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It has been commonly believed that children in developing countries pass stools that are very different from those of developed countries. A community based study on defecation frequency, stool weight, and consistency was conducted in a cohort of 300 Myanmar (Burmese) children aged 1 to 4 years. Most (80.3%) children opened their bowels daily and none passed more than three stools a day. The mean (SD) defecation frequency was 6.98 (1.94) times a week and total stool weight was 596 (221) g a week. The majority (61%) of children passed soft stools. At all ages, there was no significant difference in the defecation frequency, stool weight, and consistency between boys and girls, those on adult style diet and those partially weaned, and between age groups.

We aimed to establish whether there was a variation in orocecal transit time (OCTT) in Myanmar children and whether shortened transit time correlated with malnutrition. OCTT was measured in 90 healthy Myanmar children aged 1-5 years, using the hydrogen breath test (10g in 10% aqueous solution). The relationships between OCTT, sex, age, and malnutrition status were assessed. OCTT for 1 to 5-year old children was 90.2 +/- 20min (mean +/- SD). There was no significant difference in mean OCTT between boys and girls, breast-fed and weaned children, malnourished and non-malnourished children. There was also no difference between age groups (1-2 years, 2-3 years, 3-4 years, and 4-5 years), and no correlation was found between age and orocecal transit time. The assessment of OCTT using the lactulose breath hydrogen test was found to be feasible and acceptable in the field setting. The OCTT of Myanmar children with rice as a staple food is similar to that of children from developed countries having a different diet, and no shortening of transit time was demonstrated in children with malnutrition.

In most Western countries, colorectal cancer is an important disease in terms of morbidity and mortality. As it has a premalignant asymptomatic stage in the form of benign adenomas that might be detected by screening, and as screening leads to detection of colorectal cancer at an earlier stage, there is potential for improved and better quality survival. Most cost-effective analyses rank the various screening strategies at less than an accepted benchmark value of approximately $40,000 per added year of life. Periodic colorectal screening is therefore a cost-effective intervention and the Office of Technology Assessment of the Congress of the United States has concluded that colorectal cancer screening in average-risk adults beginning at age 50 is a relatively good investment for society. Flexible sigmoidoscopy and double contrast barium enema are the most cost-effective strategies but they both require colonoscopy if a lesion is identified. Colonoscopy at 10-yearly intervals is of comparable cost to flexible sigmoidoscopy every 5 years and less costly than FSIG every 3 years. Combination strategies, using faecal occult blood testing with periodic flexible sigmoidoscopy or double contrast barium enema are as costly as colonoscopy. The choice of screening strategies needs to be tailored to the individual, and a process of community education is an essential prerequisite to the success of any programme.

An approach to the diagnosis and treatment of patients with presumed functional disorders of the biliary tract (biliary dyskinesia) is described. The current diagnostic criteria are pain compatible with biliary pain in the absence of gallstones and other organic gastrointestinal disease, or other disorders which might produce abdominal pain, together with reproduction of the patient's symptoms by cholecystokinin, or morphine, or both. Other diagnostic methods are described together with their limitations. The results of operation in 38 of 45 patients seen in this Unit during the past six years are presented. The results were poor in 20% of patients, but two-thirds of the group have had good results in the short term.

Twenty patients with persistent diarrhoea participated in a randomised, double-blind trial of oral sodium cromoglycate and placebo. Eight patients noted significant improvement in their diarrhoea while taking sodium cromoglycate and this did not correlate with the presence of other atopic diseases, a history of food intolerance, or the presence of lactase deficiency. The results suggest that some patients with diarrhoea of unknown cause may have food allergy as a major contributing cause for their diarrhoea.

The group of conditions variously termed biliary dyskinesia, acalculous cholecystitis, biliary pain without stones, or functional disorders of the biliary tract, is poorly defined clinically, and no consistent pathological abnormalities have been previously described in patients with this diagnosis. In this paper we report histological abnormalities encountered in operative liver biopsies in such patients. The criteria for the diagnosis of a functional biliary tract disorders were: pain typical of biliary pain, negative results of investigations for organic biliary tract or other gastrointestinal disease, and reproduction of the patient's symptoms by cholecystokinin, or morphine, or both. Twenty of 45 patients with a presumptive diagnosis satisfied these criteria, and had a wedge liver biopsy at the time of operation. The 20 liver biopsy specimens were compared in a blind fashion with similar ones taken from patients having diagnostic laparotomies: patients with stones confined to the gallbladder; patients with gallstone pancreatitis; and patients with proven common bile duct stones. The biopsy findings were found to be similar to those in the latter two groups. Thus the abnormalities were similar to those found in partial or intermittent biliary obstruction, and it is suggested that they may be due to intermittent increases in biliary pressure.

Abnormalities of the haemopoietic system may produce anaemia, polycythaemia, lymphadenopathy, hepatosplenomegaly, or purpura alone or in combination. Pallor is the outstanding physical sign of anaemia and is best confirmed by inspection of the conjunctivae and palmar creases. Cardiovascular manifestations of anaemia consist of a high output state with tachycardia and perhaps cardiac failure. If the face and mucous membranes appear plethoric, polycythaemia is suggested and should be confirmed by haemoglobin estimation. A relative polycythaemia may occur in the presence of dehydration. In lymphadenopathy, examination is first carried out from behind, with the patient's neck flexed to relax the sternomastoid muscles. Lymphadenopathy may occur in relationship to the jugular vessels, submandibular and submental regions, and anterior and posterior triangles of the neck. Purpuric spots are spontaneous petechiae or ecchymoses, which represent bleeding into or under the skin. The spots do not blanch on pressure and on fading leave a bluish discolouration as with a bruise. Purpura may be thrombocytopenic or non-thrombocytopenic; it is differentiated by performing a platelet count.

The examination for disease in the gastrointestinal system commences with the inspection of the lips and oral cavity. An assessment is made of the general state of the teeth as well. The abdomen is divided into 9 areas by drawing two horizontal lines, one at the level of the lower costal margins and the other between both anterior superior iliac crests. The areas are designated as follows: (1) right hypochondrium, (2) epigastrium, (3) left hypochondrium, (4) right lumbar region, (5) umbilical region, (6) left lumbar region, (7) right iliac fossa, (8) hypogastrium, and (9) left iliac fossa. The abdomen is examined with the patient lying comfortably, hands by his sides, and head on one pillow, the bladder ideally having been emptied. To ensure that any mass felt is within the abdominal cavity and not in the abdominal wall, the patient's abdominal musculature is contracted by asking him to flex his neck against resistance by the examiner. Intra-abdominal masses become less easily palpable.

Publisher Summary This chapter discusses the ways in which respiratory disease is diagnosed. The first stage in diagnosis of respiratory disease is a combined pathological and anatomical one, such as the consolidation of the left lower lobe. The second stage in diagnosis is aetiological and usually requires special investigations, such as pneumococcal lobar pneumonia involving the left lower lobe. To carry out the first stage diagnosis, the physical signs elicited should correspond to any primary type of pathology. However, it is important to realise that all physical signs may not be present and in fact the diagnosis may be made on one physical sign alone—for example, deviation of the trachea indicating fibrosis of an upper lobe. Airways obstruction commonly occurs because of chronic, acute, or acute on chronic bronchial disease because of irritants or infection. It is the key feature of bronchial asthma. Obstruction is greater in expiration than in inspiration, and the chest becomes overinflated as in emphysema, with which airway obstruction is usually confused.

Summary The effect of iron deficiency anaemia, protein deficiency and worm infestation upon intestinal disaccharidase activity in the rat was assessed following the observation that these factors may have contributed to the premature onset of lactase deficiency in man. Adaptation of intestinal lactase occurred between eight and ten weeks of age in young rats fed a 10% lactose diet. Iron deficiency anaemia depressed jejunal and ileal lactase activity. Sucrase and maltase activities were not significantly affected by iron deficiency. Adaptation of intestinal lactase was prevented by both protein deficiency and combined iron/protein deficiency. Sucrase activity was not significantly depressed by either of these and in many instances activity was higher than the control group. Similar changes were noted with maltase. Worm infestation with Nippostrongylus brasi-liensis consistently depressed jejunal lactase and maltase activities, but had little effect on sucrase activity. It was concluded that intestinal lactase in particular was depressed by a number of environmental factors and adaptation of lactase thereby prevented.

This chapter describes how the reading of blood pressure is obtained. A systematic examination of the cardiovascular system begins with the pulse. The pulse is examined by palpating the right radial artery with the index, middle, and ring fingers. An assessment of systolic blood pressure is made by compressing the radial artery with the index finger, palpating the pulse with the middle finger, and obliterating the ulnar collateral pulse with the ring finger. The degree of pressure necessary to obliterate the radial pulse gives an estimation of the systolic pressure and that pressure is confirmed with the sphygmomanometer. The pulse pressure is the difference between the systolic and diastolic pressures. A casual reading of the blood pressure may not be a true guide to the presence or absence of meaningful hypertension as both the systolic and diastolic pressures can be elevated by emotion. The apex beat is the lowest and outermost point of cardiac pulsation and is usually found in the fifth left intercostal space internal to the mid-clavicular line. The apex beat is useful to determine the left border of the heart and is carried out by percussing along the fifth intercostal space from the axilla.

THIS investigation was prompted by the clinical observation of lactose intolerance in five Asian students who were attending a gastroenterological out-patient department for vague abdominal pain associated with intermittent diarrhoea. Lactose intolerance is now a well recognized clinical entity, being more common in asymptomatic negroes1,2 and Australian aborigines3 than in Caucasians.

This chapter discusses a general scheme for the examination of joints. A symmetrical arthritis involves small and large joints. It classically involves the proximal interphalangeal joints with sparing of the distal interphalangeal joints in the hand. A rheumatoid type of arthritis is a medical condition, which is associated with clubbing of the fingers and it occurs in carcinoma of the lung. Acute gout is typically monarticular. It classically affects the first metatarso-phalangeal joint. Chronic tophaceous gout is typically polyarticular and asymmetrical, involving any joint. It may be associated with tophi, nodules, and bursae. In osteoarthritis, large, weight bearing joints, such as the knees, hips, and ankles are typically involved. Obesity is a common problem that is associated with osteoarthritis. The characteristics of osteoarthritis are bone outgrowths, but it can occur in any proliferative arthropathy. Enlargement of bursae does not necessarily mean underlying arthropathy and commonly occurs following repeated trauma, for example, over the olecranon and knee.

The clue to the presence of endocrine disorders is often given by the appearance of the patient; those disorders may be missed as a result, unless specifically thought of at the initial interview. This chapter discusses the occurrence of common endocrine disorders. In thyrotoxicosis, the general appearance of the patient is often striking in that he is agitated, restless, speaks rapidly, is emotionally labile, pigmented, has prominent staring eyes, and has clearly lost weight. Early changes of myxoedema are subtle and easily overlooked. The facial appearance becomes characteristic with baggy eyelids and a puffy face, which may also be sallow or have a reddish tinge because of carotenaemia. The hair is dry and brittle, and the outer third of the eyebrows may be sparse. The skin of the face and hands is strikingly dry and cool. There is slowness of speech and thought associated with a husky voice.

The first meeting of the physician with the patient is important as during that session, a mutual appraisal of each other is made. The physician initially takes note of the patient's demeanour and dress as that may relate subsequently to any disorder that the patient might have. At the same time, some insight is gained into the patient's educational and social background. His general behaviour and mood may be affected by the underlying disorder or may be altered by his reaction to it. For example, the patient with thyrotoxicosis may be agitated and apprehensive; however, a similar mental state can be produced by the patient's anxiety regarding his underlying illness. Such an anxiety state need not necessarily be associated with underlying organic disease. While a serious organic disorder may not be reflected in the appearance of the patient, evidence of recent weight loss and an appearance of ill-health should alert the physician to the possibility of a serious underlying disease. During the general appraisal of the patient, a number of important physical signs may be evident.