150

lateral sclerosis in the Mariana Islands of the South

Pacific 11 and in the discovery of a new disease of the
nervous system, kuru,12 affecting natives in the eastern
highlands of New Guinea.
A third example of the importance of neurological
research in the tropics is the description, during the past
decade, by CRUICKSHANK and his colleagues in the
University of the West Indies, of " Jamaican paraplegia ".13-1The investigation of this puzzling chronic
disorder in Jamaican adults illustrates the many difficulties in the way of clinical research in local communities. The syndrome has five main elements arising
in different combinations: damage to the pyramidal
tracts and posterior columns of the spinal cord; selective
lower-motor-neurone lesions, retrobulbar neuropathy,
and nerve deafness. The condition is also found in other
Caribbean islands and has some features in common
with the myelopathies discovered in Africa and the Far
East. The latest report 18 from Jamaica is based on an
analysis of 206 cases and 11 necropsies. There seem to
be two distinct groups: ataxic (25 cases) and spastic
(181 cases). The cases that came to necropsy belonged
to the spastic group. In the ataxic group there was a
high incidence of optic atrophy and eighth-nerve
deafness, with slight evidence of pyramidal-tract
damage. Patients in this group were poorly nourished.
In the larger spastic group the incidence of optic atrophy
and eighth-nerve deafness was relatively low. The
histopathological findings in the spastic cases were
those of a chronic meningomyelitis, with damage to the
long tracts as the major lesion.
In Africa and the Far East these and similar syndromes
have usually been confined to malnourished people, but
in Jamaica, in the spastic group, nutrition seemed to be
satisfactory. Toxic elements in the diet have been
considered, in view of the resemblance to lathyrism and
the widespread consumption in the Caribbean of " bush
teas ", some of which have been incriminated in another
Jamaican syndrome-veno-occlusive disease of the
liver. But no connection has been traced between any
of the native plants and these neurological disorders.
The possibility that a treponema is responsible has also
been closely examined. Random serum samples from
adult Jamaicans have shown positive treponemal reactions
in 20-40%. In the ataxic group the treponemal reactions
in the blood were negative in 64%; in the cerebrospinal
fluid they were negative in all cases, and there was no
abnormality of protein or cell content. On the other
hand, 60% of the spastic group gave positive reactions
in the blood, although in the cerebrospinal fluid they were
positive in only 6%. A moderate increase in lymphocytes and/or protein was found in 40% of cases. The
Argyll-Robertson pupil was rare, and penicillin therapy
failed to help the patient or to influence the cerebro11.
12.
13.
14.
15.
16.
17.
18.

Kurland, L. T. Proc. Mayo Clin. 1957. 32, 449.

Gajdusek, D. C., Zigas, V. New Engl. J. Med. 1957, 257, 974.
Cruickshank, E. K. W. Ind. med. J. 1956, 5, 147.
Cruickshank, E. K. Fed. Proc. 1961, 20, suppl. 7, p. 345.
Cruickshank, E. K., Montgomery, R. D. W. Ind. med. J. 1961, 10, 211.
Cruickshank, E. K., Montgomery, R. D., Spillane, J. D. World Neurol.
1961, 2, 199.
Robertson, W. B., Cruickshank, E. K., McMenemey, W. H., Montgomery, R. D. Proc. IV Int. Congr. Neuropath. 1962; vol. III, p. 434.
Montgomery, R. D., Cruickshank, E. K., Robertson, W. B.,
McMenemey, W. H. Brain, 1964, 87, 425.

spinal-fluid changes. Lastly, endarteritis obliterans, the

characteristic feature of neurosyphilis, was not observed.
Worldwide comparative studies will obviously be
necessary before the

of these obscure
and
neuropathies are unravelled.
tropical myelopathies
They provide a fine field of clinical research which should
stir the imagination of young neurologists in the developing nations, and they offer opportunities for international liaison. The World Federation of Neurology
has already established a Commission on Tropical
Neurology, and the first international symposium was
held in Buenos Aires in 1961.19
Lathyrism has been known since the time of HippoCRATES. He wrote:" at Ainos those men and women who
continually fed on pulse were attacked by a weakness in
the legs which remained permanent". There is little
doubt that he would have been equally intrigued by
cause or causes

Jamaican paraplegia.

Annotations
HEALTH OF IMMIGRANTS

OF the

12,000

300,000 people living in Bradford in 1963, about

immigrants from Asia. Of the 353 new cases

were

of tuberculosis reported during the year, 203 were in

Asians 2°; in other words, 4% of the population accounted
for nearly 60% of the cases. Edgar 21 has shown that
nearly all these immigrants came from Pakistan. In
Birmingham, Springett 22 found that tuberculosis was
twenty-seven times as common among Pakistani immigrants as among the indigenous population.
Stevenson 23 estimated that 50% of the immigrants with
tuberculosis in Bradford had contracted it since their
arrival in this country; and Aspin 24 put the figure as high
as 80% for Indians in Wolverhampton. Their resistance
may be innately low: they are subject to the stresses of an
alien environment; they live in closed communities; even
when proper housing is available, our inhospitable climate
crowds them together in search of warmth and companionship. There is no evidence that the disease is spreading to
the rest of the community, but this may be due only to the
very isolation which is the greatest source of danger to the

immigrants themselves.
Our chest clinics may be able to deal with the existing
and discovered cases, but unaided they cannot cope with a
steady influx of undetected new infection. All the authors
we have quoted said that control was impossible unless all
immigrants had a chest X-ray on or before arrival herean opinion that we 25 and others 26 have supported.
Moreover, the British Medical Association has repeatedly
asked for compulsory X-ray examination on arrival 27 28;
and Aspin 24 suggested that the examination should be

repeated annually.
The Ministry of Health has now announced the
following arrangements to deal with the problem.
20.

Proceeding of the First International Symposium of the Commission in

Tropical Neurology, World Federation of Neurology, Buenos Aires,
1961. Buenos Aires, 1963.
Douglas, J. Annual report of the medical officer of health, Bradford,

21.
22.
23.
24.
25.
26.
27.
28.

Edgar, W. Brit. med. J. 1964, ii, 1565.

Springett, V. H. Lancet, 1964, i, 1091.
Stevenson, D. K. Brit. med. J. 1962, i,
Aspin, J. ibid. p. 1386.
Lancet, 1962, i, 843.
Tubercle, 1964, 45, 279.
Brit. med. J. 1961, ii, 1624.
ibid. 1964, ii, suppl. p. 211.

19.

1963.
1382.

151
The chief medical officer has written to all general practitioners in the Health Service asking them to look out for
immigrants among their patients and to consider the need to
arrange for X-ray examinations.
Immigrants who are medically examined at ports and airports
will be given a notice printed in languages they understand,
encouraging them to get on the list of a family doctor without
delay in the district where they go to live, instead of waiting
until they may be ill. Medical inspectors at ports and airports
will seek from these immigrants their destination addresses.
These will then be sent to the medical officers of health
concerned asking them to arrange for the immigrants to be
visited, told about the Health Service, and advised to register
with a family doctor. As far as possible the addresses of those
not subject to medical examination on arrival-for example, the
wives and children of some Commonwealth immigrants-will
also be sent from the ports and airports to local medical officers
of health to give them the same information and advice.
At London Airport, where more long-stay immigrants arrive
than anywhere else, X-ray apparatus is to be installed. When
the medical inspectors suspect, for example, tuberculosis, they
will be able to have an X-ray taken on the spot. If this confirms
their suspicion, they can then send information to the local
medical officer of health. (If the X-ray reveals a dangerous case
of open tuberculosis and the immigrant has not yet been
admitted, the medical inspector may recommend to the
immigration officer to refuse entry.)

Three years ago,

referring

to

tuberculosis among
"

Pakistanis in Bradford, Stevenson 23 wrote: We ... have

used every possible method to get them to the X-ray
machine-by advertising at Pakistani film shows, and by
household canvassing, lectures, and repeated street surveys
with the mobile X-ray van in the Pakistani districts, all
without much success." We wonder, therefore, whether
cards, telling people to get themselves on a doctors list,
will really be sufficient.
The Governments view is that medical inspection of
intending immigrants before they leave home is impracticable.29 Is it also impracticable to do it when they arrive ?
It has been said that to examine Commonwealth immigrants " would result in an invidious distinction being
drawn between them and aliens who are not subjected to
any such requirements ". But why should alien immigrants
not be examined? Could not areas. where tuberculosis is
highly prevalent be so designated, as is already done with
smallpox? And why should medical examination be
regarded as something obnoxious, instead of a service to our
new guests, done in their own interests ? For it is they,
and their compatriots here, who are suffering.
The new X-ray apparatus at London Airport will not be
used as a matter of routine, but only to examine suspicious
cases. This " should enable a clearer picture to be obtained
of the extent to which immigrants may actually be coming
into the country with tuberculosis ". But if it is to be
used only when a medical inspectors suspicions are
aroused, it is unlikely to prove more than that people who
look consumptive often are.
London Airport receives 21/2 million people every year,
and it may well be impossible to identify those who intend
to stay here and examine them on the spot; and there are
many other ports of entry to be considered. Perhaps
immigrants could be required to report to the nearest
chest clinic when they reach their new home, and not
simply advised to look for a family doctor. Naturally, the
Government is anxious to do nothing that appears to
discriminate against these new arrivals. Rightly, the aim is
to treat them like anyone else, and the ultimate object must
be to see them assimilated by the community to which
29. See

Lancet, 1964, ii, 1300.

they are making a valuable contribution. But before

accepting them, the communities in which they live will
want to

be further assured that their

own

health is

not

being endangered.
ANTIVIRAL AGENTS

PESSIMISM has for long prevailed about the prospects of

effective antiviral agents, just as it did in the
twenties and early thirties about the possibility of finding
effective in-vivo antibacterial substances. But pessimism is
giving way to cautious optimism, since at least two effective
antiviral drugs are now available commercially. The work
which led to the discovery of antiviral substances has
been reviewed from the clinical standpoint by StuartHarris and Dickinson. There is great interest in this
subject, not only because of the prospects for the cure or
prevention of virus disease but also because of the light
that antiviral agents shed on the processes of viral
synthesis. And this interest was evident in the large
attendance at a meeting of the New York Academy of
Sciences on Dec. 9-11.
One of the strongest influences in the change of opinion,
about chemoprophylaxis at least, has been the work of
Dr. D. J. Bauer and his colleagues on methisazone in the
prevention of smallpox in those exposed to infection. It
was appropriate therefore that a whole session at the
meeting was devoted to the thiosemicarbazones; and
Dr. Bauer was awarded the A. Cressy Morrison prize of the
New York Academy of Sciences for his paper on clinical
experience with methisazone. He reported the extension
of his work on contacts of smallpox treated prophylactically
with methisazone to over 2000 in the treated and control
groups, with essentially the same results as before.2Thus,
there were 114 cases and 20 deaths in the controls and 6
cases and 2 deaths in the treated group.
In a small
group who had no prior vaccination there were 28 cases
and 11 deaths amongst 100 controls and only 2 cases
amongst 102 treated contacts. Methisazone has been
shown in tissue culture (in experiments described at the
meeting by G. Appleyard) to prevent the synthesis of
pox-virus proteins which appear late in the virus growth
cycle. In sufficient dosage, the drug completely prevents
the synthesis of infectious virus; thus, a relatively short
period of treatment should suffice, and Bauer suggested
that a period of two growth cycles was enough. Such a
short treatment period may well be important in view of
the severe nausea and vomiting produced by methisazone,3
which will discourage its use except under severe threat.
Indeed, the thiosemicarbazones were abandoned as
antituberculosis. drugs mainly because of their toxicity.
Of the thiosemicarbazones, methisazone is not the most
active against pox viruses. It was selected for initial study
because it was easier to make and more was known of its
toxicity. Another thiosemicarbazone (M. & B. 7714), which
Appleyard found had a mode of action similar to methisazone but was slightly less active against rabbit pox, was
tried by J. A. McFadzean in a controlled trial for the treatment of smallpox. He found that there were 42 deaths in
132 control cases and 24 in 131 patients treated with
M. & B. 7714, a difference which was not statistically significant ; but C. H. Kempe thought that a larger series
confined to early cases might well prove the value of this

finding

Stuart-Harris, C. H., Dickinson, L. The Background to Chemotherapy

of Virus Diseases. Springfield, Ill., 1964.
2. Bauer, D. J., St. Vincent, L., Kempe, C. H., Downie, A. W. Lancet,
1963, ii, 494.
3. Landsman, J. B., Grist, N. R. ibid. 1964, i, 330. Hutfield, D. C., Csonka,
G. W. ibid. p. 329.
1.