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was found for a larg e number of men on a newmental defective institution, the aliment which theywould otherwise have received as outdoor relief beingcontributed to the District Board of Control whichwas erecting the building. Men unemployable in thepresent state of the labour market, either throughmental or physical defect or through depravedhabits, represent an even more serious difficulty. Itis customary to offer only indoor relief to these cases,but their presence in the institution is a source ofdiscomfort to the other inmates, and certainly doesnot simplify administration. It has been suggestedthat labour colonies are required for the reform ortraining of such persons.Unemployment in Scotland remains high and has

increased since 1928 ; during 1929 the averagenumber of unemployed represented 12-3 per cent. ofthe insured population. In 1927 and 1928 the

corresponding figures were 10-1 and 11-6 per cent.

respectively, and there has been a real as well as arelative increase in the numbers. In the coal-miningindustry there was improvement as compared with1928, but in shipbuilding unemployment remainedhigh; in marine engineering unemployment wasbelow the general average. Certain industrial areasshow marked improvement, Clydebank, Greenock,and Port Glasgow being among them. Vagrancy hasincreased of late years owing to movement aboutthe country of men in search of work. Applicationsfor relief are made to inspectors more especially alongthe main roads, so that the burden on parish ratesis unequally distributed. Often there is no poor-lawinstitution for 30 miles or more, and construction ofshelter houses may become necessary. Unfortunatelya taste for tramping appears to grow on those whopursue it indefinitely ; many able-bodied youngmen appear to prefer the life of a tramp, picking upoccasional odd jobs, to the monotony of steadyemployment. GEORGE BORROW and W. H. DAVIESin their defences of vagrancy might have spared moresympathy for the mournful lot of the ratepayer, who,besides drudging through the daily round, mustmaintain the road which the tramp wears out, andif necessary must subsidise the tramp as well. Not

uncommonly, in a Scottish parish where an arrange-ment is made by the council with a householder forsheltering and feeding vagrants, the tramp will askfor another egg and offer to pay for it himself. Oneof the tasks of the new authorities will be the pro-vision of better institutional accommodation. Atpresent it is not uncommon in Scotland to find

acutely sick persons, chronic invalids, senile poor,young children, able-bodied poor, vagrants, mentaldefectives, and lunatics all in the same institution ;the disadvantages of such a system, especially foryoung children, cannot be too strongly emphasised.The imminence of local government reform hasdeterred parish councils from undertaking extensivebuilding during the past few years, but the newregime will call for the provision of more satisfactoryaccommodation.

CALCIUM AND PHOSPHORUS.KNOWLEDGE of the part played by calcium and

phosphorus in the metabolism of the human body hasgreatly increased during the last ten years and thepractical value of this knowledge is beginning to berecognised. But most medical men still have but adim appreciation of what has been ascertained, whilea few have been able to grasp its value in one directionor another. Where new territories are being exploredand defined, it is difficult for those who are not

engaged in the work, difficult even for those engagedin it, to see its significance and to estimate its value tomankind. Our readers, therefore, will welcome thefull and careful review in Dr. DONALD HUNTER’SGoulstonian lectures, of which the third and lastappears in THE LANCET this week, and especially theindications he has given of the practical value toclinical medicine of the recently acquired knowledge.On the metabolic processes that concern calcium andphosphorus depend the efficient formation of the bonystructures of the skeleton, and that balance of the ionsin the body which controls the acid-base reaction oftissues and fluids, the mechanism of the heart-beat,the contractility of plain and striped muscle, theactivity of neuromuscular junctions and synapses, andthe irritability of muscle and nerve. That the meta-bolic processes that concern calcium and phosphorusshould be correctly performed depends on the ingestionof these elements in sufficient quantities, on theirabsorption by the digestive processes, on their storagein the skeleton so that they may be readily availablewhen required, and on their presence in the tissues andbody fluids in the necessary concentrations and in thenecessary physical forms so that they may be availablefor the biological needs of the tissues and organs.These manifold requirements and functions depend,also, on the integrity of a mechanism in whichan accessory food factor, vitamin D, the internalsecretion of the parathyroid glands, and an enzymecalled phosphatase, play their parts. Phosphorusfunctions in the storage and utilisation of carbo-hydrates, and since calcium is stored in the bones ascalcium phosphate and phosphorus must be set freewith calcium when the stores of the latter are drawnupon, phosphorus metabolism is as important as thatof calcium, and the one cannot well be considered apartfrom the other. It is a long chain of cause and effect.Studies of this nature, whether in human beings or inexperimental animals, are necessarily complicated anddifficult. Much information is obtained by ascer-

taining the amount of calcium and of phosphorus in theblood, but in view of the enormous capacity of theskeleton for storage such estimations are indicativemerely of the quantity of these elements available forthe tissues generally ; estimations of their intake andoutput over a considerable number of days are neededbefore the loss or gain to the body as a whole can bededuced. Part only of the calcium in the blood isdiffusible and able to pass into the tissues and tissuefluids, and of this diffusible calcium a part only isionised and available immediately for biologicalprocesses. The methods for the estimation of thesedifferent fractions are not yet satisfactory, and theestimation of the total calcium of the serum, which isthe method of study in general use, does not neces-sarily give the facts that are required. Improvedmethods of blood analysis may be expected to lead toimportant further advances. Dr. HUNTER showsclearly that histological study of the bones is requiredin addition to biochemical study before the disturb-ances of calcium and phosphorus metabolism thatoccur in disease can be accurately gauged. He hashad the help of Prof. H. M. TURNBULL in theminute examination of bony structures, and theirresults are good evidence of the productivenessof such cooperation.

Of the applications to clinical medicine none is sodramatic as the recognition of the effect of hyper-activity of the parathyroid glands on the skeleton.The isolation from the parathyroid glands by J. B.COLLIP of a substance that produces on injection a riseof calcium in the serum with increased excretion bythe kidney, and the recognition by HUNTER and AUB

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that injections of this parathyroid extract cause a lossof calcium from the bones, are important steps in

deciding that in certain cases of generalised osteitisfibrosa the diminished density of the bones, the highcalcium content of the serum, and the increasedcalcium excretion point with certainty to a lesion ofthe parathyroid glands. A number of cases havebeen recorded in which an incision in the neck hasrevealed a parathyroid tumour, after removal of whichthe patient at once improved, the calcium content ofthe serum fell, and the bones became more dense. In

exophthalmic goitre the density of bone is diminishedand the excretion of calcium greatly increased, but inthese cases the level of calcium in the blood does notrise-why we do not yet know. Prof. TURNBULL’Sobservations on the histology of the long bones makeit clear that both in exophthalmic goitre and in

hyperactivity of the parathyroid the diminisheddensity of the bone is due to lacunar resorption byosteoclasts and is quite distinct from the diminisheddensity seen in rickets and osteomalacia in which lesscalcium is laid down in the osteoid tissue. In strikingcontrast to the condition of hyper-parathyroidism isthat seen when the parathyroid glands have beenpartially removed or damaged during. the operation ofthyroidectomy. Tetany may then result, associatedwith low calcium and high phosphorus contents of theblood, and can be relieved by the injection of Collip’sparathyroid extract. Tetany may also occur in osteo-malacia and some cases of rickets, where the calciumcontent of the serum is low; but in these conditionsit is not advisable to inject parathyroid extract, forthis would cause withdrawal of calcium from thebones, which are already poor in calcium salts. Insteadthe underlying disturbance must be treated, when thecalcium content of the serum will rise and the

tetany will be relieved. In rickets and osteomalaciathe changes in the minute structure of the bones havelong been known to be similar, but it is only recentlythat many workers in many lands have contributedto show that in both the changes are due to the samecause-namely, a deficiency of vitamin D-and that theingestion of irradiated ergosterol or exposure to

sunlight can cure both conditions. In both the

phosphorus content of the plasma is low ; in osteo-malacia the calcium content of the serum is also lowand tetany is common ; but in rickets the calciumcontent may be normal and tetany is not common,being only seen in those cases in which the calciumcontent also is low. In renal rickets the phosphoruscontent of the plasma is raised and the calciumcontent lowered, probably as a secondary result of thehigh phosphorus content, and tetany is frequent.

Estimations of the calcium and phosphorus contentof the blood have, therefore, considerable value indiagnosis, and Dr. HUNTER has included in his third Ilecture a valuable table showing the results of hisestimations in typical cases. He discusses otherdiseases of bone, and indicates how estimations of thephosphatase content of the plasma may lead to

important advances. Little is known of the setiologyof osteitis deformans, but H. D. KAY has shown thatphosphatase is always in excess in the plasma inthis disease. AUB, HUNTER, and others have shown thatlead, mercury, arsenic, silver, and radium follow calciumvery closely in their behaviour, both as to storage inthe bones and elimination. This experience hasalready been applied in the treatment of lead poisoningand should help us to understand the mechanism ofmetallic poisoning in general and how to deal with it.Stiff-sickness of cattle is associated with abnormaldevelopment of the skeleton, and the investigations ofTHEILER have shown it to be an osteomalacia of the

low-phosphorus type, curable by the addition of

phosphates to the diet ; similarly, milk-fever of cowsis associated with a low calcium content of the serumand can be successfully treated by calcium injections.Accuracy of knowledge leads surely to success in

treatment, and Dr. HUNTER’S comments on the

disappointing results of the administration of calciumin disease deserve the attention of clinicians. Thestores of calcium in the body are large and it is usually,he says, the regulating mechanism that is at fault, notthe supply. From this it follows that the use ofcod-liver oil, ultra-violet light, irradiated ergosterol,parathyroid and thyroid extract may have greatervalue than the administration of calcium. These arebut examples of the way in which our increasingknowledge of calcium and phosphorus metabolismmay be applied in human and veterinary medicine,curative and preventive. They illustrate well theprogress which is made when the clinician invokesthe aid of biochemistry and of pathology and appliestheir methods to the solution of his problems.

Annotations." Ne quid nimis."

WELFARE OF THE BLIND.

THE eighth report of the Advisory Committee onthe Welfare of the Blind 1 follows on the lines of itspredecessors. According to the latest returns thereare 20,149 registered blind persons between the agesof 50 and 70 in England and Wales, and 86 per cent.of these are in receipt of pensions provided for inthe Blind Persons Act of 1920 at a cost of 437,900per annum. The committee thinks the reduction ofthe age limit from 50 to 40 would be fully justified,but they do not consider how this suggestion, ifcarried out, would affect those of the blind who havebeen trained for remunerative employment at anearlier age. Schemes for promoting the welfare ofthe blind have now been adopted and put into opera-tion by all the 146 local authorities concerned underthe Act of 1920, at a cost of je326,799 (1928-29),about one-third of this sum being allocated to assist-ance to unemployable blind on whom between twoand three times as much was spent as was the casetwo years before. Most of this money has beendistributed through voluntary agencies, who havealso received direct grants from the Ministry ofHealth to the extent of 120,000 (1928-29). Withregard to the future, the Local Government Act of1929 changes the system of Government grants, butthe committee sees no reason to fear that the amountavailable for assistance to the blind will be less thanheretofore. Indeed, it is hoped that the Act, as finallypassed, will considerably strengthen the position ofvoluntary agencies.The total number of the registered blind in England

and Wales in 1929 was 52,727. Infantile blindnessaccounts for only a small proportion of this total.The number of registered blind under the age of 5was 258, or 0-5 per cent. of the total of all ages. Wesuggest that this figure is wholly unreliable as repre-senting the actual proportion of infantile blindness,and that the vast majority of blind infants are notregistered as blind until they become inmates of ablind school after the age of 5. The main causes ofinfantile blindness are ophthalmia neonatorum,congenital syphilis, and various congenital conditions,including congenital cataract. In an examination of250 pupils and workers at the Swiss Cottage BlindSchool in 1927 it was found that out of 180 who hada degree of blindness coming under the definition

: accepted by the Ministry of Health, as many as 1021 H.M. Stationery Office. 1930. Pp. 34. 6d.