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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Inside the minds of the Isis murderers

As pressure on the terror group who claimed responsiblity for the Manchester attack intensifies, the threat to Britain will only become more acute.

The police and security services had consistently warned that a significant terrorist attack in Britain was inevitable. Yet no warning could have prepared us for the horror of the suicide attack on the Manchester Arena on Monday night. Twenty-two people were killed and at least 60 were wounded as they were leaving a concert by Ariana Grande in what was the most deadly attack in Britain since the London bombings of 7 July 2005, in which 56 people died.

Like the London bombers, the Manchester suicide attacker, Salman Ramadan Abedi, was British. He was 22, lived in Manchester and studied business management at Salford University before dropping out. He worshipped at Didsbury Mosque. The son of Libyans, Abedi is said to have returned recently from a visit to the North African country, where Islamic State has a foothold.

Ariana Grande is a former children’s TV star who made her name on channels such as Nickelodeon. Her fan base is overwhelmingly young and female, and many of those killed or wounded were children, including Saffie Rose Roussos, an eight-year-old girl from Leyland, Lancashire.

Islamic State inevitably claimed responsibility for the massacre, dismissing the victims as “crusaders”, “polytheists” and “worshippers of the cross”. This is not the first time Islamist terrorists have targeted children.

A Chechen jihadist group calling itself ­Riyad-us Saliheen (meaning “Gardens of the Righteous”) took more than 1,100 hostages, including 777 children, in a school siege in Beslan, Russia, in September 2004. In the event, more than 330 were massacred, including 186 children. Gunmen from the Pakistani Taliban also stormed a school in 2014, killing 148.

For terrorist actors, these are neither whimsical nor irrational acts. Contemporary jihadist movements have curated a broad and expansive intellectual ecosystem that rationalises and directs their actions. What they want is to create an asymmetry of fear by employing indiscriminate barbarism to intimidate and subdue their opponents into submission.

We have grown accustomed to a wave of terrorist attacks being carried out in the name of the self-styled Islamic State ever since the group’s official spokesman Abu Muhammad al-Adnani began prioritising them in 2014. (He was killed in an American air strike on Aleppo province in Syria in August last year.)

The US-led coalition against Islamic State has weakened the terror group in its former strongholds of Mosul in Iraq and Raqqa in Syria. In response, IS has been forced to concentrate more on what it calls “external operations” – by which it means inspiring its sympathisers and operatives to carry out attacks on Western countries. Indeed, al-Adnani encouraged the group’s supporters not to migrate towards IS-held territory but rather to focus their efforts on attacks in their home countries.

“The tiniest action you do in the heart of their [Western] land is dearer to us than the biggest action by us,” he said in an audio statement released last year. “There are no innocents in the heart of the lands of the crusaders.”

Islamic State refers to its strategy as “just terror”. Its framing places culpability for attacks on Western states on these nations themselves by claiming that IS actions are a response to aggression or assault. That much has been outlined in the group’s literature. “When will the crusaders end their hostilities towards Islam and the Muslims? . . . When will they recognise that the solution to their pathetic turmoil is right before their blinded eyes?” the militants ask in the IS magazine Dabiq. “Until then, the just terror will continue to strike them to the core of their deadened hearts.”

IS offered a rationale of this sort as justification for its bombing of a Russian commercial aircraft – Metrojet Flight 9268, travelling from Sharm el-Sheikh in Egypt to St Petersburg. That attack in October 2015 killed 224. Similar reasoning was offered for the attacks in Paris the following month in which 137 people were killed, in a series of co-ordinated, commando-style gun and bomb outrages across the city.

“Revenge was exacted upon those who felt safe,” IS declared in Dabiq. “Let the world know that we are living today in a new era. Whoever was heedless must now be alert. Whoever was sleeping must now awaken . . . The [caliphate] will take revenge for any aggression against its religion and people, sooner rather than later. Let the ­arrogant know that the skies and the lands are Allah’s.”

***

Through my academic research at King’s College London, I have ­interviewed scores of Westerners who became foreign fighters in Syria and Iraq to quiz them about their motives. Last year, one man from High Wycombe who had joined IS told me that it wanted to attack British targets in response to the vote in the House of Commons to extend British air strikes against IS targets to include sites in Syria (the British had only been targeting the group in Iraq until that point). “Do they [the British government] expect us to sit back and do nothing? ­Idiots,” he said.

In this respect, IS frames its attacks as acts of “revenge” and predicates its response on the Islamic principle of qisas, which is comparable to lex talionis or the doctrine of “an eye for an eye”. Qisas was always intended to be a tool of private redress for an individual or his/her family to seek justice in matters relating to bodily harm. Typically, it relates to cases of murder and manslaughter, or acts involving physical mutilation (say, leading to loss of limbs). The principle creates a framework for retributive justice.

The contemporary Salafi-jihadi movement has adopted a particularly innovative approach to the concept of qisas in two ways. First, groups such as IS have taken the idea and construed it in a way that justifies indiscriminate terrorism, such as the attack in Manchester. They argue that qisas has a political dimension and that it can be applied to international affairs in a way that holds civilians responsible for the perceived crimes of their governments.

Second, qisas is normally applied only in cases where the aggressor is known. IS, by contrast, holds every citizen-stranger of an enemy state responsible for the actions of his or her government. Thus, when it released its statement claiming responsibility for the Manchester attack, it said that it had struck against a “gathering of the crusaders . . . in response to their transgressions against the lands of the Muslims”.

It is this militaristic construction of qisas that allows IS to rationalise the bombing of a venue where large numbers of young girls had gathered to watch a pop concert, dismissing them as “crusaders”.

This is not new. In 1997, Osama Bin Laden told CBS News that “all Americans are our enemies, not just the ones who fight us directly, but also the ones who pay their ­taxes”. His rationale was that all Americans, by virtue of citizenship alone, are vicariously liable for the actions of their government.

Just a few years later, Bin Laden used the same idea to justify the 11 September 2001 attacks and also invoked it in reference to the Israeli-Palestinian conflict. “The blood pouring out of Palestine must be equally revenged,” he wrote. “You must know that the Palestinians do not cry alone; their women are not widowed alone; their sons are not orphaned alone.”

IS used the concept most dramatically in January 2015, when it burned alive a Royal Jordanian Air Force pilot, Muath al-Kasasbeh, whose plane had crashed in its territory. A video of the killing was circulated on the internet and social media. The group claimed his bombing raids had killed civilians and that it wanted to punish him with “equal retaliation”, in keeping with qisas.

What is well known about al-Kasasbeh’s murder is that he was burned alive inside a cage – but that is not the whole story. To understand how IS tethered this to the principle of qisas, it is the end of the gruesome video that is invested with most significance. After al-Kasasbeh has died, a truck emerges and dumps rubble over the cage. It was claimed this was debris from a site he had bombed, thus completing the “equal retaliation” of returning like for like. The idea was that IS had retaliated using the two principal forms in which a missile attack kills – by fire or debris.

***

The Manchester attack came on the fourth anniversary of the brutal murder of Fusilier Lee Rigby in Woolwich, south London. Rigby was killed by Michael Adebolajo and Michael Adebowale in the middle of the afternoon on a street outside a military barracks. That attack was in keeping with a pattern we have become increasingly accustomed to in Europe: an unsophisticated plot that employs ordinary, everyday items – a car, say, or a knife.

The consequences of such attacks have been seen across Europe, most notably in Nice on 14 July 2016, when 86 people were killed during Bastille Day celebrations after a jihadist drove a truck into crowds on the promenade. Similar attacks followed in Berlin, Westminster and Stockholm.

The security services find that these murderous attacks are extremely hard to disrupt because they typically involve lone actors who can mobilise quickly and with discretion. The Manchester attack was different. Explosives were used, which means the plot was inherently more sophisticated, requiring careful planning and preparation.

We know that two of the 7/7 bombers had previously trained in Pakistan’s lawless tribal regions, where they honed their skills. In other plots, such as the connected attacks in London and Glasgow Airport of 2007, the explosive devices failed mainly because the bomb-makers had found it difficult to travel abroad and develop their skills in safe environments. Whatever Abedi’s connections, the long war in Syria and Iraq has once again created a permissive environment for terrorist training and attack planning.

The devastating impact of this has already been felt across Europe. Since the Syrian uprising began in 2011, more than 800 Britons are believed to have travelled there to fight. From Europe as a whole, the figure is over 5,000, of which a significant number are believed to have joined IS. Of the British contingent, the security services estimate that about half have returned or become disengaged from the conflict. Of those who remained, a hundred are believed to be active, the rest having been killed.

It is improbable that Abedi acted alone in Manchester or that this plot had no international component. Indeed, he was already known to the authorities (and had returned recently from Libya). As pressure on IS intensifies across Syria and Iraq, the threat to Britain will only become more acute as the group’s sympathisers prepare for what they consider to be a fightback.

This speaks to the scale of the threat facing Britain, and Europe more generally. Our police and security services have been stretched and continuously tested in recent years. Just recently, in March, the Metropolitan Police assistant commissioner Mark Rowley told Radio 4’s Today programme that 13 plots had been thwarted since Lee Rigby’s murder in 2013. Put another way, the police have disrupted terrorist plots every four months for the past four years.

Naturally, Islamic State is not the only threat. On 13 May, one of Osama Bin Laden’s sons, Hamza, released a video, titled “Advice for martyrdom-seekers in the West”, on behalf of al-Qaeda. Hamza, 27, who was his father’s favoured successor to lead the group, called on its supporters to concentrate on attacks in the West rather than migrating to conflict zones in the Middle East and beyond. Scenes of previous ­terrorist attacks in Britain played throughout the video.

The central leadership of al-Qaeda is increasingly looking for opportunities to reassert itself after being eclipsed by Islamic State and losing control of its affiliates in Syria. It needs attacks and a cause in the West with which to revive itself. Hamza therefore cited the January 2015 Charlie Hebdo attack in Paris as a critical example, calling for the assassination of anyone deemed to have “insulted” Islam.

The Charlie Hebdo attack was especially important for al-Qaeda because it enabled the group to transcend the fratricidal conflicts that frequently define relations between the various jihadist groups. In Syria, for instance, al-Qaeda’s affiliates (when it had better control over them) and Islamic State have been in open war with each other.

Yet, the Charlie Hebdo attack brought warm praise from the group’s Islamist rivals because none of them wanted to appear ­unsupportive of an atrocity that had, as the terrorists proclaimed, “avenged” the Prophet Muhammad’s honour.

The British man from High Wycombe who joined IS told me the group had welcomed the attack for precisely those reasons. It was something that, in his view, had confirmed the “nobility” of the attackers, even if they had not been members of IS.

Is it too late for the West to save itself, I asked him. What if the West simply accepted all of Islamic State’s demands: would that provide respite?

The answer was as emphatic as it was stark: “We primarily fight wars due to ppl [sic] being disbelievers. Their drones against us are a secondary issue.”

He went on: “Their kufr [disbelief] against Allah is sufficient of a reason for us to invade and kill them. Only if they stop their kufr will they no longer be a target.”

In other words, we are all guilty, and we are all legitimate targets.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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