Setting the record straight for two heroes in hypertension: John J. Hay and Paul Dudley White

Papers dealing with the history of the study of hypertension1, 2, 3 provide an invaluable window to our past. They identify our misconceptions, mistakes, and advances and describe the evolution of new knowledge. New knowledge develops in the context of contemporary scientific knowledge and zeitgeist. Zeitgeist is the German word for the defining mood or spirit of a particular era as expressed in the ideas and beliefs of the time.

The limitations of a scientist's knowledge and perspective at any given point in time must be considered in historical context. Therefore, we must tread carefully when criticizing a scientist's thinking and ideas that are squarely in the context of the times.

In this paper, we make the argument that important published words of Dr John J. Hay4 and Paul Dudley White,5 pioneers in the study of hypertension, have been diminished by contextomy. Our goal is to set the record straight.

Contextomy is a word coined by Mayer6 to express the view that quoting out of context is analogous to surgical extraction.7, 8 Words are taken from their original linguistic context such that it distorts their intended meaning. This takes two forms: The first relates to the context of the written text, and the second to historical context.7, 8, 9, 10

It is our opinion that the perspectives on hypertension offered by Drs. Hay and White have been taken out of context. Hay's perspective on hypertension has been taken out of textual context and White's out of historical context. Despite major achievements in hypertension, comments by each have been singled out as examples of erroneous thinking and clinical recommendations about hypertensive disease.

We begin our argument with a quotation taken from John Hay's work by Moser (p. 1).3

The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.4

This quotation appears, among other places, prominently on the back of the book The Treatment of Hypertension: A story of Myths, Misconceptions, and Controversies by Doctor Marvin Moser.3 Given our great admiration and respect for Dr Moser's contributions to hypertension research, we speculate that the quote was used as a dramatic illustration of thinking about hypertension in 1931 as compared to 2002. The popularity of the illustration as expressed by this quotation is suggested by its use in other publications and in slides prepared for lectures and conference presentations. Use of this quotation provides a dramatic, almost theatrically alarming, beginning for the author's purpose of heralding our progress in hypertension since 1931. But is this really what Hay stated in his historic paper presented to the British Medical Society in 1931?4 Well, not exactly. We make this argument on the basis of two observations: (a) It excludes, without indication by punctuation, an important prologue to the quoted sentence: “There is some truth in the saying that…”; and (b) the quote selected is inconsistent with thoughts expressed by Hay in the full context of his comments. As to the first point, the original statement from Hay's presentation to the British Medical Journal4 was as follows: “There is some truth in the saying that the greatest danger to a man with high blood pressure lies in its discovery, because ‘then some fool is certain to try and reduce it’.”4 We supply the missing words in italics. We feel the missing words modify or qualify Hay's comment in an important way. Hay was saying “some truth,” not major truth or universal truth. In an article celebrating 50 years of the Framingham Heart Study, Messerli and Mittler11 reproduce the quote by Moser, citing Hay, but eliminate the key words beginning the complete sentence by Hay, that is, “There is some truth in the saying that…”4

We will concede that we may be overemphasizing a relatively minor point (the complete message). But there is a larger and more important point to be made. The quote is taken out of context of the full text of Hay's presentation to the British Medical Association.4

Let us examine other comments by Hay in this lecture in order to get a better sense of his presentation and his emphasis on the importance of hypertension and its treatment.

Hay opens his presentation to the British Medical Association on “The significance of a raised blood pressure”4 by saying that, “[n]o one can now afford to be indifferent to the problems associated with variations in blood pressure, for a high pressure is an abnormality which always demands investigation, supervision and careful treatment.”4 He then proceeds to elaborate on the physiology of rising blood pressure and the pathophysiology of hypertension that every medical student and investigator in the current area should read, including good rules for measuring blood pressure with the sphygmomanometer—rules that are still valid today. He criticizes the popular belief at the time that one's age plus 100 would yield the value for normal blood pressure; he suggests the following systolic/diastolic blood pressures as cut points for abnormally high readings: 40 years, 126/81 mm Hg; 50 years, 130/83 mm Hg, and 60 years, 135/85 mm Hg. He describes the effect of blood pressure on sleep‐related disturbances, advocates exercise as a valuable treatment, emphasizes the role of family history in high blood pressure, and advocates blood pressure measurement “at the first opportunity” in young adults and youth. In his closing comment, he notes that: “When the figures [sic recorded blood pressure values] pass beyond this normal there is a corresponding diminution in expectation of life. It is [hypertension] therefore a physical sign worth investigating in every patient, especially when there is a known familial tendency to cardiovascular disease. There is here a wide field for study, more particularly for the general practitioner.”4

Clearly, Hay was not ignorant of the need to treat hypertension, and quite clearly he was not advocating that we ignore it. Did he later in his career, as we say today, “walk back” his words which are supposedly suggesting the foolishness in treating hypertension? We have no evidence that he did and we have no idea why he seemed to contradict the essence of his presentation in words that seem inconsistent with the whole of his thesis. Regardless, in our opinion, the incomplete quote selected by Moser and others to represent Hay's views on hypertension does not capture the essence of a lecture which clearly expresses a concern for hypertension that was actually ahead of its time. To interpret Hay's thoughts fairly, we must read his entire lecture. We see no evidence of an argument for disregarding the importance of hypertension. Just the opposite seems true.

As was true for Hay, an early comment by an eminent Boston cardiologist, Paul Dudley White, has been used as an example of erroneous conventional wisdom of the past.

White is quoted in Moser (p. 1)3 and subsequently Kotchen,2 as follows: “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” A more complete quotation would be: “The treatment of hypertension itself is a difficult and almost hopeless task in the present state of our knowledge, and in fact for aught we know, the hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it (p. 400)”.5 The shorter form of the quote ignores the frustration felt by White, given the absence of an effective treatment for hypertension.

Quite clearly in circa 1931 White did adhere to the common medical view expressed in medical texts through the mid‐1940s of hypertension as compensatory and essential.12 However, by 1971, White appears to have rejected the theory of the compensatory value of high blood pressure. In his memoir published in 1971,13 White was concerned with the effect of chronic hypertension on heart size, and he discussed the contemporary approach to lowering blood pressure via surgery (lumbodorsal sympathectomy). White14 also meticulously summarized the many attempts (mostly failed) to treat hypertension by various lifestyle changes, chemical agents, and diets (see Table 1). To focus on White's skepticism about the compensatory effects of hypertension in 1931 excludes his lifelong contributions and focus on the necessary treatment of hypertension and detracts from his legacy. In our version of the 50 years of celebration of the Framingham Heart Study,7 we would have mentioned his many contributions to hypertension and heart disease15 that set the stage for the Framingham Studies to follow.

Table 1.

Attempted treatments for high blood pressure; none shown to be systematically effective via clinical trials^a

Drugs/agents	Lifestyle	Surgical procedures
Atropine Benzyl benzoate Bismuth subnitrate (E) Bromides (E) Calcium chloride Cathartics Chloral hydrate Cucurbocitrin Diuretics (other) Ethylene diamine (aka aminophylline, euphyllin, and metaphyllin) Garlic Iodide (E) Iodine (E) Liver extract Mistletoe Nitrites Ovarian extract Papaverine Parathyroid preparations Phenobarbital (and other sedatives/hypnotics) (E) Potassium iodide Sulfur Sulfocyanates (thiocyanates) of sodium or potassiumb (E) Sunflower seeds Testosterone Theobromine Theobromine sodiosalicylate (diuretin) Theobromine sodium acetate (thesodate) Theominal (theobromine and phenobarbital) (E) Theophylline Yohimbine	Baths of all kinds Diet, including limiting calories, limiting protein, limiting salt Electrotherapy Physical and mental rest Psychotherapy Removal of strain from professional and business life, family affairs and social activities Rest (E) Roentgen ray irradiation of the pituitary and adrenal glands Venesection Weight reduction for the obese	Bilateral thoracic and lumbar rhizotomy (E) Decortication of the kidneys Excision of deformed and diseased kidneys (E) Removal of adrenal tumors Splanchnic nerve resection (bilateral) (E)

^aWhite PD. Heart Disease. 3rd ed. New York, NY: The Macmillan Company; 1944, p. 445‐452.

^bPotassium thiocyanate was the most successful drug, effective over half the time, though often toxic and required close monitoring (p. 446‐447).

SUMMARY AND IMPLICATIONS

It is estimated that 15‐25 percent of medical articles misquote the original source,16 including errors of quotation and quoting outside of the context of the referenced materal.15 Our opinion is that Hay and White were mischaracterized as exemplars of backward thinking by contextomy. They appear to be the straw persons in a straw person fallacy. When, in three decades or more, our current understanding of hypertension is described as primitive, we hope we will not be described as foolish men and women who held untenable views, but rather as men and women who advanced the science of hypertension within the framework of existing knowledge at the time. Two heroes in hypertension, Hay and White, are now lost to us and can no longer defend their scholarship, but we can, and we do.

CONFLICT OF INTEREST

The authors have no conflicts of interest, and the opinions expressed in this paper are strictly those of the authors.

Elias MF, Goodell AL. Setting the record straight for two heroes in hypertension: John J. Hay and Paul Dudley White. J Clin Hypertens. 2019;21:1429–1431. 10.1111/jch.13650