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higher incidence of complications was to be expectedin the group with raised renin levels. Indeed, sincetreatment and consequent resolution of the malignantphase have been shown to be accompanied by a

reduction of plasma-renin activity,17 it is arguablethat both the increased renin and the higher complica-tion-rate are not causally related, but are both

independently the consequences of a higher arterialpressure. 12More interesting, therefore, is the group with low

plasma-renin, since these patients appeared relativelyimmune to complications. However, the variousgroups were not of similar racial composition, thepercentage of Blacks in those with low renin

being considerably increased. Thus, differinggenetic susceptibility to the effects of hypertension,or differing environmental or dietary influences, mayhave contributed to the varying incidence of

complications.The crucial questions left unanswered by the New

York workers concern treatment. Presumably most, ifnot all, of the patients were given hypotensive therapy,although this is not made clear. To validate theauthors’ suggestions concerning the prognostic im-portance of plasma-renin, similar therapeuticregimens should have been employed in all groups,and the hypotensive result should in all three havebeen demonstrably similar. Any effects of therapy onrenin levels should also have been reported. Unfortu-nately, none of these points is mentioned.The Glasgow and New York studies are therefore

provocative but inconclusive. Both raise the importantquestion of avoiding therapeutic measures likely toincrease renin and angiotensin, because of the possiblerisk of inducing strokes, myocardial infarction, orother vascular lesions. It seems at present reasonableto be cautious in this respect, especially in situationswhere the blood concentrations of renin or angio-tensin may already be raised. Nevertheless, strokesand heart-attacks are apparently not unknown inhypertensive patients with depression of renin, suchas those with Conn’s syndrome.8,18 Further, moredetailed, and more strictly controlled studies are

indicated to help clarify these issues.

Medical Fitness to DriveMOST general practitioners and hospital specialists,

as well as doctors in the Public Health Service,are involved at some time in assessing medicalfitness to drive. Two publications make interestingand instructive reading on this important subject.Medical Aspects of Fitness to Drive 19 is the secondedition of a booklet first published by the Medical17. McAllister, R. G., Van Way, C. W., Dayani, K., et al. Circulation

Res. 1971, 28 and 29 (suppl. 2), p. 160.18. Brown, J. J., Fraser, R., Lever, A. F., Robertson, ]. I. S. Br. med.

J. 1972, ii, 391.19. Raffle, A. (editor). Medical Aspects of Fitness to Drive. Medical

Commission on Accident Prevention, London, 1971.

Commission on Accident Prevention in 1968, and isa guide for medical practitioners on standards offitness required for drivers of private vehicles andalso for professional drivers of heavy-goods vehicles(H.G.v.) and public-service vehicles (P.s.v.). In thecase of professional drivers, medical assessment isnow statutory. A new applicant for an H.G.v. orP.s.v. licence should conform to the strictest stan-dards of fitness, with perhaps slight leniency for an ex-perienced driver applying for renewal of his licence.When sudden catastrophic incapacity strikes,

driving is obviously impossible, but with lesser

degrees of disability an experienced driver may stillmanage with safety. In patients who have progressiveor combined disabilities it may be very difficult todecide the stage at which safety is in jeopardy.Likewise with partial recovery from incapacity, thequestion arises whether resumption of drivingshould be allowed, and whether driving could bemanaged with modification of controls. To lay downstandards of quantitative assessment and legislation isvirtually impossible, but when there is doubt regard-ing the ability to manipulate the controls, a cleardecision may depend on a driving-test designedspecifically to assess the handicap. Patients shouldnot be regarded as unfit to drive on medical groundsuntil all possible ways of modifying or convertingcontrols have been considered.

Although medical conditions, excluding the effectsof alcohol, tiredness, and emotional factors, are

reckoned to be responsible for substantially less than1% of road accidents, the medical assessment ofdisabilities influencing fitness to drive remains an

important means of minimising their potentialdangers. Medical officers of health are particularlyinvolved with this, and usually assume responsibilityfor advising the licensing authority whether or not adriving licence should be refused or revoked. Of369 cases referred to the county medical officer of theWest Riding County Council between 1962 and

June, 1970, 61% were self-referred (in that the

disability was declared on the driving-licence appli-cation form); 27% were police referrals, usuallyfollowing an accident; 3% were referred by drivingexaminers, mainly for vision; and 9% were frommiscellaneous sources.2o Epilepsy was the commonestcause of referral, and before June, 1970, it was thedisability for which a licence was most frequentlyrefused in accordance with the Road Traffic Act1960. The Motor Vehicles (Driving Licences)Regulations 1970 and 1971 have made a further

impact on the work of the medical referee. A drivinglicence may now be granted to an applicant who hashad epilepsy, provided he has been free from anyepileptic attack whilst awake for at least three yearsfrom the date when the licence is to have effect, or, ifattacks have occurred whilst asleep but not whilst20. Leyshon, G. E., Elliott, R. W., Lyons, J., Francis, H. W. S. Com-

munity Med. 1972, 127, 201.

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awake since before the beginning of that period, andif the driving of a vehicle in pursuance of the licenceis not likely to be a source of danger to the public.(To have had an epileptic attack after the age of threeis a bar to obtaining a vocational licence to drive anH.G.V. or P.s.v.) Since the new regulations came intoeffect, the number of referrals for epilepsy has in-creased considerably, and a greater proportion aresuccessful in obtaining a licence to drive a privatevehicle. The change in regulations has certainlysucceeded in promoting self-disclosure, but whetherthis has reduced the number of applications withfalse denial of disability is open to doubt.21 Some

neurologists still regard the regulations for epilepsyas too lax,2 and the wisdom of placing almost totalreliance on the veracity of the applicant is also

suspect. However, the most stringent regulationsare likely to lead to greater concealment and thusmay actually increase the risks. At least the new

regulations enable licensing authorities to act withmore uniform policies, and should prevent the pre-vious conflicts caused by one authority revoking alicence granted by another.

The need for the cooperation of family doctors ishighlighted by the new regulations, since an

applicant who has epilepsy, or who has had epilepsyor sudden attacks of disabling giddiness or faintingin the past, is now asked to give the name of hisdoctor and written consent for this doctor to be

approached by the medical referee. LEYSHON et al. 20found that, unless disabling attacks occurred, onlya small proportion of applicants with diabetes orcardiovascular disease disclosed their condition, yetafter accidents more people were referred withthese conditions than with epilepsy. Altogether 78cases with medical conditions were reported to

the West Riding county medical officer after anaccident during a nine-year period: epilepsy (8),diabetes (14), cardiovascular disease (8), and otherdisorders of consciousness (29), including 3 cases ofcough syncope, accounted for three-quarters of thetotal; only 1 case was referred because of a visualdefect. Of all diabetic drivers, the proportion whohave accidents is probably very small; nevertheless,hypoglycxmia constitutes a real danger. There is notalways a warning: aggressiveness and impaired judg-ment may be the first signs, and loss of consciousnessmay not be necessary to cause an accident. FRAIS 23and CHRISTIAN 24 suspect that hypoglycxmia may alsooccasionally be responsible for accidents in non-diabetic drivers. The influence of the new regulationson road safety will only be known when there aremore statistics about accidents involving people withmedical disabilities. A separate category should be

21. Maxwell, R. D. H., Leyshon, G. E. Br. med. J. 1971, iii, 12.22. Matthews, W. B., Miller, H. Diseases of the Nervous System.

Oxford, 1972.23. Frais, J. A. Br. med. J. 1972, ii, 49.24. Christian, M. S. ibid. p. 295.

set aside for accidents due to a first fit or other suddenunexpected disability, which are unpreventablehazards and not susceptible to legislation.What more, then, can be done to prevent accidents

due to medical disabilities ? LEYSHON et al. suggestthat not only epilepsy but also other specific dis-abilities should be declared on the application formfor a driving licence. Whether this could be enforcedany more successfully than at present is debatable;but formal medical assessment of all disabilities, withspecific reference to fitness to drive, should now bean integral part of patient-care, and the possibleeffects of drug therapy on driving must be givendue consideration. Those driving with a knowndisability should be reassessed regularly, and it maybe appropriate to review the licence annually. Thenew regulations help to keep the more seriously dis-abled drivers off the road. Fulfilling the legal con-ditions does not, however, necessarily indicate fitnessto drive: anyone with a history of fits may be allowedto drive if free from attacks for three years, withor without treatment. If treatment is changedor stopped, fits may well recur, so that drivingcould be highly dangerous and should be restrictedpending an additional period of freedom from attackon the altered regimen. The problem of the singlefit in a driver presents considerable difficulty. 25 Thecause cannot always be determined, and there is

general agreement that a single unexplained seizuredoes not justify the diagnosis of epilepsy. Althoughsuch an attack would be a bar to holding an H.G.V. orP.s.v. licence ever again, there may be no legal issuewith regard to private driving. Even if a driver hashis first fit at the wheel and so causes an accident, thepresent regulations do not permanently disallow

private driving; if the driving licence and insurancehave been withheld, reinstatement will probablydepend upon specialist medical opinion.Any patient who has a disease or disability which

could make him a source of danger while drivingshould be urged to tell the licensing authority; andif he has a prescribed disability, he should be stronglyadvised to surrender his driving licence. On Oct. 6,1971, the Secretary of State for the Environmentannounced proposals for new legislation whereby" ordinary " driving licences (i.e., not provisional,P.s.v., and H.G.V.) would be valid for life (unless thedriver has certain medical conditions, when thelicence would be for defined periods). The holdersof " ordinary " licences would be statutorily obligedto notify the licensing authority if they developedany disease or physical or mental disability whichmight constitute a danger to the public by having anadverse effect, other than a purely temporary one, ontheir driving ability. If these proposals become law,doctors will be even more concerned with advisingtheir patients on their fitness to drive.25. Espir, M. L. E. Lancet, 1967, i, 375.