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disease " should be confined to cases in which there isdefinite failure of glycogenolysis. Though provisionallyclassifying cases in five main groups they agree with vanCreveld in assigning all to two main divisions, accordingto whether the deposit of glycogen is chiefly in the liveror in the muscles, including the heart muscle. Theyfound that the affected liver, although it can make

glycogen from other sources, such as loevulose and

galactose, cannot make it from glucose ; and it cannotchange glycogen back into glucose. Moreover, the lackof response to adrenaline is not due to any abnormalityin the liver glycogen itself since this was readily brokendown by a mash made from normal livers. Crawford,5who has investigated 3 further cases, agrees with thishypothesis of a double fault. He refers to the recent

change in opinion regarding the origin of the ketosis,which has been reviewed by Soskin and Levine. 6 Ketonebodies are now generally held to be normal products ofthe liver which can be utilised by the tissues. Theyare found in excess with rapid fat katabolism, when,owing to their amount, the tissues are unable to oxidisethem ; this is quite independent of the rate of carbo-hydrate metabolism. Normally hypoglycæmia andketosis appear only with inadequate glycogen storage ;but in glycogen disease these are found in associationwith abundant stores of glycogen in the liver. Instead of

Glucose→glycogen→glucosewe have

_

, ketonesGlucose→fat

"- glucoseThere is still no sign of more rational treatment.

Injection of pituitary hormones has been considered,and van Creveld reports benefit from a high carbohydratediet. In his 1939 review he mentioned several childrenwho had remained well for about ten years, sometimeswith reduction in the size of the liver, after this treatment.

LET HIM EAT CAKE

THE " won’t eat " child is a recurrent headache forthe doctor, both in general practice and in consultantpaediatrics. The aetiology and treatment have come infor a good deal of discussion, which has made it clearthat there is no royal road to success. The problempresents itself in three main groups : (1) the ill childwhose anorexia is either a symptom of the generaldisturbance or the outcome of some local conditionsuch as otitis media, dental caries, or buccal ulcer;(2) the " normal " but injudiciously handled child ; and

(3) the child suffering from a serious emotional distuib-ance. Confining himself to the second group, Bakwin 7gives advice which is likely to be more useful in preventionthan as a remedy once the feeding difficulty has set in.An -important setiological factor, in his opinion, is thatdoctors recommend the introduction of solids too early." Babies are ready to handle solid food at about 3 or4 months of age. A good sign of readiness is the responseto insertion of the tongue depressor into’the mouth."If the baby accepts it, he is ready for solids. A usefultip, but-in England at least-is solid food before3 months a common dietetic fault ? Bakwin’s otherpoints are more familiar. Mother presses too much foodon the child, insists too much on what is " good for him,"and feeds him when he - ought to be feeding himself.These errors are not always accepted as such by those whomatter most. The district nurse and the health visitorstill set their faces against kippers and chips and try tokeep the young in the straight and narrow path ofsemolina. According to Bakwin, Marie Lloyd’s precept5. Crawford, T. Quart. J. Med. 1946, 39, 285.6. Soskin, S., Levine, R. Amer. J. digest. Dis. 1944, 11, 305.

Soskin, S. Physiol. Rev. 1941, 21, 140.7. Bakwin, H. J. Pediat. 1947, 31, 584.

is an important law of dietetics and cannot be appliedtoo early. The conscientious young mother, harassedby diet sheets and ration-books, should gain reassurancefrom this view of the trouble; but it does not get to theroot of the real feeding difficulty. The problem is thatmother cannot (not will not) take advice. Her anxietiesand conflicts centre on food and force her to create ananorexia in her child.. Refusal of food by a toddler orolder child commonly goes back to a difficulty in theearliest weeks of life. It is no use telling these mothersto let the child have a little of what he fancies. Thewhole relationship between mother and child is wrongand must if possible be put right. Advice such as

Bakwin’s, if it can be disseminated to the right quarters,has its usefulness, but the important thing is to distinguishbetween the cases in which it will be acceptable and thosewhere it is a waste of time to offer it.

COMPULSORY B.C.G. IMMUNISATION

LAST December the Norwegian parliament passed anew law for the compulsory tuberculin testing andimmunisation of ceitain groups of persons againsttuberculosis. This radical measure encountered hardlyany opposition, because in the past twenty years tensof thousands of people (in a nation numbering only 3million) had had direct experience of B.C.G. ; because thedoctors, tuberculosis specialists in particular, were infavour of it ; and because the Norwegian department forsocial affairs (corresponding in some respects to ourMinistry of Health) had prepared a comprehensivememorandum as a guide to the legislators. This memo-randum recalled that in March, 1946, the head of theNorwegian army medical service pointed out that abouthalf the men called to the colours were tuberculin-

negative, and that B.C.G. immunisation could not be satis-factorily achieved on a purely voluntary basis. In the

following September a committee of experts reportedthat compulsory B.C.G. immunisation was desirable(1) for all persons in a tuberculous environment, (2) for .

doctors, nurses, hospital workers, and other groups witha high tuberculosis morbidity, (3) for men liablefor military service, and (4) for youngsters at the

school-leaving age, students and others. Soon after-wards the Norwegian Tuberculosis Doctors’ Associationunanimously passed a resolution in its favour.

In a commentary on the various paragraphs of the Billnow enacted the department for social affairs says that,though in the world at large the number of personsinoculated against tuberculosis now runs into millions,no case of tuberculosis has so far been traced to B.C.G.The Oslo public-health service has found that the positivetuberculin reaction achieved with B.C.G. immunisationis nearly always present five to six years later. On thewest coast of Norway, where opposition to vaccinationagainst smallpox is common, there is no such oppositionto vaccination against tuberculosis. In several townswhere B.C.G. vaccination has been provided for those ofschool-leaving age, the percentage voluntarily acceptingthe offer has ranged from 50 to 90. It is calculated thatif no compulsion is used the immunisation of all whoneed it will take too long ; but on the other hand com-pulsory immunisation must be confined at present tothe groups requiring it most, for the people who canundertake it are not unlimited. Doctors not yet familiarwith the technique and wishing to master it are advisedto take a four-day course.

THE INDEX and title-page to Vol. II, 1947, which wascompleted with THE LANCET of Dec. 27, is now in

preparation. A copy will be sent gratis to subscriberson receipt of a postcard addressed to the Manager ofTHE LANCET, 7, Adam Street, Adelphi, W.C.2. Subascribers who have not already indicated their desireto receive indexes regularly as published should do sonow.

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