The case described below is of interest, not only because of its rarity, but also because the patient had been observed over a large number of years. Primary carcinoma of the liver finally supervened, and the absence of ascites throughout the illness was also an unusual feature. The autopsy findings, and the pathological fact that occlusion of the hepatic veins rarely if ever occurs in a non-syphilitic cirrhosis, have led us to present the case as one of primary occlusion of the hepatic veins, with secondary fibrosis of the liver. Clinical report. The clinical records of this case extend over the years 1906 to 1929. The patient, Herbert B., first came under observation in the year 1906, being then 5 years of age. He was one of a large family, and there was no clinical reason to suspect a syphilitic taint, but of course these were the pre-Wassermann days. The abdomen was said to have been very protuberant since he was a year old, and when first seen the liver was enlarged down to the umbilicus, and smooth and firm to palpation. The spleen at that time was not felt. There was no jaundice nor ascites, and though not a robust boy he presented no other signs of disease. No diagnosis was arrived at. Two years later (1907) the notes show that the liver was 'becoming irregular' and in the following year it is stated that 'the edge of the liver is now two finger-breadths above the umbilicus and the spleen can be felt one finger-breadth below the costal margin.' By 1910 the condition was unchanged and in 1912, the patient being then 11 years old, it was noted that 'the liver is the same and the spleen can just be felt.' His general health continued fair. There is no note of his condition after this until 1920, when the liver was only about one fingerbreadth below the ribs and was 'rather firm'; the spleen could not be felt. He was then lost sight of till September, 1929. He had now reached the age of 28 and complained of severe attacks of epigastric pain which had recently begun to trouble him along with some decline in his general health. Examination showed him to be a man of rather poor physique, thin and pallid, but with none of the 'cirrhotic facies,' no icterus, nor clubbing of the fingers. There were no stigmata of congenital syphilis. The liver could be felt about two finger-breadths below the edge of the ribs, it was hard and irregular, and apparently projecting from it in the epigastrium one could easily make out three rounded masses each about the size of a walnut. There was no ascites and the spleen could not be felt. The Wassermann test was negative and his other organs normal.

ADDISON'S DISEASE rI T4E BRITISHAL 625 EDICAL JOURNA Thirty grams of cortical tissue yield only 1 c.cm.-of the final therapeutic preparation, and Levy Simpson4 tentatively suggests the dosage indicated in severely ill patients to be 50 c.cm. intravenously on the first day, and thereafter 20 c.cm. daily, until definite clinical improvement sets in. It is thus clear that effective treatment must severely strain the financial resources, not only of the individual patient, but even of the average institutionif, indeed, sufficient supplies of the preparation are to be had, apart altogether from the question of cost. We do not wish to deny the therapeutic value of cortical suprarenal extract, as this appears to have been definitely established3 4 S; but it must be admitted that, though several striking temporary successes have been reported in this country,' 4 as well as at least two cases where more lasting. benefit was obtained, the results have been less good than those claimed by American workers.3 Davidson,2 after reviewing the literature and adding four cases personally known to himself, points out that, of thirteen cases treated in this country, nine are dead, though it is true that several showed initially a good response, and that death in some was not wholly due to suprarenal insufficiency. One patient of Davidson's, in a severe relapse, failed altogether to react to intravenous injection of 25 c.cm. of a reputable preparation, though he had previously shown some-improvementunder treatment with an earlier sample. We feel, therefore, that the results so far recorded cannot be regarded as more than encouraging, and that, until the active principle has been identified and its synthesis established-on a commercial scale,-. treatment with cortical suprarenal extract must remain of limited practical utility.-Summary-A c4se-of Addison':ss disease is-described, with reference to its-clinical features 'and' to 'the pathological changes found. These were of the nature of atrophy, combined possibly with some regeneration. The value of treatment with cortical suprarenal, extract is discussed. REFERENCES

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