Two Cases of Nasal Hydror- 
rhoea. 
T. MELVILLE HAKDIE,TL A., M. B., 
PROFESSOR OF RHINOLOCnTAK© LARYNGOLOGY IK THE 
POST-GRADUATE MEDICAL SCHOOL OF CHICAGO. 
With a Report on the Eye Symptoms, 
BY 
CASEY A. WOOD, M.D., C.M., 
INSTRUCTOR IN OPHTHALMOLOGY AND OTOLOGY IN THE 
SCHOOL. 
REPRINTED PROM 
EH Neil) ¥orft fttetifcal Journal 
for September 6, 1890. Reprinted from the Neie York Medical Journal 
for September 6, 1890. 
TWO CASES OF NASAL HYDRORRHCEA.* 
By T. MELVILLE HARDIE, B. A., M. B., 
PROFESSOR OF RHINOLOGY AND LARYNGOLOGY IN THE POST-GRADUATE 
MEDICAL SCHOOL OF CHICAGO. 
WITH A REPORT ON THE EYE SYMPTOMS\ 
By CASEY A. WOOD, M. D., C. M., 
INSTRUCTOR IN OPHTHALMOLOGY AND OTOLOGY IN THE SCHOOL. 
Case I.—Mary S., aged forty-three, German, married, has one 
child, aged fourteen, healthy. Until nine years ago, when she 
came to America, she had always enjoyed good health. After 
living for two weeks in a basement, in February, 1881, she devel- 
oped a cough, which became asthmatic some time between March 
and July. She had had occasional attacks of asthma ever since, 
particularly in cold, damp weather. In July she received what 
her medical attendant told her was a sunstroke, which confined 
her to bed for some time. Some pills prescribed caused a buzz- 
ing in the ears with deafness for several days (quinine ?), and 
during the severe headaches, usually vertical, from which she 
has suffered at intervals since that time the deafness occasion- 
ally recurs. In August or September, 1881, a watery discharge 
from the nose commenced, the conjunctiva being reddened and 
lacrymation profuse at the same time. The discharge lasted 
for three or four days, stopped for a month, came on again for 
a few days, and again intermitted. Similar periods of discharge 
and absence of discharge alternated continuously until about 
two years and a half ago, since which time the discharge has 
* Bead before the Chicago Medical Society, July 7, 1890. 2 
TWO CASES OF NASAL HYDRORRIKEA. 
occurred daily, usually for three or four hours in the morning. 
The patient reports that it begins just as soon as she rises in 
the morning, whether that be at 4.30 or 6.30. Excepting on 
one or two occasions, no discharge has been noticed at night. 
She can not remember whether the discharge occurred on days 
on which she was confined to bed. Has never attempted to 
stop the discharge by lying down in the morning after the com- 
mencement of the flow. As a usual thing the fluid comes from 
both nostrils (sometimes from one), and drop by drop’ Shortly 
before stopping for the day the clear water, whitish and opal- 
escent when in quantity, becomes thicker and viscid, resem- 
bling ordinary mucus. Sneezing and formication are somewhat 
frequent accompaniments of the discharge, but they are by no 
means constant, nor does the formication appear to precede the 
discharge, as one might expect. It quite as frequently follows. 
The patient avers that this symptom has been more annoying 
since treatment was begun. While the asthma is ordinarily 
troublesome only in cold and damp weather, she is not sure that 
the hydrorrhcea is appreciably influenced by matters meteoro- 
logical. Has not noticed that it is worse on damp days. Thinks 
it is as bad in July as in November. It varies in amount from 
time to time, but without reason, so far as the patient could de- 
termine. 
History since coming under Observation.—In October, 1889, 
“ could not see to sew,” and attended Dr. Coleman’s eye clinic, 
where glasses were prescribed. She was then referred to me. 
Examination of her nose showed slight posterior hypertrophy 
of the right inferior turbinated and a dropsical condition of the 
middle turbinated bodies right and left. Ridge on septum high 
up on left side. No polypi. Sense of smell unimpaired. No 
marked departure from normal sensibility of nasal mucous mem- 
brane as tested by probe. Satisfactory posterior rhinoscopic 
view not obtainable, tongue depressor causing gagging. Pa- 
tient says this is produced by holding anything (e. g., candy) in 
the mouth for a minute even, but she has no such sensation 
when masticating and eating ordinary food. 
General health not very good. Burning pain in epigastrium 
after eating not infrequent. Painful and hypersesthetic spot TWO CASES OF NASAL IlYDRORRIKEA. 
3 
over the left eighth rib in front, which first became painful five 
years ago. No neuralgias. Is being treated in gynaecological 
clinic for laceration of the cervix. The patient has been treated 
during the past ten years by a sufficient number of regular 
practitioners and quacks, but without marked benefit. The re- 
moval by snare of portions of the middle turbinated bodies, 
with the internal administration of zinc oxide (gr. D and bella- 
donna extract (gr. £), markedly diminished the flow for a time. 
Treatment was begun on tbe 10th of April, with good results 
until the 6th of May, when a day and night discharge com- 
menced. This lasted until the 9th of May, the patient getting 
but little sleep in the interval. The nasal discharge was ac- 
companied by a flow from the eyes and a severe headache. On 
the 10th and 11th of May she had asthma; there was no dis- 
charge or headache. She was then almost free from any un- 
pleasant symptoms until the 3d of June, since which time she 
has had an almost daily recurrence of the discharge until the 
present time (7th of July), with asthma and headache from time 
to time. Patient’s attendance has been very irregular since tbe 
beginning of June. 
In view of the not infrequent association of optic-nerve 
atrophy with nasal hydrorrhoea (seven cases are recorded), 
a careful examination of the eyes was made at my request 
by Dr. Casey Wood, whose report is appended. 
The fluid had a specific gravity of 1‘006, contained 
chlorides, traces of mucin, a few cells from the olfactory 
region, and an occasional flat epithelial cell. It was feebly 
alkaline in reaction. 
Case II.—I am indebted to Dr. Lackner for the discovery of 
the case whose history I shall now give. 
Mrs. K. K., German, aged forty-two, married, two children, 
gave a history of profuse watery discharge from the nose which 
has lasted for ten years. Six months before the discharge 
began the patient suffered from “malaria” when living in a 
basement tenement. The flowr was at the beginning not very 
profuse, but in a short time was troublesome throughout the 4 
TWO CASES OF NASAL IIYDRORRHCEA. 
day and frequently all night as well. She was often wakened 
by it, and it was occasionally so profuse as to prevent sleep alto- 
gether. The intermissions have been rare and of short dura- 
tion. Patient asserts that the dropping has never ceased for 
twenty-four hours during the ten years, the amount of the 
discharge being about the same summer and winter. Upper 
lip swollen and excoriated. Watery discharge from eyes with 
occasional conjunctival injection. Fundus normal, no optic- 
nerve atrophy, and no contraction of visual fields. Dr. Wood 
kindly made the examination of the eyes in this case also. A 
troublesome and prominent symptom was sneezing, “ forty or 
fifty times a day ” being the usual thing. Unfortunately, the 
fluid was not examined, the discharge ceasing before the patient 
followed instructions in the matter of collecting it. The patient 
does not know the amount of the daily discharge, as she never 
collected it, but the constant dropping interfered very much 
with her work. Examination of the nose showed polypi right 
and left, and polypoid thickening of both middle turbinated 
bodies. 
Treatment was begun February 25th. Polypi removed. 
March 8th.—Marked lessening of discharge reported. Re- 
maining polypi removed. 
12th.—Discharge very slight. No sneezing. 
May 6th.—The same. Hypertrophy of right middle turbi- 
nated snared. 
17th.—No discharge. No sneezing. Snaring left middle 
turbinated. Patient reported absence of nasal symptoms on 
May 22d, June 5th, 12th, and 19th. To report again in one 
month. 
The chief interest in the discussion of hydrorrhoea cen- 
ters in its aetiology and in the fact of the occasional pres- 
ence of marked eye complications. The literature of the 
subject is by no means extensive; about twenty-five cases 
are reported, and, as in a number of instances for some 
reason or other an examination of the nose was not made, 
it is perhaps hardly possible as yet to formulate a theory 
applicable to all cases. In fact, a perusal of the histories TWO CASES OF NASAL HYDRORRHCEA. 
5 
of cases in which a continuous discharge of water from the 
nose was a symptom will compel one to conclude that it 
may, like atrophy of the optic nerve, be produced by a 
great many different conditions. One was evidently due 
to fracture of the base of the skull (Vieusse’s case *); it is 
an occasional accompaniment of general anasarca (Reesf); 
of meningitis (Paget J); of trifacial paralysis (Althaus #); 
of hydrocephalus internus (Leber, || who thought there 
had been bone absorption from pressure with escape of the 
cerebro-spinal fluid from the opening thus formed); while 
in some cases (Priestley Smith’s,A Nettleship’s ()) the brain 
symptoms appear to have been very marked. In two cases, 
on the other hand, reported by Bosworth,|; to whose valua- 
ble paper on the subject I have to acknowledge my indebt- 
edness, there was at the beginning apparently no visible nasal 
or other disease, and, presuming the examinations to have 
been accurate, the affection can not very well have been 
anything but a paresis of the sympathetic vaso-motor nerves, 
as Bosworth concludes. A somewhat novel idea as to the 
aetiology of this affection has been suggested by Mules,$ 
who reports three cases in support of his theory that “the 
dropping is due to overdistended lymph vessels of the 
pituitary membrane, which by their bursting cause fistulous 
openings.” Briefly they were : 1. A girl who suffered from 
a discharge of fluid from the umbilicus for six months; no 
* Gaz. hebd., 1879, No. 19, p. 298. ** 
f London Med. and Surg. Journal, 1834, vol. iv, p. 823. 
$ Transactions of the Clinical Society of London, 1879, p. 43. 
# British Medical Journal, 1878, vol. ii, p. 831. 
|| Graefe’s Archiv, vol. xxix, i, 273. 
A Ophthalmic Review, London, vol. ii, p. 4. 
() Ibid., p. 1. 
$ Treatise on Diseases of the Nose and Throat, New York, 1889, 
vol. i, pp. 261, 262. 
£ Transactions of the Ophthalmic Congress, Heidelberg, 1888. 6 
TWO CASES OF NASAL HYDRORRHOEA. 
fistula, this discharge being followed by a similar flow for 
four weeks from under right upper eyelid at frequent, though 
irregular, intervals during day and night. Stimulation of 
the lacrymal gland produced no effect. 2. A boy who had 
congenital lympho-angeioma of conjunctiva. 3. A woman 
in whom a lympho-angeioma just inside sphincter ani 
caused diarrhoea, which alternated with watery discharge 
from fistulous openings in tumor. In six weeks after liga- 
tion of the tumor an apoplectoid attack occurred which 
caused permanent paresis of one side. 
We have not far to look to see Mules’s explanation of the 
discharge from eye and nose, but are as far as ever from know- 
ing the cause of the enlarged lymph tubes. As a corollary 
to his theory, Mules concludes that the coexistence of optic- 
nerve atrophy with an abnormal watery secretion from eye 
and nose is merely a coincidence. He explains the occur- 
rence of the atrophy by suggesting that it may sometimes 
be due to the wasting character of the general disease, of 
which it and hydrorrhoea happen to be symptoms. In 
some cases of hydrorrhoea there is no atrophy, just as in 
other cases of atrophy there is no hydrorrhoea. Before, 
however, any conclusion can be arrived at respecting 
Mules’s theory, more exact knowledge with regard to the 
distribution of the nasal lymphatic system is required. In 
my opinion the affection is, with few exceptions, immedi- 
ately dependent upon a vaso-motor paresis, however that 
may be brought about. For this Bosworth has made out 
a good case. With some of his conclusions, however, it is 
difficult to coincide. I fail to see, for example, why the 
general resemblance of nasal hydrorrhoea in many particulars 
to hay fever should lead us to assert an atmospheric factor 
in its causation. In my first case the appearance of the 
interior of the nose would have been consistent with the 
hypothesis that there was a distention of the mucous TWO CASES OF NASAL HYDRORRHCEA. 
7 
membrane by lymph, or that we had to do with a lymph- 
angeioma. The fluid could be seen to ooze from the mu- 
cous membrane of the upper part of the septum, and from 
the swollen opalescent middle turbinated body opposite. 
The discharge did not come from a polypus, so far, at any 
rate, as concerned that oozing from the septum ; nor was 
the opalescent polypoid-looking middle turbinated a poly- 
pus. It became much smaller upon use of cocaine and 
pressure with a probe. The theory that the discharge is 
invariably connected with polypi has been several times 
shown to be incorrect. Cerebral symptoms likewise are 
frequently absent, as in Case II. 
An interesting occasional accompaniment is asthma, as 
in Case I. So far as I have seen, it has not been noted as 
a complication of other cases of nasal hydrorrhoea, but the 
frequency of its association with hay fever, and the general 
resemblance between the latter and such apparently un- 
complicated cases of nasal hydrorrhcea as the two reported 
by Bosworth, would at any rate prevent our surprise at 
such a complication. It will be noticed that the patient 
reports that the asthma had troubled her chiefly during the 
winter months, and that its onset did not, so far as she had 
noticed, affect the nasal discharge. My notes of the case 
since it came under my observation do not exactly cor- 
roborate the patient’s statement; for instance, during the 
latter half of April the discharge was very slight and asthma 
absent, although headache was, perhaps, worse than usual 
during a part of the time, but on May 6th (when the dis- 
charge had been absent for ten days) began one of the 
worst of her attacks, which was accompanied by headache. 
This gave way on the 10th and 11th of May to asthma 
then, on the 12th to the 15th of May, a very slight discharge 
occurred in the mornings, followed again on the 16th by 
slight asthmatic attacks. After that, as reported before, 8 
TWO CASES OF NASAL HYDRORRIKEA. 
there was absence of both unpleasant symptoms until the 
3d of June. There was then apparently an alternation 
between the attacks of hydrorrhoea and of asthma, but as 
this does not correspond exactly with the patient’s recol- 
lection of the previous course of the disease, and as the 
number of the observations is so small, I shall merely 
record the fact without further comment. I may say that 
I have in the present history neglected to discuss the re- 
lation which the so-called neurotic temperament bears to 
the disease. One reason for my omission may be found in 
the following facts: (1) Case I was that of an individual 
who would nowadays be denominated neurotic; (2) Case II 
would not in my opinion be so named. The deduction is 
obvious. 
While the presence of asthma was perhaps the most 
noteworthy feature of the first case, the second is worthy 
of record for a different reason. In it we had the two 
facts (1) that polypi were present along with the discharge, 
which is by no means unusual; and (2) that treatment 
directed to the removal of these polypi, and of those por- 
tions of the middle turbinated in which there was poly- 
poid degeneration, was efficient in stopping the discharge, 
and that, too, in cold and wet weather—a very unusual 
termination to a long-standing case of nasal hydrorrhoea. 
I think we may conclude, from a careful reading of the 
cases recorded, that nasal hydrorrhoea is not a disease per 
se, but a symptom of many pathological lesions, and that 
the prognosis and treatment of each case must be deter- 
mined by conditions aside in the majority of instances 
from the mere fact that there is a flow of water from the 
nose. 
M. S. has complained of weakness of sight, chiefly during 
the past eight months. Last November glasses were pre- 
scribed for her, which, however, she did not think enabled her TWO CASES OF NASAL HYDRORRFKEA. 
9 
to see any better. She suffers from bilateral epiphora, which 
is usually, though not always, worse in the morning. It then 
amounts to a continual flow from both eyes of a fluid resem- 
bling tears, and, generally speaking, is worse when the discharge 
from the nose is worse. During the daytime, also, when the 
nasal flow is lessened or stops altogether, there is very little 
lacrymation. The flow of tears has never produced excori- 
ation of the lids. In November last V. R. = ! V. L. = 
She was then wearing R. + 8 D., and L. + 1*75 D., which on 
trial were found not to improve the visual acuity. Both 
adduction and abduction were weak, the former showing at 
one trial a strength of 4°, at another 8°. The interni muscles 
could overcome a prism of 19°-23° only. At that time she 
complained of photophobia, and of dark spots in front of her 
eyes—in front of the right eye especially—and she thinks that 
for a time at least she was so blind that she could barely dis- 
cern large objects. Then, for a while, her vision improved, 
but it has never since been normal, nor is it possible by cor- 
recting her refractive error (compound hyperopic astigmatism) 
to greatly improve the visual acuity. The conjunctivas, both 
ocular and palpebral, are injected, but there is no purulent or 
muco-purulent secretion from the lids, and they do not adhere 
in the mornings. The last examination made shows a marked 
improvement (in the right eye particularly), as V. R. = ££, 
and Y. L. = ££, both with correction. The puncta lacrimalia 
are patent and in normal position. There is no affection of 
either lacrymal sac, and no indication of obstruction of the 
nasal duct. The ocular excursions are of normal extent on 
both sides and in all directions. Pupils are both active to 
light and accommodation. Tension normal in both eyes. The 
patient does not now complain of scotomata, only of weakness 
of vision and of inability to read or to do near work with com- 
fort. These, and the other ocular symptoms, have not to any 
appreciable degree been relieved by atropine or by a full cor- 
rection of her refractive error. A further examination of the 
case reveals the fact that she is not color-blind, and that she 
has no color scotomata. Both fields of vision for white, taken 
by means of a McHardy perimeter with a 5 mm. square object, 10 
TWO CASES OF NASAL HYDRORRIKEA. 
RIGHT EYE. 
are shown in the charts. These charts were carefully worked 
out several times, and the contractions were found to be fairly 
regular and symmetrical. This regularity is especially seen in 
the left eye, as the right field is more restricted toward the 
nasal side than was found to be the case in the left eye. The 
field for red is correspondingly limited in both eyes. 
The fundus appearances are interesting, although there is 
nothing abnormal outside of the papillae. The right disc is 
deeply and centrally excavated, and the blood-vessels come for- 
ward in a normal manner, but the whole papilla is very slightly 
paler than it should be. On the nasal border of the nerve there 
is a narrow, yellowish-white band, forming in that situation 
the rim of the physiological cup, and occupying about one third 
of its circumference. A somewhat similar appearance is to be TWO CASES OF NASAL HYDRORRHCEA. 
11 
LEFT EYE. 
DIAGRAMS OF OPTIC DISCS. 
ATROPHIC (0 
AREA 
RIGHT EYE. 
LEFT EYE. 12 
TWO CASES OF NASAL HYDRORRIKEA. 
seen in the left disc. Here there is no general pallor, and the 
normal cupping is shallow. At its bottom, however, the stip- 
pling of the cribriform fascia is to be seen. A band, yellow- 
ish-white in appearance, longer than but quite as narrow as 
that visible in the right disc, occupies the lower outer aspect of 
the left papilla. It does not extend, as in the former case, to 
the edge of the excavation toward the nerve center, nor does 
it reach in part of its course the outer rim of the disc. I have 
endeavored to illustrate this condition of things by the pre- 
ceding rough diagrams. 
I have seen a number of similar whitish areas in pa- 
pillae of eyes otherwise normal which were not accompanied 
by deterioration of vision or contraction of the field of 
vision, and I consequently hesitate to regard this picture as 
evidence of atrophic changes, however limited, of the optic 
nerve itself, and yet they are certainly not the pale spots 
on the surface of the disc which one sometimes sees due 
to variations in the light reflex from an uneven papillary 
surface. 
Whether the limited decolorization of the discs is evi- 
dence of a retro-bulbar neuritic process it would be difficult 
to say. The history of an attack, occurring six months 
before and accompanied by absolute central scotomata and 
great loss of visual acuity, certainly points in that direc- 
tion, but, in the absence of more positive proof, one can 
not very well decide. If such has been the case, it is not 
easy to say why, with some remaining impairment of vision, 
there are no central scotomata, not even for colors. 
Notwithstanding all treatment, the ocular symptoms 
since the date of writing the foregoing, the epiphora espe- 
cially, are as pronounced as ever. REASONS WET 
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