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periods of inactivity, for surgical experience teachesthat the bones in such patients may fracture fromtrivial violence."We agree with Dr. Good that the patient should be

unrestrained during the convulsion, restraint may wellincrease the incidence of fractures. Indeed we gofurther and advise against covering bed-clothes duringthe convulsion. The patients discussed in our articlewere not restrained, in consequence we were forcedto seek other explanations for their fractures.In laying the main blame on the force of the

muscular violence in intracapsular femoral neck frac-tures during convulsion therapy we were impressed bythe age-incidence in the 10 fractures reported indetail. All the patients were under 40 years, a

marked contrast to our previous experience with thisfracture. The force of the muscular contraction mustalso be the cause of the more common lesions inconvulsion treatment-namely, dislocation of the jawand compression fractures of the vertebral bodies.A distinguished Australian psychiatrist has recently

stated that " Cardiazol is the elixir of life to a hithertodoomed race" (Med. J. Aust. 1939,2, 430). If that isthe truth of the matter, then a fracture is a small priceto pay for such benefit.

I am, Sir, yours faithfully,Richmond, Surrey. WILLIAM GISSANE.

SIR,—Dr. Rankine Good disputes certain of theconclusions reached by Mr. Gissane, Mr. Rank andmyself in our article in THE LANCET of March 9.He does not agree that the fractures are the resultof muscular violence in rather brittle bones but con-siders the most important factor in their aetiology tobe restraint of the patient during the convulsion byexcessively enthusiastic doctors and nurses.

Our contention that the bones in these patients weremore brittle than normal was based on the observationsof orthopaedic specialists of considerable experience(Mr. Gissane and Mr. Rank) when they bored thebones for the insertion of Smith-Petersen nails, andseems indisputable.Regarding the strength of muscular contraction, I

agree with Dr. Good that there is little differencebetween the pattern of epileptic and Cardiazol fits,but I still maintain that in certain cases cardiazolconvulsions are muscularly more powerful than thoseof epilepsy. That muscular contractions can inthemselves cause fractures of bones is shown by theiroccurrence in cases of tetanus where the patientshave previously been in perfect health. Moreover, Ihave described a case of fractured femur due to anepileptic convulsion (Brit. med. J. 1939, 2, 1227)and come across a case of fractured vertebras inan epileptic exactly similar to those resulting fromcardiozol convulsions (paper now in the press).Finally, may I point out that in none of our

cases was restraint of any sort used on the patientsduring fits since I also hold the opinion that restraintof any form is highly undesirable. This seems torefute beyond doubt Dr. Good’s conclusion.Dr. Rankine Good also says that he has treated

many elderly people with few fractures of the longbones, but his 2 fractures out of 80 cases treated isnot an excessively low incidence. My search into theliterature on cardiazol shows that in 3000-4000 casesfractures of the femur occurred in only 0-66 per cent.and of any of the long bones in slightly over 1 percent. Before we accept Dr. Good’s contention that"age and prolonged activity bear no relation to theincidence of fractures " and that " it would be a pityif someone were prevented from employing it in

elderly people or those who have been inactive for along time by the article referred to ’’ considerablymore evidence is needed.The final verdict regarding this treatment must be

based on the proportionate risks of complicationsversus the chance of improvement unobtainable by anyother method. I personally consider the former ofsufficient importance to warrant a careful selection ofcases likely to benefit and in my experience patientswho do not benefit by the time they have had teninjections (i.e., fits) extremely rarely do so after-wards. I now make it a practice never to give morethan ten fits if there has not been very definite

improvement.I am, Sir, yours faithfully,

Cane Hill.

DONALD BLAIR.

THE E.M.S. TODAY AND TOMORROW

SIR,—I have read with interest llr. Somerville

Hastings’s comments on my article. His main pointof disagreement is in the necessity of allowing headsof departments the power to engage in a certainamount of private practice. I believe this to be essen-tial because the best men in the profession should beincorporated in the new service and it seems extremelyunjust that those capable of paying should be deprivedof the services of such men; nor can I see why thoseproviding the skilled medical help should be deniedthe reward of their skill and labour. The fact howeverthat Mr. Somerville Hastings does disagree with me onthis point confirms my view that there are certainto be considerable divergencies of opinion and thusit is of the utmost importance that a representativebody be formed as soon as possible to discuss fully allsuch divergent views, and to draw up an authoritativescheme for the future of British medicine. I agreewith Mr. Somerville Hastings that those engaged inmunicipal medicine should be represented on such abody.

I am, Sir, yours faithfully,Weymouth Street, W.1. JAMES WALTON.

THE BIRTH OF THE E.M.S.

SIR,—In your issue of March 23 Sir ErnestGraham-Little wrote that a committee appointed bySir Samuel Hoare, of which I was chairman, wasresponsible for the degrading of the London hospitals,for the dispersal of students and for the terms ofservice of the E.M.S. In your issue of April 6 hereadily admits this committee was not responsible,that it had in fact nothing to do with these measures.It was the only purpose of my letter to correct a

question of fact. Otherwise I was not concerned withthe responsibility for these measures. That was takenonce and for all by the Government when it acceptedthe Air Ministry’s estimate of casualties. The provinceof the medical advisers of the Government was not tocriticise those figures but to make preparations onthe assumption that they were correct. If they hadproved accurate there could have been no alternativeto these steps: for example if casualties had occurredon such a scale private practice would have ceased.

Sir Ernest refers to m-v " eulogy " of the E.M.S. ina letter to the Tantes of Dec. 6; the paragraph inquestion reads:

" Finally I have to ask: Has the education of themedical student suffered ? It is not true that thestudents have been left to their own devices. Pre-sently they will return to London, with some insightinto the structure of public health services. By theirdispersal over the sectors something has been lost but