The English patient: Britten in 1968. Photograph: Cecil Beaton Studio Archive, Courtesy of National Portrait Gallery.
Show Hide image

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

reddit.com/user/0I0I0I0I
Show Hide image

We need to talk about the online radicalisation of young, white women

Alt-right women are less visible than their tiki torch-carrying male counterparts - but they still exist. 

In November 2016, the writer and TED speaker Siyanda Mohutsiwa tweeted a ground-breaking observation. “When we talk about online radicalisation we always talk about Muslims. But the radicalisation of white men online is at astronomical levels,” she wrote, inspiring a series of mainstream articles on the topic (“We need to talk about the online radicalisation of young, white men,” wrote Abi Wilkinson in The Guardian). It is now commonly accepted that online radicalisation is not limited to the work of Isis, which uses social media to spread propaganda and recruit new members. Young, white men frequently form alt-right and neo-Nazi beliefs online.

But this narrative, too, is missing something. When it comes to online radicalisation into extreme right-wing, white supremacist, or racist views, women are far from immune.

“It’s a really slow process to be brainwashed really,” says Alexandra*, a 22-year-old former-racist who adopted extreme views during the United States presidential election of 2016. In particular, she believed white people to be more intelligent than people of colour. “It definitely felt like being indoctrinated into a cult.”

Alexandra was “indoctrinated” on 4Chan, the imageboard site where openly racist views flourish, especially on boards such as /pol/. It is a common misconception that 4Chan is only used by loser, basement-dwelling men. In actuality, 4Chan’s official figures acknowledge 30 percent of its users are female. More women may frequent 4Chan and /pol/ than it first appears, as many do not announce their gender on the site because of its “Tits or GTFO” culture. Even when women do reveal themselves, they are often believed to be men who are lying for attention.

“There are actually a lot of females on 4chan, they just don't really say. Most of the time it just isn't relevant,” says Alexandra. Her experiences on the site are similar to male users who are radicalised by /pol/’s far-right rhetoric. “They sowed the seeds of doubt with memes,” she laughs apprehensively. “Dumb memes and stuff and jokes…

“[Then] I was shown really bullshit studies that stated that some races were inferior to others like… I know now that that’s bogus science, it was bad statistics, but I never bothered to actually look into the truth myself, I just believed what was told to me.”

To be clear, online alt-right radicalisation still skews majority male (and men make up most of the extreme far-right, though women have always played a role in white supremacist movements). The alt-right frequently recruits from misogynistic forums where they prey on sexually-frustrated males and feed them increasingly extreme beliefs. But Alexandra’s story reveals that more women are part of radical right-wing online spaces than might first be apparent.

“You’d think that it would never happen to you, that you would never hold such horrible views," says Alexandra. "But it just happened really slowly and I didn't even notice it until too late."

***

We are less inclined to talk about radical alt-right and neo-Nazi women because they are less inclined to carry out radical acts. Photographs that emerged from the white nationalist rally in Charlottesville this weekend revealed that it was mostly polo shirt-wearing young, white men picking up tiki torches, shouting racial slurs, and fighting with counter-protestors. The white supremacist and alt-right terror attacks of the last year have also been committed by men, not women. But just because women aren’t as visible doesn’t mean they are not culpable.  

“Even when people are alt-right or sympathisers with Isis, it’s a tiny percentage of people who are willing or eager to die for those reasons and those people typically have significant personal problems and mental health issues, or suicidal motives,” explains Adam Lankford, author of The Myth of Martyrdom: What Really Drives Suicide Bombers, Rampage Shooters, and Other Self-Destructive Killers.

“Both men and women can play a huge role in terms of shaping the radicalised rhetoric that then influences those rare people who commit a crime.”

Prominent alt-right women often publicly admit that their role is more behind-the-scenes. Ayla Stewart runs the blog Wife With a Purpose, where she writes about “white culture” and traditional values. She was scheduled to speak at the Charlottesville “Unite the Right” rally before dropping out due to safety concerns. In a blog post entitled “#Charlottesville May Have Redefined Women’s Roles in the Alt Right”, she writes:

“I’ve decided that the growth of the movement has necessitated that I pick and choose my involvement as a woman more carefully and that I’m more mindful to chose [sic] women’s roles only.”

These roles include public speaking (only when her husband is present), gaining medical skills, and “listening to our men” in order to provide moral support. Stewart declined to be interviewed for this piece.

It is clear, therefore, that alt-right women do not have to carry out violence to be radical or radicalised. In some cases, they are complicit in the violence that does occur. Lankford gives the example of the Camp Chapman attack, committed by a male Jordanian suicide bomber against a CIA base in Afghanistan.

“What the research suggests in that case was the guy who ultimately committed the suicide bombing may have been less radical than his wife,” he explains. “His wife was actually pushing him to be more radical and shaming him for his lack of courage.” 

***

Just because women are less likely to be violent doesn’t mean they are incapable of it.

Angela King is a former neo-Nazi who went to prison for her part in the armed robbery and assault of a Jewish shop owner. She now runs Life After Hate, a non-profit that aims to help former right-wing extremists. While part of a skinhead gang, it was her job to recruit other women to the cause.

“I was well known for the violence I was willing to inflict on others… often times the men would come up to me and say we don’t want to physically hurt a woman so can you take care of this,” King explains. “When I brought other women in I looked for the same qualities in them that I thought I had in myself.”

King's 1999 mugshot

 

These traits, King explains, were anger and a previous history of violence. She was 15 when she became involved with neo-Nazis, and explains that struggles with her sexuality and bullying had made her into a violent teenager.

“I was bullied verbally for years. I didn't fit in, I was socially awkward,” she says. One incident in particular stands out. Aged 12, King was physically bullied for the first time.

“I was humiliated in a way that even today I still am humiliated by this experience,” she says. One day, King made the mistake of sitting at a desk that “belonged” to a bully. “She started a fight with me in front of the entire class… I’ve always struggled with weight so I was a little bit pudgy, I had my little training bra on, and during the fight she ripped my shirt open in front of the entire class.

“At that age, having absolutely no self-confidence, I made the decision that if I became the bully, and took her place, I could never be humiliated like that again.”

Angela King, aged 18

King’s story is important because when it comes to online radicalisation, the cliché is that bullied, “loser” men are drawn to these alt-right and neo-Nazi communities. The most prominent women in the far-right (such as Stewart, and Lauren Southern, a YouTuber) are traditionally attractive and successful, with long blonde hair and flashing smiles. In actuality, women that are drawn to the movement online might be struggling, like King, to be socially accepted. This in no way justifies or excuses extreme behaviour, but can go some way to explaining how and why certain young women are radicalised. 

“At the age of 15 I had been bullied, raped. I had started down a negative path you know, experimenting with drugs, drinking, theft. And I was dealing with what I would call an acute identity crisis and essentially I was a very, very angry young woman who was socially awkward who did not feel like I had a place in the world, that I fit in anywhere. And I had no self-confidence or self-esteem. I hated everything about myself.”

King explains that Life After Hate’s research reveals that there are often non-ideological based precursors that lead people to far right groups. “Individuals don’t go to hate groups because they already hate everyone, they go seeking something. They go to fill some type of void in their lives that they’re not getting.”

None of this, of course, excuses the actions and beliefs of far-right extremists, but it does go some way to explaining how “normal” young people can be radicalised online. I ask Alexandra, the former 4Chan racist, if anything else was going on in her life when she was drawn towards extreme beliefs.

“Yes, I was lonely,” she admits.                                                       

***

That lonely men and women can both be radicalised in the insidious corners of the internet shouldn’t be surprising. For years, Isis has recruited vulnerable young women online, with children as young as 15 becoming "jihadi brides". We have now acknowledged that the cliché of virginal, spotty men being driven to far-right hate excludes the college-educated, clean-cut white men who made up much of the Unite the Right rally last weekend. We now must realise that right-wing women, too, are radicalised online, and they, too, are culpable for radical acts.  

It is often assumed that extremist women are radicalised by their husbands or fathers, which is aided by statements by far-right women themselves. The YouTuber, Southern, for example, once said:  

“Anytime they [the left] talk about the alt-right, they make it sound like it’s just about a bunch of guys in basements. They don’t mention that these guys have wives – supportive wives, who go to these meet-ups and these conferences – who are there – so I think it’s great for right-wing women to show themselves. We are here. You’re wrong.”

Although there is truth in this statement, women don’t have to have far-right husbands, brothers, or fathers in order to be drawn to white supremacist or alt-right movements. Although it doesn’t seem the alt-right are actively preying on young white women the same way they prey on young white men, many women are involved in online spaces that we wrongly assume are male-only. There are other spaces, such as Reddit's r/Hawtschwitz, where neo-Nazi women upload nude and naked selfies, carving a specific space for themselves in the online far-right. 

When we speak of women radicalised by husbands and fathers, we misallocate blame. Alexandra deeply regrets her choices, but she accepts they were her own. “I’m not going to deny that what I did was bad because I have to take responsibility for my actions,” she says.

Alexandra, who was “historically left-wing”, was first drawn to 4Chan when she became frustrated with the “self-righteousness” of the website Tumblr, favoured by liberal teens. Although she frequented the site's board for talking about anime, /a/, not /pol/, she found neo-Nazi and white supremacist beliefs were spread there too. 

“I was just like really fed up with the far left,” she says, “There was a lot of stuff I didn't like, like blaming males for everything.” From this, Alexandra became anti-feminist and this is how she was incrementally exposed to anti-Semitic and racist beliefs. This parallels the story of many radicalised males on 4Chan, who turn to the site from hatred of feminists or indeed, all women. 

 “What I was doing was racist, like I – deep down I didn't really fully believe it in my heart, but the seeds of doubt were sowed again and it was a way to fit in. Like, if you don't regurgitate their opinions exactly they’ll just bully you and run you off.”

King’s life changed in prison, where Jamaican inmates befriended her and she was forced to reassess her worldview. Alexandra now considers herself “basically” free from prejudices, but says trying to rid herself of extreme beliefs is like “detoxing from drugs”. She began questioning 4Chan when she first realised that they genuinely wanted Donald Trump to become president. “I thought that supporting Trump was just a dumb meme on the internet,” she says.

Nowadays, King dedicates her life to helping young people escape from far-right extremism. "Those of us who were involved a few decades ago we did not have this type of technology, cell phones were not the slim white phones we have today, they were giant boxes," she says. "With the younger individuals who contact us who grew up with this technology, we're definitely seeing people who initially stumbled across the violent far-right online and the same holds for men and women.

"Instead of having to be out in public in a giant rally or Klan meeting, individuals find hate online."

* Name has been changed

Amelia Tait is a technology and digital culture writer at the New Statesman.

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