1082 ago. Someone is sure to tell the story-one that has been told to our knowledge for more than 30 years-of the ECT machine that broke down or was not connected properly, "and the patients did just as well." Throw in an angry MP, a lawyer or two, some confusing references to compulsory treatment under the Mental Health Act, some ancient film of straight ECT from the days of Cerletti and Bini-hardly more frightening than the very poorly modified treatment shown in some programmes-and the picture is almost complete. Few experienced psychiatrists would deny that we need more precise information about the indications for ECT, just as we need more information about other treatments, such as lithium and antidepressant drugs, that have been shown empirically to work well for many patients. And few would deny that ECT, perhaps because it often works wonderfully well, has often been used indiscriminately. But surely the consensus and the uniformity of practice throughout the United Kingdom that have emerged from 30 years of experience confirm its place as the most consistently effective treatment of severe depression that is available to us. The distortions of the media, reinforced by the malign influence of bodies such as the Citizen's Commission on Human Rights that have long campaigned against psychiatry in all its aspects, have produced so much dread and suspicion that we have moved very quickly to a point where psychiatrists are under great pressure to withhold what is often a life-saving treatment, and where patients who could benefit are too afraid to seek help of any sort. Psychiatrists have always tended to regard attacks on themselves and their profession as manifestations of neurotic reaction, the product of society's too heavily defended ego, and have responded with the essentially therapeutic bland tolerance appropriate to any negative transference. To some extent this may be good for society and good for psychiatrists; but it would be tragic if it obscured the fact that in this instance the real victims of such irrational hostility are the most vulnerable members of society. We are not alone in our anxiety, and it is good to learn from Dr Haslam's letter (13 August, p 455) that the Society of Clinical Psychiatrists is shortly to publish a report on public relations in psychiatry. So far as we are aware, only the Guardian has made a reference, somewhat lukewarm, to the Royal College of Psychiatrists' memorandum on the use of electroconvulsive therapy which appeared in the British Journal of Psychiatry in September; the long delay before its publication and its obvious lack of impact suggest that psychiatrists have much to learn about public relations. If we shrink from our responsibilities now, when and where do we make our stand ? It would be a salutary exercise for anyone who, for whatever motive, seeks to criticise ECT to read Aubrey Lewis's classic 1934 study of melancholia. No doubt enterprising journalists will soon discover that lithium sometimes causes myxoedema and tricyclic antidepressants can impair cardiac conduction; and then it would be back to 1934, when melancholia has to run its natural course, but without the resources to hospitalise the patient for 312 years. Perhaps by then our patients will fight our battles for us and we can watch the banners of CURE-Campaign Urging the Restoration of Electroplexy-from the sidelines. But that is a long way off and by then

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many thousands of patients who could have been effectively treated will have suffered the most terrible of all human afflictions. And many-perhaps the more fortunate-will have died. J F ANDERSON E J MACDONALD A MORRISON K M ARMIT D M MAcGREGOR

P SETHI S F LINDSAY A M MACLEOD I R SHERRET

Medical Committee, Stratheden Hospital,

Cupar, Fife

The debasement of consent

SIR,-YOU published (10 September, p 713), under the heading "Guidelines on ECT," a summary of the memorandum on the use of electroconvulsive therapy issued by the Royal College of Psychiatrists.' In it you allude to two recommendations, the implications of which extend beyond psychiatry to medicine as a whole: (1) "Consent ... should be obtained from ... formal [that is, detained] patients. If ECT is thought essential and the patient is unwilling ... section 26 . . should be applied and ... two consultant opinions obtained"-and then (it is clearly inferred) the treatment given all the same. (2) ". relatives cannot give legal consent. Nevertheless . obtaining relatives' consent is strongly advised"-but if they refuse it and ECT is deemed essential (again the inference is clear) it should still be given. I am in no doubt but the college's advice was given with Mind, and especially its special report A Human Condition2 and possibly Jacob < also, hanging menacingly over its head. I have heard it rumoured that the three defence bodies concur. Yet I am sure all three (or six) are wrong, and dangerously so for the proper practice of medicine. Consent should never be asked unless the decision of him asked is to be honoured. To say to patient or relative, "I seek your consent, but I shall act regardless of it," debases the value of the coin of consent: a coin of value too priceless to be debased without fundamental erosion of the standard of human discourse. The procedure smacks, furthermore, of a subtly cynical type of Hitlerism. May we please have the courage to take decisions where necessary (for the life or health of our patients) fully upon ourselves and not make a charade of shoving them off on to those unqualified to take them ? A postscript: I disagree with the "legal advice" that section 25 of the Mental Health Act is insufficient for ECT and have obtained a lawyer's corroboration of my disagreement. SEYMOUR SPENSER Oxford

Royal College of Psychiatrists, Brirish Journal of Psychiatry, 1977, 131, 261. Gostin, L 0, Mind Special Report, pp 121-2, October 1975. 3Jacob, J, The Modern Law Review, 1976, 39, 17.

ECT in underdeveloped countries

SIR,-As a member of the Special Committee on Electric Convulsion Therapy (ECT) of the Royal College of Psychiatrists I would like to make a few points which arise from the letter of Wendy Farrant (1 October, p 895). The implication is that colleagues recommending ECT are not adequate in the field of

22 OCTOBER 1977

general medical practice to administer the appropriate medication themselves. About 25 years ago I drew attention in these columns to the availability of a short-acting muscle relaxant covered by intravenous anaesthesia. At a meeting some months later of the (then) Royal Medico-Psychological Association I sought, and obtained, agreement that until anaesthetists had acquired the appropriate knowledge and skills (not yet disseminated) it was acceptable for a psychiatrist to administer the anaesthetic and relaxant himself. It was not long before the collaboration of anaesthetists became routine, but this is a professional and ethical safeguard-dare I say not an essential? Is there any reason to think that there are doctors anywhere who could not do this quite simple job ? Literacy and written consent in developing countries obviously present a different problem, but verified oral consent with the aid of an interpreter (which is what most of my colleagues and I obtain for foreign patients) could go some way towards resolving it. Having used chemical, electrical, and inhalant convulsive techniques for over 30 years, less frequently in favour of antidepressant medication since about 1957, I would encourage doctors overseas (or anywhere) to take a good look at the indications for ECT. I am still satisfied that it is the treatment of immediate choice for some patients-but only for some. Perhaps I may add a personal note. In thousands of treatments of general hospital inand out-patients and of private patients at home, in nursing homes, and here I have had two operation mishaps, both dental, before I decided not to remove incomplete dentures supporting spaced teeth. (There is no masseter jerk with flurethyl induction.) L ROSE London Wl

Dispute in Malta SIR,-With reference to the appeal launched by the British Medical Journal (10 September, p 708), allow me to draw your readers' attention to the plight of the Maltese medical profession. The current dispute between the Maltese Government and the Medical Association of Malta (MAM) arose out of disagreement over new legislation affecting newly qualified doctors and the powers of the Medical Council. In protest, the MAM directed its members to take limited action involving outpatient clinics and non-urgent surgical operations, while continuing to provide the necessary cover for emergencies. The Maltese Government reacted by ordering a lock-out of doctors and specialists from all State hospitals and by importing foreign doctors from Libya, Czechoslovakia, Pakistan, and the Palestine Liberation Organisation to man emergency hospital services. Within a few days punitive legislation was rushed through parliament prohibiting the Maltese doctors and specialists from practising in private hospitals. Further legislation culminated in their dismissal not only from their government posts but also, in some cases, from their university appointments. The latter included the professors of medicine, surgery, and obstetrics and gynaecology. The lock-out affected local as well as British external examiners, with the result that final year medical students who were due to qualify last June could not complete their

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22

OCTOBER

1977

final examinations and had to be airlifted to the United Kingdom to sit for the London Conjoint Board Examinations. The dispute is now four months old and there is, at present, little prospect of an equitable solution. The MAM is resisting legislation which has transferred licensing powers from the Medical Council to the Minister of Health in so far as foreign medical graduates are concerned. Though not, in principle, against the introduction of a twoyear preregistration period, the MAM is objecting to the imposition of permanent professional exile as a penalty for those young doctors who fail to serve for two years in Government hospitals immediately after qualification. The MAM is convinced that recruitment of housemen can be achieved by far less drastic and more humane methods. As things stand, these original issues have become overshadowed by more fundamental considerations involving minority rights in a democracy. The attitude of the Maltese Government towards the medical profession in this dispute is more reminiscent of conditions prevailing in totalitarian states. Your readers are asked to appreciate that Maltese doctors are currently engaged in a struggle in defence of professional freedom and the rights of minority groups. In this -hey deserve not only moral support but also more tangible aid from medical colleagues throughout the world. L J GERMAN Honorary Secretary, Medical Association of Malta

Paceville, Malta

**Maltese doctors who subscribe to the BMJ are invited to contact the BMJ if they wish to receive the classified advertisement section (normally excluded from overseas editions of the Journal).-ED, BM7. Children's eye clinics SIR,-The recent correspondence on screening for visual defects in children has displayed a wide measure of agreement that it is desirable, and a considerable diversity of views on how or where to do it-all of which have their merits. Perhaps the most controversial point otherwise arising is the school eye clinic, which Dr R M Ingram (1 October, p 890) describes as anachronistic and Dr J H Cameron (10 September, p 701) as a place for purveying glasses. If, as Dr Catherine S Peckham has shown (8 October, p 958), visual defects arise de novo through childhood, not to mention that many of those arising pre-school continue through childhood, where should older children go to find advice ? Anachronism is not necessarily a reason for discarding a system. To have one's own personal general physician is anachronistic and it is only by persistent argument and demand that private medicine as a whole has been prevented from becoming anachronistic. In my area over 80 % of the children found to have visual defects in school voluntarily attend the children's eye clinic rather than go elsewhere; and out of 82 new patients from school in the first nine months of 1977 31 were ordered glasses as opposed to 51 who were not. It would not be an absurd claim to state that children's eye clinics are where you should go if you do not want to be saddled with glasses (pace Dr Cameron). Added to this, there is the finding from a nationwide survey' that 22 %of

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11-year-old children possessing glasses saw 6 9 or better without their glasses and that 25 " of 1 1-year-olds with glasses were at best casual wearers. There are worse fates than possessing glasses. One of the expensive ones, both to the NHS and to children and parents who are psychologically vulnerable to suggestions of handicap, is to possess unnecessary glasses. Worse still is to become conditioned to their use, which is easily achieved in childhood. These findings, in my opinion, indicate not the need to close down eye clinics but to continue and develop the study of the visual problems of children and to reassess the criteria on which prescriptions for glasses are based. Admittedly, there are difficulties in staffing children's eye clinics, but these could be overcome if the resources of all those skilled in eye work were integrated into a children's eye service which would serve the whole infant and school population, whose physical, visual, and educational development is determining their skills and life style as future adults. P A GARDINER Research Fellow in Ophthalmology

Guy's Hospital.

London SE1 Peckham, C., and Adams, B, Child (tare, Health atnd Developnent. p 93. 1975.

Screening children for visual defects SIR,-I read the continuing correspondence about screening of infants and preschool children with growing interest. Dr Elizabeth M Davis writes (1 October, p 891) that community medical officers with the co-operation of health visitors are skilled in the detection of infant squints. What a happy position to be in! As an orthoptist I have been doing little else at Guy's Hospital for the past 12 years and can still have difficulty differentiating between a true and apparent squint in some children. When the angle is large there is little problem, but if it is a small angle-less than five degrees-it is more difficult, combined with the problem of testing the vision of young children. Dr Davis states that the visual acuity can be accurately assessed by the age of 3.' with the Sheridan cards and here I would like to take issue with her, for the majority of squints have better angular than linear vision in the squinting eye. This means that their vision may be recorded as 6, 6 right and left whereas, had they been old enough to do Snellen's test or had the linear version of the Sheridan-Gardiner test been used, it might have been found to be as bad as 6/36, 6/6. This situation is a diagnostic feature of squint. Young children and those unable to co-operate with the SheridanGardiner or Stycar letters may be tested with Stycar fixed balls and asked to pick up Smarties and "hundreds and thousands." The best vision that can be demonstrated with the fixed balls is 6/18 and "hundreds and thousands" represent a near visual acuity of reduced 6/60. Not a very high standard. Hence those that meet this standard may in reality fall well short of normal. I agree with Mr R M Ingram (1 October, p 890) that screening should be organised from the hospital ophthalmic department-he would screen by refraction. Dr Davis has testing visual acuity and diagnosing squint in mind and, while I agree that the child should be viewed as a whole, nevertheless an orthoptist

would be the first choice for this part of the screening. If school eye clinics in their present form were abolished the ophthalmologists doing them would be available to see those who need further investigation and treatment with a better chance of effective treatment at this earlier age without increase in the work load. W V MULHOLLAND Guy's Hospital, London SEI

SIR,-Dr Robert Ingram's comments (1 October, p 890) on the subject of screening children for visual defects merits the strongest support. For too long has this been a subject where the more screening the better has become accepted dogma, and it is most encouraging to observe a healthy blast of fresh air. His comments on the anachronistic school eye clinics deserve a special support. For too long, in many areas, these have been a bottomless pit into which scarce resources of ophthalmological manpower have been poured, when proper rationalisation of services and division of labour between the already established general ophthalmic services and the hospital eye services would much more appropriately meet the need. Where there is a really efficient non-duplicatory and readily staffed school eye service one would not advocate abolition, but, as, for example, in the South-east Thames Region, where circumstances are far from this case, steps have already been taken to rationalise the system and there has been no detectable deterioration of services. On visual screening, Mr Ingram's remarks again are fully apposite. It is essential that the criteria for this are fully established and that an approach is made to achieving standardised methods and equipment, as well as ages of screening, on a national basis so that practices such as the unlit test card at the end of an unlit school corridor, or an automatic visual screener designed for adults, operated by an audiology technician, become things of the past. In conclusion, may one be permitted to underline the very real defects and deficiencies by an anecdote. When I spoke at a course for school eye nurses on the topic of the visual assessment of children, in question time a practising and conscientious school eye nurse commented that I appeared to place a lot of emphasis on the distance of the child away from the test chart. It was her practice to put the little ones nearer a chart to make it easier for them to see! One or two other nurses mentioned that they also did the same thing. This is an important topic and Mr Ingram's labours do much to show us the way along which we should go. M J GILKES Sussex Eye Hospital,

Brighton

Demand for patient care

SIR,-DI S N Donaldson and others (24 September, p 799) are correct in pointing out that a number of patients in acute hospital beds were receiving an inappropriate level of care-something which is obvious to most clinicians who have responsibility for the care of patients with acute illnesses. This is certainly true for my own specialty, particularly with respect to women. I therefore analysed the female patients currently admitted