2
812 cadavers, since Goligher et al. have observed no clear indication of this and have further noted that the external sphincter is continuous in its upper part with the puborectalis portion of the levator ani muscle. The wheel has come full circle, for the internal sphincter is reinstated and restored to its full size ; it is a muscle to be reckoned with-and cut for fissure. The importance of the external sphincter recedes. How many decades will elapse before the textbooks of anatomy, which have at last accepted the Thompson-Milligan-Morgan thesis, catch up with these new disclosures ? ‘ And what does cause fissure-in-ano ? TREATMENT OF MALARIA DESPITE the dramatic effects of the residual insecticides in controlling malaria, this disease is still one of the commonest in the world, and there is a potential danger that sudden abnormal conditions might precipitate an epidemic in circumstances where control by insecticides would be difficult. Moreover, it is not certain that anopheles mosquitoes will remain sensitive to the insecti- cides ; indeed there is evidence from Greece that some species are showing resistance. Accordingly effective treatment is still essential in parts of the world (including vast areas of Africa) where malaria is endemic, and in countries, such as Britain, where the disease in patients from hot countries may present serious problems to doctors unfamiliar with it. After the 1914-18 war there were many cases in which malaria.was diagnosed too late for effective treatment ; and there must have been many more in which it was not diagnosed at all-with disastrous results when the infection was due to Plasmodium falci- parum. After the 1939-45 war there were again deaths ; yet the drugs were there, and treatment is comparatively simple. ’ The wars gave a strong impetus- to research for drugs to replace quinine. The development of compounds con- taining the quinoline ring has been most successful in the case of the 8-aminoquinolines, such as pamaquine and related substances Including primaquine, and the 4- aminoquinolines, such as chloroquine and amodiaquine. These 4-aminoquinolines have largely supplanted mepa- crine, in which the quinoline ring of plasmoquine was replaced by an acridine ring in an effort to reduce toxicity ; but mepacrine was the first of the new syn- thetic drugs to be used on a massive scale as a suppressive. It proved invaluable during the campaigns in malarious countries in the war of 1939-45 ; its remarkable power, when taken in small daily doses, of preventing overt attacks was proved beyond doubt by the classical work of Hamilton Fairley and his colleagues at Cairns in Australia during the war. Careful research by British teams has led to the introduction of proguanil and pyri- methamine, whose value is greatest in prevention. With one or other of these substances, or quinine (which still has a place in the treatment of severe attacks), the malaria parasites can now be attacked at most of their life stages. For this we are indebted to German, British, and American scientists, who tested enormous numbers of compounds against the malaria parasites of birds. The time has come when these massive contributions to chemotherapy can be evaluated-a task that has been successfully accomplished in a W.H.O. monograph.l This excellent monograph will be especially useful in malarious countries ; but it should also be in the library of all hospitals in temperate countries where malaria patients are likely to be treated, and in all medical schools. In this country we have tended to neglect malaria except in war-time, and perhaps only those who have seen the disease are aware of the tragedies which may result from ignorance of it. It is important that practi- tioners in Britain should bear in mind the possibility of 1. Covell, G., Coatney, G. R., Field, J. W., Singh, J. Chemotherapy of Malaria. W.H.O. Monograph Series, no. 27. H.M. Stationery Office, 1955. Pp. 121. 17s. 6d. malaria (and indeed of other tropical diseases) ; and, as has already been suggested, it would be wise to set aside on each hospital case-sheet a space in which the patient’s geographical history would be entered as a routine. The treatment of malaria is not difficult if the diagnosis has. been made promptly ; but delay in diagnosing P. falci- parum infections may result in the patient’s death. CARDIAC AND ŒSOPHAGEAL PAIN THE diagnosis of cardiac pain does not usually present difficulty. Such pain may occur in. the absence of coronary-artery disease-for example, in rheumatie valvular disease and in anoemia-or as true angina pectoris in coronary-artery disease.1 The character, distribution, and relation to exercise of angina of effort are usually so characteristic that objective evidence of ishcsemic heart-disease is not required-which is fortunate. since signs are often lacking. On the other hand angina pectoris at rest due to cardiac infarction is almost always accompanied by electrocardiographic abnormality. ’ But angina may occur at rest without cardiac infarction in , acute coronary insufficiency.2 Administration of nitro- glycerin does not help greatly in the diagnosis of angina pectoris 1 ; for it may relieve pain due to other causes. Grastro-oesophageal pain may resemble cardiac pain.3-7 Whether reflexes from the alimentary tract affect the coronary circulation is uncertain ; the exact action of the vagus and the sympathetic nerves on the heart in the intact animal is obscure. Baylis et a1.9 have studied the oesophagus as a source of pain resembling that of angina pectoris, by distending a rubber bag in the lower oesophagus in 8 healthy people and in 3 patients with coronary-artery disease. Inflation of the bag was accom- panied by cesophageal activity of the type described by Payne and Poulton 10 and by pain. The pain was similar in the healthy subjects and in the patients ; the patients. found that it differed from their angina pectoris, but they were unable clearly to define the difference. (Master et al.1-L had previously observed that pain in hiatus hernia. was only exceptionally like angina pectoris.) Baylis et al. found that cesophageal distension did not produce electrocardiographic changes which could be confuseel with those of myocardial ischsemia_; and, like Evans,3 they conclude that the electrocardiogram is the most reliable special method of distinguishing cardiac from oesophageal pain. If the resting electrocardiogram is normal an effort test, with proper precautions, may be necessary.12 13 The existence of another pathological condition capable of producing similar pain does not automatically exclude ischaemic heart-disease-hiatus hernia, for example, is diagnosed with increasing frequency.1415 On the other hand, it is obviously important to avoid a wrong diagnosis of angina pectoris. Ballistocardiography, though its value has not yet been fully proved,16-le may give some addi- tional help. Quantitative estimation of the amount of cardiac muscle destroyed after infarction may soon be 1. Parkinson, J. Lancet, 1951, ii, 695. 2. Master, A. M. Ann. intern. Med. 1944, 20, 661. 3. Evans, W. Lancet, 1952, ii, 1091. 4. Guyot, R., Blum, J. Arch. Mal. Cœur, 1949, 42, 544. 5. Jackson, D. E., Jackson, H. L. J. Lab. clin. Med. 1936, 21, 993. 6. Jones, C. M. New Engl. J. Med. 1941, 225, 963. 7. Jones, C. M., Chapman, W. P. Trans. Ass. Amer. Phycns, 1942, 57, 139. 8. Gregg, D. E. Coronary Circulation in Health and Disease. London, 1950. 9. Baylis, J. H., Kauntze, R., Trounce, J. R. Quart. J. Med. 1955, 24, 143. 10. Payne, W. W., Poulton, E. P. Ibid. 1923-24, 17, 53. 11. Master, A. M., Dack, S., Stone, J., Grishman, A. Arch. Surg., Chicago, 1949, 58, 428. 12. Master, A. M., Friedman, R., Dack, S. Amer. Heart J. 1942, 24, 777. 13. Wood, P., McGregor, M., Magidson, O., Whitaker, W. Brit. Heart J. 1950,363. 12, 14. Harrington, S. W. J. thorac. Surg. 1938, 8, 127. 15. Hodson, C. J. Proc. R. Soc. Med. 1954, 47, 534. 16. Starr, I. Amer. J. med. Sci. 1947, 214, 233. 17. Starr, I. J. Amer. med. Ass. 1954, 155, 1413. 18. Starr, I., Hildreth, E. A. Circulation, 1952, 5, 481.
