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Malnutrition is a major problem on a global basis and will continue if current world population trends persist. Small intestinal bacterial colonization may contribute to malnutrition in populations whose dietary intake is marginal, such as those in developing countries and many elderly in the developed world. This review focuses on the evidence for small intestinal bacterial colonization in these subjects and briefly revises current thinking on the pathogenesis and diagnosis of this condition.

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.

Murine studies have demonstrated that the presence of indigenous gut flora is crucial for the induction of systemic immune hyporesponsiveness to antigens initially encountered within the gastrointestinal lumen. This study investigated whether increased titers of such flora, as occur in human small intestinal bacterial overgrowth, may be associated with increased suppression of systemic immune responsiveness and the possible relation between systemic and mucosal immunity in this setting. Serum total immunoglobulin (Ig), immunoglobulin subclass, and soluble interleukin-2 receptor levels and lamina propria IgA plasma cell counts were determined in 50 consecutive subjects with (N = 30) and without (N = 20) small intestinal bacterial overgrowth. Luminal IgA levels were measured in 35 of these subjects. Serum concentrations of IgG3, but not of other immunoglobulin isotypes or soluble interleukin-2 receptors, were significantly reduced in subjects with bacterial overgrowth (P0.0005). Small intestinal lamina propria IgA plasma cell counts (P0.0005) and luminal IgA concentrations (P = 0.001) were significantly increased in this group. Serum IgG3 levels were significantly inversely correlated with luminal IgA levels (P0.01) and fell below the lower limit of normal (0.41 g/liter) in 17/30 (56.7%) subjects with bacterial overgrowth compared to 1/20 (5.0%) subjects without (P0.0005). These findings document an association between small intestinal bacterial overgrowth with indigenous gut flora and reduced serum IgG3 reactivity in humans, possibly via an interaction with mucosa-related immunoregulatory mechanisms. The possibility of underlying small intestinal bacterial overgrowth should be considered in patients with serum IgG3 deficiency, especially those with compatible symptoms and/or known predisposition.

Our aim was to determine the relationships between interleukin-6 and immunoglobulin levels within small intestinal luminal secretions. Twenty adult subjects with small intestinal bacterial overgrowth (N = 13), irritable bowel syndrome (N = 4), and nonulcer dyspepsia (N = 3) underwent endoscopic aspiration of secretions from the small intestinal mucosal surface for assessment of IL-6, IgA1, IgA2, IgM, IgG1, IgG2, IgG3, and IgG4 concentrations. Serum immunoglobulin concentrations and small intestinal histology were also determined. IgA2 and IgG3 were the predominant IgA and IgG subclasses in luminal secretions in 19/20 (95%) and 20/20 (100%) subjects, respectively. IgA1 and IgG1 predominated in serum in all subjects. No subject had villous atrophy. Luminal IL-6 concentrations correlated significantly with luminal IgA2, IgM, and IgG3 concentrations but not with IgA1 or any other IgG subclass levels. Conversely, luminal IL-6 or immunoglobulin concentrations did not correlate significantly with levels of any immunoglobulin isotype in serum. These observations suggest that important relationships exist between local IL-6 and IgA2, IgM, and IgG3 responses in human small intestinal luminal secretions. Local investigation is mandatory when assessing intestinal immune activity.

Elevated antigliadin antibody levels in small intestinal luminal secretions of subjects with normal or only mildly abnormal small intestinal histology are considered indicative of "latent" or "potential" celiac disease. The purpose of this study was to determine whether small intestinal bacterial overgrowth (SIBO) might provide an alternative explanation for positive luminal antigliadin antibodies in such subjects.Twenty-six adult subjects without predisposition to disturbed mucosal immunity were investigated with culture of small intestinal luminal secretions. Luminal total IgA and IgA-antigliadin antibody concentrations were measured by radial immunodiffusion and indirect enzyme immunoassay, respectively. Local mucosal counts of IgA-plasma cells were determined by immunohistochemistry. Small intestinal histology and intraepithelial lymphocyte counts were assessed by light microscopy. Corresponding serum antigliadin antibody concentrations were determined.SIBO was present in 17/26 (65.4%) subjects. No subject with SIBO had villous atrophy. Luminal total IgA concentrations (p0.0005), mucosal IgA-plasma cell counts (p0.01), and intraepithelial lymphocyte counts (p0.01) were significantly increased in subjects with SIBO. Luminal IgA-antigliadin antibodies were detected in 6/17 (35.3%) subjects with SIBO and 0/9 (0%) subjects without SIBO. Luminal IgA-antigliadin antibody concentrations correlated significantly with luminal total IgA levels (p0.01) but not with serum values (p0.1). Serum IgG-antigliadin antibody concentrations were elevated in 2/6 (33.3%) subjects with SIBO and positive luminal antigliadin antibodies.SIBO may be an alternative explanation to "latent" or "potential" celiac disease for positive luminal antigliadin antibodies in subjects with either normal or only mildly abnormal small intestinal histology, even when serum antigliadin antibody concentrations are elevated. Positive luminal antigliadin antibodies in SIBO probably occur as epiphenomena in the context of a graded mucosal immune response to local bacterial antigens.

It is unknown whether bacteriolysis due to luminal complement activation contributes to local defense mechanisms against small intestinal bacterial overgrowth, particularly with gram-negative bacteria. This study addressed this issue. Thirty adult subjects were investigated with culture of luminal secretions adherent to proximal small intestinal mucosa. Luminal and plasma concentrations of C3 and C3d and C3d/C3 ratios were determined. Activated terminal complement complex was sought in surface epithelium to which aspirated secretions had been adherent. Small intestinal bacterial overgrowth with gram-negative bacteria was present in 12/30 (40.0%) subjects. C3, C3d, and C3d/C3 profile indicated that increased local but not systemic C3 activation occurs in this group. Conversely, no activation of terminal complement complex was evident in this circumstance. Thus, complement-mediated bacteriolysis is unlike to contribute to local defense mechanisms against small intestinal bacterial overgrowth, even when overgrowth flora includes gram-negative bacteria. Factors preventing full local activation of the complement cascade in this circumstance require investigation.

1) To determine the prevalence of small intestinal overgrowth with colonic-type bacteria in symptomatic elderly subjects, particularly those without important "clues" such as clinically apparent predisposition or vitamin B12 deficiency, and 2) to investigate defense mechanisms such as gastric acidity, small intestinal motility, and luminal IgA in this setting.Fifty-two symptomatic subjects without vitamin B12 deficiency or clinically apparent predisposition to bacterial overgrowth or disturbed mucosal immunity, including 22 subjectsor = 75 yr old, underwent culture of small intestinal luminal secretions. Indicator paper was used to measure fasting gastric pH. The presence of bacteria of confirmed nonsalivary origin in small intestinal secretions served as an index of small intestinal dysmotility. Small intestinal luminal IgA concentrations were measured by radial immunodiffusion.Small intestinal overgrowth with colonic-type flora was not present in any subject investigated for dyspepsia, irrespective of age. In subjects with chronic diarrhea, anorexia, or nausea, overgrowth with colonic-type flora (Enterobacteriaceae) was present in 0/12 (0%), 1/10 (10.0%), and 9/14 (64.3%) subjects aged50 yr, 50-74 yr, andor = 75 yr, respectively. Enterobacteriaceae were not concurrently recovered from saliva of any subjector = 75 yr old with small intestinal overgrowth with these bacteria. Fasting hypochlorhydria was present in only 1/9 (11.1%) such subjects. Luminal IgA concentrations were significantly greater in subjectsor = 75 yr old with bacterial overgrowth than in culture-negative subjects (por = 0.003).Small intestinal overgrowth with colonic-type bacterial should be considered in subjectsor = 75 yr old with chronic diarrhea, anorexia, or nausea, even in the absence of clues such as clinically apparent predisposition or vitamin B12 deficiency. Small intestinal dysmotility, rather than fasting hypochlorhydria or mucosal immunosenescence, probably is responsible for the prevalence of bacterial overgrowth in this group.

Small intestinal hypomotility is an important cause of small intestinal bacterial overgrowth, yet assessment of small intestinal motility in this setting is problematic. This study was performed to investigate the validity of a bacteriological method for detecting small intestinal hypomotility.Twenty-five subjects without previous gastric surgery were studied with (i) concurrent bacteriological analyses of fasting saliva and gastric and proximal small intestinal aspirates, (ii) measurement of gastric pH, and (iii) scintigraphic assessment of small intestinal transit rates of a liquid test meal. The reproducibility of bacteriological analyses of saliva and small intestinal secretions was determined in 12 subjects.Serial bacteriological analyses of saliva and proximal small intestinal secretions yielded reproducible results over time periods of up to 1 month. Eleven subjects were deemed to harbor Enterobacteriaceae of nonsalivary origin in proximal small intestinal secretions. Orocaecal transit, but not gastric emptying, of a liquid test meal was significantly delayed in this group (p = 0.002 and p = 0.84, respectively), suggesting the presence of small intestinal hypomotility. Impaired gastric acidity unlikely confounded assessment of the origin of small intestinal Enterobacteriaceae in any instance.The presence of Enterobacteriaceae of nonsalivary origin in proximal small intestinal secretions may be taken to reflect the presence of small intestinal hypomotility. The presence of impaired gastric acidity does not confound this approach. Because small intestinal intubation and culture of aspirate are required anyway to accurately diagnose small intestinal bacterial overgrowth, the simple addition of concurrent bacteriological analysis of saliva may allow small intestinal hypomotility to be detected at the same time as the presence or absence of small intestinal bacterial overgrowth itself is established, thus streamlining the investigation of subjects for this disorder and its possible causes.

To i) document the sensitivity and specificity of a combined scintigraphic/lactulose breath hydrogen test for small intestinal bacterial overgrowth and ii) investigate the validity of currently accepted definitions of an abnormal lactulose breath hydrogen test based on "double peaks" in breath hydrogen concentrations.Twenty-eight subjects were investigated with culture of proximal small intestinal aspirate and a 10-g lactulose breath hydrogen test combined with scintigraphy. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of overgrowth flora to ferment lactulose were determined.Sensitivity (16.7%) and specificity (70.0%) of the lactulose breath hydrogen test alone for small intestinal bacterial overgrowth were poor. Combination with scintigraphy resulted in 100% specificity, because double peaks in serial breath hydrogen concentrations may occur as a result of lactulose fermentation by cecal bacteria. Sensitivity increased to 38.9% with scintigraphy, because a single rise in breath hydrogen concentrations, commencing before the test meal reaches the cecum, may occur in this disorder. Sensitivity remained suboptimal irrespective of the definition of small intestinal bacterial overgrowth used, the nature of the overgrowth flora, favorable luminal pH, the presence of concurrent gastric bacterial overgrowth, or the in vitro ability of the overgrowth flora to ferment lactulose.Definitions of an abnormal lactulose breath hydrogen test based on the occurrence of double peaks in breath hydrogen concentrations are inappropriate. Not even the addition of scintigraphy renders this test a clinically useful alternative to culture of aspirate for diagnosing small intestinal bacterial overgrowth.

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.

To document the sensitivity of the 1-g 14C-D-xylose breath test for bacterial overgrowth and to investigate luminal and nonluminal factors that may influence breath 14CO2 levels and impact on the clinical utility of this test.Thirty-five adult subjects were investigated for bacterial overgrowth by culture of gastric and small intestinal aspirates and by a 1-g 14C-D-xylose breath test. Body weight, gastroduodenal pH and the in vitro capability of overgrowth flora to ferment D-xylose were assessed. Serial breath 14CO2 levels were also recorded before and after the resolution of malabsorption in a subject with celiac disease to determine the importance of postabsorptive metabolism of this substrate.Gastric and small intestinal bacterial overgrowth were present in 19/35 (54.3%) and 21/35 (60.0%) subjects, respectively. The positivity rate of culture of aspirate exceeded that of the 1-g 14C-D-xylose breath test. Endogenous CO2 production independently influenced breath 14CO2 levels. After excluding this influence, sensitivity of the 1-g 14C-D-xylose breath test for gastric bacterial overgrowth or small intestinal bacterial overgrowth was poor, even when overgrowth with specific "marker organisms" was considered. Poor sensitivity could not be explained by unfavorable luminal pH. Overgrowth flora were proven capable of in vitro D-xylose fermentation in 81.8% of subjects. Systemic and/or colonic metabolism of 1-g 14C-D-xylose appear to be important factors influencing results of the 1-g 14C-D-xylose breath test, especially in partial gastrectomy subjects.The 1-g 14C-D-xylose breath test is not a suitable alternative to culture of aspirate for the investigation of subjects for bacterial overgrowth.

The efficacy of a string test for the detection of small bowel bacterial overgrowth (SBBO) was determined by comparison with a sterile endoscopic method for sampling small bowel secretions in 15 subjects investigated for SBBO. Clinical value was found to be limited by poor sensitivity, specificity and positive predictive value. The string test is not an adequate substitute for oro-duodenal intubation for the detection of SBBO.

In using gas-chromatographic measurement of breath methane and investigating its relationship to various carbohydrate malabsorption conditions (1,2), breath samples often have to be stored for considerable lengths of time before analysis. Foil gas envelopes, rubber-stoppered glass tubes (Vacutainer Tubes; Becton Dickinson, Rutherford, NJ 07070), and disposable plastic syringes may all be used. The advisability of using glass tubes has recently been questioned (3), after observation of contamination of sterilized, silicone-coated VacutainerTubes with methane. Plasticsyringes would appear to be the most convenient alternative when storage of large sample volumes is required. Because ofthe increase in breath-methane analysis tests used in population surveys and field studies, we examined the limits of storage of methane samples in plastic, disposable 30-mL syringes.

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.

As the incidence of liver disease in hepatitis-associated antigen (HAA) carriers has not been defined and it has been postulated that continuing liver disease is associated with incompetence of the cell-mediated immune system, a prospective study was undertaken to examine both these points.An increased incidence of HAA carriers was found in a prison population (1.3%). Eighteen of these subjects gave informed consent to further study with liver function tests, liver biopsy, and testing of cell-mediated immunity with dinitrochlorobenzene (DNCB) skin sensitization. Liver function tests were normal in 10 subjects, mildly abnormal in six (SGPT < 100 IU/litre), and abnormal in two. Serum proteins were normal in all. Liver biopsy showed that five subjects had chronic aggressive hepatitis, three of whom had normal liver function tests. Eight subjects had persistent hepatitis, three with normal liver function tests. The remainder had acute hepatitis (1), evidence of residual hepatitis (1), or non-specific changes (2). Only one subject had normal histology. Drug addicts, who comprised 56% of the group, had more severe liver disease then those who were not addicts. The hypothesis that persisting liver disease is associated with impaired cell-mediated immunity was not confirmed in that nine of the 12 subjects with persistent or chronic aggressive hepatitis had a positive response to dinitrochlorobenzene skin sensitization, thus implying normal cell-mediated immunity. The findings of this study suggest that in the presence of continuing antigenaemia liver biopsy is mandatory in order to disclose treatable liver disease.

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.

A method has been developed to record directly myoelectrical activity from the smooth muscle of the colon of intact subjects using pairs of intramuscular wires. Discrete bursts of myoelectrical activity occurred at 4–20 per min. A small interelectrode distance in this method allows contamination of colonic myoelectrical activity by the electromyogram of skeletal muscle to be excluded. This artefact has not been considered in previous recordings of ‘colonic’ activity.

The bioavailability of an iron-fortified full cream milk preparation was studied and found to be effective for supplementation of the diet with iron. It consequently could be of value in the prophylaxis against iron deficiency and serve as an additional source of dietary protein.

A Sengstaken-Blakemore tube was unable to be withdrawn 14 h after its initial insertion. Despite a number of recognized maneuvers, both gastric and esophageal balloons remained inflated leading to impaction of the tube. This uncommon complication along with other complications peculiar to the Sengstaken-Blakemore tube are described.

There are a large number of patients with chronic duodenal ulcer disease who warrant long-term maintenance therapy to diminish the risk of recurrence and thereby the risk of further complications such as gastrointestinal bleeding. The efficacy of sucralfate has been compared with both placebo and histamine (H2)-receptor antagonists and sucralfate in a dose of 1 g twice a day or 2 g taken at night. It is a safe and effective medication in preventing duodenal ulcer recurrence. However, duodenal ulcer relapse rates always exceed 20 percent and frequently approach 50 percent, whether the therapy be H2-receptor antagonists or sucralfate, and the use of dosages that are half the healing dose seems irrational. It would therefore seem reasonable to continue maintenance therapy at the healing dose, whatever medication is used. Any increased costs for drugs should be outweighed by savings in indirect costs.

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.

While there is a declining incidence of many infectious diseases, viral hepatitis persists as a major problem. In fact, there would appear to be an increasing incidence of hepatitis B paralleling the rising problem of drug addiction. The discovery of Australia antigen, now called hepatitis B surface antigen (HBsAG), represented a major breakthrough in our understanding of viral hepatitis. More recently, serological tests have become available for hepatitis A virus (HAV) which will further facilitate our understanding of acute and chronic hepatitis.

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.

A study was undertaken to adapt intestinal lactase activity in adult rats. After 5 to 8 weeks on a 30% lactose diet, a significant increase in jejunal lactase activity was observed. A similar, but smaller rise was found using a 30% glucose diet.

Publisher Summary This chapter discusses a schematic approach that a physician needs to take to make an overall assessment of the patient. The physician assesses the patient's approach to conversations and obtains some insights into the patient's educational background. Visual acuity is assessed by asking the patient to read a passage from a newspaper with one eye, the other being closed. If a visual defect is found, more formal testing can be performed using a Snellen's chart. Sensation is tested in the three major areas supplied by the sensory divisions of the fifth nerve, the forehead, cheek, and lower jaw. Minimal lesions of the seventh nerve are best detected during conversation. Lesions of the seventh cranial nerve are manifested by ipsilateral lack of wrinkling of the forehead, ptosis, and drooping of the lower face, which may not be obvious on inspection. Inspection of the trapezius is carried out with the examiner standing behind the patient and palpating the trapezius while the patient shrugs his shoulders.

THIS study is an extension of the pilot survey in Asians already reported1. The subjects studied were groups of Australian, Chinese and Indian students, and New Guinea natives.

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.