of her early conversion to a pro-European position. Many believe that McDonnell never embraced the European project. He has ruled out opposition to Brexit and is behind the toughening of the party’s line on immigration. Abbott, privately and publicly, is determined to hold Labour to a more open and pro-immigration position. She has said that Labour cannot win as “Ukip-lite”, a coded rebuke to McDonnell.

The shadow chancellor is the only MP with a comparable influence to Abbott’s on Jeremy Corbyn and, thus far, the Labour leader has struck a middle path on migration, supporting Abbott’s line that the single market cannot be traded away for restrictions on the free movement of people but stopping short of a full-throated defence of free movement in principle.

As well as winning that internal battle, Abbott faces the task of landing more blows on Amber Rudd than her predecessors – Andy Burnham, Yvette Cooper and Ed Balls – managed against Theresa May when she was the longest-serving home secretary in a century, transforming the reputation of a department once regarded as a political graveyard. Not many give Abbott much chance of success but, as always, she believes in herself and thinks that she’s up to it.

Stephen Bush is special correspondent of the New Statesman

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.

This article first appeared in the 12 January 2017 issue of the New Statesman, Putin's revenge