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-

Screening for breast cancer.

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...
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