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

Photo: ANDREW TESTA/THE NEW YORK TIMES/ EYEVINE
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Interview: Nicola Sturgeon's Scottish referendum dilemma

In a candid interview, the First Minister discusses Theresa May’s coldness, Brexit and tax rises – and why she doesn't know when a second referendum will be held. 

Nicola Sturgeon – along with her aides, who I gather weren’t given much choice – has taken up jogging in the verdant country­side that lies to the east of the Scottish Parliament. “The first time was last week,” she says, when we meet in her large, bright Holyrood office. “Loads of people were out running, which made me a bit self-conscious. But it was fine for ages because everybody’s so focused. Then, suddenly, what must have been a running group came towards me. I saw one of them look and as they ran past I turned round and all of them were looking.” She winces. “I will eventually get to the point where I can run for more than 100 yards at a time, but I’m not at the stage yet where I can go very far. So I’m thinking, God, they’re going to see me stop. I don’t know if I can do this.”

This is a very Nicola Sturgeon story – a touch of the ordinary amid the extraordinary. She may have been a frontbencher for almost two decades, a cabinet minister for half of that and the First Minister since 2014, but she retains that particularly Scottish trait of wry self-mockery. She is also exceptionally steely, evident in her willed transformation over her adult life from a shy, awkward party member to the charismatic leader sitting in front of me. Don’t be surprised if she is doing competitive ten-kilometre runs before the year is out.

I arrived at the parliament wondering what frame of mind the First Minister would be in. The past year has not been especially kind to her or the SNP. While the party is still Scotland’s most popular by a significant margin, and Sturgeon continues to be its dominant politician, the warning lights are flashing. In the 2015 general election, the SNP went from six seats out of 59 to 56, a remarkable result. However, in Theresa May’s snap election in June this year, it lost 21 of those seats (including those of Angus Robertson, the SNP leader at Westminster, and Alex Salmond), as well as half a million votes. Much of the blame has been placed on Sturgeon and her call for a second independence referendum following the vote for Brexit. For critics, it confirmed a suspicion that the SNP only cares about one thing and will manipulate any situation to that end. Her decision also seemed a little rushed and desperate, the act of a woman all too aware of the clock ticking.

But if I expect Sturgeon to be on the defensive, maybe even a little downbeat, I’m wrong. Having just come from a feisty session of First Minister’s Questions, where she had the usual barney with her Tory opposite number, Ruth Davidson, she is impressively candid. “When you come out [of FMQs], your adrenaline levels are through the roof,” she says, waggling a fist in my direction. “It’s never a good idea to come straight out and do an interview, for example.” Adrenalised or not, for the next hour, she is thoughtful, frank, funny and perhaps even a little bitchy.

Sturgeon’s office is on the fourth floor, looking out over – and down on – Holyrood Palace, the Queen’s official residence in Edinburgh. As we talk, a large artistic rendering of a saltire adorns the wall behind her. She is similarly in blue and white, and there are books about Burns on the shelves. This is an SNP first minister’s office.

She tells me that she and her husband, Peter Murrell, the party’s chief executive, took a summer break in Portugal, where his parents have a share in an apartment. “We came home and Peter went back to work and I spent a week at home, just basically doing housework…” I raise an eyebrow and an aide, sitting nearby, snorts. She catches herself. “Not really… I periodically – and by periodically I mean once a year or once every two years – decide I’m going to dust and hoover and things like that. So I did that for a morning. It’s quite therapeutic when you get into it. And then I spent a week at home, reading and chilling out.”

In a recent Guardian interview, Martin Amis had a dig at Jeremy Corbyn for having “no autodidact streak”. Amis said: “I mean, is he a reader?… It does matter if leaders have some sort of backing.” One of Sturgeon’s great strengths is that she is a committed bibliophile. She consumes books, especially novels, at a tremendous rate and raves to me about Gabriel Tallent’s astonishing debut, My Absolute Darling, as well as Bernard MacLaverty’s Midwinter Break. She has just ploughed through Paul Auster’s daunting, 880-page 4 3 2 1 (“It was OK. I don’t think it should be on the Booker shortlist.”) She also reread the works of Chimamanda Ngozi Adichie before interviewing her onstage at the Edinburgh International Book Festival in August.

The First Minister is now reading What Happened, Hillary Clinton’s book about her defeat by Donald Trump. “I’ve never been able to read any of her [previous] books because literally every word is focus-grouped to the nth degree,” Sturgeon says. “This one, there are moments of frankness and raw honesty and passages where it’s victimhood and self-pity, but that’s kind of understandable and very human. The thing that fascinates me about Hillary, apart from the politics, is just her sheer bloody resilience.  Given what she’s gone through and everything that’s been chucked at her, I genuinely don’t know how she keeps coming back.”

***

Speaking of resilience, does she have any fellow feeling for Theresa May, humiliated by the electorate and, for now, kept in No 10 like a racoon in a trap by colleagues who are both power-hungry and biding their time? “At a human level, of course,” she says. “When you’ve got an insight into how rough and tough and, at times, downright unpleasant the trade of politics can be, it’s hard not to feel some personal sympathy. Her position must be pretty intolerable. It’s tempered, though, by the fact that nobody made her call an election and she did it for purely party-political interest.”

How does she get on with May – who is formal and restrained, even off-camera – in their semi-regular meetings? Sturgeon starts laughing. “The Theresa May that the country ended up seeing in the election was the one I’ve been dealing with for however long she’s been Prime Minister. This is a woman who sits in meetings where it’s just the two of you and reads from a script. I found it very frustrating because David Cameron, whose politics and mine are very far apart, always managed to have a personal rapport. You could sit with David and have a fairly frank discussion, agree the things you could agree on and accept you disagree on everything else, and have a bit of banter as well.

“I remember just after May came back from America [in January], when she’d held Trump’s hand [Sturgeon starts laughing again], she’d also been to Turkey and somewhere else. This was the Monday morning. We sit down, it’s literally just the two of us, and I say, ‘You must be knackered.’ She said, ‘No! I’m fine!’ And it was as if I’d insulted her. It was just impossible to get any human connection.”

Given this, and the weaknesses exposed during the election, Sturgeon is scathing about how the Conservatives fought the campaign, putting May’s character and competence front and centre. “The people around her must have known that vulnerability,” she says. “God, we all make mistakes and we all miscalculate things, so this is not me sitting on high, passing judgement on others, but don’t build a campaign entirely around your own personality when you know your personality’s not capable of carrying a campaign… Even if you can’t see that yourself, somebody somewhere around you should have.”

Sturgeon might not be in May’s beleaguered position but she has problems. Her demand in March, at a press conference at Bute House, Edinburgh, for a second independence referendum by spring 2019 was a serious mistake and it has left a dent in what had seemed her impermeable personal popularity. Polls show support for the SNP and independence now share a similar downward trajectory. Over the next three years, the First Minister must persuade a sceptical electorate that her party deserves a fourth consecutive term in government.

Does she regret demanding another vote on separation?

Here she gets as close as she will go to a mea culpa. “Obviously I’m thinking pretty deeply about it. I think Brexit is a complete and utter car crash – an unfolding disaster. I haven’t changed my views on that, and I think it’s deeply wrong for [Scotland] to be taken down that path without the ability to decide whether that’s right or not.

“I recognise, as well – and it’s obviously something I have reflected on – that understandably people feel very uncertain about everything just now, partly because the past few years have been one big decision after another. That’s why I said before recess that I will not consider any further the question of a second referendum at this stage. I’m saying, OK, people are not ready to decide we will do that, so we have to come back when things are clearer and decide whether we want to do it and in what timescale.”

Will she attempt to hold a second referendum? Could it be off?

“The honest answer to that is: I don’t know,” she says. Her expression of doubt is revealing.

Would she, however, support a second EU referendum, perhaps on the final separation package? “I think it probably gets more and more difficult to resist it,” she tells me. “I know people try to draw lots of analogies [between the EU and independence referendums], and there are some, but whatever you thought of the [Scottish] white paper, it was there and it was a fairly detailed proposition.

“One of the beautiful things about the independence referendum was the extent to which ordinary folk became experts on really technical, big, macro­economic positions. Standing on a street corner on a Friday morning, an ordinary working-class elderly gentleman was talking to me in great detail about lender of last resort and how that would work. You can say the white paper was crap, or whatever, but it was there, people were informed and they knew what they were voting for.

“That was not the case in the EU referendum. People did not know what they were voting for. There was no proposition put forward by anyone that could then be tested and that they could be held to account on. The very fact we have no idea what the final outcome might look like suggests there is a case for a second referendum that I think there wasn’t in 2014. It may become very hard to resist.”

Sturgeon hasn’t found the Brexit process “particularly easy”, especially when the government at Westminster is in the grip of what is becoming an increasingly vicious succession battle. The SNP administration has repeatedly clashed with the relevant ministers at Westminster, whom it says have given little care to Scotland’s particular needs. Sturgeon’s view of David Davis, Liam Fox and Boris Johnson is not rosy.

“Probably not a day goes by where I don’t look at them and think, ‘What the hell’s going on?’” she says. “That’s not meant as a personal comment on their abilities – although [with] some of them I would have personal question marks over their abilities. But they’re completely paralysed, and the election has left them in a position where you’ve got a Prime Minister who has no control over the direction of her government, and you have other senior ministers who are prepared to keep her there only because it’s in their short-term interests to do it. If you’re sitting on the European side of the table now, how can you have a negotiation with a government where you don’t actually know what their position is, or whether the position you’re being told across the table is one that can carry support back at home? It’s a shambles and it’s increasingly going to be the case that nothing other than Brexit gets any bandwidth at all. It’s really, really not in the interests of the country as a whole.”

***

This is an accusation that is directed at the SNP, too – that the national interest takes second place to its constitutional imperative. It is undoubtedly something that Sturgeon considered over the summer as she sought to rebalance her administration. As a result, the programme for government unveiled earlier this month was impressively long-term in places: for example, its promise to create a Scottish national investment bank, the setting of some ambitious goals on climate change and the commitment to fund research into a basic income.

Most striking, however, was Sturgeon’s decision to “open a discussion about… responsible and progressive use of our tax powers”. With the Scotland Act 2016, Westminster passed control over income tax to Holyrood, and Sturgeon intends to use this new power.

“For ten years,” she says, “we have done a pretty good job of protecting public services as best we can in a period of austerity, while keeping the taxes that we’ve been responsible for low. We’re now at a stage where austerity’s continued, we’re going to have economic consequences from Brexit, we all want good public services, we want the NHS to continue to have strong investment, we want our public-sector workers to be paid more, we want businesses to have the right infrastructure. How do we progressively and responsibly, with the interests of the economy taken strongly, fund our public services going forward? Most people would think right now that there is a case for those with the broadest shoulders paying a little bit more.”

I wonder whether the success of Jeremy Corbyn has influenced her thinking – many expect that a revival of Scottish Labour would force the SNP to veer left (it will also be interesting to see how Westminster reacts to Scotland raising the top rate of income tax). “It’s not particularly Corbyn that’s made me think that,” she insists, a little unconvincingly.

Isn’t Sturgeon concerned that making Scotland the highest-taxed part of the UK could undermine its competitiveness, its attraction as a place to live and as a destination for inward investment? “We should never be in a position where we don’t factor that kind of thing into our thinking, but you talk to businesses, and tax – yes, it’s important, but in terms of attracting investment to Scotland, the quality of your infrastructure matters. Businesses want good public services as well, so it’s the whole package that determines whether Scotland is an attractive place to live and invest in and work in,” she tells me. “It’s seeing it in the round. The competitiveness of your tax arrangements are part of what makes you attractive or not, but it’s not the only part.”

As for the immediate future, she is upbeat. She believes that Ruth Davidson, her main rival, is overrated. “I think Ruth, for all the many strengths people think she might have, often doesn’t do her homework very well,” she tells me. “From time to time, Ruth slips up on that… Quite a bit, actually. I know what I want to do over the next few years, and I’m in a very good place and feeling really up for it. After ten years in office, it’s inevitable you become a victim of your own success. What’s more remarkable is that, after ten years, the SNP still polls at least 10 and usually 10-15 points ahead of our nearest rivals.”

Author's note: Shortly after this interview went to print, the SNP got in touch to say that Nicola Sturgeon’s comment, ‘the honest answer to that is: I don’t know’, was about the timescale of the next independence referendum and not whether there would be one. The misinterpretation was mine.

Chris Deerin is the New Statesman's contributing editor (Scotland). 

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