ATROPINE RHINITIS. 
BY 
LEWIS S. SOMERS, M.D., PHILADELPHIA, PA. 
[Reprint from The Laryngoscope, St. Louis, October, 1897.] ATROPINE RHINITIS. 
BY LEWIS S. SOMERS, M.D., PHILADELPHIA, PA. 
The term atropine rhinitis is here used to designate a form of irri- 
tation of the Schneiderian mucous membrane and turbinal cavernous 
tissues, from the effects of atropine instilled into the eye and passing 
through the lachrymal canal, exerting its local influence on the 
tissues of the nasal cavities. When atropine is applied in minute 
amounts to the nasal tissues, there is produced dryness of the mucous 
membranes; as the amount of the drug is increased, we find, in addi- 
tion to the dryness, signs of beginning irritation, the turbinal cavern- 
ous tissues becoming more red in color than normally and at the 
same time there is a total lack of secretion, presenting a dry, glazed 
appearance very similar to that seen in the first stage of an acute 
coryza. As the amount of atropine is still further increased, we have, 
in addition to the two symptoms already mentioned, a feeling of heat 
and discomfort in the nasal chambers, and if examination be now 
made, it will be found that the turbinals are congested and the secre- 
tions increased. The reflex action of the parts are lessened or en- 
tirely abolished, with loss of the vessel tonus. 
When applied locally, atropine is an irritant and in small amounts 
stimulates the vaso-motor centers. In large amounts, when applied 
directly to the tissues, the peripheral nerve filaments are paralyzed, 
due to a direct local action of the drug. The effects as studied by 
numerous observers on muscle tissue are peculiar, inasmuch as the 
drug first stimulates and finally paralyzes involuntary muscles, while 
no effect, even when used in large amounts, is seen with striped or 
voluntary muscles. As the venous sinuses, composing in great part 
the turbinal tissues, are surrounded by unstriped muscular fibers, we 
can readily see, from what has just been said, the effects of atropine 
on this portion of the nasal tissues. 
In ophthalmological practice the strength of the atropine solution, 
generally used to produce mydriasis, is four grains to the ounce of 
water and but one minum is used in each eye, at the same time pres- 
sure is made with the finger over the lachrymal duct so that the solu- 
tion will remain and be absorbed. It is sometimes necessary to use 
a number of drops of the solution in both eyes for several days, until 
the proper amount of mydriasis is produced. Occasionally the 4 
patient is given the solution, with directions as to the amount to be 
instilled into the eyes until the desired effect is obtained. Frequently 
no directions are given as to compressing the lachrymal duct and the 
larger amount of the solution escapes into the nasal cavity; the num- 
ber of instillations being increased to dilate the pupil, so as to com- 
pensate for the amount lost via the nasal duct. In the majority of 
cases there are no ill results from the atropine remaining in the nasal 
chambers, but in a smaller proportion, either from an excessive 
amount of the drug being used, or from a peculiar idiosyncrasy of 
the patient, atropine rhinitis results. 
The following case will illustrate the condition: M. P., age 
eleven years, female, white. Was first seen on March 30, 1897, 
complaining of a constant watery nasal discharge. Her mother 
stated that on March 6 she went to the eye clinic of a large general 
hospital on account of some impairment of vision. A number of 
drops were instilled into both eyes, which were afterwards ascer- 
tained to be atropine of the usual strength used for refractive work. 
No untoward symptoms were noticed until the evening of the same 
day when emesis occurred, without nausea, and has continued until 
the present time. On the following day she complained of a post- 
nasal discharge of a watery fluid, which was accompanied by a free 
anterior discharge ; this was then like water and in it were masses of 
thick mucous. Previous to the use of the drops there had been no 
subjective or objective signs of nasal trouble. 
On examination of the nasal cavities both sides were seen to be 
affected ; the turbinals, and especially the inferior, were pale in color, 
with that sodden appearance as observed a few days after the onset 
of hay fever, and they were soft and "boggy" to the touch of the 
probe, giving one the feeling as if the tissues were relaxed. From 
the surface of the mucous membrane a clear serum was transuding 
in considerable amounts, the nasal cavities filling immediately after 
the removal of the previous discharges. The mucous membrane was 
macerated from the excessive irritation, which had nearly passed away 
before I saw the case ; this had extended to the muco-cutaneous junc- 
tion of the vestibule, the upper lip being red and irritated from the 
acrid secretions. The treatment consisted in cleansing the nasal 
chambers with a mild antiseptic, alkaline solution followed by men- 
tholated albolene, two grains to the ounce, the irritated areas being 
then covered with an ointment composed of two grains of the yellow 
oxide of mercury to the ounce of lanoline. Recovery ensued in a 
few days, no other after effects of the atropine being observed, and 
the nasal tissues rapidly regaining their normal condition. 5 
This case was undoubtedly due to an idiosyncrasy to atropine, be- 
ing analogous to the effects seen in a minority of cases when the drug 
produces the peculiar so-called "atropine conjunctivitis" in unduly 
susceptible individuals. In these cases a minute amount will pro- 
duce irritation of the conjunctiva, with swelling and erythema of the 
skin of the eyelids and surrounding region. (Juler.) It then being 
necessary to discontinue the use of the drug, when the irritation 
promptly ceases. In persons possessed of this peculiarity of the nasal 
tissues, the use of atropine as a mydriatic must be stopped and the 
nasal irritation promptly disappears under the use of soothing local 
applications. 
There is another condition that I have met with as the result of the 
excessive use of atropine instillations, occurring in children, not 
from any undue susceptibility to atropine, but from its continued 
use in the eye. In some ocular affections when a continuous my- 
driasis was desired and the patient allowed to use one or two drops 
of the one per cent, solution in each eye, three times daily for one or 
two weeks, we will find the condition presently to be described. In 
the majority of cases from the use of the drug in both eyes the nasal 
affection is bilateral, but in a much smaller number the solution has 
been used in but one eye and then the nasal changes are unilateral, 
occurring only in the nasal chamber corresponding to the atropinized 
eye. In the cases where both nasal chambers have been saturated 
with the atropine solution for several days, we find the turbinals en- 
larged from passive congestion ; on the surface they are gray in color, 
from the sodden and macerated epithelium which comes off in flakes ; 
underneath the epithelial layer the cavernous tissue is a deep red, 
from the large amount of blood in the sinuses, their walls being re- 
laxed and active transudation of serum taking place constantly ; this 
with obstruction to nasal breathing being the two main symptoms 
complained of by the patient. 
The septal mucous membrane also partakes of the same charac- 
teristics as seen in the turbinal tissue and the cavernous tissue of the 
septum is more or less prominent from the desquimated epithelium. 
The olfactory portions of the nose are unaffected as a usual rule, but 
a moderate amount of anosmia is sometimes observed. When the 
irritation is unilateral we find the same changes as just noted, the 
other nasal chamber remaining normal. This sub-acute form is a 
continuation and later stage of the acute affection as seen in the case 
previously described. As this form is seen by the rhinologist later 
in its course than the acute cases, it is impossible to accurately de- 
scribe the first effects of the atropine on the nasal mucosa. I have 6 
seen a number of cases affected in this way and they all present the 
same characteristics, resembling to a great extent the changes and 
symptoms, except excessive sneezing, as observed in hay fever. 
The nasal septum is never ulcerated to any depth, nor is perfora- 
tion seen, but superficial areas of epithelial necrosis are constant, 
especially along the inferior edge and anterior cartilaginous plate. 
All the cases were in girls, from five to fourteen years of age, not any 
being observed in the male sex, and I have never found the condition 
in adults. The general health of the patients seemingly bearing no 
relation to the susceptibility to the drug, as all the children were in 
fair physical condition. No marked chronic changes in the nose or 
naso-pharynx were observed, the irritation apparently not being due 
to any previously existing catarrh. 
With certain drugs, when taken internally, we frequently have 
rhinitis resulting, either from an excessive dose or from the suscepti- 
bility of the patient; as an example of this class we may take iodide 
of potash, in some cases a minute dose producing violent inflamma- 
tion of the mucous membranes. I recall the case of a young woman, 
seen several years ago, in which one grain of iodide of potash pro- 
duced an intense form of coryza. 
Rhinitis, due to atropine, resembles to some extent those cases of 
hay fever caused directly by some definite object, such as certain 
fruits or animals, or various medicinal agents, as ipecac, sulphur and 
lycopodium. The condition of the nasal mucosa is very similar in 
these cases, inclining me much to the opinion that a close relation- 
ship exists between the two affections. Morrell Mackenzie, although 
not mentioning this condition in his work on the nose and throat, de- 
scribes a somewhat analogous condition under the head of traumatic 
rhinitis, due to minute particles of irritating substances suspended in 
the atmosphere and directly irritating the nasal tissues. These irri- 
tants may be in the form of vapor, as ammonia or chlorine gas, or solid 
particles, as the dust, from various metals, etc. In traumatie rhinitis, 
the mere irritation is not in toto, sufficient in all cases to produce the 
irritation of the nasal mucosa, as we frequently find that of two per- 
sons subjected to the same amount of irritation, one will show no 
effects, while the other will have a violent coryza in a few hours, or 
even immediately after exposure to the exciting cause. This, of 
course, is what occurs in "atropine rhinitis," the minority of indi- 
viduals only being affected when the drug is used for ophthalmoscopic 
purposes. 
The eye containing the atropine is affected but slightly, typical 
atropine conjunctivitis not occurring when the nasal tissues are 7 
affected and in the larger class of cases the drug having no deleterious 
effects upon the organ of vision, while in one or two cases seen, a 
mild grade of conjunctivitis existed coincident with the instillation of 
the mydriatic, not severe enough to require special treatment and 
disappearing as the nasal irritation cleared away. 
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