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of the parietal incision, and it was packed round with stripsof iodoform gauze. The after-progress was uninterrupted,and the patient left the hospital recovered on June 21st.CASE 4.-The patient was a married woman aged fifty

years, who had been jaundiced for three years. The jaundicewas preceded by an attack of very severe pain in the rightside, accompanied by profuse perspiration and vomiting.There had been many attacks of pain, and during the threeyears she had every few weeks a febrile attack with vomitingand sweating, followed by deepening of the jaundice. Owingto a reverse of circumstances she had been worn down by muchmental trouble as well as hard physical work. She wasseen to be in an unfavourable state for operation, but shewas becoming quite disabled and was anxious for relief.The operation (on June 4:h) was carried out on the sameplan as in the preceding cases. The abdomen was opened bytransverse incision. A large stone was found in the commondnct, close to the duodenum. The duct was hooked forwardwith the fingers, and an incision was made over the stone,which was delivered with a scoop. It was an inch in lengthand flattened at the ends. The duct was not sutured, butdrainage was provided for by a rubber tube and gauze packing.After the operation the patient never became quite conscious.She was restless and drowsy, vomiting now and again. Shecontinued in this condition, with rapid pulse, slight rise oftemperature (1008° F.), and increasing drowsiness, till shedied in the early morning of June 7th. The post-mortemexamination of the abdomen showed that the area of theoperation was completely shut off and that there was no peri.tonitis. The patient had apparently died from- ch01aemia.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

The Causation of AEgophony.AN ordinary meeting of this society was held on Feb. 12tb,

the President, Mr. HUTCHINSON, being in the chair.Dr. FREDERICK TAYLOR read a paper on the Causa-

tion of Icophony. He said that :-1. aegophony wasno more than, or different from, ordinary musical discordor dissonance. 2. This discord was the result of beatsoccurring between the higher harmonics of the noteuttered by the patient. 3. The beats constituting thediscord were audible because the higher harmonics werereinforced while the fundamental tone and lower harmonicswere suppressed. 4. Both the reinforcement and the sup-pression were due to modifications of the bronchial tubes,which caused them to resonate the higher harmonics and notthe lower. It was pointed out that discord as a factorin xgophony had :not been sufficiently recognised bywriters, and that the late Dr. Stone, in his CroonianLectures, confined his attention almost entirely to the

high pitch of the morbid sound. Discord was favoured by(1) the pro-existence of:high harmonics in considerab!e force,such as is known to be the case with syllables containing thevowels e and i ; (2) by reinforcements of the higher har-monics ; and (3) by suppression of the lower harmonics andfundamental tone. The last two conditions could be effectedby modifications of the resonating qualities of the bronchialtubes, such that they would resonate very high tones andwould not resonate the lower normal tone. It was arguedthat such an alteration in the resonating qualities of thetubes was a sufficient explanation of asgophony without thenecessity of conceiving that liquid in the pleural cavity cut offthe lower tones. It was shown that there was no ground forbelieving that liquid cut (ff lower notes and transmittedhigher, or that higher notes were in general more penetratingthan lower notes. It was shown, further, that the familiarsounds, such as nasal voice, the Punch and Judy voice, andothers with which asgophony were compared, did not dependon transmission of sound being affected by a layer of fluid,but on differences in the resonating spaces. Some remarkswere then made on the position in which segophony wasusually heard, with observations of twenty-one cases, fromwhich it was shown that asgophony was not always limitedto the upper part of the area of dulness. The occurrenceof ’aegophony in the abserce:rof pleural liquid was then

discussed, and a case was quoted showing its appearance inpneumonia with plugs or casts of fibrin in the bronchialtubes. The conclusion was that, though aegophony wasmost frequent in the presence of liquid because theliquid compressed the lung, it might be produced byalterations in the bronchial tubes independently of liquid.-Dr. THEODORE WILLIAMS said he regretted that the earlyuse of the aspirating needle nowadays had abolished thenecessity of the study of certain physical signs. As regardedthe nature of asgophony, he supported Dr. Taylor’s views,and thought it was more common in women and childrenthan in men. One objection to those views appearedto him to be that in intra- thoracic tumour the bronchi wereusually much compressed, but in no single case of this naturehad he ever found segophony. Why did it last such a shorttime ? The late Dr. C. J. B. Williams bad stated that segophonywould disappear whenever the fluid between the lung and thechest had accumulated to the depth of more than an inch.-Dr. MAGUIRE agreed that segophony was a sign of no prac-tical value in medicine, and that it was merely a discordant,modification of the voice due to altered conditions ofresonance in the bronchial tubes. But there was a widedifference between resonance and consonance, which twoseemed to be confused in the paper. Ordinary musical dis-cord or dissonance was quite different from segophony. Theharmonics of any given note uttered by a patient wouldnever produce a discord. The nearest to it was the chordof the seventh ; this was the product of the harmonics ofany fundamental note, but in no sense of the word was ita discord, except in so far as it produced in the musical minda feeling of expectancy which could only be relieved bythe sequence of its "resolving chord," as it was called.Consonance could only occur with regard to one particulartone, and it was utterly impossible that a series of bronchial!tubes could correspond with a consonating chamber. There’was no space for such a chamber for one note, much less for-all the notes of the human vo=ce. In excessive broncho-phony one got a kind of segophony, but that was an instance’of resonance and not of consonance. The disagreeable noiseof the phonograph was a form of aegophony; it was cer-tainly not a question of harmonics, but only of confusion oftones of different timbre but of the same pitch. The real

explanation of segophony was therefore a confusion of soundsof the same character and pitch-a confused echo, tones ofdifferent quality, but not of different elevation, jarring withone another. If this were so it was impossible to con-ceive that Dr. Taylor’s fourth prorosition could be correct.-Dr. SANSOM held that a3gophoBy had still some diagnosticimportance. He quoted the view endorsed by Barth andRoger that in cases of eff asion, at the level at which aegophonywas heard, there was a thin layer of flattened lung separatedfrom the chest wall, which was set in vibration by the voicelike the tongue of a Jew’s harp. Egophony was not likely-to be due to one cause in all instances.-Dr. SCHORSTEINsaid that musically it was impossible to produce discord fromany one note or its harmonics. In a recent case in whichaegophony was audible whm the patient said " 99 " he foundit to be still present when the patient sang a pure "Ah,"which proved, therefore, that it could not be a discord.Dr. TaJlor appeared not to have discriminated betweenwhat was musically known as discord and the popularidea of a discord-i. e., an unpleasant noise. The bleatingof a sheep, the note of a bassoon, and that of a bag.pipe, though unpleas3nt to many, were not musicaldiscords. He remarked on the rarity of segophocy in casesof recognised pleurisy.-Dr. SQUIRE stated that if, afterbathing, a little water were left in the external meatus thesounds which reached the ear were altered, being raised inpitch and somewhat resembling segophony. He had recentlyseen a case of old-standing effusion in which aegophony wasplainly heard. If the explanation in the paper were correctaegophony should be more frequently heard in pneumonia.-Dr. TAYLOR, in reply, said he had not been able fromhis reading to make out such a distinction as hadbeen drawn between discord in its popular and in its musicalsenses. He relied rather on the statement made by anauthority in acoustics that a compound tone might bharsh or dissonant in itself if it contained high harmonics.If the explanation quoted by Dr. Sansom held good aegophonyought to be heard only along the upper line of dulness, butthis was by no means the case. As intra-thoracic tumoursgrew from the root of the lung they early compressed thebronchi and cut off any possibility of resonance from thelarynx ; but he had heard a sound like aegophony in a case

403

of malignant disease of the lung. His cases were all maleswith one exception, and none of them were children.

Egophony could not be a pathognomonic sign of pleuraleffusion, and in pleuro-pneumonia it was perhaps more- common than was generally believed.

The PRESIDENT notified that in future special evenings-would be set apart for discussions. These would be intro-duced by a short and lucid account of the subject, whichwould then be left entirely to the meeting. At the next

meeting of the society a discussion will take placeupon the Affections of the Nervous System during the

Early Period of Syphilis.

MEDICAL SOCIETY OF LONDON.

,Unusual Maldevelopment of Skull unassociated with CerebralSymptoms.-High Excisionof Rectum.-Cork in Adult MaleBladder.-Right Hemiplegia with Epilepsy treated byTrephining. - Pyloroplasty. - Enteroplasty. - Gastro-enterostomy. - Pseudo-hypertrophic Paralysis, witit Fre-servation of Knee-jerks.A CLINICAL EVENING of the above society took place

on Feb. llth, the President, Sir WILLIAM DALBY, being inthe chair.

Dr. GUTHRIE showed a boy aged four years who was thesubjectof typical scaphocephalus. The boat shape was presentat birth ; the circumference of the head was 21 in., the extremeitength 8 in., and the width at the biparietal eminences 45/8in.There was synostosis of the sagittal suture, and the frontalbone was pushed forward as a whole, the keel-shaped ridge.at the top being very well marked. There had been no con-vulsions and no rickets, and the intelligence was good. Thechild was the youngest of seven, three of whom had died of-diphtheria, but none of the others had shown deformity ofthe skull. Professor Turner, in discussing the etiology ofthese cases, said that the synostosis was probably due tocauses operating in intra-uterine life. - The PRESIDENTsaid that he knew of a very exaggerated example of thisdeformity of the skull occurring in a public man of greatintellecfual attainments..

Mr. SwiNFORD EDWARDS showed a man aged sixty-oneyears who was admitted into St. Mark’s Hospital in

February, 1891, with signs of cancer of the rectum. It- extended four inches up the bowel, but he could not

get his finger above it. After inguinal colotomy, a coccygealextirpation of the rectum was performed by the methodof Kraske. The patient at the present time is in.good health and has had no further rectal trouble.-He also said that he had operated on a second case,-that of a female aged fifty years, who entered the WestLondon Hospital in August, 1891, for rectal carcinoma.The growth measured two inches in length and extended towithin three inches of the anus below ; there were no extra-rectal adhesions. The patient being placed on her left side,he made an incision from the mid-sacrum to the anus,removed the coccyx, divided the left sacro-sciatio liga-ments and dissected away a portion of the sacrum withthe saw and cutting forceps. The growth was removed andthe rectum united end to end, but this union did not hold.The patient had since much improved in health and strength.-Mr. CLUTTON held that carcinomata high up in the rectum- could be jemoved without resort to Kraske’s method. Hemade a free incision posteriorly beside the coccyx andintroduced his hand. He then opened the peritoneumfreely, pulled the sigmoid flexure down, and attached it to-the anal margin ; he next dissected out the whole of the rectum-and finally fixed the sigmoid down to the anus with manysutures. As a preliminary step it was best to perform aninguinal cclotomy and introduce a plug into the lower

portion of the colon to keep the wound clean. Kraske’soperation would rarely or ever be required in women, but itmight materially assist the operation in some cases in men.Cancer of the rectum varied much in malignancy in differentsubjects.

Mr. BUCKSTON BROWNE showed a man aged fifty-four yearsfrom whom be had removed a Cork from the Bladder in

January, 1893 The patient was a gentleman of a sensitivehabit of mind who was afflicted with occasional incontinenceof urine. He was staying with a friend in the country, andin order to prevent the chance of wetting the bed he in-serted into the end of his penis a ma’l 1 cork from an eau de

Cologne bottle. On getting up next day he failed to findthe cork either in his penis or in the bed. In March, 1893,an examination of the bladder was undertaken with a

negative result. In August, there being much pain aftermicturition and other signs of bladder irritation, he wassounded, and a foreign body was felt. Next day it was brokenup with a fenestrated lithotrite and the greater portion of itremoved. A week later the remaining portion came away inthe eye of an evacuating catheter. The patient had remainedwell to the present time. The operation was done with analmost empty bladder, and he preferred this condition of theviscus for all cases of lithotrity.

i Dr. OUTTERSON WOOD and Mr. COTTERELL showed twopatients who had been afflicted with Right Hemiplegia andEpilepsy, who had been treated by trephining. The first

patient, a female aged three years, was paralysed on theright side. When one year old she had a fall and after-wards had an epileptic seizure ; several more fits followed,always beginning in the thumb and fingers. She hadbeen trephined over the centre of the hand, and therehad been no return of fits since the operation. Thesecond patient, a girl aged twelve years, had been paralysedsince birth. There had been a difficult instrumental labour.There was no paralysis in other children of the same family.There was rigidity of the right hand, arm, and leg, withwasting of the leg and eversion of the foot. Epileptiformseizures commenced lat April, preceded by a well-markedaura of numbness and tickling of the thumb. She wastrephined over the hand centre last September, and sincethen there had been no fits ; the hand and arm were lessrigid, and she walked better.-Mr. COTTERELL said that inthe first case he found a cyst connected with the arachnoid,which was probably an old haemorrhagic extravasation. Inthe second case the dura mater was found to be thickened,but the arachnoid and brain were healthy. He did notinterfere with the exposed cerebral cortex.

Mr. HERBERT ALLINGHAM showed a patient upon whomhe had performed Pyloroplasty. The man, who was thirty-four years of age, had had an acute gastric trouble fouryears ago, and since then signs of pyloric stricture haddeveloped. He opened the abdomen in the middle line and ex-plored the pylorus. Much cicatricial tissue was found roundit, and so he divided the stricture longitudinally, then pulledthe wound open, and stitched it across transversely.

Mr. H. ALLINGHAM also showed a woman forty-nine years ofage who some years ago had complained of Dyspeptic Sym-ptoms, and had afterwards suffered from intestinal obstruc-tion with pain of a colicky nature. When admitted intothe Great Northern Central Hospital obstruction hadlasted for ten days. He opened the abdomen in the leftinguinal region and found the large intestine distendedwith flatus. He opened the large intestine in the

inguinal region. Next day, as the obstruction was

unrelieved, he made a second opening over the emeum.In the small intestine, at the junction of the jejunumwith the ileum, he found a stricture, evidently the resultof an old perforation. He performed enteroplasty, andlater resected the artificial anus, bringing the cut endstogether over a Mayo Robson’s bobbin.

Mr. H. ALLINGHAM showed a third case, of a woman agedforty-one years, who suffered from severe gastric trouble someyears previously. On opening the abdomen he found thepylorus involved in an enormous growth. He stitched thejejunum up to the stomach and united them over a bobbin.The operation was performed in July, 1894, and she had sincegained over three stones in weight. The growth appeared tohave diminished in size since the operation.-Mr. BIDWELLasked if Loreta’s operation was inferior to that described ;it seemed to him to be simpler. For gastro.enterostomy hepreferred Halstead’s method of stitching.—Mr. ALLINGHAM,in reply, said that pyloroplasty was the better operation fora rigid pylorus, a healthy piece of mucous membrane beinginserted into the strictured portion. The bobbin acted like asplint and kept the parts firmly together.

Dr. StiLL showed, for Dr. Colman, a boy aged ten yearsand three months who was the subject of HypertrophicParalysis, but in whom the knee-jerks were preserved.

, The weakness and enlargement commenced five years ago.There were three other children in the family, ncne o*

: whom were affected. The head was curiously shaped; themental condition was good. The muscles of the calves andthe infra-spinatus muscles were markedly enlarged ; the

. deltoids and triceps were enlarged to a less degree ; and the, vasti externi were enlarged ard weakened more than the