will and what will not upset the function of the foot. A long postoperative recovery period and disability from foot surgery can be avoided because we can work with the foot, not against it. We can choose a surgical procedure to suit the individual patient and his or her biomechanical fault, knowing what the end result will be. With the current emphasis on physical fitness, the foot is assuming even greater importance. Almost all the exercise programs in which large segments of our population are now taking part demand far more of the foot than usual everyday walking. Athletes are becoming more aware of specific foot problems and how they can be treated. They are not willing to accept our lack of knowledge in this area any longer. We believe our attitude towards the foot must change. First, we must realize that the foot is of great interest to the physician and of great importance to the patient. Even if the problem is only a painful callus or an ingrown toenail, it is well worth treatment by sophisticated techniques, as is any other medical problem. Our interest and training in foot disorders should expand at both the undergraduate and graduate levels. We must learn the biomechanics of foot function so that we do no harm by errors of either omission or commission. The foot is too sophisticated an appendage to be pushed to the sidelines any longer. We should also recognize the tremendous strides that have been made by podiatrists in the last few years. For most of us the podiatrist is one who is involved in palliative care and in the treatment of corns, calluses and abnormal nails, as well as one who prescribes shoe modifications and arch supports. However, the modern podiatric physician is fully trained in the biomechanics of foot function so that he can prescribe specific mechanical supports for the foot with the same accuracy with which one prescribes dental plates or lenses for the eye. Sophisticated surgical techniques are taught and practised in the podiatry profession; in the United States podiatrists have full prescribing privileges and are permitted to be members of the hospital staff. Perhaps we could learn something from them. Unfortunately Canada has no schools of podiatry.
We have tried to point out some of the deficiencies of the medical profession in the care of the foot, and have made some general comments about what can be done to remedy the situation. Of course we do not yet have all the answers; a great deal more work needs to be done before foot problems can be managed with the confidence and accuracy merited. However, if this letter provokes some thought and stimulates some interest in the foot, it will be a step in the right direction. WJ. PRos'r, MD, 15 Mountain Ave. 5, Ste. 305 Stoney Creek, Ont.
J.A. WEIR, MD
Mississauga Hospital Mississauga, Ont.
References 1. JAHsS MN: The foot - present and future, in A Selection of Papers from the Proceedings of the American Orthopedic Foot Society, Inc., 1974 and
1975, BATEMAN JE (ed), Saunders, New York, 1976
2. INMAN VT (ed): DuVries' Surgery of
the Foot, Mosby, St Louis, Mo, 1973, p 517
Screening for breast cancer To the editor: Mass screening for
evidence of early breast cancer is theoretically one way to achieve the goal of health care - that is, true patient benefit. However, it should come as no surprise that the analysis of such screening is surprisingly complex. Under these circumstances, to adopt a simplistic, categorical ap-
proach, as did Dr. T.J. Muckle (Can Med Assoc 1 118: 119, 1978), is a disservice to everyone, including himself. First, the statement to which Dr. Muckle takes exception is not that of a bureaucrat but rather that of a group of intellectually honest individuals who have foresworn the luxury of an emotional commitment to an idea. Second, Dr. Muckle knows full well the folly of asking for unqualified answers to any important question. Finally, I'm saddened to see evidence that some members of the medical profession still view, with arrogance and conviction, the problems of decision-making in the field of health care as their own private preserve. I can assure Dr. Muckle that many women in this province, on
1356 CMA JOURNAL/JUNE 10, 1978/VOL. 118
both sides of 50 years of age, would not consider a $25 expenditure trivial, especially for preventive medicine. This cavalier disregard for individuals (not even patients) is hardly less "inhuman" than the alleged bureaucratic behaviour he finds so objectionable. C.G. RAND, MD, MPH, FRCP[CJ
Associate professor Department of epidemiology and preventive medicine University of Western Ontario London, Ont.
Electroconvulsive therapy today To the editor: It is sad that the Journal chose to begin 1978 with the publication of an article extolling the virtues of electroconvulsive therapy (ECT) (Can Med Assoc 1 118: 8, 1978). Contrary to the assertion by M.R. Eastwood and S. Stiasny that it "has stood the test of time during the past 40 years... and is one of the best treatments in medicine", I believe that it is becoming more discredited and less used in North America. The article is riddled with serious errors of omission and commission. The first and most obvious attempt to mislead readers is the authors' omission of any reference to the very high recurrence rate of symptoms after ECT. As the authors state, the explanation of why ECT sometimes produces symptomatic improvement is not agreed upon. It is therefore premature to dismiss two psychologic explanations that have considerable prognostic significance: (a) obliteration of the cerebral representations of the psychologic conflicts that have produced the symptoms, so that when "brain recovery" occurs the conflicts often, though not always, return and therefore the symptoms return; and (b) many patients, especially those who are depressed, have considerable feelings of guilt and perceive ECT as a punishment or as a "shock" that relieves them of their guilt temporarily. The latter explanation clearly helps us understand the return of symptoms in many patients. Neither explanation may be the complete answer, but one or other may be true for specific patients, and there is no adequate work that dismisses them or that offers anything better.
Despite the "psychobiologic" con-
tent of the paper, and the authors' refusal to consider the psychologic factors involved in the giving of ECT, the paper has an old-fashioned, musty air about it. The paper is an antique because the authors are still stuck in the trap of discussing ECT in terms of diagnostic labels. Some years ago I proposed that the indications for ECT be considered in terms of situations. Specifically, it should be given in life-threatening situations and to patients who are otherwise "unreachable" for a variety of reasons.1 Such an approach is more realistic, appropriate and humane and could not be objected to by anyone concerned about a fellow human being. JOSEPH BERGER, FRCP[C], MB
Wycliffe House, Ste. 501 4430 Bathurst St. Downsview, Ont.
Reference 1. BERGER J: Electroshock is probably no longer of use in psychiatry (C).
Mod Med Can 28: 300, 1973 To the editor: We, too, are concerned about our fellow human beings and for that reason wrote the editorial to help clear the confusion about the treatment. Although Dr. Berger states that our article has "an oldfashioned, musty air about it", it does sum up contemporary wisdom and does not depart from comparable papers published recently in the United States, Australia and the United Kingdom.1'2 It is true that ECT has been prescribed less frequently in recent years. The reason for this, however, is not so much that the treatment has been discredited but that other effective treatment modalities have become available and the specific indications for ECT have become more precise. Dr. Berger also mentions the recurrence of symptoms after ECT has been given. The affective disorders, for which ECT should be prescribed, are known to be intermittent and it is to be expected that some patients will become ill again. In the editorial we specifically say that the therapy is given to shorten an illness episode rather than to act as a prophylactic agent. The seasonal and cyclical nature of the natural history of the affective disorder in each patient has to be determined. A decision has to be made whether ECT or an
antidepressant drug is to be given for each episode (should the illness occur once a year or less) or whether prophylactic antidepressant drugs or lithium carbonate should be prescribed (if the frequency is greater). Dr. Berger's assertions about the dynamics of depression and their response to physical modes of treatment are, we believe, of historical interest. When effective physical modes of treatment for depression were introduced into psychiatry there was much discussion as to how the physical and psychoanalytic approaches could be reconciled. The biologic action of ECT has been studied. The double-blind study undertaken by Cronholm and Ottosson in 1 96O. showed that the antidepressant effect of ECT was dependent upon seizure activity, not on other effects of electrical stimulation such as memory disturbance. The guilt reduction hypothesis, although intellectually appealing, is difficult to test. However guilt is not a strong predictor of the immediate outcome after ECT.4 We cannot agree that diagnosis is unimportant when one is discussing ECT. For 35 years it has been recognized that the response to ECT varies according to whether the patient has an affective disorder, schizophrenia or a neurotic or character disorder. Penrose and Marr5 published such findings as early as 1943 from a study of mental hospitals in Ontario.
5. PENROSE IS, M.R WB: Results of shock therapy evaluated by estimating chances of patients remaining in hospital without such treatment. J Ment Sci 89: 374, 1943
To the editor: I read with interest the editorial by M.R. Eastwood and S. Stiasny. Recently Grahame-Smith, Green and Costain1 hypothesized that ECT produces an increased postsynaptic effect by increasing the postsynaptic response to the same amount of released transmitters. They added: "There is good evidence that repeated electroshock alters the functional activity of 5-H.T., dopamine, and perhaps noradrenaline, which suggests a change either in receptor sensitivity or in the function of neuronal systems modulating the through-put of monoaminergic stimuli." Monoamine oxidase inhibitors alone and in combination with tricyclic antidepressants (e.g., amitriptyline and trimipramine) and ECT often bring relief to patients with intractable depression. Sargant and Slater2 stressed the importance of this treatment in depression, but in North America many psychiatrists are still hesitant to use ECT in patients who are receiving monoamine oxidase inhibitors (e.g., phenelzine sulfate or tranylcypromine sulfate). Patients who are taking monoamine oxidase inhibitors have been treated successfully with ECT without any complications in our unit for the past several years. Eastwood and Stiasny have stated that "ECT M.R. EAsrwooD, MD, FRCP[C] has stood the test of time during the S. STIASNY, B sc, MBA Clarke Institute of Psychiatry past 40 years ... and is one of the Toronto, Ont. best treatments in medicine if given appropriately." In addition, physi-
References 1. GREENBLATT M: Efficacy of ECT in affective and schizophrenic illness. Am J Psychiatry 134: 1001, 1977 2. KILOH LG: The use of electroconvulsive treatment in depressive illness, in Handbook of Studies on Depression, BURROWS GD (ed), Amsterdam, Excerpta Medica, 1977, pp 229-52 3. CRONHOLM B, OrrossoN J-O: Experimental studies of the therapeutic action of electroconvulsive therapy in endogenous depression. The role of the electrical stimulation and of the seizure studied by variation of stimulus intensity and modification by lidocaine of seizure discharge. Acta Psychiatr Scand 35 (suppi 145): 69, 1960 4. MAYER-GROSS W, SLATER E, ROTH M
(eds): Clinical Psychiatry, 3rd ed, London, Bailli.re, 1969, p 222
cians should not withhold the application of ECT from a patient who is
otherwise fit for anesthesia, has refractory depression, and is taking monoamine oxidase inhibitors or tricyclic antidepressants. INDRAJIT RAY, MD, DPM, MRC PsYcH, FRCP[C]
Psychiatric department Union Hospital Moose Jaw, Sask.
References 1. GRAHAME-SMITH
DG,
GREEN AR,
CosTAIN DW: Mechanism of the antidepressant action of electroconvulsive
therapy. Lancet 1: 254, 1978 2. SARGANT W, SLATER E: Introduction
to Physical Methods of Treatment in Psychiatry, 4th ed, Baltimore, Wilhams & Wilkins, 1963
CMA JOURNAL/JUNE 10, 1978/VOL. 118
1361
We have tried to point out some of the deficiencies of the medical profession in the care of the foot, and have made some general comments about what can be done to remedy the situation. Of course we do not yet have all the answers; a great deal more work needs to be done before foot problems can be managed with the confidence and accuracy merited. However, if this letter provokes some thought and stimulates some interest in the foot, it will be a step in the right direction. WJ. PRos'r, MD, 15 Mountain Ave. 5, Ste. 305 Stoney Creek, Ont.
J.A. WEIR, MD
Mississauga Hospital Mississauga, Ont.
References 1. JAHsS MN: The foot - present and future, in A Selection of Papers from the Proceedings of the American Orthopedic Foot Society, Inc., 1974 and
1975, BATEMAN JE (ed), Saunders, New York, 1976
2. INMAN VT (ed): DuVries' Surgery of
the Foot, Mosby, St Louis, Mo, 1973, p 517
Screening for breast cancer To the editor: Mass screening for
evidence of early breast cancer is theoretically one way to achieve the goal of health care - that is, true patient benefit. However, it should come as no surprise that the analysis of such screening is surprisingly complex. Under these circumstances, to adopt a simplistic, categorical ap-
proach, as did Dr. T.J. Muckle (Can Med Assoc 1 118: 119, 1978), is a disservice to everyone, including himself. First, the statement to which Dr. Muckle takes exception is not that of a bureaucrat but rather that of a group of intellectually honest individuals who have foresworn the luxury of an emotional commitment to an idea. Second, Dr. Muckle knows full well the folly of asking for unqualified answers to any important question. Finally, I'm saddened to see evidence that some members of the medical profession still view, with arrogance and conviction, the problems of decision-making in the field of health care as their own private preserve. I can assure Dr. Muckle that many women in this province, on
1356 CMA JOURNAL/JUNE 10, 1978/VOL. 118
both sides of 50 years of age, would not consider a $25 expenditure trivial, especially for preventive medicine. This cavalier disregard for individuals (not even patients) is hardly less "inhuman" than the alleged bureaucratic behaviour he finds so objectionable. C.G. RAND, MD, MPH, FRCP[CJ
Associate professor Department of epidemiology and preventive medicine University of Western Ontario London, Ont.
Electroconvulsive therapy today To the editor: It is sad that the Journal chose to begin 1978 with the publication of an article extolling the virtues of electroconvulsive therapy (ECT) (Can Med Assoc 1 118: 8, 1978). Contrary to the assertion by M.R. Eastwood and S. Stiasny that it "has stood the test of time during the past 40 years... and is one of the best treatments in medicine", I believe that it is becoming more discredited and less used in North America. The article is riddled with serious errors of omission and commission. The first and most obvious attempt to mislead readers is the authors' omission of any reference to the very high recurrence rate of symptoms after ECT. As the authors state, the explanation of why ECT sometimes produces symptomatic improvement is not agreed upon. It is therefore premature to dismiss two psychologic explanations that have considerable prognostic significance: (a) obliteration of the cerebral representations of the psychologic conflicts that have produced the symptoms, so that when "brain recovery" occurs the conflicts often, though not always, return and therefore the symptoms return; and (b) many patients, especially those who are depressed, have considerable feelings of guilt and perceive ECT as a punishment or as a "shock" that relieves them of their guilt temporarily. The latter explanation clearly helps us understand the return of symptoms in many patients. Neither explanation may be the complete answer, but one or other may be true for specific patients, and there is no adequate work that dismisses them or that offers anything better.
Despite the "psychobiologic" con-
tent of the paper, and the authors' refusal to consider the psychologic factors involved in the giving of ECT, the paper has an old-fashioned, musty air about it. The paper is an antique because the authors are still stuck in the trap of discussing ECT in terms of diagnostic labels. Some years ago I proposed that the indications for ECT be considered in terms of situations. Specifically, it should be given in life-threatening situations and to patients who are otherwise "unreachable" for a variety of reasons.1 Such an approach is more realistic, appropriate and humane and could not be objected to by anyone concerned about a fellow human being. JOSEPH BERGER, FRCP[C], MB
Wycliffe House, Ste. 501 4430 Bathurst St. Downsview, Ont.
Reference 1. BERGER J: Electroshock is probably no longer of use in psychiatry (C).
Mod Med Can 28: 300, 1973 To the editor: We, too, are concerned about our fellow human beings and for that reason wrote the editorial to help clear the confusion about the treatment. Although Dr. Berger states that our article has "an oldfashioned, musty air about it", it does sum up contemporary wisdom and does not depart from comparable papers published recently in the United States, Australia and the United Kingdom.1'2 It is true that ECT has been prescribed less frequently in recent years. The reason for this, however, is not so much that the treatment has been discredited but that other effective treatment modalities have become available and the specific indications for ECT have become more precise. Dr. Berger also mentions the recurrence of symptoms after ECT has been given. The affective disorders, for which ECT should be prescribed, are known to be intermittent and it is to be expected that some patients will become ill again. In the editorial we specifically say that the therapy is given to shorten an illness episode rather than to act as a prophylactic agent. The seasonal and cyclical nature of the natural history of the affective disorder in each patient has to be determined. A decision has to be made whether ECT or an
antidepressant drug is to be given for each episode (should the illness occur once a year or less) or whether prophylactic antidepressant drugs or lithium carbonate should be prescribed (if the frequency is greater). Dr. Berger's assertions about the dynamics of depression and their response to physical modes of treatment are, we believe, of historical interest. When effective physical modes of treatment for depression were introduced into psychiatry there was much discussion as to how the physical and psychoanalytic approaches could be reconciled. The biologic action of ECT has been studied. The double-blind study undertaken by Cronholm and Ottosson in 1 96O. showed that the antidepressant effect of ECT was dependent upon seizure activity, not on other effects of electrical stimulation such as memory disturbance. The guilt reduction hypothesis, although intellectually appealing, is difficult to test. However guilt is not a strong predictor of the immediate outcome after ECT.4 We cannot agree that diagnosis is unimportant when one is discussing ECT. For 35 years it has been recognized that the response to ECT varies according to whether the patient has an affective disorder, schizophrenia or a neurotic or character disorder. Penrose and Marr5 published such findings as early as 1943 from a study of mental hospitals in Ontario.
5. PENROSE IS, M.R WB: Results of shock therapy evaluated by estimating chances of patients remaining in hospital without such treatment. J Ment Sci 89: 374, 1943
To the editor: I read with interest the editorial by M.R. Eastwood and S. Stiasny. Recently Grahame-Smith, Green and Costain1 hypothesized that ECT produces an increased postsynaptic effect by increasing the postsynaptic response to the same amount of released transmitters. They added: "There is good evidence that repeated electroshock alters the functional activity of 5-H.T., dopamine, and perhaps noradrenaline, which suggests a change either in receptor sensitivity or in the function of neuronal systems modulating the through-put of monoaminergic stimuli." Monoamine oxidase inhibitors alone and in combination with tricyclic antidepressants (e.g., amitriptyline and trimipramine) and ECT often bring relief to patients with intractable depression. Sargant and Slater2 stressed the importance of this treatment in depression, but in North America many psychiatrists are still hesitant to use ECT in patients who are receiving monoamine oxidase inhibitors (e.g., phenelzine sulfate or tranylcypromine sulfate). Patients who are taking monoamine oxidase inhibitors have been treated successfully with ECT without any complications in our unit for the past several years. Eastwood and Stiasny have stated that "ECT M.R. EAsrwooD, MD, FRCP[C] has stood the test of time during the S. STIASNY, B sc, MBA Clarke Institute of Psychiatry past 40 years ... and is one of the Toronto, Ont. best treatments in medicine if given appropriately." In addition, physi-
References 1. GREENBLATT M: Efficacy of ECT in affective and schizophrenic illness. Am J Psychiatry 134: 1001, 1977 2. KILOH LG: The use of electroconvulsive treatment in depressive illness, in Handbook of Studies on Depression, BURROWS GD (ed), Amsterdam, Excerpta Medica, 1977, pp 229-52 3. CRONHOLM B, OrrossoN J-O: Experimental studies of the therapeutic action of electroconvulsive therapy in endogenous depression. The role of the electrical stimulation and of the seizure studied by variation of stimulus intensity and modification by lidocaine of seizure discharge. Acta Psychiatr Scand 35 (suppi 145): 69, 1960 4. MAYER-GROSS W, SLATER E, ROTH M
(eds): Clinical Psychiatry, 3rd ed, London, Bailli.re, 1969, p 222
cians should not withhold the application of ECT from a patient who is
otherwise fit for anesthesia, has refractory depression, and is taking monoamine oxidase inhibitors or tricyclic antidepressants. INDRAJIT RAY, MD, DPM, MRC PsYcH, FRCP[C]
Psychiatric department Union Hospital Moose Jaw, Sask.
References 1. GRAHAME-SMITH
DG,
GREEN AR,
CosTAIN DW: Mechanism of the antidepressant action of electroconvulsive
therapy. Lancet 1: 254, 1978 2. SARGANT W, SLATER E: Introduction
to Physical Methods of Treatment in Psychiatry, 4th ed, Baltimore, Wilhams & Wilkins, 1963
CMA JOURNAL/JUNE 10, 1978/VOL. 118
1361
