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hypertensive headache, and for some time there hasbeen evidence that the early symptoms of hypertensionare psychic in origin.29 Even if hypertension was conclu-sively shown to be more common in neurotic individualsthis would not necessarily be cause and effect; the head-ache could be due to constitutional factors associatedboth with neuroticism and hypertension. Work by Stew-art30 suggests that headache is considerably more preva-lent amongst patients who know that they have hyper-tension. Neurotic individuals consult doctors frequently,so they are more likely to have hypertension discovered. I 31The complaint of headache often leads to measurementof blood-pressure. Thus an apparent association betweenheadache and hypertension may occur in selected groupsof patients but may not be true for the community as awhole. Headache is one of the most frequent of all symp-toms. A community survey gave no evidence that blood-pressures were higher in those with headache or withmigraine than in individuals of the same age and

sex, without headache, drawn from the same popula-tion.32 However, in such a community survey the numberof hypertensives was fairly small. In hospital-clinicpatients, the prevalence of headaches in hypertensiveswith diastolic pressures up to 130 mm Hg was similar tothat of normotensive controls selected from other clinicsin the same hospital, but above 130 mm Hg the preva-lence of headache was higher. 33Now Bulpitt, Dollery, and Carne34 report that waking

headache in patients at a hypertension clinic was signifi-cantly more prevalent in a group of untreated hyperten-sives than in either treated hypertensives or normal sub-jects who had been selected from a local general-practiceregister. This study illustrates the usefulness of controlsfrom the community but also the drawbacks since theresponse-rate amongst the controls in the general prac-tice was only 51%. However, the prevalence of wakingheadache was about 15% in both the community con-trols and the treated hypertensives and over 31% in theuntreated hypertensives. Bulpitt et al. suggest that"raised blood pressure does indeed cause headache" and

give as evidence the findings of their longitudinal studythat the prevalence of headache declined more in thosepatients who had a greater fall in blood-pressure than itdid in those with smaller reductions. The only othersymptom which also improved similarly was "unsteadi-ness". For psychoneurosis to totally explain this, Bulpittet al. argue that one should have to assume that neurosisis improved more when systolic blood-pressure isreduced by an average of 60 mm Hg than when it isreduced by an average of 34 mm Hg. Further, there waslittle net improvement in other symptoms such as

depression. However, if both doctors and patientsbelieve that headaches are related to blood-pressure, andif the success of the hypotensive treatment is communi-cated to the patient, these findings could still be

explained on a psychological basis. There seems littledoubt that headaches and blood-pressure are associated,especially at higher levels of hypertension. The questionremains, is this due to knowledge of hypertension or, insome cases, to hypertension itself? The proportion of

29. Ayman, D., Pratt, J. H. Archs intern. Med. 1931, 47, 675.30. Stewart, I. M. G. Lancet, 1953, i, 1261.31 Robinson, J. O. J. psychosom. Res. 1969, 13, 154.32. Waters, W. E. Br. med. J. 1971, 1, 142.33 Al Badran, R. H., Weir, R. J., McGuiness, J. B. Scott. med. J. 1970, 15, 48.34 Bulpitt, C. J., Dollery, C. T., Carne, S. Br. Heart J. 1976, 38, 121.

people with headache caused by hypertension cannot bemore than a small percentage of all those with headachein the community.

M.E.M. AND MOD-M.E.M.

For several decades the search has been on for a speci-fic, reliable, and reproducible diagnostic laboratory testfor cancer. Many have been proposed; none has stood upto critical assessment, either because of false positives innon-neoplastic conditions or because tests were positiveonly in the later stages of neoplasia. Advances in cancerimmunology have heralded a new wave of optimismabout "cancer tests", and one approach has been to

employ methods purporting to demonstrate cell-me-diated immunity. One such method is the macrophageelectrophoretic mobility (M.E.M.) test. This is believed todepend on reaction of sensitised peripheral blood leuco-cytes in vitro with an appropriate antigen to produce, orrelease, a soluble principle which retards the electro-phoretic migration of guineapig peritoneal macrophages(measured with a cytopherometer). The procedure hasbeen made more sensitive-the modified M.E.M. test.2Both the M.E.M. and the MOD-M.E.M. tests are thought tomeasure an immune response to a plasma membrane-basic protein absent from normal adult tissues but presentin all human malignant tumours.3 This "cancer basicprotein" may be structurally related to an encephalito-genic factor (E.F.) to which sensitisation was firstdetected in cancer patients. However, other materials,including some of the histones, are also capable of actingas "antigens" for lymphocytes from patients withcancer.4

With either the M.E.M. or the MOD-M.E.M. test, positiveresults (i.e., macrophage slowing) are obtained in pa-tients with malignant tumours, irrespective of the site orhistogenesis, and at the in-situ stage as well as in peoplewho have had a tumour removed and are now clinicallyfree of disease.1-8 Nonetheless, these tests have evokedcontroversy; verbal reports at scientific meetings suggestthat there exists a considerable body of negative or in-conclusive work which has not yet been published. AsField and Pritchard and their colleagues have said, sus-tained attention to methodological detail is essential toobtain a working system, and this factor may account inpart or wholly for the discrepancies.

Although the M.E.M. tests are no longer regarded ascancer-specific-they may be positive in various reac-tive and inflammatory conditions and with some benigntumours-one of their apparent advantages has beentheir ability to detect primary malignant tumours whilethey are localised. This is something no other immunolo-gical or clinical test can reliably do.9 Tumours are saidto be detectable 9-16 years before they become clinicallyovert.7 8 In view of the other conditions which can yield

1. Field, E. J., Caspary, E. A. Lancet, 1970, ii, 1337.2. Pritchard, J. A. V., Moore, J. L., Sutherland, W. H., Joslins, C. A. F. Br.

J. Cancer, 1973, 28, suppl. 1, p. 229.3. Dickinson, J. P. in Immunological Techniques for Detection of Cancer

(edited by B. Björklund); p. 91. Bonmers, 1973.4. Johns, E. W., Pntchard, J. A. V., Moore, J. L., Sutherland, W. H., Joslin,

C. A. F., Forrester, J. A., Davies, A. J. S., Neville, A. M., Fish, R. G.Nature, 1973, 245, 98.

5. Preece, A. W., Light, P. A. Clin. exp. Immun. 1974, 18, 543.6. Goldstone, A. H., Kerr, L., Irvine, W. J. ibid. 1973, 14, 469.7. Field, E. J., Caspary, E. A., Smith, K. S. Br J. Cancer, 1973, 28, suppl.

1. p. 208.8. Pritchard, J. A. V., Sutherland, W. H., Deeley, T. J. Lancet, 1976, i, 637.

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positive results, how can one be sure that a tumour wasbeing truly detected at that time? The test has no localis-ing ability. If a truly precocious diagnostic test does

emerge, this must pose immense problems to the clin-ician.

Pritchard et al.8 have lately claimed that, since thefalse-negative rate is very low (02%) in the diagnosis ofestablished and clinically overt malignant tumours,a negative result might be of value in excluding a diag-nosis of cancer. In 1973, Field10 reported that, of 30 pa-tients with histologically proved localised prostatic car-cinoma, 6 had a negative M.E.M. test. This observation,to which Pritchard et al. do not refer, cannot be

ignored despite the variable diagnostic criteria of detect-ing "early" localised prostate cancers. True, some maynot progress to frank invasive tumours, as may be thecase for cervical carcinoma-in-situ and some breastlesions, but further long-term studies are needed beforePritchard’s claim can be accepted. The clinical value ofany test also depends upon its reproducibility, and quali-ty-control investigations do not seem to have been takenfar. Pritchard and his associates8 state that the false-

negative rate for an inexperienced operator is initially30%, declining to zero over 5 months. Could this implya subjective interpretation of data? What would happenin clinical practice with multiple operators, whose skillsand experience must vary?What then should be done to evaluate the reliability,

reproducibility, and clinical value of these tests? All thegroups with experience of the tests should mount someform of independent, but double-blind, analysis. Thismay be a suitable area for contract research funded bythe Department of Health or the major cancer grantingbodies. Such a study might need to be conducted with allthe investigators working in the same laboratory underidentical conditions, dealing with the same population oflymphocytes on sequential days, taken from age-matched controls and patients with carefully stagedcancers as well as from patients with in-situ and pre-neoplastic disease. If the tests then prove valuable weshall want to know the chemical nature of the antigenand to improve the test so that it can more easily handlean increased patient load.

PAY-BEDS AND WAITING-LISTS

As stated in the preamble to the Health Services Bill,published on April 12,11 the main purposes of the Bill areto separate from N.H.S. hospitals accommodation andfacilities used for the private practice of medicine and tointroduce new powers of control over private hospitalbuilding to safeguard the N.H.S. Clause 2 of the Billmaintains the position that consultants may be

employed part-time in the N.H.S.-in other words, it

preserves the right of doctors and dentists to work bothprivately and for the N.H.S. An independent HealthServices Board will assess the demand for private medi-cine in each area of England, Wales, and Scotland andexamine existing and forthcoming facilities to meet the

9. Neville, A. M., Cooper, E. H. Ann. clin. Biochem. 1976, 13, 283.10. Field, E. J. in Immunological Techniques for Detection of Cancer (edited by

B. Björklund); p. 79. Bonmers, 1973.11. See Lancet, April 17, 1976, p. 868.

demand. The Board will, every six months, make pro-posals for further phasing-out of private beds fromN.H.S. hospitals (the Bill requires that the first 1000should go, without reference to the Board, within sixmonths of enactment; and it breaks down this 1000 byarea health authorities, but not by individual hospitals).The Board’s recommendations will be binding on theSecretary of State.

All this was much as expected, though the Bill is nonethe more welcome for that in its opponents’ eyes. Whatis surprising is the high upper limit on the number ofbeds in projected private acute hospitals, above whichlimit the Board must grant authorisation before plan-ning permission can be sought. The limit is 100 or morebeds in Greater London and 75 or more elsewhere.There is plenty of room for unhampered expansion ofthe private sector here. Larger private enterprises willrequire approval by the Board before building canbegin, but unless the Board is satisfied that the develop-ment would to a significant extent either interfere withthe Secretary of State’s duty or operate to the disadvan-tage of N.H.S. patients it will be obliged to grant anauthorisation.

The Board is also charged with the making of recom-mendations for common waiting-lists for N.H.S. andprivate patients to ensure that "all patients are admittedto N.H.S. hospitals on the basis of medical priorityalone". The device of the common waiting-list is wellworth examining further, because it might calm the rest-lessness of the health-services trade-unions, many ofwhose voices are calling again for action to spur on theGovernment to the elimination of inequities betweenN.H.S. and private treatment. But the common waiting-list may not be all that successful in the prevention ofqueue-jumping, for it depends on the identification ofmedical priority and that may require some kind of med-ical referee to determine where a particular patientshould be placed on the list. Moreover, the commonwaiting-list is scarcely applicable to outpatients; and theperiod of sanctions by some consultants has left verylong waiting-lists for N.H.S. outpatient consultations incertain areas and specialties. The pressure has mountedon patients and parents to jump this queue by recourseto private consultation (indeed, the consultants’ strike

may have been unique in that, for some of them, it hasbrought its own built-in pay rise).

The reception of the Bill by the B.M.A., the HospitalConsultants and Specialists Association, the Indepen-dent Hospital Group, and other spokesmen for the pro-fession has been hostile. The Campaign for Indepen-dence in Medicine had already unfurled its lapel badgeswith the message "patients before politics" (1 millionare going the rounds by way of doctors to whom theywere spontaneously sent); and the Campaign has alsoreleased by the same route 3t million car stickers. AB.M.A. deputation hurried round to see the new Secre-tary of State, Mr David Ennals, soon after he was

appointed, to remind him how keen was the oppositionto the Bill. "I shall not be unbending," he said, "if theBill can be improved without sacrifice of its basic princi-ples." The Campaign for Independence will strive to winpublic support and to make Mr Ennals bend; but theCampaign is not being aided by those doctors who arenow contemplating a series of short strikes, for whichthere is not the slightest justification.