We need not give M. Clot's description of the worm. It is familiar to the reading part of the profession. The length of the worm in Egypt varies from six inches to four feet-the longest that M. Clot has observed. He has obtained no certain information on the causes of its production or appearance. The inhabitants of Cordofan, Sennar, and Darfour attribute it to the heavy rains of April, May, and June. They think that it is a small animalcula, which attaches itself to the skin of those who bathe in the waters, but no person could affirm that he had seen such an animalcula. Though commonly observed amongst the negroes, M. Clot has seen it in a great number of Arab soldiers incorporated with the negroes, and in two Europeans. Dogs brought into the hospital

have been attacked with it. It is seen in all parts of the body, but chiefly in the lower extremities. The same individual may suffer from several at the same time; indeed, so many as ten or twelve were not unfrequent. A friend of M. Clot's, Dr. Marrudri, who made the campaign of Cordofan with Defterdar-Bey, was successively tormented with twenty-eight.

The presence of the worm is detected in various ways. When placed superficially beneath the skin, it occasions a painful itching, which sometimes shifts its place, and the seat of the disease is transported to another part. In other cases, the worm may be distinguished in the form of a spiral cord, winding round the limb, and looking like an inflamed lymphatic or a vein. When present in parts not furnished with soft tissues, as the fingers, the articulations, &c. it occasions very severe suffering. When deeply placed in fleshy parts, it gives rise to an indolent swelling, which may remain for several days, and even months. In all cases, when it is about to make its exit, the pains become more intense, general symptoms arise, the part inflames, a small abscess forms and breaks, and a larger or smaller portion of the ani

greater, and the whole of the worm is found rolled up in it. In other cases, which, however, are uncommon, the worm is not seen at first, and doubts of its existence may be entertained; in a few days afterwards it shews itself, or gives rise to a fresh abscess, more or less remote from the former. The suppuration from these abscesses is thin and serous.

The treatment varies with the part cecupied by the worm, the manner in which it presents itself, and the symptoms which it occasions.

In ordinary cases, it is better to let the worm issue spontaneously; but, as soon as a part of it makes its escape, it must be tied by a piece of silk to a small cylinder of diachylum, round which it is to be rolled, a moderate degree of traction being exercised on the portion still imbedded in the body. The two extremities of the cylinder are made flat, and fixed in the vici

nity of the abscess, on which is to be applied some simple dressing, or a light poultice, according to the amount of irritation. The worm is drawn out a little at each succeeding dressing, till the whole of it is removed, great care being taken not to break it, as this accident protracts the period of treatment.

If the worm does not soon make its way out spontaneously, and if placed so superficially as to be felt or seen, M. Clot has often made an incision on its track, seized it as near its centre as possible, tied it in the manner already mentioned, and thus drawn out both ends at once.

When the animal is deeply-seated, there is sometimes great swelling of the limb, deep abscesses form, sinuses result, and serous discharge continues for several months, without the worm making its appearance. In these cases M. Clot employed general and local antiphlogistic measures, with benefit.

Two patients, in one of whom the worm was in the fore-arm, and in the other in the tibio-tarsal articulation, suffered the most excruciating pain, which produced

removed from the edge of the under lip. It was, when observed at birth, about the size of a split pea, of a livid colour, and on a level with the surrounding integuments. It remained stationary for the first three months, after which time it began to increase rapidly, and to project in a pendulous form. The integuments were entire: the apex of the tumour, which was about the size of a walnut, was irregular and doughy; whilst the neck, which was not larger than a quill, was hard and smooth, and the pulsations of its vessels were distinctly perceptible. A broad ligature of tape was firmly applied, close to the base of the tumour, and removed in 24 hours. With the use of cold this temporary ligature was perfectly successful, the tumour sphacelating, and the lip cicatrizing.

We apprehend that this practice is more likely to succeed in cases like the preceding, where there is a narrow and distinct pedicle, than in others where the origin of the tumour is more diffused. It is sometimes difficult to include the whole of the disease by the ligature applied in the most efficient manner. Indeed, Dr. Macfarlane's third case is one in point.

CASE. 3. Aneurism by Anastomosisincomplete Ligature.

W. H. aged seven months, had a soft, unequal, purple-coloured tumour, about the size of half-a-crown, on the anterior surface of the left arm, two inches above the elbow-joint. It was elevated a little above the surrounding parts; and when firmly compressed, an obscure thrilling or slightly pulsatory sensation was perceptible. It was tied with a double ligature, as in the last case, and in six days the tumour separated. The exposed surface, which had at first a sloughy appearance, soon became clean and florid; and, except a small spot in the centre, it was evident that the diseased structure was completely destroyed. Here, however, a large spongy tumour formed, which was of a dark colour, and bled profusely. Pressure by means of a compress and bandage, the free application of nitric acid, caustic, &c., were

ineffectual in checking its progress. The actual cautery was at length had recourse to; and by four applications of it, the morbid growth was destroyed, and a cure accomplished.

Whatever is capable of exciting inflammation in these vascular tumours, and of producing either ulceration or consolidation of their loose texture by the effusion of lymph, may put a stop to their progress, and ultimately lead to a cure. For this purpose I have used vaccination with success in five cases; and in one case, where the disease extended over the whole surface of the lower eye-lid, and where neither the ligature nor the knife could be employed without producing deformity, I succeeded in exciting inflammation of the tumour, by introducing a seton close to its base, and retaining it till partial suppuration was established. In another case, where the discase was confined to the inside of the lower lip, the seton proved unsuccessful, and ligatures had to be employed.

There can be no question that the ligature, when applicable, is the least tedious and the most certain method of removing nævi. Next to the ligature probably comes excision. Vaccination we have tried, and seen tried without success. It is a pretty rather than an useful plan of treatment, at least we have found it such. We have not ourselves seen any bad consequences from the operation. Erysipelas followed in one child, but it did

well.

XLII.

INJURIES OF THE HEAD. "WHEN a large quantity of blood is effused under the scalp, its evacation by incision is seldom required, unless for the purpose of ascertaining the state of the bone, and that only when symptoms of compressed brain exist. The extravasated blood will be slowly absorbed, and the detached scalp regain its former connexions, while the removal of the fluid by puncturing the tumour, will not unfre

the hernia projects, it is of an oval or spheroidal form, soft and colourless. It is attended with pulsations synchronous with those of the heart. These pulsations, when the patient is at rest, are sometimes indistinct, but are rendered very manifest both to sight and touch on the slightest exercise. The patient, when old enough to be able to give us an account of himself, says he never feels any pain in the tumour; if an infant, he seems to suffer no uneasiness, even when the swelling is subjected to gentle pressure; the size of this tumour is momentarily augmented by the efforts of coughing, sneezing, or even crying; during any respiratory effort, a blush of redness is seen rapidly to pass over it, through the skin, which is generally thin and semi-transparent where it covers the hernia. On carefully applying the fingers around the base of the tumour, the borders of the opening in the cranium, through which it has escaped, are easily felt, sometimes these borders are smooth and even; but I have in one case found them offering rough and elevated edges.

The intellectual faculties in all the cases I have witnessed, at a period of life when these could be estimated, remained entirely unimpaired."

The characters of the complaint are not always so well marked. Thus, Lallemand relates a case in which the tumour was mistaken for a wen, and an operation was in consequence commenced. The congenital encephalocele does not occur at the fontanelles so frequently as might be supposed; it more commonly protrudes through some one point of the occipital region, in the median line. At birth, the tumour presents a distinct fluctuation; in the adult, the fluid has been removed and the prominence is softer. Encephalocele, like spina bifida, generally co-exists with hydrocephalus ; but Mr. Adams thinks that spina bifida is the more dangerous of the two. Mr. A. bas not seen, in any case, paralysis of the upper or lower extremities. The danger of these cases is chiefly confined to their early period, and from hydrocephalus being, in such cases, almost uniformly present, over-dis

tention and ulceration of the hernial sac are the consequences to be dreaded.

"The chief bulk of the tumour will be found, on anatomical examination, to be formed of brain or cerebellum, and if examined, soon after birth, to be of a soft consistence, the convolutions flattened, and the whole structure infiltrated with water. The hernial sac is constituted by dura mater protruded before the brain, and lined internally with arachnoid membrane, fortified externally by that structure which in the perfect cranium constitutes its proper periosteum."

In one case, Mr. A. observed the tumour to project through the right portion of the os frontis. It has been seen at the root of the nose, where, for some weeks, a deficiency intervenes between the nasal processes of the frontal bone.

Mr. Adams observes that he has no confidence in the plan of treatment generally recommended by authors, namely, pressure. It is, he thinks, inapplicable to the first stage of the complaint, in which hydrocephalus so often co-exists, and useless in the latter stages. Mr. Adams speaks more favorably of frequent puncturing by a fine needle, after the manner recommended by Sir Astley Cooper in cases of spina bifida. He does not think a puncture made so carefully as to allow the limpid fluid to escape, but not to admit any air, a dangerous operation. The method of treatment which seems best, upon the whole, to Mr. A. is, to fortify the skin by astringent applications of oak-bark and alum; but, if over distention and ulceration of the skin threaten, he would not delay the operation of puncturing the tumour. In the second stage of the complaint, the only indications appear to be, to preserve the tumour from external violence. The medical treatment appears to consist, exclusively, in meeting any functional disturbances that may arise with appropriate remedies.

Mr. Adams relates some cases of the disease.

Case 1. "The head of the infant was the smallest I have ever seen; the forehead was depressed, and a tumour as large as an or