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in order. (2) Many local authorities have not enougharea, population or financial resources to run an efficientmedical service. These small authorities should beamalgamated to create areas of sufficient size. TheGovernment know perfectly well that their proposal tocreate joint authorities to administer certain services andto plan others is a weak compromise. They know thatthey are thereby creating further divisions in a healthservice which ought to be one and indivisible. Theyknow that they are building up immense possibilities forfriction and ill-feeling, for jealousies and non-cooperation.They could, if they had the moral courage, create splendidnew health authorities, democratically elected, and solay the foundation-stone for a finer structure of demo-cratic local government than we have ever known,but ... ’ ’

A slight modification of the statement in the white-paper (p. 15) would meet the situation admirably :—

,

The essential needs of a reorganised health service, basedon a new public duty to provide it in all its branches,are these:-

(a) The organising area needs to cover a population andfinancial resources sufficient for an adequate serviceto be secured on an efficient and economical basis.

(b) The area needs to be normally of a kind where townand country requirements can be regarded as blendedparts of a single problem, and catered for accordingly.

(c) The area needs to be so defined as to allow of mostof the varied health services (including domiciliary,hospital and specialist) being organised within itsboundaries (leaving for inter-area arrangement onlya few specialised services).

OPINION

As regards the doctors themselves opinion seems to behardening against the white-paper ; and yet in time tocome the average doctor will probably lament his short-sightedness if his opposition on points of personal interestserves to wreck the scheme :—

. " For reasons not to love him once I sought,And wearied all my thought

To vex myself and him ; I now would giveMy love, could he but live ..."

Special Articles

A CLINICAL VIEW OF SHOCK *

V. ZACHARY COPE, M D, M S LOND, FROS SSENIOR SURGEON TO ST. MARY’S HOSPITAL, LONDON

SHOCK is a clinical state, and any definition mustallow for the variation characteristic of clinical states.It is customary to’speak of primary and secondaryshock, but perhaps the terms immediate and delayedwould be clinically preferable. Immediate shock maylast for only a short time unless the causative factorscontinue to act.

It is generally agreed that shock is associated withimpending or actual failure of the peripheral circulation.As a working definition we might say :-

Shock signifies a condition following the application ofharmful stimuli, or the rapid depletion of the body fluids,in which there is a serious and clinically demonstrabledepression of the vital processes of the body, particularlyof the circulation.

This definition does not specify any particular symp-toms, for the first thing the’clinician should learn is thatthere is hardly one symptom of shock which is constant.

. RECOGNITION OF SHOCK

What are its features ? Let us take the descriptiongiven by W. B. Cannon :—

" We may say that shock is a general bodily state whichoccurs after severe injury and which is characterised by apersistent reduced arterial pressure, by a rapid thready

. pulse, by a pallid or graying or slightly cyanotic appearance* Extracts from the annual oration delivered before the Medical

Society of London on May 8.

of the skin which is cold or moist with sweat, by sweat, bythirst, by superficial rapid respiration, and commonly byvomiting and restlessness, by a lessened sensibility andofteii by a dulled mental state."

Apart from the omission of a subnormal temperature,this is a very good account of severe shock ; but itdoes not apply to the lesser degrees. Moreover someserious cases depart from the classical picture.

Reduction of blood-pressure.-Many refuse to recog-nise shock unless supported by the evidence of thesphygmomanometer ; no fall of blood-pressure, no

shock. Yet 30 years ago Parsons and Tyrrell Grayshowed that clinical symptoms of shock might appearwith a BP that was still high, and W. M. Bayliss pointed

°

out that " a high blood-pressure may coexist with asmall blood-volume, the high pressure being kept up bypowerful vasoconstriction." In a recent series of 100cases, the majority of which were clinically reported tobe suffering from shock, R. T. Grant found no less than37 with either normal or raised BP, but noted that theraised BP might be associated with a small pulse. Thisis what one would expect. As Meakins says :- .

" After the introduction of the sphygmomanometer ourthoughts were slowly, ever so slowly, directed to the belief

that a falling blood-pressure and shock were synonymous.This is to some degree correct, except that the real conditionof shock has been initiated and has travellecl well along itscourse before this spectacular and exact physiologicaldisturbance occurs. It should be considered as one ofthe later findings to indicate the condition. It occursafter all compensatory mechanisms to maintain the circu-lation have failed."

In judging the clinical significance of BP in relationto shock three considerations demand attention. (1)In a hypertensive subject the BP may appear normalthough in fact it has fallen considerably. (2) In somecases the systolic pressure remains approximatelynormal but failure of the circulation is indicated by ahigh diastolic pressure ; thus I have known a dying manshow a systolic pressure of 135 while the diastolic pres-sure was 110. (3) In the development of delayed shockthere is a time when the failing peripheral circulationis barely compensated by vasoconstriction and thepatient is on the verge of collapse though he may appearin fair condition. This I have called latent shock.

In well-developed shock it is clear that the severityof the shock can best be deduced from the fall in BP.If the systolic pressure fall below 80 the condition isvery serious, and a pulse-pressure of under 25 is of badprognosis.

Pulse.-In serious shock the pulse is usually small,weak and rapid ; but there may be no increase in therate. Cuthbert Wallace from his experience of thelast great war concluded that there was a class ofshocked men whose pulse remained slow, and he com-mented " these almost always end fatally." In hisanalysis of air-raid casualties Grant singled out agroup of clinically shocked cases in which the pulse-rate remained slow, and he called attention to the factthat most of these patients were over 50 years of age ;in younger people the rate seldom remains slow. A.Kekwick and his fellow observers reported 5 cases inwhich the rates were 86, 82, 104, 92, 70 with systolicpressures of 55 mm. or less.

Temperature.-I have come to regard a subnormaltemperature as one of the most constant signs. P. C.Kinnaman’s experiments showed that a fall in temperaturewas a better guide to shock than the fall in BP, andKekwick states that " the general temperature of allsevere cases is invariably subnormal." It is commonlythought that this fall in temperature is coincident with,and dependent upon, the fall in BP ; but we know thatthe temperature may quickly fall to 95° or 96° F. incases of immediate shock without a great fall in BP-e.g., in perforated peptic ulcer in which the pressureseldom goes below 100 mm. Hg. From this and similarfacts I think it likely that in some cases of shock thereis a direct reflex inhibition of metabolic processes.

Other evidence of shock.-The skin is usually pale orcyanotic and generally cold, and sweating may beprofuse. It is often the onset of these two symptomswhich indicate to the surgeon that shock is present.If the cheek feels cold to the back of the observer’s hand,

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and if small beads of moisture appear on the forehead,one knows that the patient on the operating-table hashad enough, even though the BP may still be withinnormal limits. Latent shock is becoming patent.Mental dullness is a variable symptom. It is quite

true that many shocked patients are dull or even

stuporose, but others are mentally alert. Kekwickremarked that 17 out of 24 shocked patients were

mentally clear and rational. It is difficult to accountfor these differences.

DIAGNOSIS

It is evident that if we are to diagnose shock early,before any damage is done to the tissues of the nervoussystem and at a time when remedial measures will havethe best chance, we must not wait till all the textbooksymptoms have appeared. We must found our diag-nosis on a general appreciation of the clinical picture.Shock may be indicated by a subnormal temperaturewith a low BP, although the pulse-rate may be withinnormal limits. Or it may reveal itself by pallor, sweating,subnormal temperature, and a small rapid pulse, whilethe BP may remain approximately normal. And thereare also cases in which the appearance and mentalcondition give no indication of the serious state ofthe circulation .which the sphygmomanometer maydemonstrate.When a . person has sustained injuries which are

likely to produce shock one must assume the presenceof latent shock .even though the general appearancesbelie this diagnosis. The good clinician does not judgethe picture by one single part of it.

AETIOLOGY AND PATHOLOGY

The experimentalist suffers from two disadvantagesin studying shock : he excludes pain and he does notdeal with human beings. The clinician on the otherhand is usually so concerned with the treatment of hispatient that he’cannot often or easily carry out allinvestigations. What view of the pathology fits inbest with the experience of the clinician ?

Let us start from the one factor in shock upon whichall experimentalists seem to agree-i.e., there is a seriousreduction in the volume of blood in effective circulation,or as Moon puts it " a volume of blood which is rela-tively inadequate to fill the vessels." Does this view findsupport from the clinician ? Certainly. As the blood-volume rapidly diminishes from severe haemorrhage, thesymptoms of shock appear ; similarly, in cholera, therapid depletion of the body fluids, which must reducethe blood-volume, is followed by an acute collapsesimulating shock. This view is also confirmed by theeffect of treatment, by transfusion or infusion. Henceit is reasonable to accept the belief that both intraumatic and other forms of shock there is a diminutionof the effective circulating blood-volume.The volume of the blood in active circulation may be

diminished in one or more of three ways : (1) by grossinternal or external haemorrhage; (2) by escape of thefluid part of the blood directly into the tissues or in-directly into the secretions (sweat) or excretions (choleraor dysentery) ; or (3) by stagnation of blood in dilatedcapillaries.Every clinician is aware that the volume of blood in

the vessels may be considerably reduced before anyserious symptoms ensue, since the reduction is com-- pensated by immediate vasoconstriction. The lossof a pint of blood has little effect on the circulation.The loss of two pints may cause faintness, a temporaryfall of BP, and acceleration of the pulse ; but re-

covery is rapid. A loss of three pints will cause serioussymptoms-pallor, sweating, subnormal temperature,coldness of the extremities, rapid pulse and loweredBP. In shock which is unaccompanied by haemorrhageit must be assumed either that the fluid part of the bloodtransudes into the tissues or that blood is lost to thecirculation by stagnating in newly dilated capillaries.Clinically both these mechanisms must be invoked toaccount for the different types of shock. Immediateshock must be due to an immediate cause-presumablya nervous reflex causing vasodilatation in some part ofthe peripheral circulation (splanchnic area, muscles, orelsewhere).The importance of this nervous reflex has been mini-

mised by many ; yet there is little doubt that strong

afferent stimuli will of themselves cause shock. G. W.Crile’s view that this was due to an exhaustion of thevasomotor centre is no longer regarded as likely, but wemust assume some inhibition or incoordination of thiscentre to account for the onset of immediate shock in(for example) cases of perforation of a peptic ulcer, acutestrangulation of intestine, or even severe colic. ThoughMoon asserts that " conditions accompanied by pro-longed intolerable pain such as renal or biliary colicdo not cause shock " the experienced clinician knowsthat this is too strong a statement. Few can doubt thatsevere pain can initiate, accelerate or aggravate shock.When the sensorium is shielded by morphine, shock ismuch later in onset or may not appear at all. Inimmediate shock there is a natural tendency to recovery,which generally takes place within an hour or two of theremoval of the causative agency ; and this supportsthe view that it is the result of a nervous reflex.What light can the clinician throw on the way in

which delayed or secondary shock is caused ? Is itdue to the loss of fluid into the tissues of the damagedpart as asserted by A. Blalock ? Does it depend partly onthe barrage of nervous impulses which ascend from thetraumatised’ area and cause reflex vasodilatation as

claimed by O’Shaughnessy and Slome ? Or is it everdue to the absorption from the injured part of sub-stances’which may injure the epithelium of the capil-,laries and permit excessive transudation of fluid fromthe peripheral circulation? The clinician must surelyanswer that none of these explanations is the wholetruth. Much blood and plasma is certainly lost intothe tissues of a traumatised area, but severe shockoccurs in cases where it seems impossible that fluid hasescaped in quantities sufficient to cause serious symptoms,and there is no reason why constant and powerfulafferent stimuli from the injured part should not con-tribute-as they appear to do in immediate shock-bycausing reflex dilatation of some part of the capillarycirculation. I

The view that toxins formed in the breaking downof injured tissues produce shock was widely held

during the last war but has since lost favour. Recentlyhowever H. N. Green obtained a shock-producing sub-stance from fresh voluntary muscle and found that it wasrapidly destroyed in the muscle after death. Givenintravenously this substance had a powerful depressantaction on the BP. Clinically one can say nothing as tothe likelihood of shock-producing toxins from muscle,but no-one who has seen the occasional rapid develop-ment of shock after the relief of obstruction of a coil ofsmall intestine can help thinking that toxins from thesmall gut may occasionally have a shock-producingeffect. Such a toxin might either increase the per-meability of the capillaries or have a direct action onthe vasomotor centre. c

It is a matter of common clinical experience that somecases of shock fail to respond to treatment or respondonly for a time. In a patient exsanguinated by heamor-rhage transfusion of blood usually brings rapid andpermanent recovery, but in a patient with severe shockthe improvement sometimes lasts only so long as thetransfusions are continued. Since the vessels cannotbe for ever dilating it is certain that the fluid must beconstantly transuding from the vessels, and quiteprobable that the vasomotor centre has in these caseslost its vitality. The damage to capillaries and nervoussystem has advanced so far that the process is irre-versible. .

Thus there are several mechanisms which may producethe same end-result-failure of the peripheral circulation.

TREATMENT

If immediate shock results from an immediate vaso-motor failure caused through nervous channels, it willbe clear that the head-down position should be adopteduntil the normal reaction re-establishes vascular tone ;at the same time the cerebrum should be shielded frompain by the administration of morphine. Body heatshould be conserved by application of warmth, but notto such an extent as to produce or increase sweating.Cardiac stimulants may also be of use in such doses.In immediate shock fluid is seldom essential.

In delayed shock, or in cases of immediate shock whichdo not recover within an hour or two, we have also to

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deal with the extravascular loss of fluid which urgentlycalls for replacement. Whole blood, plasma, or (whennothing else can be got) normal saline may be used toreplace lost fluid and maintain the blood-pressure.This treatment must be continued until the blood-pressure is stabilised or until there is no chance ofrecovery.. Operation should be postponed until thecirculation has been restored as much as possible, andevery care taken to minimise trauma during the opera-tion.While no drug will restore a terribly shocked body

to its normal state, morphine will give much-neededrest to the nervous system.

GENERAL MEDICAL COUNCILPRESIDENT’S ADDRESS

OPENING on Tuesday the 161st session, Sir HERBERTEASON announced with regret the retirement from thecouncil of Mr. John Charles Flood, representative of theApothecaries Hall of Ireland, who (in his own words) had" forsaken the scalpel for the cowl." His successor, Mr.Myles Keogh, had extensive experience in the manage-ment of Dublin hospitals. He deplored the circum-stances which had prevented them from welcoming Mr.Edward Sheridan for his final appearance at their board.The council would miss their charming colleague and theDental Board was losing one who represented the highesttraditions of the dental profession.

REVISION OF THE CURRICULUM

Inspection of qualifying examinations in medicine,surgery and midwifery is now, the President said,approaching completion, but the examinations not yetinspected’ include some held in Eire. Attendance ofinspectors at these being delayed owing to restrictionson travel, the education and examination committeesmay think it advisable to proceed, in order that thecouncil may have the advantage of the information andconclusions derived from the inspection before enteringupon the task of revising the curriculum. In view ofthe general ferment which has arisen in connexion withmedical education, it may be profitable, he added, if Irecapitulate shortly, for the benefit of the council andof the public, the action taken and the recommendationsmade by the council on such questions within the lastyear or two.

In the evidence submitted to the Departmental Committeeon Curriculum and Examinations the council called attentionto the poor standard of English which many students hadattained by the time they began their medical studies, thechief reason for this defect being premature specialisation atschool. As long ago as 1934 the council had reached the con-clusion that the standard of general education for prospectivemedical students should be at least equal to that of entry intoother learned professions, and not below that of the matricula-tion examination of universities. The council added in 1942that this education should be broad, and cannot be regardedas complete unless it includes the general principles of physicaland biological science. Courses leading to the first MBexamination should be taken in a medical school. This con-sidered view was based on the facts that laboratory facilitiesat schools vary widely, very few approaching universitystandard. The teaching of these at school encouragesstudents to start specialising too early. If taken during thefirst year in a medical school it enables the authorities to makean initial assessment of the student for the medical profession,those who prove unsuitable being advised to withdraw beforecommencing professional study.In the evidence submitted to the Inter-Departmental Com-

mittee on Medical School8, the council emphasised that in mostcommunities the medical man has always been looked on asan educated man of the world, whose opinions on problemsother than those of medical interest carry a certain weight;if this position is to be maintained, the medical student shouldhave a high standard of general education, and an outlookbeyond the confines of the best-planned examination syllabus.To ensure a complete and adequate medical education teachersshould work in close cooperation, impressing upon the studentthe bearing of preclinical subjects upon clinical studies.Clinical teachers should have associated with them theteachers of purely scientific subjects in any investigation orresearch. As regards the curriculum as a whole the council

have to bear in mind that it is primarily that required for thegeneral practitioner, higher medical education being rather amatter for postgraduate instruction. But the study andteaching of social and preventive medicine deserve furtherencouragement, in order that medical students and practi-tioners may be better acquainted with the influence of social,occupational, genetic and domestic factors on the incidenceof human disease and disability ; and that it is desirable toseek and promote measures, other than those usually employedin the practice of remedial medicine, for the protection of theindividual and of the community against such forces as inter-fere with the full development and maintenance of man’smental and physical capacity.The council had also expressed agreement with the draft

interim report of the Medical Planning Commission that themedical student who has passed his final examination shouldspend some time in practice under supervision before embark-ing on his own account. To regulate this position, however,some amendment of the Medical Acts would be essential forthe purpose of conferring upon him, during the interimperiod, those privileges of a registered medical practitionerwithout which he could not profit fully by his experience.

It is clear, the President concluded, that a revision ofthe medical curriculum is both required and desired, butI should point out that it is not the function of the GMCto impose a curriculum upon the licensing bodies. Allthat the council do, and can do, is from time to time toissue recommendations on general lines to these bodies,indicating what are the desirable essentials of a curri-culum, both as regards time and content. It is forlicensing bodies themselves to arrange the curriculum asthey think best in the interests of medical education,subject to the maintenance of the legal minimumstandard. The Medical Acts Commission of 1881-82had stated :

" It would be a mistake to introduce absolute uniformityinto medical education. One great merit of the presentsystem, so far as teaching is concerned, lies in the elasticitywhich is produced by the variety and the number of educat-ing Bodies. Being anxious not in any way to diminish theinterest which the teaching Bodies now take in medicaleducation, or to lessen their responsibility in that respect,we desire to leave to them as much initiative as possible.In certain matters of general importance, such as the dura-tion of study and the age at which a student should be per-mitted to practise, common regulations ought, we think,to be laid down ; but we wish to record our opinion thatnothing should be done to weaken the individuality of theUniversities and Corporations, or to check emulationbetween the teaching institutions of the country."

This, said the President, had reflected the policy of theGMC before that time, as it had anticipated their policysince.

DENTAL REGISTRATION AND DISCIPLINE

The council, said the President, had also completed thepresentation of evidence to the Inter-DepartmentalCommittee on Dentistry. They had proposed that adental authority fully representative of dental licensingbodies and of the dental profession should be givenresponsibility, without any reference to the GMC, formatters of dental registration and discipline, for controlof their expenditure, and for the exercise of their rule-making powers ; that this authority should also replacethe GMC as the authority responsible under the DentistsActs for dental education and examinations ; but thatthey should, when acting in this capacity, have addedto their membership a fixed proportion of members ofthe GMC appointed by the council, and should includethese members in a statutory committee on dentaleducation and examination.

REGISTER OF SPECIALISTS

The President went on to recall some apprehension hehad expressed in his last address (Nov. 27) as to the pro-ceedings of another organisation with regard to what hefelt constrained to describe as a proposal to establish aregister of specialists under the auspices of certainlicensing corporations. The council’s anxieties in thematter will, he said, have been materially allayed by theanswer given by the Minister of Health on Feb. 3 to aquestion in the House of Commons by Sir DouglasHacking, a member of the council. This reply (which