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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Rupert Goold: “A director always has to be more of a listener”

The artistic director of the Almeida Theatre on working with Patrick Stewart, the inaccessibility of the arts, and directing his wife in Medea.

Eight years ago Rupert Goold’s Macbeth made his name. The critics were unanimous in their praise, with one calling it the “Macbeth of a lifetime”. Goold’s first Olivier Award soon followed (Enron won him a second in 2009, King Charles III nearly won him a third last year). It was a family triumph; Lady Macbeth was played by Goold’s wife, Kate Fleetwood.

Now the pair has finally reunited and Fleetwood is his undisputed lead. She is playing Medea in the Almeida’s latest and final play of its Greek season. Directing your wife is one thing. Directing her in a play about a woman who murders her children because her husband abandons her is another. And it’s been harder than Goold expected.

“You live with someone every day, and they don’t age because the change is so incremental, and then you do something together and you realise how much you’ve changed. It’s like playing tennis with someone after eight years: you’re completely different players.”

As it is, Goold thinks the director-actor relationship is inevitably fraught. “There is an essential slave-master, sadomasochistic, relationship,” he says. “The incredibly complicated thing about being an actor is you’re constantly being told what to do. And one of the most damaging things about being a director – and why most of them are complete arseholes – is because they get off at telling people what to do.”

Goold doesn’t. He’s as amicable in person as the pictures – bountiful hair, loose jacket, wide grin – suggest. And when we meet in the Almedia’s crowded rehearsal rooms, tucked away on Upper Street, 100 yards from the theatre, he’s surprisingly serene given his play is about to open.

He once said that directing a play is like running towards a wall and hoping it becomes a door just before the curtain goes up. Has the door appeared? “It’s always a funny moment [at the end of rehearsal]. Sometimes you do a show and it’s a bit dead and the costumes and set transform it. Then sometimes it’s perfect and the design kills it.”

We meet shortly before last Thursday’s press night, and he can’t tell how good it is. But it “certainly feels quite private. The idea that loads of people are going to come and watch it now feels a bit weird. You bring a lot of your sense of relationships and parenting into it.”

Goold has always argued that the classics wither without intervention. So in this revival of Euripides’ 2,446-year-old play, Medea is a writer and her husband, Jason (of Argonauts fame), is an actor. “But it’s not really about that… it’s more about divorce, about what it means to separate.”

“It’s about the impact of a long-term relationship when it collapses. I don’t know whether there is a rich tradition of drama like that, and yet for most people, those kind of separations are far more profound and complicated and have greater ramifications than first love; and we have millions of plays about first love!”

Every generation discovers their own time in the Greek plays. Goold thinks he and playwright Rachel Cusk were shaped by the aftermath of the 1970s in interpreting Medea; “That’s the period when the idea of the family began to get tainted.” And when critics praised Oresteia, the Almeida’s first Greek play and a surprise West End transfer, they compared it to the Sopranos.

Yet there is something eternal about these plays. Goold says it’s the way they “stare at these problems that are totally perennial, like death,” and then offer answers that aren’t easy. Medea kills the kids and a mother rips her son to shreds in the Bakkhai (the Almeida’s predecessor to Medea). Where’s the moral compass in that?

Except there is a twist in Goold’s Medea, and it’s not one every critic has taken kindly to. It was enough to stop the Telegraph’s Dominic Cavendish, otherwise lavish in his praise, from calling it “a Medea for our times”. Nevertheless, the reviews have been kind, as they often are for Goold; although The Times’ Ann Treneman was vitriolic in her dislike (“Everyone is ghastly. The men are beyond irritating. The women even worse.”).

In theory, Goold welcomes the criticism. “I’d rather our audience hated something and talked about it than was passively pleased,” he tells me ahead of reviews.

Controversial and bracing theatre is what Goold wants to keep directing and producing; as the Almeida’s artistic director he is in charge of more than just his own shows. But how does he do it? I put a question to him: if I had to direct Medea instead of him, what advice would he have given me?

He pauses. “You’ve got to love words,” he begins. “There’s no point doing it unless you have a real delight in language. And you have to have vision. But probably the most important thing is, you’ve got to know how to manage a room.”

“It’s people management. So often I have assistants, or directors I produce, and I think ‘God, they’re just not listening to what that person is trying to say, what they’re trying to give.’ They’re either shutting them down or forcing them into a box.”

“Most people in a creative process have to focus on what they want to say, but a director always has to be more of a listener. People do it different ways. Some people spin one plate incredibly fast and vibrantly in the middle of the room, and hope all the others get sucked in. It’s about thriving off of one person – the director, the lead performer, whomever.”

“I’m more about the lowest common denominator: the person you’re most aware of is the least engaged. You have to keep lifting them up, then you get more creativity coming in.”

It’s not always simple. When actors and directors disagree, the director can only demand so much, especially if the actor is far more famous than them. When Goold directed Macbeth, Patrick Stewart was his lead. Stewart was a movie star and twice his age.

“Patrick’s take on Macbeth… I didn’t think it should be played that way. I’d played him as a student and I had an idea of what he was.”

“But then you think, ‘Ok, you’re never going to be what I want you to be, but actually let me get rid of that, and just focus on what’s good about what you want to be, and get rid of some of the crap.’”

Goold doesn’t think he’s ever really struggled to win an actor’s respect (“touch wood”). The key thing, he says, is that “they just feel you’re trying to make legible their intention”.

And then you must work around your lead. In Macbeth, Stewart was “a big deep river of energy… when normally you get two people frenetically going ‘Uhgh! Is this a dagger I see before me! Uhgh!’ and there’s lots of hysteria.”

“So we threw all sorts of other shit at the production to compensate, to provide all the adrenalin which Patrick was taking away to provide clarity and humanity.”

Many people want to be theatre directors, and yet so few are successful. The writers, actors and playwrights who sell shows can be counted on a few hands. Depressingly, Goold thinks it’s becoming harder to break in. It’s difficult to be discovered. “God, I don’t know, what I worry – wonder – most is: ‘Are there just loads of great directors who don’t make it?’”

 The assisting route is just not a good way to find great new directors. “The kind of people who make good assistants don’t make good directors, it’s almost diametrically opposite.” As for regional directors, newspaper budgets have collapsed, so they can no longer rely on a visit from a handful of national critics, as Goold did when he was based in Salisbury and Northampton. And audiences for touring shows have, by some measures, halved in the past twenty years.

Theatre has also evolved. When Goold was coming through, “There were not a lot of directors who felt they were outside the library, so for me to whack on some techno was radical! Now it’d be more commonplace.” New directors have to find new ways to capture our attention – or at least the critics’.

But the critics have changed too. A nod from a critic can still be vital in the right circles, but the days when critics “made” directors is long over. “I remember Nick de Jongh saying, ‘Oh Rupert Goold, I made him.’ Because he’d put Macbeth on the front page of the Standard. I owed my career to him, and in some ways I did! But it's an absurd idea, that would not happen now.”

“It’s all changed so much in literally the past three years. There was a time, for better or worse, when you had a big group of establishment critics: de Jongh, Michael Billington, Michael Coveney, Charlie Spencer – they were mostly men – Susannah Clapp. And if they all liked your show, you were a hit.” (“They could be horrible,” he adds.)

“Now I get more of a sense of a show by being on Twitter than reading the reviews.” It’s “probably a good thing”, Goold thinks, and it certainly beats New York, where a single review – the New York Times' – makes or breaks plays. But it’s another problem for aspiring directors, who can no longer be so easily plucked from the crowd.

It’s no longer a problem Goold needs to overcome. His star could wane, but he seems likely to be among the leading voices in British theatre for a while yet.

Harry Lambert is a staff writer and editor of May2015, the New Statesman's election website.

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What Jeremy Corbyn can learn from Orwell

Corbyn’s ideas may echo George Orwell’s – but they’d need Orwell’s Britain to work. It’s time Corbyn accepted the British as they are today.

All Labour Party leaderships since 1900 have offered themselves as “new”, but Tony Blair’s succession in 1994 triggered a break with the past so ruthless that the Labour leadership virtually declared war on the party. Now it is party members’ turn and they, for now at any rate, think that real Labour is Jeremy.

To Keir Hardie, real Labour had been a trade union lobby expounding Fellowship. To the Webbs, real Labour was “common ownership” by the best means available. Sidney’s Clause Four (adopted 1918) left open what that might be. In the 1920s, the Christian Socialist R H Tawney stitched Equality into the banner, but during the Depression young intellectuals such as Evan Durbin and Hugh Gaitskell designated Planning as Labour’s modern mission. After the Second World War, Clement Attlee followed the miners (and the London Passenger Transport Board) into Nationalisation. Harold Wilson tried to inject Science and Technology into the mix but everything after that was an attempt to move Labour away from state-regulated markets and in the direction of market-regulated states.

What made the recent leadership contest so alarming was how broken was the intellectual tradition. None of the candidates made anything of a long history of thinking about the relationship between socialism and what the people want. Yvette Cooper wanted to go over the numbers; only they were the wrong numbers. Andy Burnham twisted and turned. Liz Kendall based her bid on two words: “Have me.” Only Jeremy Corbyn seemed to have any kind of Labour narrative to tell and, of course, ever the ­rebel, he was not responsible for any of it. His conference address in Brighton was little more than the notes of a street-corner campaigner to a small crowd.

Given the paucity of thinking, and this being an English party for now, it is only a matter of time before George Orwell is brought in to see how Jeremy measures up. In fact, it’s happened already. Rafael Behr in the Guardian and Nick Cohen in the Spectator both see him as the kind of hard-left intellectual Orwell dreaded, while Charles Cooke in the National Review and Jason Cowley in the New Statesman joined unlikely fashion forces to take a side-look at Jeremy’s dreadful dress sense – to Orwell, a sure sign of a socialist. Cooke thought he looked like a “burned-out geography teacher at a third-rate comprehensive”. Cowley thought he looked like a red-brick university sociology lecturer circa 1978. Fair enough. He does. But there is more. Being a middle-class teetotal vegetarian bicycling socialistic feministic atheistic metropolitan anti-racist republican nice guy, with allotment and “squashily pacifist” leanings to match, clearly puts him in the land of the cranks as described by Orwell in The Road to Wigan Pier (1937) – one of “that dreary tribe of high-minded women and sandal-wearers and bearded fruit-juice drinkers who come flocking towards the smell of ‘progress’ like bluebottles to a dead cat”. And though Corbyn, as “a fully fledged, fully bearded, unabashed socialist” (Huffington Post), might make all true Orwellians twitch, he really made their day when he refused to sing the National Anthem. Orwell cited precisely that (see “The Lion and the Unicorn”, 1941) as an example of the distance between left-wing intellectuals and the people. It seemed that, by standing there, mouth shut, Comrade Corbyn didn’t just cut his wrists, he lay down full length in the coffin and pulled the lid shut.


Trouble is, this line of attack not only misrepresents the Labour leader, it misrepresents Orwell. For the great man was not as unflinchingly straight and true as some people think. It is impossible, for instance, to think of Orwell singing “God Save the King”, because he, too, was one of that “dreary tribe” of London lefties, and even when he joined Labour he remained ever the rebel. As for Corbyn, for a start, he is not badly dressed. He just doesn’t look like Chuka or Tristram. He may look like a threadbare schoolteacher, but Orwell was one twice over. Orwell was never a vegetarian or a teetotaller, but, like Corbyn, neither was he interested in fancy food (or drink), he kept an allotment, drove a motorbike, bicycled, cared about the poor, cared about the environment, loathed the empire, came close to pacifism at one point, and opposed war with Germany well past the time when it was reasonable to do so.

In Orwell’s thinking about socialism, for too long his main reference point was the London Marxist left. Not only did he make speeches in favour of revolutions, he took part in one with a gun in his hand. Orwell was far more interested, as Corbyn has been far more interested, in speaking truth to power than in holding office. His loyalty was to the movement, or at least the idea of the movement, not to MPs or the front bench, which he rarely mentioned. There is nothing in Corbyn’s position that would have shocked Orwell and, should they have met, there’d have been much to talk about: belief in public ownership and non-economic values, confidence in the state’s ability to make life better, progressive taxation, national health, state education, social care, anti-socially useless banking, anti-colonialism and a whole lot of other anti-isms besides. It’s hard to be sure what Orwell’s position would have been on Trident and immigration. Not Corbyn’s, I suspect. He was not as alert to feminism as he might have been but equally, few men try to write novels from a woman’s point of view and all Orwellians recognise that Julia is the dark hero of Nineteen Eighty-Four. In truth they are both austere types, not in it for themselves and not on anyone else’s expense account either. Corbyn won the leadership because this shone through from the very beginning. He came across as unaffected and straightforward – much as Orwell tried to be in his writing.

Except, as powerfully expressed in these pages by John Gray, Corbyn’s politics were made for another world. What sort of world would he need? First off, he’d need a regulated labour market: regulated by the state in partnership with a labour movement sensitive to what people wanted and experienced in trying to provide it. He would also need capital controls, a manufacturing base capable of building the new investment with Keynesian payback, an efficient and motivated Inland Revenue, a widespread public-service ethos that sees the country as an asset, not a market, and an overwhelming democratic mandate to get things done. In other words, Corbyn needs Orwell’s Britain – not this one – and at the very least, if he can’t have that, he needs the freedom to act that the European Commission forbids.

There’s another problem. Orwell did not trust left-wing intellectuals and spent half his life trying to work out their motivations as a class who spoke for the people, went in search of the people, and praised the people, but did not know them or believe in them. True, Corbyn says he wants to be open and inclusive, but we know he can’t possibly mean it when he says it will be the party, not him or the PLP, that will decide policy, just as we knew it couldn’t possibly be true when he said he’d turn PMQs into the People’s Question Time. Jeremy hasn’t changed his mind in forty years, appears to have great difficulty (unlike Tony Benn) in fusing socialism to national identity or experience (Hardie, Ben Okri and Maya Angelou were bolted on to his Brighton speech) and seems to think that not being happy with what you are given somehow captures the historic essence of socialism (rather than its opposite).

Granted, not thinking outside the ­circle is an inherent fault of the sectarian left but some of our most prominent left-wing journalists have it, too. Working-class support for nationalisation? Good. Right answer! Working-class opposition to benefit scroungers and further mass immigration? Bad. Wrong answer! Would you like to try again? In his essay “In Defence of Comrade Zilliacus” (1947) Orwell reckoned that left-wing intellectuals saw only what they wanted to see. For all their talk of representing the people, they hated the masses. “What they are frightened of is the prevailing opinion within their own group . . . there is always an orthodoxy, a parrot-cry . . .”

The game is hard and he may go down in a welter of knives, yet Corbyn still has time. He may go on making the same speech – on the benefits of apple pie to apple growers – but at some point he will have to drop the wish-list and get on the side of the British people as they are, and live with that, and build into it. Only the nation state can even begin to do the things he wants to do. The quicker he gets that, the quicker we can see if the latest incarnation of new Labour has a future.

Robert Colls is the author of “George Orwell: English Rebel” (Oxford University Press)

This article first appeared in the 08 October 2015 issue of the New Statesman, Putin vs Isis