William Einar Miall was a pioneer in research on blood pressure, which culminated in the Medical Research Council’s (MRC’s) two hypertension trials. He was born in Birmingham, the son of Rowland Miall, a scientific instrument maker. His family were Quakers. He was educated at the Quaker Bootham School in York, and in 1939 Bill registered as a conscientious objector and joined the Friends Ambulance Unit. He served in Norway, Finland and Greece, where he was taken prisoner. The Germans must have found him a rather tiresome, even if pacifist, captive, as he made several spirited, though eventually unsuccessful, attempts to escape! It was while he was a prisoner that he first met Archie Cochrane [Munk’s Roll, Vol.VIII, p.95].

Bill was repatriated in 1944 and entered St Mary’s Hospital Medical School in 1945 after passing the necessary preliminary examinations. He qualified in 1950 and became Sir George Pickering’s [Munk’s Roll, Vol.VII, p.464] house physician. This was at a time of rapid developments in research on blood pressure. Pickering’s view that pressure is characterised by a unimodal distribution determined by a variety of environmental and genetic characteristics was becoming accepted over Lord Robert Platt’s [Munk’s Roll, Vol.VII, p.470] view of two separate distributions, predominately determined genetically. But both Pickering and Platt had worked on hospital patients, often selected because of their blood pressures and the complications of hypertension. Bill realised the value of unselected, free-living population groups, which led him to join the MRC pneumoconiosis research unit in South Wales, where he renewed his association with Archie Cochrane. He organised meticulous surveys of the mining communities in the Rhondda Fach. This work, with the statistician Peter Oldham, confirmed Pickering’s view and also showed that there is a graded relationship between pressure and the risk of smoke and heart attack. In 1962, Bill was appointed director of the MRC’s epidemiological research unit in Jamaica, where he continued his work on blood pressure. In 1971 he joined Tom Meade in the MRC epidemiology and medical care unit at Northwick Park Hospital in Harrow.

During the 1950s, Bill Paton [Munk’s Roll, Vol.IX, p.410] and Eleanor ‘Nora’ Zaimis [Munk’s Roll, Vol.VII, p.628] had produced hexamethonium. Sir Horace Smirk [Munk’s Roll, Vol.IX, p.482] and Sir John McMichael [Munk’s Roll, Vol.IX, p.341] had shown its unequivocal benefit as a treatment for malignant hypertension. But ganglion-blocking agents had such unpleasant side effects that many patients could not tolerate them. In the 1960s and 1970s, however, two relatively small trials by the US Veterans Administration showed that the newer preparations, hydrochlorothiazide, resperine and hydralazine, were more acceptable and that in those with moderate to severe hypertension they reduced strokes and heart failure, though not apparently heart attacks. The next question, therefore, was whether it would be worthwhile detecting those with ‘mild hypertension’ and treating them. Prompted by Colin Dollery, the MRC set up a working party under the chairmanship of Sir Stanley Peart. Some of Bill’s old colleagues from St Mary’s – Geoff Rose [Munk’s Roll, Vol.IX, p.451], Tony Lever and Mike Hamilton – were also members. Bill was the scientific secretary. A trial in mild hypertension had to be large, since cardiovascular events are not as frequent as in severe hypertension. After lengthy debate, the Medical Research Council agreed to a trial with 18,000 participants, men and women, between 35 and 64.

Strange as it now seems, the idea of using general practice to recruit the large numbers needed was almost an afterthought, but gained encouragement from individual doctors and the Royal College of General Practitioners. The trial began in 1977 and was carried out through 176 general practitioners, recruiting just over 17,000 people. Randomisation was to bendrofluazide, propranolol or placebo. Treatment clearly reduced the stroke rate, but apparently had no effect on coronary events. Cautious post hoc analyses strongly indicated that bendrofluazide was more effective than propranolol. Towards the end of the first trial, recruitment began for a second trial in older people aged 65 to 74 through 226 general practices, using atenolol, hydrochlorothiazide with amiloride or placebo. The results showed a definite reduction in strokes and a probable reduction in coronary events, both attributable to the diuretic treatment.

It is hard to exaggerate the clinical and public health implications of the trials in confirming that screening and treatment were worthwhile. The MRC trials have also made a significant contribution to overviews of smaller previous trials and of later trials, which have resolved uncertainties arising from each separate trial on its own. These overviews have established clear reductions in heart attacks, as well as larger reductions in strokes. The diuretic treatments in the MRC’s trials remain the first choice for many doctors. Bill’s immense contributions were, first, to recruit the practices, personally to maintain the accuracy of records and electrocardiograms, and to bring large numbers of nurses into research. Secondly, the practices in the hypertension trials formed the basis of the MRC’s General Practice Research Framework, a unique and highly valued organisation, eventually consisting of over 1,000 practices throughout the whole of the United Kingdom and responsible for research on a wide variety of topics.

Bill continued his interests in hypertension and its management after retirement. An MRC grant enabled him to write a book with Gillian Greenberg about the first trial, Mild hypertension: is there pressure to treat (Cambridge, Cambridge University Press, 1987). Having lived for many years after his return to the UK in the Buckinghamshire village of Jordans – with its strong Quaker tradition – he retired to the Lake District, where he continued as an enthusiastic oil painter and took up sculpture. He was happily married to Mary Edith née Scott for over 50 years. She died in 2000. In 1997, Bill underwent surgery for colon cancer (‘better a semi-colon than a full stop’, as he put it at the time). But later secondaries were confirmed. He went on appreciating his natural surroundings and enjoying his friends and family until the last moment. Bill was survived by a daughter and four sons, one a doctor, and by 12 grandchildren.

Tom Meade
Sir Stanley Peart

[Brit.med.J.,2004 329 295; The Independent 2 August 2004]