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In England Now

A Running Commentary by Peripatetic CorrespondentsWHEN the visiting specialist makes a tour of the ward,

sister and one of the house-surgeons are in close attendanceand behind comes a staff nurse ssh-sshing any patientwho dares to so much as breathe noisily. A holy hushdescends for any doctor and, in a modified degree, formatron’s visits. Decorum thus prevails during themorning hours, but the noise in a public ward for therest of the day has to be heard to be believed. Con-versations are carried on between occupants of beds atopposite ends of the ward : probationers retail the latestsong hits, community singing is popular, and loud-speakers,tuned eternally to the light programme, add to the din.Many hospitals are built in busy streets. Our local

infirmary faces a main road, and has a railway shunting-yard behind it and a coach station next door. Trafficgoes on round the clock and I was surprised to findthat after two wakeful nights I hardly noticed it. Theregular sounds of the ward were much more disturbing.My bed was next to a cupboard with sliding doors whichseemed to be crashed open and shut about every fiveminutes all night. Screens are rattled about and shut upwith a bang. Most night-nurses wear shoes that squeak,and the bed of one unlucky patient was next to thebathroom door.Do doctors really believe that, between their visits,

the ward is so quiet that you could hear a swab drop ?* * *

Now that modern mass-production techniques haveall but ousted the single-handed preparation of mist., ung.,and tab. in the little dispensary that once flourishedin the lee of every doctor’s surgery and chemist’s shop,it is, I suppose, old-fashioned to grumble if the namesof drugs, as well as the drugs themselves, are mass-

produced. And that is the prospect before us. Accordingto the New York correspondent of the Daily Telegraph(Jan. 20) the baffled boffins of a well-known Americanpharmaceutical firm have abandoned their self-appointedtask of juggling with assorted letters of the alphabet,and turned the whole thing over to an electronic brain.Fed on a diet of -word-endings " found to be common

in the medical literature of several languages," thismachine rejected 22,000 " unsuitable combinations," andthen " proceeded to coin 40,000 words," all of a medicinalflavour suitable for drug names. Some of the wordspassed by the machine had also to be consigned by thehuman editor to the rejects, for the machine is regrettablyunable to recognise words that cannot be used in politeconversation.Some of the successful examples such as starycide,

platuphyl, cliohacyn-certainly carry a vague soupçonof the pharmacopoeia, though one might be hard put tosay just why. Certainly they suggest that the heraldednew electronic age of innocence will be supremelyuntroubled by such outdated questions as the meaningof meaning.

How doth the lowly platuphylAvert the psychic painOf starycidal tendenciesIn cliohacyn’s train ...

:k ’" *

To me, unlike my fellow peripatetic of Jan. 14, allairports are much the same airport-they run so muchto pattern. Were it not for the name picked out in largeletters and for striking variations in the temperatureI should hardly have known in which hemisphere Iwas. True that Frankfurt had an ornamental lake andwaterfalls which might look well floodlit. But it wasmaddening to be set down for three-quarters of an hourin Istanbul and confined within a sort of compoundcontaining only a buffet bar and some inferior toysand jewelry. There was a longer, drearier, and stuffierwait at Beirut where the Syrian guards seemed to lookat us with the gravest suspicion. Still perhaps I exaggerateinternational monotony. At Karachi my wife reportedthat she had found two Pakistani gentlemen, lightlvclad in shorts and vests chattering volubly, andenjoying their lunch while squatting at ease on thefloor of the ladies’ lavatory. I admit you wouldn’t seethat in England now.

Letters to the Editor

HYPERTROPHIC PULMONARY EMPHYSEMA

SiR,,--Your leader of Jan. 7 follows the familiar patternof articles upon this subject. The usual arguments forand against its causation by inspiration, expiration,coughing, resistance to air-flow, and elasticity (usedsynonymously with elastic tissue) are set out. Then, byconvention, the greater part of the article deals witb thevarious physiological function tests in vogue.Your statement that .,

any hypothesis should take intoaccount the almost invariable association of hypertrophicemphysema with bronchial diseases such as chronic bronchitisor asthma " is misleading. Surely it would have been morerealistic to have stated that in the ordinary run of post-mortem examinations hypertrophic emphysema is almostinvariably associated with chronic bronchitis. I was-unawarethat there was any particular association between emphysemaand uncomplicated asthma ; indeed, emphysema is an

unusual finding at necropsy in patients dying from asthma.The lethal feature of chronic bronchitis is inflammatioi3

of the respiratory unit-namely, the primary lobule andits associated bronchiole. Repeated infection leads toprogressive lobular and bronchiolar obliteration byfibrous tissue. This throws an added strain upon thehealthier respiratory units, whose lobules dilate to occupythe spaces previously taken by lobules which have shrunkby fibrosis. This mechanism, supplemented here and thereby valvular dilatations, leads to alveolar rupture with aconsiderable increase in interlobular ai’-drift—in otherwords, emphysema. This process is an inevitable conse-quence of chronic bronchitis ; and the question of whetheror not emphysema exists is largely academic, as it

inevitably does so, provided the chronic bronchitis issufficiently severe and lasts long enough. If physiologicalfunction tests are to be applied as an adjunct to clinicaland radiological examination, the most useful in practiceare oxygen saturation before and after exercise, andtests of pulmonary function before and after the admin-istration of relaxant drugs when associated bronchospasmis suspected.On rare occasions, emphysema develops in the absence

of infection. Little is known of the pathology in thesecases ; until detailed studies of the distribution andstate of the bronchioles, lobules, blood-vessels, andelastic tissue have been made, any explanation of themechanisms involved is bound to be hypothetical.London, W.1. 1 EYILLE C. OSWALD.NEVILLE C. OSWALD.

1. Stefanini, M. Unpublished observations, 1955.2. Glanzmann, E. Amer. Pediat. 1918, 88, 113.3. Fonio, A. Acta hœmat. 1952, 8, 363.

A PLATELET FACTOR RESPONSIBLE FORCLOT RETRACTION

SiR,-In the course of platelet-transfusion experimentsin thrombocytopenic patients it was noted that adminis-tration of non-viable, preserved platelets, although notraising the thrombocyte-count, improved the utilisationof prothrombin and the retraction of the clot.1 Thisobservation prompted a search for a constituent ofplatelets with the ability to induce retraction of platelet-poor plasma and fibrin clots. Such a factor has been

postulated by Glanzmann 2 and Fonio.3 -

Treatment of isolated and thoroughly washed humanor bovine platelets with 75% acetone-water v/v or 65%ethyl-water v/v mixtures yields an agent which inducesretraction of a clot of native platelet-free human plasmaor of purified bovine fibrinogen clotted by thrombin.This factor precipitates also in ethyl ether at -20°C.The acetone extract may be freed of thromboplasticfactor by heating at 56°C for two hours, followed bystorage at -20°C for forty-eight hours. Ethyl-etherextracts are free of platelet thromboplastic factor.