Perhaps I have said enough to make my points.

First, in the domain of ophthalmology the diagnosis is as essential as in general medicine or in surgery, and the physician who cannot make a diagnosis should not prescribe for or treat his patient.

Second, powerful drugs should not be used in the eyes without the knowledge of their action and the purpose in their prescription. Third, you cannot believe all you read, even in medical journals. This leads me to discuss what is probably an old subject to you, viz., the use of atropine in ophthalmic diseases. Not only have I seen such careless recommendations in medical journals, and in general textbooks, treating in brief chapters the whole subject of the diseases of the eye, but I have had physicians tell me that when they did not know what to do for inflamed eyes coming to them in their regular practice, they use a solution of cocaine and atropine, either mixed or alternately. I want to warn you again that this is a dangerous practice. Not only is cocaine harmful for continued use, but atropine more so. I have had a number of cases recently which will illustrate the subject. One of them, a lady with every symptom of glaucoma, whose history leads me to believe that she suffered first from iritis, in which atropine was used, correctly at first, but for such a length of time that it induced glaucoma, which was not present originally. Atropine is just as essential in an iritis, keratitis and many forms of inflammation as it is dangerous and useless in others, so that again the question of the proper diagnosis presents itself.

Another suggestion in the prescription of atropine which has often been brought to my notice is that the laity are prone to pass around their medicines, giving them to other friends and neighbors who are afflicted in a supposedly similar way. I frequently have patients come to me with atropine affections who have not been under the care of any physician, but have had somebody's eyedrops recommended to them for the cure of "sore eyes." Some patients hate to waste their medicine, so save it for future use, either of themselves or friends, and, because it was prescribed for eye disease, think it ought to be good for any other disease of the same organs in anybody else. It is a well known fact that even a dropper which has been used for atropine can retain enough of the drug to produce dilation, with consequent inability to perform near work. One of my own patients, who was perfectly familiar with the use of atropine, and who had a separate dropper for that drug and for an antiseptic

lotion, used his atropine dropper, after washing it out (the other had become broken) and produced a mydriasis which affected him sadly at a time when he sorely needed his eyesight.

I think it a good precautionary measure in prescribing atropine to explain its use and abuse, to have it labelled "poison" and not to be used for any other person or at any other time than the one indicated, and it is often still safer to prescribe only a few drops at a time, furnishing it to the patient, so that there will not be any left to pass around.

When prescribed for the purpose of producing a mydriasis for an ophthalmoscopic examination, or the determination of refraction errors, I believe it well to have the patient bring back the bottle and the dropper so that we may see them destroyed.

COCAINE.

I just mentioned the subject of cocaine, and a few words in reference to it will suffice.

Cocaine is one of our best friends. It makes it possible for us to operate upon most of our cases without a general anesthetic. It reduces congestion and relieves pain, but its danger is to the cornea. producing a loss of epithelium or an erosion of that tissue, under which circumstances the eye easily becomes infected, corneal ulcers or abscesses develop, and any one of a dozen varieties of inflammation may follow. It, therefore, should not be prescribed indiscriminately for home use or given into the hands of a patient without thorough instruction to him and a thorough comprehension of its use on the part of the physician.

Cirrhosis of the Liver in Children.-Osler reported two cases to the John Hopkins Medical Society. One was a child of seven. The vertical area of liver dulness was ten inches. The second was a boy of thirteen. This case presented ascites which Osler thought to be due to cirrhosis of the liver, and possible to tubercular condition of the peritoneum in addition. On opening the abdomen for the ascites, the liver was found to be atrophic and cirrhotic. -Medical Review of Reviews.

COLLOID CANCER OF THE INTESTINES

BY WALTER SANDS MILLS, M. D.

New York.

N March, 1900, a man, aged 46, applied to the writer to know if

"

he had Bright's disease. By profession the patient was a civil engineer and contractor. He said he had been running down and had lost twelve pounds in eighteen months. Careful examination of the urine failed to reveal any evidence of kidney trouble. Nothing more was seen of the patient for some months.

On October 4, of the same year, the patient returned. He gave the following account of the intervening time:

Late in the spring the patient had decided to take out a life insurance policy for a large amount. In consequence two of the company's most expert examiners were sent to examine him. He was rejected. After considerable effort and persistent use of "pull" the patient was informed that he was thrown out because of Bright's disease. But the sought-for policy was to be of large amount and was wanted for business purposes. Therefore, after some six weeks two other expert examiners were sent to examine the applicant. Again he was rejected. This time he was told that his kidneys were all right, but that his general "run-down" condition was against him. The examiners could give no diagnosis of the case.

These rejections were distinct shocks to the patient. He became alarmed and worried about his condition. Several physicians were consulted but without avail. As a last resort the patient gave up business temporarily and went to the country to rest during August and September. A physician consulted there gave a diagnosis of "liver trouble" and kept the patient under treatment the entire two months. Plenty of out-of-doors, golf, and relief from business improved his condition so much that when he was ready to return home the country physician assured him his "liver trouble" was cured.

A few days at home and the patient began to go down hill again. So, on October 4, he once more called on the writer for a complete physical examination, which resulted as follows:

Lungs normal. Heart action rapid. Liver area normal. Just below the liver, but not connected with it, on the right side, was a distinct mass, seemingly about the size of the clenched fist. This mass was not visible but was palpable, and slightly sensitive on percussion. There was a decided area of flatness. The bowels

were regular and caused no trouble. He had a tendency not to stand erect as it caused some pain in the abdomen if he did so. No opinion was given as to the nature of the tumor.

On October 5, Dr. St. Clair Smith went over the patient with the same result. At his suggestion the urine was examined again. Quantity for twenty-four hours, 25 oz. Specific gravity, 1028. Reaction, acid. Albumin, none. Sugar, none. Urea, 10 grains to the ounce. Flocculent precipitate. Under the microscope was found an occasional pus corpuscle, crystals of oxalate of lime, and a very few epithelia.

Dr. E. D. Klotz made a blood examination and reported, "Percentage of hemoglobin 59. Number of red corpuscles 3,480,000. Number of white corpuscles 5,980. Evidently there is no leucocytosis. There is a moderate anemia.

The red cells are seen in the

form of macrocytes, microcytes, poikilocytes. There is a slight increase in the normal number of eosinophiles. I would not say there was pernicious anemia, but there is secondary anemia.”

The patient continued in about the same condition for a couple of weeks. Some days he felt a little better, other days a little worse. Not satisfied with the progress of the case it was decided to call in a surgeon, and Dr. E. G. Tuttle was consulted.

Dr. Tuttle agreed with the diagnosis as to the presence of the tumor and recommended its removal. Preparations were made for operation and the date set for October 25. During all this time the patient, though suffering more or less discomfort, was attending to his business.

On the afternoon of October 25, 1900, the patient was anesthetised by Dr. Bennett, and operated by Dr. Tuttle, assisted by Drs. P. C. Thomas and the writer.

Incision was made in the right iliac region. On opening the peritoneum a cancerous mass was disclosed in the ileo-cecal region. It was about the size of two clenched fists, and surrounded the appendix and the intestines. It was adherent in places and was removed only with the greatest difficulty. Some fourteen inches of large and small intestine on either side of the tumor was also excised. A button-hole incision was made near the cut end of the large intestine and the free end of the small intestine stitched to it. The free end of the large intestine was then sewed up. The patient came out of the ether satisfactorily.

To the naked eye the tumor was about the size of two closed fists. In color it was red with a purplish tinge. The lumen of in

testine running through it was barely sufficient to admit an ordinary lead pencil. Bands of adhesion crossed the intestine inside the tumor in various directions. It seemed remarkable that the patient had not presented more intestinal symptoms. On section the tumor proved to be badly broken down and was in a very unhealthy condition.

The mass was sent to Dr. Louis Heitzmann for microscopical examination. His report is as follows:

"DR. E. G. TUTTLE,

October 31, 1900.

Dear Doctor:-The new growth from the intestine which you sent for examination a few days ago, was found to consist in many places of a mass of ulceration, which had more or less completely destroyed all the elements of which it was composed. Beneath the ulceration, as well as at the periphery of the growth, a varying amount of fibrous and myxomatous connective tissue, infiltrated with inflammatory and medullary corpuscles, was present, and interposed between the connective tissue a large number of irregular, coarsely granular epithelia, partly single, partly arranged in small nests and alveoli, is seen. In many places a prominent secondary change is found. This change consists of a partial or complete transformation of the epithelia into a hyaline, apparently structureless substance, with only a few epithelia remaining in this substance. Myxomatous, newly formed connective tissue was also found in different places. Blood-vessels were nowhere very

numerous.

The diagnosis is: Colloid Cancer in Ulceration.

Yours truly,

DR. LOUIS HEITZMANN."..

After the patient came out of ether, he complained of pain in the back, and every fifteen minutes or so sharp shooting pains through the abdomen caused him to cry out. Aconite was given.

October 26, 7 a. m.

severe.

Patient slept a few minutes at a time, off and on, through the night. Has pain in back and in abdomen when he moves. The pain is paroxysmal, and about 4 a. m. was very At 7 a. m. he had slight eructations and nausea for the Skin feels hot and feverish though the temperature is only 98. 3 p. m. Dr. Tuttle ordered an injection of liquid peptonoids I oz, water 4 ozs., also a little liquid peptonoids by mouth, in water. At noon, on account of gas in bowels, Dr. Tuttle prescribed calomel one-quarter grain and soda bicarbonate. This was fol