the effects of posture on heart-rate and blood pressure

1161INDUSTRIAL LEGISLATION

in cases of emergency. Unlike the charitable hospitalit is not exempt from taxation.The arrangements for admitting a patient to a

proprietary hospital are usually made by the attendantpractitioner, who after consultation with the patientor his friends, engages a bed at an agreed rate, whichdoes not include special services, such as X ray work,tests for basal metabolism, or the like. Paymentsfor ordinary hospital services are often required tobe made weekly in advance, whereas the bills of thedoctors who treat the hospital patients are not usuallypresented till the treatment has been completed. The

patient has thus two bills to pay : the first, that ofthe hospital, the second, that of the doctor ; and ofthe two the latter is the least likely to be paid in full,especially if the hospital charges have been

unexpectedly heavy. Occasionally unedifying dis-

putes arise between the hospital and the doctor asto the adjustment of their respective charges. Stillmore unedifying is the arrangement, which is said toobtain in some hospitals, whereby a doctor who hasrecommended a patient to enter a certain hospitalreceives by way of commission a part of the hospitalcharges paid by the patient. Such arrangements,which are of the nature of fee-splitting, are stronglycondemned by representative organs of medicalopinion in America, and various methods have beensuggested to discourage them and to enforce a higherstandard of ethical practice. Largely for this

purpose an incorporated organisation has recentlybeen established in New York, known as the Associa-tion of Private Hospitals Inc., members of whichsign a pledge to " (a) maintain the highest efficiencyin our service ; (b) maintain an open hospital to whichaccredited physicians and surgeons may send patients... ; (c) do everything in our power to combat theevils of fee-splitting among the physicians and

surgeons working in our institution." The hospitalauthorities pledge themselves also not to rebate anypart of a patient’s hospital charges to the doctorattending him.

THE EFFECTS OF POSTURE ON HEART-RATE

AND BLOOD PRESSURE

THE changes in pulse-rate and blood pressure whichaccompany alterations of posture have usually beenattributed to concomitant variations in the cranialand splanchnic blood pressure, but Prof. J. A.MacWilliam 1 reports observations which cannot bethus explained. It is now recognised that othermechanisms are concerned in the regulation of pulse-rate and blood pressure-notably afferent impulsesfrom the vena cava and right heart, which are

generated when the internal pressure increases andcauses the heart to beat faster, and also afferent

impulses from the carotid sinus produced by increasein pressure within the artery and leading to cardiacslowing. MacWilliam finds that the chief effects ofcarotid sinus pressure in the normal person are slowingof the pulse, weakening of its beats, fall in bloodpressure, and weakening of the heart and arterialsounds. The readiness with which these reactionsare evoked seemed to vary considerably during thecourse of the day and also from day to day ; indeed,during a single day the sensitiveness of the reflex mayalternate several times, though one of its mostconstant features was the activity of the reflex onwaking in the morning. Variation in the effect ofchange of posture on pulse-rate may perhaps beassociated with different phases of activity of thecarotid reflex. An exaggerated carotid reflex, in

1 Quart. Jour. Exper. Physiol., 1933, xxiii., 1.

conjunction with a similar response from the vaso-motor centre, may lead to over-compensation whenthe subject lies down ; this means excessive slowingof heart-rate with fall in blood pressure and giddinessis induced. Changing from the sitting to the standingposture usually resulted in acceleration of the pulse,and MacWilliam shows this to be dependent on

hydrostatic effects which occur when the thigh ismoved from the horizontal to the vertical; alteredtension in muscles plays no part in bringing aboutthe change. Artificial venous congestion of a legproduces acceleration of the pulse when the subjectis sitting or standing, but not when he is lying. Slightcontinued movements of the legs when the subjectis standing brought about a definite slowing of the pulseas compared with the rate when standing motionless.These effects are presumed to result from afferentimpulses from the leg, and are not the direct resultof alterations in blood flow. Similarly, experimentssuggest that the blood pressure adjustments whichare necessary in the standing position are affected byafferent impulses from the lower limbs. In conclu-sion MacWilliam says that " it remains to be seenwhether a study of postural effects can give informa-tion as to developing defects of coordination andcontrol in the vascular system, leading up to condi-tions of persistent high or low blood pressure, andwhether when abnormal levels have been establishedany differentiation of types is practicable."

INDUSTRIAL LEGISLATION

THE members of the Home Office Factory InspectorsDepartment celebrated the centenary of their estab-lishment on Nov. 10th by a dinner which was attendedby the Prince of Wales and the Home Secretary.It will be remembered that the first efforts at officialcontrol of working conditions were made in 1802when the Health and Morals of Apprentices Actwas passed. The aim of the early measures introducedwas cleanliness and some limitation of the hours oflabour for children, and the fixing of the age foremployment at not less than nine years. Theseso-called " apprentices " passed their lives in the millswhere they were clothed, fed, and housed; theirfate was to be awakened by being beaten and to bekept awake by the same means. If they escaped,they were pursued on horseback and hauled backto work, and, maybe, to succumb to " mill fever,"as typhus was then often called. The early Actswere however mostly ineffective for lack of means toenforce them, until 100 years ago State-paid inspectorsof factories were appointed, armed with powers ofentry into the mills and entrusted with the dutyof enforcing legal requirements. These were the dayswhen the ten-hours controversy raged and MichaelSadler said in the House "You have limited thelabour of the robust negro to nine hours ; but whenI propose that the labour of the young white slaveshall not exceed ten, the proposition is deemed

extravagant." Steadily the Factory Acts were

strengthened, but the cynic may note that the land-owners who held all power in Parliament at the

beginning of the century and resented the growingwealth of the new mill-owners, enacted the eal4yFactory Acts as a means for keeping their rising rivalsin their place ; that adult male labourers stronglysupported the ten-hour Act which would, it wasthought, by limiting the hours of the lowly paidlabour of women and children, improve their ownposition ; and that, even in these later days, the causeof industrial welfare has often been advocated byphilanthropic employers, less because of anyrealisation that their consideration for their work-