is very properly praised. Injection of the sac is now, we believe, almost entirely abandoned by the best ovariotomists. The consideration of "Peri-Uterine Fluid Tumours" is included in the section on ovarian diseases, on account of the similarity in physical aspects between these and fluid ovarian tumours. They exist as tubal dropsy, Wolffian cysts, sub-peritoneal cysts, and simple cysts of the broad ligaments, but no means of differential diagnosis are given. Generally, we believe, they are not diagnosable, though there are exceptions to this rule. "Solid Tumours of the Ovary" come next. Respecting fibrous tumours the best ovariotomists hold the opinion that they are rarely, if ever, met with in this organ. On histological grounds the possibility of their occurrence cannot, indeed, be denied, but, practically, it is the opinion of those best qualified by experience and observation to judge that they do not occur. As Dr. Farre has shown, the growths usually regarded as ovarian fibroids are really either cancerous or pediculated uterine fibroids. The different forms of adenoma, pure and cystic, are reviewed. What Dr. Thomas calls "histoid tumours, comprising dermoid, pileous, and adipose, come next, but, being only shortly discussed, need not detain us.

Composite tumours of the ovary, according to the author, comprise "all those tumours which are composed of both solid and fluid contents." We are glad to observe that Dr. Thomas avoids the common error of regarding as cancerous all ovarian tumours containing colloid material. He gives a useful and clear account of this part of the subject, such as is worthy of his deservedly high reputation. He then proceeds to describe the operation of ovariotomy. He asserts that "the first real case of ovariotomy ever undertaken was successfully performed by Dr. Ephraim McDowell, of Kentucky," and adduces evidence in support of this position. It is singular to see with what persistence the operation was opposed by some of the leading minds in Germany, even when their American, French, and English brethren were achieving brilliant successes. According to Grenser, however, Germany claims the credit of two very important improvements in the operation, viz. the external treatment of the pedicle, and the adoption of the short incision and tapping the sac in situ. Happily, as Dr. Thomas truly says:

"The time has passed away when, in an essay on this subject, the question need be discussed as to the propriety of recognising ovariotomy as a legitimate resource in surgery.'

Vaginal ovariotomy, Dr. Thomas thinks, is applicable to only a few cases, abdominal section being far more commonly called for. To most of the directions for "preparation for the operation" no exception can be taken, but we doubt the propriety of

administering "one grain of opium, or the equivalent of its preparations, every six hours," for four days before the operation, as a routine practice.

Concurring in many of the author's directions for operating, we must differ from him as to the advisability of sweeping a large steel sound round the tumour as far as the pedicle. This is quite unnecessary, not to say injudicious. The hand is a far safer as well as more intelligent instrument. We also greatly prefer ligatures of pure silk for bleeding vessels within the abdominal cavity to the cautery or persulphate of iron, experience having shown their general innocuity.

We are astonished to find that Dr. Thomas figures as the clamp Mr. Wells uses an instrument which, we believe, that gentleman did devise, but which he has not used for some years, having quite discarded it for a much superior instrument. Mr. Wells's method of closing the abdominal wound might profitably have been described.

Dr. Peaslee's plan of washing out the peritoneal cavity by solutions of salt, carbolic acid, &c., when septicemia threatens, is highly thought of, and may be valuable in the cases in which it is indicated. This part of the subject leads us to say that we are struck with the fact that Dr. Thomas makes no mention of the use of the thermometer in the after-treatment of ovariotomy. In our judgment the thermometer is an instrument which no ovariotomist should fail to have in constant use, for it will give him more timely warning of certain complications than anything else will afford.

The account of diseases of the Fallopian tubes is good. Speaking of chronic salpingitis, in which the tubes sometimes become dilated, the author says he has met with cases in which the sound passed up many inches, and that either there must have been dilatation of the tube or the instrument must have passed through the fundus uteri, and he concludes that the former was the case. There are, however, instances of the latter accident having occurred without any ill effects ensuing.

The concluding chapter is on "Chlorosis," which, the author says, "is probably a neurosis of the ganglionic system of nerves," but it may be said that he does not elucidate this opinion very satisfactorily.

It only remains for us to say of Dr. Thomas's excellent work that it is safe, reliable, and practical. It is a work which will enhance the already high reputation of its author. Nevertheless we hope he will take in kindly spirit the frank and friendly criticisms we have thought it our duty to make, and, should he think them worthy, avail himself of our hints to still further improve the next edition.

VII.-Poor-Law Medical Relief.'

THE upper and middle classes will no longer solely be called on to administer poor relief and the thousand and one other functions that have heretofore almost entirely devolved upon them, for the working man is a coming power to share with them in all such public duties, and the result must be watched with no small amount of anxiety by the friends of the English people, and with much interest by all the civilised world.

One danger that looms in the distance must be manfully resisted, namely, practical centralisation of power with the appearance of popular government.

As the recent Public Health Act constitutes country boards of guardians the rural sanitary authority, it is to be hoped that the sanitary and poor-law duties will not in future be permitted to be encroached upon, whether by matters wholly irrelevant or by apathy on the part of elected guardians, or from any other cause. It has quite recently happened in Ireland that a union lost five hundred pounds by neglecting its proper functions in not promptly accepting a tender for coal from a merchant, because the elected guardians of the union converted the boardroom into a political arena for the discussion of matters wholly unconnected with their duty. In another instance political topics so far interfered with legitimate business, that it was only after a peremptory order from the Poor-Law Commissioners that the guardians were brought to a sense of their responsibilities and duties.

Among causes of another class operating against the due guardianship of the poor is the frequency of the abuse of grants of medical relief to persons well able to pay for the same, the illegitimate expenditure of the public money, and the practical prohibition of redress to the medical men.

The abuse of gratuitous medical relief is, moreover, itself an evil, inasmuch as it fosters improvidence and drunkenness ; nor can we wonder at its prevalence, and at the consequent results, when the small trader and the publican are but too commonly the poor-law guardians and distributors of tickets for medical relief. The granting such relief is a trust that should only be placed in the hands of a responsible and paid officer, who should 11. First Report of the Local Government Board, 1871-72.

2. Annual Report of the Commissioners for Administering the Laws for Relief of the Poor in Ireland, including the Twenty-fifth Report under the 10 & 11 Vic., c. 90, and The Twentieth Report under the 14 & 15 Vic. c. 68; with Appendices. 1872.

3. Reports of the English Poor-Law Medical Officers' Association, and of the Irish Poor-Law Medical Officers' Association, for 1871.

be held accountable for a portion at least of the fee justly due to the medical officer when the recipient of relief happens to be a person able to pay.

The working of the poor-law system in England and Wales, with a population of 22,704,108, a total expenditure in relief to the poor of £7,886,724, and a rate per head of amount expended in relief to the poor on the estimated population of 6s. 11 d., contrasts with that of Ireland, with a population of 5,402,759, an expenditure of £685,668, and for the expenses under the Medical Charities Act of £135,005. The Irish expenditure, with other items under the Sanitary and Registration Acts, does not amount to 3s. per head of the population. The expenditure, small as it is, would be reduced if a more commensurate payment was made for vaccination, (which at present amounts to only about 10d. per case in Ireland instead of 18d. to 30d.,as in England), and if other duties under the Sanitary Acts were properly paid for, and encouragement given to the medical staff of the poor-law department to carry out this important branch of preventive medicine. At present these hardworked officers are not only not paid for sanitary work, but too often render themselves obnoxious to those who should be guardians of the poor if they attempt to represent the existence of preventible causes of disease.

It is within the powers of boards of guardians to award payment to their medical officers for sanitary work done by them at all times of epidemic, endemic, or contagious diseases, or at times when a locality is threatened with such, and it is clearly the interest of all to take energetic measures to meet visitations of disease as promptly and with as much effective resistance as possible, for there is nothing more capable of demonstration than the wisdom and economy of prompt and energetic measures in all such cases. Repetition of these truisms, though possibly unpalatable, is necessary when we consider the heavy mortality of many of our large cities. The reports show great variations as usual in the birth- and deathrates of various towns; thus, we find that during the second quarter of the present year (1872) the birth-rates in London, Dublin, Glasgow, and Edinburgh, were respectively 35 (per 1000), 30, 43, and 35, and the death-rates 21, 32, 29, and 30.

We have on a previous occasion observed that the increasing custom of granting out-door relief in Ireland is fraught with dangers. The serious dimensions that this mode of relief has already acquired is exhibited by the facts, that the sum expended on it has risen from £2245 in 1856 to £69,744 in 1871, and that an average daily number of 23,400 persons have

availed themselves of it. The commissioners remark as follows upon this matter:-"This rapid increase of expenditure on relief purposes it is fair to observe has taken place concurrently with the maintenance of the electoral division system of rating; and it is our conviction that the proposed change to union rating would have a salutary effect in checking the progress of any expenditure which may, perhaps, be unnecessary." To this we must add that the small expenditure of £2245 obtained under the same system of rating as now in force; it does not seem just, therefore, to blame the system, but rather to admonish those intrusted with a very serious responsibility, and this at a time too when the pay of the working classes exceeds anything ever thought of by our predecessors. We greatly doubt, however, that the present high rate of remuneration has bettered the condition of the working classes; indeed, we may judge from the large increase in the revenue derived by the Excise from the liquor trade, which amounted in the year ended September 1872, to £24,719,000 against £23,032,000 in the previous year, how much of the increase of emolument is spent, not on the workman's family, but in the gin-palaces and beer-houses of the United Kingdom.

We have seen much of the working of in-door and out-door relief, of dispensary and of hospital medical relief, and of grants of money by charitable persons or associations, and we repeat our experience stated on similar occasions before, namely, "that out-door relief offers a strong temptation to the sick to remain in their own, commonly most unfit, tenements, instead of entering suitable hospitals-so liberally provided at the present time almost everywhere, especially in Ireland-and so tends to render nugatory the best efforts and the ofttimes difficult work of the medical officer; as, for instance, the arrest of contagious disease, or the prevention of the consequences of overcrowding." This was our experience a year ago when we had before us the evidence taken before the House of Commons Committee on the very subject of union rating in Ireland, which the poor-law report now under our consideration specially advocates as a remedy for the growing lavish expenditure on pauper manufacture, for we can give no other appellation to out-door relief. And this we say with emphasis, after our experience of the dire epidemic of smallpox now hardly passed away.

The Dublin Morning Mail,' under the heading of "Abuse of Red Tickets," remarks that the following letter in the Medical Press' treats of a subject of great importance to the public as well as to the medical profession. The English system of outdoor relief is often stigmatised as tending to pauperise the independent poor, but the medical branch of the Irish poor-law