Coroner's Verdict and Industrial Compensation

Sno-Your recent leading article (1 July, p. 4) entitled " Investigating Hypertension" appears to give a somewhat incomplete and Bmseading impression of the current position in this field. Indeed, it is a little difficult to see what point your writer is trying to make. When is investigation of hypertension "fruitless " ? Apparently when continued after " the small number of potentially curable patients " have been detected-the others are to be spared. You go on to suggest that the I.V.P., " supplemented by radiographs taken during the first five minutes of the examination " (surely standard practice for years ?), together with a radioisotope renogram, may be the best way of selecting those who may benefit from further inpatient investigation. If such a practice were to be universally adopted there would be little progress in the field of hypertension. You make no reference to the complex biochemical problems which offer a considerable challenge to physicians currently engaged in this work: into the problems of recognizing aldosteronism in its various forms; or in detecting pressorsecreting tumours of the adrenals or kidneys -conditions which could not possibly be identified using the screening procedures you suggest. Nor do your comments contain more than scant reference to the merits of aortography, though you quote the series described by Chamberlain and Gleeson.' Those authors chose the rather curious parameter of surgical benefit ultimately acquired by the hypertensive patients they investigated with which to judge the value of aortography in hypertension. Quite apart from the smallness of their series and its highly selected nature, it was surely a novel approach for the radiologist to demur on the grounds of doubtful ultimate surgical benefit. There are analogies in other fields where surgical benefit may ultimately be small, such as gastric carcinoma or bronchial carcinoma, but few would suggest that full assessment was unjustified. In any event, medical benefit, in the form of accurate diagnosis and consequent more definitive medical management, might result. Surely we must get our priorities right. In good clinical practice accurate diagnosis must come before treatment whenever possible, and we should avoid the temptation to attempt to short-cut what is usually a rather painstaking and detailed inquiry. Thus without angiography it may be impossible to idenify such conditions as fibromuscular dysplasia, renal-artery aneurysm, thrombosis or embolism in a branch of the renal artery, or renal-artery anomalies. These latter are exceedingly common, and, we believe, important. We have published two papers in which these aspects have been discussed, though you refer to neither.'' It is agreed that many difficulties surround the practical aspects of investigating hypertenson, but surely the decision is still a clinical one. If the patient has hypertension sufficiently significant in the physician's judgement to warrant treatment then investigation should usually be undertaken first. If this is to be done at all then it should be complete, and requires full biochemical and radiological assessment in most instances. We are not impressed by the arguments that this is impracticable, for it is not too difficult to organize facilities to this end, and the procedure need be done only once in the lifetime of most of the patients. About 1,000 patients have been assessed in some detail (including the procedure of aortography) in recent years as part of the general medical work at this hospital.-I am, etc., PHILIP W. ROBERTSON. Royal Air Force Hospital, Wolverhampton, Staffordshire.