While it would be rash to say that every case of thrombosis of the heart, more especially of the left heart, presents a definite syndrome by which the condition can be diagnosed, yet the mere fact that a definite syndrome has occurred so often justifies the suspicion which should arise in the mind of the examiner when he is confronted with a case of mitral stenosis associated with gangrene of the lower extremities, evidence of embolic processes, or atypical peripheral manifestations. At the present time, however, one has no means of differentiating the presence of a ball thrombus from that of a pedunculated thrombus with a long, freely movable pedicle.

CONCLUSIONS

1. We accept the criteria for ballthrombus set forth by Welch: entire absence of attachment; imprisonment in consequence of an excess in the diameter of the thrombus over that of the first narrowing in the circulatory passage ahead of it; and such consistency and shape that the thrombus must not of necessity lodge as an embolus in this passage.

2. Accepting these criteria, only 19 cases can be collected from the literature, to which we add 1 new case, making a total of 20. Ball thrombus of the heart is therefore still a very rare condition.

3. Of 15 cases in which the sex was mentioned, 11 were in females and 4 in males, corresponding to the well known sex incidence of mitral stenosis. A majority of the cases in which the age was given were over thirty, the greater number being in the fifth decade.

4. While one cannot say that thrombosis of the left auricle gives rise to a definite syndrome by which the condition can be diagnosed, in the presence of the signs of mitral stenosis associated with severe disturbance of the general circulation, extreme feebleness of the pulse and the presence of gangrene or cadaveric coldness of the lower extremities, suspicion of thrombosis of the left auricle should be entertained.

5. In our present state of knowledge we have no means of differentiating clinically between the presence of a ball thrombus and other types of thrombi of the left heart.

(1) ARNOLD: Ziegler's Beitr. Z. path. Anat. u. z. all. Path., 1890, viii, 29.

(2) BATTISTINI: Giordnale d. R. Academia d. Medicina d. Torino, xiv-xv S., 1908, 1909, 313.

(3) BOSTROEM: Deutsches Arch. f. klin. Med., 1895, lv, 219.

(4) BozzoLo: Riforma medica 1896, i, 98, 328.

(5) CADY: Boston Med. and Surg. Jour., 1865, liii, 477.

(6) CURSCHMANN: Appearing in Schmorl's article.

(7) DELAFIELD AND PRUDDEN: 1912, 9th ed., 532.

(8) EICHORST: Pathologie u. Therapie, Zurich, 1895, 121.

(9) ERNST: Cor. Bl. f. schweiz. Aerzte, 1905, xxxv, 16.

(10) FISCHER: Ann. d. stadt. allg. Krankenh. zu. München (1889-9), 1901, xi, 185.

(11) French: Guy's Hosp. Rep., 1912, lxvi, 353, 357.

(12) FURBINGER: Deutsche med. Wchnschr., 1890, xvi, 505.

(13) HERTZ: Deutsches Arch. f. klin. Med., 1885, xxxvii, 74.

(14) HEWITT: Johns Hopkins Hosp. Rep., 1916, xvii, 1-80.

(15) KrumbhOLZ: Arb. a. d. med. Klin. z. Leipzig, 1893, 328.

(16) LANG, T.: Wien. klin. Wchnschr., 1892, v, 618.

(17) LEGG: Trans. Path. Soc., London, 1878, xxix, 49.

(18) LÖHLEIN: Inaugural Dissertation, Institute z. Giessen, 1900.

(19) LUTENBACHER: Arch. des. Maladies du Coeur, 1917, x, 353.

(20) MACFARLAND: Textbook of Pathology, 1910, 2nd ed., 112. Jour. Amer. Med. Assoc., 1901, xxxvi, 1577.

(21) MACLEOD: Edin. Med. Jour., 1882-3, xxviii, 696.

(22) MATHEWSON AND RUTHERFORD: Lancet, 1920, ii, 745.

(23) OGLE: Trans. Path. Soc., London, 1863, xiv, 127.

(24) OSLER: Johns Hopkins Hosp. Rep.,

rung im Deutsches Chir., 1883, 2, 3, 117.

(29) ROSENBACH: Die Krankheiten d. Herzens, 1893, 180.

(30) RUSK: State Hosp. Bull., Utica, N. Y., March, 1910.

3.

(31) SALITAN: Inaugural Dissertation d. University z. Zurich, 1906. (32) SCHMORL: Schmidt's Jahrbuch, 1892, ccxxxv, 110. Stereoscopish-photographer Atlas d. path. Anat. d. Herz. u. a. grosseren Blutgefasse, München, 1899, Tafel 20.

(33) SMITHIES: Jour. Amer. Med. Assoc., 1909, liii, 1347.

(34) STRANGE: Arb. a. d. path. Inst. in Göttingen, 1893, v, 232.

(35) SZASZ: Prest. Med. Chir., 1908, xliv,

854.

(36) TAUBER: Jahrbuch. d. Wiener K. K. Kranken-Anstalten, 1896, v, 345.

(37) VAN DER BYL: Trans. Path. Soc., London, 1858, ix, 89.

(38) WADSWORTH: Jour. Amer. Med. Assoc., 1901, xxxvi, 1577.

(39) WELCH: Allbutt's Syst. of Med., 1899, vi, 185.

(40) WOOD: Edin. Med. and Surg. Jour., 1814, x, 50.

(41) V. ZIEMSSEN: Congress f. inn. Med., 1890, 281.

CAUSES OF GALL STONE FORMATION

TH

HE most commonly accepted view contained in our textbooks as to the etiological factors concerned in the formation of gall-stones is that stasis, infection and gall-bladder activity play the chief rôle in their production. Some writers go so far as to say that without infection gall-stones do not occur. It cannot be denied that infection of the biliary tract is frequently associated with gall-stones, and that bile-stasis is a favoring factor in such formation. Yet the production of gall-stones in the human gall-bladder under conditions of surgical asepsis has been shown to take place; and Aschoff and Bacmeister have reported the occurrence of gall-stones of a certain type in human gall-bladders showing no inflammation, and which they regard as never having been infected. They, therefore, hold that one type of cholelithiasis is due to disturbances in the general metabolism. The concentrating ability of the gall-bladder has also been regarded as an occasional chief factor in the causation of cholelithiasis, and the rapid growth of stones lodging in the common duct may be taken as evidence of the occasional importance of this factor. Pathological changes in the gall-bladder mucosa other than those due to infection have also been regarded as an important cause of

stone-formation. The importance of organic nuclei, such as desquamated epithelium, cell detritus, bacteria, mucus, red or white cells, etc., has long been emphasized as an essential factor in the development of gallstones.

The experimental work of Rous and his associates (Journal of Experimental Medicine, January and March, 1924) shows that there is a well-defined tendency for calcium carbonate to come out of solution in the normal liver bile of the dog, and for it to be deposited on certain nuclei not infrequent in the bile under pathological conditions. The solubility of calcium carbonate is affected by the reaction of the fluid in which it is contained. Normal liver bile, out of which it tends to precipitate, is alkaline with an average pH of 8.20, but in the gallbladder the bile becomes acid, pH 5.18-6.00. From this acid bile no carbonate precipitation takes place, even when it becomes greatly concentrated. Moreover, carbonate precipitated out of liver bile redissolves in it when the bile is rendered neutral or slightly acid to litmus. The production of carbonate stones in the normal ducts under ordinary conditions is probably prevented by their motility, the flushing action of the bile, and possible antagonistic action of the secretion of the duct

mucosa. In the fasting animal the calcium concentration is increased, but there is at the same time a diminution in alkalinity, so that the pH often approximates that of the neutral point of litmus. Such adjustments within the organism, taken in association with test-tube experiments, suggest strongly that the reaction of the bile plays the critical part in determining the occurrence of carbonate stones. The absence of the latter from the normal gallbladder is due to the change in the bile reaction taking place there through the normal functional

activity of the bladder. The failure of this function would result in a formation of carbonate stones. happens, at least, in rabbits.

This As to

the part played by changes in the bile reaction in determining the cholelithiasis in the human individual we need further information. This much we do know, that carbonate spheroliths not infrequently form the center of formation of secondary deposits of carbonate and cholesterol, and, further, that cholesterol precipitation out of human bladder bile can be induced or inhibited by slightly altering the reaction of the fluid toward the alkaline and acid sides, respectively. Therefore, the possibility that cholelithiasis, in part, at least, may be due to the failure. on the part of the biliary channels and gall-bladder to maintain the reactions of the bile within normal limits, must be considered.

CLINICAL EFFECTS OF IRRADIATION IN

OBSTETRIC PRACTICE

W. A. N. Dorland (International Clinics, Vol. II, Series 34, 1924) has contributed an elaborate analysis of the literature on "The Influence of X-rays and Allied Substances on Living Tissues." One section deals with the action of X-rays upon mother and child when employed in pregnancy for diagnostic or therapeutic purposes. The available clinical data upon this subject are not very great, but the more recent reports, as collected by Bailey and Bagg (Am. J. Obst. and Gyn., May 1923, V, p. 461), tend to refute the statements of Edelberg, who, in 1914, concluded from the evidence at that time available that the danger of fetal injury from the use of the rays was negligible. From the experimental evidence of the effects of irradiation upon animals, we know that temporary or permanent sterility may be produced by the direct action of X-rays upon the ovary; that the ova may be so altered as to result in the production of disturbances of development of the embryo, even to the production of monsters; that the growing embryo may be so damaged by irradiation in the early stages of pregnancy as to result in early death and abortion; and that postnatal disturbances of

development and metabolism may result from irradiation in late pregnancy. With this experimental evidence at hand the possibility of similar effects upon the human embryo and fetus must be seriously considered, but the accumulation of clinical reports, substantiating this possibility has been very slow. Since 1920, however, there has been a notable increase in clinical observations showing the severe results of irradiation during pregnancy. The reports of Aschenheim, Werner, Stettner, Clark and Keene, Stacy, Berkley, Archangelsky, Bailey and Bagg, and others show a striking coincidence between the occurrence of abortion and severe disturbances of fetal development and the irradiation of the mother during pregnancy. Although the total number of cases is not great, these authors believe that it is sufficient, in connection with the results of experimental investigation, to justify the conclusions that irradiation during early pregnancy may produce death and abortion or gross developmental abnormalities of the fetus, and during late pregnancy may cause retardation of growth subsequent to birth. Bailey and Bagg believe that irradiation of the ovum during early pregnancy should never be permitted, and in later pregnancy should be resorted to only with extreme care.