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CASUALTY SERVICES IN BARCELONA
623 sadism. The recognition of a widespread impulse to cruelty is being forced upon us to-day, and, whether the psycho-analytical generalisation is correct " sadism " and " sadistic " or not, the popular use of as catchwords to indicate opprobrium and condemnation is more likely to rouse opposition than to lead to a calm discussion of a serious matter. same
EFFECT OF ADRENALINE ON NITRITE COLLAPSE
THE various vasoconstrictor drugs, of which adrenaline is one of the more powerful, have not proved very useful in the treatment of shock in its manifold forms. As is well known from therapeutic experience the nitrites may produce symptoms of collapse or shock, and the effects of sodium nitrite have been used by Wilkins, Weiss, and Haynes1 to test the action of adrenaline. It was found that after administering 3 grains of sodium nitrite to healthy young men syncope occurred after a short interval, when they were tilted up to an angle of 75° to the horizontal. It was accompanied by decrease of venous tone and of blood flow in the hand, with a fall in arterial pressure and a rise in heart-rate. When 1 mg. adrenaline was injected after giving the nitrite, the symptoms appeared more quickly after tilting ; as compared with the effects of nitrite alone the venous tone was little affected, the blood flow was further reduced, and the arterial pressure was usually much reduced, though it might remain relatively high. The results are interpreted as showing an arteriole-constrictor effect of nitrite in the upright position, which is intensified by adrenaline ; the decrease in venous tone resulting from the nitrite is not overcome by adrenaline. These observations on vascular changes in the hand, if they can be assumed to apply also to the vital centres, would explain the symptoms. It is evident at any rate that adrenaline increases the collapse symptoms caused by nitrite, and although this particular condition is not likely to be encountered in practice, it is possible that a similar mechanism underlies other and commoner forms of shock. CASUALTY SERVICES IN BARCELONA
Six months ago some account was given2 of the medical and other provision for refugees in Barcelona and elsewhere in Catalonia. Although an appalling shortage of necessities still exists, much has been done since that time to advance and reorganise the medical and social services to meet the emergency. Recently to the overcrowding and dearth of equipment has been added intensification of aerial bombardment of all coast towns and of Barcelona in particular. As many as 300 casualties, many in a dying condition, were brought to one hospital in the space of 15 minutes. It is natural that the existing civil hospitals, even with addition of the stadium which has been converted into a temporary refugee hospital, have proved inadequate to deal with the vast increase in emergency medical work of all kinds. The Public Health Council of Barcelona has now undertaken the courageous project of replacing the old dispensaries with a series of six completely modernised polyclinics, and of building in addition a large tuberculosis sanatorium and a home for incurables outside the city. In some cases it has been possible to convert pre-existing buildings-e.g., the old Bank of Barcelona by the Porta de la Pau-into polyclinics, but the construction of all follows the
recently
same
general plan.
1 Wilkins, Invest.
R.
They are
of two stories,
a
central
and Haynes, F. W., J. clin.
W., Weiss, S., p. 41. January, 1938, 2 Lancet, 1937, 2, 929.
waiting-room on the ground-floor leading to consultingrooms for general medical, psediatric, and otorhinological cases, whilst the whole of one side is devoted to a large surgical department, including two operating theatres, X ray, and diathermy. On the first floor are similar departments for gynaecology, neurology, gastro-intestinal diseases, dermato-syphilology, and dentistry; clinical and bacteriological laboratories ; dispensary; a six-bed ward for cases too ill to be moved to hospital; and accommodation for a doctor and two nurses. The construction of the buildings is now largely completed, but the equipment is proving very difficult, since almost the whole of it must be purchased in England with a greatly depleted currency. EMPLOYMENT DURING PREGNANCY
THE effects of industrial employment upon the health of the pregnant woman, her infant, and her other children has recently been studied by Dr. Margaret Balfour.1 Many women continue to work after marriage in the pottery and textile trades and in her search for statistical information Dr. Balfour has therefore sought the help of the medical officers of health of towns in which these industries figure largely. Particulars were obtained through antenatal and infant welfare centres and health visitors from 3732 primigravidae, 380 of whom were classified as weavers, 1743 as other workers for gain-in various occupations in the factory, shop, or domestic serviceand 1609 as housewives employed only in their own homes. For each of these groups calculation was made of the maternal mortality-rate, the neonatal death-rate, and the stillbirth and prematurity rates. Between the home workers and the large general group of women gainfully occupied there appears to be no significant difference in these rates, but the rates of the weavers, with the exception of stillbirths, are substantially higher than those of the other groups. A further division of the general occupied group into standing and sitting workers suggests-the figures are not sufficient to do more-that relatively high rates of neonatal deaths and stillbirths characterise the standing group. Another subdivision of the data into those who left off work before the end of the sixth month and those who continued to work beyond that time indicates a disadvantage to the latter. Very little difference, however, is to be observed between the average birth weights of the infants born to these various groups of women. Dr. Balfour, therefore, concludes that gainful work other than weaving does not lead to unfavourable results in the mother but that damage to the child may well ensue if work is continued after the sixth month of pregnancy. In the weaving group it would be of some interest to ascertain, if possible, how the women compared with those not employed in weaving but living in the same towns ; the present less controlled comparison is between weavers and a group more widely spread geographically. In a second study2 Dr. Balfour gives particulars of 1443 multipart, 410 being gainfully occupied and 1033 employed in the home. Of the children who had been born to the occupied group a slightly larger percentage were dead at the time of inquiry than was observed with the home workers. It seems difficult in this case to be sure which is the cart and which the horse. Possibly, more children may be dead because the mother is employed and therefore unable to give them proper attention ; alternatively the mother may tend to remain 1
Publ. Hlth., Lond. January, 1938, p. 2 Med. Offr, Feb. 12th, 1938, p. 67.
106.
EFFECT OF ADRENALINE ON NITRITE COLLAPSE
THE various vasoconstrictor drugs, of which adrenaline is one of the more powerful, have not proved very useful in the treatment of shock in its manifold forms. As is well known from therapeutic experience the nitrites may produce symptoms of collapse or shock, and the effects of sodium nitrite have been used by Wilkins, Weiss, and Haynes1 to test the action of adrenaline. It was found that after administering 3 grains of sodium nitrite to healthy young men syncope occurred after a short interval, when they were tilted up to an angle of 75° to the horizontal. It was accompanied by decrease of venous tone and of blood flow in the hand, with a fall in arterial pressure and a rise in heart-rate. When 1 mg. adrenaline was injected after giving the nitrite, the symptoms appeared more quickly after tilting ; as compared with the effects of nitrite alone the venous tone was little affected, the blood flow was further reduced, and the arterial pressure was usually much reduced, though it might remain relatively high. The results are interpreted as showing an arteriole-constrictor effect of nitrite in the upright position, which is intensified by adrenaline ; the decrease in venous tone resulting from the nitrite is not overcome by adrenaline. These observations on vascular changes in the hand, if they can be assumed to apply also to the vital centres, would explain the symptoms. It is evident at any rate that adrenaline increases the collapse symptoms caused by nitrite, and although this particular condition is not likely to be encountered in practice, it is possible that a similar mechanism underlies other and commoner forms of shock. CASUALTY SERVICES IN BARCELONA
Six months ago some account was given2 of the medical and other provision for refugees in Barcelona and elsewhere in Catalonia. Although an appalling shortage of necessities still exists, much has been done since that time to advance and reorganise the medical and social services to meet the emergency. Recently to the overcrowding and dearth of equipment has been added intensification of aerial bombardment of all coast towns and of Barcelona in particular. As many as 300 casualties, many in a dying condition, were brought to one hospital in the space of 15 minutes. It is natural that the existing civil hospitals, even with addition of the stadium which has been converted into a temporary refugee hospital, have proved inadequate to deal with the vast increase in emergency medical work of all kinds. The Public Health Council of Barcelona has now undertaken the courageous project of replacing the old dispensaries with a series of six completely modernised polyclinics, and of building in addition a large tuberculosis sanatorium and a home for incurables outside the city. In some cases it has been possible to convert pre-existing buildings-e.g., the old Bank of Barcelona by the Porta de la Pau-into polyclinics, but the construction of all follows the
recently
same
general plan.
1 Wilkins, Invest.
R.
They are
of two stories,
a
central
and Haynes, F. W., J. clin.
W., Weiss, S., p. 41. January, 1938, 2 Lancet, 1937, 2, 929.
waiting-room on the ground-floor leading to consultingrooms for general medical, psediatric, and otorhinological cases, whilst the whole of one side is devoted to a large surgical department, including two operating theatres, X ray, and diathermy. On the first floor are similar departments for gynaecology, neurology, gastro-intestinal diseases, dermato-syphilology, and dentistry; clinical and bacteriological laboratories ; dispensary; a six-bed ward for cases too ill to be moved to hospital; and accommodation for a doctor and two nurses. The construction of the buildings is now largely completed, but the equipment is proving very difficult, since almost the whole of it must be purchased in England with a greatly depleted currency. EMPLOYMENT DURING PREGNANCY
THE effects of industrial employment upon the health of the pregnant woman, her infant, and her other children has recently been studied by Dr. Margaret Balfour.1 Many women continue to work after marriage in the pottery and textile trades and in her search for statistical information Dr. Balfour has therefore sought the help of the medical officers of health of towns in which these industries figure largely. Particulars were obtained through antenatal and infant welfare centres and health visitors from 3732 primigravidae, 380 of whom were classified as weavers, 1743 as other workers for gain-in various occupations in the factory, shop, or domestic serviceand 1609 as housewives employed only in their own homes. For each of these groups calculation was made of the maternal mortality-rate, the neonatal death-rate, and the stillbirth and prematurity rates. Between the home workers and the large general group of women gainfully occupied there appears to be no significant difference in these rates, but the rates of the weavers, with the exception of stillbirths, are substantially higher than those of the other groups. A further division of the general occupied group into standing and sitting workers suggests-the figures are not sufficient to do more-that relatively high rates of neonatal deaths and stillbirths characterise the standing group. Another subdivision of the data into those who left off work before the end of the sixth month and those who continued to work beyond that time indicates a disadvantage to the latter. Very little difference, however, is to be observed between the average birth weights of the infants born to these various groups of women. Dr. Balfour, therefore, concludes that gainful work other than weaving does not lead to unfavourable results in the mother but that damage to the child may well ensue if work is continued after the sixth month of pregnancy. In the weaving group it would be of some interest to ascertain, if possible, how the women compared with those not employed in weaving but living in the same towns ; the present less controlled comparison is between weavers and a group more widely spread geographically. In a second study2 Dr. Balfour gives particulars of 1443 multipart, 410 being gainfully occupied and 1033 employed in the home. Of the children who had been born to the occupied group a slightly larger percentage were dead at the time of inquiry than was observed with the home workers. It seems difficult in this case to be sure which is the cart and which the horse. Possibly, more children may be dead because the mother is employed and therefore unable to give them proper attention ; alternatively the mother may tend to remain 1
Publ. Hlth., Lond. January, 1938, p. 2 Med. Offr, Feb. 12th, 1938, p. 67.
106.