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to a 4-year full-scale study of one or more medicalschools.The results of these varied types of study will be as

instructive for us as for the Americans ; and, as thereport points out, many other American medical schoolsand universities besides those in which the fund isinterested are now making experiments. Medicaleducation can never be static or defined : its content

changes constantly with our growing knowledge. Thisis well recognised ; but we have been slow perhapsto admit that even the structural pattern of teachingshould be pliable-a tent, easily pitched and struck,rather than a classic fane.

Annotations

A EUROPEAN HEALTH COMMUNITY ?THE latest proposals of the French government for a

European Health Community were discussed at a meetingin Paris this month. The plan of M. Ribeyre, theminister of public health and population, is based, likethe Schuman plan for coal and steel, on the assumptionthat certain supranational powers should be given to anew health organisation representing a Community ofthose European nations wishing to join. As in the caseof the Schuman and similar plans, the British Govern-ment made it clear at the meeting that it was not

prepared to join such a Community on those terms,though it would wish to be very closely associated withit. Further, if such a new health organisation was tobe considered without supranational powers, the Govern-ment felt that careful examination was needed to seewhether the existing intergovernmental organisations-the World Health Organisation with its RegionalOrganisation for Europe, the Brussels Treaty Organisa-tion, and the Council of Europe-could not do the jobthemselves. It was therefore agreed that a committeeof experts should examine the proposals and report backto the conference as early as possible next year.The proposals themselves fall into two groups : (1)

obligations or restrictions incumbent on all membersof the Community, such as the abolition of customs dueson pharmaceutical products or medical appliances, andthe abolition of unfair competitive practices in thesefields ; and (2) common tasks and objectives, such asthe pooling of medical products and facilities and theresults of research, as well as uniformity in social-securitylegislation. Such objectives might lead to the establish-ment of laboratories by the Community and of centresfor research into such questions as silicosis or the treat-ment of burns or of cancer by high-voltage apparatus.The suggested organisation would perhaps consist of ahigh authority, a council of ministers, and an expertadvisory committee ; and the facilities set up under theSchuman plan might be used.This is not the first proposal to give executive powers

to an international health organisation. There were theold sanitary councils of Egypt, Constantinople, and

Tangier. The fourth International Sanitary Conferencein Vienna in 1874, discussing the function of an

international commission on epidemics, rejected a sug-gestion to give the commission executive as well asadvisory powers, because it seemed unlikely that manygovernments would agree and because the step mightprejudice " the scientific nature of the commission."These arguments hold good today, particularly since amuch greater variety of activities is now proposed. Nodoubt a careful examination of the proposals by experts isproper, but without supranational powers, which fewcountries seem disposed to give, there would have to bea very strong case indeed to warrant yet anotherinternational health organisation.

TREATMENT OF SHOCK IN CARDIAC INFARCTIONWHEN cardiac infarction is accompanied by shock, the

precise mechanism by which the blood-pressure falls isnot at all clear. On the one hand, a large part of aventricle may be rendered suddenly ischaemic and

consequently non-contractile, and the effective myo-cardium remaining may well be unequal to the circu-latory burden ; disturbances of rhythm may supervene ;under such conditions the cardiac output falls,12 2and this alone may contribute largely to the hypotension.On the other hand, there is evidence of peripheralvascular collapse as well. To some extent, this may becompensatory, for a reduced load is then imposed uponthe damaged heart. At all events, the prominent featureof traumatic shock-namely, a fall in volume of thecirculating blood-is of no great significance in cardiacinfarction, and there is no justification at all for intra-venous infusions of blood or plasma. Nevertheless,persistent hypotension carries its own dangers-impairedcoronary flow, aggravated myocardial depression, therisk of further coronary occlusions, and a deprivationof blood-supply to the brain, kidneys, and liver. No

ingenious statistics are required to demonstrate con-

vincingly that, when shock occurs with cardiac infarction,the prognosis is much more serious than when theblood-pressure is scarcely affected.A direct therapeutic attack on the infarcted heart is

clearly out of the question with the resources at presentat our disposal. But it can be relieved as far as possibleof all unnecessary loads, and the hypotension which oftenfollows infarction certainly contributes in this way. If,however, the hypotension is so profound or prolongedthat it becomes a danger in itself, then its correction byimproving peripheral vascular tone may be justified inprinciple. Now orthodox teaching is against such astep : Wood 3 says that, because of the increased risk ofventricular fibrillation, " adrenaline, ephedrine and otheradrenergic substances should be avoided ... no matterhow low the blood pressure." This, of course, underlinesthe real difficulty-namely, to find a drug that will bringabout satisfactory peripheral vasoconstriction without,at the same time, stimulating the heart itself.American workers, who remark that the use of

"

pressor amines " for the treatment of shock following

cardiac infarction is a " relatively new concept," havelately subjected the idea to clinical trial. Kurland andMalach 4 have reported their results with 14 patients.Noradrenaline, given as an intravenous infusion, broughtabout a rise in blood-pressure in most cases; and, unlikethe other sympathomimetic amines that have been tried,it had no effect on heart-rate, cardiac irritability, or thecentral nervous system. Disappointingly, however, theproportion of survivors was not convincingly higher thanwould have been expected with conventional treatment.In another series, Hellerstein et awl. used mephentermine,a synthetic pressor amine, giving it intravenously to 18patients with acute cardiac infarction in whom there wasunequivocal evidence of shock ; and of these patients, 7recovered sufficiently to leave hospital. As Hellersteinet al. consider that the usual mortality in patients of thiskind is about 80%, they feel, perhaps a little optimisti-cally, that their results show a significant improvement.Unfortunately, neither of these reports’ gives full detailsabout the course of events in the individual patients, soit is impossible to make a direct comparison betweenwhat happens when shock is not treated and the develop-ments when the blood-pressure is deliberately raised.Certainly, before we can agree with Hellerstein et al.

1. Grishman, A., Master, A. M. Proc. Soc. exp. Biol., N.Y. 1941,48, 207.

2. Fishberg, A. M., Hitzig, W. M., King, F. H. Arch. intern. Med.1934, 54, 997.

3. Wood, P. In Medical Treatment. London, 1952 ; p. 185.4. Kurland, G. S., Malach, M. New Engl. J. Med. 1952, 247, 383.5. Hellerstein, H. K., Brofman, B. L., Caskey, W. H. Amer.

Heart J. 1952, 44, 407.