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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The people is sublime: the long history of populism, from Robespierre to Trump

If liberal democracy is to survive, the tide of populism will have to be turned back. The question is: how?

A spectre of populism is haunting the world’s liberal democracies. Donald Trump’s victory in the US presidential election, the narrow Leave majority in the EU referendum, Theresa May’s decision to call a snap election – breaking the spirit of the Fixed-Term Parliaments Act passed by the government of which she was a member – and Recep Tayyip Erdogan’s victory in the recent Turkish referendum all testify to the strength of the populist tide that is sweeping through the North Atlantic world. The consequences have been calamitous: a shrunken public realm, a demeaned civic culture, threatened minorities, contempt for the rule of law and an increasingly ugly public mood. If liberal democracy is to survive, the tide will have to be turned back. The question is: how?

The first essential is to understand the nature of the beast. This is more difficult than it sounds. Most democratic politicians seek popularity, but populism and popularity are not the same. Today’s populism is the descendant of a long line of ancestors. The first unmistakably populist movement in history appeared well over two centuries ago during the later stages of the French Revolution. It was led by Robespierre (Thomas Carlyle’s “sea-green incorruptible”) and the Jacobins who promised a reign of “virtue”. They were inspired by the cloudy prose of Jean-Jacques Rousseau, who believed that mere individuals should be subject to the general will of the social whole and – if necessary – “forced to be free”. As the revolution gathered pace and foreign armies mustered on France’s frontiers, the Jacobins launched the first organised, state-led and ideologically legitimised Terror in history. Chillingly, Robespierre declared, “The people is sublime, but individuals are weak.” That is the cry of populists through the ages. Appropriately, the Terror ended with Robespierre lying on a plank, screaming with pain before he was executed by guillotine.

The French Revolution – which began with the storming of the Bastille and ended with Napoleon’s ascent to an ersatz imperial throne – has an epic quality about it missing from later chapters in the populist story. Ironically, the second chapter, which opened half a century later, was the work of Louis Bonaparte, nephew of the great Napoleon. In 1848 came a second revolution and a second Republic; Louis Bonaparte was elected president by a huge majority. He tried and failed to amend the constitution to make it possible for him to have a second term; and then seized power in a coup d’état. Soon afterwards he became emperor as Napoleon III. (“Napoleon le petit”, in Victor Hugo’s savage phrase.) The whole story provoked one of Karl Marx’s best aphorisms: “History repeats itself; the first time as tragedy and the second as farce.”

There have been plenty of tragedies since – and plenty of farces, too. Trump’s victory was a tragedy, but farcical elements are already in evidence. Erdogan’s victory was even more tragic than Trump’s, but farce is conspicuously absent. The Leave victory in the referendum was tragic: arguably, the greatest tragedy in the three-century history of Britain’s union state. As with Trump, farce is already in evidence – the agitated comings and goings that have followed Theresa May’s loss of her Commons majority; the inane debate over the nature of the Brexit that Britain should seek; and the preposterous suggestion that, freed of the “Brussels” incubus, Britain will be able to conclude costless trade deals with the state-capitalist dictatorship of China and the “America First” neo-isolationists in Washington, DC. Unlike the French farce of Napoleon III’s Second Empire, however, the British farce now in progress is more likely to provoke tears than laughter.


Picture: André Carrilho

Populism is not a doctrine or a governing philosophy, still less an ideology. It is a disposition, perhaps a mood, a set of attitudes and above all a style. The People’s Party, which played a significant part in American politics in the late 19th century, is a case in point. The farmers whose grievances inspired the People’s Party wanted cheaper credit and transport to carry their products to markets in the eastern states. Hence the party’s two main proposals. One was the nationalisation of the railways, to cheapen transport costs; the other was “free silver” – the use of silver as well as gold as currency, supposedly to cheapen credit. Even then, this was not a particularly radical programme. It was designed to reform capitalism, not to replace it, as the largely Marxist social-democratic parties of Europe were seeking to do.

Rhetoric was a different matter. Mary Elizabeth Lease, a prominent member of the People’s Party, declared that America’s was no longer a government of the people by the people and for the people, but “a government of Wall Street, by Wall Street and for Wall Street”. The common people of America, she added, “are slaves and monopoly is the master”.

The Georgian populist Tom Watson once asked if Thomas Jefferson had dreamed that the party he founded would be “prostituted to the vilest purposes of monopoly” or that it would be led by “red-eyed Jewish millionaires”. The People’s Party’s constitutive Omaha Platform accused the two main parties of proposing “to sacrifice our homes, lives and children on the altar of Mammon; to destroy the multitude in order to secure corruption funds from the millionaires”. The party’s aim was “to restore the government of the Republic to the hands of ‘the plain people’ with which class it originated”. Theodore Roosevelt promised “to walk softly and carry a big stick”. The People’s Party walked noisily and carried a small stick. Jeremy Corbyn would have been at home in it.

Almost without exception, populists promise national regeneration in place of decline, decay and the vacillations and tergiversations of a corrupt establishment and the enervated elites that belong to it. Trump’s call to “make America great again” is an obvious recent case. His attacks on “crooked Hillary”, on the courts that have impeded his proposed ban on Muslim immigrants from capriciously chosen Middle Eastern and African countries, on the “fake news” of journalists seeking to hold his administration to account, and, most of all, his attack on the constitutional checks and balances that have been fundamental to US governance for more than 200 years, are the most alarming examples of populist practice, not just in American history but in the history of most of the North Atlantic world.

There are intriguing parallels between Trump’s regime and Erdogan’s. Indeed, Trump went out of his way to congratulate Erdogan on Turkey’s referendum result in April – which gives him the right to lengthen his term of office to ten years, to strengthen his control over the judiciary and to decide when to impose a state of emergency. Even before the referendum, he had dismissed more than 100,000 public servants, including teachers, prosecutors, judges and army officers; 4,000 were imprisoned. The Kurdish minority was – and is – repressed. True, none of this applies to Trump. But the rhetoric of the thin-skinned, paranoid US president and his equally thin-skinned and paranoid Turkish counterpart comes from the same repertoire. In the Turkish referendum Erdogan declared: “My nation stood upright and undivided.” It might have been Trump clamorously insisting that the crowd at his inauguration was bigger than it was.

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The best-known modern British populists – Margaret Thatcher, Nigel Farage and David Owen – form a kind of counterpoint. In some ways, all three have harked back to the themes of the 19th-century American populists. Thatcher insisted that she was “a plain, straightforward provincial”, adding that her “Bloomsbury” was Grantham – “Methodism, the grocer’s shop, Rotary and all the serious, sober virtues, cultivated and esteemed in that environment”. Farage declared that the EU referendum was “a victory for ‘the real people’ of Britain” – implying, none too subtly, that the 48 per cent who voted Remain were somehow unreal or, indeed, un-British.

On a holiday job on a building site during the Suez War, Owen experienced a kind of epiphany. Hugh Gaitskell was criticising Anthony Eden, the prime minister, on television and in the House of Commons, but Owen’s workmates were solidly in favour of Eden. That experience, he said, made him suspicious of “the kind of attitude which splits the difference on everything. The rather defeatist, even traitorous attitude reflected in the pre-war Apostles at Cambridge.” (Owen voted for Brexit in 2016.)

Did he really believe that Bertrand Russell, John Maynard Keynes and George Moore were traitorous? Did he not know that they were Apostles? Or was he simply lashing out, Trump-like, at an elite that disdained him – and to which he yearned to belong?

Thatcher’s Grantham, Farage’s real people and David Owen’s workmates came from the same rhetorical stable as the American populists’ Omaha Platform. But the American populists really were plain, in their sense of the word, whereas Thatcher, Farage and Owen could hardly have been less so. Thatcher (at that stage Roberts) left Grantham as soon as she could and never looked back. She went to Somerville College, Oxford, where she was a pupil of the Nobel laureate Dorothy Hodgkin. She married the dashing and wealthy Denis Thatcher and abandoned science to qualify as a barrister before being elected to parliament and eventually becoming prime minister. Farage worked as a metals trader in the City before becoming leader of the UK Independence Party. Owen went to the private Bradfield College before going up to Cambridge to read medicine. Despite his Welsh antecedents, he looks and sounds like a well-brought-up English public school boy. He was elected to parliament in 1966 at the age of 28 and was appointed under-secretary for the navy at 30. He then served briefly as foreign secretary in James Callaghan’s miserable Labour government in the 1970s.

Much the same is true of Marine Le Pen in France. She is a hereditary populist – something that seems self-contradictory. The Front National (FN) she heads was founded by her father, Jean-Marie Le Pen – Holocaust denier, anti-Semite, former street brawler and sometime Poujadist. In the jargon of public relations, she has worked hard to “de-toxify” the FN brand. But the Front is still the Front; it appeals most strongly to the ageing and insecure in the de-industrialised areas of the north-east. Marine Le Pen applauded the Leave victory in Britain’s referendum – she seeks to limit immigration, just as Ukip did in the referendum and as the May government does now.

Above all, the Front National appeals to a mythologised past, symbolised by the figure of Joan of Arc. Joan was a simple, illiterate peasant from an obscure village in north-eastern France, who led the French king’s forces to a decisive victory over the English in the later stages of the Hundred Years War. She was captured by England’s Burgundian allies, and the English burned her at the stake at the age of 19. She was beatified in 1909 and canonised in 1920. For well over a century, she has been a heroine for the Catholic French right, for whom the revolutionary triad of liberté, egalité, fraternité is either vacuous or menacing.

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The past to which the FN appeals is uniquely French. It is also contentious. A struggle over the ownership of the French past has been a theme of French politics ever since the French Revolution. But other mythologised pasts have figured again and again in populist rhetoric and still do. Mussolini talked of returning to the time of the Roman empire when the Mediterranean was Mare Nostrum. Trump’s “Make America great again” presupposes a past when America was great, and from which present-day Americans have strayed, thanks to Clintonesque crooks and the pedlars of fake news. “Take back control” – the mantra of the Brexiteers in the referendum – presupposes a past in which the British had control; Owen’s bizarre pre-referendum claim that, if Britain left the EU, she would be free to “rediscover the skills of blue water diplomacy” presupposed a time when she practised those skills. Vladimir Putin, another populist of sorts, is patently trying to harness memories of tsarist glory to his chariot wheels. Margaret Thatcher, the “plain, straightforward provincial” woman, sought to revive the “vigorous virtues” of her Grantham childhood and the “Victorian values” that underpinned them.

As well as mythologising the past, populists mythologise the people. Those for whom they claim to speak are undifferentiated, homogeneous and inert. Populists have nothing but contempt for de Tocqueville’s insight that the ever-present threat of majority tyranny can be kept at bay only by a rich array of intermediate institutions, including townships, law courts and a free press, underpinned by the separation of powers.

For populists, the threat of majority tyranny is a phantom, invented by out-of-touch and craven elitists. Law courts that stand in the way of the unmediated popular will are “enemies of the people”, as the Daily Mail put it. There is no need to protect minorities against the tyranny of the majority: minorities are either part of the whole, in which case they don’t need protection, or self-excluded from it, in which case they don’t deserve to be protected.

Apparent differences of interest or value that cut across the body of the people, that divide the collective sovereign against itself, are products of elite manipulation or, in Thatcher’s notorious phrase, of “the enemy within”. For there is a strong paranoid streak in the populist mentality. Against the pure, virtuous people stand corrupt, privileged elites and sinister, conspiratorial subversives. The latter are forever plotting to do down the former.

Like pigs searching for truffles, populists search for subversives. Inevitably, they find what they are looking for. Joe McCarthy was one of the most squalid examples of the populist breed: for years, McCarthyism was a baneful presence in Hollywood, in American universities, newspaper offices and in the public service, ruining lives, restricting free expression and making it harder for the United States to win the trust of its European allies. The barrage of hatred and contempt that the tabloid press unleashed on opponents of Theresa May’s pursuit of a “hard” Brexit is another example. Her astounding claim that a mysterious entity known as “Brussels” was seeking to interfere in the British general election is a third.

As the Princeton political scientist Jan-Werner Müller argues, all of this strikes at the heart of democratic governance. Democracy depends on open debate, on dialogue between the bearers of different values, in which the protagonists learn from each other and from which they emerge as different people. For the Nobel laureate, philosopher and economist Amartya Sen, democracy is, above all, “public reasoning”; and that is impossible without social spaces in which reasoning can take place. Populism is singular; democracy is plural. The great question for non-populists is how to respond to the populist threat.

Two answers are in contention. The first is Theresa May’s. It amounts to appeasement. May’s purported reason for calling a snap general election was that the politicians were divided, whereas the people were united. It is hard to think of a better – or more frightening – summary of the spirit of populism. The second answer is Emmanuel Macron’s. For the moment, at least, he is astonishingly popular in France. More important, his victory over Le Pen has shown that, given intelligence, courage and generosity of spirit, the noxious populist tide can be resisted and, perhaps, turned back. 

David Marquand’s most recent book is “Mammon’s Kingdom”: an Essay on Britain Now” (Allen Lane)

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