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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Moby: “The average American IQ is around 98”

Moby, the vegan king of chill-out pop, talks wealth, David Bowie’s hat and the average intelligence of his fellow Americans.

In January 2012, two women walking their nine dogs on the hill beneath the Hollywood sign found a man’s severed head wrapped in a plastic bag. His decomposing feet and hands were discovered nearby. First theories pointed to the work of a Mexican drug cartel, or the murderous Canadian porn actor Luka Magnotta. The story piqued the interest of the electronic dance music mogul Moby, who wrote about it in a New Statesman diary in May this year.

Today, the smell of cedar and pine hits you on the canyon path, which is hot, steep and sandy – an immediate wilderness in one of LA’s most exclusive areas. The Griffith Observatory shines like a strange white temple on the hill. Brad Pitt, a local resident, was doorstepped after the head was discovered: he lives near Moby on the streets of Los Feliz, near Griffith Park, where the only sounds are hedge strimmers and workmen’s radios. Moby’s 1920s mansion is all but obscured by Virginia creeper.

As we sit down at his kitchen table, Moby tells me that the body parts were found to belong to a 66-year-old Canadian flight attendant called Hervey Medellin. Shortly before Medellin’s disappearance, his boyfriend, Gabriel Campos-Martinez, had used a computer in the flat they shared to find an article titled, “Butchering of the human carcass for human consumption”. The head, feet and hands showed signs of having been frozen: the rest of the body was never found. He says it was one of those rare times in life where reality was more intriguing than the conspiracy theories.

Moby, of course, eats no meat. Fifteen minutes’ drive away in the hipster neighbourhood of Silver Lake, his vegan bistro, Little Pine, serves a variety of plant-based dishes, proceeds from which go to animal rights organisations including the Humane Society and Peta. His own music is never played there. We are meeting to talk about his new album – but, he says: “It’s 2016 and people neither buy nor listen to albums. And they certainly don’t listen to the 16th album made by a 51-year-old musician. I don’t care if anyone gives me money for this music or for live shows ever again. Once a record’s released, I couldn’t care less what happens with it. I liked making it, but I don’t care.”

He is currently working his way though the stages of grief outlined by the psychiatrist Elisabeth Kübler-Ross. To denial, anger, bargaining, depression and acceptance he has added a new phase: Schadenfreude. On the night of the US election, he left the house at 6pm west coast time to watch the coverage with some friends. He checked his usual round of sites on his phone: CNN, the New York Times, the Washington Post, Nate Silver’s FiveThirtyEight, the Guardian, the Huffington Post, the BBC, politico.com. He was concerned to see that no one was calling any of the early states; with Obama’s election, exit polls suggested the victory by noon. Days earlier, Moby had been predicting humanity’s “wake-up call” in the form of the destruction of Greenland or a zoonotic virus – but not this. He is softly spoken, with a quick laugh and the kind of intelligence that seems to warm him up from the inside when he talks, but today he is angry.

“It is disturbing on so many levels,” he says. “One, that we have elected an inept racist as president. Two, just seeing how dumb and delusional so many Americans are. Because really – in terms of the subsets of people who would vote for Trump – you have to be delusional, or racist, or stupid. I am so confused as to the fact that such a high percentage of Americans are either really stupid or incredibly bigoted.”

The stupidity of Americans is, he says, a matter of “anthropological curiosity” – or simply demographics. “The average American IQ is around 98,” he notes. “So that honestly means – in a vaguely non-pejorative way – that there are a lot of really, really dumb people. The nonsense that people were spouting before the election – that Trump was a good businessman, for example? This phenomenon has been particularly egregious of late: people have an almost adversarial relationship with evidence. Climate-change deniers are another example.”

As a self-described old-timey alcoholic, Richard Melville Hall (nicknamed Moby by his father in honour of his great-great-great-uncle Herman) has a pervasive interest in neurochemistry. He uses it to explain much of the past six months in Western politics. Our failing political systems – the subject, in fact, of the album he doesn’t want to talk about – are underpinned by “a kind of delusional motivation, which is basically to ignore the countless things that are actually going wrong in the world and focus all your attention on things that are arbitrary. In the United States, you have people who have perfectly good jobs in safe communities who are obsessed about Mexico, crime and unemployment. We have these quasi-Orwellian responses to stimuli, and they come from a place of fear and scarcity. Humans are still built to amass as much wealth as possible, and fight off the enemies as quickly as possible, but the only threats are the ones we generate ourselves.”

There’s a dishcloth on the table, a few magazines, a bit of a draught and Moby in a black hoodie pouring two glasses of water.

Fear and scarcity pervade American society, he says, because social policy is an extension of corporate process and “nothing is free from the cadres of professional lobbyists”. Meanwhile the ravenous news consumption that helped drive Trump reflects a human addiction to the “neurochemical jolt” of engaging with the media.

“People have a profound and almost feral attachment to that which makes them feel good in the moment,” he says. “Without thinking of long-term consequences, does their belief give them a shot of dopamine right at this second? If so, they hold on to it. Eating junk food, voting Brexit and voting for Trump.”

 

***

 

Moby is the model of an addictive personality well-practised at controlling itself. He was a fully fledged alcoholic by his early twenties: at ten, he’d been given champagne and made himself the promise, “I always want to feel this good.” Now, he cannot touch a drink, but his modern-day addiction, he says without a beat, is his phone. Every thought is pursued to extremes. He recently released an animated video for a new song, “Are You Lost In the World Like Me?”, showing a procession of grotesque, phone-addicted cartoon characters filming a girl as she throws herself off a skyscraper and hits the ground.

The house is vaguely baronial, airy and open-plan: all dark wood and furniture polish. An Annie Hall poster in the pool house; a coyote postcard on the kitchen wall.

This particular property is a result of serious downsizing: Moby has a habit of buying very big places, doing them up and then moving out. When he was still in New York, he bought a remote mountaintop retreat in Kent Cliffs, 50 miles north of Manhattan. He created a magnificent bedroom of 1,500 square feet with ten skylights – but quickly learned he could only get a decent night’s sleep when he pulled his mattress into the cupboard. He told the New York Times that, living all alone in the big house, he “felt like Orson Welles at the end of Citizen Kane”.

He moved to LA in 2010, swapped vodka for quinoa smoothies and took the keys for another large building – the Wolf’s Lair, the turreted, 1920s Gothic castle in Hollywood once inhabited by Marlon Brando, with the swimming pool historically used for porn movies and the hidden tiki bar. He bought it for $4m and sold it for $12.5m four years later – allegedly to Banksy. He rattled around in that house, too. Right on cue, he tells me: “I felt like Orson Welles at the end of Citizen Kane.”

On the one hand, these were sensible ­investments for the man who’s sold 20 million records; on the other, large impersonal spaces appealed to Moby long before he was in a position to buy them. Raised by his single mother on food stamps and welfare in Darien, Connecticut, he started his adult life squatting an abandoned lock factory, where he could ride his moped around his bedroom, piss into a bottle and read battered Star Trek paperbacks while working on early demo tapes, rather like a ragged, vegan version of the boy in the movie Big.

He was very happy in his penniless state, as he records in his memoir, Porcelain. He’d like to propose something he calls the End of Wealth – but we’ll come back to that.

In the past few years Moby has broken free from the “Beckettian purgatory of touring”. When his biggest-selling album, Play, was released in 1999, his music career was effectively “over”. Before Play, he had changed creative direction, going from progressive house to ambient to thrashy punk – to which he has just returned – and no one knew what to do with him. The only reason he hadn’t been dropped by his UK label, Mute Records, was that its owner, Daniel Miller, was “an old egalitarian socialist”.

Play sampled slave songs of the Deep South – recorded by the ethnomusicologist Alan Lomax in the 1940s – and wove them into a backdrop of cerebral chill-out. The songs of pain and emotion took on an eerie neutrality, and TV shows and ad companies came calling. He was approached by Will and Grace and Grey’s Anatomy. At that point, selling records and touring were still more lucrative than licensing a song to TV – and licensing a song to TV was still considered selling out. But Moby considers himself an ugly duckling: “If someone who was once unattractive suddenly gets asked out on loads of dates, of course they say yes a lot.” He licensed every song on Play and it became the soundtrack of the millennium.

His memoir was unusual because it concentrated on the ten-year period before he got famous. It captured his enthusiasm – and his strangeness – at its source and showed him to have a sense of humour that may have passed people by the first time round. “I’m in London! London!” he wrote. “Benny Hill, Joy Division, Peter O’Toole!” He visited the vegan café in Covent Garden.

The book is filled with money: or with the constant, practical concern of not having it. Navigating poverty is an everyday routine: he is an “alchemist” turning used beer bottles into nickels at the recycler, and thence into soya milk and oranges. In his early twenties he becomes a Christian, partly so that he can repeat the Sermon on the Mount at Bible classes in the households of Greenwich Village and “judge” the rich children.

Book two, which Faber & Faber is waiting for, is more difficult. The period of his fame and fortune in the 2000s is too much of a cliché. “Ten years ago I was entitled, narcissistic, bottoming out, alcoholic, selfish and feral. Robbie Williams has done that story, so has Ozzy and Mötley Crüe. Who wants to read that? It’s tautological.”

Instead, he has decided to write about the first ten years of his life. It will look into his relationship with his mother, who loved him but raised him in various drug dens. He was at her side when she died in 1997, but he missed her funeral, having woken late in the morning to discover that at some point in the night he must have got up and set his alarm clock three hours late. He took a taxi to the wake, worrying about the fare, and for reasons he can’t really explain, turned up cracking jokes.

He has a strange nostalgia for the kinds of friendships you have in early adulthood, when everyone is equal, “before that point when someone starts making money and they think they’ve won: they’re going to have access to a different kind of happiness”.

In 2003, when he turned 38, he was famous, wealthy and miserable. “I’ve been able to see and inhabit almost every stratum on the socioeconomic scale, from extreme poverty and obscurity to wealth and fame, and it gives me an insight into it,” he says. “Because a lot of people who experience wealth are born into it, and a lot of people who experience poverty never leave it. I can safely say that for me there has been no causal effect between increased fame and wealth and increased basic happiness and well-being.”

When Moby talks about himself, he applies many apologetic epithets: clichéd, meditating, yoga-loving, mealy-mouthed. In 2007 he developed mobygratis.com, a large online resource offering independent film-makers and film students a licence to use his music for free. If their films are commercially successful, the revenue from licence fees must go to the Humane Society. He says he wants to propose a more rational, evidence-based approach to wealth.

“We are still attached to the idea of the redistribution of wealth,” he says. “As progressive lefties, we’re all brought up to think that is a good idea. In the old days, it meant the difference between eating and not eating. Nowadays the person on $30,000 consumes twice the calories of the millionaire, and has a bigger TV and works fewer hours.

“There is an underlying assumption that if wealth were distributed more evenly then people would be happier, but there is unfortunately very little anthropological or sociological evidence to support that idea, unless there are institutions to support the basic needs of community, like food and shelter. Confusing materialism with happiness is the essence of our culture.”

While west LA is plastic surgery and gold-plated toilets, he says, his own neighbourhood is “David Lynch wearing an old T-shirt and mowing the lawn”. Among the millionaires of Los Feliz, conspicuous consumption is frowned upon. He knows several who live “incredibly austere lives. I was having tea with Jim Carrey the other day. He’s basically just giving everything away. He just realised that owning three planes was stressing him out . . .”

In his New Statesman diary, Moby said that life in LA offered him miles and miles of lavender-scented name-dropping.

“Coldplay played the Rose Bowl recent­ly,” he says. “And the Rose Bowl holds 75,000 people. It’s a struggle for me to sell 2,000. At first, I winced with a little jealousy. But then I thought, ‘If my career was at that Coldplay level, how would that actually affect my daily existence? Would it make my shoes fit better? Would it make the water pressure in my shower better?’ As long as you’ve satisfied the basic hierarchy of needs – enough to eat, clean air to breathe, bears not eating your legs – happiness is all where and how you put your attention.”

***

He goes to his kitchen cupboard and from among the colanders and measuring jugs he extracts a black velvet fedora – size seven, silk-lined, from a London company established in 1879. In green marker around the inside rim are the words “With love from David – Christmas 2005”. Bowie gave it to him over Christmas dinner that year. “It’s the hat that he wore in The Man Who Fell to Earth,” Moby says. “There’s this amazing picture of him wearing it with John Lennon and it’s clearly when he was doing a lot of cocaine.”

Moby lived on Mott Street in Little Italy and Bowie lived on Mulberry Street. “I had a little roof deck, and he had a beautiful roof terrace, and we could wave at each other.” They were neighbours and friends, worked on music together, went on tour together, had barbecues together. He says the title of Bowie’s last album, Black Star, is a reference to the 1960 Elvis Presley song of the same name “about the end of a life” (“And when a man sees his black star,/He knows his time, his time has come”).

“David had been sick for a long time,” he says. “Or ill, as you say in the UK. So, David had been ill for a long time. I was very pleased that . . . after he died, people were asking me, ‘How do you feel?’ and I’m like, ‘Actually, I’m just kind of happy that he lived as long as he did.’ Because I . . . had thought, yeah, I had thought that he was going to die a little before that. So.”

The Radiohead singer Thom Yorke lives just up the street from him in Los Angeles but Moby has never met him “as far as I know”. Apart from Bowie, he claims not to have musician friends.

“Musicians – and I’m sure you’ve encountered this many times – have a sense of self-importance that is off-putting,” he says. “It is very hard to be friends with someone who thinks that just by showing up, they’re doing something special. At the end of the day, you want to say to them, ‘You know what? You wrote a couple of good songs. Let’s put it in perspective.’”

He was born on 11 September 1965, and on his 36th birthday he watched the twin towers burning from his roof deck. He tells me that when the second plane hit and it became clear the first was no accident, he heard “the cumulative effect of ten thousand rooftops covered with people, and the weirdest scream. A scream of horror but also a scream of understanding.”

Fifteen years on, he talks about this year’s politics as a Manichaean thing. “Half the world are motivated by fear and desire to move backwards, and the other half are motivated by optimism and a desire to move forward rationally. It’s religious tolerance versus fundamentalism; it’s racism versus inclusion. I wonder if there’s a way we can make peace with that whole other half of humanity who are holding on to a non-evidence-based approach to the future. But I don’t know what it is.” He has known Hillary Clinton for two decades, was a vocal supporter of hers during the election run and released a pair of anti-Trump tracks for Dave Eggers’s music project 30 Days, 50 Songs.

He says that many celebrity Clinton backers were cautious to come out for her during the primaries “because Bernie supporters wanted to crucify you. Now Trump has united and inspired Democrats more than anything since the Vietnam War.”

The election result, he says, might just be “the equivalent of a crystal meth addict going on one last bender. Maybe this bender will finally convince Americans to stop voting for Republicans. Because they are terrible. There has always been an understanding that if everyone in America voted, there would be no Republican politicians. The reason Republicans win is that most Americans don’t vote.

“Those of us on the left who were brought up to be tolerant of people who had different opinions from us – well that’s great, ­unless the opinions are bigoted and wrong. If someone is a climate-change denier, they are wrong. If someone voted for Brexit, they are wrong. If someone voted for Trump, they are wrong. There is a lot of ambiguity in the world, but not about these things.”

The clock ticks towards 11.15am and Moby, ever punctual, is done.

“These Systems Are Failing” is out now on Little Idiot/Mute

Kate Mossman is the New Statesman's arts editor and pop critic.

This article first appeared in the 08 December 2016 issue of the New Statesman, Brexit to Trump