Benjamin Britten biography extract: was the composer's death caused by syphilis? It is possible to manage such a condition for a long time: despite its weakness, Britten's heart had functioned well for more than 50 years. There were symptoms along the way - breathlessness in tennis matches or while clambering around in the high altitudes of South America - but on the whole he managed to lead an active life. The endocarditis in 1968 changed all this, Tait concluded. Penicillin had done its job, but Britten's heart was aggravated by the infection and the valve had probably been deteriorating ever since. He needed to undergo surgery to replace the leaky valve, sooner rather than later. Britten was usually good with his doctors. He accepted their expertise and followed their instructions without demur. But not this time: Death in Venice took priority over surgery. Tait agreed it was possible to control his condition with drugs so long as Britten cut down on all other commitments and saw a cardiologist as soon as the opera was done. He responded well to the drugs and on a good day could forget about his condition. But he still found it impossible to climb stairs without wheezing, and a general, dulling tiredness overtook him. "Ben is writing an evil opera, and it's killing him," Pears complained somewhat hyperbolically to a friend. But only somewhat: both the diagnosis and Britten's obsessive response to it confirmed that this was indeed now his late period. On March 30 1973 he attended a consultation with Graham Hayward, a London cardiologist whom Tait had known at St Bartholomew's Hospital. Hayward, a beefy, ex-navy boxer with an imperious manner, was upbeat about Britten's condition, telling him that after surgery and a summer's convalescence he would be as "good as new - even conducting!" In mid-April Hayward's senior registrar at the National Heart Hospital, Michael Petch, undertook Britten's cardiac catheterisation to establish the type of surgery required. Britten complained about the canned music on the ward but was otherwise meek and co-operative. Petch was far less sanguine about the condition of Britten's heart and his prospects for a full recovery, however, despite the huge advances in heart surgery in previous decades, not least the first British transplant operation five years earlier, led by South African surgeon Donald Ross. Ross was a pioneering advocate of tissue rather than mechanical valves: biological matter was preferable because the alternative condemned a patient to a life of blood tests and anticoagulants. Hayward got it into his head that Britten was a heavy drinker (him being an artist). Alcohol is incompatible with anticoagulants, so a tissue valve was chosen. On May 2 Britten returned to the London Clinic and awaited his surgery, to take place five days later at the National Heart Hospital. He was upset about missing rehearsals for Death in Venice and the Covent Garden production of Owen Wingrave, but was otherwise a normal, scared, obedient patient. The surgery and mop-up took six hours and was hugely problematic from the outset. The complications were blamed on a number of factors: the poor condition of Britten's heart; the small stroke he suffered when debris from the old valve entered his bloodstream and lodged in the brain; the length of time it took to restart his heart and remove him from bypass. All of this was true, but the real problem was both more simple and more serious. When Ross cut open Britten's chest and began working on the grossly enlarged heart he discovered the aorta was riddled with tertiary syphilis. This was suddenly the wrong procedure. Britten's aorta was so distended that it was going to be almost impossible to make the new valve fit the space Ross and his team were about to create. Had he been using a mechanical valve Ross could, in surgery, have picked a better fit for the disfigured aorta, matching the circumference of one with the other. As it was, he had to make do with what was at hand. As Ross tried to stretch the tissue valve to make it fit the syphilitic aorta an already long operation was made longer, leaving Britten vulnerable to the host of complications that subsequently occurred. It was known that undiagnosed syphilis was then common, especially among male homosexuals, who often displayed no external symptoms. It was easy enough to overlook the infection in its dormant phase, when the external clues were as slight as a different timbre to a heartbeat, or to mistake the symptoms for another disease. The stigma was large, so tests were rarely undertaken in the absence of symptoms. Gentlemen of a certain class did not discuss such things. Yet the decades of Britten's youth and early adulthood were awash with the disease. Britten's eminence, conventionality and stories of childhood heart problems no doubt deflected any further probing into his medical history by his doctor in 1960 when the first symptoms of aortic valve disease were presented. Britten certainly had no suspicion he was syphilitic. But it seems likely that as he sweated and hallucinated his way through a bout of streptococcal tonsillitis in the early months of 1940, only two years after his heart was given the all clear and just as he was about to write his love song to Pears, Seven Sonnets of Michelangelo, his body was in fact reacting to syphilis, now in its secondary stage. All the symptoms were there. In 1940 he would still have had three to five years in which the brand new drug penicillin would cure him. But by 1960 - and certainly by 1973 - nothing could be done: tertiary syphilis is treatable, but after a certain period the damage is done. Penicillin at this late stage can actually make things worse. In 1968 Britten was given penicillin for his endocarditis (which can occur in conjunction with syphilis, though the diagnostic tests for each are distinct) and it destroyed the strange organic glue that had kept Britten's syphilitic heart functioning for many years, thereby initiating his slow, desperate decline. Nothing was said publicly. The discreet veil Ross drew over the operation gave rise to lurid rumours that lingered well past the Eighties - that the anaesthetist was incompetent, the surgeon drunk. But these were baseless. It was nothing more than a tragic chain of events. Over time Ross felt the burden of his discovery and the decisions he made in an instant about disclosure. Ten years or so after Britten's death he confided in cardiologist Hywel Davies, a close friend. Davies thinks Ross told him so as to make the news public - without his fingerprints on it. Davies did not oblige him on this point. At a chance meeting with Ross's assistant surgeon, who was in the operating theatre and watched events unfold, Davies confirmed the diagnosis, but thereafter kept his own counsel. The disease does not necessarily tell us much about Britten's relationship with Pears, even though he was the likely cause of infection. Pears probably caught syphilis before becoming Britten's lover, remaining one of the many symptomless sufferers. The personal implications become more complicated if infection occurred after 1939, though there were certainly enough hints during their time together to suggest that while Britten was monogamous (later celibate), Pears, on wet, windy Sundays in dreary hotels all over the world, played around. There was Britten's childhood friend Basil Reeve's recollection of Pears haunting gay bars in the late Thirties or early Forties, the later whispers of Pears's infidelity and Britten's gestures of forgiveness that bordered, curiously, on contrition. And there were their separate lives - not just separate bedrooms, but, from the mid-Fifties, whole parallel lives, pinched together at certain junctures, afterwards let go to run separate once more. Rita Thomson, a sparky Scottish nursing sister who looked after Britten at the National Heart Hospital with ready humour and a firm hand and who later became a trusted friend, thought "Peter was always the one with more outside interests than Ben ever had. I remember Ben saying to me, "I don't mind if Peter has little dalliances as long as he doesn't tell me." " And dally he did. None of this is to negate the loving connection between them, but it does suggest the bond was unevenly weighted, and that perhaps by the end it was primarily musical, intellectual and historical. Britten's one-time assistant Colin Matthews also identified in the composer an unsophisticated reaction to his own sexuality. He never made gay jokes or inferences, nor did he even use the word "gay"; he disliked socialising with gay couples, and was initially aghast at the idea of wearing checked trousers. Emotionally, Britten seemed happiest throughout his life when writing chatty, chummy letters to public schoolboys, as though on summer break without enough time to pen a romantic sonnet. It was this world - of chaste schoolboy crushes and unsophisticated rapport - that appealed to him. It was a psychosexual minefield, one that influenced his music to a great extent. But it left Pears, from early in their relationship, looking elsewhere for a sexual life. And in sad irony it left Britten, the more puritanical of the pair, with a sexually transmitted disease that slowly ate away at his heart, his bad behaviour increasing as his health deteriorated. Recovery was desperately slow. Rita Thomson visited when Britten was recuperating in the London Clinic and arrived to see him being served dinner on a large tray - a heavy silver dome covering a 2in-thick steak - as though supping at the Athenaeum. He was lonely - Pears was busy at Covent Garden with Owen Wingrave and only rarely at his bedside - and it was Thomson who three weeks after the operation escorted him back to the Red House. A series of nurses cared for him there, until the following Easter when Britten lured Thomson to Aldeburgh permanently. She later recalled Britten's precarious health in the first month and year, how the heart never reduced in size and how the ill-fitting valve was never able to gain in strength. He was two stone overweight, bloated with water: it was only when Michael Petch became his specialist in 1974 and changed his medication that the weight was shifted. He could not stretch out his arms, leaving him unable to work on large manuscripts, and the stroke removed his ability to sense where his right hand was. He could not find his mouth to feed himself without looking, and knowing intuitively where his hand was on a piano was impossible. It should have been a gentle time in which his wounds healed, his drugs were stabilised and his stitches removed. He needed help washing and shaving, needed to be dressed and helped down stairs. After a year or 18 months it became obvious to everyone that he was not improving. "His [valve] didn't fit perfectly from day one," Petch later said. And it leaked - it leaked more than it should have done, and so there was this continuing extra burden on the heart. Petch was never told of the syphilis and today is sceptical of the diagnosis, believing the tests for endocarditis Britten had in 1968 should have revealed any infection. Britten asked Thomson whether he would improve. There would be bursts of energy and periods of exhaustion, she replied. And there would be people who stimulated him and people who wore him out; sometimes they would be one and the same. He cried a little, yet drew strength from the knowledge. I think once he had accepted it, he felt that he must get on with everything. The celebrations for Britten's 60th birthday were as extravagant as those for his 50th. There were performances, a day of broadcasts and a BBC Two documentary. There was a concert at the Royal Albert Hall that showcased the youthful Britten, the composer of Sinfonia da Requiem and Spring Symphony. Britten stayed in Suffolk. The days fell into a simple pattern. He rose late and was bathed and dressed by Thomson, making it downstairs by around 11am. There, he would drink a light lager to take off the edge and settle down to work - perhaps with Rosamund, perhaps on the new works that increasingly occupied him from mid-1974 onward. After lunch he went to bed until four o'clock, when he came downstairs once more to work further or go for a walk. Then dinner and an early night. At no point did Britten consider stopping work. Part of his depression stemmed from how long everything now took to get down on paper, how exhausted he was after only an hour's work. This was the man who used to orchestrate his big works while holding conversations. On June 12 1976, a handful of Britten's friends gathered in the garden of the Red House for an informal drinks party, after the announcement that morning in The Times that Britten was now a life peer, a final gesture from queen to composer: he was now to be known as Baron Britten of Aldeburgh, in the County of Suffolk. At the party, in a wheelchair and wearing a garish paisley shirt, Britten smiled and talked and sipped his wine. His sister Barbara stood close by, looking prematurely funereal. And as the final guests departed, Pears wheeled Britten back into the house, the two somehow separated from their friends, alone together. For his 63rd birthday, after a terrible night of fitful sleep and oxygen from a tank, he decided he wanted a party at the Red House. Thomson and Pears assembled Britten's two sisters and a handful of close friends, and they drank champagne downstairs, going up to his bedroom one at a time to say their final goodbyes. They each had 10 minutes or so with him, trying not to be mawkish or awkward, before leaving the room with a wave or a smile. Britten was calm and direct with each: "If this is it, and I am sure it is, I want to go. I can't bear to go on any longer not being able to do all the things I used to do," he told his sister Beth. Barbara saw him one last time as he slowly faded. "Sorry, old thing," he shrugged. On Friday, December 3 Petch came to stay. After a good dinner with Pears, the wine flowing, Petch checked in on his patient once more. "Goodnight, Mike," Britten whispered as he made his retreat. Britten's breathing deteriorated in the early hours of the morning. The night nurse, sensing the end was imminent, rang the bell to summon Thomson from her exhausted sleep, which took several attempts. She eventually entered the room at 4.15am, arriving just in time to watch Britten die in Pears's arms. Two days later Britten's death was registered. In the column marked "Cause of death" was written "Congestive Cardiac Failure; Aortic Incompetence" - all of which was true, but only a small part of the story. Extracted from "Benjamin Britten: A Life in the 20th Century" (Allen Lane), available from Telegraph Books for £26 + £1.35 p&p. 0844 871 1514; books.telegraph.co.uk. ©Paul Kildea 2013 Follow Seven on Twitter @TelegraphSeven