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 for New Statesman
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1966 and all that

A year of World Cup glory, meeting Paul McCartney and eating placenta.

Fifty years ago this Saturday, on 30 July 1966, I was at Wembley. I have my ticket and my programme to prove it. I also have my 1966 ­diary, which I am looking at now. I was 30, weighed ten stone and eight pounds, and my waist was 32 inches – about as hard to believe now as England winning another World Cup final.

I am still in the same house, all these decades later, but my telephone number then was GUL 4685. GUL was short for Gulliver, I can’t remember why. In my list of contacts at the end of my diary is Melvyn Bragg, who was another recent arrival in London from Cumbria, like myself and my wife, on PRO 0790. PRO stood for Prospect, I think, which was the exchange name for somewhere over the river, possibly Kew.

My office number was TER 1234. I always thought that was a great and memorable number. It’s only now, thinking about it, that I realise that TER – meaning Terminus –
probably related to King’s Cross, which the Sunday Times was near in those days.

At the top of the charts in July 1966 were the Kinks with “Sunny Afternoon”, which I can well remember, as it was so ironically chirpy, and Georgie Fame with “Getaway”. I liked Georgie Fame – low-key, cool – but I can’t remember that tune. Both were replaced in August by the Beatles’ “Yellow Submarine”/“Eleanor Rigby”.

My day job in July 1966, on the Sunday Times staff, was writing the Atticus column. It still exists, but in a smaller, more skittery format. Previous incumbents included Ian Fleming, John Buchan and Sacheverell Sitwell, who was reputed to have got free Mateus rosé for life after giving the wine its first mention in an English newspaper.

I had been on the paper since 1960, after spending two years as a so-called graduate trainee journalist, mainly in Manchester, which was a laugh. There was no training and there were no lessons in law. You had a mentor for a few weeks and then you got on with it.

In my first few years as the boy on Atticus, I never had my name in the paper. I had to write dreary paragraphs about who might be our next man in Washington, or the bishop of London, or the master of Balliol, as if I cared. I wanted to write about footballers, gritty northern novelists, pop stars.

When I started at the Sunday Times, I felt for a while that people were prejudiced against me, because I was northern and working class and had gone to grammar school and a provincial university (Durham). Everyone else seemed to have been at Oxbridge and gone to public school.

But this prejudice was all in my head, imagined, just as it had been when I used to go from Durham to visit my girlfriend, Margaret – whom I married in 1960 – at Oxford. I was convinced that some of her posh friends were being condescending ­towards me. Total nonsense, but I had a chip on my shoulder for some years. Gone, all gone, just like my 32-inch waist. (I am now 12 stone and the new shorts I bought last week have a 38-inch waist. Oh, the horror.) If anything, these past 50 years, any prejudice has been in my favour.

Harold Wilson was the prime minister in 1966. His northern accent was even stronger than mine. I still have a letter from him, dated 21 March 1963, after I interviewed him for Atticus. In the letter, he ­describes the 1938 FA Cup final in which Preston beat Huddersfield Town 1-0, scoring in the last minute of extra time. At the bottom of the page, in handwriting, he’d added: “after hitting the crossbar”.

What I remember most about the interview was George Brown, who was deputy to
Wilson as Labour leader at the time, hanging around outside his office, drunk. Marcia Williams, Wilson’s secretary, was going around tut-tutting, making faces, complaining about George. I thought she shouldn’t have done, not in front of me, as I was a total stranger and a hack. (I don’t think we called ourselves hacks in those days, which is the normal, half-ironic self-description today.)

Harold was a football man and also a real know-all, forever boasting about his memory for facts and figures. The contents of this letter illustrate both aspects of his character. It led me later to collect a letter or autograph from every prime minister, going back to Robert Walpole. Only took me ten years.

There is a myth that England’s 1966 win helped Labour stay in power – which does not quite stand up. The general election was in March – four months before the final. But Wilson did milk England’s victory, identifying himself and the nation with our English champions.

It is possible that the reverse effect happened in 1970, when Wilson was chucked out and Edward Heath came in. England’s defeat at the 1970 World Cup by West Germany was just four days before the June general election.

***

I got my ticket for the 1966 World Cup final – for one of the best seats, priced at £5 – from my friend James Bredin, now dead, who was the boss of Border Television. Based in Carlisle, Border covered the Scottish Borders and the Isle of Man. It was a thriving, thrusting regional ITV station, now also deceased.

James’s chauffeur came to pick me up and waited for us after the match, a sign of the importance and affluence of even minor ITV stations. Border contributed quite a bit to the network, such as Mr and Mrs, starring Derek Batey, who presented 450 editions of this very popular national show. Batey was a local lad who started his show business life as an amateur ventriloquist in the little market town of Brampton, Cumbria, before becoming Carlisle’s Mr Show Business. He was so polished – lush hair, shiny suits, so starry, so glittery – that I always wondered why he was not in London, in the West End.

Border TV also produced some excellent documentaries that were networked across the ITV region, two of which I presented. One was about walking along Hadrian’s Wall and the other was about George Stephenson. For a while in the 1970s, I began to think I was going to become a TV presenter, despite being not much good. I was lousy at acting, which you need for television, and disliked asking questions to which I already knew the answers. And it took so much time. For each programme, we spent eight weeks on location with a crew of eight, just to make a one-hour documentary. Now they
do docs in a week with just two people.

For half an hour, I also imagined that I was going to become a playwright. In 1967, I had a play in the BBC’s Wednesday Play slot, awfully prestigious at the time, called The Playground. It was one of those shows that were filmed live and then wiped, so I have never seen it since, nor has anybody else. I blamed that for blighting my playwriting career, though till I was looking in my 1966 diary and saw that I was working on that play, I’d forgotten about its existence. As we go through life, we forget all the paths not trodden.

I’ve boasted endlessly about being at the 1966 Wembley final, and it was so exciting, but I can’t remember many of the details. I must have been aware of Geoff Hurst’s second goal being a bit dodgy, as there were loud complaints from the German fans, but as Sir Geoff, as he then wasn’t, went on to score a third goal, it didn’t really matter. At the time, I considered that the England-Portugal semi-final had been a better game, with our Bobby Charlton scoring two goals against one from Eusebio, but of course winning a final is winning a final and the excitement and the patriotic pride continued for weeks and months. We felt as if it had been our right to win – after all, did we not give the game to the world, lay down the first rules, show all those foreigners how to play our game?

The result was that we usually ignored all the new ideas and developments that were emerging from Europe and South America, carrying on with our old ways, stuffing our faces with steak before a game and knocking back six pints afterwards, a bit like Alf Tupper in the Rover comic. He lived on fish and chips, but on the race track he could beat anyone.

Those funny Continental players started playing in funny lightweight boots, more like slippers or ballet shoes, which seemed barmy to us. How we scoffed. How can you play properly, far less kick someone properly, unless your ankles are encased in hard leather as tough as steel? Who cared if they weighed a ton, especially in wet weather? We Brits were tough.

The top First Division stars of 1966 earned about £200 a week, including bonuses, and lived in £20,000 houses, semi-detached, on new estates with Tudor overtones. The top players drove Jaguars. But most were lucky to afford a Ford Cortina. I had one myself for a while. Awfully smart, or so I thought at the time.

Their basic wages were little more than double that of the best-paid working men, such as a foreman bricklayer or a successful plumber. Their neighbours on their estates were bank mangers or salesmen, a higher scale socially than their own background, but still fairly modest. Not like today. Footballers don’t even have neighbours any more. They are cocooned in their own gated mansions, with personal staff, gardeners, nannies, accountants, lawyers, agents.

Yet despite their modest lifestyles in those days, there were celebrity players, such as Bobby Moore, Bobby Charlton and, before them, Billy Wright, all household names, loved and admired, recognised everywhere.

None of them had an agent in 1966. The nearest thing to it was the system that operated if a team got to the FA Cup final. They would then agree to divvy up the peripheral proceeds, such as money from giving newspaper interviews, posing for staged corny photographs, opening shops, or selling their spare tickets to touts (which they were not supposed to do). They’d appoint some dodgy friend of one of the senior players to arrange the deals and collect the monies for them. Times, they always change. Otherwise, what’s the point, eh?

***

In 1966, two big events occurred in my personal life. In May that year, my son, Jake, was born – at home, in what is now our kitchen. He arrived so quickly that the midwife hadn’t turned up yet and he emerged with the cord twisted around his neck. I managed to untie it, which I have maintained since kept him alive (a trick I had learned at fathers’ classes).

Fathers’ classes – wow, what a novelty that was in the 1960s. Who says we were all chauvinist pigs back then? (Today’s young, female star writers at the New Statesman, probably.) I attended my first ones, at the Royal Free Hospital in 1964, when our firstborn, Caitlin, was about to arrive. I remember immediately thinking when the invite came that I would get 1,000 words out of this – which I did, for the Sunday Times women’s pages.

Also at those first-ever fathers’ classes at the Royal Free was a young BBC producer whose wife was also about to give birth: Wilfred De’Ath. He, too, was desperate to get a piece out of it. (He now writes occasionally for the Oldie, and he appears to be down and out and living in France.)

After Jake’s birth, I got the midwife to give me the placenta and I ate it, fried with onions. Tasted like liver. Another 1,000 words.

The other event of note in my ever-so-exciting life in 1966 was meeting Paul McCartney. When “Eleanor Rigby” came out, I thought the words – not just the tune – were so wonderful. Possibly the best poetry of the year, I said, as if I knew anything about poetry. I went to see him for Atticus in his new house in St John’s Wood, which he still has, being a very conservative feller. I talked to him about the background to the lyrics, as opposed to his hair, which interviewers were still asking him about.

A few months later, at the end of 1966, I went to see him again, wearing a different cap, as a screenwriter. I’d had a novel published the previous year, Here We Go Round the Mulberry Bush, which was being made into a film, with Clive Donner directing. We went to see Paul at his house and discussed with him if he would do the theme tune. He turned us down in the end but it was while I was with him that I suggested that there should be a proper biography of the Beatles. He said Brian (Epstein, the band’s manager) would have to agree – and there and then sat me down and helped me write a suitable arse-licking letter to him.

I eventually saw Brian, after several cancellations, at his home in Belgravia and he played me the acetate of “Strawberry Fields Forever”. I was astounded. It seemed to break every rule of what was then considered pop music. I wondered if all Beatles fans
would take to it. But I could see that it was amazing and perhaps the Beatles weren’t finished, which was what some people were saying in 1966. At my publisher, Heinemann, which paid me £3,000 for the book, there was one director who maintained the Beatles bubble was about to burst.

Brian agreed to my project and offered a clause in the contract that we had not requested or even thought of. He said he would not give any other writer access to the Beatles for two years after my book came out. This was 1966. The book came out in 1968. Two years later, in 1970, the Beatles were no more. Without realising it at the time, I became the only authorised ­biographer of the Beatles.

***

So, 1966, a big year for me, so glad I kept that diary, and also a big year for the nation. I thought at the time that the Beatles were bound to fade, eventually, while England surely would dominate world football from now on. After their humbling by Iceland at this year’s World Cup, I now realise that England will never win the World Cup again in my life, what’s left of it. And probably not even another game.

The only way to rationalise it is to tell ourselves that we are ahead of the game. We are rubbish, but in turn it will happen to all the other so-called advanced nations.

You could say Brexit is a bit like that. We are ahead of the other leading European nations in going it alone, even though it is depressing and awful and shameful. We are advanced in wilfully turning ourselves into a rubbish nation. We are leading the way, as ever. Inger-land, Inger-land.

Hunter Davies’s memoir of the postwar years, “The Co-op’s Got Bananas!” (Simon & Schuster), was published in April, followed by “Lakeland: a Personal Journal” (Head of Zeus). His final book on the Fab Four, “The Beatles Book” (Ebury), will be published on 1 September

Hunter Davies is a journalist, broadcaster and profilic author perhaps best known for writing about the Beatles. He is an ardent Tottenham fan and writes a regular column on football for the New Statesman.

This article first appeared in the 28 July 2016 issue of the New Statesman, Summer Double Issue