The English patient: Britten in 1968. Photograph: Cecil Beaton Studio Archive, Courtesy of National Portrait Gallery.
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Notes from a cardiologist: Unravelling the mystery of Benjamin Britten’s heart

Cardiologist Hywel Davies describes the origins of the syphilis claim from Paul Kildea's biography of Benjamin Britten, which began as an "ordinary conversation" in a colleague's house in the late 1980s.

In 1892, William Osler published the first edition of The Principles and Practice of Medicine, in which he stated that tertiary syphilis of the nervous system, known then as general paralysis of the insane, was due to stress. Not many years later, a bacterium, called the spirochaete, was identified as the cause of syphilis and Osler was obliged to modify his textbook for the next edition. I thought of Osler’s dilemma in the context of Paul Kildea’s recent biography Benjamin Britten: a Life in the 20th Century, which claims that Britten had syphilis. The very public denials of this, some of them by people who could not possibly know one way or the other, along with the calls for revisions in the second edition, brought Osler to mind.

In assessing this, I can only gather what seems to be reasonable evidence on either side. For me, this begins with the testimony of my friend and colleague Donald Ross, the surgeon who operated on Britten’s heart on 7 May 1973 at the National Heart Hospital in London. During this procedure, he and his assistant surgeon would have inspected the heart thoroughly, at close range and from all available angles, using feel as well as vision, inside and out. Ross cut out the native aortic valve and replaced it with a homograft, which is made of tissue from a human source. This has the practical advantage of not requiring the use of anticoagulants to prevent clots forming later on the valve, as would have been the case with a mechanical prosthesis.

Ross recorded his impressions in his operative report written immediately after the surgery. This has recently been lodged at the Britten-Pears library, together with a selection of other records from Britten’s medical history, which I have been able to examine. Apart from his account of the procedure, Ross expresses clearly that when he was in theatre he was not able to tell, with any degree of assurance, exactly which disease process he was looking at, writing: “The aetiology of this valve lesion is not clear to me and certainly not characteristic of bacterial endocarditis, nor was the valve of bicuspid structure which would suggest a congenital valve.” The significance of these words is that Britten in 1968 had been treated with heavy and prolonged doses of penicillin for bacterial endocarditis, which means infection on the heart valve. There was none of the expected evidence “whatsoever” on the valve of previous infection from bacterial endocarditis. Nor were there signs of a congenitally deformed valve, since those are usually bicuspid (have only two cusps). This speaks against heart disease in infancy and childhood.

Ross adds that, on closure of the aortotomy (the initial incision in the aorta), the heart “came off bypass without difficulty”, yet: “The external appearances were those of an enlarged, bulky and flabby myocardium with a poorly contracting left ventricle.” In other words, none of the explanations given up to that point for the weakness of Britten’s heart, many of them involving assumptions that Britten had carried since childhood, appeared to be borne out. Ross proceeded to take biopsies from several parts of the heart that, together with the excised valve, were sent to the pathologists for their opinions about what the abnormal appearances might represent. He underlined the word “biopsy” each time he used it, as if to emphasise how critical the information would be to his conclusion.

In recent months, some commentators have asserted that Ross would have announced his thoughts and reservations at once in the operating theatre. On the contrary, it is extremely unlikely that he would have done this, for both intellectual and social reasons. Unclear about causes, he would never have speculated openly about such matters to what was a semi-public audience. He did, at the same time, make clear in his notes that he had been looking at something that was in his wide experience most unusual. It would have taken some weeks for the specimens to be studied and reported on before being reviewed by him. It would not – nor should it – have been a quick and hurried process. Unfortunately, if the reports of the biopsies, together with those of the relevant blood tests, were ever included in Britten’s other medical reports, they are no longer with them, but Ross would have insisted that he see them and they would have been an essential element when he came to draw his conclusions.

Over years of working with and discussing such things with Ross, I came to appreciate how keen and incisive his judgement always was in cardiac and other matters. He probably had as great an experience of assessing beating hearts as anyone before or since and a marked interest in anatomy and structure that he pursued in academic quarters. Between 1964 and 1973, 850 patients, many of them Ross’s, underwent aortic valve replacement at the National Heart Hospital and he worked elsewhere, too. As a cardiologist at Guy’s in the 1960s, I worked closely with him on the launching of his new technique of homograft valve replacement; the world’s first case, naturally in his hands, was my patient. I cared for and studied many of his homograft patients after that.         

Thus, when, during an ordinary conversation in his house in the late 1980s, Ross chose to tell me that Britten’s heart was syphilitic, I took him at his word, knowing that his opinion was that of a seasoned professional at the peak of his power in his field of expertise. I asked no further questions, except one to his assistant surgeon, present on the same occasion, as to whether he concurred with Ross’s conclusion, which he did. Beyond that, I had no particular interest in the story and did not speak to anyone about it.

Except one person. When I lived and worked in Colorado in the 1960s and again in the 1980s, one of my friends was a senior medical scientist named Basil Reeve, an Englishman who had grown up in Lowestoft with Britten, had known him well and had played the piano with him. A qualified doctor, Basil was also friendly in the Second World War with the philosopher Ludwig Wittgenstein, then working at Guy’s Hospital as a porter during the Blitz. One day in the early 1990s when I was visiting Denver again, Basil and I were having lunch in a local restaurant. He talked about these friends and, knowing his interest in Britten, I saw no reason not to mention to him what Ross had told me freely and without pledging me to silence.   

I was surprised, however, that Basil’s reaction was swift and pointed. He said: “The world should know it and we should make the information public.” I had no wish to do this and I declined to go along with his request. He repeated it a few times on the telephone during the following years and, although I realised how strongly he felt about it, I still chose to say no. Shortly after his last request, I sold my home in Switzerland and moved elsewhere. A couple of years later, I happened to call at Basil’s house during another visit to Denver. When he opened the front door, his face paled and he said, “Good God, I thought you were dead.” He explained that in the interim he had phoned again to Switzerland to repeat his request, to be told by the operator that the line had been discontinued and I could not be contacted. He drew the perhaps understandable conclusion that I was no more and accordingly felt able to speak about what I had told him. In 1999, he told the story to Kildea, the young head of music at the Aldeburgh Festival. Kildea was sceptical but, when he came to write his biography in 2008, he tracked me down to check Basil’s information. I initially told him that I was not willing to comment but over time came to realise that he was a serious scholar, interested in getting to the bottom of a puzzling case, and I decided to help him with some of the medical aspects of his book.

Based on what Ross and others wrote at the time and what Ross told me later, we may question further what this most experienced surgeon observed in the operating theatre with such puzzlement. First, Britten’s heart was much enlarged, the bulk of this consisting of a very thick left ventricle. The reason for this was ostensibly a long-standing aortic valve insufficiency – leakage backwards from the aorta into the ventricle after the aortic valve closes. The immediate reason for the enlargement and thickening (hypertrophy) of cardiac muscles is usually excessive work, as occurs in other muscles of the body. Leakage in the aortic valve results in an increase in the amount of blood the heart has to pump.

There are two conflicting descriptions of the condition and function of Britten’s ventricle that appear in the clinical notes. The first is the report on the pre-operative angiogram, which states that the left ventricle “contracts vigorously”. The second is the operation note in which Ross describes the enlarged, bulky and flabby muscle and poorly contracting left ventricle. The use of the word “flabby” speaks for itself and Ross inserted special sutures in an attempt to secure the new valve in the friable, weakened tissue. A month after the operation, Britten’s cardiologist Graham Hayward wrote to Ian Tait, Britten’s GP in Aldeburgh: “He presented us with many problems, as you know, during and after surgery as his heart was much larger and worse than one anticipated.”

The reasons for these “many problems” might not have been evident to the surgeons. They would have gone through the main possibilities, including those that the consultant physician John Paulley of Ipswich spelled out in 1960 after seeing Britten. He was the first, it appears, to make the diag nosis of aortic valve insufficiency and, in a letter to Tait, he asked the latter to arrange a WR and Kahn blood test, the standard for syphilis. He could have ordered one himself but he preferred that Tait did it. (“Reasons will probably be obvious to you?”) We must assume that the test was carried out. Paulley’s request is proof, if any were necessary, that syphilis was and still is a major diagnostic possibility in a patient with aortic valve insufficiency. Ross would have known as well as Osler that syphilis is a great mimic of other diseases and a negative blood test does not rule out the disease, especially in patients who had been treated heavily with penicillin, as Britten had.

I have taken a position in this matter largely because I find that the strongest evidence we have is that of the surgeons and I do not believe their conclusions should be cast aside lightly. (In the 1970s, the assistant surgeon passed on Ross’s conclusions to a senior colleague who repeated them to Kildea, so I was not the only route by which they reached him.) On the basis of Ross’s surgical report and his unequivocal opinion, it seems that Kildea is substantially right in what he says, though some amendments to wording, to reflect what we now know from the report, could be made before the next edition of his book. This is a sentiment with which Osler, if he were here, might well approve.

In a long career as a consultant cardiologist, Hywel Davies held posts in leading London and US hospitals before being invited by Sir Terence English to be the cardiologist to the cardiac transplant team at Papworth Hospital

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

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Goodbye to the Confederate flag

After the shootings in Charleston, the Republican right showed it was finally ready to reject the old symbols of the Confederacy.

On 27 June, an African-American activist named Bree Newsome woke up before dawn, put on her climbing equipment and scaled a 30-foot flagpole on the lawn of State House in Columbia, South Carolina. She then removed the Confederate battle flag that flew from it. “We can’t wait any longer,” she explained later in an online statement. “It’s time for a new chapter where we are sincere about dismantling white supremacy.”

After she was led away in handcuffs, the flag was raised again.

Newsome’s protest reflected a growing impatience within America’s black community and anger about liberal inaction. Political rallies by the Democratic presidential contenders Hillary Clinton and Bernie Sanders have been disrupted by the Black Lives Matter campaign against violence committed on young African Americans and the cultural and legal biases that justify it. While promoting his book on race in the US, the writer Ta-Nehisi Coates argued that, to African Americans, the battle flag represents a lingering attempt “to bury the fact that half this country thought it was a good idea to raise an empire rooted in slavery”.

Yet, on this matter, to everyone’s surprise, the black civil rights movement and many southern Republicans have proved to be of one mind. On 9 July the House of Representatives in South Carolina voted to lower the battle flag for good. It stood, representatives said, for racism. It had to go.

The context of this agreement was a painful one. Ten days before Newsome’s act, a 21-year-old white man named Dylann Roof shot and killed nine black worshippers at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina. According to his room-mate, he wanted to start a race war. The TV screens showed a photo of him holding a gun in one hand and a Confederate battle flag in the other.

If the demands for redress made by civil rights groups didn’t come as a surprise, conservative acquiescence did. The Republican Party had built a solid base in the South by courting white voters who cherished the memory of the Confederacy. Yet the party’s presidential hopefuls from both the North and the South – including Jeb Bush, Lindsey Graham, Scott Walker and George Pataki – said that the battle flag ought to be lowered. The most striking intervention was made by the governor of South Carolina, Nikki Haley, who denounced the use of the Confederate flag and signed the bill removing it. Haley is now tipped to figure on the list of potential vice-presidential nominees.

The volte-face of the US right is in part a result of the horror of the Charleston shootings. Yet it also occurs in the context of major shifts within American society. There are still many conservatives who will defend Confederate heritage as a matter of southern pride but the culture wars are changing as the US becomes increasingly European in outlook. This is taking place across the country. It just happens to be more pronounced in the South because no other region has fought so violently and so long to resist the liberal tide.

The story of the battle flag is the story of the South. The first official Confederate flag used in the civil war of 1861-65 caused confusion during fighting – through the haze of gun smoke, its design of 13 stars and red and white bars was hard to distinguish from the Stars and Stripes. An alternative blue cross was rejected for being too sectarian; the racist Confederacy was anxious not to offend its Jewish citizens. So the cross became a diagonal X. This flag was never officially adopted by the Confederate army. In the years after the war its use was infrequent.

There was little need to visualise southern difference in a flag. It was self-evident in the physical signs of racial segregation: separate schools, pools and drinking fountains; black people confined to the back of the bus. Political displays of the battle flag of Dixie (the historical nickname for the states that seceded from the Union) only really resurfaced when that racial order was challenged by northern liberals. In 1948, the Democrats – then the party overwhelmingly in control of the South – split over modest calls for civil rights. The conservatives who refused to support that year’s presidential ticket, the “Dixiecrats”, triggered a rev­ival of flag-waving across the region.

The old battle flag suddenly appeared on private lawns, on cars and at political rallies. Supposedly ancient cultural traditions were invented overnight. For instance, the 1948 student handbook of the University of Mississippi confessed: “Many Ole Miss customs are fairly new; they lack only the savouring which time brings . . . Ole Miss has adopted the Confederate flag as a symbol of the Mississippi spirit. Each football game finds the scarlet flag frantically waving to the rhythm of the Rebel band.”

I can confirm that this “tradition” was still going as recently as in 2005. That year, I attended an American football game at Ole Miss and was surprised when the band played “Dixie” at the end. White boys and white girls stood up and belted out the folk song of the Confederacy, while black students filed out.

In 1958, South Carolina made it a crime to desecrate the battle flag. Three years later, on the 100th anniversary of the outbreak of the civil war, it was hoisted above its Capitol building in Columbia. That day, there was a struggle in the US Congress to keep federal funding going for segregated schools.

So clear is the link between the postwar white resistance to civil rights and the battle flag that many see it as the symbolic equivalent of the N-word. Jack Hunter, the editor of the conservative website Rare Politics, says: “Some people insist that it’s not about racism, not about slavery, not about segregation. But it’s about all those things.” Hunter grew up in Charleston and used to skateboard in the car park of the church that Dylann Roof attacked. When he was a young journalist, he appeared on local radio as a rabidly right-wing masked character called “the Southern Avenger”. His past was exposed in 2013 while he was working for Rand Paul, a Republican presidential candidate, and Hunter stepped down from his position. He publicly renounced his youthful association with racial conservatism. He now eschews any romanticism about the Confederate cause and its demand for states’ rights. “States’ rights to do what?” he asks: the right to discriminate against African Americans? He is glad that the State House flag is gone. He ascribes its longevity to ignorance, which was corrected by Roof’s rampage: “It was the first time that [southern Republicans] were able to see a different perspective on this symbol.”

Not everyone agrees. Richard Hines – a former South Carolina legislator, Reagan campaign state co-chair and senior activist with the Sons of Confederate Veterans – insists that the flag is “an enduring symbol of the southern fighting man”. Indeed, a poll in July found that 57 per cent of Americans think it stands for southern heritage, rather than racism. Yet that heritage has a political dimension. “Southern people are proud of who they are and there is a leftist assault to destroy the best part of America,” Hines says. “The Trotskyite elite in control of the establishment wants to root out the southern tradition” – a tradition of religious devotion, chivalry and military honour. It is possible to cast the battle flag as a pawn in a much larger cultural conflict.

In 2000, civil rights activists lobbied hard to get the battle flag removed from the top of the South Carolina Capitol and succeeded in having it shrunk in size and relocated to the grounds of State House. The issue came up in that year’s Republican presidential primaries – an unusually poisonous contest between George W Bush and John McCain. Supporters of Bush put out a false story that McCain had fathered an interracial child out of wedlock. McCain added to his woes by opining that the battle flag was “a symbol of racism and slavery”. An organisation called Keep It Flying flooded the state with 250,000 letters attacking him and he lost the crucial competition here to Bush.

The battle flag has retained a strong emotional power for a long time. This makes the Republican establishment’s abandonment of the flag all the more surprising. Then again, those who run the South are probably the people most likely to grasp how much the region has changed in just a decade.

***

In 2010 I took a trip through North Carolina. The landscape told a story. Dotted along the roadside were abandoned black buildings, the old tobacco sheds. The decline of the rural economy had rendered them obsolete. Over the fields that would once have been full of farmers were freshly tarmacked roads, stretching out to nowhere. My guide explained that these were supposed to be cul-de-sacs for new houses. North Carolina was going through a property boom. But who was going to buy all those homes, I asked? The answer: damn Yankees.

Demography is destiny. This once agri­cultural region developed fast from the 1960s onwards by keeping union membership, taxes and regulation as low as possible. Yet capitalism proved disastrous for southern conservatism. Northerners flooded in, seeking work or retirement and bringing their own values. The forecast is that North Carolina’s Research Triangle – the South’s Silicon Valley – will grow by 700,000 jobs and 1.2 million people in two decades.

White migration was accompanied by an influx of Spanish speakers as the service sector flourished. Between 2000 and 2010, the white share of the population of North Carolina fell from 70 to 65 per cent. The black proportion remained at roughly 21 per cent. The Latino proportion, however, jumped from 4.7 per cent to 8.4 per cent. Today, the proportion of people who are non-white and over 60 is about a third. But it’s approaching nearly half for those under 18. As a result, politics in the South is no longer biracial: a contest between white and black. It is increasingly multiracial and uncoupled from the region’s complex past.

The impact of these changes is reflected in voting patterns. In 2000, the South was still overwhelmingly Republican in presidential contests. Even the Democratic nominee, Al Gore, a southerner, lost his home state of Tennessee. But in 2008 and 2012, Barack Obama took those states with the fastest-changing demographics: Florida and Virginia. He won North Carolina in 2008 and lost it in 2012 – but by less than 100,000 votes. It is true that the Republicans won back control in the 2014 midterm elections, with the result that the Deep South now sends few Democrats to Congress; but the region’s political masters are not quite as traditional-minded as they once were.

The Republican relationship with the Confederate past is complex. As the party of Abraham Lincoln and the Union, the GOPs’ southern support was historically small. But in the 1960s the national Democratic Party embraced civil rights and alienated its once loyal southern following; the Republicans took the opportunity to steal some conservative white voters.

The growing southern Republican vote had a class component. Its success in local and congressional races was built more on winning over middle-class moderates than on appealing to the working-class racists who filled the ranks of the Ku Klux Klan. The southern Republican Party did enthusiastically embrace the Confederate battle flag in many quarters. But some office-holders did so only with ambiguity, while large sections of the party never identified with it at all. The period of Republican ascendancy in the South was, in reality, linked with a softening of the area’s racial politics.

Two of the Republicans’ current southern stars are Indian Americans: Bobby Jindal, the governor of Louisiana, and Nikki Haley, the anti-flag governor of South Carolina. There are just two black people in the US Senate and one of them is a Republican, the Tea Party-backed senator for South Carolina, Tim Scott. Marco Rubio, the Floridian senator and presidential candidate, is Cuban American, and the former Florida governor Jeb Bush is married to a Mexican-born woman and speaks fluent Spanish. Bush has tried to push a more moderate line on immigration, in deference to how the GOP will struggle to win the White House if it appeals only to angry white voters. The Kentucky libertarian senator Rand Paul, Jack Hunter’s former boss, has called for legal reforms to correct the trend of keeping far more black than white people in prison. And he is not the only Republican to have been moved by recent race riots sparked by police violence.

***

Violence on the streets of Ferguson, Missouri, and Baltimore, Maryland, confirmed that there still is a culture war in the US. Yet its character has changed. In the past, civil disturbances were typically leapt upon by conservative politicians as evidence of social decline. The 1992 LA riots were blamed on single parenthood and rap lyrics. In contrast, conservative leaders today are far more likely to acknowledge the problems of white racism. There is no place in their ranks for the likes of Dylann Roof. White supremacists are tiny in number.

Jack Hunter claims: “The KKK is like 12 guys in a telephone booth. Liberal groups will use their threat for fundraising but it doesn’t exist. It hasn’t properly since the 1960s.” Roof’s actions say more about gun control, mental illness and the angst of the young than they do about popular, largely liberal views on race, as polling shows.

We can see a similar liberal shift in other areas of the historic culture war. In May 2015 Gallup released the results of a “moral acceptability” survey charting changes in national attitude across all age groups, from 2001 to 2015. Approval of gay relationships jumped from 40 to 63 per cent; having a baby out of wedlock from 45 to 61 per cent; sex between unmarried men and women from 53 to 68 per cent; doctor-assisted suicide from 49 to 56 per cent; even polygamy went from 7 to 16 per cent. Abortion remained narrowly disapproved of: support for access has only crept up from 42 to 45 per cent. This is probably a result of an unusual concentration of political and religious opposition and because it involves a potential life-or-death decision. But the general trend is that young people just don’t care as much about what consenting adults get up to.

Why? It might be because old forms of identity are dying. One way of measuring that is religious affiliation. From 2007 to 2014, according to Pew Research, the proportion of Americans describing themselves as Christian fell from 78 to 71 per cent. Today, only a quarter of the population is evangelical and 21 per cent Catholic, down despite high immigration. Then there is the decline in civic or communal activity. Since 2012, the organisers of Nascar, the stock-car races, have not published attendance figures at their tracks, probably because they have fallen so sharply. The decline of this most macho and working class of sports parallels the fall in conservative forms of collective identity such as southern traditionalism.

The old culture war was, like the racial politics of the old South, binary. In the 1950s, around the same time as the South invented its tradition of flying the battle flag in colleges, the US constructed an ideal of the “normal” nuclear family unit: straight, white, patriarchal, religious. On the other side was the “abnormal”: gay, black, feminist, atheist, and the rest. The surest way to get elected in the US between 1952 and 2004 was to associate yourself with the economic needs and cultural prejudices of the majority. The approach was once summed up by a Richard Nixon strategist thus: split the country in two and the Republicans will take the larger half. But that is changing. The old normal is no longer the cultural standard but just one of many identities to choose from. The races are mixing. Women want to work more and have children later in life, possibly without marriage. Many religious people are having to rethink their theology when a child comes out as gay. And the enforcers of the old ways – the unions, churches or political parties – are far less attractive than the atomising internet.

***

Politicians are scrabbling to keep up with the diffusion of American identity. Democrats got lucky when they nominated Barack Obama and chose a presidential candidate who reflected the fractured era well: interracial, non-denominational Christian, and so on. In the 2012 presidential race the Republicans got burned when they tried to play the old culture war card on abortion. They won’t repeat that mistake. After the Supreme Court legalised gay marriage across the country in June, the right’s response was not as uniformly loud and outraged as it would have been in the past. Some protested, but serious presidential contenders such as Jeb Bush grasped the implications of the defeat. There is a cultural and political realignment going on and no one is sure where it will lead. It’s encouraging caution among the Republican top brass. It is time, they think, to abandon lost causes.

The death of southern traditionalism is part of the ebb and flow of cultural history. Identities flourish and die. As political fashions change, you find the typically American mix of triumph on one side and jeremiad on the other. Richard Hines stood vigil as the battle flag was lowered in Columbia and noted with disgust the presence of what he described as “bussed-in” activists. “They pulled out all these gay pride flags and started shouting, ‘USA, USA, USA!’ It reminded me of the Bolshevik Revolution.”

Hines reckons that more southerners will now fly the flag than ever before and says he has attended overflow rallies of ordinary folks who love their region. He may well be correct. The faithful will keep the old Confederate standard fluttering on their lawns – an act of secession from the 21st century. But in the public domain, the battle flag is on its way down and in its place will be raised the standard of the new America. The rainbow flag flutters high. For now.

Tim Stanley is a historian and a columnist for the Telegraph

This article first appeared in the 20 August 2015 issue of the New Statesman, Corbyn wars