56 4 January 1969 Correspondence MEDICAL JOURNAL
Dr. Percival explained more fully what he

meant by the third reason by stating that
children were often asked to write essays on
subjects that are not suitable for young
people to write about; he therefore made the
suggestion that they should be encouraged to
write on more attractive subjects. He con-
tinued, " The writing of tales and fables with
moral reflections might perhaps be a more
useful and entertaining exercise as it would
afford a greater latitude for invention, would
better display the powers of imagination and
would produce the happy talent of relating
familiar and trivial occurrences with ease and
elegance."

Jane Austen was given this book by her
brother Edward probably when she was
between 8 and 10 years of age; that it made
a deep impression on her mind was shown
by the fact that the name Percival at once
brought back to her memory the name of the
author whose work she had read more than
20 years previously. We know that she
began to write short tales at a very early age,
certainly from the age of 12 or 13 years,
and it is possible that the words we have
quoted above may have had some influence
in stimulating her to begin writing. We
can trace her progress in her published
juvenifia.

Moreover, though Jane Austen's novels
are read for their intrinsic interest and
masterly portrayal of character, yet behind
the story there always lies an unobtrusive
lesson that is concealed by her art. Dr.
Percival's suggestion was realized on a larger
scale.-I am, etc.,

ZACHARY COPE.
REFERENCE

7ane Austen's Letters, 1955, p. 218, ed. R. W.
Chapman. Oxford University Press, London.

Bladder Distension Causing
Oedema of Legs

SIR,-I read with interest the case reported
by Mr. Haziq-ul-Yaquin (9 November, p.
369), and thought it would be of interest to
report a similar case which came to our
attention.
A 75-year-old male, a retired rigger with

chronic bronchitis of five years' duration, was
admitted on 12 October because of gross swell-
ing of both of his lower limbs from the groin
down. His cough and breathlessness were worse
than usual as it was winter time. There was
no disturbance of micturition whatsoever, neither
was there pain in the abdomen. Physical exam-
ination showed massive pitting oedema of both
lower limbs and genitalia in rather a confused
man who was looking very ill. Examination of
the chest showed widespread rhoncti and
nothing more. A few dilated veins were visible
on the lower abdominal wall, in which the blood
flow was from below upwards. As he was an
obese man palpation of any organ per abdomen
was difficult. A diagnosis of cor pulmonale was
thought of as the cause of the oedema, even in
the absence of raised jugular venous pressure and
right ventricular hypertrophy in the electro-
cardiogram. So he was treated with digitalis
and diuretics, including antibiotics for his bron-
chitis. He developed pulsus bigeminus due to
digitalis toxicity, so it had to be stopped. Since
he remained grossly oedematous, large doses of
several diuretics like frusemide, edecrin, and
spironolactone were tried in vain. During the
course of the treatment he became anuric with
a blood urea of 85 mg./100 ml. Rectal examina-

tion showed a large prostate. Retention of urine
due to prostatic obstruction was diagnosed, and
a Foley's catheter was introduced with great
difficulty as the prepuce also was oedematous.
Four lires of urine was drained and a con-
tinuous drainage was kept. The oedema slowly
disappeared in a week's time. The blood urea
came down to 46 mg./100 ml. Later a trans-
urethral prostatectomy was performed and he
was found to have benign prostatic hypertrophy.

This case illustrates that bladder distension
can cause massive oedema of lower limbs by
pressing on the inferior vena cava or pelvic
veins. Lack of response to diuretic therapy
and complete disappearance of oedema after
continuous bladder drainage proves that the
bladder distension was the cause of the
oedema. It also illustrates that the diagnosis
may be masked by the presence of other
diseases such as bronchitis which could be the
cause of oedema as a part of the picture of
cor pulmonale.-I am, etc.*

B. BALAKRISHNA.
Grove Park Hospital,
London S.E. 12.

Solvents for Ear Wax

SIR,-Your correspondent Mr. R. P.
Grimshaw (14 December, p. 704) implies that
we claim that our cerumenolytic, Waxsol Ear
Drops, is effective when used immediately
before the ears are syringed. We make no
such claim.
The directions for use given in all our

literature is that the patient should be in-
structed to use Waxsol on two consecutive
nights before attending for syringing,
although in less severe cases the interval be-
tween Waxsol and syringing can be substan-
tiafly reduced. Reports from general practi-
tioners suggest that in an average case six
hours is the optimum interval between instil-
ling Waxsol and syringing the ear.-I am,
etc.,

HAROLD GODFREY,
Marketing Manager,
Norgine Limited.

London W.C.1.

Adversity

SIR,-I read your leading article (14
December, p. 659) with much sympathy.

However, there is another aspect to this
matter which you do not mention, and that
is to query why not all doctors make pro-
vision for themselves and their dependents.
Is it because of ignorance, of the belief " it
cannot happen to me," or to the impression
that they cannot afford it ? This last possi-
bility is hardly realistic, as it is surprising
how reasonably it is possible to insure for
sickness of oneself and benefit for one's
family in the event of one's own early
death.
May I be allowed to commend to your

readers not alone the medical charities them-
selves, but also the strong need for those who
have not yet done so to make proper insur-
ance provision.
One would like to hope that in this way

the medical charities would be able to provide

a little more jam with the bread and butter
to those families which are already afflicted
with sufficient adversity without the additional
strain of financial worries.-I am, etc.,
London W.5. GEORGE MOSES.

Medical Immigration
SIR,-A great deal of misunderstanding

surrounds the question of medical immigra-
tion, especially the immigration of doctors
from underdeveloped countries. I would like
to consider the relatively few immigrant
doctors who by virtue of many years of hard
work make good in another country. They
are often asked why they do not return to
their own land, which needs them more than
the developed nations they serve. The answer
to this question lies not with the doctor but
with his original country. I am referring
particularly to the two countries that contri-
bute the largest numbers of immigrant
doctors.
An objective measure of how " anxious"

these countries are to retrieve some of their
best men, is the virtual absence of advertise-
merits for appointments in the columns of
the B.M.7. and Lancet-journals that are
read by Asian doctors the world over. It is
understandable that these countries cannot
give every doctor a senior appointment, but
surely a place should be found for the type
of person who in the face of severe but very
fair competition can become a professor or
consultant in a western country. I know of
at least three Asian professors of sprgery or
medicine in the United States who were
quite unable to find a reasonable appointment
in their own country. A fourth, who is now
in Singapore and possesses an M.D., Ph.D.,
and D.T.M. & H., was asked to reapply in
four years when they " may " have a
vacancy.

Other difficulties include being married to
a "foreign national," which is frowned on
and makes finding an appointment very diffi-
cult in one underdeveloped country. In
another, one may be " vetted for communism,"
which has, on occasions, taken up to two
years, during which time the applicant may
be out of work. Most senior appointments
are on a temporary basis for a number of
years, so that, if you are not adequately
servile and do not "fit in," you can be
removed overnight. How secure you are
depends on how influential your family or
you yourself happen to be. Making " useful
contacts " for the sake of security can occupy
so much of a professional man's time that
he has little left for work. The need for
these techniques tends to favour the ambitious
schemer. Unless these countries wake up to
the fact that the best brains they produce are
valuable and should be given every oppor-
tunity to serve that the country can afford,
they will continue to lose such people in
numbers they can ill afford.

In times when coloured immigrants, what-
ever their profession, are rarely credited with
doing anything useful? it is only fair to point
out that many Asian doctors have not only
made some contribution to the N.H.S., but
also man health services in many countries
worse off than their own.-I am, etc.,

Edinburgh. A. J. AKHTAR.

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