F. S., a white boy, aged 6 years, was seen Nov. 17, 1928, at 11 p. m., because of "a strange look in his eyes." During the morning the child, who had previously been well, had shown a mild coryza, and to relieve this the mother had used a fluid that formerly had been prescribed by a laryngologist for an identical condition. Two drops of the medicine had been dropped into each nostril, with the head dependent, at 2 p. m. and again at 6 p. m.
The solution ordered had been a 3 per cent aqueous solution of ephedrine sulphate but, as was later determined, the original bottle had, by accident, been given a prescription number that represented an order for atropine sulphate, 1 per cent aqueous solution, and when a refill order was given by telephone, atropine was furnished. The bottle bore instructions for intraocular use but the parent