Com~pl±rnen.ts of Writer. 
REPORT OF A CASE 
—OF— 
Glycosurio Retinitis. 
By H. CULBERTSON; 
Assistant Surgeon, U. ST A. (Retired). 
'Read before the Zanesville Academy of Medicine, and 
ordered to be published.) 
Reprint from the Detroit Lancet, April, 1880 
GEO. S. DAVIS, Publisher. REPORT OF A CASE 
OF 
GLYCOSURIC RETINITIS. 
THE object of this paper is to place the 
case on record and to demonstrate that 
there is no typical lesion of the retina char- 
acteristic of diabetic retinitis. 
History.—November 2, 1877, the mother 
brought to me her child, Minnie R., set. 6 
years, for treatment. The child was pale, 
anaBmic, bright, fond of going to school and 
had light eyes and hair, and had been sick 
with some form of malarial fever, and with- 
in the last four had been losing her 
eye-sight. On examination, I found she could 
only distinguish daylight with the left eye, 
and that vision in the right eye=v61'ii. On in- 
vestigation it was found she was passing 
three pints of slightly acid urine daily, and 
an examination revealed that its s. g. was 
1.025 and thnt it contained sugar, as shown 
by Trommer’s test. Under the microscope 
no casts or renal epithelium were observed, 
and heat and nitric acid attested that there 
was no albumen in the fluid. 
Symptoms.—The eyes were normal in ap- 
pearance externally, the pupils dilated, and 
there was no pain in or about the eyeballs. 
The ophthalmoscope revealed in the left eye, 
at the outer region of the disc and near the 
macula, small white spots quite similar to 
those delineated b}r Jaeger* in plate xiv.,fig. 
"Traite des Mai. du Fond de L’Oeil, 4 
66, as occurring in albuminuric retinitis. 
The outlines of the disc on its outer side 
were obscured with a woolly veil, its arteries 
and veins were slightly smaller than normal, 
and the papilla was abnormally red on the 
outer side. The retinal arteries were indis- 
tinctly seen, the media were clear, and there 
was no hemorrhagic effusion. In the right 
eye the outlines of the disc were more dis- 
tinct than in the other eye, as well as the re- 
tinal vessels on the disc and over the fundus 
generally. Still the arteries were slightly in- 
distinct. The same spots were observed at 
the outer side of the disc as in the left eye, 
though not so marked. There were no blood 
extravasations, the media were clear, and 
there were no pigmental deposits in either 
eye. 
The pathology evidently was retinitis,with 
plasmic effusion and proliferation of the 
connective tissue of the retina, with limited 
fatty degeneration. The cause was the gly- 
cosuric process, and probably malaria su- 
perinduced the latter. The diagnosis was 
glycosuric retinitis. The prognosis given 
was, that we hoped to retain the vision now 
possessed, and even to improve the sight of 
the right eye. 
The treatment was as follows: She was 
ordered animal food and aliment free from 
starch and sugar. It was directed that she 
be clothed with flannel and rubbed over the 
surface of the body night and morning with 
a flesh brush,that she be taken out daily in the 
air, and that removal from school and reading 
and use of eyes, be prescribed for the pres- 
ent. She was given elix. iron, quinia and 
strychnia, and ordered to inhale every night 5 
at bedtime two or three drops of the nitrite 
of amyl. 
November 18.—To continue the same 
treatment and to use a +3" glass in 
methodic exercise of the left eye and a +14" 
for the right eye, as well as the + 8" lens. 
Her vision has improved in the right eye, but 
not in the left. R.V.=,112,// with a +12" glass. 
For constipation, she was given pulv. 
rhei every night. She does not now get up 
at night to urinate, and I find no sugar in her 
urine. 
December 22d.—Was given zinci phos. 
gr. ij., ext. nucis vomicae gr. ijss., iron by hy- 
drogen 3j, 20 pills, S.—one after meals. To 
continue the methodic exercise, rubbing, 
amyl, and laxative pill. 
January 9, 1878.—To continue same treat- 
ment and add h grain of santonine three 
times daily as a retinal tonic. She was also 
to bathe about the eyes, brows and temples 
with laudanum. 
January 26th.—To continue exercise and 
laudanum. To omit the other agents, and 
take elix. iron, quinine and strychnia, also 
pot. iod. in comp, syrup of sarsap. (The 
guaiac in this I believe to be useful and the 
senna beneficial as a laxative.) 
February 18.—To omit all agents and to 
take strychnia granules, each gr., tr. die, 
and emulsion of cod liver oil. 
March 9.—Ordered elix. iron, quinia 
and strychnia, and pot. iodide; other agents 
omitted. 
On examining the eyes I found the stroma 
of the left retina was atrophied at spots, the 
disc was shallow-cupped, its outlines distinct, 
irregular and pigmented, and its surface blue- 
white. The retinal arteries and veins were 6 
much reduced in size. In this eye she had 
only qualitative perception of light. The iris 
was still active in this, as well as in the right 
eye. I could not make out the limits of the 
macula. The right presented the white spot s 
observed in it during the first examination , 
which extended nearly to the macula and 
over a larger area than at first. The retinal 
vessels were now distinct on the disc and 
over the fundus, and the macula was normal. 
The color of the disc was pale, and there 
were none of the finer vessels, and its mar- 
gins were slightly irregular. The retina 
generally did not present the bright and dis- 
tinct granular aspect, but gave a slightly 
dull reflex, with a +12" lens V=I-8T" 
In the left eye the disease ended in gen- 
eral atrophy of the retina, the diseased pro- 
cess being mainly located at and about the 
optic nerve entrance—an optic neuritis, essen- 
tially—and in the right eye the atrophy was 
limited to points of the retina, the macula 
escaping injury, and the influence of the 
disease not being so profound in its effects 
upon the optic nerve. 
This case, then, we regard as a sub-acute 
retinitis, due to glycosuria. In referring to 
authorities in relation to this disease, we 
do not find in those at our command a 
great number of examples of this affection. 
Jaeger* reports a case in which retinitis, 
mainly about the disc and of the papilla, 
with a few peripheral exudative spots, and 
with obscuration of the retinal vessels, was 
observed Galezowskif says he lias seen in- 
flammations of the retina, iris, choroid, 
atrophy of the optic nerve, paralysis of the 
♦Atlas D’Ophthal., PI. xiii. Fig. H4. and p. 96. 
tReceueil D'Ophth., Feb. 1879, p. 75. 7 
sixth nerve, hemiopia and amblyopia, due 
to glycosuria (as well as cataract). Schweig- 
ger does not speak of diabetic retinitis, but 
mentions, in retinitis septica, that the an- 
atomical changes consist in hemorrhages and 
small white spots formed by thickened nerve 
fibres and fatty degenerated connective 
tissue corpuscles.* Zanderf quotes Lie- 
breich, who holds that “ idiopathic affections 
of the retina are extremely rare,” and “ to 
be almost always due to constitutional dys- 
crasia or blood poisoning.” Zander himself, 
speaking of the chronic inflammation and 
fatty metamorphosis which attend upon 
Bright’s disease, says:]; “ But it should be 
remarked that a similar or identical disease 
of the retina is seen in connection with dia 
betes mellitus, hippuria, benzuria, oxaluria, 
and so forth, as well as partially during 
pregnancy and lactation, and in syphilis.” 
Stellwag§ says, while considering the 
causes of nephritic retinitis, “ Similar oph- 
thalmoscopic appearances have been observed 
in diabetes, and even in neuro-retinitis de- 
scendens, consequent upon cerebral affec- 
tions.” The editor maintains that similar 
ophthalmoscopic appearances may be induced 
by any dyscrasia. 
Wells|| says: “Retinitis is far more fre- 
quently due to some constitutional affection, 
or consequent on some other disease of the 
eye, e. g., choroiditis.” * * * “It may 
also be caused by syphilis, by certain affec- 
tions of the kidneys, especially Bright’s dis- 
ease and diabetes, and by cerebral diseases.” 
♦Handbook of Ophth., 3d Germ. ed. by Fasley, p. 462. 
t“ The Ophth., Its Varieties and Use,” Carter, p. 156. 
flbid, p. 156. 
§Treat. on the Dis. of the Eye, Am. ed., 4th rev., p. 190. 
Treat. Dis. Eye, 3d ed., p. 373. 8 
Walton,* speaking of hemorrhagic reti- 
nitis, says: “This has been described as oc- 
curring in diabetes, but not sufficiently au- 
thentic for me to accept the report.” 
Galezowskif says, as to the pathology of 
this form of retinitis: “ What is the intimate 
cause of the alterations of the retina and 
optic nerve? The experiments of Claude 
Bernard have proved that wounds of the 
floor of the fourth ventricle occasion glyco- 
suria. But if, on the one hand, the alterations 
of this region induce glycosuria, on the other 
hand it is not doubtful that the impoverish- 
ment of the blood occasions in its turn a 
variety of alterations in different parts of 
the body. We know, indeed, that purpura 
hemorrhagica (Trousseau), spontaneous gan- 
grene (Marchal de Calvi), the softening, gray 
and red, in the fourth ventricle, and in the 
superior processes of the cerebellum, may 
be developed as a result of glycosuria.” 
“The alterations in the retina prove to us 
that it is really in the morbid state of the 
arteries that we should look for the proxi- 
mate cause of the retinitis. As a result of 
the diseased state of the blood, and the af- 
fection of the fourth ventricle, transmitted 
through the vaso-motor system of nerves, the 
walls of the vessels do not perform their 
functions well, and the capillaries are trans- 
formed little by little, and subjected to fatty 
degeneration.” 
“In atrophy of the papilla, particularly in 
the brain, the material lesion is manifested, 
as has been observed by Buys, Becquerel, 
Trousseau and others; from thence it suc- 
cessively invades the optical centers and pro- 
* Practical Treat, on the Dis. of the Eyes, 3d ed., p. 1107. 
fTraite Des Mai. Des Yeux, M ed., p. 645. 9 
duces their atrophy.” He recites, at page 
642 ibid, a case in his own practice, in which 
there was atrophy of the papilla, diminution 
in the size of its vessels, its outlines well 
marked, and the retina, in the region of the 
disc, not at all clouded and without trace of 
infiltration, similar to that found in albu- 
minuric retinitis. There were also several 
hemorrhagic effusions at different points of 
the retina. He reports also another case 
seen by himself, as well as by Courtois, in 
which there was present only hemorrhagic 
extravasations of this tunic. 
Mollein* has reported a case in which 
there was hemorrhagic spots and white ex- 
udations upon the retinae, and which re- 
covered from diabetes. 
Noyesf has recorded a case of this disease 
in which he has observed white exudations, 
more especially in the region of the macula, 
and similar in all respects to those which we 
detect in albuminuria. The optic nerves 
were congested without any clouding of the 
contours. 
Boucher}; reports a case of this affection in 
which there was venous hemorrhage in the 
retina in the region of the macula, and in 
the same work is cited the case of Mesnard, 
in which there was produced at once a gly- 
cosuric retinitis in both eyes, and about the 
same time one eye was seized with hemor- 
rhagic glaucoma. * * * * * 
According to Galezowski, the first two 
cases of this malady were reported by Des- 
marres. 
*Ibid, p. 642. 
tTrans. Am. Opth. Society, 1869. 
JTrait. Mai. Des Yeux. Gal., p. 643. 10 
Roberts,* while not referring to diabetic 
cataract, cites Bouchardt’s statement, that a 
fifth of diabetic cases are complicated with 
amblyopia. The author states that this ef- 
fect may be temporary, and often finally 
ends in permanent blindness, which result, he 
says, seems to be caused by atrophy of the 
' retina. 
Pagenstecher and Gerth are silent in their 
splendid work as to glycosuric retinitis.f 
We find in it, however, delineations of mor- 
bid states of the retina due to albuminuria, 
some of them quite similar to those some- 
times found in cases of glycosuric retinitis. 
REMARKS. 
The diabetes was cured in this case. T 
learned after several months that the little 
patient was still doing as well as when I last 
examined her. 
From a consideration of the views of the 
above authorities I cannot believe this in- 
flammation is a common affection. What- 
ever may be the nature of the diabetic pro- 
cess, we have ample evidence that all parts 
of the retina may be affected, though not 
simultaneously, or to an equal extent. In 
general, the disc and region about the papilla 
seems to suffer the most from the effects of 
the disease and the lesions would, in general 
appear to be less profound in this than in the 
albuminuric retinitis. It would seem that 
hemorrhages are more frequent in this than 
in the nephritic inflammation of this coat, in 
which latter disease exudations of plasma 
appear to be more commonly present. Still, 
the morbid process is essentially the same in 
♦Pract. Treat on Urinary and Renal Dis., 2d Am. Ed., p. 238 
tAtlas of the Path. Anat. of the Eyeball. 11 
both affections, viz., a lesion of nutrition, 
differing more in degree than in pathological 
characteristics. 
It has not been positively shown that the 
disease begins primarily in the blood vessels 
of this tunic, and we know that the inroads 
of the affection do not always fall upon the 
same layers of this coat with equal intensity. 
Sometimes the effects tell mainly on the rods 
and cones, again on the nerve fibres, or pos- 
sibly upon the ganglion elements. If the 
effusion be mainly serous, little damage may 
result to the nerve elements; if the extrava- 
sation be plastic, induration, distortion and 
destruction of these, with atrophy, may ob- 
tain, leaving the membrane impaired or unfit 
for vision. Proliferation and fatty degener- 
ation form a part of the diseased process, 
and the small white spots mentioned seem to 
be due to these effects. Pigmentation and 
hemorrhagic extravassation may or may not 
be present as a result of this dyscrasia. 
Neither is the disease always manifested 
with inflammatory symptoms, and yet pro- 
found lesions of nutrition seem to follow this 
affection of the retina—a membrane sparsely 
supplied with blood vessels, from the very 
nature of its functions. Can it, therefore, 
be that the lesions we are considering result 
from affections of the blood vessels alone, or 
even uniformly from the inflammatory pro- 
cess? May we not encounter here, as else- 
where, in the body, affections of nutrition 
without inflammation? What role does the 
vaso-motor system play, and what is the 
status of the sensory nerves in this affection? 
While then we neither adopt the views of 
Virchow or those of Cohnheim, we must 
claim inflammation to be an affection of 12 
both vessels and the perivascular area, as 
well as of the vaso-motor and sensory nerves. 
I may add, in relation to this case, that my 
notes contain no mention of counter-irrita- 
tion employed in the treatment. I cannot 
remember distinctly, but I think vesicants 
were employed. Further, there were no evi- 
dences of syphilis in the case. 
Finally, to diagnose this disease it will not 
suffice to inspect the retina alone, but the 
urine must be also carefully tested and micro- 
scopically examined. If to the urine there 
be added a slight excess of the pure sub- 
acetate of lead, then filtered, and to tho fil-' 
trate there be added a slight excess of pure 
sodium carbonate, to neutralize any excess 
of the lead salt (the process of M. Jolly*), 
Trommers, Prouts or Folding’s tests will act 
more satisfactorily. 
I do not believe lhat the quantity of the 
sugar in the urine will always indicate the 
extent of the lesion of the retina, for do we 
not have glycosuric amblyopia without de- 
tectable lesions of the retina, and how sel- 
dom is this disease present in diabetes where 
a large quantity of sugar is voided in the 
urine. 
*Cin. Lancet and Clinic, leb. 7,1880, from La France Med.