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SUGAR IN THE CHILD’S DIET.

THE LANCET.

eLONDON : SATURDAY, DECEMBER 21, 1929.

IN Victorian nurseries sugar in tea and on porridgewas strictly rationed, and jam as an alternative tobutter was discouraged except on the last slice.

Moreover, the child whose unsatisfied craving foi

sugar led him to spend pocket money on sweets wascondemned as greedy. Nursery traditions die hard;and probably the most common adjustment neededin the menus of children of the upper classes, other-wise well cared for, is a considerable increase of sugar.These children are encouraged to drink top milk andto eat plenty of cream ; butter is offered to them

freely, and a considerable amount of fat is usedin cooking their meals. But their carbohydrateration is limited. The children of the poor, on theother hand, are fed for the most part upon a diet con-taining an excess of sugar, since a calorie of fat costsmore than a calorie of sugar. Bread, biscuits,potatoes, and sugar make up too great a part of thewhole. These distinctions in dietetic habits oughtto be remembered by doctors who, as students, aretrained on the children of the poor. In hospitalsand welfare centres they see nearly all children

improve when extra milk is added to the diet, andthey are apt to forget that the regime of the privatenursery differs widely from that of the hospital class.Incidentally in most of the pamphlets issued in thepropaganda of public health authorities the needs ofthe poorer classes alone receive attention.

A certain proportion of children, mainly among theupper classes, are energetic, restless, and prone toexhaustion ; they suffer at intervals from attackscharacterised by pallor, prostration, increased irrita-bility or nervousness with pyrexia or with vomitingAt such times a relative intolerance for fat, a com-parative failure to complete the metabolism of fatin the available sugar is, in part at least, the explana-tion of the recurring waves of disturbed health ; andfor the time being a larger intake of sugar and areduction in the intake of fat may be necessary. Allforms of sugar and of starch are serviceable in thetreatment of this condition, but glucose in solutionis becoming first favourite. A more obvious devicewould be to prescribe additional quantities of theordinary cane-sugar in household use, but in certainchildren cane-sugar is apt to cause excessive fermen-tation accompanied by diarrhoea or urticaria.

Theoretically there should be no great differencebetween the food values of cane- and beet-sugar,although there is a lingering suspicion among dietitiansthat the former is in some way more useful, ounce forounce, as a foodstuff for children. The sweeter taste- of cane-sugar is not easy to explain, unless it contains

some free glucose. It has been stated that cane-sugar,even when pure, contains appreciable quantities of

monosaccharides, while beet-sugar certainly doesnot contain them. The contention that either ofthe disaccharide sugars in the form of highly refinedcrystals could contain any accessory food factor ofimportance lacks plausibility. However this may beit is clear that in the young infant the tolerance ofthe different forms of carbohydrate remains distinct.Thus, if more than 10 per cent. of maltose is givendiarrhoea may result, but a further addition of dextrinand possibly of a third carbohydrate, for example,starch, may be made without causing disturbance.Much more carbohydrate can be taken if it is given asa combination of different forms. For children whosuffer from the recurrent attacks mentioned above adiet with a relatively high content of starch and cane-sugar and a relatively low content of fat-in short, ananti-ketogenic diet-is recommended by suchauthorities as Dr. H. C. CAMERON, with the addition ofglucose. By combining different forms of carbo-

hydrate it is possible to keep within the limits oftolerance, though the total carbohydrate intake is

very high. Glucose appears far less liable than cane-sugar to cause fermentation. In infantile diarrhoeait seems to be the only sugar which does not aggravatethe excessive fermentation or interfere with appetitewhen it is taken between meals. Moreover, it is muchless sweet than cane-sugar, and can therefore be givenin greater concentration in fruit juice without makingthe mixture unpalatable. This is especially important,inasmuch as some of the nervous children who aremost in need of sugar have a dislike of sweet things.

RELIEF OF BLINDNESS IN INDIA

WE have received from the All-India Blind ReliefAssociation a printed copy of a letter addressed to theViceroy, suggesting that a suitable use of the Thanks-giving Fund raised in India to commemorate theKING’S recovery would be the inauguration of a soundscheme of ophthalmic relief for the whole of India.The President of the Association is Mr. C. G.HENDERSON (late I.C.S.), there are three Europeansand three Indians on the committee, and its head-quarters are in Bombay. The primary aim of theAssociation is to make known the fact that there isgreat need for more ophthalmic work than is beingdone at present; a secondary aim is actually to dosome of this work. Figures are given showing what hasbeen done by the agents of the Association in certaindistricts during the last seven years. In one district,for instance, 1866 operations were performed in 1927,and in the following year 29,000 cases were medicallytreated. The aggregate of cases treated in otherdistricts runs into many thousands, the workers

being paid from funds raised by the Association, andenjoying the help of a few doctors lent by the localgovernment. The breadth of view taken by theAssociation is seen in the letter which says clearlythat its sole object is the extension of work dealingwith eye disease and that it is willing to place itsexperience at the disposal of a State system, shouldone be established, even though it had itself no partin it. It suggests, however, that there may be acertain elasticity and enterprise in a non-officialagency that cannot exist in a purely governmentalagency.

There is evidence in the letter that the work hasthe approval in certain districts of the Surgeon-General with the Government of Bombay. He says,"

one aspect which has perhaps not been adequately

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realised is that it galvanises existing hospital dis-pensary work in eye diseases." India has a populationof 320 millions, and eye disease is only one of themany,important medical problems which confrontthe authorities. It is obvious that only a governmentagency, or one working closely with the government,could deal with the problem as a whole, and that allexisting medical agencies might have their place inany comprehensive scheme. The question thatarises is what is the standard of their treatment ’!Is it not capable of improvement It must beadmitted that the teaching in ophthalmology duringthe ordinary medical curriculum in India, as in othercountries, has in the past been decidedly scanty, andthe efforts now being made to remedy the deficiencycannot affect men who have already qualified. Thosewho work in outlying dispensaries are apt to fall intoa routine application of favourite remedies, not

necessarily the most efficient. In the ordinarypost-graduate classes as a rule not much attentionis given to eye work ; if an examination for promo-tion to a higher grade follows the course, as used tobe the case in India, matters of detail, so essential tosuccessful treatment, tend to take a secondary place.A well-thought-out short " refresher " course in thetreatment of trachoma, of a week’s duration, givenby an expert at a big hospital in a suitable centre,would do much good.

Such was the practice in Vienna before the war.The course here included lectures and demonstra-.tions of suitable cases, and daily attendance in thetrachoma clinic, where the usual operations on thelids were taught to practitioners working in trachomadistricts, who went back to their work keen to carryout what they had learnt. There is an inevitabletendency in districts where trachoma is common toget bored with the treatment and to devote moretime and energy to (say) operations on cataract,which give more dramatic results. It should not beforgotten, however, that inefficient treatment, or

the failure to do a lid operation at the proper time,may result in a trachoma patient losing the whole orpart of his sight and being a burden to himself andthe community for perhaps 50 years ; whereas theexpectation of life of a senile cataract case is only afraction of that period. If it were possible to sendout a keen man, well trained in ophthalmology, whowould camp for a short period near each outlyingdispensary, who would see the patients with thesub-assistant surgeon in charge, offering him sugges-tions and advice, and generally helping him with thetreatment of his eye cases, it would tend to raise thestandard of his treatment. And this could be donewithout casting any slur on the present workers inIndia. The teaching in ophthalmology in Austriabefore the war was as good as, if not better than, anyin Europe, yet they found it useful to adopt a systemof " refresher " classes.

THE HARBEN LECTURES AND VITAMIN B.By some curious twist of taste or habit, very few

people generally go to the Royal Institute of PublicHealth in Russell-square to listen to the annualHarben Lectures. It is a pity that this should be so,for learned and distinguished lecturers commonlyhave personality as well as something to say andthey will say it all the better under the stimulus ofa good audience. We hope at any rate that plentyof people who did not hear the series lately given Iby Prof. R. A. PETERS of Oxford on the " Coordinative leBiochemistry of the Cell and Tissues " will read his

discourses which are in course of publication in theJournal of State Medicine they tell us a good dealand, which is better, suggest much more. Prof. PETERSbegins by pointing out that descriptive biochemistryhas developed into dynamical biochemistry. Atfirst it was necessary to isolate and identify the variouschemical substances in live animals and plants andthere is still evidently much to be done in that line.But just as biological theory has arisen on thedescriptive foundation of the early naturalists, andzoologists now want to know how animals live as well aswhat animals there are, so biochemists are becomingmore and more concerned with how live matterworks on the basis of the substances which have beenidentified.

Life consists of a continued and orderly streamof reactions ; there is nothing chaotic about it andProf. PETERS addresses himself to the imaginationof some structural system on which this fundamentalcharacteristic might depend. It is obviously not

enough to appeal, as many have done, to the colloidalcondition of the substance of cells ; a colloid mushmight reach any limits of incoordinate behaviour.He points out that some units of living matter areso small that the ordinary statistical physico-chemicallaws can hardly apply. An organism which isjust visible (0’25 jjt.) occupies about the samevolume as 555 million molecules of water and byour ordinary conceptions will contain only one

hydrogen ion at pH 7-0 ; filter passers, with perhapsone-hundredth the bulk, will be still more remotefrom the common circumstances of chemical reactions.The perceptible histological structure of a cell fails

altogether to provide a framework on which the duesequence of its activities might be arranged.Prof. PETERS suggests that it is now legitimate toimagine a molecular framework. It is known thatmolecules at surfaces are orientated in a regularfashion ; the molecules of palmitic acid, for instance,spread in the thinnest possible film on water, arelike sausages tightly packed together with themethyl group always towards the air. The interiorof a cell may have an elaborate molecular structuremade up on this kind of plan and ultimately basedon the surfaces of the proteid constituents whichform a sort of central mosaic from which chains ofother molecules radiate in an orderly way. Theactivities of this structure are controlled in the mainby changes of reaction and consequent changes inabsorption, and in this way, the lecturer urged, it

was possible to picture the dynamic chains of chemicalreactions taking place, controlled inside the cellnot by the ordinary laws of mass action but by" the exigencies of the matrix ; " he did not, however,explain whether by this he meant the needs of theproteid basis in a teleological sense or the inevitableresults of its constitution. Such disciplined specula-tion needs no defence, and from it Prof. PETERSturned to the hard experimental facts about vitamin Bto which he and his collaborators at Oxford havedevoted so much attention. The simple fact thatthere was something in rice polishings and yeastwhich prevented and cured beri-beri has developedinto a complicated and tangled tale. Prof. EijK-MANN’S original discovery in applied bacteriology hasindeed been so fruitful in opening up new fields ofknowledge that the award of a Nobel Prize to himthe other day seems particularly appropriate.We now have B1, which cures polyneuritis in

pigeons, and B2, which cures a dermatitis in rats,which seems to be the same thing as pellagra in man ;on these and their certain distinctness GOLDBERGER,CHICK and RoscoE and other observers are agreed.