Views & Reviews Between the Lines

The nature of hypertension

BMJ 2012; 345 doi: (Published 24 August 2012) Cite this as: BMJ 2012;345:e5750
  1. Theodore Dalrymple, writer and retired doctor

In the first edition of his great poem The Vanity of Human Wishes Doctor Johnson warns us that the scholar’s life is not an easy one: “There mark what ills the Scholar’s life assail, / Toil, Envy, Want, the Garret, and the Jail.” Of these hazards, perhaps only the first two remain; and certainly scholars in medicine starve in no garrets. But the controversies on which they expend their energy can be prolonged and vigorous, sometimes—or always, according to Schopenhauer—truth seeming a lesser imperative than victory.

Among the most famous controversies in 20th century medicine was the momentous one between Sir George Pickering (1904-80) and Sir Robert Platt (1900-78) over the nature of hypertension: whether high blood pressure was merely one end of a normal distribution, or whether there was a bimodal population, one part of which suffered from the discrete disease called hypertension. The dispute rumbled on for years. It is generally thought that it was Pickering who triumphed in the end, in the process overturning what until then had been the orthodox view. It is not given to mortals, even to doctors, to live without orthodoxies.

In 1968, Pickering published his magnum opus, the second edition of his High Blood Pressure. The cover, in stark black and red, has the trace of a continuous intra-arterial blood pressure measurement, by rumour that of one of the author’s senior registrars. There is a sharp spike on the spine of the cover, and a further rumour has it that this occurred when the senior registrar arrived home to his wife. Of course, such a spike cannot tell us the precise nature of the emotion that caused it.

The book is enormous, with 717 long and closely printed pages (48 of them devoted to references, about 1500 in all). Stylistically it is a delight; a literary triumph. Though vastly learned, it is not dry, and Pickering allows himself some peppery language, especially with regard to the medical profession and his opponents. In the preface, for example, he says:

No one nowadays defends a dividing line between normotension and hypertension, though, regretfully, most are intellectually lazy enough to use it. This is a theme of the first chapter: Many of my great contemporaries have either not read what I have written, or, if they have, have not understood.

He soon goes on to excoriate the intellectual weakness of the profession:

The hypothesis [of a continuum in blood pressure and the gradation in risk that it poses] has been greeted by medical scientists “as a glimpse into the obvious,” and by physicians as “dangerous nonsense because it is against established teaching.” It is apparently difficult for doctors to understand because it is a departure from the ordinary process of binary thought to which they are brought up. Is it normal or abnormal, physiological or pathological, health or disease, good or bad? Quantity is not an idea that is as yet allowed to intrude. Medicine in its present state can count up to two but not beyond.

Pickering did not get everything right in the controversy, however, at least from the modern standpoint. He was at first inclined to therapeutic nihilism, his famous dictum being “Now it [treatment] takes the form of drugs, whose ability to produce disturbing symptoms in the recipient has been amongst their most remarkable properties . . . Nor is there any evidence that such measures prolong life—though no doubt it seems longer.”

But he retracted in the light of new evidence: for truth as well as victory has its claims on good men.


Cite this as: BMJ 2012;345:e5750

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